Every finding on record at North Houston Transitional Care

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change for 1 (Resident # 1) of 5 residents reviewed for notification of changes. The facility failed to ensure LVN A notified the physician when there were reported rashes to Resident #1's chest and back on 07/30/2026. This deficient practice could affect residents with a change of condition and result in not receiving adequate and timely invention and decline in condition.Findings included: Record review of Resident #1's face sheet, dated 08/18/26, reflected a [AGE] year-old female who was admitted into the facility on [DATE], with a principal diagnosis of Chronic Diastolic (Congestive) Heart Failure (Also known as heart failure; happens when the main pumping chamber (left ventricle) of the heart becomes stiff. It cannot relax properly to fill with enough blood between beats, leading to fluid backup, shortness of breath, and fatigue, even though the squeezing function remains normal.) Record review of Resident #1's comprehensive MDS assessment, dated 08/04/2026, reflected her BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #1's progress notes from the ADON at 5:05 pm, on 08/01/2026 read in part, ADON was notified by the charge nurse that the guest had a painful/itchy rash on her chest and back. MD was notified and referred the guest to ID doctor A. Her symptoms and most recent labs were reviewed with ID doctor A over the phone, and new orders were received to start the guest on Valacyclovir 1000 mg q12 h x 7 days and to set up contact isolation for shingles. The charge nurse was also notified and voiced understanding. Record review of Resident #1's progress notes from RN A at 5:17 pm on 08/01/2026 read in part, Resident have rashes on chest, close right under arm, upper back. notify the Dr verbal order antibiotics. set all contact isolation precautions in the room. Record review of Resident #1's progress nurse practitioner note dated 08/03/2026 read in part, pt seen and examined, awake and alert, seated on a recliner, pt stated that she has shingles lesion, not in distress, no SOB, no cough or congestion, no fever, no nausea or vomiting. During an interview on 08/18/2026 at 08:42 a.m., with Resident #1's family member, she said on 7/30/2026, a CNA discover a rash on her mother's back, but she did not remember the CNAs name. The family member said the CNA showed them the rash at around 5 pm and she reported it to LVN A. She stated LVN A said she was in training and that the regular nurse went home because of an emergency. The family member said that at around 6:45 p.m., she reported the rash to the oncoming nurse, and she said she was going to check. The family member stated she did not remember the oncoming nurse's name and she went home. During an interview on 08/18/2026 at 12:15 p.m., LVN A said on 7/30/2026 she was on orientation on [NAME] side and they told her to take the cart on East side because the nurse had an emergency and left. LVN A stated a family member told her that Resident # 1 had some rashes, and she asked another nurse to come with her for assessment. She stated she did not remember the name of the other nurse. LVN A said she believed the nurse was an agency nurse and stated she had not seen her again since that day. She said she went into the room, and asked Resident # 1 to show her the rashes; they were under her right arm. LVN A said she did not know who to call and she did not have any number because she was still in orientation. LVN A stated the other nurse told her to get in contact with wound care nurse. She said she did not have the wound care nurse number and did not ask for the number. LVN A said she looked for the wound care nurse desk and put a note on the desk. She stated she did not call the doctor to report the rash, and she went back to the floor around late afternoon. She stated the other nurse went back to her cart. LVN A stated the next day she was back on orientation on [NAME] side. She stated that in the morning, she went to talk to the wound care nurse to follow up on the note she left on his desk. LVN A stated the wound care nurse said he was going to check it out and she went back to [NAME] side. She stated she did not do any documentation about the rashes that day. LVN A said once she learned about the facility protocol, she realized that she was supposed to call the doctor that day and report the rash. She said the risk of not calling the doctor immediately to report the rash is that the rash could get worse, causing discomfort and pain to Resident # 1. LVN A stated that another risk was that the rash could be infectious and the infection could spray on other people who encountered Resident #1. During an interview on 08/18/2026 at 1:43 p.m., the Wound care nurse said on 07/28/2026, he did an initial assessment on Resident # 1. He stated she did not have any need for wound care, and he did not see any rash on her. The Wound care nurse said he did not remember anybody reporting a rash to him. He stated he did not recall seeing any note on his desk for Resident #1. Wound care nurse stated that if he assessed Resident #1 and it was not a wound but just a rash, the nurse must call the primary doctor to report it because he deals with wounds. He stated he worked with the wound doctor. Wound care nurse stated he does not have anything to do with rashes and that the nurses are responsible for taking care of rashes. During an interview on 08/18/2026 at 3:17 p.m., the ADON stated she was first notified about the rash on Saturday 08/1/2026 by a nurse who no longer worked at the facility. She said she messaged her about the rash on the chest, and it was itching. The ADON said the nurse called the PCP1 on 08/01/2026 and he referred the resident to infectious disease doctor. She stated the ID Doctor1 ordered contact isolation and stated he was coming on Monday to see the resident. She said PCP1 also looked at the resident on 08/01/2026. The ADON stated the treatment started on 08/01/2026 and ID Doctor A and PCP A came on Monday to check on the resident. ADON stated she did not see the rash, therefore she will not confirm if there was a risk of not calling the doctor on 07/30/2026 to report the rash. She said she will have to see the rash to determine what the risk will be. The ADON stated that depending on how the rash looks she can determine what to report or what to do. She said she was a visual person and must see the rash to see what the risk will be because it will depend on how the rash looks like. The ADON stated she could not tell me what the nurses saw and that she does not believe it was a delay of care because there is no documentation to back up the story. She stated her expectation is that nurses must report any change in condition immediately to the provider, follow the order and document all communications and treatments. During a phone interview on 08/18/2026 at 4:28 p.m., ID Doctor A said the nurse did not call him, but they sent him a message, and he could not remember exactly when. He stated somebody texted him on the weekend about rash on Resident #1 and he asked them to send him the pictures and he gave some orders. He said he came on Monday 08/03/2026 and examined Resident #1. ID Doctor A stated it was a residual rash, and he suspected shingles and ordered some medications the same day. He stated when he gives any order, nurses will put it in the system. He stated there was no risk if nurses did not report the rash on 7/30/2026 because there is 96 hours window protocol to receive medications for shingles and that Resident #1 was not immune suppressed. He stated medications were started on time and that there was no delay and he was supervising with staff. He said he saw the rashes; they were only in one dermatome and the risk of spreading the infection to others was minimal. During a phone interview on 08/18/2026 at 5:10 p.m., PCP1 said he was notified about the rashes on 08/01/2026 and he asked the nurse to consult the infectious disease doctor. He stated medication was ordered and started on Monday 08/03/2026. PCP1 said there was no delay of care from when they were notified. He said there was no risk if the medication was started on 08/03/2026 because it was given within 72 hours from the time of notification. He stated there is 3-5-day window to start on antiviral medication and that there was no risk. During an interview on 08/19/2026 at 11:28 a.m., LPN A said if a CNA reports a resident with a rash he will assess the resident first for any sign of bleeding, redness, pain, the CNA will stay with the resident, and he will get the supervisor. He stated he will document his findings about what he saw and what he did. LPN said he will call the doctor, document and follow the doctor order. LPN stated that for any change in condition, he will notify the doctor because it is a safer thing to do and he will also notify his supervisor. LPN said the risk of not reporting a change in condition to the doctor is that the resident will have a delay in care, the condition could get worse and the patient can die. During an interview on 08/19/2026 at 12:00 p.m., LVN B said if a CNA reports a resident with a rash, she will assess the resident and depending on how the rash looks like she will call the doctor. She stated if there is a PRN order in place for the rash, she will just follow the order but if it is a new rash, she will call the doctor, document and follow the doctor's order. LVN B said for any change in condition, she will call the doctor and follow the doctor's order. She stated the risk of not calling the doctor for any change in condition is that the resident condition can get worse and if the condition gets worse the patient can end up in the hospital or spread the disease to others. During an interview on 08/19/2026 at 12:34 p.m., LVN C stated if a CNA reports a resident with rash she will assess, document and notify the DON, the ADON, the wound nurse, and the doctor. She stated for any change of condition she will report to the doctor. LVN C stated the risk of not reporting the change in change to the doctor is that the doctor will not be aware of the change, the condition can get worse and if it gets worse, it will create more issues and if there the resident can end up in the hospital. LVN C stated if an infection is not treated the patient can become septic. Record review of facility policy titled Change in a Resident's Condition or Status undated Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).Policy Interpretation and ImplementationThe nurse will notify the resident's attending physician or physician on call when there has been a(an):accident or incident involving the resident;discovery of injuries of an unknown source;adverse reaction to medication;significant change in the resident's physical/emotional/mental condition;need to alter the resident's medical treatment significantly;refusal of treatment or medications two (2) or more consecutive times);need to transfer the resident to a hospital/treatment center;discharge without proper medical authority; and/orspecific instruction to notify the physician of changes in the resident's condition.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for 1 (Resident # 1) of 5 residents reviewed for comprehensive care plan revisions.The facility failed to review and revise Resident # 1's care plan to reflect isolation with shingles and antiviral medication.This failure could place residents at risk of contracting shingles infection and Resident # 1 not receiving appropriate interventions and treatment for shingles infection.Findings included:Record review of Resident #1's face sheet, dated 08/18/26, reflected a [AGE] year-old female who was admitted into the facility on [DATE], with a diagnosis of Chronic Diastolic (Congestive) Heart Failure (Also known as heart failure; happens when the main pumping chamber (left ventricle) of the heart becomes stiff. It cannot relax properly to fill with enough blood between beats, leading to fluid backup, shortness of breath, and fatigue, even though the squeezing function remains normal). Record review of Resident #1's comprehensive MDS assessment, dated 08/04/2026, reflected her BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #1's care plan did not reflect isolation related to shingles infection. Record review of Resident #1's care plan did not reflect antiviral medications. Record review of Resident #1's nurses note, dated 08/01/2026, read in part, Resident have rashes on chest, close right under arm, upper back. notify the Dr verbal order antibiotics. Set all contact isolation precautions in the room. During an interview on 08/18/2026 at 3:17 p.m., the ADON stated that when caring for a patient she is meeting for the first time, she will use the report from the nurse and she will look at the patient history and physical and recent progress notes to set up a plan of care in her mind for that patient. ADON said when she meets the patient physically and speaks to them, then she will use that interaction and what she previously read to factor in how she will care for that resident. She stated the care plan is important, but it does not paint the actual patient. ADON said the care plan is there for a reason to guide individual care of each patient, but she believes physical interaction and experience with a patient will help to better care for that patient. ADON said the MDS nurse was supposed to update the care plan, but she is in between two buildings therefore all the nurses are supposed to update the care plan if she is not available. ADON stated there was no risk due to the care plan not being updated for isolation and antiviral medication. She said the isolation precaution was initiated on 08/01/2026 and all the nurses knew about it. She stated isolation precaution was just prophylactic until 08/03/2026 when it was confirmed that Resident # 1 had shingles. ADON said Antiviral medication was initiated on 08/03/2026 and she gave the initial dose to Resident # 1. During an interview on 08/18/2026 at 4:51 p.m., the MDS nurse stated she was supposed to update the care plan. She stated her role is to update the care plan. MDS nurse stated the risk of not having a care plan for shingles is that proper care would not be provided. She said the care plan will address infection control and signs and symptoms to look for. MDS nurse stated the order was there and the resident was still monitored and was treated for the shingles. She stated nurses were aware of shingles infection, there was isolation sign on the door and the doctor's order was carried on even with no care plan. She stated that the doctor's order was there and the plan of care was carried out. During an interview on 08/19/2026 at 09:35 a.m., LVN D stated he cares for residents according to doctor's orders. He said before he does anything with any resident, the doctor's orders and the chart (the care plan, documentations and interventions) are his Bible. LVN D said whatever brought to his attention regarding a patient, he gets as much info about the patient before he called the doctor therefore when he is on the phone with the doctor whatever question he asks, he has the answer. LVN D stated he believed the care plan is very important. He said the risk of not having a care plan is there could be a delay in care and interruption in patient's care. LVN D stated not having a care plan placed patient at high risk of death. During an interview on 08/19/2026 at 11:28 a.m., LPN A stated to care for a resident he will get report from the previous nurse. He will look at the patient during report and rounds, and then he will review the care plan and orders. He said if there is no care plan he will report it to the supervisor. LPN A said if a resident is in isolation from shingles, he will look at the care plan to see what the diagnosis is and how to care for the resident. He stated if there is no care plan there will be a safety risk like putting other residents at risk of getting infected including himself. LPN A said the patient will be also at risk because nurses will not know how to give proper care or how to monitor patient's condition or keep patient safe. LPN A stated care plan is very important because it lets nurses know how to care for and get proper treatment for the patient while following the doctor's order. During an interview on 08/19/2026 at 12:00 p.m., LVN B stated to know how to care for residents she will take report from the night nurse and look at the progress notes in the chart. She said the chart gives information about the residents' care plan, orders and medications. LVN B said the care plan is the best place to look for instructions on how to care for residents. She stated that if there is no care plan, she will report it to the DON because the care plan is very important. LVN B stated the risk of not having a care plan for a resident on isolation with shingles, is that nurses will not know why the person is on isolation and how to treat the resident. She stated there is a risk of infection for herself and anybody going in the resident's room. LVN B said even if the PPE are in the patient's room and there is an order for isolation, she still needs a care plan to know how to treat the resident. She stated the care plan helps everybody caring for a resident to be on the same page. LVN B said for residents in isolation, she always follows infection control protocol by wearing proper PPE and properly disposing of all PPE in the biohazard bag in the patient bathroom or in the biohazard room. During an interview on 08/19/2026 at 12:34 p.m., LVN C stated to know how to take care of a resident she looked at the resident's profile, diagnosis, vital signs and care plan. She said she also gets reports from the previous nurse and the CNA. LVN C stated if there is no care plan she will look at the discharge paperwork and ask for patient's medical history. She said if there is no care plan, she will report it to the DON. LVN C stated care plan is very important because it tells how to care for the patient. She said the risk of not having a care plan is that she will not be able to give proper care to the patient. LVN C stated she worked with Resident #1 when she was in isolation and there was an order for isolation. She stated she is not aware that there was no care plan for isolation. LVN C said she was not working the day the family member reported the rash on Resident #1. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, undated, reflected - Policy: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1(Resident #1) of 7 residents . The facility failed to ensure there were complete records for Hydrocodone 10/325 mg (opioid pain medication) for Resident #1from 4/27/26 through 5/10/26. The facility received a documented total of 106 Hydrocodone 10/325 mg tablets for Resident #1. It was also alleged that 20 additional Hydrocodone 10/325 mg tablets were given to the facility on 5/10/26 from Resident #1's home supply, but no facility documentation existed. During April and May 2026, Resident #1 had a documented total of 27 doses of Hydrocodone 10/325 mg tablets administered. The facility was unable to provide narcotic sign out records for Resident #1's Hydrocodone 10/325 mg except for 7 tablets received from Resident #1's home supply. This failure could place residents at risk of not having needed medication available or a lack of pain control. Findings included: Record review of Resident #1's face sheet dated 5/19/26, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Rheumatoid Arthritis (chronic autoimmune disease that primarily affects the joints causing pain, swelling and stiffness). Resident #1 was discharged on 5/11/2026 for a length of stay of 18 days. Record review of Resident #1's admission MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 14 that indicated cognition was intact. Section N revealed Resident #1 was taking an opioid medication. Section J revealed Resident #1 received as needed pain medication or was offered or declined. Section J pain assessment revealed presence of pain with occasional frequency with rating of 3 on a 0 to 10 scale. Record review of Resident #1's Order Summary Report for order date range of 4/22/26 - 5/31/26 revealed a physician's order for Hydrocodone-Acetaminophen oral tablet 10-325 mg with instructions to give 1 tablet by mouth every 8 hours as needed with start date of 4/25/2026. Record review of Resident #1's progress note dated 4/25/26 at 11:44 a.m. by LVN A revealed pt [family member] gave this nurse a bottle of Norco (Hydrocodone) with 7 pills. Record review of email from Pharmacist B dated 5/20/26 at 3:56 p.m. revealed 40 Hydrocodone 10 mg- 325 mg tablets were delivered on 4/27/26 at 10:03 p.m. and 56 Hydrocodone 10 mg-325 mg tablets were delivered 5/10/26 at 8:30 p.m. Record review of Resident #1's April 2026 MAR revealed documentation that Hydrocodone-Acetaminophen oral tablet 10-325 mg with instructions to administer every 8 hours as needed, were administered on the following dates:* 4/25/26 at 12:30 p.m., *4/26/26 at 11:30 a.m., *4/27/26 at 9:44 a.m., *4/28/26 at 11:00 a.m. and 6:08 p.m., 4/29/26 at 5:13 a.m. and 4:22 p.m. and 4/30/26 at 9:35 a.m. Further review revealed a total of 8 doses documented as being administered during April 2026. Record review of Resident #1's narcotic sheet for date ranges from 4/25/26-4/29/26 for Hydrocodone-APAP 10/325 mg revealed that 7 tablets were provided by the family on 4/25/26 with end count of 0. Doses were signed out as being administered on the following dates:* 4/25/26 at 12:30 p.m., *4/26/26 at 11:30 a.m., *4/27/26 at 9:44 a.m., *4/28/26 at 11:00 a.m., and at 6:07 p.m., *4/29/26 at 5:13 a.m. and at 4:22 p.m. Record review of Resident #1's May 2026 MAR revealed documentation that Hydrocodone-Acetaminophen oral tablet 10-325 mg with instructions to administer every 8 hours as needed were administered on the following dates:*5/1/26 at 12:22 p.m. and 8:10 p.m.; *5/2/26 at 5:04 a.m. and 2:00 p.m.; *5/3/26 at 5:07 a.m., 2:16 p.m. and 11:00 p.m.; *5/4/26 at 7:56 a.m. 3:58 p.m.; *5/5/26 at 7:26 a.m.; *5/7/26 at midnight, 8:58 a.m. and 3:38 p.m.; *5/8/26 at 12 noon; *5/9/26 at 9:45 a.m. and 5:25 p.m.; *5/10/26 at 9:40 a.m. and 3:54 p.m.; and *5/11/26 at 11:47 a.m. Further review revealed a total of 19 doses documented as being administered in May 2026. Record review of Resident #1's progress noted dated 5/9/26 at 9:45 a.m. written by LVN B revealed [family member] gave resident dose of Norco (Hydrocodone) at 0945 am (9:45AM) for c/o of pain. Awaiting Norco (Hydrocodone) from pharmacy . Record review of Transactions by Patient report dated 5/20/2026 at 2:37 p.m. revealed three doses of Hydrocodone 10-325 mg tablets were obtained from the facility's automated medication dispensing system on the following dates:*5/9/26 at 7:12 p.m., *5/10/26 at 9:15 a.m. and at 3:35 p.m. Further review revealed a total of three tablets obtained. Record review of an email from Resident #1's family member dated 5/10/26 at 8:15 a.m. to the Discharge Planning LVN and DON revealed Resident #1's family member's concern that over the weekend family members were required to provide Resident #1's Hydrocodone because the facility had run out. Record review of an email from Resident #1's family member dated 5/18/26 at 7:40 p.m. addressed to the DON and the Discharge Planning LVN revealed Resident #1's family member's asked when they could pick up the left over Hydrocodone they provided to the facility. Resident #1's family member stated they were informed there was uncertainty about whether the Hydrocodone would arrive on 5/11/26 from the pharmacy and was asked to bring the medication just in case. Resident #1's family member stated that they were at the facility but had not received a response of when they could pick up the Hydrocodone. Record review of email from Resident #1's family member dated 5/21/26 at 9:56 a.m. to the DON and the Discharge Planning LVN revealed they were currently at the facility and was trying to get an update regarding picking up Resident #1's Hydrocodone and would like to receive the medication. Record review of email from Resident #1's family member dated 5/21/26 at 10:13 a.m. to the DON and the Discharge Planning LVN revealed Resident #1's family member's indicated there was a concern regarding 20 Hydrocodone pills that were provided to the facility and that Resident #1 did not believe that Resident #1 finished the 7 Hydrocodone pills that were documented and expressed concern that the medications appeared to have been misplaced or otherwise unaccounted for. During interview on 5/18/26 at 9:41 a.m., Resident #1's family member said the facility had asked them to bring Resident #1's Hydrocodone from home the previous weekend , 5/9-5/10/26, as the residents prescription had not come into the facility. Resident #1's family member said they had not received the remainder of the Hydrocodone that was provided to the facility since Resident #1 discharged from the facility. Resident #1's family member said they asked me to give them the pills I had and I brought some and I said I could bring more if needed. Resident #1's family member said they had talked to the Director of admission and asked if they could get Resident #1's medications back but had not heard anything yet.Observation on 5/19/26 at 2:20 p.m. of the nurse medication cart (the location where Resident #1's medications was located) did not contain narcotic records for Resident #1. During interview on 5/19/26 at 2:27 p.m., RN A said there was no longer a resident in the room where Resident #1 had resided and they no longer had medications for Resident #1 in the medication cart. RN A said if a home medication was brought then they give it back to the residents when they were discharged . RN A said she had not taken care of Resident #1. During interview on 5/20/26 at 10:44 a.m., LVN C said she remembered in April 2026 that they needed to get a prescription called into the pharmacy for Hydrocodone as Resident #1 had just arrived to the facility. LVN C said one of Resident #1's family members had brought up a few Hydrocodone pills and left them to make sure we had pain medication for Resident #1. LVN C said she could not remember when the Hydrocodone was delivered but thought she remembered it was either delivered at the end of her shift or was to be delivered soon. LVN C said Resident #1 did not go without pain medication during this time. During interview on 5/20/26 at 12:42 p.m., LVN A said she thought she remembered there were issues with not having Resident #1's Hydrocodone in stock when she was admitted . LVN A said then towards the end of Resident #1's stay, they did not have a blister pack of the Hydrocodone and had to pull from the facility's automated medication dispensing system. LVN A said she did believe that they had a home pill bottle of Hydrocodone that had been obtained upon admission. During interview on 5/20/26 at 1:02 p.m., the DON said she had not been able to find the narcotic records for Resident #1 as the resident had discharged and that her records were between us and medical records and the DON was still trying to find the records. The DON said they did not have any home medications belonging to Resident #1 and believed Resident #1's family member had picked them up. During interview on 5/20/26 at 1:30 p.m., LVN B said she worked for a staffing agency and 5/9/26 was the only shift she had worked at the facility during May 2026 as of the time of the interview. LVN B said the previous nurse had ordered Hydrocodone for Resident #1 and that she was not staffed at the facility so she would not order medications. LVN B said Resident #1's family member had given Resident #1 Hydrocodone from her home medication. LVN B said the staff nurse had told her that Resident #1's family member had given the Hydrocodone and said she guessed it was not the first time. LVN B said she did not instruct Resident #1's family member to give the Hydrocodone to Resident #1. LVN B said that the staff had instructed her that the Hydrocodone was ordered and it was coming. LVN B said the Hydrocodone was not delivered during her shift.During interview on 5/20/26 at 1:41 p.m., LVN D said he did not remember any information regarding Resident #1 and had worked at the facility three times. Observation on 5/20/26 at 2:23 p.m. of the DON's office and narcotic destruction storage revealed no Hydrocodone 10/325 mg tablets were found for Resident #1. There was a stack of narcotic records from April-May 2026 that showed the narcotic counts as 0 and none of these sheets had Resident #1's name. During interview and record review on 5/20/26 at 2:30 p.m., the DON said the last narcotic destruction was completed in April 2026 and would be completed again next Tuesday 5/26/26. The narcotic destruction binder was observed which showed the last narcotic destruction as being completed on 4/20/26. Review of the narcotic sheets with the DON at 2:23 p.m. revealed none were found for Resident #1. During interview on 5/20/26 at 2:45 p.m., LVN E said on 5/8/26 that Resident #1 was running low on her Hydrocodone and she called the doctor to get a new script. LVN E said there were four Hydrocodone tablets remaining. LVN E said when she called the pharmacy, the pharmacy said they do not deliver on the weekend, and she did not understand because they had gotten deliveries on the weekends. LVN E said she asked if she could pull from the automated medication dispensing system and got the code. LVN E said we finally got a delivery on 5/10/26 of Hydrocodone 10 mg tablets which were over 50 pills and the other blister pack was gone at that time. LVN E said she got the script for the Hydrocodone on 5/9/26 and had pulled Hydrocodone from the automated medication dispensing system on the mornings 5/9/26 and 5/10/26. LVN E said they counted narcotics at shift change with the ongoing and off going nurses. LVN E said she checked the narcotic counts before she gave the medication and signed the out the narcotics and sometimes would go back and check that she signed the medication out. LVN E said she checked the narcotics 2-3 times a shift. LVN E said on the east side of the facility (where Resident #1's room was located) the nurses administered the as needed pain medications. LVN E said she had tried to explain to Resident #1's family that they were never out of her medications, and they were pulling from the automated medication dispensing system and there had to be two nurses and there was not always another nurse available so sometimes they had to wait to administer the medication until there were two nurses available to pull the medication. During interview on 5/20/26 at 3:14 p.m., Pharmacist A said she had been the pharmacist at the facility for five years and did all of the medication destruction including narcotic destruction. Pharmacist A said she also did audits including watching shift to shift narcotic counts or she did the narcotic counts with the nurse if it was not shift change. Pharmacist A said the staff did shift to shift counts of the narcotics as well, so her checks were a double check. Pharmacist A said she had not had any narcotic discrepancies when she did her checks. Pharmacist A said for a narcotic delivery they had a staff member at the facility who signed for receipt of the medications. Pharmacist A said she had instructed the facility staff about what to do if the narcotic count was off or how they should be recording the narcotics but only did narcotic in-services if there were narcotic discrepancies.During interview on 5/20/26 at 3:35 p.m., Pharmacist B said they delivered a total of 45 tablets of Hydrocodone 10/325 mg for Resident #1 on 4/27/26. Pharmacist B said the second order of Hydrocodone 10/325 mg was delivered on 5/10/26 for a total of 56 tablets. Pharmacist B said she saw a total of three doses of Hydrocodone 10/325 mg tablets that were pulled from the Omnicell (medication dispensing system) from reports. Pharmacist B said a possible effect it could have on residents regarding a narcotic discrepancy was a lack of pain control. During interview on 5/21/26 at 10:14 a.m., Resident #1's family member said she had brought the facility 7 Hydrocodone 10 mg tablets on 5/10/26 and the nurse told her it was not enough since they were not able to get the medication and it was best to bring more. Resident #1's family member said she left the facility and brought back 20 additional Hydrocodone 10 mg tablets that same night. Resident #1's family member said she did not know the name of the nurse she gave the medication to, but she would know the person if she saw a picture. Resident #1's family member said she talked to the ADON and the Discharge Planning LVN today at the facility regarding attempting to obtain Resident #1's Hydrocodone tablets. Resident #1's family member said she was told the facility only had documentation of the seven pills that the facility was given and they were all gone. Resident #1's family member said she told the facility that they should have more as Resident #1 was only getting them every 6 hours. Resident #1's family member said it was after 9 p.m. when she brought the 20 pills back on 5/10/26 and Resident #1 left the faciity on 5/11/26 at 8 p.m. Resident #1's family member said the nurse did not have her sign anything either time she dropped the medications off and they just said they had to get another nurse to count them for the 7 Hydrocodone tablets she dropped off but for the 20 Hydrocodone tablets she dropped off there was nothing and they did not get another nurse to count. Resident #1's family member said she did not see either count of the Hydrocodone tablets that were given to the facility.During interview on 5/21/26 at 10:24 a.m., the ADON said if she was coming in for a shift before she took possession of the medication cart and keys, they did a narcotic count and once everything was counted which included checking the medication name, dosage and count were correct then the off going and ongoing nurse would sign their sections of the narcotic sheet and the ongoing nurse was signing they were taking possession of the medication cart. The ADON said the narcotic counts were done with every shift change. The ADON said when they did the narcotic count they read the medication name, dosage and the left count. The ADON denied any problems with the narcotic counts not being correct or any narcotic medications going missing. The ADON said the nurse for that scheduled shift was the only person who had the keys to the medication cart once they took ownership of the medication cart. The ADON said there were no back up keys for the medication cart. The ADON said the process when there was a delivery of narcotics came in red bags and they open them in front of the delivery person and verify the medication, patient name and quantity and compare them with the slip that was delivered with the medication and we keep a copy. The ADON said before the medication went onto the cart the nurse who received the medication checked the information with a second nurse. The ADON said when narcotics were removed from the medication carts they were given to the DON and before the nurse handed off to the DON they verified the medication name and amount correlated to the sign off sheet. The ADON said once that was done the DON took possession and cataloged the medication to be destroyed and put in a locked drawer to be destroyed when the pharmacist came. The ADON said the pharmacist came once a month to do drug destruction. The ADON said the nurses trained with a seasoned nurse who knew what the expectations were which included narcotics. The ADON said they try to do audits of the narcotics every two weeks and made sure the nurses were signing off when they do their drug counts. The ADON said that the nurses let her know if there were any narcotics that needed to be destroyed and let the DON know as she was the only one who had the key for the narcotic destruction. The ADON said when nurses accept home narcotic medications they do an initial count and make sure there was an actual order before they take possession of the medication. The ADON said then the nurse would draw up a narcotic sheet with the order amount and name of the patient and a verified amount that they start from and moving forward they used that sheet to count. The ADON said regarding Resident #1 the only thing she knew was there was a bottle of seven Hydrocodone 10/325 pills, if she remembered correctly regarding the amount, that was brought and was counted and utilized that medication while she was here and there was none left. During interview on 5/21/26 at 11:40 a.m., the DON said the oncoming and off going nurses were responsible for counting the narcotics. The DON said the process for counting the narcotics was there were always two nurses, one had the book open and the other had the box open and they go through the name, medication and number to verify what they were counting. The DON said both nurses sign the book and then the off going shift hands the key to the oncoming shift. The DON said the nurses should notify her if there was a discrepancy. The DON denied any problems with the narcotic counts not being correct or any narcotic medications going missing. The DON said the narcotics were stored in the narcotic box in the medication cart under two locks and they should always be locked. The DON said the nurses had access to the keys to the medication cart and they only had access to their own medication cart. The DON said there were extra keys to the medication carts that she kept locked up in the narcotic destruction storage cabinet in her office. The DON said when narcotics were delivered the nurse signed with the delivery person and immediately put in the narcotic lock box and put the sheet in the binder. The DON said nurses were the only staff who received the narcotic deliveries. The DON said when residents were discharged or narcotics were discontinued the nurses should leave the narcotic paper in the book and the narcotic on the cart until they see her and then the nurse gave the medication and associated paper to her and she locked it up and logs it. The DON said she made sure the count was good and counted the medication with the nurse who gave her the narcotic before she locks it up in her office for destruction. The DON said training regarding narcotics included signing out the medications at the same time you click/sign them out in the computer and regarding the residents' pain and occurs during orientation and when required. The DON said staff were taught about narcotic counts with one another, signing out and getting the medications in the building. The DON said if home narcotics were received the nurses should make a sheet and sign it out. The DON said it would be best practice for two nurses to count home narcotic medications when received and those medications also go in the count. The DON said regarding Resident #1, a family member had brought 7 Hydrocodone 10/325 mg tablets and they started a sheet and signed those out. The DON said she did not have any information regarding a second delivery. The DON said the April 2026 sign out sheet that the DON provided to the surveyor for Resident #1 was the only sign out sheet for Hydrocodone that she could find for Resident #1. The DON said the ADON did audits of the narcotics on the medication carts. The DON said if narcotic counts sheets could not be found the effect it could have on the residents was to ensure that we have an adequate supply of the medication and the narcotic sheets was a secondary check.Record review of the facility's policy Controlled Substances with revision date of November 2022 revealed the system of reconciling the receipt, dispensing and disposition of controlled substances included the records of personnel access and usage; declining inventory records; and destruction, waste and return to pharmacy records. Policy also revealed accountability record for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation. Record review of the facility's policy Discarding and Destroying Medications with revision date of October 2014 revealed completed medication disposition records shall be kept on file in the facility for at least two years or as mandated by state law governing the retention and storage of such records.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 2 of 3 residents (Resident #3 and #12) reviewed for pharmacy services. 1. The facility failed to ensure Resident #3 did not have Clotrimazole 1% cream (an antifungal medication) on his nightstand near the bedside. 2. The facility failed to ensure Resident #12 did not have a medication cup filled with unidentified white barrier cream on the bedside tray parallel to the bed. These failures could place residents at risk of accidents and hazards. The findings included: 1. Record review of Resident #3's admission record dated 08/28/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included encephalopathy (a disease that affects brain structure or function. It causes altered mental state and confusion), sepsis, and hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (weakness on one side of the body). Record review of Resident #3's care plan dated 8/27/24 revealed he had cognitive impairment. He exhibited cognitive loss related to impaired decision-making skills, CVA seizure disorder. Record review of Resident #3's Physician Orders for August 2024 revealed there was no order for Clotrimazole 1% cream. Observation on 8/28/24 at 10:40 a.m. in Resident #3's room revealed Resident #3 was lying in a low bed. There was a box that contained clotrimazole cream 1% at his bedside. Resident #3 did not respond to this Surveyor's greeting. This Surveyor asked for staff assistance. CNA D entered the room, removed the cream from the bedside, and said she would give it to the nurse. In an interview on 8/28/24 at 2:35 p.m., CNA D said she would bring any medications found in the residents' room to the nurse and would never leave medication at the bedside because it was not safe for the residents. In an interview on 8/28/24 at 1:13 p.m. the Interim DON said Resident #3's family brought the cream in, and he was not on the medication. She said a facility staff member rounded on his room this morning (8/28/24) and the cream was not there. She said the Clotrimazole cream should not be at the bedside because someone could get to it or use it inappropriately. In an interview on 8/28/24 at 1:47 p.m. the Therapy Tech said she rounded on Resident #3's room this morning (8/28/24) before 9 a.m. and did not see anything on his nightstand. 2. Record review of Resident #12's admission record dated 08/28/2024 revealed a [AGE] year-old male readmitted to the facility on [DATE]. His diagnosis included dementia, metabolic encephalopathy (a disease that affects brain structure or function. It causes altered mental state and confusion), sepsis, and hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (weakness on one side of the body). Record review of Resident #12's 5-day MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15 which indicated severe cognitive impairment. Record review of Resident #12's care plan revealed he was at risk for skin breakdown related to impaired mobility and incontinence of bowel and bladder. Interventions were to apply barrier cream as indicated, administer medication and treatments as ordered. Record review of Resident #12's physician orders for August 2024 revealed orders for: protective skin barrier ointment after each incontinent episode every shift, order date 8/16/24. Treatments: apply barrier cream, order date 8/16/24. Observation on 8/28/24 at 10:55 a.m. in Resident #12's room revealed Resident #12 was asleep in bed. There was a medication cup filled with white cream on the bedside tray next to the resident's water. The bedside tray was against the resident's wall parallel to the resident's bed. In an interview on 8/28/24 at 11:11 a.m., CNA A entered Resident #12's room with this Surveyor and said the white cream was a barrier cream used for skin prevention to the sacrum. He said he did not know the name of the cream and said the Wound Care Nurse provided the cream for the CNAs. He said after using the cream, he normally placed it in the dresser far away from the patient. In an interview on 8/28/24 at 11:14 a.m. the Wound Care Nurse said the cream used for Resident #12 was Triad Hydrophilic wound dressing with zinc oxide. She said she did not give the CNAs the cream and she applied the cream herself. She said the cream should not be left in the room because of the ingredients. In an interview on 8/28/24 at 1:13 p.m. the Interim DON said if the barrier cream was prescribed for the resident, it should not have been in the room. She said she did not want the resident to eat it, or use is it in an unintended manner. She said the nurses, CNAs, and guardian angels were responsible to ensure items (biologicals and medication) were not available in the room. In an interview on 8/28/24 at 3:40 p.m. the ADON said the previous wound care nurse had a habit of giving the CNAs barrier cream. She said the staff were leaving the cream in the resident rooms, so she provided extra training and in-services. She said if staff found cream in the room, they should notify the nurse who could throw it away. She said if the cream was in the room, the resident could eat it or apply it to the wrong location. She said CNAs, nurses, and Angel Rounder staff conducted room rounds and should say something if they saw something. In an interview on 8/28/24 at 3:54 p.m. the Administrator said staff should notify the nurse if they saw anything that was not supposed to be in the residents' rooms. He said the facility conducted Ambassador rounds that checked for physical environment and medications at the bedside. He said the facility also provided education to the residents' family on not leaving medication in the residents' rooms. Record review of the facility's in-service on Rounds, Call lights, and Patient Care dated 7/2/24 conducted by the ADON read in part, .No open containers of barrier cream is to be left at the bedside . Record review of the facility's policy, titled Storage of Medications, revised 11/2020, revealed .The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medication have access to locked mediations .

Based on 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 1 of 10 residents (CR #1) reviewed for quality of care. LVN A accepted and retained a new admission from a rehabilitation hospital, CR #1, who was actively in respiratory distress with an oxygen saturation of 73% on [DATE], at approximately 12:30 p.m. and failed to monitor and assess him frequently throughout the rest of her shift (6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m.) after she administered 5L of oxygen and assumed his condition was stable. This failure resulted in LVN A being unaware of CR #1's continued respiratory distress until he was found unresponsive between 6:00 p.m. and 7:00 p.m. and subsequently expired. CNA B failed to inform LVN A or any nursing staff of CR #1's need for nursing assessment when she observed him with shortness of breath multiple times during her shift (2:00 p.m. - 10:00 p.m.) on [DATE] even though she was aware he previously experienced respiratory distress and required clinical interventions earlier in the day. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 10:30 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on [DATE]. These failures placed residents who experience a change of condition at risk of further deterioration and death. Findings include: Record review of CR #1's face sheet dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility from a rehabilitation hospital on [DATE]. He was diagnosed with chronic congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), atherosclerotic heart disease (damage or disease in the heart's major blood vessels which causes the buildup of plaque), diabetes (a group of diseases that result in too much sugar in the blood) with polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body which causes weakness, numbness, and burning pain), chronic kidney disease, stage 3 (when the kidneys have mild to moderate damage and are less able to filter waste and fluid from the blood), venous insufficiency (improper functioning of the vein valves in the leg which causes swelling and skin changes), enterocolitis due to recurrent clostridium difficile (inflammation of the colon and large intestine caused by bacteria), cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness), essential hypertension (a form of hypertension [a condition in which the force of the blood against the artery walls is too high]without an identifiable physiologic cause), transient cerebral ischemic attack (a brief stroke -like attack that resolves within minutes to hours), sepsis (a life-threatening complication of an infection), acute respiratory failure with hypoxia (a medical emergency that occurs when the body does not have enough oxygen in its tissues and causes shortness of breath, confusion, cardiac dysfunction, and cardiac arrest), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). He was discharged from the facility on [DATE]. Record review of CR #1's entry MDS dated [DATE] revealed it only contained his personal information, such as his date of birth, marital status, insurance information, and date of admission. Record review of CR #1's electronic clinical record revealed no documentation of a care plan. Record review of CR #1's physician's orders revealed he was not prescribed scheduled or PRN oxygen therapy. Record review of CR #1's clinical records from the rehabilitation hospital dated [DATE] revealed he was admitted to the rehabilitation hospital from an acute care hospital on [DATE], and he was discharged to the facility on [DATE]. The document read, . History: This patient is a [AGE] year-old male who lived with a family member, previously independent. He has had multiple hospitalization s over the last several months, he had been here twice before. The first time was for recovery from total hip replacement, but he was transferred out acutely for change in his overall status and patient developed C. diff and a right lower extremity wound, which he currently has a wound vacuum. The patient was discharged home with family, but readmitted to acute care on [DATE] with complaints of diarrhea . He was admitted and followed for relapse of C. diff colitis . He was also followed for acute on chronic renal failure. No other major medical complications, but he remains quite weak . He has an indwelling catheter . [DATE], Cardiology Progress Note. Subjective: Patient seen and examined in the room, denies chest pain, no shortness of breath, no palpitations (feelings of fast-beating, fluttering, or pounding heart), no dizziness or syncope (fainting, or sudden temporary loss of consciousness), no orthopnea (discomfort when breathing while lying down flat), no nausea, vomiting, or diarrhea . [DATE], at 9:37 a.m.: oxygen saturation 99% . [DATE], at 4:15 p.m.: oxygen saturation 95% . Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal . [DATE]: Remains on isolation protocol. Still gets drowsy, requires full oxygen support (no details provided) . [DATE], at 1:39 p.m. - Treatment Session Conclusion - Patient Status: Location - Transport: Left in room, call light within reach, bedside table within reach (Comment: catheter intact, 2L O2 via nasal cannula .) . Further review of CR #1's medical records revealed no other documentation of oxygen administration or physician's orders for oxygen therapy. Record review of CR #1's progress notes for [DATE] revealed: view draft (typed in red). Effective date: [DATE], 7:15 p.m. LVN A wrote, Note Text: 12:15 p.m.: CR #1 was a new admit who arrived via EMS. He was accompanied by [several family members]. Resident was transferred by EMS from stretcher to bed by EMS x 2 assist. EMS woman giving report stated that resident was on isolation for C-diff and may also have COVID. Initial assessment O2 saturation at ,d+[DATE]% (according to medicinenet.com, sustained blood oxygen levels below ,d+[DATE]% can be life-threatening and may lead to death if not addressed promptly) room air, ,d+[DATE] [blood pressure], 73 [pulse]. Writer immediately directed to staff to bring a tank of oxygen and a concentrator to room. This nurse informed family that their loved one did not look too good, and that his O2 was a concern. Writer initiated O2 on 5L and decreased. Resident O2 saturation was accomplished with a reading of ,d+[DATE]% on 3L. Resident became more aroused and verbal. He communicated with writer and said that he [would] like to be addressed by his first name. Throughout assessment, EMS had already left the building. They did not ensure that resident was connected to oxygen prior to leaving. During assessment, family remained at bedside and answered questions from this nurse . Resident was provided lunch, writer noted that resident had only eaten approximately 50%. Family member stated that CR #1 did not eat much. Last time writer saw CR #1 prior to him coding, was roughly ,d+[DATE] hours earlier at approximately ,d+[DATE] p.m. Resident was quietly watching television and did not appear to be in any distress. Bed semi-Fowler (a medical position where a patient lies on their back with their head and upper body raised at a ,d+[DATE]-degree angle on the bed). Breathing non-labored. Therapist notified this nurse that resident [was] non-responsive. Nurse immediately called a code blue before getting in room. Upon arrival in room, nurse noted resident non-responsive and initiated CPR. Two nurses and several staff in room and assisted nurse with CPR and AED. 911 notified. CPR continued until 911 arrived and took over. Family members arrived five minutes behind. Resident pronounced (CR #1's death was announced) at 7:35 p.m. In an interview with the DON on [DATE], at 9:45 a.m., she stated CR #1 was admitted to the facility on Sunday, [DATE] around 12:00 p.m. then coded and passed away around 6:00 p.m. that same day. She said, according to LVN A, CR #1 did not look well, and his oxygen saturation was in the lower 70's when EMS transferred him from the gurney (stretcher) to the bed. She said to her knowledge, EMS brought CR #1 into the facility on oxygen but did not connect him to oxygen when they transferred him to the bed in his room. She said LVN A said EMS left before CR #1 was stable, but LVN A got him up to 95% oxygen saturation and he became more alert and ate lunch. She stated LVN A did not call her when CR #1 had low oxygen saturation when he was initially admitted . She said LVN A told her about the incident later that evening when CR #1 coded (experienced cardiac arrest). The DON stated she had the facility's on-call phone and LVN A did not call to notify of CR #1's change of condition earlier in the day, but she was on the phone with LVN A during the time when CR #1 coded. She stated LVN A should have followed protocol and notified her, as the DON when CR #1 had a change of condition. In a telephone interview with LVN A on [DATE], at 11:17 a.m., she stated on [DATE], EMS brought CR #1 to the facility between 12:15 p.m. and 12:30 p.m. without oxygen. She stated the EMS were not very good because they left before making sure CR #1 was connected to oxygen. She said if she did not go into CR #1's room when she did, he would have died at that time because he was already in respiratory distress when she first observed him. She stated CR #1 arrived with his family and she told his family he did not look good. She said he asked CR #1's family to raise the head of the bed and she yelled for staff to bring an oxygen concentrator and oxygen tank because his oxygen saturation was assessed at 73%. She stated she immediately started CR #1 on 5L of oxygen until his oxygen saturation went up to ,d+[DATE]%. She said she then lowered the oxygen level to 3L. She said according to CR #1's family member, he was supposed to be on 2.5L of oxygen. She said after his oxygen saturation increased to ,d+[DATE]%, CR #1 started talking and ate lunch around 1:00 p.m. She said if she was not able to get CR #1's oxygen saturation back up, she would have called 911. She said the next time she saw CR #1 was around dinnertime (4:00 p.m. - 5:00 p.m.) when she saw him through the doorway as she passed his room in the hallway. She said CR #1 did not appear to be in distress at that time. She said around 5:00 p.m. - 6:00 p.m., a therapist (OT) was on the hall checking on new residents and the OT asked a CNA (she did not recall the name of the CNA) for a nurse. She said the CNA came up to her looking anxious and said CR #1 was unresponsive. LVN A said the OT said CR #1 did not look good and he was unresponsive, so she screamed for a code blue and requested a crash cart. She said she also yelled for someone to call 911. She said they initiated CPR until EMS arrived and took over, but CR #1 did not make it. She stated she was not able to keep up with CR #1 or get more familiar with him because she was so busy doing her other nursing duties on [DATE]. She stated she could not closely monitor new residents because she did not think there were enough nurses on the shift (LVN A worked double weekend shifts, from 6:00 a.m. - 2:00 p.m. and 2:00 p.m. until 10:00 p.m.). She stated the facility did not have any protocols or action plan regarding frequent monitoring of residents who experienced a change of condition. She said maybe she should have checked on CR #1 every 30 minutes, but their protocol was to round every two hours. She stated CR #1's family member told her he needed a C-Pap machine for sleep apnea (he did not have the machine yet). She stated she resigned the night of [DATE] and did not return to the facilitybecause CR #1 should not have died and she thought there should have been more nurses assigned to her unit. She said the ADON said if she (LVN A) saw that CR #1 was not looking good, she should have sent him out. LVN A said CR #1 was a high risk patient (he had multiple comorbidities) and probably should not have been at the facility to begin with because a nurse would not be with him all the time. She said if she did not have so much other stuff to do, she could have kept up with CR #1 more. In a follow-up interview with the DON on [DATE] at 11:30 a.m., she stated LVN A was not happy on [DATE] because she had to admit two residents that day, but there was a total of four nurses in the building. She said LVN A told her that she (LVN A) told CR #1's family and the EMS who brought him to the building on [DATE] that CR #1 did not look good. The DON said LVN A called CR #1's family member on the phone to verify (prove to the DON) that she told EMS CR #1 did not look good, but EMS did not try to take CR #1 out of the building. In an interview with CNA C on [DATE], at 12:45 p.m., he stated he worked the 6:00 a.m. - 2:00 p.m. shift on [DATE] and he worked with LVN A when CR #1 was admitted to the facility that day. He said CR #1 was brought into the facility by EMS on a stretcher without oxygen. He said EMS brought in paperwork and LVN A started working with CR #1. He said CR #1 was breathing heavily when EMS brought him into the building. He said he did not recall hearing CR #1 talk. He said he did not recall CR #1's family members saying he needed oxygen, but LVN A put oxygen on him quickly. He said he did not know what happened after LVN A placed CR #1 on oxygen because it was close to the end of his shift. He said he did not see CR #1 again after he initially assisted with getting him into his room. In an interview with LVN D on [DATE], at 1:30 p.m., he stated if a resident was admitted in respiratory distress, the nursing protocol would be to send them back to the hospital. He said if they had to keep the resident, nurses should stabilize the resident with oxygen. He stated the nurse should call the resident's doctor for orders and let the DON and ADON know so they could tell them how to proceed. He said if the resident was stabilized, he would monitor them and assess frequently, make sure they had oxygen, and ensure their saturation was stable. In an interview with the ADON on [DATE], at 2:15 p.m., she stated after LVN A stabilized CR #1 with oxygen on [DATE], she did not think LVN A reported the incident to the proper chain of command (DON, ADON, and Administrator). She said as the ADON, she was not notified of the first distress incident until after CR #1 coded, which was not proper chain of command. She stated she was scheduled to work from 8:40 p.m. that night ([DATE]) to 7:40 a.m. Monday ([DATE]), but she received a call from CNA E at 7:30 p.m. and heard the commotion in the background when CR #1 coded, so she rushed to the facility. She stated CR #1 had already been pronounced deceased by the time she arrived at 8:45 p.m. She said she told LVN A if she received a resident who looked like they were in distress, nurses had the authority to refuse the admission and send the resident back to the hospital. She stated if a resident looked unstable, nurses should either send them out 911 or refuse to accept the resident. She said since LVN A did accept CR #1, and was able to stabilize him with oxygen, she should have notified his doctor about what happened and monitored him closely (checked on him frequently). She stated LVN A resigned and left the facility around 12:30 a.m. on [DATE]. In an interview with the OT on [DATE], at 2:46 p.m., she stated she worked at the facility on [DATE]. She said she did occupational therapy evaluations that day because the regular occupational therapist was unavailable. She said CR #1 was the last evaluation of the day since he was on isolation for COVID and C-diff. She said when she entered CR #1's room around 7:00 p.m. on [DATE], he looked like he was asleep. She said his arm was hanging off the bed, so she went to reposition him and wake him up. She said when CR #1 did not wake up, she did a sternal rub (a painful stimulus used by EMS to assess a patient's neurological status and brain function) and noted he was unresponsive. She said she saw a CNA (she did not say the name of the CNA) and told her to get a nurse because CR #1 was unresponsive. She stated she could hear CR #1's concentrator running when she was inside of CR #1's room. In a follow-up telephone interview with the OT on [DATE], at 8:19 a.m., she stated when she entered CR #1's room on [DATE], around 7:00 p.m., she observed that CR #1's nasal cannula was not in his nose. She said although she heard the oxygen concentrator running when she was inside the room, she did not see that nasal cannula anywhere. She stated she when she tried to reposition CR #1's head and performed the sternal rub, she did not see the nasal cannula. In a telephone interview with CR #1's physician on [DATE], at 3:10 p.m., he stated on [DATE], LVN A sent him a text with CR #1's medication list and diagnoses. He said LVN A indicated CR #1 was a transfer from a rehabilitation hospital and asked him to review his medications. He said he texted LVN A back that they would continue with the medication list received from the previous facility and he would visit the resident on Monday, [DATE]. He said that text conversation was earlier in the day on [DATE] and he did not hear anything else about CR #1 until later that night when LVN A called him after CR #1 died . He said at that time (during the phone conversation on the night of [DATE]), LVN A told him CR #1 had been unstable and in respiratory distress earlier in the day. He said he asked LVN A why she called him at 9:00 p.m. when everything was done instead of calling him earlier when CR #1 was unstable. He said LVN A told him she did not call earlier because CR #1 was more stable after she administered oxygen. He said LVN A never called him earlier on [DATE] to inform him that CR #1 was in respiratory distress, and she did not say he had an oxygen saturation of 73%, or that he required oxygen administration. He said if LVN would have called him earlier when CR #1 was in distress, he would have asked her to repeat the oxygen assessment because sometimes, the measurements were not accurate. He said CR #1's oxygen saturation was too low but sending him to the hospital immediately would have depended on her ability to stabilize him with oxygen. He said LVN A told him she gave CR #1 2L or 5L of oxygen, then his saturation went up to ,d+[DATE]%. He said he would have told LVN A to monitor CR #1 closely (check on him frequently) throughout her shift and if he became unstable, at any time, send him to the ER. He said the staff would have needed to monitor CR #1 often enough to make sure he did not crash (deteriorate quickly) and to ensure they could send him to the ER as soon as possible if he became unstable again. He said LVN A knew how to contact him. He said the facility's nurses were usually very good about calling him for guidance when they were concerned about a resident's condition. He said he expected the nurses to call him when his patients experienced a change of condition. In an interview with the DON on [DATE], at 10:15 a.m., she stated an oxygen saturation of 73% was really low and LVN A should have sent CR #1 out and contacted his doctor. She stated the EMS should have taken CR #1's vital signs before they left him at the facility on [DATE]. She stated she thought CR #1 was on oxygen when EMS brought him into the building. In a telephone interview with a representative of the transportation service that picked CR #1 up from his previous facility and brought him to the facility (on [DATE]) on [DATE], at 10:55 a.m., they stated their company only transported patients from one place to another and did not assess vital signs or write reports about the transport. At that time, a request was made to speak with the EMS who transported CR #1 to the facility, but the representative suggested to speak with the company's manager. A voicemail message was left for the manager on [DATE] at 11:00 a.m. but the call was never returned. In a telephone interview with CNA B on [DATE], at 11:20 a.m., she stated she worked the 2:00 p.m. - 10:00 p.m. shift on Sunday, [DATE]. She stated when she arrived for her shift around 2:00 p.m. - 2:15 p.m., LVN A told her CR #1 was just admitted and that he was not feeling well. She said LVN A told her CR #1 was admitted with a low oxygen saturation. She said if it was her and a resident arrived with a low oxygen saturation, she would have to send the resident back because they did not know what would happen. She said after that, she introduced herself to CR #1. She said at that time, CR #1 had on a nasal cannula with oxygen running and he was fine. She said she checked on CR #1 again at 3:00 p.m. and he was asleep, breathing heavily, shaking, and talking in his sleep, like he was having a bad dream. She said she woke CR #1 up and asked him if he had a bad dream and he said he was ok. She said she dropped off CR #1's dinner tray around 4:00 p.m. She said CR #1's breathing was fine at first, but after a few minutes, he started breathing heavily, like how it would sound of someone went up a flight of stairs. She said she picked up CR #1's dinner tray between 5:00 p.m. and 5:25 p.m. and emptied his catheter bag. She said his nasal cannula was off his nose and he was breathing heavily, so she replaced the nasal cannula, and his breathing was fine after a minute. She said the resident across from CR #1's room had his call light on, so she went in and provided incontinent care for him. She said after she left that room, she saw the OT checking on residents. She said the OT put on PPE because CR #1 was on isolation. She said after about two seconds, the OT came out of CR #1's room and said he was unresponsive. She said she went to the nurse's station and notified LVN A that CR #1 was unresponsive. She said the nurse called a code blue and initiated CPR. She said eventually, EMS and police arrived. She said she told the police that CR #1 arrived with a low oxygen saturation and the police said that if he had a low oxygen saturation, the first thing she should have done was send him back to the hospital. She said she never notified LVN A or any other nurse when she observed CR #1 breathing abnormally or when she found his nasal cannula out of place because LVN A already knew he was having trouble breathing. CNA B said LVN A told her he was having trouble when she initially reported to her shift. In an interview with LVN F on [DATE], at 11:45 a.m., she stated she worked double shifts on the weekends and she was present on [DATE]. She said she was working on another hall when she heard the code blue for CR #1. She said she grabbed the crash cart and ran to CR #1's room. She said once she got to the room, she noted CR #1's body was flaccid (soft and hanging loosely) and he was very pale in color with no other discoloration. She stated she placed the AED pads on CR #1's chest and noted his skin was warm. She stated if a new admission arrived to the facility in noticeable respiratory distress, she would not accept the resident and would try to send him right back to the hospital. She stated that an oxygen saturation of 73% was very low and LVN A never asked her or the other nurses who were present on the shift for help. She said after CR #1 coded, she told LVN A she should have asked for help earlier in the day when he had low oxygen. She said she would have monitored CR #1 every 15 minutes once he was stable after being in distress. In a follow-up telephone interview with LVN A on [DATE], at 11:37 a.m., she stated it took about ten minutes for CR #1's oxygen saturation to go from 73% to 93% once she placed him on 5L of oxygen. She said once CR #1 was stable, she sent CR #1's doctor a text about his medications. She stated she did not mention CR #1's respiratory distress to the doctor because he was stable at that time, and she continued to administer 3L of oxygen. She said she did not see any notes in the computer system about CR #1 requiring oxygen therapy. She said CNA B never told her she observed CR #1 breathing heavily or that his nasal cannula fell off throughout the day. She said that information was big, and she would not have ignored it. She said had CNA B told her that information, she would have assessed him immediately. She said she knew she should not have taken that resident (CR #1). In a telephone interview with CR #1's family member on [DATE], at 12:28 p.m., he stated on [DATE], CR #1 was brought into the facility on a stretcher. He stated the EMS person who brought CR #1 in had taken him off oxygen in the ambulance and left him in his room with no oxygen. He stated once CR #1 was in his bed, he started having trouble breathing and the nurse had to place him on a high level of oxygen. He said LVN A entered the room and noticed CR #1 had trouble breathing. He said LVN A left the room to find an oxygen concentrator, which took a while. He said LVN A told him EMS was supposed to leave CR #1 on an oxygen tank until the facility got him on one. He said LVN A told him if she could not get his oxygen saturation back up, she would have to send him to the hospital. He said CR #1 had an oxygen tank on the back of his wheelchair at his previous facility, but he was not aware that CR #1 really needed oxygen to that extent. He said the previous facility was treating CR #1 for C-diff and dehydration, but he suspected CR #1 had CHF (a chronic condition in which the heart does not pump blood as well as it should) because he was always very swollen, and his condition got worse. He said he and the rest of CR #1's family did not think he was ready to be discharged , so they were fighting to keep him in the rehabilitation hospital. He said they appealed CR #1's discharge from the hospital, but since his insurance days ran out, they were about to make the family pay out-of-pocket. He said the family went ahead and let CR #1 get transferred to the facility and the appeal for the rehabilitation hospital was approved two days after he died at the facility. He said the previous facility allowed CR #1 to use a C-Pap machine for a few days, but they took it back. He said CR #1 had an appointment scheduled to get his own machine. In an interview with the DON and Administrator on [DATE], at 12:39 p.m., the Administrator stated he did not thing CR #1 was in distress when he arrived at the facility on [DATE] because LVN A usually contacted the DON and physicians with any concern she had about residents. The DON stated LVN A was disgruntled, and she thought LVN A lied about assessing CR #1's oxygen saturation at 73%. The Administrator said he did not think the incident was a system failure and LVN A was just having a bad day. The DON said LVN A did not document the progress note in real time. The DON said after CR #1 died , LVN A said she was quitting and the ADON told her to document before she left. The DON said LVN A documented the progress not around 9:00 p.m. and she doubted CR #1's oxygen saturation was that low. Record review of the facility's policy titled Oxygen Administration dated [DATE] revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration . General Guidelines . b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head . Assessment. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (blue tone to the skin). 2. Signs or symptoms of hypoxia (rapid breathing, rapid pulse rate, restlessness, confusion). 3. Signs or symptoms of oxygen toxicity (tracheal irritation, difficulty breathing, or slow, shallow rate of breathing) . 6. Arterial blood gases and oxygen saturation . Steps in Procedure . 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. 14. Periodically re-check water level in humidifying jar . Reporting . 2. Report other information in accordance with facility policy and professional standards of practice. Record review of the facility's procedure titled, Admitting the Resident: Role of the Nursing Assistant dated [DATE] revealed, Purpose: The purposes of this procedure are to assist the resident to his/her room and to help alleviate concerns and answer questions that the resident and family may have . Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed . 3. Any observations made during the procedure. 4. The resident's vital signs . Reporting: 1. Notify the supervisor and the attending physician of any wounds that the resident may have that may need to be treated . 3. Report other information in accordance with facility policy and professional standards of practice. Record review of the facility's document titled Job Description: Charge Nurse dated [DATE] and signed by LVN A on [DATE] revealed, The basic purpose of the Charge Nurse position is to provide direct nursing care to the residents and to supervise the daily nursing activities performed by nursing personnel enlisted to your charge . Essential Duties: Assist residents in achieving the highest practicable level of self-care, independence, and well-being. Make rounds and provide report . Respond to and monitor care issues and changes in condition . Supervise, instruct, and assist nursing assistants in provision of care including prompt response to call lights . Communicate with physicians and other health professionals regarding resident care, treatment, and condition. Admit, discharge, and transfer residents according to the facility's policies and procedures . Report significant findings or changes in condition and potential concerns to the Director of Nursing . An IJ was identified on [DATE]. The IJ template was provided to the DON on [DATE] at 10:30 a.m. adn a POR was requested. The following Plan of Removal submitted by the facility was accepted on [DATE] at 11:50 a.m.: PLAN OF REMOVAL Name of Facility Date:___[DATE]____________________________ Date of compliance: [DATE] F684 Immediate action: * Resident CR#1 is no longer at the facility. * LVN A resigned and is no longer employed as off [DATE] * Nurse Management came in on [DATE] at 7p, to Assist Nurse and Monitor All Residents for Change in Condition and assist in Admission. * DON and ADON performed health checks on all Resident for Potential harm on [DATE]. Including but not limited to, pain, respiratory issues, general appearance, grievances and overall wellness- no harm found. If any Change in Condition noted would report to MD and Administrator. None noted. * DON and designee in-service nurses on [DATE] to [DATE] regarding Admissions, Readmission assessments, change in condition and follow up, notifying the physician. Facilities Plan to ensure compliance quickly * DON and/or designee to in-service nurses on O2 administration and monitoring when resident is on respiratory distress. By [DATE] * DON and/or designee to In-service nurses on calling DON/ADON/Weekend supervisor and or administrator if the [TRUNCATED]

Based on interview and record review, the facility failed to immediately inform or consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complication) for 1 of 10 residents (CR #1) reviewed for physician notification. LVN A failed to notify or seek clinical guidance from CR #1's physician, or any physician when she observed him in respiratory distress and had an oxygen saturation (blood oxygen level) of 73% upon admission to the facility from a rehabilitation hospital on [DATE]. This failure resulted in no communication/guidance from CR #1's physician and LVN A being unaware of CR #1's intermittent shortness of breath and respiratory distress throughout the day before he was found unresponsive between 6:00 p.m. and 7:00 p.m. and subsequently expired. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 10:30 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on [DATE]. This failure placed residents who experience a change of condition at risk of further deterioration and death. Findings include: Record review of CR #1's face sheet dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility from a rehabilitation hospital on [DATE]. He was diagnosed with chronic congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), atherosclerotic heart disease (damage or disease in the heart's major blood vessels which causes the buildup of plaque), diabetes (a group of diseases that result in too much sugar in the blood) with polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body which causes weakness, numbness, and burning pain), chronic kidney disease, stage 3 (when the kidneys have mild to moderate damage and are less able to filter waste and fluid from the blood), venous insufficiency (improper functioning of the vein valves in the leg which causes swelling and skin changes), enterocolitis due to recurrent clostridium difficile (inflammation of the colon and large intestine caused by bacteria), cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness), essential hypertension (a form of hypertension [a condition in which the force of the blood against the artery walls is too high]without an identifiable physiologic cause), transient cerebral ischemic attack (a brief stroke -like attack that resolves within minutes to hours), sepsis (a life-threatening complication of an infection), acute respiratory failure with hypoxia (a medical emergency that occurs when the body does not have enough oxygen in its tissues and causes shortness of breath, confusion, cardiac dysfunction, and cardiac arrest), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). He was discharged from the facility on [DATE]. Record review of CR #1's entry MDS dated [DATE] revealed it only contained his personal information, such as his date of birth, marital status, insurance information, and date of admission. Record review of CR #1's electronic clinical record revealed no documentation of a care plan. Record review of CR #1's physician's orders revealed he was not prescribed scheduled or PRN oxygen therapy. Record review of CR #1's clinical records from the rehabilitation hospital dated [DATE] revealed he was admitted to the rehabilitation hospital from an acute care hospital on [DATE], and he was discharged to the facility on [DATE]. The document reflected, . History: This patient is a [AGE] year-old male who lived with a family member, previously independent. He has had multiple hospitalization s over the last several months, he had been here twice before. The first time was for recovery from total hip replacement, but he was transferred out acutely for change in his overall status and patient developed C. diff and a right lower extremity wound, which he currently has a wound vacuum. The patient was discharged home with family, but readmitted to acute care on [DATE] with complaints of diarrhea . He was admitted and followed for relapse of C. diff colitis . He was also followed for acute on chronic renal failure. No other major medical complications, but he remains quite weak . He has an indwelling catheter . [DATE], Cardiology Progress Note. Subjective: Patient seen and examined in the room, denies chest pain, no shortness of breath, no palpitations (feelings of fast-beating, fluttering, or pounding heart), no dizziness or syncope (fainting, or sudden temporary loss of consciousness), no orthopnea (discomfort when breathing while lying down flat), no nausea, vomiting, or diarrhea . [DATE], at 9:37 a.m.: oxygen saturation 99% . [DATE], at 4:15 p.m.: oxygen saturation 95% . Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal . [DATE]: Remains on isolation protocol. Still gets drowsy, requires full oxygen support (no details provided) . [DATE], at 1:39 p.m. - Treatment Session Conclusion - Patient Status: Location - Transport: Left in room, call light within reach, bedside table within reach (Comment: catheter intact, 2L O2 via nasal cannula .) . Further review of CR #1's medical records revealed no other documentation of oxygen administration or physician's orders for oxygen therapy. Record review of CR #1's progress notes for [DATE] revealed: view draft (typed in red). Effective date: [DATE], 7:15 p.m. LVN A wrote, Note Text: 12:15 p.m.: [CR #1] was a new admit who arrived via EMS. He was accompanied by [several family members]. Resident was transferred by EMS from stretcher to bed by EMS x 2 assist. EMS woman giving report stated that resident was on isolation for C-diff and may also have COVID. Initial assessment O2 saturation at ,d+[DATE]% (according to medicinenet.com, sustained blood oxygen levels below ,d+[DATE]% can be life-threatening and may lead to death if not addressed promptly) room air, ,d+[DATE] [blood pressure], 73 [pulse]. Writer immediately directed to staff to bring a tank of oxygen and a concentrator to room. This nurse informed family that their loved one did not look too good, and that his O2 was a concern. Writer initiated O2 on 5L and decreased. Resident O2 saturation was accomplished with a reading of ,d+[DATE]% on 3L. Resident became more aroused and verbal. He communicated with writer and said that he [would] like to be addressed by his first name. Throughout assessment, EMS had already left the building. They did not ensure that resident was connected to oxygen prior to leaving. During assessment, family remained at bedside and answered questions from this nurse . Resident was provided lunch, writer noted that resident had only eaten approximately 50%. Family member stated that CR #1 did not eat much. Last time writer saw CR #1 prior to him coding, was roughly ,d+[DATE] hours earlier at approximately ,d+[DATE] p.m. Resident was quietly watching television and did not appear to be in any distress. Bed semi-Fowler (a medical position where a patient lies on their back with their head and upper body raised at a ,d+[DATE]-degree angle on the bed). Breathing non-labored. Therapist notified this nurse that resident [was] non-responsive. Nurse immediately called a code blue before getting in room. Upon arrival in room, nurse noted resident non-responsive and initiated CPR. Two nurses and several staff in room and assisted nurse with CPR and AED. 911 notified. CPR continued until 911 arrived and took over. Family members arrived five minutes behind. Resident pronounced (CR #1's death was announced) at 7:35 p.m. In an interview with the DON on [DATE], at 9:45 a.m., she stated CR #1 was admitted to the facility on Sunday, [DATE] around 12:00 p.m. then coded and passed away around 6:00 p.m. that same day. She said, according to LVN A, CR #1 did not look well, and his oxygen saturation was in the lower 70's when EMS transferred him from the gurney (stretcher) to the bed. She said to her knowledge, EMS brought CR #1 into the facility on oxygen but did not connect him to oxygen when they transferred him to the bed in his room. She said LVN A said EMS left before CR #1 was stable, but LVN A got him up to 95% oxygen saturation and he became more alert and ate lunch. She said LVN A contacted CR #1's doctor because she verified his medications. She said as far as she knew, LVN A notified CR #1's doctor when he was in distress. She said it was the facility's protocol to notify a resident's doctor when they experienced a change of condition. She stated LVN A did not call her when CR #1 had low oxygen saturation when he was initially admitted . She said LVN A told her about the incident later that evening when CR #1 coded (experienced cardiac arrest). The DON stated she had the facility's on-call phone and LVN A did not call to notify of CR #1's change of condition. She stated LVN A should have followed protocol and notified her, as the DON when CR #1 had a change of condition. In a telephone interview with LVN A on [DATE], at 11:17 a.m., she stated on [DATE], EMS brought CR #1 to the facility between 12:15 p.m. and 12:30 p.m. without oxygen. She stated EMS was not very good because they left before making sure CR #1 was connected to oxygen. She said if she did not go into CR #1's room when she did, he would have died at that time because he was already in respiratory distress when she first observed him. She stated CR #1 arrived with his family and she told his family he did not look good. She said he asked CR #1's family to raise the head of the bed and she yelled for staff to bring an oxygen concentrator and oxygen tank because his oxygen saturation was assessed at 73%. She stated she immediately started CR #1 on 5L of oxygen until his oxygen saturation went up to ,d+[DATE]%. She said she then lowered the oxygen level to 3L. She said according to CR #1's family member, he was supposed to be on 2.5L of oxygen. She said after his oxygen saturation increased to ,d+[DATE]%, CR #1 started talking and ate lunch around 1:00 p.m. She said after CR #1 was stable, she reconciled his medications (the process of comparing a patient's medication orders to all the medications that the patient has been taking) with his physician. She stated she mentioned to CR #1's physician that his oxygen saturation was a bit low because he was not on oxygen when he admitted . She said she told CR #1's physician she placed him on oxygen, and he was stable after administering 5L. She said she told the physician she lowered the oxygen to 3L after CR #1's saturation level was above 90%. She said if she was not able to get CR #1's oxygen saturation back up, she would have called 911. She said the next time she saw CR #1 was around dinnertime (4:00 p.m. - 5:00 p.m.) when she saw him through the doorway as she passed his room in the hallway. She said CR #1 did not appear to be in distress at that time. She said around 5:00 p.m. - 6:00 p.m., a therapist (OT) was on the hall checking on new residents and the OT asked a CNA (she did not recall the name of the CNA) for a nurse. She said the CNA came up to her looking anxious and said CR #1 was unresponsive. LVN A said the OT said CR #1 did not look good and he was unresponsive, so she screamed for a code blue and requested a crash cart. She said she also yelled for someone to call 911. She said they initiated CPR until EMS arrived and took over, but CR #1 did not make it. She stated she was not able to keep up with CR #1 or get more familiar with him because she was so busy doing her other nursing duties on [DATE]. She stated the facility did not have any protocols or action plan regarding frequent monitoring of residents who experienced a change of condition. She said maybe she should have checked on CR #1 every 30 minutes, but their protocol was to round every two hours. She stated she resigned the night of [DATE] and did not return to the facility because CR #1 should not have died and she thought there should have been more nurses assigned to her unit. In an interview with CNA C on [DATE], at 12:45 p.m., he stated he worked the 6:00 a.m. - 2:00 p.m. shift on [DATE] and he worked with LVN A when CR #1 was admitted to the facility that day. He said CR #1 was brought into the facility by EMS on a stretcher without oxygen. He said EMS brought in paperwork and LVN A started working with CR #1. He said CR #1 was breathing heavily when EMS brought him into the building. He said he did not recall hearing CR #1 talk. He said he did not recall CR #1's family members saying he needed oxygen, but LVN A put oxygen on him quickly. He said he did not know what happened after LVN A placed CR #1 on oxygen because it was close to the end of his shift. He said he did not see CR #1 again after he initially assisted with getting him into his room. In an interview with LVN D on [DATE], at 1:30 p.m., he stated if a resident was admitted in respiratory distress, the nursing protocol would be to send them back to the hospital. He said if they had to keep the resident, nurses should stabilize the resident with oxygen. He stated the nurse should call the resident's doctor for orders and let the DON and ADON know so they could tell them how to proceed. In an interview with the ADON on [DATE], at 2:15 p.m., she stated after LVN A stabilized CR #1 with oxygen on [DATE], she should have notified his physician of what happened and monitored him closely (checked on him more frequently). She stated she did not recall LVN A saying she notified CR #1's physician about his condition when he admitted to the facility and she did not think LVN A reported the incident to the proper chain of command (DON, ADON, and Administrator). She said as the ADON, she was not notified of the first distress incident until after CR #1 coded, which was not the proper chain of command. She stated she was scheduled to work from 8:40 p.m. that night ([DATE]) to 7:40 a.m. Monday ([DATE]), but she received a call from CNA E at 7:30 p.m. and heard the commotion in the background when CR #1 coded, so she rushed to the facility. She stated CR #1 had already been pronounced deceased by the time she arrived at 8:45 p.m. In an interview with the OT on [DATE], at 2:46 p.m., she stated she worked at the facility on [DATE]. She said she did occupational therapy evaluations that day because the regular occupational therapist was unavailable. She said CR #1 was the last evaluation of the day since he was on isolation for COVID and C-diff. She said when she entered CR #1's room around 7:00 p.m. on [DATE], he looked like he was asleep. She said his arm was hanging off the bed, so she went to reposition him and wake him up. She said when CR #1 did not wake up, she did a sternal rub (a painful stimulus used by EMS to assess a patient's neurological status and brain function) and noted he was unresponsive. She said she saw a CNA (she did not say the name of the CNA) and told her to get a nurse because CR #1 was unresponsive. She stated she could hear CR #1's concentrator running when she was inside of CR #1's room. In a follow-up telephone interview with the OT on [DATE], at 8:19 a.m., she stated when she entered CR #1's room on [DATE], around 7:00 p.m., she observed that CR #1's nasal cannula was not in his nose. She said although she heard the oxygen concentrator running when she was inside the room, she did not see that nasal cannula anywhere. She stated she when she tried to reposition CR #1's head and performed the sternal rub, she did not see the nasal cannula. In a telephone interview with CR #1's physician on [DATE], at 3:10 p.m., he stated on [DATE], LVN A sent him a text with CR #1's medication list and diagnoses. He said LVN A indicated CR #1 was a transfer from a rehabilitation hospital and asked him to review his medications. He said he texted LVN A back that they would continue with the medication list received from the previous facility and he would visit the resident on Monday, [DATE]. He said that text conversation was earlier in the day on [DATE] and he did not hear anything else about CR #1 until later that night when LVN A called him after CR #1 died . He said at that time (during the phone conversation on the night of [DATE]), LVN A told him CR #1 had been unstable and in respiratory distress earlier in the day. He said he asked LVN A why she called him at 9:00 p.m. when everything was done instead of calling him earlier when CR #1 was unstable. He said LVN A told him she did not call earlier because CR #1 was more stable after she administered oxygen. He said LVN A never called him earlier on [DATE] to inform him that CR #1 was in respiratory distress, and she did not say he had an oxygen saturation of 73%, or that he required oxygen administration. He said if LVN A would have called him earlier when CR #1 was in distress, he would have asked her to repeat the oxygen assessment because sometimes, the measurements were not accurate. He said CR #1's oxygen saturation was too low but sending him to the hospital immediately would have depended on her ability to stabilize him with oxygen. He said LVN A told him she gave CR #1 2L or 5L of oxygen, then his saturation went up to ,d+[DATE]%. He said he would have told LVN A to monitor CR #1 closely (checked on him frequently) throughout her shift and if he became unstable, at any time, send him to the ER. He said the staff would have needed to monitor CR #1 often enough to make sure he did not crash (deteriorate quickly) and to ensure they could send him to the ER as soon as possible if he became unstable again. He said LVN A knew how to contact him. He said the facility's nurses were usually very good about calling him for guidance when they were concerned about a resident's condition. He said he expected the nurses to call him when his patients experienced a change of condition. In a telephone interview with CNA B on [DATE], at 11:20 a.m., she stated she worked the 2:00 p.m. - 10:00 p.m. shift on Sunday, [DATE]. She stated when she arrived for her shift around 2:00 p.m. - 2:15 p.m., LVN A told her CR #1 was just admitted and that he was not feeling well. She said LVN A told her CR #1 was admitted with a low oxygen saturation. She said after that, she introduced herself to CR #1. She said at that time, CR #1 had on a nasal cannula with oxygen running and he was fine. She said she checked on CR #1 again at 3:00 p.m. and he was asleep, breathing heavily, shaking, and talking in his sleep, like he was having a bad dream. She said she woke CR #1 up and asked him if he had a bad dream and he said he was ok. She said she dropped off CR #1's dinner tray around 4:00 p.m. She said CR #1's breathing was fine at first, but after a few minutes, he started breathing heavily, like how it would sound if someone went up a flight of stairs. She said she picked up CR #1's dinner tray between 5:00 p.m. and 5:25 p.m. and emptied his catheter bag. She said his nasal cannula was off his nose and he was breathing heavily, so she replaced the nasal cannula, and his breathing was fine after a minute. She said she never notified LVN A or any other nurse when she observed CR #1 breathing abnormally or when she found his nasal cannula out of place because LVN A already knew he was having trouble breathing. CNA B said LVN A told her he was having trouble when she initially reported to her shift. In a follow-up telephone interview with LVN A on [DATE], at 11:37 a.m., she stated it took about ten minutes for CR #1's oxygen saturation to go from 73% to 93% once she placed him on 5L of oxygen. She said once CR #1 was stable, she sent CR #1's doctor a text about his medications. She stated she did not mention CR #1's respiratory distress to the doctor because he was stable at that time, and she continued to administer 3L of oxygen. She said she did not see any notes in the computer system about CR #1 requiring oxygen therapy. She said CNA B never told her she observed CR #1 breathing heavily or that his nasal cannula fell off throughout the day. She said that information was big, and she would not have ignored it. She said had CNA B told her that information, she would have assessed him immediately. In an interview with the DON and Administrator on [DATE], at 12:39 p.m., the Administrator stated he did not think CR #1 was in distress when he arrived at the facility on [DATE] because LVN A usually contacted the DON and physicians with any concern she had about residents. The DON stated LVN A was disgruntled, and she thought LVN A lied about assessing CR #1's oxygen saturation at 73%. The Administrator said he did not think the incident was a system failure and LVN A was just having a bad day. The DON said LVN A did not document the progress note in real time. The DON said after CR #1 died , LVN A said she was quitting and the ADON told her to document before she left. The DON said LVN A documented the progress not around 9:00 p.m. and she doubted CR #1's oxygen saturation was that low. Record review of the facility's policy titled Change in a Resident's Condition or Status revised February 2021 revealed, Policy Statement. Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation. 1. The nurse will notify the resident's attending physician or physician on-call when there has been a(an): a. accident or incident involving the resident; . d. significant change in the resident's physical/emotional/mental condition; . need to alter the resident's medical treatment significantly; . 2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Record review of the facility's document titled Job Description: Charge Nurse dated [DATE] and signed by LVN A on [DATE] revealed, . Essential Duties: Make rounds and provide report . Respond to and monitor care issues and changes in condition . Communicate with physicians and other health professionals regarding resident care, treatment, and condition . Report significant findings or changes in condition and potential concerns to the Director of Nursing . Record review of the facility's document titled, Care Path - Symptoms of Shortness of Breath dated 2014 revealed the box which read, Symptoms of Shortness of Breath: Difficult or labored breathing that is out of proportion to the resident's level of physical activity; New complaint of SOB had an arrow which pointed to the box which read, Take Vital Signs: . Oxygen saturation . The next box reflected, Vital Sign Criteria (any met?): . Oxygen saturation less than 90%, and had an arrow which pointed to Yes; Notify MD/NP/PA. An IJ was identified on [DATE]. The IJ template was provided to the DON on [DATE] at 10:30 a.m. and a POR was requested. The following Plan of Removal submitted by the facility was accepted on [DATE] at 11:50 a.m.: PLAN OF REMOVAL Name of Facility Date:___[DATE]____________________________ Date of compliance: [DATE] F580 Immediate action: * Resident CR#1 is no longer at the facility. * LVN A resigned and is no longer employed as of [DATE]. * Nurse Management Came in on [DATE] at 7p.m., to Assist Nurse and Monitor All Residents for Change in Condition and assist in Admission. * DON and ADON performed health checks on all Resident for Potential harm on [DATE]. Including but not limited to, pain, respiratory issues, general appearance, grievances and overall wellness- no harm found. If any Change in Condition noted would report to MD and Administrator. None noted. * DON and designee in-service nurses on [DATE] to [DATE] regarding Admissions, Readmission assessments and follow up, notifying the physician. * DON and/or Designee Inservice Nurses on [DATE] to [DATE] on doing Resident Assessment during admission and notifying MD of arrival and resident baseline. * DON and/or Designee will in-service all nurses on [DATE] to [DATE] on communicating with MD and nurse management changes of condition. Facility's Plan to ensure compliance quickly. * The Medical Director will review and update if needed the Notification Manual and standing orders. By [DATE] * DON and/or designee will in-service nurses on Notification Manual and Provider Standing Orders at each nurse station by [DATE]. * DON and/or designee in-service nurses on notifying MD on change in condition and if O2 saturation is below 90%. By [DATE] * DON and/or designee will review Changes of condition during the weekday clinical meeting to ensure MD was notified x 4 weeks. * DON, and/or ADON/weekend supervisor will perform daily rounds on residents with changes of condition x 72 hrs and notify MD if needed for 4 weeks. * If/when discrepancies are identified, they will be corrected immediately. * Findings and trends will be reported to QAPI Committee monthly. * All nursing Staff notified that they will not work a shift until training is completed. Monitoring of the plan of removal included the following: Record review of an In-Service Training Report dated [DATE] revealed all nursing staff (nurses, CNA's and medication aides) were educated by the DON regarding making frequent rounds of all residents, especially on new admissions and residents with a change of condition. Record review of an In-Service Training Report dated [DATE] revealed all nursing staff were educated by the DON regarding notification to the DON, ADON, RN Supervisor, or the Administrator if they were not able to make frequent rounds on their assigned residents. The staff were also educated on the use of MD/NP notification manuals and location of the manual. Record review of an In-Service Training Report dated [DATE] revealed all nursing staff were educated by the DON regarding notifying physicians and nurse practitioners of clinical issues. The document reflected in part, Notify MD/NP of baseline vs upon admission of any concerns. Notify MD/NP of any SPO2 less than 90% and document any new orders and interventions. Monitor any residents closely exhibiting signs and symptoms of respiratory distress. Notify MD/NP and send to ER if ordered/indicated. Record review of an In-Service Training Report dated [DATE] revealed the Weekend Supervisor was educated by the DON regarding performance of daily rounds, ensuring nursing staff is also making frequent rounds, and conducting assessments on new admissions and any resident with a change in condition for 72 hours. Record review of the In-Service Training Report dated [DATE] revealed all nursing staff were educated by the DON regarding admission/re-admission assessments, follow-ups and notifications to the MD/NP and administrator, assessments of residents upon arrival to the facility and notifying the MD/NP of any concerns immediately and notifying MD/NP and nurse management of any changes in condition. The nurses were advised not to accept new admissions unless they were medically stable. Record review of a facility document titled In-Service Topic dated [DATE] revealed all therapy staff (physical therapy/occupational therapy/speech therapy) were educated by the SLP regarding steps to take when a change of condition is observed and the importance of documentation. Record review of a facility document titled Compliance Documents dated [DATE] revealed the Medical Director reviewed and agreed with the facility's current standing physician's orders and care paths. Record Review of the facility's policy titled Guidelines for Notifying Physicians of Clinical Problems revised February 2014 revealed, Overview. These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record . The charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management . Immediate Notification (Acute) Problems. The following symptoms, signs, and laboratory values (which are not inclusive) should be prompt immediate notification of the physician, after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone, pager, text message, or other means. These situations include: 1. Witnessed cardiac or respiratory arrest for individuals who have full code status. 2. Rapid decline or continued instability (for example, markedly fluctuating vital signs), unless the individual is receiving only palliative care. 3. The following symptoms: a. Sudden in onset or marked change compared to usual (baseline) status; and are b. Unrelieved by measures which have already been prescribed. 4. The following signs: . h. Tachypnea (rapid and shallow breathing) and dyspnea (shortness of breath) with a pulse oximetry below 90% . Observation of two nurse's station on [DATE] at 12:20 p.m. revealed each had a Notification Manual which contained each physician's contact information and a Provider's Standing Orders Manual which contained each physician's standing orders. Interviews were conducted on [DATE] from 11:30 a.m. until 4:20 p.m. with staff on all shifts (6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. - 6:00 a.m.) including the Administrator, DON, MDS Coordinator, LVN M (Saturdays and Sundays morning and afternoon shifts), CNA AA (morning shift), LVN H (morning shift), CNA I (morning shift), CNA J (evening shift), CNA K (evening shift), LVN L (evening shift), Med Aide M (evening shift), LVN N (evening shift), LVN O (night shift), LVN P (night shift), CNA Q (night shift), and CNA R (night shift) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. The Administrator, DON, MDS Coordinator, LVN M, CNA AA, LVN H, CNA I, CNA J, CNA K, LVN L, Med Aide M, LVN N, LVN O, LVN P, CNA Q, and CNA R were able to explain the admission/readmission process related to initial assessments and communication/notifying nurse management and the physician of the resident's initial baseline and any changes of condition, the importance and location of the Notification Manual (the manual which contains each physician's contact information located at each nurse's station), the importance and location of each physician's standing orders manual (the manual which contains each physician's standing orders [written protocols that outline the circumstances in which certain members of the healthcare team can perform clinical tasks without a physician's order] located at each nurse's station), notifying physician if a resident's oxygen saturation is below 90%, oxygen administration and frequent [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that residents received the necessary treatment and services, to promote healing and prevent infection for 1 of 5 residents (Resident #2) reviewed for pressure ulcers in that: -Resident #2's posterior right knee Stage 3 and Sacrococcyx stage 4 dressings were not changed as per physician's orders on 8/17/24. -The Wound Care Nurse failed to transcribe the wound care doctor's order dated 8/13/24 for Resident #2. These failures could place residents with wounds or who are at risk of developing wounds placing them at risk of infection, a decline in health, pain, and hospitalization . Findings included: Record review of the admission sheet (undated) for Resident #2 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included sepsis (a life-threatening complication of an infection), pressure ulcer of sacral region, stage 4 (skin injuries that occur in the sacral region of the body, near the lower back and spine) and chronic kidney disease, stage 4 (longstanding disease of the kidneys leading to renal failure). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS of 14 out of 15 indicating intact cognition. He was dependent on staff for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. Further review of section M0300 revealed Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Number of Stage 3 pressure ulcers was coded 2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry was coded 2. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers was coded 2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry was coded 2. Record review of Resident #2's Care plan initiated 01/22/2024 and revised on 8/13/24 revealed the following care plan: Focus: [Resident#2] admitted to facility with multiple pressure ulcer injuries Sacrum-Stage IV Lt Flank -Stage IV -resolved Lower Mid-back-Unstageable Lt lateral leg-Stage IV resolved 7/30/24 Lt Plantar Heel- DTI resolved Rt plantar heel-DTI resolved 8/13/24 Goal: [Resident#2] Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions/Tasks: Monitor dressing to ensure it is intact and adhering. Report lose dressing to Treatment nurse. Record review of Resident#2's Surgical Note dated 08/13/24 revealed in part: . Reason for visit: To evaluate this patient for wounds located on the Sacro coccyx, right posterior knee, and right posterior heel. Change in patient health: No change since last visit. Location: Sacro coccyx. Etiology: Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. Dressing used: Betadine, Collagen and Dry dressing. Wound location: Right Posterior Knee. Etiology: Pressure injury/ulcer - Wound Stage: 3 - Pressure Injury. Dressing used: Betadine, Dry Dressing and Silvasorb gel . Record review of Resident #2's physician's order dated 06/21/2024 revealed an order for Wound Care: Posterior R Knee Pressure 3: Cleanse with ns/wc, pat dry, betadine periwound, collagen and hydro gel and cover with bordered gauze change every other day and prn. Record review of Resident #2's physician's order dated 06/21/2024 revealed an order Wound Care: Sacro Coccyx Pressure 4: cleanse with wc/ns, pat dry, apply betadine to periwound, hydrogel to wound bed, collagen particles, cover with dry dressing change every other day and prn. Observation on 08/17/2024 at 11:16a.m., revealed LVN Z providing wound care for Resident #2. LVN Z was assisted by CNA AA. LVN Z gathered the supplies at the treatment cart in the hallway before bringing them into Resident #2's room. Prior to initiation of the treatment, Resident #2 was assisted on to his left side. There was no dressing on the posterior right knee. Continued observation revealed an open area of approximately 0.4 centimeters in diameter. LVN A cleansed it with normal saline, removed his soiled gloves, and without sanitizing/washing his hands donned clean gloves. LVN Z patted dry the wound with dry gauze and applied betadine, collagen powder (not ordered) and hydro gel (not ordered) and covered the wound with a dry border dressing. LVN Z failed to apply Silvasorb gel as ordered by the physician. LVN Z removed the resident's soiled Sacro coccyx wound dressing dated 8/16/24 and placed it in the biohazard bag taped on the bedside table. Continued observation revealed an open area of approximately 6.0 centimeters in diameter. LVN Z cleansed the wound with normal saline x5. LVN Z said, The wound is bleeding. I am trying to apply pressure. LVN Z removed his soiled gloves, and without sanitizing/washing his hands donned clean gloves. LVN Z patted dry the wound with dry gauze and applied hydrogel (not ordered). LVN Z said, I need to get more gloves and removed his soiled gloves and left the room. LVN Z returned within few seconds and without sanitizing/washing his hands donned clean gloves. LVN Z applied collagen particles to the wound bed and covered it with a dry border dressing. LVN Z failed to use betadine as ordered by the physician. LVN Z left the room without washing/sanitizing his hands. In an interview and record review on 08/17/24 at 11:42 a.m., the Surveyor reviewed Resident #2's physician orders with LVN Z. LVN Z said he started working in April 2024 as PRN at the facility on weekends. He said usually the Weekend Supervisor preformed wound care on the weekends. He said on the schedule he was assigned to work on the floor but was pulled to do wound care today (8/17/24). He said he did not receive training/competency check off on wound care at this facility at the time of hire. He said he could not recall receiving infection control and hand hygiene in-service at this facility. LVA Z said not performing hand hygiene while changing gloves could result in cross contamination. He said he did not have access to the wound care doctor's evaluations. He said he was following the wound care orders in the TAR. He said it was important to follow wound care doctor order for wound healing. In an interview on 08/17/24 at 11:54 p.m., with LVN N, she said she was assigned to work west hall which was long term. She said nobody had informed her that Resident #2's dressing was missing/dislodged. She said she did not have access to the WCD's evaluation. She said nurses followed treatment orders on the TAR. In an interview on 08/17/24 at 12:01 p.m., with the Weekend Supervisor, she said she started 3 weeks ago at this facility and was on orientation. She said the nurse who had the patient on the floor was responsible to do the treatments. She said, I have never been asked to do the wound care. I am not trained to do the wound care. In an interview on 08/17/24 at 12:12p.m. with the ADON, the Surveyor shared the wound care observation from earlier. The ADON said the WCN worked Monday through Friday and on the weekends LVN Z or LVN M performed the treatments. She said LVN Z followed the agency RN upon hire and was acquainted with facility/wound care. ADON said she could not recall the exact number of days he received orientation. ADON said, I am not specialized or certified in wound care, but [LVN Z] should have followed physician orders [the] WCD ordered betadine for a reason. ADON said CNAs should notify somebody either the floor nurse or WCN if they see a wound dressing missing. ADON said the floor nurse could apply the dressing by following the physician's orders in PCC (electronic medical records)., it's in their scope of practice to follow orders. ADON said the WCD rounded every Tuesday and the WCN had access to the WCD's notes. ADON said the WCN was responsible to review the WCD's wound evaluation/orders and transcribe them in PCC . In an interview and record review on 8/17/24 at 12:09p.m. with the Administrator, he said upon hire nurses received a Facility Assessment: Skin and Wound Care Readiness checklist and watched videos on wound care. He said he expected nurses to follow physician's orders. He said the risk of not following orders would be that the wounds could get worse. He said he did not have access to the WCD's recent notes/portal. He said he looked in PCC and could find WCD's notes dated 7/16/24. He said the WCN was out of state and was unable to access the WCD's portal. He said he had contacted the WCD to get his recent notes/orders from 8/13/24. Attempted telephone interview on 08/17/24 at 12:38p.m., with the Wound Care Nurse was unsuccessful. Attempted telephone interview on 08/17/24 at 1:22p.m., with the Wound Care Doctor was unsuccessful. In an interview on 08/17/24 1:42p.m., with CNA AA, she said she changed Resident#2 twice this morning, honestly I don't remember seeing if there was a dressing on his knee. In an interview on 08/17/24 1:52p.m., with LVN M, she said floor nurses were responsible to do their own treatments on the weekend if no one was assigned to do wound care on the schedule. She said she did not have access to the WCD's evaluation. She said nurses followed treatment orders on the TAR. Record review of Facility Assessment: Skin and Wound Care Readiness revealed in part: .The purpose of this assessment is to evaluate the necessary and available resources to provide wound care services to the residents in your facility. 3. Education/Training/Competencies: Wound Care Nurses: Wound care/Dressing/infection control, skin Assessments . Record review of facility's Wound Care (Revision date October 2010) revealed in part: .Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: l. Verify that there is a physician's order for this procedure. Steps in the Procedure: 4. Put on exam glove. Loosen tape and remove dressing. 5.Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 4 residents (Resident #2) reviewed for infection. -The facility failed to ensure LVN Z performed hand hygiene during wound care on Resident #2. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. Findings included: Record review of the admission sheet (undated) for Resident #2 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included sepsis (a life-threatening complication of an infection), pressure ulcer of sacral region, stage 4 (skin injuries that occur in the sacral region of the body, near the lower back and spine) and chronic kidney disease, stage 4 (longstanding disease of the kidneys leading to renal failure). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS of 14 out of 15 indicating intact cognition. He was dependent on staff for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. Further review of section M0300 revealed Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Number of Stage 3 pressure ulcers was coded 2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry was coded 2. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers was coded 2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry was coded 2. Record review of Resident #2's Care plan initiated 01/22/2024 and revised on 8/13/24 revealed the following care plan: Focus: [Resident#2] admitted to facility with multiple pressure ulcer injuries Sacrum-Stage IV Lt Flank -Stage IV -resolved Lower Mid-back-Unstageable Lt lateral leg-Stage IV resolved 7/30/24 Lt Plantar Heel- DTI resolved Rt plantar heel-DTI resolved 8/13/24 Goal: [Resident#2] Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions/Tasks: Monitor dressing to ensure it is intact and adhering. Report lose dressing to Treatment nurse. Record review of Resident #2's physician's order dated 06/21/2024 revealed an order for Wound Care: Posterior R Knee Pressure 3: Cleanse with ns/wc, pat dry, betadine periwound, collagen and hydro gel and cover with bordered gauze change every other day and prn. Record review of Resident #2's physician's order dated 06/21/2024 revealed an order Wound Care: Sacro Coccyx Pressure 4: cleanse with wc/ns, pat dry, apply betadine to periwound, hydrogel to wound bed, collagen particles, cover with dry dressing change every other day and prn. Observation on 08/17/2024 at 11:16a.m., revealed LVN Z providing wound care for Resident #2. LVN Z was assisted by CNA A. LVN Z gathered the supplies at the treatment cart in the hallway before bringing them into Resident #2's room. Prior to initiation of the treatment, Resident #2 was assisted on to his left side. There was no dressing on posterior right knee. Continued observation revealed an open area of approximately 0.4 centimeters in diameter. LVN A cleanse with normal saline, removed soiled gloves without sanitizing/washing his hands donned clean gloves, pat dry the wound with dry gauze. Applied betadine, collagen powder (not ordered) and hydro gel (not ordered) and covered it with dry border dressing. LVN Z failed to apply Silvasorb gel as ordered by the physician. LVN Z removed the resident's soiled Sacro coccyx wound dressing dated 8/16/24 and placed in the biohazard bag taped on the bedside table. Continued observation revealed an open area of approximately 6.0 centimeters in diameter. LVN Z cleansed the wound with normal saline x5. LVN Z said, the wound is bleeding. I am trying to apply pressure. LVN Z removed soiled gloves without sanitizing/washing his hands donned clean gloves, pat dry the wound with dry gauze. Applied hydrogel (not ordered). LVN Z said, I need to get more gloves removed soiled gloves and left the room. Returned in few seconds without sanitizing/washing his hands donned clean gloves, applied collagen particles to the wound bed and covered it with dry border dressing. LVN Z failed to use betadine as ordered by the physician. LVN Z left the room without washing/sanitizing his hands. In an interview and record review on 8/17/24 at 11:42 a.m., Surveyor reviewed Resident#2's physician orders with LVN Z. LVN Z said he started working in April 2024 as PRN at this facility on weekends. He said usually the Weekend Supervisor preformed wound care on the weekends. He said on the schedule he was assigned to work on the floor but was pulled to do wound care today (8/17/24). He said he did not receive training/competency check off on wound care at this facility at the time of hire. He said he could not recall receiving infection control and hand hygiene in service at this facility. LVA Z said not performing hand hygiene while changing gloves could result in cross contamination. In an interview on 8/17/24 at 12:12p.m. with the ADON, the Surveyor shared the wound care observation from earlier. The ADON said she was a certified infection preventionist. She said she in-serviced staff twice a month on infection control. She said LVN Z told her that, it slipped my mind to sanitize. The ADON said she expected staff to follow standard infection control techniques during the provision of wound care treatments. She said the staff were expected to move from the cleaner area of the wound to the possibly soiled or contaminated area of the body. ADON said LVN Z should have changed his gloves and performed hand hygiene moving from dirty to clean as it placed risk for infections. She said she would need to do counseling with him. Record review of facility's In-Service Training Report dated 8/8/24 conducted by ADON revealed in part: . Department(s): NSG, Employee group(s) present: NSG. Topic/Title: Hand Hygiene/infection control. Contents or summary of training session (if related to OSHA standard bloodborne pathogens training indicate See Below and use that convenient check-off list): Staff will know when hygiene is indicated and be able to demonstrate procedure per guidelines. The in-service was not signed by LVN Z. Record review of facility's Hand Washing/Hand Hygiene policy (Revised October 2023) revealed in part: .Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation Administrative Practices to Promote Hand Hygiene 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene g. immediately after glove removal . Record review of facility's Policies and Practices - Infection Control (Revised October 2018) revealed in part: .Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .

Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 (CR #1) of 5 residents reviewed for accident hazards. -The facility failed to securely strap CR #1's air mattress to the bed frame, causing the mattress with the resident to fall off the bedframe to the floor and CR #1 was sent to the hospital for evaluation. This failure could place residents at risk of falls, injuries, and hospitalization . Findings include: Record review of CR #1's undated face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE], with an original admitted [DATE]. He had diagnoses of unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), TIA (mini strokes), reduced mobility, lack of coordination, type 2 diabetes (body does not produce insulin or resists it), muscle wasting and atrophy, muscle weakness, cognitive communication deficit (does not recognize everyday social cues, both verbal and non-verbal), and seizures. Record review of CR #1's Quarterly MDS assessment dated [DATE], revealed a BIMS could not be performed due to his medical condition. His cognitive skills for daily decision making were severely impaired. The resident was dependent on all ADLs. He was also dependent with all mobility. The resident had not had any previous falls. CR #1 was on a feeding tube for nutrition due to trouble swallowing. He also had 2 Stage 3 pressure ulcers (sores through the first layer of skin where fat may be visible, but bone, tendon or muscle is not exposed) and 1 Stage 4 pressure ulcer (sore extends through all layers of skin where there is exposed bone, tendon, or muscle). CR #1 was receiving pressure ulcer/injury care and had a pressure reducing device for the bed. The resident was on an anticoagulant. Record review of CR #1's Care Plan dated 4/3/24, had a Focus: Resident is at risk for falls with or without injury related to altered mental status, history of falls (initiated: 4/3/24). Goal: Will not experience a fall related to risk factors (initiated: 4/3/24, target: 7/2/24). Will not have any major injuries related to fall (initiated: 4/3/24, target: 7/2/24). Interventions: Keep personal items frequently used within reach. Keep within supervised view as much as possible. Record review of CR #1's medical record revealed a Physician Progress Note from 4/17/24 at 7:12 pm by MD A that said he had not had any falls and the resident was contracted, had limited ability to turn, and would not follow commands and was nonverbal. Record review of CR #1's medical record revealed a Fall Risk Observation/Assessment from 4/19/24 at 8:00 am by LVN A, that revealed the resident was a low risk for falls. Record review of CR #1's medical record revealed a nurse's note from LVN A on 4/19/24 at 8:51am that read, This nurse heard beeping coming from resident's room and went to check Enteral Feeding Machine [nutrition going into stomach by machine]. Upon entering room this nurse noticed that Air Mattress was on the Right side of the bed, unsecured to frame and resident was on the floor wrapped in his sheets and blankets. Resident was awake and alert, lowly moaning. Resident was laying on his Right side facing the bed w/ his right arm extended awkwardly out behind him. This nurse replaced mattress back on bed .Resident did display facial and verbal signs of pain when moved .resident is contracted in BUE and BLE .Sending resident to [hospital] ER for eval/treat as indicated to R/O head trauma. Record review of CR #1's medical record revealed an SBAR from LVN A on 4/19/24 at 9:13am that read, The Change in Condition/s reported on this CIC Evaluation are/were: Falls .Blood Pressure: 114/74 Lying L arm, Pulse: 112, RR: 18, Temp: 98.6 Forehead, Weight: 122.4lb Hoyer, Pulse Oximetry: 97% Room Air .Nursing observations, evaluation, and recommendations are: it appears that resident fell out of bed d/t air mattress not being secured to bed frame. Record review of CR #1's hospital records from 4/19/24 at 5:08pm read .Pt fell at SNF and was taken to the ER today. At baseline pt is AOx1 and bedbound The hospital records did not indicate there were any injuries from the fall. Interview with the family on 4/20/24 at 2:45pm, she said CR #1 was sent to the hospital after falling out of bed. She said the hospital staff asked her how CR #1 fell out of bed since he was contracted and could not move. She was unsure how the fall happened, but knew the staff had to turn him because he could not turn himself. Interview with LVN A on 7/2/24 at 12:05pm, he said he was the nurse who found CR #1 on the floor on 4/19/24. He said he heard beeping coming from the room and knew it was the PEG tube beeping. He said he found the resident wrapped up in sheets on the floor and the air mattress standing up on the side of the bed. He said Maintenance was responsible for putting the air mattresses on the beds and securing them. He said if he was in the room when Maintenance was applying one, he would double check to make sure it was secured, but typically he assumed it was if it was already there. He said when he found CR #1 on the floor, the mattress was not secured to the bed like it was supposed to be and he felt bad for the resident. Interview with the DON on 7/2/24 at 12:19pm, she said Maintenance puts the air mattresses on the beds and ensured they were strapped on and secured. She said the nurses only ensured they were plugged in and aired up. The DON said after CR #1 fell and they realized the air mattress was not secured to the bed, they performed a facility wide air mattress sweep and no other air mattresses were found unsecured. The DON also said she performed in-service training on abuse, neglect, fall reporting, and resident monitoring with all the staff after the incident. She said leadership added inspection of air mattresses to their Ambassador Rounds, which happened every morning. The DON said Ambassador Rounds were when leadership would round on the residents every morning and ensured they had their needs met and did not have any grievances. She said the Maintenance Director at the time said he secured it, but apparently it was not. She said the Maintenance Director no longer worked at the facility. She also said CR #1 did not have an order for the air mattress, but they automatically put residents on them if they had a Stage II Pressure Ulcer or higher. Interview with the ADM on 7/2/24 at 2:19pm, he said his expectations were for the air mattresses to be maintained in a working order and applied safely to the beds. He said the Maintenance Director was ultimately responsible for putting the air mattress on the bed and for checking them routinely to ensure they were attached properly. He said the air mattresses were checked during room rounds now, so everyone ensured they were secured. The ADM said if the air mattress was not secured to the bed, when the resident's weight was shifted the resident could topple over and fall on the ground. Record review of the facility's air mattress bed sweep conducted on 4/28/24 by the previous Maintenance Director, revealed there were 5 other air mattresses in the facility with a note that said, All accounted for, no holes .witnessed [in] air mattresses-secured, no broken frames. Record review of the facility's current Room Check: Mattresses performed by the current Maintenance Director, for the month of June revealed, there were 5 rooms with air mattresses that were all checked on different days in June with no problems. Record review of the facility's In-Service Training Report conducted on 4/22/24 at 1pm by the DON revealed, it was conducted on notification of all falls, accidents, and hazards, checking on all residents frequently; especially high-risk residents, wounds, air mattress, fall mats .frequently for changes. Record review of the facility's policy and procedure on Assessing Falls and Their Causes (revised March 2018) read in part: The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .Falls are a leading cause of morbidity and mortality among the elderly in nursing homes .Falling may be related to underlying clinical or medical conditions .and/or environmental risk factors. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly .Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred .Within 24 hours of a fall, begin to try to identify possible of likely causes of the incident .Evaluate chains of events or circumstances preceding a recent fall .Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found . A policy on Accidents/Hazards and/or Air Mattresses was requested on 7/2/24 but the facility did not provide one.

47531 Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered careplan describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 14 residents, (Resident #10 and #53), in that: -Resident #10 was not care planned for nutritional deficits adequately, functional status, bladder and bowel status, heart related disease and respiratory failure. -Resident #53 was not care planned for foley catheter use and dialysis. These failures placed residents at risk of not receiving adequate medical care in a timely manner. Findings include: Resident #10 Record Review of Resident # 10's Face Sheet revealed a [AGE] year old female who had an initial admitted [DATE] and a readmitted [DATE] with diagnoses of Other mechanical complications of other electronic device (Complications from implanted cardiac device), subsequent encounter, Other specified pleural conditions (Punctured lung), encounter for surgical aftercare following surgery on the respiratory system (At facility for rehab after surgery), Acute respiratory failure with hypoxia (not enough oxygen), Unspecified severe protein-calorie malnutrition (Not enough dietary intake of protein), Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (Right sided weakness following stroke). Record Review of Resident #10's MDS (Minimum Data Set) dated 1/23/2024 revealed a BIMS score of 15 out of 15 indicating resident was cognitively intact. Resident was dependent on toileting, showering and bathing, lower body dressing, rolling to left and right, lying to sitting, sitting to lying, chair to bed transfers, toilet transfer, car transfer. Resident substantial maximum assist with walking 150 feet, oral hygiene, upper body dressing. Resident incontinent of bladder and frequently incontinent of bowel. Diagnoses: Anemia (Low blood count), Coronary Artery Disease (Disease of the hearts blood vessels), Hypertension (High blood pressure), Hyperlipidemia (High blood fats), Cerebrovascular Accident (Loss of blood to part of the brain) and Hemiplegia or Hemiparesis (Weakness on one side), Malnutrition (not eating enough), Respiratory failure (Difficulty breathing). Record Review of Resident #10's Care Plan dated 11/15/2023 last review date 12/11/2023 read in part . Advance Directive: Resident #10 has advance directive for full code status .Skin: Resident is at risk for skin breakdown related to Braden Risk Score revision on 11/15/2023 . Nutritional deficits, functional status, bladder and bowel status, heart related disease and respiratory failure were not addressed. Record Review of Resident #10's physician orders read in part . Admit for skilled services .1/18/2-24 .Med Pass 2.0 three times a day for nutrition supplement .1/29/2024 Regular diets, regular texture, thin liquids .1/18/2024 . Interview on 2/22/2024 at 2:45 pm with the DON (Director Of Nursing) she said the purpose of a care plan was to provide care for the patient. She said nurses used the care plan in conjunction with orders to provide care for the patient. She said the IDT (Interdisciplinary team) team was responsible for creating and updating the care plan by discussing and updating the care plan in the areas they specialized in. She said the IDT team consisted of the DON, ADON, MDS, Dietary, SW, Activities and Therapy. She said there were discussions from the care plan meetings and other meetings at the facility that went into creation of the care plan. She said if the care plan was not updated it could have impacted patient care. Interview on 2/22/2024 at 3:05pm with the ADON (Assistant Director of Nursing) she said if there were no care plan, or the care plan was not updated it could have impacted general care and there could have been potential mishaps with patient care. She said there could have been gray areas that could have impacted the quality of patient care. Resident #53 Record review of Resident #53's face sheet, dated 02/22/2024, revealed a [AGE] year-old male who was admitted into the facility on [DATE] and diagnosed with stage 4 pressure ulcer on left buttock, end stage renal disease, and personal history of malignant neoplasm of prostate. Record review of Resident #53's MDS, dated [DATE], revealed the resident was documented to have a BIMS score of 14, indicating his cognition was intact, and the resident was marked for having an indwelling catheter. Record review of Resident #53's physician's orders revealed the resident was ordered, since 01/24/2024, to receive foley catheter care, including changing out the foley catheter and foley bag monthly and as needed. The resident was also ordered to receive dialysis treatments three times a week starting 01/24/2024. Record review of Resident #53's care plan revealed resident's need for dialysis and the use of an indwelling foley catheter were not mentioned or documented. Interview with Resident #53 on 02/21/24 at 02:58 PM, he stated he has a foley catheter and last had his foley catheter changed out early in the morning by an LVN before his dialysis appointment . Interview with the Interim DON on 02/22/2024 at 4:07PM, she stated treatments, such as dialysis, and the use of an indwelling catheter needs to be care planned because it is a need that the resident has. She stated the care plan was used for nurses to references and get a picture of the resident. She stated the risk of not having complete comprehensive care plan was the provision of incomplete care to residents due to staff having limited information outside of orders. Record review of facilities policy titled, Care Plans, Comprehensive Person-Centered dated March 2022 read in part . A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the psychosocial and functional needs The comprehensive person-centered care plan should be developed within 7 days of the completion of the required MDS assessment and should be completed within 21 days of admission describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental and psychosocial wellbeing that the resident desires or that is possible .interventions should address the underlying sources of the problem.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for 3 ( rooms 143, 144 and 145) of 3 rooms reviewed for infection control, in that: The facility failed to: - ensure proper posted signage on 3 residents' doors (143, 144 and 145) that identified they were on transmission-based precautions (TBP). - ensure the doors closed to 3 residents' rooms that were COVID-19 positive. - ensure there was signage to indicate the COVID-19 Hall/Wing. - ensure staff donned and doffed PPE as trained when entering and exiting resident rooms. - ensure an infection control protocols were taken when a meal tray was taken from room [ROOM NUMBER] (COVID-19 positive room) These deficient practices placed residents at risk of transmission and/or spread of infection. Findings included: Interview on 12/16/2021 at 8:50 a.m. with Maintenance Director said the facility had 3 COVID-19 positive residents on the hot zone. Observation on 12/16/2021 at 8:57 a.m. revealed the hall (rooms 142-147 dedicated to COVID-19 positive residents) was not identified as a COVID-19 positive hall. Observations on 12/16/2021 at 8:59 a.m. of 3 rooms (143, 144 and 145) that were identified by LVN A that had COVID-19 positive residents in the rooms and did not have signage that identified transmission-based precaution. Observation on 12/16/2021 9:00 a.m. of 3 rooms (143, 144 and 145) did not have the doors closed to COVID-19 positive residents' rooms. Observation on 12/16/2021 9:03 a.m. of the East wing (101 - 133 rooms) had a sign that indicated the wing was a green zone. The West wing (134-166 rooms) had a sign that identified the wing as yellow zone. Rooms 142-147 did not have a sign. Interview on 12/16/2021 at 9:07 a.m. with OT A said rooms 143, 144 and 145 had a COVID-19 positive resident in each room. OT A said she was not aware why there was no signage to indicate transmission-based precautions on the door. OT A said she was on the hall to refill the PPE binds in front of each COVID-19 positive resident's room. OT A said she had not been on the hall long enough to know why the doors to the residents' rooms were not closed. OT A said this surveyor would have to speak to the nurse on the hall. Observation on 12/16/2021 9:09 a.m. of CNA A took a meal tray from room [ROOM NUMBER] (COVID-19 positive resident room) without placing the contaminated meal tray from COVID-19 positive room in a plastic bag and brought it through the clean area. CNA A took the tray to the kitchen and put it outside of the dishwashing area which is considered clean (also green zone). Interview on 12/16/2021 at 9:10 a.m. with LVN A said she was assigned to rooms 148, 149 and 150 which contained residents that were COVID-19 positive. LVN A said the hall was considered hot and before going into each room it was required to have on full PPE (gloves, gown, n95 mask and eye protection). LVN A was not able to explain why the doors to the COVID-19 positive residents were not closed and there was no signage to identify which kind of transmission-based precaution to use before going into each room. LVN A said the rooms should be closed to prevent the spread of infection. LVN A said that the staff verbally explain the status of residents during shift change. LVN A was not able to explain how visitors of the facility would know the precautions for the COVID-19 positive rooms or hall. LVN A said the facility has trained her on infection control and COVID-19 protocols. LVN A said the entire facility was warm and they were wearing full PPE throughout the building for every room. LVN A said we should inform visitors before they walk on the hall dedicated to COVID-19 positive residents. LVN A said she was not able to explain how visitors would know rooms 142-147 was dedicated to COVID-19 positive residents. LVN A said before the recent COVID-10 positive resident we use to have a sign to identify the COVID-19 positive hall and a barrier, but she was not sure if they needed a barrier anymore. Interview on 12/16/2021 at 9:40 a.m. with the Receptionist said, she had not been told to inform visitors which hall/wing had COVID-19 positive residents. The Receptionist said she was not aware of the what the different zones (yellow, green, or red) meant. Interview on 12/16/2021 at 9:55 a.m. with CNA A said the hot hall was rooms 142-147. CNA A said there were 3 residents on the hall that were COVID positive. CNA A said he did take a meal tray off the hot hall from room [ROOM NUMBER] and took it back to the kitchen. He said the room was open to room [ROOM NUMBER] and was not closed. CNA said he should not have removed the tray from the hall to prevent cross contamination and prevent the spread of infection or COVID-19. CNA A removed the tray because I was trying to help out. CNA A said there should have been signs to identify and alert anyone entering the hall that the hall/wing had COVID-19 positive residents. CNA A said he was not the CNA working the COVID-19 hall and was not focused on making sure the doors were closed to the COVID-19 positive residents' doors. CNA A said he has had in-services on infection control protocols, PPE usage and handwashing. Interview on 12/16/2021 at 10:15 a.m. with the DON said the red zone (rooms 142-147) are rooms with 3 residents who are COVID-19 positive (143, 144 and 145). The DON said there should have been signs to identify the zone had COVID-19 positive residents and which transmission-based precautions to use. The DON said currently staff are wearing full PPE when they enter in all rooms and have contact with the resident. The DON said the signs to identify the COVID-19 unit and transmission-based precautions will help reduce the spread of germs. The DON said the doors should be closed to the COVID-19 positive residents' rooms to aide in the prevention of the spread of infection. The DON said it was the responsibility of nurses and cna's to close the doors to COVID-19 positive residents. The DON said she was responsible to ensure the signage throughout the building was changed and updated. The DON said the west and east wings should have been all yellow zone. The DON said staff should not remove items from COVID-19 positive residents' rooms. The DON said items taken from COVID-19 positive rooms should not be brought into the hall that are clean. The DON said by taking contaminated items from COVID-19 positive rooms could increase the spread of COVID-19 throughout the building Interview on 12/16/2021 at 11:53 a.m. with the Corp. RN said the doors to the resident who were COVID-19 positive should have been closed to prevent the spread of COVID-19. The Corp. RN said the staff are told verbally which rooms had COVID-19 positive residents. The Corp. RN said the signage should reflect the correct zones. The Corp RN said she was not sure but thought the receptionist (screener) would let visitors know which halls the hot halls. The Corp. RN said the facility following the guidance of the Nursing Facility COVID-19 Response Plan provided by HHS. Interview on 12/16/2021 at 12:46 p.m. with the Dietary Manager said food trays that come from the COVID-19 hall should be put in plastic before taken off the hall to prevent the spread of COVID-19. The Dietary Manager said she nor her staff were aware that a tray was brought from the COVID-19 hall today and placed to be cleaned with the regular dishes. The Dietary Manager said they are using disposable dishware but that may have been placed on plastic trays. Observation on 12/16/2021 at 1:14 p.m. of CNA B went in and out of rooms (157, 167, 163 and 165 Yellow zone) without her PPE donned properly and according to facility trainings. CNA B did not have the gown tied at the neck or around her waist. The gown draped below each shoulder. Interview on 12/16/2021 at 1:18 p.m. with CNA B said she did pick up meal trays out of rooms 154 - 166. CNA B said she had been trained to tie the back of her gowns to protect herself, residents and prevent the spread of germs. Thee CNA B said if the gown is donned properly it will reduce cross contamination. Interview on 12/16/2021 at 1:56 p.m. with the DON said when a gown is donned it should be tied in the back at the neck and around the waist. The DON said the facility had trained on the buddy system where staff have been trained and encouraged to tie a fell ow staff's gown to ensure it is donned properly to prevent the spread of germs and bodily fluids. The DON said she performed competencies constantly to ensure staff are donning and doffing PPE correctly. Interview on 12/16/2021 at 3:59 p.m. with the Administrator said it would be best practice to have the doors closed to residents' rooms who were COVID019 positive to reduce the spread of COVID-19. The Administrator said all staff are responsible for ensuring infection control protocols are followed. The Administrator said all PPE should be donned and doffed according to CDC guidance. Interview on 12/17/2021 at 11:25 a.m. with CNA C said she helped push the meal cart while she and CNA B picked up the meal trays. CNA C said she did not notice CNA B's gown was not tied in the back. CNA C said the gown should be tied in the back to protect ourselves and the resident from cross contamination. Record review of facility training Wearing PPE dated 11/10/2021 revealed the following: Please make sure when entering guest rooms on the East Yellow Zone/Warm Zone that you are properly wearing full PPE, N95's, Face shield or goggles and gown signed by CNA B. Record review of facility provided training Sequence for donning person protection equipment (PPE) - CDC (not dated) revealed the following: Gown: a. Fully cover torso from neck to knees, arms to the end of wrist, and wrap around the back. b. Fasten the back of the neck and waist Record review of Nursing Facility COVID-19 Response Plan dated 7/20/2021 revealed the following in part: .be separated from others (kept in their room with the door closed). Appropriate PPE should be used by HCW when encountering the resident. Record review of nursing facility policy Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures (revised July 2020) revealed the following in part: The facility follows recommended standard and transmission-based precautions .practices to prevent the transmission of COVID-19 within the facility. 1. This policy is based on current CDC recommendations for the infection prevention and control practices for COVID-19. .C. appropriate use of PPE. D. transmission-based precautions, where indicated . Personal Protection Equipment .3. For a resident with known or suspected COVID-19 . c. Resident is placed in a private room with a dedicated bathroom (if available) and closed door . d. 4. If there is moderate to substantial COVID-19 transmission in the surrounding community: a. Staff wear all recommended PPE (i.e., gloves, gown, eye protection and facemask) for the care of all residents .regardless of symptoms. 6. Signage on the use of specific PPE (for staff) is posted in appropriate locations in the facility (e.g. outside of the resident's room, wing or facility-wide) Record review CDC COVID-19 Infection Control for Nursing Homes of (Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Nursing Homes & Long-Term Care Facilities) (updated as of September 10 ,2021) revealed the following: Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Ideally, a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending. In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit. However, in some circumstances (e.g., memory care units), keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#visitation Updated Sept. 10, 2021

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene for 1 (Resident #1) of 11 residents reviewed for activities of daily living care. The facility failed to ensure Resident #1 received toenail care. This failure could place residents at risk of diminished quality of life by not receiving care and services to meet their needs. Findings include: Record review of Resident #1's face sheet dated 12/17/2021 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Podiatry care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's 5-day MDS dated [DATE] revealed Resident #1 had a BIMS of 11 which indicated Resident #1 was moderately impaired cognitively. Resident #1's The MDS further reflected she required limited assistance of one person for personal hygiene. Record Review of Resident #1's care plan last revised on 11/19/2021 revealed she had, ADL self-care performance deficit related to [CONDITION(S)], impaired balance, stroke. The care plan did not address hygiene (nail care). Resident #1's care plan further revealed she was impaired visually. Review of Resident #1's progress notes from 10/6/2021 - 12/16/2021, did not reveal any documentation refusals of nail care. Review of Resident #1's Task sheet dated 11/18/2021 - 12/17/2021 for ADL-Personal hygiene revealed Resident #1 did not refuse ADL care. Record review of facility podiatrist list of residents' seen dated 12/7/2021 revealed Resident #1 was listed but was not seen for podiatry services. Interview on 12/17/2021 at 10:45 a.m. with Resident #1 said her toenails needed to be cut. Resident #1 could not remember the exact time she told staff her toenails needed to be trimmed. Resident #1 said she was told the last time by the podiatrist who said he would not be able to get to see her due to time constraints. Resident #1 said she had not refused care from the podiatrist. Resident #1 said she had told the DON that her toenails needed to be cut last month. Resident #1 said they told her that she would be put on the list for the podiatrist next visit. Resident #1 said both of her big toes were sore because they pushed up against her closed toed slippers. Resident #1 said it felt like two toenails growing out. Resident #1 said it was not comfortable. Observation on 12/17/2021 10:48 a.m. of Resident #1 sitting in her wheelchair revealed her right and left big toenail was a half of an inch past the tip of her toe. The toenail was thick. The toenail was dark brown on the edges. The toenail underneath had layer of white thick matter. The toenails were c-shaped that curved into her skin on each side of the toenail. Interview on 12/17/2021 at 12:27 p.m. with SW said the residents are placed on the list to see the podiatrist if the resident asks or if a nurse informs her that a resident needed to be seen. SW said she was not told by a staff that Resident #1 needed to see the podiatrist. The SW said Resident #1's Son told her that the resident needed her toenails clipped in late November, but she could not remember an exact date. She said it was prior to the 12/7/2021 podiatrist visit. The SW said Resident #1 was put on that list with an * mark to indicate urgent. The SW said it was urgent because Resident #1's Son called and requested the service. The SW said she did not have any documentation or knowledge of Resident #1 refused nail care. The SW said it is was important to keep toenails clipped and trimmed because it is important for hygiene and to prevent potential infection. Interview on 12/17/2021 at 12:54 p.m. with DON said Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON described Resident #1's two big toenails as too thick and needed to be cut by the podiatrist. The DON said it is important to keep Resident #1's toenails clipped to prevent pain or injury to her feet. Interview on 12/17/2021 at 1:24p.m. with the Podiatrist said Resident #1 refused the last visit on 12/7/2021 to have her toenails trimmed. The Podiatrist said he did not document or inform anyone that Resident #1 refused care. Interview on 12/17/2021 at 2:55 p.m. with Resident #1's Son said Resident #1 told him her toenails needed to be cut shortly after her admission in October 2021. He said he had been told by Resident #1 that when she participated in physical therapy that her feet hurt because of the long toenails. Resident #1's Son said a therapy staff (unknown) was going to inform nursing that Resident #1 needed to have her nails clipped. He said Resident #1 continued to complain throughout the month of November and December that her toenails needed to be clipped and they hurt her. Resident #1's Son said he eventually informed the DON at the beginning of December and he was told the staff nor her could clip Resident #1's toenails and they would schedule the podiatrist to see her. Record review of facility policy Activities of Daily Living (ADLs) Supporting (revised March 2018) revealed the following in part: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish . 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming .) Record review of facility policy Foot Care (revised March 2018) revealed the following in part: Residents will receive appropriate care and treatment in order to maintain mobility and foot health. 1. Resident will be provided with foot care and treatment in accordance with professional standards of practice. 3 .Residents will be assisted in making transportation appointments to and from specialist (podiatrist .) 4. Residents with foot complications will be referred to qualified professionals.

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health for one (Resident #1) of one residents reviewed for foot care. The facility failed to provide foot care for Resident #1. Record review of Resident #1's face sheet dated 12/17/2021 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Podiatry care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's 5-day MDS dated [DATE] revealed Resident #1 had a BIMS of 11 which indicated Resident #1 was moderately impaired cognitively. Resident #1's The MDS further reflected she required limited assistance of one person for personal hygiene. Record Review of Resident #1's care plan last revised on 11/19/2021 revealed she had, ADL self-care performance deficit related to [CONDITION(S)], impaired balance, stroke. The care plan did not address hygiene (nail care). Resident #1's care plan further revealed she was impaired visually. Review of Resident #1's progress notes from 10/6/2021 - 12/16/2021, did not reveal any documentation refusals of nail care. Review of Resident #1's Task sheet dated 11/18/2021 - 12/17/2021 for ADL-Personal hygiene revealed Resident #1 did not refuse ADL care. Record review of facility podiatrist list of residents' seen dated 12/7/2021 revealed Resident #1 was listed but was not seen for podiatry services. Interview on 12/17/2021 at 10:45 a.m. Resident #1 said her toenails needed to be cut. Resident #1 could not remember the exact time she told staff her toenails needed to be trimmed. Resident #1 said she was told the last time by the podiatrist who said he would not be able to get to see her due to time constraints. Resident #1 said she had not refused care from the podiatrist. Resident #1 said she had told the DON that her toenails needed to be cut last month. Resident #1 said they told her that she would be put on the list for the podiatrist next visit. Resident #1 said both of her big toes were sore because they pushed up against her closed toed slippers. Resident #1 said it felt like two toenails growing out. Resident #1 said it was not comfortable. Observation on 12/17/2021 10:48 a.m. of Resident #1 sitting in her wheelchair revealed her right and left big toenail was a half of an inch past the tip of her toe. The toenail was thick. The toenail was dark brown on the edges. The toenail underneath had layer of white thick matter. The toenails were c-shaped that curved into her skin on each side of the toenail. Interview on 12/17/2021 at 12:27 p.m. SW said the residents are placed on the list to see the podiatrist if the resident asks or if a nurse informs her that a resident needed to be seen. The podiatrist visits the facility weekly. SW said she was not told by a staff that Resident #1 needed to see the podiatrist. The SW said Resident #1's Son told her that the resident needed her toenails clipped in late November, but she could not remember an exact date. She said it was prior to the 12/7/2021 podiatrist visit. The SW said Resident #1 was put on that list with an * mark to indicate urgent. The SW said it was urgent because Resident #1's Son called and requested the service. The SW said she did not have any documentation or knowledge of Resident #1 refused nail care. The SW said it is important to keep toenails clipped and trimmed because it is important for hygiene and to prevent potential infection. Interview on 12/17/2021 at 12:54 p.m. DON said Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON described Resident #1's two big toenails as too thick and needed to be cut by the podiatrist. The DON said it is important to keep Resident #1's toenails clipped to prevent pain or injury to her feet. Interview on 12/17/2021 at 1:24p.m. the Podiatrist said Resident #1 refused the last visit on 12/7/2021 to have her toenails trimmed. The Podiatrist said he did not document or inform anyone that Resident #1 refused care. Interview on 12/17/2021 at 2:55 p.m. Resident #1's Son said Resident #1 told him her toenails needed to be cut shortly after her admission in October 2021. He said he had been told by Resident #1 that when she participated in physical therapy that her feet hurt because of the long toenails. Resident #1's Son said a therapy staff (unknown) was going to inform nursing that Resident #1 needed to have her nails clipped. He said Resident #1 continued to complain throughout the month of November and December that her toenails needed to be clipped and they hurt her. Resident #1's Son said he eventually informed the DON at the beginning of December and he was told the staff nor her could clip Resident #1's toenails and they would schedule the podiatrist to see her. Record review of facility policy Activities of Daily Living (ADLs) Supporting (revised March 2018) revealed the following in part: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish . 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming .) Record review of facility policy Foot Care (revised March 2018) revealed the following in part: Residents will receive appropriate care and treatment in order to maintain mobility and foot health. 1. Resident will be provided with foot care and treatment in accordance with professional standards of practice. 3 .Residents will be assisted in making transportation appointments to and from specialist (podiatrist .) 4. Residents with foot complications will be referred to qualified professionals.

Based on interview and record review the facility failed promptly notify the ordering physician of laboratory results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to immediately notify CR #1's physician when a STAT lab was ordered in response to a reported change in condition from the residents' Responsible Party and lab results showed high WBC, BUN, and BUN/Creatinine ratio. The out of range laboratory results were not reported to the physician until 12 hours after they were resulted causing a delay in treatment. CR #1 was transferred to the hospital 18 hours after the labs were resulted and she was diagnosed with [CONDITION(S)] and heart failure and passed away the following day. This failure could place residents at risk of delayed treatment/intervention, decline in health, and/or death. CR #1 Record review of CR#1's facesheet revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] at 7:41PM to the hospital. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on [DATE] at 12:00 PM, CR #1's RP said other family was at the facility on [DATE] visiting with CR #1 and they called her to report CR #1 seemed unwell. The RP said she was a registered nurse, so the family wanted her opinion on CR #1's condition. The RP said she went to the facility on the afternoon of [DATE] and observed CR #1 was very weak, not talking coherently, and was not able to stay awake. The RP said herself and other family reported their concerns of CR #1 being more tired than usual and not as alert to a therapist (PTA A) who came in to do therapy with CR #1 and to other nursing staff. The RP said a nurse (LVN A) came to report to them the physician was made aware of their concerns and had ordered labs and an IV because he was concerned about the resident being dehydrated. CR #1 was also taking scheduled [MEDICATION(S)] which the RP said was discontinued because they had concerns the medication caused her to be more lethargic. CR #1's RP said on [DATE] around 10 AM, other family was at the facility visiting CR #1 when they called her on speaker phone to talk with the nursing staff regarding CR #1's condition. The RP said a nurse reported CR #1's lab results had come in and the physician was aware of the results. The RP said the nurse reported the lab results showed CR #1 was dehydrated and her WBC's were elevated so they were going to start her on some IV fluids and the doctor was going to the facility later to evaluate CR #1. The RP said she went to the facility so she could speak with the physician when he went to evaluate CR #1. The RP said she arrived at the facility around 4 PM on [DATE] and observed CR #1's condition had deteriorated more from the previous day and the IV fluids had not been started. She said CR #1 was unable to open her eyes or fully wake up and could not get her to say anything. The RP said around 6:00 PM the facility was getting the IV inserted and fluids were started but the physician had not showed up, so they demanded the nurse on shift (RN A) call the physician for them. The RP said they finally got RN A to call the physician from the nurse's station and the physician answered and reported he had not spoken with a nurse from the facility and had not told anyone he was going to the facility. The RP said she spoke with the physician over the phone about the lab results and he seemed unaware of the results and CR #1's condition deteriorating. The RP said the physician agreed he wanted CR #1 transferred to the hospital based on their report of the condition she was in and the lab results. The RP said CR #1 was transferred to the hospital by 7PM. The RP reported CR #1 expired on [DATE] at 1:00 PM from [CONDITION(S)] and heart failure. Interview on [DATE] at 1:30 PM, the physician said he recalled a nurse from the facility reaching out to him on [DATE] and stated the family had concerns about CR #1 being more tired than usual and said he had his own concerns of the CR #1 not eating or drinking enough so he ordered labs and to get her an IV for fluids. The physician said he did recall the following day getting a call from the facility in the evening with the family present and the family stated someone told them he was going to the facility. The physician said he did not know who told the family that or why because he had not told anyone he was going to the facility. The physician said he spoke to the family about CR #1's lab results and CR #1's condition and the family informed him CR#1 had declined significantly from the previous day by constantly sleeping and would not awake or respond to them, so he decided to transfer CR #1 to the hospital. The physician said when he spoke to family on [DATE] on the facility phone and decided to transfer to the hospital it was the first time he learned of CR #1's lab results. The physician said he could not remember the exact time but said it was later in the evening on [DATE] around 6PM. Record review of CR #1's physical therapy notes dated [DATE] by PTA A revealed in part, .Patients daughter and caregiver in room during treatment and communicate with them about patient's functional status. Patient seemed different today because sleepy and more weak than other days and reported to nurse . Interview on [DATE] at 4:00 PM, PTA A said [DATE] was her first time working with CR #1 so she was not sure what her baseline was but the resident was very lethargic and not able to assist in therapy exercises, she stated she had to assist CR #1 in all movements. PTA A said there was family in the room, and they stated CR #1 was usually not as tired and helpless as she was. PTA A said she documented in her notes what the family had reported to her and then she reported it to the nursing staff because she was not sure if the resident had a change in condition. PTA A did know the name of the nurse she reported the concerns to or what happened after she reported them to the nurse. Record review of CR #1's electronic and paper records dated [DATE] revealed no documentation of the RP's concerns, PTA A's concerns, physician notification, or if orders were given for labs and IV fluids. Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility 24-hour shift report dated [DATE] revealed no documentation of change in condition, new orders, or concerns for CR #1. Record review of CR #1's electronic lab results revealed lab specimen was collected on [DATE] at 7:05PM, received on [DATE] at 8:15PM, and reported on [DATE] at 12:32AM. Further review of the results revealed: CO2 was high at 36mmol/L with reference range of 22- 29mmol/L BUN was high at 39mg/dL with reference range of 8- 23mg/dL BUN/Creat Ratio was high at 45.3 with reference range of 10.0 - 28.0 WBC was high at 21.97 x10(3)/uL with reference range of 4.00 - 10.10 x10(3)/uL Interview and record review on [DATE] at 1:40 PM, the DON said labs were completed on [DATE] for CR #1. The DON reviewed the electronic record and agreed she did not see orders or documentation of who ordered CR #1's lab or why. The DON said she did not know of anyone speaking with the physician on [DATE] about a change in condition and said she would look into it. Interview and record review on [DATE] at 2:00 PM, the DON presented surveyor with a printed off sheet from the lab company portal which showed who ordered labs (LVN A), what labs were ordered and when for CR #1 on [DATE]. The DON said the order for the labs was not documented in the record because they were drawn as routine labs since CR #1 was a new admit and stated the labs were not ordered because of concerns voiced by the family. The DON said if the labs were just the new admit routine lab orders a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's lab company portal sheet revealed STAT BMP and CBC with Diff Platelets labs were ordered on [DATE] at 2:17PM by LVN A. Interview on [DATE] at 1:49 PM, RN A said he worked the 2 PM - 10 AM shift and had not observed nor was he told about a change in condition for CR #1 on [DATE]. RN A denied speaking with CR #1's physician on [DATE] and said he knew nothing about CR#1 having labs ordered. RN A said he was approached on the evening of [DATE] by CR #1's family insisting CR #1 had a change in condition, he assessed CR #1 but did not observe any changes. RN A said the family tried calling the doctor but could not get him to answer and said the family was questioning when the physician was going to the facility because a nurse had reported to them the physician was going to the facility to evaluate CR #1. RN A said he did not know anything about the physician going to the facility, so he had the family go with him to the nurse's station and he called the physician. He said the physician answered the phone and spoke in length with the family and the physician ordered to send CR #1 to the hospital after he spoke with the family. RN A said that was the first time he had spoken with CR #1's physician and denied knowing anything about CR #1 labs being ordered/completed or the results being communicated to the physician. RN A said if labs were ordered and results were pending it would be on the shift report and the previous nurse would tell him there were results pending and he would have to periodically check the electronic record for the results. Phone interview on [DATE] at 2:06 PM, LVN A said she worked the 6 AM - 2 PM shift and did not recall CR #1 having a change in condition or anyone reporting concerns to her. LVN A said she could not recall speaking with CR #1's family, speaking to CR #1's physician, placing lab orders for CR #1, or receiving lab results for CR #1. LVN A said she remembered CR #1 being very weak and sickly since she admitted and doesn't recall a change from her baseline. LVN A said the procedure for lab orders would be to enter the order into the record and place order with the lab company, then document labs were ordered either in the shift report or progress notes so staff would know to check for results. LVN A said they found lab results in the electronic record under the lab results tab and they periodically checked for results during their shift if they knew lab results were pending for a resident. LVN A said she did not recall placing any orders for CR #1 on [DATE] or [DATE]. Interview on [DATE] at 4:40 PM, the ADON said she did not recall speaking to CR #1's family about their concerns of change in condition and said she did not recall speaking to CR #1's physician or CR #1 having any new orders on [DATE] or [DATE]. The ADON denied observing a change in condition in CR #1 and stated CR #1's baseline was tired and lethargic, and she had not observed an increase in lethargy. The ADON also stated CR #1's labs from [DATE] were completed as routine baseline labs, not because of a change in condition which was why there was not an order or documentation in the system for the labs. Record review of CR #1's electronic record revealed no documentation dated [DATE] regarding CR #1 pending labs, laboratory results or if results were reported to the physician. Record review of the facility's 24-hour shift report dated [DATE] revealed no mention of CR #1's pending labs, laboratory results or if results were reported to physician. Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR 1's consent form for Midline insertion was signed and dated on [DATE] by family and LVN A. Record review of CR #1's Midline insertion sheet dated [DATE] revealed the midline was ordered on [DATE] at 2:18PM and Midline was inserted on [DATE] at 5:35PM. Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility 24-hour shift report dated [DATE] revealed comments from morning shift noting in part, .midline ordered, stable . Record review of CR #1's nursing notes dated [DATE] at 5:49PM written by RN A revealed, Guest family here today evening. Daughter concerned about her mother condition ,d+[DATE] P 66 Oxygen sats 94%. Daughter stated the she is waiting for doctor to come to the facility. Daughter tried to call doctor on her cell phone, but the phone went unanswered. This writer told daughter to accompany him to nurse station and try to call the doctor. Doctor answered facility phone and the daughter talked in length with the doctor. Doctor and daughter agreed that it is the best interest that patient be transported to hospital. The writer immediately called 911 and patient was sent out to hospital in an ambulance. Interview on [DATE] at 12:18 PM, LVN A said since she was able to review CR #1's record she still did not recall speaking to CR #1's physician or placing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A said someone else could of spoke to the physician and asked her to put the order in and that was why her name was in the system as the nurse who placed the order. LVN A said CR #1 was at her baseline and did not recall family having concerns for change in condition. LVN A said she did recall CR #1's family visiting around lunch time, approximately 1PM on [DATE] and them wanting to speak with the physician. LVN A said she called the physician and he reported he was already aware of CR #1's lab results and he gave her an order to have a midline placed but did not give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A said she then spoke to CR #1's family and told them about the lab results and what the physician had ordered. LVN A said she was sure she talked to the physician on [DATE] afternoon and was sure of what he said and ordered despite the physician saying he had not talked to her about lab results or ordered the midline on [DATE]. LVN A stated she did not know who informed the physician of the results and suggested it might have been the night nurse. LVN A denied receiving an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A said she had written a paper note on [DATE] about the conversation with the family and the physician and the new orders from the physician. LVN A said she completed a paper note because there were only two computers at the nurse's station, and both were in use. LVN A reported the paper note was probably in CR #1's closed paper chart. Record review of CR #1's paper chart revealed one paper progress note dated [DATE] at 2:20PM by LVN A which revealed, Covering MD aware of lab results. New order received for midline placement; consent received for midline placement per family/RP. Pharmacy called to schedule midline placement. MD also informed of family's request to speak to him. MD stated he would be at the facility to assess guest for further treatment. Family informed that MD would be at facility to see guest this afternoon. No question or concerns voiced at this time. Will continue care as ordered. Interview on [DATE] at 2:00 PM, the physician said he clearly recalled someone contacting him on [DATE] about the family's concerns and he ordered the IV to be started while they waited on lab results because he was mostly concerned about CR #1's nutrition because she had not been eating or drinking. The physician said he would not receive lab results showing CR #1 was dehydrated and not give orders to start fluids and said if he had spoken to a night nurse early in the morning about the lab results he would of given orders then, not after being contacted a second time later in the afternoon as LVN A claimed. The physician said there was no chance he was not remembering correctly and again stated he was not informed the lab results were in for CR #1 until late evening on [DATE] and had told no one he was going to the facility. Interview on [DATE] at 2:10 PM, the Regional Nurse said their policy did not quote a specific time frame abnormal lab results had to be reported to physician, but her expectations would be within the nurse's shift. The Regional Nurse agreed 12 hours would be longer than she would expect but said there was no delay in CR #1's physician being informed of results because the night shift nurse informed him of results before her shift ended at 6 AM. The Regional Nurse agreed there was no documentation the night nurse had notified the physician or what time he was notified. The Regional Nurse stated she knew the night nurse informed the physician because the night nurse had told LVN A during shift report she had informed the physician of CR #1's lab results. The Regional Nurse suggested the surveyor ask LVN A to clarify what she meant by her not knowing who told the physician the lab results first and she would work on locating who the night nurse was so she could be interviewed. Interview on [DATE] at 2:16 PM, the Staffing Coordinator and Regional Nurse reported the nurse who worked the 10 PM - 6 AM on [DATE] was an agency nurse. The Staffing Coordinator explained the agency was an app where open shifts could be posted, and nurses could sign up to take the shifts. The Staffing Coordinator said since it was an app there was no one to contact to get the nurses contact information and the facility did not have it. The Regional Nurse confirmed she looked up the app and did not see a way to contact the app or the nurse, so she was not able to be interviewed. Interview on [DATE] at 4:20PM, LVN A said on the morning of [DATE], the night nurse gave her a verbal report that CR #1's lab results had come in and she had reported the results to the physician. LVN was reminded of previous conversation where she stated she did not know who had previously told the physician the results and she said she meant she did not know what the nurse's name was. Record review of the facility Test Results policy (Revised [DATE]) revealed in part, .The resident's Attending Physician will be notified of the results of diagnostic tests . 1. Results of laboratory, radiological, and diagnostic tests shall be reported to the resident Attending physician or to the facility. 2. Should the test results be provided to the facility; the Attending Physician shall be notified of the results. 3. The Director of Nursing, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of test results .

Based on record review and interviews, the facility failed to conduct a comprehensive assessment within 14 calendar days after admission as required for 1 (Resident# 249) of 16 resident records reviewed, in that: -Resident # 249's comprehensive assessment was not completed and was 26 days past due. This failure affected one resident and placed him at risk of not having his care and treatment needs assessed to ensure necessary care and services were provided to meet these needs. Findings included: Record review of Resident #249's face sheet, dated 09/15/2021, revealed the resident was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on 09/15/2021, 03:39 p.m., of Resident #249's electronic admission MDS Assessment, dated 08/13/2021, revealed a status of in progress and no completion date in Sections H, I, J, K, L and Z. Record review on 09/16/2021, 9:40 a.m., of Resident #249's MDS Assessment printout dated 08/13/2021, revealed sections H, I, J, K, L and Z were completed by MDS Nurse A on 09/15/2021. Interview on 09/16/2021 at 10:47 a.m., with MDS Nurse A, MDS Nurse B and Regional Nurse, MDS Nurse B said they have 14 days to complete a resident's assessment after admission. And confirmed Resident #249's admission comprehensive assessment was completed yesterday, because it was MDS Nurse A's first day yesterday, and MDS Nurse B was here to help. Regional Nurse said the person in charge was MDS left the company about 2 to 3 weeks ago. That person was the regional MDS nurse who overlooked the MDS assessments at this facility and all other facilities the corporate has. And things fell short on her end, so she was no longer with the company, they recognized there was a deficiency in MDS area, that is why they have new people to get it fixed. They work hard to be in compliance. Record review of facility's policy titled Comprehensive Assessment and the Care Delivery Process revised December 2016 revealed in part Complete the Minimum Data Set within 14 days after admission, within 14 days after it is determined that the resident has had a significant change in physical or mental condition, and annually.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care, including [CONDITION(S)] care, were provided such care, consistent with professional standards of practice, for 1 (#94) of four residents reviewed for respiratory care. -The facility failed to administer Residents #94's oxygen as ordered by the physician. This failure could affect residents receiving oxygen therapy at risk of adverse impact on their health and decreased quality of life. Findings included: Record review of Resident #94's face sheet dated 09/15/2021, revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE]. His admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #94's admission Minimum Data Set assessment (MDS) dated [DATE] revealed his Brief Interview for Mental Status (BIMS) was 9 out of 15 which indicated he was moderately impaired. Resident #94 required extensive assistance from two staff members for his bed mobility and one staff for transfer, locomotion on unit, dressing, eating toilet use and personal hygiene. Resident #94 was always continent for bladder and always incontinent of bowel. Section O Special Treatments, Procedures and Programs revealed Resident #94 received oxygen therapy while not a resident and while a resident. Record review of Resident #94's Care plans initiated 08/05/2021 revealed in part: -Focus: Resident #94 has oxygen therapy r/t [CONDITION(S)]. -Goal: Resident will have no signs and symptom of poor oxygen absorption; -Interventions: Oxygen settings: O2 via nasal cannula @ 2L. In observations on 09/15/2021 at 10:57 am, and on 09/16/2021 at 03:58 pm, revealed Resident #94 in lying in bed with upper body slightly elevated, he was receiving oxygen per nasal cannula at 4 liters per minute. In an observation and interview on 09/16/2021 at 04:05 pm with RN A, he said the nurses are in charge of making sure residents are receiving proper oxygen care, and he does rounds twice per shift. He checked Resident #94's oxygen order and said it is ordered by physician at 2L and the setting of 4L is incorrect. There could be all kinds of causes of it as sometimes the residents might touch the oxygen machine, somebody might move it and unplug it, he was not certain what might have caused the incorrect setting for both residents. In an interview on 09/17/2021 at 01:53 pm, the DON said ADON was the person to make sure the oxygen orders are in and setup properly for residents, afterwards the charge nurses are responsible of monitoring them on their shift daily. She was not aware that Resident #94's oxygen was setup at 4L instead of 2L, and she will talk to the nurses and make sure physician orders are followed and continually monitored. Record review of Resident # 94's physician's order dated 08/05/2021 revealed oxygen at 2 liters per minute via nasal cannula continuously every shift. Record review of Resident #94's Treatment Administration Record (TAR) dated 09/01/2021 -09/16/2021 revealed Oxygen at 2 liters per minute via nasal cannula continuously every shift. The TAR was initialed to indicated it was provided from 09/01/2021 -09/16/2021. Record review of the facility policy titled Oxygen Administration dated 2001 Med-Pass, Inc (Revised 2010) read in part: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration . Preparation 1. Verify that there is a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review the resident's care plan to assess for any special needs of the resident .

Based on interview and record review, the facility failed to ensure that 1 of 3 residents (resident #41) reviewed for comprehensive centered care plans, in that: Resident #41's care plan did not include care areas realted to antipsychotic medication use, anitcoagulant use, diuretic therapy and diabetes management. This failure could affect residents' medication management resulting in poor medication effectiveness and adverse outcomes. Findings included: Record review of Resident #41's face sheet revealed a [AGE] year-old female who admitted into the facility on [DATE], and was diagnosed with cerebral infarction, type 2 diabetes melitus [CONDITION(S)] and anxiety disorder. Record review of Resident #41's physician orders, dated 09/17/2021, revealed the resident had active orders to be receiving [MEDICATION(S)] tablet 20 mg for [CONDITION(S)], [MEDICATION(S)] KwikPen Suspension Pen-Injector 100 unit/ml for Type 2 Diabetes Melitus, [MEDICATION(S)] Solution 100 unit/ml for [Diabetes Melitus], [MEDICATION(S)] tablet 5mg for [CONDITION(S)] disorder, [MEDICATION(S)] tablet 5mg for AFIB, and Aspirin tablet 81 mg for prophylaxis that all started on 07/20/2021. Record review of resident #41's MDS, dated [DATE], revealed the resident was assessed to use insulin injections, antipsychotic medication, anticoagulant medication and diuretic medication during their first 7 days at the facility. Record review of Resident #41's care plan, dated 09/17/2021, revealed resident #4 was not care planned for [CONDITION(S)], diuretic therapy, anticoagulant use and diabetes melitus. Interview on 09/16/2021 at 10:47 am with MDS Nurse A, MDS Nurse B and Regional Nurse, MDS Nurse B said they have 14 days to complete a resident's assessment after admission and 21 days to complete the care plan. MDS Nurse A stated it was her first day yesterday, and MDS Nurse B stated she was here to help train MDS Nurse A. MDS Nurse A and B both stated they noticed that multiple residents care plans were not complete because the data MDS assessments were not carried over in time. Regional Nurse said the former MDS Nurse left the company about 2 to 3 weeks ago and she was the regional MDS Nurse who overlooked the MDS assessments at this facility and, as a result, things fell short on her end. In an interview with the DON on 09/17/2021 at 3:51PM, she stated she was aware resident #41's care plan was incomplete and the issue with incomplete care plans have occurred since the former MDS Nurse quit three weeks ago. Since then, they have not been able to permanently fill the position until 09/15/2021. She stated in their last QAPI meeting, it was noticed that the former MDS Nurse, who also happened to be the regional MDS nurse, was not completing care plans on time. She said the said care plans were being missed and they were not monitored by anyone beyond the former MDS nurse. Record review of the facility's policy on comprehensive assessments, dated 2001, revealed that in the resident assessment, the facility is to . c) define current treatments and series, link with problems/Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . leading to a person-centered plan of care.

Based on interview, record review, review of policies and procedures, and review of Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH Revised memo, the facility failed to implement outbreak testing of staff and residents to prevent the spread of COVID-19 upon identification that a student nurse tested positive for COVID-19 on 08/10/21. This failure increased the likelihood of COVID-19 transmission to the 62 residents living at the facility. Findings included: Record review of CMS QSO-20-38-NH, issued 08/26/20 and revised on 04/27/21, revealed that upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , regardless of vaccination status, and all staff and residents that tested negative should be retested every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result . 'Facility staff' includes employees, consultants, volunteers, contractors, and care givers who provide care and services to residents on behalf of the facility . If the 48-hour turn-around time cannot be met due to community testing supply shortages, limited access or inability of laboratories to process tests within 48 hours, the facility should have documentation of its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and contact with the local and state health departments . Record review of the facility's policy tiled Coronavirus Disease (COVID-19) Revised Policy on Surveillance, Reporting & Management © MED-PASS, inc. (April 2020) revealed that Strategies used for rapid identification and management of COVID-19 infected residents include . testing . Response Driven Testing. As soon as possible after one (or more) COVID-19 positive individuals (resident or staff) is identified in a facility, serial testing of all residents and staff who test negative upon the prior round of testing (regardless of their vaccination status) will be performed every 3-7 days until no new cases are identified among residents in sequential rounds of testing over 14 days; the facility may then resume their previous routine their previous routine diagnostic screening testing for staff schedule. Further review of this policy revealed that staff was not included in the section will be performed every 3-7 days until no new cases are identified among residents . Further review of this policy revealed no definition of who was considered staff in the facility. Upon entrance in the facility on 08/18/20 at 10:45 AM, the Administrator and DON stated that the facility had just completed a 14-day round of outbreak testing of residents and staff based on COVID-19 positive staff identified on 07/26/21, with no new cases of COVID -19 identified in residents or staff. Record review of a Staff Call Off Tracker for COVID-19 identified that on 07/24/21 a staff member tested positive for COVID-19, and on 07/26/21 two additional staff members tested positive. During an interview on 08/19/21 at 11:00 AM, the DON, who was also the Infection Control Preventionist (ICP), stated that the facility initiated COVID-19 outbreak testing in the facility starting on 07/25/21 in accordance with their policy and CDC guidelines. During an interview on 08/20/21 at 9:00 AM, the DON/ICP stated that on 08/06/21 the facility's administrative staff obtained COVID-19 specimens to test staff twice a week due to a high county positivity rate; however, the Houston Health Department (HHS) did not pick up the staff COVID-19 PCR (Polymerase Chain Reaction) testing samples obtained on 08/06/21 and was told by HHS that twice a week testing would begin on 08/09/21. The DON/ICP stated that testing staff twice a week started on 08/09/21 per HHS direction. Record review of an e-mail to the Administrator from HHS, dated 08/03/21, revealed that the County COVID-19 positivity rate is 14.2 (as of Monday, August 2, 2021). Twice a week testing will start the week of August 9th, 2021. Sorry for any inconvenience this may have caused. On 08/20/21 at 9:30 AM, the Administrator provided the survey team with the facility's county positivity rate obtained from https://data.cms.gov/covid-19/covid-19-nursing-home-data which documented a 14.2% positivity rate on 07/27/21, and a 17.5% positivity on 08/03/21. Record review of a Staff Call Off Tracker for COVID-19 revealed that a student nurse tested positive for COVID-19 on 08/10/21. During an interview on 08/20/21 at 11:40 AM, the Administrator and DON informed the survey team coordinator that the facility just received notification of four new COVID positive staff for the entity, three of them work in the skilled nursing facility, and the facility was initiating outbreak testing for all staff and residents regardless of vaccination status, 10 days after outbreak testing should have been implemented when the student nurse tested positive. During an interview on 08/20/18 at 7:00 PM, the DON/ICP stated that the student nurse was tested repeatedly in the 14-day time period, from 7/26/21, and when she tested positive on 8/10/21 the clock [outbreak] does not restart per CDC and CMS guidelines; it doesn't count and felt she had no need to continue outbreak testing and/or restart outbreak testing because the student nurse was not an employee of the facility. The DON/ICP stated that she conferred with the former DON who is a Regional Registered Nurse (RRN) who was also the former IP. However, the student nurse was in the facility and cared for residents on 07/17/21, 07/24/21, and on 08/07/21. The DON confirmed that the residents were not tested on [DATE]. On 08/10/21 the facility performed another round of staff testing based on the county positivity rate not because the facility identified that outbreak testing was to begin. During an interview on 08/20/21 at 7:00 PM, the RRN stated that every positive result was reported to CMS and the CMS employee, who they are responsible to report data to, cleared them. The RRN stated that she knew about refusal of HHS to process their staff COVID-19 specimens on 08/06/21 and called them to no avail. The RRN stated the facility does not have any other agreement for lab processing of PCR COVID-19 tests, thus she did not contact another laboratory for processing the staff COVID-19 specimens. During an interview on 08/20/21 at 7:34 PM, the CMS employee stated that the facility is required to report raw numbers of COVID positive individuals in the facility to CMS, and she does not provide any guidance regarding outbreak testing. If the facility is in an outbreak situation, they are required to follow CMS policy on outbreak testing and mitigation procedures. During an interview on 8/20/21 at 8:22 PM, the Assistant Director of Nursing stated that she performs all the COVID tests in the facility and confirmed that all residents were tested on [DATE] and not tested again until 08/20/21.

Based on observation, interviews, record review, review of facility policy, and review of Centers for Medicare and Medicaid Services (CMS) QSO 20-39-NH, the facility failed to suspend visitation upon the identification of a new COVID-19 outbreak on 08/20/21 until the first round of testing was complete and no new cases of COVID-19 was identified among staff and residents, and failed to implement the use of full Personal Protective Equipment (PPE- gown , gloves, eye protection, and N95 masks) when providing care for residents who had a potential exposure to a COVID positive staff on 08/20/21, and when providing care for one resident (Resident (R) 14) out of 32 residents on quarantine for COVID-19. These deficient practices had the potential to affect all 62 residents in the facility. Findings included: Record review of QSO 20-39-NH, dated 02/17/20 and revised on 04/27/21, revealed When a new case of COVID-19 among residents or staff is identified, a facility should immediately begin outbreak testing and suspend all visitation (except that required under federal disability rights law), until at least one round of facility-wide testing is completed. Visitation can resume based on the following criteria: If the first round of outbreak testing reveals no additional COVID-19 cases in other areas (e.g., units) of the facility, then visitation can resume for residents in areas/units with no COVID-19 cases. However, the facility should suspend visitation on the affected unit until the facility meets the criteria to discontinue outbreak testing .NOTE: In all cases, visitors should be notified about the potential for COVID-19 exposure in the facility (e.g., appropriate signage regarding current outbreaks), and adhere to the core principles of COVID-19 infection prevention, including effective hand hygiene and use of face-coverings . Residents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for compassionate care situations, with adherence to transmission-based precautions. Record review of the facility's titled Revised Visitation Policy, updated March 2021, directs that The facility's revised visitation policy is developed in compliance with the most recent guidance from Centers for Medicare and Medicaid Services (CMS) issued AFL 20-22.6 . The Administrator, in conjunction with Local Public Health, California [sic] Department of Public Health, Medical Director and Infection Preventionist, has the authority to restrict or ban facility visitation during outbreaks, whether these originate in the facility or in the community and listed QSO 20-39 NH Nursing Home Visitation as another reference. However, the facility's policy did not specifically direct that staff suspend all visitation until the first round of outbreak testing was complete with no new cases of COVID-19 identified and did not contain language about notifying visitors about potential COVID exposure in the facility. During entrance into the facility on [DATE] at 9:00 AM via the main front entrance, there was no signage that the facility was in a current COVID-19 outbreak. The two surveyors were screened by Concierge 1, who asked screening questions; however, she did not provide any information regarding COVID incidence in the facility. During the Entrance Conference on 08/18/20 at 10:45 AM, the Administrator and Director of Nursing (DON), who is also the facility's Infection Control Preventionist (ICP), stated that the facility had just completed a 14-day round of outbreak testing, based on COVID positive staff identified on 07/26/21, with no new cases of COVID-19 identified. In addition, the Administrator and DON stated that the facility was allowing full visitation on both units; the East Unit is a Green Zone for residents who are not on isolation and the West Unit in a Yellow Zone for new admission residents on quarantine. Record review of the Staff Call Off Tracker identified that a student nurse tested positive for COVID-19 on 08/10/21. During an additional interview on 08/20/18 at 7:00 PM, the DON/ICP stated that when the student nurse tested COVID positive on 8/10/21, no outbreak testing or restriction of visitation was initiated because the student nurse was not an employee of the facility. Cross Reference: F886-L-Staff and Resident Testing. During an interview on 08/20/21 at 11:40 AM, the Administrator and DON informed the team coordinator that the facility just received notification of four new COVID-19 positive staff for the entity, three of them work in the skilled nursing facility, and the facility was initiating outbreak testing for all staff and residents regardless of vaccination status. When asked if the facility planned to make any changes to their visitation policy related to the new outbreak, the Administrator and DON stated there were no changes planned. Record review of the COVID rapid tests result dated 08/20/21 revealed Licensed Vocational Nurse (LVN) 5, Registered Nurse (RN)1, and Physical Therapy Assistant (PTA) all tested positive for COVID-19. Record review of the East Wing Daily Assignment Sheets revealed LVN 5 worked on the East Unit on from 08/16/21 to 08/19/21 from 2:00 PM to 10 PM and was assigned to Rooms 103-116 on the Green Zone. Further review of the Daily Assignment Sheets revealed RN1 worked on the West Wing Yellow Zone from 08/16/21 to 08/19/21 and was assigned to Rooms 148-166, thus both units in the facility were affected by the 08/20/21 outbreak. During an observation on 08/20/21 at 1:03 PM, Family Member (F)1 entered the facility via the front door and was screened by Concierge (C) 2 who asked COVID screening questions, told F1 to put on full personal protective equipment (PPE) consisting of N95 mask, face shield, gown, and gloves upon entering the resident room; however, she did not inform F1 of the current COVID outbreak. During an interview on 08/20/21 at 1:05 PM, F1 confirmed that he was not told of any COVID outbreak in the facility and stated he was going to visit Resident (R)17 who resided on the Yellow Zone (quarantine unit). During an observation on 08/20/21 at 1:06 PM, F2 entered the facility via the front door and was screened by C 2 who asked COVID screening questions, told F2 to put on full personal protective equipment (PPE) consisting of N95 mask, face shield, gown, and gloves upon entering the resident room; however, she did not inform F2 of the current COVID outbreak. During an interview on 08/20/21 at 1:08 PM, F2 confirmed that she was not told of any COVID outbreak in the facility and stated she was going to visit R18 who was in the Yellow Zone. During an observation on 08/20/21 at 1:11 PM, F3 entered the facility via the front door and was screened by C2 who asked COVID screening questions, told F2 to put on an N95 mask and face shield; however, she did not inform F3 of the current COVID outbreak. During an interview on 08/20/21 at 1:12 PM, F3 confirmed that he was not told of any COVID outbreak in the facility and stated he was going to visit R13 who was in the Green Zone (residents with no COVID-19 infection or exposure) . During an observation on 08/20/21 at 1:16 PM, F4 entered the facility via the front door and was screened by C2 who asked COVID screening questions, told F4 to put on full personal protective equipment (PPE) consisting of N95 mask, face shield, gown, and gloves upon entering the room; however, she did not inform F4 of the current COVID outbreak. During an interview on 08/20/21 at 1:18 PM, F4 confirmed that he was not told of any COVID outbreak in the facility and stated he was going to visit R19 who was in the Yellow Zone. During an interview on 08/20/21 at 1:29 PM, C2 stated she screens all visitors and employees when they enter the building and all visitors were required to wear an N95 mask and face shield and if they go to the yellow zone, they are required to wear a gown. C2 stated the egress into the facility was busy because employees were entering the building for mandatory COVID testing and visitation was busy because it was Friday. When asked if she was informed about any visitor restrictions or any COVID outbreak in the facility, C2 stated that she had not received any instructions from administrative staff indicating there were any restrictions in visitation or that there were current COVID cases in the facility. C2 stated she did not know of any current COVID incidence in the building and had not received any instruction from the administration staff other than to instruct visitors on the PPE they should use depending on the zone they go to. During an additional interview on 08/20/21 at 1:30 PM, the DON/ICP stated the facility had not stopped visitation based on CMS guidelines. When asked why visitors entering the facility were not informed by the concierge about the current COVID outbreak, the DON/ICP stated that the stated that every family had been notified via their people profile; an electronic notification system that is based on a list pulled off the facility's electronic medical record (EMR). Observation on 08/20/21 at 1:50 PM, revealed the Regional Director of Operations (RDO) posted a sign at the main entrance that indicated the facility had a current COVID-19 outbreak. During an interview on 08/20/21 at 1:50 PM, the RDO stated that he was posting the COVID-19 outbreak signage now. When asked why the facility was not informing visitors who entered the building about the COVID outbreak since the facility knew about the outbreak since 11:40AM, the RDO stated that the facility was getting notifications out as fast as possible, and the facility was in compliance with CMS notification guidance. When asked if he was aware of the CMS and/or CDC guidance regarding notifying visitors who entered the building about a COVID outbreak to allow them to make an informed choice about entering the facility, the RDO stated he was not aware of any such guidance. Record review of the Visitor Coronavirus Disease COVID-19 Symptom Monitoring Log dated 08/20/21 from 11:48 AM to 1:49 PM revealed 19 visitors entered the building without the first round of testing completed. 2. Record review of the Center for Disease Control and Prevention (CDC) guideline titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated on 03/29/21, directs that In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission .Exceptions include residents within 3 month of a [CONDITION(S)]-CoV-2 infection and fully vaccinated residents .HCP [Health Care Personnel] should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these [quarantine] residents. Record review of the facility's policy titled Coronavirus Disease 2019 (COVID-l9) Revised Policy on Surveillance, Reporting & Management © 2001 MED-PASS, Inc. (April 2020) states that, The facility's revised policy on COVID-19 is developed in compliance with the most recent guidance from Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) issued AFL20-534 . Testing and 14-day quarantine are recommended for unvaccinated or partially vaccinated residents readmitted after hospitalization or who leave the SNF for more than 24 hours, as well as for residents who leave the SNF for ambulatory care (e.g., emergency department, outpatient procedures, [CONDITION(S)] or other clinic visits) when there is suspected or confirmed COVID-19 transmission at the outside facility. Observations on 08/20/21 at 12:00PM and on 08/21/21 at 7:00 PM revealed that staff on the East Unit were wearing N95 masks and shields; however, no signage for transmission-based precautions or personal protective equipment was observed in the hallways for the rooms, except for one resident. During an interview on 08/21/21 at 3:43 PM, the DON confirmed that all residents on the West wing are on COVID surveillance and quarantine and confirmed that staff were required to wear full PPE in all resident rooms on the West Wing. When questioned about any changes to PPE requirements due to the 08/20/21 outbreak, the DON stated that on the East Wing, the facility mandated staff to wear shields or goggles along with an N95 mask and did not implement full PPE because that is a Green Zone. And according to the facility policy staff are not required to wear a gown on that unit. During an observation on 08/21/21 at 6:40 PM, LVN8 entered room [ROOM NUMBER] to administer medications and was only wearing an N95 mask and face shield. During an interview on 08/21/21 at 6:41 PM, LVN8 stated that when she reported for work, she was informed that staff were now required to wear N95 masks and face shields on the East Unit green zone and she was not informed that any additional personal protective equipment (PPE) was required on the East Unit. During an interview on 08/21/21 at 7:50 PM, the DON/ICP stated that she re-reviewed COVID policies and the facility decided to place the residents on the East Unit on full PPE, gowns gloves, N95 masks and face shield in resident rooms, since the facility had ample PPE supplies and the residents were exposed to LVN5 who tested positive for COVID-19 on 08/20/21. 3. During an observation on 08/18/21 at 9:17 AM on the West Wing Yellow Zone during the Entrance Tour, the Human Resource Director (HRD) was noted in Resident (R) 14's room at the foot of the resident's bed, wearing only a N95 mask. The HRD exited the room and got a gown and face shield from the isolation drawers located in the hall next to the resident's door, re-entered the room and went to the resident's bedside. The HRD then exited the room wearing the gown and went to the isolation cart to obtain gloves and re-entered the room. During an interview on 08/18/21 at 9:20 AM, the HRD acknowledged that she was in R14's room without wearing a gown and stated she did not touch anything. After further interview the HRD acknowledged as a precaution staff are required to wear a gown in the Yellow Zone rooms and stated she forgot to put on the gloves before she went into the room, that's why she came out and got them again stating, she didn't touch anything. During the Entrance Conference on 08/18/21 at 10:45 AM, the DON/IP verified that the West Wing is a Yellow Zone for new admissions who are on quarantine for COVID-19 precautions and staff are expected to wear an N95 mask and shield in the hall and wear full PPE upon entering the room and doff the gown and gloves prior to exiting the room.

Based on record review, interviews, and policy review, the facility failed to ensure that the residents' physician was notified when medications were not available and/or clarification was needed for dosages and administration times for two of three residents (Resident (R) 12, and R2) reviewed for physician notification out of a total of 18 sampled residents. These deficient practices have the potential to affect residents who are admitted or readmitted to the facility after hospitalization . Findings included: Rrcord review of the facility's policy titled Change in a Resident's Condition or Status © 2001 MED-PASS, lnc. (Revised February 2021)revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's attending physician or physician on call when there has been a(an) . need to alter the resident's medical treatment significantly . 1. Record review of R12's Admission Record located in the electronic medical record (EMR) revealed that R12 was admitted to the facility on [DATE] with [CONDITION(S)] and [CONDITION(S)] and readmitted on [DATE] with the same diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/21/21 revealed R12 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Record review of physician Orders, located under the Orders tab in the EMR, revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication end date was 08/13/21. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no physician notification documented in the progress notes until 08/15/21 two days after the nursing staff administered the last dose of [MEDICATION(S)] on 08/13/21. Record review of nursing Progress Notes located in the EMR documented on 08/15/21 at 10:53 PM that the resident's [MEDICATION(S)] was discontinued from the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to this progress note, the resident's physician was notified. Further review of this progress note revealed the physician (Medical Director) stated R12 was not supposed to be off medication and needs to be put back on. Record review of physician Orders, dated 08/16/21 at 8:00 AM and located in the EMR, revealed a new order for [MEDICATION(S)], 1000 MG (10 ML in [MEDICATION(S)] 0.9% every 12 hours for [CONDITION(S)]. Record review of the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the August 2021MAR revealed R12 did not receive [MEDICATION(S)] on 08/16/21. Review of the medical record revealed no documentation that the physician was notified that R12 did not receive the [MEDICATION(S)] the morning of 08/16/21. Record review of a change of condition nursing Progress Note, dated 08/16/21 at 10:39 AM and located in the EMR, revealed nursing observations of seizures [MEDICATION(S)] more than 5 minutes less than 3 minutes apart 911 [emergency hospital transport] called per recommendation of MD [Medical Doctor]. Record review of untitled hospital records, dated 08/18/20 and located in the Documents tab in the EMR, revealed R12 was hospitalized from 08/16/21 through 08/18/21 for seizures and [CONDITION(S)]. R12 was diagnosed with a tonic-clonic [CONDITION(S)] (convulsion) and given [MEDICATION(S)] 1000 MG in the emergency department (ED) and continued [MEDICATION(S)] 500 MG IV twice a day. Further review of the untitled hospital records dated 08/18/20 revealed R12 was hospitalized on [DATE] for seizures and [CONDITION(S)]. The septic shock had an Unclear etiology. Maybe [CONDITION(S)] [urinary tract infection]? [sic] likely secondary to seizures .continue empiric [MEDICATION(S)] [[MEDICATION(S)]-antibiotic] for now. Further review of the hospital records revealed R12 last received [MEDICATION(S)] (generic [MEDICATION(S)]) 500 MG IV on 8/18/21 at 9:55 AM, and [MEDICATION(S)] 1000 MG IV on 08/18/21 at 9:50 AM prior to discharge from the hospital back to the facility. Review of these hospital records revealed instructions for [MEDICATION(S)] 1000 MG IV daily and to continue [MEDICATION(S)] 500 mg every 12 hours. Record review of a Nursing Admission Assessment located in the Assessments tab in the EMR revealed R12 was readmitted to the facility on [DATE] at 8:01 PM with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an additional nursing eMAR Medication Administration Note in the Progress Note located in the EMR dated 08/18/21 at 9:08 PM documented nursing was waiting for clarification of [MEDICATION(S)] 1000 MG in [MEDICATION(S)] 0.9% every 12 hours for [CONDITION(S)] precaution since the hospital records indicated 500mg of [MEDICATION(S)] was to be administered every 12 hours. Record review of a nursing Progress Note dated 08/19/21 at 4:31 AM located in the EMR documented that Pharmacy was called twice to deliver the [MEDICATION(S)] 1000 mg and said it should arrive around 7:30 AM on 08/19/21. Record review of a nursing eMAR Medication Administration Note in the Progress Note dated 08/19/21 at 9:16 AM and located in the EMR documented that staff was awaiting pharmacy deliver of [MEDICATION(S)] 1 GM (Gram) intravenously every 12 hours for infection for 5 days for infection. Further review of the nursing progress notes and eMAR notes revealed no documentation that the physician was notified of the delay in R12 receiving the [MEDICATION(S)] or the [MEDICATION(S)]. During an observation on 08/19/21 at 10:40 AM, LVN6 was observed hanging [MEDICATION(S)] 1 GM IV to R12. During the observation LVN 6 confirmed that this was the first dose of IV antibiotic medication R12 received since returning from the hospital on 08/18/21. LVN6 acknowledged that the IV [MEDICATION(S)] delivery was delayed from pharmacy and the medication that she administered to the resident was obtained from the stock medications stored in the Omnicell cabinet (a pharmacy storage unit for stock medications) in the medication room. During an interview on 08/20/21 at 12:00 PM, the Medical Director, who was also R12's physician, stated she recalled that she was contacted about the discontinuation of the [MEDICATION(S)] and did not know why restarting the medication was delayed and could not recall any specifics regarding the reinstatement order. The Medical Director stated she should have been contacted on 08/13/21 when the medication was stopped. The Medical Director stated that she would expect the admission nurse to notify her if there is a change in the medication and dosage. In addition, the Medical Director stated that if there is a problem with getting medications, she expects to receive notification so she can determine if it is acceptable for the resident's medical care to have a delay in treatment. The Medical Director could not provide an explanation for why the antibiotic dosage was altered nor why the anti-[CONDITION(S)] medication administrations were delayed and stated she should have been notified. Record review of physician Orders, dated 07/14/21 and located in the EMR, revealed R12 was receiving a TPN solution (total [MEDICATION(S)] nutrition- artificial feeding through an IV line) that did not contain potassium. Record review of a Basic Metabolic Profile (BMP - baseline bloodwork), dated 08/05/21 and located under the Results tab of the EMR, revealed R12 had a low potassium level of 3.0 mmol/L (millimoles per Liter - normal 3.5-5.0). Review of the physician Orders in the EMR revealed no orders related to this low potassium level. Record review of a nursing Progress Note, dated 08/12/21, revealed that the facility's pharmacy was called with a new order to add electrolytes [including potassium]. Further review of this nursing note revealed the IV department [of the pharmacy] had gone home for the day; the pharmacy could not make changes to the order verbally and the facility need to fax a new order or call back in the morning. Review of the progress notes revealed no physician notification for the 3.0 potassium level and/or the need for a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an 08/12/21 BMP revealed R12 had a critically low potassium level of 2.6 mmol/L. Although the physician signature is on the lab, it is not dated, thus it is unknown when the physician became aware of the critical potassium level. [CONDITION(S)] (low potassium levels) can cause abnormal heart rhythm, heart attack, or sudden [CONDITION(S)]. During an interview on 08/19/21 at 1:32 PM, the Assistant Director of Nursing (ADON) stated that she receives all the labs in the facility and acknowledged that she knew about the critically low potassium level of 2.6 and stated that she informed the physician about the labs and believed that she documented it. During an additional interview on 08/19/21 at 2:42 PM, when asked to show where she informed the physician about the critical potassium level, the ADON made reference to a nursing Progress Note in the EMR dated 08/13/21 that indicated she called the pharmacy about the potassium level of 3.0. The was no documentation in the medical record indicating the physician was notified of the 2.6 potassium until a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the physician Orders in the EMR dated 08/14/21 for the TPN solution revealed the addition of KCl (potassium chloride) 120 meq (milliequivalents) in a total volume of 1800 ml infusion at 75 cc/hr over 24 hours to the TPN solution. During an interview on 08/20/21 at 12:00 PM, Medical Director stated that she did not recall being notified of the critical potassium value of 2.6. The physician stated that she should have been notified and stated that delaying treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Record review of R 2's Admission Record located in the EMR revealed that R2 was admitted to the facility on [DATE]. Record review of the undated and untitled hospital records provided to the facility and located under the Documents tab in the EMR revealed on 10/16/20 R2 was admitted to the hospital and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Orders, revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was entered by Registered Nurse (RN)2 dated 10/24/21 and signed by the Medical Director, who is also the resident's physician. Record review of a Late Entry nursing Progress Note, dated 10/24/20 at 10:00 PM, revealed the facility was waiting for the antibiotic to arrive and the night nurse was informed of the missing medication; however, there is no indication the resident's physician was notified. Record review of an eMar Medication Administration Note in the Progress Note, in the EMR and dated 10/25/20 at 5:24 AM, documented the [MEDICATION(S)] was not available. Record review of R2's October 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] on 10/25/20 at 12:00 AM or 6:00 AM. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no progress notes in the EMR indicating the resident's physician was informed about the delay in administering the two IV antibiotic doses. During an interview on 08/20/21 at 12:00 PM, Medical Director, who was also the resident's physician, stated that she should have been notified that R2 missed two doses of antibiotics for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .