Every finding on record at Navasota Nursing & Rehabilitation

Based on observation, interview and record review, the facility failed to ensure prompt efforts were made by the facility to resolve grievances for one (1) of five (5) Residents (Residents #1) reviewed for grievances, in that; The facility did not investigate or take prompt action to resolve grievances voiced by Resident #1's RP during a care plan meeting on 06/10/2026 regarding his wishes for Resident #1 not to be given morphine sulfate (narcotic pain reliever) unless he was first notified and that he would like to add a routine acetaminophen to take the edge off and prevent the use of morphine sulfate which caused the resident sedation and confusion. This deficient practice could place facility residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life. Findings Included: Review of Resident #1's face sheet dated 07/31/2026 reflected a 92- year -old female admitted to the facility on [DATE] diagnoses included Alzheimer's disease (progressive mental deterioration that can occur in middle or old age due to generalized degeneration of the brain), anemia (a deficiency of healthy red blood cells), pressure ulcer of right heel. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 3 which indicated severe cognitive impairment. Resident #1 rejected care one to three days a week. Resident #1 had unstageable pressure ulcers and did not have pain during the assessment period. Resident #1 was on hospice. Review of Resident #1's comprehensive care plan reflected a focus area [Resident#1] has chronic pain related to end stage disease process. Interventions included; Administer analgesia as per orders. Give 1/2 hour before treatments or care. Evaluate the effectiveness of pain interventions q shift and as needed. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Review of Resident #1's consolidated physician orders reflected an order dated 12/13/2024 for acetaminophen (OTC pain reliever) 500 mg one tab every 6 hours as needed for pain. Further review reflected an order dated 07/07/2025 for Morphine Sulfate (narcotic pain reliever) 15 mg every 4 hours as needed for pain (The order did not include any instruction for notification to family prior to administration.) Review of Resident #1's Care Plan conference dated 06/10/2026 reflected Resident #1's RP, MDS Coordinator, and DON were in attendance. The documentation reflected that the resident was not able to attend related to inability to comprehend due to impaired cognition. Further review of the care plan conference reflected .He reports that narcotic medicaiton cause his mother to become sedated and confused. Son would like to add some routine acetaminophen for resident to see if it will aid in repositioning and take the edge off. He reports he would like to try it.Hospice will be contacted for orders. In an interview on 07/31/2026 at 11:22 am Resident #1's RP stated he had a care plan meeting with the facility in June and discussed with them his wishes regarding the use of Resident #1's Morphine Sulfate (MS). He stated he told them not to give it to her unless he was first notified because if he needed to, he could be at the facility in a few minutes. He stated he never gets a follow up on any complaints he voices. He stated a nurse called him on 07/27/2026 that she was given the MS, but they did not call before. He stated that was how he knew they did not tell the nurses his wishes. Review of the facility's grievance log dated June 2026 reflected no entries for Resident #1. Observation and interview on 07/31/2026 at 10:20 am revealed Resident #1 in her room in bed. She was getting bed bath from a hospice aide. She stated she was very good, stated she was not in pain and stated her pain was ok. Review of Resident #1's MAR reflected she was given MS once on 7/27/2026. Resident #1's medical record reflected no documentation that her RP was notified. In an interview on 07/31/2026 at 12:44 pm, RN A stated she worked with Resident #1. She stated she has given Resident #1 her MS when she was having pain. She stated she was unaware the family wanted to be notified prior to administration. She stated it was not documented anywhere in her medical record to call the family prior to MS administration. In an interview on 07/31/2026 at 12:58 pm, the MDS Coordinator stated she did the care plan meeting. She stated when a resident's family had complaints during the meetings they would do a grievance form and give to who it needs to go to. She stated if order changes were needed then it would go to the nurse to call the doctor. She stated she would follow up to make sure it was done. She stated they have had several care plan meetings with Resident #1's RP. She stated any special instructions should be put in the resident's medical record. The MDS Coordinator stated after reviewing Resident #1's medical record the instructions for the RP to be notified prior to MS administration was not in Resident #1's record and it should have been. She stated Resident #1's RP complaints during the care plan meeting should have been translated into a grievance and should have been followed up on, but she did not follow up. She stated she did not usually do the follow up but she would do the grievances. She stated she did not do a grievance regarding this one. She stated she contacted hospice for orders but did not follow up to ensure they were carried out. In an interview on 07/31/2026 at 2:41 pm, the DON stated she did not follow up on the complaints from Resident #1's RP that were voiced during the care plan meeting in June. She stated she recalled talking about the resident's medicaiton but did not recall exactly was discussed. She stated it would have been her responsibility to follow up but she did not. In an interview on07/31/2026 at 3:15 pm, the RNC stated that when residents or residents families voice concerns at any time not just in care plan meetings the grievance process should be used to ensure the ones who are responsible for addressing the issue follow up to ensure the issues are addressed. Review of the facility's grievance policy dated 11/02/2016 reflected The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievances the resident may have.

Based on 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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of five residents (Resident #1) reviewed for care plans. The facility failed to revise a comprehensive care plan to reflect Resident #1's RP's wishes for her pain medication administration. These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial and medical needs.Finding included: Review of Resident #1's face sheet dated 07/31/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] diagnoses included Alzheimer's disease (progressive mental deterioration that can occur in middle or old age due to generalized degeneration of the brain), anemia (a deficiency of healthy red blood cells), pressure ulcer of right heel. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 3 indicating severe cognitive impairment. Resident #1 rejected care one to three days a week. Resident #1 had unstageable pressure ulcers and did not have pain during the assessment period. Resident #1 was on hospice. Review of Resident #1's Care Plan conference dated 06/10/2026 reflected Resident #1's RP, MDS Coordinator, and DON were in attendance. The documentation reflected that the resident was not able to attend related to inability to comprehend due to impaired cognition. Further review of the care plan conference reflected .He reports that narcotic medicaiton cause his mother to become sedated and confused. Son would like to add some routine acetaminophen for the resident to see if it will aid in repositioning and take the edge off. He reports he would like to try it.Hospice will be contacted for orders. In an interview on 07/31/2026 at 11:22 am, Resident #1's RP stated he had a care plan meeting with the facility in June and discussed with them his wishes regarding the use of Resident #1's Morphine Sulfate (MS). He stated he told them not to give it to her unless he was first notified because if he needed to, he could be at the facility in a few minutes. He stated he never gets a follow up on any complaints he voices. He stated a nurse called him on 07/27/2026 that she was given the MS, but they did not call before. He stated the is how he knew they did not tell the nurses his wishes. Review of Resident #1's comprehensive care plan reflected a focus area [Resident#1] has chronic pain related to end stage disease process. Interventions included; Administer analgesia as per orders. Give 1/2 hour before treatments or care. Evaluate the effectiveness of pain interventions q shift and as needed. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. The care plan did not the Resident #1's RP wishes for care. In an interview on 07/31/2026 at 12:58 pm, the MDS Coordinator stated she did the care plan meetings. She stated when residents families had complaints during the meetings they would do a grievance form and give to who it needs to go to. She stated if order changes were needed they would go to the nurse to call the doctor. She stated she would follow up to make sure it was done. She stated they have had several care plan meetings with Resident #1's RP. She stated any special instructions should be put in the resident's medical record. The MDS Coordinator stated after reviewing Resident #1's medical record the instructions for the RP to be notified prior to MS administration was not in Resident #1's record and should have been. She stated Resident #1's care plan should have been updated to reflect the Resident's RP wishes. In an interview on07/31/2026 at 3:15 pm, the RNC stated that when residents or residents families voiced concerns at any time not just in care plan meetings, the grievance process should be used to ensure the ones who are responsible for addressing the issue follow up to ensure the issues are addressed and the care plan should be updated. Review of the facility's undated policy comprehensive care planning reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the residents' preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident toassist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type ofcare and services that a resident receives.

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 observed in that:The facility failed to date and label food found in the facility's refrigerator on 07/12/2026.The facility failed to properly seal food products in the facility's freezer on 07/12/2026.The facility failed to ensure the ice dispenser in the main dining hall was clean on 07/12/2026. These failures could place the residents who ate food or drank beverages from the kitchen at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illnesses. Findings included: Observation for 07/12/2026 at 9:10 am revealed:-the ice machine with a brown-colored substance on the panel where the ice comes out.-In the freezer a gallon storage bag with frozen chicken dated 07/07/2026. The top of the chicken had freezer burn.-In the freezer an opened bag of hamburger patties with freezer burn and date of 03/31 with no year.-In the refrigerator a gallon storage bag with a piece of watermelon. Unlabeled and Undated.During an interview on 07/12/2026 at 9:30am the DA E said she has worked at the facility for two years. The DA E told me food and beverages should be dated and labeled with the name of the item before putting it in the refrigerator or freezer. The DA E said if food is not sealed or used pass the use by date you could get sick. The DA E said she had been trained in labeling and dating food.During an interview on 07/12/2026 at 9:35 am the DC F said she has worked in this department for about two years. The DC F said all food should be labeled and dated. The DC F said if food is not dated, labeled, or sealed, the food could get contaminated and make resident sick. The DC F said she has been trained in labeling and dating food.During an interview on 07/12/2026 at 10:00 am the DM has been in this position for almost one year. The DM said if a bag is left open in the freezer it could get contaminated and make resident sick. The DM said if food is not labeled or dated you will not know when to use the food by and the food could spoil and make resident sick. I showed the DM the ice machine with the brown colored substance and asked what could happen if that gets in someone's drink. She said it could contaminate and make them sick. She has been in service and instructed staff on labeling and dating food.During an interview on 07/14/2026 at 1:00 pm the ADM said she expected all food to be labeled and dated before it is stored in the kitchen. I told the ADM about the brown substance on the ice machine dispenser and asked her what could happen if that got into a resident's drink. She said it could make the resident sick.Did not receive a policy addressing cleaning sanitization of ice maker.Review of the facility's policy dated 2012 Titled: Food Storage and Supplies IC 00-8.00Policy Statement: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin and insects.4. Open Packages of food are stored in closed containers with covers or in sealed bags and dated as to when open.

Based on observations, interviews, and record reviews, the facility failed to ensure residents rights to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 3 of 10 residents (Resident #26, Resident #30, and Resident #47) reviewed for resident rights.1.The facility failed to ensure RN A feed Resident #26 when she gave him his lunch meal tray on 07/12/2026.2.The facility failed to ensure RN A knocked on Resident #30's door before entering the room on 07/12/2026.3.The facility failed to ensure CNA D knocked on Resident #47's door before entering the room on 07/12/2026.These failures placed residents at risk of not having their nutritional needs met, to feel like their privacy was being invaded and diminished quality of life.Findings included: 1. Record review of Resident #26's face sheet, dated 07/14/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #26 had diagnoses that included hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (paralysis and weakness on right side after stroke), major depressive disorder (mental health disorder characterized by persistent depressed mood), protein-calorie malnutrition (inadequate intake of both protein and calories), polyneuropathy (damage affecting the nerves roughly the same area on both sides of the body), and contracture right hand (condition where the tissue in the hand shortens or tightens, causing fingers to permanently bend inward towards the palm). Record review of Resident #26's quarterly MDS dated [DATE] revealed Resident #26 had a BIMS score of 11, which indicated moderate impairment. The MDS also indicated [Resident #26] was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) on staff for eating. Record review of Resident #26's care plan, dated 04/16/2026 revealed: Focus [Resident #26] has potential nutritional problems related to impaired dentition, wounds, protein calorie malnutrition, and dependence for meals. Goals: None Interventions: Provide, serve diet as ordered. Monitor intake and record every meal. RD to evaluate and make diet recommendations PRN. Weigh at the same time of day and record monthly as needed. During an observation of lunch meal tray pass on the halls on 07/12/2026 at 12:01p.m., revealed that RN A took Resident #26 his meal tray at 12:07p.m. She put Resident#26's meal tray on the over the bed table that was over the resident's lap. RN A then left Resident #26's room and closed his door. During an interview with Resident #26 on 07/12/2026 at 12:12p.m., who said that staff left his meal tray in front of him all the time and would leave and not come back for a while. He said he wanted to eat when staff brought his meal tray. He said by the time the staff came back to feed him his food was cold. He said it upset him when staff brought his meal tray and walked out, and he had to wait so long to eat when his food was in front of him. During an observation of lunch meal tray pass on 07/12/2026 at 12:21p.m., revealed RN A went back into Resident #26's room to feed him.2. Record review of Resident #30's face sheet, dated 07/14/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #30 had diagnoses that included dementia (memory, thinking, difficulty), insomnia (difficulty sleeping), cerebral infraction (stroke), sepsis (a life-threatening complication of an infection), chronic obstructive pulmonary disease (chronic progressive- lung disease), hyperlipidemia (high cholesterol), and anxiety (feeling of uneasiness or worry). Record review of Resident #30's quarterly MDS dated [DATE] revealed Resident #30 had a BIMS score of 03, which indicated severe cognitive impairment. The MDS also indicated Resident #30 did not have anything on the MDS for knocking and privacy. Record review of Resident #30's care plan, dated 04/16/2026 revealed his care plan did not have anything regarding knocking and privacy. During an observation of meal tray pass on 07/12/2026 at 12:08p.m., RN A did not knock on Resident #30's door before entering the room. During an interview with Resident #30 on 07/12/2026 at 1:34p.m., when asked about staff knocking and how he felt resident responded with no problems.3. Record review of Resident #47's face sheet, dated 07/14/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47 had diagnoses that included severe dementia (memory, thinking, difficulty), insomnia (difficulty sleeping), hyperlipidemia (high cholesterol), Alzheimer's disease (progressive disease that destroys memory and other important mental function), Wernicke's Encephalopathy (an acute neurological emergency caused by thiamine (vitamin B1) deficiency, often associated with alcohol misuse, and can progress to irreversible brain damage if untreated), and anxiety (feeling of uneasiness or worry). Record review of Resident #47's quarterly MDS dated [DATE] revealed Resident #47 had a BIMS score of 02, which indicated severe cognitive impairment. The MDS also indicated Resident #47 did not have anything on the MDS for knocking and privacy. Record review of Resident #47's care plan, dated 07/02/2026 revealed her care plan did not have anything regarding knocking and privacy. During an observation of meal tray pass on 07/12/2026 at 12:10p.m., CNA D did not knock on Resident #47's door before entering the room. During an attempted interview with Resident #47 on 07/12/2026 at 1:43p.m., was unsuccessful due to Resident #47 being unable to answer questions.During an interview with RN A on 07/12/2025 at 2:01p.m., she said she had been trained on residents' rights. She said the policy for knocking on the resident's door was to knock, introduce themselves and tell the resident what the staff member was there for. She said staff were supposed to knock all the time before entering the resident's room. She said that the residents may feel their privacy was being invaded if staff do not knock. She said the only time staff did not have to knock was when a resident was unresponsive. She said all staff monitored to ensure staff were knocking. She all staff monitored through observations. She said she did not knock on Resident #30's door because the door was already opened and she was more focused on making sure the resident's food was correct. She said the policy for passing meal trays on the halls was staff were to pass all the trays and then go back and feed the residents. She said the nursing staff were responsible for feeding the residents in the halls that needed assistance. She said if a resident did not get feed when their meal tray was delivered the resident could spill the meal tray. She said the residents may feel anxious if the meal tray was placed in front of them and the staff walked off. She said the nurse monitored to ensure staff were feeding the resident when the resident got their meal tray. She said she monitored to ensure staff were feeding the residents through observation. She said she placed Resident #26's meal tray in his room because as a nurse her CNA's were supposed to feed Resident #26.During an interview with CNA D on 07/12/2026 at 2:35p.m., she said she had been trained on residents' rights. She said that the policy for knocking on the resident's door was that staff were to knock before entering, announcing themselves and telling the resident what the staff was there for. She said all staff were to knock anytime they wanted to go into the resident's room. She said if staff did not knock the residents may feel like someone was invading their privacy. She said there was no time that staff did not have to knock before entering the resident's room. She said the nurse monitored, to ensure staff were knocking. She said the nurse monitored by walking up and down the halls and observing from the nurse's station. She said she did not knock on Resident #47's door before entering because she got busy.During an interview with the DON on 07/15/2026 at 8:48a.m., she said she had been trained on resident rights. She said the policy for knocking was that staff were to knock before entering and announce themselves. She said all staff were responsible for knocking, she said a lot of residents had told her that staff do not knock, and they felt like someone was breaking into their house and the residents would tell her they felt irritated. She said the last time the residents told her anything about knocking was a month ago. She said she had done training on knocking and resident rights. She said there was never a time when staff did not have to knock before entering. She said the managers monitored to ensure staff were knocking. She said the managers monitored through observations. She said she did not know why RN A and CNA D did not knock on Resident #30 and Resident #47's door before entering. She said the policy for meal tray pass on the halls was residents who needed assistance eating staff were to pass their meal tray last. She said the nursing staff were responsible for feeding the residents. She said if staff put the resident's meal tray in front of them and walked out the resident could knock the tray over and the resident could get agitated. She said the nurses monitored to ensure staff were feeding the residents when they got their meal tray. She said the nurses monitored, by walking down the halls and making sure every resident was fed. She said she did not know why RN A put Resident #26's meal tray down in front of him and did not feed him until fourteen minutes later. During an interview with the ADM on 07/15/2026 at 9:10a.m., she said she had been trained on resident rights. She said the policy for knocking was that staff were to knock before entering and announce themselves. She said all staff were responsible for knocking, she said if staff did not knock the residents may feel disrespected. She said she had not gotten any complaints about staff knocking. She said all staff monitored to ensure staff were knocking. She said staff monitored by watching each other. She said she did not know why RN A and CNA D did not knock on Resident #30 and Resident #47's door before entering. She said the policy for meal tray pass on the halls was residents who needed assistance eating staff were to pass their meal tray last. She said the nursing staff were responsible for feeding the residents. She said if staff put the resident's meal tray in front of them and walked out the resident may try to pick up the food and choke. She added leaving the meal tray in front of the resident and walking out the room was a dignity issue. She said if staff did not feed a resident when they got their meal tray the resident may not feel important. She said all staff monitored to ensure staff were feeding the residents when they got their meal tray. She said all staff monitored by rounds and observations. She said she did not know why RN A put Resident #26's meal tray down in front of him and did not feed him until fourteen minutes later. Record review of Nursing Responsibility at Meal Service Policy dated 2012 revealed All feeding assistance programs should be closely monitored and supervised by appropriate facility staff, including nursing and dietary services. If a resident has a critical care need related to their ability to consume and process food, that resident should receive assistance from appropriately trained and experienced staff and/or individuals. The facility needs to address these concerns when conducting the resident assessment and the required services should be included in the resident's care plan. Record review of the Resident Rights Policy not dated revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must respect the residents right to personal privacy.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to 3 of 6 medication carts (MC #1, MC#2 and MC #3) reviewed for drug storage and labeling. The facility failed to ensure MC #1, MC#2 an MC #3, was locked, medications secured, and not accessible to other staff, residents, or visitors on 07/08/2026. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings include:During an Observation of the Station II Nurse's Station on 07/08/2026 at 5:01a.m., revealed LVN A was down the hall in a resident's room. MC #1, MC #2, and MC #3 were up against the nurse's station unattended and unlocked. During an interview with LVN A on 07/08/2026 at 05:03a.m., who said MC # 1, MC #2 and MC #3 were all assigned to her. She said she was trained on medication storage. She said the policy was staff must lock the medication carts. She said the nurse was responsible for locking the medication cart. She said if staff left the medication cart unlocked and unattended a resident could take something out of the medication cart that they should not have. She said the DON and ADM monitored to ensure the medication carts were locked. She said the DON and ADM monitored the medication carts through observation. She said she left the medication cart unlocked because she went to give a resident pain medication and change a dressing. She said she knew she should have locked the medication cart. During an interview with the DON on 07/15/2026 at 09:01a.m., who said she was trained on medication storage. She said the policy was the medication cart was to be locked when staff were not using them. She said the nurse who was on the medication cart was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked and unattended a resident could get into the medication cart and take medications. She said the managers monitored them to ensure staff locked the medication cart. She said the managers monitored by doing rounds. She said she did not know why LVN A left the medication carts unlocked. During an interview with the ADM on 07/15/2026 at 09:11a.m., she was trained on medication administration. She said the policy for medication storage was that the medication cart was to always be locked. She said the nurse who was on the medication cart was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked and unattended a resident could take medication that was harmful to them. She said everyone should be monitoring to ensure the staff were locking the medication cart. She said everyone should be monitoring the medication carts by observations. She said she did not know why LVN A left the medication cart unlocked. Record review of Medication Storage in the Facility Policy, dated 2025, reflected Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

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 diseases and infections for 3 (TN, RN B, and CNA D) of 7 staff reviewed for infection control The facility failed to ensure the TN performed hand hygiene or wore a gown on 07/14/2026 when she provided wound care to Resident #15. The facility failed to ensure RN B performed hand hygiene on 07/07/2026 when passing meal trays on the halls. The facility failed to ensure CNA D performed hand hygiene on 07/07/2026 when passing meal trays on the halls. These failures could place residents at risk for cross contamination and the spread of infection. Findings included:Record review of Resident #15's face sheet, dated 07/14/2026, reflected at [AGE] year-old male who was admitted to the facility on [DATE]. Resident #15's diagnoses included chronic venous hypertension with ulcer of right lower extremity (a condition where long-standing high pressure in the veins of the legs leads to skin and tissue changes), non-pressure chronic ulcer of other part of right lower leg with necrosis of muscle (a type of wound that develops on the skin but also has muscle tissue death), and peripheral vascular disease (a progressive disorder that restricts blood flow to the arms, legs, or other body parts). Record review of Resident #15's quarterly MDS assessment, dated 06/05/2026, reflected Resident #15 had a BIMS score of 14, which indicated intact cognitive response. The MDS also revealed Resident #15 was at risk of developing pressure ulcers/injuries. Record review of Resident #15's care plan, dated 05/07/2024 revealed: Focus [Resident #15] is on enhanced barrier precautions r/t wounds. Goals: There will not be any transmission of infection from or to the resident. Interventions: Gloves and gown should be donned [put on] if any of the following activities are to occur linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high contact activity. Review of Resident #15's order summary, dated 07/14/2026, reflected: Enhanced Barrier Precautions r/t wounds with a start date of 07/02/2026. Right lower lateral leg (Venous ulcer): Cleanse with wound cleaner, pat dry, apply calcium alginate, and cover with dry dressing 3 times weekly and as needed for Venous stasis Ulcer with a start date of 06/29/2026. Right lower Lateral Leg (Venous ulcer): Cleanse with NS/wound cleaner, pat dry, apply calcium alginate, and cover with dry dressing 3X weekly and PRN one time a day every Monday, Wednesday, Friday for Venous Stasis with a start date of 07/01/2026. During an Observation of lunch meal trays being passed on the halls on 07/12/2026 at 12:01p.m., revealed RN A did not sanitize or wash her hands before checking the meal trays. RN A took meal trays to residents and did not wash or sanitize her hands between the meal trays. CNA D delivered meal trays to residents and did not wash or sanitize her hands between the meal trays. During an observation on 07/14/2026 at 01:05 PM, the TN gathered all wound care supplies, performed hand hygiene by using hand sanitizer, knocked on Resident #15's door and entered the room. She did not put on PPE that was provided in the room. There was also a sign above Resident #15's bed. She placed the wax paper with all the supplies on the over the bed table and put on gloves without performing hand hygiene or putting on a gown. The TN taped the biohazard bag to the over the bed table, then turned to Resident #15 and pulled the covers up exposing Resident #15's right leg. She removed the old dressing off Resident #15's right outer lower leg. The TN placed the old dressing in the biohazard bag, took off her gloves, and placed them in the biohazard bag. She put on new gloves without performing hand hygiene, she then removed her gloves, left the room, and returned with wound cleaner. The TN put on gloves without performing hand hygiene and completed the remainder of the wound care. She removed her gloves, tied the top of the biohazard bag, and left the room with the biohazard bag in her hand.During an interview with RN A on 07/12/2026 at 2:01p.m., she said she had been trained on infection control. She said the policy for hand hygiene when passing meal trays was staff were to wash their hands before passing the trays, and between each meal tray. She said all staff were responsible for infection control and hand hygiene. She said if staff did not perform properly hand hygiene it could cause bacteria to be transferred to residents through staff members. She said all staff monitored to ensure staff were washing their hands. She said all staff monitored through observations. She said she did not wash her hands when passing meal trays because it did not occur to her that she needed to wash her hands.During an interview with CNA D on 07/12/2026 at 2:35p.m., she said she had been trained on infection control. She said the policy for hand hygiene when passing meal trays was staff were to wash their hands before starting and then use hand sanitizer between each meal tray. She said everyone was responsible for infection control and hand hygiene. She said if staff did not perform proper hand hygiene the residents could get an infection. She said the nurse monitored it to ensure staff were performing hand hygiene. She said the nurse monitored staff through observations. She said she did not know why she did not wash her hands between each meal tray. During an interview with the TN on 07/14/2026 at 1:33p.m., she said she had been trained on infection control. She said the policy for hand hygiene was that staff were to wash their hands before and after any care. She added if something was soiled while doing care staff would need to wash their hands in between the care. She said staff were to wash their hands before assisting with care of a resident, before feeding a resident and in between care of a resident. She said all staff were responsible for hand hygiene. She said if staff did not perform hand hygiene it increased the risk of infections spreading. She said the DON, ADON and ADM monitored to ensure staff were performing hand hygiene. She said the DON, ADON and ADM monitored through doing in-service training. She said she did not sanitize her hands when providing care to Resident #15 because she forgot to take her sanitizer into the room. She said the policy for EBP was that staff were to wear a gown, gloves and mask when needed. She said residents who were on EBP had a sign inside their room, above the PPE bin. She said all staff were responsible for wearing PPE when working with a resident on EBP. She said if staff did not wear PPE it could increase the risk of the residents or staff getting an infection. She said the DON monitored to ensure staff were wearing PPE when providing care to a resident on EBP. She said the DON monitored through observations. She said she did not put on PPE when providing care to Resident #15 because she was under the impression, she only needed to wear the PPE if the resident had a chronic wound. During an interview with the ICP on 07/14/2026 at 1:52p.m., she said she had been trained on infection control. She said the policy for EBP was staff were to wear a gown, gloves, and a mask when a resident had wounds, or IV lines. She said that if a resident was on EBP the resident would have a sign over the resident's bed. She said anyone who was caring for a resident who was on EBP was responsible for wearing PPE. She said if staff did not wear PPE when providing care to a resident with EBP it could cause the resident to get an infection. She said the ICP monitored to ensure staff were wearing PPE when providing care to a resident on EBP. She said she monitored through observations. She said she did not know the TN did not wear PPE when providing care to Resident #15. She said the policy for hand hygiene was that staff were to wash their hands before going into a resident's room and when the staff member came out of the resident's room. She said all staff were responsible for preforming hand hygiene. She said if staff did not perform hand hygiene properly, the resident could get an infection. She said the ICP was responsible for ensuring staff performing proper hand hygiene. She said she monitored hand hygiene through in-services every month. She said she did not know why the TN did not perform hand hygiene when providing care to Resident #15.During an interview with the DON on 07/15/2026 at 08:48a.m., she said she had been trained on infection control. She said the policy for EBP was that staff were to wear a gown and gloves, sometimes a mask, when performing care on a resident on EBP. She said if a resident was on EBP the resident would have a sign over the head of their bed and a container in the room with PPE. She said all staff were responsible for wearing PPE when a resident was on EBP. She said if staff did not use PPE when providing care to a resident on EBP it could cause the resident to get an infection. She said she monitored to ensure staff were wearing PPE when providing care to a resident on EBP. She said she monitored to ensure staff were wearing PPE through observation. She said she did not know why the TN did not wear PPE when providing care for a resident on EBP. She said the policy for hand hygiene was staff were to wash their hands when providing care, between each meal tray and when going form clean items to dirty items. She said all staff were responsible for performing hand hygiene. She said if staff did not perform proper hand hygiene the staff could pass on germs and infections to themselves and the residents. She said the ICP monitored to ensure staff were performing proper hand hygiene. She said the ICP monitored by doing rounds and checking for proficiency. She said she did not know why RN A; CNA D did not perform hand hygiene when passing meal trays. She said she did not know why the TN did not perform hand hygiene when she provided care to Resident #15. During an interview with the ADM on 07/15/2026 at 09:10a.m., she said she had been trained on infection control. She said the policy for PPE was that all staff were expected to wear PPE when providing care for residents with wounds, ports, or external tubes. She said if a resident was on EBP the resident would have a sign over their bed. She said all staff were to use PPE when providing care for a resident on EBP. She said if staff did not use PPE when providing care for a resident on EBP the resident could get an infection, or cause bacteria to spread. She said the ICP monitored to ensure staff were wearing PPE when providing care for a resident on EBP. She said the ICP should be monitoring through observations. She said she did not know why RN A did not wear PPE when she provided care to Resident #15. She said the policy for hand hygiene was staff were to wash their hands and sanitize between each meal tray and before and after providing care and between glove changes. She said all staff were responsible for hand hygiene. She said if staff did not perform proper hand hygiene a bacterial infection could spread. She said managers and the ICP should be monitoring to ensure staff are performing hand hygiene. She said management and the ICP monitored through observation. She said she did not know why RN A and CNA D did not wash or sanitize their hands between meal trays.Record review of the Fundamentals of Infection Control Policy not dated revealed: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. Gowns and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganisms in the LTCF. Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures. Gowns that are selected for use in the facility will be impermeable to liquids. Activities to reduce infection risk includes surveillance such as observation of insertion sites, routine dressing changes, use of appropriate PPE and hand hygiene during the care and treatment of residents with venous catheters, and review of the resident for clinical evidence of infection. It is important that practices reflect the most current CDC guidelines. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: When coming on duty. When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice). Before and after performing any invasive procedure (e.g., fingerstick blood sampling). Before and after entering isolation precaution settings. Before and after eating or handling food (hand washing with soap and water). Before and after assisting a resident with meals. Before and after assisting a resident with personal care (e.g., oral care, bathing). Before and after handling peripheral vascular catheters and other invasive devices. Before and after inserting indwelling catheters. Before and after changing a dressing. Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident). After personal use of the toilet (hand washing with soap and water). Before and after assisting a resident with toileting (hand washing with soap and water). After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile (hand washing with soap and water). After blowing or wiping nose. After contact with a resident's mucous membranes and body fluids or excretions. After handling soiled or used linens, dressings, bedpans, catheters, and urinals. After handling soiled equipment or utensils. After performing your personal hygiene (hand washing with soap and water). After removing gloves or aprons; and After completing duty.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to 1 of 3 medication carts (Medication Cart #1) reviewed for drug storage and labeling.The facility failed to ensure Medication Cart #1, was locked, medications secured, and not accessible to other staff, residents, or visitors and was left unlocked by RN A two times at 6:49 a.m. and 7:30 a.m. on 06/23/2026.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings include: Observation of Station 3 hall Nurses Station on 06/23/2026 at 6:49 a.m., revealed Medication Cart #1 was facing toward the hall area near the nurses' station. There were not any staff in the hall or near the nurse's station. RN A exited a room approximately 6:55 a.m. on 300 hall and walked toward the nurse's station to the unlocked medication cart. Interview with RN A on 06/23/2026 at 6:51 a.m., stated she was trained on medication storage. She stated the nurse or medication aide who was working on the cart was responsible for locking the medication cart. RN A stated if the staff left the medication cart unlocked and unattended a resident, staff or a visitor could get into the medication cart and take medication that did not belong to them. RN A stated there was a possibility that a resident may have an allergic reaction if ingested medication ordered for another resident. She stated it was a possibility a resident may need to be transferred to emergency room for an evaluation. She stated she had been in-serviced on locking medication carts however; she did not recall the date or time. Observation of Station 3 hall Nurses Station on 06/23/2026 at 7:30 a.m., revealed Medication Cart #1 was facing toward the hall area near the nurses' station. There was not any staff in the hall or near the nurse's station. RN A exited a room approximately 6:55 a.m. on 300 hall and walked toward the nurse's station to the unlocked medication cart #1. Interview on 06/23/2026 at 7:33 a.m., RN A stated she forgot to lock the medication cart. She stated she had been in-service on locking medication cart however; she did not recall the date or time. She stated a staff, a resident or a visitor had opportunity to obtain medications from the med cart. She stated she did not know why she forgot to lock the medication cart for the second time. Interview with the Director of Nurses on 06/23/2026 at 3:00 p.m., she stated all medication carts was expected to be locked when the med-aide or nurse was not standing in front of the medication cart. She stated if the medication cart was left unlocked and unattended, a resident could get into the medication cart and take medications. She stated there was a possibility a resident may become severely ill such a low blood pressure if the resident ingested numerous blood pressure pills. She stated a resident may need to be admitted to hospital for further evaluation. She stated nurse leadership was to monitor by doing observations and in-service training. She stated she did not know why RN A left the medication carts unlocked two times on 06/23/2026. Requested in-service records for locking medication cart and these was not provided prior to exit. Interview with the Administrator on 06/23/2026 at 4:00 p.m., stated the medication cart was to always be locked. She stated no matter what time of day the medication cart should be locked. She stated the nurse or medication aid who was on the medication cart were responsible for ensuring the medication cart was locked. The Administrator stated if the medication cart was left unlocked and unattended a resident could take medication that was harmful to them and the resident may need medical attention from the hospital. She stated she did not know why RN A left the medication cart unlocked. She stated the staff had received in-services on locking medication cart. Requested the Facility's Locking Medication Cart Policy, dated 2025, reflected Medications and biologicals are stored, safely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to ensure residents received care and services, consistent with professional standards of practice to maintain skin integrity to prevent the development of pressure ulcers and other skin conditions for three (Resident #1, Resident #3 and Resident #4) of four residents reviewed for skin integrity. The facility failed to consistently complete, and documents required skin checks weekly for three residents (Resident #1, Resident #3 and Resident #4).This failure put residents at risk for undetected skin issues, worsening skin issues and decreased quality of life.Findings included: Review of Resident #1's face sheet shows an admission to the facility on [DATE]. Diagnoses include Alzheimer's Disease, protein calorie malnutrition, anemia, depression, insomnia, and cerebral infarction. Review of Resident #1's Minimum Data Set Assessment and Care Screening dated 3-26-2026 Resident #1 requires maximum assistance of the helper to roll left to right, for toileting, dressing, and complete personal hygiene. Resident #1's Brief Interview of Mental Status is scored a 4- indicating severe cognitive impairment. Review of Resident #1's care plan dated 3-31-2026, states resident is at risk for malnutrition and has the potential for pressure ulcer development related to decreased mobility and end stage disease. Care plan includes interventions for Resident #1 wishing to be bedfast all the time, requires maximal assistance with incontinent care and skin inspection weekly and as needed.Review of Resident #3's face sheet shows admitted to the facility on [DATE] with diagnosis list of Alzheimer's disease with late onset, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, varicose veins of bilateral lower extremities with other complications, lymphedema, edema, and unspecified protein calorie malnutrition. Review of Resident #3's Minimum Data Set Assessment and Care Screening dated 4-9-2026 Resident #3 requires maximum aid of a helper to roll left to right, for toileting, and to dress or complete personal hygiene. Resident #3 Brief Interview of Mental Status scored an 8 showing resident has moderately cognitive impairment. Review of Resident #3's care plan states Resident #3 has an Activities of daily living self-care performance deficit related to impaired cognition and decreased mobility. Review of Resident #3's care plan dated 4-16-2026 includes interventions to dress, provide personal hygiene, and aid with any mobility. Resident #3's care plan also mentions behaviors being non-compliant with staff, has potential for nutritional problems, and has pressure ulcer potential for ulcer development.Review of Resident #4 face sheet shows an admission date to the facility of 4-11-2024. Resident #4's main diagnosis are dementia, anxiety, protein calorie malnutrition, essential hypertension and chronic heart failure. Review of Resident #4 's Brief Interview of Mental Status done on 2-26-2026 was listed as a 9 which is moderately cognitive impaired. Review of Resident #4's Care Plan dated 3-27-2026, lists potential for pressure ulcer development related to decreased mobility and incontinence. Record Review showed Resident # 1's skin assessments were completed on 4-8-26, 4-21-2026 and then again on 5-5-2026. Each skin check being more than 7 days apart. Weekly ulcer assessments were dated 4-6-2026; 4-20-2026, 4-21-2026 and 5-5-2026. There was no evidence staff consistently identified skin concerns timely or implemented interventions based on ongoing assessment record review findings. Record review of Resident #3 weekly skin assessments has dates of 4-8-2026, 4-19-2026, 4-21-2026 and 5-5-2026. Weekly ulcer Assessments are dated 4-21-2026, and 5-5-2026. There was no evidence staff consistently identified skin concerns timely or implemented interventions based on ongoing assessment record review. Record review of Resident #4 weekly skin assessments listed assessments done 4/9/2026, 4/21/2026 and 5/5/2026. Observation/Interview of Resident #1 on 5-5-2026 at 1:20pm. Resident #1 in bed, head of bed up, long grey hair on pillow, no odor, appears clean. Resident #1 new dressing to R heel, dressing clean dry intact and dated 5-5-2026. Resident's bilat feet on pillow with noted stiffness/contractures- in-toeing position. Resident # 1 grimaced when sheet lifted to look at feet and 5-5-26 was the date on the dressing. Resident #1 stated any movement of her feet hurts her. Observation of Resident #1 on 5-5-2026 at 3:30 pm observed CNA B and RNC doing peri care and skin check on Resident #1. Coccyx -Sacral area intact, no red areas noted, resident's dressing to right heel/foot in place. Resident #1 refuses feet raised on multiple pillows and requests to be flat on back in bed. When questioned if there was pain, Resident #1 stated no pain, until repositioned or moved. Observation of Resident #3 on 5-5-2026 at 1:05pm with CNA B in room with resident, CNA B states she had just changed resident CNA B stated new small red area was noted to her foot. CNA B said it wasn't there before- she will notify nurse. Resident #3 alert and not oriented to time or place, dressed and appears clean with no foul odor present. Observation 5-5-26 at 3:07 pm Resident#3 seen in chair, CNA B and RNC aids with changing resident to check report by CNA B. Resident's bed moved to lowest position, resident transferred from chair to bed. Resident #3's buttocks appeared covered with barrier cream. When cleaned on sacrum there was skin sheering in appearance areas small skin areas that are previously noted in record review for wound care. Areas around red sacral areas are assessed by RNC. CNA B reports foot change and foot assessed by RNC. Resident #3 foot appears bruised or red, RNC states new injury. Resident #3 states she does sit in recliner and wants to be put back in recliner after brief changed. After CNA B opens brief wiping and cleaning peri area, CNA B applies barrier ointment applied to buttocks for protection. New incontinence brief applied and patient moved back in recliner per her request. Interview on 5-5-26 at 2:11pm with Resident #1's RP in room with resident. RP states resident has been bed bound for 1 1/2 years and in the past had a wound to buttocks that did heal. Wound was not at this facility. Resident #1's RP has no complaints about nursing and hospice nurses are good. RP states he comes and visits facility at least 3 times a week. States anything that changes they let him know and he is aware of feet issues. Resident#1 is not compliant; RP said Resident #1 refused to wear heel protectors. RP said Resident #1 hates to be turned. RP was happy with the pressure-relief mattress and their attempts to keep her skin from breaking down. RP says he isn't aware how often they check Resident #1's skin. Interview on 5-5-26 at 3:30 pm RNC states wound care will be completed on Resident #3 as previously ordered they just wanted to change Resident #3 because dressing must have fallen off and RNC needed to look at foot as reported by CNA B, because the skin checks weren't done last week. Interviews with RNC on 5-5-26 at 3:30 pm and 5-6-2026 at 12:50 pm confirmed skin assessments were expected per facility policy and in-service. Inservice was led by RNC on 4-21-2026 and 4-24-2026; however, RNC acknowledged skin checks were not consistently completed as in-service. RNC states that by not providing skin assessments weekly it places residents at risk for undetected skin impairment, delayed skin interventions, avoidable breakdown, pressure ulcer development, worsening wounds, infection, and compromised health outcome.Interview with ADON 5/6/2026 at 1:13pm stated skin assessments are important often because the assessment tends to find things that weren't there before. ADON tells the facility's plan said every 7 days, and normally the wound care nurse should have completed. If assessments are not done ADON states harm from skin health can occur, pain and can have issues needing hospital or antibiotics. If wounds are not given to the wound care team timely, it is overlooked and the harm will be worse. Overlooking wound care referrals can cause infection, breakdown, or other sores missed. Nurses and Administration should oversee wounds and skin assessments. Interview with DON on 5/6/2026 at 1:37pm -stated the skin assessments were missed because the system is to trigger skin sweep. The sweeps were going to be changed from the trigger dates to match the shower list, and so skin care checks would coincide with the showers. When DON worked on Saturday 4-26-2026 skin checks were done. DON says they did checks but DON didn't follow up to see that all was charted. Nurse that did assessments no longer work for the facility so DON should have followed up. Nurse was let go. Stated that was DON's fault. DON said facility cannot prove they were completed because they were never charted. DON states issues with missing the skin assessment was residents can end up in the hospital, with stage IV ulcers, it can be patient neglect, end in trouble with facility and nursing licenses. Recently DON was part of the plan for skin assessments and sat in on the in-services and was aware of the plan on 4-21-2026. DON states it was not followed because it was not charted, DON didn't have time. DON said administration handles ensuring compliance with skin assessment protocols for all residents.Interview with ADM on 5-6-2026 at 2:33 pm and ADM was unable to provide evidence that skin monitoring was being done as policy states. ADM states if the policy isn't followed skin can develop wounds, wounds can get worse and harm can happen. States nurses oversee skin assessments and as of yesterday 5-5-2026 have an acting treatment nurse RN A providing wound care and weekly skin assessments. In a follow-up interview conducted on 5/6/2026 at 2:40 PM with DON and ADM, they confirmed skin assessments were expected per facility policy; however, they acknowledged skin checks were not consistently completed as needed. Leadership was unable to provide evidence that monitoring systems were effective in ensuring compliance with skin assessment protocols for all at-risk residents. They stated this deficient practice placed residents at increased risk for undetected skin impairment, delayed intervention, avoidable skin breakdown, pressure ulcer development, worsening wounds, infection, and compromised health outcomes.Record review of facility policies showed that the facility failed to consistently complete, and document required skin checks weekly for 3 of 4 residents (Resident#1, Resident #3, and Resident #4) reviewed. Weekly skin assessments are listed in facility policy and updated on an in-service dated 4-21-2026 and 4-24-2026. Record Review of Facility Policy sent by RNC 5-6-2026 at 2:15pm labeled Pressure Injury: Prevention, Assessment and Treatment lists on page 3 under assessment reflected the following: All residents should have a skin assessment on a weekly basis completed in the EMR.Record Review of The Facility's Action Plan dated 4-21-2026 titled Skin Integrity Management and Weekly Skin Assessment and Daily Wound Care lists: Under Procedure- Weekly Skin Assessment Responsibility Licensed nurse (RN/LVN) and under frequency -weekly (every 7 days). Process is to perform head to toe skin inspection. Review of the facility policy (undated) directed that comprehensive skin assessments/skin checks were to be completed routinely and prompt, including upon admission, weekly, and with any change in condition, to find alterations in skin integrity and implement prompt interventions. However, the facility failed to consistently complete, and documents required skin checks for multiple residents, as outlined in its policy.

Based on observation, interviews, and record review, the facility failed to ensure each resident was treated with respect, dignity and care for 1 of 6 residents (Resident #2) observed for resident rights. The facility failed to ensure Resident #2's door was closed when provided with personal care on 5/5/2026.This failure could place residents at risk of feeling embarrassed, loss of dignity and decrease in quality of life.Findings included:Review of Resident 2's Face sheet dated 05/05/2026 reflected an admission date of 12/23/2025 with diagnoses of unspecified dementia (cognitive decline,) monoclonal gammopathy (blood disorder where cells produce abnormal; proteins) and end stage renal disease (final irreversible stage of kidney failure). Review of Resident 2's MDS assessment, dated 03/27/2026, reflected Resident #2 had a BIMS score of 11 out of 15, indicating moderative cognitive impairment. Review of Resident 2's comprehensive care plan on 05/05/2026, reflected resident has an ADL Self Care Performance Deficit related to impaired cognition and debility.Observation on 5/05/2026 at 9:12 AM, revealed CNA C and HA E provided personal care to Resident #2 with her door open. Resident#2 was observed to be completely naked in her bed from the hallway.Interview conducted on 05/05/2026 at 10:43 AM, Resident #2, stated she did not notice that the door had been left open during her personal care; however, she stated it would bother her if the door was left open while receiving care.Interview conducted on 05/05/2026 at 4:12 PM, HA E revealed that he had been trained in dignity and resident rights. He stated that when providing personal care, staff should close the door to ensure privacy. HA E stated he was in Resident #2's room for an observation. The HA E acknowledged that not closing the door could affect the resident's dignity, stating it could be embarrassing for the resident and she could feel ashamed.Interview conducted on 05/06/2026 at 12:26 PM, CNA C stated she had worked at the facility for 3 days and she has been a CNA since October 2025. She stated she had received training regarding dignity and resident rights. CNA C stated the door should not have been left open while providing personal care to Resident #2. She stated things happened quickly due to the shower bed being in the room leaving less space and the hospitality aide being present for observation because he had an upcoming CNA test. CNA C stated the incident could cause a resident embarrassment and a loss of privacy and dignity.Interview conducted on 05/06/2026 at 2:30 PM, the ADM stated it was her expectation for the nursing staff, when providing care, to provide privacy and should pull the privacy curtain at a bare minimum and should have closed the door. The ADM stated it could make residents feel as their privacy was invaded.Review of facility's Resident Rights policy, undated, reflected: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.Respect and dignity- The resident has a right to be treated with respect and dignity. Privacy and confidentiality - The resident has a right to personal privacy and confidentiality of his or her personal and medical records. 1. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

Based on observation, interview and record review the facility failed to ensure that the call light system was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from residents room for 1 of 6 (Resident #1) residents reviewed for resident call system. The facility failed to ensure the call light system in Resident #1's room was functioning on 05/05/2026. This failure could place residents at risk of harm by not being able to call for help when needed and at risk of not receiving the care and services to maintain their highest level of well-being.Findings included: Review of Resident 1's Face sheet dated 05/05/2026 reflected an admission date of 12/13/2024 with diagnoses of Alzheimer's Disease (progressive irreversible brain disorder affecting memory, thinking, behavior), anemia (deficiency of healthy red blood cells) and depression (sadness in mood, loss of interest).Review of Resident 1's MDS assessment, dated 03/26/2026, reflected Resident #1 had a BIMS score of 4 out of 15, indicating significant cognitive impairment. Observation and interview on 5/05/2026 at 11:05 AM, Resident #1 was observed sitting in her bed. She stated she needed some help, then stated she does not remember what she needed help with at the time. Resident #1 stated she could call someone by pressing the button that was on her tray table. The button was observed not to be attached to anything. Resident #1 pressed the button while surveyor was present. Surveyor then advised Resident #1 that surveyor would go across the hall to wait and see if anyone responded.Observation and interview on 5/05/2026 at 11:30 AM, CNA D who was also a medication aid, stated she was there to give resident #1 some medicine, and she was not responding to the call button CNA D stated the call button rings at the nurses station and that Resident#1's call button should work, however she will check it. MTS was passing by the room, and CNA D asked him to check the call device, he led surveyor to the nurse's station, and the call button did not alert at the nurses station after being tested. MTS stated the call button was not working and he provided a new call button which worked immediately. Resident # 1 was given a new call button.In an interview conducted on 05/06/2026 at 11:09 AM, the ADM stated the facility did not have a policy on call buttons. She stated the facility followed the state regulations. In an interview conducted on 05/06/2026 at 11:20 AM, CNA D stated they are trained to answer call lights once activated. She stated the new call buttons system provides a specific number identifying the resident room that initiated the call. CNA D stated staff had not been provided guidance regarding routine checks to ensure the call light system was functioning properly unless a resident reported an issue. CNA D stated the potential harm is that residents may not be able to call for assistance when needed which could result in delayed care.In an interview conducted on 05/06/2026 at 12:50 PM, the MTS stated he was responsible for checking the new call system. He stated the new system was put in place one month prior. He stated his department checks the call system once a month. The MTS stated the call button Resident #1 had on the previous day was an old button. He stated he did not follow up to make sure all residents had a new replacement. The MTS stated the potential harm was residents would not be able to call for help when needed.In an interview conducted on 05/06/2026 at 2:28 PM, the ADON stated she was not aware Resident #1's call button did not work. She stated maintenance check for malfunctioning call buttons. The ADON stated that a broken call button could lead to several hazards.In an interview conducted on 05/06/2026 at 2:34 PM, the ADM stated the MTS check the call buttons monthly for correct functioning. She stated they are supposed to be checked daily by facility staff for any signs of malfunctions or broken parts. The ADM stated her expectation is for staff to report broken call buttons immediately. She states a resident could be on the floor and unable to call for help if needed.

Based on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 2 of 2 days (05/05/2026 - 05/06/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information from 04/29/2026 to 05/05/2026. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.Findings included:During an observation on 05/05/2026 at 09:20 A.M., a document labeled [facility name] Federal and State Staffing Level Requirements, dated 04/28/2026, was posted on a wall outside the ADM's office passed following entry to the facility. The document included the following information: census and the number and hours worked of registered nurses, licensed vocational nurses, medication aides, and certified nurse aides for day shift, evening shift, and night shift. During an observation on 05/06/2026 at 08:39 A.M, a document labeled [facility name] Federal and State Staffing Level Requirements, dated 05/05/2026, was posted on a wall outside the ADM's office passed following entry to the facility. The document included the following information: census and the number and hours worked of registered nurses, licensed vocational nurses, medication aides, and certified nurse aides for day shift, evening shift, and night shift. During an interview on 05/06/2026 at 11:09 a.m., the ADM stated the facility did not have a policy on the daily nurse staffing and census posting. She stated the facility followed the state regulations. During an interview on 05/06/2026 at 11:55 A.M., the DON stated she has been with the facility for only two weeks. She stated she had not been previously involved with posting the nurse staffing and census information; however, the ADON was just designated to complete the postings 3 to 4 days ago. The DON stated the staff postings are required to be posted daily and are important because they provide information regarding staffing coverage for the residents. She stated it let families know there is enough staffing coverage in the building.During an interview on 05/06/2026 at 1:13 P.M., the ADON stated she had recently been designated the duty of putting up the nurse staffing information. She stated she was not aware that the previous ADON posted the information as she is new to the position as of the end of March 2026. The ADON stated she received training this week on posting the staffing information. She commented that she posted the staffing information late this morning.During an interview on 05/06/2026 at 1:13 P.M., the ADM stated the nursing department is responsible for posting the daily nurse staffing and census posting, specifically the ADON and charge nurse on the weekends. The ADM stated the posting had been overlooked and she realized something must have been missed when she saw surveyor was taking a picture of the wall.

Based on interview, and record review the facility failed ensure the comprehensive care plan, consistent with resident rights, included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of five residents (Resident #1) reviewed for care plans completion. The facility failed to ensure Resident #1's care plan was completed to reflect Resident #1 was lying on a mattress located on the floor and was crawling on the floor toward his roommate's bed. This failure could place residents at risk of not receiving appropriate interventions to meet their medical and safety needs. Findings include:Record review of Resident #1's face sheet, dated 03/04/2026, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with a diagnoses of Alzheimer's disease with late onset ( a progressive brain disorder characterized by memory loss, confusion often influenced by a mix of genetics, environmental factors, and lifestyle), abnormalities of gait and mobility ( deviations from normal walking patterns and reduced ability to move freely and safely), bipolar disorder, current episode depressed, severe, with psychotic features ( a severe form where intense mood episodes are accompanied by a temporary loss of contact with reality, specifically hallucinations - sensory experiences or delusions - false, fixed beliefs), generalized muscle weakness ( a widespread, non-localized reduction in physical strength affecting muscles throughout the body rather than one specific area), and cerebral infarction, unspecified ( actual death of brain tissue due to lack of blood flow).Record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 was unable to complete the BIMS assessment. He had poor short- and long-term memory recall. His decision-making abilities was severely impaired. Resident #1 had difficulty focusing. He was easily distracted and had difficulty keeping track of what was being said. Resident #1 had disorganized thinking- rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. Resident #1 was assessed to require supervision or touching assistance (helper provides verbal cues and/ or touching assistance as resident completes activity):EatingOral hygieneToileting hygieneUpper and lower body dressingPersonal hygieneTransfersRecord review of Resident #1's Comprehensive Care Plan dated 01/19/2026 and revised on 02/05/2026 did not reflect Resident #1 had mattress beside his bed and he would lie on the mattress and would crawl off the mattress toward roommate's bed.Record review of Resident #1's nurses notes dated 01/31/2026 at 3:35 a.m. read: upon entering room Resident #1 was found on mattress lying parallel with is bed. Record review of Resident #1's nurses notes dated 01/31/2026 at 4:00 a.m. read: upon entering room, resident noted lying on mattress on floor next to bed parallel with bed.Record review of Resident #1's nurses notes dated 01/31/2026 at 7:05 p.m. read: Resident #1 lying on mattress next to bed.Record review of Resident #1's nurses notes dated 01/31/2026 at 8:20 p.m. read: Resident #1 lying on mattress next to bed on floor.Record review of Resident #1's nurses notes dated 02/02/2026 4:46 p.m. reflected Resident #1 not staying on the mattress located on the floor. He crawled off the mattress two times. Resident #1 observed crawling toward roommate's bed.Record review of Resident #1's nurses notes dated 02/02/2026 at 11:58 p.m. reflected Resident #1 rolled off the mattress onto floor and toward roommates' bed, awakening roommate. Record review of Resident #1's nurses notes dated 02/04/2026 at 1:20 p.m. reflected Resident #1 had a change of condition. He was placed on oxygen, and he was on hospice and respiratory rate was 28. Resident passed away at the facility and hospice was present on 02/04/2026.In an interview on 03/04/2026 at 11:50 a.m. the MDS Coordinator stated if Resident #1 had a mattress beside his bed and he was lying on the mattress and was crawling off the mattress toward roommates' bed; this behavior was expected to be care planned. She stated the purpose of having a Comprehensive Care Plan was to inform staff how to give the care each resident needed such as physical, behaviors, emotional, activities, type of diet and any other interventions to prevent falls or any injuries. The MDS Coordinator stated the nurses assigned to the residents was responsible for any new interventions with residents. She stated the nurses, social worker, activities, dietary manager, DON, and/or ADON was qualified to make any changes to a resident care plan. The MDS Coordinator stated all nursing staff had been in-serviced on how to enter any information on a resident's care plan. She stated she could not recall who gave the in-service or the date of the in-service. She stated she was responsible to monitor the care plans to ensure they were correct and completed on time. The MDS Coordinator stated the information the CNAs follows on Kardex came from the care plan. She stated if a resident needed certain type of care or had behaviors and it was not care planned, the CNAs would not have that information on their Kardex to know what type of care to give the residents.In an interview on 03/04/2026 at 12:40 p.m. The DON stated her expectations was the care plan to be revised as needed. She stated her date of hire at this facility was on 02/15/2026. The DON stated she had begun to review any issues in the morning meeting with all department heads (Administrator, MDS Coordinator, Social Worker, Activity Director, etc.) and maybe nurse supervisor. She stated the following was some of the issues discussed: if residents had a fall, any behaviors occurred over the past 24 hours, skin concerns, etc. The DON stated they did this twice a day in the morning meeting and afternoon meeting. She stated the group would make decisions on interventions for the resident and she expected MDS Coordinator to make changes on the care plan. She stated with a mattress being beside Resident #1's bed and he was lying on that mattress and was crawling to roommate's bed should have been care planned. She stated the care plan was a plan for all staff to know what type of care, needs, and resident preferences, of each resident in the facility. The DON stated if a resident had a specific preference, she expected that preference be care planned. She stated it was the nurses who worked directly with the residents, herself, ADON, or MDS coordinator to make changes to a resident's care plan. She stated the Kardex where CNAs reviews information of how to care for a resident comes from the resident's care plan. The DON stated if a resident had a change in ADLs and it was not care planned the CNAs may not know this information.In an interview on 03/04/2026 at 1:05 p.m. CNA/MA A stated Resident #1 had mattress on the floor by his bed approximately two weeks before he passed away at the facility. She stated she did not recall the date he passed away but it was the first week of February 2026. She stated she gave care to Resident #1, and he preferred lying on the mattress on the floor. She stated he began to crawl toward roommate's bed. CNA/MA A stated it was safer for Resident #1 to be on the mattress on the floor instead being in bed. She stated he frequently would roll out of bed. bed related to him would roll out of the bed. She stated she did not know who placed the mattress on the floor. CNA/MA A stated she did not recall seeing having a mattress beside his bed on the Kardex or about his behavior of crawling on the Kardex. She stated the Kardex was what the CNAs followed to know what type of care to give the residents. She stated she had been trained on how to use the Kardex, however, she did not recall the date. CNA/MA A stated if a new staff was working with Resident #1 and they reviewed his information on the Kardex the new staff may remove the mattress from the floor, and it was a possibility the resident would roll out of bed and have some type of injury such as broken bone or a cut on his head.In an interview on 03/04/2026 at 1:30 p.m. the Administrator stated her expectations of care plans was the IDT discuss care of each Resident and if there was a change with anything including resident preferences the care plan was expected to be revised. She sated if Resident #1 required a mattress beside his bed, this was expected to be care planned. She stated if the mattress was for his protection from an injury, it should have been on the care plan. She stated CNAs Kardex information came from the care plans and there was a possibility someone new working with Resident #1 or a new staff may not realize the reason the mattress was needed by his bed. She stated he was a fall risk, and he had a recent fall with injury. The Administrator stated she reported the injury and it had been investigated and was unsubstantiated. She stated the IDT was expected to ensure the residents information to give appropriate care to each resident was documented on the care plan whether it was physical, emotional, resident preference, activities, etc. The Administrator stated the charge nurse could make revisions to the care plan but ultimately it was the MDS Coordinators responsibility to ensure the care plan was completed and correct. She sated the IDT consisted of the following disciplines: DON, Social Worker, MDS Coordinator, Dietary Manager, Activity Director, Resident and Family. She stated staff had been in-serviced on how to document on the care plan; however, she did not recall the date of this in-service.In an interview on 03/04/2026 at 1:55 p.m. LVN B stated she had not been trained on how to document on a care plan. She stated she knew how to view a care plan; however, she did not know how to revise a care plan or enter a new problem on a care plan. LVN B stated she had worked at this facility over a year. She stated no one had in-service her about documenting anything on a care plan. LVN B stated care plans were very important for the staff to know what type of care to give a resident such as: ADLs, diet, what they preferred to do in activities, what interventions to use when resident is at risk for falls or have behaviors. She stated the information from the care plan would go on the CNAs Kardex on each resident. She stated if there were any changes with a resident she reported the change to the DON, ADON, family and Physician.In an interview on 03/04/2026 at 3:05 p.m. LVN C stated she had been trained on how to document on the care plan. She stated she worked at another facility owned by same company as this facility, and she was trained at the other facility. LVN C stated this was her first day to work at this facility. She stated at the other facility owned by same company as this facility did complete an in-service on how to document on a care plan. LVN C stated it was very important for a resident's care plan be changed if there were any changes with their ADLS, behaviors, or any type of interventions related to physical or emotional needs. She stated the information on the care plan was transferred over to the CNAs Kardex and that was how the CNAs knew what type of care to give a resident. Interview on 03/04/2026 at 3:30 p.m. the Nurse Consultant stated all nursing staff had been in serviced on how to document on care plans. She stated she did not know when they were in-serviced. The Nurse Consultant stated she did not have any documentation of nurses or any staff being in-service on how to document on care plans. (She did not respond to any other questions about care plans).Review of the facility's Comprehensive Care Plan, not dated, reflected The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS Assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on interview, and record review , the facility failed to ensure a resident who was diagnosed with a mental illness or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for four (Resident #1, Resident #2, and Resident #3 ) of five resident reviewed for behavioral health.The facility failed to ensure Resident #1, Resident #2, and Resident #3 received appropriate psychiatric services. This failure could place residents at risk because their mental and psychosocial needs not being met and a decreased quality of life. Findings included: Record review of Resident #1's Face Sheet, dated 12/12/2025, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of anxiety disorder ( involves repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes with panic attack - a sudden, intense wave of extreme fear or discomfort that triggers severe physical and mental symptoms, like racing heart, shortness of breath, trembling, dizziness, and a feeling of losing control or dying), unspecified dementia, severe, with other behavioral disturbance (advanced dementia where cognition decline (memory thinking) is profound, impacting daily life significantly, and accompanied by disruptive behaviors like agitations, aggression, wandering, shouting often stemming from unmet needs or environmental triggers), and alcohol use, unspecified with alcohol-induced persisting dementia ( a type of cognitive decline from long-term heavy drinking, causing permanent brain damage, severe memory loss, impaired judgement, personality changes, and difficulty with thinking, learning, and coordination).Record review of Resident #1's Significant Change MDS , dated 05/02/2025, reflected Resident #1 had a BIMS score of 7 indicating her cognition was severely impaired. Resident #1 had disorganized thinking. She had difficulty focusing and was easily distracted. Resident #1 was assessed to have a diagnosis of anxiety Ddisorder, Aalcohol use, and not-traumatic brain dysfunction ( damage or impairment to the brain caused by internal factors such as : stroke - where blood flow to part of the brain stops - causing brain cells to die due to lack of oxygen - the body or its tissues aren't getting enough oxygen , tumors - abnormal mass of tissue from excessive cell growth, infections- invasion and growth of germs in the body, rather than an external blow to the head). Record review of Resident #1's Quarterly MDS Assessment, dated 12/02/2025, reflected Resident #1 had a BIMS score of 4 indicating her cognition was severely impaired. Resident had behavior of wandering ( 1 to 3 days per week). Resident was assessed to have a diagnosis of anxiety disorder, alcohol use, and not-traumatic brain dysfunction ( damage or impairment to the brain caused by internal factors such as : stroke - where blood flow to part of the brain stops- causing brain cells to die due to lack of oxygen- the body or its tissues aren't getting enough oxygen , tumors - abnormal mass of tissue from excessive cell growth, infections - invasion and growth of germs in the body, rather than an external blow to the head). Review of Resident #1's Comprehensive Care Plan dated, 10/27/2025, reflected Resident #1 had a history of trauma related to domestic violence that may have a negative impact initiated on 04/29/2025. Interventions, initiated 04/29/2025, included arrange Licensed Mental Health Provide as ordered by physician. Identify situation/ even/ images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. If the resident escalated, if at all possible, do not touch the resident unless absolutely necessary for resident's or others safety. Monitoring for escalating anxiety, depression, or suicidal thought and report immediately to the nurse. Problem initiated on 01/23/2025 and revised on 08/25/20225- Resident #1 had a behavior problem related to resident would eat soap from dispensers, history of removing water from toilet, and scooping into the trash can. She wanders into other rooms and rummages through other belongings. Attempt to assist and dictate the care of others. Resident #1 had history of lifting her shirt up and pants down to expose her breast and vagina to others. She had history of defecating on the floor. Resident #1 had history of returning from out of pass with family or friends with alcohol on breath and in her personal possession. She has urinated in the hallway and in other residents' rooms. She has hit glass doors when wanting attention. Interventions Resident had activity memory boxes made to help with distraction. If Resident #1exposes herself cover her and escort to her bedroom. Intervene as necessary. Approach Resident #1 and speak in a calm manner. Divert Resident #1's attention. Anticipate Resident #1's and meet her needs. Monitor Resident #1's behavior episodes and attempt to determine underlying causes. Consider Resident #1's location, time of day, people involved and situations. Document Resident #1's behavior and potential causes. Problem: initiated on 04/17/2025 and revised on 09/16/2025 Resident #1 had physical aggression towards others related to dementia ( a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory). Resident #1 had history of knocking over chairs. Intervention initiated on 08/02/2025, 1:1 monitoring until staff feels she is stable with behaviors. Analyze key times, circumstances, triggers, and what de-escalates behavior and document findings. Assess and address for contributing sensory deficits. Assess Resident #1's needs such as: hunger, thirst, toileting needs, comfort level, body positioning, pain, etc. Psychiatric/ Psychogeriatric consult as indicated. When Resident #1 becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If Resident #1 becomes aggressive, staff walk calmly away, and approach at later time. Resident #1 was resistive to care such as refusing vital signs , spitting out medications . Interventions: Allow Resident #1 to make decisions about treatment regimen , to provide sense of control. Encourage Resident #1 as much participation/ interaction as possible during care. If Resident #1 resists with ADLs, reassure Resident #1, ensure safety, leave and return five to 10 minutes later and reapproach Resident #1 with assistance with ADL care. Review of Resident #1's Social Worker notes, dated, 08/04/2025, reflected Resident #1 allegedly placed her hands on another resident's neck in the day room. Resident #1 was placed on 1:1 .Review of Resident #1's one on one records from August 2025 until December 2025, reflected Resident #1 continued 1:1 supervision with staff due to behaviors toward other residents, self, and staff. Review of Resident #1's Psychiatry Progress Note, dated 08/19/2025 and signed by PMHNP-BC, reflected Resident #11 did not have any hostility toward peers and care givers. Resident #1 was not depressed and had no sleep complaints. Resident #1's energy level was normal. She had no social isolation or crying. Resident #1 continued with current medications. Review of Resident #1's Psychiatry Progress Note, dated 09/16/2025 and signed by PMHNP-BC, reflected Resident #1 had no anxiety, irritability, and hostility toward peers. She did not have any depression and no sleep complaints. Resident #1's energy level was normal. She did not have any paranoid ideations and was not resisting assistance with ADLs Resident #1 did not have any social isolation or refuse treatment. She did not have any verbal aggression. Resident #1 needed to continue with her medications.Review of Resident #1's Psychiatry Progress Note, dated 09/30/2025 and signed by PMHNP-BC, reflected Resident #1 did not have hostility toward peers or caregivers. She was not depressed and did not have any sleep complaints. Resident #1 energy level was normal. She did not have any physical aggression. Resident #1 did not have paranoid ideations and did not resist assistance with activities of daily living. Resident #1 did not socially isolate or refuse treatment. Resident #1 had anxiety, irritability and verbally aggressive.Review of Resident #1's Psychiatry Progress Note, dated 10/14/2025 and signed by PMHNP-BC, reflected Resident #1 had normal appetite. No anxiety and no hostility toward peers. Resident #1 did not have hostility toward care givers. She did not have depression and did not have any sleep complaints. Resident #1 energy level was normal. She did not have any paranoid ideations and was not resisting assistance with activities of daily living. She did not have any social isolation or was crying. She was oriented towards person and place. She was disoriented to time. Her mood was euthymic. (a normal stable and balanced mood state). Resident #1's thought process: no thought insertion was noted, no thought broadcast was noted, and no thought control was noted. Resident #1's Plan: medication list reviewed and will continue with medication. Resident #1's attempt dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating and underlining psychiatric disorder. Continue management options: risks and benefits have been considered. Medication Effectiveness: Multiple non-pharmacologic approaches have been ineffective in relieving significant patient distress and /or behavioral symptoms dangerous to this patient or others. Unless otherwise noted, and therefore not clinically contraindicated, continue current medications as per current standards of practice; any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating an underlying psychiatric disorder. PMHNP-BC prescribed Resident #1 t medications necessary to treat a specific condition as diagnosed and documented in this clinical record. Certain disorders such as chronic functional and organic mood, anxiety, impulse control, and thought disorders will require psychoactive medications indefinitely. Resident #1 diagnosis, Assessment and Plan: Acute anxiety, Alcohol dependence with alcohol-induced persisting dementia, Unspecified dementia, severe, with other behavioral disturbance. Review of Resident #1's Psychiatry Progress Note, dated 10/28/2025 and signed by PMHNP-BC, reflected Resident #1 had a normal appetite, no irritability, no depression, and no sleep complaints. Resident #1 did not have any loss of interest in activities. Her energy level was normal. She did not have any physical aggression, paranoid ideations and did not refuse treatment. Resident #1 did not have any auditory hallucinations and no visual hallucinations. She did not have any persecutory delusions or any verbal aggression. Resident #1 needs to continue with current medication: unless otherwise noted in this encounter, continue current medication regimen; any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating an undermine psychiatric disorder. No diagnosis of adverse effect of psychotropic agents noted otherwise, a psychotropic gradual dose reduction is contraindicated. Monitor Resident #1's behavioral signs and symptoms on each subsequent encoder. Medication reconciliation performed . Mental Status Exam: Resident 1 was not in acute distress; she was smiling and interacting. She was oriented towards person and place. Resident #1 was disoriented by time and situation. Her mood was euthymic. Resident #1's effect was reactive. Her thought process was not impaired, and thought disorder was not noted. The thought content revealed no impairment. Plan: Resident #1 medication list reviewed and continue with current medication and attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatrics instability by exacerbating and underlining psychiatric disorder. Medication effectiveness: Resident #1 had multiple non-pharmacologic approaches have been ineffective in relieving significant patient distress and/ or behavioral symptoms dangerous to this patient or others. Diagnosis, Assessment, and Plan for Resident #1: Acute anxiety, alcohol dependence with alcohol-induced persisting dementia, and unspecified dementia, severe, with other behavioral disturbance. Review of Resident #1's Psychiatric Progress Note, dated 11/11/2025 and signed by PMHNP-BC, reflected Resident #1 had normal appetite. She stated she was alright. She did not have any of the following: irritability, depressions, sleep complaints and/ or loss of appetite. Her energy level was normal. Resident #1 did not have physical aggression. She was not refusing treatment. She did not have any verbal aggression. Mental Status Exam: Resident 1 was not in acute distress. She was smiling and interactive. She was oriented to person and place and disoriented to time and situation. Resident #1's mood was euthymic, and affect was reactive. Her thought process was not impaired, and thought disorder was not noted. Resident #1 thought content revealed no impairment. Resident #1's Plan: Resident's #1 medication list reviewed. Continuing with Resident #1's medication, any attempted dose reduction would impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating an underline psychiatric disorder. Resident #1 had multiple non-pharmacologic approaches that have been ineffective in relieving significant patient distress and /or behavioral symptoms dangerous to this patient or others. Diagnosis , Assessment and Plan for Resident #1: Acute anxiety, alcohol dependence with alcohol-induced persisting dementia, and unspecified dementia, severe, with other behavioral disturbance. Review of Resident #1's Psychiatric Progress Note, dated 11/25/2025 and signed by PMHNP-BC , reflected Resident #1' had normal appetite, no irritability, no depression, and no sleep complaints. She did not have loss of interest in activities. Her energy level was normal. Resident #1 did not have the following: no physical aggression, no paranoid ideations, no refusing treatment, no auditory/visual hallucinations and no verbal aggression. Mental Status Exam: Resident 1 was not in acute distress. She was smiling and interactive. She was oriented to person and place and disoriented to time and situation. Resident #1's mood was euthymic, and affect was reactive. Her thought process was not impaired, and thought disorder was not noted. Resident #1 thought content revealed no impairment. Resident #1's Plan: Resident's #1 medication list reviewed. Continue with Resident #1's medication, any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating and underlining psychiatric disorder. Resident #1 had multiple non-pharmacologic approaches that have been ineffective in relieving significant patient distress and /or behavioral symptoms dangerous to this patient or others. Diagnosis , Assessment and Plan for Resident #1: Acute anxiety, alcohol dependence with alcohol-induced persisting dementia, and unspecified dementia, severe, with other behavioral disturbance. Review of Resident #1's Psychiatric Progress Note, dated 12/09/2025, reflected Resident #1 had normal appetite. She did not have any anxiety, irritability, and no hostility toward peers or caregivers. Resident #1 did not have any depression or any sleep complaints. Her energy level was normal. Resident #1 did not have any physical aggression, did not resist assistance with activities of daily living. She did not have verbal aggression. Mental Status Exam: Resident #1 was not in acute distress. She was smiling and interactive. She was oriented to person and place and disoriented to time and situation. Resident #1's mood was euthymic, and affect was reactive. Her thought process was not impaired, and thought disorder was not noted. Resident #1 thought content revealed no impairment. Resident #1's Plan: Resident's #1 medication list reviewed. Continue with Resident #1's medication, any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating and underlining psychiatric disorder. Resident #1 had multiple non-pharmacologic approaches that have been ineffective in relieving significant patient distress and /or behavioral symptoms dangerous to this patient or others. Diagnosis , Assessment and Plan for Resident #1: Acute anxiety, alcohol dependence with alcohol-induced persisting dementia, and unspecified dementia, severe, with other behavioral disturbance. Signed by PMHNP-BC. 2. Review of Resident #2's face sheet, dated 12/12/2025, reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of major depressive disorder ( a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep or feelings of guilt), diarrhea, unspecified ( a condition in which feces are discharged from the bowels frequently and in a liquid form), other depressive disorder, recurrent without psychotic features (someone having repeated , severe depression episodes but without delusions, meaning they stay grounded in reality).Review of Resident #2's Quarterly MDS, dated [DATE], reflected Resident #2 had a BIMS score oof 15indicating his cognition was intact. Resident #2 felt down, depressed , or hopeless 7-11 days out of the 14-day assessment period. He had trouble falling asleep or sleeping too much. He felt tired or had very little energy. Resident #2 had difficulty concentrating on things. Review of Resident #2's Comprehensive Care Plan with completion date of 09/25/2025, reflected Resident #2 had chronic diarrhea. Intervention: diet as tolerated. Give Anti-diarrheal medications. Monitor lab values and inform physicians of abnormal findings. Resident #2 had potential for alterations in mood related to depression. Interventions: Arrange for psych consult, follow up as indicated. Monitor/ document/ report to nurse/ MD of signs and symptoms of depression, including hopelessness, sadness, negative statements, tearfulness, etc.Review of Resident #2's Nurses notes on 12/04/2025 reflected Resident # 5 called him by a name. Resident #2 stated he asked the other resident to stop. The conflict escalated when the other resident allegedly continued to call him names after Resident #2 refused to take a bath. Resident #2 hit Resident #5 on the nose. Review of Resident #2's Psychiatric Notes, dated 12/09/2025, reflected Resident #2 had normal appetite. He did not have any anxiety, no irritability, and no hostility toward peers or caregivers. He did not have any depression or any sleep complaints. His energy level was normal. He did not have any physical aggression. Resident #2 did not have any paranoid ideations and did not resist assistance with activities of daily living. He was not socially isolated from others. He did not refuse treatment or had verbal aggression. Mental Status Exam: Resident 2 was not in acute distress. He was smiling and interactive. Resident #2 was oriented to person, place, time and situation. His mood was euthymic. His speech was normal. Resident #2 did not have any thought insertion, not thought broadcast was noted, and no thought control was noted. He did not have any short- or long-term memory impairment. Resident #2's Plan: Resident #2's medication list reviewed. Continue with Resident #2's medication, any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating and underlining psychiatric disorder. Resident #2 had multiple non-pharmacologic approaches that have been ineffective in relieving significant patient distress and /or behavioral symptoms dangerous to this patient or others. Diagnosis, Assessment and Plan: Major depressive disorder, recurrent severe without psychotic features. Interview on 12/12/ 2025 at 11:00 a.m., Resident #2 stated he had diarrhea and came out of his bathroom. He stated his roommate, Resident #5 , told him to take a shower. Resident #1 stated he walked in hallway and talked to CNA A about his shower. Resident #2 stated he asked if he could get a shower after his therapy. Resident #2 stated Resident #5 overheard the conversation between him and the CNA A. Resident #2 stated when he went to therapy room and sat in chair Resident #5 entered the therapy room cursing and yelling at him. He stated the therapy staff attempted to talk to Resident #5 and he continued to walk toward him. Resident #2 stated he informed Resident #5 if he thought he was big enough to fight him to come on and they would fight. Resident #2 stated Resident #5 approached him while he was sitting in the chair in therapy room and hit him in the nose. Resident #2 stated he did not want to be near Resident #5 until he became calmer about the situation. He stated he would not harm Resident #5, but he was still upset over the situation. Resident #2 stated he had diarrhea because of the foods he ate, and he had history of diarrhea most of his life. He stated he did not eat the proper food, and his family brought food for him that hurt his stomach and caused diarrhea, but he did not report this to his family. Resident #2 stated his roommate stayed mad at him due to his diarrhea and the odor in the room. He stated this was the entire argument last week when he was hit by Resident #5 about the odor in his room and he did not immediately take a shower. Resident #2 stated he did see psychiatrist after the incident with Resident #5, but she did not ask him any questions about the incident and him being mad toward Resident #5. He stated he thought that is why Psychiatrist came to see people to help them when they were upset about something. Resident #2 stated he had seen the same Psychiatrist for several months and she never asked about his feelings and how he was having a hard time dealing with his depression. He stated she talked to him in front of his roommate (Resident #5) and he did not feel comfortable telling the psychiatrist about his feelings in front of the person ( Resident #5) giving him problems and making him depressed and upset prior to him seeing her this week ( week of 12/08/2025) Resident # 2 stated he had never had a normal appetite. He stated he ate all the time, and his appetite has never been normal. He stated this is why he had diarrhea all the time because of overeating and eating things that upset his stomach. Resident #2 stated, I don't know who told you I had a normal appetite because that was a lie. Resident #2 stated he had problems sleeping since that incident because it upset him. Resident #2 stated sometimes he refused to take a bath. He stated Psychiatrist saw him two days ago and never asked him how he felt toward the incident or asked him about any of his feelings. He stated after she was in the room for a few minutes the psychiatrist told him she needed to visit other patients. Resident #2 stated she was not in his new room long enough to know what was going on with him. Resident #2 stated he saw the same psychiatrist for the past several months. 3. Review of Resident #3's face sheet, dated 12/12/2025, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] had a diagnosis of mild intellectual abilities ( involves challenges with thinking, learning, and daily skills (like communication, self-care, and social skills) but allows individuals to learn practical life skills), major depressive disorder, recurrent severe without psychotic features ( causing significant life impairment such as work, social and self-care but without hallucinations or delusions- seeing hearing tasting or feeling things that seems real but isn't, having no external source), featuring symptoms like sadness, loss of pleasure, energy loss, and guilt), and generalized anxiety disorder ( a mental health condition causing persistent , excessive, and uncontrollable worry about everyday things).Review of Resident #3's Annual MDS, dated [DATE], reflected Resident #3 had a BIMS score of 15 indicating his cognition was intact. Resident #3 had verbal behavioral symptoms directed at others such as: threatening others, screaming at others or cursing at others. Notified the MD.Review of Resident #3's Comprehensive Care Plan, dated 09/03/2025, reflected Resident #3 demonstrated verbal abusive behaviors towards staff and other residents. Resident #3 had history of entering other residents' rooms and making racial slurs. Resident #3 threatened others with physical harm. He yells and screams profanities. Intervention: Psychiatric consult as indicated. Resident #3 to be redirected to his room where there is less stimulus and allow him to become calm. When Resident #3 becomes agitated: intervene before agitation escalates; guide Resident #3 away from source of distress; Engage calmly in conversation; if Resident # 3's response was aggressive, ensure all residents involved were safe and staff to walk calmly away and approach at a later time. Analyze the key times, places, circumstances, triggers, and what de-escalate behavior and document. Review of Resident #3's Nurses Notes, dated 11/17/2025, reflected Resident #3 had experienced verbal behaviors directed toward others 1 to 3 days. Resident #3 did not have any physical behaviors toward others in the last week. Review of Resident #3's Psychiatric Progress Note, dated 10/14/2025, reflected Resident #3 had normal appetite. He did not have any anxiety or hostility toward peers or care givers. He did not have any depression and no sleep complaints. His energy level was normal. He did not resist assistance with activity of daily living. He did not isolate himself from others or had any crying episodes. Mental Status Exam: Resident 3 was not in any acute distress. He was smiling and interactive. He was oriented to person, place, and situation. Resident #3 was disoriented to time. His mood was euthymic. Resident #3's thought process: no thought insertion was noted, no thought broadcast was noted, and no thought control was noted. Plan: Resident 3's medication list reviewed. Continue with Resident #3's medication, any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating and underlining psychiatric disorder. Resident #3 had multiple non-pharmacologic approaches that have been ineffective in relieving significant patient distress and /or behavioral symptoms dangerous to this patient or others. Resident #3's Diagnosis, Assessment and Plan: Major Depressive disorder, recurrent without psychotic features. Generalized anxiety disorder, and Mild intellectual disabilities. Review of Resident #3's Psychiatric Progress Note, dated 10/28/2025, reflected Resident #3 had normal appetite, no irritability, no depression, and no sleep complaints. He did not have any loss of activity interest. Resident #3 energy level was normal. He did not have any physical aggression or verbal aggression. Mental Status Exam: Resident 3 was not in any acute distress. He was smiling and interactive. He was oriented to person, place, and situation. Resident #3 was disoriented to time. His mood was euthymic. Resident #3's thought process: no thought insertion was noted, no thought broadcast was noted, and no thought control was noted. Plan: Resident 3's medication list reviewed. Continue with Resident #3's medication, any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating and underlining psychiatric disorder. Resident #3 had multiple non-pharmacologic approaches that have been ineffective in relieving significant patient distress and /or behavioral symptoms dangerous to this patient or others. Resident #3's Diagnosis, Assessment and Plan: Major Depressive disorder, recurrent without psychotic features. Generalized anxiety disorder, and Mild intellectual disabilities. Review of Resident #3's Psychiatric Progress Note, dated 11/25/2025, reflected Resident #3 had normal appetite, no irritability, no depression, and not have any sleep complaints. He did not have any loss of interest. Resident #3 energy level was normal. He did not have any physical aggression or verbal aggression. Mental Status Exam: Resident 3 was not in any acute distress. He was smiling and interactive. He was oriented to person, place, and situation. Resident #3 was disoriented to time. His mood was euthymic. Resident #3's thought process: no thought insertion was noted, no thought broadcast was noted, and no thought control was noted. Plan: Resident 3's medication list reviewed. Continue with Resident #3's medication, any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating and underlining psychiatric disorder. Resident #3 had multiple non-pharmacologic approaches that have been ineffective in relieving significant patient distress and /or behavioral symptoms dangerous to this patient or others. Resident #3's Diagnosis, Assessment and Plan: Major Depressive disorder, recurrent without psychotic features. Generalized anxiety disorder, and Mild intellectual disabilities. Review of Resident # 3's Psychiatric Progress Note, dated 12/09/2025, reflected Resident #3 had normal appetite, no irritability, no depression, and not have any sleep complaints. He did not have any loss of interest. Resident #3 energy level was normal. He did not have any physical aggression or verbal aggression. Mental Status Exam: Resident 3 was not in any acute distress. He was smiling and interactive. He was oriented to person, place, and situation. Resident #3 was disoriented to time. His mood was euthymic. Resident #3's thought process: no thought insertion was noted, no thought broadcast was noted, and no thought control was noted. Plan: Resident 3's medication list reviewed. Continue with Resident #3's medication, any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating and underlining psychiatric disorder. Resident #3 had multiple non-pharmacologic approaches that have been ineffective in relieving significant patient distress and /or behavioral symptoms dangerous to this patient or others. Resident #3's Diagnosis, Assessment and Plan: Major Depressive disorder, recurrent without psychotic features. Generalized anxiety disorder, and Mild intellectual disabilities. Interview on 12/12/2025 at 11:30 a.m., Resident #3 stated the psychiatrist did visit him but she never asked about his feelings or if he was depressed. He stated she would come in and would say you are smiling and ask about pets. He stated they mostly talked about dogs and cats. Resident #3 stated sometimes he did become mad at other people and would yell at them, and he said sometimes he would say ugly words at people. Resident #3 stated the Psychiatrist never asked him about him yelling and cursing at other people. He said one time she came to visit me , and I just got finished yelling at someone who lived close by, and I was mad at them for not speaking to me and she never asked me if I had problems with getting upset with other people.Interview on 12/11/2025 at 2:47 p.m., the Psychiatrist stated he trained PMHNP-BC for three months prior to her entering a nursing facility to counsel any resident. He stated his expectations were for any Psychiatrist to speak with the DON, ADON, MDS nurse and make rounds with the DON prior to counseling the residents. He stated he expected any Psychiatric staff, including PMHNP-BC, to review orders with the DON or designee and discuss any behaviors of the residents. He stated he expected PMHNP-BC to counsel the residents of any new behaviors [TRUNCATED]

Based on interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 59 residents reviewed for activities. The facility failed to provide activities for all residents in the facility for the entire months of August 2025 and September 2025. This failure could place residents at risks of boredom, depression, behavior, diminished quality of life and decreased cognitive function. Findings included:Record review of the activity participation record binder for the year of 2025 reflected there were not any participation records for the months of August 2025 and September of 2025. Record review of the QAPI, dated 12/08/2025, reflected the Activity Director and Activity Department were discussed and a plan developed. Review of Resident #2's face sheet, dated 12/12/2025, reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of major depressive disorder ( a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep or feelings of guilt), diarrhea, unspecified ( a condition in which feces are discharged from the bowels frequently and in a liquid form), other depressive disorder, recurrent without psychotic features (someone having repeated , severe depression episodes but without delusions, meaning they stay grounded in reality).Review of Resident #2's Annual MDS, dated [DATE], reflected Resident #2 had a BIMS score of 15 indicating his cognition was intact. His activity preferences were the following: being around pets, going outside for fresh air when the weather was good, keeping up with the news, listening to music, and doing favorite activities. Review of Resident #2's Quarterly MDS, dated [DATE], reflected Resident #2 had a BIMS score of 15 indicating his cognition was intact. Resident #2 felt down, depressed, or hopeless 7-11 days out of the 14-day assessment period. He had trouble falling asleep or sleeping too much. He felt tired or had very little energy. Resident #2 had difficulty concentrating on things. Review of Resident #2's Comprehensive Care Plan with completion date of 09/25/2025, reflected Resident #2 had Problem initiated on 05/21/2025 Resident #2 had little or no activity involvement. Interventions: Establish and record the resident's level of activity involvement. Explain to Resident #2 the importance of social interaction, leisure activity time. Encourage Resident #2 to participate in activities. Interview on 12/12/2025 at 11:00 a.m. Resident #2 stated there were approximately two or three months where there were not many activities in the facility. He stated in the past 2 months there were activities daily. Resident #2 stated he was getting bored without anything to do except read and watch tv. He stated he enjoyed the socials and parties more than any other type of activities. Review of Resident #3's face sheet, dated 12/12/2025, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] had a diagnosis of mild intellectual abilities ( involves challenges with thinking, learning, and daily skills (like communication, self-care, and social skills) but allows individuals to learn practical life skills), major depressive disorder, recurrent severe without psychotic features ( causing significant life impairment such as work, social and self-care but without hallucinations or delusions- seeing hearing tasting or feeling things that seems real but isn't, having no external source), featuring symptoms like sadness, loss of pleasure, energy loss, and guilt), and generalized anxiety disorder ( a mental health condition causing persistent , excessive, and uncontrollable worry about everyday things).Review of Resident #3's Annual MDS, dated [DATE], reflected Resident #3 had a BIMS score of 15 indicating his cognition was intact. Resident #3's activity preferences was the following: have books to read, listen to music, keep up with news, doing things in groups of people, doing favorite activities, going outside to get fresh air when the weather was good, and participating in religious activities. Review of Resident #3's Comprehensive Care Plan, dated 09/03/2025, reflected Resident #3 needed out-of-room social, spiritual, and stimulus activities and mental stimulation. Intervention: Activity Director will encourage and remind resident of current activities. Interview on 12/12/2025 at 11:30 a.m., Resident #3 stated he liked to do activities on his own most of the time but liked to go to music and parties. He stated there were a few months where there were no activities except sometimes church. He stated for the past two months there were activities every day. Resident #3 stated he did not get bored because he had lots to do. He stated his family brought him things to do and he would sit in the dining room and do his own activity. Review of Resident #5's face sheet, dated 12/12/2025, reflected a [AGE] year-old male resident admitted on [DATE] and readmitted on [DATE] with the following diagnoses bipolar disorder, current episode mixed, severe, with psychotic features ( Manic symptoms: high energy, racing thoughts , irritability, less need for sleep, rapid speech, and agitation. Depressive symptoms: sadness, loss of interest, low energy, and feelings of worthlessness. Psychotic features which involved losing touch with reality, Hallucinations seeing hearing or feeling things that are not there. Delusions: firmly held false beliefs believing you have superpowers or are being ruined), and generalized anxiety disorder (a mental health condition causing persistent, excessive, and uncontrollable worry about everyday things (work, health or family). Review of Resident #5's Quarterly MDS Assessment, dated 09/05/2025, reflected Resident # 5 had a BIMS score of 15 indicating his cognition was intact. Resident #5 had a diagnosis of anxiety and bipolar disorder.Review of Resident # 5's Significant Change MDS Assessment, dated 12/05/2025, reflected Resident #5 had a BIMS score of 15 indicating his cognition was intact. Resident #5 activity preference was the following: have books to read, listen to music, be around animals, do favorite activities, go outside to get fresh air when the weather was good, and participate in religious activities. Review of Resident #5's Comprehensive Care Plan, revised on 12/04/2025 and 12/07/2025, reflected Resident #5 needed out of room social, spiritual, and mental stimulation. Interventions: Will encourage Resident #5 to attend current activities. The Activity Director will provide resident reading material as needed. Interview on 12/12/2025 at 3:30 p.m. Resident #5 stated he did become bored sometimes. He stated there were a few months he did not see activities in the dining room and other areas. Resident #5 stated the past two months they had activities every day. Resident #5 stated he did not attend very many activities, but he would go listen to music. He said sometimes he liked to go to parties when they had food, but he didn't like to socialize with other residents so he would sit away from everyone. Interview on 12/12/2025 at 12:15 p.m. the Activity Director stated she did not have an excuse why activities were not always provided for the residents in the months of August 2025 and September of 2025. She stated she had no documentation of any activities provided during these two months (August 2025 and September of 2025). The Activity Director stated it was her fault, and she did not request help from anyone. She stated sometimes she provided activities during August 2025 and September 2025, however, she had no documentation proving activities were provided to any residents. She stated if a resident was not receiving activities there was a potential a resident may become depressed or more depressed, bored, isolate themselves, have a decline in their mental status, and a decline in their quality of life. She stated she was a certified activity director for over 10 years. She did not respond to any further questions about the activity programming not provided for the residents. Interview on 12/12/2025 at 1:05 p.m., the Administrator stated she expected all activity programming to be documented on the participation logs. She stated she was not aware of the activity director not documenting activity programs. The Administrator stated she had been an Administrator at the facility for less than a year and she was monitoring one department at a time and was observing one department before she went to another department. She stated she was working with nursing department for the longest and she had not made any monitoring of the activity participation records until October 2025, and this is when she realized the Activity Director did not have any participation records for the months of August and September of 2025. She stated she had the Activity Director on action plan in QAPI meeting on 12/08/2025. The Administrator stated the Activity Director was responsible for all her documentation and she was responsible for monitoring the Activity Director. She stated the Activity Director was to document each in room activity and each group activity on the participation record every time she provided an activity for a resident. Record review of the Activity Director's personnel record, dated 10/2024, reflected that she was a certified activity director. She was an Activity Director at this facility since 05/05/2025. Record review of the Facility Activity Director Job Description, not dated, signed by the Activity Director on 05/05/2025, reflected the following was non -exhaustive criteria related to the job of an Activity Director, and it was consistent with the business of the facility. These were legitimate measures of qualifications for an Activity Director and related to the functions essential to the job of an Activity Director. Knowledge base:Must be Certified Activity DirectorExcellent creative and communication skillsAbility to organize, document, and implement detailed programs.Genuine caring for and interest in elderly and handicapped people.Ability to comply with the Patient [NAME] of Rights and the Employee Responsibilities.Experience with creating and implementing effective care plans.Ability to develop, organize and implement a program of activities for the social, emotional, physical and other therapeutic needs of the residents. Maintain detailed records of activity programs and participation of individual residents, identifying progress toward established care plan goals.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained as free of accidents and hazards as possible for 1 of 3 shower rooms reviewed for accidents and supervision.The facility failed to ensure the shower door located on Mc [NAME] Hall was closed and locked.This failure could place residents at risk of injuries, illness, and hospitalization. Findings included:Observation on 12/12/2025 at 10:15 a.m. revealed the shower room door on [NAME] Hallway was left opened and propped open 1 time. Observation revealed no staff or residents in the hallway or near the shower room. In the shower room there was no-rinse scented spray cleanser, shampoo and body wash, and shaving cream located on top of the clothes barrel.Interview on 12/12/2025 at 10: 20 a.m. CNA A stated he unlocked the shower room door and closed it when he exited the shower room to assist a resident to the shower room. He stated the door was closed when he left it unlocked. He stated he knew not to leave the shower room unlocked and it was required to be locked at all times. CNA A stated he was in-serviced on ensuring the shower room door was closed and locked at all times but did not recall the last time he was in-serviced on securing the shower room. CNA A stated if a resident drank the cleanser there was a possibility of becoming severely ill and, if a resident was allergic to the ingredients, the resident may die. Interview on 12/12/2025 at 10: 50 a.m., the Director of Nurses stated all shower doors were expected to be closed and locked at all times. She stated a resident may enter the shower room and close the door and would not know how to open the door to leave the shower room. She stated a resident may fall and have difficulty finding the call light to get nursing assistance. The DON stated death was a possibility if a resident ingested the cleanser. She stated there were not any residents on the [NAME] Hall who wandered into other residents' rooms or any room in the facility. Interview on 12/12/2025 at 1:05 p.m., the Administrator stated her expectation was for the shower door to remain closed and locked at all times. She stated there was a possibility a resident may fall into the shower room and be unable to reach the call light or yell for help. The Administrator stated if a resident ingested the cleanser there was a possibility the resident may need to be hospitalized , and it was possible a resident may die from the chemical. She stated the staff were in-service on locking and closing shower doors and keeping all chemicals locked. The Administrator did not remember the date or time of the most recent in-service. She stated it was everyone's responsibility to ensure the shower doors were locked and secured. She stated if any staff walked down the hall and saw a shower door opened, they were too close and ensured it was locked and report it to the DON. Record review of the Safety Data Sheet for the scented cleanser, not dated, reflected may cause eye damage or irritation. Skin Contact: if irritation develops, wash area with water. Get medical attention if irritation persists. Inhalation: treat symptomatically. Not expected to be toxic. Toxicological information: Ingestion may be harmful if swallowed.During an interview on 12/12/2025 at 1:05 p.m., the Administrator was asked for the Safety Data Sheet for the shaving cream, body and hair wash, which was not provided prior to exit. During an interview on 12/12/2025 at 1:05 p.m., the Administrator stated the facility did not have a protocol for Accidents and Hazards.

Based on interview, observation, and record review, the facility failed to ensure the residents had the right to be free from abuse and neglect for two (Resident #2 and Resident #5) of four residents reviewed for abuse and neglect. The facility failed to protect Resident #2 from physical abuse by Resident #5.This failure placed residents at risk of abuse, neglect, trauma, and psychosocial harm.Findings included: 1.Review of Resident #2's face sheet, dated 12/12/2025, reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of major depressive disorder ( a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep or feelings of guilt), diarrhea, unspecified (a condition in which feces are discharged from the bowels frequently and in a liquid form), other depressive disorder, recurrent without psychotic features (someone having repeated, severe depression episodes but without delusions, meaning they stay grounded in reality). Review of Resident #2's Quarterly MDS, dated [DATE], reflected Resident #2 had a BIMS score oof 15indicating his cognition was intact. Resident #2 felt down, depressed, or hopeless 7-11 days out of the 14-day assessment period. He had trouble falling asleep or sleeping too much. He felt tired or had very little energy. Resident #2 had difficulty concentrating on things. Review of Resident #2's Comprehensive Care Plan with completion date of 09/25/2025, reflected Resident #2 had chronic diarrhea. Intervention: diet as tolerated. Give Anti-diarrheal medications. Monitor lab values and inform physicians of abnormal findings. Resident #2 had potential for alterations in mood related to depression. Interventions: Arrange for psych consult, follow up as indicated. Monitor/ document/ report to nurse/ MD of signs and symptoms of depression, including hopelessness, sadness, negative statements, tearfulness, etc. During an interview and observation on 12/12/ 2025 at 11:00 a.m., Resident #2 was in his room seated on his bed. He stated he had diarrhea and came out of the bathroom the day of the incident with Resident #5. He stated his roommate, Resident #5, told him to take a shower. Resident #2 stated he walked to the hallway and talked to CNA A about his shower. Resident #2 stated he asked if he could get a shower after his therapy. Resident #2 stated Resident #5 overheard the conversation between him and CNA A. Resident #2 stated when he went to the therapy room and sat in the chair, Resident #5 entered the therapy room cussing and yelling and very angry toward me. He stated the therapy staff attempted to talk to Resident #5 and Resident #5 continued to walk toward him. Resident #2 stated he informed Resident #5 if he thought he was big enough to fight him to come on and they would fight. Resident #2 stated Resident #5 approached him while he was sitting in the chair in therapy room and hit him in the nose. He stated there were therapy staff in the room and they tried to talk to Resident #5, and he became angrier. Resident #2 stated one therapist stood beside him for a few seconds, but no one tried to intervene when Resident #5 walked up and hit him in the nose. He stated there was not any staff who tried to protect him, but he was the one who threatened Resident #5 and Resident #5 threatened him. He stated it was just a hostile situation, and he believed if someone had gotten in front of him Resident #2) he would not have been hit by Resident #5. Resident #2 stated he did not want to be near Resident #5 until he became calmer about the situation. He stated he would not harm Resident #5, but he was still upset over the situation. Resident #2 stated he had diarrhea because of the foods he ate, and he had history of diarrhea most of his life. He stated he did not eat the proper food, and his family brought food for him that hurt his stomach and caused diarrhea, but he did not report this to his family. Resident #2 stated his roommate stayed mad at him due to his diarrhea and the odor in the room. He stated this was the entire argument last week when he was hit by Resident #5 about the odor in his room and him not immediately taking a shower. Resident #2 stated he did see the psychiatrist after the incident with Resident #5, but she did not ask him any questions about the incident and him being mad toward Resident #5. Resident #2 stated he did feel safe at this facility and did not want to move to another facility or go anywhere else to live. 2. Review of Resident #5's face sheet, dated 12/12/2025, reflected a [AGE] year-old male resident admitted on [DATE] and readmitted on [DATE] with the following diagnoses bipolar disorder, current episode mixed, severe, with psychotic features ( Manic symptoms: high energy, racing thoughts , irritability, less need for sleep, rapid speech, and agitation. Depressive symptoms: sadness, loss of interest, low energy, and feelings of worthlessness. Psychotic features which involved losing touch with reality, Hallucinations seeing hearing or feeling things that are not there. Delusions: firmly held false beliefs believing you have superpowers or are being ruined), and generalized anxiety disorder (a mental health condition causing persistent, excessive, and uncontrollable worry about everyday things (work, health or family). Review of Resident #5's Quarterly MDS Assessment, dated 09/05/2025, reflected Resident # 5 had a BIMS score of 15 indicating his cognition was intact. Resident #5 had a diagnosis of anxiety and bipolar disorder. Review of Resident #5's Comprehensive Care Plan, revised on 12/04/2025 and 12/07/2025, reflected Resident #5 exhibited physical aggression. Resident #5 punched his roommate (Resident #2) in the nose. Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, pain, etc. (and similar things). Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist in setting goals for more pleasant behaviors, encourage seeing out of staff member when agitated. Evaluate side effects of medications. Give the resident as man choices as possible about care and activities. If Resident #5 had physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening is unsafe, call out for staff assistance immediately. Monitor, document, and report to MDS of danger to self and others. Notify the charge nurse of any physically abusive behaviors. Psych consult as indicated. Move Resident #5 to another room. Resident #5 had potential to exhibit verbal threats. Interventions: Assist resident in avoiding other residents that may cause outbursts. Be non-judgmental but firm that inappropriate behavior was not acceptable. Coordinate care to help maintain control of his behavior for example: in a group have Resident #5 to sit from other residents according to his preferences. Educate Resident #5 in alternative ways of dealing with anger. If Resident #5 becomes angry- leave him alone- give him time to calm. If Resident #5 has altercation with another resident separate immediately to separate locations, notify MD, notify Administrator, Responsible Party and if needed call sheriff department or 911. Monitor residents' location every 15 minutes until resolved. Provide 1:1 with Resident #5 as ordered. Record review of Resident #5's one on one interventions reflected staff was with the resident one on one for 72 hours after the incident on 12/04/2025. Interview on 12/12/2025 at 9:15 AM Resident #5 stated he was mad at his roommate at the time (Resident #2). He stated Resident #2 always had diarrhea and the room would smell like poop. He stated on 12/04/2025 Resident #2 came out of the bathroom and had poop odor on him, in the bathroom, and in the room. Resident #5 stated he became angry due to Resident #2 would not changing his clothes taking a shower. He stated he told Resident #2 to get a shower before he went to therapy, and Resident #2 would not listen to him. Resident #5 stated Resident #2 entered the hallway and spoke to CNA A about getting a shower. Resident #5 stated Resident #2 refused the shower and went to the therapy room. Resident #5 stated he became very angry about the situation of how Resident #2 had poop odor and was going to therapy. Resident #5 stated he had been arguing with his roommate. Resident #2, about his diarrhea and how he smelled and how the room smelled. Resident #2 stated housekeeping cleaned but Resident #2 still had an odor of poop. Resident #5 stated this argument was occurring more frequently and he was getting more agitated and angrier toward Resident #2. He stated he followed Resident #2 to the therapy room, and he began to yell and cuss at Resident # 2. He stated he called Resident #2 a son of a bitch and intended oof knocking some sense into him. Resident #5 stated two female therapists tried to stop him by telling him to calm down and go for a walk. Resident #5 stated that was the wrong thing to say to him because no one told him to calm down and that made him angrier. He stated Resident #2 was sitting in a chair with his walker in front of him and made a statement if you think you are big enough and can do something why don't you come over here and try to hit me. Resident #5 stated no one was trying to stop him at that point and he walked directly to Resident #2 and hit him in the nose. Resident #5 stated no staff attempted to prevent him from hitting Resident#2. He stated he left the therapy room, and the nurse checked him from head to toe. Resident #5 stated they moved him to another room and had someone with him all day and night for several days. He stated he did not want to see Resident #2 right now, but he would eventually like to talk to him in a calm manner but not now. Resident #5 stated he would not hit Resident #2 or cause any problems with him as long as he wasn't his roommate and stayed on the other side of the building. Resident #5 stated he had not seen Resident #2 since the incident, and he had no intention of hurting anyone or himself. Resident #5 stated he did not report to any staff of him having issues with his roommate. He stated he did not voice a grievance or concern about his roommate to anyone. He stated he thought it would get better, and he did not want to snitch on anyone. Resident #5 stated he felt safe living at this facility. During an interview on 12/12/2025 at 10:40 a.m., CNA A stated Resident #2 exited his room and he asked Resident #2 if he wanted a shower. CNA A stated Resident #2 he wanted to get a shower after therapy. CNA A stated he was not aware of any arguments between Resident #2 and Resident #5. He stated he thought both residents, Resident #2 and Resident #5, were friends and did not argue with one another. CNA A stated, after the incident, Resident #2 refused a shower that particular day. CNA A stated Resident #2 never refused showers when he was assigned to him. During an interview on 12/12/2025 at 12:20 p.m., the Director of Therapy stated she was present when Resident #5 entered the therapy room cursing and yelling. She stated Resident #5 called Resident #2 a son of a bitch and continued to curse and yell. She started to walk to Resident #2 and attempted to talk to him and asked him to calm down and go for a walk with her. The Director of Therapy stated Resident #5 became angrier and more agitated. She stated OT was standing near Resident #2 providing therapy. The Director of Therapy stated Resident # 5 continued to walk toward Resident #2 very agitated and angry. She stated Resident #2 made the statement, Why don't you try and hit me. The Director of Therapy stated they did not know what to do because she attempted to take Resident #5 for a walk and asked him to calm down, but it did not work. She stated Resident #5 walked to Resident #2, who was seated, and hit him in the nose. The Director of Therapy stated the OT helped her with Resident #5 to get him to go for a walk. She stated if one of them had stepped in front of Resident #2 then Resident #5 would not have hit Resident #2. She stated she was in-serviced on interventions on behaviors with residents. She stated after talking about it she realized they did not implement the proper interventions. The Director of Therapy stated the intervention they did escalated the situation, and what they should have removed Resident #2 from the situation when they realized Resident #5 was not going to leave the therapy room. Interview on 12/12/2025 at 1:05 p.m., the Administrator stated they did a complete investigation following their abuse and neglect protocol. She stated when the incident with Resident #2 and Resident #5 was brought to her attention, the facility staff immediately moved Resident #5 into another room on the opposite side of the facility. She stated Resident #2 and Resident #5 did not have roommates. She stated she was not aware of any issues between Resident #2 and Resident #5 until 12/04/2025. She stated a staff was with Resident #5 1:1 for 72 hours or more. She stated incident and accident reports, and skin assessments were completed on both residents. She stated Resident #2 had a nosebleed. The Administrator stated the care plans were updated and the MD, Ombudsman and families were contacted as well as HHSC. She stated all staff were in-serviced on abuse and neglect. The administrator stated all interviewable residents were asked if they felt safe in the facility and if they were abused by anyone. She stated no residents reported any abuse and all felt safe in the facility including Resident #2 and Resident #5. She stated they finished their investigation of the incident on 12/11/2025. During an attempted interview on 12/12/2025 at 3:00 p.m., a voice message was left for the OT including return contact information. Record review of the Facility's Policy on Abuse and Neglect, not dated, reflected, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.DefinitionsAbuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observation, interviews, and record review, the facility failed to ensure residents received care and services consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. The facility failed to:A. Ensure Resident #1 had appropriate interventions in place to prevent unstageable pressure ulcers under her C- Collar neck brace.B. Perform thorough skin assessments under Resident #1's C-collar to ensure pressure ulcers were not developing.C. Ensure Resident #1's C-collar was applied properly and maintained, as it was noted to be taped in place to prevent removal, with fecal matter smeared on tape.These failures resulted in an Immediate Jeopardy (IJ) situation on 09/17/2025. The IJ template was provided to the facility on [DATE] at 1:01PM. While the IJ was removed on 09/18/2025, the facility remained out of compliance at a scope of isolated and a severity level potential for more harm than minimal harm that is not Immediate Jeopardy, due to staff needing more time to monitor the plan of removal for effectiveness.These failures could place residents at risk of physical harm.Record review of Resident #1 face sheet, dated 09/16/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia, dissection of vertebral artery (small tear in artery wall), nondisplaced posterior arch fracture of first cervical vertebra(hairline break in back part of top neck), and non-displaced fracture of seventh cervical vertebra(small break in seventh bone).Record Review of Resident #1's Significant Change MDS assessment, dated 09/11/2025, reflected she was assessed with a BIMS score of 00, indicating severe cognitive impairment. Further review reflected she was assessed as not having any pressure ulcers.Record Review of Resident #1's initial skin assessment, dated 09/04/2025, reflected she was assessed as having no pressure ulcers. Record Review of Resident #1's comprehensive care plan reflected a focus area, dated 09/12/2025, Resident #1 has cervical fractures related to falling from her wheelchair-neck brace in place per MD orders. Review of interventions included neck brace as orders and skin assessment per facility protocol and prn. The care plan did not include interventions for brace removal.Record Review of Resident #1's physician orders reflected an order dated 09/05/2025, C-Collar on at all times except for showers. Further review reflected an order for Philadelphia collar, dated 09/05/2025, for showers (soft collar). Further review of Resident #1's physician orders reflected no order for removal of the collar to perform skin checks.Record Review of Resident #1's hospital record, dated 09/15/2025, reflected, Patient diagnosis pressure ulcer unstageable.Skin.bruising under c-collar, inspection findings include pressure ulcer, wound behind left ear and on chin under c-collar. Inspection findings include swelling to the anterior neck. Notes . c-collar taped to patient with fecal matter smeared on tape.During an interview on 09/16/2025 at 2:54 pm, the ER RN stated the ER did a head-to-to-toe assessment, and the ER was concerned about: ER removed the Aspen Collar which was missing all padding from the plastic collar, no padding at all noted and the collar was wrapped with 2-inch silk tape all the way around, rolled around the brace to adhere it to the neck. ER RN stated the tape was not on the skin, but the neck brace was wrapped so tightly around the neck that they had to use bandage scissors to remove the 10 -12 wrapped circles of tape around the brace and around her neck. ER RN stated, I understand she was probably pulling it off, but the tape was excessive and if it was an emergency they would not be able to get it off of the resident's neck. The ER RN stated in the ER they cut it off with bandage scissors and it took about 5 minutes to get off. The silk tape was soiled with food and fecal matter. The ER RN stated when they finally got it loose, there was bloody tissue where a skin adhesion to the collar had occurred. It was difficult to get the collar off the skin. The skin had a very strong smell the ER RN described as rotting flesh, putrid, or a bacteria smell. The smell was so strong the ER cultured the wounds on the left ear area of the neck, and chin for bacteria. The ER RN described the wounds as ulcers from the c-collar. In an interview on 09/16/2025, at 3:39 PM, the RP stated on 9/11/2025, she visited the facility to pick up Resident #1's cell phone for repair. The RP stated the facility had her sign a form acknowledging Resident #1 may fall and sustain injury due to her behaviors. The RP stated that during that visit, her loved one was wearing a brace that was covered with cotton gauze which had a foul odor and appeared dirty. She further stated that each time she visited, she requested that the facility clean Resident #1's room. She also reported observing fecal matter on the resident's bedsheets and fingers. Review of Resident #1's weekly skin assessment dated [DATE] performed by LVN C reflected no identified pressure ulcers.Review of Resident #1's weekly skin assessment dated [DATE] performed by the Treatment Nurse reflected no identified pressure ulcers.In an interview conducted on 09/16/2025 at 4:35 PM, the Treatment Nurse stated she had been in her position for a few months but was with the company for 6 years. The Treatment Nurse stated when she assessed Resident #1 on 09/13/2025 she stated she noticed some redness but that she did not remove the c-collar or loosen it to do a full assessment. She stated she did not notice any tape on the c-collar. The Treatment nurse stated on yesterday she sent Resident #1 to the ER, and she did not notice any tape on resident.In an interview conducted on 09/16/2025 at 5:17 PM, LVN D stated Resident #1 had tape on her C-Collar since she returned from the 9/10/2025 ER visit. LVN D stated he was off work two days and when he returned Resident #1 had tape on the collar. LVN D stated there were no instructions given on the tape.In an interview conducted on 09/16/2025 at 5:24 PM, LVN C stated Resident # 1 returned from the ER with tape at the bottom of her collar. The LVN stated this information was not documented but stated vanilla tape was at the bottom of the collar. LVN C volunteered this information without being prompted by the surveyor. LVN C stated she knew the tape was a concern. LVN C further explained that the nurses removed the C-collar at bath times and applied a different type of collar that could get wet. LVN C stated the C-collar was only removed when Resident #1 did not refuse shower. LVN C stated she was PRN and her last time at work was last Thursday, 9/11/2025. LVN C stated the Treatment Nurse checked the resident on that same day.In an interview conducted on 09/16/2025 at 6:00 PM, CNA A stated she worked at the facility since March of 2024. CNA A stated she worked with Resident #1. CNA A stated she did not shower Resident #1 the previous day. She stated the night shift normally provides the showers for Resident #1. She further explained that Resident #1 showers had recently been changed to daily. CNA A stated the last gave Resident #1 a shower on 9/5/2025. She also stated that LVN C removed the gray C-Collar and placed a tan collar on Resident #1 that could get wet.Review of Resident #1's ADL flow sheet for bathing reflected Resident #1 was documented as having a bath on 09/05/2025 and 09/13/2025.In an interview conducted on 09/17/2025 at 10:53 am, CNA B stated she worked with Resident #1 one day. She stated she provided Resident #1 with a bed bath on 9/13/25 but did not remove the collar. CNA B stated she didn't touch that area during bath. CNA B stated only the nurses touch the collars and wounds; the aids do not.In an interview conducted on 09/17/2025 at 9:44 am, Resident #1's physician stated it was his expectation that staff check the resident's skin for pressure areas when a splint was in use. He explained the brace/ collar must be fitted correctly by medical staff. Resident #1's physician stated a collar should not necessarily be taped unless there was a malfunction with the splint. The physician stated there should be a follow up with orthopedic surgeon, based on orthopedic recommendation. Resident #1's physician stated the splint should not be altered unless it was cleared by the medical doctor.In an interview conducted on 09/17/2025 at 12:30 PM, the RCN stated Resident #1 should have had orders in place to remove the splints and conduct skin assessments every shift. The RCN further stated a thorough skin assessment should have been completed upon the resident's readmission from the hospital.Review of the facility's policy immobilization devices, splint/slings/collars/straps (not rated) reflected, Immobilization devices are splints, slings, cervical collars and clavicle straps that are applied to restrict movement, support and preserve the integrity of an injured arm, shoulder or neck. 3. Secure with Velcro, strips of cloth, pin, or tape the loose end. Secure the material with firmness but without compromising circulation. 4. Remove the splint periodically to assess skin and maintain cleanliness and dryness under the splint. 8. All immobilization devices, except clavicle straps, should be removed periodically. All devices will be monitored on every two-hour schedule. Monitoring will be documented in the clinical record or flow sheet.Review of the facility's policy pressure injury: prevention, assessment and treatment (not rated) 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. 9. Assess early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet.This was determined to be an Immediate Jeopardy (IJ) on 09/17/2025, the Administration was notified. The Administrator was provided with the IJ template on 09/17/25 at 1:01 PM and a plan of removal was requested. The following POR was accepted on 09/18/2025 at 8:30 AM. Plan of removalProblem: F686 Failure to prevent pressure injury On 09/16/2025 an abbreviated survey was initiated at the facility. On 09/16/2025 the surveyor provided an Immediate Jeopardy (IJ)Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to residents' health and safety. The facility failed to ensure Resident #1 had interventions in place to prevent unstageable pressure ulcers from forming under her C-Collar neck brace. The facility failed to perform through skin checks under her C-Collar to ensure pressure ulcers were not forming. The facility failed to ensure the C-Collar was applied properly and maintained when it was noted to be taped to prevent removal with fecal matter smeared on tape.There are 3 residents with braces and splints ordered that could potentially be affected by the deficient practice. 1. Resident #1 remains in the hospital as of 09/15/2025. No other residents in the facility have cervical collars. 2. Action: o 100% resident head to toe skin assessments initiated 09/17/2025 by DON, ADON, and treatment nurse. No further residents were noted with any skin integrity issues. o Head-toe assessment skin assessments were completed for the two residents with orders for a leg brace and bilateral hand splints. No further skin integrity issues were noted. No tape was noted. Start Date: 09/17/2025 Completion Date: 09/17/2025Responsible: These assessments were completed by DON, ADON, and treatment nurse with oversight from Regional Compliance Nurse. 3. Action: o The two residents identified with a brace and a splint were verified to have physician orders to remove for skin assessment and showers. o The two residents identified with a brace and a splint were verified to have the orders to remove for skin assessments and showers were also care planned. Start Date: 09/17/2025 Completion Date: 09/17/2025Responsible: The orders were care planned by Regional Compliance Nurse, DON, and treatment nurse. 4. Inservice Action (Leadership): The Administrator and DON were in serviced 1:1 and for the following policies:o Pressure ulcer prevention and treatment: Turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. In-service also includes to ensure braces and splints are removed as ordered to prevent skin integrity issues. o Braces/Splints: Braces and splints must be removed every shift, during showers and bed baths, and weekly skin assessments to check skin integrity.o Initial Skin Assessment: A thorough initial skin assessment is to be completed within 4 hours of admission or readmission.o Weekly Skin Assessment: Skin assessments must be done weekly and as needed for any skin issues for every resident in the facility. Report changes in a resident's skin condition to wound care and DON immediately.o Abuse and Neglect: Residents have the right to be free from abuse and neglect. Not following MD orders to remove braces and assess skin could be considered neglect. Any Allegation of abuse, neglect, or exploitation/misappropriation of funds should be immediately reported to the abuse preventionist.o New Process: The Weekly Skin Assessment UDA in PCC has been revised to include assessment questions related to braces, immobilizers, and other devices. An alert will trigger the clinical PCC dashboard if a device is present.Employee Retention Checks: Administrator and DON were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained by regional compliance nurse for Administrator and DON understanding.Start Date: 09/17/2025Completion Date: 09/17/2025Responsible: This Inservice was completed by Regional Compliance Nurse.5. Inservice Action (All Staff): All staff were inserviced on the following topics. Any staff member not present or inserviced as of 9/17/2025 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will inserviced prior to assuming their next assignment.o Pressure ulcer prevention and treatment: Turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. In-service also includes to ensure braces and splints are removed as ordered to prevent skin integrity issues. o Braces/Splints: Braces and splints must be removed every shift, during showers and bed baths, and weekly skin assessments to check skin integrity.o Initial Skin Assessment: A thorough initial skin assessment is to be completed within 4 hours of admission or readmission.o Weekly Skin Assessment: Skin assessments must be done weekly and as needed for any skin issues for every resident in the facility. Report changes in a resident's skin condition to wound care and DON immediately.o Abuse and Neglect: Residents have the right to be free from abuse and neglect. Not following MD orders to remove braces and assess skin could be considered neglect. Any Allegation of abuse, neglect, or exploitation/misappropriation of funds should be immediately reported to the abuse preventionist.o New Process: The Weekly Skin Assessment UDA in PCC has been revised to include assessment questions related to braces, immobilizers, and other devices. An alert will trigger the clinical PCC dashboard if a device is present.Employee Retention Checks: All staff were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained by Administrator of all staff understanding.Start Date: 09/17/2025Completion Date: 09/17/2025Responsible: These in services were completed by Administrator and DON.6. Monitoring: Monitoring steps will be documented on the individual monitoring tools.o The DON/designee will monitor all new residents with braces to ensure orders are in place for removal of brace per physician orders, treatments have been ordered, ensure assessments done daily, 7 days a week X's 6 weeks, to ensure compliance using the monitoring tool. o The DON / designee will view each pressure ulcer weekly X's 6 weeks using available monitoring tool.o The DON / designee will audit all skin assessments weekly to ensure all assessments match the resident's current condition for 6 weeks using current monitoring tool.o DON/designee will audit charting daily for accuracy of weekly skin assessments x's 6 weeks.o DON/designee will monitor all treatments being done for accuracy per orders using monitoring tools, x's 6 weeks o The QA committee will review findings at the monthly QA meeting and makes changes as needed. o Monitoring will be initiated 9/17/25 and will continue indefinitely. 7. ADHOC QAPI: This meeting was completed by the interdisciplinary team to include the Medical Director and wound care doctor on 09/17/2025.8. Involvement of the Medical Director: The medical director as notified of the immediate jeopardy on 09/17/2025 by the Administrator.Monitored the POR on 9/18/2025 as followed:In an interview on 9/18/2025 at 9:25 AM, the RA stated all in services were completed and provided surveyor with the plan of removal binder.In an interview on 9/18/2025 at 11:07 AM, the RCN stated she in serviced the facility leadership 1on 1 which includes, the ADM, Interim DON, ADON, and the Treatment nurse on proper precautions that need to be in place for residents with collars, braces, and splints. RNC stated the topics were pressure ulcer prevention and treatment, braces/splints, initial skin assessments, weekly skin assessments, abuse and neglect, and new process on weekly skin assessments. RNC stated she completed a 1 on 1 with Treatment Nurse on skin assessments and stated she also trained the ADM on nursing items as she can follow-up in morning meetings.RNC stated she also in- serviced CNAs, medication aids, the Activity Director, therapy staff housekeeping, dietary, and administration staff. She stated all staff were in serviced, some in person, some by phone and some were notified through their electronic message system, COVR. RNC stated everyone that worked on yesterday reviewed and signed off on their trainings, and the staff who were trained via phone and their electronic system will have to sign in-service sheet prior to working their shift. RNC stated monitoring will be ongoing by Interim DON and herself.In an interview on 9/18/2025 at 12:25 PM, the physical therapist assistant stated she was in serviced on 9/17/2025 by the RA and the ADM on abuse and neglect and resident rights. The physical therapist assistant stated she also trained on refusal of care, the process to notify when there is refusal of care, pressure ulcers, showers, braces/splints, and notification of changes. The physical therapist assistant stated they were given a cheat sheet to keep with their name badge for reference.In an interview on 9/18/2025 at 12:47 PM, the ADM stated the RNC in serviced her on pressure ulcer prevention and treatment, braces/splints, initial skin assessments, weekly skin assessments, showers, abuse and neglect. ADM stated they will review skin reports in morning meetings. ADM showed surveyor the cheat sheet for in services they all have in their name badge.In an interview on 9/18/2025 at 1:46 PM, the Interim DON stated she was in serviced by the RNC. The Interim DON stated she was trained on pressure ulcer prevention and treatment, braces/splints, initial skin assessments, weekly skin assessments, abuse and neglect. She stated the trainings included procedures to take for notification in skin changes, refusals, showers, and maintaining integrity of the skin. Interim DON stated training included removal of braces every shift per physician orders. In an interview on 9/18/2025 at 1:55PM, the ADON stated she was in serviced by the RNC. ADON stated she was trained on abuse an neglect, pressure ulcer and treatment, she provided examples of turning residents every two hours, elevating elbows, and making sure body parts are offloading. ADON described the process for braces/splints, initial skin assessments, weekly skin assessments, and refusals indicating she received all in servicing.In an interview on 9/18/2025 at 2:04 PM, the TN stated she was in serviced by the RNC on weekly skin assessments, pressure ulcer prevention and treatment, braces/splints, initial skin assessments, and abuse and neglect. TN stated she will be completing initial skin assessments with in the first 4 hours of arriving to the facility and at readmission. TN stated if she is not available the assessments will be completed by the charge nurse. TN provided examples of braces/splint checks and pressure ulcer prevention treatment.Interviews conducted on 9/18/2025 with nurses on shift between 2:11 PM -2:35PM [LVN E, MDS Nurse, LVN C] indicated they participated in the mandatory in service training about Pressure ulcer and treatment, Braces/Splints, Initial Skin Assessments, Weekly Skin Assessments, Abuse and Neglect, and new process in Point Click Care weekly skin assessments will include assessment questions related to braces and other devices. The nurses summarized the topics of discussion in their own words of procedures to follow. Nurses stated they would notify the treatment nurse, DON, and physician immediately of resident change in condition.Interviews conducted on 9/18/2025 with CNAs on shift between 2:43 PM-3:04 PM [CNA G, CNA H] indicated they participated in an in-service training about reporting refusal of care, abuse and neglect, resident rights, pressure ulcer prevention, braces/splints, showers, and notification of change in condition. The CNAs summarized the topic of discussion - stating understanding regarding concerns about resident skin, identifying, reporting altered skin integrity, and change in condition. Each CNA stated in their own words the protocol was to notify the charge nurse about refusals, a resident change in condition or discovered skin issues.Interviews conducted on 9/18/2025 with night nurses and night CNAs scheduled for night shift between 3:19 PM-4:35 PM [RN K, LVN J, LVN L, LVN M, CNA B, CNA F] indicated they participated in the mandatory in-services. The LVN nurses indicated they received training via phone with RNC about Pressure ulcer and treatment, Braces/Splints, Initial Skin Assessments, Weekly Skin Assessments, Abuse and Neglect, and new process in Point Click Care weekly skin assessments will include assessment questions related to braces and other devices. RN K stated she received her training through the facility's electronic notification system, she summarized the topic of discussions and stated she will sign off before working her next shift. The CNAs stated they received their in-service training prior to starting their shift on 9/17/2025. The night CNAs both summarized the topic of discussion - stating understanding regarding concerns about resident skin, identifying, reporting altered skin integrity, and change in condition. Each CNA stated in their own words the protocol was to notify the charge nurse about refusals, a resident change in condition or discovered skin issues.Interviews attempted via outbound calls to LVN D, RN N, and RN P, the calls were unanswered and forwarded to an automated service that prompted to leave a voicemail. A return call was not received prior to exit on 9/18/2025.Record Review on 9/18/2025 of the In-Service Training Sheets reflected all facility staff had been in-serviced on all training topics listed on the plan of removal. About 5 percent of signatures were still needed as those employees had not worked a shift, those employees will reconfirm understanding of the training and sign off prior to working their shift. Record Review on 9/18/2025 of skin assessments completed, reflected all 56 residents in the facility had been completed.Record Review of care plans on 9/18/2025 for Resident #2 and Resident #3 reflected they were updated to include removal of braces/splints for skin assessments and showers.The Administrator was informed the Immediate Jeopardy was removed on 09/18/25 at 5:50 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and scope of isolated.

Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure CNA A, on 07/30/25, did not transfer Resident #1 from his bed to a shower chair without using two people and a mechanical lift. Resident #1 fell and suffered pain to his right ankle and behind his right knee. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 07/30/25 and ended on 07/30/25. The facility had corrected the noncompliance before the survey began.This deficient practice placed residents at risk of pain, injury, and hospitalization. Findings included:Review of Resident #1's face sheet dated 08/08/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebral palsy (a group of neurological disorders that primarily affect movement and muscle coordination), other reduced mobility (a situation where an individual's ability to move is impaired, but not due to a specific condition), and lack of coordination (refers to a condition where a person experiences difficulty with smooth, precise movements).Review of Resident #1's care plan revised on 05/21/2025 reflected Resident #1 had an ADL self-care deficit related to impaired cognition and decreased mobility with intervention dated 07/30/25 that stated Resident #1 required a mechanical lift and assist of 2 staff for transfers. Review of Resident #1's Quarterly MDS dated [DATE], reflected a BIMS score of 15 indicating no cognitive impairment. Review of nursing notes dated 07/30/2025 by LVN B reflected Resident #1 had a fall in his room when he was being assisted by CNA A and slid out of chair. LVN B was notified by CNA A that Resident #1 was lowered to the floor in room. CNA A stated that Resident #1 was being transferred to a shower wheelchair and wheels on wheelchair would not lock completely and CNA A then lowered Resident #1 to the ground for safety to get nurses' help. CNA A and LVN B got Resident #1 onto [mechanical lift] pad and lifted Resident #1 via [mechanical lift] onto the shower bed. Resident #1 appeared and/or states to be in pain. Resident #1 described the pain as Sharp, Location of pain: right ankle Pain relieving intervention used at this time. PRN pain medication given and STAT x-ray in place. Resident Statement: The wheels on the chair wouldn't locked and CNA A helped me to the floor. MD/NP and RP notified. Review of witness statement by CNA A dated 07/30/25 reflected CNA A was going to give [Resident #1] a shower and planned to put him in the shower chair. When I was transferring him to the chair the brakes didn't fasten enough and the chair went back I assisted him down to the floor and made sure he was ok I went and got my nurse to assist and assessed him and we got him back in the shower bed with the [mechanical lift] and give him the shower and we put him back in the wheelchair for the day. Review of Resident #1's 07/30/25 radiology results reflected no fracture of Resident #1's right ankle. Interview on 08/08/25 at 9:39 am with Resident #1 reflected he fell a while ago when he was being transferred to a chair. He said he was sore for several days after he fell. He said he asked CNA A why there was not another person in there when she was transferring him from the bed to the chair because he said it took two people to transfer him. He said CNA A told him it did not take two people to transfer him. Interview on 08/08/25 at 1:40 pm with CNA A reflected she was going to transfer Resident #1 from his bed to a shower chair, but the chair went back, and she assisted Resident #1 to the floor. She stated Resident #1 did not hit his head. CNA A said Resident #1 was care planned for a mechanical lift, which required two people when transferring a resident, and she was in Resident #1's room alone transferring him not using the mechanical lift. CNA A said she was transferring him alone because she was just going to move him to the shower chair and she could transfer him to the shower chair not using a mechanical lift, which required two people. She said she had not previously transferred him alone, she always used the mechanical lift but because she was going to transfer him from the bed to shower chair, she felt like she could transfer him without using two people and a mechanical lift. CNA A said Resident #1 did not ask her why there were not two people transferring him or why she did not use a mechanical lift. She stated she was familiar with the Kardex (a documentation system that provides a concise summary of patient information, aiding nurses in organizing and referencing patient care details). She said the Kardex gave information about the residents' transfer status and included how to transfer Resident #1 when he was going to have a shower. She stated she was trained at the facility on how to use a mechanical lift and was told a mechanical lift always required two people. CNA A said she thought Resident #1 used a mechanical lift because he was obese, and he did not have a lot of control of his legs. She said she made the decision to transfer him alone because she was confident she was going to be able to do it and never expected the chair to go backwards. She said she was aware that he could have been hurt and she thought it was unsafe to transfer Resident #1 on her own. She said knowing the transfer status of the resident was the responsibility of everybody who worked with residents, and it was her responsibility to follow information in the Kardex and she had full access to the Kardex. CNA A stated she was aware prior to this transfer that Resident #1 needed a mechanical lift transfer that required two people. She said after Resident #1 went to the floor she asked Resident #1 if he was okay then found the nurse and together, CNA A and LVN B, put the mechanical lift sling under Resident #1 and picked him up by the mechanical lift. CNA A said she had not transferred any other facility residents who used mechanical lifts by herself. Interview on 08/08/25 at 1:40 pm with LVN B reflected that on 07/30/25 CNA A was the aide on charge nurse LVN B's assigned hall where Resident #1's room was located. LVN B said CNA A called her to Resident #1's room and Resident #1 was on the floor and there was a shower chair in the room. LVN B said she did not see a mechanical lift in Resident #1's room and no other person was assisting CNA A with transferring Resident #1. LVN B said Resident #1 told her he did not hit his head and initially denied he was in pain, but about 30 minutes later Resident #1 complained of right ankle pain and Resident #1 said he did not want to go to the hospital. STAT x-rays were ordered and reflected no fracturs. A day after the incident Resident #1 complained of the back of his right knee hurting and he was successfully treated with Tylenol and bio freeze. LVN B said he might have had some soreness from the fall on 07/30/25. LVN B said Resident #1 was care planned for a two-person transfer using a mechanical lift. She said there was enough staff at the time of the incident for Resident #1 to have received a two-person mechanical lift transfer. LVN B said she was not aware of CNA A not conducting a two-person mechanical lift transfer when a resident was care planned for a two-person mechanical lift transfer. LVN B said it was the responsibility of CNAs and the charge nurses to ensure residents were transferred appropriately according to their care plan. LVN B said there was no reason for CNA A to be in Resident #1's room doing a transfer alone without a mechanical lift. The possible negative effects of not having two people when using a mechanical lift transfer was the resident could get hurt. LVN B said she did not believe Resident #1 sustained a severe physical injury; it was more mental because staff were constantly redirecting Resident #1 to let him know that he was okay. LVN B did not witness transfers of other residents in the facility who were care planned for mechanical lift transfers that always required two people who were transferred using a mechanical lift using one person. Interview on 08/08/25 at 5:16 pm with CNA C reflected Resident #1 was to always be transferred by 2 people using a mechanical lift. CNA C said all residents who required a transfer using a mechanical lift were a two-person transfer. She said it did not matter if they were going to transfer them to a wheelchair or a shower chair, a mechanical lift required two people for the transfer. She said it was very unsafe to not have two people when transferring a resident using a mechanical lift. She said the resident could be dropped on the floor. She said everyone was responsible for looking at the Kardex before transferring a resident to confirm the residents' transfer safety needs. Interview on 08/08/25 at 5:47 pm with LVN D reflected she was a charge nurse and if a resident used a mechanical lift transfer, they required two people for a transfer no exception. She said if staff were working with her, they better get two people to do a mechanical lift transfer. She said CNAs had access to the Kardex. She said it was everybody's responsibility to make sure the Kardex was followed for safe transfers.Interview on 08/08/25 at 5:47 pm with the Administer reflected it was the responsibility of everyone, CNAs and nurses, who provided care to residents, to know the required transfer needs of all residents. She said CNAs could find resident transfer requirements on the Kardex. The Administer stated that when the resident status stated mechanical lift was required, two people were required for the transfer using a mechanical lift with no exceptions to that rule for the safety of the residents. The negative outcome of not following the resident's care planned required transfer status was there could be either major or minor injuries to the resident. The Administer stated that CNA A had returned to work but as of 08/12/25, she had not worked in the capacity of a CNA after the incident. Interview on 08/08/25 at 6:45 pm with the CN reflected it was the responsibility of the person who transferred the resident to know the safe transfer needs of the resident. She stated CNAs could locate resident transfer information on the Kardex and they could ask the charge nurse. She said it took two people for a safe mechanical lift transfer and there were no exceptions to that requirement. She said if a resident was care planned and required a mechanical lift transfer it was for the safety of the resident. She said if a resident was care planned and required a mechanical lift transfer it was because they were not able to stand. She said all CNAs were trained by the facility to use a mechanical lift when they were hired by the facility. Interview on 08/12/25 at 7:00 pm with the Administrator revealed she reviewed facility policies on Mechanical Lift Transfers, Abuse and Neglect, Trauma Informed Assessment, and how to use the Kardex and trained the MDS Coordinator and former DON on these policies and procedures prior to the MDS Coordinator and former DON administering the in-services, skills training, and mechanical lift demonstration to the facility staff. Interview on 08/12/25 at 4:25 pm with the MDS Coordinator reflected she administered 50 - 75 percent of the in-services given to the staff on 07/30/25. The remainder of the staff were in-serviced by the former DON. The MDS Coordinator said she and the former DON immediately began in-services to the staff after the morning meeting on 07/30/25. The MDS Coordinator said she received her instructions for all in-servicing from the former DON and the Administrator. She said staff was in-serviced at a 100 percent completion rate on 07/30/25.Observation on 08/12/25 at 3:40 pm of CNA A and RN E who conducted a transfer of Resident #2 from her wheelchair to her bed reflected a safe transfer.Interview on 08/12/25 at 3:04 pm with Resident #5 reflected the staff treated her respectfully. She said two people always assisted when she was transferred by a mechanical lift. Interview on 08/12/25 at 3:08 pm with Resident #3 reflected the staff treated her respectfully, she felt safe at the facility, and the staff used two people when they used a mechanical lift to transfer her. Interview on 08/12/25 at 3:17 pm with Resident #4 reflected she was transferred by a mechanical lift and felt safe when staff used a mechanical lift and staff always used two people when they transferred her using the mechanical lift. Interview on 08/12/25 at 2:54 pm with Resident #6 revealed the staff treated her respectfully and she felt safe at the facility. She said staff used a mechanical lift to transfer her, and they always had two people when they used the mechanical lift. She did not have any concerns about her care or treatment at the facility. During interviews on 08/12/25 from 4:25 pm - 6:23 pm, two RNs, two LVNs, and six CNAs from different shifts all stated they were in-serviced on 07/30/25 on Mechanical Lift Transfers, Abuse and Neglect, Trauma Informed Assessment, and how to use the Kardex. All staff interviewed stated that if a person was care planned for a mechanical lift transfer, always use a mechanical lift to transfer the resident and always have two people to transfer the resident to ensure resident safety. All staff interviewed stated they knew where to locate the resident transfer information in the Kardex. Review of the facility's self-report to HHSC, dated 07/30/25 reflected the Administrator reported the incident with CNA A not using a mechanical lift to transfer Resident#1 as care planned the same day it occurred. Record review of CNA A's Employee Disciplinary Report dated 07/30/25 reflected CNA A was placed on investigatory suspension pending an investigation into allegations of not following a resident's care plan. CNA A would remain on investigatory suspension until the investigation was completed. Record review of in-service dated 07/30/25 given by the MDS Coordinator to the nursing and CNA staff on Mechanical Lift Transfer Skills Check and demonstration on using a mechanical lift was administered to 100 percent of facility nurses and CNAs included training for CNA A.Record review of in-services dated 07/30/25 on Abuse and Neglect administered to all facility staff at 100 percent staff completion rate included training for CNA A.Record review of in-service dated 07/30/25 on Trauma Informed Assessment administered to all facility staff at 100 percent completion rate. Record review of in-service dated 07/30/25 on how to use the Kardex located in the eMAR was administered to all nurses and CNAs at 100 percent completion including CNA A. Review of facility undated Hydraulic Lift Policy reflected the hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. Goals:a. The resident will achieve safe transfer to bed or chair via a mechanical lift device.b. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift.The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment, and interventions to provide a comfortable, safe transfer.

Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for one of three ([NAME] Hall) medication carts reviewed for medication storage. The facility failed to ensure [NAME] Hall medication cart was locked and medications were secure and not accessible to other staff, resident, or visitors. This failure could place residents at risk of having unauthorized access to prescription, biologicals, and over-the-counter medications. Findings included: Observation on 07/01/2025 at 8:35 AM revealed an unlocked medication cart 1 across from station one nurses station and near the entrance to [NAME] hallway. The back of the cart was against the wall with the drawers facing the nurse's station. The locking mechanism was protruding outward on the medication cart. The state surveyor opened the drawers and captured photos. The nursing staff or any staff was not near the nurse's station or the unlocked medication cart. Observation on 07/01/2025 at 8:43 AM revealed RN A walking from the Mc [NAME] Hall toward the unlocked medication cart 1. Interview on 07/01/2025 at 8:44 AM RN A stated he did leave the medication cart unlocked. He stated he was in a resident room assisting with a transfer. He stated the medication cart was not in view where he was in a resident room. Interview on 07/01/2025 at 9:10 AM RN A stated the medication cart was to always be locked except when he was dispensing medications from the medication cart. He stated it was his responsibility to ensure the medication cart was locked and secure. RN A stated the key to the medication cart was in his pocket. He stated if residents had accessed the medication cart they could have overdosed, taken wrong medication, had an allergic reaction, and could require admission to the hospital. He stated he had previously been in-serviced on locking the medication carts and could not recall the specific date. He stated he was aware the medication cart should have been locked. RN A stated the narcotics was locked in the medication cart 1. He stated there was PRN medications, glucose monitor, and blood pressure cuff. Interview on 07/01/2025 at 4:45 PM the Director of Nurses stated her expectation was for all medication carts to be locked when the nurse was not administering medications. She stated the staff had been in-serviced on securing the medication carts when not in use. The Director of Nurses stated she did not the exact date of the in-service. She stated residents, other staff, and visitors would have access to the medications in the unlocked medication cart. She stated if a resident ingested medications not prescribed to them, there was a potential the resident may have an allergic reaction or may need to be admitted to the hospital. She stated it was the nurse responsibility to ensure the medication cart was locked when not dispensing a resident's medication. The Director of Nurses stated she was responsible for monitoring the nurse supervisor. Interview on 07/01/2025 at 5:05 PM the Administrator stated her expectations was for the medication carts to be locked when the nurses were not administering medications from the carts. She stated there was a possibility a resident may get medications out of the medication cart. The Administrator stated if a resident did take the medications by mouth there was a possibility a resident may have an allergic reaction. She stated it depended on the medication the resident ingested. She stated the nurse assigned to the medication cart was responsible for locking the medication cart after administering medications to a resident. The Administrator stated the Director of Nurses was responsible to monitor the nurse supervisor. Review of the facility's Policy on Medication Storage in the Facility, dated 2025, reflected Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview, and record review the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for five of six residents (confidential residents) reviewed for grievances. The facility failed to post the grievance procedure in a prominent and accessible locations throughout the facility; provide residents with access to grievance forms, and instruction on how to file an anonymous grievance. This failure could place residents at risk by limiting their access to the grievance process, which may result on unresolved concerns that impact their well-being and overall quality of care. Findings include: Observation on June 4, 2025, at 10:38 AM, revealed the facility's grievance procedure posted in the first hallway near the front entrance. The notice was affixed approximately nine feet above the floor, which made it difficult to read. The height rendered it inaccessible to residents who use wheelchairs or those who were shorter in height, and it was not positioned in a way that supported easy viewing by all residents, resident's representatives, staff, or visitors. A walkthrough of other hallways and common areas revealed one additional posting located at the station 2 nurse's station. The posting was positioned on the wall behind the nurse's station desk, in a small area not accessible to residents. Due to the confined space and placement behind staff work areas, residents would not be able to view or access the information independently. During a confidential resident interview five of six residents stated they had not received information regarding the process for filing grievances or concerns within the facility. The residents reported they were unaware of their right to formally voice concerns or complaints and did not know who to contact or where to find grievance forms or related resources. An interview was conducted with the ADM on June 4, 2025 at 3:43 PM, the ADM stated residents were provided information regarding the grievance process and how to file grievances by the facility conducting daily Champion Rounds, during which department managers were assigned to check in with different residents to ask how they were doing and if they had any concerns. She also stated grievance information was included in the admission packet and added, Hopefully it's posted on the open board. The ADM was then led to the open board in the front entry hallway. She experienced some difficulty locating the grievance posting. The state surveyor pointed it out and asked if she believed the posting was accessible to residents or family members, considering its high placement on the wall. The ADM responded the posting needs to be brought down to be more accessible. The ADM was also shown the second grievance posting located behind Nurse's Station #2. When asked if this posting was accessible to residents, she stated, That is mostly for the nurses to have the information to provide if a family member asks how to file. She would work on making the grievance signs more available to residents and families. Record review of the facility's Grievance Policy dated November 2, 2016, reflected, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal .The facility will notify residents on how to file a grievance orally, in writing, or anonymously with postings in prominent locations.

Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #21) of six residents reviewed for pressure ulcers. The facility failed to ensure Resident #21 who was at risk for skin breakdown was turned every two hours and provided incontinent care. on 05/07/2024, Resident #21 was left in the same position in her Geri-chair (specialized recliners that are upholstered in non-permeable, easily sanitized vinyl.) for 6 and a half hours from 8:00 AM till 2:30 PM. Once Resident #21 was placed in bed she was observed to have two DTIs (A pressure-related injury to subcutaneous tissues under intact skin.) to her coccyx that were previously unidentified by the facility. An immediate Jeopardy (IJ) situation was identified on 05/07/2024 at 5:10 PM. While the IJ was removed on 05/09/2024 at 3:12 PM, the facility remained out of compliance at a scope of isolated with no further actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Findings Include: Review of Resident #21's face sheet dated 05/07/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.) and chronic lymphocytic leukemia (is a type of cancer in which the bone marrow makes too many lymphocytes (a type of white blood cell). Review of Resident #21's quarterly MDS dated [DATE] reflected Resident #21 was assessed to have a BIMS assessment was not conducted indicating Resident #21 had severe cognitive impairment. Resident #21 was assessed to be dependent on staff for all areas of ADL care and was assessed to be incontinent of bowel and bladder. Review of Resident #21's comprehensive care plan reflected: -problem dated 09/26/2022 Resident #21 is incontinent of bowel and bladder. Interventions included .Check resident every two hours and assist with toileting as needed. Provide peri care after each incontinent episode and report any skin change to nurse immediately. -problem dated 11/22/2023 and revised 04/19/2024 Resident #21 has actual impairment to skin integrity related to fragile skin, prone to easily bruising with pressure due to chronic lymphocytic leukemia. Interventions included .Keep skin clean and dry .reposition resident to prevent pressure for body parts . further review of Resident #21's care plan reflected no plan of care for pressure ulcers. Review of Resident #21's consolidated physician orders dated 05/07/2024 no orders for pressure ulcer wound care. Further review reflected an order dated 09/27/2022 pad all boney prominences with pillows to prevent breakdown. Review of Resident #21's weekly skin assessment dated [DATE] and locked on 05/06/2024 reflected no MASD or pressure ulcers were identified. Observation and interview on 05/07/2024 at 8:00 AM, revealed Resident #21 in her Geri chair in her room. Resident #21 was not interviewable. Observation on 05/07/2024 at 9:43 AM, revealed Resident #21 in her Geri chair in the same position in her room. Observation on 05/07/2024 at 12:00 PM, revealed CNA E passing out meal trays on Resident #21's hall. CNA E arrived at Resident #21's room at 12:25 PM and started feeding Resident #21. CNA E did not reposition Resident #21. Observation on 05/07/2024 at 12:45 PM, revealed Resident #21 up in her Geri chair in the same position. Observation on 05/07/2024 at 1:45 PM, revealed Resident #21 up in her Geri chair in the same position. In an interview on 05/07/2024 at 1:54 PM, CNA E stated she had not done incontinent care or repositioned Resident #21 since she got her up at around 8:00 AM. She stated she was fixing to go get help since she was on the hall by herself, and she needed help to put her to bed. Observation on 05/07/2024 at 2:30 PM, revealed CNA E and CNA F in Resident #1's room to put her in bed via the Hoyer lift. Observation of Resident #21's brief revealed it was saturated with urine and had a strong odor. CNA E turned Resident #21 to her right side to reveal a DTI approximately 0.1cm x 0.1cm to her right ischial tuberosity surrounded by a blanchable area of redness approximately 3 cm long and a 0.2 cm x 0.2 cm DTI to her lower coccyx area. In an interview on 05/07/2024 at 3:00 PM, the ADON state Resident #21 did not currently have skin breakdown so any areas on her would be new. After observing the areas to Resident #21's coccyx area she stated Resident #21 did have breakdown areas on her boney prominences. In an interview on 05/07/2024 at 3:15 PM, the DON stated she looked at Resident #21 yesterday and her skin was clear. When asked if the area could have resulted from her being up in her chair for an extended period of time she stated, I did not know she was up all day. In an interview on 05/07/2024 at 3:20 PM, Resident #21's Hospice Nurse stated Resident #21 was at risk for breakdown and her skin was very delicate. She stated Resident #21's coccyx area was clear on her last visit a few days ago. Observation and interview on 05/08/2024 at 10:38 AM, revealed Resident #21 in room being prepped for wound care with the Wound care physician. Observation of Resident #21's coccyx area DTIs revealed both had declined and were darker in color from 05/07/2024. Resident #21's wound care physician stated both areas on Resident #21's coccyx were DTIs. He stated the areas could definitely be caused by not being turned and being on the same bony prominences for an extended period of time. Review of Resident #21's Physician wound evaluation and management summary dated 05/08/2024 reflected Resident #21 was assessed to have an unstageable DTI to the distal sacrum measuring 0.1cm x 0.1cm and undetermined depth. Further review reflected an unstageable DTI to the sacrum measuring 0.3cm x 0.3cm and undetermined depth. In an interview on 05/08/2024 at 2:13 PM, the DON stated she expected the CNAs to check on the residents every 2 hours and do position changes. She stated CNA E could have asked anyone to help her and she did not. The DON stated CNA E did not give her an explanation of why she did not change Resident #21. The DON stated she expected the nurses as well to make rounds every two hours to ensure the CNAs are doing their jobs and to make sure the residents are taken care of to prevent skin breakdown. Review of the facility policy pressure injury prevention, assessment and treatment dated 08/12/2016 reflected 1.Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury, and infection. 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the Treatment Nurse/designee of any potential problems . 4. Causes of Pressure Injuries: Unrelieved pressure over a bony prominence resulting in ischemia at the area of pressure. 1.Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan. 1. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. 2. Do the blanching test by pressing the finger into a reddened area, a normal blood supply to the reddened area is seen when the area blanches white and then turns pink again. If the area remains red, a pressure sore is impending due to impaired circulation, keep resident off the area for 24 hours and then repeat the test. Review of the facility' policy Perineal care dated 04/27/2022 reflected An incontinent resident of urine and/or bowl should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible . Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. One form of early skin breakdown is maceration or the softening of tissue by soaking. Macerated skin has a white appearance and a very soft, sometimes soggy texture. The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe dermatitis, skin erosion and/or ulcerations. Skin erosion is the loss of some or all of the epidermis (comparable to a deep chemical peel), leaving a slightly depressed area of skin. Because frequent washing with soap and water can dry the skin, the use of a perineal rinse may be indicated. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . The Administrator was notified on 05/07/2024 at 5:10 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/09/2024 at 11:40 AM: Date: 5/7/2024 On 5/6/2024 an annual survey was initiated at the facility. 5/7/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate jeopardy to resident health and safety. Plan of Removal for F686 Approximately 48 residents who are incontinent and/or require assistance with turning and repositioning could be affected by this deficient practice. Problem: Failure to prevent pressure injury Root cause analysis was conducted. CNA E failed to change the resident's brief timely. CNA E failed to reposition the resident at minimum of every two hours while in the Geri chair. This caused pressure injuries. The Administrator, DON, and ADON will review the schedule daily to include weekends. This review will include that 2 staff members will be present at all times on station #1 to assist with ADLs. The call-in process is that they call the DON's cell phone when calling in. DON is responsible for initiating finding additional coverage. The DON will utilize the PRN call list, shift bonuses, staff from nearby sister facilities, or agency staffing if needed. Interventions: Weekly ulcer assessments for Residents #21 were completed to include measurements by DON, ADON, and Tx Nurse on 5/7/24. Two new pressure wounds were identified, measured, and treated according to physician orders. The MD was notified on 5/7/24 of Resident #21 new pressure wounds by the Tx Nurse. Orders were received for treatment and implemented on 5/7/24. Wound care treatments for Residents #21 were completed as ordered by the Tx Nurse on 5/7/24. 100% skin rounds were initiated 5/7/24 by DON, ADON, Treatment Nurse. No additional pressure wounds were identified. Administrator, DON, ADON, and Tx Nurse were in-serviced 1:1 by the Regional Compliance Nurse on 5/7/24 on the following topics. Completed 5/7/24. Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. CNA E was in-serviced 1:1 by the DON on 5/7/24 for the following topics. Completed on 5/7/24. Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The hall is adequately staffed with 1 nurse, 1 med aide, and 2 CNAs. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. In-services: The following in-services were initiated by Regional Compliance Nurse, DON on 5/7/24 for all clinical staff. Any clinical staff not present or in-serviced on 5/7/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. Pressure Injury Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours while in bed or chair could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. The Administrator, DON, and ADON/designee will be responsible for ensuring that residents are checked for incontinence, brief changed, turned, and repositioned while in bed or Geri chair. Monitoring will occur during rounds daily for 10-15 randomly selected residents 7 days per week across all shifts including weekends. Monitoring will be documented on a form will continue for a minimum of 6 weeks. The Medical Director was notified of the immediate jeopardy situation on 5/7/24 by the administrator. An ADHOC QAPI meeting was held with the Administrator, DON, ADON, Tx Nurse and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 5/7/24. The Survey Team monitored the POR on 05/08/2024 through 05/09/2024 as followed: Review of the facility's weekly wound assessment for Resident #21 reflected it was complete and conducted by the wound care physician on 05/08/2024. Review of Resident #21's nursing progress notes and weekly wound assessment dated [DATE] reflected Resident #21's physician was notified, and orders received for treatment and consult with wound care physician. Observation on 05/08/2024 at 10:38 AM, revealed wound care treatment conducted by the ADON and wound care physician. Review of the facility's skin round documentation initiated on 05/07/2024 reflected skin assessments conducted on all residents without new pressure ulcers being identified. Review of the one-on-one in-services for the Administrator, DON, ADON and Treatment Nurse dated 05/08/2024 reflected it was conducted by the RNC and covered the following areas: Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing included requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. In an interview on 05/08/2024 at 9:29 AM, the DON stated she was in-serviced by the RNC regarding pressure ulcer prevention, ADL care and monitoring staff to ensure care is provided. In an interview on 05/08/2024 at 9:45 AM the Administrator stated the RNC performed the one on one inservices for her and the DON and ADON. Review the one-on-one in-service for CNA E dated 05/08/2024 reflected it was conducted and covered the following topics: Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The hall is adequately staffed with 1 nurse, 1 med aide, and 2 CNAs. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. Attempts to interview CNA E on 05/09/2024 were unsuccessful. Review of the facility conducted in-services for Pressure Injury Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024. Review of the facility conducted in-services for Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours while in bed or chair could result in skin breakdown which is neglect was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024. Review of the facility conducted in-services for Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024. In an interview on 05/09/2024 at 9:18 AM, CNA H stated she had been trained on rounds. She stated that the training covered doing rounds every two hours, changing the resident, and getting them off their bottoms. She stated residents on the secure unit were changed every hour to every hour and a half. She stated that when a resident had a change in skin condition that it should be reported to the nurse. She stated she was trained on pressure injury prevention. She stated the training covered making sure the resident was not on their bottom for an extended period and to keep them dry. She felt like the facility had enough staff and that the staff could do all their tasks and showers. In an interview on 05/09/2024 at 9:23 AM, the ADON stated she had been trained on doing rounds. She stated that the training covered turning the resident and changing the resident. She stated residents were checked every two hours. She stated that when changing a resident staff were to reposition the resident to ensure the resident was not on the same side they had been on. The ADON stated she had been trained on change in skin condition. She stated that she would take care of the resident. She said she would assess the skin, so she could get measurements. She said she would then call the wound doctor and the family about the change in skin. She stated she would get an order in place. She stated that she had been trained on pressure injury prevention. She stated the training covered making sure that the resident is turned or repositioned every two hours. She stated when the resident was in a chair staff are supposed to repositioned in the chair. She stated that she felt the facility had enough staff. She stated everyone worked together and the staff were able to get everything done. She said she felt she had enough time to do all tasks and rounds. In an interview on 05/09/2024 at 9:37 AM, CNA G stated he was trained on rounds. He stated the training covered making sure the rounds were done every two hours and repositioned when finished changed. He stated that if the resident had a change in skin condition, he would report it to the nurse. He stated he was trained on pressure injury prevention. He stated the pressure injury prevention training covered turning the resident every two hours, making sure the resident was of the injury and put a pillow under the resident and keeping them dry. He stated he did not think the facility had enough staff. He stated he was able to complete all tasks because the shift is 12 hours. He stated he will do a shower for 30 minutes and then check the residents. He stated that the nurses and CMAs were good about helping. In an interview on 05/09/2024 at 9:12 AM CNA I stated she has been in-serviced this morning on turning every 2 hours, abuse, and neglect, not feeding 2 patients at one time, and reporting skin issues. I asked if you see a change in skin condition what do you do? She stated she tells her charge nurse immediately. When asked her if she felt there is enough staff working on the floor. She said yes. There is always 2 people on the locked unit. She stated if someone calls in sick, they bring someone else in. In an interview on 05/09/2024 at 9:22 AM LVN C stated she had been in-serviced this morning on abuse and neglect, pressure injury, skin breakdown, turning residents every 2 hours, not to feed 2 patients at one time and reporting skin issues. I asked if you see a change in skin condition what do you do? She told me she does an assessment, reports to the DON, lets the doctor know, and then puts treatment into place. I asked her how often she checks on residents, and she told me every 2 hours and if resident is having diarrhea more often. I asked her if she felt there is enough staff. She said for the most part yes. There is a shortage everywhere. I asked her what happens when there is not enough staff on the floor. She said there are enough resources and people come help. In an interview on 05/09/2024 at 9:32 AM, CNA J stated she had in serviced on rounds, checking residents every 2 hours, abuse, and neglect, and who to report skin breakdown to. I asked her how often she checks on her residents she said every 2 hours. I asked her if she felt there was enough staff on the floor. She said yes. I asked her what happens when there is not enough staff. She said she does her job and does what she needs to do. In an interview on 05/09/2024 at 9:38 AM, CMA D stated she has been in serviced this morning on not feeding 2 people at once, completing rounds every 2 hours, abuse, and neglect. I asked her if she sees a change in skin condition what she does. She reported she goes to the charge nurse. I asked her who she reports skin changes to she said the charge nurse. I asked her how often rounds are she said every 2 hours. In an interview on 05/09/2024 at 9:42 AM, LVN B stated she has been in-serviced this morning on abuse and neglect, skin breakdown, incontinent care, cleaning glucometers. I asked her how often they check on residents. She said every 2 hours. I asked her if she felt there was enough staff she said yes. That they always call people in if someone does not come in. In an interview on 05/09/24 at 12:55 PM, LVN K worked 6P to 6 A on 5/8 to 5/9 She stated they were in serviced on a lot last night and she was half asleep and will try to remember 1. Incontinent care 2. Using barrier cream 3. Foley catheter and using PPE when giving care to Foley Catheter 4. Abuse and Neglect 5. Reporting any new skin concerns 6. Pressure Ulcers She stated there was more, but she could not remember. In an interview on 05/09/2024 at 12:49 PM, CNA O stated she was in serviced on abuse neglect the rounds and PPE for open wound and foley. Reposition the resident every two hours with the rounds. Was in serviced on pressure injury precautions put a pillow under the resident. The resident has heel protectors on to prevent pressure. Stated she thinks there is enough. No task not able to complete has not been short in over a month. Yes, stated she can do all her rounds and shower she is the only aid for two halls. In an interview on 05/09/2024 at 12:58 PM, CNA P stated he had been in serviced on rounds, checking residents every 2 hours, abuse, and neglect. He said he checks on residents every 2 hours and felt there was enough staff on the floor. He said they will call and see if more people come in she stated there is not enough staff. On 05/09/2024 at 3:12 PM, the Administrator was notified the IJ was removed on 05/09/2024 at 3:12 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

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 14 residents (Residents #1 and 2) reviewed for quality of care. The facility failed to ensure TLVN and LVN C assessed and reported a new new skin injury to Resident #1's first two toes of the right foot and a new skin injury to Resident #'s first and fifth toes of the right foot. An Immediate Jeopardy (IJ) situation was identified on 03/06/24. While the IJ was removed on 03/08/24 at 03:00 PM., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of new or worsening pressure ulcers. Findings included: 1. Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses of quadriplegia (paralysis of all four limbs), type two diabetes mellitus with diabetic polyneuropathy (nerve damage causing weakness, numbness, and/or tingling), and history of transient ischemic attack and cerebral infarction (stroke). Review of the Discharge MDS for Resident #1, dated 02/18/24, reflected she could not participate in the brief interview for mental status. The section for Functional Status reflected in the activities of rolling left to right and transfer from chair to bed that she was Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The section related to Skin Conditions reflected she did not have any unhealed pressure ulcers. Review of the care plan for Resident #1, dated 02/17/24, reflected the following: Notify the charge nurse for open areas, sores, pressure areas, blisters, edema or redness to the feet. It also reflected the following: The resident has a pressure ulcer or potential for pressure ulcer development: The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Review of the initial skin assessment for Resident #1, dated 02/08/24, and completed by the LVN C, reflected she had no skin issues noted. Review of the weekly skin assessment for Resident #1, dated 02/14/24, and completed by LVN C, reflected she had no skin issues noted. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 02/08/24, and completed by the TLVN, reflected she had a score of 7, which indicated a severe risk for pressure ulcers. Review of physician's orders for Resident #1, on 03/05/24, reflected there were no orders related to prevention of pressure ulcers. Review of the skin observation tool in the CNA documentation portal for Resident #1, dated 02/16/24, reflected a new skin tear on the buttocks and discoloration on the left lower foot, documented by CNA A. Review and observation of hospital records for Resident #1, dated 02/18/24, reflected a photograph, taken on 02/18/24 at 09:11 PM, of her right anterior foot showing a red discoloration of the first and second toes. The first toe also had a partial thickness opening in the center of the reddened area that had a yellow tint. An attempt was made on 03/06/24 at 08:30 AM at the hospital to identify and interview the nurse who took the photograph of wounds on Resident #1's foot on 02/18/24, was unsuccessful. An attempt was made to interview the hospital physician who saw Resident #1 in theER on [DATE], but the hospital administrator would not provide direct contact information for him. During an interview on 03/06/24 at 09:58 AM, LVN C stated her process for conducting a skin assessment was during an initial skin, she looked at the resident's entire body, starting at their neck, to go down their legs to their feet and looked at their heels and then turned them over to look at their front, under the breasts, and in the perineal area. LVN C stated she looked between their toes and fingers, as well. LVN C stated when she conducted the initial skin assessment for a new resident, she did not know who cared for the resident or what state their skin might have been in, so she checked very carefully. LVN C stated the toes and feet were important during skin checks due to them being areas vulnerable to injury and skin breakdown. LVN C stated she conducted the initial skin assessment for Resident #1 on 02/08/24 and the weekly skin assessment on 02/14/24. She stated she did not see any new skin issues during either procedure. LVN C stated she had gotten Resident #1 dressed on the morning of 02/18/24 when she was sent to the hospital, and LVN C had not seen any marks or skin issues on Resident #1's legs or feet. LVN C stated she did not know what anyone was talking about when they asked her about wounds on Resident #1's feet. LVN C stated if she thought she would have seen any marks on Resident #1 especially if they were on the front, because she helped her dress. LVN C stated Resident #1 required total assistance with all of her activities of daily living, so they had a large amount of observation of and contact with her body. During an interview on 03/06/24 at 11:40 AM, CNA A stated she and her coworker, CNA B, showered Resident #1 on 02/16/24 and noticed a scratch under her right buttock, a blister on her big toe, and redness on both her big toe and her second toe. CNA A stated she and CNA B reported the skin changes to LVN C that day. CNA A stated she cared for Resident #1 while she was in the facility, and Resident #1 sat mostly in her chair and only got in bed at night. CNA A stated Resident #1 seemed uncomfortable in her chair, but the resident's FM had insisted she be placed in her chair during the day. CNA A stated she and her colleagues floated Resident #1's heels while she was in bed, but in the chair, they could not float her heels. CNA A stated was taught to place wheelchair leg rests at a 45 degree angle when the resident did not use them, but CNA A noticed Resident #1's feet, which were very contracted so the toes almost faced downward, would graze the foot rests sometimes on the tops of her toes. CNA A stated she and CNA B removed the footrests while Resident #1 was at rest in her chair and not being moved so her feet would not hit the footrests. CNA A stated she thought it was possible the wounds on Resident #1's right foot had occurred that way. CNA A stated after Resident #1's shower on 02/16/24, she and CNA B took Resident #1 to the dining room for her meal, and they stopped and showed the new wounds on her right foot to LVN C. CNA A stated she also documented the wounds in the CNA documentation portal. She stated the notations in the Skin Observation tool for 02/16/24 referred to the new wounds she saw on Resident #1's right foot. During an interview on 03/06/24 at 11:50 AM, CNA B stated on 02/16/24, which was a Friday, she and her coworker CNA A showered Resident #1 and saw marks on her. CNA B stated that day she saw a water blister on her big toe and a red mark on the next toe where the bone was. CNA B stated the injuries might have been from the footrest on the wheelchair, but she was not sure how they occurred, because the FM would not let Resident #1 stay in bed during the day. CNA B stated the day they discovered the wounds on Resident #1's toe, they were bringing her to lunch, and LVN C was sitting at the second nurse's station. CNA B stated they showed the toe wounds to LVN C. CNA B stated she did not remember LVN C being distracted or talking on the phone or to anyone else at the nurse's station. CNA B stated she thought the TLVN was sitting at the nurse's station with LVN C. CNA B stated CNA A did most of the documentation for Resident #1, but CNA B was pretty sure the new skin problems were documented in the skin observation tool by CNA A. CNA B stated they showed LVN C the toe wounds and told her about the scratch under Resident #1's buttock. Review of the, undated, face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia, cerebral vascular disease (a condition that affects blood flow to the brain), type two diabetes mellitus, and hemiplegia affecting right dominant side (paralysis on one side of the body). Review of the quarterly MDS for Resident #2, dated 02/24/24, reflected her cognition was too poor to take part in the brief interview for mental status. The section for Functional Status reflected in the activities of rolling left to right and transfer from chair to bed that she was Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The section related to Skin Conditions reflected she was at risk of pressure ulcers but did not have any unresolved pressure ulcers. Review of the Braden Scale for Predicting Pressure Sore Risk for Resident #2, dated 10/23/23, and completed by LVN F, reflected she had a score of 10, which indicated a high risk for pressure ulcers. Review of the care plan for Resident #2, dated 01/17/24, reflected the following: Notify the charge nurse for open areas, sores, pressure areas, blisters, edema or redness to the feet. Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Weekly skin assessments. Review of physician's orders for Resident #2 on 03/06/24 reflected no order for treatment of any wounds on her foot. Review of the skin observation tool for Resident #2 reflected a discoloration on the right lower leg or foot was documented on 02/14/24, 02/15/24, 02/19/24, 02/20/24, 02/24/24, 02/25/24 and 02/28/24 by CNA E. An additional documentation of a right leg or foot discoloration was documented on 02/27/24 by CNA D. Review of the weekly skin assessment for Resident #2, dated 02/26/24, and completed by the TLVN, reflected the following notes 2x1cm open area to left shin below knee, no drainage noted, skin-prep applied; 4x2cm open area to left leg, no drainage noted, skin-prep applied and LUQ Peg tube. The answers to the following questions Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete The Ulcer Assessment and Are there any new areas that have not been communicated to the physician/NP or family? was marked as No. As of 03/06/24, this was the most recent skin assessment. Review of wound physician progress notes, dated 03/06/24, reflected Resident #2 received wound care and assessment for a non-pressure wound of the left leg- full thickness. It also reflected the following: Chief Complaint Patient has wounds on her left leg; left shin. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. She has condition(s) as listed above. Details about current wound(s) and any skin conditions are outlined below. There is no indication of pain associated with this condition. There was no mention of any wound on the toes of her right foot. Record review of the most recent podiatry progress note for Resident #2, dated 01/10/24, reflected no skin issues on either foot. The podiatrist marked the resident had diabetes and peripheral vascular disease. During observation on 03/06/24 at 12:10 PM, CNA D removed Resident #2's socks and shoes to observe Resident #2's feet. The fifth (pinky) toe of Resident #2's foot had black tissue covering the entire toe, and her first (big) toe was black surrounding the proximal nail fold (part of the nail bed closet to the rest of the foot and ankle) and a portion of the skin around the distal nail plate (part of the nail bed farthest away from the rest of the foot and ankle). During an interview on 03/06/24 at 12:10 PM, CNA D stated the wounds on Resident #2's feet were very black, and they were there for several months. CNA D stated she had not seen Resident #2 receive any treatment for the injuries on her right toes. CNA D stated she had not been the person to initially report the injuries to a charge nurse, but she had documented the injuries on the Skin Observation tool. CNA D stated she did not know who discovered the injuries, but she thought they were well known, because the CNAs were documenting them in the Skin Observation for quite some time. During observation and an interview on 03/06/24 at 12:30 PM, the DON observed the injuries on Resident #2's right toes. The DON touched the injuries on Resident #2's fifth toe and watched the resident's reaction. Resident #2 did not wince or exhibit any other sign of pain. The DON stated the black area on the pinky toe was hard like a scab. She stated the injuries should not necessarily have been documented in a weekly skin assessment because they were not open areas but instead were scabbed. During an interview on 03/06/24 at 12:56 PM, the MD stated he expected a resident with Resident #1's clinical condition would develop pressure ulcers given the protein status, poor immunity and immobility. He stated the important thing was for new wounds to be identified and treated so they did not worsen. The MD stated he was not aware of any wounds that had developed on Resident #1 during her stay in the facility. The MD stated he expected to be notified of new skin conditions. He stated he could not say how a wound like the one Resident #1 had could worsen over a two-day period without being addressed, but any medical diagnosis needed intervention as early as possible. The MD stated he did look at residents' feet normally when he did an exam or an assessment. The MD stated Resident #1 was only in the facility for ten days, and he had not done an in-person exam with her. The MD stated he was not aware of any black wounds on Resident #2's feet. The MD stated he did not have his computer and could not say exactly when the last time he performed a physical exam with Resident #2, but she did not have any wounds on her feet at that time. The MD stated most of her skin assessments were being done by the WCD. The MD stated once wound care was involved with a resident, it was a professional courtesy to defer to the WCD for decision-making. An attempt was made on 03/06/24 at 01:12 PM to interview the POD by telephone. A voicemail was left on the clinic's main phone line. An attempt was made on 03/06/24 at 01:14 PM to interview CNA E about Resident #2's skin observations. A voicemail was left. During an interview on 03/06/24 at 01:44 PM, the WCD stated he saw Resident #2 earlier that day. He stated they did not conduct a full skin assessment. The WCD stated Resident #2 had a wound on her shin that he was treating. The WCD stated he did not think he saw her feet recently and was sure he did not see her feet that day. The WCD stated he saw Resident #2 on and off for pressure ulcers and skin tears. The WCD stated no one from the facility reported any new skin issue to him on Resident #2. The WCD looked at a photograph of Resident #2's toe wounds taken by the State Surveyor, and he stated he could not diagnose from a photograph, but the wound on her fifth toe looked like it was probably a pressure or arterial wound. The WCD stated the treatment for that type of wound would like be Betadine or something similar. He stated the rest of her foot looked healthy, and he was not very aggressive with debriding so he would probably only monitor and treat with Betadine. During an interview on 03/06/24 at 02:16 PM, the TLVN stated her protocol when she saw a wound like the ones on Resident #2's toes was to refer to the physician, the wound care surgeon and notify the family. She stated she had not noticed an alert that would notify her a CNA had documented a skin observation. The TLVN stated she had not seen the wounds on Resident #2's toes prior to the State Surveyor pointing them out to her, but she had now gone to look at the wounds, and she thought they might be purpura (a condition of red or purple discolored spots on the skin that do not blanch on applying pressure). The TLVN stated she did not see the wounds a few weeks ago. The TLVN stated she would not document something like that on the weekly skin assessment, because it was a scab. The TLVN stated the wound was a closed wound and had never been opened and had not bled and was not from trauma, so it did not quality as a wound to be documented on the weekly skin assessments. The TLVN stated the wound might have been a pressure or arterial ulcer, and she would have documented a pressure or arterial ulcer on the skin assessment. The TLVN stated she was not qualified to diagnose a wound and only the physician could diagnose. The TLVN stated she should have reported the wound to the nurse management team and the physician. She could not or would not say why she did not do so and stated she was very nervous. The TLVN stated potential negative outcomes of not addressing a skin issue immediately were infection and ultimately, amputation. During an interview on 03/06/24 at 03:20 PM, the DON stated she monitored for new wound and skin conditions by discussing any new issues with the IDT and communicating frequently. The DON stated CNAs communicated new skin observations in the point of care documentation system, an alert showed up on the EMR dashboard, and the IDT pulled the records describing the new skin issue every shift. The DON stated the people responsible for noticing the alerts on the EMR were her, the ADON, the TLVN, and the charge nurses. She stated the CNAs were instructed to document in the EMR instead of relying on a verbal notification of a new skin issue. The DON stated she was mistaken when she stated the wound on Resident #2's fifth toe had not needed to be documented on the weekly skin assessments. The DON stated she called the MD when she learned of the wound on Resident #2's toe, and he ordered a venous doppler (a special ultrasound technique that evaluates blood as it flowed through a blood vessel) to ensure the toes were still receiving blood flow. The DON stated the wound could have been a blood blister that progressed. The DON stated she did not know why nobody noticed the alerts that should have triggered when CNAs entered skin observations for Residents #1 and #2. She stated she was still investigating why the failure occurred. The DON stated if the wounds were on Resident #2's foot for months as CNA D reported they were, then the TLVN should have seen them during previous skin assessments. The DON stated the fact the TLVN did not notice the wounds was concerning. The DON stated a potential outcome of the failures was the wounds would tend to get worse, because the body might not self-heal without medical intervention. During an interview on 03/06/24 at 04:30 PM, the ADM stated she monitored for compliance with the skin program in the facility by discussing issues in care plan meetings and their morning meetings. The ADM stated she was notified of the unidentified wounds on Resident #2's foot. The ADM stated she had also been made aware Resident #1 had something on her foot that she thought was a blister and CNAs had documented the area but LVN C had not followed up on the wound before Resident #1 was sent to the hospital. The ADM stated Resident #1 had not returned to the facility. The ADM stated the process for identifying new skin issues was the CNAs put the skin observation into the EMR, and it alerted for anyone to see on the EMR dashboard. The ADM stated the TLVN had access to the same information as the rest of the team, and the ADM did not know why the TLVN did not follow up on reports of either Resident #1's or Resident #2's wounds. The ADM stated a potential negative outcome of the failure was a worsening of wounds, but particularly for someone with Resident #2's clinical condition, a wound on her foot had the potential to become a major issue where it would be detrimental, possibly causing sepsis. Review of facility policy, dated 08/12/16, and titled Pressure Injury: Prevention, Assessment and Treatment reflected the following: Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation and prevent, breakdown, injury, and infection. 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission, and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sores is indicated and notify the treatment nurse/design of any potential problems. 3. Assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of sore and obtain any follow any orders as directed by the physician. 2. Notify family and dietary department. Document Notification. This was determined to be an Immediate Jeopardy (IJ) on 03/06/24 at 5:00 PM. The ADM was notified . The ADM was provided with the IJ template on 03/06/24 at 05:05 PM. The following Plan of Removal submitted by the facility was accepted on 03/07/24 at 05:30 PM: [The facility] Plan of Removal: 3/6/24 On 3/5/2024 an abbreviated survey was initiated at [the facility]. 3/6/2024 the surveyor provided an Immediate Threat (I) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. F686 The facility failed to prevent pressure ulcers and ensure residents did not develop pressure ulcers. All residents had the potential to be affected by the deficient practice. Head to toe assessments were completed on all residents in the facility to ensure no other residents were identified. Interventions: Resident #1 no longer resides in the facility as of 3/6/24. The MD was notified by the DON for resident #2 on 3/6/24. Treatment orders are in place. All residents in the facility received a head-to-toe skin assessment by the DON/ADON/Tx Nurse. Assessments will be completed 3/6/24. No new skin issues were identified. A 1:1 in-service was completed by the Regional Compliance Nurse with the DON/ADON/Tx Nurse on the policy for Pressure Prevention and the Completion of Skin Assessments. Completed 3/6/24. The Regional Compliance Nurse is a part of the corporate structure. The DON /designee will review the EMR dashboard daily and throughout shifts for clinical alerts pertaining to skin issues that are documented to ensure that all skin issues have been addressed by a nurse. This will start 3/6/24 and continue indefinitely. The DON or ADON will conduct skin rounds weekly with the treatment nurse to ensure skin issues are identified, MD/family notified, and a treatment is ordered. This will start 3/6/24 and continue indefinitely. The Medical Director was notified of the immediate jeopardy situation on 3/6/24. An ADHOC QAPI meeting was conducted on 3/6/24 to include the IDT Team to discuss the immediate jeopardy and subsequent plan of removal. Identification: All residents residing in the facility received a head-to-toe assessment by the DON/ADON and treatment nurse. No new skin issues were identified on 3/6/2024. In-services: All direct care staff were in-serviced on the following topics below on 3/6/24 by the DON/ADON. All staff not present for in-servicing will not be allowed to resume their scheduled assignment until in-serviced. All new hired staff will be in-serviced during facility orientation. All agency staff will be in-serviced prior to start of their shift. Verification of comprehension will be made through a post test for topics in-serviced on. o Pressure Prevention Policy o Completing Skin Assessments o Notification of change in condition to the charge nurse and DON including new skin issues. Monitoring of the Plan of Removal included the following: Review of physician's orders for Resident #2 on 03/06/24 reflected an order had been entered for Bilateral Arterial legs Ultrasound Verbal Active 03/08/2024 ultrasound of both legs. Cleanse Right 5th toe Wound W/WC or NS, Pat Dry, Apply Betadine 3xwk every 12 hours as needed for R 5th Toe Wound Phone Active 03/06/2024, 03/06/2024 Cleanse Right 5th toe Wound W/WC or NS, Pat Dry, Apply Betadine 3xwk one time a day every Mon, Wed, Fri for right 5th toe wound. Review of the March 2024 TAR for Resident #2 reflected Betadine was administered to her right toes by the TLVN on 03/06/24 and 03/08/24. Review of skin assessments for Residents #3-#7 and #9-#21 conducted on 03/06/24 and 03/07/24 reflected no new skin issues identified. Review of the weekly skin assessment tool for Resident #8 completed on 03/08/24 reflected the following: Red flat rash to back; skin intact; TX PRN. 28/24 Review of physician orders for Resident #8 reflected the following with a start date of 05/28/24: Nystatin Powder 100000 UNIT/GM. Apply to affected area topically as needed for rash twice daily. Review of the March 2024 TAR for Resident #8 reflected Nystatin powder was administered to her back on 03/08/24 at 01:35 PM. Review of in-services conducted one-to-one with the TLVN, ADON, and DON reflected they had each signed the following in-service on 03/06/24: Pressure prevention, injury, completion of skin assessment, and treatment weekly and with changes in skin integrity. Review of an in-service conducted by the DON on 03/06/24 reflected the following content: Notification of change in condition to the charge nurse and DON, including new skin issues. See attachment of policy and procedures. 39 staff members had signed the signature page of the in-service. An additional 29 staff were listed as being notified by phone on 03/06/24. During an interview on 03/08/24 at 08:40 AM, the ADM stated education of staff was ongoing. She stated the staff in the facility today were in-serviced by phone and were to be tested on their knowledge today. She stated copies of in-service education and the staff who completed it were ready. She stated she was re-educated by the RCN to monitor the nursing for compliance with the plan and program. During an interview on 03/08/24 at 09:05 AM, LVN F stated she completed in-service education in ANE and Assessment. She stated topics included skin assessment, changes in skin, reporting, documentation and informing the ADON and DON. She stated skin assessments were documented in the computer and an incident report was to be completed and forwarded to risk management. She stated as a charge nurse she was also to initiate treatment and inform the physician and family of changes. During an interview on 03/08/24 at 09:10 AM, MA G stated she completed in-service education and testing for ANE and Assessments. She stated she was informed she was to report any skin tears, bleeding or observed skin changes to the charge nurse and the DON. She stated as a med aide she would occasionally see a skin tear. During an interview on 03/08/24 at 09:19 AM, the RCN stated she instructed 100 percent of staff (nurses and CNAs) on ANE and Assessment at this time. She stated changes in residents were to be reported to the Administrator and DON. She stated nurses must assess residents when a change was reported and initiate treatment. Nurses must report changes to physicians and family. She stated education did not reflect any knowledge gaps among staff, and she was unsure how the IJ occurred. She stated the facility was nearing 100 percent of staff completing the posttest knowledge check. During an interview on 03/08/24 at 09:50 AM, RN H stated she received in-service education on ANE and skin assessments. She stated she was taught about the reporting system and reporting changes to the DON and charge nurse. She stated as a nurse she would also report changes to the physician and family. She stated skin assessments were to be completed weekly, as needed and on admission. She stated she completed a test after the in-service. During an interview on 03/08/24 at 09:55 AM, the ADON stated she was in-serviced and tested on ANE and skin assessments. She stated any changes had to be assessed, reported to the doctor and the DON and family. She stated skin assessments were to be completed weekly and incident reports were to be filled out for changes in skin condition (such as bruises, scrapes and skin tears). She stated the nurse documented the change and entered orders for treatment from the physician. During an interview on 03/08/24 at 10:09 AM, CNA I stated he received in-service education on ANE and assessments. He stated aides were informed any changes in skin condition must be reported to the nurse, the ADON and DON. He stated if no one responded to his report he was to report to the administrator. He stated most observations were documented in the computer but the facility also utilized shower sheets to assessed resident skin health. During observation and an interview on 03/08/24 at 10:10 AM, Resident #19 stated he had no discomfort to his below the knee amputation site. He stated he received wound care three times a week. He stated he was taking pain medications. He was observed ambulating in his wheelchair in his room. During an interview on 03/08/24 at 10:15 AM, CNA E stated she received in-service education on ANE and skin assessments. She stated she completed a post education test, she added they always wanted to test them. She stated she would report any skin changes to the nurse, DON or Administrator. She stated the situation was as simple as see something report something. She stated any changes had to be reported as soon as they were discovered. Observation on 03/06/24 at 11:20 AM revealed LVN F assisted to show Resident #2's right fifth toe which revealed no drainage, skin was intact and a 1.5 cm long dark black area was present on the outside of her little toe. Resident #2 did not indicate any discomfort to the area. The tip of the toenail had been removed and a purple swollen area was seen to the inside of margin of the toenail. During an interview on 03/06/24 at 11:20 AM, LVN F stated Resident #2 was receiving betadine lotion to the site daily per instructions from the wound care physician. During an interview on 03/08/24 at 11:27 AM, CNA J stated she received in-service education on ANE and assessments. She stated the facility emphasized skin assessments and reporting changes to the charge nurse. She stated the DON and administrator were also to be informed. She stated she had not observed any concerns among residents she worked with at the facility. During an interview on 03/08/24 at 11:30 AM, the TLVN stated she completed the in-service education and posttest knowledge check. She stated the ANE and skin assessment requirements were known, that she needed to check the EMR for skin alerts daily, and the DON would be rounding on wounds with her for the time being. She stated she was requested to assess the toe of Resident #2 on a Wednesday. She stated she was not aware of any problems with Resident #2 prior to that time. She stated she never met the other resident named in the issue. The TLVN stated she worked at the facility infrequently. She stated she was aware the facility received an IJ citation for the wounds. She stated Resident #2 was not ambulatory so she could not imagine how the black spot occurred, other than diabetic or circulatory problems. Observation on 03/08/24 at 12:00 PM of wound care for Resident #20 by RN H revealed no concerns. Resident #20 had two small spots (0.5 cm circular) open to her right shin. The area was cleansed with normal saline, dried and then triple antibiotic ointment was applied. The two areas were covered by a non-adherent dressing and it was dated an initialed. During an interview on 03/08/24 at 12:00 PM, Resident #20 stated she had no discomfort and no concerns about her care. During a[TRUNCATED]

Based on interview, and record review the facility failed to develop and implement written policies and procedures that ensured reporting of crimes in federally funded long-term care facilities in accordance with section 1150B of the Act, any incident that involved an emergency situation that posed a threat to resident health and safety immediately, but not later than 24 hours after the incident occurs or is suspected. The facility failed to: 1. The facility failed to report to State Survey Agency (HHSC), immediately, but not later than 24 hours, when, on [DATE], two employees witnessed another employee with a gun in the facility. 2. The facility failed to follow their own procedures when a verbal altercation between employees occurred, and, on [DATE], one of the employees involved in the verbal altercation brought a handgun into the facility, and the incident was not immediately reported to the administrator or the DON. 3. The facility failed to call the police and to follow its own facility protocol for an armed individual listed in the emergency preparedness manual. 4. The facility failed to implement their written policies and procedures to ensure the reporting of crimes to State Agency and law enforcement within the appropriate timeframes. 5. The facility failed to in-service all staff on reporting to the Administrator emergency situations including reporting handguns brought into the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:53 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This failure could place the residents at risk for unreported allegations of a threat to resident health and safety and potential for injury or death. The findings were: In an interview on [DATE] at 5:24 PM with CNA C revealed she saw LVN A take a gun from underneath the driver's side of her truck and put it into her lunch box and carry the lunch box into the facility and put the lunch box below the top counter on a shelf at nurses' station one. The lunch box with the gun remained there until LVN A ended her shift on [DATE] at 6:00 am. When surveyor asked why she did not call the police, LVN A said she did not seem like she was for sure going to use the gun. CNA C revealed she called her DON two times and left her a message, but the DON did not return her calls. CNA C revealed she was never told they could not bring guns into the building. She said there were no signs on the outside of the doors telling them they could not enter the facility with a gun. CNA C said it was her 2nd or 3rd day working at the facility and she did not know the rules about when it was legal to carry a gun and when it was not legal to carry a gun. She said she knew that people carried guns all the time. She said when she began working the facility front doors were under repair and there no signs posted outside the facility about the prohibition of carrying guns into the facility. In an interview on [DATE] at 5:54 PM with CNA D revealed LVN A was having a dispute with CNA E and a lot of racial comments were made. CNA D saw LVN A's partially unzipped lunch bag and saw the butt of a gun in the lunch bag. CNA D revealed that the lunch bag was at nurses' station one on top of the desk below the counter next to the printer. CNA D revealed she heard LVN A make a statement that CNA E was going to get what was coming to her. CNA D revealed it was reported to the ADON on Friday, [DATE]. CNA D revealed she was not at all concerned about the residents' safety and thought the situation was under control. LVN A never mentioned anything about hurting the residents. In an interview on [DATE] at 5:54 PM with CNA D when asked why she did not call the police when she knew that LVN A had a gun she said she did not see it as a threat at the time. CNA D said that LVN A always talked about having her gun with her and LVN A never made a threat of using it against the residents. When the surveyor asked CNA D if she saw the signs posted on the outside entrance to the facility reading handguns prohibited she said the signage was not posted outside, it was posted inside on the side of the wall in the lobby. She said she told the ADON next day, on [DATE], about LVN A having the gun inside the facility. In an interview on [DATE] at 3:07 PM LVN B revealed LVN A was always a little difficult to get along with. LVN B did not see a gun. He revealed that LVN A was very racial. He revealed he was not worried about the resident safety that evening. In an interview on [DATE] at 11:15 am with the ADON she stated the staff came and reported to her about the LVN A and a handgun during the Christmas party on [DATE]. She stated she reported it to the DON and the DON told her to in-service the staff about reporting incidents. The ADON stated she did not report it to the Administrator because it was 10 o'clock at night. In an interview on [DATE] at 12:58 PM with LVN A revealed she was the charge nurse on station one on [DATE] and her shift began at 6:00 PM. She said that it was, bull crap that she brought in a gun into the facility and there were no racial slurs and none of this happened. LVN A revealed she knew it was a criminal offense to bring a gun into the nursing facility. In an interview on [DATE] at 4:00 PM with the DON revealed no staff member contacted her on [DATE] and told her about LVN A having a gun in the facility. The DON revealed that on [DATE] the ADON told her that CNA D told her that LVN A brought a gun into the facility. The DON did not tell the ADM about the report of the gun in the facility until Monday, [DATE]. The DON said that if a staff member saw another staff member with a gun, that staff member should have called the police and the ADM should have been notified immediately. When the surveyor asked the DON why she did not tell the ADM about the gun in the facility until Monday she said, there was no particular reason why she did not call her. When the surveyor asked the DON about the reports of racial slurs the DON said that she did not feel it was racial. A review of TULIP facility self-report revealed the facility investigation summary that on [DATE] at 6:30 PM a facility charge nurse was witnessed bringing a handgun into the facility and the facility first learned of the incident on [DATE]. Investigation summary reported on [DATE] LVN A brought a handgun into the facility. Two staff members reported seeing the handgun. CNA C reported she witnessed LVN A go to LVN A's vehicle, remove the handgun from under the seat of her trunk, place it in LVN A's lunch box and bring it into the building. Later, CNA D reported standing at the nurses' station and observed the gun in the green and black lunch bag when LVN A went into it to get something. LVN A denied owning a gun. A review of TULIP revealed the HHSC TULIP reporter was contacted on [DATE], AT 4:55 PM, the date and Time of the incident: was [DATE] 6:30:00 PM. The date facility first learned of Incident was [DATE] 10:00:00 AM. The Actions and Notifications taken by the facility were statements were taken alleged perpetrator was terminated, in-services were provided, notifications were made to facility administration, police dispatcher and HHSC. Review of written statement of CNA C, undated, revealed on [DATE] LVN A said that us white people need to stick together because there are a lot of nigger clicks out here. A resident call light went off and CNA C said she would answer the call light even though the resident was the responsibility of CNA E. CNA C revealed that LVN A told her, no let that nigger get off her ass & do something . LVN A walked to the resident's room beside CNA E and told CNA E she would take care of the resident and CNA E could clock out and go home. CNA E told LVN A she was not going to clock out and told LVN A to, stop talking crazy. LVN A and CNA E kept arguing. CNA C said she stepped in to calm down the situation. When CNA E walked away LVN A said, I wish you touched me because then it would be self-defense. CNA C asked LVN A why she did not call and the DON or ADM about CNA E not answering the call light and LVN A said the ADM had (illness) and was weak and that is why, these niggers are out of control. CNA C followed LVN A out the front door and LVN A went to her truck and took a gun from underneath the seat and put the gun in a lunchbox. CNA C revealed, I told her it was not that serious or worth her freedom and she said yes it was she would kill those niggers and LVN B. CNA C revealed LVN A was walking around CNA E's car taking pictures. CNA C asked LVN A why she did not like LVN B and LVN A said it was because, the nasty MF deals with niggers. CNA C revealed LVN A walked to LVN B's station and LVN A told him you are going to get what is coming to you. CNA C revealed in her statement, at this point myself and the other workers feel for our safety as well as the safety of the residents when LVN A is here. Review of statement, undated, of CNA D revealed on [DATE] she observed a gun in LVN's lunch bag. CNA D revealed this was, after several incidents when her & a fell a CNA had words. LVN A was, nit picking with all of the staff in a degrading racist manner. Everybody black was a nigger and I tried very hard to keep the peace. LVN A is a very confrontational nurse lies, starts mess with the patients and other staff . The lady is very delusional, suicidal, homicidal, bipolar, and she needs help. We fear for our safety and the residents when she is here. Review of statement, undated, of CNA E revealed on [DATE] LVN A told her to go home and said negative comments about African American people. CNA E revealed that LVN A, started to walk up on me like she was going to do something so I told her to stop walking up on me or it would be an issue. CNA E revealed she told LVN A to leave her alone and stop harassing her. And LVN A told her this is my hall and CNA E will do what she tells her to do. CNA E revealed, I told her to her face I don't care who hall it is don't come tell me how to do my job. LVN A told her to go home and LVN A would do her hall and CNA E told her she would not go home. LVN A yelled from station one desk to station two desk for LVN B to send her home. CNA E revealed LVN A told her LVN B would not send her home because, yall F*ucking. CNA E revealed that she told LVN A she needed to stop harassing them and let them do their jobs that is when LVN A was making comments involving nigger this and nigger that. CNA E revealed LVN A walked outside and stayed out for about thirty minutes and came in with a lunch kit. Review of statement dated [DATE] of CNA F revealed she, overheard LVN A making racist remarks this is not the first time if anything doesn't go her way, she gets upset and goes in a uproar. We (staff) have already came to the DON about it. It's a very hostile environment when LVN A is here. Review of statement, undated, LVN B revealed LVN A told him, I should stick up for my own kind and LVN A pointed a finger at him and stated one day I would be sorry. Review of statement, undated, of ADON revealed that on [DATE] she was asked to be on standby when LVN A arrived for her shift and instructed to not allow LVN A in the build, lock the door, and call non- emergency to issue LVN A criminal trespass for the handgun a that was reported to have been in the building on [DATE]. Review of LVN A's employee time sheet revealed she worked at the facility on [DATE]. Review of statement of ADON, undated, revealed LVN A's employment was terminated on [DATE]. Review of inservices conducted on [DATE] reflected not all staff were in-serviced on reporting to the Administrator emergency situations including reporting handguns brought into the facility. Review of facility employee abuse prevention proficiency test revealed that it was the responsibility of the facility to train employees, report, and investigate incidents and prevent abuse. Review of facility reporting crimes test, undated, revealed, as an employee of the facility you are considered a covered individual. Each covered individual has an obligation to report the suspicion of a crime against a resident directly to local law enforcement and the State Survey Agency. Any other crime against a resident described in the Texas Penal code time frame requirements to report: No serious bodily injury - not later than 24 hours after forming the suspicion. If you have any questions regarding reporting of crimes contact your administrator immediately. Review of facility reporting crimes test revealed each individual has an obligation to report the suspicion of a crime against a resident directly to local law enforcement and the State Survey Agency. Review of facility Abuse/Neglect policy, undated revealed, all reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated per facility protocol. Investigations will be reviewed by the facility administrator and/or abuse preventionist within 24 hours of compliant. Appropriate notification to state and home office will be the responsibility of the administrator per policy. When a suspected abused, collected, exploitative, mistreated or potential victim of misappropriation of property comes to the attention of an employee, that employee will make an immediate verbal report to the abuse preventionist or designee. If the discovery occurs outside of normal business hours, the abuse preventionist and or designee will be called. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter ,d+[DATE] dated [DATE]. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. A report to the appropriate agency will include the following: The name and address of the suspected victim. The name and address of the suspected victim's care giver, if known. The nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injury of unknown source The nursing facility will make an addendum to any reportable incident in its report to HHSC if the resident subsequently experiences a negative outcome. Other pertinent information as available. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form. With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee(s) will immediately be suspended pending an investigation. Abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property of residents by employees of any facility will be grounds for immediate termination. Review of facility Corporate Code of Conduct, from facility personnel handbook dated [DATE], revealed the types of behavior this facility feels are inappropriate include having unauthorized firearms on this facilities premises or while on this facilities business. Review of facility personnel handbook dated [DATE] revealed Weapons in the Workplace - it is not permissible for any person to carry firearms on the property in this facility. It is prohibited for anyone to possess or carry firearms. Review of Employee Disciplinary Report Action Request for LVN A, charge nurse hire date [DATE] termination dated [DATE] date of infraction [DATE], Specific reason for the disciplinary action revealed on the [DATE]O23 a CNA witnessed [sic] LVN A take a gun from under the seat of her truck and bring it into the building in a green and black lunch bag after having several confrontations with one of the CNA's, another CNA observed the gun in her lunch bag as well. She made threatening remarks about shooting staff members due to her dislike for them. She also directly threatened the charge nurse at LVN B (because he doesn't stick with his kind). In addition to this she made racial remarks about an African American resident (deceased ) and staff. LVN A failed to adhere to the corporate code of conduct and weapons in the workplace by possession of weapons on company property. On [DATE] after making several harassing and racial remarks LVN A was seen getting a gun out of her personal vehicle and brining into the in a lunch box. The weapon was seen by at least two individuals while it was in the facility. LVN A is a threat to other staff members and is aware of the corporate code of conduct and weapons policy via her signature on the employee acknowledgment form. Review of LVN A's [DATE] signed acknowledgement and signature that LVN A, read, understand, and agree to abide by the facilities rules of behavior for general users. Review of in-service training attendance roster dated [DATE] revealed LVN A received a reprimand for conduct unbecoming of an employee of the company. Review of facility armed intruder/active shooter emergency policy, undated, reflected the presence of any person on the premises with the presumed intention of harming others. Victims are family members or associates with a weapon. Oftentimes the incident is domestic in nature and targeted victims are family members or associates of the intruder. Purpose to outline steps for the facility to take, if there is a reported threat to a resident, associate, or visitor of the building, from an individual outside the facility period to also provide direction with this staff to follow, should an armed intruder enter the facility and slash or become violent with staff, residents or visitors period to ensure law enforcement is familiar with the layout of the facility by inviting law enforcement into the facility and providing a facility floor plan to enforcement. Procedure Do not confront or attempt to reason with the individual. Stay calm period call 911 and give the facility name, and your name. Give as many details of this situation as you can to the dispatcher, such as how many perpetrators, location of the armed intruder and their description, type of weapons being used, any hostages, casualties, etcetera. Announce over the pager system code white open parent security slash aggression close parent and the location of the situation. If safe passage is available, leave the area immediately, by way of the nearest exit. Move as far away from the facility as possible protecting their residents' safety. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 6:53 PM. The DON was notified. The DON was provided with the IJ template on [DATE] at 6:53 PM. The following POR was accepted on [DATE] at 5:07 PM Date: [DATE] F609 The facility failed to develop and implement written policies and procedures that: Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. Interventions: As of [DATE] the Charge Nurse suspended and terminated from the facility by the Administrator. As of [DATE] the allegation was reported to the police and HHS by the Administrator. As of [DATE] the DON was in-serviced 1:1 by the Regional Compliance Nurse on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. As of [DATE] the Administrator was in-serviced 1:1 by the Area Director of Operations on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. As of [DATE] the CNA who witnessed the handgun was in-serviced 1:1 by the Regional Compliance Nurse to call 911 and the administrator immediately. Medical Director was notified of the immediate jeopardy on [DATE] by the DON. An ADHOC QAPI meeting was conducted on [DATE] to discuss the immediate jeopardy and subsequent plan. In-services: All Staff: All staff were in-serviced on the following in-services below on [DATE] by the Regional Compliance Nurse and DON. All staff not present will be in-serviced prior to start of their shift. All new hires will be in-serviced during orientation prior to start of their assignment. All agency staff will be in-service prior to the start of their shift. To notify 911 immediately in the event that a firearm is suspected in the facility and not with law enforcement. Then notify the Administrator and DON. Abuse and Neglect Policy. Timely reporting of abuse and neglect to the abuse coordinator. Monitoring: Monitoring was initiated on [DATE]. Reviewed the payroll/input personnel action form that reflected LVN A's employment at the facility was involuntary terminated for bringing a gun into the facility. Reviewed of Self-reporting ad hoc QAPI - Emergency Situation Document that reflected both law enforcement and the State of Texas were informed of the incident. Interview with the DON revealed she had been in-serviced by the Regional Compliance Nurse on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. She stated she was also in-serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator. Interview with the Administrator revealed she was on vacation but reached by phone on [DATE] and confirmed she was in-serviced on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. Interview with the CNA who witnessed the handgun confirmed that she received an in-service that if someone brings a gun into the facility, she needs to call 911 then report to the administrator immediately. Interview with the DON revealed she contacted the Medical Director and notified him of the immediate jeopardy. Reviewed ADHOC QAPI meeting was conducted on [DATE] to discuss the immediate jeopardy and subsequent plan. In-services: All Staff: All staff were in-serviced on the following in-services below on [DATE] by the Regional Compliance Nurse and DON. All staff not present will be in-serviced prior to start of their shift. All new hires will be in-serviced during orientation prior to start of their assignment. All agency staff will be in-service prior to the start of their shift. To notify 911 immediately in the event that a firearm is suspected in the facility and not with law enforcement. Then notify the Administrator and DON. Abuse and Neglect Policy. Timely reporting of abuse and neglect to the abuse coordinator. Interviews on [DATE] from 10:37AM to 12:22PM with 3 Nurses, 6 CNAs and 1 MA revealed the following: *10:37 AM ADON J stated she was in serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator. *11:30 AM CNA H stated she was in serviced on the facility's abuse and reporting policy. She stated she was also in serviced on who and how soon you would report altercations or observations of a handgun to. She stated the abuse coordinator the administrator. *11:40 AM LVN I stated she was in serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator. She further stated she was in serviced on firearm awareness and armed intruder. *11: 45 CNA J stated she was in serviced and she would report anyone with a firearm immediately and call the police. *11:50 AM CAN K stated she was in serviced and would immediately report anyone with gun to the administrator and the police. *11:55 AM CNA L stated she was in serviced and would immediately report anyone with gun to the administrator and the police. *12:00 PM CNA M stated she was in serviced yesterday on abuse reporting and who to report it to. She stated she would report to Administrator right away and if she saw someone with a gun, she would call 911. *12:05 PM CNA M stated he was in serviced on who to call if someone had firearm and what to do if someone brought one to the facility. He stated he would let the administrator know and call the police. *12:10 PM CNA N stated she was in serviced on the facility policy regarding reporting abuse and you would tell the administrator right away. If I saw someone with a gun, yes, I would report it and call 911. *12:18 PM Medication Aide O stated she was in serviced and would immediately report anyone with gun to the administrator and the police. *12: 22 PM LVN P stated she was in serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator. She further stated she was in serviced on firearm awareness and armed intruder. Review of in-service records reflected the facility in serviced staff on abuse and neglect, Firearm awareness and armed intruder/active shooter. Review of the facility's abuse and neglect policy reflected the policy included the key components of screening, training, prevention, identification, investigation, protection and reporting alleged incidents of abuse, neglect, and exploitation/misappropriation. The Administrator/ DON/Designee will interview ,d+[DATE] staff members weekly on what they would do if a handgun was observed in the facility that doesn't belong to law enforcement. Monitoring will continue for 6 weeks. Administrator/DON will monitor PCC documentation daily during the morning meeting for any evidence of an emergency situations to ensure timely reporting. Monitoring will begin [DATE] and will continue for 6 weeks. Review of staff list and in service trainings reflected 80% of staff in serviced. The DON was informed the Immediate Jeopardy was removed on [DATE] at 6:18 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Based on interviews and record review, the facility failed to protect the residents right to request, refuse, and/or discontinue treatment for one (Resident #1) out of three residents reviewed for advanced directives, in that: The facility failed to ensure Resident #1's DNR was signed by the MD until [DATE] when it was ready to be signed on [DATE]. Resident #1's DNR was not uploaded into the EHR, resulting in LVN A having an incomplete OOH-DNR form with which to make her determination of whether to begin CPR. This failure also resulted in Resident #1's Care Plan reflecting a now incorrect code status at the time Resident #1 became unresponsive. These failures resulted in LVN A performing CPR for 5 minutes, and in 911 being called, who continued CPR for an additional 30 minutes, intubated Resident #1 and transported Resident #1 to the hospital. An IJ was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 06:00PM. While the POR was accepted on [DATE] at 1:40 PM and the immediacy was removed on [DATE] at 4:20 PM, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of not having their wishes known, respected, and implemented in emergency. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Chronic Combined Systolic and Diastolic Heart Failure (heart failure affect the left ventricle), Abnormalities of breathing, Chronic Obstructive Pulmonary Disease (Difficulty to breath) , Hypertension, Depressive episodes, Acute and Chronic Respiratory Failure, Paroxysmal Atrial Fibrillation ( irregular shallow heart beat), Type 2 Diabetes Mellitus, Obstructive Sleep Apnea ( breathing obstruction while sleeping) , Anemia, Mood Disorder and Cellulitis of face. Review of Resident #1's MDS assessment dated [DATE], reflected a BIMS of 4, indicating a severe cognitive impairment. Section I (active diagnoses) reflected Resident #1's primary medical condition was debility from Cardiorespiratory Conditions. Review of Resident #1's initial care plan, dated [DATE] reflected, Resident #1 requested a full code status, and the relevant interventions were: Initiate BLS CPR if the resident is without a heartbeat or not breathing. Notify the charge nurse immediately if the resident is not breathing or does not have a heartbeat. Review of Resident #1's DNR revealed, it had been signed by the responsible party and notarized on [DATE] and the MD signed on it on [DATE]. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 11:50PM, reflected the following: Nurse called into resident's room at 6:20 PM. CNA found resident unresponsive, and very pale. Resident was lying in bed and had no response to calling of his name or to touch. CPR started at about 6:23PM. Requested that 911 be called, since resident did not have a signed DNR. Resident was on Hospice [company], also instructed that they be contacted. EMS arrived at 6:30PM and continued CPR. Upon other help arriving EMS placed resident on floor and continued working with patient. Was informed that they had a faint pulse, they prepared to transport resident to hospital at 7:02PM. Nurse thereafter contacted [family member] of resident to inform her that resident was taken to hospital by EMS, at which time she became very upset and hung up the phone. DON contacted and informed of the situation. [MD] contacted and was informed that resident was transferred to hospital, however informed nurse that resident was supposed to have DNR on file. DNR was in file however it was not signed by doctor, and resident full code was indicated on system. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 03:36AM, reflected: deceased . Review of Resident #1's Death Report from the hospital dated, [DATE] reflected the resident expired on [DATE] at 7:23PM. Review of Resident #1's hospital record dated [DATE] reflected: Patient in cardiac arrest on arrival to emergency department. Patient in respiratory arrest on arrival to emergency department. Length of downtown time, (min) one hour. Patient intubated prior to arrival with endotracheal tube [a tube that is placed between the vocal cords through the trachea to provide oxygen and inhaled gases to the lungs.]: size (mm) 7.0, at lip(cm)21. Patient not on spinal immobilization on arrival. Blood pressure:0, pules0, respiratory rate :0, cardiac rhythm in field pulseless electrical activity . Record review of the doctor's note at the hospital on [DATE] at 05:28AM reflected: Patient is a [AGE] year-old male brought in by EMS after being found in cardiac arrest at the nursing home. ACLS was performed by EMS and then continued on arrival to the ER. Patient was found after the conclusion of ACLS to be in systolic and resuscitative measures were halted . Of note on patient's physical exam there was an unusual articulation between the neck and the head when the patient had his neck turned to the side given the impression of a possible broken neck. There was a palpable discontinuity at the back of the base of the skull where it meets the cervical spine suggesting a possible cervical spine fracture. These findings were communicated to the patient's primary care physician who recommended an autopsy and also to have JP evaluate the case. During an interview on [DATE] at 10:30AM ADM stated, the DNR was notarized and received from FM on [DATE] however was not signed by MD until [DATE]. She stated it was a mistake from the facility that DNR was not get signed by MD immediately after received from the family. She stated MD visits the facility every month and the facility was waiting for his next visit to get it signed. She added, this incident was an opportunity to learn from the mistakes. ADM stated LVN A conducted the CPR based on the DNR on the E H R, which was not signed by MD. ADM stated MD signed the DNR on [DATE] before the incident occurred however the code status was not changed in the system as soon as it got signed. ADM stated, the mistake from the facility side was, the DNR did not get signed by MD in a timely manner. During an interview on [DATE] at 11:00AM, Resident #1's FM stated she was the responsible party for Resident#1, and she was horrified with what had happened to Resident #1. She stated, she wanted to know what had really happened and why his DNR was not respected. The FM stated after discussing various aspects of the DNR with Resident #1, it was signed by her and notarized on [DATE]. She stated she wanted to know why it was not get signed by MD immediately after the facility received it. The FM stated this negligence from the facility lead to denying Resident #1's right to have a peaceful and dignified death wished by him and the family. She stated, she heard from the facility that the medical report from the hospital stated Resident #1 had a broken neck and wanted to know how, when and where this was occurred. During a telephone interview on [DATE] at 4:00PM MD stated he visited the residents at the facility once a month. MD reported on [DATE] he met with Resident #1 and his FM at the facility and there was no concern about Resident #1 at that time, other than his normal presentation of labored breathing. MD stated on [DATE] there was no abnormality with the neck noticed and the resident did not report of any discomfort with his neck. MD stated he interacted with Resident #1's FM too and no concerns of any kind raised by them. MD said, he heard about the report of the broken neck of the resident at the hospital on [DATE] and was looking forward for the autopsy result. MD stated he signed on Resident #1's DNR dated [DATE] on ,d+[DATE] / 23 in that afternoon and did not remember the exact time. The MD stated he was not aware of the existence of a DNR as the facility did not inform him about it, which was why the DNR was not signed immediately after it was signed and notarized on [DATE]. He stated it was a concern that the DNR was not executed on time and Resident #1's wish was not respected. During an interview and observation on [DATE] at 6:00PM, LVN A stated she was the one who initiated CPR. She stated on [DATE] at about 6:15pm one of the staff members stated, Resident #1 was unresponsive. She said, she immediately went into E H R and confirmed his code status. She said she decided to initiate CPR since the copy of the DNR in the E H R was not duly signed by the MD and thus it was not valid. She said she did the CPR for about 5 minutes while Resident #1 was in bed and mean time ER arrived and took over. She said, they continued CPR for about 5 minutes while resident was in bed and then took him to the floor and continued the process for about 30 minutes. Later they took him to the hospital and later came to know that the resident was pronounced dead at the hospital. LVN A provided a copy of the DNR in which there was no signature of the MD. This was contrary to the copy of the DNR in the E H R uploaded on [DATE], in which there was a MD's signature. When investigator asked why there were two copies of DNR, one with and the other without MD's signature, LVN A stated the copy without MDs signature was in the E H R at the time of the incident and the one with MD's signature was uploaded to the system after the incident occurred. She sated she was an LVN for more than [AGE] years and she knew it was a complicated situation and that was why she decided to preserve the copy of the DNR that was effective at the time of the incident. When the investigator asked about Resident #1's broken neck, LVN A stated when she was conducting CPR there were no abnormalities noticed. Record Review of E H R on [DATE] revealed, the copy of the DNR uploaded to the system on [DATE] was duly signed by the MD and the responsible party. Record Review of the facility's undated policy Resident Rights reflected the following: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regard less of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States Self-determination: The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice 2. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. The ADM was notified on [DATE] at 06:00PM that an IJ situation was identified due to the above failures and the IJ template was provided. The plan of Removal was accepted on [DATE] at 01:39PM, and included: F578 - The facility failed to protect Resident #1's right to request, refuse, and/or discontinue treatment. All residents could be affected by this deficient practice at the facility. Interventions: 1. 100% audit was completed for resident advance directives by the DON and ADON as of [DATE]. All DNRs are completed and signed by the resident or person acting on behalf of the resident, along with witnesses or notary and physician. All advance directive orders are care planned. No additional issues were discovered during the audit. Completed [DATE]. Once notified by medical records and/or administrative staff, nursing personnel will change the status in PCC and update care plan 2. The Administrator and DON were in-service 1:1 on the completion and implementation of advance directives, Abuse and Neglect, and the CPR policy by the Area Director of Operations. Completed [DATE]. All nurses are certified in CPR and the team have verified that each shift has a nurse certified in CPR. 3. The Medical Director was notified of the immediate jeopardy on [DATE] by the Administrator. 4. An ADHOC QAPI meeting was conducted as of [DATE] to discuss the immediate jeopardy and plan of removal. In-services: 1. All staff were in-serviced on Abuse and Neglect by the Administrator and DON on [DATE]. All staff not present will not work their next assignment until in-serviced. All newly hired staff/agency staff will be in-serviced at orientation before assuming an assignment. 2. All Charge Nurses were in-serviced on policy for CPR and procedures for performing CPR by the Administrator and DON on [DATE]. All staff not present will not work their next assignment until in-serviced. All newly hired staff/agency staff will be in-serviced at orientation before assuming an assignment. 3. All Charge Nurses and M/R were in serviced on the process to obtain and implement a DNR by the Administrator and Don on [DATE] All staff not present will not work their next assignment until in-serviced. All newly hired staff/agency staff will be in-serviced at orientation before assuming an assignment. Staff will demonstration understanding/comprehension of process by teach back. A change to obtaining the physician's signature if not completed as soon as requested was put in place (Medical Records or designee will fax DNR to the physician. If not received back medical records or designee will deliver DNR to physician. Once signed medical records or designee will upload DNR to PCC. DON or designee will change status in PCC and notify staff of status change during nursing stand up. Care plan will be updated by nursing management). Monitoring: 1. At least 5 times per week, advance directive orders will be reviewed by Administrator/DON and/ADON and ensure that all orders are completed and entered correctly. Monitoring will start [DATE] and continue x 6 weeks. The Survey Team monitored the Plan of Removal on [DATE] Interview on [DATE] at 12:37PM with DON and Administrator revealed the one-on-one training was done with Compliance Nurse regarding resident rights and advance directives. The DON stated they reviewed all residents records for code status stating she reviewed DNRs and ensured the out of hospital was in the resident record and that the records reflected the DNR status she stated she also reviewed full code residents to ensure they had not initiated a DNR she stated Resident #1 was a hospice resident and hospice usually does the DNRs and stated the facility needed to ensure the records reflected the residents status. She stated the record reflected the resident was a full code and the nurse did what she was supposed to since she had no way of knowing his code status had changed. Interview on [DATE]PM started at 12:50PM with 8 nursing staff in the facility revealed they were in serviced on resident rights, CPR, and DNRs and were able to explain the procedure for identifying a residents code status, locating the documents. Record review of In-services revealed an Inservice for CPR/ and Code policy conducted on [DATE] and ongoing for staff coming to work which reviewed the facility ' s policy Cardiopulmonary resuscitation and inservice for steps to execute a DNR conducted on [DATE] and ongoing for staff coming to work which reviewed the facility ' s policy for out of hospital DNRs. The ADM was notified on [DATE] at 4:30 PM that the Immediate Jeopardy was lowered, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to keep two (Resident #1, Resident #2) of sixteen residents free from accident hazards and supervision. The facility failed to: 1. Ensure Resident #1, who had exit-seeking behaviors and resided in the secure unit, did not elope from the facility on 12-16-22. 2. Ensure Resident #2, who had exit-seeking behaviors and resided in the non-secure unit, did not elope from the facility on 09-14-22. On 1-2-23 at 5:17 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 1-5-23 at 7:00 PM, the facility remained out of compliance at a scope of J isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of abuse, harm, or hospitalization . Findings Included: Record review of Resident #1's undated admission record reflected, Resident #1 was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #1's diagnoses included dementia with behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities., agitation, anxiety, and psychosis ), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs ), and major depressive disorder (causes a persistent feeling of sadness and loss of interest and can interfere with your daily), recurrent, severe with psychotic symptoms (hallucinations, delusion, confused/disturbed thoughts). Record review of Resident #1's MDS assessment, dated 12-21-2022, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. The MDS further reflected Resident #1 had a behavior of wandering that occurred daily during the look-back period of the assessment. Resident #1 did not require any assistive mobility devices. Record review of Resident #1's care plan, initiated on 10-22-21, reflected Resident #1 is at risk for wandering. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system. Resident #1 had cognitive function/dementia or impaired thought processes Dementia. Record review of Resident #1's Securecare Environment Screening Tool dated 7-18-22, reflected Resident #1 had a diagnosis of Alzheimer's disease, continued to exhibit exit seeking behavior and resident is continuously wandering and looking for an exit. Record review of Resident #1's progress note, dated 7-23-22, reflected Resident #1 had pushed his way through the doors of the locked unit and took off running down the street. Law enforcement assistance had been required because Resident #1 was running down the road and Licensed Vocational Nurse D had to block traffic. 911 was called, resident [#1] was restrained after swinging at officers. Resident #1 had been transferred to local hospital. Resident #1 returned to the facility with a diagnosis of altered mental status with no new orders. Record review of Resident #1's progress note, dated 7-24-22, reflected Resident #1 was increasingly agitated and commenting I'm going to the house. Resident #1 had set off the back door alarm 3 times. Staff attempted to redirect him and he charged at them with a closed fist. Record review of Resident #1's progress note, dated 8-6-22, reflected Resident #1 had been observed due to increased agitation. Resident #1 had been walking from one door to the next, and walking away from the front door down to the hall. Record review of Resident #1 progress note, dated 10-29-22, reflected Resident #1 tried to push the courtyard door open and stated I want to go home. Resident #1 was shaking the front doors to the secure unit and became combative with staff, and law enforcement was called. The law enforcement officer spoke to Resident #1 and Resident #1 was redirected to his room without complaints. Record review of Resident #1 progress note, dated 12-16-22 reflected, Resident #1 had run and hit the exit doors in the secure unit which caused it to open. Resident #1 ran down the sidewalk and was followed by Certified Nurse Aide F. Resident #1 was in view of Certified Nurse Aide F at all times. Record review of Texas Department of Aging and Disability Services Form 3613-A provided by the Administrator reflected the Investigation Findings to be confirmed. Staff were moving residents from the dining room to the day room following an activity. [Certified Nurse Aide F] was coming out of the dining room, she spotted resident [Resident #1] running down the hall toward the door. When he [Resident #1] reached the door he pushed hard on it until it released. [Certified Nurse Aide F] was running after him calling for help as she went. [Certified Nurse Aide E] was asked to help. He [Certified Nurse Aide E] told [Licensed Vocational Nurse B], what was going on and joined the pursuit. Resident [#1] was in eye sight at all times. Staff caught up with the resident [#1] (as he was running down the sidewalk), calmed him down and coaxed him into a care to return him to the facility. Resident [#1] had been taken out on a pass the day before. The form was signed by the Administrator and dated on 12-20-2022. On 1-2-23 at 10:05 AM, an observation revealed, the nurse's station outside of the secure unit. Two locked clear doors led to the secure unit. Licensed Vocational Nurse A pressed the doorbell located on the left side of the wall and unlocked the doors to the secure unit. On 1-2-23 at 10:07 AM, Resident #1 was observed in the secure unit at the end of the hall, trying to push the emergency doors open. Certified Nurse Aide C and Licensed Vocational Nurse A stood in front of the doors and redirected him away from the doors. Resident #1 was angry and agitated, and continued trying to push the doors open. Resident #1 continued to talk loudly and aggressively to staff as he walked away from the exit doors. On 1-3-23 at 9:15 AM, an observation revealed the distance between the private driveway in front of the home where Resident #1 was found and the facility was .26 miles. Record review of the posted speed limit on the busy street in front of the facility to be 30 miles per hour. During an interview on 1-3-23 at 10:56 AM, Certified Nurse Aide E stated he had been trained in elopement procedures and had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide E stated the Maintenance Supervisor notified the nurse who in turn notified him that Resident #1 had eloped. Certified Nurse Aide E stated he ran down the sidewalk located next to a busy street and saw Resident #1 on the opposite side of the street running away from the facility. Certified Nurse Aide E stated he saw cars slowing down as Resident #1 continued to run down the street. Certified Nurse Aide E stated Resident #1 was found approximately 2 blocks away in a private driveway in front of a home. Certified Nurse Aide E stated the street located in front of the facility was very busy and there was traffic on the day Resident #1 eloped. Certified Nurse Aide E stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Certified Nurse Aide E stated Resident #1 has a history of trying to exit the facility and has witnessed him push and pull the front doors of the secure unit attempting to leave when he is mad or agitated. During an interview on 1-3-23 at 9:04 AM, Licensed Vocational Nurse B stated she had been trained in elopement procedures and she had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Licensed Vocational Nurse B stated Resident #1 had a history of being upset after the family visited and attempted to leave the facility after those visits. Licensed Vocational Nurse B stated a family member visited Resident #1 the day before and he had been upset since then. Licensed Vocational Nurse B stated she had been told by Certified Nurse F that Resident #1 was running back and forth down the hallway of the secure unit when he hit the exit doors and they opened. Licensed Vocational Nurse B stated she and Certified Nurse Aide E ran out of the facility and saw Resident #1 running down the sideway next to a busy street. Licensed Vocational Nurse B stated Resident #1 ran fast and finally stopped near a fast food restaurant, a couple of blocks away. Licensed Vocational Nurse B stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Licensed Vocational Nurse B stated a head-to-toe assessment was done on Resident #1 and no injuries were noted, vitals were taken and all were normal. She stated he was also hydrated, and was assigned a one to one person for the next 72 hours. Licensed Vocational Nurse B stated on 12-30-22, Resident #1 was moved from his room located at the end of the hall to the first room at the beginning of the hall because the facility need his room for a new admission. During an interview on 1-3-23 at 10:56 AM, Certified Nurse Aide E stated he had been trained in elopement procedures and had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide E stated the Maintenance Supervisor notified the nurse who in turn notified him that Resident #1 had eloped. Certified Nurse Aide E stated he ran down the sidewalk located next to a busy street and saw Resident #1 on the opposite side of the street running away from the facility. Certified Nurse Aide E stated he saw cars slowing down as Resident #1 continued to run down the street. Certified Nurse Aide E stated Resident #1 was found approximately 2 blocks away in a private driveway in front of a home. Certified Nurse Aide E stated the street located in front of the facility was very busy and there was traffic on the day Resident #1 eloped. Certified Nurse Aide E stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Certified Nurse Aide E stated Resident #1 has a history of trying to exit the facility and has witnessed him push and pull the front doors of the secure unit attempting to leave when he is mad or agitated. During an interview on 1-3-23 at 3:38 PM, Certified Nurse Aide F stated she had been trained in elopement procedures and she had worked on the secure unit on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide F stated she was in the dining room in the secure unit when she heard the alarm door beeping and saw Resident #1 standing at the exit doors. Certified Nurse Aide F stated she knew she had 15 seconds before the door released and opened. Certified Nurse Aide F stated the door opened and Resident #1 ran out the door and it shut behind him. Certified Nurse Aide F stated when she opened the door, Resident #1 was running in a private driveway located next to the facility. Certified Nurse Aide F stated she could see Resident #1 as he ran away from the facility. Certified Nurse Aide F stated Resident #1 stopped at the grocery store near the facility. During an interview on 1-3-23 at 10:36 AM, the Licensed Vocational Nurse I stated she had been trained in elopement procedures. Licensed Vocational Nurse I stated she was in orientation on 12-16-22 when Resident #1 eloped from the secure unit. Licensed Vocational Nurse I stated she got into her personal vehicle and traveled down the road and saw Resident #1 and other staff members across the street in the private driveway of a home. Licensed Vocational Nurse I stated she coaxed Resident #1 into her vehicle and transported him back to the facility. Licensed Vocational Nurse I stated the street had a normal flow of traffic. Licensed Vocational Nurse I stated she was stationed at the nurse's station outside of the secure unit and will do rounds every hour or as needed. During an interview on 1-2-23 at 10:10 AM, Certified Nurse Aide D stated she had been trained on elopement procedures. Certified Nurse Aide D stated Resident #1 was agitated and attempted to push the doors open on 1-2-23. Certified Nurse Aide D stated she had redirected Resident #1 away from the door. Certified Nurse Aide D stated Resident #1 had exit seeking behaviors and had eloped from the facility in the past. Certified Nurse Aide D stated when Resident #1 is agitated, extra eyes were kept on him to prevent him from eloping. Certified Nurse Aide D stated Resident #1 had touched the exit door bar and waited for the staff to respond. Certified Nurse Aide D stated Resident #1 had acted up after past family visits. Resident #1 had been visited by family on 1-1-23 and that is what caused him to become angry and agitated. Certified Nurse Aide D stated Resident #1's room was located at the end of the hall, near the exit doors. Certified Nurse Aide D stated Resident #1 had been in the secure unit for a couple of months and he had eloped a couple of times before. Certified Nurse Aide D stated when she worked in the secure unit, she always kept an eye on Resident #1 to ensure that she knew where he was at all times. Certified Nurse Aide D stated Resident #1 liked to sit in the dining room, listen to music, and drink coffee. Certified Nurse Aide D stated rounds are done at least every 2 hours, but more frequently in the secure unit. Certified Nurse Aide D stated 2 CNA's and 1 nurse covered the secure unit. During an interview on 1-2-23 at 10:29 AM, Certified Nurse Aide M stated she had been trained on elopement procedures. Certified Nurse Aide M stated she worked in the secure unit with Resident #1 and when he was upset, he would attempt to leave the secure unit through the exit doors. Certified Nurse Aide M stated Resident #1 had been redirected away from the exit doors. Certified Nurse Aide M stated Resident #1 had been verbally aggressive when he was angry or agitated. Certified Nurse Aide M stated rounds are done at least every 2 hours but more frequently in the secure unit. Certified Nurse Aide M stated 2 CNA's and 1 nurse covered the secure unit. Certified Nurse Aide M stated 16 residents resided on the secure unit. During an interview on 1-2-23 at 10:36 AM, Licensed Vocational Nurse A stated she had been trained in elopement procedures. Licensed Vocational Nurse A stated she had been working the secure unit on 1-2-23 and Resident #1 attempted to push the exit doors open. Licensed Vocational Nurse A stated Resident #1 stated, I figured it out as he attempted to push the exit door open. Licensed Vocational Nurse A stated she and Certified Nurse Aide B stood in front of the exit door to prevent Resident #1 from eloping. Licensed Vocational Nurse B stated Resident #1 was agitated and high strung because he had a family visit the day before [1-1-23] and he kept stating he wanted to go home. Licensed Vocational Nurse A stated the exit door push bar had to be held for 15 seconds before the door was unlocked and released. Licensed Vocational Nurse A stated the exit door alarm will beep loudly during the 15 seconds. Licensed Vocational Nurse A stated the beeping could be heard at the nurse's station located outside the secure unit. Licensed Vocational Nurse A stated after 15 seconds the door will open and the alarm will sound at which time all available staff is to respond to the opened door. Licensed Vocational Nurse A stated she sits at the nurse's desk located outside the clear doors of the secure unit. Licensed Vocational Nurse A stated a doorbell is located on the left side of the wall next to the clear doors leading to the secure unit and the doorbell had to be pushed to release the lock and open the doors to the secure unit. Licensed Vocational Nurse A stated a code to the keypad is needed to exit the secure unit. During an interview on 1-2-23 at 10:50 AM, Certified Nurse Aide D stated she had been trained on elopement procedures. Certified Nurse Aide D stated she had worked the secure unit and cared for Resident #1. Certified Nurse Aide D stated Resident #1 had a history of being agitated after family visits and would attempt to exit through the back exit doors. Certified Nurse Aide D stated when she worked the secure unit, Resident #1 was with her or within eyesight because of his past history of elopement. Certified Nurse Aide D stated Resident #1 did respond to redirection when he is upset and wanting to go home. Certified Nurse Aide D stated Resident #1 pressed the push bar and when she heard the beeping she immediately responded to the exit door and redirected him to activity room. Certified Nurse Aide D stated Resident #1 is very strong and can be physically/verbally aggressive when upset. Certified Nurse Aide D stated she had been told Resident #1 ran very fast when he eloped from the facility. Certified Nurse Aide D stated rounds in the secure unit are completed at least every 2 hours, but she did them every 30 minutes because some residents like to walk up and down the hallway. Certified Nurse Aide D stated the doorbell outside the secure unit must be pressed and it will open the door. Certified Nurse Aide D stated when the push bar on the exit door is held it will beep for 15 seconds then the door is opened and the alarm will sound. Certified Nurse Aide D stated the alarm can be heard outside the doors of the secure unit and all available staff are to respond. She stated the code, to the keypad, is needed to exit through the clear doors located at the front of the secure unit. During an interview on 1-2-23 at 10:59 AM, the Maintenance Supervisor stated he checked all exit doors every other day. The Maintenance Supervisor stated he checked all keypads daily to make sure they were working. The Maintenance Supervisor stated he did not keep a daily log of the checks, but if a repair is needed, it will be logged in the system and then show up on a report when it is completed. The Maintenance Supervisor stated the push bar to the exit doors, in the secure unit, is very sensitive and will beep if it is touched and the constant beeping will sound when the push bar is held and the alarm will go off when the door is opened. The Maintenance Supervisor stated the push bar had to be held for 15 seconds, before it would open and set off the alarm. The Maintenance Supervisor stated the alarm in the memory care unit is loud and can be heard through the clear doors of the unit. The Maintenance Supervisor stated a code is needed to exit through the door that leads to the courtyard in the secure unit. The Maintenance Supervisor stated staff and visitors must press a doorbell located on the right side of the wall and someone from inside the facility will come to the front door and open it. The Maintenance Supervisor stated a red push button located on the right side of the wall near the front doors had to be pressed before the doors will open automatically. The Maintenance Supervisor stated a code is not needed to exit the facility through the front doors. On 1-2-23 at 11:05 AM an observation revealed the exit door to beep when touched and then a long beeping sound when the push bar was held for 15 seconds before being opened. The exit doors led to the side of the building and a sidewalk that leads to the facility parking lot. On the other side of the sidewalk is a grassy area which leads to an open part of the fence that leads to a private property. The sidewalk ends at the parking lot. A sidewalk is located between the facility parking lot and a street. The street was observed to be busy with traffic. On 1-2-23 at 11:08 AM an observation revealed a red button located on top of a blue handicap mount was located on the wall near the front entrance doors. During an interview on 1-3-23 at 10:00 AM, Certified Nurse Aide D stated she had been trained on elopement procedures and worked in the secure unit with Resident #1. Certified Nurse Aide D stated Resident #1 had a history of exit seeking behaviors and would attempt to leave the facility when upset or agitated after family visits. Certified Nurse Aide D stated she had not worked in the secure unit on 12-16-22, when Resident #1 eloped. Certified Nurse Aide D stated the facility had been short staffed during the month of December 2022, and she worked the secure unit alone a few times because of staffing issues. Certified Nurse Aide D stated at least 2 Certified Nurse Aides needed to work the secure unit to meet the residents needs and ensure they get proper care. During an interview on 1-3-23 at 10:20 AM, Certified Nurse Aide G stated he had been trained in elopement procedures and worked in the secure unit at the facility. Certified Nurse Aide G stated Resident #1 had a history of elopement and had eloped from the secure unit back in July 2022. Certified Nurse Aide G stated Certified Nurse Aide D was the only person working on the secure unit on that day. Certified Nurse Aide G stated the facility was short staffed and there had been times where only one person worked the secure unit. Certified Nurse Aide G stated Resident #1 is fast and no one here can catch him once he gets to running. Certified Nurse Aide G stated all staff are aware Resident #1 will be upset after family visits and will try to leave the facility. Certified Nurse Aide G stated Resident #1 can be redirected sometimes but when he was upset he would not listen. During an interview on 1-3-23 at 12:45 PM, the Director of Nursing stated she and all staff had been trained on elopement procedures. The Director of Nursing stated she had worked on 12-16-22 when Resident #1 eloped from the facility. The Director of Nursing stated Resident #1 eloped through the exit doors of the secure unit. The Director of Nursing stated Certified Nurse Aide F ran after Resident #1 and kept him within eyesight. The Director of Nursing stated she and other staff members ran down the sidewalk next to a busy street and finally reached Resident #1 on the opposite side of the street in a private driveway. The Director of Nursing stated there was a steady flow of traffic on the street located next to the facility. The Director of Nursing stated Resident #1 was transported back to the facility by Licensed Vocational Nurse I. Resident #1 was assessed from head to toe with no injuries noted, vitals were taken, he had been given fluids for hydration, and then had dinner. Resident #1 was placed on a one to one watch for the next 72 hours. The Director of Nursing stated Resident #1's room was located at the end of the hallway near the exit doors in the secure unit, but he was moved on 12-30-22 because the facility needed that room for a new admission. The Director of Nursing stated Resident #1 would have been able to stay in his room located at the end of the hall near the exit doors if the facility had not needed it for a new admission. The Director of Nursing stated rounds were done every 2 hours and more frequently in the secure unit and there are 2 Certified Nurse Aides and 1 Medication Aide assigned to the secure unit on a daily basis. The Director of Nursing stated 1 Licensed Vocational Nurse is stationed outside the secure unit and will conduct rounds and coverage as needed. The Director of Nursing stated the Licensed Vocational Nurse is responsible for performing rounds throughout the facility and there will be times when she is not at the nurse's station to keep an eye on the secure unit. The Director of Nursing stated that the doorbell must be pressed before the entry doors to the secure unit are opened and an exit code on the keypad is needed to exit. The Director of Nursing stated the press bar, located at the end of the hallway on the secure unit, must be held for 15 seconds before it is released and it will beep until opened at which time the alarm sounds and all available staff are to respond to the door. The Director of Nursing stated there is always a risk that a resident will elope from the secure unit. During an interview on 1-3-23 at 8:55 AM, the Administrator stated she and all staff were trained in elopement procedures. The Administrator stated Resident #1 eloped through the exit doors located in the secure unit on 12-16-22. The Administrator stated Resident #1 had a history of exit seeking behaviors and would attempt to leave the facility when upset after family visits. The Administrator stated a family member had visited Resident #1 the day before and he had been upset since the visit. The Administrator stated Resident #1 was placed on one to one monitoring for 72 hours after the elopement. The Administrator stated Resident #1's room was located at the end of the hall next to the exit doors but was moved to the first room at the beginning of the hallway close to the nurses station because his room was needed for a new admission. Record review of Resident #2's undated admission record reflected, Resident #2 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included dementia without behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (causes a persistent feeling of sadness and loss of interest and can interfere with your daily), primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and asthma (disease that affects your lungs. It causes repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing). Record review of Resident #2's MDS assessment, dated 12-21-2022, revealed Resident #2's BIMS score was blank which indicated it could not be completed. The MDS further reflected Resident #2 had a behavior of wandering that occurred daily during the look-back period of the assessment. Resident #2 required any assistive mobility devices. The MDS reflected daily decision making as being severely impaired. Record review of Resident #2's care plan, initiated on 9-8-22, reflected Resident #2 is at risk for wandering, and at shift change if staff see resident outside, staff will invite resident to come inside. Resident #2 hadcognitive function/dementia or impaired thought processes Dementia, communication problem, and impaired visual function. Record review of Resident #2's progress note, dated 5-15-22, reflected, Resident #2 remained tearful and continues to ask to go home and went back to her room to get her belongings. Resident #2 wandering the halls and was found on hall 3 tearful and upset with a bag in her hand that contained her belongings. Urine sample was taken and 15-minute checks will be done until reports are back from the lab. Record review of Resident #2's elopement risk assessment, dated 6-13-22, reflected she was not on a secured unit and ambulated independently or with a device. Assessment also indicated Resident #2 stated and/or threatened to leave the facility, frequent request to go home, confused expression related to tasks to complete, and verbalizes anger and frustration in reference to placement. Resident #2 did not recognize stop lights and signs and does not know precautions when crossing the street. Record review of Resident #2's Event Nurse Note 12 hour-Elope or Attempt, dated 6-13-22, reflected Resident #2 was sitting outside with another staff around 6:30 PM when night shift nurse came on. Around 7:00 PM staff noticed that Resident #2 was not in the building and went outside to get her she was not sitting where she had been. Resident #2 was found in the parking lot next door. Resident #2 had been missing for 30 minutes; no injures resulted from elopement. Resident #2 was brought back inside to her room and given something to drink. Cognition/Behavior at the time of event were marked cognitive impairment, wanders and requires cueing. Record review of Resident #2's progress note, dated 9-14-22, reflected Resident #2 was brought back from the porch area at approximately 3:30 PM. She went to the bathroom and then back to the nurses station. At 4:00 PM, Resident #2 was informed not to go back outside at which time she continued to go outside. Licensed Vocational Nurse B was informed that Resident #2 was down the street from the facility. Licensed Vocational Nurse B got into her car and went to look for Resident #2. Certified Nurse Aide E and Human Resources were walking around and looking for Resident #2. Licensed Vocational Nurse B stated she received a call from Human Resources that Resident #2 was found near the community hospital. Licensed Vocational Nurse B stated Resident #2 refused to get into her vehicle and was escorted back to the facility by Certified Nurse Aide E and Human Resources. Resident #1 was assessed upon return, no injuries, hydrated and he was moved to the secure area. On 12-28-22 at 1:24 PM, an observation revealed the community hospital area where Resident #2 was found was approximately .17 mile from the facility. There was a steady flow of traffic on the road that led from the facility to the hospital. Record review of the posted speed limit on the busy street in front of the facility to be 30 miles per hour. During an interview on 1-2-23 at 11:48 AM, the Dishwasher stated she had been trained in elopement procedures. The Dishwasher stated on 9-14-22, she had finished her shift and clocked out at 4:00 PM and ran some errands. The Dishwasher she had traveled down the busy street located in front of the facility and saw Resident #2 walking on the opposite side of the street near a private residence and called the facility and notified them of what she had seen. The Dishwasher stated Resident #2 was approximately half a block away from the facility on the opposite side of the street. The Dishwasher stated Resident #2 had to have crossed the busy street to end up in front the house where she saw her. The Dishwasher stated the street located in front of the facility was busy at all times of the day. The Dishwasher stated she was in an uber car when she saw Resident #2 down the street from the facility. The Dishwasher stated she had not asked the uber driver to stop when she saw Resident #2. During an interview on 1-2-23 at 12:33 PM, Certified Nurse Aide E stated he was trained in elopement procedures. Certified Nurse Aide E stated he was working in the facility on 9-14-22 when Resident #2 eloped from the facility. Certified Nurse Aide E stated he was told by another staff member that Resident #2 had left the facility and was next door at a grocery store. Certified Nurse Aide E stated he and Human Resources left the facility and began looking for Resident #2 and did not see her in the parking lot of the grocery store near the facility. Certified Nurse Aide E stated he looked across the busy street, located next to the facility, and saw Resident #2 across the street near the community hospital. Certified Nurse Aide E stated he and Human Resources ran across the street and up a side road and stopped Resident #2 near a county owned building. Certified Nurse Aide E stated Resident #2 was walking on the sidewalk next to the community hospital. Certified Nurse Aide E stated Resident #2 required the assistance of her walker to elope from the facility. Certified Nurse Aide E that at some unknown point Resident #2 had to have crossed the busy street located in front of the facility to end up in front of the community hospital. Certified Nurse Aide E stated the street in front of the facility was a busy street and there is traffic on it at all times of the day. Certified Nurse Aide E stated Resident #2 stated she left the facility because she was going to visit family. Certified Nurse Aide E and Human Resources had to cross the busy street and walked Resident #2 back to the facility which took about 10 minutes. Certified Nurse Aide E stated Resident #2 was assessed by the nursing staff. Certified Nurse Aide E stated Resident #2 lived in the non-secure part of the facility on the day she eloped. Certified Nurse Aide E stated Resident #2 had to have left the facility through the front door

Based on observation, interview and record review the facility failed to immediately consult with the resident's physician; and notify the resident representative when there was a deterioration in health with a need to commence a new treatment for two (2) of four (4) residents reviewed for notifications (Resident #1 and Resident #2). A) The facility failed to ensure that when Resident #1 developed pressure ulcers that the physician was notified (Resident #1 was found to have a previously unidentified Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling) to her sacral area on 03/04/2019.) The facility failed to notify Resident #1's physician of her pressure ulcers and failed to notify her physician when the pressure ulcer to her sacral area continued to decline which resulted in Resident #1's admission to the hospital on [DATE] with an infected Stage IV pressure ulcer (Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI.) with the bone exposed. Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 was also found to have a unstageable pressure ulcer to her right heel that was unidentified by the facility. B) The facility failed to ensure Resident #2's physician was notified when her Stage IV pressure ulcer declined on 03/21/2019 and failed to notify her physician when her Stage IV pressure ulcer continued without improvement and further decline until surveyor intervention on 04/08/2019. These failures resulted in an Immediate Jeopardy situation on 04/08/2019. While the IJ was removed on 04/09/2019, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures could cause severe pain, and lead to systemic infections causing harm or death for residents that have or are at risk for pressure ulcers. Findings: A) Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan dated 01/23/2019 reflected a problem I have the potential for skin breakdown due to decreased cognition and psych medications. Interventions included assess skin on a weekly basis and PRN (as needed) report any breakdown to MD (medical doctor) and RP (reasonable party). Encourage dietary. Fluid intake within dietary limits. Monitor for incontinence every two hours and PRN and change promptly. [MEDICATION NAME] powder to ABD (abdomen) folds BID (twice daily) PRN (as needed) redness. Provide pressure relieving and positioning devices on my bed as indicated. Review of Resident #1's Significant Change minimum data set ((MDS) dated [DATE] reflected Resident #1 was assessed to have a brief interview for mental status (BIMS) score of one (1) indicating severe cognitive impairment. Resident was assessed to require extensive assist in all areas of activities of daily living (ADL). Resident #1 was further assessed to have a 5% or more weight loss in the last month. Resident #1 was assessed to have a feeding tube. Resident #1 was assessed to not be at risk for pressure ulcers and was assessed to not have pressure ulcers. Review of Resident #1's Nursing progress note dated 02/28/2019 at 9:00 PM reflected Pt (patient) noted to have open area to both buttocks area cleansed and Allevyn (an absorbent foam) dressing applied, tolerating feeding with no problem. No physician notification was documented. Note was signed by LVN B. Review of Resident #1's Physician Telephone orders reflected no order written on 02/28/2019 for treatment of Resident's pressure ulcers. Review of Resident #1's Nursing Progress notes dated 03/02/2019 at 6:00 PM reflected area to buttock remains open, area cleansed and Allevyn applied to area, tolerating [DEVICE] feeding. (No physician notification documented) signed by LVN B. Review of Resident #1's Physician Telephone orders reflected an order written [REDACTED]. Signed by LVN B. In an interview on 04/08/2019 at 2:58 PM LVN B stated she found the pressure ulcers on Resident #1's buttock. LVN B stated she put ointment on the pressure ulcers on 02/28/2019. LVN B stated she did not call Resident #1's physician. When asked if she sent the physician any notification she stated she could not recall but if she faxed the doctor it would be in the chart. LVN B stated she wrote an order on 03/02/2019 for an Allevyn dressing for Resident #1 and that she wrote the order from the facility wound care protocol and did not contact the physician. LVN B stated she was not sure if she put the information regarding Resident #1's pressure ulcers on the 24-hour report. LVN B stated the Treatment Nurse took care of Resident #1's treatments when she came to work on Monday 03/04/2019. Review of Resident #1's Medical record reflected no fax notification to Resident #1's physician on 02/28/2019 or 03/02/2019. Review of the facility's 24-Hour report sheets dated 02/28/2019 through 03/02/2019 reflected no entries regarding resident's pressure ulcers or treatment. In an interview on 04/09/2019 at 11:34 PM CNA D stated she worked on Station III when she was scheduled to work which was at least five (5) times a week. CNA D stated Resident #1 had a sore on her coccyx (sacral) area when she moved to station III from the secured unit. CNA D stated Resident #1 would get up in a wheelchair, but she would not get her up every day because the sore on her bottom was getting so bad. CNA D stated Resident #1 moved to Station III in February, but she did not know the date. CNA D stated Resident #1 the sore on her bottom was small when she came to Station III. CNA D stated Resident #1 was not on an air mattress when she came to Station III. When asked if she told the nursing staff about Resident #1's sore she stated she did. CNA D stated she thought the nurses were treating the sore because Resident #1 would have a dressing on. When asked if she would find Resident #1 without a dressing to her sore she stated, yes a lot of times. CNA D stated Resident #1's sore kept getting worse and she would tell the treatment nurse. CNA D stated she did not know what treatment the Treatment nurse was doing but it was not helping. Review of Resident #1's Nursing progress notes reflected an entry on 02/13/2019 at 1:00 PM that reflected Resident #1 was moved from the secure unit to Station III. Review of Resident #1's Medical Record reflected no documentation of pressure ulcers prior to 02/28/2019 although CNA D indicated Resident #1 had a pressure ulcer on 2/13/2019. Review of the facility's Weekly Pressure Injury QI Log facility acquired dated 02/28/2019 reflected no entry for Resident #1. Review of Resident #1's Acute Pressure Ulcer Care plan dated 03/04/2019 reflected the following interventions Perform treatment per order, if no improvement within two weeks- report to M.D .Keep family/ responsible party, resident and M.D. (medical doctor) informed of resident progress .provide pressure reducing device for bed and chair LALM (low air loss mattress) . Review of Resident #1's Physician Telephone order dated 03/04/2019 reflected treatment orders for calcium Alginate Ag (a natural wound dressing derived from carbohydrate sources and are used on wounds that have a large amount of exudate.) and cover QOD and PRN. Further review reflected a treatment order Clean Stage III to sacrum with normal saline pat dry apply [MEDICATION NAME] gel (a broad-spectrum bactericidal hydrogel), Calcium Alginate Ag and cover with dressing QOD and PRN. Low Air loss Mattress. Review of the facility's Weekly Pressure Injury QI Log facility acquired dated 03/07/2019 reflected Resident #1 with Stage II pressure ulcers to her right and left buttock and a Stage III to her sacrum. Date listed as the pressure ulcer start date was 03/01/2019 and listed under M.D notified was 03/01/2019. In an interview and Record Review on 04/08/2019 at 11:45 AM the Treatment Nurse stated she did Resident #1's skin assessments weekly on Mondays. She stated she was in the facility on Friday 03/01/2019 but she did not assess Resident #1 until 3/4/2018. The Treatment Nurse stated she assessed Resident #1's pressure ulcers but did not call Resident #1's Physician because she assumed the LVN who found the wounds on 02/28/2019 did the notifications. The Treatment Nurse stated she did not follow up to see if the nurse notified the physician. The Treatment Nurse stated when she assessed Resident #1 on 03/04/2019 she had the two (2) stage II's and had a Stage III to her coccyx which were previously unidentified. While reviewing the weekly skin assessments with the treatment nurse (for Resident #1) it was noted that Resident #1 had a decline in the Stage III pressure ulcer to her sacrum on her next assessment on 03/14/2019. The pressure ulcer increased in size from 2 cm x 1.5 cm with 0.5cm depth to 2.7 cm x 1.5 cm x 0.5 cm. The Treatment nurse stated she did not notify the physician of the decline. The Treatment nurse stated the only time she notified Resident #1's physician of the Resident #1's pressure ulcers was on 03/18/2019. The Treatment Nurse handed the Surveyor a physician fax dated 03/18/2019. Review of the fax reflected the fax did not describe Resident #1's pressure ulcer and only reflected a request for a referral to wound care center. No other information on Resident #1's pressure ulcer was documented. The Treatment Nurse stated she made an appointment for Resident #1 to have a wound care consultation on 03/21/2019. Review of Resident #1's Stage III pressure ulcer measurements and assessment from 03/14/2019 to 3/21/2019 reflected Resident #1's pressure ulcer declined and increased in size to 6.5 cm x 4.5 cm with 1cm depth. In an interview on 04/08/2019 at 12:05 PM the Treatment nurse stated she did not notify Resident #1's Physician of the decline and Resident #1's order was not changed. When asked how she got the initial order for [MEDICATION NAME], and calcium Alginate if she did not contact the physician she stated she used the facility protocol. The Treatment Nurse stated Resident #1 was sent out of the facility on 03/21/2019 for the wound care consultation. The Treatment nurse stated Resident #1 was not on an air mattress until 03/5/2019 after pressure ulcers developed. The Treatment Nurse stated she wrote the order for the air mattress on 03/04/2019, but it was not available until 03/05/2019. The Treatment Nurse stated Resident #1 was having weight loss and was dependent on staff at that time which was a change for her. The Treatment nurse stated to her knowledge Resident #1 did not have a pressure reduction cushion in her wheelchair prior to pressure ulcer development. The Treatment Nurse was asked if she contacted Resident #1's Guardian with Resident #1's change of condition and pressure ulcers she stated she did not contact Resident #1's Guardian until 03/20/2019. When asked why she did not contact Resident #1's Physician or Guardian she stated, I try I am not perfect. The Treatment Nurse stated the Wound Care Physician stopped coming to the facility in (MONTH) (YEAR) and that was when she started having problems with the pressure ulcers. Review of Resident #1's Wound Care Consultation Report reflected Resident #1 was admitted to the hospital on [DATE]. The Wound Care Physician documented Patient is a [AGE] year-old female with history of dementia and immobility with Stage IV pressure ulceration. She was seen for initial visit 3/21 at the wound care center for initial visit regarding sacrum pressure ulceration. At the time the wound was unstageable it had purulent drainage, odor and feces in the wound bed. Patient had [MEDICAL CONDITION] fever of 101 degrees. We sent the patient to ER and she was admitted for [MEDICAL CONDITION]. Patient is trying to talk however it is hard to comprehend .Decubitus Ulcer Stage 4 (sacrum 10.1 x 13.2 x 4.4 cm undermining 10-4 o'clock 2.6 cm tunnel 3 o'clock 12.2 cm bone exposed, 95% granulation tissue present, unknown (meaning unstageable) (right heel 0.4 x 1.1 x 0.3 cm 100% eschar.) In an interview on 04/08/2019 at 8:20 AM Resident #1's Guardian stated Resident #1 was admitted to the hospital on [DATE] with a very dirty and infected pressure ulcer. Resident #1's Guardian stated she was not made aware Resident #1 had a pressure ulcer until it was a Stage III and they were needing to send her to the hospital. Resident #1's Guardian stated Resident #1 had a Stage IV pressure ulcer on admission to the hospital and required surgery as soon as she got to the hospital. Resident #1's Guardian further stated Resident #1 was septic. Resident #1's Guardian stated Resident #1 was transferred after surgery to a wound care specialty hospital with a wound vac. In an interview with Resident #1's Physicians Nurse on 04/08/2019 at 1:06 PM the Nurse stated Resident #1's Physician would be out of the office all week for a conference. The Nurse stated she would look through Resident #1's office records for notifications from the nursing facility. The Nurse stated she did not find any notifications for changes of condition or pressure ulcers that she just found standard nursing home visit notes. The Nurse stated she would leave a message for Resident #1's Physician to call Surveyor. (No return call was received prior to exit.) In an interview on 04/08/2019 at 3:23 PM the DON stated she knew about Resident #1's pressure ulcers she stated she did not know the treatment nurse was not notifying the doctor of her changes. The DON stated when a resident has a change of condition we usually meet as a team and go over residents with change in condition and what preventative measures are needed. The DON stated Resident #1 fell through the crakes with her preventive and ulcer care. The DON further stated she expected the treatment nurse to stay on top on changes in residents' wounds. The DON stated Resident #1 was placed in a wheelchair after she stopped eating, then she had a peg tube put in. The DON stated Resident #1 was in a decline and she expected staff to put interventions in place for prevention before pressure ulcers develop. The DON stated in regard to Resident #1 that the ball was dropped, there was no follow up because it was not on the 24-hour report sheet. B) Review of Resident #2's Face Sheet reflected a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #2's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score of 15 indicating she was cognitively intact. Resident was assessed to be dependent on staff for all areas of ADL's. Resident was assessed to be at risk for pressure ulcers and to have one (1) Stage 4 pressure ulcer. Review of Resident #2's Comprehensive Care Plan dated 04/04/2018 reflected Pressure ulcer .Left Ischium Stage 4 . Interventions included pressure reducing cushion to chair and mattress to bed. Pressure ulcer assessment and physician notification were not noted on the care plan as interventions. In an interview and observation on 04/08/2019 at 1:20 PM Resident #2 was in bed. Resident #2 was on an air mattress. Resident #2 stated she had a pressure ulcer. Resident #2 stated she did not know how her pressure ulcer was doing because the Treatment Nurse does not tell her if it is better or worse. Resident #2 stated it has been a long time since a doctor has seen her pressure ulcer. Resident #2 stated her pressure ulcer hurts sometimes. Resident #2 stated she had her treatment done early this morning. Resident #2 stated her physician came to the facility to see her, but he did not look at her pressure ulcer. In an interview on 04/09/2019 at 11:34 AM CNA D stated Resident #2 complained about her wound all the time. CNA D stated she helped the Treatment Nurse and stated she has seen Resident #2's pressure ulcer and it has not been getting any better. Review of Resident #2's Consolidated Physician order [REDACTED]. Review of the facility's Weekly Pressure Injury QI Log admitted With reflected Resident #2's pressure ulcer was assessed on 03/14/2019 to be a Stage 4 measuring 2.5cm x 3cm x 0.5 cm. Resident #2' pressure ulcer declined on 03/21/2019 to measure 3.5cm x 2.5cm x 0.6cm. (No physician notification was indicated on the log, under the physician notification column on the form the last date the physician was notified was 12/03/2019.) Review of Resident #2's Medical Record reflected a physician notification dated 12/03/2018. No description of the pressure ulcer was documented on the notification. The only information listed on the notification was Current treatment: wound vac. Recommended treatment: Collagen and calcium alginate, QOD and PRN soiled/ displaced. Review of Resident #2's Nursing Progress notes reflected an entry dated 04/02/2019 Resident in bed .removed dressing. Noted moderate serous drainage and 10%yellow slough and 90% granulation, Measurement 3.3 cm x 2.4 cm x 0.6 cm noted at 10:30 AM notified physician awaiting call back. In an interview on 04/08/2019 at 11:45 AM the Treatment Nurse stated she called and left a message for Resident #2's physician to call back regarding a decline in Resident #2's pressure ulcer. The Treatment Nurse stated she did not get a call back and stated, Unfortunately I did not follow up. In an interview on 04/08/2019 at 5:00 PM the DON stated she contacted Resident #2's Physician and got an order to send Resident #2 to the hospital for a wound consultation. In an interview on 04/08/2019 at 5:15 PM Resident #2 stated she was glad she was going to the hospital, she stated it had been a long time since a doctor has seen her pressure ulcer. Review of Resident #2's Hospital Record dated 04/08/2019 reflected Resident #2 was admitted with the primary [DIAGNOSES REDACTED]. The hospital records did not reflect measurements of Resident #2's pressure ulcer. In an interview on 04/09/2019 at 1:45 PM the DON stated When we lost the wound care doctor in (MONTH) we should have changed our way of thinking, we were used to having the physician see the wounds every week. We should have consulted the primary physicians for wound orders and consults. In an interview on 04/09/2019 at 1:50 PM the Administrator stated she expected the nurses to follow up and stay on top of the residents with pressure ulcers and unfortunately that did not happen. Review of the facility's Policy Change of Condition dated 07/2017 reflected To follow state and federal guidelines regarding a change of condition of a resident A significant change in the resident's physical .status, such as a deterioration in health. A need to alter treatment significantly .When a resident is noted to have a change in condition .conduct a thorough evaluation using the SBAR form (situation, background, appearance, review and notify) process .The attending physician should be notified by the charge nurse .if immediate attention is required and the attending physician is not available, call the alternate physician .if you are unable to reach this physician call the medical director .notify resident's representative . On 04/08/2019 at 4:35 PM the Administrator, DON, and Regional Director were notified the facility had an IJ situation for the above failures pressure sores. The following Plan of Removal Action Plan was submitted by the facility's Administrator on 04/09/2019 at 10:28 AM. Goal: To ensure treatment of pressure injuries that will result in healing. Goal: To prevent worsening of pressure injuries Approaches: -Obtain and carry out orders to direct admit Resident #2 to the hospital for wound care. - In-service licensed nurses on change of condition and physician notification per policy/procedure, as well as notification of administrative nurses, treatment nurse and Administrator to ensure all interventions, notifications and treatment needs are met. -Conduct head to toe skin assessments on all residents identified with pressure injuries to ensure current treatment orders are appropriate and to prevent worsening of pressure injuries. Physician will be notified when a deterioration in skin is noted for treatment change. -Obtain and carry out orders for pressure relieving devices to ensure prevention and healing of pressure areas. -In the event the Medical Director is unavailable, he will leave a designee and notify facility of their contact information to take call and follow up on issues as they arise. -Care planning of pressure injury prevention and treatment will be initiated immediately upon identification after assessment by licensed nursing staff and notification to physician, administrative nursing and Administrator. This action plan will be at least 70% complete as of 3:00 PM on 04/09/2019 and 100% by 10:30 PM on 04/09/2019. The POR was accepted by the Program Manager on 04/09/2019 at 10:53 AM Monitoring for the Plan of Removal began on 04/09/2019 at 11:00 AM and staff were interviewed for understanding regarding timely MD/RP notification for changes of condition and obtaining orders, monitoring for the development of pressure ulcers and monitoring the pressure ulcers weekly once they developed and notify MD/ RP of changes. The staff seemed to have a good understanding of the training. Resident #2 was sent to hospital for evaluation on 04/08/2019 at 5:50 AM. Resident #2 was admitted to the hospital for care. Approximately 90% of the staff had received their training. On 04/09/2019 at 3:30 PM the IJ was removed at exit. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interview, and record review the facility failed to ensure based on the comprehensive assessment that residents received care consistent with professional standards of practice and received treatment and services to prevent ulcers, promote healing, and prevent new ulcers from developing for two (2) of four (4) residents reviewed for pressure ulcer (Resident #1, and Resident #2). A) The facility failed to ensure Resident #1 was provided with pressure ulcer prevention measures when Resident #1 had a significant change of condition and decline which lead to Resident #1 developing pressure ulcers. The facility failed to ensure that when Resident #1 developed pressure ulcers that the physician was notified (Resident #1 was found to have a previously unidentified Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling) to her sacral area on 03/04/2019.) The facility failed to notify Resident #1's physician of her pressure ulcers and failed to notify her physician when the pressure ulcer to her sacral area continued to decline which resulted in Resident #1's admission to the hospital on [DATE] with an infected Stage IV pressure ulcer (Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI.) with the bone exposed. Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 was also found to have an unstageable pressure ulcer to her right heel that was unidentified by the facility. B) The facility failed ensure Resident #2's was physician was notified when her Stage IV pressure ulcer declined on 03/21/2019 and failed to notify her physician when her Stage IV pressure ulcer continued without improvement and further decline until surveyor intervention on 04/08/2019. These failures resulted in an Immediate Jeopardy situation on 04/08/2019. While the IJ was removed on 04/09/2019, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures could cause severe pain, and lead to systemic infections causing harm or death for residents that have or are at risk for pressure ulcers. Findings: A) Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan dated 01/23/2019 reflected a problem I have the potential for skin breakdown due to decreased cognition and psych medications. Interventions included assess skin on a weekly basis and PRN (as needed) report any breakdown to MD (medical doctor) and RP (reasonable party). Encourage dietary. Fluid intake within dietary limits. Monitor for incontinence every two hours and PRN and change promptly. [MEDICATION NAME] powder to ABD (abdomen) folds BID (twice daily) PRN (as needed) redness. Provide pressure relieving and positioning devices on my bed as indicated. Review of Resident #1's Significant Change minimum data set ((MDS) dated [DATE] reflected Resident #1 was assessed to have a brief interview for mental status (BIMS) score of one (1) indicating severe cognitive impairment. Resident was assessed to require extensive assist in all areas of activities of daily living (ADL). Resident #1 was further assessed to have a 5% or more weight loss in the last month. Resident #1 was assessed to have a feeding tube. Resident #1 was assessed to not be at risk for pressure ulcers and was assessed to not have pressure ulcers. Review of Resident #1's Nursing progress note dated 02/28/2019 at 9:00 PM reflected Pt (patient) noted to have open area to both buttocks area cleansed and Allevyn (an absorbent foam) dressing applied, tolerating feeding with no problem. No physician notification was documented. Note was signed by LVN B. Review of Resident #1's Physician Telephone orders reflected no order written on 02/28/2019 for treatment of [REDACTED]. Review of Resident #1's Nursing Progress notes dated 03/02/2019 at 6:00 PM reflected area to buttock remains open, area cleansed and Allevyn applied to area, tolerating [DEVICE] feeding. signed by LVN B. No physician notification was documented Review of Resident #1's Physician Telephone orders reflected an order written [REDACTED]. Signed by LVN B. In an interview on 04/08/2019 at 2:58 PM LVN B stated she found the pressure ulcers on Resident #1's buttock. LVN B stated she put ointment on the pressure ulcers on 02/28/2019. LVN B stated she did not call Resident #1's physician. When asked if she sent the physician any notification she stated she could not recall but if she faxed the doctor it would be in the chart. LVN B stated she wrote an order on 03/02/2019 for an Allevyn dressing for Resident #1 and that she wrote the order from the facility wound care protocol and did not contact the physician. LVN B stated she was not sure if she put the information regarding Resident #1's pressure ulcers on the 24-hour report. LVN B stated the Treatment Nurse took care of Resident #1's treatments when she came to work on Monday 03/04/2019. Review of Resident #1's Medical record reflected no fax notification to Resident #1's physician on 02/28/2019 or 03/02/2019. Review of the facility's 24-Hour report sheets dated 02/28/2019 through 03/02/2019 reflected no entries regarding resident's pressure ulcers or treatment. In an interview on 04/09/2019 at 11:34 PM CNA D stated she worked on Station III when she was scheduled to work which was at least five (5) times a week. CNA D stated Resident #1 had a sore on her coccyx (sacral) area when she moved to station III from the secured unit. CNA D stated Resident #1 would get up in a wheelchair, but she would not get her up every day because the sore on her bottom was getting so bad. CNA D stated Resident #1 moved to Station III in February, but she did not know the date. CNA D stated Resident #1 the sore on her bottom was small when she came to Station III. CNA D stated Resident #1 was not on an air mattress when she came to Station III. When asked if she told the nursing staff about Resident #1's sore she stated she did. CNA D stated she thought the nurses were treating the sore because Resident #1 would have a dressing on. When asked if she would find Resident #1 without a dressing to her sore she stated, yes a lot of times. CNA D stated Resident #1's sore kept getting worse and she would tell the treatment nurse. CNA D stated she did not know what treatment the Treatment nurse was doing but it was not helping. Review of Resident #1's Nursing progress notes reflected an entry on 02/13/2019 at 1:00 PM that reflected Resident #1 was moved from the secure unit to Station III. Review of Resident #1's Medical Record reflected no documentation of pressure ulcers prior to 02/28/2019 although CNA D indicated Resident #1 had a pressure ulcer on 2/13/2019. Review of the facility's Weekly Pressure Injury QI Log facility acquired dated 02/28/2019 reflected no entry for Resident #1. Review of Resident #1's Acute Pressure Ulcer Care plan dated 03/04/2019 reflected the following interventions Perform treatment per order, if no improvement within two weeks- report to M.D .Keep family/ responsible party, resident and M.D. (medical doctor) informed of resident progress .provide pressure reducing device for bed and chair LALM (low air loss mattress) . Review of Resident #1's Physician Telephone order dated 03/04/2019 reflected treatment orders for calcium Alginate Ag (a natural wound dressing derived from carbohydrate sources and are used on wounds that have a large amount of exudate.) and cover QOD and PRN. Further review reflected a treatment order Clean Stage III to sacrum with normal saline pat dry apply [MEDICATION NAME] gel (a broad-spectrum bactericidal hydrogel), Calcium Alginate Ag and cover with dressing QOD and PRN. Low Air loss Mattress. Review of the facility's Weekly Pressure Injury QI Log facility acquired dated 03/07/2019 reflected Resident #1 with Stage II pressure ulcers to her right and left buttock and a Stage III to her sacrum. Date listed as the pressure ulcer start date was 03/01/2019 and listed under M.D notified was 03/01/2019. In an interview and Record Review on 04/08/2019 at 11:45 AM the Treatment Nurse stated she did Resident #1's skin assessments weekly on Mondays. She stated she was in the facility on Friday 03/01/2019 but she did not assess Resident #1 until 3/4/2018. The Treatment Nurse stated she assessed Resident #1's pressure ulcers but did not call Resident #1's Physician because she assumed the LVN who found the wounds on 02/28/2019 did the notifications. The Treatment Nurse stated she did not follow up to see if the nurse notified the physician. The Treatment Nurse stated when she assessed Resident #1 on 03/04/2019 she had the two (2) stage II's and had a Stage III to her coccyx which were previously unidentified. While reviewing the weekly skin assessments with the treatment nurse (for Resident #1) it was noted that Resident #1 had a decline in the Stage III pressure ulcer to her sacrum on her next assessment on 03/14/2019. The pressure ulcer increased in size from 2 cm x 1.5 cm with 0.5cm depth to 2.7 cm x 1.5 cm x 0.5 cm. The Treatment nurse stated she did not notify the physician of the decline. The Treatment nurse stated the only time she notified Resident #1's physician of the Resident #1's pressure ulcers was on 03/18/2019. The Treatment Nurse handed the Surveyor a physician fax dated 03/18/2019. Review of the fax reflected the fax did not describe Resident #1's pressure ulcer and only reflected a request for a referral to wound care center. No other information on Resident #1's pressure ulcer was documented. The Treatment Nurse stated she made an appointment for Resident #1 to have a wound care consultation on 03/21/2019. Review of Resident #1's Stage III pressure ulcer measurements and assessment from 03/14/2019 to 3/21/2019 reflected Resident #1's pressure ulcer declined and increased in size to 6.5 cm x 4.5 cm with 1cm depth. In an interview on 04/08/2019 at 12:05 PM the Treatment nurse stated she did not notify Resident #1's Physician of the decline and Resident #1's order was not changed. When asked how she got the initial order for [MEDICATION NAME], and calcium Alginate if she did not contact the physician she stated she used the facility protocol. The Treatment Nurse stated Resident #1 was sent out of the facility on 03/21/2019 for the wound care consultation. The Treatment nurse stated Resident #1 was not on an air mattress until 03/5/2019 after pressure ulcers developed. The Treatment Nurse stated she wrote the order for the air mattress on 03/04/2019, but it was not available until 03/05/2019. The Treatment Nurse stated Resident #1 was having weight loss and was dependent on staff at that time which was a change for her. The Treatment nurse stated to her knowledge Resident #1 did not have a pressure reduction cushion in her wheelchair prior to pressure ulcer development. The Treatment Nurse was asked if she contacted Resident #1's Guardian with Resident #1's change of condition and pressure ulcers she stated she did not contact Resident #1's Guardian until 03/20/2019. When asked why she did not contact Resident #1's Physician or Guardian she stated, I try I am not perfect. The Treatment Nurse stated the Wound Care Physician stopped coming to the facility in (MONTH) (YEAR) and that was when she started having problems with the pressure ulcers. Review of Resident #1's Wound Care Consultation Report reflected Resident #1 was admitted to the hospital on [DATE]. The Wound Care Physician documented Patient is a [AGE] year-old female with history of dementia and immobility with Stage IV pressure ulceration. She was seen for initial visit 3/21 at the wound care center for initial visit regarding sacrum pressure ulceration. At the time the wound was unstageable it had purulent drainage, odor and feces in the wound bed. Patient had [MEDICAL CONDITION] fever of 101 degrees. We sent the patient to ER and she was admitted for [MEDICAL CONDITION]. Patient is trying to talk however it is hard to comprehend .Decubitus Ulcer Stage 4 (sacrum 10.1 x 13.2 x 4.4 cm undermining 10-4 o'clock 2.6 cm tunnel 3 o'clock 12.2 cm bone exposed, 95% granulation tissue present, unknown (meaning unstageable) (right heel 0.4 x 1.1 x 0.3 cm 100% eschar.) In an interview on 04/08/2019 at 8:20 AM Resident #1's Guardian stated Resident #1 was admitted to the hospital on [DATE] with a very dirty and infected pressure ulcer. Resident #1's Guardian stated she was not made aware Resident #1 had a pressure ulcer until it was a Stage III and they were needing to send her to the hospital. Resident #1's Guardian stated Resident #1 had a Stage IV pressure ulcer on admission to the hospital and required surgery as soon as she got to the hospital. Resident #1's Guardian further stated Resident #1 was septic. Resident #1's Guardian stated Resident #1 was transferred after surgery to a wound care specialty hospital with a wound vac. In an interview with Resident #1's Physicians Nurse on 04/08/2019 at 1:06 PM the Nurse stated Resident #1's Physician would be out of the office all week for a conference. The Nurse stated she would look through Resident #1's office records for notifications from the nursing facility. The Nurse stated she did not find any notifications for changes of condition or pressure ulcers that she just found standard nursing home visit notes. The Nurse stated she would leave a message for Resident #1's Physician to call Surveyor. (No return call was received prior to exit.) In an interview on 04/08/2019 at 3:23 PM the DON stated she knew about Resident #1's pressure ulcers she stated she did not know the treatment nurse was not notifying the doctor of her changes. The DON stated when a resident has a change of condition we usually meet as a team and go over residents with change in condition and what preventative measures are needed. The DON stated Resident #1 fell through the crakes with her preventive and ulcer care. The DON further stated she expected the treatment nurse to stay on top on changes in residents' wounds. The DON stated Resident #1 was placed in a wheelchair after she stopped eating, then she had a peg tube put in. The DON stated Resident #1 was in a decline and she expected staff to put interventions in place for prevention before pressure ulcers develop. The DON stated in regard to Resident #1 that the ball was dropped, there was no follow up because it was not on the 24-hour report sheet. B) Review of Resident #2's Face Sheet reflected a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #2's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score of 15 indicating she was cognitively intact. Resident was assessed to be dependent on staff for all areas of ADL's. Resident was assessed to be at risk for pressure ulcers and to have one (1) Stage 4 pressure ulcer. Review of Resident #2's Comprehensive Care Plan dated 04/04/2018 reflected Pressure ulcer .Left Ischium Stage 4 . Interventions included pressure reducing cushion to chair and mattress to bed. Pressure ulcer assessment and physician notification were not noted on the care plan as interventions. In an interview and observation on 04/08/2019 at 1:20 PM Resident #2 was in bed. Resident #2 was on an air mattress. Resident #2 stated she had a pressure ulcer. Resident #2 stated she did not know how her pressure ulcer was doing because the Treatment Nurse does not tell her if it is better or worse. Resident #2 stated it has been a long time since a doctor has seen her pressure ulcer. Resident #2 stated her pressure ulcer hurts sometimes. Resident #2 stated she had her treatment done early this morning. Resident #2 stated her physician came to the facility to see her, but he did not look at her pressure ulcer. In an interview on 04/09/2019 at 11:34 AM CNA D stated Resident #2 complained about her wound all the time. CNA D stated she helped the Treatment Nurse and stated she (CNA D) had seen Resident #2's pressure ulcer and it has not been getting any better. Review of Resident #2's Consolidated Physician order [REDACTED]. Review of the facility's Weekly Pressure Injury QI Log admitted With reflected Resident #2's pressure ulcer was assessed on 03/14/2019 to be a Stage 4 measuring 2.5cm x 3cm x 0.5 cm. Resident #2' pressure ulcer declined on 03/21/2019 to measure 3.5cm x 2.5cm x 0.6cm. (No physician notification was indicated on the log, under the physician notification column on the form the last date the physician was notified was 12/03/2019.) Review of Resident #2's Medical Record reflected a physician notification dated 12/03/2018. No description of the pressure ulcer was documented on the notification. The only information listed on the notification was Current treatment: wound vac. Recommended treatment: Collagen and calcium alginate, QOD and PRN soiled/ displaced. Review of Resident #2's Nursing Progress notes reflected an entry dated 04/02/2019 Resident in bed .removed dressing. Noted moderate serous drainage and 10%yellow slough and 90% granulation, Measurement 3.3 cm x 2.4 cm x 0.6 cm noted at 10:30 AM notified physician awaiting call back. In an interview on 04/08/2019 at 11:45 AM the Treatment Nurse stated she called and left a message for Resident #2's physician to call back regarding a decline in Resident #2's pressure ulcer. The Treatment Nurse stated she did not get a call back and stated, Unfortunately I did not follow up. In an interview on 04/08/2019 at 5:00 PM the DON stated she contacted Resident #2's Physician and got an order to send Resident #2 to the hospital for a wound consultation. In an interview on 04/08/2019 at 5:15 PM Resident #2 stated she was glad she was going to the hospital, she stated it had been a long time since a doctor has seen her pressure ulcer. Review of Resident #2's Hospital Record dated 04/08/2019 reflected Resident #2 was admitted with the primary [DIAGNOSES REDACTED]. The hospital records did not reflect measurements of Resident #2's pressure ulcer. In an interview on 04/09/2019 at 1:45 PM the DON stated When we lost the wound care doctor in (MONTH) we should have changed our way of thinking, we were used to having the physician see the wounds every week. We should have consulted the primary physicians for wound orders and consults. In an interview on 04/09/2019 at 1:50 PM the Administrator stated she expected the nurses to follow up and stay on top of the residents with pressure ulcers and unfortunately that did not happen. Review of the facility's Policy Change of Condition dated 07/2017 reflected To follow state and federal guidelines regarding a change of condition of a resident A significant change in the resident's physical .status, such as a deterioration in health. A need to alter treatment significantly .When a resident is noted to have a change in condition .conduct a thorough evaluation using the SBAR form (situation, background, appearance, review and notify) process .The attending physician should be notified by the charge nurse .if immediate attention is required and the attending physician is not available, call the alternate physician .if you are unable to reach this physician call the medical director .notify resident's representative . On 04/08/2019 at 4:35 PM the Administrator, DON, and Regional Director were notified the facility had an IJ situation for the above failures pressure sores. The following Plan of Removal Action Plan was submitted by the facility's Administrator on 04/09/2019 at 10:28 AM. Goal: To ensure treatment of [REDACTED]. Goal: To prevent worsening of pressure injuries Approaches: -Obtain and carry out orders to direct admit Resident #2 to the hospital for wound care. - In-service licensed nurses on change of condition and physician notification per policy/procedure, as well as notification of administrative nurses, treatment nurse and Administrator to ensure all interventions, notifications and treatment needs are met. -Conduct head to toe skin assessments on all residents identified with pressure injuries to ensure current treatment orders are appropriate and to prevent worsening of pressure injuries. Physician will be notified when a deterioration in skin is noted for treatment change. -Obtain and carry out orders for pressure relieving devices to ensure prevention and healing of pressure areas. -In the event the Medical Director is unavailable, he will leave a designee and notify facility of their contact information to take call and follow up on issues as they arise. -Care planning of pressure injury prevention and treatment will be initiated immediately upon identification after assessment by licensed nursing staff and notification to physician, administrative nursing and Administrator. This action plan will be at least 70% complete as of 3:00 PM on 04/09/2019 and 100% by 10:30 PM on 04/09/2019. The POR was accepted by the Program Manager on 04/09/2019 at 10:53 AM Monitoring for the Plan of Removal began on 04/09/2019 at 11:00 AM and staff were interviewed for understanding regarding timely MD/RP notification for changes of condition and obtaining orders, monitoring for the development of pressure ulcers and monitoring the pressure ulcers weekly once they developed and notify MD/ RP of changes. The staff seemed to have a good understanding of the training. Resident #2 was sent to hospital for evaluation on 04/08/2019 at 5:50 AM. Resident #2 was admitted to the hospital for care. Approximately 90% of the staff had received their training. On 04/09/2019 at 3:30 PM the IJ was removed at exit. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit neglect for one (1) of nine (9) residents reviewed for neglect. (Resident #1). LVN A, the facility's charge nurse, failed to transfer Resident #1 from the facility to the local hospital emergency department in a timely manner as ordered by the Resident's Primary Care Physician (PCP). LVN A contacted local Emergency Medical Services 2 hours and 18 minutes after receiving the telephone order for transfer. On arrival at the emergency room , physicians diagnosed the resident as having incurred a [MEDICAL CONDITIONS]. This deficient practice could place 79 residents at risk for delayed emergency care resulting in increased injury or death. Findings Included: Review of the facility's Policy and Procedure for Abuse and Neglect Abuse-Reportable Events (Texas Homes) dated 01/2008 reflected Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility's Policy and Procedure for Emergency Care-Emergency Transport-911 Protocol dated 03/2012 reflected: If resident's condition has changed, call attending physician and report changes and nursing observations. Provide emergency care as necessary. 911 Emergency Transport will be called when a resident is found to have experienced a change of condition indicating life threatening event occurred or the resident shows signs that impending life threatening event is suspected. Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted [DATE] and readmitted [DATE]. Diagnoses' included [MEDICAL CONDITION], Type 2 Diabetes, Hypertension, [MEDICAL CONDITION] Disorder, Dementia and Anxiety State. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment reflected a Brief Interview for Mental Status (BIMS) score of four (4) indicating severe cognitive impairment. Diagnoses' included Hypertension. Review of Resident #1's Comprehensive Plan of Care dated 03/27/14 reflected the resident required Total Assistance with the assistance of one (1) person for all Activities of Daily Living. Review of Resident #2's Comprehensive Plan of Care dated 03/27/14 reflected a Problem/Need of history of hypertension. Observation of Resident #1 on 06/05/15 at 8:32 AM revealed the resident in bed. The resident's eyes were open and staring at the ceiling of her room. The resident did not respond either verbally or physically to the surveyor's questions. In an interview on 06/05/15 at 8:38 AM the Director of Nursing (DON) stated Resident #1 had been able to speak and was able to be heard all the way down the hallway when she spoke to staff at the nurse's station. The DON further stated that on 05/24/15 (time unknown) Resident #1 experienced shortness of breath and was unable to maintain viable O2 sats. (Percentage of Oxygen in the bloodstream). The resident was sent to the local hospital for evaluation and treatment. Prior to the incident the resident was able to eat meals by mouth with only some coaxing required at times. After the resident's return to the facility the resident received bolus feeding only by way of a gastrostomy tube. (feeding tube). In an interview on 06/05/15 at 9:05 AM LVN A stated he started his shift on 05/24/15 at 2:00 PM and noted Resident #1 to show no signs or symptoms of a change in condition at that time. LVN A further stated he initially became aware of a change in Resident #1's condition when he observed that the Resident had a poor appetite during the evening meal at 5:00 PM. The resident was also experiencing difficulty in responding to facility staff at that time. LVN A further stated Normally, she was very talkative. The LVN further stated he notified the resident's responsible party (RP) as well as her Primary Care Physician (PCP) at 5:15 PM. The PCP ordered the resident to be transferred to the local hospital's emergency room for evaluation. LVN A then called Emergency Medical Services (EMS) at 5:30 PM and requested a transport for the resident. The LVN then called the emergency room at the hospital and provided a report of the resident ' s status. EMS arrived at the facility at 6:15 PM. The LVN could not recall what time EMS left with the Resident. Review of Resident #1's Physician order [REDACTED]. to (local hospital) ER for evaluation. Review of Resident #1's Nurse's Notes dated 05/24/15 at 5:15 PM reflected Pt. (patient) noted to have poor meal intake. Pt. noted to have difficulty responding to staff and difficulty to arouse. (PCP) notified. Received order to transfer to (local hospital). Review of Resident #1's Nurse's Notes dated 05/24/15 at 5:30 PM reflected Report called to (emergency room employee) at (hospital) ER (emergency room ). Review of Resident #1's Nurse's Notes dated 05/24/15 at 6:15 PM reflected EMS here for pt. transport to hospital. Pt. RP (Responsible Party) notified of transfer. Review of Resident #1's computer printout of the local EMS Patient Care Record reflected EMS was contacted by facility staff on 05/24/15 at 7:33 PM (Two Hours and Eighteen Minutes after LVN A stated he had received the transfer order). The ambulance arrived at the facility at 8:11 PM (One Hour and Eighteen Minutes later than the time of arrival stated by LVN A). Narrative notes on the same Patient Care Record reflected Arrived to find 78 y/o female lying in bed in distress Pt. has GCS (Glasgow Coma Scale) of 11. (Indicating Moderate Brain Impairment) Pt. has O2 (Oxygen) sat of 89% on room air. Pt. placed on O2 via NRB (Non-Rebreather Mask) at 14 lpm (liters per minute). Pt. placed on monitor. Sinus [MEDICAL CONDITION]@ 102 bpm (beats per minute). IV established. Noticeable left-sided facial droop and weakness in upper left extremity. Review of Resident #1's Emergency Department Physician Documentation dated 05/24/15 at 10:28 PM reflected a preliminary [DIAGNOSES REDACTED]. Review of the website: <https://www.cayugamed.org/content.cfm?page=library&articleID=217&topicID=42> reflected Stroke is the third leading cause of death in the U.S. and the number one cause of adult disability. Of the people who survive stroke, 90 percent have a deficit. However, if you suffer an ischemic stroke and you get to the Emergency Department within two hours, you may receive medication that will dissolve the clot and minimize brain damage. In an interview on 06/05/15 at 1:52 PM LVN A stated he could not explain the time discrepancies between his nurse's notes dated 05/24/15 and the EMS computer printout of the Patient Care Record of the same date. In an interview on 06/05/15 at 2:58 PM the Director of Nursing (DON) stated her expectations of nursing staff, when changes of condition are observed, were for the staff to assess the Resident, notify the Resident's PCP, and follow any orders from the PCP accordingly and in a timely manner. If the change of condition is emergent in nature, the facility nurse can call 911 without delay rather than waiting for a physician's orders [REDACTED].>In an interview on 06/08/15 at 12:30 PM the Director of Nursing (DON) stated potential results of a staff member failing to immediately follow physician orders [REDACTED]. In an interview on 06/08/15 at 1:25 PM Resident #1's Primary Care Physician (PCP) stated his standard of expectations was for all orders he writes or telephones to a facility were to be followed immediately. When caring for a resident suspected of experiencing a [MEDICAL CONDITION], time is critical. When I am in the emergency room and we have a patient come in that we suspect is having a stroke we like to know specifically when the stroke began in order to best treat the patient. The PCP further stated failure to rapidly treat a resident experiencing [MEDICAL CONDITION] increased the chance for increased complications and death. The facility Administrator provided a census list of 79 residents.

Based on observation, interview, and record review the facility failed to ensure staff provided services that met professional standards of quality for one (1) of nine (9) residents reviewed for professional standards. (Resident #1). LVN A, the facility's charge nurse, failed to transfer Resident #1 from the facility to the local hospital emergency department in a timely manner as ordered by the Resident's Primary Care Physician (PCP). LVN A contacted local Emergency Medical Services 2 hours and 18 minutes after receiving the telephone order for transfer. On arrival at the emergency room , physicians diagnosed the resident as having incurred a [MEDICAL CONDITIONS]. This deficient practice could place 79 residents at risk for delayed emergency care resulting in increased injury or death. Findings Included: Review of Texas Administrative Code Title 22 Examining Boards, Part 11 Texas Board of Nursing, Chapter 217 Licensure, Peer Assistance and Practice, Rule 217.11 Standards of Nursing Practice reflected: All vocational nurses, registered nurses, and registered nurses with advanced practice authorization shall: Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications. Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted [DATE] and readmitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment reflected a Brief Interview for Mental Status (BIMS) score of four (4) indicating severe cognitive impairment. Diagnoses' included Hypertension. Review of Resident #1's Comprehensive Plan of Care dated 03/27/14 reflected the resident required Total Assistance with the assistance of one (1) person for all Activities of Daily Living. Review of Resident #2's Comprehensive Plan of Care dated 03/27/14 reflected a Problem/Need of history of hypertension. Observation of Resident #1 on 06/05/15 at 8:32 AM revealed the resident in bed. The resident's eyes were open and staring at the ceiling of her room. The resident did not respond either verbally or physically to the surveyor's questions. In an interview on 06/05/15 at 8:38 AM the Director of Nursing (DON) stated Resident #1 had been able to speak and was able to be heard all the way down the hallway when she spoke to staff at the nurse's station. The DON further stated that on 05/24/15 (time unknown) Resident #1 experienced shortness of breath and was unable to maintain viable O2 sats. (Percentage of Oxygen in the bloodstream). The resident was sent to the local hospital for evaluation and treatment. Prior to the incident the resident was able to eat meals by mouth with only some coaxing required at times. After the resident's return to the facility the resident received bolus feeding only by way of a gastrostomy tube. (feeding tube). In an interview on 06/05/15 at 9:05 AM LVN A stated he started his shift on 05/24/15 at 2:00 PM and noted Resident #1 to show no signs or symptoms of a change in condition at that time. LVN A further stated he initially became aware of a change in Resident #1's condition when he observed that the Resident had a poor appetite during the evening meal at 5:00 PM. The resident was also experiencing difficulty in responding to facility staff at that time. LVN A further stated Normally, she was very talkative. The LVN further stated he notified the resident's responsible party (RP) as well as her Primary Care Physician (PCP) at 5:15 PM. The PCP ordered the resident to be transferred to the local hospital ' s emergency room for evaluation. LVN A then called Emergency Medical Services (EMS) at 5:30 PM and requested a transport for the resident. The LVN then called the emergency room at the hospital and provided a report of the resident's status. EMS arrived at the facility at 6:15 PM. The LVN could not recall what time EMS left with the Resident. Review of Resident #1's Physician order [REDACTED]. to (local hospital) ER for evaluation. Review of Resident #1's Nurse's Notes dated 05/24/15 at 5:15 PM reflected Pt. (patient) noted to have poor meal intake. Pt. noted to have difficulty responding to staff and difficulty to arouse. (PCP) notified. Received order to transfer to (local hospital). Review of Resident #1's Nurse's Notes dated 05/24/15 at 5:30 PM reflected Report called to (emergency room employee) at (hospital) ER (emergency room ). Review of Resident #1's Nurse's Notes dated 05/24/15 at 6:15 PM reflected EMS here for pt. transport to hospital. Pt. RP (Responsible Party) notified of transfer. Review of Resident #1's computer printout of the local EMS Patient Care Record reflected EMS was contacted by facility staff on 05/24/15 at 7:33 PM (Two Hours and Eighteen Minutes after LVN A stated he had received the transfer order). The ambulance arrived at the facility at 8:11 PM (One Hour and Eighteen Minutes later than the time of arrival stated by LVN A). Narrative notes on the same Patient Care Record reflected Arrived to find 78 y/o female lying in bed in distress Pt. has GCS (Glasgow Coma Scale) of 11. (Indicating Moderate Brain Impairment) Pt. has O2 (Oxygen) sat of 89% on room air. Pt. placed on O2 via NRB (Non-Rebreather Mask) at 14 lpm (liters per minute). Pt. placed on monitor. Sinus [MEDICAL CONDITION]@ 102 bpm (beats per minute). IV established. Noticeable left-sided facial droop and weakness in upper left extremity. Review of Resident #1's Emergency Department Physician Documentation dated 05/24/15 at 10:28 PM reflected a preliminary [DIAGNOSES REDACTED]. Review of the website: <https://www.cayugamed.org/content.cfm?page=library&articleID=217&topicID=42> reflected Stroke is the third leading cause of death in the U.S. and the number one cause of adult disability. Of the people who survive stroke, 90 percent have a deficit. However, if you suffer an ischemic stroke and you get to the Emergency Department within two hours, you may receive medication that will dissolve the clot and minimize brain damage. In an interview on 06/05/15 at 1:52 PM LVN A stated he could not explain the time discrepancies between his nurse's notes dated 05/24/15 and the EMS computer printout of the Patient Care Record of the same date. In an interview on 06/05/15 at 2:58 PM the Director of Nursing (DON) stated her expectations of nursing staff, when changes of condition are observed, were for the staff to assess the Resident, notify the Resident's PCP, and follow any orders from the PCP accordingly and in a timely manner. If the change of condition is emergent in nature, the facility nurse can call 911 without delay rather than waiting for a physician's orders [REDACTED].>In an interview on 06/08/15 at 12:30 PM the Director of Nursing (DON) stated potential results of a staff member failing to immediately follow physician orders [REDACTED]. In an interview on 06/08/15 at 1:25 PM Resident #1's Primary Care Physician (PCP) stated his standard of expectations was for all orders he writes or telephones to a facility were to be followed immediately . When caring for a resident suspected of experiencing a [MEDICAL CONDITION], time is critical. When I am in the emergency room and we have a patient come in that we suspect is having a stroke we like to know specifically when the stroke began in order to best treat the patient. The PCP further stated failure to rapidly treat a resident experiencing [MEDICAL CONDITION] increased the chance for increased complications and death. Review of the facility's Policy and Procedure for Emergency Care-Emergency Transport-911 Protocol dated 03/2012 reflected: If resident's condition has changed, call attending physician and report changes and nursing observations. Provide emergency care as necessary. 911 Emergency Transport will be called when a resident is found to have experienced a change of condition indicating life threatening event occurred or the resident shows signs that impending life threatening event is suspected. Review of the facility's Policy and Procedure for Abuse and Neglect Abuse-Reportable Events (Texas Homes) dated 01/2008 reflected Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility Administrator provided a census list of 79 residents.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect for one (1) of nine (9) residents reviewed for neglect. (Resident #1). LVN A, the facility's shift charge nurse, failed to transfer Resident #1 from the facility to the local hospital emergency department in a timely manner as ordered by the Resident's Primary Care Physician (PCP). LVN A contacted local Emergency Medical Services 2 hours and 18 minutes after receiving the telephone order for transfer. On arrival at the emergency room , physicians diagnosed the resident as having incurred a [MEDICAL CONDITIONS]. This deficient practice could place 79 residents at risk for delayed emergency care resulting in increased injury or death. Findings Included: Review of Resident # 1's Face Sheet reflected a [AGE] year old female admitted [DATE] and readmitted [DATE]. Diagnoses' included [MEDICAL CONDITION], Type 2 Diabetes, Hypertension, [MEDICAL CONDITION] Disorder, Dementia and Anxiety State. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment reflected a Brief Interview for Mental Status (BIMS) score of four (4) indicating severe cognitive impairment. Diagnoses' included Hypertension. Review of Resident #1's Comprehensive Plan of Care dated 03/27/14 reflected the resident required Total Assistance with the assistance of one (1) person for all Activities of Daily Living. Review of Resident #2's Comprehensive Plan of Care dated 03/27/14 reflected a Problem/Need of history of hypertension. Observation of Resident #1 on 06/05/15 at 8:32 AM revealed the resident in bed. The resident's eyes were open and staring at the ceiling of her room. The resident did not respond either verbally or physically to the surveyor's questions. In an interview on 06/05/15 at 9:05 AM LVN A stated he started his shift on 05/24/15 at 2:00 PM and noted Resident #1 to show no signs or symptoms of a change in condition at that time. LVN A further stated he initially became aware of a change in Resident #1's condition when he observed that the Resident had a poor appetite during the evening meal at 5:00 PM. The resident was also experiencing difficulty in responding to facility staff at that time. LVN A further stated Normally, she was very talkative. LVN A further stated he notified the resident ' s responsible party (RP) as well as her Primary Care Physician (PCP) at 5:15 PM. The PCP ordered the resident to be transferred to the local hospital ' s emergency room for evaluation. LVN A then stated he called Emergency Medical Services (EMS) at 5:30 PM and requested a transport for the resident. LVN A stated he then called the emergency room at the hospital and provided a report of the resident's status. LVN A stated EMS arrived at the facility at 6:15 PM. The LVN could not recall what time EMS left with the Resident. Review of Resident #1's Physician order [REDACTED]. to (local hospital) ER for evaluation. Review of Resident #1's Nurse's Notes dated 05/24/15 at 5:15 PM reflected Pt. (patient) noted to have poor meal intake. Pt. noted to have difficulty responding to staff and difficulty to arouse. (PCP) notified. Received order to transfer to (local hospital). Review of Resident #1's Nurse ' s Notes dated 05/24/15 at 5:30 PM reflected Report called to (emergency room employee) at (hospital) ER (emergency room ). Review of Resident #1's Nurse ' s Notes dated 05/24/15 at 6:15 PM reflected EMS here for pt. transport to hospital. Pt. RP (Responsible Party) notified of transfer. Review of Resident #1's computer printout of the local EMS Patient Care Record reflected EMS was contacted by facility staff on 05/24/15 at 7:33 PM (Two Hours and Eighteen Minutes after LVN A stated he had received the transfer order). The ambulance arrived at the facility at 8:11 PM (One Hour and Eighteen Minutes later than the time of arrival stated by LVN A). Narrative notes on the same Patient Care Record reflected Arrived to find 78 y/o female lying in bed in distress Pt. has GCS (Glasgow Coma Scale) of 11. (Indicating Moderate Brain Impairment) Pt. has O2 (Oxygen) sat of 89% on room air. Pt. placed on O2 via NRB (Non-Rebreather Mask) at 14 lpm (liters per minute). Pt. placed on monitor. Sinus [MEDICAL CONDITION]@ 102 bpm (beats per minute). IV established. Noticeable left-sided facial droop and weakness in upper left extremity. Review of Resident #1's Emergency Department Physician Documentation dated 05/24/15 at 10:28 PM reflected a preliminary [DIAGNOSES REDACTED]. Review of the website: <https://www.cayugamed.org/content.cfm?page=library&articleID=217&topicID=42> reflected Stroke is the third leading cause of death in the U.S. and the number one cause of adult disability. Of the people who survive stroke, 90 percent have a deficit. However, if you suffer an ischemic stroke and you get to the Emergency Department within two hours, you may receive medication that will dissolve the clot and minimize brain damage. In an interview on 06/05/15 at 8:38 AM the Director of Nursing (DON) stated Resident #1 had been able to speak and was able to be heard all the way down the hallway when she spoke to staff at the nurse's station. The DON further stated that on 05/24/15 (time unknown) Resident #1 experienced shortness of breath and could not maintain viable O2 sats. (Percentage of Oxygen in the bloodstream). The resident was sent to the local hospital for evaluation and treatment. Prior to the incident the resident was able to eat meals by mouth with only some coaxing required at times. After the resident's return to the facility the resident received bolus feeding only by way of a gastrostomy tube. (feeding tube). In an interview on 06/05/15 at 1:52 PM LVN A stated he could not explain the time discrepancies between his nurse's notes dated 05/24/15 and the EMS computer printout of the Patient Care Record of the same date. In an interview on 06/05/15 at 2:58 PM the DON stated her expectations of nursing staff, when changes of condition are observed, were for the staff to assess the Resident, notify the Resident's PCP, and follow any orders from the PCP accordingly and in a timely manner. If the change of condition is emergent in nature, the facility nurse can call 911 without delay rather than waiting for a physician's orders [REDACTED].>In an interview on 06/08/15 at 12:30 PM the Director of Nursing (DON) stated potential results of a staff member failing to immediately follow physician orders [REDACTED]. In an interview on 06/08/15 at 1:25 PM Resident #1's Primary Care Physician (PCP) stated his standard of expectations was for all orders he writes or telephones to a facility were to be followed immediately . The PCP statd when caring for a resident suspected of experiencing a [MEDICAL CONDITION], time is critical. When I am in the emergency room and we have a patient come in that we suspect is having a stroke we like to know specifically when the stroke began in order to best treat the patient. The PCP further stated failure to rapidly treat a resident experiencing [MEDICAL CONDITION] increased the chance for increased complications and death. Review of the facility's Policy and Procedure for Emergency Care-Emergency Transport-911 Protocol dated 03/2012 reflected: If resident's condition has changed, call attending physician and report changes and nursing observations. Provide emergency care as necessary. 911 Emergency Transport will be called when a resident is found to have experienced a change of condition indicating life threatening event occurred or the resident shows signs that impending life threatening event is suspected. Review of the facility's Policy and Procedure for Abuse and Neglect Abuse-Reportable Events (Texas Homes) dated 01/2008 reflected Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility Administrator provided a census list of 79 residents.

Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practible physical, mental, and psychosocial well-being for one (1) of nine (9) residents reviewed for quality of care. (Resident #1). LVN A, the facility's charge nurse, failed to transfer Resident #1 from the facility to the local hospital emergency department in a timely manner as ordered by the Resident's Primary Care Physician (PCP). LVN A contacted local Emergency Medical Services 2 hours and 18 minutes after receiving the telephone order for transfer. On arrival at the emergency room , physicians diagnosed the resident as having incurred a [MEDICAL CONDITIONS]. This deficient practice could place 79 residents at risk for delayed emergency care resulting in increased injury or death. Findings Included: Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted [DATE] and readmitted [DATE]. Diagnoses' included [MEDICAL CONDITION], Type 2 Diabetes, Hypertension, [MEDICAL CONDITION] Disorder, Dementia and Anxiety State. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment reflected a Brief Interview for Mental Status (BIMS) score of four (4) indicating severe cognitive impairment. Review of Resident #1's Comprehensive Plan of Care dated 03/27/14 reflected the resident required Total Assistance with the assistance of one (1) person for all Activities of Daily Living. [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Plan of Care dated 03/27/14 reflected a Problem/Need of history of hypertension. Observation of Resident #1 on 06/05/15 at 8:32 AM revealed the resident in bed. The resident's eyes were open and staring at the ceiling of her room. The resident did not respond either verbally or physically to the surveyor's questions. In an interview on 06/05/15 at 8:38 AM the Director of Nursing (DON) stated Resident #1 had been able to speak and was able to be heard all the way down the hallway when she spoke to staff at the nurse's station. The DON further stated that on 05/24/15 (time unknown) Resident #1 experienced shortness of breath and was unable to maintain viable O2 sats. (Percentage of Oxygen in the bloodstream). The resident was sent to the local hospital for evaluation and treatment. Prior to the incident the resident was able to eat meals by mouth with only some coaxing required at times. After the resident's return to the facility the resident received bolus feeding only by way of a gastrostomy tube. (feeding tube). In an interview on 06/05/15 at 9:05 AM LVN A stated he started his shift on 05/24/15 at 2:00 PM and noted Resident #1 to show no signs or symptoms of a change in condition at that time. LVN A further stated he initially became aware of a change in Resident #1's condition when he observed that the Resident had a poor appetite during the evening meal at 5:00 PM. The resident was also experiencing difficulty in responding to facility staff at that time. LVN A further stated Normally, she was very talkative. The LVN further stated he notified the resident's responsible party (RP) as well as her Primary Care Physician (PCP) at 5:15 PM. The PCP ordered the resident to be transferred to the local hospital's emergency room for evaluation. LVN A then called Emergency Medical Services (EMS) at 5:30 PM and requested a transport for the resident. The LVN then called the emergency room at the hospital and provided a report of the resident ' s status. EMS arrived at the facility at 6:15 PM. The LVN could not recall what time EMS left with the Resident. Review of Resident #1's Physician order [REDACTED]. to (local hospital) ER for evaluation. Review of Resident #1's Nurse's Notes dated 05/24/15 at 5:15 PM reflected Pt. (patient) noted to have poor meal intake. Pt. noted to have difficulty responding to staff and difficulty to arouse. (PCP) notified. Received order to transfer to (local hospital). Review of Resident #1's Nurse's Notes dated 05/24/15 at 5:30 PM reflected Report called to (emergency room employee) at (hospital) ER (emergency room ). Review of Resident #1's Nurse's Notes dated 05/24/15 at 6:15 PM reflected EMS here for pt. transport to hospital. Pt. RP (Responsible Party) notified of transfer. Review of Resident #1's computer printout of the local EMS Patient Care Record reflected EMS was contacted by facility staff on 05/24/15 at 7:33 PM (Two Hours and Eighteen Minutes after LVN A stated he had received the transfer order). The ambulance arrived at the facility at 8:11 PM (One Hour and Eighteen Minutes later than the time of arrival stated by LVN A). Narrative notes on the same Patient Care Record reflected Arrived to find 78 y/o female lying in bed in distress Pt. has GCS (Glasgow Coma Scale) of 11. (Indicating Moderate Brain Impairment) Pt. has O2 (Oxygen) sat of 89% on room air. Pt. placed on O2 via NRB (Non-Rebreather Mask) at 14 lpm (liters per minute). Pt. placed on monitor. Sinus [MEDICAL CONDITION]@ 102 bpm (beats per minute). IV established. Noticeable left-sided facial droop and weakness in upper left extremity. Review of Resident #1's Emergency Department Physician Documentation dated 05/24/15 at 10:28 PM reflected a preliminary [DIAGNOSES REDACTED]. Review of the website: <https://www.cayugamed.org/content.cfm?page=library&articleID=217&topicID=42> reflected Stroke is the third leading cause of death in the U.S. and the number one cause of adult disability. Of the people who survive stroke, 90 percent have a deficit. However, if you suffer an ischemic stroke and you get to the Emergency Department within two hours, you may receive medication that will dissolve the clot and minimize brain damage. In an interview on 06/05/15 at 1:52 PM LVN A stated he could not explain the time discrepancies between his nurse's notes dated 05/24/15 and the EMS computer printout of the Patient Care Record of the same date. In an interview on 06/05/15 at 2:58 PM the Director of Nursing (DON) stated her expectations of nursing staff, when changes of condition are observed, were for the staff to assess the Resident, notify the Resident's PCP, and follow any orders from the PCP accordingly and in a timely manner. If the change of condition is emergent in nature, the facility nurse can call 911 without delay rather than waiting for a physician's orders [REDACTED].>In an interview on 06/08/15 at 12:30 PM the Director of Nursing (DON) stated potential results of a staff member failing to immediately follow physician orders [REDACTED]. In an interview on 06/08/15 at 1:25 PM Resident #1's Primary Care Physician (PCP) stated his standard of expectations was for all orders he writes or telephones to a facility were to be followed immediately . When caring for a resident suspected of experiencing a [MEDICAL CONDITION], time is critical. When I am in the emergency room and we have a patient come in that we suspect is having a stroke we like to know specifically when the stroke began in order to best treat the patient. The PCP further stated failure to rapidly treat a resident experiencing [MEDICAL CONDITION] increased the chance for increased complications and death. Review of the facility's Policy and Procedure for Emergency Care-Emergency Transport-911 Protocol dated 03/2012 reflected: If resident's condition has changed, call attending physician and report changes and nursing observations. Provide emergency care as necessary. 911 Emergency Transport will be called when a resident is found to have experienced a change of condition indicating life threatening event occurred or the resident shows signs that impending life threatening event is suspected. Review of the facility's Policy and Procedure for Abuse and Neglect Abuse-Reportable Events (Texas Homes) dated 01/2008 reflected Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility Administrator provided a census list of 79 residents.

Based on observation, interview and record review the facility Administrator and Director of Nruses (DON) A failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator failed to develop and implement facility policies and procedures, failed to ensure training of all employees in emergency procedures to meet all potential emergencies and disasters. The Administrator also failed to supervise, monitor and consult with the Director of Nursing (DON) A to ensure residents received the care and services to meet their individual needs and ensure the nursing staff was provided pertinent information and education relating to the care and needs of each resident to ensure residents received care to attain and maintain their highest practicable physical, mental, and psychosocial well-being. DON A failed to ensure nursing staff responsible for providing quality care for residents reviewed for pressure sores, pain, emergency [MEDICAL CONDITION] care and admission assessments received training and were competent to perform nursing tasks when: A.) Facility staff were not trained and supervised for the staging of pressure sores for two (2) of 9 Residents (Resident # 13 and #18) reviewed for pressure sores. This failure resulted in Residents # 13 and # 18 did not receive necessary treatment and services to promote healing, pressure sores were not accurately assessed and staged, and once developed, did not receive necessary treatment and services to promote healing. 1) Resident #13 was admitted to the facility with a Stage IV sacral pressure sore (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). The facility did not accurately stage the pressure sore on admit resulting in Resident #13 receiving inappropriate treatment and the Stage IV sacral sore worsened. 2) Resident #18's Stage III pressure sores (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) was not appropriately staged and the Resident received inappropriate treatment from the physician to promote healing. This deficient practice placed 13 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. B.) The facility failed to to ensure staff assessed and treated two (2) of nine (9) residents (Resident #13 and # 9) reviewed for pain management with pressure sores. 1.) The facility did not assess Resident #13 for pain resulting in Resident #13 not having physician orders for medication for pain management and the Resident endured painful pressure sore treatments. 2.) The facility did not assess Resident #9 for pain during wound care resulting in Resident #9 endured painful pressure sore treatments. This deficient practice placed 13 residents at risk for enduring painful pressure sore treatments. C.) The facility failed to ensure admission assessments were complete and addressed residents immediate care needs and ensure a Registered Nurse (RN) conducted or coordinateed each assessment for two (2) of 10 residents ( Residnt # 13 and # 20) reviewed for swallowing difficulty: 1.) Resident #13 was admitted to the facility with a risk for aspiration and need for mechanically altered diet. The facility did not identify Resident #13's risk for aspiration or obtain orders for a mechanically altered diet resulting in Resident #13 chocking on 7/12/2013 and being sent to the emergency room for Aspiration. 2.) The facility failed to coordinate Resident #20's nectar thickened liquid orders and aspiration risk. This deficient practice could affect 10 residents at risk for aspiration which could cause aspiration pneumonia,[MEDICAL CONDITION], and possible death. D.) The facility failed to ensure staff were trained and competent in the care of residents with tracheotomies for three (3) of three (3) residents (Resident # 4, # 5, and # 12) with a [MEDICAL CONDITION] in the event of an emergency. Resident # 4, # 5 and # 12 did not have a replacement [MEDICAL CONDITION] in their rooms for emergency care in the event of dislodgement of the [MEDICAL CONDITION] and staff were not trained in the event of an emergency. This deficient practice placed 3 residents at risk for upper respiratory infections, respiratory distress, compromised airway and death. E) The facility failed to train all employees in emergency procedures to meet all potential emergencies and disasters for two (2) of five (5) Residents (Resident # 2 and # 5) reviewed for evacuation when: Resident # 2 and # 5 required special needs to be transferred out of their bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals), into a wheel chair and evacuated into an area that would accommodate her special sized wheel chair in order to evacuate to areas of refuge from the building when necessary. This deficient practice had the potential to delay or prevent the safe, rapid, and efficient evacuation from the facility, for the five (5) Residents identified as utilizing the Bariatric beds, in the event of an emergency. The above failures resulted in an Immediate Jeopardy (IJ) on 07/09/2013. While the IJ was removed on 07/15/13, the facility remained out of compliance at a Severity Level of Actual Harm with a Scope of pattern that is not IJ. Findings Include: A.) 1.) Review of Resident #13's face sheet reflected a [AGE] year old male admitted to the facility on [DATE]. No diagnoses were listed. Review of Resident #13' Start Up Orders dated 07/08/2013 reflected the following Diagnosis: [REDACTED]. Review of Resident #13's Admission/ Readmission Data Summary dated 07/08/2013 at 3:45 PM done by Licensed Vocational Nurse (LVN) F reflected Resident #13 to require total assistance with meals, assistance of one for mobility, assist of two for transfer, and incontinence of bladder and bowel. The assessment further reflected Resident #13 to be on a regular no salt on tray, low concentrated sweet diet. Under cognitive status Resident #13 was coded to be alert with long and short-term memory problems and sometimes able to make self understood. The admission further reflected under the respiratory section that Resident #13's lung sounds were clear. Under the skin condition section the assessment reflected Resident #13 to have a pressure sore to coccyx with no further description. Review of Resident #13's Care Plan reflected Resident #13 did not have a Plan of Care. Observation on 07/08/2013 at 7:50 PM revealed Resident #13 in bed asleep on initial tour. Review of Resident #13's Start Up Orders reflected no order for treatment for [REDACTED]. Review of a Facsimile to Resident #13's Physician dated 07/08/2013 no time reflected "Patient has unstagable (Unstageable Pressure Ulcers: Full-tissue thickness loss in which the base of the ulcer is covered by slough or an eschar and, therefore, the true depth of the damage cannot be estimated until these are removed.) to coccyx, will pack with hydrogel dressing and cover with secondary dressing every Monday, Wednesday, Friday and PRN. Will start Patient on Zinc 220 mg every day times 14 days." Review of Resident #13's Physician Telephone Orders reflected an order dated 07/09/2013 "Clean coccyx wound with wound cleanser, apply hydrogel dressing every Monday, Wednesday Friday, and PRN." Review of the Skin Assessment Flow Sheet- Pressure Ulcer for Resident #13 reflected an assessment dated [DATE] no time "Site one (1) stage unstagable, length 4.0, width 4.0, depth-slough and eschar, odor present, eschar, slough. Under the comments section " odorous, slough, and necrotic tissue, undermining from one (1) o'clock to four (4) o'clock 3 cm." There was no indication of location on form. Review of Resident #13's Nursing Documentation Record reflected Resident #13 on 07/11/2013 at 08:10 AM Resident #13 "staff and nurse in room to do dressing change and resident agitated and yelling and hitting at staff, states he wants out of here. " In an interview on 07/11/2013 at 4:20 PM DON A stated that Resident #13 did not have a plan of care for his needs because she does those on admission and she had not gotten to it. Observation on 07/11/2013 at 4:25 PM revealed Resident #13 in bed on right side Resident #13 was restless and did not communicate with surveyor. Observation on 07/11/2013 at 7:00 PM revealed Treatment Nurse LVN C setting up for wound care for Resident #13's sacral pressure sore. LVN C used bare hands to grab 4x4 gauze from treatment cart and sprayed wound cleanser on 4x4 gauze without gloves. LVN C did this multiple times until she had four (4) stacks of 4x4 gauze on wax paper outside of Resident #13's room on top of treatment cart. LVN C then removed an adhesive [MEDICATION NAME] dressing and two (2) hydrogel dressings from cart and placed on wax paper. LVN C then brought items into Resident #13 room and placed on bedside table after cleaning with an antiseptic wipe. LVN C then used alcohol based hand sanitizer to clean hands and then donned gloves. DON A then removed Resident #13's covers and turned him to his left side. Observation of the pressure sore revealed a Stage IV pressure sore approximately 6.0 cm x 4.0 cm x 2.0 cm (approximation made by surveyor) no dressing was present to be removed, wound bed of red granulation tissue was noted at the posterior aspect of wound from 6 o'clock to 9 o' clock the rest of the wound bed was covered in yellow slough and eschar. Resident #13's sacral Stage IV pressure sore had a pervasive odor. LVN C then took one (1) of the stacks of 4x4's and placed them in Resident #13's sacral pressure sore and cleaned using a twisting motion. Resident #13 began making incoherent verbalizations, becoming increased as LVN C cleaned pressure sore using the twisting motion. LVN C then cleansed Resident #13's sacral pressure sore again using the twisting motion with a new stack of 4x4 gauze. Resident #13's entire body began to shake and he had his right hand in a fist formation. Resident #13's incoherent verbalizations increased in volume. Surveyor then asked Resident #13 if he was in pain. Resident #13 continued to shake and make incoherent verbalizations. LVN C did not stop cleaning the wound or address Resident #13. DON A did not address Resident #13 but continued to observe LVN C clean Resident #13's sacral pressure sore. Resident # 13 continued with loud verbalization and shaking while LVN C repeated the cleaning, again using the twisting motion, LVN C then took hydrogel gauze and shoved it with force into Resident #13's sacral pressure sore. Resident #13 made a loud verbalization, his entire body was shaking and he grabbed at DON A. DON A did not respond to Resident # 13's grabbing, she continued to hold the resident in position and observed the LVN C. LVN C then shoved another hydrogel gauze into Resident #13's sacral pressure sore and covered area with a [MEDICATION NAME] dressing. In an interview on 07/11/2013 at 7:35 PM LVN C stated she staged Resident #13's sacral pressure sore as unstagable and did not measure depth because the wound bed had slough in it. LVN C further stated she could see some wound bed but because of the slough she could not stage. In an interview on 07/11/2013 at 7:40 PM DON A stated she felt Resident #13's sacral pressure sore was Stage IV when she assessed it, however LVN C is assessing the pressure sores and she had been to training so she might have seen something I did not. DON A stated she let LVN C staged Resident #13's sacral pressure sore as unstagable and stood by the LVN's decision. DON A further stated she saw Resident #13's sacral pressure sore when he was admitted "It did not seem that bad, it seems to be getting worse." DON A further stated that Resident #13's physician had not seen Resident #13's the sacral pressure. DON A stated she would expect her nurse to measure depth on a pressure sore that you can see a wound bed. Surveyor then asked DON A if she felt Resident #13 physician was informed properly in regard to Resident #13 s sacral pressure sore, DON A stated "no I would not think it was enough information to make a treatment decision." DON A further stated she would wait till Monday for measurements of Resident #13's sacral pressure sore to notify physician of changes to pressure sore. DON A stated Resident # 13's physician had instructed her to make an appointment for the Resident at the Wound Clinic on Monday, 7/08/2013, and she will do that when she gets to it. Observation on 07/11/2013 at 8:15 PM revealed DON A presented surveyor with an Admission Care Plan for Resident #13. Review of the Admission Care Plan for Resident #13 reflected "16. Pressure Sores/ Skin Care. Goal: Prevent/ heal pressure sores and skin breakdown. TX: see treatment sheet and order. Follow facility protocol. Turn every 2 hours and PRN. Report to charge nurse any redness or skin breakdown immediately. Low air mattress." There was no Care Plan for pain. In an interview on 07/11/2013 at 8:18 PM DON A " I just got that done. " Observation on 07/12/2013 at 10:00 AM revealed an ambulance at the facility to transport Resident #13 to the emergency room . In an interview on 07/12/2013 at 11:26 AM the Facility Medical Director, who is also Resident # 13's Primary Care Physician, stated he was told that Resident #13 was going to be admitted but he had not seen him yet. The Facility Medical Director stated he was unaware that Resident had a Stage IV pressure sore to his sacral area "I was told that Resident #13 had an unstagable pressure to coccyx." The Facility Medical Director further stated he expected to get a full picture of the resident, and if he had been notified fully of Resident #13's Stage IV pressure sore he would have "definitely " changed the treatment to the pressure sore and probably would not have taken the Resident at the facility. The Facility Medical Director further stated "I do not think they knew what they were getting into with this patient." "I have told them they have to see the patients before they come in." "Sounds like she (DON A) did an incomplete assessment." In an interview on 07/12/2013 at 12:25 PM the emergency room (ER) Physician stated Resident #13 was brought into the ER after aspiration at the facility. An x-ray was done and showed no pneumonia but that it can take days for aspiration to show up on an x-ray. The ER Physician stated Resident #13 had raspy lung sounds. The ER Physician further stated that Resident #13 had a large Stage IV pressure sore "deep" on his upper sacral area, odorous, with drainage. The ER Physician stated he was able to see the wound bed of Resident #13's sacral pressure sore and the pressure sore was infected. The ER Physician stated Resident #13's Stage IV sacral pressure sore needed surgical debridement. In an interview on 07/12/2013 at 12:30 PM the ER RN stated the odor of Resident # 13's Stage IV Pressure sore had odor that was nauseating and "there is no excuse for what happened to this man." Observation on 07/12/2013 at 12:40 PM revealed Resident #13 lying on left side in the emergency room . Resident #13 did not respond to surveyor. In an interview on 07/12/2013 at 12:50 PM Resident #13's Responsible Party stated that the facility had told her on admit that they would get a wound doctor to see his pressure sore. Resident #13's Responsible Party further stated that the facility told her he had a Stage IV pressure sore. Review of Resident #13's Physician's Telephone Orders reflected an order dated 07/12/2013 no time to refer Resident #13 to wound care doctor for wound care of coccyx area. 2.) Record review of Resident #18's Face Sheet reflected the admission date of [DATE] and the latest re-admission date of [DATE] with diagnoses of Attention to Gastrostomy (Primary), Dysphagia, [MEDICAL CONDITION], Convulsions, [MEDICAL CONDITIONS], Paranoid State, [MEDICAL CONDITIONS], Hepatic [MEDICAL CONDITION], Hypopotassemia, and Acute Pain. Record review of Resident #18's Admission/Readmission Data Summary dated 01/31/2013 reflected "Skin Condition" with no markings indicated on the body diagram of any skin conditions. This Summary was signed by Licensed Vocational Nurse (LVN) D. Record review of Resident #18's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected the Resident was totally dependent upon staff for activities of daily living (ADL). The MDS also reflected she had one stage III pressure sore (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) that measured 2.5 centimeters (cm) x 2.5 cm x 0.1 cm with granulation tissue. Record review of Resident #18's Comprehensive Care Plan dated 07/06/2013 reflected a Pressure Sore to the Right Hip at a Stage II. The Care Plan reflected an update on 07/14/13 of an Approach change of treatment, but the stage remained at a Stage II. Record review of Resident #18's Comprehensive Care Plan dated 04/25/2013 reflected a Pressure Sore to the Left Hip at Unstageable. The Care Plan reflected an update on 05/20/2013 written in at the bottom "Stage III-Tx (treatment) changed collagen M-W-F (Monday-Wednesday-Friday)". Record review of Resident #18's Skin Evaluation Flowsheet--Pressure Ulcer dated 07/08/2013 reflected left hip "#1 Site"; "Stage II"; "Dimensions (CM) L 3.2 W 3.0 D 0.01"; "Comments clear". The Flowsheet also reflected "#2 Site R hip"; "Stage II"; "Dimensions (CM) L 2.5 W 2.5 D 0.01"; "Comments clear". Record review of Resident #18's Facsimile to the Physician dated 07/03/2013 reflected "Wound to L (left) hip is increasing in size and drainage. Treatment was changed to calcium alginate with silver to try to improve this. Wound is still showing deteriation. Can I do a culture on the site?" This Facsimile was signed by LVN C. The Facsimile does not describe the pressure sore on Resident #18--the stage, latest measurements, drainage color, and odor were not addressed in the Facsimile to the Physician. Record review of Resident #18's Facsimile to the Physician dated 07/06/2013 reflected "Pt (Patient) found to have Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) to R (right) hip will apply dermaceptin (cream with zinc and menthol) Q day & prn till resolved. Please notify if this is acceptable or if further orders are necessary." This Facsimile was signed by LVN C. The Facsimile did not describe the pressure sore on Resident #18's right hip--the measurements, drainage, and odor were not addressed in the Facsimile to the Physician. Record review of Resident #18's Physician's Telephone Orders dated 07/06/2013 reflected "apply dermaceptin to R hip Q day & prn". This Order was signed by LVN C. This Order did not address the pressure sore's stage. Record review of Resident #18's Facsimile to the Physician dated 07/11/2013 reflected "Pt wounds not responding to treatment. Can I change treatment to bilat (bilateral) hips to: clean wound with WC (wound cleanser), apply hydrogel and cover with dressing M-W-F and prn." This Facsimile was signed by LVN C. The Facsimile did not describe the pressure sores on Resident #18--the stage, measurements, drainage, and odor were not addressed in the Facsimile to the Physician. Observation on 07/12/2013 at 4:30 PM revealed Resident #18 with a Stage III Pressure Sore to the right hip area. There was no dressing with the Stage III pressure sore open to air. LVN C measured the pressure sore after cleansing, measurements were 1.7 cm x 1.0 cm x 0.4 cm. The Stage III pressure sore had a dark red wound bed with granulation tissue. The surrounding skin had a beveled, white edge and a dark pigmented skin color around the pressure sore which appeared to be possible redness indicating infection or healed scar tissue. LVN C cleansed the pressure sore with normal saline and after discussion with DON B, LVN C covered the Stage III with a dry composite dressing until the Physician could be called for new orders. The orders for the pressure sore were to cleanse with normal saline then apply dermaceptin cream (a cream with zinc and menthol) to the open pressure sore. In an interview on 07/12/2013 at 4:40 PM, DON B stated the right hip pressure sore was a stage III. DON B stated she would notify the physician to clarify the treatment due to the stage, measurements, no drainage, and no odor. Observation on 07/12/2013 at 4:45 PM revealed Resident #18 also had a Stage III to the left hip area. There was a dressing with visible yellow and dark red drainage on the outside of the dressing. LVN C measured the pressure sore after cleansing, the measurements were 3.5 cm x 3.2 cm x 0.7 cm. The Stage III pressure sore had a red wound bed with granulation tissue. The surrounding skin had a pink, beveled edge and a dark pigmented skin color around the pressure sore which appeared to be possible redness indicating infection or healed scar tissue. LVN C cleansed the pressure sore with normal saline, placed calcium alginate with silver in the wound bed, and covered with a dry composite dressing. In an interview on 07/12/2013 at 4:50 PM the DON B stated the left hip pressure sore was a stage III. DON B stated she would notify the physician to clarify the treatment due to the stage, measurements, drainage, and no odor. Record review of Resident #18's Physician Order Report dated 06/01/2013-07/31/2013 and signed by the Physician on 06/22/2013 reflected "Wound Treatments. flow sheet" with a start date of 05/27/2013 to "CLEAN L (left) HIP W (with) WC (wound cleanser) COLLAGEN AND COVER W SECONDARY DRESSING Q (every) M-W-F (Monday-Wednesday-Friday) AND PRN (as needed)". Resident #18's Physician Orders did not reflect the stage of the pressure sore or the current treatment as observed by the surveyor. In an interview on 07/13/2013 at 11:30 AM the DON B stated she had not yet contacted the Physician for Resident #18 to give a full description of the pressure sores to include the stage, measurements, drainage, or odor to receive new orders. DON B stated she would address the right hip stage III pressure sore and ask the Physician to change the treatment on the right hip area from the Dermaceptin cream to a dressing with hydrogel for moisture. Record review of Resident #18's Physician's Telephone Orders dated 07/14/2013 reflected "1) D/C (discontinue) Dermaceptin to R hip 2) Begin treatment to R hip--clean with NS (normal saline), apply Hydrogel and cover with gauze Q day & prn". This Order was signed by DON B. This Order did not address the pressure sore's stage. Record review of Resident #18's Physician Telephone Orders dated 07/14/2013 reflected "1) Stage III L hip clean with WC, apply Silver Calcium Alginate and cover with island dressing M-W-F & prn 2) Stage III R hip Clean with NS apply Hydrogel and cover with gauze q day & prn". This Order was signed by DON B. This Order reflected the stages. In an interview on 07/13/2013 at 2:00 PM the LVN C stated she faxed the Physician about the "wounds" on the right and left hip area to get the treatment orders changed but did not describe the pressure sores in the facsimile to the physician to include the stage, measurements, drainage, or odor. LVN C also stated that DON A did not assess Resident #18's pressure sores at the same time with LVN C, but that DON A staged the pressure sores for LVN C. In an interview on 07/12/2013 at 11:26 AM the Facility Medical Director, who is also Resident # 18's Primary Care Physician, stated he expected to get a full picture of the resident, and if he had been notified fully of Resident #18's Stage III pressure sore he would have "definitely " changed the treatment to the pressure sore. Record review of the Policy and Procedure for Skin--Treatment Guidelines for Pressure Ulcers revised 03/2012 reflected under "Policy It is the policy of this home to utilize treatment guidelines when providing care for residents with pressure ulcers and to prevent further deterioration of pressure ulcers. Note: These are treatment suggestions, and do not supersede a Physician's order for any treatment. A physician order will be obtained for the pressure ulcer treatment and will be specific for each site. -Each pressure ulcer must have a separate order. -Each pressure ulcer site must be identified by location. (Example: left elbow, coccyx, etc.)..." B.) 1) Review of Resident #13's face sheet reflected a [AGE] year old male admitted to the facility on [DATE]. No diagnoses were listed. Review of Resident #13's Start Up Orders dated 07/08/2013 reflected the following Diagnosis: [REDACTED]. Review of Resident #13's Admission/ Readmission Data Summary dated 07/08/2013 at 3:45 PM done by LVN F (Licensed Vocational Nurse) reflected Resident #13 to require assistance of one for mobility, assist of two for transfer, total assistance with meals, and incontinence of bladder and bowel. The assessment further reflected Resident #13 to be on a regular no salt on tray low concentrated sweet diet. Under cognitive status Resident #13 was coded to be alert with long and short-term memory problems and sometimes able to make self understood. The admission further reflected under respiratory section that Resident #13 lung sounds were clear. Under the skin condition section the assessment reflected Resident #13 to have a pressure sore to coccyx with no further description. The assessment did not address pain. Review of Resident #13's Care Plan reflected Resident #13 did not have a plan of care. Review of Resident #13's medical record reflected no assessment for pain. Review of Resident #13's Start Up Orders dated 07/08/2013 reflected an order for [REDACTED]. Review of Resident #13's Nursing Documentation Record reflected Resident #13 on 07/11/2013 at 08:10 AM Resident #13 "staff and nurse in room to do dressing change and resident agitated and yelling and hitting at staff, states he wants out of here." Observation on 07/11/2013 at 7:00 PM revealed LVN C providing treatment to Resident # 13's Stage IV pressure sore (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). LVN C then took one (1) stack of 4x4's and placed them in Resident #13's sacral pressure sore and cleaned using a twisting motion. Resident #13 began making incoherent verbalizations, becoming increased as LVN C cleaned pressure sore using the twisting motion. LVN C then cleansed Resident #13's sacral pressure sore again using the twisting motion with a new stack of 4x4 gauze. Resident #13's entire body began to shake and he had his right hand in a fist formation. Resident #13's incoherent verbalizations increased in volume. Surveyor then asked Resident #13 if he was in pain. Resident #13 continued to shake and make incoherent verbalizations. LVN C did not stop cleaning the wound or address Resident #13. DON A did not address Resident #13 but continued to observe LVN C clean Resident #13's sacral pressure sore. Resident # 13 continued with loud verbalization and shaking while LVN C repeated the cleaning, again using the twisting motion, LVN C then took hydrogel gauze and shoved it with force into Resident #13's sacral pressure sore. Resident #13 made a loud verbalization, his entire body was shaking and he grabbed at DON A. DON A did not respond to Resident # 13's grabbing, she continued to hold the resident in position and observed LVN C. LVN C then shoved another hydrogel gauze into Resident #13's sacral pressure sore and covered area with a [MEDICATION NAME] dressing. In an interview on 07/11/2013 at 7:20 PM surveyor asked Resident #13 if he was hurting after wound care was complete. Resident #13 stated "Yes I am hurting" surveyor then asked Resident #13 where he was hurting and Resident #13 used his right arm to show surveyor his sacral area. In an interview on 07/11/2013 at 7:30 PM LVN C stated when she cleaned Resident #13's sacral pressure sore deeper Resident became more verbal. LVN C further stated she was not expecting Resident #13 to react that way. Surveyor then asked LVN C if she should have stopped the procedure when she noted Resident #13's reaction. LVN C stated she should have stopped the procedure. LVN C stated she should have pre-medicated Resident #13 with pain medication prior to procedure but she was unsure what kind of medication Resident #13 had for pain. In an interview on 07/11/2013 at 8:00 PM DON A stated that she would notify Resident #13's physician regarding Resident #13's pain since he only had Tylenol ordered PRN for pain. DON A stated that LVN C should have stopped the treatment to Resident #13's sacral pressure sore "the resident was in pain." DON A further stated that Resident #13 should have been assessed for pain prior to procedure and during procedure for signs of pain. DON A stated she knew LVN C was in a hurry to leave so she did not stop the procedure. Surveyor then asked DON A if a resident with a pressure sore that size would be in pain all time and DON A stated they would be in continuous pain and that Resident #13's pain was not addressed because she missed it. Observation on 07/11/2013 at 8:15 PM revealed DON A presented surveyor with an Admission Care Plan for Resident #13. Review of the Admission Care Plan for Resident #13 reflected "16. Pressure Sores/ Skin Care. Goal: Prevent/ heal pressure sores and skin breakdown. TX: see treatment sheet and order. Follow facility protocol. Turn every 2 hours and PRN. Report to charge nurse any redness or skin breakdown immediately. Low air mattress." There was no Care Plan for pain. In an interview on 07/11/2013 at 8:18 PM DON A stated "I just got that done." Review of Resident #13's Physician's Telephone orders dated 07/11/2013 at 8:10 PM reflected an order "Give [MEDICATION NAME] 5/325 mg one tab PO every six (6) hours PRN for pain and 30 minutes before wound care." In an interview on 07/12/2013 at 11:26 AM the Facility Medical Director stated he would expect the nurses to notify him if a resident was in need of pain medication. 2.) Review of Resident #9's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility 05/13/2013 with the following Diagnosis: [REDACTED]. Review of Resident #9 ' s Significant Change Minimum Data Set ((MDS) dated [DATE] reflected the Resident to score a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #9 to was cognitively intact. The assessment reflected the Resident needed limited one person assist with transfers, bed mobility, dressing, and hygiene. Resident #9 was coded to require extensive assistance with bathing. The assessment further reflected Resident #9 to be continent of bowel and frequently incontinent of bladder. The assessment reflected Resident #9 to have one Stage II pressure sore(Partial thickness loss of dermis presentian as a shallow open ulcer with red pink wound bed, without slough.) and was coded not to have pain. Review of Resident #9 ' s Comprehensive Plan of Care dated 06/18/2013 reflected a plan of care for a Stage II pressure sore to left thigh with no approaches for pain. The Comprehensive Plan of Care further reflected a care plan for Risk for Pain, redness, swelling and warmth of leg related to [MEDICAL CONDITION]. Observation on 07/09/2013 at 3:00 PM revealed LVN C preparing to perform wound care on Resident #9's Stage II pressure sore to back of left thigh. LVN

Based on observation, interview, and record review the facility failed to provide services that meet professional standards of quality for one (1) of one (1)Director of Nurses (DON) when DON A failed to: A.) Ensure proper staff staged and supervised for the staging of pressure sores for two (2) of 9 Residents (Resident # 13 and #18) reviewed for pressure sores. This failure resulted in Residents # 13 and # 18 did not receive necessary treatment and services to promote healing, pressure sores were not accurately assessed and staged, and once developed, did not receive necessary treatment and services to promote healing. 1.) Resident #13 was admitted to the facility with a Stage IV sacral pressure sore (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). The facility did not accurately stage the pressure sore on admit resulting in Resident #13 receiving inappropriate treatment and the Stage IV sacral sore worsened. 2). Resident #18's Stage III pressure sores (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) was not appropriately staged and the Resident received inappropriate treatment from the physician to promote healing. B.) DON A failed to ensure staff assessed and treated two (2) of nine (9) residents (Resident #13 and # 9) reviewed for pain management with pressure sores. 1.) The facility did not assess Resident #13 for pain resulting in Resident #13 not having physician orders for medication for pain management and the Resident endured painful pressure sore treatments. 2.) The facility did not assess Resident #9 for pain during wound care resulting in Resident #9 endured painful pressure sore treatments. C.) DON A failed to ensure admission assessments were complete and addressed residents immediate care needs and ensure a Registered Nurse (RN) conducted or coordinateed each assessment for two (2) of 10 residents ( Residnt # 13 and # 20) reviewed for swallowing difficulty: 1.) Resident #13 was admitted to the facility with a risk for aspiration and need for mechanically altered diet. The facility did not identify Resident #13's risk for aspiration or obtain orders for a mechanically altered diet resulting in Resident #13 chocking on 7/12/2013 and being sent to the emergency room for Aspiration. 2.) The facility failed to coordinate Resident #20's nectar thickened liquid orders and aspiration risk. D.) DON A failed to ensure staff were trained and competent in the care of residents with tracheotomies for three (3) of three (3) residents (Resident # 4, # 5, and # 12) with a [MEDICAL CONDITION] in the event of an emergency. 1.) The facility failed to provide Resident #12 with a [MEDICAL CONDITION] an ambu bag in the resident's room for emergency care, and failed to ensure staff were trained in the event of an emergency. Resident #12 had no orders [MEDICAL CONDITION] and suctioning and failed to ensure staff were trained in the event of an emergency. 2.) The facility failed to ensure Resident #4 had a replacement [MEDICAL CONDITION] in the Resident's room or in the facility for emergency care in the event of dislodgement of the [MEDICAL CONDITION] and failed to ensure staff were trained in the event of an emergency. 3.) The facility failed to ensure Resident #5 had a replacement [MEDICAL CONDITION] and in the Resident's room or in the facility for emergency care in the event of dislodgement of the [MEDICAL CONDITION] and failed to ensure staff were trained in the event of an emergency. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2013. While the IJ was removed on 07/15/2013, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. A.) This deficient practice placed 13 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. B.) This deficient practice placed 13 residents at risk for enduring painful pressure sore treatments. C.) This deficient practice could affect 10 residents at risk for aspiration which could cause aspiration pneumonia,[MEDICAL CONDITION], and possible death. D.) This deficient practice placed 3 residents at risk for upper respiratory infections, respiratory distress, compromised airway and death. Findings Include: Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; (P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; (Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client; (ii) making nursing diagnoses that serve as the basis for the strategy of care; (iii) developing a plan of care based on the assessment and nursing diagnosis; (iv) implementing nursing care; and (v) evaluating the client's responses to nursing interventions; (B) Delegate tasks to unlicensed personnel in compliance with Chapter 224 of this title, relating to clients with acute conditions or in acute are environments, and Chapter 225 of this title, relating to independent living environments for clients with stable and predictable conditions. A.) 1.) Review of Resident #13's face sheet reflected a [AGE] year old male admitted to the facility on [DATE]. No diagnoses were listed. Review of Resident #13' Start Up Orders dated 07/08/2013 reflected the following Diagnosis: [REDACTED]. Review of Resident #13's Admission/ Readmission Data Summary dated 07/08/2013 at 3:45 PM done by Licensed Vocational Nurse (LVN) F reflected Resident #13 to require total assistance with meals, assistance of one for mobility, assist of two for transfer, and incontinence of bladder and bowel. The assessment further reflected Resident #13 to be on a regular no salt on tray, low concentrated sweet diet. Under cognitive status Resident #13 was coded to be alert with long and short-term memory problems and sometimes able to make self understood. The admission further reflected under the respiratory section that Resident #13's lung sounds were clear. Under the skin condition section the assessment reflected Resident #13 to have a pressure sore to coccyx with no further description. Review of Resident #13's Care Plan reflected Resident #13 did not have a Plan of Care. Observation on 07/08/2013 at 7:50 PM revealed Resident #13 in bed asleep on initial tour. Review of Resident #13's Start Up Orders reflected no order for treatment for [REDACTED]. Review of a Facsimile to Resident #13's Physician dated 07/08/2013 no time reflected "Patient has unstagable (Unstageable Pressure Ulcers: Full-tissue thickness loss in which the base of the ulcer is covered by slough or an eschar and, therefore, the true depth of the damage cannot be estimated until these are removed.) to coccyx, will pack with hydrogel dressing and cover with secondary dressing every Monday, Wednesday, Friday and PRN. Will start Patient on Zinc 220 mg every day times 14 days." Review of Resident #13's Physician Telephone Orders reflected an order dated 07/09/2013 "Clean coccyx wound with wound cleanser, apply hydrogel dressing every Monday, Wednesday Friday, and PRN." Review of the Skin Assessment Flow Sheet- Pressure Ulcer for Resident #13 reflected an assessment dated [DATE] no time "Site one (1) stage unstagable, length 4.0, width 4.0, depth-slough and eschar, odor present, eschar, slough. Under the comments section " odorous, slough, and necrotic tissue, undermining from one (1) o'clock to four (4) o'clock 3 cm." There was no indication of location on form. Review of Resident #13's Nursing Documentation Record reflected Resident #13 on 07/11/2013 at 08:10 AM Resident #13 "staff and nurse in room to do dressing change and resident agitated and yelling and hitting at staff, states he wants out of here. " In an interview on 07/11/2013 at 4:20 PM DON A stated that Resident #13 did not have a plan of care for his needs because she does those on admission and she had not gotten to it. Observation on 07/11/2013 at 4:25 PM revealed Resident #13 in bed on right side Resident #13 was restless and did not communicate with surveyor. Observation on 07/11/2013 at 7:00 PM revealed Treatment Nurse LVN C setting up for wound care for Resident #13's sacral pressure sore. LVN C used bare hands to grab 4x4 gauze from treatment cart and sprayed wound cleanser on 4x4 gauze without gloves. LVN C did this multiple times until she had four (4) stacks of 4x4 gauze on wax paper outside of Resident #13's room on top of treatment cart. LVN C then removed an adhesive [MEDICATION NAME] dressing and two (2) hydrogel dressings from cart and placed on wax paper. LVN C then brought items into Resident #13 room and placed on bedside table after cleaning with an antiseptic wipe. LVN C then used alcohol based hand sanitizer to clean hands and then donned gloves. DON A then removed Resident #13's covers and turned him to his left side. Observation of the pressure sore revealed a Stage IV pressure sore approximately 6.0 cm x 4.0 cm x 2.0 cm (approximation made by surveyor) no dressing was present to be removed, wound bed of red granulation tissue was noted at the posterior aspect of wound from 6 o'clock to 9 o' clock the rest of the wound bed was covered in yellow slough and eschar. Resident #13's sacral Stage IV pressure sore had a pervasive odor. LVN C then took one (1) of the stacks of 4x4's and placed them in Resident #13's sacral pressure sore and cleaned using a twisting motion. Resident #13 began making incoherent verbalizations, becoming increased as LVN C cleaned pressure sore using the twisting motion. LVN C then cleansed Resident #13's sacral pressure sore again using the twisting motion with a new stack of 4x4 gauze. Resident #13's entire body began to shake and he had his right hand in a fist formation. Resident #13's incoherent verbalizations increased in volume. Surveyor then asked Resident #13 if he was in pain. Resident #13 continued to shake and make incoherent verbalizations. LVN C did not stop cleaning the wound or address Resident #13. DON A did not address Resident #13 but continued to observe LVN C clean Resident #13's sacral pressure sore. Resident # 13 continued with loud verbalization and shaking while LVN C repeated the cleaning, again using the twisting motion, LVN C then took hydrogel gauze and shoved it with force into Resident #13's sacral pressure sore. Resident #13 made a loud verbalization, his entire body was shaking and he grabbed at DON A. DON A did not respond to Resident # 13's grabbing, she continued to hold the resident in position and observed the LVN C. LVN C then shoved another hydrogel gauze into Resident #13's sacral pressure sore and covered area with a [MEDICATION NAME] dressing. In an interview on 07/11/2013 at 7:35 PM LVN C stated she staged Resident #13's sacral pressure sore as unstagable and did not measure depth because the wound bed had slough in it. LVN C further stated she could see some wound bed but because of the slough she could not stage. In an interview on 07/11/2013 at 7:40 PM DON A stated she felt Resident #13's sacral pressure sore was Stage IV when she assessed it, however LVN C is assessing the pressure sores and she had been to training so she might have seen something I did not. DON A stated she let LVN C staged Resident #13's sacral pressure sore as unstagable and stood by the LVN's decision. DON A further stated she saw Resident #13's sacral pressure sore when he was admitted "It did not seem that bad, it seems to be getting worse." DON A further stated that Resident #13's physician had not seen Resident #13's the sacral pressure. DON A stated she would expect her nurse to measure depth on a pressure sore that you can see a wound bed. Surveyor then asked DON A if she felt Resident #13 physician was informed properly in regard to Resident #13 s sacral pressure sore, DON A stated "no I would not think it was enough information to make a treatment decision." DON A further stated she would wait till Monday for measurements of Resident #13's sacral pressure sore to notify physician of changes to pressure sore. DON A stated Resident # 13's physician had instructed her to make an appointment for the Resident at the Wound Clinic on Monday, 7/08/2013, and she will do that when she gets to it. Observation on 07/11/2013 at 8:15 PM revealed DON A presented surveyor with an Admission Care Plan for Resident #13. Review of the Admission Care Plan for Resident #13 reflected "16. Pressure Sores/ Skin Care. Goal: Prevent/ heal pressure sores and skin breakdown. TX: see treatment sheet and order. Follow facility protocol. Turn every 2 hours and PRN. Report to charge nurse any redness or skin breakdown immediately. Low air mattress." There was no Care Plan for pain. In an interview on 07/11/2013 at 8:18 PM DON A " I just got that done. " Observation on 07/12/2013 at 10:00 AM revealed an ambulance at the facility to transport Resident #13 to the emergency room . In an interview on 07/12/2013 at 11:26 AM the Facility Medical Director, who is also Resident # 13's Primary Care Physician, stated he was told that Resident #13 was going to be admitted but he had not seen him yet. The Facility Medical Director stated he was unaware that Resident had a Stage IV pressure sore to his sacral area "I was told that Resident #13 had an unstagable pressure to coccyx." The Facility Medical Director further stated he expected to get a full picture of the resident, and if he had been notified fully of Resident #13's Stage IV pressure sore he would have "definitely " changed the treatment to the pressure sore and probably would not have taken the Resident at the facility. The Facility Medical Director further stated "I do not think they knew what they were getting into with this patient." "I have told them they have to see the patients before they come in." "Sounds like she (DON A) did an incomplete assessment." In an interview on 07/12/2013 at 12:25 PM the emergency room (ER) Physician stated Resident #13 was brought into the ER after aspiration at the facility. An x-ray was done and showed no pneumonia but that it can take days for aspiration to show up on an x-ray. The ER Physician stated Resident #13 had raspy lung sounds. The ER Physician further stated that Resident #13 had a large Stage IV pressure sore "deep" on his upper sacral area, odorous, with drainage. The ER Physician stated he was able to see the wound bed of Resident #13's sacral pressure sore and the pressure sore was infected. The ER Physician stated Resident #13's Stage IV sacral pressure sore needed surgical debridement. In an interview on 07/12/2013 at 12:30 PM the ER RN stated the odor of Resident # 13's Stage IV Pressure sore had odor that was nauseating and "there is no excuse for what happened to this man." Observation on 07/12/2013 at 12:40 PM revealed Resident #13 lying on left side in the emergency room . Resident #13 did not respond to surveyor. In an interview on 07/12/2013 at 12:50 PM Resident #13's Responsible Party stated that the facility had told her on admit that they would get a wound doctor to see his pressure sore. Resident #13's Responsible Party further stated that the facility told her he had a Stage IV pressure sore. Review of Resident #13's Physician's Telephone Orders reflected an order dated 07/12/2013 no time to refer Resident #13 to wound care doctor for wound care of coccyx area. 2.) Record review of Resident #18's Face Sheet reflected the admission date of [DATE] and the latest re-admission date of [DATE] with diagnoses of Attention to Gastrostomy (Primary), Dysphagia, [MEDICAL CONDITION], Convulsions, [MEDICAL CONDITIONS], Paranoid State, [MEDICAL CONDITIONS], Hepatic [MEDICAL CONDITION], Hypopotassemia, and Acute Pain. Record review of Resident #18's Admission/Readmission Data Summary dated 01/31/2013 reflected "Skin Condition" with no markings indicated on the body diagram of any skin conditions. This Summary was signed by Licensed Vocational Nurse (LVN) D. Record review of Resident #18's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected the Resident was totally dependent upon staff for activities of daily living (ADL). The MDS also reflected she had one stage III pressure sore (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) that measured 2.5 centimeters (cm) x 2.5 cm x 0.1 cm with granulation tissue. Record review of Resident #18's Comprehensive Care Plan dated 07/06/2013 reflected a Pressure Sore to the Right Hip at a Stage II. The Care Plan reflected an update on 07/14/13 of an Approach change of treatment, but the stage remained at a Stage II. Record review of Resident #18's Comprehensive Care Plan dated 04/25/2013 reflected a Pressure Sore to the Left Hip at Unstageable. The Care Plan reflected an update on 05/20/2013 written in at the bottom "Stage III-Tx (treatment) changed collagen M-W-F (Monday-Wednesday-Friday)". Record review of Resident #18's Skin Evaluation Flowsheet--Pressure Ulcer dated 07/08/2013 reflected left hip "#1 Site"; "Stage II"; "Dimensions (CM) L 3.2 W 3.0 D 0.01"; "Comments clear". The Flowsheet also reflected "#2 Site R hip"; "Stage II"; "Dimensions (CM) L 2.5 W 2.5 D 0.01"; "Comments clear". Record review of Resident #18's Facsimile to the Physician dated 07/03/2013 reflected "Wound to L (left) hip is increasing in size and drainage. Treatment was changed to calcium alginate with silver to try to improve this. Wound is still showing deteriation. Can I do a culture on the site?" This Facsimile was signed by LVN C. The Facsimile does not describe the pressure sore on Resident #18--the stage, latest measurements, drainage color, and odor were not addressed in the Facsimile to the Physician. Record review of Resident #18's Facsimile to the Physician dated 07/06/2013 reflected "Pt (Patient) found to have Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) to R (right) hip will apply dermaceptin (cream with zinc and menthol) Q day & prn till resolved. Please notify if this is acceptable or if further orders are necessary." This Facsimile was signed by LVN C. The Facsimile did not describe the pressure sore on Resident #18's right hip--the measurements, drainage, and odor were not addressed in the Facsimile to the Physician. Record review of Resident #18's Physician's Telephone Orders dated 07/06/2013 reflected "apply dermaceptin to R hip Q day & prn". This Order was signed by LVN C. This Order did not address the pressure sore's stage. Record review of Resident #18's Facsimile to the Physician dated 07/11/2013 reflected "Pt wounds not responding to treatment. Can I change treatment to bilat (bilateral) hips to: clean wound with WC (wound cleanser), apply hydrogel and cover with dressing M-W-F and prn." This Facsimile was signed by LVN C. The Facsimile did not describe the pressure sores on Resident #18--the stage, measurements, drainage, and odor were not addressed in the Facsimile to the Physician. Observation on 07/12/2013 at 4:30 PM revealed Resident #18 with a Stage III Pressure Sore to the right hip area. There was no dressing with the Stage III pressure sore open to air. LVN C measured the pressure sore after cleansing, measurements were 1.7 cm x 1.0 cm x 0.4 cm. The Stage III pressure sore had a dark red wound bed with granulation tissue. The surrounding skin had a beveled, white edge and a dark pigmented skin color around the pressure sore which appeared to be possible redness indicating infection or healed scar tissue. LVN C cleansed the pressure sore with normal saline and after discussion with DON B, LVN C covered the Stage III with a dry composite dressing until the Physician could be called for new orders. The orders for the pressure sore were to cleanse with normal saline then apply dermaceptin cream (a cream with zinc and menthol) to the open pressure sore. In an interview on 07/12/2013 at 4:40 PM, DON B stated the right hip pressure sore was a stage III. DON B stated she would notify the physician to clarify the treatment due to the stage, measurements, no drainage, and no odor. Observation on 07/12/2013 at 4:45 PM revealed Resident #18 also had a Stage III to the left hip area. There was a dressing with visible yellow and dark red drainage on the outside of the dressing. LVN C measured the pressure sore after cleansing, the measurements were 3.5 cm x 3.2 cm x 0.7 cm. The Stage III pressure sore had a red wound bed with granulation tissue. The surrounding skin had a pink, beveled edge and a dark pigmented skin color around the pressure sore which appeared to be possible redness indicating infection or healed scar tissue. LVN C cleansed the pressure sore with normal saline, placed calcium alginate with silver in the wound bed, and covered with a dry composite dressing. In an interview on 07/12/2013 at 4:50 PM the DON B stated the left hip pressure sore was a stage III. DON B stated she would notify the physician to clarify the treatment due to the stage, measurements, drainage, and no odor. Record review of Resident #18's Physician Order Report dated 06/01/2013-07/31/2013 and signed by the Physician on 06/22/2013 reflected "Wound Treatments. flow sheet" with a start date of 05/27/2013 to "CLEAN L (left) HIP W (with) WC (wound cleanser) COLLAGEN AND COVER W SECONDARY DRESSING Q (every) M-W-F (Monday-Wednesday-Friday) AND PRN (as needed)". Resident #18's Physician Orders did not reflect the stage of the pressure sore or the current treatment as observed by the surveyor. In an interview on 07/13/2013 at 11:30 AM the DON B stated she had not yet contacted the Physician for Resident #18 to give a full description of the pressure sores to include the stage, measurements, drainage, or odor to receive new orders. DON B stated she would address the right hip stage III pressure sore and ask the Physician to change the treatment on the right hip area from the Dermaceptin cream to a dressing with hydrogel for moisture. Record review of Resident #18's Physician's Telephone Orders dated 07/14/2013 reflected "1) D/C (discontinue) Dermaceptin to R hip 2) Begin treatment to R hip--clean with NS (normal saline), apply Hydrogel and cover with gauze Q day & prn". This Order was signed by DON B. This Order did not address the pressure sore's stage. Record review of Resident #18's Physician Telephone Orders dated 07/14/2013 reflected "1) Stage III L hip clean with WC, apply Silver Calcium Alginate and cover with island dressing M-W-F & prn 2) Stage III R hip Clean with NS apply Hydrogel and cover with gauze q day & prn". This Order was signed by DON B. This Order reflected the stages. In an interview on 07/13/2013 at 2:00 PM the LVN C stated she faxed the Physician about the "wounds" on the right and left hip area to get the treatment orders changed but did not describe the pressure sores in the facsimile to the physician to include the stage, measurements, drainage, or odor. LVN C also stated that DON A did not assess Resident #18's pressure sores at the same time with LVN C, but that DON A staged the pressure sores for LVN C. In an interview on 07/12/2013 at 11:26 AM the Facility Medical Director, who is also Resident # 18's Primary Care Physician, stated he expected to get a full picture of the resident, and if he had been notified fully of Resident #18's Stage III pressure sore he would have "definitely " changed the treatment to the pressure sore. Record review of the Policy and Procedure for Skin--Treatment Guidelines for Pressure Ulcers revised 03/2012 reflected under "Policy It is the policy of this home to utilize treatment guidelines when providing care for residents with pressure ulcers and to prevent further deterioration of pressure ulcers. Note: These are treatment suggestions, and do not supersede a Physician's order for any treatment. A physician order will be obtained for the pressure ulcer treatment and will be specific for each site. -Each pressure ulcer must have a separate order. -Each pressure ulcer site must be identified by location. (Example: left elbow, coccyx, etc.)..." B.) 1.) Review of Resident #13's face sheet reflected a [AGE] year old male admitted to the facility on [DATE]. No diagnoses were listed. Review of Resident #13's Start Up Orders dated 07/08/2013 reflected the following Diagnosis: [REDACTED]. Review of Resident #13's Admission/ Readmission Data Summary dated 07/08/2013 at 3:45 PM done by LVN F (Licensed Vocational Nurse) reflected Resident #13 to require assistance of one for mobility, assist of two for transfer, total assistance with meals, and incontinence of bladder and bowel. The assessment further reflected Resident #13 to be on a regular no salt on tray low concentrated sweet diet. Under cognitive status Resident #13 was coded to be alert with long and short-term memory problems and sometimes able to make self understood. The admission further reflected under respiratory section that Resident #13 lung sounds were clear. Under the skin condition section the assessment reflected Resident #13 to have a pressure sore to coccyx with no further description. The assessment did not address pain. Review of Resident #13's Care Plan reflected Resident #13 did not have a plan of care. Review of Resident #13's medical record reflected no assessment for pain. Review of Resident #13's Start Up Orders dated 07/08/2013 reflected an order for [REDACTED]. Review of Resident #13's Nursing Documentation Record reflected Resident #13 on 07/11/2013 at 08:10 AM Resident #13 "staff and nurse in room to do dressing change and resident agitated and yelling and hitting at staff, states he wants out of here." Observation on 07/11/2013 at 7:00 PM revealed LVN C providing treatment to Resident # 13's Stage IV pressure sore (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). LVN C then took one (1) stack of 4x4's and placed them in Resident #13's sacral pressure sore and cleaned using a twisting motion. Resident #13 began making incoherent verbalizations, becoming increased as LVN C cleaned pressure sore using the twisting motion. LVN C then cleansed Resident #13's sacral pressure sore again using the twisting motion with a new stack of 4x4 gauze. Resident #13's entire body began to shake and he had his right hand in a fist formation. Resident #13's incoherent verbalizations increased in volume. Surveyor then asked Resident #13 if he was in pain. Resident #13 continued to shake and make incoherent verbalizations. LVN C did not stop cleaning the wound or address Resident #13. DON A did not address Resident #13 but continued to observe LVN C clean Resident #13's sacral pressure sore. Resident # 13 continued with loud verbalization and shaking while LVN C repeated the cleaning, again using the twisting motion, LVN C then took hydrogel gauze and shoved it with force into Resident #13's sacral pressure sore. Resident #13 made a loud verbalization, his entire body was shaking and he grabbed at DON A. DON A did not respond to Resident # 13's grabbing, she continued to hold the resident in position and observed LVN C. LVN C then shoved another hydrogel gauze into Resident #13's sacral pressure sore and covered area with a [MEDICATION NAME] dressing. In an interview on 07/11/2013 at 7:20 PM surveyor asked Resident #13 if he was hurting after wound care was complete. Resident #13 stated "Yes I am hurting" surveyor then asked Resident #13 where he was hurting and Resident #13 used his right arm to show surveyor his sacral area. In an interview on 07/ 3 at 7:30 PM LVN C stated when she cleaned Resident #13's sacral pressure sore deeper Resident became more verbal. LVN C further stated she was not expecting Resident #13 to react that way. Surveyor then asked LVN C if she should have stopped the procedure when she noted Resident #13's reaction. LVN C stated she should have stopped the procedure. LVN C stated she should have pre-medicated Resident #13 with pain medication prior to procedure but she was unsure what kind of medication Resident #13 had for pain. In an interview on 07/11/2013 at 8:00 PM DON A stated that she would notify Resident #13's physician regarding Resident #13's pain since he only had Tylenol ordered PRN for pain. DON A stated that LVN C should have stopped the treatment to Resident #13's sacral pressure sore "the resident was in pain." DON A further stated that Resident #13 should have been assessed for pain prior to procedure and during procedure for signs of pain. DON A stated she knew LVN C was in a hurry to leave so she did not stop the procedure. Surveyor then asked DON A if a resident with a pressure sore that size would be in pain all time and DON A stated they would be in continuous pain and that Resident #13's pain was not addressed because she missed it. Observation on 07/11/2013 at 8:15 PM revealed DON A presented surveyor with an Admission Care Plan for Resident #13. Review of the Admission Care Plan for Resident #13 reflected "16. Pressure Sores/ Skin Care. Goal: Prevent/ heal pressure sores and skin breakdown. TX: see treatment sheet and order. Follow facility protocol. Turn every 2 hours and PRN. Report to charge nurse any redness or skin breakdown immediately. Low air mattress." There was no Care Plan for pain. In an interview on 07/11/2013 at 8:18 PM DON A stated "I just got that done." Review of Resident #13's Physician's Telephone orders dated 07/11/2013 at 8:10 PM reflected an order "Give [MEDICATION NAME] 5/325 mg one tab PO every six (6) hours PRN for pain and 30 minutes before wound care." In an interview on 07/12/2013 at 11:26 AM the Facility Medical Director stated he would expect the nurses to notify him if a resident was in need of pain medication. 2.) Review of Resident #9's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility 05/13/2

Based on observation, interview and record review the facility failed to ensure two (2) of nine (9) Residents (Resident # 13 and #18) reviewed for pressure sores received necessary treatment and services to promote healing, accurately assess and stage, and once developed, failed to ensure necessary treatment and services to promote healing. A.) Resident #13 was admitted to the facility with a Stage IV sacral pressure sore (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). The facility did not accurately stage the pressure sore on admit resulting in Resident #13 receiving inappropriate treatment and worsening of sacral pressure sore. B.) The facility failed to accurately stage Resident #18's Stage III pressure sores (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) and received inappropriate treatment from the physician to promote healing. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 07/11/2013. While the IJ was removed on 07/15/2013, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern. This deficient practice placed 13 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Finding Include: A.) Review of Resident #13's face sheet reflected a [AGE] year old male admitted to the facility on [DATE]. No diagnoses were listed. Review of Resident #13' Start Up Orders dated 07/08/2013 reflected the following Diagnosis: [REDACTED]. Review of Resident #13's Admission/ Readmission Data Summary dated 07/08/2013 at 3:45 PM done by Licensed Vocational Nurse (LVN) F reflected Resident #13 to require assistance of one for mobility, assist of two for transfer, total assistance with meals, and incontinence of bladder and bowel. The assessment further reflected Resident #13 to be on a regular no salt on tray, low concentrated sweet diet. Under cognitive status Resident #13 was coded to be alert with long and short-term memory problems and sometimes able to make self understood. The admission further reflected under the respiratory section that Resident #13's lung sounds were clear. Under the skin condition section the assessment reflected Resident #13 to have a pressure sore to coccyx with no further description. Review of Resident #13's Care Plan reflected Resident #13 did not have a Plan of Care. Observation on 07/08/2013 at 7:50 PM revealed Resident #13 in bed asleep on initial tour. Review of Resident #13's Start Up Orders reflected no order for treatment for [REDACTED]. Review of a Facsimile to Resident #13 physician dated 07/08/2013 no time reflected "Patient has unstagable (Unstageable Pressure Ulcers: Full-tissue thickness loss in which the base of the ulcer is covered by slough or an eschar and, therefore, the true depth of the damage cannot be estimated until these are removed.) to coccyx, will pack with hydrogel dressing and cover with secondary dressing every Monday, Wednesday, Friday and PRN. Will start Patient on Zinc 220 mg every day times 14 days." Review of Resident #13's Physician Telephone Orders reflected an order dated 07/09/2013 "Clean coccyx wound with wound cleanser, apply hydrogel dressing every Monday, Wednesday Friday, and PRN." Review of the Skin Assessment Flow Sheet- Pressure Ulcer for Resident #13 reflected an assessment dated [DATE] no time "Site one (1) stage unstagable, length 4.0, width 4.0, depth-slough and eschar, odor present, eschar, slough. Under the comments section " odorous, slough, and necrotic tissue, undermining from one (1) o'clock to four (4) o'clock 3 cm." There was no indication of location on form. Review of Resident #13's Nursing Documentation Record reflected Resident #13 on 07/11/2013 at 08:10 AM Resident #13 "staff and nurse in room to do dressing change and resident agitated and yelling and hitting at staff, states he wants out of here. " In an interview on 07/11/2013 at 4:20 PM DON A stated that Resident #13 did not have a plan of care for his needs because she does those on admission and she had not gotten to it. Observation on 07/11/2013 at 4:25 PM revealed Resident #13 in bed on right side Resident #13 was restless and did not communicate with surveyor. Observation on 07/11/2013 at 7:00 PM revealed Treatment Nurse LVN C setting up for wound care for Resident #13's sacral pressure sore. LVN C used bare hands to grab 4x4 gauze from treatment cart and sprayed wound cleanser on 4x4 gauze without gloves. LVN C did this multiple times until she had four (4) stacks of 4x4 gauze on wax paper outside of Resident #13's room on top of treatment cart. LVN C then removed an adhesive [MEDICATION NAME] dressing and two (2) hydrogel dressings from cart and placed on wax paper. LVN C then brought items into Resident #13 room and placed on bedside table after cleaning with an antiseptic wipe. LVN C then used alcohol based hand sanitizer to clean hands and then donned gloves. DON A then removed Resident #13's covers and turned him to his left side. Observation of the pressure sore revealed a Stage IV pressure sore approximately 6.0 cm x 4.0 cm x 2.0 cm (approximation made by surveyor) no dressing was present to be removed, wound bed of red granulation tissue was noted at the posterior aspect of wound from 6 o'clock to 9 o' clock the rest of the wound bed was covered in yellow slough and eschar. Resident #13's sacral Stage IV pressure sore had a pervasive odor. LVN C then took one (1) of the stacks of 4x4's and placed them in Resident #13's sacral pressure sore and cleaned using a twisting motion. Resident #13 began making incoherent verbalizations, becoming increased as LVN C cleaned pressure sore using the twisting motion. LVN C then cleansed Resident #13's sacral pressure sore again using the twisting motion with a new stack of 4x4 gauze. Resident #13's entire body began to shake and he had his right hand in a fist formation. Resident #13's incoherent verbalizations increased in volume. Surveyor then asked Resident #13 if he was in pain. Resident #13 continued to shake and make incoherent verbalizations. LVN C did not stop cleaning the wound or address Resident #13. DON A did not address Resident #13 but continued to observe LVN C clean Resident #13's sacral pressure sore. Resident # 13 continued with loud verbalization and shaking while LVN C repeated the cleaning, again using the twisting motion, LVN C then took hydrogel gauze and shoved it with force into Resident #13's sacral pressure sore. Resident #13 made a loud verbalization, his entire body was shaking and he grabbed at DON A. DON A did not respond to Resident # 13's grabbing, she continued to hold the resident in position and observed the LVN C. LVN C then shoved another hydrogel gauze into Resident #13's sacral pressure sore and covered area with a [MEDICATION NAME] dressing. In an interview on 07/11/2013 at 7:35 PM LVN C stated she staged Resident #13's sacral pressure sore as unstagable and did not measure depth because the wound bed had slough in it. LVN C further stated she could see some wound bed but because of the slough she could not stage. In an interview on 07/11/2013 at 7:40 PM DON A stated she felt Resident #13's sacral pressure sore was Stage IV when she assessed it, however LVN C is assessing the pressure sores and she had been to training so she might have seen something I did not. DON A stated she let LVN C staged Resident #13's sacral pressure sore as unstagable. DON A further stated she saw Resident #13's sacral pressure sore when he was admitted "It did not seem that bad, it seems to be getting worse" DON A further stated that Resident #13's physician had not seen Resident #13's the sacral pressure. DON A further stated she would expect her nurse to measure depth on a pressure sore that you can see a wound bed. Surveyor then asked DON A if she felt Resident #13 physician was informed properly in regard to Resident #13 s sacral pressure sore, DON A stated "no I would not think it was enough information to make a treatment decision." DON A further stated she would wait till Monday for measurements of Resident #13's sacral pressure sore to notify physician of changes to pressure sore. DON A stated Resident # 13's physician had instructed her to make an appointment for the Resident at the Wound Clinic on Monday, 7/08/2013, and she will do that when she gets to it. Observation on 07/11/2013 at 8:15 PM revealed DON A presented surveyor with an Admission Care Plan for Resident #13. Review of the Admission Care Plan for Resident #13 reflected "16. Pressure Sores/ Skin Care. Goal: Prevent/ heal pressure sores and skin breakdown. TX: see treatment sheet and order. Follow facility protocol. Turn every 2 hours and PRN. Report to charge nurse any redness or skin breakdown immediately. Low air mattress." There was no Care Plan for pain. In an interview on 07/11/2013 at 8:18 PM DON A " I just got that done. " Observation on 07/12/2013 at 10:00 AM revealed an ambulance at the facility to transport Resident #13 to the emergency room . In an interview on 07/12/2013 at 11:26 AM the Facility Medical Director, who is also Resident # 13's Primary Care Physician, stated he was told that Resident #13 was going to be admitted but he had not seen him yet. The Facility Medical Director stated he was unaware that Resident had a Stage IV pressure sore to his sacral area "I was told that Resident #13 had an unstagable pressure to coccyx." The Facility Medical Director further stated he expected to get a full picture of the resident, and if he had been notified fully of Resident #13's Stage IV pressure sore he would have "definitely " changed the treatment to the pressure sore and probably would not have taken the Resident at the facility. The Facility Medical Director further stated "I do not think they knew what they were getting into with this patient." "I have told them they have to see the patients before they come in." "Sounds like she (DON A) did an incomplete assessment." In an interview on 07/12/2013 at 12:25 PM the emergency room (ER) Physician stated Resident #13 was brought into the ER after aspiration at the facility. An x-ray was done and showed no pneumonia but that it can take days for aspiration to show up on an x-ray. The ER Physician stated Resident #13 had raspy lung sounds. The ER Physician further stated that Resident #13 had a large Stage IV pressure sore "deep" on his upper sacral area, odorous, with drainage. The ER Physician stated he was able to see the wound bed of Resident #13's sacral pressure sore and the pressure sore was infected. The ER Physician stated Resident #13's Stage IV sacral pressure sore needed surgical debridement. In an interview on 07/12/2013 at 12:30 PM the ER Registered Nurse (RN) stated the odor of Resident # 13's Stage IV Pressure sore was nauseating and "there is no excuse for what happened to this man." Observation on 07/12/2013 at 12:40 PM revealed Resident #13 lying on left side in the emergency room . Resident #13 did not respond to surveyor. In an interview on 07/12/2013 at 12:50 PM Resident #13's Responsible Party stated that the facility had told her on admit that they would get a wound doctor to see his pressure sore. Resident #13's Responsible Party further stated that the facility told her he had a Stage IV pressure sore. Review of Resident #13's Physician's Telephone Orders reflected an order dated 07/12/2013 no time to refer Resident #13 to wound care doctor for wound care of coccyx area. B.) Record review of Resident #18's Face Sheet reflected the admission date of [DATE] and the latest re-admission date of [DATE] with diagnoses of Attention to Gastrostomy (Primary), Dysphagia, [MEDICAL CONDITION], Convulsions, [MEDICAL CONDITIONS], Paranoid State, [MEDICAL CONDITIONS], Hepatic [MEDICAL CONDITION], Hypopotassemia, and Acute Pain. Record review of Resident #18's Admission/Readmission Data Summary dated 01/31/2013 reflected "Skin Condition" with no markings indicated on the body diagram of any skin conditions. This Summary was signed by Licensed Vocational Nurse (LVN) D. Record review of Resident #18's Comprehensive Care Plan dated 04/25/2013 reflected a Pressure Sore to the Left Hip at Unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.). The Care Plan reflected an update on 05/20/2013 written in at the bottom "Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) -Tx (treatment) changed collagen M-W-F (Monday-Wednesday-Friday)". Record review of Resident #18's Physician Order Report dated 06/01/2013-07/31/2013 and signed by the Physician on 06/22/2013 reflected "Wound Treatments. flow sheet" with a start date of 05/27/2013 to "CLEAN L (left) HIP W (with) WC (wound cleanser) COLLAGEN AND COVER W SECONDARY DRESSING Q (every) M-W-F (Monday-Wednesday-Friday) AND PRN (as needed)". Resident #18's Physician Orders did not reflect the stage of the pressure sore or the current treatment as observed by the surveyor. Record review of Resident #18's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected the Resident was totally dependent upon staff for activities of daily living (ADL). The MDS also reflected she had one stage III pressure sore that measured 2.5 centimeters (cm) x 2.5 cm x 0.1 cm with granulation tissue. Record review of Resident #18's Facsimile to the Physician dated 07/03/2013 reflected "Wound to L (left) hip is increasing in size and drainage. Treatment was changed to calcium alginate with silver to try to improve this. Wound is still showing deteriation. Can I do a culture on the site?" This Facsimile was signed by LVN C. The Facsimile did not give adequate information to describe the pressure sore on Resident #18's right hip to the Physician--the measurements, drainage, and odor were not addressed in the Facsimile. Record review of Resident #18's Comprehensive Care Plan dated 07/06/2013 reflected a Pressure Sore to the Right Hip at a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.). The Care Plan reflected an update on 07/14/13 of an Approach change of treatment, but the stage remained at a Stage II. Record review of Resident #18's Facsimile to the Physician dated 07/06/2013 reflected "Pt (Patient) found to have Stage II to R (right) hip will apply dermaceptin (cream with zinc and menthol) Q day & prn till resolved. Please notify if this is acceptable or if further orders are necessary." This Facsimile was signed by LVN C. The Facsimile did not give adequate information to describe the pressure sore on Resident #18's right hip to the Physician--the measurements, drainage, and odor were not addressed in the Facsimile. Record review of Resident #18's Physician's Telephone Orders dated 07/06/2013 reflected "apply dermaceptin to R hip Q day & prn". This Order was signed by LVN C. This Order did not address the pressure sore's stage. Record review of Resident #18's Skin Evaluation Flowsheet--Pressure Ulcer dated 07/08/2013 reflected left hip "#1 Site"; "Stage II"; "Dimensions (CM) L 3.2 W 3.0 D 0.01"; "Comments", "clear" was written in the box. The Flowsheet also reflected "#2 Site R hip"; "Stage II"; "Dimensions (CM) L 2.5 W 2.5 D 0.01"; "Comments", "clear" was written in the box. Record review of Resident #18's Facsimile to the Physician dated 07/11/2013 reflected "Pt wounds not responding to treatment. Can I change treatment to bilat (bilateral) hips to: clean wound with WC (wound cleanser), apply hydrogel and cover with dressing M-W-F and prn." This Facsimile was signed by LVN C. The Facsimile did not give adequate information to describe the pressure sore on Resident #18's right hip to the Physician--the measurements, drainage, and odor were not addressed in the Facsimile. Observation on 07/12/2013 at 4:30 PM revealed Resident #18 with a Stage III Pressure Sore to the right hip area. There was no dressing with the Stage III pressure sore open to air. LVN C measured the pressure sore after cleansing, measurements were 1.7 cm x 1.0 cm x 0.4 cm. The Stage III pressure sore had a dark red wound bed with granulation tissue. The surrounding skin had a beveled, white edge and a dark pigmented skin color around the pressure sore which appeared to be possible redness indicating infection or healed scar tissue. LVN C cleansed the pressure sore with normal saline and after discussion with DON B, LVN C covered the Stage III with a dry composite dressing until the Physician could be called for new orders. The orders for the pressure sore were to cleanse with normal saline then apply dermaceptin cream (a cream with zinc and menthol) to the open pressure sore. In an interview on 07/12/2013 at 4:40 PM, DON B stated the right hip pressure sore was a stage III. DON B stated she would notify the physician to clarify the treatment due to the stage, measurements, no drainage, and no odor. Observation on 07/12/2013 at 4:45 PM revealed Resident #18 also had a Stage III to the left hip area. There was a dressing with visible yellow and dark red drainage on the outside of the dressing. LVN C measured the pressure sore after cleansing, the measurements were 3.5 cm x 3.2 cm x 0.7 cm. The Stage III pressure sore had a red wound bed with granulation tissue. The surrounding skin had a pink, beveled edge and a dark pigmented skin color around the pressure sore which appeared to be possible redness indicating infection or healed scar tissue. LVN C cleansed the pressure sore with normal saline, placed calcium alginate with silver in the wound bed, and covered with a dry composite dressing. In an interview on 07/12/2013 at 4:50 PM the DON B stated the left hip pressure sore was a stage III. DON B stated she would notify the physician to clarify the treatment due to the stage, measurements, drainage, and no odor. In an interview on 07/12/2013 at 11:26 AM the Facility Medical Director, who is also Resident # 18's Primary Care Physician, stated he expected to get a full picture of the resident, and if he had been notified fully of Resident #18's Stage III pressure sore he would have "definitely " changed the treatment to the pressure sore. In an interview on 07/13/2013 at 11:30 AM the DON B stated she had not yet contacted the Physician for Resident #18 to give a full description of the pressure sores to include the stage, measurements, drainage, or odor to receive new orders. DON B stated she would address the right hip stage III pressure sore and ask the Physician to change the treatment on the right hip area from the Dermaceptin cream to a dressing with hydrogel for moisture. In an interview on 07/13/2013 at 2:00 PM the LVN C stated she faxed the Physician about the "wounds" on the right and left hip area to get the treatment orders changed but did not describe the pressure sores in the facsimile to the physician to include the stage, measurements, drainage, or odor. LVN C also stated that DON A did not assess Resident #18's pressure sores at the same time with LVN C, but that DON A staged the pressure sores for LVN C. Record review of Resident #18's Physician's Telephone Orders dated 07/14/2013 reflected "1) D/C (discontinue) Dermaceptin to R hip 2) Begin treatment to R hip--clean with NS (normal saline), apply Hydrogel and cover with gauze Q day & prn". This Order was signed by DON B. Record review of Resident #18's Physician Telephone Orders dated 07/14/2013 reflected "1) Stage III L hip clean with WC, apply Silver Calcium Alginate and cover with island dressing M-W-F & prn 2) Stage III R hip Clean with NS apply Hydrogel and cover with gauze q day & prn". This Order was signed by DON B. This Order reflected the stages. Record review of Policy and Procedure for Skin Integrity Monitoring System revised 03/2012 reflected under the "Procedure...4. When pressure ulcers are identified, the assessment of the ulcer must be documented on the (Skin Assessment Flow Sheet--Pressure Ulcer) form. 5. When a pressure ulcer is identified, treatment orders are obtained from physician." The Skin Integrity Monitoring System also reflected "Pressure Ulcer Stages" with the definitions of the stages. The "Goals...2. Accurately identifying existing tissue destruction and optimize healing by utilizing consistent treatment." The Skin Integrity Monitoring System also reflected "Guidelines--Skin Assessment 4. Document the following parameters under 'Description of Skin Alterations' for each pressure ulcer. Use the indicated codes on the form...a. stage b. size; including length, width, and depth in centimeters c. drainage--'D' d. eschar--'E' e. granulation--'G' f. induration--'I' g. necrotic tissue--'N' h. odor present--'O' i. edges inflamed--'R' j. sloughing--'S' k. underminig--'U' l. skin debridement--'S/D' m. tunneling--'T''. The Policy reflected "When a Pressure Ulcer is Identified 1. Assessment of the pressure ulcer is documented using the (Skin Assessment Flow Sheet--Pressure Ulcer). 2. All notifications to physician, interested party of the resident and the resident are to be completed and documented." Record review of the Policy and Procedure for Skin--Treatment Guidelines for Pressure Ulcers revised 03/2012 reflected under "Policy It is the policy of this home to utilize treatment guidelines when providing care for residents with pressure ulcers and to prevent further deterioration of pressure ulcers. Note: These are treatment suggestions, and do not supersede a Physician's order for any treatment. A physician order will be obtained for the pressure ulcer treatment and will be specific for each site. -Each pressure ulcer must have a separate order. -Each pressure ulcer site must be identified by location. (Example: left elbow, coccyx, etc.)..." The Policy also reflected the definition of a stage III pressure sore. The Policy reflected "Procedure ...6. Confirm the physician has been notified that the resident has a pressure ulcer and is aware of the current status. Document in the progress notes...10. Stage III...with NO or LIGHT drainage: ...c. Apply gel impregnated gauze, cover with gauze, change BID (twice a day) and PRN (as needed). OR d. Hydrogel, and cover with gauze e. Collagen or Calcium Alginate (Rope or Pad may be used) f. Enzymatic Agents (as needed) g. Cover with foam or composite dressing...11. Stage III...with MODERATE to HEAVY drainage: ...c. Calcium Alginate. d. Collagen. e. Cover with foam or composite dressing use ABD (abdominal) pad on wounds with copious drainage." The Policy and Procedure for Skin--Treatment Guidelines for Pressure Ulcers also reflected the definition of a stage IV pressure sore. The Policy reflected under "Procedure...11. Debridement (per physician order) if indicated, of necrotic tissue using one of the following methods: a. Enzymatic agents. b. Mechanical action via wet-to-dry dressings c. Sharp debridement performed by physician. d. Autolytic debridement using synthetic dressings. e. Cover with foam or composite dressing...13. Stage IV...with MODERATE to HEAVY drainage: ...c. Calcium Alginate, cover with foam dressing secure, with tape change Q (every) Day and prn (dependant on drainage) OR d. Calcium Alginate, cover with foam or composite dressing or ABD pad (only with copious drainage)". The Policy and Procedure for Skin--Treatment Guidelines for Pressure Ulcers also reflected the definition of an "Unstagable" pressure sore. The Policy reflected under "Interventions...12. Once wound base is visible, follow guidelines for Stage III or Stage IV pressure ulcers." The facility Administrator was notified on 07/11/2013 at 9:00 PM that an IJ situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator on 07/12/2013 at 2:08 PM. The final Plan of Removal was accepted by the surveyor on 07/13/2013 at 4:05 PM. Plan of Removal IJ #4. Pressure Sores not staged appropriately for Resident #13, Physician not appropriately notified of wound assessment. 1. Current facility DON has been suspended and will be terminated upon final Human Resource evaluation on 07/15/2013. 2. Two Regional Nurse Consultants will arrive to assist in plan of removal tasks. Start 07/12/2013, completion 07/13/2013. 3. All licensed nurses will be in serviced by Interim DON/ Regional Nurse Consultant on wound care procedures to included that the RN is to stage the wound. Staff not working will be in-serviced prior to working their next shift. Newly hired nurses will be in serviced during their orientation period. Start 07/11/2013, Completion 07/13/2013. 4. All residents with pressure ulcers will have wounds re-assessed by Regional Nurse Consultant to ensure wound is documented correctly to include correct stage. Any wound found to be incorrectly documented will be re-assessed to include: dimensions, description of wound, presence and description of drainage and odor if present. Presence of slough and or necrotic tissue and correct stage. Start 07/12/2013, Completion 07/13/2013. 5. Treatment orders will be reviewed concurrently with the re-assessment of the pressure ulcer to ensure treatment is appropriate for wound and wound is improving. Start 07/12/2013, Completion 07/13/2013. 6. If wound is not improving or treatment is not appropriate, physician will be notified and appropriate orders received and initiated. The treatment nurse will relay accurate information to the physician to include stage of wound, measurements, drainage, odor etc. to allow physician to make an appropriate treatment order. Start 07/12/2013, Completion 07/13/2013. 7. The Physician for #13 was notified and order received for wound consult with wound physician. Wound Clinic notified. Waiting for return call.(Resident transferred to acute care setting due to change of condition.) Resident will not return to facility due to Medical Director expressed acuity is not appropriate for this facility. Start 07/12/2013, Completion 07/13/2013. 8. A Regional Nurse Consultant will make wound rounds weekly and daily PRN with the LVN to assess for accuracy of wound documentation and to Stage pressure ulcers. The LVN treatment nurse has been educated on documentation to reflect proper location, measurements procedure for accuracy, depth, Physician notification, odor, drainage, and to evaluate labs, nutritional intake, support surfaces. Start 07/12/2013, Completion 07/13/2013. 9. LVN treatment nurse has a fax cover page with critical information such as measurements, stage, location, drainage and odor to ensure proper communication with physician for any declines or improvements in wounds. LVN treatment nurse received in-service from the RN Assistant Director of Clinical Services to utilize fax cover page with above information anytime a order change is needed from physician related to wounds, i.e. treatment change, lab, nutrition, etc. Start 07/12/2013, Completion 07/13/2013. 10. Residents admitted to the facility with pressure ulcers will be assessed by a Regional Nurse Consultant within 24 hours after admission to assure wound documentation is correct to include dimensions, description of wound, presence and description of drainage and odor. The Regional Nurse Consultant will stage the wound and document stage. Start 07/12/2013, Completion 07/13/2013 and ongoing. 11. Pressure ulcer surveillance will be completed weekly by the Regional Nurse Consultant weekly and results presented to the QA (Quality Assurance) monthly. Start 07/12/2013, Completion ongoing. 12. Administrator will notify Medical Director of IJ status of home. Start 07/12/2013, Completion 07/12/2013. The survey team monitored the current plan of removal as follows: Monitored nine (9) of the 13 Resident with pressure sores. Pressure sore observations were made and documentation were reviewed. No further problems identified. Treatment orders were reviewed for appropriateness. No further problems identified. All in-service documentation was reviewed and attendance checked to ensure all licensed nurses were in-serviced. No further problems identified. In an interview on 07/13/2013 at 2:00 PM Treatment Nurse LVN C stated she had received in-service training on new fax form, communication with physician to give accurate information, to include location, size and depth, drainage and odor. Treatment Nurse LVN C further stated she was not to stage pressure sores that an RN would be available to consult on staging. On 07/15/2013 at 11:03 AM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list of 13 residents with pressure sores.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of nine (9) residents (Resident #13 and 9) reviewed for pain management with pressure sores. A.) 1) The facility did not assess Resident #13 for pain resulting in Resident #13 not having physician orders [REDACTED]. 2) The facility did not assess Resident #9 for pain during wound care resulting in Resident #9 enduring painful pressure sore treatments. This deficient practice placed 13 residents at risk for enduring painful pressure sore treatments. B) In addition, based on observation, interview and record review, the facility failed develop and implement a policy and failed to train all employees in emergency procedures to meet all potential emergencies and disasters for two (2) of five (5) Residents (Resident # 2 and # 5) reviewed for evacuation. 1) The facility failed to train staff regarding Resident # 2's special need to be transferred out of the bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals), into a wheel chair and evacuated into an area that would accommodate her special sized wheel chair in order to evacuate to areas of refuge from the building when necessary. 2) The facility failed to train staff regarding Resident # 5's special need to be transferred out of the bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals), into a wheel chair and evacuated into an area that would accommodate her special sized wheel chair in order to evacuate to areas of refuge from the building when necessary. This deficient practice had the potential to delay or prevent the safe, rapid, and efficient evacuation from the facility, for the five (5) Residents identified as utilizing the Bariatric beds, in the event of an emergency. These deficient practices resulted in an Immediate Jeopardy (IJ) on 07/09/2013. While the IJ was removed on 07/15/13, the facility remained out of compliance at a Severity Level of Actual Harm with a Scope of pattern that is not IJ. Findings Include: A) 1) Review of Resident #13's face sheet reflected a [AGE] year old male admitted to the facility on [DATE]. No diagnoses were listed. Review of Resident #13's Start Up Orders dated 07/08/2013 reflected the following Diagnosis: [REDACTED]. Review of Resident #13's Admission/ Readmission Data Summary dated 07/08/2013 at 3:45 PM done by LVN F (Licensed Vocational Nurse) reflected Resident #13 to require assistance of one for mobility, assist of two for transfer, total assistance with meals, and incontinence of bladder and bowel. The assessment further reflected Resident #13 to be on a regular no salt on tray low concentrated sweet diet. Under cognitive status Resident #13 was coded to be alert with long and short-term memory problems and sometimes able to make self understood. The admission further reflected under respiratory section that Resident #13 lung sounds were clear. Under the skin condition section the assessment reflected Resident #13 to have a pressure sore to coccyx with no further description. Review of Resident #13's Care Plan reflected Resident #13 did not have a plan of Care. Review of Resident #13's medical record reflected no assessment for pain. Review of Resident #13's Start Up Orders dated 07/08/2013 reflected an order for [REDACTED]. Review of Resident #13's Nursing Documentation Record reflected Resident #13 on 07/11/2013 at 08:10 AM Resident #13 "staff and nurse in room to do dressing change and resident agitated and yelling and hitting at staff, states he wants out of here." Observation on 07/11/2013 at 7:00 PM revealed LVN C providing treatment to Resident # 13's Stage IV pressure sore (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). That measured approximately 6.0 cm x 4.0 cm x 2.0 cm (approximation made by surveyor) no dressing was present to be removed, wound bed of red granulation tissue was noted at the posterior aspect of wound from 6 o'clock to 9 o' clock the rest of the wound bed was covered in yellow slough and eschar. Resident #13's sacral Stage IV pressure sore had a pervasive odor. LVN C then took one (1) of the stacks of 4x4's and placed them in Resident #13's sacral pressure sore and cleaned using a twisting motion. Resident #13 began making incoherent verbalizations, becoming increased as LVN C cleaned pressure sore using the twisting motion. LVN C then cleansed Resident #13's sacral pressure sore again using the twisting motion with a new stack of 4x4 gauze. Resident #13's entire body began to shake and he had his right hand in a fist formation. Resident #13's incoherent verbalizations increased in volume. Surveyor then asked Resident #13 if he was in pain. Resident #13 continued to shake and make incoherent verbalizations. LVN C did not stop cleaning the wound or address Resident #13. DON A did not address Resident #13 but continued to observe LVN C clean Resident #13's sacral pressure sore. Resident # 13 continued with loud verbalization and shaking while LVN C repeated the cleaning, again using the twisting motion, LVN C then took hydrogel gauze and shoved it with force into Resident #13's sacral pressure sore. Resident #13 made a loud verbalization, his entire body was shaking and he grabbed at DON A. DON A did not respond to Resident # 13's grabbing, she continued to hold the resident in position and observed LVN C. LVN C then shoved another hydrogel gauze into Resident #13's sacral pressure sore and covered area with a [MEDICATION NAME] dressing. In an interview on 07/11/2013 at 7:20 PM surveyor asked Resident #13 if he was hurting after wound care was complete. Resident #13 stated "Yes I am hurting" surveyor then asked Resident #13 where he was hurting and Resident #13 used his right arm to show surveyor his sacral area. In an interview on 07/ 3 at 7:30 PM LVN C stated when she cleaned Resident #13's sacral pressure sore deeper Resident became more verbal. LVN C further stated she was not expecting Resident #13 to react that way. Surveyor then asked LVN C if she should have stopped the procedure when she noted Resident #13's reaction. LVN C stated she should have stopped the procedure. LVN C stated she should have pre-medicated Resident #13 with pain medication prior to procedure but she was unsure what kind of medication Resident #13 had for pain. In an interview on 07/11/2013 at 8:00 PM DON A stated that she would notify Resident #13's physician regarding Resident #13's pain since he only had Tylenol ordered PRN for pain. DON A stated that LVN C should have stopped the treatment to Resident #13's sacral pressure sore "the resident was in pain." DON A further stated that Resident #13 should have been assessed for pain prior to procedure and during procedure for signs of pain. DON A stated she knew LVN C was in a hurry to leave so she did not stop the procedure. Surveyor then asked DON A if a resident with a pressure sore that size would be in pain all time and DON A stated they would be in continuous pain and that Resident #13's pain was not addressed because she missed it. Observation on 07/11/2013 at 8:15 PM revealed DON A presented surveyor with an Admission Care Plan for Resident #13. Review of the Admission Care Plan for Resident #13 reflected "16. Pressure Sores/ Skin Care. Goal: Prevent/ heal pressure sores and skin breakdown. TX: see treatment sheet and order. Follow facility protocol. Turn every 2 hours and PRN. Report to charge nurse any redness or skin breakdown immediately. Low air mattress." There was no Care Plan for pain. In an interview on 07/11/2013 at 8:18 PM DON AN "I just got that done." Review of Resident #13's Physician's Telephone orders dated 07/11/2013 at 8:10 PM reflected an order "Give [MEDICATION NAME] 5/325 mg one tab PO every six (6) hours PRN for pain and 30 minutes before wound care." In an interview on 07/12/2013 at 11:26 AM the Facility Medical Director stated he would expect the nurses to notify him if a resident was in need of pain medication. 2.) Review of Resident #9's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility 05/13/2013 with the following Diagnosis: [REDACTED]. Review of Resident #9 ' s Significant Change Minimum Data Set ((MDS) dated [DATE] reflected the Resident to score a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #9 to was cognitively intact. The assessment reflected the Resident needed limited one person assist with transfers, bed mobility, dressing, and hygiene. Resident #9 was coded to require extensive assistance with bathing. The assessment further reflected Resident #9 to be continent of bowel and frequently incontinent of bladder. The assessment reflected Resident #9 to have one Stage II pressure sore(Partial thickness loss of dermis presentian as a shallow open ulcer with red pink wound bed, without slough.) and was coded not to have pain. Review of Resident #9 ' s Comprehensive Plan of Care dated 06/18/2013 reflected a plan of care for a Stage II pressure sore to left thigh with no approaches for pain. The Comprehensive Plan of Care further reflected a care plan for Risk for Pain, redness, swelling and warmth of leg related to [MEDICAL CONDITION]. Observation on 07/09/2013 at 3:00 PM revealed LVN (Licensed Vocational Nurse) C preparing to perform wound care on Resident #9's Stage II pressure sore to back of left thigh. LVN C used bare hands to grab 4x4 gauze from inside of treatment cart and sprayed wound cleanser on 4x4 gauze without gloves on. LVN C did this two (2) times until she had two (2) stacks of four by four gauze on wax paper outside of Resident #9's room on top of treatment cart. LVN C then went into Resident #9's room and cleaned off Resident's bedside table with an antiseptic wipe. LVN C then brought supplies into Resident #9's room and placed on bedside table. LVN C used hand sanitizer and donned gloves. Resident #9 was lying on side. No dressing was present on Resident #9's Stage II pressure sore. LVN C did not assess Resident #9 for pain. LVN C grabbed a stack of four by four gauze and approached Resident #9. Resident #9 then stated "You are not going to use that Q-tip are you." LVN C then stated no we measure on Monday ' s." Resident #9 then stated "good, because that hurts " . LVN C then cleaned Resident #9's Stage II pressure sore by wiping from 9 o'clock to 3 o'clock across pressure sore. Resident #9 made a hissing nose as LVN C cleaned pressure sore. Surveyor then asked Resident #9 if she was in pain. Resident #9 stated "yes, it hurts all the time" . LVN C did not address Resident #9's pain. LVN C then applied dermaceptin (a zinc based cream with [MEDICATION NAME]) to a pad type dressing then applied to Resident #9's pressure sore with the dressing, and made circular motions rubbing the deraceptin in with the dressing. LVN then applied dressing securing with tape. In an interview on 07/09/2013 at 3:30 PM Resident #9 stated the nurses never ask her if she is hurting before they do treatments. Resident #9 further stated they give me a pain pill twice a day but it does not help with the pain in the pressure sore. Review of Resident #9's Medication orders reflected Resident #9 had an order for [REDACTED]. Review of the facilities Policy and Procedure for Pain Management dated 08/2009 reflected "It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life." "Procedure 1. Each resident's pain will be assessed using the (Comprehensive Pain Assessment) upon admission.." "3. The home recognizes that a resident response to pain is subjectie and individual." "5. The home will treat the resident under the premise that pain is present whenever the resident says that it is." "6. Nursing staff will identify situations or interventions where a increase in the resident's pain may be anticipated (i.e. wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities." "How To Assess Pain...Behavioral Responses. These include altered body position, moaning, signing, grmacing, withdrawal, crying, restlessness, muscle twitching, and immobility." B) Observations during initial tour on 07/08/2013 between 7:15 PM and 9:00 PM revealed five (5) Residents (Resident # 2, # 5, #9, # 15 and # 16) required the use of bariatric beds that would not fit through the door in case of an emergency to evacuate quickly. In an interview on 07/08/2013 at 9:20 PM the Administrator stated there were five (5) bariatric beds in use the facility with two (2) Residents that required assistance to transfer from the bed to the wheel chair. The Administrator stated Resident # 2 and Resident # 5 required total assistance to transfer along with the use of a Hoyer lift. The Administrator stated she had educated staff regarding evacuating Residents that utilized the bariatric beds during her last disaster in-service and when asked if all staff attended the in-service the Administrator replied "I think I got most of them." In an interview on 07/09/2013 at 6:05 PM Certified Nurse Aide (CNA) L stated she had not been trained to evacuate Residents who require bariatric beds. When asked how she was attempt to evacuate Resident # 2 and Resident # 5 in case of an emergency she replied "honestly and truthfully, I don't know." CNA L further stated she thought it would take a few of us to get them out. In an interview on 07/09/2013 at 6:25 PM Licensed Vocational Nurse (LVN) E stated staff would have to use a Hoyer lift because the bariatric bed does not come out of the room. LVN E stated Residents # 2 and # 5 use a wheel chair and they would use a Hoyer lift to transfer from the bed to the wheel chair. In an interview on 07/09/2013 at 6:45 PM the Director of Nurses (DON) stated she would think staff would put Resident # 2 and # 5 on a sheet to evacuate during an emergency. The DON stated the facility would have to call the Emergency Medical Technicians (EMT) to assist with getting her out of bed. The DON stated the facility used a Hoyer lift to get the residents to the chair or recliner. In an interview on 07/09/2013 7:00 PM the Administrator stated she had discussed the evacuation process for Residents in bariatric beds that could not transfer themselves with the Fire Marshall and EMT's. The Administrator stated the facility would use a big tarp with a blanket inside to evacuate the Residents, after having used a Hoyer lift to get them to the floor. When asked if the facility Disaster Plan included those plans to evacuate Residents who required bariatric beds the Administrator replied "no written disaster plan - do I need to?" 1) Observation made on 07/08/2013 at 8:15 PM revealed Resident # 2 to be laying in her bariatric bed. Resident # 2 was a morbidly obese female. In an interview on 07/09/2013 at 3:20 PM Resident # 2 stated she is unable to transfer herself from the bed to the chair and required the assistance of two (2) staff members and a Hoyer lift in order to get out of bed. Resident # 2 stated she does not get out of bed on a regular basis, maybe once or twice a week. Review of Resident # 2's Record of Admission reflected a [AGE] year old female who entered the facility on 07/06/2010 with [DIAGNOSES REDACTED]. Review of Resident # 2's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected the Resident scored 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) and indicated she was cognitively intact. Resident # 2 was coded as not having walked in the look-back period and was totally dependent upon two (2) staff members for assistance with transfer. Resident # 2 used a wheel chair as a mobility device. Review of Resident # 2's Comprehensive Plan of Care date 05/15/2013 reflected the Resident required two (2) staff members to assist with bed mobility at times and two (2) staff members with a Hoyer lift for transfer. The Plan of Care reflected Resident # 2 had a history of [REDACTED]. Approaches included 1) encourage resident to ask for assistance of staff and 4) anticipate needs, provide prompt assistance. Review of Resident # 2's Weight History reflected the Resident currently weighed 629 pounds (lbs). 2) Observation on 07/08/2013 at 7:40 PM revealed Resident # 5 laying supine in a bariatric bed. Review of Resident # 5's Admission Summary reflected a [AGE] year old female who entered the facility on 01/20/2012 with the following Diagnosis: [REDACTED]. Review of Resident #5's Quarterly MDS dated [DATE] reflected Resident to score a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #5 to was cognitively intact. Resident #5 was coded to require total dependence on staff for bed mobility, transfers, locomotion on unit, dressing, personal hygiene and bathing. Resident #5 was coded to have a urinary ostomy and was incontinent of bowel. Review of Resident # 5's Comprehensive Plan of Care dated 12/13/2011 reelected the Resident required the assistance of two (2) staff members for bed mobility and transfer assistance. The Plan of Care reflected Resident # 5 had a history of [REDACTED]. Review of Resident # 5's Weight Variance Report reflected on 07/08/2013 the Resident weighed 295.4 lbs. Review of the facility Disaster Plan reflected no evacuation plan for Residents who required bariatric beds. Observation on 07/14/2013 at 11:00 AM revealed the Maintenance Supervisor measured the bariatric beds in use at the facility and the door clearance with the following measurements revealed: Bed 63B (Resident # 2) - 51 inches (") x 88" - Door clearance was 44.5". Bed 29A (Resident # 5) - 47" x 88" - Door clearance was 39 and 3/4 ". Bed 2B - 47" x 88 " - Door clearance was 39 and 3/4" - Resident did not require transfer assistance. Bed 25B - 51" x 87" - Door clearance was 39.5" - Resident did not require transfer assistance. Bed 63A - 51" x 88" - Door clearance was 39.5". Resident did not require transfer assistance. In an interview on 07/10/2013 at 4:40 PM the Medical Director stated Residents # 2 and # 5 could not transfer herself due to [MEDICAL CONDITION]. The Medical Director stated Resident # 2 had been a risk for the facility all along and he had advised facility Administrative Staff that the Resident was a risk. The Medical Director stated Resident # 2 had already broken two (2) Hoyer lifts. The Medical Director stated he had told the Administrator, approximately one year ago, the facility was not going to be able to take care of Resident # 2. The Medical Director stated he was not surprised when the facility advised him of the IJ regarding bariatric beds, "I knew it was coming." The Administrator and DON were notified on 07/09/2013 at 9:28 PM that an IJ was identified due to the above failures. A) The following Plan of Removal was submitted by the Administrator on 07/12/2013 at 2:08 PM. The final Plan of Remvoal was accepted on 07/13/2013 at 3:45 PM. Plan of Removal IJ #3, Failure to provide adequate pain management to Residentsw #9 and #13. 1. Current faility DON has been suspended and will be terminated upon final Human Resource evaluation on 07/15/2013. 2. Two Regional Nurse Consultants will arrive to assist in plan of removal tasks. Start: 07/12/2013, Completion: 07/13/2013. 3. Resident #9's pain is being managed during treatment by pre-medicating prior to treatement being done. Start: 07/12/2013, Completion: 07/13/2013. 4. Physician for Resident #13 was notified at 8:00 PM and pain medication order received. Resident was monitored and pain managed throughout the night. Start: 07/11/2013, Completed: 07/12/2013. 5. Regional Nurse Consultant/ designee will assess all residents with pain to include those currently receiving scheduled or PRN pain medications, to ensure their pain is being addressed and treated effectiely. Those found not having their pain treated effectively will be referred to the physician for further evaluation and treatment. Start: 07/12/ , Completed: 07/13/2013. 6. Regional Nurse Consultant/ designee will review all residents MARS (medication administration records)/ TARS (treatment administration records) for accurate pain medication orders and resident pain is assessed every shift on flowsheet. Start: 07/12/2013, Completed: 07/13/2013. 7. A documented pain assessment will be completed on admission, re-admission, change of condition, with events that could increase pain. Start: 07/12/2013, Completed: Ongoing. 8. Resgional Nurse Consultant/ designee will in-service licensed staff (RN's, LVN's) on Pain Management to included assessing pain on admission, readmission, change of condition, with events that could increase pain (i.e. therapy, wound care, transfers, etc.) and each shift. Start: 07/12/2013, Completed 07/13/2013. 9. Licensed nurses not working during the pain in-service presentation, will be in-serviced prior to their working their next scheduled shift. New employees (licensed nurses) will recive the aforementioned in-service during their orientation period. Start: 07/12/2013, Completed: 07/13/2013 and ongoing. 10. Administrator will notify Medical Director of IJ status of home. Start: 07/12/2013, Completed 07/12/2013. 11. Nursing empolyees will be educated on accepting subjective complaints of pain from residents and addressing with appropriate pain management. Start: 07/11/2013, Completed: 07/13/2013 and ongoing. 12. Residents will be educated regarding voicing complaints of pain and advised of their plan of care. This will be done annually, quarterly and with change of condition. Start: 07/12/2013, Completed: ongoing. 13. Resuts of audits will be presented at QA meeting for the next three (3) months. Start: 07/12/2013. Completed: ongoing. The survey team monitored the current plan of removal as follows. A sample of 14 out of 51 listed at high risk for pain were reviewed to ensure pain assessments were completed, and interventions put into place were needed. No further problems were noted. Wound care on Resident #1 was observed on 07/13/2013 and resident was pre-medicated for pain prior to procedure. Wound care on Resident # 6 was observed on 07/13 /2013 and resident was pre-medicated for pain prior to procedure. Resident # 13 had been transferred to the hospital and was unavailable to view wound care. In an interview on 07/15/2013 at 10:00 AM LVN D stated she would assess residents for pain while doing care, and medicate as needed. In an interview on 07/13/2013 at 10:30 AM the LVN C stated Resident #1 was " pre-medicated with [MEDICATION NAME] " prior to the wound care for pain. In an interview on 07/13/2013 at 11:35 AM the LVN C stated Resident #6 was " pre-medicated with [MEDICATION NAME] earlier and Tylenol not too long ago " prior to the wound care. LVN C stated, when Resident #6 complained of pain during wound care, " I will try again later " . LVN C stated she will place a clean dry dressing on the area at this time. LVN C stated she would report Resident #6 ' s pain to the charge nurse. All in-service documentation was reviewed and attendance checked to ensure all licensed nurses were in-serviced. No further problems identified. Review of Resident #9's Medical Record reflected a care plan for pain dated 07/13/2013. B) The following Plan of Removal was submitted by the Administrator on 07/10/2013 at 5:20 PM The final Plan of Removal was accepted by the survey team on 07/ 3 at 10:39 AM. 1. An addendum has been attached to the facility's current disaster plan related to evacuation of Bariatric residents. The Addendum Includes: A. Current Route of evacuation for transferring Resident # 2 with assistance of two or more Certified Nurse Aides, into a wheelchair, utilizing the 1000 lb mechanical lift, roll to Station three (3) and turn to the right to 3 East exit and proceed down the sidewalk to a safe area. Resident # 5 was transferred out of facility on 12:05 AM on 07/10/2013. 2. In-services were started on 07/09/2013 with all nursing staff in the facility related to the transfer of bariatric resident # 2 utilizing the 1000 lb mechanical lift in the event of an emergency evacuation. Lift will be stored/located on Station 3 in the storage room directly across from Resident # 2's room. In-servicing will be completed by 07/12/13. 3. Nursing staff will be in-serviced on use of 1000 lb mechanical lift prior to going on the floor to provide care for Resident # 2. 4. All staff will be provided a copy of the new addendum for emergency evacuation of bariatric residents and will be placed in the disaster manual. 5. Administrator or designee will perform random reviews on each shift weekly to ensure the complete understanding of transferring a bariatric resident. 6. Training will be provided to all new hires prior to working on the floor with bariatric residents on the specific evacuation techniques for all bariatric residents. 7. A smooth walking surface for Station 3 dining room to the north end of Station 3 will be extended to a width of five (5) feet to accommodate bariatric wheelchairs. Will be completed by 7/12/13 8. Resident # 2 will be evacuated by the Station3 East Hall or Station 3 North Hall, prior to the completion of the smooth walking surface at Station 3 Dining Room exit door on 7/12/13. The survey team monitored the Plan of Removal as follows: Observation made on 07/11/2013 at 9:00 AM revealed Resident # 2 being transferred out of bed using the 1000 lb Hoyer lift. Resident # 2 was evacuated to the East Station 3 exit as reflected in the Plan of Removal. Review of the Addendum to Emergency Evacuation of Residents, inserted into page 18 - Priority of Movement for Emergency Evacuation...added # 4 for bariatric transfer. This addendum was signed by the Administrator and dated 07/11/2013 and reflected. 4) Bariatric Residents Transfer resident with assist of two or more CNA's into wheelchair utilizing Hoyer lift. Roll resident out of home utilizing designated evacuation route. Interviews were conducted with Staff Members, LVN D, LVN E, CNA L, Certified Medication Aide (CMA) M and Housekeeping Aide T. All answered disaster plan questions correction and knew the evacuation process of Resident # 2 and other residents that required bariatric beds and assistance with transfer. Observation made on 07/11/2013 at 10:00 AM revealed a work crew had been put into place to widen the sidewalk to ensure safe evacuation at the north exit of Station 3. Review of the In-Services conducted regarding the evacuation process of bariatric residents revealed 70% of the staff had been trained. On 07/15/2013 at 11:03 AM the Administrator and Interim DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. A) The facility provided a list of 51 residents at risk for pain. B) The facility provided a list of five (5) residents who required use of a bariatric bed. At any time all 5 Residents could require transfer assistance.

Based on observation, interview and record review, the facility failed to train all employees in emergency procedures to meet all potential emergencies and disasters for two (2) of five (5) Residents (Resident # 2 and # 5) reviewed for evacuation. A) The facility failed to train staff regarding Resident # 2's special need to be transferred out of the bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals), into a wheel chair and evacuated into an area that would accommodate her special sized wheel chair in order to evacuate to areas of refuge from the building when necessary. B) The facility failed to train staff regarding Resident # 5's special need to be transferred out of the bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals), into a wheel chair and evacuated into an area that would accommodate her special sized wheel chair in order to evacuate to areas of refuge from the building when necessary. The facility disaster plan did not include procedures to break down the Bariatric beds and deflate the mattresses on these beds to enable them to move efficiently through the facility doorways in the event of an emergency evacuation of residents from the facility. This resulted in an Immediate Jeopardy (IJ) on 07/09/2013. While the IJ was removed on 07/11/13, the facility remained out of compliance at a Severity Level of Potential for More Than Minimal Harm with a Scope of pattern that is not IJ. This deficient practice had the potential to delay or prevent the safe, rapid, and efficient evacuation from the facility, for the five (5) Residents identified as utilizing the Bariatric beds, in the event of an emergency. Findings include: Observations during initial tour on 07/08/2013 between 7:15 PM and 9:00 PM revealed five (5) Residents (Resident # 2, # 5, #9, # 15 and # 16) required the use of bariatric beds that would not fit through the door in case of an emergency to evacuate quickly. In an interview on 07/08/2013 at 9:20 PM the Administrator stated there were five (5) bariatric beds in use the facility with two (2) Residents that required assistance to transfer from the bed to the wheel chair. The Administrator stated Resident # 2 and Resident # 5 required total assistance to transfer along with the use of a Hoyer lift. The Administrator stated she had educated staff regarding evacuating Residents that utilized the bariatric beds during her last disaster in-service and when asked if all staff attended the in-service the Administrator replied "I think I got most of them." In an interview on 07/09/2013 at 6:05 PM Certified Nurse Aide (CNA) L stated she had not been trained to evacuate Residents who require bariatric beds. When asked how she was attempt to evacuate Resident # 2 and Resident # 5 in case of an emergency she replied "honestly and truthfully, I don't know." CNA L further stated she thought it would take a few of us to get them out. In an interview on 07/09/2013 at 6:25 PM Licensed Vocational Nurse (LVN) E stated staff would have to use a Hoyer lift because the bariatric bed does not come out of the room. LVN E stated Residents # 2 and # 5 use a wheel chair and they would use a Hoyer lift to transfer from the bed to the wheel chair. In an interview on 07/09/2013 at 6:45 PM the Director of Nurses (DON) stated she would think staff would put Resident # 2 and # 5 on a sheet to evacuate during an emergency. The DON stated the facility would have to call the Emergency Medical Technicians (EMT) to assist with getting her out of bed. The DON stated the facility used a Hoyer lift to get the residents to the chair or recliner. In an interview on 07/09/2013 7:00 PM the Administrator stated she had discussed the evacuation process for Residents in bariatric beds that could not transfer themselves with the Fire Marshall and EMT's. The Administrator stated, as a result of their conversation, the facility would use a big tarp with a blanket inside to evacuate the Residents, after having used a Hoyer lift to get them to the floor. When asked if the facility Disaster Plan included those plans to evacuate Residents who required bariatric beds the Administrator replied "no written disaster plan - do I need to?" A) Observation made on 07/08/2013 at 8:15 PM revealed Resident # 2 to be laying in her bariatric bed. Resident # 2 was a morbidly obese female. In an interview on 07/09/2013 at 3:20 PM Resident # 2 stated she is unable to transfer herself from the bed to the chair and required the assistance of two (2) staff members and a Hoyer lift in order to get out of bed. Resident # 2 stated she does not get out of bed on a regular basis, maybe once or twice a week. Review of Resident # 2's Record of Admission reflected a [AGE] year old female who entered the facility on 07/06/2010 with [DIAGNOSES REDACTED]. Review of Resident # 2's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected the Resident scored 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) and indicated she was cognitively intact. Resident # 2 was coded as not having walked in the look-back period and was totally dependent upon two (2) staff members for assistance with transfer. Resident # 2 used a wheel chair as a mobility device. Review of Resident # 2's Comprehensive Plan of Care date 05/15/2013 reflected the Resident required two (2) staff members to assist with bed mobility at times and two (2) staff members with a Hoyer lift for transfer. The Plan of Care reflected Resident # 2 had a history of [REDACTED]. Approaches included 1) encourage resident to ask for assistance of staff and 4) anticipate needs, provide prompt assistance. Review of Resident # 2's Weight History reflected the Resident currently weighed 629 pounds (lbs). B) Observation on 07/08/2013 at 7:40 PM revealed Resident # 5 laying supine in a bariatric bed. Review of Resident # 5's Admission Summary reflected a [AGE] year old female who entered the facility on 01/20/2012 with the following Diagnosis: [REDACTED]. Review of Resident #5's Quarterly MDS dated [DATE] reflected Resident to score a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #5 to was cognitively intact. Resident #5 was coded to require total dependence on staff for bed mobility, transfers, locomotion on unit, dressing, personal hygiene and bathing. Resident #5 was coded to have a urinary ostomy and was incontinent of bowel. Resident #5 was coded t Review of Resident # 5's Comprehensive Plan of Care dated 12/13/2011 reelected the Resident required the assistance of two (2) staff members for bed mobility and transfer assistance. The Plan of Care reflected Resident # 5 had a history of [REDACTED]. Review of Resident # 5's Weight Variance Report reflected on 07/08/2013 the Resident weighed 295.4 lbs. Review of the facility Disaster Plan reflected no evacuation plan for Residents who required bariatric beds. Observation on 07/14/2013 at 11:00 AM revealed the Maintenance Supervisor measured the bariatric beds in use at the facility and the door clearance with the following measurements revealed: Bed 63B (Resident # 2) - 51 inches (") x 88" - Door clearance was 44.5". Bed 29A (Resident # 5) - 47" x 88" - Door clearance was 39 and 3/4 ". Bed 2B - 47" x 88 " - Door clearance was 39 and 3/4" - Resident did not require transfer assistance. Bed 25B - 51" x 87" - Door clearance was 39.5" - Resident did not require transfer assistance. Bed 63A - 51" x 88" - Door clearance was 39.5". Resident did not require transfer assistance. The Administrator and DON were notified on 07/09/2013 at 9:28 PM that an IJ was identified due to the above failures. In an interview on 07/10/2013 at 4:40 PM the Medical Director stated Residents # 2 and # 5 could not transfer herself due to [MEDICAL CONDITION]. The Medical Director stated Resident # 2 had been a risk for the facility all along and he had advised facility Administrative Staff that the Resident was a risk. The Medical Director stated Resident # 2 had already broken two (2) Hoyer lifts. The Medical Director stated he had told the Administrator, approximately one year ago, the facility was not going to be able to take care of Resident # 2. The Medical Director stated he was not surprised when the facility advised him of the IJ regarding bariatric beds, "I knew it was coming." The following Plan of Removal was submitted by the Administrator on 07/10/2013 at 5:20 PM The final Plan of Removal was accepted by the survey team on 07/ 3 at 10:39 AM. Immediate Jeopardy #2 - Evacuation of Bariatric Residents 1. An addendum has been attached to the facility's current disaster plan related to evacuation of Bariatric residents. The Addendum Includes: A. Current Route of evacuation for transferring Resident # 2 with assistance of two or more Certified Nurse Aides, into a wheelchair, utilizing the 1000 lb mechanical lift, roll to Station three (3) and turn to the right to 3 East exit and proceed down the sidewalk to a safe area. Resident # 5 was transferred to (name of the hospital) a 12:05 AM on 07/10/2013. 2. In-services were started on 07/09/2013 with all nursing staff in the facility related to the transfer of bariatric resident # 2 utilizing the 1000 lb mechanical lift in the event of an emergency evacuation. Lift will be stored/located on Station 3 in the storage room directly across from Resident # 2's room. In-servicing will be completed by 07/12/13. 3. Nursing staff will be in-serviced on use of 1000 lb mechanical lift prior to going on the floor to provide care for Resident # 2. 4. All staff will be provided a copy of the new addendum for emergency evacuation of bariatric residents and will be placed in the disaster manual. 5. Administrator or designee will perform random reviews on each shift weekly to ensure the complete understanding of transferring a bariatric resident. 6. Training will be provided to all new hires prior to working on the floor with bariatric residents on the specific evacuation techniques for all bariatric residents. 7. A smooth walking surface for Station 3 dining room to the north end of Station 3 will be extended to a width of five (5) feet to accommodate bariatric wheelchairs. Will be completed by 7/12/13 8. Resident # 2 will be evacuated by the Station3 East Hall or Station 3 North Hall, prior to the completion of the smooth walking surface at Station 3 Dining Room exit door on 7/12/13. The survey team monitored the Plan of Removal as follows: Observation made on 07/11/2013 at 9:00 AM revealed Resident # 2 being transferred out of bed using the 1000 lb Hoyer lift. Resident # 2 was evacuated to the East Station 3 exit as reflected in the Plan of Removal. Review of the Addendum to Emergency Evacuation of Residents, inserted into page 18 - Priority of Movement for Emergency Evacuation...added # 4 for bariatric transfer. This addendum was signed by the Administrator and dated 07/11/2013 and reflected. 4) Bariatric Residents Transfer resident with assist of two or more CNA's into wheelchair utilizing Hoyer lift. Roll resident out of home utilizing designated evacuation route. Interviews were conducted with Staff Members, LVN D, LVN E, CNA L, Certified Medication Aide (CMA) M and Housekeeping Aide T. All answered disaster plan questions correction and knew the evacuation process of Resident # 2 and other residents that required bariatric beds and assistance with transfer. Observation made on 07/11/2013 at 10:00 AM revealed a work crew had been put into place to widen the sidewalk to ensure safe evacuation at the north exit of Station 3. Review of the In-Services conducted regarding the evacuation process of bariatric residents revealed 70% of the staff had been trained. On 07/11/2013 at 11:20 the Administrator and Interim DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list of five (5) residents who required use of a bariatric bed. At any time all 5 Residents could require transfer assistance.

Based on observation, interview and record review, the facility failed to develop a policy and procedure in an emergency to meet all potential emergencies and disasters for two (2) of five (5) Residents (Resident # 2 and # 5) reviewed for evacuation. A) The facility failed to develop a policy regarding Resident # 2's special need to be transferred out of the bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals), into a wheel chair and evacuated into an area that would accommodate her special sized wheel chair in order to evacuate to areas of refuge from the building when necessary. B) The facility failed to develop a policy regarding Resident # 5's special need to be transferred out of the bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals), into a wheel chair and evacuated into an area that would accommodate her special sized wheel chair in order to evacuate to areas of refuge from the building when necessary. This resulted in an Immediate Jeopardy (IJ) on 07/09/2013. While the IJ was removed on 07/11/13, the facility remained out of compliance at a Severity Level of Potential for More Than Minimal Harm with a Scope of pattern that is not IJ. This deficient practice had the potential to delay or prevent the safe, rapid, and efficient evacuation from the facility, for the five (5) Residents identified as utilizing the Bariatric beds, in the event of an emergency. Findings include: Observations during initial tour on 07/08/2013 between 7:15 PM and 9:00 PM revealed five (5) Residents (Resident # 2, # 5, #9, # 15 and # 16) required the use of bariatric beds that would not fit through the door in case of an emergency to evacuate quickly. In an interview on 07/08/2013 at 9:20 PM the Administrator stated there were five (5) bariatric beds in use the facility with two (2) Residents that required assistance to transfer from the bed to the wheel chair. The Administrator stated Resident # 2 and Resident # 5 required total assistance to transfer along with the use of a Hoyer lift. In an interview on 07/09/2013 7:00 PM the Administrator stated she had discussed the evacuation process for Residents in bariatric beds that could not transfer themselves with the Fire Marshall and EMT's. The Administrator stated, as a result of their conversation, the facility would use a big tarp with a blanket inside to evacuate the Residents, after having used a Hoyer lift to get them to the floor. When asked if the facility Disaster Plan included those plans to evacuate Residents who required bariatric beds the Administrator replied "no written disaster plan - do I need to?" A) Observation made on 07/08/2013 at 8:15 PM revealed Resident # 2 to be laying in her bariatric bed. Resident # 2 was a morbidly obese female. In an interview on 07/09/2013 at 3:20 PM Resident # 2 stated she is unable to transfer herself from the bed to the chair and required the assistance of two (2) staff members and a Hoyer lift in order to get out of bed. Resident # 2 stated she does not get out of bed on a regular basis, maybe once or twice a week. Review of Resident # 2's Record of Admission reflected a [AGE] year old female who entered the facility on 07/06/2010 with [DIAGNOSES REDACTED]. Review of Resident # 2's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected the Resident scored 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) and indicated she was cognitively intact. Resident # 2 was coded as not having walked in the look-back period and was totally dependent upon two (2) staff members for assistance with transfer. Resident # 2 used a wheel chair as a mobility device. Review of Resident # 2's Comprehensive Plan of Care date 05/15/2013 reflected the Resident required two (2) staff members to assist with bed mobility at times and two (2) staff members with a Hoyer lift for transfer. The Plan of Care reflected Resident # 2 had a history of [REDACTED]. Approaches included 1) encourage resident to ask for assistance of staff and 4) anticipate needs, provide prompt assistance. Review of Resident # 2's Weight History reflected the Resident currently weighed 629 pounds (lbs). B) Observation on 07/08/2013 at 7:40 PM revealed Resident # 5 laying supine in a bariatric bed. Review of Resident # 5's Admission Summary reflected a [AGE] year old female who entered the facility on 01/20/2012 with the following Diagnosis: [REDACTED]. Review of Resident #5's Quarterly MDS dated [DATE] reflected Resident to score a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #5 to was cognitively intact. Resident #5 was coded to require total dependence on staff for bed mobility, transfers, locomotion on unit, dressing, personal hygiene and bathing. Resident #5 was coded to have a urinary ostomy and was incontinent of bowel. Resident #5 was coded t Review of Resident # 5's Comprehensive Plan of Care dated 12/13/2011 reelected the Resident required the assistance of two (2) staff members for bed mobility and transfer assistance. The Plan of Care reflected Resident # 5 had a history of [REDACTED]. Review of Resident # 5's Weight Variance Report reflected on 07/08/2013 the Resident weighed 295.4 lbs. Review of the facility Disaster Plan reflected no evacuation plan for Residents who required bariatric beds. Observation on 07/14/2013 at 11:00 AM revealed the Maintenance Supervisor measured the bariatric beds in use at the facility and the door clearance with the following measurements revealed: Bed 63B (Resident # 2) - 51 inches (") x 88" - Door clearance was 44.5". Bed 29A (Resident # 5) - 47" x 88" - Door clearance was 39 and 3/4 ". Bed 2B - 47" x 88 " - Door clearance was 39 and 3/4" - Resident did not require transfer assistance. Bed 25B - 51" x 87" - Door clearance was 39.5" - Resident did not require transfer assistance. Bed 63A - 51" x 88" - Door clearance was 39.5". Resident did not require transfer assistance. The Administrator and DON were notified on 07/09/2013 at 9:28 PM that an IJ was identified due to the above failures. In an interview on 07/10/2013 at 4:40 PM the Medical Director stated Residents # 2 and # 5 could not transfer herself due to [MEDICAL CONDITION]. The Medical Director stated Resident # 2 had been a risk for the facility all along and he had advised facility Administrative Staff that the Resident was a risk. The Medical Director stated Resident # 2 had already broken two (2) Hoyer lifts. The Medical Director stated he had told the Administrator, approximately one year ago, the facility was not going to be able to take care of Resident # 2. The Medical Director stated he was not surprised when the facility advised him of the IJ regarding bariatric beds, "I knew it was coming." The following Plan of Removal was submitted by the Administrator on 07/10/2013 at 5:20 PM The final Plan of Removal was accepted by the survey team on 07/ 3 at 10:39 AM. Immediate Jeopardy #2 - Evacuation of Bariatric Residents 1. An addendum has been attached to the facility's current disaster plan related to evacuation of Bariatric residents. The Addendum Includes: A. Current Route of evacuation for transferring Resident # 2 with assistance of two or more Certified Nurse Aides, into a wheelchair, utilizing the 1000 lb mechanical lift, roll to Station three (3) and turn to the right to 3 East exit and proceed down the sidewalk to a safe area. Resident # 5 was transferred to (name of the hospital) a 12:05 AM on 07/10/2013. 4. All staff will be provided a copy of the new addendum for emergency evacuation of bariatric residents and will be placed in the disaster manual. 7. A smooth walking surface for Station 3 dining room to the north end of Station 3 will be extended to a width of five (5) feet to accommodate bariatric wheelchairs. Will be completed by 7/12/13 8. Resident # 2 will be evacuated by the Station3 East Hall or Station 3 North Hall, prior to the completion of the smooth walking surface at Station 3 Dining Room exit door on 7/12/13. The survey team monitored the Plan of Removal as follows: Observation made on 07/11/2013 at 9:00 AM revealed Resident # 2 being transferred out of bed using the 1000 lb Hoyer lift. Resident # 2 was evacuated to the East Station 3 exit as reflected in the Plan of Removal. Review of the Addendum to Emergency Evacuation of Residents, inserted into page 18 - Priority of Movement for Emergency Evacuation...added # 4 for bariatric transfer. This addendum was signed by the Administrator and dated 07/11/2013 and reflected. 4) Bariatric Residents Transfer resident with assist of two or more CNA's into wheelchair utilizing Hoyer lift. Roll resident out of home utilizing designated evacuation route. Interviews were conducted with Staff Members, LVN D, LVN E, CNA L, Certified Medication Aide (CMA) M and Housekeeping Aide T. All answered disaster plan questions correction and knew the evacuation process of Resident # 2 and other residents that required bariatric beds and assistance with transfer. Observation made on 07/11/2013 at 10:00 AM revealed a work crew had been put into place to widen the sidewalk to ensure safe evacuation at the north exit of Station 3. Review of the In-Services conducted regarding the evacuation process of bariatric residents revealed 70% of the staff had been trained. On 07/11/2013 at 11:20 the Administrator and Interim DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list of five (5) residents who required use of a bariatric bed. At any time all 5 Residents could require transfer assistance.

Based on observation, interview and record review, the facility failed to ensure the proper treatment and care was immediately available for three (3) of three (3) residents (Resident # 4, # 5, and # 12) with a [MEDICAL CONDITION] in the event of an emergency. A.) The facility failed to provide Resident #12 with a [MEDICAL CONDITION] an ambu bag in the resident's room for emergency care, or ensure staff were trained in the event of an emergency. Resident #12 had no orders [MEDICAL CONDITION] and suctioning and failed to ensure staff were trained in the event of an emergency. B.)The facility failed to ensure Resident #4 had a replacement [MEDICAL CONDITION] in the Resident's room or in the facility for emergency care in the event of dislodgement of the [MEDICAL CONDITION] and failed to ensure staff were trained in the event of an emergency. C.) The facility failed to ensure Resident #5 had a replacement [MEDICAL CONDITION] and in the Resident's room or in the facility for emergency care in the event of dislodgement of the [MEDICAL CONDITION] and failed to ensure staff were trained in the event of an emergency. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2013. While the IJ was removed on 7/15/2013, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as pattern. This deficient practice placed 3 residents at risk for upper respiratory infections, respiratory distress, compromised airway and death. Findings include: A.) Record review of Resident #12's Face Sheet reflected he was admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #12's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected his cognitive status was intact, Resident #12 scored a 14 on the Brief Interview for Mental Status (BIMS). The MDS reflected Resident #12 was totally dependent on staff for all activities of daily living (ADL). Resident #12 was coded on the MDS for special treatments while a resident for suctioning and [MEDICAL CONDITION] care. Record review of Resident #12's Comprehensive Care Plan dated 05/30/2013 reflected a problem of "Resident has a [MEDICAL CONDITION] and is at risk for Increased Secretions/Congestion and Infections". The Care Plan listed the approaches as: "1) Monitor for needed suctioning of increased secretions/congestion--assess for relief 2) Provide O2 (oxygen),[MEDICAL CONDITION], and tubing change per order...". Observation on 07/09/2013 at 7:05 PM revealed Resident #12 was lying in bed, the head of his bed was raised, and [MEDICAL CONDITION] in place in the middle of his neck with a strap holding it in place. There were no replacement trachs in the room, nor was there an ambu bag. Licensed Vocational Nurse (LVN) E looked in all the drawers in the room and did not locate a [MEDICAL CONDITION] ambu bag. In an interview on 07/09/2013 at 7:06 PM LVN E stated Resident #12 should have a [MEDICAL CONDITION] an ambu bag attached to the wall at his bedside. LVN E stated he could not find a [MEDICAL CONDITION] ambu bag in this resident's room. Observation on 07/09/2013 at 7:10 PM the DON A walked into Resident #12's room with an ambu bag and placed the ambu bag to the wall with a thumb tack. In an interview on 07/09/2013 at 7:10 PM the DON A stated the facility does not have a [MEDICAL CONDITION] Resident #12 at this time. DON A stated the facility would get some replacement trachs tomorrow. DON A stated if Resident #12'[MEDICAL CONDITION] out she would first place [MEDICAL CONDITION] came out back into the [MEDICAL CONDITION], then send the resident to the emergency room . In an interview on 07/09/2013 at 7:24 PM the LVN E stated that in an emergency situation when [MEDICAL CONDITION] out for Resident #12, he would check the resident's oxygen saturation, place an oxygen mask over his nose, then call 911 to send the resident to the emergency room . LVN E repeated that Resident #12 should have [MEDICAL CONDITION] in a bag on the wall. Record review of the Start Up Orders for Resident #12 dated 05/13/2013 reflected no orders for suctioning [MEDICAL CONDITION]. Record review of the Start Up Orders for treatments and medications administration record(TAR and MAR) for Resident #12 dated 05/13/2013 reflected no orders for suctioning [MEDICAL CONDITION]. Record review of the Respiratory Flowsheet (TAR) for Resident #12 dated 06/01/2013-06/30/2013 reflected no orders for suctioning [MEDICAL CONDITION]. Record review of the Respiratory Flowsheet (TAR) for Resident #12 dated 07/01/2013-07/31/2013 reflected no orders for suctioning [MEDICAL CONDITION]. Record review of the Progress Notes (Nurse's Notes) for Resident #12 reflected Resident #12 was documented as being suctioned on the following dates: 05/21/2013, 05/23/2013, 05/30/2013, 06/01/2013, 06/11/2013, 06/12/2013, 06/20/2013, and 07/09/2013. The Notes also reflected Resident #12 [MEDICAL CONDITION] documented on the following dates: 05/20/2013, 05/21/2013, 05/23/2013, 05/24/2013, 05/25/2013, 05/30/2013, 05/31/2013, 06/01/2013, 06/11/2013, 06/12/2013, 06/17/2013, 06/18/2013, 06/20/2013, 06/29/2013, and 07/09/2013. Record review of the Physician order [REDACTED]. Shift-Every Shift-PRN;PRN 1;PRN 2; PRN 3". The Orders also reflected the order "TRACH CARE Q SHIFT AND PRN Q Shift-Every Shift; NIGHTS, DAYS, EVENINGS" with a "Start Date" of 07/01/2013. The Physician order [REDACTED]. Record review of the Physician's Telephone Orders for Resident #12 reflected no written order for [MEDICAL CONDITION] or suctioning. Observation on 7/10/2013 at 4:00 PM revealed LVN E looking in the TAR for the orders for Resident #12'[MEDICAL CONDITION] and suctioning. In an interview on 07/10/2013 at 4:00 PM the LVN E stated he could not find the orders for suctioning [MEDICAL CONDITION] on the TAR for Resident #12. LVN E stated there should be orders written [MEDICAL CONDITION] and suctioning. In an interview on 07/10/2013 at 4:34 PM the ADON stated there should be orders on the TAR for Resident #12'[MEDICAL CONDITION] and suctioning. ADON stated [MEDICAL CONDITION] should be ordered every shift and the suctioning as needed on the Respiratory Flowsheet (TAR). B.) Review of Resident #4 ' s Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #4's Quarterly Minimum Date Set ((MDS) dated [DATE] reflected Resident to have severe cognitive impairment. Resident #4 was coded to be totally dependent on staff for bed mobility, transfer, dressing, hygiene and bathing. Resident #4 was coded incontinent of bowel and bladder. The MDS further reflected Resident #4 was coded for suctioning and [MEDICAL CONDITION] care. Review of Resident #4's Comprehensive Plan of Care dated 06/26/2013 reflected "Resident has episodes of Shortness of Breath and is at Risk for Respiratory Distress/ Failure. " "Resident has a [MEDICAL CONDITION] and is at Risk for Increased Secretion/ Congestion and Infections. Approach 9. May [MEDICAL CONDITION]." Review of Resident #4's Consolidated Physician orders [REDACTED]. Observation on 07/09/2013 at 4:30 PM revealed Resident #4 to be in bed with oxygen on per tracheotomy mask. Resident #4 was not able to communicate with surveyor. Observation on 07/09/2013 at 5:00 PM revealed a dusty Ziploc bag on the wall of Resident #4 ' s room with a box in it. At request of surveyor, LVN H removed a box labeled 6 CFS [MEDICAL CONDITION]. When LVN H opened the box the [MEDICAL CONDITION] was in, it revealed the [MEDICAL CONDITION] package to be open. In an interview on 07/09/2013 at 5:10 PM LVN H stated the [MEDICAL CONDITION] was no longer sterile if opened to air. In an interview on 07/09/2013 at 7:15 PM LVN H stated that in an emergency situation regarding a [MEDICAL CONDITION] becoming dislodged she would call 911 and send resident to the emergency room and would not try to insert another [MEDICAL CONDITION]. LVN H further stated she was unsure why the extra [MEDICAL CONDITION] were in the room "maybe it is because the doctor needs it." C.) Review of Resident #5's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #5's Quarterly MDS dated [DATE] reflected Resident to score a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #5 to was cognitively intact. Resident #5 was coded to require total dependence on staff for bed mobility, transfers, locomotion on unit, dressing, personal hygiene and bathing. Resident #5 was coded to have a urinary ostomy and was incontinent of bowel. Resident #5 was coded to have [MEDICAL CONDITION] care. Review of Resident #5's Comprehensive Plan of Care dated 05/13/2013 reflected "Resident has episodes of Shortness of Breath and is at risk for respiratory distress/ failure rated [MEDICAL CONDITION]. Monitor for s/s of rspiratory infection, report to M.D 7.[MEDICAL CONDITION] as orderd". "Resident has a [MEDICAL CONDITION] and is at risk for increased secretions/ congestion and infections 2. Provide 02, trach. care and tubing change per order." Review of Resident #5's Consolidated Physician orders [REDACTED]. Review of Resident #5's History and Physical Report dated 01/03/2013 reflected "Chief Complaint: Displaced [MEDICAL CONDITION] with [DIAGNOSES REDACTED]and need for revision." The History and Physical Report further reflected that on the night of admission Resident #5's [MEDICAL CONDITION] was dislodged. Resident #5 was also noted to have [DIAGNOSES REDACTED]and fatty tissue causing obstruction, and required revision of the [MEDICAL CONDITION]. Observation on 07/09/2013 at 7:00 PM revealed a Ziploc bag on the wall of Resident #5 ' s room. At request of surveyor, LVN H removed a box labeled 4 DCT [MEDICAL CONDITION]. When LVN H opened the box the [MEDICAL CONDITION] fell out of box onto Resident #5 ' s night stand. The packaging was open. Further Observation revealed Resident #5 did not have [MEDICAL CONDITION] care kits or suction kits at bedside. In an interview on 07/09/2013 at 6:55 PM the DON A stated "We have no replacement trachs in the building." In an interview on 07/09/2013 at 7:35 PM the Respiratory Therapist (RT) stated that she gave an in-service to this facility in October 2012 and [MEDICAL CONDITION] and suctioning. She stated a nurse should be able to re-insert [MEDICAL CONDITION] training about emergency situations of decannulation. She also stated the training included teaching the nurse to have a [MEDICAL CONDITION] ambu bag attached to the wall near the head of the bed for all residents with tracheostomies. RT stated the facility should have at least one nurse every shift to be available in case of an emergency situation and trained to re-insert a trach. RT stated she would recommend the facility to have the necessary equipment in every room that has [MEDICAL CONDITION], including a replacement trach. RT stated she [MEDICAL CONDITION] for this facility when and if the facility calls to order the kits. In an interview on 07/09/2013 at 7:45 PM the RT stated that once a [MEDICAL CONDITION] is opened and no longer sterile it must be thrown away, it can not be used. In an interview on 07/09/2010 DON A stated the facility did not have a policy on emergency [MEDICAL CONDITION] care. DON A further stated "Any prudent nurse would know what to do." In an interview on 07/10/2013 at 4:43 PM the Medical Director stated that Respiratory Therapy services was removed in this facility by Corporate "back in the winter". The Medical Director stated he was not consulted about removing Respiratory Therapy services. The Medical Director stated he was not aware that the nursing staff was not able to re-insert trachs, and if not "we have a problem". The Medical Director further stated that if a resident had obstruction of some short it would be a huge risk if the nurses did not know how to handle the situation. The Medical Director stated his expectations of the facility were to have orders for [MEDICAL CONDITION] and suctioning. The facility Administrator was notified on 07/09/2013 at 9:28 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 07/10/2013 at 10:04 AM. The final Plan of Removal was accepted on 07/10/2013 at 5:20 PM. Plan of Removal IJ #1 Immediate Jeopardy-Failed to provide for safety [MEDICAL CONDITION]. 1. Respiratory therapist was notified and delivered the required replacement trachs to the facility on [DATE] at or around 8:35 PM for Residents #4, #5, and #12. 2. Residents #4, #5, and #12 were provided with emergency equipment of ambu bags, suction machines, supplemental oxygen, and [MEDICAL CONDITION] bedside 07/09/2013. 3. Residents #4, #5, and #12 have been transferred to theHospital and their trachs have been evaluated: #4 transferred at 11:46 PM 07/09/2013; #5 at 12:05 AM 07/10/2013; #12 10:45 PM 07/09/2013. 4. Residents #4 and #5 will be transferred to a sister facility where Full time Respiratory Therapy and Nursing Services in [MEDICAL CONDITION] and Ventilator Care are provided. Resident #12 will be transferring home. 5. [MEDICAL CONDITION] will be admitted or readmitted until nursing staff have been trained on emergency procedures for decannulation [MEDICAL CONDITION] by respiratory therapist. Training was arranged on 07/09/2013 to be started on 07/10/2013 (see attached). 6. Additional training for nursing staff [MEDICAL CONDITIONS] will be provided by the respiratory therapist (see attached). 7. Emergency equipment will be provided and available in [MEDICAL CONDITION] ' s room to include: 1. Clean gloves-extra pair recommended 2. Sterile gloves-extra pair recommended 3. [MEDICAL CONDITION] kit 4. Normal saline or sterile water (if not in care kit) 5. Disposable inner cannula (if applicable) 6. Trach ties or Velcro collar type 7. Biohazard bag 8. Mask and/or Eye shield 9. Suction Machine with connecting tubing (in working order) 10. Suction kit with catheter 11. [MEDICAL CONDITION] same type and size at bedside 12. Obturator (for existing trach) or curved hemostat at bedside 13. Lubricating Jelly 8. Emergency oxygen supply and ambu bag [MEDICAL CONDITION] at bedside 9. [MEDICAL CONDITION] same type and size (or same type or 1 size smaller) will be in zip lock bag located on wall at head of bed 10. Clipboard with emergency kit and equipment checklist will be on wall in [MEDICAL CONDITION] ' s room and checked daily by Director of Nurses or designee. 11. Facility will have at least one [MEDICAL CONDITION] same type and size in stock for [MEDICAL CONDITION]. 12. Director of Nursing or designee will pre-screen [MEDICAL CONDITIONS], types, and special needs. Required equipment and supplies will be available upon admission. 13. All information will be reviewed during a QA meeting to be held 07/10/2013 and then ongoing for 3 consecutive months then quarterly. The survey team monitored the current plan of removal as follows: All residents with tracheostomies were transferred out of the facility. On 07/15/2013 at 11:03 AM the facility Administrator was informed the IJ was removed, However, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm with a scope identified as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list of three (3) residents with tracheostomies.

Based on observation, interview, and record review, the facility failed to have physician orders [REDACTED]. (Resident #12 and #13) A) Resident # 13 1.) Resident #13 was admitted to the facility with a Stage IV sacral pressure sore (Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). The facility did not accurately stage pressure sore on admission resulting in Resident #13 receiving inappropriate treatment and deterioration of sacral Stage IV pressure sore. 2) Resident #13 was admitted to the facility with a risk for aspiration and need for mechanically altered diet. The facility did not identify Resident #13's risk for aspiration or obtain orders for a mechanically altered diet resulting in Resident #13 choking on 7/12/2013 and being sent to the emergency room for Aspiration. 3.) The facility did not assess Resident #13 for pain resulting in Resident #13 not having orders for medication for pain management and the Resident endured painful pressure sore treatments. B.) The facility failed to provide Resident #12 with admission orders [REDACTED]. [MEDICAL CONDITION] care and suctioning was provided without physician orders. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2013. While the IJ was removed on 07/15/2013, the facility remained out of compliance at a severity of actual harm with a scope identified of pattern. A.) These deficient practices placed 13 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death; placed 10 residents at risk for aspiration which could cause aspiration pneumonia,[MEDICAL CONDITION], and possible death and placed 13 residents at risk for enduring painful pressure sore treatments. B) This deficient practice placed 3 residents at risk for [MEDICAL CONDITION] aspiration (the entry of material such as pharyngeal secretions, food or drink, or stomach contents), upper respiratory infections, respiratory distress, compromised airway and possible death. Finding Include: A.) Review of Resident #13's face sheet reflected a [AGE] year old male admitted to the facility on [DATE]. No diagnoses were listed. Review of Resident #13's Start Up Orders dated 07/08/2013 reflected the following Diagnosis: [REDACTED]. Although there was no Minimum Data Set (MDS) assessment started, review of Resident #13's Admission/ Readmission Data Summary dated 07/08/2013 at 3:45 PM completed by Licensed Vocational Nurse (LVN) F reflected Resident #13 required assistance of one for mobility, assist of two for transfer, total assistance with meals, and incontinence of bladder and bowel. The assessment further reflected Resident #13 to be on a regular no salt on tray low concentrated sweet diet. Under cognitive status Resident #13 was coded to be alert with long and short-term memory problems and sometimes able to make self understood. The admission further reflected under respiratory section that Resident #13 lung sounds were clear. There was no indication Resident # 13 was at risk for aspiration. Under the skin condition section the assessment reflected Resident #13 to have a pressure sore to coccyx with no further description. There was no assessment for pain. Review of Resident #13's Care Plan reflected Resident #13 did not have a plan of care. In an interview on 07/11/2013 at 4:20 PM Director of Nursing (DON) A stated that Resident #13 did not have a plan of care for his needs because she does those on admission and she had not gotten to it. 1.) Observation on 07/08/2013 at 7:50 PM revealed Resident #13 in bed asleep on initial tour. Review of Resident #13's Start Up Orders reflected no order for treatment for [REDACTED]. Review of a Fax to Resident #13 physician dated 07/08/2013 no time reflected "Patient has unstagable (Unstageable Pressure Ulcers: Full-tissue thickness loss in which the base of the ulcer is covered by slough or an eschar and, therefore, the true depth of the damage cannot be estimated until these are removed.) to coccyx, will pack with hydrogel dressing and cover with secondary dressing every Monday, Wednesday, Friday and PRN. Will start Patient on Zinc 220 mg every day times 14 days." Review of Resident #13's Physician Telephone Orders reflected an order dated 07/09/2013 "Clean coccyx wound with wound cleanser, apply hydrogel dressing every Monday, Wednesday Friday, and PRN." Review of the Skin Assessment Flow Sheet- Pressure Ulcer for Resident #13 reflected an assessment dated [DATE] no time "Site one (1) stage unstagable, length 4.0, width 4.0, depth-slough and eschar, odor present, eschar, slough. Under the comments section " odorous, slough, and necrotic tissue, undermining from one (1) o'clock to four (4) o'clock 3 cm." There was no indication of location on form. Observation on 07/11/2013 at 4:25 PM revealed Resident #13 in bed on right side Resident #13 was restless and did not communicate with surveyor. Observation on 07/11/2013 at 7:00 PM revealed Licensed Vocational Nurse (LVN) C setting up for wound care for Resident #13 ' s sacral pressure sore. LVN C used bare hands to grab 4x4 gauze from treatment cart and sprayed wound cleanser on 4x4 gauze without gloves. LVN C did this multiple times until she had four (4) stacks of 4x4 gauze on wax paper outside of Resident #13's room on top of treatment cart. LVN C then removed an adhesive [MEDICATION NAME] dressing and two (2) hydrogel dressing from cart and placed on wax paper. LVN C then brought items into Resident #13 room and placed on bedside table after cleaning with an antiseptic wipe. LVN C then used alcohol based hand sanitizer to clean hands and donned gloves. DON A removed Resident #13's covers and turned him to his left side. Observation of the pressure sore revealed a Stage IV pressure sore approximately 6.0 cm x 4.0 cm x 2.0 cm (approximation made by surveyor) no dressing was present to be removed, wound bed of red granulation tissue was noted at the posterior aspect of wound from 6 o'clock to 9 o' clock the rest of the wound bed was covered in yellow slough and eschar. Resident #13's sacral Stage IV pressure sore had a pervasive odor. LVN A then took one (1) of the stacks of 4x4 ' s and placed them in Resident #13's sacral pressure sore and cleaned using a twisting motion. Resident #13 began making incoherent verbalizations, becoming increased as LVN C cleaned pressure sore using the twisting motion. LVN C then cleansed Resident #13's sacral pressure sore again using the twisting motion with a new stack of 4x4 gauze. Resident #13's entire body began to shake and he had his right hand in a fist formation. Resident # 13 ' s incoherent verbalizations increased in volume. Surveyor then asked Resident #13 if he was in pain. Resident #13 continued to shake and make incoherent verbalizations. LVN C did not stop cleaning the wound or address Resident #13. DON A did not address Resident #13 but continued to observe LVN C clean Resident #13's sacral pressure sore. Resident # 13 continued with loud verbalization and shaking while LVN C repeated the cleaning, again using the twisting motion, LVN C then took hydrogel gauze and shoved it with force into Resident #13's sacral pressure sore. Resident #13 made a loud verbalization, his entire body was shaking and he grabbed at DON A. DON A did not respond to Resident # 13's grabbing, she continued to hold the resident in position and observed the LVN C. LVN C then shoved another hydrogel gauze into Resident #13's sacral pressure sore and covered area with a [MEDICATION NAME] dressing. In an interview on 07/11/2013 at 7:35 PM LVN C stated she staged Resident #13's sacral pressure sore as unstagable and did not measure depth because the wound bed had slough in it. LVN C further stated she could see some wound bed but because of the slough she could not stage. In an interview on 07/11/2013 at 7:40 PM DON A stated she felt Resident #13's sacral pressure sore was Stage IV when she assessed it, however LVN C is assessing the pressure sores and she had been to training so she might have seen something I did not. DON A stated she let LVN C staged Resident #13's sacral pressure sore as unstagable. DON A further stated she saw Resident #13's sacral pressure sore when he was admitted "It did not seem that bad, it seems to be getting worse" DON A further stated that Resident #13's physician had not seen Resident #13's the sacral pressure. DON A further stated she would expect her nurse to measure depth on a pressure sore that you can see a wound bed. Surveyor then asked DON A if she felt Resident #13 physician was informed properly in regard to Resident #13 s sacral pressure sore, DON A stated "no I would not think it was enough information to make a treatment decision." DON A further stated she would wait till Monday for measurements of Resident #13's sacral pressure sore to notify physician of changes to pressure sore. DON A stated Resident # 13's physician had instructed her to make an appointment for the Resident at the Wound Clinic on Monday, 7/08/2013, and she will do that when she gets to it. Observation on 07/11/2013 at 8:15 PM revealed DON A presented surveyor with an Admission Care Plan for Resident #13. Review of the Admission Care Plan for Resident #13 reflected "16. Pressure Sores/ Skin Care. Goal: Prevent/ heal pressure sores and skin breakdown. TX: see treatment sheet and order. Follow facility protocol. Turn every 2 hours and PRN. Report to charge nurse any redness or skin breakdown immediately. Low air mattress." There was no Care Plan for pain. In an interview on 07/11/2013 at 8:18 PM DON A stated "I just got that done." 2.) Observation on 07/12/2013 at 10:00 AM revealed an ambulance at the facility to transport Resident #13 to the emergency room . The Facility Medical Director who is also Resident #13 physician stated he was told that Resident #13 was going to be admitted but he had not seen him yet. In an interview on 07/12/2013 at 11:26 AM The Facility Medical Director stated he was unaware that Resident had a Stage IV pressure sore to his sacral area "I was told that Resident #13 had an unstagable pressure to coccyx." The Facility Medical Director further stated he expected to get a full picture of the resident, and if he had been notified fully of Resident #13's Stage IV pressure sore he would have "definitely" changed the treatment to the pressure sore and probably would not have taken the Resident at the facility. The Facility Medical Director further stated "I do not think they knew what they were getting into with this patient." "I have told them they have to see the patients before they come in." "Sounds like she (DON A) did an incomplete assessment." In an interview on 07/12/2013 at 12:25 PM the emergency room (ER) Physician stated Resident #13 was brought into the ER after aspiration at the facility. An x-ray was done and showed no pneumonia but that it can take days for aspiration to show up on an x-ray. The ER Physician stated Resident #13 had raspy lung sounds. The ER Physician further stated that Resident #13 had a large Stage IV pressure sore "deep" on his upper sacral area, odorous, with drainage. The ER Physician stated he was able to see the wound bed of Resident #13's sacral pressure sore and the pressure sore was infected. The ER Physician stated Resident #13's Stage IV sacral pressure sore needed surgical debridement. In an interview on 07/12/2013 at 12:30 PM the ER Registered Nurse (RN) stated Resident # 13's Stage IV pressure sore had a nauseating odor to it and "there is no excuse what happened to this man". Observation on 07/12/2013 at 12:40 PM revealed Resident #13 lying on left side in the emergency room . Resident #13 did not respond to surveyor. In an interview on 07/12/2013 at 12:50 PM Resident #13' Responsible Party stated that the facility had told her on admit that they would get a wound doctor to see his pressure sore. Resident #13's Responsible Party further stated that the facility told her he had a Stage IV pressure sore. Review of Resident #13's Physician ' s Telephone Orders reflected an order dated 07/12/2013 no time to refer Resident #13 to wound care doctor for wound care of coccyx area. Record review of the Policy and Procedure for Skin--Treatment Guidelines for Pressure Ulcers revised 03/2012 reflected under "Policy It is the policy of this home to utilize treatment guidelines when providing care for residents with pressure ulcers and to prevent further deterioration of pressure ulcers. Note: These are treatment suggestions, and do not supersede a physician's orders [REDACTED]. -Each pressure ulcer must have a separate order. -Each pressure ulcer site must be identified by location. (Example: left elbow, coccyx, etc.)..." 2.) Review of Resident #13's History and Physical dated 05/10/2013 reflected Resident #13 to be at risk for aspiration. Review of Resident #13's transfer orders from previous facility dated 05/31/2013 reflected an order for [REDACTED]. Review of Resident #13's Start Up Orders dated 07/08/2013 reflected diet order to be Regular No Salt on Tray, No Concentrated Sweets. Review of Resident #13's Care Plan reflected Resident #13 did not have a plan of Care. In an interview on 07/11/2013 at 4:20 PM DON A stated that Resident #13 did not have a plan of care for his needs because she does those on admission and she had not gotten to it. Review of Resident #13's Nutrition assessment dated [DATE] reflected Resident #13 to be dependent of staff for eating. The assessment further reflected diet texture to be normal. Under skin concerns "Unstagable wound to coccyx per admit paper work and DON." " BMI (Body Mass Index) indicates that resident is underweight." The assessment did not reflect information regarding aspiration risk or need for mechanically altered diet. Observation on 07/12/2013 at 10:00 AM revealed an ambulance at the facility to transport Resident #13 to the emergency room . In an interview on 07/12/2013 at 10:15 AM DON B stated that while Resident #13 was being fed his breakfast he began to cough and his oxygen saturations went down so they sent him to the ER. In an interview on 07/12/2013 at 10:20 AM LVN D stated she was called to Resident #13's room at 8:30 AM and found Resident #13 was restless, clearing his throat and was coughing. LVN B stated she took Resident #13 ' s oxygen saturation and it was 81% and she then placed resident on oxygen at two (2) liters per nasal cannula. LVN D stated at 9:35 AM Resident #13's color was pale and she had to go get a suction machine and set up because there was not one in Resident #13 s room. LVN D stated she suctioned Resident #13 and food particles were brought up. LVN D stated he was anxious and moaning and his lung sounds were noted to have congestion to upper lobes. LVN D stated she got an order to send Resident #13 to the ER at 9:50 AM. LVN D stated Resident left facility at 10:00 AM. Review of Resident #13's Patient Transfer Form dated 07/12/2013 no time noted reflected "Low oxygen saturation and coughing and slight congestion." In an interview on 07/12/2013 at 11:55 AM the Facility Medical Director, who is also Resident # 13's Primary Care Physician, stated the facility did not inform him that Resident #13 was an aspiration risk. The Facility Medical Director further stated "I do not think they knew what they were getting into with this patient." " I have told them they have to see the patients before they come in." "Sounds like she (DON A) did an incomplete assessment." Review of Resident #13's portable chest x-ray dated 07/12/2013 from the emergency room reflected History of Aspiration "There are some interstitial alveolar lung changes seen in both lung fields, more basilar in distribution." "There is not a definite confluent infiltrate ...Follow-up chest films would be recommended " In an interview on 07/12/2013 at 12:25 PM the ER Physician stated Resident #13 was brought into the ER after aspiration at the facility. An x-ray was done and showed no pneumonia but that it can take days for aspiration to show up on an x-ray. The ER Physician stated Resident #13 had raspy lung sounds. Observation on 07/12/2013 at 12:40 PM revealed Resident #13 lying on left side in the emergency room . Resident #13 did not respond to surveyor. In an interview on 07/12/2013 at 1:00 PM Resident #13's Responsible Party further stated that he was on a purred diet at the other facility and she did not know why he was not on that diet now. In an interview on 07/13/2013 at 11:00 AM the facilities Registered Dietitian (RD) stated she assessed Resident #13 on 07/11/2013 and was not aware of the Resident's history of aspiration risk. The RD further stated "I usually will look at orders from other facility, and if I need to recommend speech therapy. I guess I did not pick up on it. " Review of the facilities Policy and Procedure Admission of a Resident dated 01/2008 reflected "It is the policy of this home to admit only those residents whose medical and nursing care needs can be met" "Guidelines 1. Review available transfer information." Review of the facilities Policy and Procedure Assessment- Comprehensive Resident dated 01/2008 reflected "It is the policy to this home that staff will upon admission..conduct an accurate comprehensive assessment of the resident's functional ability.." "All resident care providers under the supervision of the attending physician. A registered nurse coordinates all assessments." "Procedure 1. Review all pre-admission and transfer information." 3.) Review of Resident #13's medical record reflected no assessment for pain. Review of Resident #13's Start Up Orders dated 07/08/2013 reflected an order for [REDACTED]. Review of Resident #13's Nursing Documentation Record reflected Resident #13 on 07/11/2013 at 08:10 AM Resident #13 "staff and nurse in room to do dressing change and resident agitated and yelling and hitting at staff, states he wants out of here." Observation on 07/11/2013 at 7:00 PM revealed LVN C performing wound care on Resident # 13's Stage IV pressure sore. Observation of the pressure sore revealed a Stage IV pressure sore approximately 6.0 cm x 4.0 cm x 2.0 cm (approximation made by surveyor) no dressing was present to be removed, wound bed of red granulation tissue was noted at the posterior aspect of wound from 6 o'clock to 9 o' clock the rest of the wound bed was covered in yellow slough and eschar. Resident #13's sacral Stage IV pressure sore had a pervasive odor. LVN C then took one (1) of the stacks of 4x4's and placed them in Resident #13's sacral pressure sore and cleaned using a twisting motion. Resident #13 began making incoherent verbalizations, becoming increased as LVN C cleaned pressure sore using the twisting motion. LVN C then cleansed Resident #13's sacral pressure sore again using the twisting motion with a new stack of 4x4 gauze. Resident #13's entire body began to shake and he had his right hand in a fist formation. Resident #13's incoherent verbalizations increased in volume. Surveyor then asked Resident #13 if he was in pain. Resident #13 continued to shake and make incoherent verbalizations. LVN C did not stop cleaning the wound or address Resident #13. DON A did not address Resident #13 but continued to observe LVN C clean Resident #13's sacral pressure sore. Resident # 13 continued with loud verbalization and shaking while LVN C repeated the cleaning, again using the twisting motion, LVN C then took hydrogel gauze and shoved it with force into Resident #13's sacral pressure sore. Resident #13 made a loud verbalization, his entire body was shaking and he grabbed at DON A. DON A did not respond to Resident # 13's grabbing, she continued to hold the resident in position and observed LVN C. LVN C then shoved another hydrogel gauze into Resident #13's sacral pressure sore and covered area with a [MEDICATION NAME] dressing. In an interview on 07/11/2013 at 7:20 PM surveyor asked Resident #13 if he was hurting after wound care was complete. Resident #13 stated "Yes I am hurting" surveyor then asked Resident #13 where he was hurting and Resident #13 used his right arm to show surveyor his sacral area. In an interview on 07/ 3 at 7:30 PM LVN C stated when she cleaned Resident #13's sacral pressure sore deeper Resident became more verbal. LVN C further stated she was not expecting Resident #13 to react that way. Surveyor then asked LVN C if she should have stopped the procedure when she noted Resident #13's reaction. LVN C stated she should have stopped the procedure. LVN C stated she should have pre-medicated Resident #13 with pain medication prior to procedure but she was unsure what kind of medication Resident #13 had for pain. In an Interview on 07/11/2013 at 8:00 PM DON A stated that she would notify Resident #13's physician regarding Resident #13's pain since he only had Tylenol ordered PRN for pain. DON A stated that LVN C should have stopped the treatment to Resident #13's sacral pressure sore "the resident was in pain." DON A further stated that Resident #13 should have been assessed for pain prior to procedure and during procedure for signs of pain. DON A further stated she knew LVN C was in a hurry to leave so she did not stop the procedure. Surveyor then asked DON A if a resident with a pressure sore that size would be in pain all time and DON A stated they would be in continuous pain and that Resident #13's pain was not addressed because she missed it. Observation on 07/11/2013 at 8:15 PM revealed DON A presented surveyor with an Admission Care Plan for Resident #13. Review of Resident #13's Admission Care Plan reflected no care plan for pain. In an interview on 07/11/2013 at 8:18 PM DON A stated "I just got that done." Review of Resident #13's Physician's Telephone orders dated 07/11/2013 at 8:10 PM reflected an order "Give [MEDICATION NAME] 5/325 mg one tab PO every six (6) hours PRN for pain and 30 minutes before wound care." Review of the facilities Policy and Procedure for Pain Management dated 08/2009 reflected "It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life." "Procedure 1. Each resident's pain will be assessed using the (Comprehensive Pain Assessment) upon admission.." "3. The home recognizes that a resident response to pain is subjective and individual." "5. The home will treat the resident under the premise that pain is present whenever the resident says that it is." "6. Nursing staff will identify situations or interventions where a increase in the resident's pain may be anticipated (i.e. wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities." "How To Assess Pain...Behavioral Responses. These include altered body position, moaning, signing, grimacing, withdrawal, crying, restlessness, muscle twitching, and immobility." B.) Record review of Resident #12's Face Sheet reflected he was admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #12's Quarterly MDS dated [DATE] reflected his cognitive status was intact, Resident #12 scored a 14 on the Brief Interview for Mental Status (BIMS). The MDS reflected Resident #12 was totally dependent on staff for all activities of daily living (ADL). Resident #12 was coded on the MDS for special treatments while a resident for suctioning and [MEDICAL CONDITION] care. Record review of Resident #12's Comprehensive Care Plan dated 05/30/2013 reflected a problem of "Resident has a [MEDICAL CONDITION] and is at risk for Increased Secretions/Congestion and Infections". The Care Plan listed the approaches as: "1) Monitor for needed suctioning of increased secretions/congestion--assess for relief 2) Provide O2 (oxygen),[MEDICAL CONDITION], and tubing change per order...". Record review of the Start Up Orders for Resident #12 dated 05/13/2013 reflected no orders for suctioning [MEDICAL CONDITION]. Record review of the Start Up Orders for treatments and medications administration record(TAR and MAR) for Resident #12 dated 05/13/2013 reflected no orders for suctioning [MEDICAL CONDITION]. Record review of the Physician's Telephone Orders for Resident #12 reflected no written order for [MEDICAL CONDITION] or suctioning. Record review of the Respiratory Flowsheet (TAR) for Resident #12 dated 06/01/2013-06/30/2013 reflected no orders for suctioning [MEDICAL CONDITION]. Record review of the Respiratory Flowsheet (TAR) for Resident #12 dated 07/01/2013-07/31/2013 reflected no orders for suctioning [MEDICAL CONDITION]. Record review of the Progress Notes (Nurse's Notes) for Resident #12 reflected Resident #12 was documented as being suctioned on the following dates: 05/21/2013, 05/23/2013, 05/30/2013, 06/01/2013, 06/11/2013, 06/12/2013, 06/20/2013, and 07/09/2013. The Nurse's Notes also reflected Resident #12 [MEDICAL CONDITION] documented on the following dates: 05/20/2013, 05/21/2013, 05/23/2013, 05/24/2013, 05/25/2013, 05/30/2013, 05/31/2013, 06/01/2013, 06/11/2013, 06/12/2013, 06/17/2013, 06/18/2013, 06/20/2013, 06/29/2013, and 07/09/2013. Record review of the Physician order [REDACTED]. Shift-Every Shift-PRN;PRN 1;PRN 2; PRN 3". The Orders also reflected the order "TRACH CARE Q SHIFT AND PRN Q Shift-Every Shift; NIGHTS, DAYS, EVENINGS" with a "Start Date" of 07/01/2013. The Physician order [REDACTED]. Observation on 7/10/2013 at 4:00 PM revealed LVN E looking in the TAR for the orders for Resident #12'[MEDICAL CONDITION] and suctioning. In an interview on 07/10/2013 at 4:00 PM the LVN E stated he could not find the orders for suctioning [MEDICAL CONDITION] on the TAR for Resident #12. LVN E stated there should be orders written [MEDICAL CONDITION] and suctioning. In an interview on 07/10/2013 at 4:34 PM the ADON stated there should be orders on the TAR for Resident #12'[MEDICAL CONDITION] and suctioning. ADON stated [MEDICAL CONDITION] should be ordered every shift and the suctioning as needed on the Respiratory Flowsheet (TAR). In an interview on 07/10/2013 at 4:43 PM the Medical Director stated his expectations of the facility were to have orders for [MEDICAL CONDITION] and suctioning. The Medical Director stated if we are going to take skilled patients, we have to provide skilled services. Record review of the Policy and Procedure entitled [MEDICAL CONDITION] Care revised 08/2012 reflected "It is the policy of this home to provide [MEDICAL CONDITION] care in accordance with current standards of practice to ensure airway patency, maintain skin integrity and prevent infection." The Policy also reflected under "MISCELLANEOUS...6. [MEDICAL CONDITION] care will be provided as ordered by the physician and as needed...7. Replacement [MEDICAL CONDITION] of the appropriate type and size must be available at the bedside or an obturator and curved hemostat in the event of accidental dislodgement or other emergency. 8. Suction machine (in working order) connecting tubing, a supply of size appropriate sterile catheters, flushing solution (sterile water/normal saline) and sterile and non sterile gloves at the bedside at all times." The facility Administrator was notified on 07/09/2013 at 9:28 PM that an IJ situation had been identified due to above failures. Facility Plan of Removal is as follows: a.) The following Plan of Removal was submitted by the Administrator on 07/10/2013 at 10:04 AM. The final Plan of Removal was accepted on 07/10/2013 at 5:20 PM. Immediate Jeopardy-Failed to provide for safety [MEDICAL CONDITION]. 1. Respiratory therapist was notified and delivered the required replacement trachs to the facility on [DATE] at or around 8:35 PM for Residents #4, #5, and #12. 2. Residents #4, #5, and #12 were provided with emergency equipment of ambu bags, suction machines, supplemental oxygen, and [MEDICAL CONDITION] bedside 07/09/2013. 3. Residents #4, #5, and #12 have been transferred to theHospital and their trachs have been evaluated: #4 transferred at 11:46 PM 07/09/2013; #5 at 12:05 AM 07/10/2013; #12 10:45 PM 07/09/2013. 4. Residents #4 and #5 will be transferred to a sister facility where Full time Respiratory Therapy and Nursing Services in [MEDICAL CONDITION] and Ventilator Care are provided. Resident #12 will be transferring home. 5. [MEDICAL CONDITION] will be admitted or readmitted until nursing staff have been trained on emergency procedures for decannulation [MEDICAL CONDITION] by respiratory therapist. Training was arranged on 07/09/2013 to be started on 07/10/2013 (see attached). 6. Additional training for nursing staff [MEDICAL CONDITIONS] will be provided by the respiratory therapist (see attached). 7. Emergency equipment will be provided and available in [MEDICAL CONDITION] ' s room to include: 1. Clean gloves-extra pair recommended 2. Sterile gloves-extra pair recommended 3. [MEDICAL CONDITION] kit 4. Normal saline or sterile water (if not in care kit) 5. Disposable inner cannula (if applicable) 6. Trach ties or Velcro collar type 7. Biohazard bag 8. Mask and/or Eye shield 9. Suction Machine with connecting tubing (in working order) 10. Suction kit with catheter 11. [MEDICAL CONDITION] same type and size at bedside 12. Obturator (for existing trach) or curved hemostat at bedside 13. Lubricating Jelly 8. Emergency oxygen supply and ambu bag [MEDICAL CONDITION] at bedside 9. [MEDICAL CONDITION] same type and size (or same type or 1 size smaller) will be in zip lock bag located on wall at head of bed 10. Clipboard with emergency kit and equipment checklist will be on wall in [MEDICAL CONDITION] ' s room and checked daily by Director of Nurses or designee. 11. Facility will have at least one [MEDICAL CONDITION] same type and size in stock for [MEDICAL CONDITION]. 12. Director of Nursing or designee will pre-screen [MEDICAL CONDITIONS], types, and special needs. Required equipment and supplies will be available upon admission. 13. All information will be reviewed during a QA meeting to be held 07/10/2013 and then ongoing for 3 consecutive months then quarterly. The survey team monitored the current plan of removal as follows: All residents with tracheostomies were transferred out of the facility. b.) The following Plan of Removal was submitted by the Administrator on 07/12/2013 at 2:08 PM. The final Plan of Removal was accepted on 07/13/2013 at 4:05 PM and reflected:. Pressure Sores not staged appropriately for Resident #13, Physician not appropriately notified of wound assessment. 1. Current facility DON has been suspended and will be terminated upon final Human Resource evaluation on 07/15/2013. 2. Two Regional Nurse Consultants will arrive to assist in plan of removal tasks. Start 07/12/2013, completion 07/13/2013. 3. All licensed nurses will be in serviced by Interim DON/ Regional Nurse Consultant on wound care procedures to included the RN is to stage the wound. Staff not working will be in-serviced prior to working their next shift. Newly hired nurses will be in serviced during their orientation period. Start 07/11/2013, Completion 07/13/2013. 4. All residents with pressure ulcers will have wounds re-assessed by Regional Nurse Consultant to ensure wound is documented correctly to include correct stage. Any wound found to be incorrectly documented will be re-assessed to include: dimensions, description of wound, presence and

Based on observation, interview, and record review the facility failed to effectively consult Resident #18's physician when there was a significant change in the resident's physical status (i.e., a deterioration in health status in either life threatening conditions or clinical complications); or a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (1) of 9 residents (Resident #18) who had pressure sores. Resident #18's pressure sores deteriorated as a result of not effectively notifying the physician. This deficient practice placed 13 residents who had pressure sores at risk for inaccurate assessments and therefore ineffective notification to the physician which could place the residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Findings include: Record review of Resident #18's Face Sheet reflected the admission date of [DATE] and the latest re-admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #18's Admission/Readmission Data Summary dated 01/31/2013 reflected "Skin Condition" with no markings indicated on the body diagram of any skin conditions. This Summary was signed by Licensed Vocational Nurse (LVN) D. Record review of Resident #18's Comprehensive Care Plan dated 04/25/2013 reflected a Pressure Sore to the Left Hip at Unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.). The Care Plan reflected an update on 05/20/2013 written in at the bottom "Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) -Tx (treatment) changed collagen M-W-F (Monday-Wednesday-Friday)". Record review of Resident #18's Physician Order Report dated 06/01/2013-07/31/2013 and signed by the Physician on 06/22/2013 reflected "Wound Treatments. flow sheet" with a start date of 05/27/2013 to "CLEAN L (left) HIP W (with) WC (wound cleanser) COLLAGEN AND COVER W SECONDARY DRESSING Q (every) M-W-F (Monday-Wednesday-Friday) AND PRN (as needed)". Resident #18's Physician Orders did not reflect the stage of the pressure sore or the current treatment as observed by the surveyor. Record review of Resident #18's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected the Resident was totally dependent upon staff for activities of daily living (ADL). The MDS also reflected she had one stage III pressure sore that measured 2.5 centimeters (cm) x 2.5 cm x 0.1 cm with granulation tissue. Record review of Resident #18's Facsimile to the Physician dated 07/03/2013 reflected "Wound to L (left) hip is increasing in size and drainage. Treatment was changed to calcium alginate with silver to try to improve this. Wound is still showing deteriation. Can I do a culture on the site?" This Facsimile was signed by LVN C. The Facsimile did not give adequate information to describe the pressure sore on Resident #18's right hip to the Physician--the measurements, drainage, and odor were not addressed in the Facsimile. Record review of Resident #18's Comprehensive Care Plan dated 07/06/2013 reflected a Pressure Sore to the Right Hip at a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.). The Care Plan reflected an update on 07/14/13 of an Approach of change of treatment, but the stage remained at a Stage II. Record review of Resident #18's Facsimile to the Physician dated 07/06/2013 reflected "Pt (Patient) found to have Stage II to R (right) hip will apply dermaceptin (cream with zinc and menthol) Q day & prn till resolved. Please notify if this is acceptable or if further orders are necessary." This Facsimile was signed by LVN C. The Facsimile did not give adequate information to describe the pressure sore on Resident #18's right hip to the Physician--the measurements, drainage, and odor were not addressed in the Facsimile. Record review of Resident #18's Physician's Telephone Orders dated 07/06/2013 reflected "apply dermaceptin to R hip Q day & prn". This Order was signed by LVN C. This Order did not address the pressure sore's stage. Record review of Resident #18's Skin Evaluation Flowsheet--Pressure Ulcer dated 07/08/2013 reflected left hip "#1 Site"; "Stage II"; "Dimensions (CM) L 3.2 W 3.0 D 0.01"; "Comments", "clear" was written in the box. The Flowsheet also reflected "#2 Site R hip"; "Stage II"; "Dimensions (CM) L 2.5 W 2.5 D 0.01"; "Comments", "clear" was written in the box. Record review of Resident #18's Facsimile to the Physician dated 07/11/2013 reflected "Pt wounds not responding to treatment. Can I change treatment to bilat (bilateral) hips to: clean wound with WC (wound cleanser), apply hydrogel and cover with dressing M-W-F and prn." This Facsimile was signed by LVN C. The Facsimile did not give adequate information to describe the pressure sore on Resident #18's right hip to the Physician--the measurements, drainage, and odor were not addressed in the Facsimile. Observation on 07/12/2013 at 4:30 PM revealed Resident #18 with a Stage III Pressure Sore to the right hip area. There was no dressing with the Stage III pressure sore open to air. LVN C measured the pressure sore after cleansing, measurements were 1.7 cm x 1.0 cm x 0.4 cm. The Stage III pressure sore had a dark red wound bed with granulation tissue. The surrounding skin had a beveled, white edge and a dark pigmented skin color around the pressure sore which appeared to be possible redness indicating infection or healed scar tissue. LVN C cleansed the pressure sore with normal saline and after discussion with DON B, LVN C covered the Stage III with a dry composite dressing until the Physician could be called for new orders. The orders for the pressure sore were to cleanse with normal saline then apply dermaceptin cream (a cream with zinc and menthol) to the open pressure sore. In an interview on 07/12/2013 at 4:40 PM, DON B stated the right hip pressure sore was a stage III. DON B stated she would notify the physician to clarify the treatment due to the stage, measurements, no drainage, and no odor. Observation on 07/12/2013 at 4:45 PM revealed Resident #18 also had a Stage III to the left hip area. There was a dressing with visible yellow and dark red drainage on the outside of the dressing. LVN C measured the pressure sore after cleansing, the measurements were 3.5 cm x 3.2 cm x 0.7 cm. The Stage III pressure sore had a red wound bed with granulation tissue. The surrounding skin had a pink, beveled edge and a dark pigmented skin color around the pressure sore which appeared to be possible redness indicating infection or healed scar tissue. LVN C cleansed the pressure sore with normal saline, placed calcium alginate with silver in the wound bed, and covered with a dry composite dressing. In an interview on 07/12/2013 at 4:50 PM the DON B stated the left hip pressure sore was a stage III. DON B stated she would notify the physician to clarify the treatment due to the stage, measurements, drainage, and no odor. In an interview on 07/12/2013 at 11:26 AM the Facility Medical Director, who is also Resident # 18's Primary Care Physician, stated he expected to get a full picture of the resident, and if he had been notified fully of Resident #18's Stage III pressure sore he would have "definitely " changed the treatment to the pressure sore. In an interview on 07/13/2013 at 11:30 AM the DON B stated she had not yet contacted the Physician for Resident #18 to give a full description of the pressure sores to include the stage, measurements, drainage, or odor to receive new orders. DON B stated she would address the right hip stage III pressure sore and ask the Physician to change the treatment on the right hip area from the Dermaceptin cream to a dressing with hydrogel for moisture. In an interview on 07/13/2013 at 2:00 PM the LVN C stated she faxed the Physician about the "wounds" on the right and left hip area to get the treatment orders changed but did not describe the pressure sores in the facsimile to the physician to include the stage, measurements, drainage, or odor. LVN C also stated that DON A did not assess Resident #18's pressure sores at the same time with LVN C, but that DON A staged the pressure sores for LVN C. Record review of Resident #18's Physician's Telephone Orders dated 07/14/2013 reflected "1) D/C (discontinue) Dermaceptin to R hip 2) Begin treatment to R hip--clean with NS (normal saline), apply Hydrogel and cover with gauze Q day & prn". This Order was signed by DON B. Record review of Resident #18's Physician Telephone Orders dated 07/14/2013 reflected "1) Stage III L hip clean with WC, apply Silver Calcium Alginate and cover with island dressing M-W-F & prn 2) Stage III R hip Clean with NS apply Hydrogel and cover with gauze q day & prn". This Order was signed by DON B. This Order reflected the stages. Record review of Policy and Procedure for Skin Integrity Monitoring System revised 03/2012 reflected under the Procedure "4. When pressure ulcers are identified, the assessment of the ulcer must be documented on the (Skin Assessment Flow Sheet--Pressure Ulcer) form. 5. When a pressure ulcer is identified, treatment orders are obtained from physician." The Skin Integrity Monitoring System also reflected "Guidelines--Skin Assessment 4. Document the following parameters under 'Description of Skin Alterations' for each pressure ulcer. Use the indicated codes on the form...a. stage b. size; including length, width, and depth in centimeters c. drainage--'D' d. eschar--'E' e. granulation--'G' f. induration--'I' g. necrotic tissue--'N' h. odor present--'O' i. edges inflamed--'R' j. sloughing--'S' k. undermining--'U' l. skin debridement--'S/D' m. tunneling--'T''. The Policy reflected "When a Pressure Ulcer is Identified 1. Assessment of the pressure ulcer is documented using the (Skin Assessment Flow Sheet--Pressure Ulcer). 2. All notifications to physician, interested party of the resident and the resident are to be completed and documented." Record review of the Policy and Procedure for Skin--Treatment Guidelines for Pressure Ulcers revised 03/2012 reflected under Policy "Note: These are treatment suggestions, and do not supersede a Physician's order for any treatment. A physician order will be obtained for the pressure ulcer treatment and will be specific for each site. -Each pressure ulcer must have a separate order. -Each pressure ulcer site must be identified by location. (Example: left elbow, coccyx, etc.)..." The Policy also reflected "Stage III Procedure ...6. Confirm the physician has been notified that the resident has a pressure ulcer and is aware of the current status. Document in the progress notes..." The facility provided a list of 13 residents with pressure sores in the facility.

Based on interview and record review, the facility failed to notify the physician of a change in the resident's physical condition and a need to alter treatment for one (1) of four (4) residents (Resident # 1) reviewed for tubefeedings. Resident #1 had high body temperatures of 99.1 degrees Fahrenheit (F) to 99.9 F, high pulses of 92 beats per minute (BPM) to 110 BPM with loose stools from 03/14/13 through 03/23/13 . On 03/22/13 and 03/23/13 the resident also had diaphoresis (excessive sweating). The facility did not contact Resident #1's physician until 03/24/13. On 03/26/13 Resident #1 was transferred to the hospital, due to family request for a secondary consult, where she was diagnosed with [REDACTED]. This failure contributed to a delayed in treatment for Resident #1, who receives nutrition though a feeding tube and experienced a change in condition. The findings include: Review of Resident #1's hospital history and physical dated 02/27/13 reflected she had a left pontine stoke (stroke within the [DIAGNOSES REDACTED] due to a hemorrhage). With continued decline her consult report dated 02/27/13 documented: "left pontine stroke, associated basilar stenosis, worsening dysphagia and quadriparesis concerning for extension of her brainstem stroke." Review of Resident #1's Admission/Readmission Data Summary dated 03/13/13 reflected she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her clinical record documented she was discharged from the facility on 03/26/13. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented she had severely impaired cognitive skills for daily decision making and required total assistance by two people for activities of daily living. She rarely/never understood verbal content and did not speak. She received nothing by mouth (NPO) and nutrition from a feeding tube and was always incontinent of bowel and bladder. Resident #1's Hospital Discharge Packet dated 03/13/13 documented her pulse was 108 BPM, her temperature was 97.4 F, her respirations were 24 breaths per minute, and her blood pressure was 172/82 mm/Hg on 03/13/13 at 8:00 AM. Resident #1's admitting nursing assessment dated [DATE] at 1:30 PM documented her pulse was 96 BPM, her respirations were 16 breaths per minute, and her temperature was 96.0 F. Resident #1's Start Up Orders dated 03/13/13 included [MEDICATION NAME] (osmotic laxative), 15 ml liquid per feeding tube every eight hours. Resident #1's Start Up Orders dated 03/13/13 also included [MEDICATION NAME] (calcium channel blocker used to treat high blood pressure and [MEDICAL CONDITION]), [MEDICATION NAME] and [MEDICATION NAME] (anti-hypertensives), and [MEDICATION NAME] (a beta-blocker used to treat several conditions related to the heart and blood vessels). Resident #1's Medication/Treatment Administration Records documented she received [MEDICATION NAME] three times a day beginning on 03/13/13 through 03/24/13. In an interview on 04/02/13 at 4:05 PM Resident #1's Responsible Party stated Resident #1 had [DIAGNOSES REDACTED] (aware and awake but unable to move or communicate verbally due to complete paralysis of voluntary muscles) following a stroke. The resident had a fever from 03/22/13 to 03/24/13. The Responsible Party was told the facility would administer Tylenol, but they did not. The resident was also supposed to have lab studies, but there was two-day delay. Resident #1 was transferred from the facility to the hospital on [DATE] at the family's request. Another family member had arranged for a consult with a cardiac specialist there to see if she might be a candidate for surgery. At the emergency room , she had a temperature of 104 F and was diagnosed with [REDACTED]. In an interview on 04/03/13 at 10:15 AM Assistant Director of Nurses (ADON) A stated Resident #1 came to the facility after almost three months in the hospital following a stroke. She did not respond to verbal stimuli. Her eyes were opened but were fixed. The facility's Medical Director assumed care as her physician, and had no prior familiarization with her. She received Glucerna 1.2 at 55 milliliters (ml) per hour continuously for 22 hours a day with 60 ml of water before and after medication administration and 10 cubic centimeters (cc) of water between each medication. She received an additional 150 cc flush of water each shift (confirmed with record review of her Start Up Orders and Medication/Treatment Administration Records). The ADON continued to state that was the most the resident could tolerate. Resident #1 did not exhibit physical signs or symptoms of dehydration, such as sunken eyes, swollen tongue or cracked lips. She consistently had an elevated temperature of 99 F. According to the ADON, the facility did not treat temperatures lower than 100 F. The ADON stated that as documented in the Nurses' Notes, the resident's temperature reached 101.2 F on the 03/24/13, at which time the nurse contacted the physician and administered Tylenol. Resident #1 had a lot of loose stools every day she was at the facility. She was receiving [MEDICATION NAME] every eight hours, so they stopped the [MEDICATION NAME]. Review of Resident #1's All Disciplines' Progress Notes dated 03/14/13 to 03/26/13 reflected the following. - 03/14/13 at 8:00 AM her temperature was 99.3 F, her pulse was 93 BPM, her blood pressure was 166/85 mm/Hg, her respirations were 20 breaths per minute, and her oxygen saturation (SpO2) was 99%. - 03/15/13 at 9:00 AM her temperature was 99.1 F, pulse was 94 BPM, blood pressure was 144/86 mm/Hg, respirations were 20, and her SpO2 was 98%. - 03/19/13 at 5:00 PM the Medical Director made rounds with no new orders. - 03/22/13 at 9:00 AM. "Resident very diaphoretic. Sponge bath with cool towel administered." Her temperature was 99.4 F. - 03/23/13 at 5:45 AM. Her temperature was 99.5, pulse 107 BPM, blood pressure 124/76 mm/Hg, and SpO2 was 99%. - 03/23/13 at 12:00 PM. "Afebrile at this time." Her temperature was 99.9 F, pulse 110 BPM, respirations 22, blood pressure 147/99 mm/Hg, and SpO2 99%. "Remains very diaphoretic. Continues soft BM (bowel movements) from moderate to large amount." - 03/23/13 at 8:00 PM. "Slight labored breathing noted." Her blood pressure was 138/85 mm/Hg, pulse 112 BPM, SpO2 94% on 2 liters of oxygen (L of O2) by nasal cannula. "Diaphoresis continued, sheets/cover taken off resident to possibly help with diaphoresis . . . Slight cough noted while in room. Fax sent to MD earlier about elevated blood sugar." - 03/23/13 at 9:00 PM. Her SpO2 was 95% on 2 L of O2. Her pulse was 108 BPM. - 03/24/13 at 00:30 AM. "CNA (Certified Nurse Aide) reported finding open area to coccyx. Area continues to be red and is noted to have loose/water stool . . . Skin moist and warm." Her temperature was 101.2 F, Pulse 122 BPM, blood pressure 128/76, respirations 20, and SpO2 94% to 95%. Tylenol, 325 milligrams (mg) was administered. "Temperature frequently in 99s and will be reported to MD (physician) along with notice of open area and high pulse = 122 (BPM)." [MEDICATION NAME] (anti-diarrhea) was administered for loose stool. - 03/24/13 at 6:00 AM. Her temperature was 99.1 F. - 03/24/13 at 11:30 AM. Her temperature was 100.6 F and her pulse was 134 BPM. She was "clammy." "Dr. called and message left, awaiting call back." - 03/24/13 at 4:30 PM the on-call physician returned the call and gave orders for laboratory studies: complete blood count (CBC) and urine analysis (UA) with cultures and sensitivities. The United States National Library of Medicine, National Institute of Health, documented the following in an article "Vital Signs" updated 03/22/13 and accessed on 04/15/13 (http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm). The normal vital sign ranges for the average healthy adult while resting are: - Blood pressure: 90/60 milliliters of mercury (mm/Hg) to 120/80 mm/Hg, - Breathing: 12 to 18 breaths per minute, - Pulse: 60 to 100 BPM, and - Temperature: 97.8 F to 99.1 F; average 98.6 F. Resident #1's Activities of Daily Living Tracking Log for March 2013 documented large amounts of incontinent stool on all of the first shift from 03/21/13 to 03/25/13; medium, large and extra-large amounts of incontinent stool on all of the second shift from 03/21/13 to 03/27/13; and large amounts of incontinent stool on all of the third shift on 03/20/13 to 03/25/13 except on 03/22/13. Review of Resident #1's Physician Telephone Orders dated 03/24/13 reflected an order for [REDACTED]. In a telephone interview on 04/03/13 at 1:15 PM LVN C said she did not call Resident #1's physician regarding her elevated pulses and temperatures before Sunday, 03/24/13. She documented that Resident #1 was diaphoretic on 03/23/13, but did not call the physician because really the resident was just sweaty. Comfort measures of removing her covers resolved her diaphoresis. They received an order for [REDACTED]. Review of Resident #1's laboratory study reflected the CBC was collected on 03/26/13 at 5:55 AM. The results printed on 03/27/13 at 4:09 PM reflected her white blood cell count (WBC) was 20.6 thou/uL (thousand per microliter) with a reference range of 4.8 thou/uL to 10.8 thou/uL. Her urine sample, collected from a Foley (indwelling urinary) catheter, was collected on 03/26/13 at 5:55 AM and was negative for a urinary tract infection. In an interview on 04/03/13 at 2:15 PM the Director of Nurses (DON) said no labs were done on the weekend unless the lab was ordered STAT (immediately). Resident #1's physician did not write orders for a STAT lab on Sunday, 03/24/13, so samples should have been drawn/collected on Monday, 03/25/13. The lab requisition showed the lab technician came on Monday, 03/25/13 at 5:55 AM for a CBC and UA, but there was no explanation for why the CBC or UA was not collected. Review of the facility's laboratory services requisition form reflected the laboratory technician initialed that he received the requisition for a CBC and UA with culture on 03/25/13 at 5:55 AM. In an interview on 04/03/13 at 2:20 PM a staff member from the facility's laboratory services provider said the results of a CBC and the initial results of the UA received at 5:55 AM would have been available by noon the same day. The culture and sensitivity results would have been available a few days later. She had no explanation for why the lab technician signed the requisition on 03/25/13 noting that Resident #1 was to have a UA and CBC study, but did not collect the samples. In a follow-up interview on 04/03/13 at 2:24 PM the DON said the facility's nurse did not collect Resident #1's sample on 03/25/13 because the resident had severe diarrhea. She had constant diarrhea since admission that probably caused her pressure ulcer on her coccyx. [MEDICATION NAME] was discontinued on 03/25/13 and a urine sample was collected the next day, 03/26/13. The lab technician said he did not draw the CBC on the morning of 03/25/13 because he forgot to bring a purple-top tube to collect the sample. He was sending someone back to draw the sample, but no one from the lab came back on 03/25/13. In an interview on 04/03/13 at 2:35 AM ADON A stated she noticed Resident #1's CBC was not collected on 03/25/13. She called the lab technician who signed the requisition, and he said he would send someone for the CBC later the same day. ADON A said she did not know why someone did not come back and collect the CBC sample on 03/25/13. The UA was not missed by the lab collection. The sample was to have been collected that morning by the nurse. The nurse could not collect the urine sample even with an in/out urine catheter because the resident had severe diarrhea. In a follow-up interview on 04/03/13 at 5:00 PM LVN C said she took care of Resident #1 on 03/21/13, 03/23/13 and 03/24/13. On 03/23/13 at 8:00 PM she charted that the resident was having difficulty breathing but it was not "labored." She just "seemed to me like she was warm." When she got her medications at 8:00 PM they took the covers off and she got better. Her pulse went down to 108 BPM, her temperature improved and her SpO2 was 95%. She was stable. There were no facility parameters for calling the physician for elevated pulse. The books say the regular pulse rate is 60 BPM to 90 BPM, but it depended on the resident. If her pulse was 130 BPM to 140 BPM or higher with medication she would have called the physician. Resident #1's pulse always ran high. She was not showing signs of distress. Review of Resident #1's clinical record reflected a Fax transmittal to the physician on 03/23/13 related only to elevated blood sugars. It did not address pulse, temperature, diaphoresis, or loose stools. There were no other Fax transmittals to Resident #1's physician regarding vital signs, diaphoresis or loose stools until 03/24/13. In an interview on 04/03/13 at 3:45 PM the DON said the facility had no written parameters to call the physician for abnormal pulse. Temperatures of 100 F to 101 F or above were considered a fever, for which the physician should be called. They did not call before a temperature reached 100 F. The nurse should call the physician for a pulse at or above 100 BPM. The nurse should have called the physician on the morning of 03/23/13 when Resident #1's pulse was 107 BPM. The temperature was starting to climb then too at 99.9 F. An infection was probably starting. In an interview on 04/03/13 at 4:00 PM ADON A said the facility did not have written parameters for calling the physician regarding pulse unless the resident was on a heart or blood pressure medication, in which case there might be parameters for administering the medication. ADON A said she would have called the physician when Resident #1's pulse reached or exceeded 100 BPM. In an interview on 04/03/13 at 4:45 PM LVN E said he did not call Resident #1's physician regarding abnormal vital signs. He only called the physician to request to discontinue the scheduled [MEDICATION NAME] on 03/25/13. He called because he could not get a clean urine sample for the urine analysis due to her constant diarrhea. He observed that Resident #1 was sweaty and said it was probably because of her diabetes. Resident #1 received [MEDICATION NAME] and [MEDICATION NAME], but there were no parameters to call the physician for abnormal vital signs. Review of Resident #1's Fax transmittal dated 03/24/15, transmitted at 7:28 AM reflected the following: "CNA found Stage II open area to coccyx . . . Also, resident had temp = 101.2 (F). Apap (Tylenol) 650 mg (milligrams) per G/T (feeding tube) given. Temps usually are 99 (F) to 100 (F}. Pulse has increased and is 122 (BPM) at this time. This morning blood sugar 341; currently resident takes Glucerna 1.2 at 65 ml/hr (milliliters per hour) and also has [MEDICATION NAME] included in her routine meds. It is given at 15 ml every 8 hours. CNAs report she has loose stools often throughout the day. She does have a PRN (as needed) [MEDICATION NAME] order and she was given 2 mg per G/T (as ordered to be given 2 mg every 12 hours PRN)." The Fax transmittal documented the physician noted receipt of it on 03/25/13. In an interview on 04/03/13 at 12:15 PM the facility's Medical Director stated he visited Resident #1 once while she was at the facility. The resident had no purposeful response. He did not feel she would progress. He was not aware her pulse rate or temperatures were as high as 110 BPM or 99.9 F. With a pontine stroke, a resident could lose their auto-regulation, causing elevated pulse and breathing, but she could have possibly also needed more in her feeding tube. Because of her history of [MEDICAL CONDITION] and hypertension, they had to be conservative with her fluid intake. He did not know her white blood cell count from a sample collected on 03/26/13 was 20.6 thou/uL. She had already discharged from the facility on 03/27/13. That would have meant something was going on, for example, aspiration pneumonia. He was not aware that the resident was diaphoretic. Her blood sugars were high, but only low blood sugars would cause diaphoresis related to her diabetes. Review of the Laboratory Agreement between the laboratory services provider and the facility dated 08/01/12 reflected: "Routine testing is conducted weekly with STAT services available at all times including nights, weekends and holidays. STAT turn around time goal of the facility and the laboratory is two hours maximum. All laboratory patient results will be reported by the next business day. Final reports of cultures, depending on the nature of the culture, will be reported within seven days for blood cultures and 72 hours for all other cultures. Preliminary culture reports will be available within 24 hours, 48 hours and 72 hours from the time the culture is set up." Review of Resident #1's hospital laboratory study dated 03/27/13 reflected her Sodium level was 165 mEq/L (milliequivalents per Liter), with a reference range of 135 mEq/L to 148 mEq/L. Her Chloride level was 126 mEq/L with a reference range of 99 mEq/L to 109 mEq/L. Her hospital history and physical dated 03/27/13 documented "1. [MEDICAL CONDITION]. 2. Leukocytosis. . . . It is likely that she started sacral wound infection. 3. Dehydration, which is severe along with [MEDICAL CONDITION]. . . " Continued review of her microbiology labs dated 04/01/13 reflected no growth in her blood cultures, ruling [MEDICAL CONDITION]. A sacrum wound culture dated 03/28/13 documented "few white blood cells, occasional gram positive rods, few yeast, and few gram positive cocci in pairs." The hospital was unable to provide to provide documentation of a wound consult. An Adult Assessment Intervention dated 03/29/13 documented that there was a pressure ulcer present on admission and that on 03/29/13 (after the 76-mile ambulance ride, emergency room visit, and three days in the hospital) there was a Stage III pressure ulcer on the resident's sacral spine. Review of the facility's Nursing Policy and Procedure Change of Condition - Observing, Reporting and Recording dated March 2012 reflected the following. "Policy. It is the policy of this home to inform the resident, the resident's physician and if indicated the resident's responsible party of the following . . . 2. A significant change in the resident's physical, mental or psychosocial status, such as deterioration in health, mental or psychosocial status, in life-threatening conditions or clinical complications. . . . 4. A need to alter treatment significantly . . . Procedure. 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline. . . . 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable (change in condition is resolved such as a fall without injury or head trauma). . . " The American Association for Clinical Chemistry documented the following in an article "Sodium" updated October 11, 2012, and accessed on 04/15/13 (http://labtestsonline.org/understanding/analytes/sodium/tab/test). "A high blood sodium level is almost always due to inadequate water intake and dehydration." In an interview on 04/03/13 at 9:00 AM the DON stated the facility census was 103.

Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible for 1 of 1 resident (Resident #4) reviewed for indwelling urinary catheter care (tube that drains urine from the bladder into a drainage bag), in that: The facility failed to change the Foley catheter for 1 of 5 residents (#4) on a monthly basis. This deficient practice could cause serious infections for Resident #4 as well as 4 other residents with catheters. Findings include: Review of web site resources regarding best clinical practices for indwelling catheter care reflected the web address http://www.suna.org/resources/indwellingCatheter.pdf obtained on 04/20/2012, Society of Urologic Nurses and Associates, "Clinical Practice Guidelines: Care of the Patient with an Indwelling Catheter reflected "Nursing Considerations: No evidence supports rigid timing of catheter changing. Currently the mainstay of practice is to change chronic catheters every 4 weeks; however, the catheter should be changed as needed." Review of Resident #4's admission record reflected that he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #4 was [AGE] years old. Review of Resident #4's Minimum Data Set (MDS), dated [DATE], reflected Resident #4 as having an indwelling catheter. Observation on 04/16/12 at 9:25 AM revealed Resident #2 laying in bed awake and alert. The Foley catheter was covered with privacy bag. Review of the Re-admission orders [REDACTED]. Review of the Nurses's Cart Station III [DEVICE] and Special Needs ( where documentation for catheters is maintained) and the Nurses Notes in the clinical record reflected Resident #4's treatment record, dated for the months of March 2012 and April 2012, reflected no documentation of his catheter being changed. In an interview on 04/19/12 at 10:20 AM, Licensed Vocational Nurse (LVN) D stated there should have been on the re-admit orders as to when to change Resident # 4's catheter. She stated the residents who have catheters have them changed on the 15th of each month unless contraindicated by the Physician. LVN D stated Resident #4 should have had his changed one the 15th of the month. She stated the 10:00 PM - 6:00 AM staff are the ones to change catheters and should have made sure it occurred and was documented. She stated she can't be sure the catheter was changed. In an interview on 04/19/12 at 1:50 PM, the Director Of Nursing stated that the nurses should have changed Resident #4's catheter on the15th of the month and documented when they had changed the catheter. She stated the unchanged catheter could have contributed to [MEDICAL CONDITION]. In an interview on 04/19/12 at 3:10 PM, Physician P [MEDICAL CONDITION] could have been caused due to a catheter not being changed over time but the resident had other health issues that could have contributed to it. Review of the emergency room Physician Report dated 04/17/12 reflected: - Resident #4 was admitted with [DIAGNOSES REDACTED]. - Post Operative Diagnoses: [REDACTED]. - Assessment, Septic Shock, Urinary Tract Infection and Bilateral pneumonia. In an interview on 04/19/12 at 5:20 PM in the Hospital Resident #4 stated he had not had his catheter changed since he returned to the facility at the end of February. Review of the facility's policy and procedures on Catheters - Insertion and Care - Indwelling, Straight, Supra pubic and External dated 01/2008 documented in part: reflected Physician order [REDACTED]. Type of catheter, size of catheter and size of bulb Frequency to change catheter. Review of form CMS 672 Residents Census and Conditions of Residents documented there were 5 residents in the facility with a catheter.