Every finding on record at Oakmont Healthcare and Rehabilitation of Humble

Based on observation, record review, and interview, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident # 4) of 5 residents reviewed for quality of care. -Resident #4's right hand splint was not put on in the AM of 06/11/26. This failure could place residents at risk for a decline in movement. The findings included: Record review of Resident #4's admission Record, dated 06/11/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis (hemiplegia is paralysis of one side of the body, while hemiparesis is weakness on one side) following cerebral infarction (ischemic stroke and requiring targeted rehabilitation for recovery) affecting right dominant side, contracture right hand (condition where the muscles in the right hand become tight and stiff, making it difficult to move; this can significantly impact a person's ability to perform daily activities and may lead to deformity in the hand), and cognitive communication deficit (occurs when a person struggles to communicate effectively because of impairments in cognitive processes such as attention, memory, and executive function rather than problems with speech or language itself). Record review of Resident #4's physician orders, start date: 04/06/26, revealed an order for splint to right hand to be donned in the AM and removed in the PM or as tolerated. Complete hand hygiene prior to donning. Monitor for skin irritation, skin breakdown, swelling and/or pain. Directions for order read every night shift. Record review of Resident #4's June 2026 Treatment Administration Record, dated 06/11/26, revealed order for splint to right hand to be donned in the AM and removed in the PM or as tolerated. Complete hand hygiene prior to donning. Monitor for skin irritation, skin breakdown, swelling and/or pain. Every night shift. Further review revealed order was scheduled for June 2026, Hours: Night, and was checked off splint was removed every night. Record review of Resident #4's Quarterly MDS Assessment, dated 05/23/26, revealed a BIMS score of 5, indicating severely impaired cognition. Further review revealed resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) when completing oral hygiene, toileting, shower/bathe, upper and lower body dressing, and personal hygiene. Resident #4 also had a functional limitation in range of motion with upper extremity (shoulder, elbow, wrist, hand). Record review of Resident #4's Care Plan, undated, revealed resident had an alteration in musculoskeletal status r/t pain in right upper extremity and swelling in right hand. Intervention included encourage/supervise/assist with the use of splints as recommended. Resident had right splint with interventions including to follow orders. Observation and interview on 06/11/26 at 9:09 a.m. revealed, Resident #4 was not in her room or currently in the building. MA A said resident was out on a medical appointment. Observation and interview on 06/11/26 at 12:58 p.m. revealed Resident #4 was sitting in her wheelchair and watching television in an area located in front of the nursing station. She had a white hand towel rolled up in her right hand. An interview was attempted but responses were not understood. During a telephone interview on 06/11/26 at 9:53 a.m., revealed a family member of Resident #4 met resident at her medical appointment today and resident was not wearing her splint. The family member said they spoke to someone (date and name unknown) in rehabilitation and was told they did not know when she should be wearing her splint. The family member said Resident #4's right hand was now clenched tight. During an interview on 06/11/26 at 10:32 a.m., the Director of Rehabilitation said Resident #4 received an order to wear a splint in the AM and to be removed in the PM. She said the resident was evaluated on 03/11/26, the authorization for OT was received on 03/31/26, and resident received services until 05/08/26. She said by 05/08/26, Resident #4 was able to tolerate her splint. She said resident has a hard custom splint that she wears during the AM and is off at PM. She said nursing staff is responsible for putting on and removing the splint. She said resident is not receiving OT at this time because the splint has taken its place. During an interview on 06/11/26 at 11:13 a.m., the DON said the CNAs put Resident #4's splint on but it is the nurses' responsibility to ensure that it is put on. She said the resident's order is for splint to be placed on in the AM and removed in PM. During an interview on 06/11/26 at 11:30 a.m., CNA A said Resident #4 was sent to her morning medical appointment today without her splint. She said it was a busy morning, and she did not put the splint on after she got the resident up this morning. She said the resident's hand could become more contracted if the splint was not worn as ordered. During an interview on 06/11/26 at 11:52 a.m., Nurse A said it is the responsibility of the nurses to make sure the splint is put on and taken off per orders. She said she did not put the splint on the resident this morning because she did not believe the order was still there. During an interview on 06/11/26 at 3:00 p.m., the DON said she started working at the facility on 03/24/26 and was not aware Resident #4 did not have her splint placed on her this morning. She said it could cause further contraction or further immobilization.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for residents, staff, and the public, for 2 of 21 resident rooms (Resident #39 and #28) reviewed for physical environment.The facility failed to maintain clean privacy curtains for Resident #39 and clean bed linen for an unoccupied bed in Resident #28's room.This failure could lead to residents experiencing a diminished quality of life. Findings included:Record review of Resident #39's face sheet dated 02/26/26 revealed a [AGE] year-old admitted to the facility on [DATE]. His diagnoses included stroke, contractures, Hemiplegia (one sided paralysis or severe loss of strength on one side), diabetes (a chronic condition that occurs when blood glucose levels are too high) and peripheral vascular disease (a disorder of blood vessels outside the heart that affects blood flow to the limbs).Record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderate cognitive impairment. He required substantial assistance with all ADLs and he was frequently incontinent of bowel and bladder.Record review of Resident #28's face sheet dated 02/26/26 revealed a [AGE] year-old admitted to the facility on [DATE]. Her diagnoses included dementia (a general term for a group of symptoms that cause a loss of cognitive functioning), depression, anxiety, gastrostomy status (presence of abdominal feeding tube), colostomy status (presence of abdominal appliance to collect waste to manage bowel function), stroke, hemiplegia (paralysis or severe loss of strength on one side) and pressure ulcers.Record review of Resident #28's quarterly MDS dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. Resident #28 required maximum assistance from staff for all ADLs.Observation on 02/25/26 at 8:20 AM of the privacy curtain for Resident #39 revealed it had multiple large orange-brown stains.Observation on 02/25/26 at 10:45 AM, Resident #28 had an unoccupied bed in the room. The white bedspread had multiple brown and black stains.Observation and interview on 02/26/26 at 7:30 AM revealed the privacy curtain had multiple large orange-brown stains. Resident #39 stated the curtain was dirty and needed to be changed. CNA V stated that the privacy curtain had stains and should be clean. CNA V stated that if privacy curtains needed attention, she would notify maintenance to bring it down off the hooks and laundry to bring clean curtains for replacement.In an interview on 02/26/26 at 11:35 AM, the Housekeeping Supervisor stated that the privacy curtain in Resident #39's room had multiple yellow/orange stains and should be changed out because it was an infection control issue. The Housekeeping Supervisor stated the unoccupied bed in Resident #28's room had stains and she could not tell if the blanket had ever been washed. The Housekeeping Supervisor stated that the blanket should have never even made it on the clean linen cart and should not have been used to make up the bed because it did not look clean and would leave a bad impression. The Housekeeping Supervisor stated that if it was her loved one and saw the bed with a blanket with stains, she would feel bad about the facility.In an interview on 02/26/26 at 11:40 AM, the Administrator stated she oversees the housekeeping department. The Administrator stated she expected housekeepers when making rounds to report dirty privacy curtains or dirty bedding covers to the Housekeeping Supervisor. The Administrator stated she also expected facility staff to make their rounds and those who go into resident rooms to provide care, report anything that would need to be cleaned or replaced to the housekeeping supervisor. The Administrator stated she expected linen and privacy curtains to be in good repair and to be clean, free of odors and stains to help keep residents comfortable.Record review of the undated facility policy for Resident Rights revealed in part: .The facility must provide - 1. A safe, clean, comfortable and homelike environment.2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; 3. Clean bed and bath linens that are in good condition.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 19%, based on 5 errors out of 26 opportunities, which involved 2 of 6 residents (Resident #26 and #28) and 2 of 4 staff (LVN J and LVN D) observed during medication administration reviewed for medication errors.LVN J administered insulin to Resident #26 at the incorrect time according to the facility MAR.LVN D failed to flush with water between medications during g-tube administration for Resident #28.These failures could place residents at risk of not receiving the desired therapeutic effect of their medications.Findings include:Resident #26Record review of Resident #26's admission record dated 2/26/26 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), hyperglycemia (high blood sugar), and moderate protein-calorie malnutrition.Record review of Resident #26's quarterly MDS assessment dated [DATE] revealed a BIMS score of 1 out of 15 which indicated severe cognitive impairment. He required assistance from staff with ADL care and was on insulin.Record review of Resident #26's order summary report revealed an order for Humalog Kwikpen inject as per sliding scale: if 150-200 = 0 monitor; 201-250 = 2U; 251 - 300 = 4U; 301 - 350 = 6U; 351-400 = 8U; 401-450 = 10U; 451-500 = 15U notify provider, two times a day for diabetes related to type 2 diabetes, order date 1/14/26.Record review of Resident #26's February 2025 MAR revealed the Humalog Kwikpen per sliding scale was scheduled twice a day for AM and PM. 8 units of Humalog was marked as administered on 2/25/26 by LVN J for the AM dose for a blood sugar level of 382.Record review of the facility's undated Medication Administration Times revealed AM times were 6:30 a.m. - 10:30 a.m.; Midday was 11:00 a.m. - 2:00 p.m.; afternoon was 6:00 p.m. - 10:00 p.m. and bedtime was 8:00 p.m. - 10:00 p.m. In an observation on 2/25/26 at 11:01 a.m. LVN J retrieved Resident #26's blood sugar which was 463. She reviewed Resident #26's insulin orders on his order sheet but did not reference the electronic MAR. She administered 15 units of Insulin lispro (Humalog) to Resident #26. LVN J pulled up the electronic MAR to document the insulin as administered but the Humalog insulin was colored green (which indicated the medication was already administered). LVN J said she already administered insulin to Resident #26 this morning when his blood sugar was 383. She said nurses rechecked Resident #26's blood sugar around lunch time if his blood sugar ran over 250 in the morning and would administer insulin according to the sliding scale. She said she should have called Resident #26's NP first to get an order to administer the insulin but there was no order to check his blood sugar or give insulin at this time. She said prior to administering medication she usually reviewed the eMAR to see what medication to give. She said there was no risk to the resident because his blood sugar level was high. Resident #28Record review of Resident #28 admission record dated 2/25/26 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included dementia, gastrostomy status (a surgically created opening into the stomach, typically with a feeding tube (G-tube) in place for nutrition, hydration, or medication delivery), hypotension (low blood pressure), generalized anxiety disorder, and epilepsy (chronic brain disorder characterized by recurrent unprovoked seizures).Record review of Resident #28's discharge MDS assessment dated [DATE] revealed her cognitive level was not assessed. She was dependent on staff for ADL care and had a feeding tube.Record review of Resident #28's care plan completed on 11/12/25 revealed she required a tube feeding related to swallowing problem, late effects of CVA. Interventions: the resident is dependent on tube feeding and water flushes. See MD orders for current feeding orders.Record review of Resident #28's order summary report revealed orders for: Enteral feed order every shift flush enteral tube with at least 10 mls of water between each medication, order date 9/17/25; Gabapentin 100 mg 1 capsule via g-tube three times a day for nerve pain, order date 1/19/26, Midodrine 2.5 mg 1 tablet via g-tube three times a day for hypotension, order date 8/13/25,Lorazepam 1 mg 1 tablet via PEG tube three times a day for anxiety, order date 11/8/25,Valproate sodium oral solution 250 mg/5 mL give 3 mL via g-tube three times a day for seizure, order date 8/13/25.In an observation on 2/25/26 at 1:05 p.m. revealed LVN D prepared the following medications for Resident #28: Gabapentin 100 mg, Midodrine 2.5 mg, Lorazepam 1 mg, and Valproate acid 3 mL. LVN D entered Resident #28's room and began medication administration via g-tube to Resident #28. LVN D checked for g-tube placement and residual. She administered the four medications without flushing with water in between each one. After administering the last medication, she flushed the tube with 30 mL of water. LVN D said she forgot the water flush in between the medications and said she did not have an order to flush with water in between the medications. After completing the medication pass, LVN D exited the room and began to document the medication administration on the computer. She reviewed the medication orders for Resident #28 and when the order for flush enteral tube with at least 10 mL of water between each medication appeared, she said she got nervous and forgot to flush between each medication. In an interview on 2/26/26 at 10:22 a.m. the interim DON said medications should be given per order. She said nursing staff should ensure they review the physician order from the eMAR to ensure the medication matches and is provided at the right time. She said the PM timeframe was scheduled from 6:00 p.m. - 10:00 p.m. She said g-tube medications should be flushed per the MD order and the purpose of the water flush in between medications was to ensure all medication has gone through the tubing. In an interview on 2/26/26 at 11:34 a.m. the Administrator said she expected the medication error rate to be 5% or less. She said medication passes were a part of the rapid response team. Record review of the facility's Medication Administration and General Guidelines dated 2025 read in part, .Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the attending physician. 6. All current medications and dosage schedules, except topicals used for treatments, are listed on the resident's medication administration record (MAR). 10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specifictime then the med must be given 30 minutes prior to 30 minutes after the specified time (unless facility policy directs otherwise). Before or after meal orders are administered precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. Checklist for completing proper steps in the administration of medications. Adheres to the 6 Rights of Medication Administration.5) Right Time.Record review of the facility's Enteral Tube Medication Administration dated 2025 read in part, .The facility assures the safe and effective administration of enteral formulas and medications. 7. Read medication label three times before administering, checking with MAR.Administer each medication separately, flushing tube with 5-15 ml of water after each dose.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights set forth to attain or maintain the residents highest practicable physical, mental, and psychosocial needs and well-being for 1 of 14 (Resident #69) residents.The facility failed to ensure that Resident #69's care plan documented interventions for hand contractures.This failure could result in residents being at risk and not receiving proper care.Findings included:Record review of Resident #69's undated admission record revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included multiple sclerosis (long lasting disease or central nervous system), tremor, muscle weakness, lack of coordination (muscle control problem), mild cognitive impairment, and muscle spasm.Record review of Resident #69's SBAR Assessments for dates ranging 07/16/2024-02/23/2026 did not reveal a change in condition for left hand contracture.Record review of Resident #69's MDS Quarterly assessment dated [DATE] revealed a BIMS score of 10 out of 15 indicating he had moderately impaired cognition. He had impairment on one side to the upper extremity (shoulder, elbow, wrist, hand) and no impairment on both sides to the lower extremity (hip, knee, ankle, foot).Record review of Resident #69's MAR revealed an order for Cyclobenzaprine 10mg tablets, one tablet three times a day for multiple sclerosis, Baclofen 10mg tablets, one tablet three times a day for muscle spasms, and Propranolol 20mg tablets, one tablet two times a day for tremor.Record review of Resident #69's Care Plan dated 08/20/2024 did not identify interventions for contracted left hand.In Observation and Interview on 02/25/2026 at 10:12am Resident #69 was observed lying in bed with a left-hand contracture without a brace in place. Resident #69 stated he sometimes experiences pain in his left hand and is unable to fully open it. Resident #69 stated he was not receiving therapy at this time and began to dose off.In an interview with DOR on 02/25/2026 at 11:28am she stated she was recently made aware of Resident #69's left hand contracture and he is currently being trialed with a splint every day for one hour. Resident #69 was recently placed on therapy case load three times a week for the hand contracture and when the services are discharged , he will be recommended to wear a splint up to four hours, daily. At this time, the contracture concern is being actively addressed to prevent potential harm. In an interview with LVN J on 02/25/2026 at 12:28pm she stated she has noticed the left-hand contracture for Resident #69, because the staff has been setting up the tray for him to eat. LVN J stated the resident was admitted to the facility with the left hand contracted, and he does not complain of pain, but if he was to complain, he has been prescribed PRN Norco. To her knowledge the resident was admitted with the contracture, which should be indicated in the care plan, although she has not noticed a decline in his hand usage. Should the contracture not be care planned, she would reassess for a change in condition and follow the plan for treatment according to MDS, IDT, DON, PT, and NP/MD. The risk of if the care plan is not revised to address the hand contracture; the resident could lose total control and continue to get worse if therapy is not being provided.In an interview with MDS RN on 02/25/2026 at 12:41pm she stated care plans are updated through IDT process which includes initials, annuals, and acute care. MDS RN stated she is aware Resident #69 has multiple sclerosis and it could affect his hands. She also stated if Resident #69 was admitted with contractures, it would have been addressed on the MDS assessment. The expectation for assessments and care plans is communication from nursing by a communication form, CNA report, verbal, or communication meetings. If the information is not communicated, she cannot assess any changes to ensure the care plan is updated. In addressing the concern for Resident #69, the contracture should have been incorporated into the care plan, as failure to do so could place him at risk for reduced mobility and increased need for assistance with eating.In an interview with ADMN on 02/25/2026 at 1:01pm she stated the expectation for revising care plans is that the clinical team discusses residents daily and ensures medication reviews and other relevant items are incorporated and updated in the care plan as needed. She stated when there is a change in condition, the expectation is to notify the NP/MD and the family so that any necessary test can be completed to update the residents plan of care. The clinical team consisting of the ADON, Treatment Nurse, Rehab, DON, and ADMN is responsible for informing MDS and IDT of changes in a resident's status. The ADMN further stated she is aware that Resident #69 has a diagnosis of multiple sclerosis, which may have contributed to the hand contracture not being adequately addressed in the care plan. Failure to revise the care plan to include interventions for the contracture could result in the resident not receiving needed care and experiencing delays in services. In an interview with Interim DON on 02/26/2026 at 10:35am she stated she was not aware of Resident #69's left-hand contracture; however, the expectation is that nursing staff immediately report any observed change so the resident can be properly assessed. If the SBAR is not completed, the care plan cannot be updated, resulting in a missed opportunity to provide necessary care and placing the resident at risk. In an interview with ADON on 02/26/2026 at 2:50pm she stated SBAR is the assessment tool used to determine when the family and the physician must be notified. As soon as the change is observed, anything that is not the resident's normal status, staff are expected to report it immediately. The SBAR provides real time guidance on what actions to take and how to process the change. She is responsible for acute care updates and stated she revises care plans daily. ADON stated with every change in condition, the physician is notified, and each concern is evaluated promptly. She is familiar with Resident #69's contracture, though she was not entirely aware of its extent, and noted that she would have updated the care plan or completed an assessment had the concern been communicated to her. Failure to act on a change could lead to worsening symptoms or severe outcomes, which is why staff are expected to intervene early regardless of how the change presents.The facility policy for Change in Condition, Notifying the Physician of Change in Status undated, reads.This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nursewhen to notify the physician.1. The nurse will notify the physician or their delegated nurse practitioner or physician assistant withchange in status. The nurse will document signs and symptoms of significant change, time/date of callto physician, and interventions that were implemented in the resident's clinical record.8. If the resident remains in the facility and a significant change has occurred, update the care planaccordingly.

Number of residents sampled: Number of residents cited: Based on interviews, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision for 1 (Residents #71) of five residents reviewed for accidents and hazards.The facility failed to ensure that Resident #71's face was not pressed against the nightstand while she was getting incontinent care. This failure could place residents at risk of injury. Findings included:Record review of a face sheet dated 2/25/2026 indicated Resident #71 was a [AGE] year-old female who admitted on [DATE] with diagnoses including Type 2 Diabetes, Hypermetropia, farsighted, Age-Related Nuclear Cataract, Bilateral (A Major cause of blindness), Dementia, Major depressive disorder, Anxiety disorder, Heart Failure, and Edema (Swelling caused by excess fluid trapped in the body's tissues).Record review of the comprehensive care plan dated 01/07/2026 indicated Resident #71 was at risk to falls related to impaired cognition, confusion, gait/balance problems, incontinence, functional quadriplegia (complete immobility). The intervention for Resident #71 included anticipate and meet the resident's needs and be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The comprehensive care plan indicated Resident #71 was incontinent of bowel and bladder. The interventions included apply barrier cream after every incontinent episode, check resident every two hours and assist with toileting as needed. Check resident every two hours and assist with toileting as needed. Record review of an admission MDS dated [DATE] indicated Resident #71 had a BIMS score 07 which indicated she had severe cognitive impairment. Section GG Functional Status of the MDS indicated Resident #71 required a wheelchair and was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, lower body dressing, putting on/taking off footwear, sit to stand, chair/bed to chair transfer and tub/shower transfer. The MDS in Section H Bladder and Bowel indicated Resident #71 was always incontinent of bowel and bladder.In an interview on 02/24/2026 at 9:39AM with Resident #71, she stated there was an incident last month in which she was getting incontinent care and her face was pressed up against the nightstand when CNA-JK turned her over. She stated she did not think CNA JK did it on purpose but reported that it caused discomfort to her right side of her jaw.In an interview on 02/25/2026 at 2:59PM with CNA JK, she stated she was familiar with Resident #71 because she had worked with her in the past. She stated about a month ago, she and another CNA were doing incontinent care with Resident #71 and they turned her carefully and her face was placed on the nightstand. She stated the resident did not complain of any pain. She stated she never noticed that her face was swollen. She stated after incontinent care was finished, they carefully turned the resident back over. She stated no one ever informed her that the resident complained that she was hurt or that she was in discomfort. She stated the resident was a two person assist and another CNA was assisting her that day. She stated she worked with the resident prior to the incident and she does not recall the resident complaining of pain to her jaw just pain to her legs. She stated an in-service was done after the incident with the former DON to educate her of the situation due to the residents face being place on the dresser during incontinent care.In an interview on 02/26/2026 at 9:47AM with Previous DON - She stated she was employed at facility from November 2025- February 03, 2026. She stated Resident #71 informed her that she did not want CNA JK working with her anymore due to her not listening and stated she was not doing what she wanted her to do so she requested that the staff member not be assigned to her anymore. She stated they reassigned the staff member to another hall. She stated a few days later Resident #71 came up to her and implied during incontinent care that CNA JK turned her over and her face touched the nightstand. She stated she assessed the resident's face and she did not complain of pain and she did not observe any swelling. She stated the resident's face was asymmetrical so the right side of her face was slightly larger than the left side of her face. She stated a little while after, the Rehab Director informed her that the resident was unable to wear her dentures due to swelling to the right side of her face. When asked if she reassessed the resident, she stated she did not because she had already assessed the resident and the resident's face was asymmetrical. She stated she informed the abuse coordinator, which was the administrator, of the incident. She stated out of an abundance of caution, the Administrator informed her that the resident get an X-Ray due to the resident's previous allegations against other staff members and because the resident complained of swelling to her face. She stated the resident's X ray results came back negative. She reiterated that when she observed the resident her face was not swollen, the resident's face was asymmetrical and that the resident did not complain of pain. She stated she did an in-service with CNA JK. In an interview on 02/26/2026 at 3:30PM with CNA JL she stated Resident #71 was a 2 person assist. She stated she recalled doing a 2 person assist with CNA JK for Resident #71. She stated she was standing on the window side and CNA JK was standing on the opposite side and they were turning the resident like normal. She stated Resident #71's face was towards the nightstand, and it was close to the nightstand, but it never touched the nightstand. She stated Resident #71 never said anything to her about her face being pressed up against the nightstand and she never complained of any pain. She stated she never observed Resident #71's face being swollen or any lumps. In an interview on 02/26/2026 with the Administrator at 3:45PM, she stated the former DON stated she did a one on one with CNA JK (ensuring she was gentle and respectful to the resident while performing incontinent care and customer service). She stated she was unable to provide the documentation from the in-service due to the former DON taking items with her when she was terminated. Record review of Resident #71's Xray findings dated 01/09/2026 revealed views of the facial bones demonstrated no acute fracture or dislocation. Record review of facilities undated Resident Rights policy revealed; Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. a. a. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.On 02/26/2026, a Policy for Accidents/Supervision was requested and the Administrator reported the facility did not have a policy as such.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of three (Resident #6) residents reviewed for respiratory care.The facility failed to ensure Resident #6's oxygen was administered at the prescribed setting.These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included:Record review of Resident #6's face sheet dated 02/25/26 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #6's diagnoses included progressive supranuclear ophthalmoplegia (a rare neurological disorder characterized by the gradual loss of voluntary eye movement), chronic respiratory failure with hypoxia (a long-term condition where lungs cannot supply enough oxygen to the blood, leading to persistently low oxygen levels), Alzheimer's disease, bipolar disorder (a mental illness characterized by mood swings and depressive episodes) and shortness of breath (SOB).Record review of Resident #6's quarterly MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderate cognitive impairment. Section O of the MDS revealed she was receiving oxygen therapy treatments.Record review of Resident #6's order summary report revealed a physician's order for oxygen 3L/m via nasal cannula every shift r/t chronic respiratory failure with hypoxia, date ordered 02/24/26. Further review revealed a Hospice Services, date ordered 03/20/25.Record review of Resident #6's undated care plan revealed: focus - Resident #6 has Oxygen Therapy - date initiated 09/16/25. Goal - Resident #6 will have no s/sx of poor oxygen absorption. Interventions included - give medications as ordered by physician; oxygen as ordered per nasal cannula.Record review of Resident #6's Physician Progress Notes effective date 02/23/26 included pulmonary function testing results from 12/02/25 read in part: .Clinical Significance: Confirms severe restrictive lung disease.Patient reports shortness of breath with history of 2 years smoking. Findings support continued supplemental oxygen for comfort, respiratory status monitoring, and optimization of comfort measures for dyspnea management given hospice status.Record review of Resident #6's Oxygen Saturation Summary revealed on 02/24/26 at 12:30 AM, Resident #6's oxygen saturation rate was 98%, with oxygen via nasal cannula.Observation and interview on 02/24/26 at 10:00AM revealed Resident #6 was receiving oxygen via nasal cannula and the oxygen concentrator setting was 4L/min. Resident #6 stated the oxygen was to help her breathing.Observation and interview on 2/25/26 at 9:43 AM revealed Resident #6 did not have the nasal cannula on her face. The nasal cannula was draped over the bedside table out of reach for Resident #6. The oxygen concentrator was set at 4L/m. Resident #6 stated that sometimes she did not like the nasal cannula on because it hurt the back of her ears and she did not know why it was on the table. Resident #6 was not in any respiratory distress.Observation and interview on 02/25/26 at 10:40 AM revealed LVN G replaced the nasal cannula on Resident #6 and stated sometimes Resident #6 takes off the nasal cannula d/t pain behind the ears. LVN G stated he would get something to help cushion the back of the ears. LVN G stated the oxygen setting was supposed to be at 3L/m and then reduced the oxygen from 4L/m to 3L/m. When asked if he checked the oxygen setting, LVN G stated he replaced the humidifier early in the morning and checked her O2 saturation rate which was in the 90's. When asked why the oxygen concentrator was set at 4L/m, LVN G stated he would check her saturation rates.In an interview on 2/25/26 at 11:00 AM, LVN G stated Resident #6's oxygen saturation rate was currently 97 to 98%. LVN G stated he was responsible for ensuring the oxygen was set correctly as per physician orders. LVN G stated the reason Resident #6 was receiving oxygen was d/t her diagnoses of chronic respiratory failure and shortness of breath and that the order was for continuous oxygen. LVN G stated the goal for oxygen saturation is to be no less than 92% and 93% or greater would be more than ideal. LVN G stated the risk of not having enough oxygen delivered would be shortness of breath and the resident may pass out. LVN G stated Hospice services were in Resident #6's room earlier in the day and maybe took the nasal cannula off, forgetting to replace it after providing care to Resident #6.In an interview on 2/26/26 at 8:30 AM the Interim DON stated it was the nurse's responsibility to ensure oxygen was set correctly by physician orders and that she expected the nurses to monitor settings every shift to ensure residents did not have breathing issues because they are on oxygen for a reason and orders should be followed. The Interim DON stated the risk to a resident was potential shortness of breath. The Interim DON stated Hospice services was with Resident #6 on 2/24/26 and on 2/25/26 and may have set the oxygen to 4L/m.Record review of the facility's undated policy for Oxygen Administration read in part: .Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse.

Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident #1) of 5 residents reviewed for range of motion.The facility failed to ensure Resident #1's leg and hand splint was offered and applied according to MD orders.This failure could result in worsening of contractures and ADL decline.Findings include:Record review of Resident #1's admission record dated 1/28/26 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included cerebral infarction (stroke), contracture, left knee (onset: 7/2/25; contracture is a permanent shortening producing deformity or distortion), hemiplegia (one-sided paralysis or weakness) affecting left nondominant side, and cognitive communication deficit.Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care. His range of motion in his upper and lower extremities was impaired on one side. Record review of Resident #1's care plan reviewed on 12/29/25 revealed he had alteration in musculoskeletal status related to contracture left hand, left knee. Interventions were to encourage/supervise/assist the resident with the use of supportive devices splints, as recommended. Monitor left hand and left knee splint/carrot (designed to position the finger away from the palm) daily and wear as tolerated.Record review of Resident #1's Order Summary Report revealed orders for:Splint order: Don/doff (put on/remove) left knee splint and will safely wear during daily tasks without redness, skin irritation, swelling, pain or discomfort, every day shift for contracture patient to wear up to 4 hours daily or as tolerated, order date 7/2/25;Splint order: complete hand hygiene prior to donning. [NAME] left hand orthotic daily and wear as tolerated. Monitor for skin irritation, skin breakdown, swelling, and/or pain every day shift for left hand contracture wear splint 4 hours or as tolerated, order date 7/2/25.Record review of Resident #1's MAR for January 2026 revealed the left knee splint for contracture, patient to wear up to 4 hours daily or as tolerated was signed as administered every day from 1/1/26 - 1/27/26. LVN A documented as administered on 1/1/26, 1/5/26, 1/6/26, 1/9/26, 1/10/26, 1/11/26, 1/14/26, 1/15/26, 1/19/26, 1/20/26, 1/23/26, 1/24/26, and 1/25/26. The left hand orthotic wear as tolerated every day shift for 4 hours or as tolerated was documented as administered every day from 1/1/26 - 1/27/26. LVN A documented as administered on 1/1/26, 1/5/26, 1/6/26, 1/9/26, 1/10/26, 1/11/26, 1/14/26, 1/15/26, 1/19/26, 1/20/26, 1/23/26, 1/24/26, and 1/25/26.In an interview on 1/28/26 at 10:22 a.m. Resident #1's family member said his legs were restricted from his knee and it was not like that when he admitted to the facility. She said he remained in the same position and staff did not rotate him or anything. In an observation on 1/28/26 at 10:56 a.m. Resident #1 was lying on his right side and his lower extremities were contracted and folded toward the right side. There was no splint observed on his legs. In an observation on 1/28/26 at 11:26 a.m. of Resident #1 there was no splint on his left hand.In an interview on 1/28/26 at 12:40 p.m. LVN A said he sometimes put a pillow in place for Resident #1's contractures. In an interview on 1/28/26 at 12:59 p.m. the Director of Rehabilitation said when Resident #1 was on therapy services for PT they worked on left lower extremity strength, passive ROM of the left knee and issued a left knee splint. When therapy applied the splint, the resident tolerated it for a short amount of time and would become aggressive. For OT they supplied a left-hand carrot. She said Resident #1 was no longer on PT or OT and ended services at the end of October 2025.In an interview on 1/28/26 at 1:16 p.m. LVN A said the nurse was responsible for applying the splint to Resident #1 on the day shift, and he did not wear a splint at night. He said the last time he saw a splint on Resident #1's left hand was a few weeks ago. He could not find the splint for Resident #1's hand because the resident moved rooms. The hand splint was needed for contractures, and he did not ask the therapy department for a replacement splint. He said he could not remember the last time he applied a splint on the leg, maybe last year. His leg splint was needed for his contracture; his leg contracture was the same and had not worsened. He said sometimes he forgot about the resident's splints and if Resident #1 was up in the wheelchair that would remind him that he needed his splint on. He said the nurses document application of the splints on the computer. He said he signed off on the computer that the splint was applied but that was not correct. He said sometimes the resident would refuse and was a difficult patient but if he refuses, there should be a nursing note and a notification to the NP. He said his contractures could get worse if his splints were not applied as ordered.In an interview on 1/28/26 at 1:30 p.m. CNA J said she did not normally work with Resident #1 but was assigned to him today. She said his legs were contracted and she had never seen a splint on him and was not told one should be on.In an observation on 1/28/26 at 1:55 p.m. LVN A placed a splint on Resident #1's left leg.In an interview on 1/28/26 at 2:11 p.m. the DON said PT could monitor to ensure the splints were in place but ultimately the charge nurse was responsible. She expected physical therapy staff to train staff on splints. She said if the care was documented as done she expected it to be done. The purpose of the splint was to ensure the contracture did not worsen. She said if a resident refused care the nurse should report it to the ADON, DON, and PT for advice. In an interview on 1/28/26 at 2:11 p.m. the Regional Compliance Nurse said the application of Resident #1's splints was transferred over to the nursing department. He said if the resident refused the splints staff should contact the provider to determine if it should be continued or not. He said a waiver would also be signed.In an interview on 1/28/26 at 2:19 p.m. LVN E said she thought Resident #1 wore splints but could not remember because there were a lot of residents who wore splints. She said the nurses were responsible for putting on the splints. She could not remember the last time she applied the splints on Resident #1 but said if she charted it she did it. In an interview on 1/28/26 at 3:36 p.m. CNA B said she normally worked with Resident #1. She said he used to have splints but the last time she saw one on the resident's leg was about 1 month ago. She said she never saw a splint on his hand. Record review of the facility's undated Immobilization Devices, Splints/Slings/Collars/Straps policy read in part, .Splintsare also used to treat contractures to prevent further decline. Goals 1. The resident will achieve safe and effective application of supportive immobilization devices. Procedure. 1. Review physician's order. Perform hand washing. 15. Document all care and the residents' response to treatment in the clinical record.

Based on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 5 residents reviewed for comprehensive care plans.The facility failed to ensure Resident #1's fall mat was in place on 1/28/26 according to the care plan. The facility failed to ensure Resident #1 was changed with 2 people instead of 1 on 1/28/26 as indicated in the care plan. The facility failed to check Resident #1's brief every 2 hours on 1/28/26 as indicated in the care plan. These failures could place residents at risk of not being cared for according to their wishes and specialized care plan.Findings include: Record review of Resident #1's admission record dated 1/28/26 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included cerebral infarction (stroke), contracture, left knee (onset: 7/2/25; contracture is a permanent shortening producing deformity or distortion.), hemiplegia (one-sided paralysis or weakness) affecting left nondominant side, need for assistance with personal care and cognitive communication deficit.Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 which indicated moderate cognitive impairment. He required substantial/maximal assistance from staff with toileting hygiene and rolling left and right. He had no falls since admission/entry or reentry or the prior assessment.Record review of Resident #1's care plan reviewed on 12/29/25 revealed he was at risk for falls related to hypertension (high blood pressure) and actual fall (dated 5/7/25). Interventions included: actual fall 5/7/25 bilateral fall mats to both sides of bed. He had an ADL self care performance deficit related to CVA and contracture. Interventions included bed mobility requires staff x 2 for assistance, toilet use: requires staff x 2 for assistance. Resident #1 had bowel incontinence. Interventions were to check the resident every two hours and assist with toileting as needed.Record review of Resident #1's Kardex (care plan chart or template) dated 1/28/26 revealed he had an actual fall 5/7/25 bilateral fall mats to both sides of bed. Toileting: check resident every two hours and assist with toileting as needed. Toilet use: requires staff x 2 for assistance. Bed mobility requires staff x 2 for assistance. Incontinent care at least every 2 hours and apply moisture barrier after each episode.In an observation and interview on 1/28/26 at 10:09 a.m. of Resident #1 he was lying on a scoop mattress. There was no fall mat to the left or right side of the bed. Resident #1 nodded his head yes that someone changed him this morning, but he did not know who or when.In an observation and interview on 1/28/26 at 11:07 a.m. of Resident #1 with LVN W his brief was soiled and displayed a blue line. LVN W said the blue line indicated the brief was wet. Resident #1 shook his head no when asked if he was wet.In an interview on 1/28/26 at 11:15 a.m. CNA J said she was assigned to 18 residents. Her shift started at 6 a.m. but said she arrived at 9 a.m. and had not changed Resident #1 yet. She said she had not been in the room with Resident #1 since she arrived. In an interview on 1/28/26 at 11:19 a.m. CNA K said he was in orientation and was following the assigned CNAs. He said he had not changed Resident #1 since the start of his shift at 6:00 a.m.In an observation on 1/28/26 at 11:25 a.m. CNA J entered Resident #1's room and changed his brief alone. Observation of the soiled brief revealed Resident #1 had a bowel movement.In an interview on 1/28/26 at 11:43 a.m. CNA L said she was in orientation and was following the assigned CNAs and had not checked on Resident #1 since the start of her shift at 6:00 a.m. In an interview on 1/28/26 at 11:45 a.m. LVN A said he arrived at the facility around 6:20 a.m. this morning and when he arrived the night CNA (assigned to Resident #1) had already left. He said CNA J arrived late but CNA A and two orientees (CNA K and CNA L) were present. He said he began to obtain blood sugars and did not change any residents.In an interview on 1/28/26 at 11:59 a.m. CNA A said she arrived at work around 6:03 a.m. and did not provide care for CNA J's section (including Resident #1) before CNA J arrived at an unknown time.In an interview on 1/28/26 at 12:40 p.m. LVN A said Resident #1 had a fall in the past and that was why he had a fall mat. In an observation and interview on 1/28/26 at 1:30 p.m. CNA J said Resident #1 was a one person assist with incontinent care but was unsure what the Kardex said. CNA J reviewed the Kardex and said Resident #1 was a 2 person assist. She said she was unsure why he required two people for incontinent care but said it could be because his legs were contracted, and he did not help with turning in the bed. She said she was supposed to check and change him every 2 hours and last changed him at 11 a.m. She said she never saw a fall mat at the bedside and the Kardex would notify her if he needed one. Observation revealed the fall mat was in the resident's closet.In an interview on 1/28/26 at 2:11 p.m. the DON said the facility was working on personalizing the care plan to the resident but had not reviewed Resident #1's yet. She said the charge nurses should monitor to ensure the fall mat was in place and the purpose of the mat was to provide cushion in the event of a fall. She said if the care plan specified two people were required for care she expected staff to have two people for safety and not do it by themselves so the residents and staff would not be at risk. She said she expected her staff to be present at the beginning of their shift to receive a shift report and start their day. If not, it could impact resident care.In an interview on 1/28/26 at 2:11 p.m. the Regional Consultant Nurse said Resident #1 was weaker and required more assistance on admission. He said his care plan should be updated (to reflect his current needs). In an interview on 1/28/26 at 4:04 p.m. LVN W said fall mats were one of the first fall interventions for Resident #1 but since they got the scoop mattress, he did not need the mats anymore and had not fallen since. She said the facility needed to update his care plan. Record review of the facility schedule for 1/28/26 revealed CNA J was assigned to Resident #1 from 6 a.m. - 2 p.m. Record review of the facility's undated Comprehensive Care Planning policy read in part, .The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.

Based on observation, interview and record review, the facility failed to ensure the residents have the right to a safe, clean comfortable, and home like environment, including but not limited to receiving treatment and supports for daily living safely for residents, staff and the public for 3 of 4 days (09/15/2025, 09/16/2025, 09/18/2025) for 2 (Resident #2 and Resident #7) of 21 residents.The facility failed to maintain a clean and sanitary environment in resident rooms, specifically regarding the cleanliness of the floors.This failure could place risk for the residents by slipping, tripping, pest attraction, or infection control.Findings include:Record review of Resident #2's undated face sheet revealed he was a [AGE] year-old male with an initial admission date of, 03/20/2025. Resident #2 had diagnosis of, other lack of coordination, need assistance with personal care, epilepsy-unspecified not intractable without status epilepticus (a seizure within 5 minutes), gastro-esophageal reflux disease without esophagitis, and dysphagia- oropharyngeal phase. Record review of Resident #2's Quarterly MDS assessment dated [DATE], revealed a BIMS of 10. Resident #2 had no cognitive patterns that could affect his memory for long or short term when it comes to making daily decisions.In an observation of Residents #2's floor on 09/15/2025 at 10:18am revealed a large sticky red substance/spill on the right side of the resident's bed, with a plastic cup faced down over the spill. In an observation of Residents #2's floor on 09/16/2025 at 9:24am revealed a large sticky red substance/spill on the right side of the residents' bed.In an observation of Resident #2's floor on 09/17/2025 2 12:14pm revealed a plastic cup with red like juice substance on the bedside tray table, with a slight red substance on the floor, as if it were partially cleaned up. Record review of Resident #7's undated face sheet revealed she was a [AGE] year-old female with an initial admission date of, 07/18/2025. Resident #7 had diagnosis of gastrostomy status (surgical opening through the skin of the abdomen to the stomach), colostomy status (opening to the stomach to creak an opening to the colon through the belly), muscle wasting and atrophy- not elsewhere classified left lower leg, epilepsy- unspecified not intractable without status epilepticus, and dysphagia-unspecified. Record review of Resident #7's Quarterly MDS assessment dated [DATE] did not reveal the resident's BIMS. Resident #7 could not make decisions on her own and was severely impaired. In an observation of Resident #7's floor on 09/18/2025 at 9:32 am revealed a brown thick liquid substance on the right side of the bed.In an interview on 09/16/2025 with CNA P at 09:26am stated HSKP is responsible for the cleanliness of the resident's room and throughout the building. If the residents' rooms needed to be cleaned, the staff would inform housekeeping, and they are able to refresh the residents' room and floors within a substantial time. In an interview on 09/17/2025 with HSKP G at 11:56am stated HSKP use bold power floor cleaner, which is a non-bleach cleaner. Each room is cleaned on a schedule and the HSKP staff, including herself, does try to clean 4-5 rooms daily. The risk of residents' rooms and floors not being clean could attract bugs, ants, or any pest. HSKP G stated they were not informed of any floor spilling for Resident #2 but will take care of the floors on 09/17/2025.In an interview on 09/18/2025 with Resident #7 at 9:32am revealed it does take staff a little time to clean up spots on the floor. Resident #7 asked the staff to clean up from the feeding tube and has told the staff various times that they know what to do to keep the room and the floors clean something is on the floor.In an interview on 09/18/2025 with Resident #2's family member at 2:50pm stated she does visit the resident daily, she might miss one day out of the week. Resident #2's family member stated three days ago (09/15/2025) she noticed red juice and a cup on the floor when she came to visit Resident #2. The same red juice stain remained on the floor on 09/16/2025 and on 09/17/2025 the red stain was gone, but the substance was still visible on the floor. In an interview on 09/18/2025 with the ADMN at 1:02pm revealed the expectation for cleanliness of the resident rooms is to continue working with the housekeeping supervisor and staff to schedule deep cleanings for rooms in need. Another expectation is during champion rounds, staff are expected to report when the rooms and floors are not clean to inform appropriate staff to maintain the expectation of a clean environment for the residents/family. At this time, the ADMN was informed of two resident rooms with stains on the floor.Record review of the facility's resident rights policy (revised on 11/28/2016) revealed in part: Safe environment - The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely. The facility must be provided--A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.Housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior.

Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 (Resident# 1) of 6 residents reviewed for activities of daily living in that: The facility failed to provide mouth care to Resident #1 on 6/24/2025. This failure placed residents who need assistance with ADL at risk for psychological embarrassment, sadness, and decrease in quality of life. Record review of Resident #1's face sheet dated 07/10/25 revealed a [AGE] year-old female who was admitted to the facility initially on 02/25/2021 and readmitted on [DATE]. The resident's diagnoses included the following: Alzheimer's Disease (a disease that destroys memory and other important memory function), muscle weakness (decreased strength in the muscle), lack of coordination (impaired balance), hypertension (high blood pressure) constipation (difficulty having bowel movement) hyperlipidemia (high levels of fat in the blood) anemia (inadequate healthy red blood cells), and dementia (loss of memory and thinking skills). Record review of Resident #1's significant change MDS dated [DATE] reflected a BIMS score of 12 indicating that resident cognition was intact. Had no behavior issues. Further review section GG-Functional abilities reflected the resident required supervision or touching assistance with personal hygiene. Record review of Resident #1's Comprehensive Care Plan revised 06/16/2025 with a target date of 9/20/2025 revealed the resident was care planned for ADL self-care performance deficit related to impaired cognition.Goal: Resident will maintain current level of functions in ADL's. Intervention: Personal hygiene and Oral Care: Resident requires extensive assistance with personal care and oral hygiene. Observation on 06/24/2025 at 10:20 AM revealed Resident #1 was sitting up in bed dressed in a gown. Resident #1 was clean with no lingering offensive odors. The call light was observed to be within reached. Interview on 06/24/25 at 10:20 AM Resident #1 said she was doing good. She said the only problem she had was her teeth were not brushed that morning. She said they brushed her hair but not brush her teeth. In an interview and observation on 6/24/2025 at 11:30am with CNA B, she said she got Resident #1 up for breakfast. She said she brushed her hair, but she did not brush her teeth. She said the Hospice Aide gave her a bed bath, but she did not know if the hospice aide brushed her teeth. Further interview with CNA B revealed that when she provided morning care to a resident, she usually got them up, cleaned their face and hands, dressed them and gave them their breakfast. Further interview with CNA B regarding when oral care was done, CNA B said, Oral care was done after breakfast. At that point CNA B asked Resident #1 if she wanted her teeth to be brushed and the resident said yes. CNA B then assisted Resident #1 with brushing her teeth. In an interview on 6/24/2025 at 11:45 am with LVN A, he said the expectation of the CNAs when providing morning care was to check residents for incontinent care, change them, clean their face, brush their teeth and give them a shower if needed. They should dress them, comb their hair, set up their bed at 45 degrees and pass breakfast trays and assist any resident who needed assistance with eating. Interview on 07/10/25 at 4:39 PM the DON said the CNAs and nurses were responsible for keeping the residents groomed. The DON said it was the responsibility of the nurse to ensure the CNAs were keeping the residents groomed by providing ADL care and oral care to residents. The DON said it was important to keep the residents groomed for their dignity and hygiene. The DON said staff were trained on ADL care, abuse and neglect every other week. She said they also have one and one training with the CNAs. Record review of the facility's undated policy on Dressing and Personal Grooming reflected in part:PurposesThe purposes of this procedure are to assist the resident as necessary with dressing and undressing to promote cleanliness. Should be performed according to the resident centered plan od care.

Based on observation, interview and record review, the facility failed to ensure parental fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 residents (Resident #1) reviewed for parental fluids. The facility failed to ensure Resident #1's right arm PICC line (a thin, flexible tube that is inserted into a vein and threaded into a larger vein near the heart for long-term intravenous treatments) dressing was changed weekly (the dressing was dated 01/06/2025 upon observation on 01/16/2025) as ordered by her physician. This failure placed residents with intravenous (within the vein) lines at risk of developing infection. Findings included: Record review of Resident #1's face sheet dated 01/16/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with sepsis (a life-threatening complication of an infection), urinary tract infection (an infection in any part of the urinary tract), dysphagia (difficulty swallowing), and mild cognitive impairment (a brain condition that causes subtle changes in thinking and memory). Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMS score of 0 (severe cognitive impairment) and she did not exhibit behaviors or reject care. Record review of Resident #1's care plan, revised on 01/10/2025 revealed the following care areas: * Resident #1 has intravenous PICC line. Goal included: The resident will not have any complications related to IV therapy. Interventions included: Administer IV medications as ordered. Check dressing at site daily. Monitor for signs and symptoms of infection. Flush the ports/lines as ordered. Monitor location of implanted port for signs and symptoms of infection: redness, tender, swelling, and drainage. Report to the physician if noted. Monitor/document/report to physician PRN s/sx of infiltration at the site (when fluid from the IV leaks into the surrounding tissue). * Resident #1 was on antibiotic therapy related to infection (sepsis). Goal included: Resident #1 will be free of any discomfort or adverse side effects of antibiotic therapy. Interventions included: Administer medication as ordered. Record review of Resident #1's physician's orders for January 2025 revealed the following: * Change Right Arm PICC Line Dress (dressing) Q Weekly on Mondays in the morning every Monday. Order Date: 12/30/2024. Start date: 12/30/2024. Record review of Resident #1's TAR for January 2025 revealed the following: * Change Right Arm PICC Line Dress (dressing) Q Weekly on Mondays in the morning every Monday. Further review of Resident #1's TAR revealed the entry block for Monday, 01/13/2025 was checked (indicating the treatment was completed) and initialed by LVN A. Observation and interview with Resident #1 on 01/16/2025 at 12:30 p.m. revealed she was asleep in her bed with her eyes closed. Resident #1's RP was present and stated the dressing on Resident #1's PICC line should be changed every seven days, which meant it should have been changed by then. Observation of Resident #1's right arm revealed the dressing on her PICC line was dated, 01/06/2025. Resident #1 woke up and said hello at her RP's request, but she did not answer questions. In a telephone interview with Resident #1's NP on 01/16/2025 at 1:12 p.m., he stated he was not sure of what Resident #1's dressing change order was, but typically, the dressing on a PICC line should be changed once per week. He said the dressing was impregnated (soaked or saturated with a substance) with chlorohexidine (an antiseptic which kills bacteria), which fights the risk of infection. He stated changing the dressing weekly was important because it fought infection. He stated if the dressing was dated 01/06/2025, it should have been changed by the 13th, or the 14th at the latest. In an interview with the DON on 01/16/2025 at 1:25 p.m., she stated if 01/06/2025 was written on Resident #1's dressing, that was the last date it was changed. She said if the dressing was supposed to be changed on Monday, 01/13/2025, it was three days behind. She said LVN A worked the morning shift on 01/13/2025 and was responsible for changing the dressing. In a telephone interview with LVN A on 01/16/2025 at 1:31 p.m., she stated she normally worked the 6:00 a.m. to 6:00 p.m. shift on Resident #1's hall. She stated Resident #1 had an intravenous line because she received antibiotic therapy. She stated Resident #1 had an order to change the dressing on the line every Monday. She stated she was not sure if she changed the dressing on Monday, 01/13/2025. She stated staff wrote dates on the dressings to document the day it was put on or changed and if Resident #1's dressing was dated 01/06/2025, then that was the last date it was changed. She said she was not sure what happened or why the TAR indicated it was changed on 01/13/2025 but the dressing was dated 01/06/2025. She stated the dressing had to be changed weekly for hygiene reasons. She said when she changed the dressing, she checked the skin and cleaned the area around the line to make sure the tissue stayed healthy. She said not changing the dressing weekly could produce infection. In an interview with the DON and Regional Director of Operations on 01/16/2025 at 1:55 p.m., the DON stated staff dated residents' dressings to indicate the date it was changed. The DON said if the order said the dressing should be changed weekly, then it should be changed weekly. The Regional Director of Operations stated the dressing itself did not contain medication, but the dressing change equipment came in a kit, which included Chloraprep (a sterile, antiseptic solution used to prepare the skin that contains 2% chlorhexidine gluconate). The DON and Regional Director of Operations went to Resident #1's room and looked at the dressing on her right arm. The dressing was still dated 01/06/2025. Observation on 01/16/2025 at 2:10 p.m. revealed the DON cleaned and changed Resident #1's PICC line dressing. In an interview with Resident #1's physician on 01/16/2025 at 2:20 p.m., she stated if Resident #1's dressing change order said weekly, then staff should be changing the dressing weekly. She said it was important to clean and change the dressings on IV lines to protect against infection. He said she was not aware that orders were not being followed. She said it was important for staff to follow orders to keep the resident healthy. Record review of the facility's undated policy titled, Nursing Facility Medication Administration revealed, . 2. The facility staff administering medication shall comply with the following: a. No medication shall be given to any resident unless ordered by a physician. B. Medications shall be administered unless the resident refuses or exhibits symptoms that contraindicate medication administration. C. If a medication is not administered, the staff member shall document in the resident's record why the medication was not administered . 3. Medications shall be administered only to the resident for whom they are prescribed, given in accordance with directions on the prescription or the physician's order, and recorded on the resident's medication record . 6. The facility shall maintain an individual medication record for each resident to whom the facility administers medication in which: a. Physician orders are recorded and signed. B. All medications are recorded as given, documenting name of the medication, date and time given, and signed by the individual administering the medication. Record review of the facility's undated policy titled, Peripheral IV Dressing Change revealed, . Procedure . 12. Label new dressing with date of insertion, date of change (if not insertion date), gauge used, and initials .

Based on observation, interview, and record reviews the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 3 of 6 residents (Resident #43, Resident #45, and Resident #7) reviewed for pressure ulcers. - The facility failed to provide daily wound care for Resident #43 on 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24, resulting in worsening of his L Heel, R Heel, R Distal (closest to foot) Leg, R Proximal (furthest away from foot) Leg, L Ischium (buttock), and R Ischium (buttock) pressure ulcers. - The facility failed to receive Resident #43's biopsy/culture results for his R heel that was performed 9/30/24, until 10/24/24. - The facility failed to start Resident 43's antibiotic for MRSA and osteomyelitis (bone infection) to his R heel until 10/31/24, when results were received on 10/24/24. - The facility failed to have the Wound Care MD see Resident #43 after 10/7/24 due to not having staff to assist him. - The facility failed to measure Resident #43's wounds throughout October 2024. - The facility failed to prevent a Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer to Resident #45's toe while at the facility between 9/9/24 and 10/1/24. - The facility failed to provide daily wound care to Resident #45's R middle toe on 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24. - The facility failed to provide daily wound care to Resident #7's Left Lateral Forefoot and Left Sacrum on 10/1/24, 10/6/24, 10/11/24, 10/12/24, 10/13/24, 10/17/24, 10/24/24, 10/27/24, 10/28/24, and 10/29/24, which resulted in worsening of the Sacrum pressure ulcer. An Immediate Jeopardy (IJ) was identified on 10/31/2024. The IJ Template was provided to the facility on [DATE] at 4:15pm. While the IJ was removed on 11/2/2024, the facility remained out of compliance at a level of more than minimal harm and a severity of no actual harm with potential for more than minimal harm that not Immediate Jeopardy and a scope of pattern due to the need for implementation of corrective measures and the effectiveness of its corrective plan. Findings included: 1.Record review of Resident #43's undated face sheet revealed he was a [AGE] year-old male admitted originally on 3/3/22, with the most recent admission being 8/30/23. His diagnoses included pressure ulcer of the sacrum (buttocks), type 2 diabetes (body does not produce insulin or is resistant to it), quadriplegia (complete or severe loss of motor function in all four limbs), muscle spasms (involuntary muscle contractions), muscle wasting and atrophy (muscle shrinkage/contraction due to not using), and neuromuscular dysfunction of the bladder (bladder does not work due to nerve issues). Record review of Resident #43's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. He had impairment on both sides of his upper and lower extremities and used an electric wheelchair. The resident was dependent with all ADLs and had a suprapubic catheter (a hole from the bladder through the abdomen to the outside to drain urine) and a colostomy (a hole through the abdomen from the colon to the outside to drain stool). The MDS revealed Resident #43 had 5 Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it ) pressure ulcers, and only 1 was present on admission. Record review of Resident #43's care plan dated 3/10/22 revealed a Focus: The resident has pressure ulcers: L heel Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) Reopened, R heel Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), R lower leg Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), R ischium (R side of buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), L ischium (L side of buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), R lateral leg Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) Resident refuses visits from wound care doctor and refuses treatments frequently. (Initiated: 8/10/24, Revised: 10/29/24) Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date (Initiated: 3/30/22, Revised: 9/29/22, Target: 11/26/24). Interventions: Assess/record/monitor wound healing at lease weekly. Measure length, width and depth. Obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated. Refer to wound care MD. Turn/reposition every 2 hours. Focus: Resident is on antibiotic therapy r/t diagnosis of osteomyelitis (Initiated: 11/12/23, Revised: 10/31/24). Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date (Initiated: 11/12/23, Revised: 2/5/24, Target: 11/26/24). Interventions: Administer medication as ordered. Report pertinent lab results to MD. Focus: The resident has IV access (Initiated: 10/31/24). The resident will not have any complications related to IV therapy through the review date (Initiated: 10/31/24, Target: 11/26/24). Interventions: Administer IV medications as ordered. The resident has PICC line IV access to right upper arm. Record review of Resident #43's Physician Orders revealed the following orders from MD A: - Calcium Alginate-Silver External Pad 2, Cleanse wound to R Heel with wound cleanser/ns, pat dry, apply calcium alginate w/ silver and santyl (wound care medications), cover with dry dressing. Every day for wound care. Ordered on 6/3/24. - Calcium Alginate, Cleanse wound to R Posterior leg with wound cleanser/ns, pat dry, apply calcium alginate and santyl, cover with dry dressing. Every day for wound care. Ordered on 6/17/24. - Calcium Alginate-Silver External Pad 2'x2', Cleanse wound to R Heel with wound cleanser/ns, pat dry, apply calcium alginate w/ silver (wound care medications), and cover with dry dressing. Every day for wound care. Ordered on 8/19/24. - Cleanse wound to L Ischium with wound cleanser/ns, pat dry, apply Dakins 125% (wound care medication) and cover with dry dressing. Every day for wound care. Ordered on 10/9/24. - Cleanse wound to R Ischium with wound cleanser/ns, pat dry, apply Dakins 125% (wound care medication) and cover with dry dressing. Every day for wound care. Ordered on 10/9/24. - Santyl External Ointment 250U/gm (Collagenase) (wound care medication), Apply to R Heel/Lateral Leg, Every day for wound care. Ordered on 10/9/24. - No orders for any antibiotics were found for his MRSA/osteomyelitis. Record review of Resident #43's Wound Care Note dated 9/30/24, revealed a L Ischium (L side buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer that was 5.6cm x 1.9cm x 0.1cm, a R Ischium (R side buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer that was 3.5cm x 3.9cm x 0.1cm, L Heel Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.2cm x 1.2cm x 0.1cm, R Heel Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 6.1cm x 5.2cm x 0.4cm, and a R Lateral Lower Leg Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 2.8cm x 1.9cm x 0.1cm. Debridement (removal of dead tissue) was performed on the L Ischium (L buttock), R Ischium (R buttock), R Heel, and a biopsy (tissue sent to the lab) was taken from the R Heel d/t suspicion of osteomyelitis (bone infection). Wound orders were entered for daily wound care. Record review of Resident #43's October 2024 MAR-TAR revealed blank spots where wound care was not provided to his L Heel, R Heel, R Distal (closest to foot) Leg, R Proximal (furthest away from foot) Leg, L Ischium (buttock), and R Ischium (buttock) pressure ulcers, for the following dates: 10/1/24, 10/6/24, 10/12/24, 10/13/24, and 10/26/24. Record review of Resident #43's Wound Care Note dated 10/7/24, revealed a L Ischium (L buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 5.6cm x 2cm x 0.1cm, a R Ischium (R buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 3.7cm x 3cm x 0.1cm, a L Heel Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.2cm x 2.2cm x 0.1cm, a R Heel Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 5.3cm x 3.9cm x 0.2cm, a R Lateral Lower Leg Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 2.6cm x 1.5cm x 0.1cm, and a new R Proximal Lateral Lower Leg Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 4.5cm x 1.6cm x 0.1cm. Debridement (removal of dead tissue) was performed on the R Heel and the R Proximal Lateral Lower leg. Record review of Resident #43's medical record, revealed a final report from [lab] dated 10/9/24 was faxed from the Wound Care MD's office to the nursing facility on 10/10/24, with results of acute osteomyelitis (bone infection) that was found during the biopsy (tissue removal sent to lab) on 9/30/24. Record review of Resident #43's Weekly Ulcer Assessments for 10/14/24 and 10/28/24, were the same as the last measurements from the Wound Care MD on 10/7/24. Record review of Resident #43's medical record, revealed culture results from [lab] dated 10/24/24 was faxed from the Wound Care MD's office to the nursing facility on 10/24/24, with results of high amounts of MRSA (a drug resistant bacteria) and multiple other bacteria that was found during the culture on 9/30/24. In an interview and observation with Resident #43 on 10/29/24 at 11:15am, the resident was observed laying on his back receiving wound care by the floor nurse, directed by the ADON. The resident said the facility no longer had a Wound Care Nurse, so the floor nurses had to perform wound care and they did not come every day. He said they were only doing it because State was there and the last time he had received wound care was on 10/27/24. In an interview with Resident #43 on 10/30/24 at 12:15pm, he said the Wound Care MD would not see him because the facility did not have a Wound Care Nurse to help him. He said the Wound Care MD wanted someone to help him position and take orders and the floor nurses were too busy to come help, so the doctor did not have time to wait around and would not see him. The resident also said the staff would get him into his chair and then want him to get back to bed for wound care and then get back into his chair and that was too much work, so a couple times he refused. He said he felt like they would wait for him to get in his chair on purpose so they could offer it then and they know he would refuse. Resident #43 stated he felt like his pressure ulcers had worsened since the Wound Care MD had not seen him since 10/7/24. In an interview with a family member of Resident #43 on 10/30/24 at 1:45pm, who said the facility had a big problem with performing wound care daily since they did not have a wound care nurse. She said Resident #43 may have refused a few times, but he did not refuse often because he has become septic in the past and knew how important wound care was. She said the problem was staff would get him into his chair and then wanted him to get back into bed for wound care, and then get back into his chair. She said that was a lot of work for him and he would not want to do it. She said she did not understand why they would not do his wound care first and then put him in his chair. In an interview with the Wound Care MD on 10/30/24 at 1:48pm, he said he came every Monday to see residents. He said Resident #43 was complex, had a lot of wounds, and needed help getting ready before he arrived. He said he would call the facility and give them an hour notice before he arrived, but the resident still would not be ready when he arrived, and he would not have time to sit around and wait when he had other residents to get to. He said it was hard for nursing staff to keep up with wound care when there was not a dedicated wound care nurse, so it frequently did not get done or fell through the cracks. He said they had not had a wound care nurse in about a month. The Wound Care MD said he received the labs, he thought on 10/24/24 but was not sure when, and the resident had osteomyelitis before. He said he talked to NP B on Monday (10/28/24) and told her to order the antibiotics for the resident. He said he wanted to make sure she ordered the antibiotics, and they did not get missed. In an interview with NP B on 10/30/24 at 2:40pm, she said the Wound Care MD called her to inform her Resident #43 would be on Cipro/Vancomycin (antibiotics for wound infection) but did not tell her to order them. She said the Wound Care MD would inform the nurse at the facility and they would enter the orders. She said she did not enter orders for the Wound Care MD. She said she saw labs come in for the resident but if the Wound Care MD ordered them, he would be responsible for following up on them. In an interview with the DON on 10/30/24 at 3:05pm, she said she was kind of familiar with Resident #43's wounds. She was not sure if the wounds were getting better or worse. She said the floor nurse was the one responsible for measuring the wounds. She said [username] was her and that was who logged all the measurements of Resident #43's wounds for October 2024, so she must have performed the measurements. She said she thought the wounds had not changed. She did not know if the resident had had any labs/biopsies (tissue removal and sent to lab) on any of his wounds. The DON said the Wound Care MD did not give any orders to NP B because she did not work for him. She said the Wound Care MD would tell a nurse at the facility and they would enter the orders, or he would slide the orders under her door, and she would enter them. She said she did not know anything about the antibiotic orders for Resident #43 and she was going to go call the Wound Care MD. In an interview and observation of Resident #43 on 10/30/24 at 4:00pm, he said the DON never measured his wounds and that he had never even seen her face before. Measurements were performed with the DON and the Clinical Resource Nurse and were as follows: L Heel: 3.5 x 2.5 = 8.89cm x 6.35cm R Heel: 6.5 x 5 = 16.51cm x 12.7cm R Distal Leg: 2.5 x 1 = 6.35cm x 2.54 R Proximal Leg: 6 x 1 = 15.24cm x 2.54cm In an observation of Resident #43 on 10/31/24 at 10:00am with the ADON, DON, and the Clinical Resource Nurse the resident's L Ischium (L buttock) and R Ischium (R buttock) were measured as follows: L Ischium (L buttock): 6.5 x 2.5 x .1 = 16.51cm x 6.35cm R Ischium (R buttock): 6 x 3 x .2. = 15.24cm x 7.62cm There was also new maceration (skin breakdown due to moisture) to both sides. The resident was observed with a right upper arm PICC line. In an interview with the DON on 10/31/24 at 10:40am, she said she copied the last measurements the Wound Care MD entered on 10/7/24 and entered those measurements throughout October, because she did not want to enter the wrong information or the wrong staging. She said the wound care nurse left about 3 weeks ago and then before that they had another wound care nurse that was there that left. She said she expected her floor nurses to provide wound care but not touch anything having to do with measurements. She said she would know if the wounds got worse without measuring by noting the smell, drainage, and pain. In an interview with RN C on 10/31/24 at 12:51pm, she said she did not know of any labs/biopsies (tissue removed and sent to lab) that Resident #43 had to his wounds. She looked in his chart and said she did not see anything. She said when cultures/biopsies (tissue removed and sent to lab) are done, they put it on the 24hr report so they can keep track of it. She said the other nurses did not have enough time to perform wound care and that they really need a wound care nurse, but she makes time. She said Resident #43's wound care was mainly done at night, and she did not know of him refusing, maybe once or twice. In an interview with the ADON on 10/31/24 at 1:00pm, she said she did not know anything about the culture/biopsy (tissue removed and sent to lab) results for Resident #43 until the results were recently brought to her attention. She said the Wound Care MD did not communicate well and only communicated with the wound care nurse when they had one. If they did not have a wound care nurse, he kept to himself. She was not sure how it was ordered because there were no orders in the system. She said the results were always sent to the Wound Care MD's office and then they would fax them to the nursing facility. In an interview with the Administrator on 10/31/24 at 1:40pm, she said the ADON, and the floor nurses were assigned to handle the wound care treatment for the residents since they no longer had a wound care nurse. She said the floor nurses were aware they would be providing treatment and if they were not able to round with the Wound Care MD, then the ADON was responsible for rounding and entering orders. She said the ADON, and the DON were responsible for following up on the orders. The Administrator said when the last wound care nurse left there were no loose ends, or anything left outstanding that she was aware of. She said only the Wound Care MD measures the wounds and then the nurse enters the measurements in the system. She said if the Wound Care MD had not seen the resident in a while, like Resident #43, then the DON/ADON should have seen the resident and taken measurements. In an interview with the Wound Care MD on 10/31/24 at 3:15pm, he said he did his own biopsies (tissue removed and sent to lab)/cultures and took them to the lab himself. He said he left a copy of his handwritten notes and a copy of the order at the facility. He said he usually gave it to the wound care nurse but if the wound care nurse was not there, he would give it to the floor nurse. If the floor nurse was not available or he could not find anyone, then he would give it to the DON or slide it under her door. He said he gave it to a floor nurse, but he did not remember who it was. He said the results were faxed to the facility. He said he got a biopsy/culture because the wound was deteriorating, and it appeared to look like it had osteomyelitis. 2.Record review of Resident #45's undated face sheet revealed he was a [AGE] year-old male originally admitted on [DATE], with the most recent admission on 4/8/24. He had diagnoses of unspecified dementia (decline in cognitive abilities, such as thinking, remembering, and reasoning), pressure induced deep tissue damage of left heel (a type of pressure ulcer that occurs when underlying soft tissue is damaged by pressure or shear forces), protein calorie malnutrition (reduced availability of nutrients leads to changes in body), contractures of right and left knees (inelastic fiber-like tissue in the knees preventing normal movement), muscle wasting and atrophy (thinning of your muscle mass), dehydration, type 2 diabetes (body does not produce insulin or resists it), and iron deficiency anemia (body is not producing enough iron). Record review of Resident #45's Annual MDS assessment dated [DATE], revealed a BIMS score was unable to be obtained due to medical issues. The MDS revealed he had severely impaired cognitive skills for daily decision making. He had impairment of both sides of his upper and lower extremities and was dependent with all ADLs. The resident had a nephrostomy (hole into kidney through abdomen to drain urine) and a colostomy (hole from colon through abdomen for stool to collect in bag outside of body). Resident #45 had a Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer that was not present on admission. Record review of Resident #45's care plan dated 4/20/23 revealed a Focus: The resident has a pressure ulcer: R Second toe (Initiated: 4/24/24, Revised: 10/14/24). Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review period (Initiated: 4/24/24, Revised: 4/24/24, Target: 11/17/24). Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing at least weekly. Measure length, width, and depth. Turn every 2 hours. Record review of Resident #45's Physician Orders from MD A revealed the following orders: - Zinc Oxide External Cream 10%, Cleanse abrasion to left buttock with wound cleanser/ns, pat dry, apply zinc oxide (wound medication). Every shift for wound care. Ordered on 10/27/23. - Cleanse right great toe with normal saline or wound cleanser, pat dry, and apply skin prep, leave open to air. Every day for wound care. Ordered on 9/24/24. - Calcium Alginate, Cleanse right second toe with NS/Wound cleanser, pat dry, apply calcium alginate/silver (wound medications), cover with dry dressing. Every day for wound care. Ordered on 9/29/24. - Skin Prep Spray, Clean posterior left heel with normal saline, pat dry, apply skin prep daily (wound medication), float heels, leave open to air. Every day for deep tissue injury (a type of pressure ulcer that occurs when underlying soft tissue is damaged by pressure or shear forces). Ordered on 11/1/24. Record review of Resident #45's October 2024 MAR-TAR revealed blank spots where wound care was not provided for the following dates: 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24. Record review of Resident #45's Wound Care Note dated 10/7/24, revealed R Medial (middle) Second Toe Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.1cm x 1.5cm x 0.3cm with bone exposed (Wound Care MD should have classified it as a Stage 4 since bone was exposed). Record review of Resident #45's progress note from MD A dated 10/9/24, revealed a note that read 9-9-24: Since last evaluation, chronic medical conditions remain stable .No present wound issues. Staff reinforcement done to promote turning, pressure relief, skin care and safety. Another note read 10-9-24 Since last eval, chronic medical issues have been stable .Has developed wound on right second toe, followed by wound care service . In an observation of Resident #45 on 10/29/24 at 9:16am, he was lying on his left side in bed, without his pressure relieving boots on. In an observation of Resident #45 on 10/30/24 at 9:06am, he was asleep on his left side with his pressure relieving boots on his nightstand. In an observation of Resident #45 on 11/1/24 at 10:30am, he was lying on his left side with hand splints on and his bilateral boots on. Record review of Resident #45's SBAR dated 11/1/24, revealed he had a skin change which was a deep tissue injury to his left heel (a type of pressure ulcer that occurs when underlying soft tissue is damaged by pressure or shear forces). 3. Record review of Resident #7's undated face sheet revealed she was a [AGE] year-old female originally admitted on [DATE], with the most recent admitted [DATE]. She had diagnoses of Alzheimer's disease (brain disorder that gradually destroys memory and thinking skills), muscle wasting and atrophy (thinning of your muscle mass), protein calorie malnutrition (reduced availability of nutrients leads to changes in body), dementia (decline in cognitive abilities, such as thinking, remembering, and reasoning), and cerebral infarction (stroke). Record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed a BIMS score was unable to be performed due to medical concerns. She had impairment on both sides of her lower extremities and was bedbound. She was dependent with all ADLs and was always incontinent of bowel and bladder. The MDS revealed she had 2 Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcers that she was not admitted with. Record review of Resident #7's care plan dated 1/31/20, revealed a Focus: The resident has a pressure ulcer to L Lateral (outside) foot, L Sacrum (buttock) (Initiated: 3/6/24, Revised: 10/14/24). Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date (Initiated: 3/6/24, Revised: 4/4/24, Target: 12/30/24). Interventions: Administer medications and treatments as ordered. Assess/record/monitor wound healing at lease weekly. Measure length, width, and depth. Enforce turning/repositioning. Record review of Resident #7's Physician Orders revealed the following orders from MD A: - Zinc Oxide External Paste (wound medication), apply to sacrum (buttocks) two times a day. Ordered on 7/18/24. - Zinc Oxide External Cream 10%, cleanse sacrum (buttocks) with wound cleanser/ns, pat dry, apply zinc oxide (wound medication), every shift. Ordered on 7/22/24. - Skin Prep Wipes, apply to right lateral (outside) ankle every day for wound care. Ordered on 7/29/24. - Betadine External Solution, apply to left plantar (bottom) foot every day for wound care. Ordered on 8/26/24. - Cleanse left lateral (outside) foot with normal saline or skin cleanser, apply medi-honey and calcium alginate (wound medications), cover with dry dressing, daily and PRN. Every day for wound care. Ordered on 10/4/24. - Calcium Alginate Powder, cleanse sacrum (buttocks) with normal saline, pat dry, apply calcium alginate (wound medication), cover with dry dressing. Every day for wound care. Ordered on 10/4/24. - Cleanse sacrum (buttocks) with normal saline or skin cleanser, pat dry and apply calcium alginate (wound medication), cover with dry dressing, daily and PRN. Every day for wound care. Ordered on 10/8/24. Record review of resident #7's Wound Care MD Note from 9/30/24, revealed a Left Lateral Forefoot (outside front part of foot) arterial ulcer (due to bad circulation) 2.5cm x 1.2cm x 0.3cm, and a Left Sacrum Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.7cm x 1.5cm x 0.1cm. Record review of Resident #7's October 2024 MAR-TAR revealed blank spots where wound care was not provided for the following dates: 10/1/24, 10/6/24, 10/11/24, 10/12/24, 10/13/24, 10/17/24, 10/24/24, 10/27/24, 10/28/24, and 10/29/24. Record review of Resident #7's Weekly Ulcer Assessment performed by the Clinical Resource Nurse on 10/30/24, revealed measurements for the sacrum (buttocks) 9.5cm x 6cm. In an observation of Resident #7 on 10/29/24 at 10:02am, she was asleep on her left side in bed. In an interview with Resident #7's family member on 10/29/24 at 1:48pm, she said she would like to see the resident up in her wheelchair at least once a month. She said the facility never got Resident #7out of bed and into her wheelchair and she laid in bed every day. She said she spoke to the Administrator and DON about it, but still nothing changed. In an observation of Resident #7 on 11/1/24 at 10:35am, she was asleep on her left side in bed. Record review of the facility's policy and procedure on Pressure Injury: Prevention, Assessment and Treatment (Revised 8/12/16) read in part: Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone [color], turgor [elasticity of skin] and circulation to prevent breakdown, injury and infection. 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the Treatment Nurse/designee of any potential problems. 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document Notification . Nursing Action/Rationale: 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan. 1. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. 2. Do the blanching test by pressing the finger into a reddened area, a normal blood supply to the reddened area is seen when the area blanches white and then turns pink again. If the area remains red, a pressure sore is impending due to impaired circulation, keep resident off the area for 24 hours and then repeat the test . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., Stage I through Stage IV). 11. Director of Nursing or designee to inservice nurses and CNA's on above prevention. 2. Pressure sore identification: Director of Nursing or treatment nurse/designee will classify the pressure injury according to the following descriptions of the different stages. Staging definitions are per the guidelines of the National Pressure injury Advisory Panel February 2016 definitions .7. Nursing Care Plan. 1. Identify the problem of pressure injuries on the Nursing Care Plan 2. Under Nursing Intervention, list physician ordered treatments .Assessment of the pressure injury should also include the site, size, and W x L x D, of the injury. Surrounding tissue, color, exudate [drainage], wound edges, sinus tracts [narrow abnormal channel that connects a cavity], odor, tunneling [passageway that extends from the wound into deeper tissue] and undermining [closed passageway originating from the wound's edges and spreading outwards] should also be documented at least weekly and upon decline. An Immediate Jeopardy (IJ) was identified on 10/31/24 at 4:15pm. The Administrator and DON were notified. The Administrator was provided with the IJ template, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 11/1/24 at 2:52pm and read as follows: [Facility] Plan of Removal 10/31/24 F686 Failure to Prevent Pressure Ulcers Interventions 1. A head-to-toe assessment was completed on resident #43 as of 10/31/24 by the DON and Regional Compliance Nurse. No additional pressure wounds were identified. 2. All of resident #43's wounds were measured by the DON and Regional Compliance Nurse as of 10/31/24. The MD was notified of all changes in measurements by the Regional Compliance on 10/31/24. All measurements were documented in the chart by the Regional Compliance nurse as of 10/31/24. 3. Resident #43's antibiotic medication was initiated as of 10/31/24 by the charge nurse. 4. As of 10/31/24 the Administrator has designated that the ADON will round with the wound care MD. In the event the ADON is unavailable the designated nurse for the resident will round with the MD. 5. As of 10/31/24 the Administrator has designated that the ADON (LVN) will measure all resident wounds in the facility and document findings in the resident's chart. Wound assessments will be completed weekly. DON/Weekend RN will oversee the ADON (LVN) /Charge Nurse to ensure wound measurements and treatments have been completed and ar[TRUNCATED]

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for dietary services in that: -The facility failed to ensure that drink items in the dry storage area were not expired. -The facility failed to ensure that the refrigerator temperatures were logged daily. These findings could place residents at risk for food contamination and/ or food borne illnesses. Findings included: Observation of the facility's kitchen area on [DATE] beginning at 8:35 am revealed the refrigerator temperature log was not filled out since [DATE]. In an interview on [DATE] at 9:00am the Dietary Manager stated the logs should be checked daily but they have been short staffed so they may have been missed. She said she told her staff to check the temperatures daily. Observation of the pantry on [DATE] at 8:45 am revealed an expired box of thickener dated [DATE]. In an interview on [DATE] at 9:00 am the Dietary Manager stated she was unaware of the expired thickener being in the pantry. She said they started using a new brand of thickener and knew none of the residents received this expired box. In an interview on [DATE] at 4:42 p.m. the Administrator said she expected all expired items to be discarded. Record review of the facility's Storage Refrigerators policy dated 2012 read in part, .all storage refrigerators shall be maintained clean and have a proper temperature for food storage and to ensure a proper environment and temperature for food storage. Procedure: . 2. Storage refrigerators shall have thermometers frequently monitored throughout the day and recorded in the am and pm shifts. Temps are recorded on the Refrigerator/Freezer Temperature Log. The refrigerator should be 41 degrees F or less, and the freezer should be maintained at less than 0 degrees F . Record review of the facility's Food Safety policy dated 2012 read in part, .2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly. Perishable opened foods shall be used within 7 days or less, in compliance with the Texas Food Establishment rules. Non-perishable foods will be used as long as the quality of the product is maintained . 8. Do not keep potentially hazardous food in refrigerator past the labeled expiration date .

Based on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for 3 of 4 residents (Resident #14, #26, and #36) reviewed for resident assessment. The facility failed to ensure Resident #14, #26, and #36's PASRR Level I screening reflected their mental illness diagnosis. These failures could place residents at risk of not receiving specialized services for their mental illness. Findings included: 1.Record review of Resident #14's undated face sheet revealed he was a [AGE] year-old male originally admitted on [DATE], with the most recent admission being 5/7/24. He had diagnoses of bipolar disorder (mood swings, affecting a person's energy, activity levels, and concentration), and major depressive disorder, recurrent (serious mood disorder that affects how a person feels, thinks, and acts). Record review of Resident #14's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 9 out of 15, which indicated moderately impaired cognition. The MDS revealed he had diagnoses of depression and bipolar disorder. According to the MDS, the resident was taking antidepressants. Record review of Resident #14's care plan, dated 7/26/21 revealed a Focus: Resident is at risk for potential mood problem related to dx: bipolar disorder (Initiated: 11/1/21, Revised: 11/1/21). Goal: The resident will have improved mood state through the review date (Initiated: 11/1/21, Revised: 11/2/21, Target: 1/13/25). Interventions: Monitor/record/report to MD PRN acute episode feelings or sadness. Monitor mood. Focus: The resident requires antidepressant medication for Major Depressive Disorder (Initiated: 6/19/23, Revised: 6/19/23). Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date (Initiated: 6/19/23, Revised: 6/21/23, Target: 1/13/25). Interventions: Give antidepressant medications as ordered. Record review of Resident #14's Level 1 PASRR dated 12/12/19, revealed a no for mental illness, no for an intellectual disability, and no for a developmental disability, which made the screening negative. Record review of Resident #14's Psychiatric Subsequent Assessment performed by NP D on 8/23/22, revealed a diagnosis of bipolar disorder. Record review of Resident #14's medical record revealed there was not a new Level 1 PASRR completed after the new diagnosis on 08/23/22. Record review of Resident #14's Psychiatric Subsequent Assessment performed by NP E on 10/14/24, revealed he was still being treated for bipolar disorder. 2.Record review of Resident #26's undated face sheet revealed he was a [AGE] year-old male originally admitted on [DATE], with the most recent admission being 6/22/21. He had diagnoses of major depressive disorder with psychotic symptoms (serious mental illness that combines depression with psychosis, or a loss of touch with reality), and anxiety disorder (persistent and uncontrollable feelings of fear or anxiety that can interfere with daily life). Record review of Resident #26's Annual MDS assessment dated [DATE] revealed a BIMS score of 7 out of 15, which indicated severely impaired cognition. The MDS revealed diagnoses of depression and a psychotic disorder, and indicated he was taking antipsychotics and antidepressants. Record review of Resident #26's care plan dated 10/28/19, revealed a Focus: Resident #26 uses antipsychotic medications related to dx: depressive disorder recurrent, severe with psychotic symptoms, at risk for side effects (Initiated: 4/13/22, Revised: 3/10/23). Goal: The resident will be/remain free of psychotropic drug related complications through review date (Initiated: 4/13/22, Target: 1/5/25). Interventions: Administer antipsychotic medications as ordered. Resident #26 uses antidepressant medication related to depressive disorder, at risk for drug side effects (Initiated: 4/13/22, Revised: 4/13/22). Goal: The resident will be free from discomfort or adverse reactions through the review date (Initiated: 4/13/22, Target: 1/5/25). Interventions: Administer antidepressant medications as ordered. The resident uses anti-anxiety medications for anxiety disorder (Initiated: 8/14/24). Goal: The resident will be free from discomfort/adverse reactions through the review date (Initiated: 8/14/24, Revised: 10/21/24, Target: 1/5/25). Interventions: Give anti-anxiety medications as ordered. Record review of Resident #26's Level 1 PASRR Screening dated 10/25/19, revealed no for mental illness, no for intellectual disability, and no for developmental disability, which made the screening negative. Record review of Resident #26's Psychiatric Initial Assessment from PA F dated 2/18/20, revealed a diagnosis of major depressive disorder, recurrent, with severe psychotic symptoms. Record review of Resident #26's medical record revealed there was not a new Level 1 PASRR completed after the new diagnosis on 2/18/20. Record review of Resident #26's Physician Orders revealed the following orders from MD A: - Cymbalta Oral Capsule Delayed Release Particles 20mg, 1 PO QD for depressive disorder, recurrent with psychotic symptoms. Discontinued on 10/7/24. - Quetiapine Fumarate Tablet 25mg, 1 PO QHS for major depressive disorder, recurrent with psychotic symptoms. Give 25mg with Quetiapine 50mg for a total of 75mg QHS. Discontinued on 10/7/24. - Quetiapine Fumarate Tablet 50mg, 1 PO QHS for major depressive disorder, recurrent with psychotic symptoms. Ordered on 10/7/24. Record review of Resident #26's Psychiatric Subsequent Assessment from NP E dated 10/29/24, revealed he was still being treated for major depressive disorder, recurrent with severe psychotic symptoms, and for anxiety disorder. In an interview on 11/1/24 at 2:05 p.m. the MDS Coordinator said she started a 100% audit of residents with mental health diagnoses and was going through them to see if any had exclusionary diagnoses like Dementia. If not, she would perform a new PASRR level 1 screening for them. She said she just started last year and most of the ones she found occurred before she started. 3.Record review of Resident #36's Admission Record dated 11/2/24 revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnosis included schizoaffective disorder - bipolar (primary diagnosis), schizophrenia, bipolar disorder, mild cognitive impairment (secondary diagnosis), major depressive disorder, chronic obstructive pulmonary disorder, and cerebral infarction (stroke). Record review of Resident #36's quarterly MDS assessment, dated 8/26/24 revealed a BIMS score of 8 out of 15 which indicated moderate cognitive impairment. Record review of Resident #36's care plan dated 10/29/24 revealed the resident required anti-psychotic medications related to schizoaffective disorder. Record review of Resident #36's PASRR Level I screening dated 7/13/24 indicated the resident had a primary diagnosis of dementia. The screening also indicated the resident did not have a mental illness (Schizophrenia). In an interview on 10/30/24 at 2:46 p.m. the MDS Coordinator said Resident #36 did not have a diagnosis of dementia but did have cognitive deficits and schizophrenia (which qualifies as a mental illness). She said her PASRR screening should have been marked no for dementia and yes for mental illness. She said the resident's previous facility sent over the screening and she entered the information into the system, and it (the inaccuracies) must have slipped by her. She said she was responsible for ensuring the PASRR screening was accurate. She said the purpose of the PASRR screening was to see if the resident had a mental illness and the State could provide more resources to the resident. In an interview on 11/2/24 at 4:42 p.m. the Administrator said she expected the PASRR to be checked for accuracy and updated when there was a new mental illness diagnosis. She said the MDS Coordinator was responsible. She said the purpose of the PASRR screening was to ensure resident received services and treatments that they qualified for. She said residents could fail to receive needed services if the PASRR was not coded accurately. Record review of Detailed Item by Item Guide for Local Authorities and Nursing Facilities to Complete the PASRR Level 1 Screening Form dated June 2023 retrieved from Texas Health & Human Services read in part, .C0090. Primary Diagnosis of Dementia- Is there evidence that dementia is the primary diagnosis for this individual? (This must be listed in the medical record as the primary diagnosis by the physician) . Examples of MI diagnoses are: Schizophrenia, Mood disorder (bipolar disorder, major depressive disorder, or other mood disorder) . Schizoaffective Disorder . A policy on PASRR was requested from the facility on 11/2/24 at 8:16 a.m. but however the policy received titled, PASRR Maintenance in the Active Paper Medical Record, did not obtain information regarding the PASRR process.

Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 8 residents (Resident #3) reviewed for dental services. The facility failed to ensure Resident #3 was referred to the dentist after she complained of tooth pain. This failure could place residents at risk of pain and decline in health. Findings included: Record review of Resident #3's Admission Record dated 11/2/24 revealed an [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnosis included pain, type 2 diabetes, malnutrition, and cerebral infarction (stroke). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #3's nursing note dated 10/18/24 written by the ADON read in part, late entry: followed up with concern RP (name) shared regarding resident's teeth. Resident states, I don't have any pain in my mouth. I don't know what (RP) is talking about. Denies pain at this time. Resident consuming gummy bears at the time. Resident able to consume all meals without any complaints of pain. Will continue plan of care. Record review of Resident #3's Customer Concern/Grievance Communication Form dated 10/24/24 completed by the Administrator indicated the resident's family member left a message and thought the resident may need to see the dentist. The resident was assessed per ADON, and resident denied pain. The resident did not complain of pain. There were no signs or symptoms of pain or discomfort. The resident was eating gummy bears while speaking to ADON. The concern was resolved, and the resident would be monitored. In an observation and interview on 10/29/24 at 2:46 p.m. Resident #3 said she has had a bad tooth for a few weeks and needed to see the dentist. She said she told several nurses. Resident #3 opened her mouth and pointed to the bottom right side. Observation of her tooth revealed it appeared cracked. In an interview on 10/31/24 at 8:56 a.m. LVN E said Resident #3 told her more than two weeks ago that her tooth was hurting, and she asked for pain medicine. LVN E said she gave her pain medicine and the resident never complained about the pain again. She said she did not report the pain to anyone because it was a one-time event. She said if it was persistent, she would report it to the Social Worker so the resident could get on the dental list. She said Resident #3's family member came to the facility yesterday (10/30/24) and asked when the dentist was coming to the facility. LVN said she did not know if Resident #3 was being seen by the dentist. In an interview on 10/31/24 between 11:00 a.m. - 12:00 p.m. this Surveyor informed the Administrator that Resident #3 said she had tooth pain and had reported it to several nurses. The Administrator said the resident was previously assessed (on an earlier date) and denied having tooth pain but said the facility would send the resident to the dentist for evaluation. In a telephone interview on 10/31/24 at 11:40 a.m. Resident #3's family member said Resident #3 told him her tooth was hurting last week and he reported it to the nurses (unknown which nurse) and Administrator. He said the nurse informed him that she would give the resident pain medicine. He said he did not receive any other feedback. He said the facility contacted him yesterday and said Resident #3 said her tooth was not hurting. He said he did not know if the resident would see the dentist. Record review of Resident #3's nursing note dated 10/31/24 at 12:20 p.m. written by LVN E read in part, Resident out on pass to Dental appointment accompanied by an executive driver via wheelchair and facility staff. Denies any pain or discomfort. Record review of Resident #3's Dental Statement dated 10/31/24 revealed the resident was seen for a limited emergency exam and x-rays. Record review of an undated email from the dental office read in part, .Attached is the invoice for [Resident #3's] visit. [Dentist Name] did note that #29 could be painful for the patient, it looks like there is an infection starting and recommended having the tooth extracted . Record review of Resident #3's nursing note dated 10/31/24 at 2:22 p.m. written by the previous DON read in part, Resident returned from Dental appointment with x-rays and recommendation, call placed to NP [name] received new orders for prn Tylenol and orajel for tooth pain and antibiotic for 7 days will continue to monitor resident for tooth discomfort and infection to tooth. In an interview on 10/31/24 at 3:24 p.m. LVN E said a few weeks ago she gave Resident #3 Tramadol for tooth pain. She said the resident never complained of tooth pain before and was unsure if this was a new area of pain. She said when a resident complained of pain the nurse would do a pain assessment. She said she did not notify the MD because the resident had medication orders for pain. She said the only thing she may have done differently was tell the Social Worker to add the resident to the dental list. She said the risk of not reporting tooth pain could be infection. In an interview on 11/1/24 at 2:56 p.m. the ADON said she was informed during a staff meeting to follow up with Resident #3's tooth pain after the grievance was filed from her family member (on 10/24/24). She said she assessed Resident #3 and the resident said she did not have pain in her mouth. She said she did not look in her mouth and the resident was eating gummy bears. She said she spoke with CNAs about any eating or chewing problems with the resident and there were no issues. She said the dentist was scheduled to come to the facility on [DATE] and she was unsure if the resident was on the dental list. She said if the resident was not on the list, it was still possible for the dentist to see the resident that day or the facility would have made her an appointment. She said the Social Worker was out on leave. She said she was not aware the resident had previously complained of tooth pain to the nurse and if she had known, and if it were recurrent, she would have notified the MD. She said a SBAR should be done anytime a resident said anything about pain because it was a change in condition, and you do not don't want anyone to suffer in pain. In an interview on 11/2/24 at 1:16 p.m. LVN S said Resident #3 had a toothache last week, but he was waiting for the Social Worker. He said the resident told him one side of her tooth had pain on a scale of 4 out of 10. He said he did not look inside of the resident's mouth but did assess for swelling with none found. He said he gave her Tramadol, and it was effective. He said he did not report the resident's pain to anyone else. He said he would notify the MD if there were no orders for pain medication. He said he looked for the social worker and someone told him she was on leave. He said he did not ask if anyone else (besides the social worker) could put the resident on dental list. He said he could have reported the dental pain to the Administrator for follow up. He said the risks of not reporting could include her tooth pain getting worse. In an interview on 11/2/24 at 4:42 p.m. the Administrator said the facility should have proceeded to get other entities involved to see if something was going on with Resident #3. She said the nurses should have assessed the resident, notified the social worker and the MD for a dental visit consultation. She said if the social worker was unavailable, they should contact the Administrator. She said there could or could not be risk to the resident. She said the mouth could be irritated or inflamed but it would vary. Record review of the facility's Dental Services policy dated 2003 read in part, .Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care . Policy Interpretation and Implementation: 1. Oral health services are available to meet the resident's needs. 2. Routine and emergency dental services are provided to our residents through: a contract agreement with a local dentist; referral to the resident's personal dentist; referral to community dentists; or referral to other health care organizations that provide dental services. 3. The Director of Nursing Services, or his/her designee, is responsible for notifying Social Services of a resident's need for dental services. 4. Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary.

Based on observation, interview, and record review the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of five residents reviewed for accidents hazards and supervision, in that: -Resident #2 fell from lift, sustained a head abrasion and L foot fracture during a Hoyer lift transfer (a device designed to assist caregivers in safely transferring patients or individuals with limited mobility) when CNA K operated the Hoyer lift by herself. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 1/2/24 and ended on 1/3/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of injury and hospitalization s. The findings include: Record review of Resident #2's face sheet dated 6/20/24 revealed an [AGE] year-old female who admitted on [DATE]. Her diagnosis included cerebral infarction (stroke), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food.), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (one-sided weakness), and depression. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15 which indicated severe cognitive impairment. She was totally dependent on staff for ADL care including chair/bed to chair transfer. She had no falls since admission/entry or reentry or the prior assessment. Record review of Resident #2's care plan revised on 1/10/24 revealed she had an ADL self-care performance deficit related to impaired cognition, dx: vascular dementia, impaired mobility, hemiplegia, impaired balance, hx: cerebral infarction, incontinence, wheelchair dependent (revised on 10/20/22). She was at risk for injury due to falls related to impaired cognition, impaired mobility, gait/balance problems, hemiplegia, and incontinence. Interventions were: required 2 person assist with transfers and the use of a mechanical lift (initiated 1/10/24). Record review of Resident #2's Event Nurses-Note 12 hr Fall dated 1/2/24 by LVN E read in part, .I was informed by an AID (sic) that resident was on the floor. On entering room, resident was on the floor with a visible wound to the forehead. I provided first aid and obtained vital signs . 19. Gait and Mobility at time of event c. transferring x2 or more staff assist. Record review of CNA K's witness statement dated 1/3/24 read in part, .I went in to (Resident #2's) room and started cleaning her up. (CNA J) came in to assist me. I asked her to get a sling and we put it under (Resident #2). I asked her to go get the Hoyer lift. I hooked (Resident #2) up and (CNA J) went to get the chair. I had her raised up and when I got ready to turn with her, she slipped out of the Hoyer pad. I tried to help but it was too late . Record review of CNA J's undated witness statement read in part, .On Tuesday [DATE] at around 11:55 a.m. I (CNA J) and (CNA K) were getting (Resident #2) out of bed with Hoyer lift. While (CNA K) was operating the Hoyer lift to get (Resident #2) out of bed I stepped out the room as asked to retrieve the wheelchair. As I walked back into the room, I seen the Hoyer lift strap release and (Resident #2) fell to the floor. We immediately called for help and started applying pressure to her wound . In a telephone interview on 6/20/24 at 3:25 p.m. CNA J said on the day of Resident #2's incident, she notified CNA K that she was stepping out of the room to get the wheelchair. She said as soon as she walked back in the room, she saw CNA K lift Resident #2 up so that her bottom was not on the bed. She said there appeared to be some tension and then she fell . She said she was not in the room when CNA K raised the resident up and in that moment the aide was operating the Hoyer alone. She said one of the loops on the Hoyer strap may not have been on correctly. She said she might have seen the sling was not on the loop correctly if she was in the room. She said staff could tell if the sling was not fastened correctly while moving a resident. She said she was trained that while using a Hoyer lift 2 people should be in the room at all times. She said staff normally did not move the resident until everything was set in place. She said staff should never transfer resident by themselves because there could be an accident. Record review of Resident #2's nursing note dated 1/2/24 by LVN E read in part, Resident was transported to (Hospital) on an EMS ambulance that responded to 911 call on behalf of resident. Resident alert and oriented to own ability 3 cm skin tear to right forehead . Record review of Resident #2's hospital records dated 1/2/24 revealed Resident #2 presented to the emergency department after an unwitnessed fall with positive head strike. An x ray of the left ankle was conducted. Findings were a minimally displaced (slight shift in position) intra-articular fracture of the medial malleolus (inner ankle) with large overlying soft tissue swelling. Mild soft tissue swelling over the lateral malleolus (outside ankle), consistent with sprain. Record review of Resident #2's nursing note dated 1/2/24 by the DON read in part, Resident returned from ER, transported via EMS via stretcher, assisted to bed . hospital dx: abrasion to head, left medial malleolar fracture . splint/cast brace in place to left lower extremities. Resident reports pain, medicated with PRN pain management . Record review of the facility's provider investigation report dated 1/10/24 revealed the sling being used on the mechanical lift was potentially not secured correctly at the time of transfer. The sling and lift were determined to be in proper working order. Staff using mechanical lift were immediately re-educated on the proper procedures for using a mechanical lift and competency check was performed for CNA K. CNA J would receive a competency check on her next scheduled shift. The findings were confirmed. In an observation and attempted interview on 4/16/24 at 2:00 p.m. of Resident #2 revealed she was lying in bed on her right side. Resident nodded yes when asked if she was ok. She was unable to say how she fell . Interview on 6/20/24 at 3:51 p.m. the ADON said CNA K and another aide transferred Resident #2 and she slid to the floor and hit her head. She said there should be two people at all times during a Hoyer transfer because you never know what could happen with the lift. She said the resident could fall if only one person was operating it. She said the facility always educated the staff on two person Hoyer lift transfers. She said she and other nurses ensured the aides were transferring residents properly via Hoyer lift. She said CNA K no longer worked at the facility. Interview on 6/20/24 at 3:58 p.m. the Administrator said he did not remember the details of the incident. He said additional training was certainly conducted after the incident. He said a Hoyer lift transfer required 2 people at all times for safety. Attempted telephone interview on 6/20/24 at 4:26 p.m. with CNA K was unsuccessful. Surveyor was unable to leave voicemail. Record review of the facility's Inservice binder revealed the following in services were conducted prior to Resident #2's incident on 1/2/24: *Safe Patient Handling - 7/30/23, *Fall Prevention - 7/24/23, *Transfer Training - 7/3/23, *(Hoyer) sling care - 7/3/23, *Moving a Resident, Bed to Chair/Chair to Bed - 7/3/23, *Safe Patient Handling - 7/3/23, *Hydraulic Lift - 7/3/23. Record review of the facility's undated Hydraulic Lift policy read in part, The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair .The number of staff to provide assistance with the transfer should be determined by the manufacturer recommendations . Goals: 1. The resident will achieve safe transfer to bed or chair via a mechanical lift device . Procedure: 2. Involve as many staff members as needed to ensure feelings of security by the resident .6. Place the chair next to the head of the bed with the front facing the foot . lock the wheelchair. 7. Raise the bed to accommodate the lift under the bed .11. Check to be sure that the hooks with open ends are turned away from the resident . 12. Pump the life while holding the steering arm until a sitting position is assumed and the buttocks are lifted off the bed . It was determined these failures placed Resident #2 in an IJ situation from 1/2/24 to 1/3/24. The Administrator was notified by telephone and provided with the IJ template on July 9, 2024 at 4:30 p.m. via email. The facility took the following action to correct the non-compliance on 1/3/24. Record review of the provider investigation report dated 1/10/24 read in part, . Provider Response: upon notification of the fracture, the event was reported to TX HHSC. In-services were initiated regarding transfer training. Slings in the facility were inspected for wear and tear . and determined to be in proper working order, including the sling that was used on (Resident #2). Mechanical lifts were inspected . and determined to be in proper working order, including the mechanical lift being used for transfer of (Resident #2) . Investigation summary: . revealed the sling being used on the mechanical lift was potentially not secured correctly at the time of transfer. The sling and lift were determined to be in proper working order. Staff using mechanical lift were immediately re-educated on the proper procedures for using a mechanical lift and competency check was performed for (CNA K). (CNA J) will also receive competency check on her next scheduled shift . Provider Action Taken Post-Investigation: . no further complications or events have occurred since 1/2/24 for this resident or any resident being transferred with a mechanical lift. Transfer training and competency checks continue to be performed for CNA staff . Record review of the facility's in-service training attendance roster revealed a Hoyer lift training was conducted on 1/3/23 (sic). The in-service was on proper placement of sling, how to safely operate Hoyer lift and secure patient in sling, bed, proper positioning, requires 2 people for safe use of Hoyer. There were 12 CNA signatures which included CNA K and CNA J. Record review of Resident #2's care plan revised on 1/10/24 revealed she was at risk for injury due to falls related to impaired cognition, impaired mobility, gait/balance problems, hemiplegia, and incontinence. Interventions were: required 2 person assist with transfers and the use of a mechanical lift. Interview on 6/20/24 at 12:47 p.m. CNA D said Hoyer lift transfers required 2 people. She explained the Hoyer lift procedure and said she checked the Hoyer lift and slings for any wear and tear. She said any concerns would be reported to Central supply staff. In an observation on 6/20/24 at 1:40 p.m. of CNA P and CNA M revealed they transferred Resident #2 from her wheelchair to her bed using a Hoyer lift safely and without incident. The resident no longer had a brace on her leg. Interview on 6/20/24 at 2:09 p.m. Medical Records who also works as a CNA said Hoyer lift transfers always required 2 persons. She said she checked the Hoyer slings for any rips or tears. She said she would notify the Administrator or DON about the integrity of the sling. Interview on 6/20/24 at 2:35 p.m. RN K said two persons were required for Hoyer transfer. She said she checked for any holes on the sling and strap defects. She said if there was a concern during transfer, she would immediately stop and correct the problem, get another pad/Hoyer lift to prevent injury. In a telephone interview on 6/20/24 at 3:25 p.m. CNA J said after the incident with Resident #2 the DON conducted an in-service on Hoyer transfer. She was reminded there should be 2 people to conduct a Hoyer transfer and to not move the individual without 2 people.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 5 residents viewed for infection control. -LVN A did not wear appropriate PPE when providing peg-tube care (PEG tubes allow you to receive nutrition through your stomach) to Resident #1 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes). This failure could place residents at risk of infections. Findings include: Record review of Resident #1's face sheet dated 6/20/24 revealed a [AGE] year-old male who admitted on [DATE]. His diagnosis included metabolic encephalopathy (a problem with your brain that is due to an underlying condition), seizures, hypertension (elevated blood pressure), and open wound of unspecified part of neck. Record review of Resident #1's discharge-return anticipated MDS assessment dated [DATE] revealed he was dependent on staff for ADL care. He had a feeding tube. There was no cognitive status assessment completed. Record review of Resident #1's care plan dated 4/26/24 indicated he was on enhanced barrier precautions related to g-tube placement. Interventions were: gloves and gown should be donned if any of the following activities are to occur - linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Record review of Resident #1's Physician Orders revealed an order for Jevity 1.5 peg tube feeding at 65 mL/hr for 22 hours every day and night shift for feeding, order date 6/10/24. In an observation on 6/20/24 at 9:36 a.m. of Resident #1's doorway revealed a sign on the door that read in part Enhanced Barrier Precautions (EBP) Steps perform hand hygiene, wear gown, wear gloves, dispose of gown and gloves in room . Use EBP during high-contact care activities for residents with: 1. Indwelling medical devices (e.g. central line, urinary catheter, feeding tube .) . protect residents and stop the spread of germs . There was a bin with PPE in the hallway near the room. In an observation on 6/20/24 at 9:38 am LVN A was in Resident #1's room near his bedside with on gloves and an N95 mask, he did not have on a gown. LVN A was working with the resident's tubing and g-tube machine. After working with the machine, LVN A connected the feeding tube to Resident #1. Interview on 6/20/24 at 9:45 a.m. LVN A said he just administered Resident #1's medications via g-tube and replaced his empty feeding bottle with a new one. He said he did not wear a gown while performing those activities and did not have to wear any special PPE with Resident #1 because he was not on contact isolation. LVN A said he was not sure what enhanced barrier precautions was but said staff had to wear gloves and gowns for residents who had multidrug resistant organisms (a drug that is resistant to many antibiotics). He said the DON trained him a couple of weeks ago and said the CDC instructed them to wear PPE for residents with multi-resistant organisms. He said the purpose of the PPE was to protect himself and residents. He said if he did not wear the appropriate PPE, he could pass infection to himself and the residents. Interview on 6/20/24 at 11:53 a.m. the ADON said residents who had a g-tube or other internal devices were placed on enhanced barrier precautions to protect the resident from infection. She said the nurse should have put on a gown, gloves, and used proper hand hygiene when providing care to the resident who was on enhanced barrier precautions. She said staff were previously trained on enhanced barrier precautions and were provided with tools on the electronic health system. She said if proper PPE was not worn with residents on enhanced barrier precautions, staff could transfer infection to the next resident. Record review of the facility's undated Enhanced Barrier Precautions policy read in part, . Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . EBP are indicated for residents with any of the following . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies Administer medications enterally [NAME] gloves and gown: Yes . Device care or use: central, urinary catheter, feeding tube, tracheostomy/ventilator [NAME] gloves and gown: Yes . Any other high-contact activity that includes close bodily contact or coming into contact with the indwelling medical device don gloves and gown: Yes .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 3 of 5 residents (Residents #1, #2, #3) reviewed for pests, in that: -Resident #1 had multiple gnats flying around his face and room. -Resident #2 had multiple gnats flying around her bed and room. - Resident #3 had a fly on her walker in her room. This deficient practice could place residents at risk of residing in an environment with pests. Findings included: Resident #1 Record review of Resident #1's face sheet dated 6/7/24 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included burns involving 50-59% of body surface with 0%-9% third degree burns, burned of third degree (left lower limb, forehead, cheek, abdominal wall, right and left thigh) exposure keratoconjunctivitis -bilateral (condition that occurs when your eyelids don't close all the way, exposing your eye to the air), major depressive disorder, anxiety disorder, unspecified open wound-lower leg, muscle weakness (generalized), lack of coordination. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 out of 15 which indicated severe cognitive impairment. Resident #1 Section GG - Functional Limitation in Range of Motion - Impairment on both sides (Upper and Lower extremities). Functional Abilities - Total Dependent for Self-Care. Record review of Resident #1's care plan last reviewed 5/1/24 revealed the following: Focus: [Resident #1] has limited physical mobility related to third degree burns all over my body, bed bound status, prefers to stay in bed. Revised 4/13/22. Goal: [Resident #1] will increase level of mobility by increasing wheelchair mobility to limited assistance. Revised 7/27/21. Intervention: Provide supportive care, assistance with mobility as needed . Resident #2 Record review of Resident #2's face sheet dated 6/7/24 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes mellitus with hyperglycemia (disorder in which the body has high sugar levels for prolonged periods of time), muscle weakness, lack of coordination, cognitive communication deficit. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed a BIMS score of 6 out of 15 which indicated severe cognitive impairment. Resident #2 - Section GG - Total Dependent for sit to lying in bed, bed to chair transfer. Record review of Resident #2's care plan last reviewed 5/8/24 revealed the following: Focus: [Resident #2] has communication problems related to impaired cognition, confusion at times, hx of stroke, fluctuations in cognition. Revision 10/12/22. Goal: The resident will maintain current level of communication function through the review date. Revised 5/18/22 Interventions: Anticipate and meet needs. Resident #3 Record review of Resident #3's face sheet dated 6/7/24 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included Unspecified Dementia (group of symptoms affecting memory), Anemia (condition of low red blood cells), major depressive disorder, diabetes mellitus (disorder in which the body has high sugar levels for prolonged periods of time), blindness right eye, muscle weakness. Record review of Resident #3's Annual MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. Observation and Interview on 6/7/24 at 9:11 a.m. of Resident #1 revealed he was lying in bed. Resident #1 had multiple gnats flying around his head. Resident #1 had a light-yellow discharge leaking from his left eye. One gnat landed on Resident #1's forehead. Resident #1 said he was not able to see the gnats but could feel them when they have landed on his nose area in the past. He said it made him feel uncomfortable when the gnats have landed on him. Observation and Interview on 6/7/24 at 9:55 a.m. of Resident #2 revealed she was lying in bed. Resident #2 had multiple gnats flying around the room. Resident #2 said she did not like the gnats in her room and it makes her feel bad. She said she had complained in the past but did not feel the problem had been solved. Observation and Interview on 6/7/24 at 11:07 a.m. of Resident #3 revealed she was sitting up in the bed reading. A fly swatter was observed next to her in the bed. A fly was observed on her walker next to her bed. Resident #3 said she kept the fly swatter next to her to kill flies. She said she ate in her room and had to wave off flies occasionally while she ate. Interview on 6/7/24 at 11:17 a.m. the Administrator said he did see gnats in Resident #2's room today. He said he was aware of the gnats and flies in the building . He said he thought the monthly pest control took care of the issue. He said he was not sure of the risk to resident who had gnats and flies around them or if they landed on them. He said if pests were found in resident rooms, the resident is moved, the room is deep cleaned and treated by pest control and the resident is returned to the room. He said the facility should be pest free and it is facility staff that are responsible to keep the facility clean and free of pests. He said gnats increased because of the time of year. Interview on 6/7/24 at 12:05 p.m. with Police Officer A said she observed Resident #2 while she ate lunch and observed gnats in Resident #2's room. Police Office A said the Administrator was present and observed the gnats as well. Interview on 6/7/24 at 1:45 p.m. with the DON said there had been a few residents who had insects in their room. She said Resident #1 had insects in his room and he is not able to move to swat away insects when they are on or near him. She said Resident #2 had insects in her room and had to be moved from the room to deep clean and treat the room. She said the facility staff make rounds to observe and look for insects daily. DON said residents are at risk of being bit and possible infection. Record review of the facility's pest control policy titled Insect and Rodent Control not dated revealed the following in part: The facility will maintain an effective pest control program in order to provide an insect and vermin free . Procedure: 1. Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required. 2. Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. 3. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents. Record review of facility May 2024 Pest Control Service Notification dated 5/10/24 revealed the following in part: . completed your monthly service for the month of May . they had some ants in these rooms . [Residents #1 and #2's rooms] . Targeted issues: Flies, Fruit flies, ants (several types)

Based on observation, interview, and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 6 staff ( RN C) and 2 of 5 residents ( CR #19 and Resident #317) reviewed for nursing competency. - RN C failed to administer Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - RN C failed to send CR #19 through 911 emergency transport after being diagnosed with critical vitals. - RN C failed to administer Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. An IJ was identified on [DATE] at 09:00 AM. While the IJ was removed on [DATE] at 06:37 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk for hypoglycemia, drug overdose, decline in health and death. Findings included: CR #19 Record review of CR #19's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: gangrene, absence of right leg below knee, MDD, panic disorder, hypertension, stage 4 pressure ulcers, bacterial bone infection and type 2 diabetes. The resident was transferred to the hospital on [DATE] at 08:50 PM. Record review of CR #19's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of CR #19's Discharge Return Anticipated MDS dated [DATE] revealed, the resident had an unplanned discharge to an acute hospital, the resident had a fever and no documented falls since prior assessment. CR #19 had 4 stage four pressure ulcers of which 3 were facility acquired and 1 facility acquired unstageable ulcer. Record review of CR #19's Care Plan last reviewed on [DATE] revealed, focus- advance directive as evidenced by full code, focus- pressure ulcers. Record review of CR #19's Physician's Orders dated [DATE] revealed, Glucagon Emergency Kit 1 MG- Inject 1 mg IM every 12 hours as needed for s/s of hypoglycemia, unresponsive and BS </= 70, recheck BS in 15 minutes and notify MD. Glucose Gel 40%- give 15 grams every 15 minutes as needed for s/s hypoglycemia and responsive, May administer 2nd dose and recheck in 15 minutes, notify MD only if not above 70. Record review of CR #19's SBAR note dated [DATE] signed by RN C revealed, CR #19 suffered from: mental status change, respiratory change-suspected infection, cardiovascular change, fever with unknown focus of infection, neurological change, BP of ,d+[DATE], HR 107 and irregular, RR of 20, oral temperature of 101.1 and a BS of 62. All vitals were collected at 07:23 PM. CR #19 had decreased level of consciousness (very lethargic), had increased confusion/disorientation, experienced rigors (shaking chills), experienced SOB, weakness or hemiparesis. RN C documented that the symptoms first appeared on [DATE] and no ordered treatments/medications had been attempted to help resolve the symptoms. NP A was notified at 07:49 PM and a request was made to transfer the resident to the hospital. Record review of CR #19's Transfer Notification dated [DATE] at 08:50 PM signed by RN C revealed, CR #19 was transferred to a hospital on [DATE] at 08:50 PM related to lethargy, hypotension, rapid shallow breathing, elevated heart rate and body temperature. There was no documentation of hypoglycemia. Record review of CR #19's Progress Notes dated [DATE] at 8:55 PM signed by RN C revealed, While making rounds to administer medication, resident was found lying in bed very lethargic and hard to arouse. Further assessment PB ,d+[DATE] manually, T 101.1, P 107, R 20, O2 Sat 97% on room air, and BS 62 mg/dl at around 1923 (07:23 AM). NP A was notified of CR #19's change in condition at about 1938 (7:38 PM) and an order was given to send the resident out via contracted EMS while monitoring BP. CR #19 started exhibiting muscle tremors, increased SOB and BP lowered to ,d+[DATE] so NP A was notified of the further change of condition. CR #19 was transferred to the ER via 911 EMS at 8:50 PM, almost 1 ,d+[DATE] hours after symptoms were first observed. There was no documentation of treatment of CR #19's low blood sugar. Record review of CR #19's August MAR revealed, CR #19 was never administered Glucagon. In an interview on [DATE] at 10:18 AM, CR #19's family member said while at the facility CR #19 had multiple pressure wounds and was hospitalized for the wounds on multiple occasions. CR #19's family member said when the resident would go to the hospital his wounds would get better but would worsen when he returned to the facility. She said her father was transferred to the hospital on [DATE] where he was diagnosed with sepsis which the hospital tried to treat with dialysis and antibiotics. CR #19's family member said the resident expired in the hospital 2 days after arrival ([DATE]) of severe sepsis. In an interview on [DATE] at 12:52 PM, RN C said she found CR #19 unresponsive with critical values. She said he had low blood pressure, an elevated heart rate, was running a fever, had blood sugar lower than 70 and was in and out of consciousness She said she contacted NP A who said to monitor CR #19's blood pressure and send him out, she did not remember if NP A said the resident should be sent out using a contracted transport company of 911. She said she called the contracted EMS company to send him to the hospital and continued to monitor the resident. RN C said on following rounds she observed CR #19 to be suffering from tremors and the contracted service was not there yet so she called 911 to send him out. RN C said that CR #19's symptoms appeared to indicate sepsis and looking back she would have sent him out initially using 911. She stated she instead tried to give him Glucagon gel by mouth but due to the resident's condition, it could not be administered that method. RN C said she did not think to administer glucagon by injection because things were moving too fast and she instead focused on the resident's dropping blood pressure. In an interview with the DON on [DATE] at 01:25 PM, after reviewing CR #19's vitals on the day of his hospitalization ([DATE]) the nurse should have administered Glucagon to the resident to treat his hypoglycemia. She said nursing staff do not specifically have training on how to manage emergency situations like what CR #19 experienced but it is an expected nurse competency. The DON said there was nothing stopping RN C from administering Glucagon to CR #19 since the resident had an active order for the medication. She said based on CR #19's symptoms she would expect the nurse to send the resident to the hospital by calling 911 because it is unknown how long the contracted EMS service would take. The DON said if a contracted EMS service was called and had not arrived in ,d+[DATE] minutes then 911 should have been called She said the time it took for CR #19 to be transferred to the hospital was too long. The DON said delay in transfer to the hospital could result in CR #19 experiencing further decline since his BP could not be treated at the facility and failure to treat CR #19's low blood sugar could lead to further hypoglycemia. In an interview on [DATE] at 04:00 PM, NP A said she was notified by a nurse that CR #19 was experiencing signs and symptoms of infection and sepsis so she gave the order to send the resident to the hospital for emergency care. She said the facility had standard orders for Glucagon which were stored on their carts so CR #19 should have been treated for his hypoglycemia regardless of his critical vitals. When the surveyor notified NP A of the vitals reported by RN C at the time of the incident, NP A said with those vitals the facility would not be able to treat the resident so he had to be hospitalized . NP A said she did not specify the method of transfer to the nurse (contract vs. 911) but based on CR #19's critical vitals the expectation was that the resident be sent out by calling 911. She said any delay in transfer to the hospital would result in a delay in identification and treatment of acute issues. In an interview on [DATE] at 02:22 PM, the Administrator said the facility did not have a policy addressing critical labs/vitals. Record review of the facility in-service titled Medication Safety Alert dated [DATE] presented by the Director of Clinical Education revealed, RN C was trained on the administration of Gvoke an antihypoglycemic agents indicated for severe hypoglycemia. Gvoke pre-filled is for subcutaneous injection only and should be administered as soon as possible when server hypoglycemia is recognized. Gvoke is premixed and ready for immediate us. Attached was a policy on Diabetes Management that defined hypoglycemia as BS </= 70. Record review of the facility in-service titled Diabetes management education and the use of Glucagon dated [DATE] presented by the Director of Clinical Education revealed, RN C was trained on diabetes management and hypoglycemia. Glucagon injection is an emergency medicine used to treat severe hypoglycemia in diabetes patients treated with insulin who have passed out or cannot take some form of sugar by mouth. Administer Glucagon as directed per physician orders. Notify Physician if Blood sugar less than 70 or per physicians orders, if unresponsive or unable to swallow position on side and give Glucagon 1 mg IM or as directed per physician orders. This is a Medical Emergency requiring close observation and/or 911. Resident #317 Record review of Resident #317's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility with diagnoses which included: anemia, paraplegia, colostomy and stage 4 pressure ulcer of the back. Record review of Resident #317's undated Care Plan revealed, focus- potential for uncontrolled pain due to osteomyelitis, muscle spasms, pressure ulcer and surgical wound upon admission; interventions- administer analgesia as ordered, monitor/document for side effects of pain medication. Focus- use of anti-anxiety medications, interventions- give anti-anxiety medications as ordered and monitor/document side effects. Record review of Resident #317's Order Summary Report dated [DATE] at 09:20 Am revealed the following active orders: - Acetaminophen 500 mg- 2 tablets by mouth every 8 hours for pain. - Alprazolam 1 mg- 1 tablet by mouth every 8 hours as needed for anxiety. - Baclofen 5 mg- give 4 tablets by mouth four times a day for muscle spasms. - Gabapentin 400 mg- 2 capsules by mouth three times a day for neuropathy (nerve pain). - Methadone 5 mg- give 7.5 mg by mouth every 8 hours for pain. - Methocarbamol 750 mg- give 1 tablet by mouth three times a day for muscle spasms. - Naloxone 4mg/0.1 ML- 0.1 mL alternating nostrils every 2 minutes as needed for opioid overdose may repat every ,d+[DATE] minutes as needed. - Hydrocodone/Acetaminophen ,d+[DATE] mg- give 1 tablet by mouth every 8 hours as needed for pain. - Oxycodone 5 mg- give 1 tablet by mouth every 6 hours as needed for pain score ,d+[DATE]. Record review of Resident #317's Progress Notes dated [DATE] at 12:47 PM signed by NP C revealed, Reviewed Prescription Monitoring Program and patient is at high risk for unintentional overdose with a score of 650 above average. Risk for unintentional overdose discussed with patient, and he reports that he has been taking medications for a long time and that he never overdosed before. PMP monitoring only shows Hydrocodone, and Alprazolam that has been prescribed by his PCP in the community, in which his PCP ordered him Alprazolam yesterday [DATE] and was filled at pharmacy. Narcan nasal spray is ordered as needed. Record review of Resident #317's MAR dated [DATE] revealed, Resident #317 received the following medications the night ([DATE]) before his overdose - Gabapentin 800 mg- scheduled for 06:00 PM. - Methocarbamol 750 mg- scheduled for 06:00 PM. - Baclofen 20 mg - scheduled for 06:00 PM. - Methadone 7 mg- scheduled for 10:00 PM. Record review of Resident #317's Progress Note dated [DATE] at 04:18 AM signed by RN C revealed, Resident transferred to [Hospital] via 911 EMS at approximately 04:18a.m. for further evaluation and treatment related to decreased level of consciousness and respiratory distress. EMS personnel given copy of resident's face sheet, order summary, and clinical notes containing past medical history. Resident's personal belongings including two backpacks, one [NAME] pack,computer laptop, cell phone, earbuds, wrist watch, colostomy supplies, and several bottles of prescription medication remained behind in resident's room. [NP A] notified of [Resident #317] emergency transfer to [Hospital] at approximately 04:30a.m. Record review of the Hospital Ambulance Record dated [DATE] for Resident #317 revealed, Primary impression- overdose other opioids. Narrative- the fire department was dispatched to the facility for a cardiac arrest. Resident #317 was found to be drowsy with deep snoring and the nursing staff said they were unsuccessful in waking Resident #317 and he might have had a seizure. Review of the Resident #317's chart showed multiple medications for sleep, pain and muscle reactions and the resident had constricted pupils. Resident #317 was administered 1 mg of Naloxone Intranasally and the patients response improved; he was easily arousable to verbal and talked to the crew without falling asleep. Record review of the Hospital ED Record dated [DATE] revealed, Resident #317 was found unresponsive and hard to arouse at the facility and the EMS administered 1 mg of Naloxone. Record review of the Resident #317's Progress Note dated [DATE] at 08:10 AM revealed, Resident #317 returned to the facility in elate and high spirit. Resident #317 was diagnosed with opiate overuse in the hospital and NP A gave new orders to check the residents vitals and signs/symptoms of CNS depression on each shift. NP A ordered Resident #317's Oxycodone & Xanax 1 mg to be discontinued, Methocarbamol 750 mg decreased from three times daily to two times daily and a new order for Xanax 0.5 mg every 12 hours. An observation and interview on [DATE] at 11:40 AM revealed, Resident #317 lying on stomach in bed in no immediate distress. He said the previous day ([DATE]) when he was asleep his mother placed his prescriptions in his backpack because she did not know what to do with it. He said this morning ([DATE]) the facility staff tried to wake him up but he was not moving so they called 911. Resident #317 said he was informed that he had an opioid overdose. An observation on [DATE] at 12:03 PM revealed, a ziplock bag containing Resident #317's following home medications: - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 43 tablets remaining. - 1 bottle of Gabapentin 300 mg filled for 810 capsules with 3 capsules remaining. - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 56 tablets remaining. - 1 bottle of Naproxen 500 mg filled for 180 tablets with 116 tablets remaining. - 1 bottle of Baclofen 20 mg filled for 180 tablets with 169 tablets remaining. - 1 bottle of Alprazolam/Xanax filled for 270 tablets with 197 tablets remaining. In an interview on [DATE] at 12:52 PM, RN C said on Saturday morning ([DATE]) during her hourly monitoring of residents she observed Resident #317 sitting in bed slumped over, unresponsive and slipping in and out of consciousness. She said he was breathing strange, would not wake up and was making gurgling/chocking sounds. RN C said she immediately placed him on oxygen, talked to him and tried to wake him which he could not so she made a judgement call to call 911. She said based on his symptoms she suspected he had a seizure/blood sugar or medication related overdose. Specifically to medications RN C knew the resident was on multiple pain medications like oxycodone/methadone/hydrocodone and Xanax/baclofen/methocarbamol. RN C said all these medications in unison can lead to respiratory depression and CNS depression. RN C A said the facility has Naloxone available to treat overdoses but she did not administer Naloxone to Resident #317. She said she was supposed to give Narcan immediately and call 911 but did not because there was just a lot going on. RN C said when 911 arrived she told them she suspected either a seizure or overdose and looking back she should have administered Narcan. After the resident left the DON said to check his belongings in case he took something and she found several bottles of medications including Gabapentin, and Ativan. She counted it all and gave it to the DON. RN C said failure to administer Naloxone in response to an opioid overdose is dangerous and the resident could experience increased slurred speech/difficulty breathing, lose consciousness, and it could lead to death. In an interview on [DATE] at 01:25 PM, the DON said signs and symptoms of opioid overdose included: shallow breathing and the resident being un-responsive. She said based on the information RN C provided about the incident Resident #317 showed symptoms of an opioid overdose. The DON said when a resident shows signs and symptoms of an opioid overdose the nurse must administer Naloxone, and RN C did not administer Naloxone to Resident #317. She said calling 911 was absolutely not an excuse for failure to render services during emergency situations. The DON said nursing staff was trained on the use of Naloxone at the end of 2022 when the facility started receiving Naloxone, and no training was performed after that. In an interview on [DATE] at 04:00 PM, NP A said Resident #317 suffered an overdose after consuming medications that the facility was unaware of. She said signs of overdose included respiratory distress and the facility had Naloxone on hand to treat overdoses. NP A said the expectation is that nurses call 911 and then administer Naloxone and failure to do could cause the resident worsening of condition and potential harm. In an interview on [DATE] at 09:27 AM, the DON said no training was performed on the emergency administration of Glucagon between CR #19's hospitalization on [DATE] and [DATE]. She said she was just focused on CR #19 being sent out to the hospital and not the failure to administer Glucagon. The DON said no training has been performed on opioid overdoses and the administration of Naloxone since Resident #317's overdose on [DATE] and the last training was performed in December of 2022. Record review of the facility in-service record titled 'Opioid Overdose dated [DATE] revealed, patients who are prescribed opioid medication receive the necessary care and services to avoid complications associated with opioid overdose by: ensuring appropriate monitoring and treatment as may be required utilizing opioid reversal agents such as Naloxone. RN C was noted in attendance as indicated by her name and signature. Record review of RN C's Nurse Proficiency Audit dated [DATE] completed by the DON revealed, RN C was assessed as satisfactory for skills which included: administering medication properly (Oral/IM/SQ), and knowledge of emergency procedures (CPR, Crash Cart/AED, Activate EMS). Proficiency in Glucagon and Naloxone administration were not assessed. On [DATE] at 11:00 AM, the Administrator and was notified of the Immediate Jeopardy (IJ) due to the above failures. The IJ template was provided and a plan of removal (POR) was requested at that time. The following plan of removal was approved on [DATE] at 11:34 AM and read: IJ Component: F726 Competent Nursing Staff: Facility failed to administer glucagon to CR#19 as ordered when identified with a BS of 62. Facility failed to send CR#19 out immediately following an acute change of condition. Facility failed to administer Naloxone to Resident #317 after the resident suffered from an overdose. Immediate Actions: CR#19 was transferred to theER on [DATE] and did not readmit to the facility. Resident #317 was transferred to theER on [DATE] at approximately 415am and readmitted to the facility on [DATE] at approximately 810am with diagnosis of Opioid Use and Anemia. Resident #317 was discharged home with home health services on [DATE]. Facility Plan to ensure compliance: 1. 100% review of all facility residents prescribed Glucagon completed by DON, ADON, and Regional Compliance Nurse on [DATE] to identify any other residents that did not receive prescriber ordered Glucagon for hypoglycemia. No other resident from audit identified as not receiving ordered Glucagon. 2. 100% assessment of all facility residents prescribed an opioid completed by DON, ADON, and Regional Compliance Nurse on [DATE] to assess for s/s of opioid overdose. No resident currently residing in the facility as of [DATE] identified from audit as having any s/s of opioid overdose. 3. Facility residents with a diagnosis of Diabetes Mellitus (DM) were audited on [DATE] to ensure all prescriptions were documented correctly. Audit revealed all residents with a diagnosis of DM with a prescription for treatment, either by mouth and/or with insulin orders, were transcribed correctly. 4. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on [DATE] regarding a. Abnormal Blood Sugar readings to include process for administering glucagon, when ordered, and process for treating an unresponsive resident. b. Change of Condition: When to Report to MD/NP/PA c. Conditions that require immediate transfer d. Signs and symptoms of Opioid Overdose e. How to use Narcan/Naloxone 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Abnormal Blood Sugar Readings to include the process for administering glucagon, when ordered, and the process for treating an unresponsive resident. Goal for completion of this education to be completed by end of day on [DATE]. 6. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Change of Condition to include when to Report to MD/NP/PA. Goal for completion of this education to be completed by end of day on [DATE]. 7. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Conditions That Require Immediate Transfer. Goal for completion of this education to be completed by end of day on [DATE]. 8. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Signs/Symptoms of Opioid Overdose. Goal for completion of this education to be completed by end of day on [DATE]. 9. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Narcan/Naloxone Administration. Goal for completion of this education to be completed by end of day on [DATE]. 10. Licensed nurses (LVN/RNs) will be tested to evaluate competency of the education/in-services initiated on [DATE]. Competency tests will be initiated on [DATE] upon completion of the education with goal for completion by end of day on [DATE]. 11. Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to abnormal blood sugars or signs of opioid overdose in EMR (), the facility's electronic medical record (EMR). 12. All nurses (LVN/RNs) not in service on [DATE] will be in service prior to working their next scheduled shift. 13. The Medical Director, was notified by Administrator on [DATE] at 1:55pm on the immediate jeopardy citation. 14. An Ad-hoc QAPI meeting was held on [DATE] by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: Record review of the facility schedule revelaed, the facility had 2 nursing shifts 06:00 AM to 06:00 PM day shift and 06:00 PM to 06: 00 AM night shift. Monitoring involved interviews with both day shift and night shift staff. Interviews conducted on [DATE] from 11:20 AM to 11:40 AM revealed, LVN A, LVN B, RN B, and the ADON A received in-service training on the treatment of hypoglycemia, opioid overdose and immediate transfer to the hospital. The staff showed competency in the emergent treatment of hypoglycemia and immediate transfer to the hospital but were not competent in the administration of Naloxone. LVN A and LVN B did not know when to repeat Naloxone, RN B did not know the formulation of Naloxone used in the facility and where it could be located. An interview on [DATE] at 12:34 PM revealed, the DON did not know the formulation of naloxone used in the facility and did not know that Naloxone could be administered if a resident became unconscious after a previous dose was administered. An interview on [DATE] at 12:45 PM with the Regional Clinical Nurse revealed, the facility was not trained on the re-administration of Naloxone if a resident became unconscious after a previous dose was administered. He said the facility had just focused on training the staff to administer the first dose of Naloxone and then call 911. The Regional Clinical Nurse said nursing staff was not trained on readministering Naloxone and all staff would be trained appropriately. In an interview on [DATE] at 01:36 PM, the Regional Clinical Nurse said the DON and Administrator were re-trained on the administration of Naloxone and training of the nursing staff was ongoing. He said since the IJ was called the facility: - audited all residents with opioid prescriptions to ensure they had orders for PRN Naloxone - audited all blood sugars to ensure treatments were given for any abnormal values Interviews conducted on [DATE] from 05:28 AM to 06:27 AM revealed the following: - LVN B was re-trained in the administration of Naloxone showed competency in its administration. - RN A, RN C, LVN D, LVN G, LVN H, received training on treatment of hypoglycemia, immediate transfer to the hospital and opioid overdose. The staffed interviewed showed competency in the use of Glucagon for the treatment of hypoglycemia, resident symptoms that require immediate hospital transfer and the treatment of an opioid overdose using Naloxone. Record review completed on [DATE] revealed: - on [DATE] the [NAME] Clinical Nurse audited all resident's receiving opioids and reassessed them for s/s of opioid overdose and residents displayed any signs or symptoms - on [DATE] the DON reviewed all resident orders for Glucagon administration. - on [DATE] the DON completed a Nurse Proficiency Audit on RN C, she was found to be satisfactory. - on [DATE] a QAPI meeting was held regarding the IJ- the DON, Regional Clinical Nurse, Administrator were in attendance. - on [DATE] the facility trained the ADON, Administrator and DON were trained on change in conditions, conditions that require immediate transfer, signs and symptoms of opioid overdose and responding to an overdose - on [DATE] the facility completed training with nursing staff on: responding to an overdose how to give naloxone, signs/symptoms of opioid overdose, conditions that require immediate transfer, blood sugars: abnormal readings, change in conditions: when to report to the provider. The Nurses were assessed with a competency test and found satisfactory. - on [DATE] the Regional Clinical Nurse reviewed residents with Glucagon ordered and discontinued glucose gel if Glucagon was on order. - on [DATE] the Regional Clinical Nurse audited all residents with a diagnosis of diabetes to ensure they received appropriate treatment and all mediations were appropriate - on [DATE] at 1:00 PM ADON A, the DON and the Administrator were retrained on the administration of Naloxone with emphasis of subsequent administration after a resident becomes unconscious or declines after an effective first dose. - On [DATE] the facility retrained the following staff on the administration of Naloxone with emphasis of subsequent administration after a resident becomes unconscious or declines after an effective first dose: MDS Nurse A, RN A, LVN B, LVN A, RN C, LVN D The Administrator was informed the IJ was removed on [DATE] at 06:37 PM. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, for 1 of 6 residents (Resident #8) reviewed for enteral nutrition, the facility failed to ensure whoever was able to eat enough was not fed by enteral methods unless the resident's clinical condition demonstrated that the enteral feeding was clinically indicated and consented to by the resident, in that: - Resident #8 had a PEG tube deemed non-functional for over 5 months without enteral feeds or water flushes. - Resident #8 experienced multiple episodes of infections at her PEG tube site. - The NP convinced Resident #8's RP to not remove PEG tube in case it needed to be used for emergency enteral feedings or medications. She did not communicate resident's complications related to PEG tube or that it was non-functional. - Resident #8 was found on 08/16/2023 with PEG tube pulled out with tip broken off and was hospitalized as a result. - Resident #8 experienced a decline in ADLs as evidenced by downgrade from Regular heart healthy pureed diet to enteral feeds after tube replacement post- partial bowel obstruction. An Immediate Jeopardy (IJ) was identified on 09/08/23 at 4:05PM. While the IJ was removed on 09/12/23 at 06:25 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for a decline in ADL, decline in health, injury and death. Findings include: Resident #8 Record review of Resident #8's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE] and was diagnosed with Alzheimer's disease (progressive mental deterioration), cerebral infarction (stroke), dysphasia (difficulty swallowing) and paralytic ileus (impaired motor activity of the bowel). Observation of Resident #8 on 09/05/2023 at 10:30AM, the resident was lying in bed, being fed enteral feed continously via PEG tube in place, and the resident was non-verbal at the time. Record review of Resident #8's MDS, dated [DATE], the resident was identified to have a feeding tube. Record review of Resident #8's care plan, undated, revealed the resident had no care plan related to tube feedings. Record review of Resident #8's clinical physician orders, undated, revealed the resident's history of diet orders included: - NPO diet from 01/31/2020 to 2/18/2020 - Regular mechanical soft diet with ground meat texture from 2/2/2023 to 4/3/2023 - Regular diet or Heart healthy diet, puree texture, regular consistency from 4/3/2023 to 8/18/2023. - Enteral feed order of 1.5cal/ml isosource at 50ml/hr for 22 hours every shift from 09/01/2023 to present. Record review of Resident #8's order summary report, dated 3/1/2023 - 08/18/2023, revealed the resident did not have any enteral feed orders prescribed from 3/1/2023 until day of discharge on 8/16/2023, and the resident took all medications by mouth. Record review of Resident #8's nurses notes, dated 02/03/2023 - 03/06/2023, revealed the resident was assessed by the NP on 02/04/2023, who noted the resident had a diet order of dysphagia advanced texture, was eating fair and had a peg-tube in place but not in use. NP's plan of care regarding Malnutrition/Dysphagia including monitoring weights, peg flushes and dressing changes per protocol. Record review of Resident #8's physician orders, dated 03/01/2023 to 09/09/2023, revealed the resident had an order for KUB STAT Dx. Check Peg tube placement one time for 1 day, on 03/06/2023. Record review of Resident #8's nurses notes, dated 03/06/2023 - 04/06/2023, revealed the NP assessed the resident for a Peg Tube Malfunction on 03/07/2023 and noted, . Nursing reported peg tube appears to be displaced from normal position yesterday . KUB performed and recommended gastrograffin [a contrast medium used for x-ray imaging] for definitive placement verification . Nursing to notify RP of order, will proceed if RP agreeable, peg tube not currently in use . In the NP's assessment and plan regarding her peg tube, she noted, . KUB performed, will await approval before proceeding with gastrograffin . Peg appears to be in normal position as when last assessed by myself . Order given not to use peg tube for now . Abdominal exam benign . Record review of Resident #8's progress notes, dated 03/06/2023 - 04/06/2023, revealed the NP assessed the resident on 03/09/2023 and noted the resident was lying in bed being fed by a staff. The NP also noted, . RP does not desire to proceed with additional X-ray procedure to confirm placement of peg tube . Will DC all peg tube orders . No acute concerns or complaints . In the NP's assessment and plan regarding her peg tube, she noted, . RP declines any additional studies for peg tube . DC all peg tube orders . Apply abdominal binder . Monitor provider for any changes . Record review of Resident #8's progress notes, dated 03/06/2023 - 04/06/2023, revealed LVN G wrote a note on 03/09/2023 that stated, . NP . here in the building this am to visit resident NP . called RP . to ask if she wanted resident to be sent out for gtube replacement or removal RP . stated no then RP . also came to this facility to visit resident and stated she does not want anything done to the gtube removed or replaced she only wants gtube site clean. NP gave new order to d/c all gtube orders . Record review of Resident #8's progress notes, dated 06/07/2023 - 07/08/2023, revealed, RN F wrote, RESIDENT IS AGITATED AND WOULD NOT ALLOW ME TO DRESS HER G-TUBE. SMALL AMOUNT OF BRIGHT RED BLOOD NOTED TO SHIRT. SMALL AMOUNT OF BLOOD NOTED AROUND G-TUBE INSERTION SITE. WAS ABLE TO CLEAN AREA. NO OPEN AREA NOTED. RESIDENT ARM REST AGAINST G-TUBE AND MAY HAVE CAUSED IRRITATION. NO ACTIVE BLEEDING NOTED AFTER CLEANED. Record review of Resident #8's progress notes, dated 07/08/2023 - 08/08/2023, revealed the NP assessed Resident #8 on 07/26/2023, reason being for rash, drainage from peg site . The NP wrote: . Peg Tube Infection - Noted to have breakdown around peg tube with purulent drainage - Continue Doxycycline - Peg site care daily - Non-functioning peg tube Record review of Resident #8's physician's orders, dated 03/01/2023 - 08/16/2023, it revealed the resident was ordered: - Clotrimazole External Cream 1% was ordered on 07/26/2023 and was to be applied periumbilical area topically two times a day for infection. The treatment lasted for 14 days; 07/26/2023 - 08/09/2023. -Doxycycline Hyclate Oral Capsule (100mg) was ordered on 07/26/2023, to be administered by mouth two time a day for peg tube infection for 10 days. Instructions were given to cleanse peg tube site with normal saline, pat dry and apply dressing until healed. The treatment lasted 10 days; from 07/26/2023 - 08/05/2023. Record review of Resident #8's progress notes on 08/02/2023, the NP documented her assessment of PEG tube infection and wrote about her conversation she had with Resident #8's RP, in which she wrote: . #Peg Tube Infection - Improved - Continue Doxycycline until 8/5 - Peg site care daily - Non-functioning peg tube - F/U with [GI] RP conversation: Per nursing RP is requesting removal of PEG tube. Call placed to RP. Spoke with [Responsible Party] Discussed risk and benefits of peg tube placement. Patient has periods of being uncooperative, agitated, and refusing to eat and drink. RP is agreeable to have peg tube placed as it is non-functioning at this time . Record review of Resident #8's progress notes, dated 08/08/2023 - 09/08/2023, revealed on 08/13/2023, LVN E noted, . increased redness around stoma, skin irritation . profuse sticky drainage . Record review of Resident #8's physician's orders, dated 03/01/2023 - 08/16/2023, it revealed the resident was ordered: - Doxycycline Hyclate Oral Capsule (100mg) was ordered on 08/13/2023, to be administered by mouth two time a day for peg tube stoma infection for 7 days. The treatment lasted 4 days and was discontinued to resident's discharge to hospital. Record review of Resident #8's progress notes, dated 08/08/2023 - 09/08/2023, revealed on 08/16/2023, LVN D noted resident was found at 6:00AM with tubing from her old non-functioning PEG tube in her hand while asleep. She also noted, . redness, irritation and profuse sticky drainage . Resident currently on antibiotic therapy related to infection at Peg tube site . LVN D also noted the catheter tip was not in place on the tubing. On 08/16/2023, LVN E also documented, .Resident pulled out her peg tube last night . looks like she had the tip of peg tube did not came out . LVN E noted Resident #8 was transferred out to the hospital ER for evaluation and treatment by 11:30AM. Record review of Resident #8's physician orders, dated 03/01/2023 to 09/09/2023, revealed the resident had an order for transfer resident to [hospital] ER for evaluations and peg tube replacement, on 08/16/2023. Record review of Resident #8's hospital records, dated 08/22/2023, revealed the resident was admitted into the hospital on 08/16/2023, and a physician wrote, . [AGE] year-old female with a past medical history of hypertension, severe dementia, cholecystectomy presents to the hospital with a dislodged gastrostomy . CAT scan completed on arrival demonstrated that the gastrostomy tube was located at the terminal ileum [end of small intestine located before the entrance to the colon]. Gastroenterology consulted for the findings above . Assessment: Partial bowel obstruction secondary to dislodgement of PEG tube. Colonoscopy completed yesterday . On 08/21/2022, another physician noted, . PEG tube from ileocecal valve . Patient underwent colonoscopic retrieval of the PEG tube successfully . Interview with a family member on 09/06/23 at 03:29 PM, she said Resident #8's PEG tube was placed 3 years ago but had since not been removed to serve as a backup in case the resident were to ever refuse food or medication. She said she ate by mouth and was never notified by staff of them needing to use her PEG tube due to the resident refusing meals or medications. She said she never requested to have the PEG tube removed because it not her call, considering she had no medical background. She said when the resident was discharged to the hospital on 08/16/2023, she learned from the hospital staff that a piece of the PEG tube had broken off and the CT scan showed it was in her intestines. She said a few days before the resident's hospitalization , she noticed her PEG tube was leaking, with thick, off-yellow pus and the resident stoma site appeared red and raw with rashes on her abdomen. She said she did not tell the nurses what she saw because she assumed the nurses were taking care of it. She said she did not feel persuaded to keep it in and it was never a topic of discussion because of how independent the resident had always been. She said the resident has shown to have a decline since returning to the hospital is no longer eating like she used to. Interview with LVN G on 09/07/23 at 01:43 PM, she said if a patient has a PEG tube that is not being used, nurses should keep flushing if there is an order to keep the line clean and prevent blockages because it can clog up. She said Resident #8's family did not want the PEG tube out because the resident was due to her age, therefore, they wanted to prevent any unnecessary surgical procedures. She said she only kept flushing Resident #8's PEG tube it only if it was in the doctor's order. LVN G said the risks of keeping a non-functioning tube in place was infection and aspiration. She said she had seen Resident #8 with some excoriation to abdomen and around the PEG tube site and had orders to apply cream to around the PEG tube site. She said the resident had since experienced a decline following her hospitalization , she could talk and eat by mouth before, but has snow been on enteral feeds via PEG tube. Interview with LVN E on 09/18/23 at 12:58 PM, he said he worked often with Resident #8 and saw the resident's tube was pulled out after LVN D reported the incident to him during shift change. He said he had called the NP and told it appeared as if a piece of the PEG tube was missing. The NP later ordered for the resident's transfer to the ER for evaluation and he notified the resident's family. He said at the time of assessment, the resident had clear drainage the stoma site. The resident had a history of drainage for a period of time before her discharge and was prescribed antibiotics and daily cleaning of the stoma. He said the resident always ate by mouth and did not have any enteral feeds. Interview with LVN D on 09/18/23 at 01:19 PM, she said the only peg tube care she provided for Resident #8 was dressing changes as ordered. She said she did not flush the pegs tube or use it to administer medication. She said she saw drainage on the date she pulled the PEG tube out. She said the PEG tube was pulled out at around the time of shift change at 6AM, and she noticed the tip of the PEG tube was not intact. She notified the doctor by leaving a message and she texted the NP, but eventually LVN E followed up with the NP to have the resident transferred to the hospital. In a phone interview with the Medical Director on 09/07/23 at 02:09 PM, he said for residents who used PEG tubes, they were to have to water flushes in place, have monitoring for signs of infection, and If the PEG tube was not being used, if it was non-functioning, and/or the patient was eating well by mouth, the tube should be removed due to risks of infections around the stoma site. He said, at the least, the PEG tube should have been flushed to ensure there were no blockages or increased risks of infection. In a phone in interview with NP B on 09/07/23 at 02:38 PM, she said the risks of using a PEG tube included bowel obstructions, infections, perforation, and aspiration. She said Resident #8's PEG tube remained in place because the family member did not want the resident to be sent out for any procedures due to her age. She said the family member, who makes the decisions for the resident, did not allow the resident out until the tube broke on 08/16/2023. She said the tube became non-functional in March when the resident pulled on the tube because she could not confirm the tube was still placed correctly in the resident's stomach. She said if could not confirm placement, she did not want the PEG tube to be used. She said Resident #8 also had an order for an abdominal binder in place to help prevent the Resident from pulling the PEG tube. She said she later ordered for the abdominal binder to be taken off to allow excoriated and rashy skin, caused by the drainage from the PEG tube site, on the abdomen to be left open to air to heal. She said any moist dark areas on the skins can be at risk of skin breakdown and fungus. When asked if the abdominal binder contributed to the rash, she refused to answer. She said the rashes and excoriation on the abdomen and stoma site would not have been a core reason to have the PEG tube removed, but it could have served as an argument to encourage PEG tube removal. She said she did not recall having another conversation with the family member about the risks and benefits removing the non-functional PEG tube until it was pulled out on 08/16/2023. NP B said she did not believe she talked to the family member about the resident PEG tube site infections but believed the facility nursing staff were talking to the family about it. In an phone interview with the family member on 09/07/23 at 02:25 PM, she said she was never informed of the risks of leaving a PEG tube in place for Resident #8 and she was never told that it was nonfunctional. She said she vaguely remembered being called by a physician's assistant or nurse practitioner asking if they could do some testing to related to concerns about the PEG tube and she gave them the okay to do so, but there was no follow up afterwards. The family member said she thought this whole time the PEG tube was functional and was able to use as back up, and if she would have known it was non-functional she would have had no problem with them taking it out. In a phone interview with NP B on 09/11/2023 at 10:44 AM, when asked about what she meant in the progress note she wrote on 08/02/2023, she refused to provide a description but said she would never convince the family member to keep a non-functional PEG tube in Resident #8. She said she needed more time to review Resident #8's chart. There was no follow-up interview with NP B. In an interview with the DON on 09/18/2023 at 9:53 AM, she said Resident #8 had been eating by mouth for at least two years and decisions about the PEG tube were always determined by NP B and the family member. She said, to her knowledge, the family member never wanted the PEG tube removed. While the resident ate by mouth, the nurses were just flushing the PEG tube until the placement could no longer be verified in March. She said NP B wanted to send her out, but the family refused, which could not be disputed. She said the note written by NP B on 08/02/2023 seemed contradictory to her, but she believed after the first conversation NP B had with the family member in March, she did not see the need for any additional conversations to be had after the family made their decision. She said changes in conditions should had been documented by nurses in the progress notes or in a SBAR assessment and documentation was supposed to reflect what was going on with the patient and if treatments were effective. She said if the PEG tube site was observed to be draining, it should have been documented daily and any treatments for drainage or rashes related to the PEG tube that were ordered, should have been reported to Resident #8's RP as a notice as to what was going on with the patient. The DON said she believed the best choice would have been to have the PEG tube taken out and the notifications of rashes and drainage related to the non-functioning PEG tube could have been communicated to the RP to serve as education for reasons why the PEG tube removal would have been beneficial. Record review of the facility's policy on Gastrostomy Tube Care, dated February 2007, revealed goals of the policy was, . 1. The resident will maintain nutritional status, within optimal parameters via gastrostomy feedings. 2. The resident will be free of infections at the gastrostomy site. 3. The resident will maintain intact skin free from breakdown at the stoma site . It also stated, . Gastrostomy is a surgically created abdominal opening into the stomach for the purpose of administering feedings. A stoma is created to allow for long-term feedings . it can also contain an inflatable tube inserted into the stomach and skin disc to secure the position of the tube for the purpose of feedings Check tube placement . if the tube has moved or has come out, do not use and call the physician. On 09/08/2023 at 4:00 PM the Administrator was notified of the Immediate Jeopardy (IJ), due to the above failures. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 09/09/2023 at 1:17 PM. The POR revealed: IJ Component: F693 Enteral Nutrition: Facility failed to ensure Resident #8's enteral feeding was clinically indicated. Immediate Actions: Resident #8's g-tube site was assessed by RN on 9/8/23 for s/s of infection, no adverse findings noted. Facility Plan to ensure compliance: 1. 100% reassessment by RN of all g-tube sites completed 9/8/23, including resident #8. One resident identified with new onset of redness at enteral tube site, new treatment implemented. No other adverse finding noted on reassessment of enteral tube sites noted on 9/8/23. 2. Skin sweep completed on 100% of facility residents on 9/8/23 to ensure all enteral tubes were accounted for. Six residents identified with an enteral tube. No additional tubes were identified on a resident residing in the facility as of 9/8/23. 3. Residents with enteral tubes/enteral feedings reviewed for appropriate treatment on 9/8/23. Six of the facility residents identified as receiving enteral feedings with the majority of nutrition/hydration received via enteral tube for these six residents. 4. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/8/23 regarding Changes/Discontinuation of Enteral tubes/Enteral feedings should be reviewed with family/responsible party to include removal of enteral tube, if appropriate. If disagreements between provider and family/responsible party arise, the Medical Director and the Ombudsman will be involved in a formal care plan to review the plan regarding the enteral tube. 5. DON/ADON have in-serviced charge nurses by phone and/or in person as of 9/8/23 regarding notifying provider (NP/MD) of any complications with enteral tube and notifying DON/ADON of enteral tube changes to ensure compliance with this procedure. 6. DON/ADON have in-serviced charge nurses by phone and/or in person as of 9/8/23 regarding notifying the provider (NP/MD) of any change of condition related to enteral tube site and/or feedings to ensure compliance with this procedure. 7. Registered Dietician (RD) will be consulted for residents with enteral feedings to ensure enteral feedings/water flushes meet the resident's needs. Registered Dietician (RD) notified on 9/9/23 of need for reassessment of residents with enteral tubes/enteral feedings and RD will review/reassess residents with enteral tube/enteral feedings on Monday, 9/11/23. 8. Regional Compliance Nurse provided in-service to DON and Administrator on 9/9/23 regarding RD recommendations to include if provider/extender does not approve the RD recommendation, Medical Director will be consulted. 9. Charge Nurses will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to enteral tubes in [EHR system], the facility's electronic medical record (EMR). 10. All nurses not in service on 9/8/23 will be in-serviced prior to working their next scheduled shift. 11. The Medical Director was notified by Administrator on 9/8/23 at 5:08pm on the immediate jeopardy citation. 12. An Ad-hoc QAPI meeting was held on 9/8/23 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. MONITORING: Record review of PEG tube assessments, dated 09/08/2023, revealed 6 of 6 residents with PEG tubes, were assessed with enteral feeding orders noted. Record review of enteral feedings assessment completed by Dietitian, dated 09/11/2023, revealed all residents fed via PEG tube had diets assessed and provided recommendations as needed. Record review of in-service, dated 09/08/2023, revealed Regional Compliance Nurse provided in-service to DON, ADON, and Administrator regarding Changes/Discontinuation of Enteral tubes/Enteral feedings review with family/responsible party to include removal of enteral PEG tube. Record review of in-service on Non-functioning or Not in Use Enteral Tubes, dated 09/08/2023, revealed 10 nursing staff received training on notifying physicians of changes regarding enteral tube feed. Record review of QAPI meeting, dated 09/08/2023, revealed plans to remove immediate jeopardy regarding PEG tubes and neglect were discussed. Interview with the Wound Care Nurse on 09/12/2023 at 4:30 PM, she said she would notify the NP if any change were observed in residents with PEG tubes and write her report and doctor's orders on a progress notes. She said she would observe for changes such as: drainage, redness, odor on the surrounding PEG site, looking for signs of infection. She said if it was observed to be dislodged, she would immediately notify the NP and family and DON, document what she saw, and follow the doctor's orders from there. Interview with LVN B on 09/12/2023 at 4:44 PM, said while assessing her patients with PEG tubes, she would look for signs of infection including redness and leaks in the case it is dislodged. She said in the case where she observes a resident's PEG tube dislodged, she would notify the doctor or NP and turn off feed in the meantime. She said she would document change of condition using a SBAR and nurses notes and would also notify the family. Interview with LVN G 09/12/2023 at 4:51 PM, she while assessing her patients with PEG tubes, she would look for signs of infection, placement, and skin integrity. She said she would call the NP and let them know about any changes observed and get orders and then do a change of condition note, or SBAR, and notify the family and the DON. She stated she was not currently working with any residents who had a PEG tube that was not being used. Observations of Resident #8 on 09/12/2023 at 5:30 PM was observed lying in bed resting while receive continuous enteral feeding vis PEG tube with orders matching the dietitian's recommendations. Interview with RN C on 09/12/2023 at 5:40 PM, she said performed dressing changes on resident with PEG tubes and checked for placement, signs of infection including drainage, bleeding, color, smell, redness or tenderness. She said she would notify the NP or DON if she observed anything abnormal and document findings in the SBAR and progress notes. She said she knew no residents using a nonfunctioning tube feeding on her wing at the time. Interview with RN A on 09/12/2023 at 6:13 PM, she said she checked peg tube site for dryness, redness, drainage, tenderness, and tube for displacement, feel around and look for signs of pain. She said she would notify the physician for treatment plan, apply dry dressing and ointments as ordered and would document changes in a SBAR or progress note. She said SBARs are used and can trigger for every nurse to notify them of changes in resident from shift to shift. The facility was notified the IJ was removed on 9/12/23 at 6:25 PM however, the facility remained out of compliance, at a scope of pattern and a severity level of actual harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their corrective systems.

Based on observation, interview and record review, the facility failed to ensure treatment and care in accordance with professional standards of practice provided to 3 of 16 residents, (CR #19, Resident #1 and Resident #317), reviewed for quality of Care. - The facility failed to ensure RN C administered Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - The facility failed to ensure RN C sent CR #19 through immediate emergency transport after being diagnoses with critical vitals. - The facility failed to ensure RN C administered Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. -The facility failed to reinstate Resident #1's Metformin after readmission to the facility. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:05PM. While the IJ was removed on [DATE] at 06:25 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for a decline in ADL, decline in health, injury and death. Findings include: CR #19 Record review of CR #19's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: gangrene, absence of right leg below knee, MDD, panic disorder, hypertension, stage 4 pressure ulcers, and bacterial bone infection. The resident was transferred to the hospital on [DATE] at 08:50 PM. Record review of CR #19's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of CR #19's Discharge Return Anticipated MDS dated [DATE] revealed, the resident had an unplanned discharge to an acute hospital, the resident had a fever and no documented falls since prior assessment. CR #19 had 4 stage four pressure ulcers of which 3 were facility acquired and 1 facility acquired unstageable ulcer. Record review of CR #19's Care Plan last reviewed on [DATE] revealed, focus- advance directive as evidenced by full code, focus- pressure ulcers. Focus- diagnosis of diabetes, goal- resident will have no complications related to diabetes, interventions- diabetes medication as ordered by doctor and monitor/document for side effects and effectiveness. Record review of CR #19's Physician's Orders dated [DATE] revealed, Glucagon Emergency Kit 1 MG- Inject 1 mg IM every 12 hours as needed for s/s of hypoglycemia, unresponsive and BS </= 70, recheck BS in 15 minutes and notify MD. Glucose Gel 40%- give 15 grams every 15 minutes as needed for s/s hypoglycemia and responsive, May administer 2nd dose and recheck in 15 minutes, notify MD only if not above 70. Record review of CR #19's SBAR note dated [DATE] signed by RN C revealed, CR #19 suffered from: mental status change, respiratory change-suspected infection, cardiovascular change, fever with unknown focus of infection, neurological change, BP of ,d+[DATE], HR 107 and irregular, RR of 20, oral temperature of 101.1 and a BS of 62. All vitals were collected at 07:23 PM. CR #19 had decreased level of consciousness (very lethargic), had increased confusion/disorientation, experienced rigors (shaking chills), experienced SOB, weakness or hemiparesis. RN C documented that the symptoms first appeared on [DATE] and no ordered treatments/medications had been attempted to help resolve the symptoms. NP A was notified at 07:49 PM and a request was made to transfer the resident to the hospital. Record review of CR #19's Transfer Notification dated [DATE] at 08:50 PM signed by RN C revealed, CR #19 was transferred to a hospital on [DATE] at 08:50 PM related to lethargy, hypotension, rapid shallow breathing, elevated heart rate and body temperature. There was no documentation of hypoglycemia. Record review of CR #19's Progress Notes dated [DATE] at 8:55 PM signed by RN C revealed, While making rounds to administer medication, resident was found lying in bed very lethargic and hard to arouse. Further assessment PB ,d+[DATE] manually, T 101.1, P 107, R 20, O2 Sat 97% on room air, and BS 62 mg/dl at around 1923 (07:23 AM). NP A was notified of CR #19's change in condition at about 1938 (07:38 PM) and an order was given to send the resident out via contracted EMS while monitoring BP. CR #19 started exhibiting muscle tremors, increased SOB and BP lowered to ,d+[DATE] so NP A was notified of the further change of condition. CR #19 was transferred to the ER via 911 EMS at 8:50 PM, almost 1 ,d+[DATE] hours after symptoms were first observed. There was no documentation of treatment of CR #19's low blood sugar. Record review of CR #19's August MAR revealed, CR #19 was never administered Glucagon. Interview on [DATE] at 10:18 AM, CR #19 family member said while at the facility CR #19 had multiple pressure wounds and was hospitalized for the wounds on multiple occasions. CR #19's family member said when the resident would go to the hospital his wounds would get better but would worsen when he returned to the facility. She said her father was transferred to the hospital on [DATE] where he was diagnosed with sepsis which the hospital tried to treat with dialysis and antibiotics. CR #19's family member said the resident expired in the hospital 2 days after arrival ([DATE]) of severe sepsis. Interview on [DATE] at 12:52 PM, RN C said she found CR #!19 unresponsive with critical values. She said he had low blood pressure, an elevated heart rate, was running a fever, had blood sugar lower than 70 and was in and out of consciousness She said she contacted NP A who said to monitor CR #19's blood pressure and send him out, she did not remember if NP A said the resident should be sent out using a contracted transport company of 911. She said she called the contracted EMS company to send him to the hospital and continued to monitor the resident. RN C said on following rounds she observed CR #19 to be suffering from tremors and the contracted service was not there yet, so she called 911 to send him out. RN C said that CR #19's symptoms appeared to indicate sepsis and looking back she would have sent him out initially using 911. She said she tried to give him Glucagon gel by mouth but due to the resident's condition, it could not be administered that method. RN C said she did not think to administer glucagon by injection because things were moving too fast, and she instead focused on the resident's dropping blood pressure. Interview on [DATE] at 01:25 PM, the DON said after reviewing CR #19's vitals on the day of his hospitalization ([DATE]) the nurse should have administered Glucagon to the resident to treat his hypoglycemia. She said nursing staff do not specifically have training on how to manage emergency situations like what CR #19 experience, but it was an expected nurse competency. The DON said there was nothing stopping RN C from administering Glucagon to CR #19 since the resident had an active order for the medication. She said based on CR #19's she would expect the nurse to send the resident to the hospital by calling 911 because it was unknown how long the contracted EMS service would take. The DON said if a contracted EMS service was called and had not arrived in ,d+[DATE] minutes then 911 should have been called She said the time it took for CR #19 to be transferred to the hospital was too long. The DON said delay in transfer to the hospital could result in CR #19 experiencing further decline since his BP could not be treated at the facility and failure to treat CR #19's low blood sugar could lead to further hypoglycemia. Interview on [DATE] at 04:00 PM, NP A said she was notified by a nurse that CR #19 was experiencing signs and symptoms of infection and sepsis, so she gave the order to send the resident to the hospital for emergency care. She said the facility had standard orders for Glucagon which were stored on their carts so CR #19 should have been treated for his hypoglycemia regardless of his critical vitals. When the surveyor notified NP A of the vitals reported by RN C at the time of the incident, NP A said with those vitals the facility would not be able to treat the resident, so he had to be hospitalized . NP A said she did not specify the method of transfer to the nurse (contract vs. 911) but based on CR #19's critical vitals the expectation was that the resident be sent out by calling 911. She said any delay in transfer to the hospital would result in a delay in identification and treatment of acute issues. Interview on [DATE] at 02:22 PM, the Administrator said the facility did not have a policy addressing critical labs/vitals. Record review of the facility in-service titled Medication Safety Alert dated [DATE] presented by the Director of Clinical Education revealed, RN C was trained on the administration of Gvoke an antihypoglycemic agents indicated for severe hypoglycemia. Gvoke pre-filled is for subcutaneous injection only and should be administered as soon as possible when server hypoglycemia is recognized. Gvoke is premixed and ready for immediate us. Attached was a policy on Diabetes Management that defined hypoglycemia as BS </= 70. Record review of the facility in-service titled Diabetes management education and the use of Glucagon dated [DATE] presented by the Director of Clinical Education revealed, RN C was trained on diabetes management and hypoglycemia. Glucagon injection is an emergency medicine used to treat severe hypoglycemia in diabetes patients treated with insulin who have passed out or cannot take some form of sugar by mouth. Administer Glucagon as directed per physician orders. Notify Physician if Blood sugar less than 70 or per physicians orders, if unresponsive or unable to swallow position on side and give Glucagon 1 mg IM or as directed per physician orders. This is a Medical Emergency requiring close observation and/or 911. Resident #317 Record review of Resident #317's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility with diagnoses which included: anemia, paraplegia, colostomy and stage 4 pressure ulcer of the back. Record review of Resident #317's undated Care Plan revealed, focus- potential for uncontrolled pain due to osteomyelitis, muscle spasms, pressure ulcer and surgical wound upon admission; interventions- administer analgesia as ordered, monitor/document for side effects of pain medication. Focus- use of anti-anxiety medications, interventions- give anti-anxiety medications as ordered and monitor/document side effects. Record review of Resident #317's Order Summary Report dated [DATE] at 09:20 Am revealed the following active orders: - Acetaminophen 500 mg- 2 tablets by mouth every 8 hours for pain started [DATE]. - Alprazolam 1 mg- 1 tablet by mouth every 8 hours as needed for anxiety started [DATE]. - Baclofen 5 mg- give 4 tablets by mouth four times a day for muscle spasms started [DATE]. - Gabapentin 400 mg- 2 capsules by mouth three times a day for neuropathy (nerve pain) started [DATE]. - Methadone 5 mg- give 7.5 mg by mouth every 8 hours for pain started [DATE]. - Methocarbamol 750 mg- give 1 tablet by mouth three times a day for muscle spasms started [DATE]. - Naloxone 4mg/0.1 ML- 0.1 mL alternating nostrils every 2 minutes as needed for opioid overdose may repat every ,d+[DATE] minutes as needed started [DATE]. - Hydrocodone/Acetaminophen ,d+[DATE] mg- give 1 tablet by mouth every 8 hours as needed for pain started [DATE]. - Oxycodone 5 mg- give 1 tablet by mouth every 6 hours as needed for pain score ,d+[DATE] started [DATE]. Record review of Resident #317's Progress Notes dated [DATE] at 12:47 PM signed by NP C revealed, Reviewed Prescription Monitoring Program and patient is at high risk for unintentional overdose with a score of 650 above average. Risk for unintentional overdose discussed with patient, and he reports that he has been taking medications for a long time and that he never overdosed before. PMP monitoring only shows Hydrocodone, and Alprazolam that has been prescribed by his PCP in the community, in which his PCP ordered him Alprazolam yesterday [DATE] and was filled at pharmacy. Narcan nasal spray is ordered as needed. Record review of Resident #317's MAR dated [DATE] revealed, Resident #317 received the following medications the night ([DATE]) before his overdose - Gabapentin 800 mg- scheduled for 06:00 PM. - Methocarbamol 750 mg- scheduled for 06:00 PM. - Baclofen 20 mg - scheduled for 06:00 PM. - Methadone 7 mg- scheduled for 10:00 PM. Record review of Resident #317's Progress Note dated [DATE] at 04:18 AM signed by RN C revealed, Resident transferred to [Hospital] via 911 EMS at approximately 04:18a.m. for further evaluation and treatment related to decreased level of consciousness and respiratory distress. EMS personnel given copy of resident's face sheet, order summary, and clinical notes containing past medical history. Resident's personal belongings including two backpacks, one [NAME] pack, computer laptop, cell phone, earbuds, wrist watch, colostomy supplies, and several bottles of prescription medication remained behind in resident's room. [NP A] notified of [Resident #317] emergency transfer to [Hospital] at approximately 04:30a.m. Record review of the Hospital Ambulance Record dated [DATE] revealed, Primary impression- overdose other opioids. Narrative- the fire department was dispatched to the facility for a cardiac arrest. Resident #317 was found to be drowsy with deep snoring and the nursing staff said they were unsuccessful in waking Resident #317, and he might have had a seizure. Review of the Resident #317's chart showed multiple medications for sleep, pain and muscle reactions and the resident had constricted pupils. Resident #317 was administered 1 mg of Naloxone Intranasally, and the patients response improved; he was easily arousable to verbal and talked to the crew without falling asleep. Record review of the Hospital ED Record dated [DATE] revealed, Resident #317 was found unresponsive and hard to arouse at the facility and the EMS administered 1 mg of Naloxone. Record review of the Progress Note dated [DATE] at 08:10 AM revealed, Resident #317 returned to the facility in elate and high spirit. Resident #317 was diagnosed with opiate overuse in the hospital and NP A gave new orders to check the residents vitals and signs/symptoms of CNS depression on each shift. NP A ordered Resident #317's Oxycodone & Xanax 1 mg to be discontinues, Methocarbamol 750 mg decreased from three times daily to two times daily and a new order for Xanax 0.5 mg every 12 hours. Observation and Interview on [DATE] at 11:40 AM revealed, Resident #317 lying on stomach in bed in no immediate distress. He said the previous day ([DATE]) when he was asleep his mother placed his prescriptions in his backpack because she did not know what to do with it. He said this morning ([DATE]) the facility staff tried to wake him up, but he was not moving so they called 911. CR #317 said he was informed that he had an opioid overdose. An Observation on [DATE] at 12:03 PM revealed, a ziplock bag containing Resident #317's following home medications: - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 43 tablets remaining. - 1 bottle of Gabapentin 300 mg filled for 810 capsules with 3 capsules remaining. - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 56 tablets remaining. - 1 bottle of Naproxen 500 mg filled for 180 tablets with 116 tablets remaining. - 1 bottle of Baclofen 20 mg filled for 180 tablets with 169 tablets remaining. - 1 bottle of Alprazolam/Xanax filled for 270 tablets with 197 tablets remaining. Interview on [DATE] at 12:52 PM, RN C said on Saturday morning ([DATE]) during her hourly monitoring of residents she observed Resident #317 sitting in bed slumped over, unresponsive and slipping in and out of consciousness. She said he was breathing strange, would not wake up and as making gurgling/chocking sounds. RN C said she immediately placed him on oxygen, talked to him and tried to wake him which he could not so she made a judgement call to call 911. She said based on his symptoms she suspected he had a seizure/blood sugar or medication related overdose. Specifically to medications RN C knew the resident was on multiple pain medications like oxycodone/methadone/hydrocodone and Xanax/baclofen/methocarbamol. RN C said all these medications in unison can lead to respiratory depression and CNS depression. RN C A said the facility has Naloxone available to treat overdoses, but she did not administer Naloxone to Resident #317. She said she was supposed to give Narcan immediately and call 911 but did not because there was just a lot going on. RN C said When 911 arrived she told them she suspected either a seizure or overdose and looking back she should have administered Narcan. After the resident left the DON said to check his belongings in case he took something and she found several bottles of medications including Gabapentin, and Ativan. She counted it all and gave it to the DON. RN C said failure to administer Naloxone in response to an opioid overdose is dangerous and the resident could experience increased slurred speech/difficulty breathing, lose consciousness, and it could lead to death. Interview on [DATE] at 01:25 PM, the DON said signs and symptoms of opioid overdose included: shallow breathing and the resident being un-responsive. She said based on the information RN C provided about the incident Resident #317 showed symptoms of an opioid overdose. The DON said when a resident shows signs and symptoms of an opioid overdose the nurse must administer Naloxone, and RN C did not administer Naloxone to Resident #317. She said calling 911 was absolutely not an excuse for failure to render services during emergency situations. The DON said nursing staff was trained on the use of Naloxone at the end of 2022 when the facility started receiving Naloxone, and no training was performed after that. Interview on [DATE] at 04:00 PM, NP A said Resident #317 suffered an overdose after consuming medications that the facility was unaware of. She said signs of overdose included respiratory distress and the facility had Naloxone on hand to treat overdoses. NP A said the expectation is that nurses call 911 and then administer Naloxone and failure to do could cause the resident worsening of condition and potential harm. Interview on [DATE] at 09:27 AM, the DON said no training was performed on the emergency administration of Glucagon between CR #19's hospitalization on [DATE] and [DATE]. She said she was just focused on the CR #19 being sent out to the hospital and not the failure to administer Glucagon. The DON said no training has been performed on opioid overdoses and the administration of Naloxone since Resident #317's overdose on [DATE] and the last training was performed in December of 2022. Record review of the facility in-service record titled 'Opioid Overdose dated [DATE] revealed, patients who are prescribed opioid medication receive the necessary care and services to avoid complications associated with opioid overdose by: ensuring appropriate monitoring and treatment as may be required utilizing opioid reversal agents such as Naloxone. RN C was noted in attendance as indicated by her name and signature. Record review of RN C's Nurse Proficiency Audit dated [DATE] completed by the DON revealed, RN C was assessed as satisfactory for skills which included: administering medication properly (Oral/IM/SQ), and knowledge of emergency procedures (CPR, Crash Cart/AED, Activate EMS). Proficiency in Glucagon and Naloxone administration were not assessed. Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female who admitted into the facility on [DATE] and was diagnosed with Type 2 Diabetes with Unspecified Diabetic Retinopathy with Vascular Edema, Anemia and Hypertension. Record review of Resident #1's care plan, dated [DATE], revealed the resident had Diabetes Mellitus, the goal was for the resident to, .have no complications related to diabetes through the review date of [DATE] ., and the intervention was to, Diabetes medication as ordered by doctor. Monitor/document for sides effects and effectiveness . Record review of Resident #1's progress note dated [DATE], revealed the resident readmitted to the facility from the hospital. Resident returned to the facility from the hospital by ambulance. NP notified of the resident's return to the facility. The hospital did not send any orders for the resident's medication. NP stated to reactivate the previous medications the resident was taking at this facility before she went to the hospital . Records review of Resident #1 discontinued orders dated [DATE], revealed Resident #1's metFormin HCI oral Tablet 500 MG order discontinued on [DATE]. Record review of revealed Resident #1 did not have an active prescription for Metformin. Interview on [DATE] at 01:14 PM, the DON said Resident #1 received Metformin and Insulin for DM management. Interview on [DATE] at 02:45 PM, NP A said she was unaware that Resident #1 was no longer receiving Metformin and she did not approve for the medication to be discontinued. She said discontinuation of Metformin was not appropriate because Resident #1 had family members that bring her food throughout the day so Metformin was important to control her blood sugars. NP A said failure to administer Metformin to Resident #1 as ordered placed her at risk of increased blood sugars which could negatively impact wound healing. Interview with the DON on [DATE] at 11:48 AM, revealed the resident returned to the facility she did not come with any discharge records, she stated the hospital faxed over paperwork but the only medication that was listed was the insulin. She stated the metformin medication was not listed on the medication list received from the hospital. She stated she was not aware that the medication was left off the list and she was responsible for ensuring the medication was added to the resident's medication list. The risk of the resident not getting metformin is her blood sugar increasing, she stated the resident has had elevated blood sugar since not being on her medication. Interview on [DATE] at 03:06 PM, NP A said Metformin once daily was added back to Resident #1's DM medications. Record review of MAR from June, July an [DATE], revealed that Resident #1 did not receive Metformin. The resident went without Metformin from [DATE]-[DATE]. Resident #1's first dose was on [DATE]. Record review of the facility policy Medication Reconciliation revised [DATE]. At any time a change is made to a patients medication regiment, practitioners must ensure that the change is made carefully, is documented, and accords with prescribing instructions for the relevant medications. Medications reconciliation should be performed every time a patient is admitted to a facility. It is common for changes to be made to a patient's medications when he or she is hospitalized . Upon transition back to the SNF, medication reconciliation should be performed again and the patient's current medications checked against those he or she was taking before being hospitalized . Nursing staff should notify the practitioner of changes to or omissions from the medication regimen and verify whether the practitioner wishes to reorder any medications that were stopped during the patient's hospitalization . On [DATE] at 11:00 AM the Administrator and was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The following plan of removal was approved on [DATE] at 11:34 AM and Indicated: IJ Component: F658: Services Provided Meet Professional Standards: Facility failed to administer glucagon to CR#19 as ordered when identified with a BS of 62. Facility failed to send CR#19 out immediately following an acute change of condition. Facility failed to administer Naloxone to Resident #317 after the resident suffered from an overdose. Immediate Actions: CR#19 was transferred to theER on [DATE] and did not readmit to the facility. Resident #317 was transferred to theER on [DATE] at approximately 415am and readmitted to the facility on [DATE] at approximately 810am with diagnosis of Opioid Use and Anemia. Resident #317 was discharged home with home health services on [DATE]. Facility Plan to ensure compliance: 1. 100% review of all facility residents prescribed Glucagon completed by DON, ADON, and Regional Compliance Nurse on [DATE] to identify any other residents that did not receive prescriber ordered Glucagon for hypoglycemia. No other resident from audit identified as not receiving ordered Glucagon. 2. 100% assessment of all facility residents prescribed an opioid completed by DON, ADON, and Regional Compliance Nurse on [DATE] to assess for s/s of opioid overdose. No resident currently residing in the facility as of [DATE] identified from audit as having any s/s of opioid overdose. 3. Facility residents with a diagnosis of Diabetes Mellitus (DM) were audited on [DATE] to ensure all prescriptions were documented correctly. Audit revealed all residents with a diagnosis of DM with a prescription for treatment, either by mouth and/or with insulin orders, were transcribed correctly. 4. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on [DATE] regarding a. Abnormal Blood Sugar readings to include process for administering glucagon, when ordered, and process for treating an unresponsive resident. b. Change of Condition: When to Report to MD/NP/PA c. Conditions that require immediate transfer d. Signs and symptoms of Opioid Overdose e. How to use Narcan/Naloxone 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Abnormal Blood Sugar Readings to include the process for administering glucagon, when ordered, and the process for treating an unresponsive resident. Goal for completion of this education to be completed by end of day on [DATE]. 6. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Change of Condition to include when to Report to MD/NP/PA. Goal for completion of this education to be completed by end of day on [DATE]. 7. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting [DATE] regarding Conditions That Require Immediate Transfer. Goal for completion of this education to be completed by end of day on [DATE]. 8. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting [DATE] regarding Signs/Symptoms of Opioid Overdose. Goal for completion of this education to be completed by end of day on [DATE]. 9. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting [DATE] regarding Narcan/Naloxone Administration. Goal for completion of this education to be completed by end of day on [DATE]. 10. Licensed nurses (RNs/LVNs) will be tested to evaluate competency of the education/in-services initiated on [DATE]. Competency tests will be initiated on [DATE] upon completion of the education with goal for completion by end of day on [DATE]. 11. Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to abnormal blood sugars or signs of opioid overdose in the facility's electronic medical record (EMR). 12. All nurses (LVN/RNs) not in service on [DATE] will be in-serviced prior to working their next scheduled shift. 13. The Medical Director, was notified by Administrator on [DATE] at 1:55pm on the immediate jeopardy citation. 14. An Ad-hoc QAPI meeting was held on [DATE] by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. MONITORING: Interviews conducted on [DATE] from 11:20 AM to 11:40 AM revealed, LVN A, LVN B, RN B, and the ADON A received in-service training on the treatment of hypoglycemia, opioid overdose and immediate transfer to the hospital. The staff showed competency in the emergent treatment of hypoglycemia and immediate transfer to the hospital but were not competent in the administration of Naloxone. LVN A and LVN B did not know when to repeat Naloxone, RN B did not know the formulation of Naloxone used in the facility and where it could be located. Interview on [DATE] at 12:34 revealed, the DON did not know the formulation of naloxone used in the facility and did not know that Naloxone could be administered if a resident became unconscious after a previous dose was administered. Interview on [DATE] at 12:45 PM with the Regional Clinical Nurse revealed, the facility was not trained on the re-administration of Naloxone if a resident became unconscious after a previous dose was administered. He said the facility had just focused on training the staff to administer the first dose of Naloxone and then call 911. The Regional Clinical Nurse said nursing staff was not trained on readministering Naloxone and all staff would be trained appropriately. Interview on [DATE] at 01:36 PM, the Regional Clinical Nurse said the DON and Administrator were re-trained on the administration of Naloxone and training of the nursing staff was ongoing. He said since the IJ was called the facility: - audited all residents with opioid prescriptions to ensure they had orders for PRN Naloxone - audited all blood sugars to ensure treatments were given for any abnormal values Interviews conducted on [DATE] from 05:28 AM to 06:27 AM revealed the following: - LVN B stated she was re-trained in the administration of Naloxone and showed competency in its administration. - RN A, RN C, LVN D, LVN G, LVN H, stated they received training on treatment of hypoglycemia, immediate transfer to the hospital and opioid overdose. The staffed interviewed showed competency in the use of Glucagon for the treatment of hypoglycemia, resident symptoms that require immediate hospital transfer and the treatment of an opioid overdose using Naloxone. Record reviews completed on [DATE] revealed the following: - on [DATE] the [NAME] Clinical Nurse audited all resident's receiving opioids and reassessed them for s/s of opioid overdose and residents displayed any signs or symptoms - on [DATE] the DON reviewed all resident orders for Glucagon administration. - on [DATE] the DON completed a Nurse Proficiency Audit on RN C she was found to be satisfactory. - on [DATE] a QAPI meeting was held regarding the IJ- the DON, Regional Clinical Nurse, Administrator were in attendance. - on [DATE] the facility trained the ADON, Administrator and DON were trained on change in conditions, conditions that require immediate transfer, signs and symptoms of opioid overdose and responding to an overdose - on [DATE] the facility completed training with nursing staff on: responding to an overdose how to give naloxone, signs/symptoms of opioid overdose, conditions that require immediate transfer, blood sugars: abnormal readings, change in conditions: when to report to the provider. The Nurses were assessed with a competency test and found satisfactory. - on [DATE] the Regional Clinical Nurse reviewed residents with Glucagon ordered and discontinued glucose gel if Glucagon was on order. - on [DATE] the Regional Clinical Nurse audited all residents with a diagnosis of diabetes to ensure they received appropriate treatment, and all mediations were appropriate - on [DATE] at 1:00 PM ADON A, the DON and the Administrator were retrained on the administration of Naloxone with emphasis of sub [TRUNCATED]

Based on observation, interview and record review, the facility failed to consult with 1 of 16 residents (Resident #8) representatives when there was a significant change in the resident's physical status and a need to alter treatment significantly, in that: - The facility failed to notify Resident #8 family of a PEG tube was deemed non-functional for over 5 months resulting in multiple infections at the site of the G-tube and the resident was ultimately hospitalized when Resident #8's tube became dislodged and caused a partial bowel obstruction. - Resident #8 experienced a decline in ADLs as evidenced by downgrade from Regular heart healthy pureed diet to enteral feeds after tube replacement post- partial bowel obstruction. An Immediate Jeopardy (IJ) was identified on 09/08/23 at 4:05PM. While the IJ was removed on 09/12/23 at 06:25 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure caused Resident #8 to experience hospitalization and a decline in ADLs and placed other residents at risk of not receiving adequate medical care in a timely manner. Findings include: Record review of Resident #8's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE] and was diagnosed with Alzheimer's disease (progressive mental deterioration), cerebral infarction (stroke), dysphasia (difficulty swallowing) and paralytic ileus (impaired motor activity of the bowel). Record review of Resident #8's MDS, dated [DATE], the resident was identified to have a feeding tube. Record review of Resident #8's care plan, undated, revealed the resident had no care plan related to tube feedings. Record review of Resident #8's clinical physician orders, undated, revealed the resident had the following diet orders: - NPO diet from 01/31/2020 to 2/18/2020 - Regular mechanical soft diet with ground meat texture from 2/2/2023 to 4/3/2023 - Regular diet or Heart healthy diet, puree texture, regular consistency from 4/3/2023 to 8/18/2023 Observation of Resident #8 on 09/05/2023 at 10:30AM, he was lying in bed, with a PEG tube in place, and the resident was non-verbal. Record review of resident #8's order summary report, dated 3/1/2023 - 08/18/2023, revealed the resident did not have any enteral feed orders prescribed from 3/1/2023 until day of discharge on 8/16/2023, and the resident took all medications by mouth. Record review of Resident #8's nurses notes, revealed the resident was assessed by the NP on 02/04/2023, who noted the resident had a diet order of dysphagia advanced texture, was eating fair and had a peg-tube in place but not in use. NP's plan of care regarding Malnutrition/Dysphagia including monitoring weights, peg flushes and dressing changes per protocol. Record review of Resident #8's physician orders, dated 03/01/2023 to 09/09/2023, revealed the resident had an order for KUB STAT Dx. Check Peg tube placement one time for 1 day, on 03/06/2023. Record review of Resident #8's Nurses Notes, revealed the NP assessed the resident for a Peg Tube Malfunction on 03/07/2023 and noted, . Nursing reported peg tube appears to be displaced from normal position yesterday . KUB performed and recommended gastrograffin [a constrast medium used for x-ray imaging] for definitive placement verification . Nursing to notify RP of order, will proceed if RP agreeable, peg tube not currently in use . In the NP's assessment and plan regarding her peg tube, she noted, . KUB performed, will await approval before proceeding with gastrograffin . Peg appears to be in normal position as when last assessed by myself . Order given not to use peg tube for now . Abdominal exam benign . Record review of Resident #8's progress notes, revealed the NP assessed the resident on 03/09/2023 and noted the resident was lying in bed being fed by a staff. The NP also noted, . RP does not desire to proceed with additional X-ray procedure to confirm placement of peg tube . Will DC all peg tube orders . No acute concerns or complaints . In the NP's assessment and plan regarding her peg tube, she noted, . RP declines any additional studies for peg tube . DC all peg tube orders . Apply abdominal binder . Monitor provider for any changes . Record review of Resident #8's progress notes, revealed LVN G wrote a note on 03/09/2023 that stated, . NP . here in the building this am to visit resident NP . called RP . to ask if she wanted resident to be sent out for gtube replacement or removal RP . stated no then RP . also came to this facility to visit resident and stated she does not want anything done to the gtube removed or replaced she only wants gtube site clean. NP gave new order to d/c all gtube orders . Record review of Resident #8's progress notes, revealed the NP assessed Resident #8 on 07/26/2023, reason being for rash, drainage from peg site . The NP wrote: . Peg Tube Infection - Noted to have breakdown around peg tube with purulent drainage - Continue Doxycycline - Peg site care daily - Non-functioning peg tube Record review of Resident #8's progress notes on 08/02/2023, the NP documented her assessment of PEG tube infection and wrote about her conversation she had with Resident #8's RP, in which she wrote: . #Peg Tube Infection - Improved - Continue Doxycycline until 8/5 - Peg site care daily - Non-functioning peg tube - F/U with [GI] RP conversation: Per nursing RP is requesting removal of PEG tube. Call placed to RP. Spoke with [Responsible Party] Discussed risk and benefits of peg tube placement. Patient has periods of being uncooperative, agitated, and refusing to eat and drink. RP is agreeable to have peg tube placed as it is non-functioning at this time . Record review of Resident #8's progress notes, revealed on 08/13/2023, LVN E noted, . increased redness around stoma, skin irritation . profuse sticky drainage . There was no documentation of notification to the family. Record review of Resident #8's progress notes, revealed on 08/16/2023, LVN D noted resident was found at 6:00AM with tubing from her old non-functioning PEG tube in her hand while asleep. She also noted, . redness, irritation and profuse sticky drainage . Resident currently on antibiotic therapy related to infection at Peg tube site . LVN D also noted the catheter tip was not in place on the tubing. On 08/16/2023, LVN E also documented, .Resident pulled out her peg tube last night . looks like she had the tip of peg tube did not came out . LVN E noted Resident #8 was transferred out to the hospital ER for evaluation and treatment by 11:30AM. Record review of Resident #8's physician orders, dated 03/01/2023 to 09/09/2023, revealed the resident had an order for transfer resident to [hospital] ER for evaluations and peg tube replacement, on 08/16/2023. Record review of Resident #8's hospital records, dated 08/22/2023, revealed the resident was admitted into the hospital on 08/16/2023, and a physician wrote, . [AGE] year-old female with a past medical history of hypertension, severe dementia, cholecystectomy presents to the hospital with a dislodged gastrostomy . CAT scan completed on arrival demonstrated that the gastrostomy tube was located at the terminal ileum [end of small intestine located before the entrance to the colon]. Gastroenterology consulted for the findings above . Assessment: Partial bowel obstruction secondary to dislodgement of PEG tube. Colonoscopy completed yesterday . On 08/21/2022, another physician noted, . PEG tube from ileocecal valve . Patient underwent colonoscopic retrieval of the PEG tube successfully . Interview with a Family Member on 09/06/23 at 03:29 PM she said Resident #8's PEG tube was placed 3 years ago but had since not been removed to serve as a backup in case the resident were to ever refuse food or medication. She said she ate by mouth and was never notified by staff of them needing to use her PEG tube due to the resident refusing meals or medications. She said she never requested to have the PEG tube removed because it not her call, considering she had no medical background. She said when the Resident was discharged to the hospital on 08/16/2023, she was told by the facility nurses the resident pulled her PEG tube out, however, she learned from the hospital staff that a piece of the PEG tube had broken off and the CT scan showed it was in her intestines. She said a few days before the resident's hospitalization , she noticed her PEG tube was leaking, with thick, off-yellow pus and the resident stoma site appeared red and raw with rashes on her abdomen. She said she did not tell the nurses what she saw because she assumed the nurses were taking care of it. She said she did not feel persuaded to keep it in and it was never a topic of discussion because of how independent the resident had always been. She said the resident has shown to have a decline since returning to the hospital and was no longer eating like she used to. In a Telephone Interview with the Medical Director on 09/07/23 at 02:09 PM, he said for residents who used PEG tubes needed to have to water flushes, be monitored for signs of infection, and if the PEG tube was not used or non-functioning, and the patient was eating well by mouth, the tube should be removed due to risks of infections around the stoma site. He said, at the least, the PEG tube should have been flushed to ensure there were no blockages or increased risks of infection. In a Telephone Interview with NP B on 09/07/23 at 02:38 PM, she said the risks of using a PEG tube included bowel obstructions, infections, perforation, and aspiration. She said Resident #8's PEG tube remained in place because the family member did not want the resident to be sent out for any procedures due to her age. She said the family member, who made the decisions for the resident, did not allow the resident to be sent out until the tube was pulled on 08/16/2023. She said the tube became non-functional in March 2023 when the resident pulled on the tube because she could not confirm the tube was still placed correctly in the resident's stomach. She said if she could not confirm placement, she did not want the PEG tube to be used. She said Resident #8 also had an order for an abdominal binder in place to help prevent the Resident from pulling the PEG tube. She stated she later ordered for the abdominal binder to be taken off to allow excoriated and rash on the skin, caused by the drainage from the PEG tube site, on the abdomen to be left open to air to heal. She said any moist dark areas on the skins can be at risk of skin breakdown and fungus. When asked if the abdominal binder contributed to the rash, she refused to answer. She said the rashes and excoriation on the abdomen and stoma site would not have been a core reason to have the PEG tube removed, but it could have served as an argument to encourage PEG tube removal. She said she did not recall having another conversation with the family member about the risks and benefits removing the non-functional PEG tube until it was pulled out on 08/16/2023. NP B stated she did not believe she talked to the family member about the resident PEG tube site infections but believed the facility nursing staff were talking to the family about it. In a Telephone Interview with the family member on 09/07/23 at 02:25 PM, she said she was never informed of the risks of leaving a PEG tube in place for Resident #8 and she was never told that it was nonfunctional. She said she vaguely remembered being called by a physician's assistant or nurse practitioner asking if they could do some testing to related to concerns about the PEG tube and she gave them the okay to do so, but there was no follow up afterwards. The family member said she thought this whole time the PEG tube was functional and was able to use as back up, and if she would have known it was non-functional, she would have had no problem with them taking it out. In a Telephone Interview with NP B on 09/11/2023 at 10:44 AM, NP B was asked about what she meant in the progress note she wrote on 08/02/2023, she refused provide a description but said she would never convince the family member to keep a non-functional PEG tube in Resident #8. She sd she needed more time to review Resident #8's chart. There was no follow-up interview with NP B. Interview with the DON on 09/18/2023 at 9:53AM, she said Resident #8 had been eating by mouth for at least two years and decisions about the PEG tube were always determined by NP B and the family member. She said, to her knowledge, the family member never wanted the PEG tube removed. While the residents ate by mouth, the nurses were just flushing the PEG tube until the placement could no longer be verified in March. She said NP B wanted to send her out, but the family refused, which could not be disputed. She stated the note written by NP B on 08/02/2023 seemed contradictory to her, but she believed after the first conversation NP B had with the family member in March, she did not see the need for any additional conversations to be had after the family made their decision. She stated changes in conditions should had been documented by nurses in the progress notes or in a SBAR assessment and documentation was supposed to reflect what was going on with the patient and if treatments were effective. She said if the PEG tube site was observed to be draining, it should have been documented daily and any treatments for drainage or rashes related to the PEG tube that were ordered, should have been reported to Resident #8's RP as a notice as to what was going on with the patient. The DON stated she believed the best choice would have been to have the PEG tube taken out and the notifications of rashes and drainage related to the non-functioning PEG tube could have been communicated to the RP to serve as education for reasons why the PEG tube removal would have been beneficial. Record review of the facility's policy on Notifying the Physician of Change in Status, dated March 11, 2013, revealed it said, . 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident had specified otherwise. 6. The nurse will monitor and reassess the resident's status and response to interventions Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions . On 09/08/2023 at 4:00 PM the Administrator was notified of the Immediate Jeopardy (IJ), due to the above failures. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 09/09/2023 at 1:17 PM. The POR revealed: IJ Component: F693 Enteral Nutrition: Facility failed to ensure Resident #8's enteral feeding was clinically indicated. Immediate Actions: Resident #8's g-tube site was assessed by RN on 9/8/23 for s/s of infection, no adverse findings noted. Facility Plan to ensure compliance: 1. 100% reassessment by RN of all g-tube sites completed 9/8/23, including resident #8. One resident identified with new onset of redness at enteral tube site, new treatment implemented. No other adverse finding noted on reassessment of enteral tube sites noted on 9/8/23. 2. Skin sweep completed on 100% of facility residents on 9/8/23 to ensure all enteral tubes were accounted for. Six residents identified with an enteral tube. No additional tubes were identified on a resident residing in the facility as of 9/8/23. 3. Residents with enteral tubes/enteral feedings reviewed for appropriate treatment on 9/8/23. Six of the facility residents identified as receiving enteral feedings with the majority of nutrition/hydration received via enteral tube for these six residents. 4. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/8/23 regarding Changes/Discontinuation of Enteral tubes/Enteral feedings should be reviewed with family/responsible party to include removal of enteral tube, if appropriate. If disagreements between provider and family/responsible party arise, the Medical Director and the Ombudsman will be involved in a formal care plan to review the plan regarding the enteral tube. 5. DON/ADON have in-serviced charge nurses by phone and/or in person as of 9/8/23 regarding notifying provider (NP/MD) of any complications with enteral tube and notifying DON/ADON of enteral tube changes to ensure compliance with this procedure. 6. DON/ADON have in-serviced charge nurses by phone and/or in person as of 9/8/23 regarding notifying the provider (NP/MD) of any change of condition related to enteral tube site and/or feedings to ensure compliance with this procedure. 7. Registered Dietician (RD) will be consulted for residents with enteral feedings to ensure enteral feedings/water flushes meet the resident's needs. Registered Dietician (RD) notified on 9/9/23 of need for reassessment of residents with enteral tubes/enteral feedings and RD will review/reassess residents with enteral tube/enteral feedings on Monday, 9/11/23. 8. Regional Compliance Nurse provided in-service to DON and Administrator on 9/9/23 regarding RD recommendations to include if provider/extender does not approve the RD recommendation, Medical Director will be consulted. 9. Charge Nurses will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to enteral tubes in [EHR system], the facility's electronic medical record (EMR). 10. All nurses not in service on 9/8/23 will be in-serviced prior to working their next scheduled shift. 11. The Medical Director was notified by Administrator on 9/8/23 at 5:08pm on the immediate jeopardy citation. 12. An Ad-hoc QAPI meeting was held on 9/8/23 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. IJ MONITORING: Record review of PEG tube assessments, dated 09/08/2023, revealed 6 of 6 residents with PEG tubes, were assessed with enteral feeding orders noted. Record review of enteral feedings assessment completed by Dietitian, dated 09/11/2023, revealed all residents fed via PEG tube had diets assessed and provided recommendations as needed. Record review of in-service, dated 09/08/2023, revealed Regional Compliance Nurse provided in-service to DON, ADON, and Administrator regarding Changes/Discontinuation of Enteral tubes/Enteral feedings review with family/responsible party to include removal of enteral PEG tube. Record review of in-service on Non-functioning or Not in Use Enteral Tubes, dated 09/08/2023, revealed 10 nursing staff received training on notifying physicians of changes regarding enteral tube feed. Record review of QAPI meeting, dated 09/08/2023, revealed plans to remove immediate jeopardy regarding PEG tubes and neglect were discussed. Interview with the Wound Care Nurse on 09/12/2023 at 4:30 PM, she said she would notify the NP if any change were observed in residents with PEG tubes and write her report and doctor's orders on a progress notes. She said she would observe for changes such as: drainage, redness, odor on the surrounding PEG site, looking for signs of infection. She said if it was observed to be dislodged, she would immediately notify the NP and family and DON, document what she saw, and follow the doctor's orders from there. In an interview with LVN B on 09/12/2023 at 4:44 PM, she said while assessing her patients with PEG tubes, she would look for signs of infection including redness and leaks in the case it is dislodged. She stated in the case where she observes a resident's PEG tube dislodged, she would notify the doctor or NP and turn off feed in the meantime. She said she would document change of condition using a SBAR and nurses notes and would also notify the family. Interview with LVN G 09/12/2023 at 4:51 PM, she said while assessing her patients with PEG tubes, she would look for signs of infection, placement, and skin integrity. She said she would call the NP and let them know about any changes observed and get orders and then do a change of condition note, or SBAR, and notify the family and the DON. She said she was not currently working with any residents who had a PEG tube that was not being used. Observations of Resident #8 on 09/12/2023 at 5:30 PM was observed lying in bed resting while receive continuous enteral feeding vis PEG tube with orders matching the dietitian's recommendations. Interview with RN C on 09/12/2023 at 5:40 PM, she said performed dressing changes on resident with PEG tubes and checked for placement, signs of infection including drainage, bleeding, color, smell, redness or tenderness. She said she would notify the NP or DON if she observed anything abnormal and document findings in the SBAR and progress notes. She said she knew no residents using a nonfunctioning tube feeding on her wing at the time. In an interview with RN A on 09/12/2023 at 6:13 PM, she said she checked peg tube site for dryness, redness, drainage, tenderness, and tube for displacement, feel around and look for signs of pain. She said she would notify the physician for treatment plan, apply dry dressing and ointments as ordered and would document changes in a SBAR or progress note. She said SBARs are used and can trigger for every nurse to notify them of changes in resident from shift to shift. The facility was notified the IJ was removed on 9/12/23 at 6:25 PM however, the facility remained out of compliance, at a scope of pattern and a severity level of actual harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. 43049

Based on interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 2 of 5 residents (CR #19 and Resident #317) reviewed for professional standards. - The facility failed to ensure RN C administered Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - The facility failed to ensure RN C sent CR #19 through immediate emergency transport after being diagnoses with critical vitals. - The facility failed to ensure RN C administered Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of Pattern and a severity level of actual harm due to the facility continuing need to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk for hypoglycemia, drug overdose, decline in health, hospitalization , and death. Findings include: CR #19 Record review of CR #19's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: gangrene, absence of right leg below knee, MDD, panic disorder, hypertension, stage 4 pressure ulcers, and bacterial bone infection. The resident was transferred to the hospital on [DATE] at 08:50 PM. Record review of CR #19's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of CR #19's Discharge Return Anticipated MDS dated [DATE] revealed, the resident had an unplanned discharge to an acute hospital, the resident had a fever and no documented falls since prior assessment. CR #19 had 4 stage four pressure ulcers of which 3 were facility acquired and 1 facility acquired unstageable ulcer. Record review of CR #19's Care Plan last reviewed on [DATE] revealed, focus- advance directive as evidenced by full code, focus- pressure ulcers. Focus- diagnosis of diabetes, goal- resident will have no complications related to diabetes, interventions- diabetes medication as ordered by doctor and monitor/document for side effects and effectiveness. Record review of CR #19's Physician's Orders dated [DATE] revealed, Glucagon Emergency Kit 1 MG- Inject 1 mg IM every 12 hours as needed for s/s of hypoglycemia, unresponsive and BS </= 70, recheck BS in 15 minutes and notify MD. Glucose Gel 40%- give 15 grams every 15 minutes as needed for s/s hypoglycemia and responsive, May administer 2nd dose and recheck in 15 minutes, notify MD only if not above 70. Record review of CR #19's SBAR note dated [DATE] signed by RN C revealed, CR #19 suffered from: mental status change, respiratory change-suspected infection, cardiovascular change, fever with unknown focus of infection, neurological change, BP of ,d+[DATE], HR 107 and irregular, RR of 20, oral temperature of 101.1 and a BS of 62. All vitals were collected at 07:23 PM. CR #19 had decreased level of consciousness (very lethargic), had increased confusion/disorientation, experienced rigors (shaking chills), experienced SOB, weakness or hemiparesis. RN C documented that the symptoms first appeared on [DATE] and no ordered treatments/medications had been attempted to help resolve the symptoms. NP A was notified at 07:49 PM and a request was made to transfer the resident to the hospital. Record review of CR #19's Transfer Notification dated [DATE] at 08:50 PM signed by RN C revealed, CR #19 was transferred to a hospital on [DATE] at 08:50 PM related to lethargy, hypotension, rapid shallow breathing, elevated heart rate and body temperature. There was no documentation of hypoglycemia. Record review of CR #19's Progress Notes dated [DATE] at 8:55 PM signed by RN C revealed, While making rounds to administer medication, resident was found lying in bed very lethargic and hard to arouse. Further assessment PB ,d+[DATE] manually, T 101.1, P 107, R 20, O2 Sat 97% on room air, and BS 62 mg/dl at around 1923 (07:23 AM). NP A was notified of CR #19's change in condition at about 1938 (07:38 PM) and an order was given to send the resident out via contracted EMS while monitoring BP. CR #19 started exhibiting muscle tremors, increased SOB and BP lowered to ,d+[DATE] so NP A was notified of the further change of condition. CR #19 was transferred to the ER via 911 EMS at 8:50 PM, almost 1 ,d+[DATE] hours after symptoms were first observed. There was no documentation of treatment of CR #19's low blood sugar. Record review of CR #19's August MAR revealed, CR #19 was never administered Glucagon. Interview on [DATE] at 10:18 AM, CR #19 family member said while at the facility CR #19 had multiple pressure wounds and was hospitalized for the wounds on multiple occasions. CR #19's family member said when the resident would go to the hospital his wounds would get better but would worsen when he returned to the facility. She said her father was transferred to the hospital on [DATE] where he was diagnosed with sepsis which the hospital tried to treat with dialysis and antibiotics. CR #19's family member said the resident expired in the hospital 2 days after arrival ([DATE]) of severe sepsis. Interview on [DATE] at 12:52 PM, RN C said she found CR #19 unresponsive with critical values. She said he had low blood pressure, an elevated heart rate, was running a fever, had blood sugar lower than 70 and was in and out of consciousness She said she contacted NP A who said to monitor CR #19's blood pressure and send him out, she did not remember if NP A said the resident should be sent out using a contracted transport company of 911. She said she called the contracted EMS company to send him to the hospital and continued to monitor the resident. RN C said on following rounds she observed CR #19 to be suffering from tremors and the contracted service was not there yet, so she called 911 to send him out. RN C said that CR #19's symptoms appeared to indicate sepsis and looking back she would have sent him out initially using 911. She stated she tried to give him Glucagon gel by mouth but due to the resident's condition, it could not be administered that method. RN C said she did not think to administer glucagon by injection because things were moving too fast, and she instead focused on the resident's dropping blood pressure. Interview on [DATE] at 01:25 PM, the DON said after reviewing CR #19's vitals on the day of his hospitalization ([DATE]) the nurse should have administered Glucagon to the resident to treat his hypoglycemia. She said nursing staff do not specifically have training on how to manage emergency situations like what CR #19 experience, but it was an expected nurse competency. The DON said there was nothing stopping RN C from administering Glucagon to CR #19 since the resident had an active order for the medication. She said based on CR #19's she would expect the nurse to send the resident to the hospital by calling 911 because it was unknown how long the contracted EMS service would take. The DON said if a contracted EMS service was called and had not arrived in ,d+[DATE] minutes then 911 should have been called She said the time it took for CR #19 to be transferred to the hospital was too long. The DON said delay in transfer to the hospital could result in CR #19 experiencing further decline since his BP could not be treated at the facility and failure to treat CR #19's low blood sugar could lead to further hypoglycemia. Interview on [DATE] at 04:00 PM, NP A said she was notified by a nurse that CR #19 was experiencing signs and symptoms of infection and sepsis, so she gave the order to send the resident to the hospital for emergency care. She said the facility had standard orders for Glucagon which were stored on their carts so CR #19 should have been treated for his hypoglycemia regardless of his critical vitals. When the surveyor notified NP A of the vitals reported by RN C at the time of the incident, NP A said with those vitals the facility would not be able to treat the resident, so he had to be hospitalized . NP A said she did not specify the method of transfer to the nurse (contract vs. 911) but based on CR #19's critical vitals the expectation was that the resident be sent out by calling 911. She said any delay in transfer to the hospital would result in a delay in identification and treatment of acute issues. Interview on [DATE] at 02:22 PM, the Administrator said the facility did not have a policy addressing critical labs/vitals. Record review of the facility in-service titled Medication Safety Alert dated [DATE] presented by the Director of Clinical Education revealed, RN C was trained on the administration of Gvoke an antihypoglycemic agents indicated for severe hypoglycemia. Gvoke pre-filled is for subcutaneous injection only and should be administered as soon as possible when server hypoglycemia is recognized. Gvoke is premixed and ready for immediate us. Attached was a policy on Diabetes Management that defined hypoglycemia as BS </= 70. Record review of the facility in-service titled Diabetes management education and the use of Glucagon dated [DATE] presented by the Director of Clinical Education revealed, RN C was trained on diabetes management and hypoglycemia. Glucagon injection is an emergency medicine used to treat severe hypoglycemia in diabetes patients treated with insulin who have passed out or cannot take some form of sugar by mouth. Administer Glucagon as directed per physician orders. Notify Physician if Blood sugar less than 70 or per physicians orders, if unresponsive or unable to swallow position on side and give Glucagon 1 mg IM or as directed per physician orders. This is a Medical Emergency requiring close observation and/or 911. Resident #317 Record review of Resident #317's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility with diagnoses which included: anemia, paraplegia, colostomy and stage 4 pressure ulcer of the back. Record review of Resident #317's undated Care Plan revealed, focus- potential for uncontrolled pain due to osteomyelitis, muscle spasms, pressure ulcer and surgical wound upon admission; interventions- administer analgesia as ordered, monitor/document for side effects of pain medication. Focus- use of anti-anxiety medications, interventions- give anti-anxiety medications as ordered and monitor/document side effects. Record review of Resident #317's Order Summary Report dated [DATE] at 09:20 Am revealed the following active orders: - Acetaminophen 500 mg- 2 tablets by mouth every 8 hours for pain started [DATE]. - Alprazolam 1 mg- 1 tablet by mouth every 8 hours as needed for anxiety started [DATE]. - Baclofen 5 mg- give 4 tablets by mouth four times a day for muscle spasms started [DATE]. - Gabapentin 400 mg- 2 capsules by mouth three times a day for neuropathy (nerve pain) started [DATE]. - Methadone 5 mg- give 7.5 mg by mouth every 8 hours for pain started [DATE]. - Methocarbamol 750 mg- give 1 tablet by mouth three times a day for muscle spasms started [DATE]. - Naloxone 4mg/0.1 ML- 0.1 mL alternating nostrils every 2 minutes as needed for opioid overdose may repat every ,d+[DATE] minutes as needed started [DATE]. - Hydrocodone/Acetaminophen ,d+[DATE] mg- give 1 tablet by mouth every 8 hours as needed for pain started [DATE]. - Oxycodone 5 mg- give 1 tablet by mouth every 6 hours as needed for pain score ,d+[DATE] started [DATE]. Record review of Resident #317's Progress Notes dated [DATE] at 12:47 PM signed by NP C revealed, Reviewed Prescription Monitoring Program and patient is at high risk for unintentional overdose with a score of 650 above average. Risk for unintentional overdose discussed with patient, and he reports that he has been taking medications for a long time and that he never overdosed before. PMP monitoring only shows Hydrocodone, and Alprazolam that has been prescribed by his PCP in the community, in which his PCP ordered him Alprazolam yesterday [DATE] and was filled at pharmacy. Narcan nasal spray is ordered as needed. Record review of Resident #317's MAR dated [DATE] revealed, Resident #317 received the following medications the night ([DATE]) before his overdose - Gabapentin 800 mg- scheduled for 06:00 PM. - Methocarbamol 750 mg- scheduled for 06:00 PM. - Baclofen 20 mg - scheduled for 06:00 PM. - Methadone 7 mg- scheduled for 10:00 PM. Record review of Resident #317's Progress Note dated [DATE] at 04:18 AM signed by RN C revealed, Resident transferred to [Hospital] via 911 EMS at approximately 04:18a.m. for further evaluation and treatment related to decreased level of consciousness and respiratory distress. EMS personnel given copy of resident's face sheet, order summary, and clinical notes containing past medical history. Resident's personal belongings including two backpacks, one [NAME] pack, computer laptop, cell phone, earbuds, wrist watch, colostomy supplies, and several bottles of prescription medication remained behind in resident's room. [NP A] notified of [Resident #317] emergency transfer to [Hospital] at approximately 04:30a.m. Record review of the Hospital Ambulance Record dated [DATE] revealed, Primary impression- overdose other opioids. Narrative- the fire department was dispatched to the facility for a cardiac arrest. Resident #317 was found to be drowsy with deep snoring and the nursing staff said they were unsuccessful in waking Resident #317, and he might have had a seizure. Review of the Resident #317's chart showed multiple medications for sleep, pain and muscle reactions and the resident had constricted pupils. Resident #317 was administered 1 mg of Naloxone Intranasally, and the patients response improved; he was easily arousable to verbal and talked to the crew without falling asleep. Record review of the Hospital ED Record dated [DATE] revealed, Resident #317 was found unresponsive and hard to arouse at the facility and the EMS administered 1 mg of Naloxone. Record review of the Progress Note dated [DATE] at 08:10 AM revealed, Resident #317 returned to the facility in elate and high spirit. Resident #317 was diagnosed with opiate overuse in the hospital and NP A gave new orders to check the residents vitals and signs/symptoms of CNS depression on each shift. NP A ordered Resident #317's Oxycodone & Xanax 1 mg to be discontinues, Methocarbamol 750 mg decreased from three times daily to two times daily and a new order for Xanax 0.5 mg every 12 hours. Observation and Interview on [DATE] at 11:40 AM revealed, Resident #317 lying on stomach in bed in no immediate distress. He said the previous day ([DATE]) when he was asleep his mother placed his prescriptions in his backpack because she did not know what to do with it. He said this morning ([DATE]) the facility staff tried to wake him up, but he was not moving so they called 911. CR #317 said he was informed that he had an opioid overdose. An Observation on [DATE] at 12:03 PM revealed, a ziplock bag containing Resident #317's following home medications: - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 43 tablets remaining. - 1 bottle of Gabapentin 300 mg filled for 810 capsules with 3 capsules remaining. - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 56 tablets remaining. - 1 bottle of Naproxen 500 mg filled for 180 tablets with 116 tablets remaining. - 1 bottle of Baclofen 20 mg filled for 180 tablets with 169 tablets remaining. - 1 bottle of Alprazolam/Xanax filled for 270 tablets with 197 tablets remaining. Interview on [DATE] at 12:52 PM, RN C said on Saturday morning ([DATE]) during her hourly monitoring of residents she observed Resident #317 sitting in bed slumped over, unresponsive and slipping in and out of consciousness. She said he was breathing strange, would not wake up and as making gurgling/chocking sounds. RN C said she immediately placed him on oxygen, talked to him and tried to wake him which he could not so she made a judgement call to call 911. She said based on his symptoms she suspected he had a seizure/blood sugar or medication related overdose. Specifically to medications RN C knew the resident was on multiple pain medications like oxycodone/methadone/hydrocodone and Xanax/baclofen/methocarbamol. RN C said all these medications in unison can lead to respiratory depression and CNS depression. RN C A said the facility has Naloxone available to treat overdoses, but she did not administer Naloxone to Resident #317. She said she was supposed to give Narcan immediately and call 911 but did not because there was just a lot going on. RN C said When 911 arrived she told them she suspected either a seizure or overdose and looking back she should have administered Narcan. After the resident left the DON said to check his belongings in case he took something and she found several bottles of medications including Gabapentin, and Ativan. She counted it all and gave it to the DON. RN C said failure to administer Naloxone in response to an opioid overdose is dangerous and the resident could experience increased slurred speech/difficulty breathing, lose consciousness, and it could lead to death. Interview on [DATE] at 01:25 PM, the DON said signs and symptoms of opioid overdose included: shallow breathing and the resident being un-responsive. She said based on the information RN C provided about the incident Resident #317 showed symptoms of an opioid overdose. The DON said when a resident shows signs and symptoms of an opioid overdose the nurse must administer Naloxone, and RN C did not administer Naloxone to Resident #317. She said calling 911 was absolutely not an excuse for failure to render services during emergency situations. The DON said nursing staff was trained on the use of Naloxone at the end of 2022 when the facility started receiving Naloxone, and no training was performed after that. Interview on [DATE] at 04:00 PM, NP A said Resident #317 suffered an overdose after consuming medications that the facility was unaware of. She said signs of overdose included respiratory distress and the facility had Naloxone on hand to treat overdoses. NP A said the expectation is that nurses call 911 and then administer Naloxone and failure to do could cause the resident worsening of condition and potential harm. Interview on [DATE] at 09:27 AM, the DON said no training was performed on the emergency administration of Glucagon between CR #19's hospitalization on [DATE] and [DATE]. She said she was just focused on the CR #19 being sent out to the hospital and not the failure to administer Glucagon. The DON said no training has been performed on opioid overdoses and the administration of Naloxone since Resident #317's overdose on [DATE] and the last training was performed in December of 2022. Record review of the facility in-service record titled 'Opioid Overdose dated [DATE] revealed, patients who are prescribed opioid medication receive the necessary care and services to avoid complications associated with opioid overdose by: ensuring appropriate monitoring and treatment as may be required utilizing opioid reversal agents such as Naloxone. RN C was noted in attendance as indicated by her name and signature. Record review of RN C's Nurse Proficiency Audit dated [DATE] completed by the DON revealed, RN C was assessed as satisfactory for skills which included: administering medication properly (Oral/IM/SQ), and knowledge of emergency procedures (CPR, Crash Cart/AED, Activate EMS). Proficiency in Glucagon and Naloxone administration were not assessed. On [DATE] at 11:00 AM the Administrator and was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The following plan of removal was approved on [DATE] at 11:34 AM and Indicated: IJ Component: F658: Services Provided Meet Professional Standards: Facility failed to administer glucagon to CR#19 as ordered when identified with a BS of 62. Facility failed to send CR#19 out immediately following an acute change of condition. Facility failed to administer Naloxone to Resident #317 after the resident suffered from an overdose. Immediate Actions: CR#19 was transferred to theER on [DATE] and did not readmit to the facility. Resident #317 was transferred to theER on [DATE] at approximately 415am and readmitted to the facility on [DATE] at approximately 810am with diagnosis of Opioid Use and Anemia. Resident #317 was discharged home with home health services on [DATE]. Facility Plan to ensure compliance: 1. 100% review of all facility residents prescribed Glucagon completed by DON, ADON, and Regional Compliance Nurse on [DATE] to identify any other residents that did not receive prescriber ordered Glucagon for hypoglycemia. No other resident from audit identified as not receiving ordered Glucagon. 2. 100% assessment of all facility residents prescribed an opioid completed by DON, ADON, and Regional Compliance Nurse on [DATE] to assess for s/s of opioid overdose. No resident currently residing in the facility as of [DATE] identified from audit as having any s/s of opioid overdose. 3. Facility residents with a diagnosis of Diabetes Mellitus (DM) were audited on [DATE] to ensure all prescriptions were documented correctly. Audit revealed all residents with a diagnosis of DM with a prescription for treatment, either by mouth and/or with insulin orders, were transcribed correctly. 4. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on [DATE] regarding a. Abnormal Blood Sugar readings to include process for administering glucagon, when ordered, and process for treating an unresponsive resident. b. Change of Condition: When to Report to MD/NP/PA c. Conditions that require immediate transfer d. Signs and symptoms of Opioid Overdose e. How to use Narcan/Naloxone 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Abnormal Blood Sugar Readings to include the process for administering glucagon, when ordered, and the process for treating an unresponsive resident. Goal for completion of this education to be completed by end of day on [DATE]. 6. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Change of Condition to include when to Report to MD/NP/PA. Goal for completion of this education to be completed by end of day on [DATE]. 7. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting [DATE] regarding Conditions That Require Immediate Transfer. Goal for completion of this education to be completed by end of day on [DATE]. 8. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting [DATE] regarding Signs/Symptoms of Opioid Overdose. Goal for completion of this education to be completed by end of day on [DATE]. 9. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting [DATE] regarding Narcan/Naloxone Administration. Goal for completion of this education to be completed by end of day on [DATE]. 10. Licensed nurses (RNs/LVNs) will be tested to evaluate competency of the education/in-services initiated on [DATE]. Competency tests will be initiated on [DATE] upon completion of the education with goal for completion by end of day on [DATE]. 11. Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to abnormal blood sugars or signs of opioid overdose in the facility's electronic medical record (EMR). 12. All nurses (LVN/RNs) not in service on [DATE] will be in-serviced prior to working their next scheduled shift. 13. The Medical Director, was notified by Administrator on [DATE] at 1:55pm on the immediate jeopardy citation. 14. An Ad-hoc QAPI meeting was held on [DATE] by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. MONITORING Interviews conducted on [DATE] from 11:20 AM to 11:40 AM revealed, LVN A, LVN B, RN B, and the ADON A received in-service training on the treatment of hypoglycemia, opioid overdose and immediate transfer to the hospital. The staff showed competency in the emergent treatment of hypoglycemia and immediate transfer to the hospital but were not competent in the administration of Naloxone. LVN A and LVN B did not know when to repeat Naloxone, RN B did not know the formulation of Naloxone used in the facility and where it could be located. Interview on [DATE] at 12:34 revealed, the DON did not know the formulation of naloxone used in the facility and did not know that Naloxone could be administered if a resident became unconscious after a previous dose was administered. Interview on [DATE] at 12:45 PM with the Regional Clinical Nurse revealed, the facility was not trained on the re-administration of Naloxone if a resident became unconscious after a previous dose was administered. He said the facility had just focused on training the staff to administer the first dose of Naloxone and then call 911. The Regional Clinical Nurse said nursing staff was not trained on readministering Naloxone and all staff would be trained appropriately. Interview on [DATE] at 01:36 PM, the Regional Clinical Nurse said the DON and Administrator were re-trained on the administration of Naloxone and training of the nursing staff was ongoing. He said since the IJ was called the facility: - audited all residents with opioid prescriptions to ensure they had orders for PRN Naloxone - audited all blood sugars to ensure treatments were given for any abnormal values Interviews conducted on [DATE] from 05:28 AM to 06:27 AM revealed the following: - LVN B stated she was re-trained in the administration of Naloxone and showed competency in its administration. - RN A, RN C, LVN D, LVN G, LVN H, stated they received training on treatment of hypoglycemia, immediate transfer to the hospital and opioid overdose. The staffed interviewed showed competency in the use of Glucagon for the treatment of hypoglycemia, resident symptoms that require immediate hospital transfer and the treatment of an opioid overdose using Naloxone. Record reviews completed on [DATE] revealed the following: - on [DATE] the [NAME] Clinical Nurse audited all resident's receiving opioids and reassessed them for s/s of opioid overdose and residents displayed any signs or symptoms - on [DATE] the DON reviewed all resident orders for Glucagon administration. - on [DATE] the DON completed a Nurse Proficiency Audit on RN C she was found to be satisfactory. - on [DATE] a QAPI meeting was held regarding the IJ- the DON, Regional Clinical Nurse, Administrator were in attendance. - on [DATE] the facility trained the ADON, Administrator and DON were trained on change in conditions, conditions that require immediate transfer, signs and symptoms of opioid overdose and responding to an overdose - on [DATE] the facility completed training with nursing staff on: responding to an overdose how to give naloxone, signs/symptoms of opioid overdose, conditions that require immediate transfer, blood sugars: abnormal readings, change in conditions: when to report to the provider. The Nurses were assessed with a competency test and found satisfactory. - on [DATE] the Regional Clinical Nurse reviewed residents with Glucagon ordered and discontinued glucose gel if Glucagon was on order. - on [DATE] the Regional Clinical Nurse audited all residents with a diagnosis of diabetes to ensure they received appropriate treatment, and all mediations were appropriate - on [DATE] at 1:00 PM ADON A, the DON and the Administrator were retrained on the administration of Naloxone with emphasis of subsequent administration after a resident becomes unconscious or declines after an effective first dose. - On [DATE] the facility retrained the following staff on the administration of Naloxone with emphasis of subsequent administration after a resident becomes unconscious or declines after an effective first dose: MDS Nurse A, RN A, LVN B, LVN A, RN C, LVN D The Administrator was informed the IJ was removed on [DATE] at 06:37 PM. The facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 12 residents (Resident #62, Resident #217 and Resident #317) reviewed for pain management. - The facility failed to acquire, dispense, and timely administer pain medications and failed to assess Resident #317's pain resulting in pain of 10 out of 10. - The facility failed to assess and document Resident #62 pain accurately or at all. - The facility failed to assess and document Resident #217's pain. An IJ was identified on 09/06/23. The IJ template was provided to the facility on [DATE] at 04:20 PM. While the IJ was removed on 09/11/23 at 1:57 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failures could place residents at risk for uncontrolled, irretractable pain, and decreased quality of life. Findings Include: Resident #317 Record review of Resident #317's Face Sheet dated 09/11/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: anemia, paraplegia, colostomy and stage 4 pressure ulcer of the back. Record review of Resident #317's undated Care Plan revealed, focus- potential for uncontrolled pain due to osteomyelitis, muscle spasms, pressure ulcer and surgical wound upon admission; interventions- administer analgesia as ordered, monitor/document for side effects of pain medication. Focus- use of anti-anxiety medications, interventions- give anti-anxiety medications as ordered and monitor/document side effects. Record review of Resident #317's Admission Note dated 09/05/23 at 2:51 PM revealed, Resident #317 admitted to the facility on [DATE] at 01:38 PM from a hospital. Record review of Resident #317's Progress Notes dated 09/05/23 at 4:34 PM revealed, Medications reconciled with NP. Triplicate request given to NP for Oxycodone, Norco, Methadone, and Xanax. There was no documentation of Resident #317's pain. Record review of Resident #317's Progress Notes dated 09/05/23 at 9:06 PM revealed, Methadone 5 mg was not available new admission and NP is aware. Record review of Resident #317's Progress Notes dated 09/06/23 at 5:15 AM revealed, the facility was waiting for delivery of Methadone 5 mg from the facility. Record review of Resident #317's Order Summary Report dated 09/06/23 at 09:20 AM revealed the following active orders: - Acetaminophen 500 mg- 2 tablets by mouth every 8 hours for pain. - Methadone 5 mg- give 7.5 mg by mouth every 8 hours for pain. - Hydrocodone/Acetaminophen 10-325 mg- give 1 tablet by mouth every 8 hours as needed for pain. - Oxycodone 5 mg- give 1 tablet by mouth every 6 hours as needed for pain score 4-6. Record review of Resident #317's MAR printed 09/06/23 at 09:21 AM revealed, - Resident #317 was not administered his Methadone 7.5 mg scheduled for 09/05/23 at 10:00 PM. - Resident #317 was not administered his Methadone 7.5 mg scheduled for 09/06/23 at 06:00 AM. Record review of Resident #317's Medication Administration Audit Report dated 09/09/23 at 12:00 PM revealed, Resident #317 received Methadone 7.5 mg- scheduled for 09/06/23 at 02:00 PM at 03:11 PM. There was no documentation for the reason why the medication was administered late. Record review of Resident #317's Clinical Assessments printed 09/06/23 at 09:33 AM revealed, a pain assessment was not completed upon Resident #317's admission into the facility. Record review of Resident #317's Admission Note dated on 09/05/23 and signed by LVN H revealed, Resident #317 reported constant pain up to 10 out of 10 in the last 5 days leading to his admission on 09/05/23. There was no documented pain scale for the resident's pain at admission. Record review of Resident #317's Pain Score printed 09/06/23 at 09:33 AM revealed, no documented pain scores for Resident #317 since admission. Record review of Resident #317's Pharmacy Records faxed 09/20/23 at 10:40 AM revealed, - The Medical Director send an eScript for Hydrocodone/Acetaminophen 10-325 mg- 1 tablet by mouth every 8 hours as needed for pain with an effective date of 09/06/23 on 09/06/23 at 09:48 (over 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM. - The Medical Director send an eScript for Oxycodone 5 mg- 1 tablet by mouth every 6 hours as needed for pain with an effective date of 09/06/23 on 09/06/23 at 09:33 (almost 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM. - The Medical Director send an eScript for Methadone 7.5 5 mg- 1 tablet by mouth every 8 hours with an effective date of 09/06/23 on 09/06/23 at 09:33 (almost 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM by LVN B. An observation and interview on 09/06/23 at 07:37 AM revealed, MA B informed LVN A that Resident #317 was complaining of pain. LVN A told the surveyor that Resident #317 arrived to the facility the previous afternoon and his pain medications had not yet arrived from the pharmacy. An observation and interview on 09/06/23 at 08:25 AM revealed, Resident #317 lying in bed with his face slightly protruding from under the sheets. He had a grimace on his face and could be heard saying oh shit intermittently. Resident #317 said he had not received his pain medications Methadone, Oxycodone and Hydrocodone/Acetaminophen since the morning of his admission (09/05/23) and reported pain at a 10 out of 10. Resident #317 said he had not been offered or received any alternative pain medications like Tramadol or Tylenol #3. Interview on 09/06/23 at 08:30 AM, LVN A looked at Resident #317's MAR and said the resident did not have any orders for alternative pain medications and he had not been offered any alternatives. She said Resident #317 had orders for PRN Hydrocodone/Oxycodone and scheduled Methadone and he had not received them since he admitted to the facility yesterday. Interview on 09/06/23 at 08:48 AM, the Pharmacist said Resident #317 had not received his Hydrocodone, Methadone and Oxycodone because the pharmacy was pending a prescription so NP A was notified that a triplicate prescription was necessary. He said that as of that moment the pharmacy had not received an electronic prescription. He said in Texas LTC (facilities like nursing homes or assisted living facilities) facilities are allowed to call in/fax in emergency CIIs (schedule 2 controlled substances which include naracotics with high addictive potential) but nothing had been sent in at the time of our conversation. Interview on 09/06/23 at 09:02 AM, the DON said when a resident arrives at the facility the admitting nurse must reconcile the medications with the NP and once confirmed the orders are entered into the EMR. She said if a resident has orders for a narcotic medication, the information is provided to the NP and the provider will have to send an eScript while non-controlled substances can be found in the stat kit (emergency medication dispensing system). The DON said if the pharmacy received a medication order before 06:00 PM the medication would be delivered on the same day, but if the order arrives later the medication can be sent to the facility as a stat delivery. Interview on 09/06/23 at 09:10 AM, NP A said the medical director should have sent the order for Resident #317's medication to the pharmacy. She said since the medication had not arrived at the facility Resident #317 should be offered appropriate alternatives like Tramadol 50 mg and Tylenol #3 should be offered based on the resident's pain. NP A said based on Resident #317's previous pain medication use plain Acetaminophen is not appropriate coverage for his pain. She said she saw the resident yesterday as he arrived at the facility and he was not experiencing pain at the time. When the surveyor notified NP A of Resident #317's reported pain at 10 out of 10 NP A said that was the first she had heard of the resident experiencing pain. NP A said she would contact the Medical Director to follow up on Resident #317's prescriptions. Interview at 09/06/23 at 12:25 PM, the DON said Resident #317 had been offered pain medications this morning because he was reporting pain at 10 out of 10. She said he was offered Tramadol but he declined. When asked if Resident #317 had an active order for Tramadol in this system, she said not because the order was just received from the NP so nursing staff had not had the chance to enter it into the EMR. The DON said the facility did not perform pain assessments every shift, at there was no assigned task for nursing staff to ask residents if they were experiencing pain. When the surveyor asked the DON how nursing staff would know if a resident was in pain if they didn't ask about pain, she would not answer. Resident #62 Record review of Resident #62's face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE] and was diagnosed with Unspecified Dementia, Anorexia, Hyperlipidemia, Chronic Kidney Disease. Record review of Resident #62's care plan, dated 08/16/2023, revealed the resident had potential for uncontrolled pain related to fractured right hip, the goal was for the resident to, .verbalize adequate relief of pain ., and the intervention was to, Administer analgesia as per orders. Give 1/2 hour before treatments or care, anticipate resident's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions, monitor/document for probable cause of each pain episode. Remove/limit causes where possible . Resident #62 had an order for Tylenol Extra Strength 500 MG for Pain. Date initiated 05/17/2023, Tylenol 325 MG as needed for Pain. Date Initiated 08/01/2023, Tylenol with Codeine #3 300-30 MG as needed for Pain/Discomfort. Date initiated 08/01/2023 Record review of Resident #62's Pain Level Summary from 08/01/2023-09/18/2023, the resident's pain level was only documented on 08/01/2023, 08/03/2023, 08/28/2023, 08/29/2023, 08/31/2023, and 09/01/2023. An observation on 09/07/23 at 08:25 AM revealed, MA D administering medication to Resident #62. She retrieved 1 tablet of Acetaminophen 500 mg as well as 4 other solid form medications and administered it to Resident #62; MA D did not ask Resident #62 any questions prior to administering the medications, she did not ask the resident about his pain. After medication administration she exited the room and documented the medications administered recording a pain score at 0 when she administered Resident #62's Acetaminophen 500 mg even though she never asked him about his pain. Interview on 09/15/23 at 09:16 AM, MA D said she administered Acetaminophen to Resident #62 on 09/07/23 she did not ask about his pain and did not remember recording a pain score for him. She said nurses are expected to document accurately and she should not have documented a pain score since she did not ask the resident. MA D said failure to document accurately could lead to records that do not reflect what was done. Interview on 09/18/23 at 09:58 AM, the DON said nurses are expected to document accurately to reflect what is going on with the patient and what was communicated. She said documentation should only reflect the actions taken. Interview on 09/10/23 at 11:55 AM, the surveyor notified the DON and Regional Clinical Nurse that residents receiving pain management reported they were not assessed for their pain and some resident's reported uncontrolled and new pain. The surveyor specifically notified the facility on Residents #10,#29 and #35. The Regional Clinical Nurse said they would audit their resident's receiving pain management to address the identified issues. Interview on 09/18/23 at 02:06 PM, the DON said medications should be administered +/- 1 hour of the scheduled time and failure to administer medications timely could change their therapeutic window for medications with multiple doses administered during the day leaving residents in pain, and conditions untreated. Resident #217 Record review of Resident #217 revealed a [AGE] year-old male was admitted into the facility on [DATE] and was diagnosed with dementia, acute kidney failure, dysphasia, muscle wasting, and cachexia. Record review of Resident #217's MDS, dated [DATE], revealed the resident's BIMS assessment and pain assessment was not completed due to the resident being rarely/never understood. The staff assessment for pain was completed and showed resident had no signs observed or documented related to pain such as: non-verbal sounds (e.g., crying, whining, gasping, moaning or groaning), vocal complaints of pain, facial expression (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) and protective body movements or postures (e.g., bracing guarding, rubbing or massaging). Record review of Resident #217's physician's orders revealed the resident had an active order for two Tylenol oral tablets 325 MG via PEG-tube two times a day for pain starting 04/26/2023. Record review of the Resident #217's pain assessments, from 04/20/2023 - 09/07/2023, revealed only pain assessment was documented on 04/20/2023, upon admission, and was rated at a 0. There was no other pain assessment performed. An observation and interview with Resident #217 on 09/07/2023 at 8:07 AM, the resident was lying in a fetal position due to multiple contractures, receiving enteral feeding via PEG tube. Resident was observed frowning and sighing. When asked if he was uncomfortable, he did not respond. When asked if he was in pain, he frown and nodded his head, yes. LVN G was called to observe the resident and she stated frowning, facial grimacing was the resident's baseline behavior. She stated it is more related to the resident's depression. She stated the resident does, however, experience pain due to his contractures, but he had been already placed on a regimen of two Tylenol tablet twice a day. She stated since then, the resident has not had a need for increased pain management. She stated she did not perform pain assessments on Resident #217, but she can tell if the resident is pain whenever she repositions him and moans and groans more loudly, but that had not been a problem as of recent. Interview with the MDS nurse on 09/18/2023 at 12:39 PM she stated anyone who is ordered medication or has potential pain-related diseases, they should have a pain management section on their care plan and be assessed for pain on the MDS as well. She stated there a visual pain assessments that can be used on nonverbal residents. She stated due to lack of documentation related to pain for Resident #217, she would have to rely on staff interviews to accurately assess the resident, but she cannot remember if she talked to any staff about Resident #217 and she has no documented interviews that she had about Resident #217. She said she had not expressed her concerns about lack of documentation to the DON or corporate MDS staff. Interview with the DON on 09/18/2023 at 9:53 AM, she stated Resident #217's care plan should have stated the resident was at risk for pain related to contracture and goal would be to keep the resident as pain free as possible through the next assessment date, to notify doctor if there was an increase in pain and maybe a PRN medication for breakthrough pain. She said care plans should address concerns for patients the goals, interventions which are then made accessible to the nursing staff caring for the residents. She stated acute concerns that come up between assessment periods are care planned by nurse management, herself and the ADONs, and chronic concerns are care planned through the MDS assessment. Risk to patient, they can get missed with interventions for unnoticed pain. Record review of the facility policy titled 'Pain Management, Assessment Scale' revised 11/25/16 revealed, 1- assess resident's physical symptoms of pain, physical complaints, and daily activities. 9- have the resident rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. 12- talk with the resident about pain and assess for pain relief after interventions. Record review of the facility policy titled 'Medication Reconciliation' revised 11/14/16 revealed, At any. time a change is made to a patients medication regimen, practitioners must ensure that the change is made carefully, is documented, and accords with prescribing instructions for the relevant medications Record review of MA D's Medication Aide Proficiency dated 03/15/23 revealed, MA D had satisfactory competency for skills : 7- documents accurately and 22- checks MARs for accuracy. Record review of the facility police titled Medication Orders with no revision date revealed, the following steps are initiated to complete documentation: clarify the order, enter orders on the medication order and receipt record, call (or fax) the medication order to the provider pharmacy. Accept verbal orders for schedule II medications only in an emergency, to be followed with a written order from the prescriber within (72) hours. The Pharmacy will need to talk directly to the physician on all Emergency Schedule II medication orders. The policy did not address submission of eScript(electronic prescriptions) to the pharmacy. On 09/06/23 at 04:20 PM the Administrator and was notified of the Immediate Jeopardy (IJ) due to the above failures. The IJ template was provided and a plan of removal (POR) was requested at that time. The following plan of removal was approved on 09/07/23 at 03:58 PM and read: IJ Component: F697 Pain Management: Facility failed to acquire and dispense Oxycodone, Methadone, and Hydrocodone as ordered upon admission for resident #317. Facility failed to enter an order for alternative pain medication for resident #317. Facility provider failed to submit a prescription to the pharmacy for resident #317. Facility failed to monitor Resident #317's pain level while waiting for delivery of pain medication. Immediate Actions: 1. Resident #317 received pain medication on September 6, 2023 at 12:30pm. 2. Pain assessment was completed and documented on September 6, 2023 at 5:33pm. 3. Change of condition (Pain SBAR) for resident #317 was assessed and documented on September 6, 2023 at 5:40pm. 4. Resident #317's Physician was notified of resident's pain on September 6, 2023 at 5:41pm Facility Plan to ensure compliance: 1. Abuse and Neglect policy in-service initiated on 9/6/23. The Regional Compliance Nurse and Area Director of Operations provided in-service to DON, ADON, and Administrator. DON/ADON will in-service facility staff thereafter. 2. Receipt of Pain Medication orders in-service initiated on 9/6/23 to include ensuring pharmacy has received the order and verifying that the required items (i.e Script) was received by pharmacy. The Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance for this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 3. Notifying physician of estimated timeframe to get medications in-service initiated on 9/6/23. The Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance for this procedure as of 9/7/23. Charge nurses will be in- serviced as needed thereafter. 4. Notifying pharmacy of new orders in-service initiated on 9/6/23 to include notifying pharmacy of any new order, including pain medication, received after 4pm. Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance with this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 5. Contacting Physician for Alternative Pain Medication that is appropriate based on the resident's pain needs in-service initiated on 9/7/23 to include obtaining a new order for an available pain medication from the Stat-safe (facility's emergency medication kit). Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/7/23. DON/ADON will in-service charge nurses to ensure compliance with this procedure by end of day on 9/7/23. Charge nurses will be in-serviced as needed thereafter. 6. Offering prescribed alternative pain medication in-service initiated on 9/6/23. Regional Compliance Nurse in-serviced DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance with this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 7. Pain assessment in-service, to include verbal and non-verbal signs of pain and reporting pain to provider (NP/MD) in-service initiated on 9/6/23. Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/6/23. DON/ADON have in- service direct care staff to include CNAs, CMAs, and Charge Nurses (LVN/RNs) in person and/or by phone to ensure compliance with this procedure as of 9/7/23. 8. Charge Nurses will utilize the skilled nurse's notes, SBAR, and/or other routine follow- up documentation that contains a Pain Assessment element in the EMR. 9. Charge Nurses will notify practitioner of pain not controlled adequately on current treatment plan. If physician's recommendations do not meet the resident's needs, residents will be transferred to hospital for evaluation and treatment of uncontrolled pain. 10. All nurses not in-serviced on 9/6/23 will be in-serviced prior to their next shift. 11. The Medical Director, was notified by Administrator on 9/6/23 at 5:55pm on the immediate jeopardy citation. 12. An Ad-hoc QAPI meeting was held on 9/6/23 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. 13. A complete audit of medication availability was completed on 9/7/23 to ensure all medications were available, including pain medications. MONITORING: Record review of the facility schedule revelaed, the facility had 2 nursing shifts 06:00 AM to 06:00 PM day shift and 06:00 PM to 06: 00 AM night shift. Monitoring involved interviews with both day shift and night shift staff. Interview on 09/08/23 at 12:30 PM (day shift), LVN E said he received training on neglect approximately a week ago. He said he was trained on pain management, new admission orders on 09/05/23. He said the training addressed escalating uncontrolled pain to the MD. LVN E said most of the time the facility does not have medication on hand residents who admit to the facility with CII medications so it is important to ask for an alternative. He said if a medication had not arrived from the pharmacy nursing staff must notified the MD for an alternative medication or a stat order. LVN E said plain Acetaminophen is not an appropriate alternative for residents who are not opioid naive, so nurses should ask the provider for Tramadol or Tylenol #3. He said pain can be assessed by asking a resident to rate their pain on a scale of 0-10 or assessments of facial expression, body postering for those that are non-vocal, He said there is no EMR related task to assess a resident's pain but nurses should ask about pain pre and post scheduled and PRN medications. LVN E said the efficacy of a pain medication is measured by asking for a pain assessment 1 hr. after oral pain medication is administered and all reported pain should be documented in the residents' EMR. Interview on 09/08/23 at 12:27 PM (day shift), LVN C said the last time she received an in-service on neglect was last week. She said she recently received training on admission meds, escalation to the MD for unavailable meds and pain assessments. SLVN C said if a resident's pain medication is not available nursing staff must immediately call for an alternative like T tramadol and Tylenol #3. She said resident's should be assessed pre and 1 hour post pain medication administration and the provider should be notified of uncontrolled pain. Interview on 09/08/23 at 12:35 PM (day shift), LVN H said she received an in-service on neglect on 09/08/23. She said she also received training on admission meds, focusing on pain medications, and pain management. She said when a resident admits, a CII prescription should be immediately received and the pharmacy should be contacted for an ETA. LVN H said if the medication is unavailable nursing staff should contact the provider requesting an alternative like Tramadol or Tylenol #3. She said pain should be assess before medication administration and 1 our post administration through visual and verbal assessments. LVN H said if pain was not adequately controlled the resident's provider should be contacted and pain should be documented in the EMR as vitals or in a nursing note. Interview on 09/09/23 at 12:56 PM, the DON said the facility completed a cart audit to ensure that all residents medications were present as well as audited resident's pain assessments. She said nursing staff are expected to ask resident's for their pain score 0-10 and there are non-pharmacological and pharmacological treatment. The DON said after administering pain medications nursing staff should follow up with the resident in 30 minutes and pain should be documented in the progress notes or daily skilled notes. The DON said nursing staff are not asking every resident about pain but only does on a pain management program. Interview on 09/09/23 at 01:18 PM, the Regional Clinical Nurse said the facility has identified a failure in its pain management system. He said the audits have shown nursing staff were not documenting pain, assessing residents for pain or performing post administration assessments of the efficacy of a medication. The Regional Clinical Nurse said the facility put systems in place to monitor the pain management system. Interview on 09/09/23 at 07:10 PM (night shift), the Medical Records Staff said she received an in-service on neglect, pharmacy services, physician notifications, admissions medications and pain management on 09/08/23. The training addressed acquisition of pain medications for new admissions, getting alternative medications for unavailable medications, completing pain assessments, provider notification of ineffective pain control and documentation of pain in the EMR. Interview on 09/09/23 at 07:18 PM (night shift), LVN F said she received training on neglect, pharmacy services, physician notifications, admissions medications and pain management a couple of days ago. She said the training addressed the acquisition of pain medications, use of alternatives if pain medications are not available, notification of providers of unavailable pain medications, completion of pain assessments and notification of providers of ineffective pain control. Interview on 09/09/23 at 07:28 PM (night shift), LVN I said received training on neglect, pharmacy services, physician notifications, admissions medications and pain management a couple of earlier in the week. She said the training addressed the acquisition of pain medications, use of alternatives if pain medications are not available, notification of providers of unavailable pain medications, completion of pain assessments and notification of providers of ineffective pain control. An observation and interview on 09/10/23 at 11:20 AM revealed, Resident #35 lying in bed well-groomed with visible burns to the face and body. The resident said he did not feel his pain was well controlled and the facility staff never asked him about his pain. Resident #35 said he had never thought of informing the staff that his pain was not controlled and the facility needs to do better to control his pain. An observation and interview on 09/10/23 at 11:21 AM revealed, Resident #25 lying in bed in no immediate distress. She said she received Tylenol three times a day and her pain was well controlled. Resident #25 said she was happy with her pain medication but the facility staff never asks her about her pain, they just administer her medication. An observation and interview on 09/10/23 at 11:28 AM revealed, Resident #10 lying in bed in no immediate distress. She said her pain was not ok and the facility could do better since they don't follow up on her pain. Resident #10 said she is fine when she gets her pain medications and she hasn't not been asked about her pain nor does she report her pain to others. An observation and interview on 09/10/23 at 11:37 AM revealed, Resident #29 lying in bed in a contracted position. She said gets her pain medication on time now and her pain is much better. Resident #29 said when she first started the facility would run out of her pain medications and it takes at least 1 hour for her to receive her medications. She said no one asks her about her pain and she had bad aching pain. Resident #29 could not elaborate on her pain any further. Interview on 09/10/23 at 11:55 AM, the surveyor notified the DON and Regional Clinical Nurse that residents receiving pain management reported they were not assessed for their pain and some resident's reported uncontrolled and new pain. The surveyor specifically notified the facility on Residents #10,#29 and #35. The Regional Clinical Nurse said they would audit their resident's receiving pain management to address the identified issues. Record review of the facility in-service document titled Abuse/Neglect dated 09/06/23 revealed, the Administrator, the DON and ADON A were trained on neglect. The training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility in-service document titled Abuse/Neglect dated 09/06/23 presented by the DON revealed, The following staff were trained on neglect and the training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - LVN C, LVN E, RN E, CNA U, CNA M, CNA T, LVN G, LVN B, MA B, MA A, RN E, LVN C, CNA C, RN A, CNA J, Medical Records Staff, CNA H, Hospitality Aide and CNA I. Record review of the facility in-service document titled Pain Assessments dated 09/06/23 presented by the Regional Clinical Nurse revealed, the Administrator, the DON and ADON A were trained on pain assessments. The training read, pain assessments are incorporated into every assessment completed in the EMR. If pain is triggered and is new onset pain or worsened pain the nurse must follow up and report to the provider. CNAs observing/hearing signs of pain should report to the nurse. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/06/23 presented by the Regional Clinical Nurse revealed, the Administrator, the DON and ADON A were trained on alternative pain medications. The training read, the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if an alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. Record review of the facility in-service document titled New Med Orders dated 09/06/23 presented by the Regional Clinical Nurse revealed, the Administrator, the DON and A [TRUNCATED]

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 4 of 10 residents (Resident #24, Resident #54, Resident #61 and Resident #317) reviewed for pharmaceutical services. - The facility failed to acquire, dispense, and timely administer medications to Resident #317 upon admission resulting in pain of 10 out of 10. An IJ was identified on 09/06/23. While the IJ was removed on 09/11/23 at 1:57 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes and uncontrolled pain. Non-IJ - The facility failed to administer Pantoprazole, a medication used to treat acid reflux, timely to Resident #24 - The facility failed to administer Pantoprazole timely to Resident #54 - The facility failed to administer medications timely to Resident #61 These failures could place residents receiving medication at risk of inadequate therapeutic outcomes and acid reflux. Findings included: Record review of Resident #317's Face Sheet dated 09/11/23 revealed, a [AGE] year-old male who admitted to the facility with diagnoses which included: anemia, paraplegia, colostomy and stage 4 pressure ulcer of the back. Record review of Resident #317's undated Care Plan revealed, focus- potential for uncontrolled pain due to osteomyelitis, muscle spasms, pressure ulcer and surgical wound upon admission; interventions- administer analgesia as ordered, monitor/document for side effects of pain medication. Focus- use of anti-anxiety medications, interventions- give anti-anxiety medications as ordered and monitor/document side effects. Record review of Resident #317's Admission Note dated 09/05/23 at 2:51 PM revealed, Resident #317 admitted to the facility on [DATE] at 01:38 PM from a hospital. Record review of Resident #317's Progress Notes dated 09/05/23 at 9:06 PM revealed, Methadone 5 mg was not available new admission and NP is aware. Record review of Resident #317's Progress Notes dated 09/06/23 at 5:15 AM revealed, the facility was waiting for delivery of Methadone 5 mg from the facility. Record review of Resident #317's Progress Notes dated 09/05/23 at 4:34 PM revealed, Medications reconciled with NP. Triplicate request given to NP for Oxycodone, Norco, Methadone, and Xanax. There was no documentation of Resident #317's pain. Record review of Resident #6's Order Summary Report dated 09/06/23 at 09:20 AM revealed the following active orders: - Acetaminophen 500 mg- 2 tablets by mouth every 8 hours for pain. - Methadone 5 mg- give 7.5 mg by mouth every 8 hours for pain. - Hydrocodone/Acetaminophen 10-325 mg- give 1 tablet by mouth every 8 hours as needed for pain. - Oxycodone 5 mg- give 1 tablet by mouth every 6 hours as needed for pain score 4-6. - Methocarbamol 750 mg- 1 tablet by mouth three times a day for muscle spasms. - Augmentin XR 100-62.5 mg- 1 tablet every 12 hours for osteomyelitis (bacterial bone infection) - Melatonin 1 mg/mL- give 2.5 mL by mouth at bedtime for sleep. - Celecoxib- give 1 capsule by mouth two times a day for pain. - PEG 3350- 17 gm two times a day for bowel regimen - Baclofen 5 mg- 4 tables by mouth four times a day for muscle spasms. - Pantoprazole 40 mg DR- 1 tablet by mouth one time a day for GERD. - Enoxaparin 4mg/0.4mL- inject 1 syringe SQ for blood thinning - Multivitamin w/ Minerals- 1 tablet by mouth in the morning for wound care. - Vitamin C 500 mg- 1 tablet by mouth for wound care - Zinc Sulfate 220 mg- 1 tablet be mouth in the morning for wound care. - Lactobacillus- 2 capsules by mouth one time a day as a probiotic. - Docusate - Gabapentin 400 mg- 2 capsules by mouth three times a day for neuropathy (nerve pain). Record review of Resident #317's MAR printed 09/06/23 at 09:21 AM revealed Resident #317 did not receive the following medications: - Melatonin 1mg/mL scheduled for 09/05/23 at Bedtime - Augmentin XR scheduled for 09/05/23 at 06:00 PM - Methocarbamol 750 mg scheduled for 09/05/23 at 06:00 PM - Methadone 7.5 mg scheduled for 09/05/23 at 10:00 PM. - Methadone 7.5 mg scheduled for 09/06/23 at 06:00 AM. - Augmentin XR scheduled for 09/06/23 at 06:00 AM Record review of Resident #317's Medication Administration Audit Report dated 09/09/23 at 12:00 PM revealed, Resident #317 received medications late on 23 occasions between 09/05/23 and 09/09/23 at 12:00 PM without a documented reason: 1. Methadone 7.5 mg- scheduled for 09/06/23 at 02:00 PM and administered at 03:11 PM. 2. Gabapentin 400 mg- Scheduled for 09/06/23 at 06:00 PM and administered at 07:31 PM. 3. Methocarbamol 750- Scheduled for 09/06/23 at 06:00 PM and administered at 07:31 PM. 4. Baclofen 5 mg- scheduled for 09/05/23 at 04:00 PM and administered at 06:32 PM. 5. Baclofen 5 mg- scheduled for 09/06/23 at 06:00 PM and administered at 07:31 PM. 6. Baclofen 5 mg- scheduled for 09/08/23 at 04:00 PM and administered at 06:06 PM. 7. Celecoxib- scheduled for 09/05/23 at 04:00 and administered at 05:04 PM. 8. Celecoxib- scheduled for 09/06/23 at 08:00 AM and administered at 09:23 AM. 9. Celecoxib- scheduled for 09/08/23 at 04:00 PM and administered at 06:06 PM. 10. Acetaminophen 500- Scheduled for 09/08/23 at 10:00 PM and administered at 11:14 PM. 11. PEG 3350- scheduled for 09/05/23 at 04:00 and administered at 06:32 PM. 12. PEG 3350- scheduled for 09/06/23 at 08:00 AM and administered at 09:19 AM. 13. PEG 3350- scheduled for 09/06/23 at 06:00 PM and administered at 07:31 PM. 14. Pantoprazole 40 mg- scheduled for 09/06/23 at 06:30 AM administered at 09:19 AM. 15. Pantoprazole 40 mg- scheduled for 09/07/23 at 06:30 AM administered at 07:50 AM. 16. Pantoprazole 40 mg- scheduled for 09/08/23 at 06:30 AM administered at 07:40 AM. 17. Enoxaparin 40 mg/0.4 mL- Scheduled for 09/06/23 at 06:30 AM and administered at 12:24 PM 18. Multivitamins- scheduled for 09/06/23 at 07:00 AM and administered at 09:19 AM. 19. Multivitamins- scheduled for 09/09/23 at 07:00 AM and administered at 08:31 AM. 20. Vitamin C 500 mg- scheduled for 09/06/23 at 07:00 AM and administered at 09:19 AM. 21. Vitamin C 500 mg- scheduled for 09/09/23 at 07:00 AM and administered at 08:31 AM. 22. Zinc Sulfate 220 mg- scheduled for 09/06/23 at 07:00 AM and administered at 09:20 AM. 23. Zinc Sulfate 220 mg- scheduled for 09/09/23 at 07:00 AM and administered at 08:31 AM. Record review of Resident #317's Pharmacy Records faxed 09/20/23 at 10:40 AM revealed: - The Medical Director sent an eScript for Hydrocodone/Acetaminophen 10-325 mg- 1 tablet by mouth every 8 hours as needed for pain with an effective date of 09/06/23 on 09/06/23 at 09:48 (over 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM. - The Medical Director sent an eScript for Oxycodone 5 mg- 1 tablet by mouth every 6 hours as needed for pain with an effective date of 09/06/23 on 09/06/23 at 09:33 (almost 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM. - The Medical Director sent an eScript for Methadone 7.5 5 mg- 1 tablet by mouth every 8 hours with an effective date of 09/06/23 on 09/06/23 at 09:33 (almost 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM by LVN B. An observation and interview on 09/06/23 at 07:37 AM revealed, MA B informed LVN A that Resident #317 was complaining of pain. LVN A told the surveyor that Resident #317 arrived to the facility the previous afternoon and his pain medications had not yet arrived from the pharmacy. An observation and interview on 09/06/23 at 08:25 AM revealed, Resident #317 lying in bed with his face slightly protruding from under the sheets. He had a grimace on his face and could be heard saying oh shit intermittently. Resident #317 said he had not received his pain medications Methadone, Oxycodone and Hydrocodone/Acetaminophen since the morning of his admission (09/05/23) and reported pain at a 10 out of 10. Resident #317 said he had not been offered or received any alternative pain medications like Tramadol or Tylenol #3. In an interview on 09/06/23 at 08:30 AM, LVN A looked at Resident #317's MAR and said the resident did not have any orders for alternative pain medications and he had not been offered any alternatives. She said Resident #317 had orders for PRN Hydrocodone/Oxycodone and scheduled Methadone and he had not received them since he admitted to the facility yesterday. In an interview on 09/06/23 at 08:48 AM, the Pharmacist said Resident #317 had not received his Hydrocodone, Methadone and Oxycodone because they pharmacy was pending a prescription so NP A was notified that a triplicate prescription was necessary. He said that as of that moment the pharmacy had not received an electronic prescription. He said in Texas LTC facilities are allowed to call in/fax in emergency CIIs but nothing had been sent in at the time of our conversation. In an interview on 09/06/23 at 09:02 AM, the DON said when a resident arrives at the facility the admitting nurse must reconcile the medications with the NP and once confirmed the orders are entered into the EMR. She said if a resident has orders for a narcotic medication, the information is provided to the NP and the provider will have to send an eScript while non-controlled substances can be found in the stat kit (emergency medication dispensing system). The DON said if the pharmacy received a medication order before 06:00 PM the medication would be delivered on the same day, but if the order arrives later the medication can be sent to the facility as a stat delivery. In an interview on 09/06/23 at 09:10 AM, NP A said the medical director should have sent the order for Resident #317's medication to the pharmacy. She said since the medication had not arrived at the facility Resident #317 should be offered appropriate alternatives like Tramadol 50 mg and Tylenol #3 should be offered based on the resident's pain. NPA said based on Resident #317's previous pain medication use plain Acetaminophen is not appropriate coverage for his pain. She said she saw the resident yesterday as he arrived at the facility and he was not experiencing him pain at the time. When the surveyor notified NP A of Resident #317's reported pain at 10 out of 10 NP A said that was the first she had heard of the resident experiencing pain. NP A said she would contact the Medical Director to follow up on Resident #317's prescriptions. In an interview at 09/06/23 at 12:25 PM, the DON said Resident #317 had been offered pain medications this morning because he was reporting pain at 10 out of 10. She said he was offered Tramadol but he declined. When asked if Resident #317 had an active order for Tramadol in this system, she said not because the order was just received from the NP so nursing staff had not had the chance to enter it into the EMR. Record review of the facility policy titled 'Medication Reconciliation' revised 11/14/16 revealed, medications reconciliation should be performed every time a patient is admitted to a facility. Record review of the facility police titled Medication Orders with no revision date revealed, the following steps are initiated to complete documentation: clarify the order, enter orders on the medication order and receipt record, call (or fax) the medication order to the provider pharmacy. Accept verbal orders for schedule II medications only in an emergency, to be followed with a written order from the prescriber within (72) hours. The Pharmacy will need to talk directly to the physician on all Emergency Schedule II medication orders. On 09/06/2023 at 4:20 PM the Administrator was notified of the IJ due to the above failures. The IJ template was provided and a plan of removal (POR) was requested at that time. The following plan of removal was approved on 09/07/23 at 03:58 PM and read: IJ Component: F755 Pharmacy Services: Facility failed to acquire and dispense Oxycodone, Methadone, and Hydrocodone as ordered upon admission for resident #317. Facility failed to enter an order for alternative pain medication for resident #317. Facility provider failed to submit a prescription to the pharmacy for resident #317. Facility failed to monitor Resident #317's pain level while waiting for delivery of pain medication. Immediate Actions: 1. Resident #317 received pain medication on September 6, 2023 at 12:30pm. 2. Pain assessment was completed and documented on September 6, 2023 at 5:33pm. 3. Change of condition (Pain SBAR) for resident #317 was assessed and documented on September 6, 2023 at 5:40pm. 4. Resident #1's Physician was notified of resident's pain on September 6, 2023 at 5:41pm Facility Plan to ensure compliance: 1. Abuse and Neglect policy in-service initiated on 9/6/23. The Regional Compliance Nurse and Area Director of Operations provided in-service to DON, ADON, and Administrator. DON/ADON will in-service facility staff thereafter. 2. Receipt of Pain Medication orders in-service initiated on 9/6/23 to include ensuring pharmacy has received the order and verifying that the required items (i.e Script) was received by pharmacy. The Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance for this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 3. Notifying physician of estimated timeframe to get medications in-service initiated on 9/6/23. The Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance for this procedure as of 9/7/23. Charge nurses will be in- serviced as needed thereafter. 4. Notifying pharmacy of new orders in-service initiated on 9/6/23 to include notifying pharmacy of any new order, including pain medication, received after 4pm. Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance with this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 5. Contacting Physician for Alternative Pain Medication that is appropriate based on the resident's pain needs in-service initiated on 9/7/23 to include obtaining a new order for an available pain medication from the Stat-safe (facility's emergency medication kit). Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/7/23. DON/ADON will in-service charge nurses to ensure compliance with this procedure by end of day on 9/7/23. Charge nurses will be in-serviced as needed thereafter. 6. Offering prescribed alternative pain medication in-service initiated on 9/6/23. Regional Compliance Nurse in-serviced DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance with this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 7. Pain assessment in-service, to include verbal and non-verbal signs of pain and reporting pain to provider (NP/MD) in-service initiated on 9/6/23. Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/6/23. DON/ADON have in- service direct care staff to include CNAs, CMAs, and Charge Nurses (LVN/RNs) in person and/or by phone to ensure compliance with this procedure as of 9/7/23. 8. Charge Nurses will utilize the skilled nurse's notes, SBAR, and/or other routine follow- up documentation that contains a Pain Assessment element in the EMR the facility's electronic medical record (EMR). 9. Charge Nurses will notify practitioner of pain not controlled adequately on current treatment plan. If physician's recommendations do not meet the resident's needs, residents will be transferred to hospital for evaluation and treatment of uncontrolled pain. 10. All nurses not in-serviced on 9/6/23 will be in-serviced prior to their next shift. 11. The Medical Director, was notified by Administrator on 9/6/23 at 5:55pm on the immediate jeopardy citation. 12. An Ad-hoc QAPI meeting was held on 9/6/23 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. 13. A complete audit of medication availability was completed on 9/7/23 to ensure all medications were available, including pain medications. Monitoring: Record review of the facility schedule revealed, the facility had 2 nursing shifts 06:00 AM to 06:00 PM day shift and 06:00 PM to 06: 00 AM night shift. Monitoring involved interviews with both day shift and night shift staff. In an interview on 09/08/23 at 12:30 PM, LVN E said he received training on neglect approximately a week ago. He said he was trained on pain management, new admission orders on 09/05/23. He said the training addressed escalating uncontrolled pain to the MD. LVN E said most of the time the facility does not have medication on hand residents who admit to the facility with CII medications so it is important to ask for an alternative. He said if a medication had not arrived from the pharmacy nursing staff must notified the MD for an alternative medication or a stat order. LVN E said plain Acetaminophen is not an appropriate alternative for residents who are not opioid naive, so nurses should ask the provider for Tramadol or Tylenol #3. He said pain can be assessed by asking a resident to rate their pain on a scale of 0-10 or assessments of facial expression, body postering for those that are non-vocal, He said there is no EMR related task to assess a resident's pain but nurses should ask about pain pre and post scheduled and PRN medications. LVN E said the efficacy of a pain medication is measured by asking for a pain assessment 1 hr. after oral pain medication is administered and all reported pain should be documented in the residents' EMR. In an interview on 09/08/23 at 12:27 PM, LVN C said the last time she received an in-service on neglect was last week. She said she recently received training on admission meds, escalation to the MD for unavailable meds and pain assessments. SLVN C said if a resident's pain medication is not available nursing staff must immediately call for an alternative like T tramadol and Tylenol #3. She said resident's should be assessed pre and 1 hour post pain medication administration and the provider should be notified of uncontrolled pain. In an interview on 09/08/23 at 12:35 PM, LVN H said she received an in-service on neglect on 09/08/23. She said she also received training on admission meds, focusing on pain medications, and pain management. She said when a resident admits, a CII prescription should be immediately received and the pharmacy should be contacted for an ETA. LVN H said if the medication is unavailable nursing staff should contact the provider requesting an alternative like Tramadol or Tylenol #3. She said pain should be assess before medication administration and 1 our post administration through visual and verbal assessments. LVN H said if pain was not adequately controlled the resident's provider should be contacted and pain should be documented in the EMR as vitals or in a nursing note. In an interview on 09/09/23 at 12:56 PM, the DON said the facility completed a cart audit to ensure that all residents medications were present as well as audited resident's pain assessments. She said nursing staff are expected to ask resident's for their pain score 0-10 and there are non-pharmacological and pharmacological treatment. The DON said after administering pain medications nursing staff should follow up with the resident in 30 minutes and pain should be documented in the progress notes or daily skilled notes. The DON said nursing staff are not asking every resident about pain but only does on a pain management program. In an interview on 09/09/23 at 01:18 PM, the Regional Clinical Nurse said the facility has identified a failure in it's pain management system. He said the audits have shown nursing staff were not documenting pain, assessing residents for pain or performing post administration assessments of the efficacy of a medication. The Regional Clinical Nurse said the facility put systems in place to monitor the pain management system. In an interview on 09/09/23 at 07:10 PM, the Medical Records Staff said she received an in-service on neglect, pharmacy services, physician notifications, admissions medications and pain management on 09/08/23. The training addressed acquisition of pain medications for new admissions, getting alternative medications for unavailable medications, completing pain assessments, provider notification of ineffective pain control and documentation of pain in the EMR. In an interview on 09/09/23 at 07:18 PM, LVN F said she received training on neglect, pharmacy services, physician notifications, admissions medications and pain management a couple of days ago. She said the training addressed the acquisition of pain medications, use of alternatives if pain medications are not available, notification of providers of unavailable pain medications, completion of pain assessments and notification of providers of ineffective pain control. In an interview on 09/09/23 at 07:28 PM, LVN I said received training on neglect, pharmacy services, physician notifications, admissions medications and pain management a couple of earlier in the week. She said the training addressed the acquisition of pain medications, use of alternatives if pain medications are not available, notification of providers of unavailable pain medications, completion of pain assessments and notification of providers of ineffective pain control. Record review of the facility in-service document titled Abuse/Neglect dated 09/06/23 revealed, the Administrator, the DON and ADON A were trained on neglect. The training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility in-service document titled Abuse/Neglect dated 09/06/23 presented by the DON revealed, The following staff were trained on neglect and the training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - LVN C, LVN E, RN E, CNA U, CNA M, CNA T, LVN G, LVN B, MA B, MA A, RN E, LVN C, CNA C, RN A, CNA J, Medical Records Staff, CNA H, Hospitality Aide and CNA I. Record review of the facility in-service document titled Pain Assessments dated 09/06/23 presented by the Regional Clinical Nurse revealed, the Administrator, the DON and ADON A were trained on pain assessments. The training read, pain assessments are incorporated into every assessment completed in the EMR. If pain is triggered and is new onset pain or worsened pain the nurse must follow up and report to the provider. CNAs observing/hearing signs of pain should report to the nurse. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/06/23 presented by the Regional Clinical Nurse revealed, the Administrator, the DON and ADON A were trained on alternative pain medications. The training read, the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if a alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. Record review of the facility in-service document titled New Med Orders dated 09/06/23 presented by the Regional Clinical Nurse revealed, the Administrator, the DON and ADON A were trained on medication orders. The training read, any new order for medications after 4 pm require a follow up phone call to the pharmacy. This is to ensure the pharmacy after-hours is aware of the need for medication and is sent out timely. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/06/23 presented by the DON revealed, the following staff were trained on alternative pain medications and the training read, , the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if an alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. - LVN G, LVN B, Medical Records Staff, RN C, RN A, CNA Q, LVN A and Treatment Nurse B. Record review of the facility in-service document titled Pain Assessments dated 09/06/23 presented by the DON revealed, the following staff were trained on pain assessment and the training read, pain assessments are incorporated into every assessment completed in the EMR. If pain is triggered and is new onset pain or worsened pain the nurse must follow up and report to the provider. CNAs observing/hearing signs of pain should report to the nurse - RN E, LVN E, LVN C, CNA M, CNA T and CNA U. Record review of the facility in-service document titled Pain Medication Orders dated 09/06/23 presented by the DON revealed, the following staff were trained on pain medication order. the training read, when an order for pain medication has been received by the nurse, the nurse must ensure the pharmacy has received the order and verified that required items such as the prescription have been received as well. If unavailable the nurse must notify the provider and DON for follow up and document in the clinical Record. - RN E, LVN E, LVN C. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/06/23 presented by the DON revealed, the following staff were trained on alternative pain medications and the training read, , the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if an alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. -RN E, LVN C and LVN E. Record review of the facility in-service document titled Pain Assessments dated 09/07/23 presented by the Regional Clinical Nurse revealed, MDS Nurse A, CNA G and CNA D were trained on pain assessments. The training read, pain assessments are incorporated into every assessment completed in the EMR. If pain is triggered and is new onset pain or worsened pain the nurse must follow up and report to the provider. CNAs observing/hearing signs of pain should report to the nurse. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/07/23 presented by the MDS Nurse A was trained on alternative pain medications. The training read, the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if an alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. Record review of the facility in-service document titled Pain Assessments dated 09/07/23 presented by the DON revealed, the following staff were trained on pain assessments and the training read, pain assessments are incorporated into every assessment completed in the EMR. If pain is triggered and is new onset pain or worsened pain the nurse must follow up and report to the provider. CNAs observing/hearing signs of pain should report to the nurse. - LVN A, LVN B, LVN C, CNA J, CNA H, MA D, MA B, RN C, RN A, Hospitality Aide, CNA Q, Treatment Nurse B, CNA C and CNA K. Record review of the facility in-service document titled Pain Assessment- Unresponsive to Treatment Plan dated 09/07/23 presented by the DON revealed, the following staff were trained on unresponsive pain management. The training read, if ordered pain modality is not effective the patient should be transferred out to the hospital - LVN G, LVN B, Medical Records Staff, RN C, RN A, CNA Q, LVN A and Treatment Nurse B. Record review of the facility in-service document titled Pain Medication Orders dated 09/07/23 presented by the DON revealed, the following staff were trained on pain medication order. the training read, when an order for pain medication has been received by the nurse, the nurse must ensure the pharmacy has received the order and verified that required items such as the prescription have been received as well. If unavailable the nurse must notify the provider and DON for follow up and document in the clinical Record. - RN E, LVN E, LVN C. Record review of the facility in-service document titled Abuse/Neglect dated 09/07/23 presented by the DON revealed, The following staff were trained on neglect and the training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Cook A, Cook B, Cook C, Dietary Staff A and Dietary Staff B, MDS Nurse A, LVN G, CNA D, Rehab Director, PT A, PTA A, OT A, Floor Tech A, HR Coordinator, Activities Director and Food Nutrition Director. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/07/23 presented by the DON revealed, the following staff were trained on alternative pain medications and the training read, , the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if an alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. - LVN H, LVN B, Medical Records Staff, Treatment Nurse B and LVN G. Record review of the facility Medication Admission Audit dated 09/07/23 signed by the DON revealed, the facility audited all new admissions in the last 30 days and no discrepancies outside of Resident #317 were identified. Record review of the facility Medication Cart Audit dated 09/07/23 signed by the Regional Clinical Nurse revealed, the facility audited all resident medications located in the nursing cart and all discrepancies were addressed. Record review of the facility QI Tool: Pain for 09/07/23-09/08/23 revealed, the DON reviewed residents reporting pain. Record review of the facility Pain Assessment Audit, signed by the Regional Clinical Nurse and the DON revealed, the facility audited all residents receiving pain management for pain assessments. Record review of the facility in-service document titled Abuse/Neglect dated 09/09/23 presented by the DON revealed, The following staff were trained on neglect and the training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - CNA J, CNA L, LVN B, MA C, CNA E, Hospitality Aide, RN B, Medical Records Staff, Treatment Nurse A, CNA T, LVN E, CNA R, Dietary Staff B, and MA E. Record review of an email dated 09/10/23 04:11 PM titled Supporting Documentation for Pain Management revealed, the facility audited all resident's receiving pain management and interviewed them about the efficacy of their pain management regimen. The facility identified the following residents with new issues with pain: Resident #10, Resident #25, Resident #29, Resident #34, Resident #35 an Resident #38. The Adminis [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision, a safe, clean and homelike environment and assistance devices to prevent accidents for one (CR#1) of seven residents reviewed for accidents, hazards, and supervision. --The facility failed to adequately supervise CR#1 who was found to have 2 fractures of unknown origin. --The facility failed to provide adequate supervision for CR#1 who was cognitively impaired and had a history of falls and resulted in multiple falls with injuries including a right acetabular fracture (break in ball and socket hip joint) on 2/20/23 and back pain on 2/5/23 and the facility did not make any changes to the interventions for CR#1's Care Plan for each fall. --The facility failed to provide adequate care and supervision for CR #1, who was wheelchair bound, when CNA A pushed his wheelchair over a large section of missing floor tiles causing CR#1 to fall from the wheelchair. --The facility failed to keep the facility tiled floors in good repair to prevent falls. --The facility failed to determine the causative factors of the falls and address those factors as indicated in the care plan. Findings included: Record review of CR#1's face sheet dated 2/27/23 admitted [DATE] revealed a [AGE] year-old male with congestive heart failure (heart not pumping blood well), hypothyroidism (thyroid fail make enough hormone), Type 2 diabetes mellitus (blood sugar), obesity, asthma, gastro-esophageal reflux disease (acid reflux), pneumonia, hyperlipidemia (high cholesterol), Down syndrome and bradycardia (slow heart rate). Record review of CR#1's Care Plan dated 1/13/23 revealed CR#1 was a risk for falls related to impaired cognition, impaired mobility, muscle weakness, gait/balance problems, unaware of safety needs, history of falls. Interventions: Anticipate and meet the resident's needs .Ensure that the resident is wearing appropriate footwear when transferring and/or mobilizing in w/c. Follow facility fall protocol. PT evaluate and treat as ordered or PRN. CR#1 has had an actual fall 12/31/22 no acute injuries. Interventions: Continue interventions on the at-risk plan. For no apparent acute injury, determine and address causative factors of the fall. Monitor/document/report PRNx72h to MD for s/sx: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Neuro-checks as ordered. PT consult for strength and mobility. Vital signs as ordered, notify MD for abnormal findings. Record review of CR#1's MDS dated [DATE] revealed Cognitive Patterns BIMS Summary Score of 00 indicating severe cognitive impairment. Functional Status revealed total dependence with one-person physical assist for locomotion on and off unit, toilet use, personal hygiene, walking in room and corridor did not occur, extensive assistance with one-person physical assist for bed mobility, transfer, and dressing. Balance During transitions and walking no activity occurred and CR#1 was not steady, only able to stabilize with staff assistance, needed some help from another person to complete activities for self-care, indoor mobility (ambulation), stairs and functional cognition. Record review of CR#1's local Hospital records including emergency room notes including radiology reports dated 2/24/23 revealed on 2/20/23 at 4:33 p.m. exam of fracture of right Pelvis clinical indication: injury or trauma; Fall . Record review of CR#1's local Hospital records including pain post trauma . dated 2/24/23 revealed on 2/20/23 at 6:24 p.m. In short, patient is a [AGE] year-old male with a past medical history of Down Syndrome, epilepsy and bradycardia who presents status post suspected seizure with fall from bed. During his work-up patient was noted to have a right acetabular fracture, was given IV Keppra for concerns of seizures and was also treated for concerns of multifocal pneumonia. Record review on 12/31/22 at 8 p.m. of CR#1's progress notes written by LPN A revealed Resident was observed laying on the floor of his room between his bed and the window. He was laying on his left side. Resident was asked what he was doing to cause him to fall. He Stated Nothing. Checked for injuries. No apparent injuries. No c/o pain or discomfort. Resident denies pain or discomfort. He stated, I'm okay. Assisted him back to bed and gave him his call light and told him to use it for help. Neuro checks, NP notified of the fall. Resident's RP notified. No distress. Resident is stable. Record review of CR#1's progress notes dated 1/16/23 at 4:50 p.m. written by Charge Nurse A revealed, Resident was being wheeled to dining room by assigned CNA and according to the CNA, the wheelchair got cut on cracked floor and resident fell out the wheelchair . Resident according to CNA A, resident did not hit his head Resident unable to say what happened due to intermittent confusion. Head To Toe Assessment done with no visible injury noted. Resident denied any pain or discomfort and moved all extremities to command. Resident able to assist himself off the floor. NP, RP, and the DON all notified. Record review of CR #1's Nurse Practitioner Progress note dated 1/20/23 at 7:02 a.m. revealed History and Presenting Illness: Sitting in wheelchair at nursing station, alert and oriented x 1-2, follows commands, able to make some of his needs known .Sustained fall 1/16, no visible injuries, no head strike . Record review of CR#1's Nurse Practitioner Progress note dated 2/7/23 at 10:25 a.m. revealed History and Presenting Illness: Sitting at nursing station, follows commands, able to make some of his needs known, history of intellectual disability .Sustained a fall on 2/5, unwitnessed, Patient saying ouch when B lateral lower back is being touched, no bruising, no other visible signs of injury noted, denies any acute concerns or complaints, continue current medical management . Record review of CR#1's Nurse Practitioner Progress note dated 2/9/23 at 6:35 p.m. revealed History and Presenting illness: lying in bed, sleeping, arousable to voice, able to make some of his needs known, history of intellectual disability, incontinent of bowel and bladder, wearing a brief, required assistance with all ADL's with one staff assist, sustained a fall on 2/5, unwitnessed, x-rays not performed, nursing to re-order, denies any acute concerns or complaints, continue medical management .s/p fall 2/5 complained of back pain, no midline tenderness, x-ray T/L spine, re-ordered and continue with Tylenol prn . Observation on 3/8/23 at 10:40 a.m. of CR#1's bedroom revealed the bed was not made and it was in low position. The call light was observed to be pinned to the bed and there was no fall mat. Observation on 3/8/23 at 11:45 a.m. revealed on 200 Hall by room [ROOM NUMBER] and 227 on Station 2 the entire design section of the tile was missing from the concrete floor and on another designer tile near room [ROOM NUMBER] revealed a small part of the design was missing causing an indentation in the concrete floor. Observation by main dining room revealed there was an indentation and break in white tile floor at the door and throughout the middle of the hallway right next to the dining area. This Surveyors cart did stumble passing over the broken tile. In an interview on 3/8/23 at 11:47 a.m. with Charge Nurse A she stated CR#1 had a seizure and that is why the facility transferred CR#1 to the hospital on 2/20/23 at 5:01 p.m. When Charge Nurse A was asked about the missing part of the middle of the designer tile floor by room [ROOM NUMBER] and another hole in the tile by room [ROOM NUMBER]. Charge Nurse A stated the holes have caused falls, but the facility was trying to fix it. Charge Nurse A stated CR#1 had a fall and she was working that day and she was the nurse. Charge Nurse stated CR#1 always sits up and CNA A was pushing him to dining room and CR#1's wheelchair was caught on the first hole that she saw and CR#1 slid to the floor on 1/16/23. In an interview on 3/8/23 at 12:08 p.m. with Charge Nurse B she stated CR#1 fell on Station 2 in the section where the tile is missing, and CNA A was pushing him in his wheelchair. Charge Nurse B stated when the CNA got to that point where the design was missing in the floor the wheelchair dipped and she was here at the facility that day. Charge Nurse B stated CR#1's Responsible Party came to the facility and looked at the spot in the floor. Charge Nurse B stated the CNA caught CR#1, but he did fall. Charge Nurse B stated the fall happened in January or February 2023. In an interview on 3/8/23 at 12:39 p.m. with the Maintenance Director he stated he had all the parts for tile that came off the floor and he needed to get some glue to get it all glued to the floor. The Maintenance Director stated the facility was using a type of floor steam cleaning machine and it sucked the water up and it picked a few of the floor parts off and it was on his list to put them back on the floor as we speak. The Maintenance Director stated he needed one more piece for the other section of the tiled floor. He stated the facility was trying to match the tiles on the floor in front the dining room. The Maintenance Director stated the floor had been here since the building had been up. He stated that he spoke to his last Supervisor before the new company took over and they were supposed to be pricing the tiles. The Maintenance Director stated now he has a new manager that he is speaking to and he was just beginning in his position and he has to get back with him. The Maintenance Director stated no one reported any incidents or injuries that he knows of for the floor, but he knows they need to get the floor fixed. The Maintenance Director stated no one told him about CR#1 falling there. This is his first-time hearing about someone falling. This is shocking and he has been here for a year. The holes are getting bigger and bigger. He cannot make a call yet until they tell him who to contact. In an interview on 3/8/23 at 1:02 p.m. with the DON she stated on 2/20/23, CR#1 was sitting in the wheelchair at the Nurses station with Charge Nurse C and he stepped away from the station to assist another resident. LVN B was sitting at the Nurses Station, and she said it appeared as if CR #1 was having a seizure so she yelled for assistance and Charge Nurse C retuned and ADON A went to get one of the PTA and they took CR#1 from the wheelchair and transferred CR#1 to his bed because he was somewhat lethargic so to prevent injury they transferred him from wheelchair to the bed. EMS was called, the physician and the responsible party. Charge Nurse C and PTA transferred CR#1 to the bed. The DON stated CR#1 is a short man but was really [NAME] up top Charge Nurse C and PTA had his top and ADON A had his legs. The DON stated they removed the arm from the wheelchair, and they slid him over to the bed and paramedics arrived and they took him to the local hospital and did a couple of x-rays the next day found CR#1 had a fracture 2/20/23 at around 4:30 p.m. The DON denied CR#1 had a fall from the bed. The DON stated CR#1 was a Down Syndrome patient and it took him some time to get used to being around the facility. CR#1's recent fall prior to that was 2/5/23 where he was found sitting on the floor at 4:22 a.m. and they notified CR#1's Responsible party and continued neuro checks. The fall that occurred on 1/16/23 was when CNA A was wheeling CR#1 to the dining room and the stars in the tile floor and one piece of a second tile was missing and the wheelchair stopped, and CR#1 fell to the floor. In an interview on 3/8/23 at 1:36 p.m. with the Administrator she stated there were two holes in the tile floor on station 2 and one hole in the tile floor by therapy. The Administrator stated in January the floors were damaged and the tiles on Station 2 came up and the floors across from therapy were chipped since she had been the Administrator and she has been here since May 2021, but no one has fallen in those. The Administrator stated she and the Maintenance Director had spoken with their environment management team regarding the floors in the past and this was a year ago. The Administrator stated she was not aware CR#1 fell there. She stated prior to CR#1 falling, she mentioned on a few occasions that the tiles were missing by Station 2 and the tiles had a chip in them by therapy because it is unsightly. The Administrator stated she mentioned it to the Environmental Service Team, and she had the Maintenance Director to purchase tiles so they could fix them. She stated the tiles the Maintenance Director purchased were not the same color and they were instructed by Corporate not to lay the tiles down and the Corporate maintenance team said they would try to match the tiles up for them, but it did not happen prior to the Nursing Facility being sold. The Administrator stated now they have a new team that was here and they are high lighting all the areas that need to be fixed to beautify the center and make sure it was a safe place for visitors and staff. The Administrator explained that she does not know why she did not know CR#1's fall on 1/16/23 was from the tile, but she just spoke with the new boss, and she sent him photos of the floor and he gave her instructions to get the floor fixed right away. The Administrator stated the DON was made aware so she would have expected the DON to tell her. The Administrator stated the hospital did call the facility and asked them if CR #1 had a fall and they informed the hospital that CR #1 did not have a fall on 2/20/23. In an observation and interview on 3/8/23 at 2:30 p.m. with CR#1 at local hospital he was observed lying in bed sleeping deeply. CR#1 stated that he fell a long time ago and he told the facility that he had pain a long time ago. CR#1 stated he could not remember when he fell . In an interview on 3/8/23 at 2:45 p.m. with local hospital RN she stated CR#1 had an acetabular fracture. The RN stated CR #1 stated he was in pain, so the hospital did x-rays to see why CR #1 had pain. The RN stated the local hospital did call the facility to ask if CR #1 had a fall in the facility. In an interview on 3/8/23 at 3 p.m. with local hospital Charge Nurse she stated per EMS CR #1 was transferred to the hospital for seizures, no due to a fall, but the hospital diagnosed CR #1 with multiple fractures. The Charge Nurse stated CR#1 had a right acetabular and right pubic Ramus fracture. The Charge Nurse stated at first glance, they did not see the fracture, but CR #1 said he was in pain from his right thigh, and they did find osteoarthritis. In an interview on 3/9/23 at 8:41 a.m. with PTA he stated CR#1 was sitting in his wheelchair on 2/20/23 slumped back and they just lifted him up and put him in the chair and PTA stated he was behind CR#1 and grabbed his two shoulders and the other Nurses grabbed CR#1's hips and legs and moved him over to his bed. The PTA stated the transfer was appropriate for CR#1 being that he was dead weight. PTA stated CR#1 did therapy with him and CR#1 walked maybe 20 feet, always got tired and wanted to sit down. PTA stated CR#1 with walking he needed guidance with turning and he does not know if he could see far enough. PTA stated most of the time when walking with CR#1, they walked straight so they did not have to go around things. In an interview on 3/9/23 at 9:10 a.m. with the Administrator she clarified that on 1/16/23 CR#1 fell from the wheelchair and staff did not assist him to the floor. She stated on 2/5/23 CR#1 fell again when he was observed in his room on the floor. The Administrator stated when CR#1 had the fall on 2/5/23 he complained of back pain and the NP ordered an x-ray of CR#1's spine on 2/14/23. In an interview on 3/9/23 at 10:17 a.m. with CNA A she stated she was pushing CR#1 in his wheelchair to the dining room and while they were on Station and the tile was missing in the floor and CR#1 fell out of the wheelchair and CNA A got the nurse on 1/16/23. CNA A stated she was not able to brace CR#1's fall. CNA A stated she hit the bump in the tile floor and CR#1 went out the wheelchair. In an interview on 3/9/23 at 10:44 a.m. with the DON she stated CR#1 admitted to the facility on [DATE] and the facility had general interventions that they normally do in place for CR#1's Care Plan. The DON stated CR#1 fell on [DATE], 1/16/23 and 2/5/23 and for the first fall on 12/30/22, CR#1 was in bed and fell on to the floor next to the bed with no injuries so they reassessed the interventions they currently had and said they would continue the same interventions for the Care Plan. The DON stated CR#1 had the second fall on 1/16/23 and it was witnessed by CNA A when CR#1 fell from the wheelchair while she was pushing him. CR#1 did not hit his head and there was nothing ongoing from the fall. The DON stated they reassessed the care plans and decided not to make any changes again. The DON stated she alerted the Maintenance Director about the floor on 1/18/23. On 2/5/23 CR#1 had another fall at 4:30 a.m. and they reviewed the Care plan again to make sure what they had in place was appropriate and they did not make any changes to the care plan again. The DON stated IDT Team reviews the Care Plans and that consists of the DON, Administrator, MDS Nurse, Therapy, and Social Services. Record review of Facility's policy on Falls/Ambulation Difficulty dated 2003 revealed More than half of falls are related to medically diagnosed conditions. Many residents will have more than one diagnosed condition. In the event that the conditions are not curable, relief of symptoms and treatment of symptoms may reserve certain aspects that may have a significant impact on functional mobility of the resident. Risk factors should be assessed upon admission and thereafter as necessary .Risk factors include: 1. Level of consciousness/mental status, 2. history of falls 3. Ambulation/elimination status 4. Vision status .Look for uneven surfaces, slippery floors, obstacles in the walkway, or absence of handrails. Repair uneven surfaces as soon as possible. Post signs and clean spills on surfaces immediately . Record review of facility's policy on Abuse/Neglect dated 2003 revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .

Based on observations, record review and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent accidents for 3 of 8 residents (R#1, R#2, and R#3) reviewed for accidents The facility failed to prevent Resident#1 from eloping from the facility on 8/20/22. Resident #1 eloped from the facility around 7:30 PM when EMS arrived at the facility. Resident #1 let the EMS personnel into the building and then eloped from the facility. Resident #1 was not found until Monday, August 22 at 10:30 AM, 4 miles from the facility. Resident #1 had crossed a heavily trafficked four-lane street. The facility failed to have a working wander guard system to protect the 3 residents (R#1, R#2, and R#3) who have current physician ordered wander guards due to identified wandering behaviors. An Immediate Jeopardy (IJ) situation was identified on 08/24/2022 at 3:45 PM. While the IJ was removed on 08/28/2022, the facility remained out of compliance at a scope of a isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The failures placed all residents at risk of unsafe environment without proper supervision. Findings include: Record review of Resident #1's face sheet dated 8/24/22 revealed a [AGE] year-old male, who admitted to the facility on [DATE]. His diagnoses include alcoholic dementia (impaired memory) kidney failure, altered mental status (change in mental function) and metabolic [CONDITION(S)] (problem in the brain). Record review of Resident #1's MDS dated [DATE] indicated a BIMS of 5, indicating cognitive impairment. Resident #1 also required limited assistance with ADLS. Record review of Resident #1's care plan dated 5/26/22 indicated he had impaired cognition and required assistance from one staff member. Further review of Resident #1's care plan indicated he was an elopement risk and wanderer, had history of attempts to leave facility unattended and impaired safety awareness. Resident #1's interventions included checking placement of wander guard, distract resident from wandering by offering pleasant diversions, activities and television. Record review of Resident #1's elopement risk assessment dated [DATE] read in part, Resident is at risk for elopement due to cognitive status and ability to ambulate. Wander guard place to right ankle. Record review of Resident #1's August 2022 physician orders indicated Resident #1 was to have a wander guard on at all times due to risk of elopement. Further review of physician's orders indicated staff are to monitor the wander guard each shift to ensure proper function. Staff were to be documented 0 if it was not working or alarming. Record review of Resident #1's August 2022 MAR revealed there were 0's in place for wander guard effectiveness on August 10, 11, 12, 13, 14, 16, 17, 19, 20, 22 and 23rd. No documentation indicating any intervention was done. Record review of Resident #1's nursing note dated 8/20/22 written by LVN A read in part, .At approximately [8:15 PM] [Resident #1] was searched for to administer his medication. However, was unable to locate him. In depth search of inside facility as well as perimeter was conducted . Record review of Resident #1's nursing note dated 8/22/22 at 3:30 PM written by LVN A read, Resident has been located, safe and sound. Record review of Resident #1's nursing note dated 8/22/22 at 11 AM written by Administrator read in part, Writer followed up with RP . regarding need for placement to secure unit due to exit seeking behavior. RP acknowledged understanding. RP stated he will presently look for a memory care unit . Writer informed of current plan of care which included [one-to-one] monitoring until alternate placement is found for resident . Record review on 8/23/22 at 1:15 PM of maintenance door checked from 7/11/22 through 8/11/22 indicated each door was working properly. No issues noted. In an interview on 8/23/22 at 10:48 AM with CNA B, she said on 8/20/22 around 7:30 PM she saw Resident #1 standing at the nursing station. She said during that time, the residents were watching TV. She said she had just started working at the facility and was training with another CNA that was assigned to Resident #1. She said during the rounds, unable to recall time, she heard LVN A say they were looking for Resident #1. CNA B said it was about 45 minutes after she had seen him that the nurse said Resident #1 was missing. CNA B did not state she knew if Resident #1 was an elopement risk. In an interview on 8/23/22 at 11:03 AM with LVN F, she said she was to check residents pretty frequently on her hall as they often walk around. She said for residents who are elopement risk, they have orders in the computer to check the residents and their wander guard bracelets every shift. She said they have a wand that they will use to check the wander guard bracelets. If the wand lights up green, it is working properly, but if it is red, then it needs to be replaced. She said staff are to notify the DON if the wander guard is not working properly and the DON will provide the staff a new wander guard for the resident. She said they also should be documenting if the bracelet is working or not. LVN F said if a resident elopes staff are to immediately start looking for the resident inside and outside of the building. In an interview on 8/23/22 at 11:20 AM with the Maintenance Director, he said he was to check all doors once a week for the alarm to be working properly and to make sure the wander guard system was working. He said he would document on his maintenance log if the doors passed or failed. He said if it is not alarming properly, he will try to fix it or call out a company to come service the doors. He stated the last time he checked the doors was on 8/18/22 and they were working properly. In an interview on 8/23/22 at 11:27 AM with CNA C she said she was to sit with Resident #1 during her 6AM-2PM shift due to Resident #1s recent elopement. She said if she had to leave for break, she was to notify another staff member to sit with him. In an interview on 8/23/22 at 12:06 PM with the Maintenance Director, he said he got a call on Sunday evening (8/21/22) from the Administrator stating that the wander guard door wasn't working on the 200-hall. He said he came to the facility, checked all doors and they were working properly. He said he called for the fire safety company to come out to check the doors but did not get an answer. He said the company came out on Monday (8/22/22) to check the wander guards/doors and said they did not see anything wrong with them and they were working properly. The Maintenance Director said at the time of checking the doors on Sunday (8/21/22), he was not aware of Resident #1 eloping. He said he was made aware on Monday (8/22/22) that he eloped. In an interview on 8/23/22 at 12:18 PM with CNA D, she said on Saturday (8/20/22), she worked with Resident #1 on 2-10 shift. She said she arrived at 2pm, did her rounds and dinner. She said she took her break around 7PM and she saw Resident #1 walking around the nursing station. She said when she came back around 7:30 PM another resident was going to the hospital, so she went to assist the nurse with getting that resident ready. CNA D said around 8 PM LVN A asked her if she seen Resident #1 because she could not find him. She said she did not hear any alarms going off and she said she has not known for Resident #1 to elope before and he only required minimum supervision. She said Resident #1 has a wander guard but has not attempted to elope before. CNA D said she went outside, went room to room and started yelling his name. She said she checked the emergency exit doors that they were still locked. She said she there were visitors in the facility, but during that time she was not aware of Resident #1 being missing. She said she asked other stations to help look for him as well, but they were unable to locate him. In an interview on 8/23/22 at 12:24 PM with LVN A, she was the night nurse for Resident #1 and worked 6pm-6AM on 8/20/22. She said when she arrived, she sat at the nursing station, and she saw Resident #1 walking around in the nursing station and was talking to staff and other residents. She said around 6PM the nurses did shift report and she recalled Resident #1 standing at the desk. She said he was standing at the desk for a while. She said he was talking to the nurses and telling others that he wanted to go home, which was the first time she ever heard him saying that. LVN A said every 15-30 minutes she would scope the area and check each resident to see their location. She said close to 8 PM she was sending another resident out to the hospital and CNA B and CNA D were assisting in the room while EMS was there. She said after she completed that she went to go look for Resident #1 to give him his medication. She said Resident #1 wanders often and you have to be on guard with him. LVN A said when she went back to the cart, she was getting ready to go to Resident #1's room, and when she went to his room, she didn't see him. She said she started going down the hallway and checking for his common areas that he would be at. She said Resident #1 was unable to be located and the staff started looking for him all over the building and some staff went outside. She said after several minutes of not being able to locate him, she called 911 and the Administrator. LVN A said she did not hear any door alarms going off and while her and CNA B and CNA D were in the room assisting another resident, no one was on the hallway monitoring the other residents. In an interview on 8/23/22 at 1:30 PM with the Administrator, she said she was told by LVN A that Resident #1 was last observed at the nursing station by staff around 7:30 PM. She stated during her investigation, she spoke with one of the EMS staff that came to the building and the EMS staff informed her that Resident #1 was at the door and when EMS came in, he went out. She said EMS informed her that she was not aware that Resident #1 was a resident and thought he was a family member of another resident. The Administrator said around 8/:10 PM, LVN A began looking for Resident #1 to administer his medications but was unable to locate him. She said the staff began looking for Resident #1 inside the building and in surrounding areas outside of the facility. She said the police were involved with looking for the resident and she also looked at his last known address for Resident #1 but was unable to locate him. The Administrator said she conducted audits of the doors and wander guard system to ensure they were functioning properly on 8/21/22 and asked the Maintenance Director to come fix the door on 200-hall as it was not locking properly. She stated she was not aware of the door not working properly until she checked it during her rounds. She said Resident #1 was found two days later (Monday, 8/22/22) by the police. She said Resident #1 was taken to the hospital to be assessed before being brought back to the facility and was placed on one-to-one supervision once he arrived at the facility. She stated Resident #1's family members were made aware that he was found and his plan of care was updated to reflect the elopement and will continue to one-to-one until secure placement is found. The Administrator stated staff are to check every day, every shift for the functioning of the wander guard bracelet and to make sure it is on each resident. She said the maintenance director is to check the doors weekly and perform any maintenance that is needed. In an interview on 8/23/22 at 2:11 PM with Resident #1 he said he walked to his old house a couple nights ago because he had to go home. Resident #1 said he left so that he could also go back to work. In an interview on 8/23/22 at 2:45 PM with the DON, she said on 8/20/22 she was notified by the Unit Manager that Resident #1 had eloped. She said staff immediately began looking for the resident in the facility and in the community. She said in interviewing LVN A (on 8/20/22), she said she last saw Resident #1 around 7:30 PM. She said LVN A went to go administer Resident #1 medication around 8 PM and was unable to locate him. The DON stated when she arrived at the facility on Saturday night (8/20/22) she checked the wander guard alarms with the wand to ensure they were all working properly, and they were. She said she started educating the staff on Saturday about the elopement policy and re-educated the nurses on how to check the wander guard system. She said if the wander guard was not working or not in place, the staff are to notify her immediately and she will provide them with a replacement. She said upon Resident #1 returning, his wander guard was checked to make sure it was working and it was. The DON said staff should be rounding frequently to ensure the residents are safe and inside the facility. The DON stated she was responsible for training staff on resident elopement and elopement drills. In an interview on 8/23/22 at 3:30 PM with community partner, they said around 6:30 AM on Monday (8/22/22), Resident #1 was sitting down on the ground by their office. He stated Resident #1 was not able to get up by himself and was scooting himself on the ground trying to get into the building. The community partner stated he assisted Resident #1 up and into a chair in the office. He stated Resident #1 was visibly confused and kept repeating himself, which prompted him to call 911. The community partner stated he was not aware that Resident #1 was missing from nursing facility. An attempt was made various times during survey to speak with EMS personnel regarding Resident #1. Call was not returned prior to survey exit. Observation on 8/23/22 at 10:00 AM of the front entrance of the facility revealed a busy four-laned street. There were four highly trafficked lanes going parallel to the facility. Observation on 8/23/22 at 11:30 AM of Resident #1 sleeping in bed. CNA C was sitting with him. Observation on 8/23/22 at 1:07 PM of door by alarm by 100-hall being tested by the Maintenance Director revealed the door alarm was not working. Wander guard was brought to the door and right on alarm system and no sound was noted. Wander guard was waved at the door and past the wander guard alarm and no alarm was heard. Observation on 8/23/22 at 1:10 PM of 200-hall door, zone one, door was tested with wander guard alarm. When wander guard was waved at the door and walked through the door with wander guard, the door alarm did not go off. Resident #2 Record review of Resident #2s face sheet dated 8/23/22 revealed an [AGE] year-old male, who admitted to the facility on [DATE]. His diagnosis included Alzheimer's disease, chronic obstructive pulmonary disease (damaged airway of the lungs) and hypertension (high blood pressure). Record review of Resident #2's MDS dated [DATE] indicated a BIMS of 10, indicating mild cognitive impairment. Resident #2 also required limited assistance with ADLS from one staff. Record review of Resident #2's care plan dated 6/3/22 indicated he had impaired cognition and required assistance from one staff member. Further review of Resident #2's care plan indicated he was an elopement risk and wanderer with impaired safety awareness. Resident #2's interventions included checking placement of wander guard and monitor for effectiveness of wander guard. Record review of Resident #2's August 2022 physician orders indicated an order written dated 4/8/22 indicating Resident #2 was to have a wander guard on at all times due to risk of elopement. Further review of physician's orders indicated staff are to monitor the wander guard each shift to ensure proper function. Staff were to be documented 0 if it was not working or alarming. Record review of Resident #2's August 2022 MAR revealed there were 0's in place for wander guard effectiveness on August 1, 3, 4,5,6,8,10, 15, 17, 21 and 22nd. The 0's were placed by several nurses working with Resident #2. No documentation indicated any follow up was done to address the wander guards not working properly. Record review of Resident #2's nursing note dated 6/11/22 written by LVN F read, Staff reported that resident went past alarm and wander guard did not alarm. This nurse checked wander guard that is on resident left ankle with wander guard device and current wander guard on resident left ankle is functioning good . [sic] Observation on 8/23/22 at 2:07 PM of Resident #2 being to the door by CNA E to test the door alarm on 200-hall. The door alarm did not go off when Resident #2 went through the door, wearing a wander guard bracelet. When the resident was brought back into the facility, the door alarm did not go off. Resident #3 Record review of Resident #3's face sheet dated 8/23/2022 revealed a [AGE] year-old-male, who admitted to the facility on [DATE]. His diagnosis included dementia, hypertension (high blood pressure), [CONDITION(S)] and chronic fatigue (extreme tiredness). Record review of Resident #3's MDS dated [DATE] indicated a BIMS of 8, indicating mild cognitive impairment. Resident #3 also required limited assistance with ADLS from one staff. Record review of Resident #3's August 2022 physician orders indicated an order written dated 6/28/22 indicating Resident #3 was to have a wander guard on at all times due to risk of elopement. Further review of physician's orders indicated staff are to monitor the wander guard each shift to ensure proper function. Staff were to be documented 0 if it was not working or alarming. Record review of Resident #3's August 2022 MAR revealed there were 0's in place for wander guard effectiveness on August 2, 4, 5, 6, 8, 10 and 21, 2022. The 0's were placed by several nurses working with Resident #3. No documentation indicated any follow up was done to address the wander guards not working properly. Observation on 8/23/22 at 1:14 PM of Resident #3 at the 200-hall door with wander guard bracelet on. Door alarm not sounding. Observation and interview on 8/23/22 at 2:00 PM with the Administrator, she tested the door alarms and said it is supposed to sound when a resident goes through the doors with a wander guard bracelet on. Resident #3 was used as a demonstration and when the staff took him through the door, wearing wander guard bracelet, the alarm did not go off. The Administrator said the door alarm should go off when residents go through the door. She said each shift the nurses are to check for the wander guard to be working and for the bracelet to be placed on the residents. In an interview on 8/23/22 at 2:05 PM with CNA E, she said the wander guard alarms goes off when residents are sitting too close to the door. She said sometimes when staff are leaving the shift and Resident #3 is sitting too close to the door, the alarm will go off. CNA E said the nurses are to check the wander guards and if the CNAs notice the bracelet is not on a resident, they are to notify the nurse immediately to have it replaced. The Administrator was notified of the Immediate Jeopardy on 8/24/22 at 3:45 PM and the IJ template was provided. The Plan of Removal was accepted on 8/26/22 at 2:28 PM and included the following: 8-24-2022 Immediate Action: Actions taken to immediately ensure there were no other residents in jeopardy or threat of harm included assuring all other residents were present and accounted for on the night of 8/20/22. The Administrator and Director of Nursing Services searched each resident room and common area in the center. Additional audits included medical record reviews and observations by the Director of Nursing Services and Director of Clinical Operations of all residents identified at risk for elopement to assure proper placement and function of wander guards with up-to-date care plans. No negative findings resulted from the audit. The audit was completed on 8-20-2022 by the Director of Nursing Services and Director of Clinical Operations. Resident # 1 was successfully located and returned to the center after being assessed in theER on [DATE]. Nursing staff completed a full body assessment upon his return to the center. His care plan was reviewed and updated to include his recent exit seeking behavior. Upon his return, we placed him on 1:1 monitoring until such time that we can assure that he is no longer actively exit seeking. Staff will redirect from exit doors as needed. Patterns of wandering will be monitored. An activity referral was initiated to enhance participation and diversion. An update photo was taken and placed in the elopement book. A care plan conference was conducted with the Responsible Party (RP) regarding need for alternate placement in a secured unit. The center is currently seeking alternate placement. Until alternate placement is secured, the resident will remain on 1:1. The RP and center staff were updated on the changes in the care plan on 8/22/22. On 8/20/22, an immediate investigation was initiated by the administrator to determine how the resident was able to get outside. 8/20/22- the Director of Nursing Services and Director of Clinical Operations audited the elopement books to assure pictures and care plans were up to date to assure inclusion of all at risk residents. The Centers plan to ensure compliance quickly included: On 8/20/2022- All exits doors and windows were audited by the Administrator. All doors where noted to be secured and functioning properly. On 8-20-2022, an order was placed by the administrator for additional door alarms that enunciate louder. These alarms are scheduled for arrival and instillation by the maintenance director on 8-25-2022. 8/20/22, Elopement policies and procedures were reviewed by the center leadership including the Administrator, Director of Nursing and Director of Clinical Operations. On 8-20-2022, education was initiated by Director of Nursing Services for staff on Elopement guidelines, abuse and neglect prevention, responding to alarms timely with conducting immediate search of grounds and center. The education will be completed by 8-23-2022. Any staff that has not received education by this date will not be allowed to work prior to education. On 8 -22-2022, The Total Fire and Safety Company arrived at the center to perform a complete check of the exit doors and alarms. Documentation was provided to support the proper function of the doors. 8/22/22-Signage was placed on the doors by the Administrator to instruct visitors and others to notify nursing staff prior to allowing residents to exit the building unsupervised. 8/22/2022- the Maintenance Director will check doors daily to assure proper working order. The door checks will consist of checking the functionality of the door alarms with the wander guard alarm wand and include checking the locking mechanism. The documentation of the door checks will be completed by the Maintenance Director and monitored by the Administrator. 8-22-2022, a focused QAPI meeting addressing the findings and corrective action was initiated and completed. The attendance of the Administrator, Director of Nursing, Regional Vice President, Director of Clinical Operations, Medical Director, MDS and Social Services. 8-24-2022, team member(s) will monitor the door 24/7 with a designated staff member to ensure that no one is able to leave without our knowledge. This will continue until new alarms are installed and functioning properly. The monitoring of the door will be captured by the staff member and monitored by the Administrator. 8-24-2022, education continues by the Director of Nursing for staff to include how the wander guard system functions, answering alarms immediately, who to report elopement events t, reporting timelines and need to immediately report a nonfunctioning alarm. Nursing staff will audit placement and function of wander guards daily. The education included identifying and recognizing s/s of resident with the potential of elopement such as verbally expressing wanting to leave the facility, anxious behaviors, restlessness, frequent observations of resident by doorways The education will be documented and monitored for compliance by the Administrator. Additionally, the staff were educated to report exit seeking or escalating behaviors to the Director of Nurses and Administrator. The training will be complete by 08/25/22. Any staff member not trained before this date will be educated prior to working. New staff will be educated in new hire orientation. The medical record documentation of the functionality of the wander guards was reviewed. The documentation requirements were clarified to accurately reflect the proper function of the wander guard system for all 3 residents. This documentation will be reviewed by the DNS starting 08/24/22. Director of Nursing or designee will conduct Elopement drills on different shifts every week times 4 weeks to ensure proper procedure. Elopement drills were started on 08/23/22. These drill will assure staff responds to the alarms promptly and efficiently. Drill findings will be presented in QAPI monthly for a minimum of 3 months. Any negative findings will be corrected immediately. Maintenance and or designee will check doors and alarms daily times 4 weeks to ensure they are functioning properly. Functionality of the doors were started on 08/20/22. Findings will be addressed in QAPI monthly for a minimum of 3 months. Any negative findings will be corrected immediately. 8/25/22- Total Fire arrived to enhance the enunciation of the door alarms down the middle hall so that it can be heard at the nurse station. Door screechers will be installed by the Maintenance Director upon their arrival on 8/25/22. The administrator will monitor and assure 100% compliance with attendance and participation with education. Surveyor Monitored the Plan of Removal as follows: Observations were started on 8/26/22 at 3:00 PM and continued through 8/28/22 at 3:30 PM. Resident #1 was observed at various times and shifts with a one-on-one sitters CNA C, CNA D, CNA H and CNA M. No concerns with supervision noted. Resident #1 appears to be in bed and sleeping on and off throughout the day. All staff documented every 30 minutes what Resident #1 was doing during three shifts. Observations made on 8/26/22 through 8/28/22 at various times of the wander guard doors being tested and were sounding when residents wearing wander guard bracelets were close to the door and when the wander guard went through the doors. The door alarm volume was increased, and all staff responded to door alarm when it rung. Record review of Resident #1's nursing notes revealed nursing staff documenting and also monitoring Resident #1. No issues were observed. Interviews were started on 8/26/22 at 3:00 PM and continued through 8/28/22 at 3:30 PM with staff across all three shifts, including weekdays and weekends. That staff interviewed regarding the plan of removal: LVN A, CNA B, CNA C, CNA D, CNA E, LVN F, CNA G, CNA H, LVN I, CMA J, LVN K, CNA L, CNA M, LVN N, LVN O, Receptionist P, Receptionist Q, Laundry, Social Service Director, Housekeeping, Maintenance, Administrator, Director of Nursing, Assisted Director of Nursing and Unit Manager. All staff interviewed verbalized adequate understanding of plan of removal training received regarding elopement risk and protocol, wander guard documentation, recognizing elopement behaviors, wander guard system, immediately responding to door alarms, location of elopement binders and abuse and neglect. In interviews started on 8/26/22 at 3:00 PM and continued through 8/28/22 at 3:30 PM with ADON, LVN A, LVN F, LVN I, LVN N and LVN O, all stated they have been in-serviced on documenting the effectiveness of Resident #1, Resident #2 and Resident #3's wander guard bracelet. All nurses stated if the wander guard is not working properly, they are to immediately notify the DON and also get a replacement. An extra wander guard bracelet is kept at each nurse's cart to be accessed if the DON is not in the building. In an interview on 8/29/22 at 11:13 AM with the Administrator and the DON, both stated this situation occurred due to someone letting a resident out that they thought looked like a family member. The Administrator stated they have in-serviced staff on elopement protocol and placed signs at the exit doors notifying visitors to not let anyone out of the building. They both stated the alarms have been increased to notify all staff when the door is opened. The DON said she is glad Resident #1 returned safely because the facility is in front of a highly trafficked street and he could have possibly been hit by a car. The DON stated Resident #1 will be discharged to with family on 9/1/22. Record review of the POR binder revealed: A binder kept at each nursing station that showed the residents who are elopement risks, how to place wander guard bracelet and wander guard policy. Signs were placed at all exit doors to instruct visitors and others to notify nursing staff prior to allowing residents to exit the building unsupervised. In-services conducted were Elopement policy and guidelines, abuse and neglect prevention, responding to alarms timely with conducting immediate search of grounds and center. The education was be completed on 8-23-2022. On 8/25/22 in-services were conducted on how the wander guard system functions, answering alarms immediately, who to report elopement events to, reporting timelines and need to immediately report a nonfunctioning alarm. Nursing staff will audit placement and function of wander guards daily. The education included identifying and recognizing signs and symptoms of resident with the potential of elopement such as verbally expressing wanting to leave the facility, anxious behaviors, restlessness, frequent observations of resident by doorways. The staff were educated to report exit seeking or escalating behaviors to the Director of Nurses and Administrator. The facility conducted elopement drills starting 8/23/22 and will continue on weekly. Maintenance will continue to monitor the functioning of the doors and the wander guard system. The fire safety company came to enhance the door alarms to ring down the hallway so it can be heard at the nurses' stations. Policies reviewed were Elopement Policy dated April 2017 and Abuse and Neglect policy dated January 2019. While the IJ was removed 08/28/22 at 3:30 PM and the Administrator was notified, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to the need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 5 of 9 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5 ) reviewed for abuse. - Resident #1 hit Resident #2 on 07/08/21 and pushed Resident #2 on 07/09/21 causing a fall with a head injury. Resident #2 was sent to the hospital to receive treatment. - Residents #3, #4, and# 5 did not feel safe in the facility while Resident #1 resided in the facility. An Immediate Jeopardy (IJ) was identified on 09/17/2021. While the IJ was lowered on 09/20/2021, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of the Plan of Removal An Immediate Jeopardy (IJ) was identified on 09/17/2021. While the IJ was lowered on 09/20/2021, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of the Plan of Removal. These failures placed residents at risk of abuse, neglect, pain, decline in health, and being displaced or hospitalized . Findings Included: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating he had severe cognitive impairment. His speech was unclear. He sometimes made himself understood and sometimes understood others. He required supervision only for walking in the corridor and supervision with set up only when resident moved to and returned from off-unit locations. He had no impairments to upper or lower extremities. He had no physical or verbal behaviors symptoms towards others. Record review of Resident #1's admission MDS dated [DATE] revealed he had physical and verbal behavior symptoms directed towards others that occurred 1 to 3 days and other behavior symptoms not directed to others that occurred 1 to 3 days. Record review of Resident #1's undated care plan printed on 07/29/2021 revealed in part . he had potential to be physically aggressive. The goal: resident will demonstrate effective coping skills and the interventions included, to keep resident away from any resident that tends to cause distress. Monitor behaviors every shift. Document observed behavior and attempted interventions in behavior log. When the resident becomes agitated: intervene before agitation escalates . Resident #1 had potential to be verbally aggressive. The goal: the resident will verbalize understanding of need to control verbally abusive behavior through the review date. Interventions included, give the resident as many choices as possible about care and activities and monitor behaviors every shift . Record review of Resident #1's Physicians Order's from 11/04/20 (admission) to 09/17/21 revealed no changes to the frequency of behavioral management orders since admission: - Order initiated on 11/04/20 and discontinued on 08/02/21 read Behavior Management attempts document aggression, verbal outbursts, and or physical aggression, number of behavior episodes, interventions and outcomes every shift document details in progress note 0= none present, 1= not present. - Order initiated on 08/02/21 and ongoing as of 09/17/21 read: Behavior Management attempts document aggression, verbal outbursts, and or physical aggression, number of behavior episodes, interventions and outcomes every shift document details in progress note 0= none present, 1= not present. Record review of Resident #1's Physicians Orders 11/04/20 (admission) to 09/13/21 revealed: no active, completed or discontinued orders for one-on-one supervision. Record review of Resident #1's facility progress notes dated 07/09/2021 at 6:45 AM, written by LVN A noted, this nurse observed resident exit his room this morning as usual for the coffee cart, this morning another female resident was helping herself to coffee before he could, one on one side the cart and one on the other side of the cart, he called her outside her name, to be exact [OBSCENITY] give it here, let it go, when he did not get his way, he pushed the resident, the other resident lost balance and fell to the floor. Record review of Resident #1's hospital records with the admitted [DATE] and discharge date of [DATE], revealed in part . the patient was having paranoid delusions with the belief that people wanted to harm him, he physically assaulted another resident by knocking her down causing her to hit her head, verbally and physically threatening staff and other residents . Record review of Resident #1's Behavioral Hospital Discharge Summary dated 08/24/21 revealed: Reason for Termination, Other- Patient refused to participate in psychotherapy. Symptoms are being treated with medication .If patient shows the ability to benefit from treatment, he may be referred again for therapy if he remains in or returns to the facility. Record review of Resident #1's July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Clinical Progress Notes revealed resident had at least 19 documented incidents of verbal and physical aggression from 07/30/21 to 09/17/21: 1. Progress Note dated 07/30/21 at 11:48 AM read: Continues to curse both staff and resident out. Continues on contact isolation but comes out often. Unable to reorient resident due to continuous confusion. 2. Progress Note dated 07/31/21 at 06:51 AM read: . resident cursed this nurse shut up b***h, you stupid, go on now, resident cannot be redirected easily. 3. Progress Note dated 07/31/21 at 09:26 AM read: . resident has been verbally inappropriate, saying things like you N*****s need to leave me alone, you stupid b***h, resident came to nursing station . took his pants down and bent over opening his buttocks cheeks exposing himself to staff. 4. Progress Note dated 07/31/21 at 11:33 AM revealed: Resident was adamant about leaving his room, cursing the sitter and this writer out with vulgar language, the resident then said you think I'm playing with you MF, and grabbed the broom from his closet, and [NAME] it back like a bat . 5. Progress Note dated 07/31/21 at 10:21 PM revealed: Patient is coming out of his room instead of staying in isolation as directed. When directed, he screamed at staff and called them name by using B and F words. He even tried to hit one of the nurses, he refused his medication because he said we tried to poison him which is not true. 6. Progress Note dated 08/01/21 at 10:42 PM revealed: Patient kept going to the kitchen disturbing the kitchen crew . while trying to redirect patient he got aggressive and screaming and cursing using B and F words. He even tried to hit writer, he finally calmed down and went to his room. 7. Progress Note dated 08/02/21 at 07:17 AM revealed: Resident out of his room started cursing staff and as staff wanted to redirect resident, resident started throwing punches on all staff randomly. Resident punched this nurse on her left shoulder, threw coffee on nurse's station, punched another staff and another staff lost 2 of her nails trying to redirect resident. 8. Progress Note dated 08/03/21 at 05:31 AM revealed: Resident came out from his room severally just walking up and down aimlessly. Writer was busy writing her notes and resident walked up to her and was cursing at her using all kinds of profanities. 9. Progress Note dated 08/03/21 at 06:49 AM revealed: This nurse tried to help resident with coffee, and he pushed, punched, tried to choke nurse from the back. Two other nurses came to the nurse's rescue. NP made aware. 10. Progress Note dated 08/08/21 at 06:00 AM revealed: Was a behavior observed? Yes. Observed patient walk out of his room behind the nursing station to the mobile coffee stand. Patient (pt) attempted to get some coffee but could not get the pump to work. CNA came to assist pt with coffee. Patient became aggressive with staff member and began to yell at her Patient redirected in his behavior and instructed to stop and informed he could not take all the sugar. Patient became aggressive and began to argue, curse and yell at staff member. Patient yelling and calling all staff members mother***er and B*****s. Patient instructed to go back to his room. Patient yelled at staff and eventually went to his room. 11. Progress Note dated 08/08/21 at 09:25 AM revealed: Was a behavior observed? Yes. Resident continues to curse staffing using M F words and does not follow orientation. 12. Progress Note dated 08/23/21 at 09:17 AM revealed: This nurse had to redirect resident after going up to another resident saying, I'm going to f**k him up, let him keep on, this nurse did not hear the conversation, I just redirected him back to his room and he complied. 13. Progress Note dated 08/28/21 at 04:13 PM revealed: Situation- resident was verbally abusive to another patient. 14. Progress Note dated 08/30/21 at 08:23 PM read: Late entry 6-2. Resident continues to be monitored for aggressive behaviors with none noted. Resident though intermittently will curse staff but then back to his room. Will continue to monitor. 15. Progress Note dated 09/04/21 at 06:57 PM read: Was behavior observed? Yes. 16. Progress Note dated 09/14/21 at 01:33 PM read: Resident continues to curse staff, stupid, I don't want to f . with you. Resident quietly puts himself on the floor and says pillow, pillow, pillow. Resident gets himself up and started counting his money still cursing staff. Unable to reorient resident and NP made aware by the DON. 17. Progress Note dated 09/14/21 at 07:40 PM read: Resident ran after another resident who had a jacket on and said mine, mine, mine. This nurse and a CNA ran after and stopped him from getting closer to the resident. Resident continued to curse nurse, funky M F unable to reorient resident as he was pacing up and down the hallway. 18. Progress Note dated 09/15/21 at 01:06 PM read: Resident continues to curse staff intermittently, stupid M F, you crazy, crazy, crazy. 19. Progress Note dated 09/17/21 at 01:33 PM read: Resident earlier this morning passed room [ROOM NUMBER] (Resident #5's room), looked into the room and said to the resident in the room n*****, n*****, n*****, M F. This nurse reminded resident not to curse residents especially one minding his business not saying a word to him. Resident said to this nurse, shut up ugly M F. In an observation on 07/29/2021 at 10:30 AM, Resident #1 walked rapidly out of his isolation room three times. His eyes were shifting in all directions. There were two nurses at the station and each time they redirected him back to his room. In an interview on 07/29/2021 at 10:35 AM, LVN C said Resident #1 has behaviors, he had OCD and he repeat things. He thinks he owns everything and does not want anyone else to have them, like the coffee cart. When asked how to do you monitor him if you are not at the nurse station to redirect him, LVN C threw her arms and shoulders up towards the air, indicating she did not know and then she walked away. In an interview on 07/29/2021 at 3:45 PM CNA M said she had Abuse/Neglect and Exploitation in-service a few days ago because Resident #1 gets out of hand. She said that Resident #1 goes to the desk and says horrible things. CNA M said she felt he was in the wrong place. CNA M said every day he comes out fussing. An anonymous staff interview on 09/13/21 at 10:00 revealed: Resident #1 was not on one-on-one supervision, was observed for aggressive behaviors and the resident's normal status was aggressive. The staff said, the resident was in a room by himself and normally walks around the facility unattended, staff are not required to walk with him. The staff said when the nursing staff feel he was a danger, they intervene but it can be random, the resident believes everything was his and he curses at people for no reason. The staff said, the facility knows he is not supposed to be here and the anonymous staff does not feel there was adequate supervision of Resident #1 to ensure the safety of the other residents. The anonymous staff said the resident had a sitter in the past, but now he does not, you can't control him, he is everywhere. In an observation and interview with an anonymous staff interview on 09/13/21 at 10:10 AM revealed: Resident #1 came out of his room into the common area, where 3 other residents were present, and sat down in a chair facing the nursing station. Resident #1 continuously cursed incoherently at staff. The anonymous staff said Resident #1 wanders around the facility all the time, and even when he was on one-on-one supervision in the past, he would fight his sitter. He screams at other residents every other day. The anonymous staff said they do not believe the facility can do enough to make sure other residents are safe, since he was not on one-on-one supervision and he was allowed to roam the facility. The anonymous staff said that nursing staff have to use a medication cart to obstruct one of the entrances to the nursing station so that Resident #1 does not attack them from the back. The staff said Resident #1 had not hit them because they did not give him the opportunity. In an interview at 09/13/21 at 10:35 AM the DON said, Resident #1 was previously on one-on-one supervision in August (07/27/21 to 08/03/21), but it had been discontinued. The DON said there were not clear changes in his aggression that led to ending his one-on-one supervision, but he does not have aggressive behaviors on a daily basis. The DON said nursing staff know to monitor the resident, know what he was doing, anticipate his needs and take care of his triggers. She said recently the only incident the resident was involved in was with Resident #5 and it was reported to the state. The DON said that Resident #1 was not on one-on-one supervision because an interdisciplinary team decided that he was not a danger. She said the resident walks around the facility with a final destination in mind, but he does so unattended. The DON said, she does not feel Resident #1 was appropriate for the facility and in her professional opinion she is uncertain if they can keep staff and residents safe from him because he is unpredictable. In an observation and interview on 09/13/21 at 10:53 AM the surveyor said hello to the Resident #1 while standing in his doorway with nursing staff in an attempt to assess his reactions. Resident #1 cursed at staff and surveyor, he said, he said yal ain't nobody, f**k that and other incoherent expletives. In an observation on 09/13/21 at 10:55 AM, Resident #1 came out of his room yelling at staff. He slid behind the nursing cart blocking the back of the nursing station and continued to talk incoherently at the nursing staff, asking for shoes and clothes he was already wearing and called staff crazy crazy. After about 5 minutes, the nursing staff was able to redirect Resident #1 and he returned to his room. An observation and Interview on 09/13/21 at 12:06 revealed: Resident #1 was no longer in room, MA A said that the resident left his room unattended and most likely went to the dining room. The surveyor went to locate the resident in the dining room, the resident was observed to be sitting alone in the dining room unattended. An anonymous staff interview conducted on 09/17/21 at 01:30 PM revealed: Resident #1's behavior had worsened since 09/13/21 and the day before the resident ran down the hall after another resident that passed his room. They said Resident #1 ran down the hall and grabbed the resident saying mine, mine, staff chased him down the hall and got between the residents as Resident #1 grabbed at the other resident. The staff said after the investigation, Resident #1 had chased down the resident due to the fact that she was wearing his jacket. An observation and Interview on 09/17/21 at 01:58 PM revealed: Resident #1 attempting to exit his room with a sitter at his door . The sitter redirected the resident and he returned to his room. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 Record review of Resident #2's face sheet, printed on 07/29/2021 revealed a [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating she was cognitively intact. She required supervision only for walking in the corridor and supervision with set up only when resident moved to and returned from off-unit locations. She was steady at all times during transitions and walking. She had impairments to lower extremities. She used both a walker and a wheelchair. In an interview on 07/29/2021 at 10:25 AM, Resident#2 said she did not feel safe at the facility. She said Resident #1 was dangerous. Resident #2 said I don't think he should be here, it's not right. The first time(07/08/21) was at the coffee cart which was outside my room, he grabbed my arm, it hurt, and I got a bruise. Resident #2 said on the next day the coffee cart was again in the hallway just outside her room. He pushed her and pushed the cart at her; she fell hit her head there was a lot of blood. Resident #2 said she went to the ER and they had to glue her scalp and after second incident she said she pressed charges. She said she told her therapist about her concerns and has not told anyone else in the facility about how she feels. She said they told her the facility will take care of it, but It took 3 days after the incident before he left the facility. Resident # 2 said a few days ago she saw him at bingo, he never comes to bingo, she said she was afraid he might hurt her again. Record review of the Provider Investigation Report revealed Resident #4 was a witness to 07/08/2021 incident between Resident #1 and Resident #2. In an interview on 07/29/2021 at 3:10 PM, Resident #4 said I don't know his name, but he lives in room [ROOM NUMBER]. Resident #4 said he saw Resident #1 hit Resident #2 with his fist the first time and said she got bruised up. He said the second time Resident #1 hit Resident #2 there were two constables and he thought they would take him away, but they didn't. He said today he saw Resident #1 walking around the halls and told Resident #2 to be careful as he's out again. He said Resident #1 does not like anyone, he does not like white people and the nurses don't mess with him either. Resident #4 said he tried to hit me about a month ago, but I told him if he does, I'll hit him with my cane. Resident #4 said he felt safe when Resident #1 was not in the building and he likes to go all over the building, and someone showed him how to get to the dining room a different way, so he did not go by Resident #1's room anymore. Resident #4 said something needs to be done about Resident #1, he's going to hurt these ladies one day. Resident #4 said he has seen that when Resident #1 enters the dining room the other residents will move away from him. Record review of Resident #2's facility progress notes dated 07/09/2021 at 6:45 AM, written by LVN A read in part . Per 2nd nurse observation she witnessed Resident #1 and Resident #2 playing tug of war with the coffee cart, Resident #1 then said [OBSCENITY] let me have it, let it go, then agitated Resident #1 pushed the cart so hard in Resident #2's direction, she lost balance off of both feet landed on the floor on her back, hit her head, sustained head injury, impact injury to bilateral hands, this writer observed as I arrived to the incident Resident #2 laying on the floor, 2nd nurse was trying to get agitated Resident #1 away from the area and calmed down, Resident #2's head was facing the back hallway and feet facing the nursing station, Resident #2 had on slippers and appropriately attired, Resident #2 walker noted in hallway, eyewear noted, 3rd nurse got on floor with Resident #2 to calm her down, and this writer called for emergency 911 transport for fall with head injury, vitals immediately started, Resident #2 was not moved due to head injury and bleeding noted, compression started, Resident #2 complained of her head hurting/pounding, and her hands hurting and her bilateral heels hurting. Resident #2 assisted per 911 EMS to stretcher and transported to nearest hospital . In an interview on 08/02/2021 at 1:50 PM, LVN A said she was the nurse assigned to Resident #1 on 07/09/2021. She said Resident #1 had a routine in the mornings: sweeping floor, then getting coffee. She said prior to the incident Resident #1 would go to end of hall where dietary would leave the coffee cart and he would roll the coffee cart to the nurse station. Another resident was at the coffee cart before he got there. She said during the incident, Resident #2 was knocked off balance by Resident #1 and she helped Resident #2. LVN A stated, It was a territorial thing. She said she did see him walk from his room and on way to cart. LVN A continued by stating she was unaware of the altercation between Resident #1 and Resident #2 the day before (7/08/2021). She said It was not mentioned in morning report. It was not mentioned in nurse to nurse report. It should have been communicated between the nurses (nurse leaving and nurse just coming on shift). If I knew about the altercation, I wouldn't have allowed Resident #2 to go down to that area where the coffee cart was. I only heard about the altercation , like it was a rumor. I float and I depend on my reports. Record review of Resident #2's facility progress notes dated 07/09/2021 at 7:14 AM, written by LVN D read in part . Resident #2 standing in room [ROOM NUMBER] doorway, dietary placed coffee cart near Resident #2's door. Resident #2 was standing in front of cart attempting to fix her a cup of coffee when Resident #1 walked down the hall to coffee cart and try to pull coffee cart away. Resident #2 then grab the cart both began to pull cart and began to yell when this nurse heard yelling from Resident #1 and Resident #2, went to see what was going on .Resident #1 took his hands off the cart and yelled [OBSCENITY] LET IT GO, then Resident #1 pushed with both hands with force . Resident #2 fell straight backwards, this nurse removed Resident #1 while other nurses attended to Resident #2. 911 called and abuse coordinator called this nurse stayed with Resident #1 . In a telephone interview on 07/30/2021 at 8:55 AM, LVN D said the incident with Resident #1 and Resident #2 occurred in the morning of 7/9/2021. LVN D said Resident #1 was down the hall at the coffee cart outside Resident #2's room and both had their hands on the coffee cart. After the incident LVN D said she took Resident #1 back to his room. She said LVN A was Resident #2's assigned nurse and LVN A went to Resident #2 to administer first aid. LVN D said before the incident Resident #1 was just walking, and she did not notice any unusual behavior. Record review of Resident #2's hospital records dated 07/09/2021 revealed a CT (computer tomography) scan of the head and spine was performed for a fall with bleeding to the head area. X-ray of both hands was also performed. The findings were: Resident #1 had a moderate soft tissue bruise to back of her head and a small bruise to the left front of her scalp. The wound was closed. Interview on 07/29/2021 at 11:50 AM, the Administrator said the facility incident report from 7/8/2021 incident between Resident #1 and Resident #2, was a professional review and was unsubstantiated. In an interview on 07/30/2021 at 4:15 PM, the Administrator said actions were taken to protect Resident #1 from further abuse while an investigation was in process. She said the first time on 7/8/2021, we did observations on Resident #2, kept the residents apart and second time Resident #2 was sent to the hospital. In an interview on 09/13/21 at 11:03 AM, the Administrator said after the first incident on 07/08/21 the staff interviewed the residents involved and referred Resident #1 to psych services ; she said Resident #1 was monitored for 6 hours by keeping him at the nursing station and one on one supervision was ended because the resident was not considered a threat to other residents. The Administrator said she did not believe that Resident #1 intentionally hurt Resident #2 and the interdisciplinary team decided that he no longer needed to be supervised one on one. She said there were no notes for the IDT meeting that decided to end one-on-one supervision of Resident #1. The Administrator said there was no policy on dealing with residents with combative behaviors or one-on-one supervision. She said decisions are made based on each individual situation, but residents who are known to be aggressive should be placed on one-on-one supervision. The administrator said prior to the incident on 07/08/21 Resident #1 was not known to have aggressive behaviors. The Administrator said in retrospect he should have remained on one-on-one supervision. In an interview on 09/13/21 at 11:30 AM, the Regional Nurse said looking back Resident #1 should have remained on one-on-one supervision after the incident with Resident #2 on 07/08/21 to protect Resident #2 and other residents but at that time he was not considered a risk to resident safety. Resident #5 Record review of Resident #5's face sheet dated 09/19/21 revealed: resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's quarterly MDS dated [DATE] revealed: resident admitted from a hospital, usually makes himself understood, usually understands, wore corrective lenses, had moderately impaired cognition as indicated by a BIMS score of 11 out of 15 and had no potential indicators of [CONDITION(S)], no hallucinations or delusions. The resident needed supervision with most ADLs, used a wheelchair/walker and was frequently incontinent of bladder and bowel. Record review of Resident #5's Care Plan revised 09/19/21 revealed: focus- risk for communication problem related to impaired cognition, goal- resident will be able to make basic needs known on a daily basis, interventions- discuss with resident/family concerns or feelings regarding communication difficulty, encourage resident to continue stating thoughts even if resident is having difficulty. Focus- uses anti-anxiety medications related to anxiety disorder, goal- resident will be free from discomfort or adverse reactions related to anti-anxiety therapy, interventions- administer anti-anxiety medications as ordered by physician, monitor for side effects and effectiveness every shift. Focus- risk for mood problems related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor/document for side effects and effectiveness. Record review of facility accident/incident report dated 08/28/21 at 04:13 PM completed by the DON revealed: Incident Description Resident (Resident #5) was by the nursing station and decided to go to his room. While wheeling his wheelchair to go to him room another patient (Resident #1) started screaming at him and calling him names using B and F words. This patient is also screaming at him and they were about to fight when 2 nurses intervene to redirect them to their room Record review of facility accident/incident report dated 08/28/21 at 04:13 PM completed by LVN B revealed: Resident #1 was cursing and using B and F words at another patient and even trying to fight the patient because the other patient (Resident #5) was passing his room. The patient did not go to his room, he was just passing, and this resident get mad and want to fight. Nurse and other staff were able to intervene and avoid the incident. In an interview on 09/13/21 at 10:25 AM, when Resident #5 was asked if he had any problems with anyone on his hallway he said, the guy next door is crazy he said Resident #1 walked around the facility by himself and had cursed him out before. Resident #5 said Resident #1 comes to his door regularly and tries to come into his room, but he won't let him in. He said that he does not feel safe because he (Resident #1) is crazy. In an interview on 09/17/21 at 01:35 PM, when Resident #5 was asked about the incident on 08/28/21 he said he tries to stay away from Resident #1. Resident #5 said I have the right to defend myself, he (Resident #1) can say whatever he wants in the hallway because I can close my door but don't want him coming to my room and messing with me. He said he finds Resident #1 scary and doesn't want to get in trouble with him, so he avoids going to places he is, leaves when he sees him and hopes Resident #1 is moved from the building. Resident #5 said someone has to do something about him he comes into his room every week. He said Resident #1 was came to his doorway earlier and cursed at him. In an interview on 09/13/21 at 11:03 AM, the Administrator said that on 08/28/21 Resident #1 and Resident #5 had an incident. She said that staff reported that Resident #1 cursed and yelled at Resident #5 as he walked past his room. The administrator said the incident was reported on 08/28/21. Record review of facility accident/incident report dated 08/28/21 at 04:13 PM completed by the DON revealed: Incident Description Resident(Resident #5) was by the nursing station and decided to go to his room. While wheeling his wheelchair to go to him room another patient (Resident #1) started screaming at him and calling him names using B and F words. This patient is also screaming at him and they were about to fight when 2 nurses intervene to redirect them to their room Record review of facility accident/incident report dated 08/28/21 at 04:13 PM completed by LVN B revealed: Resident #1 was cursing and using B and F words at another patient and even trying to fight the patient because the other patient was passing his room. The patient did not go to his room, he was just passing, and this resident get mad and want to fight. Nurse and other staff were able to intervene and avoid the incident. In an interview on 09/17/21 at 01:35 PM, when Resident #5 was asked about the incident on 08/28/21 he said he tries to stay away from Resident #1. Resident #5 said I have the right to defend myself, he (Resident #1) can say whatever he wants in the hallway because I can close my door but don't want him coming to my room and messing with me. He said he finds Resident #1 scary and doesn't want to get in trouble with him, so he avoids going to places he is, leaves when he sees him and hopes Resident #1 is moved from the building. Resident #5 said someone has to do something about him he comes into his room every week. He said Resident #1 was came to his doorway earlier and cursed at him. In an interview on 07/29/2021 at 11:05 AM, Resident #3 took a long pause when asked if he felt safe in the facility. He shook his head, looked down and turned his head away. He said there was a fell ow down the hall: Resident #1, he [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that resident's environment remains as free of accident hazards as is possible, and residents received adequate supervision and assistance devices to prevent accidents : for 5 of 9 residents (Resident #1, Resident #2,Resident #3, Resident #4, Resident #5) reviewed for accidents and supervision. The facility failed to adequately supervise Resident # 1, who had a documented history of aggressive behaviors, to prevent repeated attacks of aggression, physical and mental harm to Resident #2 and Resident #5. The facility failed to put in place effective interventions to protect the psychosocial well-being of Resident #2, Resident #3, Resident #4, and Resident #5 by not preventing Resident #1 from approaching other residents, scaring them with his verbally and physically aggressive behaviors. An Immediate Jeopardy (IJ) was identified on 09/17/2021. While the IJ was lowered on 09/20/2021, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of the Plan of Removal. These failures could affect residents by placing them at risk of minor and major injuries due to inadequate supervision. Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on admitted on [DATE]. His diagnoses included dementia, adjustment disorder, delusional disorders, alcohol induced mood disorder, substance abuse, autistic disorder, [CONDITION(S)], [CONDITION(S)] in one eye, hearing loss, hypertension, and restlessness/agitation. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating he had severe cognitive impairment. His speech was unclear. He sometimes made himself understood and sometimes understood others. He required supervision only for walking in the corridor and supervision with set up only when resident moved to and returned from off-unit locations. He had no impairments to upper or lower extremities. He had no physical or verbal behaviors symptoms towards others. Record review of Resident #1's admission MDS dated [DATE] revealed he had physical and verbal behavior symptoms directed towards others that occurred 1 to 3 days and other behavior symptoms not directed to others that occurred 1 to 3 days. Record review of Resident #1's undated care plan printed on 07/29/2021 revealed in part . he had potential to be physically aggressive. The goal: resident will demonstrate effective coping skills and the interventions included, to keep resident away from any resident that tends to cause distress. Monitor behaviors every shift. Document observed behavior and attempted interventions in behavior log. When the resident becomes agitated: intervene before agitation escalates . Resident #1 had potential to be verbally aggressive. The goal: the resident will verbalize understanding of need to control verbally abusive behavior through the review date. Interventions included, give the resident as many choices as possible about care and activities and monitor behaviors every shift . Record review of Resident #1's Physicians Order's from 11/04/20 (admission) to 09/17/21 revealed no changes to the frequency of behavioral management orders since admission: - Order initiated on 11/04/20 and discontinued on 08/02/21 read Behavior Management attempts document aggression, verbal outbursts, and or physical aggression, number of behavior episodes, interventions and outcomes every shift document details in progress note 0= none present, 1= not present. - Order initiated on 08/02/21 and ongoing as of 09/17/21 read: Behavior Management attempts document aggression, verbal outbursts, and or physical aggression, number of behavior episodes, interventions and outcomes every shift document details in progress note 0= none present, 1= not present. Record review of Resident #1's Physicians Orders 11/04/20 (admission) to 09/13/21 revealed: no active, completed or discontinued orders for one-on-one supervision. Record review of Resident #1's facility progress notes dated 07/09/2021 at 6:45 AM, written by LVN A noted, this nurse observed resident exit his room this morning as usual for the coffee cart, this morning another female resident was helping herself to coffee before he could, one on one side the cart and one on the other side of the cart, he called her outside her name, to be exact [OBSCENITY] give it here, let it go, when he did not get his way, he pushed the resident, the other resident lost balance and fell to the floor. Record review of Resident #1's hospital records with the admitted [DATE] and discharge date of [DATE], revealed in part . the patient was having paranoid delusions with the belief that people wanted to harm him, he physically assaulted another resident by knocking her down causing her to hit her head, verbally and physically threatening staff and other residents . Record review of Resident #1's Behavioral Hospital Discharge Summary dated 08/24/21 revealed: Reason for Termination, Other- Patient refused to participate in psychotherapy. Symptoms are being treated with medication .If patient shows the ability to benefit from treatment, he may be referred again for therapy if he remains in or returns to the facility. Record review of Resident #1's July MAR revealed in part . [MEDICATION(S)] 500 mg by mouth two times a day for dementia (start date 07/06/2021 and discontinue date 07/28/2021); [MEDICATION(S)] 5 mg by mouth two times a day for antipsychotic (start date 07/28/2021). Record review of Resident #1's Clinical Progress Notes revealed resident had at least 19 documented incidents of verbal and physical aggression from 07/30/21 to 09/17/21: 1. Progress Note dated 07/30/21 at 11:48 AM read: Continues to curse both staff and resident out. Continues on contact isolation but comes out often. Unable to reorient resident due to continuous confusion. 2. Progress Note dated 07/31/21 at 06:51 AM read: . resident cursed this nurse shut up b***h, you stupid, go on now, resident cannot be redirected easily. 3. Progress Note dated 07/31/21 at 09:26 AM read: . resident has been verbally inappropriate, saying things like you N*****s need to leave me alone, you stupid b***h, resident came to nursing station . took his pants down and bent over opening his buttocks cheeks exposing himself to staff. 4. Progress Note dated 07/31/21 at 11:33 AM revealed: Resident was adamant about leaving his room, cursing the sitter and this writer out with vulgar language, the resident then said you think I'm playing with you MF, and grabbed the broom from his closet, and [NAME] it back like a bat . 5. Progress Note dated 07/31/21 at 10:21 PM revealed: Patient is coming out of his room instead of staying in isolation as directed. When directed, he screamed at staff and called them name by using B and F words. He even tried to hit one of the nurses, he refused his medication because he said we tried to poison him which is not true. 6. Progress Note dated 08/01/21 at 10:42 PM revealed: Patient kept going to the kitchen disturbing the kitchen crew . while trying to redirect patient he got aggressive and screaming and cursing using B and F words. He even tried to hit writer, he finally calmed down and went to his room. 7. Progress Note dated 08/02/21 at 07:17 AM revealed: Resident out of his room started cursing staff and as staff wanted to redirect resident, resident started throwing punches on all staff randomly. Resident punched this nurse on her left shoulder, threw coffee on nurse's station, punched another staff and another staff lost 2 of her nails trying to redirect resident. 8. Progress Note dated 08/03/21 at 05:31 AM revealed: Resident came out from his room severally just walking up and down aimlessly. Writer was busy writing her notes and resident walked up to her and was cursing at her using all kinds of profanities. 9. Progress Note dated 08/03/21 at 06:49 AM revealed: This nurse tried to help resident with coffee, and he pushed, punched, tried to choke nurse from the back. Two other nurses came to the nurse's recuse. NP made aware. 10. Progress Note dated 08/08/21 at 06:00 AM revealed: Was a behavior observed? Yes. Observed patient walk out of his room behind the nursing station to the mobile coffee stand. Patient (pt) attempted to get some coffee but could not get the pump to work. CNA came to assist pt with coffee. Patient became aggressive with staff member and began to yell at her Patient redirected in his behavior and instructed to stop and informed he could not take all the sugar. Patient became aggressive and began to argue, curse and yell at staff member. Patient yelling and calling all staff members mother***er and B*****s. Patient instructed to go back to his room. Patient yelled at staff and eventually went to his room. 11. Progress Note dated 08/08/21 at 09:25 AM revealed: Was a behavior observed? Yes. Resident continues to curse staffing using M F words and does not follow orientation. 12. Progress Note dated 08/23/21 at 09:17 AM revealed: This nurse had to redirect resident after going up to another resident saying, I'm going to f**k him up, let him keep on, this nurse did not hear the conversation, I just redirected him back to his room and he complied. 13. Progress Note dated 08/28/21 at 04:13 PM revealed: Situation- resident was verbally abusive to another patient. 14. Progress Note dated 08/30/21 at 08:23 PM read: Late entry 6-2. Resident continues to be monitored for aggressive behaviors with none noted. Resident though intermittently will curse staff but then back to his room. Will continue to monitor. 15. Progress Note dated 09/04/21 at 06:57 PM read: Was behavior observed? Yes. 16. Progress Note dated 09/14/21 at 01:33 PM read: Resident continues to curse staff, stupid, I don't want to f . with you. Resident quietly puts himself on the floor and says pillow, pillow, pillow. Resident gets himself up and started counting his money still cursing staff. Unable to reorient resident and NP made aware by the DON. 17. Progress Note dated 09/14/21 at 07:40 PM read: Resident ran after another resident who had a jacket on and said mine, mine, mine. This nurse and a CNA ran after and stopped him from getting closer to the resident. Resident continued to curse nurse, funky M F unable to reorient resident as he was pacing up and down the hallway. 18. Progress Note dated 09/15/21 at 01:06 PM read: Resident continues to curse staff intermittently, stupid M F, you crazy, crazy, crazy. 19. Progress Note dated 09/17/21 at 01:33 PM read: Resident earlier this morning passed room 225 (Resident #5's room), looked into the room and said to the resident in the room n*****, n*****, n*****, M F. This nurse reminded resident not to curse residents especially one minding his business not saying a word to him. Resident said to this nurse, shut up ugly M F. In an observation on 07/29/2021 at 10:30 AM, Resident #1 walked rapidly out of his isolation room three times. His eyes were shifting in all directions. There were two nurses at the station and each time they redirected him back to his room. In an interview on 07/29/2021 at 10:35 AM, LVN C said Resident #1 has behaviors, he had OCD and he repeat things. He thinks he owns everything and does not want anyone else to have them, like the coffee cart. When asked how to do you monitor him if you are not at the nurse station to redirect him, LVN C threw her arms and shoulders up towards the air, indicating she did not know and then she walked away. In an interview on 07/29/2021 at 3:45 PM CNA M said she had Abuse/Neglect and Exploitation in-service a few days ago because Resident #1 gets out of hand. She said that Resident #1 goes to the desk and says horrible things. CNA M said she felt he was in the wrong place. CNA M said every day he comes out fussing. An anonymous staff interview on 09/13/21 at 10:00 revealed: Resident #1 was not on one-on-one supervision, was observed for aggressive behaviors and the resident's normal status was aggressive. The staff said, the resident was in a room by himself and normally walks around the facility unattended, staff are not required to walk with him. The staff said when the nursing staff feel he was a danger, they intervene but it can be random, the resident believes everything was his and he curses at people for no reason. The staff said, the facility knows he is not supposed to be here and the anonymous staff does not feel there was adequate supervision of Resident #1 to ensure the safety of the other residents. The anonymous staff said the resident had a sitter in the past, but now he does not, you can't control him, he is everywhere. In an observation and interview with an anonymous staff interview on 09/13/21 at 10:10 AM revealed: Resident #1 came out of his room into the common area, where 3 other residents were present, and sat down in a chair facing the nursing station. Resident #1 continuously cursed incoherently at staff. The anonymous staff said Resident #1 wanders around the facility all the time, and even when he was on one-on-one supervision in the past, he would fight his sitter. He screams at other residents every other day. The anonymous staff said they do not believe the facility can do enough to make sure other residents are safe, since he was not on one-on-one supervision and he was allowed to roam the facility. The anonymous staff said that nursing staff have to use a medication cart to obstruct one of the entrances to the nursing station so that Resident #1 does not attack them from the back. The staff said Resident #1 had not hit them because they did not give him the opportunity. In an interview at 09/13/21 at 10:35 AM the DON said, Resident #1 was previously on one-on-one supervision in August (07/27/21 to 08/03/21), but it had been discontinued. The DON said there were not clear changes in his aggression that led to ending his one-on-one supervision, but he does not have aggressive behaviors on a daily basis. The DON said nursing staff know to monitor the resident, know what he was doing, anticipate his needs and take care of his triggers. She said recently the only incident the resident was involved in was with Resident #5 and it was reported to the state. The DON said that Resident #1 was not on one-on-one supervision because an interdisciplinary team decided that he was not a danger. She said the resident walks around the facility with a final destination in mind, but he does so unattended. The DON said, she does not feel Resident #1 was appropriate for the facility and in her professional opinion she is uncertain if they can keep staff and residents safe from him because he is unpredictable. In an observation and interview on 09/13/21 at 10:53 AM the surveyor said hello to the Resident #1 while standing in his doorway with nursing staff in an attempt to assess his reactions. Resident #1 cursed at staff and surveyor, he said, he said yal ain't nobody, f**k that and other incoherent expletives. In an observation on 09/13/21 at 10:55 AM, Resident #1 came out of his room yelling at staff. He slid behind the nursing cart blocking the back of the nursing station and continued to talk incoherently at the nursing staff, asking for shoes and clothes he was already wearing and called staff crazy crazy. After about 5 minutes, the nursing staff was able to redirect Resident #1 and he returned to his room. An observation and Interview on 09/13/21 at 12:06 revealed: Resident #1 was no longer in room, CMA A said that the resident left his room unattended and most likely went to the dining room. The surveyor went to locate the resident in the dining room, the resident was observed to be sitting alone in the dining room unattended. An anonymous staff interview conducted on 09/17/21 at 01:30 PM revealed: Resident #1's behavior had worsened since 09/13/21 and the day before the resident ran down the hall after another resident that passed his room. They said Resident #1 ran down the hall and grabbed the resident saying mine, mine, staff chased him down the hall and got between the residents as Resident #1 grabbed at the other resident. The staff said after the investigation, Resident #1 had chased down the resident due to the fact that she was wearing his jacket. An observation and Interview on 09/17/21 at 01:58 PM revealed: Resident #1 attempting to exit his room with a sitter at his door . The sitter redirected the resident and he returned to his room. Record review of Resident #1's Physician's Orders dated 09/17/21 revealed: resident was on one-on-one observation at this time related to exhibiting signs and symptoms of verbal aggression effective at 01:30 PM. Resident #2 Record review of Resident #2's face sheet, printed on 07/29/2021 revealed a [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included soft tissue disorder, orthopedic aftercare, fracture of left femur, headache syndrome, muscle weakness, diabetes, major depressive disorder, hypertension, and [CONDITION(S)] . Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating she was cognitively intact. She required supervision only for walking in the corridor and supervision with set up only when resident moved to and returned from off-unit locations. She was steady at all times during transitions and walking. She had impairments to lower extremities. She used both a walker and a wheelchair. In an interview on 07/29/2021 at 10:25 AM, Resident#2 said she did not feel safe at the facility. She said Resident #1 was dangerous. Resident #2 said I don't think he should be here, it's not right. The first time(07/08/21) was at the coffee cart which was outside my room, he grabbed my arm, it hurt, and I got a bruise. Resident #2 said on the next day the coffee cart was again in the hallway just outside her room. He pushed her and pushed the cart at her; she fell hit her head there was a lot of blood. Resident #2 said she went to the ER and they had to glue her scalp and after second incident she said she pressed charges. She said she told her therapist about her concerns and has not told anyone else in the facility about how she feels. She said they told her the facility will take care of it, but It took 3 days after the incident before he left the facility. Resident # 2 said a few days ago she saw him at bingo, he never comes to bingo, she said she was afraid he might hurt her again. Record review of the Provider Investigation Report revealed Resident #4 was a witness to 07/08/2021 incident between Resident #1 and Resident #2. In an interview on 07/29/2021 at 3:10 PM, Resident #4 said I don't know his name, but he lives in Room 231. Resident #4 said he saw Resident #1 hit Resident #2 with his fist the first time and said she got bruised up. He said the second time Resident #1 hit Resident #2 there were two constables and he thought they would take him away, but they didn't. He said today he saw Resident #1 walking around the halls and told Resident #2 to be careful as he's out again. He said Resident #1 does not like anyone, he does not like white people and the nurses don't mess with him either. Resident #4 said he tried to hit me about a month ago, but I told him if he does, I'll hit him with my cane. Resident #4 said he felt safe when Resident #1 was not in the building and he likes to go all over the building, and someone showed him how to get to the dining room a different way, so he did not go by Resident #1's room anymore. Resident #4 said something needs to be done about Resident #1, he's going to hurt these ladies one day. Resident #4 said he has seen that when Resident #1 enters the dining room the other residents will move away from him. Record review of Resident #2's facility progress notes dated 07/09/2021 at 6:45 AM, written by LVN A read in part . Per 2nd nurse observation she witnessed Resident #1 and Resident #2 playing tug of war with the coffee cart, Resident #1 then said [OBSCENITY] let me have it, let it go, then agitated Resident #1 pushed the cart so hard in Resident #2's direction, she lost balance off of both feet landed on the floor on her back, hit her head, sustained head injury, impact injury to bilateral hands, this writer observed as I arrived to the incident Resident #2 laying on the floor, 2nd nurse was trying to get agitated Resident #1 away from the area and calmed down, Resident #2's head was facing the back hallway and feet facing the nursing station, Resident #2 had on slippers and appropriately attired, Resident #2 walker noted in hallway, eyewear noted, 3rd nurse got on floor with Resident #2 to calm her down, and this writer called for emergency 911 transport for fall with head injury, vitals immediately started, Resident #2 was not moved due to head injury and bleeding noted, compression started, Resident #2 complained of her head hurting/pounding, and her hands hurting and her bilateral heels hurting. Resident #2 assisted per 911 EMS to stretcher and transported to nearest hospital . In an interview on 08/02/2021 at 1:50 PM, LVN A said she was the nurse assigned to Resident #1 on 07/09/2021. She said Resident #1 had a routine in the mornings: sweeping floor, then getting coffee. She said prior to the incident Resident #1 would go to end of hall where dietary would leave the coffee cart and he would roll the coffee cart to the nurse station. Another resident was at the coffee cart before he got there. She said during the incident, Resident #2 was knocked off balance by Resident #1 and she helped Resident #2. LVN A stated, It was a territorial thing. She said she did see him walk from his room and on way to cart. LVN A continued by stating she was unaware of the altercation between Resident #1 and Resident #2 the day before (7/08/2021). She said It was not mentioned in morning report. It was not mentioned in nurse to nurse report. It should have been communicated between the nurses (nurse leaving and nurse just coming on shift). If I knew about the altercation, I wouldn't have allowed Resident #2 to go down to that area where the coffee cart was. I only heard about the altercation , like it was a rumor. I float and I depend on my reports. Record review of Resident #2's facility progress notes dated 07/09/2021 at 7:14 AM, written by LVN D read in part . Resident #2 standing in room 230 doorway, dietary placed coffee cart near Resident #2's door. Resident #2 was standing in front of cart attempting to fix her a cup of coffee when Resident #1 walked down the hall to coffee cart and try to pull coffee cart away. Resident #2 then grab the cart both began to pull cart and began to yell when this nurse heard yelling from Resident #1 and Resident #2, went to see what was going on .Resident #1 took his hands off the cart and yelled [OBSCENITY] LET IT GO, then Resident #1 pushed with both hands with force . Resident #2 fell straight backwards, this nurse removed Resident #1 while other nurses attended to Resident #2. 911 called and abuse coordinator called this nurse stayed with Resident #1 . In a telephone interview on 07/30/2021 at 8:55 AM, LVN D said the incident with Resident #1 and Resident #2 occurred in the morning of 7/9/2021. LVN D said Resident #1 was down the hall at the coffee cart outside Resident #2's room and both had their hands on the coffee cart. After the incident LVN D said she took Resident #1 back to his room. She said LVN A was Resident #2's assigned nurse and LVN A went to Resident #2 to administer first aid. LVN D said before the incident Resident #1 was just walking, and she did not notice any unusual behavior. Record review of Resident #2's hospital records dated 07/09/2021 revealed a CT (computer tomography) scan of the head and spine was performed for a fall with bleeding to the head area. X-ray of both hands was also performed. The findings were: Resident #1 had a moderate soft tissue bruise to back of her head and a small bruise to the left front of her scalp. The scalp was closed. Interview on 07/29/2021 at 11:50 AM, the Administrator said the facility incident report from 7/8/2021 incident between Resident #1 and Resident #2, was a professional review and was unsubstantiated. In an interview on 07/30/2021 at 4:15 PM, the Administrator said actions were taken to protect Resident #1 from further abuse while an investigation was in process. She said the first time on 7/8/2021, we did observations on Resident #2, kept the residents apart and second time Resident #2 was sent to the hospital. In an interview on 09/13/21 at 11:03 AM, the Administrator said after the first incident on 07/08/21 the staff interviewed the residents involved and referred Resident #1 to psych services ; she said Resident #1 was monitored for 6 hours by keeping him at the nursing station and one on one supervision was ended because the resident was not considered a threat to other residents. The Administrator said she did not believe that Resident #1 intentionally hurt Resident #2 and the interdisciplinary team decided that he no longer needed to be supervised one on one. She said there were no notes for the IDT meeting that decided to end one-on-one supervision of Resident #1. The Administrator said there was no policy on dealing with residents with combative behaviors or one-on-one supervision. She said decisions are made based on each individual situation, but residents who are known to be aggressive should be placed on one-on-one supervision. The administrator said prior to the incident on 07/08/21 Resident #1 was not known to have aggressive behaviors. The Administrator said in retrospect he should have remained on one-on-one supervision. In an interview on 09/13/21 at 11:30 AM, the Regional Nurse said looking back Resident #1 should have remained on one-on-one supervision after the incident with Resident #2 on 07/08/21 to protect Resident #2 and other residents but at that time he was not considered a risk to resident safety. Resident #5 Record review of Resident #5's face sheet dated 09/19/21 revealed: resident admitted to the facility on [DATE] with diagnoses which included: dementia, type 2 diabetes, difficulty swallowing, unsteadiness on feet, major depressive disorder, anxiety disorder, muscle weakness, hypertension, skin cancer and brief psychotic disorder. Record review of Resident #5's quarterly MDS dated [DATE] revealed: resident admitted from a hospital, usually makes himself understood, usually understands, wore corrective lenses, had moderately impaired cognition as indicated by a BIMS score of 11 out of 15 and had no potential indicators of [CONDITION(S)], no hallucinations or delusions. The resident needed supervision with most ADLs, used a wheelchair/walker and was frequently incontinent of bladder and bowel. Record review of Resident #5's Care Plan revised 09/19/21 revealed: focus- risk for communication problem related to impaired cognition, goal- resident will be able to make basic needs known on a daily basis, interventions- discuss with resident/family concerns or feelings regarding communication difficulty, encourage resident to continue stating thoughts even if resident is having difficulty. Focus- uses anti-anxiety medications related to anxiety disorder, goal- resident will be free from discomfort or adverse reactions related to anti-anxiety therapy, interventions- administer anti-anxiety medications as ordered by physician, monitor for side effects and effectiveness every shift. Focus- risk for mood problems related to diagnoses of dementia, goal- resident will have improved sleep pattern by reporting adequate rest or fewer episodes of [CONDITION(S)], interventions- administer medications as order. Monitor/document for side effects and effectiveness. Record review of facility accident/incident report dated 08/28/21 at 04:13 PM completed by the DON revealed: Incident Description Resident (Resident #5) was by the nursing station and decided to go to his room. While wheeling his wheelchair to go to him room another patient (Resident #1) started screaming at him and calling him names using B and F words. This patient is also screaming at him and they were about to fight when 2 nurses intervene to redirect them to their room Record review of facility accident/incident report dated 08/28/21 at 04:13 PM completed by LVN B revealed: Resident #1 was cursing and using B and F words at another patient and even trying to fight the patient because the other patient (Resident #5) was passing his room. The patient did not go to his room, he was just passing, and this resident get mad and want to fight. Nurse and other staff were able to intervene and avoid the incident. In an interview on 09/13/21 at 10:25 AM, when Resident #5 was asked if he had any problems with anyone on his hallway he said, the guy next door is crazy he said Resident #1 walked around the facility by himself and had cursed him out before. Resident #5 said Resident #1 comes to his door regularly and tries to come into his room, but he won't let him in. He said that he does not feel safe because he (Resident #1) is crazy. In an interview on 09/17/21 at 01:35 PM, when Resident #5 was asked about the incident on 08/28/21 he said he tries to stay away from Resident #1. Resident #5 said I have the right to defend myself, he (Resident #1) can say whatever he wants in the hallway because I can close my door but don't want him coming to my room and messing with me. He said he finds Resident #1 scary and doesn't want to get in trouble with him, so he avoids going to places he is, leaves when he sees him and hopes Resident #1 is moved from the building. Resident #5 said someone has to do something about him he comes into his room every week. He said Resident #1 was came to his doorway earlier and cursed at him. In an interview on 09/13/21 at 11:03 AM, the Administrator said that on 08/28/21 Resident #1 and Resident #5 had an incident. She said that staff reported that Resident #1 cursed and yelled at Resident #5 as he walked past his room. The administrator said the incident was reported on 08/28/21. Record review of facility accident/incident report dated 08/28/21 at 04:13 PM completed by the DON revealed: Incident Description Resident(Resident #5) was by the nursing station and decided to go to his room. While wheeling his wheelchair to go to him room another patient (Resident #1) started screaming at him and calling him names using B and F words. This patient is also screaming at him and they were about to fight when 2 nurses intervene to redirect them to their room Record review of facility accident/incident report dated 08/28/21 at 04:13 PM completed by LVN B revealed: Resident #1 was cursing and using B and F words at another patient and even trying to fight the patient because the other patient was passing his room. The patient did not go to his room, he was just passing, and this resident get mad and want to fight. Nurse and other staff were able to intervene and avoid the incident. In an interview on 09/17/21 at 01:35 PM, when Resident #5 was asked about the incident on 08/28/21 he said he tries to stay away from Resident #1. Resident #5 said I have the right to defend myself, he (Resident #1) can say whatever he wants in the hallway because I can close my door but don't want him coming to my room and messing with me. He said he finds Resident #1 scary and doesn't want to get in trouble with him, so he avoids going to places he is, leaves when he sees him and hopes Resident #1 is moved from the building. Resident #5 said someone has to do something about him he comes into his room every week. He said Resident #1 was came to his doorway earlier and cursed at him. In an interview on 07/29/2021 at 11:05 AM, Resident #3 took a long pause when asked if he felt safe in the facility. He shook his head, looked down and turned his head away. He

Based on observation, interview and record review the facility failed to establish and maintain an infection control program to provide a safe and sanitary environment to help prevent the development and transmission of disease and infections for 5 of 26 residents (Residents #1, #2, #3, #4, and #5) reviewed for infection control. -The facility failed, due to improper isolation procedures, and standard and droplett precautions, to prevent the spread of COVID-19 to 10 residents who were hospitalized , 33 residents in isolation at the facility, and 21 staff. -The facility failed to provide hand sanitizers at the COVID unit's only authorized entrance/exit door requiring staff to search for the medication cart to hand sanitize before donning PPE. -The facility's staff moved between the Observation/Quarantine hall and the Non-COVID without changing their PPE. -Facility Staff failed to perform hand hygiene when entering and exiting resident rooms. An Immediate Jeopardy (IJ) was identified on 4/22/2020. While the IJ was lowered on 5/12/2020, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility still monitoring the effectiveness of the Plan of Removal These failures placed all residents and staff at risk infection or re-infection with the potential spread of infection to the public which could cause a decline in health or death. Findings Include: Record review of facility census report dated 04/29/2020 revealed there were 33 residents in the COVID positive unit, 10 COVID positive residents in the hospital, 8 residents in the Observation/Quarantine unit and 38 residents in the COVID negative unit. Record review of site visit assessment by the Local County Health Department Epidemiologist dated 04/25/2020 revealed: .Due to the quantity of positive, asymptomatic cases at this facility, we recommend following respiratory droplet precaution guidelines facility-wide . Typical, Standard COVID Transmission-Based Precautions are not being followed. Resident #1 Record review of Resident #1's admission record revealed an [AGE] year old female who was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Admission's minimum data set ((MDS) dated [DATE] revealed a BIMS scored 7 indicating severe cognitive impairment. The functional status section revealed she required extensive assistance with bed mobility, transfers, dressing and grooming. She required supervision for eating. Record review of Resident #1's undated care plan, revealed she was at risk for infection of opportunistic infection related to (r/t): presence of signs and symptoms of respiratory infection and/or risk of respiratory infection due to [MEDICAL CONDITIONS]. She had a respiratory infection (r/t) COVID-19. Interventions included; .provide a clean, well-ventilated environment . Record review of Resident #1's physician order [REDACTED]. Record review of Resident #1's Nursing progress note dated 05/08/2020 revealed she was pronounced dead at the facility on 05/08/2020. Resident #2 Record review of Resident #2's admission record revealed a [AGE] year old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS dated [DATE] staff assessment for mental status revealed she had a short term and long term memory problem and that her cognitive skills were severely impaired. The functional status section revealed she required extensive assistance with bed mobility, dressing and personal hygiene. She required total assistance with transfer and supervision for eating. Record review of Resident #2's undated care plan, revealed she was at risk for infection of opportunistic infection related to (r/t): presence of signs and symptoms of respiratory infection and/or risk of respiratory infection due to [MEDICAL CONDITION]. She had a respiratory infection r/t COVID-19. Interventions included: .provide a clean, well-ventilated environment . Record review of Resident #2's physician order [REDACTED]. Record review of Resident #2's nursing progress note dated 05/03/2020 revealed time of death at the facility on 05/03/2020 09:02 AM. In a telephone interview on 05/26/2020 at 4:40 p.m., the Local County Health Department Epidimiologist said that Resident #2's death was related to COVID. Resident #3 Record review of Resident #3's admission record revealed an [AGE] year old male re-admitted on [DATE] and original admission on 07/24/2015. His [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. The functional status section revealed he required extensive assistance with bed mobility, toilet use and personal hygiene. He required supervision for eating. Record review of Resident #3's undated care plan revealed he was at risk for infection (progression/onset of opportunistic infection) r/t: presence of signs and symptoms of Respiratory infection. Interventions included: .provide a clean, well-ventilated environment . Record review of Resident #3's physician order [REDACTED]. Resident #4 Record review of Resident #4's admission record revealed a [AGE] year old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating she was cognitively intact. The functional status section revealed she was independent with all activities of daily living (ADLs). Record review of Resident #4's undated care plan revealed he was at risk for infection (progression/onset of opportunistic infection) r/t: presence of signs and symptoms of Respiratory infection and/or risk of respiratory infection due to [MEDICAL CONDITION] etc. The interventions included: .provide a clean, well-ventilated environment .wash hands before and after all care contacts . Record review of Resident #4's physician order [REDACTED]. Resident #5 Record review of Resident #5's admission record revealed a [AGE] year old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. The section on skin condition revealed she had a pressure ulcer. Record review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS score of 11 moderate cognitive impairment. The functional status section revealed she required extensive assistance in all ADLs and was totally dependent for toilet use. Record review of Resident #5's undated care plan revealed he was at risk for infection (progression/onset of opportunistic infection) r/t: presence of signs and symptoms of Respiratory infection and/or risk of respiratory infection due to [MEDICAL CONDITION] etc. The interventions included: .provide a clean, well-ventilated environment .wash hands before and after all care contacts . Record review of Resident #5's April 2020 Medication Administration Record [REDACTED]. Record review of Epidemiologist notes from visit on 04/24/2020 revealed notes/areas of improvement Health care professional (HCP) dedicated to COVID care are on an isolated unit, and under no circumstances interact with non COVID units. 11 COVID+ staff are still working, but isolated to COVID+ unit. Use separate door of entry, and under no circumstances are allowed in other areas of facility . In an interview and observation on 04/29/2020 at 11:30 AM revealed the Administrator showing where residents were located in the facility on the floor plan. She said residents who were recently transferred from hospital or had recently left facility and returned and were in 14 day quarantine in the Observation/Quarantine unit or transitional hall, rooms 115-121. Residents positive for COVID-19 were located in the COVID unit. She said there was only one entrance to this unit and staff entered and exited through an the outside door. Staff working on the COVID unit were not permitted to enter or exit unit through the building. In an observation on 04/29/2020 at 12:00 PM, of the Observation/Quarantine hall revealed it was occupied by 7 residents, at the far end of the Observation/Quarantine hall there was one resident who was symptomatic. The double doors to the hall were closed. The doors to resident rooms were open. There was a cart outside only one room. In a telephone interview on 04/30/2020 at 9:30 AM, the local county Epidemiologist said each room in the Observation/Quarantine unit should have closed doors and isolation carts. He said these residents were being monitored for 14 days and were presumptive positive for COVID. Record review of the COVID-19 Response for Nursing Facilities, Version 2.5 dated 4/27/20, Attachment 1: Immediate Response Guidelines revealed .Create an isolation wing/unit In an observation and interview on 04/29/2020 at 12:45 AM, revealed there was no hand sanitizer on the PPE cart located at the entrance/exit door to COVID positive unit. In an observation and interview on 04/30/2020 at 12:00 PM in the COVID positive unit, revealed the COVID Positive Unit Manager assisted the Surveyor by opening doors, checking residents behind curtains, checking paper towels and soap supply at sinks inside resident rooms. She had gloves on while in the hallway and did not change the gloves or perform hand sanitizer when entering and exiting rooms. She entered the semi-private room for Resident #1 and Resident #2, both in bed. She touched the privacy curtain, paper towel dispenser and soap dispenser all which are touched by all staff entering the room provide resident care. She exited the room. When asked when should gloves be changed and hand hygiene performed she said, it depended on what she will be doing and would start with a new pair of gloves if doing resident care. She said she was not doing resident care, so she did not need to change gloves. Record review of CDC instructions on when to use gloves revealed: -Use disposable gloves when cleaning and disinfecting the area around the person who is sick or other surfaces that may be frequently touched in the home. -Use disposable gloves when touching or having contact with blood, stool, or body fluids, such as saliva, mucus, vomit, and urine. -After using disposable gloves, throw them out in a lined trash can. Do not disinfect or reuse the gloves. -Wash your hands after you have removed the gloves. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/gloves.html In an observation and interview on 04/30/2020 at 12:30 PM, revealed the entrance/exit to COVID positive unit had personal protective equipment (PPE) cart and no hand sanitizer. The COVID positive Unit Manager said there were hand sanitizers on the med carts. The Med carts were not close to the entrance or PPE cart. The Med carts were approximately 20 feet away at each end of nurse station. She said they usually moved hand sanitizer to the back door between shifts. When asked when hand hygiene was supposed to be performed and why it was important, she said hand hygiene was done after removing gloves. She said hand hygiene was done in order to prevent transmission of germs from the outside into the unit; and to prevent transmission of germs from unit to the outside. In an interview on 05/01/2020 at 11:35 AM, LVN A said infection control was to keep from spreading germs, hand hygiene was supposed to be done before entering residents' rooms, after every task, and to wash hands when tasks were completed. If soap and water were not available, they could use hand sanitizer. In an observation and interview on 05/01/2020 at 12:30 PM in the COVID negative unit revealed CNA A was wearing gloves. CNA A removed a meal tray from cart and delivered the tray to Resident #3. She touched overbed table before she exited the room. She did not change her gloves or perform hand hygiene. CNA A touched every tray in the cart (6 trays) and the outside of the cart. Then, she took a tray to Resident #4's room and touched the overbed table. She exited the room without performing hand hygiene and changing her gloves. She touched the coffee cart, coffee cup, coffee dispenser, and returned to room and gave coffee mug to Resident #4. She exited Resident #4's room and returned to the lunch cart without performing hand hygiene and changing gloves. CNA A picked up a tray, entered Resident #5's room, and touched overbed table. She exited the room and picked up a beverage glass, entered Resident #5's room, placed beverage on Resident #5's lunch tray, assisted resident with items on the tray and exited room. CNA A said she just started working at the facility about a month ago. When asked about when gloves should be used, she said she did not know how to answer because she spoke a different language. Then, CNA A said that she knew that during care, like changing or cleaning residents or touching their blankets, she should wash hands. When asked why hand hygiene was important, she said hand washing was to keep from spreading germs. In an observation on 05/01/2020 at 11:35 AM, revealed there were multiple staff in the hallways of the COVID negative and Observation/Quarantine units wearing gloves; not changing and hand sanitizing before they entered another room. They were not providing resident care. Record review of the CDC website revealed: Nonsterile disposable patient examination gloves, which are used for routine patient care in healthcare settings, are appropriate for the care of patients with suspected or confirmed COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html#Gloves In an observation and interview on 05/01/2020 at 1:45 PM, revealed a staff member entered unit from outside door and placed belongings on a side table. She took an isolation gown from PPE cart. She did not have a mask on when she walked away from the PPE cart to a nearby office. She returned wearing a N95 respirator. The COVID Unit Manager said she kept the N95 respirators in her office and not in the PPE cart so they did not disappear. In an interview on 05/04/2020 at 2:15 PM, the Administrator said as of the current date, 11 COVID positive staff were asymptomatic, assigned to working COVID positive unit, and they were moved around during staffing crises. This meant that they would work on the COVID negative hall as well. Eight staff were quarantined and 2 were in the hospital. Record review of the facility employee list dated 5/4/2020, comparing the list with time sheets of team members tested positive for [MEDICAL CONDITION]. Revealed that 3 out of 21 COVID positive employees had worked in the COVID negative unit between April 24 and May 5. -CNA A worked on the Negative unit on 05/01/2020, 05/02/2020 and 05/03/2020 CNA C worked on the negative unit on 04/24/2020, 04/25/2020, 04/26/2020, 05/30/2020 and 05/01/2020. COVID Positive Unit Manager worked on the Negative Unit on 05/01/2020. In an interview on 05/04/2020 at 2:30 PM, the Wound Care Nurse said she provided care to residents with on the COVID unit and residents in the Observation/Quarantine hall. She said her schedule for COVID unit was Monday, Wednesday, and Friday. In an observation on 05/04/2020 at 2:45 PM, revealed CNA A and MA A both wearing gowns, were in in resident rooms on the Observation/Quarantine unit. MA A was passing medication in a resident room in the Observation/Quarantine unit, MA A entered the Observation/Quarantine unit from the COVID negative hall through double doors with CNA A. MA A returned to Observation/Quarantine Unit to get the med cart and brought it to room [ROOM NUMBER] which was in the COVID negative hall (residents who have not recently left building). MA A said she was assigned to residents in Negative area as well as Observation/Quarantine Hall. She did not change her PPE when moving between the halls. In an interview on 05/04/2020 at 2:45 PM, the ARNP, the physician's nurse practitioner who visits the facility almost daily, said residents in Observation/Quarantine unit are the same as the rest of the residents in hall 100, it was really an extension of the non-COVID unit. They are all COVID negative, asymtomatic, and being monitored for development of symptoms. Record review of HHS website regarding how to implement quarantine revealed: Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. These people may have been exposed to a disease and do not know it, or they may have the disease but do not show symptoms. https://www.hhs.gov/answers/public-health-and-safety/what-is-the-difference-between-isolation-and-quarantine/index.html In a telephone interview on 05/05/2020 at 10:00 AM, COVID negative Unit Manager said the Observation/Quarantine hall was for residents who were newly admitted or readmitted and returned from the hospital. They were to be monitored for 14 days. All the residents on the unit tested negative for COVID. If they were symptom-free after 14 days, they would return to the COVID negative hall. She said the staff were not expected to change gowns if they entered these rooms. Gowns were required when entering one of the designated Isolation rooms at the end of hall. Record review of the admission records for the residents quarantined on the Observation/Quarantine hall revealed Resident 6 was readmitted on [DATE], Resident 7 on 4/13/2020, Resident 8 on 4/17/2020 and 3 residents on 4/27/2020. Resident 9 was admitted on [DATE] and had not been moved out of the hall when the hall was converted to an observation or quarantine hall. Record review of CDC Guidelines for Transmission-Based Precautions revealed: Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission . Contact Precautions, Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission . Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens .Droplet Precautions Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking . https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html During a telephone interview on 5/10/2020 at 4:35 PM, regarding a facility inspection conducted on 05/05/2020, the Epidemiologist he said he observed a male staff member in the Observation/Quarantine hall entering resident rooms serving food trays and not performing hand hygiene. He said he saw same staff member picking up trays with gloves on and not doing hand hygiene. He said he observed another male staff in the Observation/Quarantine hall walking in and out of the isolation rooms not performing hand hygiene. He said he saw this staff do this twice. During a telephone interview on 05/12/2020 at 9:00 AM, regarding a facility inspection conducted on 05/05/2020, the Public Health Nurse said approximately 12:30 or 1:00 PM she was on the COVID negative unit. She observed the male dietary staff providing meals on both COVID negative unit and the Observation/Quarantine hall passing trays with gloved hands. She said the male dietary staff did not remove gloves and perform hand hygiene between resident rooms. She said she observed the same practice on the Observation/Quarantine hall and that she did not observe removal of gloves. Record review of Epidemiologist follow-up visit notes dated 05/05/2020 revealed .Rather than donning and doffing between encounters, staff wear same PPE for entirety of shift. This may provide an exposure risks if there are additional asymptomatic COVID+ residents . COVID negative unit - Staff are instructed by facility to don PPE at beginning of work shift and doff prior to exiting unit. - We observed nurses off unit wearing full PPE - We observed patient care interaction with a symptomatic resident (Pending tested results) where staff member entered and exited room without donning and doffing PPE. - We observed several patient care interactions where gloves were not disposed upon exiting patient room. Record review of the COVID-19 Response for Nursing Facilities, Version 2.5 dated 4/27/20, Attachment 1: Immediate Response Guidelines .Create an isolation wing/unit revealed .Health care worker (HCW)/staff leaving and entering isolation wing/unit - Directly after entering the isolation area and prior to donning PPE, perform hand hygiene - Put on proper PPE . In an interview on 5/6/2020 at 11:15 AM, the Administrator said that the reason the facility had as many COVID positive cases is because they tested all the staff and residents. In an interview on 05/08/2020 at 11:40 AM, the COVID Negative Unit Manager said she expected staff to perform hand hygiene after touching surfaces in resident rooms. She said gloves were used for resident contact and gloves should then be removed and hand hygiene performed. In an interview on 5/10/2020 at 11:30 AM, the Regional Director of Clinical Operations and the Regional Clinical Nurse were asked about the facility expectation for staff delivering meal trays to resident rooms. Both said it would be just like delivering trays in the dining room; staff should perform hand hygiene between trays, that was why there are hand sanitizers on the walls. They said hand hygiene between trays was to prevent the spread of infection. Record review of facility policy for Droplet Precautions, COVID-19 Education, Prevention & Response Guide, Diversicare, dated 14 April 2020 revealed Advise healthcare personnel to observe droplet precautions (i.e wearing a surgical or procedure mask for close contact), in addition to Standard Precautions, when examining a patient with symptoms of a respiratory infection, particularly if fever is present. These precautions should be maintained until it is determined that the cause of symptoms is not an infectious agent that requires Droplet Precautions. Record review of facility policy for Handwashing/Hand Hygiene, Diversicare, 14 April 2020, effective date: March 2020 revealed on page 7; General Infection Control Practices .7. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections. 8. Single-use disposable gloves should be used: c. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions .page. 21 COVID-19 Education, Prevention & Response Guide If COVID-19 cases WIDE SPREAD in the surrounding community for (patient) referrals with (a) COVID-19 positive test or with clinically suspected COVID symptoms . place patient in droplet and contact precautions . page 60 Appendix E. Suspected/Confirmed COVID-19 [DIAGNOSES REDACTED].Prior to entering and exiting the unit and a patient room, team members must perform hand hygiene The facility Administrator was notified on 5/6/2020 at 11:15 AM that an Immediate Jeopardy (IJ) had been identified in the above areas and a Plan of Removal was requested. A copy of the IJ Template was left with the Administrator. A Plan of Removal was submitted by the Administrator on 5/6/2020. After several revisions, the final Plan of Removal was accepted on 5/9/2020 at 11:20 AM. The plan of removal included the following: - Assessments conducted on negative (100 unit) by licensed nurses and residents remain with no change in condition and in no apparent distress - Assessments conducted on positive (200 unit) by licensed nurses and residents remain with no change in condition and in no apparent distress - Assessments conducted on dedicated observation area by licensed nurses and residents remain with no change in condition and in no apparent distress - Residents residing on the 100 unit, 200 unit, and dedicated observation area remain under stringent screening and infection control processes --- Initiated on 5/6/20 and completed on 5/7/20 responsible staff ADNS/Designee All potentially affected residents were reviewed for changes in condition via an IDT analysis, which encompassed: - An inquiry of nursing progress notes - An evaluation of documentation for monitoring signs and symptoms of COVID-19 - A critique of temperature reports set to trigger temps > 99 - An exploration of laboratory and imaging interpretations --- Initiated on 5/6/20 and remains on-going; responsible staff ADNS/Designee Modification and locality of hand sanitizer dispensers within immediate vicinity of entering and exiting COVID positive unit (completed 5/5/20). Modification and locality of team member break room within the COVID positive unit (completed 5/5/20). All residents with a change in condition will be immediately referred to medical providers for further assessment via a telehealth platform (initiated 5/6/20). Implemented droplet precaution signage and door closure to residents in observation areas (5/7/20). Implemented dedicated team members for negative (100 unit), positive (200 unit), and observation area (5/7/20). To slow the spread of infectious outbreaks, any resident or team member exhibiting COVID symptoms will result in: - Testing - Investigation and elicitation (via daily tracking tool) - Trace ( Process: identify, contact, enlighten) - Quarantine or isolate - Follow-up - Notification of local health authority, HHSC, and CDC (NHSN) regarding confirmed cases Team members (all departments) educated by ADNS on: - Hand hygiene to include handwashing and hand sanitizing - Donning and doffing of PPE - Proper disposal of PPE - Droplet Precautions - Mitigating access and spread of COVID-19 (meal tray pass, affixed appropriate isolation signage and secured doors on residents' rooms, identified and initiated dedicated team members). Monitoring: In an observation and interview on 05/08/2020 at 11:40 AM the COVID Negative Unit Manager said the facility had now instituted no gloves in hallways. She said she expected staff to hand hygiene after touching surfaces in resident rooms. She used hand sanitizer, donned clean gloves and was pushing a resident in his wheelchair. She said gloves are used for resident contact and gloves should then be removed and hand hygiene performed. Observation on 05/09/2020 at 09:45AM, revealed CNA R picking up meal trays. She was masked, gowned and using hand sanitizer between resident rooms. Observation starting on 5/9/2020 at 9:55 AM revealed the Wound Care Nurse and another staff are at the nurses' station without gloves. None of the staff were wearing gloves in the halls. They were using hand sanitizer before they entered and after they exited rooms. room [ROOM NUMBER], in the Observation/Quarantine unit, had a closed door. Housekeeping staff was cleaning hand rails. The MA was performing hand hygiene when he entered and exited resident room. Staff were not moving between the COVID negative unit, the Observation/Quarantine unit and the COVID positive unit. In an observation and interview on 04/30/2020 at 11:45 AM the COVID negative Unit Manager said some resident rooms had hand sanitizer. She said there were sinks in residents' rooms and the facility encouraged hand washing with soap and water instead of alcohol based rub. Hand sanitizer dispensers were mounted in the hallway every 2-3 rooms apart. In an interview on 05/09/2020 at 10:00 AM, LVN D said he worked in the COVID negative hall yesterday and today he was assigned to just to work in the Observation/Quarantine hall. He said he did not work in the other halls. In an interview on 05/09/ at 10:25 AM, the COVID Positive Unit Manager said we staff were not to wear gloves anymore unless we enter residents' rooms or to provide resident care. Observation on 5/9/2020, at 10:25 AM revealed a red sign on outside of entrance/exit door for full PPE before entering COVID unit. At the exterior door there was a hand sanitizer dispenser, a tracking log, a thermometer, a PPE cart, and a biohazard container. Three nurses were in the lobby and they were not wearing gloved hands. All staff were wearing blue gown, goggles, and N95 masks. Staff entering were screened by nurse at the screening table. There was no trash can outside the entrance/exit door. Observation of the Observation/Quarantine unit on 05/10/2020 at 11:50 AM revealed the LVN passing medications was performing hand hygiene between residents and staff passing meal trays performing hand hygiene between residents. In an interview on 11/10/2020 at 11:50 AM, LVN B said she was in charge of doing all care for residents in Observation/Quarantine hall today. She said she was assigned to work in this hall only and did not leave the area or work in the other halls. She said each resident's room had a PPE cart. She said she put on a new gown when entering each room, then the gowns were placed in a biohazard bag in the resident's bathroom. Observation of the COVID negative hall on 05/10/2020 at 12:15 PM revealed when the beverage cart arrived, staff performed hand hygiene prior to entering residents' rooms and after exiting residents' rooms. No staff observed moving between the units. On 05/11/2020 at 8:40 AM, Record review of facility's new infection control inservices completed by staff revealed pre/post tests and audit checklists on the following topics: handwashing/hand hygiene, droplet precautions, PPE, Alcohol-based hand rub. In an interview on 05/11/2020 at 09:30 AM the PT Director said she had 7 staff working and split between the 2 units. She said she only assigned COVID negative staff working permanently on 100 Hall. <b (TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 1 of 5 residents (CR #1) reviewed for pressure ulcers. - The facility failed to provide CR #1 with treatments ordered by a physician. - The facility discontinued CR #1's wound vac without a physician's orders [REDACTED].>- CR #1 was admitted to the hospital with [REDACTED]. - The facility's wound care nurse, RN #1, did not use proper hand hygiene technique and did not measure Resident #6's wound properly. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 6/8/18. While the IJ was lowered on 6/14/18, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. These failures affected one discharged and one current resident and placed 12 residents with pressure ulcers and 58 residents receiving preventive skin care at risk for developing new pressure ulcers or a decline in existing pressure ulcers. Findings Include: Intake # 4 CR #1 Record review of CR #1's Face Sheet revealed she was an [AGE] year-old female admitted to the facility 3/5/18. Her [DIAGNOSES REDACTED]. She was admitted with a catheter, peg tube, contractures and one stage 4 pressure sore. She was discharged to the hospital on [DATE]. Record review of CR #1's MDS assessment dated [DATE] revealed the staff assessment of cognitive skills indicated she had severely impaired cognitive skills and was totally dependent on staff for all of her activities of daily living care. She had a stage 4 pressure ulcer measuring 4.0 cm x 4.4 cm x 2.0 cm. It was assessed as granulation tissue-pink or red tissue with shiny, moist, granular appearance. Interventions did not list turning/repositioning. Record review of CR #1's Care Plan dated 3/6/18 revealed CR #1 has a stage 4 pressure ulcer to sacrum. At risk for further breakdown; has bilateral contractures of knees and elbows and incontinent episodes of bowel. The goal stated pressure ulcer will be healed and she will not experience any unidentified infections by 6/18/18. Approaches included turning and repositioning via two staff, wound care as ordered by physician, wound vac as ordered, mechanical lift, weekly evaluation of wound healing, daily observation of skin with routine care, full skin evaluation weekly with bath/shower, float heels on pillow as needed, observe for changes in skin status that may indicate worsening of pressure ulcer and notify the physician. Record review of CR #1's sacral wound assessment report dated 3/9/18 revealed her stage 4 pressure ulcer was 5.5 cm x 4.5 cm x 2 cm. There was 70% granulation tissue and 30% slough. The boarder of the wound was well-defined normal healthy skin. Record review of CR #1's sacral wound assessment reports dated 3/16/18, 3/23/18, 3/30/18, 4/6/18, 4/13/18, 4/20/18, 4/27/18, and 5/4/18 all recorded the same measurement: 4 cm x 4.4 cm x 2. These assessments all indicated there was 100% granulation tissue and the boarder of the wound was well-defined normal healthy skin. Record review of CR #1's Bath Sheets dated 3/29/18-5/1/18 only identified the sacral wound. Record review of CR #1's Medication Administration Record [REDACTED] -Stage 4 pressure ulcer to sacrum: cleanse with normal saline, pat dry, apply continuous negative pressure vacuum at 125 mmGh three times a week. Ordered 3/6/18 and started 3/9/18. Treatments were signed that they were received. Record review of CR #1's Treatment Administration Record dated (MONTH) (YEAR) revealed the following: -Apply wet to dry to affected area every day or as needed until further evaluations. Ordered 4/23/18 and discontinued 5/1/18. Treatments were signed as being received. -Stage 4 pressure ulcer to sacrum: cleanse with normal saline, pat dry, apply continuous negative pressure vacuum at 125 mmHg three times a week. Ordered 3/7/18 and discontinued 4/23/18. Treatments were signed as being received. -Stage 4 ulcer to sacrum: clean with normal saline, pat dry, apply wet to dry dressing, and cover with dry protective dressing daily. Ordered 4/26/18 and discontinued 5/6/18. Treatments were signed as being received. Record review of CR #1's Clinical Chart revealed an order dated 4/23/18 Discontinue wound vac . three times a week to sacrum. Apply wet to dry dressing to affected area every day or as needed until further evaluations. The order did not have a physician's signature. Record review of CR #1's Treatment Administration Record dated (MONTH) (YEAR) revealed the following: -Stage 4 ulcer to sacrum: clean with normal saline, pat dry, apply wet to dry dressing, and cover with dry protective dressing daily. Ordered 4/26/18 and discontinued 5/6/18. Treatments were signed as being received. Record review of CR #1's Nursing Note dated 4/25/18 and signed by LVN #2 revealed Skin assessment done this shift. Resident with open area to sacrum. Resident with area to left ankle, left outer side of foot, left heel, right foot great toe, next to great toe, inner aspect of foot next to great toe, inner heel to right foot, left top foot ankle area small, no drainage to any area, but all areas are dark in color. Resident on air mattress. In an interview on 6/8/18 at 1:40 p.m., LVN #2 stated she turned in a communication form into the treatment nurse following CR #1's 4/25/18 skin assessment. She was informed by treatment nurse that there was treatment in place for the wounds she noted on the heels and feet. She did not notify CR #1's physician. Record review of CR #1's Wound Assessment Reports dated 5/4/18 and signed by LVN #5 revealed Resident continues to have a stage 4 pressure ulcer to sacrum measuring 4.0 cm x 4.4 cm x 2.0 cm. Wound has moderate amount of serosanguineous drainage with 100% of granulated tissue. Surrounding skin is well defined. No signs and symptoms of infection present. NP and RP notified. However, this assessment was different than the emergency room assessment conducted. Record review of CR #1's Nursing Note dated 5/6/18 and signed by LVN #4 revealed MD notified STAT lab results from 5/5/18. CBC, CMP Potassium 6.6, BUN 95, WBC 42.2, Creatinine 4.8. BP 136/72, P 81, R 18, O2 Sat 97% RA. DR. notified. N/O Send to KW for further eval. Message left for RP, DON informed. Transported via EMS x 2. Record review of CR #1's emergency room Note dated 5/6/18 revealed CR #1 is an [AGE] year-old female who lives in a nursing facility with known history of a sacral decubitus for a year was brought to the hospital [MEDICAL CONDITION] picture with multiorgan dysfunctio[DIAGNOSES REDACTED], pneumonia was suspected as well as UTI and severe rhabdomyolysis. Upon admission, the patient was found to have acute [MEDICAL CONDITION] with a creatinine of 4, elevation of the liver enzymes and a CK of 12,000 with lactic acidosis. The patient was started empirically on antibiotics and cultures were sent. Urine was quite [MEDICAL CONDITION]. It is worth mentioning that the patient had advanced dementia and she had a PEG tube for nutrition. There were some concerns about aspiration. During the exam, it was found that the patient has discharge around the PEG tube that has a foul smell. She is contracted. She lies in a fetal position. Examination of the sacral area, she has a deep tissue injury that measures at least 15 cm in diameter in the middle of it that she has a wound that is 5-6 cm in diameter. It is deep to the bone. The entire wound almost 90% in necrotic with a foul-smelling discharge coming out. The edges of the wounds are everted an it tunnels all the way at least 2 cm all around. Now coming down to the bony prominences on her feet including the ankles, the fifth metatarsals, and the first metatarsals whatever she has a bone in her foot all of these has deep tissue injuries with foul smelling wounds, most of them are deep to the bones. She needs surgical debridement of all her wounds including the sacral wound. Labs collected revealed WBC is 38,000, hemoglobin 9, and platelet count 254. Sodium is 132, potassium 5.8, creatinine is 4, BUN is 103, creatinine kinase is 112,000. Procalcitonin is more than 200. Clinical impressions included [MEDICAL CONDITION], failure to thrive, and pneumonia. Record review of CR #1's Wound Care Consultation dated 5/14/18 revealed There are multiple ulcerations noted to bilateral lower extremities. There is a large fibrotic ulceration to the right lateral ankle that is boggy with significant fibrotic tissue. There are multiple other deep tissue injuries noted to the right lateral foot. The right foot is dusky in appearance. On the medial posterior heel, there is also ulceration as well as multiple deep tissue injuries on the medial aspect of the right foot. On the left foot, there are medial deep tissue injuries with the posterior heel ulceration as well as multiple open ulcerations on the left lateral foot and ankle. On the left, there is dusky appearance as well. The plan revealed The patient is seen and evaluated at bedside. Overall, the patient has poor prognosis and is a poor surgical candidate for any wound debridement to the right or left lower extremities. The patient has significant signs of decrease blood flow and ultimately would not tolerate any surgical procedures to the right lower extremity. If any debridement that would be performed would likely further expose the patient and the patient's functional status is limited at this time. If anything was to be contemplated, most likely the patient would require bilateral above-the-knee amputations. However, the patient still has sacral osteo[DIAGNOSES REDACTED], sacral wounds. Podiatry will not proceed forward with any surgical interventions at this time. Record review of Facility's Wound care List received 6/5/18 revealed a total of 11 residents receiving treatments. At least 5 other residents were identified with pressure ulcers after surveyor entered facility. In an interview on 6/7/18 at 9:30 a.m., LVN #5 revealed she graduated in (MONTH) (YEAR) and this was her first nursing position. She started as a floor nurse and when the facility's previous treatment nurse resigned she was appointed the position. After one day of shadowing the previous treatment nurse in January, she took over doing wound care. LVN #5 stated she asked several times for training or a wound care doctor to which DON and previous Administrator denied. She inquired about a wound care certification class and according to DON, corporate denied the request. LVN #5 was responsible for treating nearly 20 residents during the week. The charge nurses were responsible for treatments. on the weekend. However, there were several instances where LVN #5 treated wounds that had a bandage dated from the previous Friday. LVN #5 tried to resign twice in which the second time DON agreed to start looking to fill the position. LVN #5 stated CR #1 did not have any open wounds besides the sacrum but had DTI on her feet. She stated her documentation could have been better and she should have documented everything she was doing for the resident. In an interview on 6/7/18 at 10:15 a.m., LVN #5 stated the wound vac was discontinued by LVN #1 on 04/26/18, she said LVN #1 stated she did not think the wound vac is working effectively because of its beeping, she said she did not know if the physician signed the order or not. Attempts to reach LVN #1 by phone for an interview were unsuccessful. In an interview on 6/8/18 at 4:40 p.m., NP #1 stated she had been seeing CR #1 since (MONTH) (YEAR). She completed a skin assessment on her first visit, but she didn't see the sacral wound because the wound vac covered the wound. NP #1 stated she never saw CR #1's wound and her condition was the same as baseline. NP #1 was never informed that the wound vac was not working and never gave the order to discontinue it. In an interview on 6/12/18 at 10:40 a.m., Administrator stated unit manager rounds, morning meetings, stand down meetings was how she ensured nursing needs of residents were being met. However, now she will validate information given to her. The DON is also now responsible for doing weekly rounds with the treatment nurse for residents receiving treatment and skin rounds will be done every 60 days for all residents. In an interview on 6/12/18 at 1:00 p.m., DON stated the process has always been to call the physician, responsible party, and get new orders for any new wound, however, DON will now supervise by looking at weekly skin assessments and validating the information. Staff are to notify DON of any changes in condition. DON felt this incident came about due to a lack of documentation, lack of notification to the responsible party, and her not monitoring/validating documentation. In an interview and record review on 6/12/18 at 1:00 p.m., the DON stated all nurses received training guided by the nurse competency checklist. The training LVN #5 received as a treatment nurse was no different from the other nurses. LVN #5 had two weeks of training from the previous treatment nurse and computer based training. The DON rounded with LVN #5 once or twice and felt she was doing a good job. LVN #5 did ask for extra training and there was communication between the DON and corporate via email about the wound care certification class. The DON saw CR #1's wound once when LVN #5 asked her to observe her replace the wound vac, however she didn't measure it or notice necrosis. The DON said she was informed of treatments not being done on the weekends and in-serviced the nurses. The Email dated 3/2/18 provided by the DON indicated she had written I found an online course that I believe would be sufficient enough to increase her knowledge and competency which was sent to Administrator. LVN #5's computer based training list provided by the DON included: Pressure Injury/Ulcer Prevention Training dated 4/2/18 - 1 hour course and Infection Control and Prevention dated 5/1/18 - 1 hour course. In a later interview on 6/13/18 LVN #2 stated the facility was having a problem with skin so they cracked down on skin sheets. When she did the skin assessment on CR #1 she walked through the shower sheet with the treatment nurse who said she was already treating the areas. She stated she only saw the wound once and described it as irregular, no odor, and medium sized (being able to fit at least three fingers inside). In an interview on 6/14/18 at 11:39 a.m., Former Treatment Nurse stated she trained LVN #5 for 2-3 days for wound care. The training was supposed to be a week, but due to call ins LVN #5 would have to work the floor. She told the DON that LVN #5 wasn't ready and offered to stay to help, but it didn't happen. Resident #6 Record review of Resident #6's Face Sheet documented she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #6's Care Plan dated 05/01/2018, revealed she required weekly evaluation of wound healing. Record review of Resident #6's admission re-entry MDS dated [DATE], revealed BIMS score of 12 of 15, indicating she had moderate cognitive loss. She was totally dependent on two staff for mobility and transfer. During an observation on 06/14/18 between 09:00 a.m. and 12:24 p.m., the wound treatment nurse RN #1 provided Resident #6's wound care. She documented the wound measurements incorrectly as follows: -Upper sacral wound 2.3 cm X 1.5 cm X 0.2 cm -Right buttock wound 3.0 cm X 1.3 cm X 0.2 cm -Left buttock wound 1.5 cm X 1.4 cm X 0.2 cm During an observation on 06/14/18 between 09:00 a.m. and 12:24 p.m., the wound treatment nurse RN#1 observed with poor hand hygiene by digging her hands into her pocket to get gloves Observation and interview on 06/14/18 at 3:33 p.m., revealed LVN #8, providing Resident #6's wound treatment. The measurements were correctly documented as: -Upper sacral wound 1.9 cm X 1.2 cm -Right buttock wound 5.4 cm X 3.5 cm -Left buttock wound 7.5 cm X 1.5 cm In an interview on 6/14/18 at 3:33 p.m., LVN #8 said she trained RN #1 on wound measuring when she came on board. She said the RN #1 nurse would step down and be given more effective training. Record review of Notification of Change in Resident's Health Status Policy dated (MONTH) (YEAR) revealed The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient representative when there is an acute illness or a significant change in the resident's physical, mental, or psychosocial status. Notification will be immediate. Record review of Facility's Skin Care Policy dated (MONTH) (YEAR) revealed DON will be responsible to implement and monitor the skin integrity program. Documentation should include any deterioration of wound status. If within 14 days there is no progress reassessment, reevaluation, and interventions are to be revised. The facility Administrator and DON were notified on 6/8/18 at 4:48 p.m. that an IJ was identified due to the above failures and a Plan of Removal PoR was requested. The POR was submitted by the Administrator on 06/08/18. After two revisions, the final plan of removal was accepted on 06/11/18 at 4:11 p.m Immediate Action All residents were reviewed for any change of condition by Nursing Administration beginning on 06/08/18. If there were any changes in condition, DNS, charge nurse and or wound care nurse contacted the medical Director or Nurse Practitioner to obtain orders as required for care as needed. If the Nurse practitioner does not return the call after 2nd attempts, the DNS, charge nurse, or wound care nurse will call the Medical Director. The attempts to contact the Medical Director or Nurse practitioner will be documented in progress notes. Education All staff were re-educated by DNS beginning 6/8/18 and 6/9/18, regarding Abuse and Neglect policy, skin Guidelines, Wound care Guidelines, Assessment of skin, Hospice Referrals, and change in condition. Wound care nurse provided wound training on skin Guidelines, Wound Guidelines which includes wound measurement, Assessment of skin and Wound care on 6/8/18. The DNS provided effective education proven by demonstrations. Regional Nurse conducted audits to verify effective education. DNS observed wound care provided for competency. DNS will conduct skin rounds beginning 6/8/18 and will continue skin rounds weekly RNs, LVNs, Permitted Medication Aides and Certified Nursing Assistants were re educated beginning on 6/8/18 and 6/9/18, by the DNS or designee regarding the system for responding to change of condition, when to notify the physician with a change of condition and to notify nursing if any skin issues noted then nursing will notify MD/NP for treatment orders and document accordingly. Administrator received training on Abuse and Neglect and Supervision of Nursing Administration by Regional Vice President for Texas and Director of Clinical Operations Any staff members that were not available at this time will not be allowed to work until education is completed. Personnel Roster was utilized to monitor attendance for education Monitoring Systemic changes and monitoring have been developed and approved by the Administrator, DNS and Medical Director. These changes went into on 06/08/18. The systemic changes and guidelines includes: Stop and Watch from Interact Implemented to assist in effective communication; review of any shower sheets in daily clinical start up meeting; and weekly skin assessment to be brought to daily clinical start up. These changes and monitoring have been put into place and put into Quality Assurance Performance Improvement (QAPI) for monthly reporting. Education has been provided by the DNS or Designee concerning the guidelines and changes on 6/8/2018. Content of education provided regarding the systematic changes includes: guidelines for Stop and Watch, guidelines for skin care including weekly skin assessments, wound care guidelines, shower sheets, Interdisciplinary communication regarding change of condition, Hospice Referrals and education on Abuse and Neglect. A QAPI meeting was held on 6/8/18. In attendance were the Administrator, DNS, ADNs, Medical Director, Unit Managers and other department leaders. Also, in attendance were support staff resource members from Diversicare. Allegations from survey were reviewed. Findings from the initial skin audits were discussed, along with any follow up assignments. Monitored results will be reviewed by the administrator and any adjustment to plan will be shared with the IDT team during QAPI. The surveyors monitored the PoR. Interviews were conducted with CNAs, LVNs, on each shift about change of condition and they described how they would recognize changes in residents' condition and what to do with that information. CNAs said they would report that information to the nurses. Nurses said that they would document the information in the resident's clinical record and consult with the resident's physician. Nurses were interviewed to determine if they were trained in wound care. Interview on 06/14/18 at 1:11 p.m., with the DON who was present during the wound care observation, she said she was aware of the wound treatment nurse RN #1 lacking technique skills by not following the infection control protocol. She said she had reached out to the District Nurse to train all the nursing staff to improve infection control and wound care technique. She said the nurse educator was informed about the skill needs and training would be put in place to improve infection control and wound care technique. She said that was why they brought a treatment nurse from a sister facility to help train RN #1. Interview on 06/14/18 at 02:05 p.m., RN #2 said the wound care nurse, RN #1, would be pulled out of the assignment. The training educator, LVN #8, would take over the wound treatment until they are able to get a good treatment nurse. She said they have contract with wound care physician, she said they will be coming in weekly to assess residents with wounds. Record review of the training records revealed in-services were conducted neglect, changes in condition, hospice process, ADL care, wound/skin care, and proper clinical documentation. Observations revealed the new treatment nurse, RN #1, performed wound care with poor hand hygiene. She also did not properly measure and document the size of Resident #6's wound. The facility removed wound care from responsibilities and gave her other duties until she receives additional training. She was replaced by the LVN #8, who was responsible for training at the corporate level. The Administrator and the DON were notified on 6/14/18 at 4:11 p.m. that the IJ was lowered. The facility remains out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. Facility's 672 dated 6/5/18 revealed 13 residents with pressure ulcers and and 58 residents receiving preventive skin care.

Based on interview and record review it was determined the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED].#1, Resident #6). - LVN #5 provided CR #1 with wound care with no physician orders. She did not consult with CR #1's physician to obtain orders when LVN #2 notified her about new wounds on both feet. She did not properly document wound size. - CR #1 was admitted to the hospital with [REDACTED]. CR #1's wounds on both feet and ankles were open wounds and deep tissue injuries. She also [MEDICAL CONDITION], pneumonia, and osteomeylitis when admitted to the hospital. - RN #1 provided Resident #6 wound care without using proper hand hygiene. She did not correctly measure Resident #6's wounds. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 6/8/18. While the IJ was lowered on 6/14/18, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. These failures affected one current and one discharged resident and placed placed 12 residents with pressure ulcers and 58 residents receiving preventive skin care at risk for developing new pressure ulcers or a decline in existing skin condition. Findings included: Intake # 4 CR #1 Record review of CR #1's Face Sheet revealed she was an [AGE] year-old female admitted to the facility 3/5/18. Her [DIAGNOSES REDACTED]. She was admitted with a catheter, peg tube, contractures and one stage 4 pressure sore. She was discharged to the hospital on [DATE]. Record review of CR #1's MDS assessment dated [DATE] revealed the staff assessment of cognitive skills indicated she had severely impaired cognitive skills and was totally dependent on staff for all of her activities of daily living care. She had a stage 4 pressure ulcer measuring 4.0 cm x 4.4 cm x 2.0 cm. It was assessed as granulation tissue-pink or red tissue with shiny, moist, granular appearance. Interventions did not list turning/repositioning. Record review of CR #1's Care Plan dated 3/6/18 revealed CR #1 has a stage 4 pressure ulcer to sacrum. At risk for further breakdown; has bilateral contractures of knees and elbows and incontinent episodes of bowel. The goal stated pressure ulcer will be healed and she will not experience any unidentified infections by 6/18/18. Approaches included turning and repositioning via two staff, wound care as ordered by physician, wound vac as ordered, mechanical lift, weekly evaluation of wound healing, daily observation of skin with routine care, full skin evaluation weekly with bath/shower, float heels on pillow as needed, observe for changes in skin status that may indicate worsening of pressure ulcer and notify the physician. Record review of CR #1's sacral wound assessment report dated 3/9/18 revealed her stage 4 pressure ulcer was 5.5 cm x 4.5 cm x 2 cm. There was 70% granulation tissue and 30% slough. The boarder of the wound was well-defined normal healthy skin. Record review of CR #1's sacral wound assessment reports dated 3/16/18, 3/23/18, 3/30/18, 4/6/18, 4/13/18, 4/20/18, 4/27/18, and 5/4/18 all recorded the same measurement: 4 cm x 4.4 cm x 2. These assessments all indicated there was 100% granulation tissue and the boarder of the wound was well-defined normal healthy skin. Record review of CR #1's Bath Sheets dated 3/29/18-5/1/18 only identified the sacral wound. Record review of CR #1's Nursing Note dated 4/25/18 and signed by LVN #2 revealed Skin assessment done this shift. Resident with open area to sacrum. Resident with area to left ankle, left outer side of foot, left heel, right foot great toe, next to great toe, inner aspect of foot next to great toe, inner heel to right foot, left top foot ankle area small, no drainage to any area, but all areas are dark in color. Resident on air mattress. Record review of CR #1's Wound Assessment Report dated 4/27/17 completed by LVN #5 revealed, Resident continues to have a stage 4 pressure ulcer to sacrum measuring 4.0 cm x 4.4 cm x 2.0 cm. Wound has decreased in size and has moderate amount of serosanguineous drainage with 100% of granulated tissue. Surrounding skin is well defined. No signs and symptoms of infection present. Wound vac changed on today and is intact, will continue to monitor. Record review of CR #1's Wound Assessment Report dated 5/4/18 and signed by LVN #5 revealed Resident continues to have a stage 4 pressure ulcer to sacrum measuring 4.0 cm x 4.4 cm x 2.0 cm. Wound has moderate amount of serosanguineous drainage with 100% of granulated tissue. Surrounding skin is well defined. No signs and symptoms of infection present. NP and RP notified. However, CR #2's emergency room assessment reflected a different skin assessment. Record review of CR #1's emergency room Note dated 5/6/18 revealed CR #1 is an [AGE] year-old female who lives in a nursing facility with known history of a sacral decubitus for a year was brought to the hospital [MEDICAL CONDITION] picture with multiorgan dysfunctio[DIAGNOSES REDACTED], pneumonia was suspected as well as UTI and severe rhabdomyolysis. She is contracted. She lies in a fetal position. Examination of the sacral area, she has a deep tissue injury that measures at least 15 cm in diameter in the middle of it that she has a wound that is 5-6 cm in diameter. It is deep to the bone. The entire wound almost 90% in necrotic with a foul-smelling discharge coming out. The edges of the wounds are everted an it tunnels all the way at least 2 cm all around. Now coming down to the bony prominences on her feet including the ankles, the fifth metatarsals, and the first metatarsals whatever she has a bone in her foot all of these has deep tissue injuries with foul smelling wounds, most of them are deep to the bones. She needs surgical debridement of all her wounds including the sacral wound. In an interview on 6/7/18 at 9:30 a.m., LVN #5 revealed she graduated in (MONTH) (YEAR) and this was her first nursing position. She started as a floor nurse and when the facility's previous treatment nurse resigned she was appointed the position. After one day of shadowing the previous treatment nurse in January, she took over doing wound care. LVN #5 stated she asked several times for training or a wound care doctor to which DON and previous Administrator denied. She inquired about a wound care certification class and according to DON, corporate denied the request. LVN #5 was responsible for treating nearly 20 residents during the week. The charge nurses were responsible for treatments. on the weekend. However, there were several instances where LVN #5 treated wounds that had a bandage dated from the previous Friday. LVN #5 tried to resign twice in which the second time DON agreed to start looking to fill the position. LVN #5 stated CR #1 did not have any open wounds besides the sacrum but had DTI on her feet. She stated her documentation could have been better and she should have documented everything she was doing for the resident. In an interview and record review on 6/12/18 at 1:00 p.m., the DON stated all nurses received training guided by the nurse competency checklist. The training LVN #5 received as a treatment nurse was no different from the other nurses. LVN #5 had two weeks of training from the previous treatment nurse, and two computer based training courses. The DON rounded with LVN #5 once or twice and felt she was doing a good job. LVN #5 did ask for extra training and there was communication between the DON and corporate via email about the wound care certification class. The DON saw CR #1's wound once when LVN #5 asked her to observe her replace the wound vac, however she didn't measure it or notice necrosis. The DON said she was informed of treatments not being done on the weekends and in-serviced the nurses. The Email dated 3/2/18 provided by the DON indicated she had written I found an online course that I believe would be sufficient enough to increase her knowledge and competency which was sent to Administrator. LVN #5's computer based training provided by the DON included: Pressure Injury/Ulcer Prevention Training dated 4/2/18 - 1 hour course and Infection Control and Prevention dated 5/1/18 - 1 hour course. In an interview on 6/14/18 at 11:39 a.m., Former Treatment Nurse stated she trained LVN #5 for 2-3 days for wound care. The training was supposed to be a week, but due to call ins LVN #5 would have to work the floor. She told the DON that LVN #5 wasn't ready and offered to stay to help, but it didn't happen. Resident #6 Record review of Resident #6's Face Sheet documented she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #6's Care Plan dated 05/01/2018, revealed she required weekly evaluation of wound healing. Record review of Resident #6's admission re-entry MDS dated [DATE], revealed BIMS score of 12 of 15, indicating she had moderate cognitive loss. She was totally dependent on two staff for mobility and transfer. During an observation on 06/14/18 between 09:00 a.m. and 12:24 p.m., the wound treatment nurse RN #1 provided Resident #6's wound care. She documented incorrect wound measurements as follows: -Upper sacral wound 2.3 cm X 1.5 cm X 0.2 cm -Right buttock wound 3.0 cm X 1.3 cm X 0.2 cm -Left buttock wound 1.5 cm X 1.4 cm X 0.2 cm During an observation on 06/14/18 between 09:00 a.m. and 12:24 p.m., the wound treatment nurse RN#1 observed with poor hand hygiene by digging her hands into her pocket to get gloves Observation and interview on 06/14/18 at 3:33 p.m., revealed LVN #8, providing Resident #6's wound treatment. The measurements were correctly documented as: -Upper sacral wound 1.9 cm X 1.2 cm -Right buttock wound 5.4 cm X 3.5 cm -Left buttock wound 7.5 cm X 1.5 cm In an interview on 6/14/18 at 3:33 p.m., LVN #8 said she trained RN #1 on wound measuring when she came on board. She said the RN #1 nurse would step down and be given more effective training. Documentation Policy was requested from the DON on 6/13/18 at 3:00 p.m., but not received prior to exit. Record review of Facility's Statement of Resident Rights, undated, revealed You, (the resident), have a right to all care necessary for you to have the highest possible level of health. Record review of the Texas Board of Nursing Standards of Practice SECTION 217.11 revealed each nurse must .(B) Implement measures to promote a safe environment for clients and others; . (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; . (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; . The facility Administrator and DON were notified on 6/8/18 at 4:48 p.m. that an IJ was identified due to the above failures and a Plan of Removal PoR was requested. The POR was submitted by the Administrator on 06/08/18. After two revisions, the final plan of removal was accepted on 06/11/18 at 4:11 p.m Immediate Action All residents were reviewed for any change of condition by Nursing Administration beginning on 06/08/18. If there were any changes in condition, DNS, charge nurse and or wound care nurse contacted the medical Director or Nurse Practitioner to obtain orders as required for care as needed. If the Nurse practitioner does not return the call after 2nd attempts, the DNS, charge nurse, or wound care nurse will call the Medical Director. The attempts to contact the Medical Director or Nurse practitioner will be documented in progress notes. Education All staff were re-educated by DNS beginning 6/8/18 and 6/9/18, regarding Abuse and Neglect policy, skin Guidelines, Wound care Guidelines, Assessment of skin, Hospice Referrals, and change in condition. Wound care nurse provided wound training on skin Guidelines, Wound Guidelines which includes wound measurement, Assessment of skin and Wound care on 6/8/18. The DNS provided effective education proven by demonstrations. Regional Nurse conducted audits to verify effective education. DNS observed wound care provided for competency. DNS will conduct skin rounds beginning 6/8/18 and will continue skin rounds weekly RNs, LVNs, Permitted Medication Aides and Certified Nursing Assistants were re educated beginning on 6/8/18 and 6/9/18, by the DNS or designee regarding the system for responding to change of condition, when to notify the physician with a change of condition and to notify nursing if any skin issues noted then nursing will notify MD/NP for treatment orders and document accordingly. Administrator received training on Abuse and Neglect and Supervision of Nursing Administration by Regional Vice President for Texas and Director of Clinical Operations Any staff members that were not available at this time will not be allowed to work until education is completed. Personnel Roster was utilized to monitor attendance for education Monitoring Systemic changes and monitoring have been developed and approved by the Administrator, DNS and Medical Director. These changes went into on 06/08/18. The systemic changes and guidelines includes: Stop and Watch from Interact Implemented to assist in effective communication; review of any shower sheets in daily clinical start up meeting; and weekly skin assessment to be brought to daily clinical start up. These changes and monitoring have been put into place and put into Quality Assurance Performance Improvement (QAPI) for monthly reporting. Education has been provided by the DNS or Designee concerning the guidelines and changes on 6/8/2018. Content of education provided regarding the systematic changes includes: guidelines for Stop and Watch, guidelines for skin care including weekly skin assessments, wound care guidelines, shower sheets, Interdisciplinary communication regarding change of condition, Hospice Referrals and education on Abuse and Neglect. A QAPI meeting was held on 6/8/18. In attendance were the Administrator, DNS, ADNs, Medical Director, Unit Managers and other department leaders. Also, in attendance were support staff resource members from Diversicare. Allegations from survey were reviewed. Findings from the initial skin audits were discussed, along with any follow up assignments. Monitored results will be reviewed by the administrator and any adjustment to plan will be shared with the IDT team during QAPI. The surveyors monitored the PoR. Interviews were conducted with CNAs, LVNs, on each shift about change of condition and they described how they would recognize changes in residents' condition and what to do with that information. CNAs said they would report that information to the nurses. Nurses said that they would document the information in the resident's clinical record and consult with the resident's physician. Nurses were interviewed to determine if they were trained in wound care. The DON said that the facility also arranged with a wound care physician to make weekly rounds at the facility. Interview on 06/14/18 at 1:11 p.m., with the DON who was present during the wound care observation, she said she was aware of the wound treatment nurse RN #1 lacking technique skills by not following the infection control protocol. She said she had reached out to the District Nurse to train all the nursing staff to improve infection control and wound care technique. She said the nurse educator was informed about the skill needs and training would be put in place to improve infection control and wound care technique. She said that was why they brought a treatment nurse from a sister facility to help train RN #1. Interview on 06/14/18 at 02:05 p.m., RN #2 said the wound care nurse, RN #1, would be pulled out of the assignment. The training educator, LVN #8, would take over the wound treatment until they are able to get a good treatment nurse. She said they have contract with wound care physician, she said they will be coming in weekly to assess residents with wounds. Record review of the training records revealed in-services were conducted neglect, changes in condition, hospice process, ADL care, wound/skin care, and proper clinical documentation. Observations revealed the new treatment nurse, RN #1, performed wound care with poor hand hygiene. She also did not properly measure and document the size of Resident #6's wound. The facility removed wound care from responsibilities and gave her other duties until she receives additional training. She was replaced by the LVN #8, who was responsible for training at the corporate level. The Administrator and the DON were notified on 6/14/18 at 4:11 p.m. that the IJ was lowered. The facility remains out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. Facility's 672 dated 6/5/18 revealed 13 residents with pressure ulcers and 58 residents receiving preventive skin care.

Based on observation, interview, and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of 1 of 5 residents (Resident CR #1) reviewed for administration. The Administrator failed to: - Implement the facility's Abuse, Neglect, and Exploitation; Resident Rights; and Quality of Care policies and procedures. - Supervise the DON by ensuring a staff were trained and competent to recognize changes in residents' condition; consult with physician; and manage wound care. The Director of Nurses failed to: - Implement the facility's Abuse, Neglect, and Exploitation; Resident Rights; and Quality of Care policies and procedures. - Supervise, sufficiently train, and monitor staff to ensure they were competent to assess wounds, consult with physicians, and complete clinical documentation. The above failures resulted in an IJ situation on 6/8/18. While the IJ was lowered on 6/14/18, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures affected one discharged resident and placed placed 101 residents at risk of not receiving proper care when experiencing a change in condition. The findings include: In an interview on 6/12/18 at 10:40 a.m., Administrator stated although she was unaware of the situation, she believed the IJ was is a result of miscommunication between physicians and the facility. Unit manager rounds, morning meetings, QAPI meetings, and stand down meetings were ways she ensured nursing needs of residents were met. The DON was also now responsible for doing weekly rounds with the treatment nurse for residents receiving treatment, and bi-monthly skin rounds on all residents. New nurses were evaluated for 3 days using a competency worksheet. In an interview on 6/12/18 at 1:00 p.m., the DON stated she believed this incident came about due to a lack of documentation and communication with the responsible party. She also stated she was responsible for not monitoring and validating documentation made by nursing staff. CR #1 Record review of CR #1's Face Sheet revealed she was an [AGE] year-old female admitted to the facility 3/5/18. Her [DIAGNOSES REDACTED]. She was admitted with a catheter, peg tube, contractures and one stage 4 pressure sore. She was discharged to the hospital on [DATE]. Record review of CR #1's MDS assessment dated [DATE] revealed the staff assessment of cognitive skills indicated she had severely impaired cognitive skills and was totally dependent on staff for all of her activities of daily living care. She had a stage 4 pressure ulcer measuring 4.0 cm x 4.4 cm x 2.0 cm. It was assessed as granulation tissue-pink or red tissue with shiny, moist, granular appearance. Interventions did not included turning or repositioning. Record review of CR #1's Care Plan dated 3/6/18 revealed CR #1 has a stage 4 pressure ulcer to sacrum. At risk for further breakdown; has bilateral contractures of knees and elbows and incontinent episodes of bowel. The goal stated pressure ulcer will be healed and she will not experience any unidentified infections by 6/18/18. Approaches included turning and repositioning via two staff, wound care as ordered by physician, wound vac as ordered, mechanical lift, weekly evaluation of wound healing, daily observation of skin with routine care, full skin evaluation weekly with bath/shower, float heels on pillow as needed, observe for changes in skin status that may indicate worsening of pressure ulcer and notify the physician. Record review of CR #1's sacral wound assessment report dated 3/9/18 revealed her stage 4 pressure ulcer was 5.5 cm x 4.5 cm x 2 cm. There was 70% granulation tissue and 30% slough. The boarder of the wound was well-defined normal healthy skin. Record review of CR #1's sacral wound assessment reports dated 3/16/18, 3/23/18, 3/30/18, 4/6/18, 4/13/18, 4/20/18, 4/27/18, and 5/4/18 all recorded the same measurement: 4 cm x 4.4 cm x 2. These assessments all indicated there was 100% granulation tissue and the boarder of the wound was well-defined normal healthy skin. Record review of CR #1's Bath Sheets dated 3/29/18-5/1/18 only identified the sacral wound. Record review of CR #1's Clinical Chart revealed an order dated 4/23/18 Discontinue wound vac . three times a week to sacrum. Apply wet to dry dressing to affected area every day or as needed until further evaluations. The order did not have a physician's signature. Record review of CR #1's Treatment Administration Record dated (MONTH) (YEAR) revealed the following: -Stage 4 ulcer to sacrum: clean with normal saline, pat dry, apply wet to dry dressing, and cover with dry protective dressing daily. Ordered 4/26/18 and discontinued 5/6/18. Treatments were signed as being received. Record review of CR #1's Nursing Note dated 4/25/18 and signed by LVN #2 revealed Skin assessment done this shift. Resident with open area to sacrum. Resident with area to left ankle, left outer side of foot, left heel, right foot great toe, next to great toe, inner aspect of foot next to great toe, inner heel to right foot, left top foot ankle area small, no drainage to any area, but all areas are dark in color. Resident on air mattress. In an interview on 6/8/18 at 1:40 p.m., LVN #2 stated she turned in a communication form into the treatment nurse following CR #1's 4/25/18 skin assessment. She was informed by treatment nurse that there was treatment in place for the wounds she noted on the heels and feet. She did not notify CR #1's physician. Record review of CR #1's Wound Assessment Reports dated 5/4/18 and signed by LVN #5 revealed Resident continues to have a stage 4 pressure ulcer to sacrum measuring 4.0 cm x 4.4 cm x 2.0 cm. Wound has moderate amount of serosanguineous drainage with 100% of granulated tissue. Surrounding skin is well defined. No signs and symptoms of infection present. NP and RP notified. However, CR #1's emergency room assessment reflected a different skin assessment. Record review of CR #1's Nursing Note dated 5/6/18 and signed by LVN #4 revealed MD notified STAT lab results from 5/5/18. CBC, CMP Potassium 6.6, BUN 95, WBC 42.2, Creatinine 4.8. BP 136/72, P 81, R 18, O2 Sat 97% RA. DR. notified. N/O Send to KW for further eval. Message left for RP, DON informed. Transported via EMS x 2. Record review of CR #1's emergency room Note dated 5/6/18 revealed CR #1 is an [AGE] year-old female who lives in a nursing facility with known history of a sacral decubitus for a year was brought to the hospital [MEDICAL CONDITION] picture with multiorgan dysfunctio[DIAGNOSES REDACTED], pneumonia was suspected as well as UTI and severe rhabdomyolysis. She lies in a fetal position. Examination of the sacral area, she has a deep tissue injury that measures at least 15 cm in diameter in the middle of it that she has a wound that is 5-6 cm in diameter. It is deep to the bone. The entire wound almost 90% in necrotic with a foul-smelling discharge coming out. The edges of the wounds are everted an it tunnels all the way at least 2 cm all around. Now coming down to the bony prominences on her feet including the ankles, the fifth metatarsals, and the first metatarsals whatever she has a bone in her foot all of these has deep tissue injuries with foul smelling wounds, most of them are deep to the bones. She needs surgical debridement of all her wounds including the sacral wound. Labs collected revealed WBC is 38,000, hemoglobin 9, and platelet count 254. Sodium is 132, potassium 5.8, creatinine is 4, BUN is 103, creatinine kinase is 112,000. Procalcitonin is more than 200. Clinical impressions included [MEDICAL CONDITION], failure to thrive, and pneumonia. In an interview on 6/7/18 at 9:30 a.m., LVN #5 revealed she graduated in (MONTH) (YEAR) and this was her first nursing position. She started as a floor nurse and when the facility's previous treatment nurse resigned she was appointed the position. After one day of shadowing the previous treatment nurse in January, she took over doing wound care. LVN #5 stated she asked several times for training or a wound care doctor to which DON and previous Administrator denied. She inquired about a wound care certification class and according to DON, corporate denied the request. LVN #5 was responsible for treating nearly 20 residents during the week. The charge nurses were responsible for treatments. on the weekend. However, there were several instances where LVN #5 treated wounds that had a bandage dated from the previous Friday. LVN #5 tried to resign twice in which the second time DON agreed to start looking to fill the position. LVN #5 stated CR #1 did not have any open wounds besides the sacrum but had DTI on her feet. She stated her documentation could have been better and she should have documented everything she was doing for the resident. In an interview and record review on 6/12/18 at 1:00 p.m., the DON stated all nurses received training guided by the nurse competency checklist. The training LVN #5 received as a treatment nurse was no different from the other nurses. LVN #5 had two weeks of training from the previous treatment nurse and computer based training. The DON rounded with LVN #5 once or twice and felt she was doing a good job. LVN #5 did ask for extra training and there was communication between the DON and corporate via email about the wound care certification class. The DON saw CR #1's wound once when LVN #5 asked her to observe her replace the wound vac, however she didn't measure it or notice necrosis. The DON was informed of treatments not being done on the weekends and in-serviced the nurses. The Email dated 3/2/18 provided by the DON indicated she had written I found an online course that I believe would be sufficient enough to increase her knowledge and competency which was sent to Administrator. LVN #5's computer based training list provided by the DON included: Pressure Injury/Ulcer Prevention Training dated 4/2/18 - 1 hour course and Infection Control and Prevention dated 5/1/18 - 1 hour course. In an interview on 6/13/18 LVN #2 stated the facility was having a problem with skin so they cracked down on skin sheets. When she did the skin assessment on CR #1 she walked through the shower sheet with the treatment nurse who said she was already treating the areas. She stated she only saw the wound once and described it as irregular, no odor, and medium sized (being able to fit at least three fingers inside). In an interview on 6/14/18 at 11:39 a.m., Former Treatment Nurse stated she trained LVN #5 for 2-3 days for wound care. The training was supposed to be a week, but due to call ins LVN #5 would have to work the floor. She told the DON that LVN #5 wasn't ready and offered to stay to help, but it didn't happen. Record review of Facility's Abuse Policy dated (MONTH) (YEAR) revealed During orientation, new team members shall be trained on the obligation to report alleged violations. Training shall include definitions of alleged violations and examples of reportable incidents to assist staff in detection of such incidents. The Administrator/Director of Nursing shall identify, intervene and correct situations in which abuse, neglect, or misappropriation of resident property are more likely to occur. All other staff is required to report such potential situations to the Administrator/Director of Nursing as soon as identified. Reporting of suspected alleged violations is required of every team member. All alleged violations involving mistreatment, neglect, abuse, or exploitation including injuries of unknown source and misappropriation of resident/patient property are reported immediately to the Administrator/Director of Nursing and to other officials in accordance with State law through established procedures. Immediately means as soon as possible: Any neglect, mistreatment, exploitation or injuries of unknown source resulting in serious injury within two hours. Record review of Facility's Statement of Resident Rights, undated, revealed You, (the resident), have a right to all care necessary for you to have the highest possible level of health. Record review of Notification of Change in Resident's Health Status Policy dated (MONTH) (YEAR) revealed The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient representative when there is an acute illness or a significant change in the resident's physical, mental, or psychosocial status. Notification will be immediate. The facility Administrator and DON were notified on 6/8/18 at 4:48 p.m. that an IJ was identified due to the above failures and a Plan of Removal PoR was requested. The POR was submitted by the Administrator on 06/08/18. After two revisions, the final plan of removal was accepted on 06/11/18 at 4:11 p.m Immediate Action All residents were reviewed for any change of condition by Nursing Administration beginning on 06/08/18. If there were any changes in condition, DNS, charge nurse and or wound care nurse contacted the medical Director or Nurse Practitioner to obtain orders as required for care as needed. If the Nurse practitioner does not return the call after 2nd attempts, the DNS, charge nurse, or wound care nurse will call the Medical Director. The attempts to contact the Medical Director or Nurse practitioner will be documented in progress notes. Education All staff were re-educated by DNS beginning 6/8/18 and 6/9/18, regarding Abuse and Neglect policy, skin Guidelines, Wound care Guidelines, Assessment of skin, Hospice Referrals, and change in condition. Wound care nurse provided wound training on skin Guidelines, Wound Guidelines which includes wound measurement, Assessment of skin and Wound care on 6/8/18. The DNS provided effective education proven by demonstrations. Regional Nurse conducted audits to verify effective education. DNS observed wound care provided for competency. DNS will conduct skin rounds beginning 6/8/18 and will continue skin rounds weekly RNs, LVNs, Permitted Medication Aides and Certified Nursing Assistants were re educated beginning on 6/8/18 and 6/9/18, by the DNS or designee regarding the system for responding to change of condition, when to notify the physician with a change of condition and to notify nursing if any skin issues noted then nursing will notify MD/NP for treatment orders and document accordingly. Administrator received training on Abuse and Neglect and Supervision of Nursing Administration by Regional Vice President for Texas and Director of Clinical Operations Any staff members that were not available at this time will not be allowed to work until education is completed. Personnel Roster was utilized to monitor attendance for education Monitoring Systemic changes and monitoring have been developed and approved by the Administrator, DNS and Medical Director. These changes went into on 06/08/18. The systemic changes and guidelines includes: Stop and Watch from Interact Implemented to assist in effective communication; review of any shower sheets in daily clinical start up meeting; and weekly skin assessment to be brought to daily clinical start up. These changes and monitoring have been put into place and put into Quality Assurance Performance Improvement (QAPI) for monthly reporting. Education has been provided by the DNS or Designee concerning the guidelines and changes on 6/8/2018. Content of education provided regarding the systematic changes includes: guidelines for Stop and Watch, guidelines for skin care including weekly skin assessments, wound care guidelines, shower sheets, Interdisciplinary communication regarding change of condition, Hospice Referrals and education on Abuse and Neglect. A QAPI meeting was held on 6/8/18. In attendance were the Administrator, DNS, ADNs, Medical Director, Unit Managers and other department leaders. Also, in attendance were support staff resource members from Diversicare. Allegations from survey were reviewed. Findings from the initial skin audits were discussed, along with any follow up assignments. Monitored results will be reviewed by the administrator and any adjustment to plan will be shared with the IDT team during QAPI. The surveyors monitored the PoR. Interviews were conducted with CNAs, LVNs, on each shift about change of condition and they described how they would recognize changes in residents' condition and what to do with that information. CNAs said they would report that information to the nurses. Nurses said that they would document the information in the resident's clinical record and consult with the resident's physician. Nurses were interviewed to determine if they were trained in wound care. The DON said that the facility also arranged with a wound care physician to make weekly rounds at the facility. In an interview on 6/12/18 at 10:40 a.m., Administrator stated Unit manager rounds, morning meetings, QAPI meetings, and stand down meetings were ways she ensured nursing needs of residents were met. However, now she would validate information given to her. The DON was also now responsible for doing weekly rounds with the treatment nurse for residents receiving treatment, and bi-monthly skin rounds on all residents. Previously, new nurses were evaluated for 3 days using a competency worksheet. From this point forward, new nurses would be evaluated for 5 days. She would also make rounds to ensure policies and procedures are being followed and hold people accountable. In an interview on 6/12/18 at 1:00 p.m., the DON stated moving forward she planned to round weekly with the treatment nurse. During these rounds, she would validate documents from staff, and be a better supervisor. Staff have been in-serviced on change in condition, abuse and neglect, and documentation. Record review of the training records revealed in-services were conducted neglect, changes in condition, hospice process, ADL care, wound/skin care, and proper clinical documentation. Observations revealed the new treatment nurse, RN #1, performed wound care with poor hand hygiene. She also did not properly measure and document the size of Resident #6's wound. The facility removed wound care from responsibilities and gave her other duties until she receives additional training. She was replaced by the LVN #8, who was responsible for training at the corporate level. The Administrator and the DON were notified on 6/14/18 at 4:11 p.m. that the IJ was lowered. The facility remains out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. CMS 672 dated 6/5/18 revealed a census of 101 residents.

Based on interview, and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 2 of 5 residents (Resident #4 and CR #1) reviewed for a change of condition, in that: - The physician was not consulted when LVN #2 identified CR #1's new wounds and deep tissue injuries on both feet. - The facility discontinued using CR #1's wound vac without physician's orders [REDACTED]. - The facility's failure to treat her wounds with physician supervision and consultation resulted in CR #1's hospital admission [MEDICAL CONDITION], pneumonia, and osteomeylitis. - The physician was not consulted for 6 hours after the wound care nurse identified that Resident #4 had increased drainage and foul odor smelling at his surgical stump. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 6/8/18. While the IJ was lowered on 6/14/18, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. These failures affected one discharged resident and one current resident and placed 100 residents at risk of a delay of appropriate medical treatment and worsening of condition. Findings include: Intake # 4 Intake # 9 CR #1 Record review of CR #1's Face Sheet revealed she was an [AGE] year-old female admitted to the facility 3/5/18. Her [DIAGNOSES REDACTED]. She was admitted with a catheter, peg tube, contractures and one stage 4 pressure sore. She was discharged to the hospital on [DATE]. Record review of CR #1's MDS assessment dated [DATE] revealed the staff assessment of cognitive skills indicated she had severely impaired cognitive skills and was totally dependent on staff for all of her activities of daily living care. She had a stage 4 pressure ulcer measuring 4.0 cm x 4.4 cm x 2.0 cm. It was assessed as granulation tissue-pink or red tissue with shiny, moist, granular appearance. Record review of CR #1's Care Plan dated 3/6/18 revealed CR #1 has a stage 4 pressure ulcer to sacrum. At risk for further breakdown; has bilateral contractures of knees and elbows and incontinent episodes of bowel. The goal stated pressure ulcer will be healed and she will not experience any unidentified infections by 6/18/18. Approaches included turning and repositioning via two staff, wound care as ordered by physician, wound vac as ordered, mechanical lift, weekly evaluation of wound healing, daily observation of skin with routine care, full skin evaluation weekly with bath/shower, float heels on pillow as needed, observe for changes in skin status that may indicate worsening of pressure ulcer and notify the physician. Record review of CR #1's sacral wound assessment report dated 3/9/18 revealed her stage 4 pressure ulcer was 5.5 cm x 4.5 cm x 2 cm. There was 70% granulation tissue and 30% slough. The boarder of the wound was well-defined normal healthy skin. Record review of CR #1's sacral wound assessment reports dated 3/16/18, 3/23/18, 3/30/18, 4/6/18, 4/13/18, 4/20/18, 4/27/18, and 5/4/18 all recorded the same measurement: 4 cm x 4.4 cm x 2. These assessments all indicated there was 100% granulation tissue and the boarder of the wound was well-defined normal healthy skin. Record review of CR #1's Bath Sheets dated 3/29/18-5/1/18 only identified the sacral wound. Record review of CR #1's Medication Administration Record [REDACTED] -Stage 4 pressure ulcer to sacrum: cleanse with normal saline, pat dry three times a week, apply continuous negative pressure vacuum at 125 mmHg . Ordered 3/6/18 and started 3/9/18. Treatments were signed that they were received. Record review of CR #1's Treatment Administration Record dated (MONTH) (YEAR) revealed the following: -Apply wet to dry to affected area every day or as needed until further evaluations. Ordered 4/23/18 and discontinued 5/1/18. Treatments were signed as being received. -Stage 4 pressure ulcer to sacrum: cleanse with normal saline, pat dry three times a week, apply continuous negative pressure vacuum at 125 mmHg . Ordered 3/7/18 and discontinued 4/23/18. Treatments were signed as being received. -Stage 4 ulcer to sacrum: clean with normal saline, pat dry, apply wet to dry dressing, and cover with dry protective dressing daily. Ordered 4/26/18 and discontinued 5/6/18. Treatments were signed as being received. Record review of CR #1's Clinical Chart revealed a telephone order dated 4/23/18 Discontinue wound vac . Apply wet to dry dressing to affected area every day or as needed until further evaluations. The order was written by LVN #1 and did not have a physician's signature. Record review of CR #1's Treatment Administration Record dated (MONTH) (YEAR) revealed the following: -Stage 4 ulcer to sacrum: clean with normal saline, pat dry, apply wet to dry dressing, and cover with dry protective dressing daily. Ordered 4/26/18 and discontinued 5/6/18. Treatments were signed as being received. In an interview on 6/7/18 at 10:15 a.m., LVN #5 stated the wound vac was discontinued by LVN #1 on 04/26/18, she said LVN #1 stated she did not think the wound vac is working effectively because of its beeping, she said she did not know if the physician signed the order or not. Attempts to reach LVN #1 by phone for an interview were unsuccessful. In an interview on 6/7/18 at 2:40 p.m., NP #1 said she did not give any order to discontinue the wound vac, she said no staff discussed the wound vac discontinuation with her before they removed it In an interview on 6/7/18 at 3:50 p.m., NP #2 said she did not give any order to discontinue the wound vac In an interview on 6/7/18 at 5:10 p.m., MD #1 stated he did not give an order for [REDACTED]. In an interview on 6/7/18 at 6:04 p.m., MD #2 stated he only came on 3/30/18 to get to know the resident, he said he cannot recall if he saw the wound or not, he said he did not know the measurement, he said he did not believe he gave any order for wound treatment, he said he did not give any order to discontinue the wound vac, he said if I don't put a wound vac, I don't discontinue it In an interview on 6/7/18 at 6:30 p.m., MD #1 stated he has confirmed from all his NPs and MD, he said they did not give order to discontinue the wound vac. Record review of CR #1's Nursing Note dated 4/25/18 and signed by LVN #2 revealed Skin assessment done this shift. Resident with open area to sacrum. Resident with area to left ankle, left outer side of foot, left heel, right foot great toe, next to great toe, inner aspect of foot next to great toe, inner heel to right foot, left top foot ankle area small, no drainage to any area, but all areas are dark in color. Resident on air mattress. In an interview on 6/8/18 at 1:40 p.m., LVN #2 stated she turned in a communication form into the treatment nurse following CR #1's 4/25/18 skin assessment. She was informed by treatment nurse that there was treatment in place for the wounds she noted on the heels and feet. She did not notify CR #1's physician. Record review of CR #1's Wound Assessment Reports dated 5/4/18 and signed by LVN #5 revealed Resident continues to have a stage 4 pressure ulcer to sacrum measuring 4.0 cm x 4.4 cm x 2.0 cm. Wound has moderate amount of serosanguineous drainage with 100% of granulated tissue. Surrounding skin is well defined. No signs and symptoms of infection present. NP and RP notified. However, CR #1's emergency room assessment reflected a different skin assessment. Record review of CR #1's Nursing Note dated 5/6/18 and signed by LVN #4 revealed CR #1 was noted with coughing, MD notified, STAT lab results from 5/5/18. CBC, CMP Potassium 6.6, BUN 95, WBC 42.2, Creatinine 4.8. BP 136/72, P 81, R 18, O2 Sat 97% RA. DR. Franks notified. N/O Send to KW for further eval. Message left for RP, DON informed. Transported via EMS x 2. Record review of CR #1's emergency room Note dated 5/6/18 revealed CR #1 is an [AGE] year-old female who lives in a nursing facility with known history of a sacral decubitus for a year was brought to the hospital [MEDICAL CONDITION] picture with multiorgan dysfunctio[DIAGNOSES REDACTED], pneumonia was suspected as well as UTI and severe rhabdomyolysis. Upon admission, the patient was found to have acute [MEDICAL CONDITION] with a creatinine of 4, elevation of the liver enzymes and a CK of 12,000 with lactic acidosis. The patient was started empirically on antibiotics and cultures were sent. Urine was quite [MEDICAL CONDITION]. It is worth mentioning that the patient had advanced dementia and she had a PEG tube for nutrition. There were some concerns about aspiration. During the exam, it was found that the patient has discharge around the PEG tube that has a foul smell. She is contracted. She lies in a fetal position. Examination of the sacral area, she has a deep tissue injury that measures at least 15 cm in diameter in the middle of it that she has a wound that is 5-6 cm in diameter. It is deep to the bone. The entire wound almost 90% in necrotic with a foul-smelling discharge coming out. The edges of the wounds are everted an it tunnels all the way at least 2 cm all around. Now coming down to the bony prominences on her feet including the ankles, the fifth metatarsals, and the first metatarsals whatever she has a bone in her foot all of these has deep tissue injuries with foul smelling wounds, most of them are deep to the bones. She needs surgical debridement of all her wounds including the sacral wound. Labs collected revealed WBC is 38,000, hemoglobin 9, and platelet count 254. Sodium is 132, potassium 5.8, creatinine is 4, BUN is 103, creatinine kinase is 112,000. Procalcitonin is more than 200. Clinical impressions included [MEDICAL CONDITION], failure to thrive, and pneumonia. Record review of CR #1's Wound Care Consultation dated 5/14/18 revealed There are multiple ulcerations noted to bilateral lower extremities. There is a large fibrotic ulceration to the right lateral ankle that is boggy with significant fibrotic tissue. There are multiple other deep tissue injuries noted to the right lateral foot. The right foot is dusky in appearance. On the medial posterior heel, there is also ulceration as well as multiple deep tissue injuries on the medial aspect of the right foot. On the left foot, there are medial deep tissue injuries with the posterior heel ulceration as well as multiple open ulcerations on the left lateral foot and ankle. On the left, there is dusky appearance as well. The plan revealed The patient is seen and evaluated at bedside. Overall, the patient has poor prognosis and is a poor surgical candidate for any wound debridement to the right or left lower extremities. The patient has significant signs of decrease blood flow and ultimately would not tolerate any surgical procedures to the right lower extremity. If any debridement that would be performed would likely further expose the patient and the patient's functional status is limited at this time. If anything was to be contemplated, most likely the patient would require bilateral above-the-knee amputations. However, the patient still has sacral osteo[DIAGNOSES REDACTED], sacral wounds. Podiatry will not proceed forward with any surgical interventions at this time. In an interview on 6/7/18 at 9:30 a.m., LVN #5 revealed she graduated in (MONTH) (YEAR) and this was her first nursing position. She started as a floor nurse and when the facility's previous treatment nurse resigned she was appointed the position. After one day of shadowing the previous treatment nurse in (MONTH) (YEAR), she took over doing wound care. LVN #5 stated she asked several times for training or a wound care doctor to which DON and previous Administrator denied. She inquired about a wound care certification class and according to DON, corporate denied the request. LVN #5 was responsible for treating nearly 20 residents during the week. The charge nurses were responsible for treatments on the weekend. However, there were several instances where LVN #5 treated wounds that had a bandage dated from the previous Friday. LVN #5 said she tried to resign twice in which the second time DON agreed to start looking to fill the position. LVN #5 stated CR #1 did not have any open wounds besides the sacrum but had DTI on her feet. She stated her documentation could have been better and she should have documented everything she was doing for the resident. In an interview on 6/8/18 at 4:40 p.m., NP #1 stated she had been seeing CR #1 since (MONTH) (YEAR). She completed a skin assessment on her first visit, but she didn't see the sacral wound because the wound vac covered the wound. NP #1 stated she never saw CR #1's wound and her condition was the same as baseline. NP #1 was never informed that the wound vac was not working and never gave the order to discontinue it. In an interview and record review on 6/12/18 at 1:00 p.m., the DON stated all nurses received training guided by the nurse competency checklist. The training LVN #5 received as a treatment nurse was no different from the other nurses. LVN #5 had two weeks of training from the previous treatment nurse and computer based training. The DON rounded with LVN #5 once or twice and felt she was doing a good job. LVN #5 did ask for extra training and there was communication between the DON and corporate via email about the wound care certification class. The DON saw CR #1's wound once when LVN #5 asked her to observe her replace the wound vac, however she didn't measure it or notice necrosis. The DON said she was informed of treatments not being done on the weekends and in-serviced the nurses. The Email dated 3/2/18 provided by the DON indicated she had written I found an online course that I believe would be sufficient enough to increase her knowledge and competency which was sent to Administrator. The training was a Relias training. LVN #5's computer based training provided by the DON included: Pressure Injury/Ulcer Prevention Training dated 4/2/18 - 1 hour course and Infection Control and Prevention dated 5/1/18 - 1 hour course. In a later interview on 6/13/18 at 12:10 p.m, LVN #2 stated the facility was having a problem with skin so they cracked down on skin sheets. When she did the skin assessment on CR #1 she reviewed through the shower sheet with the treatment nurse who said she was already treating the areas. She stated she only saw the wound once and described it as irregular, no odor, and medium sized (being able to fit at least three fingers inside). In an interview on 6/14/18 at 11:39 a.m., Former Treatment Nurse stated she trained LVN #5 for 2-3 days for wound care. The training was supposed to be a week, but due to call ins LVN #5 would have to work the floor. She told the DON that LVN #5 wasn't ready and offered to stay to help, but it didn't happen. Resident #4 Record review of Resident #4's Face Sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #4's 02/21/18 Admission MDS assessment revealed he had severely impaired cognitive skills. Record review of Resident #4's care plan dated 05/21/18, printed on 6/08/18, revealed there were no approaches addressing care for his resident bilateral knee amputation surgical wound. Record review of Resident #4's care plan dated 05/21/18, printed on 06/14/18, revealed a problem of bilateral knee amputation surgical wound, but did not address the goals and approaches for the wound Record review of Resident #4's discharge report dated 05/21/18 revealed the name of the surgeon that operated on him. Record review of Resident #4's physician's orders [REDACTED]. Record review of facility facsimile transmission verification report dated 5/31/18 revealed facility requested for Resident #4 medical records from local hospital, the verification report status showed busy/no response. Record review of Resident #4's physician's orders [REDACTED]. Observation of Resident #4 during tour with the wound care nurse RN #1 on 6/7/18 at 11:10 a.m. tour revealed resident was in his room awake, he has a bilateral below knee amputation wound that was noted with an open suture, medium drainage and foul odor. Record review of Resident #4's Nurses' Notes dated 06/01/18 through 06/06/18 did not reveal documentation by the wound care nurse RN #1 of any drainage and foul odor observed prior to touring with surveyor on 06/07/18. Record review of Resident #4's Nurses' notes on 06/07/18, did not reveal documentation indicating attempts were made to get in touch with the Surgeon to schedule a follow up appointment for the surgical site. During an observation and interview on 6/8/18 at 09:20 a.m. with LVN A, LVN A observed assessing Resident #4, LVN A said the NP #3 was here this morning to assess Resident #4, she said the NP #3 prescribed IV antibiotic for infection at the surgical stump site. During an interview on 6/8/18 at 09:35 a.m. with NP #3, she said someone called her and left a message on 06/07/18 around 5 p.m NP #3 was unsure who called, but the person left a message that Resident #4 had an open suture on his stump. She came in on 06/08/18 around 8 a.m. to assess the resident and found out that Resident #4's stump site had drainage and a foul odor. She ordered an IV antibiotic. NP #3 stated the person that called on 06/07/18 did not inform her that there was drainage or odor at the stump surgical site. During an interview on 6/8/18 at 3:20 p.m. with RN #1 revealed she started working for the facility on 5/23/18. Surveyor asked RN #1 if she reported the discharge observed on 06/07/18, RN #1 said there was not much drainage and felt like it was not worth reporting to the physician or NP. RN #1 stated the drainage is just a drop and not much. Surveyor asked her how to determine a change in condition, she said if there is any change in baseline, she will call the physician, notify the DON and the responsible party. During an interview on 6/8/18 at 3:40 p.m. LVN #7 stated in order to determine a change in condition she would look at the resident's baseline and obtain vitals. If a difference is noted, the resident's physician, RP, and DON would be notified. When Resident #4 was re admitted on [DATE], there was no drainage noted. LVN #7 stated she was unaware of Resident #4's drainage at the surgical stump because she had not taken care of him in a while. During an interview on 6/8/18 at 3:45 p.m. LVN #6 stated if she saw anything unusual going on with the resident she would then read the resident notes to get the baseline. She would assess the resident and if there was any concern, she would notify the physician, DON and the responsible party. LVN #6 stated she usually works station 2 and is only covering for an open shift. She has never worked with Resident #4. During an interview on 6/8/18 at 3:52 p.m. RN #1 stated she did not get in touch with the surgeon to report the Resident #4's change in condition or schedule a follow-up appointment because she thought it was the floor nurse's responsibility. During an interview on 6/8/18 at 3:58 p.m., the ADON stated she had been trying to get in touch with the surgeon to schedule Resident #4's post-surgical appointment but attempts have been unsuccessful. ADON stated attempts were not documented. She said they did not have correct information of the surgeon on file. ADON stated the order to remove the surgical staples on 6/4/18 was written by NP #3. The facility cannot follow the order and they must get an order from the surgeon before removing the surgical staples. In an interview on 6/8/18 at 4:05 p.m. LVN #7 stated she sent a fax to the local hospital to request Resident #4's medical records to get in touch with the surgeon. LVN #7 stated she always follows up on faxes and there was no feedback from the hospital. LVN #7 provided the fax confirmation to surveyor who observed the fax report which stated the fax did not got through. Surveyor asked LVN #7 if she noticed that the fax report read busy/no response, LVN #7 said she did not realize the fax did not go through. She said she called the hospital and spoke with one of the staff on 06/07/18, who told her to re-fax the request. The medical records were sent that day and she was then able to schedule Resident #4's post-surgical follow-up appointment for on 06/11/18. During an interview on 6/8/18 at 4:15 p.m. the DON stated she was unaware of Resident #4's drainage and foul odor. NP #3 came in for routine care and notified her that Resident #4 would be treated with an antibiotic. NP #3 told DON that since she knew the baseline of the Resident #4, and he had been treated for [REDACTED].#3 went ahead to order for the IV antibiotic to treat the drainage and the foul odor for infection. Nurses are to be responsible to report any change of condition of a resident to the NP or DON. In an interview on 6/12/18 at 1:00 p.m., the DON stated the process has always been to call the physician, responsible party, and get new orders for any new wound, however, the DON will now supervise by looking at weekly skin assessments and validating the information. Staff are to notify the DON of any changes in condition. The DON was unable to verbalize training given to staff on residents with splints, contractures, and post-surgical operations. The DON felt this incident came about due to a lack of documentation, lack of notification to the responsible party, and her not monitoring/validating documentation. Record review of Facility's Statement of Resident Rights, undated, revealed You, (the resident), have a right to all care necessary for you to have the highest possible level of health. Record review of Notification of Change in Resident's Health Status Policy dated (MONTH) (YEAR) revealed The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient representative when there is an acute illness or a significant change in the resident's physical, mental, or psychosocial status. Notification will be immediate. The facility Administrator and DON were notified on 6/8/18 at 4:48 p.m. that an IJ was identified due to the above failures and a Plan of Removal PoR was requested. The POR was submitted by the Administrator on 06/08/18. After two revisions, the final plan of removal was accepted on 06/11/18 at 4:11 p.m Immediate Action All residents were reviewed for any change of condition by Nursing Administration beginning on 06/08/18. If there were any changes in condition, DNS, charge nurse and or wound care nurse contacted the medical Director or Nurse Practitioner to obtain orders as required for care as needed. If the Nurse practitioner does not return the call after 2nd attempts, the DNS, charge nurse, or wound care nurse will call the Medical Director. The attempts to contact the Medical Director or Nurse practitioner will be documented in progress notes. Education All staff were re-educated by DNS beginning 6/8/18 and 6/9/18, regarding Abuse and Neglect policy, skin Guidelines, Wound care Guidelines, Assessment of skin, Hospice Referrals, and change in condition. Wound care nurse provided wound training on skin Guidelines, Wound Guidelines which includes wound measurement, Assessment of skin and Wound care on 6/8/18. The DNS provided effective education proven by demonstrations. Regional Nurse conducted audits to verify effective education. DNS observed wound care provided for competency. DNS will conduct skin rounds beginning 6/8/18 and will continue skin rounds weekly RNs, LVNs, Permitted Medication Aides and Certified Nursing Assistants were re educated beginning on 6/8/18 and 6/9/18, by the DNS or designee regarding the system for responding to change of condition, when to notify the physician with a change of condition and to notify nursing if any skin issues noted then nursing will notify MD/NP for treatment orders and document accordingly. Administrator received training on Abuse and Neglect and Supervision of Nursing Administration by Regional Vice President for Texas and Director of Clinical Operations Any staff members that were not available at this time will not be allowed to work until education is completed. Personnel Roster was utilized to monitor attendance for education Monitoring Systemic changes and monitoring have been developed and approved by the Administrator, DNS and Medical Director. These changes went into on 06/08/18. The systemic changes and guidelines includes: Stop and Watch from Interact Implemented to assist in effective communication; review of any shower sheets in daily clinical start up meeting; and weekly skin assessment to be brought to daily clinical start up. These changes and monitoring have been put into place and put into Quality Assurance Performance Improvement (QAPI) for monthly reporting. Education has been provided by the DNS or Designee concerning the guidelines and changes on 6/8/2018. Content of the education provided regarding the systematic changes includes: guidelines for Stop and Watch, guidelines for skin care including weekly skin assessments, wound care guidelines, shower sheets, Interdisciplinary communication regarding change of condition, Hospice Referrals and education on Abuse and Neglect. A QAPI meeting was held on 6/8/18. In attendance were the Administrator, DNS, ADNs, Medical Director, Unit Managers and other department leaders. Also, in attendance were support staff resource members from Diversicare. Allegations from survey were reviewed. Findings from the initial skin audits were discussed, along with any follow up assignments. Monitored results will be reviewed by the administrator and any adjustment to plan will be shared with the IDT team during QAPI. The surveyors monitored the PoR. Interviews were conducted with CNAs, LVNs, on each shift about change of condition and they described how they would recognize changes in residents' condition and what to do with that information. CNAs said they would report that information to the nurses. Nurses said that they would document the information in the resident's clinical record and consult with the resident's physician. Nurses were interviewed to determine if they were trained in wound care. The DON said that the facility also arranged with a wound care physician to make weekly rounds at the facility. Record review of the training records revealed in-services were conducted neglect, changes in condition, hospice process, ADL care, wound/skin care, and proper clinical documentation. Observations revealed the new treatment nurse, RN #1, performed wound care with poor hand hygiene. She also did not properly measure and document the size of Resident #6's wound. The facility removed wound care from responsibilities and gave her other duties until she receives additional training. She was replaced by the LVN #8, who was responsible for training at the corporate level. The Administrator and the DON were notified on 6/14/18 at 4:11 p.m. that the IJ was lowered. The facility remains out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. CMS 672 dated 6/5/18 revealed a census of 101 residents.

Based on observation, interview, and record review the facility failed to ensure residents were free from neglect for 3 of 5 residents (CR #1, Residents #1, & Resident #4) reviewed for abuse and neglect, in that: - The facility failed to provide CR #1 with treatments to promote wound healing ordered by a physician and prevent further wound development which led to hospitalization and infection. - The facility discontinued CR #1's wound vac without a physician's orders [REDACTED].>- The facility's failure to treat her wounds with physician supervision and consultation resulted in CR #1's hospital admission [MEDICAL CONDITION], pneumonia, and osteomeylitis. - The facility failed to provide Resident #1 with treatments to prevent further decline in range of motion causing an infection on his contracted hand. - The facility failed to inform Resident #4's physician when foul odor and discharge was noted coming from his stump following bilateral [MEDICAL CONDITION]. This resulted in the need for intravenous antibiotics. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 6/8/18. While the IJ was lowered on 6/14/18, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. This failures affected one discharged and 2 current residents and placed 99 residents at for not receiving necessary care and services. Findings include: Intake # 4 Intake # 9 Record review of CR #1's Face Sheet revealed she was an [AGE] year-old female admitted to the facility 3/5/18. Her [DIAGNOSES REDACTED]. She was admitted with a catheter, peg tube, contractures and one stage 4 pressure sore. She was discharged to the hospital on [DATE]. Record review of CR #1's MDS assessment dated [DATE] revealed the staff assessment of cognitive skills indicated she had severely impaired cognitive skills and was totally dependent on staff for all of her activities of daily living care. She had a stage 4 pressure ulcer measuring 4.0 cm x 4.4 cm x 2.0 cm. It was assessed as granulation tissue-pink or red tissue with shiny, moist, granular appearance. It did not include approaches for turning or repositioning. Record review of CR #1's Care Plan dated 3/6/18 revealed CR #1 has a stage 4 pressure ulcer to sacrum. At risk for further breakdown; has bilateral contractures of knees and elbows and incontinent episodes of bowel. The goal stated pressure ulcer will be healed and she will not experience any unidentified infections by 6/18/18. Approaches included turning and repositioning via two staff, wound care as ordered by physician, wound vac as ordered, mechanical lift, weekly evaluation of wound healing, daily observation of skin with routine care, full skin evaluation weekly with bath/shower, float heels on pillow as needed, observe for changes in skin status that may indicate worsening of pressure ulcer and notify the physician. Record review of CR #1's sacral wound assessment report dated 3/9/18 revealed her stage 4 pressure ulcer was 5.5 cm x 4.5 cm x 2 cm. There was 70% granulation tissue and 30% slough. The boarder of the wound was well-defined normal healthy skin. Record review of CR #1's sacral wound assessment reports dated 3/16/18, 3/23/18, 3/30/18, 4/6/18, 4/13/18, 4/20/18, 4/27/18, and 5/4/18 all recorded the same measurement: 4 cm x 4.4 cm x 2. These assessments all indicated there was 100% granulation tissue and the boarder of the wound was well-defined normal healthy skin. Record review of CR #1's Bath Sheets dated 3/29/18-5/1/18 only identified the sacral wound. Record review of CR #1's Medication Administration Record [REDACTED] -Stage 4 pressure ulcer to sacrum: cleanse with normal saline, pat dry three times a week, apply continuous negative pressure vacuum at 125 mmHg . Ordered 3/6/18 and started 3/9/18. Treatments were signed that they were received. Record review of CR #1's Treatment Administration Record dated (MONTH) (YEAR) revealed the following: -Apply wet to dry to affected area every day or as needed until further evaluations. Ordered 4/23/18 and discontinued 5/1/18. Treatments were signed as being received. -Stage 4 pressure ulcer to sacrum: cleanse with normal saline, pat dry three times a week, apply continuous negative pressure vacuum at 125 mmHg . Ordered 3/7/18 and discontinued 4/23/18. Treatments were signed as being received. -Stage 4 ulcer to sacrum: clean with normal saline, pat dry, apply wet to dry dressing, and cover with dry protective dressing daily. Ordered 4/26/18 and discontinued 5/6/18. Treatments were signed as being received. Record review of CR #1's Clinical Chart revealed a telephone order dated 4/23/18 Discontinue wound vac . Apply wet to dry dressing to affected area every day or as needed until further evaluations. The order was written by LVN #1 and did not have a physician's signature. Record review of CR #1's Treatment Administration Record dated (MONTH) (YEAR) revealed the following: -Stage 4 ulcer to sacrum: clean with normal saline, pat dry, apply wet to dry dressing, and cover with dry protective dressing daily. Ordered 4/26/18 and discontinued 5/6/18. Treatments were signed as being received. In an interview on 6/7/18 at 10:15 a.m., LVN #5 stated the wound vac was discontinued by LVN #1 on 04/26/18, she said LVN #1 stated she did not think the wound vac is working effectively because of its beeping, she said she did not know if the physician signed the order or not. Attempts to reach LVN #1 by phone for an interview were unsuccessful. In an interview on 6/7/18 at 2:40 p.m., NP #1 said she did not give any order to discontinue the wound vac, she said no staff discussed the wound vac discontinuation with her before they removed it In an interview on 6/7/18 at 3:50 p.m., NP #2 said she did not give any order to discontinue the wound vac In an interview on 6/7/18 at 5:10 p.m., MD #1 stated he did not give an order for [REDACTED]. In an interview on 6/7/18 at 6:04 p.m., MD #2 stated he only came on 3/30/18 to get to know the resident, he said he cannot recall if he saw the wound or not, he said he did not know the measurement, he said he did not believe he gave any order for wound treatment, he said he did not give any order to discontinue the wound vac, he said if I don't put a wound vac, I don't discontinue it In an interview on 6/7/18 at 6:30 p.m., MD #1 stated he has confirmed from all his NPs and MD, he said they did not give order to discontinue the wound vac. Record review of CR #1's Nursing Note dated 4/25/18 and signed by LVN #2 revealed Skin assessment done this shift. Resident with open area to sacrum. Resident with area to left ankle, left outer side of foot, left heel, right foot great toe, next to great toe, inner aspect of foot next to great toe, inner heel to right foot, left top foot ankle area small, no drainage to any area, but all areas are dark in color. Resident on air mattress. In an interview on 6/8/18 at 1:40 p.m., LVN #2 stated she turned in a communication form into the treatment nurse following CR #1's 4/25/18 skin assessment. She was informed by treatment nurse that there was treatment in place for the wounds she noted on the heels and feet. She did not notify CR #1's physician. Record review of CR #1's Wound Assessment Reports dated 5/4/18 and signed by LVN #5 revealed Resident continues to have a stage 4 pressure ulcer to sacrum measuring 4.0 cm x 4.4 cm x 2.0 cm. Wound has moderate amount of serosanguineous drainage with 100% of granulated tissue. Surrounding skin is well defined. No signs and symptoms of infection present. NP and RP notified. However, CR #1's emergency room assessment reflected a different skin assessment. Record review of CR #1's Nursing Note dated 5/6/18 and signed by LVN #4 revealed CR #1 was noted with coughing, MD notified, STAT lab results from 5/5/18. CBC, CMP Potassium 6.6, BUN 95, WBC 42.2, Creatinine 4.8. BP 136/72, P 81, R 18, O2 Sat 97% RA. DR. notified. N/O Send to KW for further eval. Message left for RP, DON informed. Transported via EMS x 2. Record review of CR #1's emergency room Note dated 5/6/18 revealed CR #1 is an [AGE] year-old female who lives in a nursing facility with known history of a sacral decubitus for a year was brought to the hospital [MEDICAL CONDITION] picture with multiorgan dysfunctio[DIAGNOSES REDACTED], pneumonia was suspected as well as UTI and severe rhabdomyolysis. Upon admission, the patient was found to have acute [MEDICAL CONDITION] with a creatinine of 4, elevation of the liver enzymes and a CK of 12,000 with lactic acidosis. The patient was started empirically on antibiotics and cultures were sent. Urine was quite [MEDICAL CONDITION]. It is worth mentioning that the patient had advanced dementia and she had a PEG tube for nutrition. There were some concerns about aspiration. During the exam, it was found that the patient has discharge around the PEG tube that has a foul smell. She is contracted. She lies in a fetal position. Examination of the sacral area, she has a deep tissue injury that measures at least 15 cm in diameter in the middle of it that she has a wound that is 5-6 cm in diameter. It is deep to the bone. The entire wound almost 90% in necrotic with a foul-smelling discharge coming out. The edges of the wounds are everted an it tunnels all the way at least 2 cm all around. Now coming down to the bony prominences on her feet including the ankles, the fifth metatarsals, and the first metatarsals whatever she has a bone in her foot all of these has deep tissue injuries with foul smelling wounds, most of them are deep to the bones. She needs surgical debridement of all her wounds including the sacral wound. Labs collected revealed WBC is 38,000, hemoglobin 9, and platelet count 254. Sodium is 132, potassium 5.8, creatinine is 4, BUN is 103, creatinine kinase is 112,000. Procalcitonin is more than 200. Clinical impressions included [MEDICAL CONDITION], failure to thrive, and pneumonia. Record review of CR #1's Wound Care Consultation dated 5/14/18 revealed There are multiple ulcerations noted to bilateral lower extremities. There is a large fibrotic ulceration to the right lateral ankle that is boggy with significant fibrotic tissue. There are multiple other deep tissue injuries noted to the right lateral foot. The right foot is dusky in appearance. On the medial posterior heel, there is also ulceration as well as multiple deep tissue injuries on the medial aspect of the right foot. On the left foot, there are medial deep tissue injuries with the posterior heel ulceration as well as multiple open ulcerations on the left lateral foot and ankle. On the left, there is dusky appearance as well. The plan revealed The patient is seen and evaluated at bedside. Overall, the patient has poor prognosis and is a poor surgical candidate for any wound debridement to the right or left lower extremities. The patient has significant signs of decrease blood flow and ultimately would not tolerate any surgical procedures to the right lower extremity. If any debridement that would be performed would likely further expose the patient and the patient's functional status is limited at this time. If anything was to be contemplated, most likely the patient would require bilateral above-the-knee amputations. However, the patient still has sacral osteo[DIAGNOSES REDACTED], sacral wounds. Podiatry will not proceed forward with any surgical interventions at this time. In an interview on 6/7/18 at 9:30 a.m., LVN #5 revealed she graduated in (MONTH) (YEAR) and this was her first nursing position. She started as a floor nurse and when the facility's previous treatment nurse resigned she was appointed the position. After one day of shadowing the previous treatment nurse in (MONTH) (YEAR), she took over doing wound care. LVN #5 stated she asked several times for training or a wound care doctor to which DON and previous Administrator denied. She inquired about a wound care certification class and according to DON, corporate denied the request. LVN #5 was responsible for treating nearly 20 residents during the week. The charge nurses were responsible for treatments on the weekend. However, there were several instances where LVN #5 treated wounds that had a bandage dated from the previous Friday. LVN #5 said she tried to resign twice in which the second time DON agreed to start looking to fill the position. LVN #5 stated CR #1 did not have any open wounds besides the sacrum but had DTI on her feet. She stated her documentation could have been better and she should have documented everything she was doing for the resident. In an interview on 6/8/18 at 4:40 p.m., NP #1 stated she had been seeing CR #1 since (MONTH) (YEAR). She completed a skin assessment on her first visit, but she didn't see the sacral wound because the wound vac covered the wound. NP #1 stated she never saw CR #1's wound and her condition was the same as baseline. NP #1 was never informed that the wound vac was not working and never gave the order to discontinue it. In an interview and record review on 6/12/18 at 1:00 p.m., the DON stated all nurses received training guided by the nurse competency checklist. The training LVN #5 received as a treatment nurse was no different from the other nurses. LVN #5 had two weeks of training from the previous treatment nurse, and computer based training. The DON rounded with LVN #5 once or twice and felt she was doing a good job. LVN #5 did ask for extra training and there was communication between the DON and corporate via email about the wound care certification class. The DON saw CR #1's wound once when LVN #5 asked her to observe her replace the wound vac, however she didn't measure it or notice necrosis. The DON said she was informed of treatments not being done on the weekends and in-serviced the nurses. The Email dated 3/2/18 provided by the DON indicated she had written I found an online course that I believe would be sufficient enough to increase her knowledge and competency which was sent to Administrator. LVN #5's computer based training list provided by the DON included: Pressure Injury/Ulcer Prevention Training dated 4/2/18 - 1 hour course and Infection Control and Prevention dated 5/1/18 - 1 hour course. In an interview on 6/13/18 at 12:10 p.m, LVN #2 stated the facility was having a problem with skin so they cracked down on skin sheets. When she did the skin assessment on CR #1 she reviewed through the shower sheet with the treatment nurse who said she was already treating the areas. She stated she only saw the wound once and described it as irregular, no odor, and medium sized (being able to fit at least three fingers inside). In an interview on 6/14/18 at 11:39 a.m., Former Treatment Nurse stated she trained LVN #5 for 2-3 days for wound care. The training was supposed to be a week, but due to call ins LVN #5 would have to work the floor. She told the DON that LVN #5 wasn't ready and offered to stay to help, but it didn't happen. Resident #1 Record review of Resident #1's Face sheet revealed he was a [AGE] year-old male originally admitted to the facility 12/20/17 and readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Physician's Notes dated 12/21/17 revealed, Fingers to bilateral hands contracted but has no pain, according to resident they have been like that for 6 months. Record review of Resident #1's Progress Notes dated 1/10/18 revealed, Resident came into facility with contracture in left hand. Upon assessment on today, skin tear noted due to nails embedded into hand. NP and RP aware, new orders to apply TAO and dry protective dressing daily x 7 days and PRN soiled/dislodged dressing, and to reassess after 7 days. Will continue to monitor. The note was signed by LVN #5. Record review of Resident #1's Physician's Notes dated 2/6/18 revealed, Pt has contracture to right hand and digs nail in palm. Okay to keep ace on right hand to help prevent resident from digging nails into palm. Record review of Resident #1's Physician's Notes dated 3/1/18 revealed, Staff reports strong odor from right hand due to resident having contracture and unable to open hand. Resident has history of abrasion to right hand due to nails digging into palm. Responded well to regular soaking of hand in soapy water and applying TAO and gauze. staff to clip finger nails. Record review of Resident #1's Progress Notes dated 3/1/18 revealed, -NP onsite, writes new order to continue treatment on left inner hand skin tear indefinitely. Left hand has noted swelling and contracture history. Resident hand soaked in warm soapy water, patted dry, TAO applied, clean dry dressing QD. Resident continuously removes dressing, gauze daily after application. NP aware. RP aware. Will continue to treat and monitor. Record review of Resident #1's Physician's Notes dated 3/8/18 revealed, Abrasion to right hand has healed, patient has contracture to left hand and digs nails in palm. Okay to keep ace on left hand or roll of washcloth to help prevent resident from digging nails into palm. Refer to hand surgeon for possible contracture release. Record review of Resident #1's Therapy Prescription dated 3/16/18 revealed bilateral hand contractures of unknown origin, possible past stroke. Daily passive hand/finger extension by therapy and the nursing staff for hand hygiene. OT: hand passive stretching, and if the hand can open up enough, need to make a splint for nighttime use to keep the hand/fingers open. Left side is much worse. If he fails treatment, we would need his family member for consent for surgery to release the flexors and STP transfers. Record review of Resident #1's Progress Notes dated 3/25/18 revealed, Left palm cleansed with warm soap and water. Palm noted to be macerated, raw in appearance, middle, ring and small nails noted to be yellow in color and thick in appearance. The middle, ring, and small finger resident is unable to straighten, index finger and thumb resident is able to bend slightly more than the index finger. During hand care resident did state area was sore. Gentle ROM was attempted. Resident did remove hand brace/splint. Nonadherent pad and hand roll was placed in palm. Noted strong odor from hand prior to dressing changed, odor not gone but did decrease. Will continue to monitor. The note signed by LVN #11. Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. Behaviors including [MEDICAL CONDITION], behaviors toward others, rejection of care, and wandering were not exhibited. He required extensive assistance of two staff for the following ADL care: dressing, toilet use, and personal hygiene. Bed mobility, transfer, walking, and eating required extensive assistance of one staff. He had no impairment in range of motion to upper extremity or lower extremity. A skin tear was checked as an active diagnosis. Record review of Resident #1's Care Plan, undated, revealed the following: -He is at risk for impaired skin integrity related to an open area to inner left hand and to apply splint device as ordered. The goal stated, Impaired ROM will not impede resident's health or safety. -He requires staff assistance for ADL care. Care plan did not indicate amount of assistance needed. Record review of Resident #1's OT Discharge Summary dated 3/29/18 revealed the long-term goal was Pt will be able to tolerate hand splint 6-8 hours a day in preparation for wearing as a night splint as recommended by his physician. Further review revealed Restorative program established/trained = other restorative program (nursing staff and restorative staff have been trained in splint application.) Record review of Resident #1's Medication Administration Record [REDACTED] -Skin tear to inner left hand: Soak hand in warm soapy water, pat dry, apply TAO and cover with dry protective dressing daily. Ordered 4/11/18 and discontinued 5/8/18. Treatments were signed as being received. Record review of Resident #1's Progress Notes dated 6/2/18 revealed, MD here to see resident and consulted with physician concerning left hand and ordered to send to ER for said left hand. SEE SBAR. Family member notified, and executive transport was called. Record review of Resident #1's Physician's Notes dated 6/2/18 revealed, He now has foul smelling drainage from the hand. The smell fills the room and he has increasing pain and tenderness. Discussed with MD and he agrees with evaluation in ER and possible admission. He needs some form of amputation. WBC is 7.5. Record review of Resident #1's Physician's Notes dated 6/5/18 revealed, He was admitted recently to the hospital due to left hand infection [MEDICAL CONDITION] with foul smelling drainage from the hand and received IV antibiotics [MEDICATION NAME] and [MEDICATION NAME]/tazobactam. His nails are embedded in the palm of his left hand. No bleeding or drainage. Left hand contracted with a fist, very tight to open with nails embedded in the left hand. In an interview on 6/5/18 at 2:30 p.m., the DON stated Resident #1's hand was severely contracted to where nothing could be put in the hand and he is scheduled to have a tendon release surgery. DON stated there's no time frame for nail care to be done, but if a resident's nails are observed to be elongated then CNAs or nurses should clip them. Record review of Resident #1's Progress Notes dated 6/6/18 revealed, Skin assessment done this shift. No open areas noted or break down. Left hand with contracture. Unable to open hand. Observation of Resident #1 during tour with LVN #6 on 6/7/18 at 9:55 a.m. revealed Resident #1 was in bed awake, his left palm was noted with foul smelling drainage. In an interview and record review on 6/7/18 at 10:00 a.m., LVN #6 said Resident #1 had a wound on his palm. She said it resolved sometime in (MONTH) before he went to the hospital. She said the NP#2 came in on 06/6/18 to discharge the order given .soak hand in soapy water and applying TAO and gauze. The order was dated 3/1/18. In an interview on 06/07/18 at 10:15 a.m., with RN #1 and the DON, they said the NP #2 gave an order to soak his palm in water, pat dry, apply TAO and wrap with Ace, but does not seem to be effective. Resident #1 has been scheduled for tendon release surgery and because of appointment NP withdrew the order. Staff are supposed to still be cleaning the palm if there is any drainage to keep the palm moist. Record review of Resident #1's Rehab to Nursing Recommendations dated 6/11/18 revealed Pt to wear carrots bilateral to hands as tolerated. He is to also wear a resting hand splint up to 6 hours as tolerated. In an interview on 6/12/18 at 1:00 p.m., the DON stated restorative aides were responsible for putting on splints and they worked until four. The DON stated she had never observed Resident #1 wearing a splint. In an interview on 6/13/18 at 2:05 p.m., the Unit Manager stated Resident #1's contracture management was handled by restorative in which they would use carrots. Resident #4 Record review of Resident #4's Face Sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #4's 02/21/18 Admission MDS assessment revealed he had severely impaired cognitive skills. Record review of Resident #4's care plan dated 05/21/18, printed on 6/08/18, revealed there were no approaches addressing care for his resident bilateral knee amputation surgical wound. Record review of Resident #4's care plan dated 05/21/18, printed on 06/14/18, revealed a problem of bilateral knee amputation surgical wound, but did not address the goals and approaches for the wound Record review of Resident #4's discharge report dated 05/21/18 revealed the name of the surgeon that operated on him. Record review of Resident #4's physician's orders [REDACTED]. Record review of facility facsimile transmission verification report dated 5/31/18 revealed facility requested for Resident #4 medical records from local hospital, the verification report status showed busy/no response. Record review of Resident #4's physician's orders [REDACTED]. Observation of Resident #4 during tour with the wound care nurse RN #1 on 6/7/18 at 11:10 a.m. tour revealed resident was in his room awake, he has a bilateral below knee amputation wound that was noted with an open suture, medium drainage and foul odor. Record review of Resident #4's Nurses' Notes dated 06/01/18 through 06/06/18 did not reveal documentation by the wound care nurse RN #1 of any drainage and foul odor observed prior to touring with surveyor on 06/07/18. Record review of Resident #4's Nurses' notes on 06/07/18, did not reveal documentation indicating attempts were made to get in touch with the Surgeon to schedule a follow up appointment for the surgical site. During an observation and interview on 6/8/18 at 09:20 a.m. with LVN A, LVN A observed assessing Resident #4, LVN A said the NP #3 was here this morning to assess Resident #4, she said the NP #3 prescribed IV antibiotic for infection at the surgical stump site. During an interview on 6/8/18 at 09:35 a.m. with NP #3, she said someone called her and left a message on 06/07/18 around 5 p.m NP #3 was unsure who called, but the person left a message that Resident #4 had an open suture on his stump. She came in on 06/08/18 around 8 a.m. to assess the resident and found out that Resident #4's stump site had drainage and a foul odor. She ordered an IV antibiotic. NP #3 stated the person that called on 06/07/18 did not inform her that there was drainage or odor at the stump surgical site. During an interview on 6/8/18 at 3:20 p.m. with RN #1 revealed she started working for the facility on 5/23/18. Surveyor asked RN #1 if she reported the discharge observed on 06/07/18, RN #1 said there was not much drainage and felt like it was not worth reporting to the physician or NP. RN #1 stated the drainage is just a drop and not much. Surveyor asked her how to determine a change in condition, she said if there is any change in baseline, she will call the physician, notify the DON and the responsible party. During an interview on 6/8/18 at 3:40 p.m. LVN #7 stated in order to determine a change in condition she would look at the resident's baseline and obtain vitals. If a difference is noted, the resident's physician, RP, and DON would be notified. When Resident #4 was re admitted on [DATE], there was no drainage noted. LVN #7 stated she was unaware of Resident #4's drainage at the surgical stump because she had not taken care of him in a while. During an interview on 6/8/18 at 3:45 p.m. LVN #6 stated if she saw anything unusual going on with the resident she would then read the resident notes to get the baseline. She would assess the resident and if there was any concern, she would notify the physician, DON and the responsible party. LVN #6 stated she usually works station 2 and is only covering for an open shift. She has never worked with Resident #4. During an interview on 6/8/18 at 3:52 p.m. RN #1 stated she did not get in touch with the surgeon to report the Resident #4's change in condition or schedule a follow-up appointment because she thought it was the floor nurse's responsibility. During an interview on 6/8/18 at 3:58 p.m., the ADON stated she had been trying to get in touch with the surgeon to schedule Resident #4's post-surgical appointment but attempts have been unsuccessful. ADON stated attempts were not documented. She said they did not have correct information of the surgeon on file. ADON stated the order to remove the surgical staples on 6/4/18 was written by NP #3. The facility cannot follow the order and they must get an order from the surgeon before removing the surgical staples. In an interview on 6/8/18 at 4:05 p.m. LVN #7 stated she sent a fax to the local hospital to request Resident #4's medical records to get in touch with the surgeon. LVN #7 stated she always follows up on faxes and there was no feedback from the hospital. LVN #7 provided the fax confirmation to surveyor who observed the fax report which stated the fax did not got through. Surveyor asked LVN #7 if she noticed that the fax report read busy/no response, LVN #7 said she did not realize the fax did not go through. She said she called the hospital and spoke with one of the staff on 06/07/18, who told her to re-fax the request. The medical records were sent that day and she was then able to schedule Resident #4's post-surgical follow-up appointment for on 06/11/18. During an interview on 6/8/18 at 4:15 p.m. the DON stated she was unaware of Resident #4's drainage and foul odor. NP #3 came in for routine care and notified her that Resident #4 would be treated with an antibiotic. NP #3 told DON that since she knew the baseline of the Resident #4, and he had been treated for [REDACTED].#3 went ahead to order for the IV antibiotic to treat the drainage and the foul odor for infection. Nurses are to be responsible to report any change of condition of a resident to the NP or DON. In an interview on 6/12/18 at 1:00 p.m., the DON stated the process has always been to call the physician, responsible party, and get new orders for any new wound, however, the DON will now supervise by looking at weekly skin assessments and validating the information. Staff are to notify the DON of any changes in condition. The DON was unable to verbalize training given to staff on residents with splints, contractures, and post-surgical operations. The DON felt this incident came about due to a lack of documentation, lack of notification to the responsible party, and her not monitoring/validating documentation. Record review of Facility's Abuse Policy dated (MONTH) (YEAR) revealed During orientation, new team members shall be trained on the obligation to report alleged violations. Training shall include definitions of alleged violations and examples of reportable incidents to assist staff in detection of such incidents. The Administrator/Director of Nursing shall identify, intervene and correct situations in which abuse, neglect, or misappropriation of resident property are more likely to occur. All other staff is required to report such potential situations to the Administrator/Director of Nursing as soon as identified. Reporting of suspected alleged violations is required of every team member. All alleged violations involving mistreatment, neglect, abuse, or exploitation including injuries of unknown source and misappropriation of resident/patient property are reported immediately to the Administrator/Director of Nursing and to other officials in accordance with State law through established procedures. Immediately means as soon as possible: Any neglect, mistreatment, exploitation or injuries of unknown source resulting in serious injury within two hours. Record review of Facility's Statement of Resident Rights, undated, revealed You, (the resident), have a right to all care necessary for you to have the highest possible level of health.<br (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for four (Resident #1, Resident #3, Resident #4, and Resident #5) of 5 residents reviewed for ADL care, in that: The facility failed to provide Resident #1 with timely nail care which led to his nails digging into his palm causing an hospitalization with [MEDICAL CONDITION] The facility failed to provide Resident #3, Resident #4, and Resident #5, with timely nail care. They had long, untrimmed fingernails with brown substance underneath the nails. These failures affected four residents and placed 97 residents who required assistance for baths, at risk for poor personal hygiene and a decline in their quality of life. Findings include: Intake # 4 Intake # 9 Resident #1 Record review of Resident #1's Face sheet dated 6/5/18 revealed he was a [AGE] year-old male originally admitted to the facility 12/20/17 and readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Physician's Notes dated 12/21/17 revealed, Fingers to bilateral hands contracted but has no pain, according to resident they have been like that for 6 months. Record review of Resident #1's Physician's Notes dated 2/6/18 revealed, Pt has contracture to right hand and digs nail in palm. Okay to keep ace on right hand to help prevent resident from digging nails into palm. Record review of Resident #1's Physician's Notes dated 3/1/18 revealed, Staff reports strong odor from right hand due to resident having contracture and unable to open hand. Resident has history of abrasion to right hand due to nails digging into palm. Responded well to regular soaking of hand in soapy water and applying TAO and gauze. staff to clip finger nails. Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. His behaviors included [MEDICAL CONDITION], behaviors toward others, rejection of care, and wandering were not exhibited. He required extensive assistance of two staff for the following ADL care: dressing, toilet use, and personal hygiene. According to this assessment, he had no impairments in range of motion to upper extremity or lower extremity. A skin tear was checked as an active diagnosis. Record review of Resident #1's Care Plan, undated, revealed the following: -He is at risk for impaired skin integrity related to an open area to inner left hand and to apply splint device as ordered. The goal stated Impaired ROM will not impede resident's health or safety. -He requires staff assistance for ADL care. Care plan did not indicate amount of assistance needed. Observation of Resident #1 during tour with LVN #6 on 6/7/18 at 9:55 a.m. revealed Resident #1 was in bed awake, his nails were long and has brown substances underneath. Resident #3 Record review of Resident #3's Face Sheet dated 6/5/18 revealed he was a [AGE] year-old male admitted to the facility 2/23/18. His [DIAGNOSES REDACTED]. Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 12, indicating in-tact cognition. ROM was coded as having impairment on both sides for upper and lower extremities. He required total dependence with personal hygiene. Record review of Resident #3's Care Plan, undated, revealed ADL assistance nor his contracture were addressed. Observation and interview on 6/5/18 revealed Resident #3 lying on the bed on his back. Both hands were contracted, and his nails were long and yellow. He stated he doesn't like his nails that long and wanted them trimmed. Resident #4 Record review of Resident #4's Face Sheet documented he was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's admission MDS dated [DATE], revealed BIMS score of 03 of 15, Resident #4 has severally impaired memory, he is a total dependent, he required extensive assistance of two-person physical assist for personal hygiene, and extensive assistance of two-person physical assist for dressing. Record review of Resident #4 nurses' progress notes from 05/01/18 through 06/13/18 did not reveal any documentation on refusal of care of finger nails. Record review of Resident #4's Care Plan dated 05/21/2018, revealed resident required extensive care with one or two-person physical assist with ADL care. The goal was for Resident #4 to be clean and well groomed daily. Observation and interview on 6/7/18 at 11:10 a.m. revealed Resident #4 was in his room awake. His finger nails on both hands were approximately an inch long and curved with a dark brown colored substance underneath the nail. Surveyor asked resident if anyone had ever asked him if he really wanted his fingernails trimmed. He said it would be good if the staff could trim his finger nails. Interview on 06/07/18 at 4:40 p.m., LVN #7 said the residents' finger nails were supposed to be trimmed while the aides provided showers. She said the nurses were responsible for nail trimming if the resident was diabetic. LVN #7 said Resident #4 was diabetic and said she would trim Resident #4's nails now. Interview on 06/07/18 at 04:55 p.m., the DON said Resident #4's fingernails were supposed to be trimmed by the nurses because he was diabetic, she said she will make sure the finger nails were trimmed. Interview on 06/08/18 at 02:10 p.m., LVN #8 said the resident's nails were supposed to be trimmed as needed. She said there was no schedule time for the nails to be clipped, she said the CNA either clipped nails during their showers or as soon as they were aware of the long nails. Resident #5 Record review of Resident #5's Face Sheet documented he was an [AGE] year-old female blind in both eyes re-admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's Care Plan dated 08/28/2017, revealed she required extensive assistance from one-person physical for ADL care. The goal was that she was clean and well-groomed daily. Record review of Resident #5's nurses' progress notes from 05/01/18 through 06/13/18 did not reveal any documentation of resident refusing care of finger nails . Record review of Resident #5's quarterly MDS dated [DATE], revealed BIMS score of 00 of 15, indicating Resident #5 had severely impaired memory. She required extensive assistance from one-person for personal hygiene, and extensive assistance from one-person for dressing. Observation on 6/7/18 at 11:50 a.m. revealed Resident #5 was in her room asleep. Her left finger nails were approximately an inch long, dark brown in color and curved. Interview on 06/07/18 at 11:55 a.m., the DON said though, it was Resident #5's left fingernails that were long, she said the right nails were not, she said probably the staff are trying to clip the finger nails and they did not finish it or the resident refused care. Interview on 06/08/18 at 01:55 p.m., CNA #2 said Resident #5's fingernails were supposed to be trimmed by the nurses because she was diabetic. She said she always made sure all her residents' finger nails were trimmed during their showers or as needed. Interview on 06/08/18 at 02:00 p.m., CNA #3 said if the resident was not diabetic, she would be responsible for nail care. She said she provided nail care during shower days and as needed. She said Resident #5 was diabetic, she said the nurses were responsible for clipping her nails. Interview on 06/08/18 at 02:10 p.m., LVN #10 said the resident's nails were supposed to be trimmed as needed. She said there was no schedule time for the nails to be clipped. She said the CNA either clipped them during their showers or as soon as they were aware of the long nails. Record review of Facility's Personal Hygiene Policy, undated, revealed Include nail and foot care in a patient's daily hygiene; the best time is during the bath. Facility's 672 dated 6/5/18 revealed a census of 101.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of 5 residents (Resident #1) reviewed for range in motion. Resident #1, who entered the facility with a contracture, was not provided services to prevent a further decline in range of motion, which led to need for a tendon release surgery and [MEDICAL CONDITION], This failure affected one resident and placed 21 residents with contractures at risk for further decline in ROM. Findings included: Resident #1 Record review of Resident #1's Face sheet revealed he was a [AGE] year-old male originally admitted to the facility 12/20/17 and readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. His behaviors included [MEDICAL CONDITION], behaviors toward others, rejection of care, and wandering were not exhibited. He required extensive assistance of two staff for the following ADL care: dressing, toilet use, and personal hygiene. Bed mobility, transfer, walking, and eating required extensive assistance of one staff. According to this assessment, he had no impairments in range of motion to upper extremity or lower extremity. A skin tear was checked as an active diagnosis. Record review of Resident #1's Care Plan, undated, revealed the following: -He is at risk for impaired skin integrity related to an open area to inner left hand and to apply splint device as ordered. The goal stated Impaired ROM will not impede resident's health or safety. -He requires staff assistance for ADL care. Care plan did not indicate amount of assistance needed. Record review of Resident #1's Physician's Notes dated 12/21/17 revealed, Fingers to bilateral hands contracted but has no pain, according to resident they have been like that for 6 months. Record review of Resident #1's Progress Notes dated 1/10/18 revealed, Resident came into facility with contracture in left hand. Upon assessment on today, skin tears noted due to nails embedded into hand. NP and RP aware, new orders to apply TAO and dry protective dressing daily x 7 days and PRN soiled/dislodged dressing, and to reassess after 7 days. Will continue to monitor. The note was signed by LVN #5. Record review of Resident #1's Progress Notes dated 1/12/18 revealed, Wound care performed to left hand. Aseptic technique. Cleansed with normal saline, TAO applied, and gauze roll applied to hand as much as tolerated. Record review of Resident #1's Physician's Notes dated 2/6/18 revealed, Pt has contracture to right hand and digs nail in palm. Okay to keep ace on right hand to help prevent resident from digging nails into palm. Record review of Resident #1's Physician's Notes dated 3/1/18 revealed, Staff reports strong odor from right hand due to resident having contracture and unable to open hand. Resident has history of abrasion to right hand due to nails digging into palm. Responded well to regular soaking of hand in soapy water and applying TAO and gauze. staff to clip finger nails. Record review of Resident #1's Progress Notes dated 3/1/18 revealed, NP onsite, writes new order to continue treatment on left inner hand skin tear indefinitely. Left hand has noted swelling and contracture history. Resident hand soaked in warm soapy water, patted dry, TAO applied, clean dry dressing QD. Resident continuously removes dressing, gauze daily after application. NP aware. RP aware. Will continue to treat and monitor. Record review of Resident #1's Physician's Notes dated 3/8/18 revealed, Abrasion to right hand has healed, patient has contracture to left hand and digs nails in palm. Okay to keep ace on left hand or roll of washcloth to help prevent resident from digging nails into palm. Refer to hand surgeon for possible contracture release. Record review of Resident #1's Therapy Prescription dated 3/16/18 revealed bilateral hand contractures of unknown origin, possible past stroke. Daily passive hand/finger extension by therapy and the nursing staff for hand hygiene. OT: hand passive stretching, and if the hand can open up enough, need to make a splint for nighttime use to keep the hand/fingers open. Left side is much worse. If he fails treatment, we would need his family member for consent for surgery to release the flexors and STP transfers. Record review of Resident #1's Progress Note dated 3/25/18 revealed Left palm cleansed with warm soap and water. Palm noted to be macerated, raw in appearance, middle, ring and small nails noted to be yellow in color and thick in appearance. The middle, ring, and small finger resident is unable to straighten, index finger and thumb resident is able to bend slightly more than the index finger. During hand care resident did state area was sore. Gentle ROM was attempted. Resident did remove hand brace/splint. Nonadherent pad and hand roll was placed in palm. Noted strong odor from hand prior to dressing changed, odor not gone but did decrease. Will continue to monitor. Record review of Resident #1's OT Discharge Summary dated 3/29/18 revealed the long-term goal was Pt will be able to tolerate hand splint 6-8 hours a day in preparation for wearing as a night splint as recommended by his physician. Further review revealed Restorative program established/trained = other restorative program (nursing staff and restorative staff have been trained in splint application.) Record review of Resident #1's Medication Administration Record [REDACTED]. Ordered 4/11/18 and discontinued 5/8/18. Treatments were signed as being received. Record review of Resident #1's Progress Notes dated 6/2/18 revealed, MD here to see resident and consulted with another MD concerning left hand and ordered to send to Kingwood ER for said left hand. SEE SBAR. Family member notified and executive transport was called. Record review of Resident #1's Physician's Notes dated 6/2/18 revealed, He now has foul smelling drainage from the hand. The smell fills the room and he has increasing pain and tenderness. Discussed with MD and he agrees with evaluation in ER and possible admission. He needs some form of amputation. WBC is 7.5. Record review of Resident #1's Physician's Notes dated 6/5/18 revealed, He was admitted recently to the hospital due to left hand infection [MEDICAL CONDITION] with foul smelling drainage from the hand and received IV antibiotics [MEDICATION NAME] and [MEDICATION NAME]/tazobactam. His nails are embedded in the palm of his left hand. No bleeding or drainage. Left hand contracted with a fist, very tight to open with nails embedded in the left hand. In a later interview on 6/5/18 at 2:30 p.m., the DON stated Resident #1's hand was severely contracted to where nothing could be put in the hand and he is having surgery to get his hand opened. The DON stated there's no time frame for nail care to be done, but if a resident's nails are observed to be elongated then CNAs or nurses should clip them. Record review of Resident #1's Progress Notes dated 6/6/18 revealed, Skin assessment done this shift. No open areas noted or break down. Left hand with contracture. Unable to open hand. Observation of Resident #1 during tour with LVN #6 on 6/7/18 at 9:55 a.m. revealed Resident #1 was in bed awake, his left palm was noted with foul smelling drainage. In an interview on 6/7/18 at 2:35 p.m., the DOR stated Resident #1 should be wearing a hand splint at night time and as tolerated. Either the nurses or restorative aides were responsible for putting the splint on. In an interview on 6/7/18 at 10:45 a.m., Family Member stated Resident #1 had the contracture since being admitted . To her knowledge, the facility provided therapy and would put socks in his hand. In an interview on 6/9/18 at 8:10 a.m. CNA #4 stated CNAs do not do anything for Resident #1's contractures. Restorative used to put carrots in his hand for most of the shift, although they had not done so in a while. She had never seen him with a splint. CNA #4 stated his hand did have odors, but she did not use the stop and watch form or inform the nurse. In an interview on 6/12/18 at 1:00 p.m., DON stated restorative aides are responsible for putting on splints and they work until four. She was unable to verbalize who puts on splints at nighttime if that's the order. DON stated she had never observed Resident #1 wearing a splint. In an interview on 6/13/18 at 2:05 p.m., the Unit Manager stated Resident #1's contracture management was handled by restorative in which they would use carrots. Unit manager stated he is very protective of his hand not letting staff touch it at times. Record review of Facility's Skin Care Policy dated (MONTH) (YEAR) revealed When an open area is identified implement resident specific interventions immediately: .evaluation and interventions, notify physician and document notification, ., complete new risk assessment, update care plan to address change in skin condition including interventions for each problem. Facility's 672 dated 6/5/18 revealed 22 residents with contractures.

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from neglect for 2 of 4 residents (CR #2 and Resident #1) reviewed for neglect, in that: -CR #2 was found on the floor and nursing failed to conduct a thorough assessment. CR #2's STAT x-ray was delayed 6 hours, resulting in a left femur fracture. -Resident #1's STAT x-ray was not completed timely. These failure affected one current resident and one discharged resident and placed 58 additional residents residing on the 100 hall at risk of not receiving goods and services necessary to avoid physical harm or pain. Findings included: CR #2 Record review of CR #2 facesheet date unknown revealed admission date of [DATE] and a readmitted [DATE]. Resident was discharged from the facility on [DATE] with return anticipated. CR #2 had [DIAGNOSES REDACTED]. Record review of CR #2's Significant Change in Status Minimum Data Set Assessment (MDS) on [DATE] revealed: - Staff interview of cognition indicated short and long term memory problems. Severely impaired- never/ rarely made decisions. - He needed limited assistance with one person physical assist for transfers and walking in room. CR #2's gait was not steady, only able to stabilize with staff assistance. - He had one fall after admission with major injury. Record review of nursing note, SBAR by LVN #4 for [DATE] at 3:30pm revealed at 1:10pm CR #2 was found on the floor in his room by a staff. He was assisted back to bed. He complained of pain to left hip. [MEDICATION NAME] given for pain, and patient instructed to stay in bed. Did not remove pants; because of pain to left hip. A call was placed to hospice nurse at 1:30pm. On [DATE] at 2:06pm a return call by the physician; and new orders for a STAT x-ray to the left hip. At 2:15pm, [MEDICATION NAME] was given and CR #2 was resting with family at bedside. Record review of nursing facility investigation summary undated and unsigned, revealed when CR #2 was in bed, LVN #4 initiated a head to toe assessment but unable to complete full assessment to left lower limb due to CR #2's complaints of pain to hip area. After completion of assessment, CR #2 was medicated for pain accordingly. STAT X-ray ordered. Hospice nurse arrived around 4:00pm and had attempted to call local mobile imaging company multiple times for an x-ray. At 7:22pm, CR #2's family member requested he be sent to the hospital. At approximately 7:30pm orders were obtained to send CR #2 to the hospital for evaluation and treatment. When EMS arrived, CR #2's pants were removed and his left hip appeared deformed. CR #2 left the nursing facility on [DATE] at 7:50pm. Record review of pain evaluation completed on [DATE] at 3:07am revealed CR #2 had pain to left hip after a fall. The pain completely interfered with residents: ability to ambulate, bath, dress, eat, enjoyment of daily activities, mood, sleep, and toilet. The pain was identified as sharp and stabbing on an intensity scale of 8. Narrative note within the same record revealed after receiving [MEDICATION NAME] 0.5mg at 6:00pm, patient was able to rest. He was calm and cooperative when EMS paramedics transferred him to stretcher. Record review of CR #2's physician orders [REDACTED]. Record review of physician orders [REDACTED]. Record review of local hospital records revealed CR #2 was sent to the hospital on [DATE] at 8:19pm. The chief complaint noted patient lost his balance at the nursing home and fell on his left hip. He is complaining of left hip pain. His left leg is shortened and rotated. Further review of the record revealed the left hip x-ray showed nondisplaced intertrochanteric [MEDICAL CONDITION] femur. It was noted that the patient revoked hospice to be transferred to the hospital. Further review revealed on [DATE], CR #2 had concerns of respiratory distress/ change of status and expired at approximately 7:30pm with a [DIAGNOSES REDACTED]. Interview with the Former Administrator on [DATE] at 4:28pm revealed CR #2's family member had texted her on [DATE] at 7:25pm informing her that CR #2 had fallen at 2:30pm. CR #2's family member had informed her that the nursing facility was waiting on a mobile x-ray company for a STAT x-ray of the left hip. Former Administrator had contacted the DON. Former Administrator revealed on [DATE] at 7:34pm a text was sent to CR #2's family member to inform that EMS was on the way to the nursing facility. When the surveyor asked why there was a delay in care, she did not answer. She revealed once she became aware of the concern, she initiated care immediately. She revealed after the incident, a 5 point plan was initiated with the nurses involved with CR #2's care. She stated a QAPI action plan was initiated on the plan of care for a change of condition after this incident. Interview with the DON on [DATE] at 4:49pm revealed she was notified of any resident's falls even on weekends. The DON stated when LVN #4 called to inform her of CR #2's fall on [DATE], LVN #4 indicated there was no apparent injuries. DON revealed she was not aware of any change of condition for CR #2. She stated she received a call around 7:30pm that evening from the Former Administrator regarding a possible change of condition for CR #2. She indicated she instructed the nursing staff to send CR #2 to the hospital for evaluation immediately. The DON revealed if a resident was on hospice, the hospice orders should be transferred onto the physician orders [REDACTED]. DON revealed on [DATE] in-services with nursing for change of condition were initiated due to this incident. CR #2's [MEDICATION NAME] count sheet was requested from the DON during the same interview but was not received prior to exit. Record review of the facility Change of Condition in-service on [DATE] with all nursing staff in attendance revealed the following: If a resident falls and has a limb deformity or actual visualized open fracture, obtain orders to send to ER immediately . even if a resident is on hospice services. Record review revealed a QAPI initiated on [DATE] for CR #2's fall and interventions. Resident #1 Record review of Resident #1's facesheet revealed a [AGE] year old male who admitted to the facility on [DATE] for rehabilitation services. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's admission Quarterly Minimum Data Set Assessment (MDS) on [DATE] revealed: - Staff interview of cognition indicated short-term memory ok. Long-term memory problems. - He needed supervision of 1 staff for transfer and walking in room. - He was identified with a history of falls and was a fall risk. Observation and interview on [DATE] at 2:58pm, Resident #1 revealed he had an incident at the nursing facility. He stated he attempted to transfer himself and slipped and fell on to his knee. He indicated he was in pain for some time before the nursing staff sent him to the hospital. He revealed the hospital diagnosed the knee pain as a contusion, but he was referred to a specialist. Resident #1 revealed he never saw a specialist after the fall and wondered why the appointment had never been scheduled. Observation of the resident revealed he was able to stand on his own and pivot from his wheelchair but indicated the nursing facility wanted him to turn his light on for assistance. Interview on [DATE] at 10:43am Resident #1 revealed it took staff a long time to answer call lights at times. He revealed he was supposed to transfer with supervision. He stated the day he had fallen he was aware that staff were supposed to assist with his transfer, but staff did not answer his call light. He stated his pain had improved, but it still hurts with therapy and exercise. Record review of nursing notes for Resident #1 revealed a note on [DATE] at 4:59pm by LVN #2 which stated CNA reported resident fell at 5:15pm. Entered room and seen resident on knees. Pain of 7. Tylenol given. Interview on [DATE] at 4:49pm with LVN #2 revealed Resident #1 fell on [DATE] at 5:15pm. LVN #2 revealed she did not write the nurses note as a late entry, but acknowledged that the date in the nurses' notes was [DATE]. She revealed she informed the physician at the time of the incident. She stated the physician ordered a STAT x-ray to both knees for Resident #1. Record review of Resident #1's physician order [REDACTED].#2. Order revealed a stat x-ray of bilateral knees related to pain. Record review of Resident #1's x-ray report revealed an x-ray was completed on [DATE] at 2:12am. Further review revealed the x-ray report was faxed to the nursing facility on [DATE] at 3:12am. The x-ray results indicated right knee no gross acute fracture is seen. Left knee revealed narrowing of the medial knee compartment with osteophyte formation. Patellar fracture superolaterally. Record review of Resident #1's nursing notes dated [DATE] by LVN #2 revealed Resident x-ray results received. Concluded left patella fracture superolaterally. No gross acute [MEDICAL CONDITION] knee. NP notified and orders to send to ER. Tylenol given 500mg for pain. Further review of the same record revealed Resident #1 was transported to the hospital on [DATE] at 3:20pm via ambulance stretcher. Continued review revealed no date or time in which the NP was notified. Record review of Resident #1's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #1's hospital emergency room visit on [DATE] at 6:55pm revealed a [DIAGNOSES REDACTED]. There was no x-ray results in the hospital paperwork provided. The hospital emergency room recommended a follow-up with orthopedic surgeon within ,[DATE] days. Record review of a nursing note dated [DATE] at 11:01pm revealed Resident #1 returned to the facility with no acute fracture. Interview with LVN #3 on [DATE] at 3:06pm revealed Resident #1 did not follow-up with an orthopedic surgeon after the review of the appointment book for off-campus appointments. She indicated she was unsure why the resident was not sent for the follow-up with the orthopedic surgeon. Interview on [DATE] at 4:50pm with the DON revealed the Social Worker was working on getting Resident #1 into an orthopedic surgeon. Resident #1 was Medicaid pending and the nursing facility could not find an orthopedic surgeon who would accept him. DON revealed the nurse practitioner had come out and reassessed Resident #1 and wrote a note to discontinue orthopedic surgeon follow-up on [DATE]. She stated she had just forgot to write orders to d/c the orthopedic surgeon appointment for Resident #1. DON revealed she was unsure why a STAT x-ray took so long for Resident #1 to receive. DON stated she was unsure why there was a delay in treatment. Record review of Resident #1's nurse practitioner's progress note dated [DATE] at 12:48pm revealed a note D/C ortho appointment; No indication for follow-up. Pt denies any pain to bilateral legs/ knees. Positive ROM. Interview on [DATE] at 3:47pm with the facility's contracted mobile x-ray company staff revealed that their policy was to complete the x-ray ,[DATE] hours after receiving the STAT x-ray order. Interview on [DATE] at 11:50am with LVN #5 revealed the protocol for a resident who falls and was complaining of pain was to call 911 due to possible fracture. Interview on [DATE] at 2:49pm with RN #1 revealed if a resident fell , a head to toe assessment should be completed. She stated she would not move the resident if they hit their head. Nursing staff should call 911, physician, DON, and RP. The nursing staff should rate the residents' pain level from a ,[DATE]. Record review of the facility Falls policy dated (MONTH) (YEAR) revealed: Purpose: To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. Post fall: The patient is physically assessed for injuries and medical attention is rendered as needed. IDT reviews post fall investigations and summarizes the team recommendations. The facility census dated [DATE] revealed 59 residents resided on the 100 hall.

Based on interviews and record review, the facility failed to prohibit and prevent neglect when staff did not execute the physician's orders to perform STAT lab work and to transfer the resident to the hospital after a change in condition had been identified for one of four residents (CR#1) reviewed for neglect in that: RN#1 failed to correctly transcribe physician orders for CR#1 to include STAT Labs after a change in condition was identified by the Nurse Practitioner (NP). LVN #1 failed to promptly send CR#1 to the hospital, after a physician's order was received from the NP to send CR#1 to the hospital. LVN #1 received the order to transfer the resident to the hospital at 3:40 p.m. and then transferred the resident when he became unresponsive and had no respirations approximately four hours later. The DNS failed to initiate the NP's verbal orders to send CR#1 to the hospital after a change in condition was identified at approximately 4:00 PM and failed to transfer CR#1 to the hospital. CR#1 was found to be unresponsive at approximately 8:00 PM (4 hours later) and CR #1 expired in route to the hospital. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of wide spread because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. This affected one resident who died in the process of being transferred to the hospital and placed 90 other residents at risk for neglect, which could cause serious harm to the resident's health and safety or even loss of life. Findings include: Complaint # 2 CR # 1 Record review of CR #1's face sheet revealed he was admitted to the facility on [DATE], and was readmitted on [DATE]. He was discharged from the facility on [DATE] at 8:30 PM and the discharge status read Death in Facility. He was [AGE] years old and was diagnosed with [REDACTED]. Record review of CR#1's inital/admission care plan, dated [DATE], revealed CR#1 was at risk for abnormal bleeding related to anticoagulation therapy. The interventions included reporting changes to the attending physician and to complete lab work as ordered by the physician. Record review of CR#1's Admission MDS, dated [DATE], revealed he was moderately impaired for cognition, required extensive assistance with his ADL care by 1 or 2 staff members. Further review revealed there was an active plan to discharge CR#1 back to the community. Record review of CR #1's NP Progress Note, dated [DATE] at 2:07 PM revealed CR#1 was complaining of blood in the urine. It read patient reports that he is having blood in his urine which he noticed today. Patient also reports burning with urination. Patient does have a history of CKD. He was supposed to get discharged tomorrow per his request, but he has agreed to stay back for further test and treatment. Further review revealed a [DIAGNOSES REDACTED]. The NP's plan included STAT U/A with C&S, CMP and CBC. Record review of CR #1's Departmental Notes, dated [DATE], revealed: 2:11 PM- Patient has hematuria, he complained that it started today, he complained of burning upon urination. Vital signs within normal limit. Patient assessed by NP, new order for urinalysis, culture and sensitivity test, CBC, CMP. Further review revealed this note was signed by RN #1. 4:16 PM- (Retracted Note by LVN#1 on [DATE] at 9:36 PM) The resident was complaining of left flank and lower abdominal pain. An assessment was done that revealed a firm abdomen. CR#1 was passing blood and clots in his urine and was having difficulty empting his bladder. Resident's Vital signs were within normal limits, lungs were clear. NP notified, new (verbal) order received to send resident to emergency room for evaluation and treatment. CR#1's family member was notified and informed of treatment plan. Resident will be going to local hospital ER by local transportation company. Further review revealed this note was signed by LVN #1. 4:37 PM- (Retracted Note by LVN #1 on [DATE] at 4:54 PM) same note as previous entry at 4:16 PM. Further review revealed this note was signed by LVN #1. 4:54 PM- Resident complaining of left flank and lower abdomen pain. States having difficulty emptying bladder. Resident is having hematuria. Bowels sounds positive times' 4, lower abdomen firm. Vital signs within normal limits, lungs clear bilateral. NP notified, new orders noted to do CBC, CMP, U/A C&S STAT. Lab called will continue to monitor. Further review revealed this note was signed by LVN #1. 9:37 PM-entered residents room (approximetly 8:00 PM), resident unresponsive unable to get blood pressure or oxygen saturations. Resident had a faint pulse, no respirations, 911 (emergency medical services-EMS) called, resident left with CPR in progress unable to reach Resident's spouse with 5 attempts, will continue to try to get in contact, NP notified. Record review of CR#1's Physician Telephone Orders, dated [DATE], revealed no written orders were written by LVN #1 or the DON to send CR#1 to the hospital, after receiving a verbal order from the NP to send CR#1 to the hospital. Further review revealed orders: 1:00 PM-Urinalysis (U/A), culture and sensitivity (C&S) test CBC, CMP on [DATE]. Further review revealed this note was signed by RN #1 and by the NP on [DATE]. 5:00 PM-CBC, CMP, U/A C&S STAT. Further review revealed this note was signed by LVN #1. Record review of the facility's 24 Hour Report, dated [DATE] on ,[DATE] PM shift, read CR#1 needs urine specimen (hematuria). On [DATE] on ,[DATE] PM shift read CR#1 U/A C&S, CBC, CMP STAT. Under the section identified as Discharge/LOA/Death revealed CR#1 was sent to local hospital. Further review of the facility's 24 Hour Report, revealed on [DATE] CR#1 was deceased . Interview on [DATE] at 3:05 PM, LVN #1 stated during his shift CR#1 was complaining of pain. LVN#1 assessed CR#1 and had texted the NP to notify her of the resident's change of condition. He stated the resident complained of low abdominal pain, was not able to empty his bladder, his stomach was firm, and he had blood in his urine. He stated he also called CR#1's family member, but she could not be reached. He said he reassessed CR#1 at 6:30 PM and stated the resident was not in as much pain as earlier. Further interview with LVN #1, he stated at approximately 8:00 PM, CR#1 was found unresponsive, was not breathing, and had a faint pulse. LVN#1 started CPR, and asked someone to call EMS. He stated EMS arrived, took over CPR, and CR#1 was transported to the hospital. He stated later that evening he received notification from the hospital that CR#1 had expired on his way to the hospital. He further stated he had texted the NP to notify her of CR#1's death. Interview on [DATE] at 3:20 PM, the NP stated she had seen CR#1 on [DATE] at approximately 2:00 PM. She stated CR#1 was complaining of pain and burning sensation while urinating. She stated she examined his urine and saw blood in his urine and it was dark in color. She informed RN #1 that she wanted STAT labs ordered. She stated she did not want to start the resident on any antibiotic until the results came back. She stated the resident was supposed to be discharged home the next day on [DATE], and the NP convinced CR#1 to allow the facility to complete labs and stay at the facility for any further treatment. She completed her charting and signed the telephone order from RN #1. She further stated she did not read the telephone order prior to signing it and RN #1 did not read it to her prior to signing the order. She was unaware the orders she gave to RN #1 were not written as STAT labs. She stated approximately two hours later she had received a text message from LVN #1 stating CR#1 was having flank pain and trouble urinating. She responded to the text message to send CR#1 to the hospital. She stated approximately 45 min later, she had received a telephone call from the DNS. She stated the DNS talked about the labs being written for [DATE], instead of STAT Labs. She stated she directed the DNS to send CR#1 to the hospital for further evaluation. She stated he had a change in condition and had new symptoms from when she had last assessed him, and thought it was best to send him to the hospital for further treatment. She stated the DNS kept talking about the Labs and how the hospital would not treat UTI, and did not want to send CR#1 to the hospital. She informed the DNS that the labs were not written correctly that they should have been STAT labs. She kept telling the DNS to send CR#1 to the hospital and she thought the DNS understood her orders. She was not informed CR#1 was not sent to the hospital, until she had received another text message from LVN #1 that CR#1 had coded. She stated she was shocked that the DNS and LVN #1 did not follow her order to send CR#1 to the hospital when he had a fatal change in condition. She stated she attempted to speak to the DNS on [DATE] about her concerns, but was not successful. She further stated she had received a text message from the DNA at [DATE] at 2:53 PM that informed her of what to say if the State (surveyor) asked her any questions. She was not waiting on the STAT labs to make any decision and wanted CR#1 sent to the hospital for evaluation. Record review of screen shot text messages, provided by the NP, sent between LVN #1 and the NP, dated [DATE], revealed: 3:39 PM, LVN#1 wrote CR#1 was complaining of left lower and flank pain and was having trouble urinating and was still passing blood. NP responded to the text message with send him to the hospital. He was not complaining of flank pain earlier when I saw him. LVN #1 wrote ok. NP responded to the text message with Something is going on in his kidney. He has CKD . 9:04 PM, LVN #1 wrote to the NP CR#1 just coded. 10:56 PM, LVN #1 wrote I just found out CR#1 passed away. Record review of screen shot text messages, provided by the Unit Manager, sent between LVN #1 and the Unit Manager, dated [DATE] revealed: 4:13 PM: LVN #1 wrote I'm having to send CR#1 out to the hospital hematuria and flank pain Unit Manager responded with hmm ok. 5:51 PM LVN #1 wrote we are not sending CR#1 out after all. 5:56 PM Unit Manager responded ok not sending him out that's fine. 5:58 PM LVN #1 responded ok 8:55 PM LVN #1 wrote CR#1 just coded. 9:00 PM, Unit Manager responded whoa he a full code too right? Did he have a heartbeats when he left? 9:01 PM, LVN #1 responded No. 9:02 PM, Unit Manager wrote Awww man. Happened they did not send him out. Record review of screen shot text messages, provided by the NP, sent between the DNS to the NP, dated [DATE] at 2:53 PM, revealed the DNS wrote do you have your progress note from yesterday .If the state lady talk to you just say you were waiting for the STAT lab results to make a follow up decision whether to send out or not, that is all she needs to hear. Interview on [DATE] at 8:15 AM, the Administrator stated she had interviewed staff, the NP, and the DNS concerning the events and timeline of [DATE] for CR#1. She stated the NP's story was consistent and believed the NP told the DNS to send CR#1 to the hospital. She agreed the DNS did not send CR#1 to the hospital. Interview on [DATE] at 8:40 AM, LVN #2 stated she worked with the NP daily during her shift. She stated the NP was usually very clear on her orders and had a good relationship with other nurses in the building. She stated she would only contact the NP by text message for minor information, and would contact the NP by phone if the message was more urgent. She stated if the physician/NP gave the order to send resident to the hospital, she would call transportation for non-emergency and would call EMS for emergency. She would have made sure the resident was sent out and then contact the DNS, ADNS, or Unit Manager, and the RP to notify them of the hospital transfer. She further stated if she was told a different order from her supervisor, she would have contacted the NP to verify orders before writing any new orders. She again stated if she received orders to send out to the hospital, she would have sent the resident out to the hospital for further evaluation and then notified everyone else. Interview on [DATE] at 9:35 AM, RN #1 stated CR#1 had blood in his urine. She looked inside CR#1's urinal and saw blood and the urine color was pink. She stated she assessed CR#1 and found that CR#1 was complaining of burning while urinating. She stated CR#1's vital signs were within normal limits and reported her findings to the NP, who was at the facility. She stated the NP ordered regular labs and not STAT Labs. She wrote the verbal NP's orders for labs to be drawn on [DATE]. She later went back to CR#1's room to collect a urine sample and was not able to collect it. She documented in the 24 hour communication log for the next shift to collect the sample. She agreed bloody urine could be identified as a change in condition. She stated she should have read back the verbal order or asked for a clarification order due to the change of condition. She further stated the NP was at the facility on a daily basis and communicated physician's orders well. She stated that if the NP would have given her the order to send CR#1 out to the hospital, she would have written the order, contacted transportation services, prepared his paperwork, and then notified her manager of the transfer, and document. She stated the NP knows what was best for CR#1 and the facility should have sent CR#1 to the hospital at the time of the order. Telephone Interview on [DATE] at 10:15 AM, the Unit Manager (UM) stated she was not at work today, because the DNS had asked her to take off. She stated she had been informed that CR#1 had a change in condition on [DATE] by LVN #1 and had blood in his urine. The NP was in the building and assessed him and ordered STAT labs. She stated on [DATE] at 4:29 PM, she had received a text message from LVN #1 stating he was sending CR#1 to the hospital. At 5:51 PM, text message stated not sending CR#1 out to the hospital, and at 8:55 PM CR#1 had coded. She further stated that after she had received the text message about CR#1 had coded, she spoke to LVN#1 and was informed that the DNS had made the decision not to send the resident out to the hospital for a possible UTI. She stated LVN #1 never wrote the verbal order from the NP to send CR#1 to the hospital and instead wrote verbal orders from the DNS for STAT labs to be completed. She further stated LVN#1 should have contacted the NP to clarify orders after the DNS said not to send out to hospital. She stated she expected the nurses to follow the physician's orders and to send residents' to the hospital when instructed by the physician/NP. Interview on [DATE] at 1:35 PM, LVN #1 stated he had notified the NP and the Unit Manager by text messages about CR#1's status. He stated he also reported to another nurse who instructed him to contact the DNS prior to sending CR#1 out to the hospital. He stated after he had received the verbal order to send CR#1 out to the hospital from the NP, he charted in the clinical notes, prepared the paperwork, and called CR#1's responsible party and told her that CR#1 was being sent to the hospital. He did not write the verbal telephone order from the NP to send CR#1 to the hospital. He saw the DNS and both went to assess the resident at approximetly 4:00 PM. He stated after their assessment, he heard the DNS speaking to the NP over the telephone near the nurse's station. He stated he did not hear their conversation. He stated when the DNS was done with the conversation, she had instructed him to write the orders for CR#1's STAT labs. He wrote the verbal orders from the DNS and retracted his previous nursing notes and made a new entry. When asked why he changed the orders after the NP had instructed him to send CR#1 out to the hospital, he stated the DNS was his supervisor and he assumed the DNS had received the verbal order for STAT labs and did not question her. He stated he received verbal orders from the NP to send to the hospital and verbal orders from his DNS to do STAT Labs. He further stated he did not contact the NP to verify the orders. Interview on [DATE] at 2:40 PM, the DNS stated CR#1 had been complaining of lower back pain, blood in his urine, burning with urination, and difficulty urinating. She stated his symptoms sounded like a urinary tract infection. She stated she assessed the patient and left the facility. She stated she had contacted CR#1's NP over the telephone while she was driving home. She stated the NP gave her the verbal order to make CR#1's labs STAT. She stated after she ended the call with the NP, she contacted LVN #1 and told him to change the orders to STAT labs. She stated she told LVN #1 to make sure to write STAT on the orders. When asked about the text message between the DNS and the NP that read do you have your progress note from yesterday .If the state lady talk to you just say you were waiting for the STAT lab results to make a follow up decision whether to send out or not, that is all she needs to hear, she confirmed that she wrote that statement. The DNS did not have any further comments concerning the text message. Other attempts to contact the DNS for further interview were made on [DATE], [DATE], and [DATE], but was not successful. Record review of the facility's in-service, dated [DATE], revealed: Before writing or carrying out any order, it must be given by MD/NP first and on the telephone order it must read T.O.R.B and with the MD/NP name of whom order was given. Further review revealed LVN #1 signed the in-service form. When a patient/resident is being discharged whether it is planned/or not, you must notify the MD/NP to get an order/make sure you write on order T.O.R.B. Further review revealed LVN #1 signed the in-service form. Record review of the facility's Notification of Change in Patient/Resident Health Status policy, no date, revealed the facility was to consult with the resident's physician, nurse practitioner or physician assistant, and the resident's legal representative or an interested family member when there is a decision to transfer or discharge the resident from the facility. It further read Nursing judgement is an integral part of the skilled care provided in this facility, therefore, such judgment must be applied in a case by case basis in keeping with acceptable nursing practice. Record review of the facility's Abuse policy, dated ,[DATE], read .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriations of resident/patient property (alleged violations), are reported immediately to the Administrator/Director of Nursing of the enter. Further review of the policy read Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress. An Immediate Jeopardy (IJ), was identified and the Administrator and Nurse Consultant were both notified of the IJ on [DATE] at 11:35 AM. Plan of Removal was accepted on [DATE] at 2:43 PM after multiple revisions in that: Residents in Center were reviewed for change in condition- DNS, ADNS and attending nurse reviewed and discussed any patients with a change in condition. When change of condition was noted MD/NP was notified by attending nurse. 3 Residents with change in condition were noted by attending nurse who then contacted MD/NP and received subsequent orders. All 3 residents were sent to the hospital when change of condition was noted on [DATE]. The system will be when a resident has a change in condition, the Attending Nurse will notify MD/NP via Center phone and follow up on orders obtained. Documentation will include resident condition, orders received and monitoring that has occurred for the resident until transferred to the hospital. DNS, ADNS, and Clinical Educator will review 24 hour report for change in condition in Clinical Start-up, (Which is the daily reporting structure for Clinical communication) and validate that residents change in condition was followed up appropriately with any new orders noted daily times 30 days. RNs and LVNs were re-educated by the DNS of a sister facility regarding change in condition, following MD orders, and documentation of change in condition. RNS, LVNs, Certified Medication Aides and Certified Nursing Assistants were re-educated regarding Abuse and Neglect policy. DNS of a sister facility conducted training. Full time employees were re-educated. PRN employees will not work until education was completed. DNS, ADNS and or designee will review changes of condition immediately to include observation of the 24 hour report and Physician telephone orders. DNS, ADNS and or designee will conduct walking rounds daily to identify any acute change of condition with immediate notification of MD/NP. Regional Director of Clinical Operations will review re-hospitalization s daily beginning [DATE]. Monitoring began on [DATE], [DATE], and [DATE]. Staff interviewed on [DATE], [DATE], and [DATE] at various times. This included CNAs, MAs, LVNs, and RNs on two of three shifts. Staff were able to appropriately identify abuse/neglect, when to report, and whom to report too. The staff were able to identify a change in condition, whom to notify, and when to report changes. Further interview revealed staff were trained on documentation. Record review of facility In-services on Abuse/Neglect were conducted on [DATE], [DATE], [DATE], [DATE] at various times. Record review of the facility's Change in Condition Review, dated [DATE] for [DATE], revealed the facility had identified 3 other residents for a change in condition. Interview on [DATE] at 2:00 PM, the Administrator stated when a change of condition occurred, she felt the orders to send a patient to the hospital superseded all other orders including STAT Labs orders. She stated the facility used protocols for change of condition. She further agreed the Nurse who took the order should have written the order and documented why the change occurred. She stated she had interviewed the NP and the verbal order was to send CR#1 out to the hospital. She stated she was monitoring the DNS by checking the 24 hour reports, looking at the clinical records, any retracted notes, telephone orders, and reports from the ADNSs. She stated the facility's nursing staff have been trained and in-serviced by the Director of Clinical Operations (Regional Consultant) and another DNS from a sister facility on policy and procedures for HIPAA, Abuse/Neglect, and Change of Condition. She stated staff were not to use personal cell phones for medical/resident communication to providers and to use the facility's telephone for any resident related communication. She stated all nursing staff were retrained on when to report abuse/neglect, whom to report allegations, and trained on following physician's orders, who to notify, verify the orders, and documentation. She stated resources available to the staff included regional consultants, RNs, other administrators, the medical Director, and the QA process. On [DATE] the surveyor confirmed the Plan of Removal had been implemented sufficiently to lower the IJ. The Administrator and Nurse Consultant were informed on [DATE] at 1:15 PM that the IJ was lowered; however, the facility remained out of compliance at scope of widespread and severity actual harm that was not immediate jeopardy because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. The facility's census was 90 residents.

Based on observation, interview, and record review, the facility failed to use its resources effectively to attain and or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in that: The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect for CR #1. The Administrator failed to supervise and monitor the DNS and carried out her responsibilities in the areas of staff training/monitoring, to provide the appropriate treatment, complete assessments and implement preventive measures to identify a change in condition. The DNS failed to train staff to follow the physician orders, and to implement measures to provide the appropriate treatment, complete assessment and follow the Nurse Practitioner's (NP) order to send CR#1 to the hospital after a change in condition was identified. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of widespread because the facility was continuing to in-service staff and monitor the Plan of Removal for effectiveness. These failure affected one resident (CR#1) who died when being transferred to the hospital and placed 90 other residents at risk for abuse, neglect, loss of life, and serious harm to the resident's health and safety. Findings include: Complaint # 2 CR # 1 Record review of CR #1's face sheet revealed he was admitted to the facility on [DATE], and was readmitted on [DATE]. He was discharged from the facility on [DATE] at 8:30 PM and the discharge status read Death in Facility. He was [AGE] years old and was diagnosed with [REDACTED]. Record review of CR#1's inital/admission care plan, dated [DATE], revealed CR#1 was at risk for abnormal bleeding related to anticoagulation therapy. The interventions included reporting changes to the attending physician and to complete lab work as ordered by the physician. Record review of CR#1's Admission MDS, dated [DATE], revealed he was moderately impaired for cognition, required extensive assistance with his ADL care by 1 or 2 staff members. Further review revealed there was an active plan to discharge CR#1 back to the community. Record review of CR #1's NP Progress Note, dated [DATE] at 2:07 PM revealed CR#1 was complaining of blood in the urine. It read patient reports that he is having blood in his urine which he noticed today. Patient also reports burning with urination. Patient does have a history of CKD. He was supposed to get discharged tomorrow per his request, but he has agreed to stay back for further test and treatment. Further review revealed a [DIAGNOSES REDACTED]. The NP's plan included STAT U/A with C&S, CMP and CBC. Record review of CR #1's Departmental Notes, dated [DATE], revealed: note written at 2:11 PM- Patient has hematuria, he complained that it started today, he complained of burning upon urination. Vital signs within normal limit. Patient assessed by NP, new order for urinalysis, culture and sensitivity test, CBC, CMP. Further review revealed this note was signed by RN #1. note written at 4:16 PM- (Retracted Note by LVN #1 on [DATE] at 9:36 PM) the resident was complaining of left flank and lower abdominal pain. An assessment was done that revealed a firm abdomen. CR#1 was passing blood and clots in his urine and was having difficulty empting his bladder. Resident's Vital signs were within normal limits, lungs were clear. NP notified, new (verbal) order received to send resident to emergency room for evaluation and treatment. CR#1's family member was notified and informed of treatment plan. Resident will be going to local hospital ER by local transportation company. Further review revealed this note was signed by LVN #1. note written at 4:37 PM- (Retracted Note by LVN #1 on [DATE] at 4:54 PM) same note as previous entry at 4:16 PM. Further review revealed this note was signed by LVN #1. note written at 4:54 PM- Resident complaining of left flank and lower abdomen pain. States having difficulty emptying bladder. Resident is having hematuria. Bowels sounds positive times' 4, lower abdomen firm. Vital signs within normal limits, lungs clear bilateral. NP notified, new orders noted to do CBC, CMP, U/A C&S STAT. Lab called will continue to monitor. Further review revealed this note was signed by LVN #1. note written at 9:37 PM-entered residents room (approximetly 8:00 PM), resident unresponsive unable to get blood pressure or oxygen saturations. Resident had a faint pulse, no respirations, 911 (emergency medical services-EMS) called, resident left with CPR in progress unable to reach Resident's spouse with 5 attempts, will continue to try to get in contact, NP notified. Record review of CR#1's Physician Telephone Orders, dated [DATE], revealed no written orders from LVN #1 or the DNS to send CR#1 to the hospital. Further review revealed orders: 1:00 PM-Urinalysis (U/A), culture and sensitivity (C&S) test CBC, CMP on [DATE]. Further review revealed this note was signed by RN #1 and by the NP on [DATE]. 5:00 PM-CBC, CMP, U/A C&S STAT. Further review revealed this note was signed by LVN #1. Record review of the facility's 24 Hour Report, dated [DATE] on ,[DATE] PM shift, read CR#1 needs urine specimen (hematuria). On [DATE] on ,[DATE] PM shift read CR#1 U/A C&S, CBC, CMP STAT. Under the section identified as Discharge/LOA/Death revealed CR#1 was sent to local hospital. Further review of the facility's 24 Hour Report, revealed on [DATE] CR#1 was deceased . Interview on [DATE] at 3:05 PM, LVN #1 stated during his shift CR#1 was complaining of pain. LVN#1 assessed CR#1 and had texted the NP to notify her of his change of condition. He stated the resident complained of low abdominal pain, was not able to empty his bladder, his stomach was firm, and he had blood in his urine. He stated he also called CR#1's family member, but she could not be reached. He stated he reassessed CR#1 at 6:30 PM and stated the resident was not in as much pain as earlier. Continued interview LVN #1 stated at approximately 8:00 PM, CR#1 was found unresponsive, was not breathing, and had a faint pulse. LVN#1 started CPR, and asked someone to call EMS. He stated EMS arrived, and took over CPR, and CR#1 was transported to the hospital. He stated later that evening he received notification from the hospital that CR#1 had expired on his way to the hospital. He further stated he had texted the NP to notify her of CR#1's death. Interview on [DATE] at 3:20 PM, the NP stated she had seen CR#1 on [DATE] at approximately 2:00 PM. She stated CR#1 was complaining of pain and burning sensation while urinating. She stated she examined his urine and saw blood in his urine and it was dark in color. She informed RN #1 that she wanted STAT labs ordered. She stated she did not want to start the resident on any antibiotic until the results came back. She stated the resident was supposed to be discharged home the next day on [DATE], and the NP convinced CR#1 to allow the facility to complete labs and stay at the facility for any further treatment. She completed her charting and signed the telephone order from RN #1. She further stated she did not read the telephone order prior to signing it and RN #1 did not read it to her prior to signing the order. She stated approximately two hours later she had received a text message from LVN #1 stating CR#1 was having flank pain and trouble urinating. She responded to the text message to send CR#1 to the hospital. She stated approximately 45 min later, she had received a telephone call from the DNS. She stated the DNS talked about the labs being written for [DATE], instead of STAT Labs. She stated she directed the DNS to send CR#1 to the hospital for further evaluation. She stated he had a change in condition and had new symptoms from when she had last assessed him, and thought it was best to send him to the hospital for further treatment. She stated the DNS kept talking about the Labs and how the hospital would not treat UTI, and did not want to send CR#1 to the hospital. She informed the DNS that the labs were not written correctly that they should have been STAT labs. She kept telling the DNS to send CR#1 to the hospital and she thought the DNS understood her orders. She was not informed CR#1 was not sent to the hospital, until she had received another text message from LVN #1 that CR#1 had coded. She stated she was shocked that the DNS and LVN #1 did not follow her order to send CR#1 to the hospital when he had a fatal change in condition. She stated she attempted to speak to the DNS on [DATE] about her concerns, but was not successful. She further stated she had received a text message from the DNS at [DATE] at 2:53 PM that informed her of what to say if the State (surveyor) asked her any questions. She was not waiting on the STAT labs to make any decision and wanted CR#1 sent to the hospital for evaluation. Record review of screen shot text messages provided by the NP, sent between LVN #1 and NP, dated [DATE], revealed: 3:39 PM, LVN#1 wrote CR#1 was complaining of left lower and flank pain and was having trouble urinating and was still passing blood. NP responded to the text message with send him to the hospital. He was not complaining of flank pain earlier when I saw him. LVN #1 wrote ok. NP responded to the text message with Something is going on in his kidney. He has CKD . 9:04 PM, LVN #1 wrote to the NP CR#1 just coded. 10:56 PM, LVN #1 wrote I just found out CR#1 passed away. Record review of screen shot text messages provided by the Unit Manager, sent between LVN #1 and the Unit Manager, dated [DATE] revealed: 4:13 PM: LVN #1 wrote I'm having to send CR#1 out to the hospital hematuria and flank pain Unit Manager responded with hmm ok. 5:51 PM LVN #1 wrote we are not sending CR#1 out after all. 5:56 PM Unit Manager responded ok not sending him out that's fine. 5:58 PM LVN #1 responded ok 8:55 PM LVN #1 wrote CR#1 just coded. 9:00 PM, Unit Manager responded whoa he a full code too right? Did he have a heartbeats when he left? 9:01 PM, LVN #1 responded No. 9:02 PM, Unit Manager wrote Awww man. Happened they did not send him out. Record review of screen shot text messages provided by the NP, sent between the DNS to the NP, dated [DATE] at 2:53 PM, revealed the DNS wrote do you have your progress note from yesterday .If the state lady talk to you just say you were waiting for the STAT lab results to make a follow up decision whether to send out or not, that is all she needs to hear. Interview on [DATE] at 8:15 AM, the Administrator stated she had interviewed staff, the NP, and the DNS concerning the events and timeline of [DATE] for CR#1. She stated the NP's story was consistent and believed the NP told the DNS to send CR#1 to the hospital. She agreed the DNS did not send CR#1 to the hospital. Interview on [DATE] at 8:40 AM, LVN #2 stated she worked with the NP daily during her shift. She stated the NP was usually very clear on her orders and had a good relationship with other nurses in the building. She stated she would only contact the NP by text message for minor information, and would contact the NP by phone if the message was more urgent. She stated if the physician/NP gave the order to send resident to the hospital, she would call transportation for non-emergency and would call EMS for emergency. She further stated she would have made sure the resident was sent out, and then contact the DNS, ADON, or Unit Manager, and the RP to notify them of the hospital transfer. She further stated if she was told a different order from her supervisor, she would have contacted the NP to verify orders before writing any new orders. She again stated if she received orders to send out to the hospital, she would have sent the resident out to the hospital for further evaluation and then notified everyone else. Interview on [DATE] at 9:35 AM, RN #1 stated CR#1 had blood in his urine. She looked inside the CR#1's urinal and saw blood and the urine color was pink. She stated she assessed CR#1 and found that CR#1 was complaining of burning while urination. She stated CR#1's vital signs were within normal limits and reported her findings to the NP, who was at the facility. She stated the NP ordered regular labs and not STAT Labs. She stated she wrote the verbal orders for labs to be drawn on [DATE]. She stated she later went back to CR#1's room to collect a urine sample and was not able to collect it. She documented in the 24 hour communication log for the next shift to collect the sample. She agreed bloody urine could be identified as a change in condition. She stated she should have read back the verbal order or asked for a clarification order due to the change of condition. She further stated the NP was at the facility on a daily basis and communicated physician's orders [REDACTED].#1 out to the hospital, she would have written the order, contacted transportation services, prepared his paperwork, and then notified her manager of the transfer, and document. She stated the NP knows what was best for CR#1 and the facility should have sent CR#1 to the hospital at the time of the order. Telephone Interview on [DATE] at 10:15 AM, the Unit Manager (UM) stated she was not at work today, because the DNS had asked her to take off. She stated she had been informed that CR#1 had a change in condition on [DATE] by LVN #1 and had blood in his urine. The NP was in the building and assessed him and ordered STAT labs. She stated on [DATE] at 4:29 PM, she had received a text message from LVN #1 stating he was sending CR#1 to the hospital. At 5:51 PM, text message stated not sending CR#1 out to the hospital, and at 8:55 PM CR#1 had coded. She further stated that after she had received the text message about CR#1 had coded, she spoke to LVN#1 and was informed that the DNS had made the decision not to send the resident out to the hospital for a possible UTI. She stated LVN #1 never wrote the verbal order from the NP to send CR#1 to the hospital and instead wrote verbal orders from the DNS for STAT labs to be completed. She further stated LVN#1 should have contacted the NP to clarify orders after the DNS said not to send out to hospital. She stated she expected the nurses to follow the physician's orders [REDACTED]. Interview on [DATE] at 1:35 PM, LVN #1 stated he had notified the NP and the Unit Manager by text messages about CR#1's status. He stated he also reported to another nurse who instructed him to contact the DNS prior to sending CR#1 out to the hospital. He stated after he had received the verbal order to send CR#1 out to the hospital from the NP, he charted in the clinical notes, prepared the paperwork, and called CR#1's responsible party and told her that CR#1 was being sent to the hospital. He did not write the verbal telephone order from the NP to send CR#1 to the hospital. He saw the DNS and both went to assess the resident. He stated after their assessment, he heard the DNS speaking to the NP over the telephone near the nurse's station. He stated he did not hear their conversation. He stated when the DNS was done with the conversation, she had instructed him to write the orders for CR#1's STAT labs. He wrote the verbal orders from the DNS and retracted his previous nursing notes and made a new entry. When asked why he changed the orders after the NP had instructed him to send CR#1 out to the hospital, he stated the DNS was his supervisor and he assumed the DNS had received the verbal order for STAT labs and did not question her. He stated he received verbal orders from the NP to send to the hospital and verbal orders from his DNS to do STAT Labs. He further stated he did not contact the NP to verify the orders. Interview on [DATE] at 2:40 PM, the DNS stated CR#1 had been complaining of lower back pain, blood in his urine, and burning with urination, and difficulty urinating. She stated his symptoms sounded like a urinary tract infection. She stated she assessed the patient and left the facility. She stated she had contacted CR#1's NP over the telephone while she was driving home. She stated the NP gave her the verbal order to make the labs STAT. She stated after she ended the call with the NP, she contacted LVN #1 and told him to change the orders to STAT labs. She stated she told LVN #1 to make sure to write STAT on the orders. When asked about the text message between the DNS and the NP that read do you have your progress note from yesterday .If the state lady talk to you just say you were waiting for the STAT lab results to make a follow up decision whether to send out or not, that is all she needs to hear, she confirmed that she wrote that statement. The DNS did not have any further comments concerning the text message. Other attempts to contact the DNS for further interview were made on [DATE], [DATE], and [DATE], but was not successful. Interview on [DATE] at 8:15 AM and continued on [DATE] at 2:00 PM, the Administrator stated when a change of condition occurred, she felt the orders to send a patient to the hospital superseded all other orders including STAT Labs orders. She stated the facility used protocols for change of condition. She further agreed the Nurse who took the order should have written the order and documented why the change occurred. She stated she had interviewed the NP and the order was to send CR#1 out to the hospital. She stated she was monitoring the DNS by checking the 24 hour reports, looking at the clinical records, any retracted notes, telephone orders, and reports from the ADONs. She stated the facility's nursing staff have been trained and in-serviced by the Director of Clinical Operations (Regional Consultant) and another DNS from a sister facility on policy and procedures for HIPAA, Abuse/Neglect, and Change of Condition. She stated staff were not to use personal cell phones for medical/resident communication to providers and to use the facility's telephone for any resident related communication. She stated all nursing staff were retrained on when to report abuse/neglect, whom to report allegations, and trained on following physician's orders [REDACTED]. She stated resources available to the staff included regional consultants, RNs, other administrators, the medical Director, and the QA process. In the same interviews with the Administrator she was asked: What type of procedure was there to make sure the nursing needs of resident's are being met? Administrator's Response: The facility uses protocols to ensure the resident's needs were being met and to identify a change in condition-follow the physician's orders [REDACTED]. How do you monitor staff to ensure the systems they monitor were being done sufficiently? Ensure competency of the staff? Evaluate Policy/Procedure? Ensure effectiveness of facility processes? Administrator's Response: Reviews 24 hour report, clinical records, any retracted notes, review telephone orders to ensure they match the nursing notes. She stated she had multiple staff including the DNS, ADON, and unit managers to help with the monitoring of staff. She stated the nursing staff received in-services by the DCO and another DNS from a sister facility about the facility's policy and procedure. She stated nursing staff were trained on HIPAA and the use of personal cell phones was prohibited for any communication of patient care. She stated other in-services included Neglect, following physician orders, and identifying a change in condition. She stated the steps included notification and documentation. How do you think this incident came about? Were you aware of the situation? If so, did you investigate and/or implement corrective measures? Administrator's Response: She believed the incident occurred due to nursing staff not following the verbal/written orders from the NP. She stated if the MD/NP gave a verbal order to send a resident to the hospital, she expected her staff to follow the orders. She stated she thought the order send to the hospital superseded all other verbal orders including STAT labs. She further stated she was not aware of the incident, until the next day at the morning meeting. She was told CR#1 had been discharged and had expired, but was not told in depth of the situation. She stated she completed an internal investigation and did not report the investigation to the State office. She stated the NP's story was consistent and reviewed the NP's progress Note. She stated she believed the NP gave the verbal/written order to send CR#1 to the hospital and LVN #1 and the DNS did not follow the order. What resources are available to you and your staff? Administrator's Response: The Medical Director was also CR#1's physician and stated she contacted the Medical Director concerning the incident involving CR#1. She stated the NP worked directly with the Medical Director. She stated the facility had a Quality Assurance committee and met monthly. She stated the facility created a 4-point plan that included the use of regional consultants, RNs, other administrators, and the vice president of the corporation. She stated she would be working with all the resources to implement a plan of correction. She stated the facility would look at their policy and procedures and would evaluate them for their effectiveness once the Quality Assurance committee had met. Record review of the facility's in-service, dated [DATE], revealed: Before writing or carrying out any order, it must be given by MD/NP first and on the telephone order it must read T.O.R.B and with the MD/NP name of whom order was given. Further review revealed LVN #1 signed the in-service form. When a patient/resident is being discharged whether it is planned/or not, you must notify the MD/NP to get an order/make sure you write on order T.O.R.B. Further review revealed LVN #1 signed the in-service form. Record review of the facility's Notification of Change in Patient/Resident Health Status policy, no date, revealed the facility was to consult with the resident's physician, nurse practitioner or physician assistant, and the resident's legal representative or an interested family member when there is a decision to transfer or discharge the resident from the facility. It further read Nursing judgement is an integral part of the skilled care provided in this facility, therefore, such judgment must be applied in a case by case basis in keeping with acceptable nursing practice. Record review of the facility's Abuse policy, dated ,[DATE], read .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriations of resident/patient property (alleged violations), are reported immediately to the Administrator/Director of Nursing of the enter. Further review of the policy read Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress. An Immediate Jeopardy (IJ), was identified and the Administrator and Nurse Consultant were both notified of the IJ on [DATE] at 11:35 AM. Plan of Removal was accepted on [DATE] at 2:43 PM with multiple revisions in that: Residents in Center were reviewed for change in condition- DNS, ADNS and attending nurse reviewed and discussed any patients with a change in condition. When change of condition was noted MD/NP was notified by attending nurse. 3 Residents with change in condition were noted by attending nurse who then contacted MD/NP and received subsequent orders. All 3 residents were sent to the hospital when change of condition was noted on [DATE]. The system will be when a resident has a change in condition, the Attending Nurse will notify MD/NP via Center phone and follow up on orders obtained. Documentation will include resident condition, orders received and monitoring that has occurred for the resident until transferred to the hospital. DNS, ADNS, and Clinical Educator will review 24 hour report for change in condition in Clinical Start-up, (Which is the daily reporting structure for Clinical communication) and validate that residents change in condition was followed up appropriately with any new orders noted daily times 30 days. RNs and LVNs were re-educated by the DNS of a sister facility regarding change in condition, following MD orders, and documentation of change in condition. RNS, LVNs, Certified Medication Aides and Certified Nursing Assistants were re-educated regarding Abuse and Neglect policy. DNS of a sister facility conducted training. Full time employees were re-educated. PRN employees will not work until education was completed. DNS, ADNS and or designee will review changes of condition immediately to include observation of the 24 hour report and Physician telephone orders. DNS, ADNS and or designee will conduct walking rounds daily to identify any acute change of condition with immediate notification of MD/NP. Regional Director of Clinical Operations will review re-hospitalization s daily beginning [DATE]. Monitoring began on [DATE], [DATE], and [DATE]. Staff interviewed on [DATE], [DATE], and [DATE] at various times. This included CNAs, MAs, LVNs, and RNs on two of three shifts. Staff were able to appropriately identify abuse/neglect, when to report, and whom to report too. The staff were able to identify a change in condition, whom to notify, and when to report changes. Further interview revealed staff were trained on documentation. Record review of facility In-services on Abuse/Neglect were conducted on [DATE], [DATE], [DATE], [DATE] at various times. Record review of the facility's Change in Condition Review, dated [DATE] for [DATE], revealed the facility had identified three other residents for a change in condition. All three residents had been provided care, physician consult and transferred to the hospital as ordered by the physician. On [DATE] the surveyor confirmed the Plan of Removal had been implemented sufficiently to lower the IJ. The Administrator and Nurse Consultant were informed on [DATE] at 1:15 PM that the IJ was lowered; however, the facility remained out of compliance at scope of widespread and severity actual harm that was not immediate jeopardy because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. The facility's census was 90 residents.

Based on interviews and record review, the facility failed to ensure services were provided by the facility in accordance with the resident's written plan of care for one of four residents (CR #1) reviewed for following physician's orders [REDACTED]. RN#1 failed to correctly transcribe verbal physician orders [REDACTED]. LVN #1 failed to promptly send CR#1 to the hospital, after a physician's orders [REDACTED].#1 to the hospital. LVN #1 received the order to transfer the resident to the hospital at 3:40 PM. and then transferred the resident when he became unresponsive and had no respirations approximately four hours later. The DNS failed to initiate the NP's verbal orders to send CR#1 to the hospital after a change in condition was identified at approximately 4:00 PM and failed to transfer CR#1 to the hospital. CR#1 was found to be unresponsive at approximately 8:00 PM (4 hours later) and CR #1 expired in route to the hospital. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of wide spread because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. This affected one resident who died in the process of being transferred to the hospital and placed 90 other residents at risk for neglect, which could cause serious harm to the resident's health and safety or even loss of life. Findings include: Complaint # 2 CR # 1 Record review of CR #1's face sheet revealed he was admitted to the facility on [DATE], and was readmitted on [DATE]. He was discharged from the facility on [DATE] at 8:30 PM and the discharge status read Death in Facility. He was [AGE] years old and was diagnosed with [REDACTED]. Record review of CR#1's inital/admission care plan, dated [DATE], revealed CR#1 was at risk for abnormal bleeding related to anticoagulation therapy. The interventions included reporting changes to the attending physician and to complete lab work as ordered by the physician. Record review of CR#1's Admission MDS, dated [DATE], revealed he was moderately impaired for cognition, required extensive assistance with his ADL care by 1 or 2 staff members. Further review revealed there was an active plan to discharge CR#1 back to the community. Record review of CR #1's NP Progress Note, dated [DATE] at 2:07 PM revealed CR#1 was complaining of blood in the urine. It read patient reports that he is having blood in his urine which he noticed today. Patient also reports burning with urination. Patient does have a history of CKD. He was supposed to get discharged tomorrow per his request, but he has agreed to stay back for further test and treatment. Further review revealed a [DIAGNOSES REDACTED]. The NP's plan included STAT U/A with C&S, CMP and CBC. Record review of CR #1's Departmental Notes, dated [DATE], revealed: 2:11 PM- Patient has hematuria, he complained that it started today, he complained of burning upon urination. Vital signs within normal limit. Patient assessed by NP, new order for urinalysis, culture and sensitivity test, CBC, CMP. Further review revealed this note was signed by RN #1. 4:16 PM- (Retracted Note by LVN#1 on [DATE] at 9:36 PM) The resident was complaining of left flank and lower abdominal pain. An assessment was done that revealed a firm abdomen. CR#1 was passing blood and clots in his urine and was having difficulty empting his bladder. Resident's Vital signs were within normal limits, lungs were clear. NP notified, new (verbal) order received to send resident to emergency room for evaluation and treatment. CR#1's family member was notified and informed of treatment plan. Resident will be going to local hospital ER by local transportation company. Further review revealed this note was signed by LVN #1. 4:37 PM- (Retracted Note by LVN #1 on [DATE] at 4:54 PM) same note as previous entry at 4:16 PM. Further review revealed this note was signed by LVN #1. 4:54 PM- Resident complaining of left flank and lower abdomen pain. States having difficulty emptying bladder. Resident is having hematuria. Bowels sounds positive times' 4, lower abdomen firm. Vital signs within normal limits, lungs clear bilateral. NP notified, new orders noted to do CBC, CMP, U/A C&S STAT. Lab called will continue to monitor. Further review revealed this note was signed by LVN #1. 9:37 PM-entered residents room (approximetly 8:00 PM), resident unresponsive unable to get blood pressure or oxygen saturations. Resident had a faint pulse, no respirations, 911 (emergency medical services-EMS) called, resident left with CPR in progress unable to reach Resident's spouse with 5 attempts, will continue to try to get in contact, NP notified. Record review of CR#1's Physician Telephone Orders, dated [DATE], revealed no written orders were written by LVN #1 or the DON to send CR#1 to the hospital, after receiving a verbal order from the NP to send CR#1 to the hospital. Further review revealed orders: 1:00 PM-Urinalysis (U/A), culture and sensitivity (C&S) test CBC, CMP on [DATE]. Further review revealed this note was signed by RN #1 and by the NP on [DATE]. 5:00 PM-CBC, CMP, U/A C&S STAT. Further review revealed this note was signed by LVN #1. Record review of the facility's 24 Hour Report, dated [DATE] on ,[DATE] PM shift, read CR#1 needs urine specimen (hematuria). On [DATE] on ,[DATE] PM shift read CR#1 U/A C&S, CBC, CMP STAT. Under the section identified as Discharge/LOA/Death revealed CR#1 was sent to local hospital. Further review of the facility's 24 Hour Report, revealed on [DATE] CR#1 was deceased . Interview on [DATE] at 3:05 PM, LVN #1 stated during his shift CR#1 was complaining of pain. LVN#1 assessed CR#1 and had texted the NP to notify her of the resident's change of condition. He stated the resident complained of low abdominal pain, was not able to empty his bladder, his stomach was firm, and he had blood in his urine. He stated he also called CR#1's family member, but she could not be reached. He said he reassessed CR#1 at 6:30 PM and stated the resident was not in as much pain as earlier. Further interview with LVN #1, he stated at approximately 8:00 PM, CR#1 was found unresponsive, was not breathing, and had a faint pulse. LVN#1 started CPR, and asked someone to call EMS. He stated EMS arrived, took over CPR, and CR#1 was transported to the hospital. He stated later that evening he received notification from the hospital that CR#1 had expired on his way to the hospital. He further stated he had texted the NP to notify her of CR#1's death. Interview on [DATE] at 3:20 PM, the NP stated she had seen CR#1 on [DATE] at approximately 2:00 PM. She stated CR#1 was complaining of pain and burning sensation while urinating. She stated she examined his urine and saw blood in his urine and it was dark in color. She informed RN #1 that she wanted STAT labs ordered. She stated she did not want to start the resident on any antibiotic until the results came back. She stated the resident was supposed to be discharged home the next day on [DATE], and the NP convinced CR#1 to allow the facility to complete labs and stay at the facility for any further treatment. She completed her charting and signed the telephone order from RN #1. She further stated she did not read the telephone order prior to signing it and RN #1 did not read it to her prior to signing the order. She was unaware the orders she gave to RN #1 were not written as STAT labs. She stated approximately two hours later she had received a text message from LVN #1 stating CR#1 was having flank pain and trouble urinating. She responded to the text message to send CR#1 to the hospital. She stated approximately 45 min later, she had received a telephone call from the DNS. She stated the DNS talked about the labs being written for [DATE], instead of STAT Labs. She stated she directed the DNS to send CR#1 to the hospital for further evaluation. She stated he had a change in condition and had new symptoms from when she had last assessed him, and thought it was best to send him to the hospital for further treatment. She stated the DNS kept talking about the Labs and how the hospital would not treat UTI, and did not want to send CR#1 to the hospital. She informed the DNS that the labs were not written correctly that they should have been STAT labs. She kept telling the DNS to send CR#1 to the hospital and she thought the DNS understood her orders. She was not informed CR#1 was not sent to the hospital, until she had received another text message from LVN #1 that CR#1 had coded. She stated she was shocked that the DNS and LVN #1 did not follow her order to send CR#1 to the hospital when he had a fatal change in condition. She stated she attempted to speak to the DNS on [DATE] about her concerns, but was not successful. She further stated she had received a text message from the DNA at [DATE] at 2:53 PM that informed her of what to say if the State (surveyor) asked her any questions. She was not waiting on the STAT labs to make any decision and wanted CR#1 sent to the hospital for evaluation. Record review of screen shot text messages, provided by the NP, sent between LVN #1 and the NP, dated [DATE], revealed: 3:39 PM, LVN#1 wrote CR#1 was complaining of left lower and flank pain and was having trouble urinating and was still passing blood. NP responded to the text message with send him to the hospital. He was not complaining of flank pain earlier when I saw him. LVN #1 wrote ok. NP responded to the text message with Something is going on in his kidney. He has CKD . 9:04 PM, LVN #1 wrote to the NP CR#1 just coded. 10:56 PM, LVN #1 wrote I just found out CR#1 passed away. Record review of screen shot text messages, provided by the Unit Manager, sent between LVN #1 and the Unit Manager, dated [DATE] revealed: 4:13 PM: LVN #1 wrote I'm having to send CR#1 out to the hospital hematuria and flank pain Unit Manager responded with hmm ok. 5:51 PM LVN #1 wrote we are not sending CR#1 out after all. 5:56 PM Unit Manager responded ok not sending him out that's fine. 5:58 PM LVN #1 responded ok 8:55 PM LVN #1 wrote CR#1 just coded. 9:00 PM, Unit Manager responded whoa he a full code too right? Did he have a heartbeats when he left? 9:01 PM, LVN #1 responded No. 9:02 PM, Unit Manager wrote Awww man. Happened they did not send him out. Record review of screen shot text messages, provided by the NP, sent between the DNS to the NP, dated [DATE] at 2:53 PM, revealed the DNS wrote do you have your progress note from yesterday .If the state lady talk to you just say you were waiting for the STAT lab results to make a follow up decision whether to send out or not, that is all she needs to hear. Interview on [DATE] at 8:15 AM, the Administrator stated she had interviewed staff, the NP, and the DNS concerning the events and timeline of [DATE] for CR#1. She stated the NP's story was consistent and believed the NP told the DNS to send CR#1 to the hospital. She agreed the DNS did not send CR#1 to the hospital. Interview on [DATE] at 8:40 AM, LVN #2 stated she worked with the NP daily during her shift. She stated the NP was usually very clear on her orders and had a good relationship with other nurses in the building. She stated she would only contact the NP by text message for minor information, and would contact the NP by phone if the message was more urgent. She stated if the physician/NP gave the order to send resident to the hospital, she would call transportation for non-emergency and would call EMS for emergency. She would have made sure the resident was sent out and then contact the DNS, ADNS, or Unit Manager, and the RP to notify them of the hospital transfer. She further stated if she was told a different order from her supervisor, she would have contacted the NP to verify orders before writing any new orders. She again stated if she received orders to send out to the hospital, she would have sent the resident out to the hospital for further evaluation and then notified everyone else. Interview on [DATE] at 9:35 AM, RN #1 stated CR#1 had blood in his urine. She looked inside CR#1's urinal and saw blood and the urine color was pink. She stated she assessed CR#1 and found that CR#1 was complaining of burning while urinating. She stated CR#1's vital signs were within normal limits and reported her findings to the NP, who was at the facility. She stated the NP ordered regular labs and not STAT Labs. She wrote the verbal NP's orders for labs to be drawn on [DATE]. She later went back to CR#1's room to collect a urine sample and was not able to collect it. She documented in the 24 hour communication log for the next shift to collect the sample. She agreed bloody urine could be identified as a change in condition. She stated she should have read back the verbal order or asked for a clarification order due to the change of condition. She further stated the NP was at the facility on a daily basis and communicated physician's orders [REDACTED].#1 out to the hospital, she would have written the order, contacted transportation services, prepared his paperwork, and then notified her manager of the transfer, and document. She stated the NP knows what was best for CR#1 and the facility should have sent CR#1 to the hospital at the time of the order. Telephone Interview on [DATE] at 10:15 AM, the Unit Manager (UM) stated she was not at work today, because the DNS had asked her to take off. She stated she had been informed that CR#1 had a change in condition on [DATE] by LVN #1 and had blood in his urine. The NP was in the building and assessed him and ordered STAT labs. She stated on [DATE] at 4:29 PM, she had received a text message from LVN #1 stating he was sending CR#1 to the hospital. At 5:51 PM, text message stated not sending CR#1 out to the hospital, and at 8:55 PM CR#1 had coded. She further stated that after she had received the text message about CR#1 had coded, she spoke to LVN#1 and was informed that the DNS had made the decision not to send the resident out to the hospital for a possible UTI. She stated LVN #1 never wrote the verbal order from the NP to send CR#1 to the hospital and instead wrote verbal orders from the DNS for STAT labs to be completed. She further stated LVN#1 should have contacted the NP to clarify orders after the DNS said not to send out to hospital. She stated she expected the nurses to follow the physician's orders [REDACTED]. Interview on [DATE] at 1:35 PM, LVN #1 stated he had notified the NP and the Unit Manager by text messages about CR#1's status. He stated he also reported to another nurse who instructed him to contact the DNS prior to sending CR#1 out to the hospital. He stated after he had received the verbal order to send CR#1 out to the hospital from the NP, he charted in the clinical notes, prepared the paperwork, and called CR#1's responsible party and told her that CR#1 was being sent to the hospital. He did not write the verbal telephone order from the NP to send CR#1 to the hospital. He saw the DNS and both went to assess the resident at approximetly 4:00 PM. He stated after their assessment, he heard the DNS speaking to the NP over the telephone near the nurse's station. He stated he did not hear their conversation. He stated when the DNS was done with the conversation, she had instructed him to write the orders for CR#1's STAT labs. He wrote the verbal orders from the DNS and retracted his previous nursing notes and made a new entry. When asked why he changed the orders after the NP had instructed him to send CR#1 out to the hospital, he stated the DNS was his supervisor and he assumed the DNS had received the verbal order for STAT labs and did not question her. He stated he received verbal orders from the NP to send to the hospital and verbal orders from his DNS to do STAT Labs. He further stated he did not contact the NP to verify the orders. Interview on [DATE] at 2:40 PM, the DNS stated CR#1 had been complaining of lower back pain, blood in his urine, burning with urination, and difficulty urinating. She stated his symptoms sounded like a urinary tract infection. She stated she assessed the patient and left the facility. She stated she had contacted CR#1's NP over the telephone while she was driving home. She stated the NP gave her the verbal order to make CR#1's labs STAT. She stated after she ended the call with the NP, she contacted LVN #1 and told him to change the orders to STAT labs. She stated she told LVN #1 to make sure to write STAT on the orders. When asked about the text message between the DNS and the NP that read do you have your progress note from yesterday .If the state lady talk to you just say you were waiting for the STAT lab results to make a follow up decision whether to send out or not, that is all she needs to hear, she confirmed that she wrote that statement. The DNS did not have any further comments concerning the text message. Other attempts to contact the DNS for further interview were made on [DATE], [DATE], and [DATE], but was not successful. Record review of the facility's in-service, dated [DATE], revealed: Before writing or carrying out any order, it must be given by MD/NP first and on the telephone order it must read T.O.R.B and with the MD/NP name of whom order was given. Further review revealed LVN #1 signed the in-service form. When a patient/resident is being discharged whether it is planned/or not, you must notify the MD/NP to get an order/make sure you write on order T.O.R.B. Further review revealed LVN #1 signed the in-service form. Record review of the facility's Notification of Change in Patient/Resident Health Status policy, no date, revealed the facility was to consult with the resident's physician, nurse practitioner or physician assistant, and the resident's legal representative or an interested family member when there is a decision to transfer or discharge the resident from the facility. It further read Nursing judgement is an integral part of the skilled care provided in this facility, therefore, such judgment must be applied in a case by case basis in keeping with acceptable nursing practice. Record review of the facility's Abuse policy, dated ,[DATE], read .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriations of resident/patient property (alleged violations), are reported immediately to the Administrator/Director of Nursing of the enter. Further review of the policy read Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress. An Immediate Jeopardy (IJ), was identified and the Administrator and Nurse Consultant were both notified of the IJ on [DATE] at 11:35 AM. Plan of Removal was accepted on [DATE] at 2:43 PM after multiple revisions in that: Residents in Center were reviewed for change in condition- DNS, ADNS and attending nurse reviewed and discussed any patients with a change in condition. When change of condition was noted MD/NP was notified by attending nurse. 3 Residents with change in condition were noted by attending nurse who then contacted MD/NP and received subsequent orders. All 3 residents were sent to the hospital when change of condition was noted on [DATE]. The system will be when a resident has a change in condition, the Attending Nurse will notify MD/NP via Center phone and follow up on orders obtained. Documentation will include resident condition, orders received and monitoring that has occurred for the resident until transferred to the hospital. DNS, ADNS, and Clinical Educator will review 24 hour report for change in condition in Clinical Start-up, (Which is the daily reporting structure for Clinical communication) and validate that residents change in condition was followed up appropriately with any new orders noted daily times 30 days. RNs and LVNs were re-educated by the DNS of a sister facility regarding change in condition, following MD orders, and documentation of change in condition. RNS, LVNs, Certified Medication Aides and Certified Nursing Assistants were re-educated regarding Abuse and Neglect policy. DNS of a sister facility conducted training. Full time employees were re-educated. PRN employees will not work until education was completed. DNS, ADNS and or designee will review changes of condition immediately to include observation of the 24 hour report and Physician telephone orders. DNS, ADNS and or designee will conduct walking rounds daily to identify any acute change of condition with immediate notification of MD/NP. Regional Director of Clinical Operations will review re-hospitalization s daily beginning [DATE]. Monitoring began on [DATE], [DATE], and [DATE]. Staff interviewed on [DATE], [DATE], and [DATE] at various times. This included CNAs, MAs, LVNs, and RNs on two of three shifts. Staff were able to appropriately identify abuse/neglect, when to report, and whom to report too. The staff were able to identify a change in condition, whom to notify, and when to report changes. Further interview revealed staff were trained on documentation. Record review of facility In-services on Abuse/Neglect were conducted on [DATE], [DATE], [DATE], [DATE] at various times. Record review of the facility's Change in Condition Review, dated [DATE] for [DATE], revealed the facility had identified 3 other residents for a change in condition. Interview on [DATE] at 2:00 PM, the Administrator stated when a change of condition occurred, she felt the orders to send a patient to the hospital superseded all other orders including STAT Labs orders. She stated the facility used protocols for change of condition. She further agreed the Nurse who took the order should have written the order and documented why the change occurred. She stated she had interviewed the NP and the verbal order was to send CR#1 out to the hospital. She stated she was monitoring the DNS by checking the 24 hour reports, looking at the clinical records, any retracted notes, telephone orders, and reports from the ADNSs. She stated the facility's nursing staff have been trained and in-serviced by the Director of Clinical Operations (Regional Consultant) and another DNS from a sister facility on policy and procedures for HIPAA, Abuse/Neglect, and Change of Condition. She stated staff were not to use personal cell phones for medical/resident communication to providers and to use the facility's telephone for any resident related communication. She stated all nursing staff were retrained on when to report abuse/neglect, whom to report allegations, and trained on following physician's orders [REDACTED]. She stated resources available to the staff included regional consultants, RNs, other administrators, the medical Director, and the QA process. On [DATE] the surveyor confirmed the Plan of Removal had been implemented sufficiently to lower the IJ. The Administrator and Nurse Consultant were informed on [DATE] at 1:15 PM that the IJ was lowered; however, the facility remained out of compliance at scope of widespread and severity actual harm that was not immediate jeopardy because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. The facility's census was 90 residents.

Based on record review and interview, the facility failed to ensure 3 of 7 sampled residents with a [DIAGNOSES REDACTED].# 3). received necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being as evidenced by: -CR # 1 had a blood glucose result of greater than 600 mg/dl (normal 70 to 110 mg/dl) on [DATE] at 6:30 AM and extra insulin was administered without a physician's orders [REDACTED]. CR # 1 coded (had no pulse or respirations) and died later that morning. -Resident # 2's insulin was held on [DATE] when there were no orders or parameters to hold the insulin. The blood glucose was in the normal range. -Resident # 3's blood glucose consistently ran greater than 200 in the afternoons in the month of [DATE] and the physician was not notified. These failures affected 3 residents, one of whom died , and placed an additional 29 residents with diabetes at risk of not receiving the necessary care and services to prevent complications of diabetes and a decline in health status. Findings Include: Complaint # 7 CR # 1 Record review of CR # 1's face sheet revealed that she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review was conducted of CR # 1's electronic nursing notes. The [DATE] at 11:03 PM read: "[MEDICATION NAME] 25 mg/ml (medication used to treat nausea/vomiting) was administered intramuscularly to right thigh for vomiting large quantity of orange fluid with large chunks of food in it". It revealed that the note was prepared by RN A. The [DATE] nursing note at 12:48 AM read in part: "Medication Follow-up . . . Medication was effective . . . no further vomiting or complaints of nausea, sleeping". It revealed that the note was prepared by RN A. The [DATE] nursing note at 10:34 AM read: "Late entry for 6:30 AM. Received report from night nurse that resident had vomited blood sugar checked meter reading stated 'Blood sugar over 600' administered 7.5 units via pump". It revealed that the note was prepared by LVN C. CR # 1's [DATE] nursing note at 10:35 AM read: "Late entry for 7:15 am rechecked blood sugar. Meter reading 398. Asked resident where her bag where she keeps her meter was and she stated 'its (sic) right there' resident responsive and still in bed". It revealed that the note was prepared by LVN C. CR # 1's [DATE] nursing note at 10:51 AM read: "Nurse went into resident's room to administer medication. Found resident lying in bed unresponsive. No pulse felt upon palpation. Nurse proceeded with chest compressions. Nurse delegated to CNA to announce code blue". CR # 1's [DATE] nursing note at 10:52 AM read in part: "summoned to resident's room, CNA stated that resident was unresponsive and not breathing. Upon assessment could not auscultate any breath sounds or palpate a pulse, unable to obtain a blood pressure. CPR initiated at 10:30 AM and 911/EMS response unit called and arrived at facility approximately 10:35. EMS team stated time of death approximately 10:45am, this am resident was alert verbalizing well, and had no complaints. CNA assigned to resident states she had seen resident about 9:45am and earlier resident had stated she wanted her breakfast later when it was brought to her . . . ". Record review of CR # 1's [DATE] physician orders [REDACTED]. -Blood Glucose checks before meal and at bedtime daily. - Humalog 100 units/ml via pump according to accucheck indicated by [MEDICATION NAME] wizard. -Humalog 100 units/ml via pump at 1.35 units per hour form 6 AM to 9 PM daily. Document total dose at the end of shift. The MAR further revealed on the following dates and times the resident's blood glucose was greater than 300 or less than 60. It also revealed the amount of insulin administered when the blood glucose was greater than 300: -At 6:30 AM: --[DATE] BG 45 --[DATE] BG 592 Insulin administered: 7 units --[DATE] BG 57 --[DATE] BG 399 Insulin administered: 8 units --[DATE] BG 400 Insulin administered: 7 units --[DATE] BG 313 Insulin administered: 4 units --[DATE] BG 316 Insulin administered: 4.1 units --[DATE] BG 390 Insulin administered: 6 units (this amount and blood glucose were different than the amounts documented in the nursing notes). -At 11:30 AM --[DATE] BG 395 Insulin Administered: 6.1 units --[DATE] BG 545 Insulin administered: 7.5 units --[DATE] BG 323 Insulin administered: 4 units --[DATE] BG 434 Insulin administered: 7 units --[DATE] BG 387 Insulin administered: 5.1 units --[DATE] BG 386 Insulin administered: 7 units --[DATE] BG 311 Insulin administered: 4.7 units --[DATE] BG 411 Insulin administered: 6.5 units --[DATE] BG 414 Insulin administered: 6.6 units --[DATE] BG 492 Insulin administered: 7.2 units --[DATE] BG 390 Insulin administered: 6 units -At 4:30 PM --[DATE] BG 383 Insulin Administered: 5.8 units --[DATE] BG 382 Insulin Administered: 5.8 units --[DATE] BG 338 Insulin Administered: 3.8 units --[DATE] BG 364 Insulin Administered: 5.8 units --[DATE] BG 338 Insulin Administered: 4.7 units --[DATE] BG 438 Insulin Administered: 7.2 units --[DATE] BG 348 Insulin Administered: 4.9 units --[DATE] BG 385 Insulin Administered: 7.5 units --[DATE] BG 429 Insulin Administered: 6.5 units --[DATE] BG 390 Insulin Administered: 7.5 units --[DATE] BG 388 Insulin Administered: 7.5 units --[DATE] BG 308 Insulin Administered: 3.9 units --[DATE] BG 386 Insulin Administered: 7.5 units -At 8:00 PM --[DATE] BG 305 Insulin Administered: 3.6 units --[DATE] BG 514 Insulin Administered: 7.5 units --[DATE] BG 372 Insulin Administered: 5.7 units --[DATE] BG 354 Insulin Administered: 5.1 units --[DATE] BG 386 Insulin Administered: 7.5 units --[DATE] BG 315 Insulin Administered: 3.9 units --[DATE] BG 475 Insulin Administered: 7.5 units --[DATE] BG 365 Insulin Administered: 7.5 units --[DATE] BG 392 Insulin Administered: 7.5 units --[DATE] BG 327 Insulin Administered: 3.5 units --[DATE] BG 386 Insulin Administered: 5.9 units The MAR revealed no written explanation for the blood sugar of greater than 600 documented in the nursing note. The only explanation note for blood glucose was recorded and read in part: " 8:51 AM, [DATE] (Scheduled: 6:30 AM, [DATE]; BLOOD GLUCOSE CHECK BEFORE MEALS AND AT BEDTIME DAILY) Blood Glucose = 390.00 . . . " Record review of CR # 1's physician's orders [REDACTED]. According to www.diabetesnet.com <http://www.diabetesnet.com> "Humalog . . . begin working in about 10 minutes, peaks at one to one and a half hours and are gone in about three and a half to four hours. Record review of CR # 1's nursing notes revealed no calls to the doctor regarding increased blood sugar. Record review of 2006 Medtronic MiniMe Pardigm Real Time Insulin Pump provided by LVN B on [DATE] read in part: " . . . Unexplained high glucose levels . . . This can be an urgent situation. It is important to act quickly to know when to give insulin by syringe to prevent DKA (Diabetic Ketoacidosis). You should use the guidelines for high glucose levels and prevention of DKA given to you by your health care provider. Check urine [MEDICATION NAME] for all single reading over 200mg/dl or any two unexplained blood sugar above 250mg/dl. Preventing DKA If nausea or vomiting is present, immediately check your blood glucose and [MEDICATION NAME]. If your blood glucose is above 250 mg/dl . . . and/or [MEDICATION NAME] are present: Take a correction injection of insulin a syringe or insulin pen (NOT THROUGH THE PUMP). Call your healthcare provider. Change the infusion set, reservoir and use a new bottle of insulin. Drink 8 -12 ounces of liquids with no sugar every hour (for example water, broth, diet soda). Check your blood glucose and [MEDICATION NAME] in one hour and take insulin if required. Continue to take insulin as discussed with your healthcare provider. Contact your healthcare provider or call 911 if your blood glucose and [MEDICATION NAME] are not decreasing or you are vomiting. Continue to test blood glucose and [MEDICATION NAME] hourly, or as advised your healthcare provider. According to the American Diabetes Association [MEDICATION NAME] at www.diabetes.org is defined as a chemical produced when there is a shortage of insulin in the blood and the body breaks down body fat for energy. High levels of [MEDICATION NAME] can lead to diabetic ketoacidosis and coma. Sometimes referred to as [MEDICATION NAME] bodies. Record review of the other nursing notes revealed a nursing note on [DATE] that was related to changing the insulin pump and infusion set. There were no other nursing notes from that nursing note to the nursing note on [DATE]. In an interview with LVN B on [DATE] at 8:35 AM she said that she was called to CR # 1's room by the CNA A on the day CR #1 died . At that time she said the resident was sallow, grayish with her mouth open. She further stated she did not see any respirations. LVN B said that the resident skin's was clammy to touch, but not cold. She said that (CR # 1) was normally alert and oriented. She stated that the CNA had reported to her the resident did not want to go to breakfast. She further stated that she saw the breakfast tray in the room and knew that the CNA had seen the resident that morning. LVN B stated that CR # 1's glucometer (machine used to test blood glucose levels) was linked to her insulin pump. She further stated that the resident was able to take her own blood sugar and adjust the insulin pump. In a telephone interview with LVN C on [DATE] at 9:00 AM she said was not assigned to care for CR #1 on [DATE], she was only doing the blood sugar checks. She stated that night nurse (RN A) did not test CR # 1's blood sugar. LVN C stated that she did call the doctor regarding CR # 1's high blood glucose and gave additional insulin. LVN C stated that she went back an hour later tested the resident's blood sugar again. LVN C said that she had informed the day nurse of the blood sugar at 7:15 AM. She said that the charge nurse on that day was LVN B. In an interview with CNA A on [DATE] at 9:40 AM she said she was assigned to care for CR #1 on [DATE]. She stated that she saw the resident for the first time that day between 6:00 and 6:30 AM and she was asleep. She further stated that she went in another time and the resident told her she was going to the bathroom. CNA A said that the resident refused her breakfast that morning. She further stated the resident never refused breakfast and always ate her food. CNA A said that CR # 1 did not tell her that she felt bad that morning and she looked " ok " . She stated that she left the breakfast tray in the resident's room. CNA A said that she either told the charge nurse that the resident did not eat or she put in on the ADL sheet. She stated she and another CNA went back to CR # 1 ' s room at about 10:00 AM to pick up her tray and " she was gone ". She further stated that she was a full code and they started a code (to attempt to restore respiration and heart beat) In an interview with LVN A and LVN B on [DATE] at 10:30 AM they were given CR # 1's notes and MAR. They were asked about the discrepancies between the nursing notes and the MARs for CR #1. LVN B said if the blood sugar was greater than 600 the doctor should be called. She said she did not know what the blood sugar was at 6:30 AM and she would need the notes that LVN C wrote. In an interview with Dr. # 1 on [DATE] at 11:15 AM he said he had CR # 1 on sliding scale insulin. He said that he saw the resident three days before she died . Dr. # 1 said that he did not remember her having a blood sugar of over 600. He further stated that he did not take care of her insulin pump and if she had an elevated blood sugar he would order sliding scale insulin to be administered by injection, not by the insulin pump. He was informed there was not an order for [REDACTED]. At that time he looked through the medical record. Dr. # 1 said he thought she had sliding scale insulin. More than one time during the interview he said he never gave an order to give 7.5 units of insulin for CR # 1. He said that in this case he would have ordered the staff to do every two hour blood sugar checks. Record review of CR # 1's physician's orders [REDACTED]. There was only one order on [DATE] and that was to transfer the resident's remains to the mortuary. In an interview with LVN C on [DATE] at 1:40 PM she said that the first time she saw CR # 1 on [DATE] was between 6:15 AM and 6:30 AM. She further stated that at that time she was lethargic. LVN C said that the resident was awake but was slow to answer. She further stated the resident did open her eyes. She said that she called the doctor to inform him of the blood sugar greater than 600 and he asked what the pump would administer. LVN C said that she told him the maximum it would administer was 7.5 units. LVN C stated that he told her to give the 7.5 units and then give an additional 7.5 units for a total of 15 units. She said that she had to manually enter the 15 units, overriding the pump. She said that she administered a total of 15 units of insulin. She said she told the day shift nurse (LVN B) about the blood sugar but since she gave the insulin she went back to check the resident's blood sugar. LVN C stated that she went back on her own after an hour and the second time she saw the resident she was responding and had her eyes open. She said that the second time was between 7:15 AM and 7:30 AM. She said that the blood sugar had decreased but the resident had not eaten breakfast. At that time she was shown the MAR and asked about the 390 charted at 6:30 AM and the 6 units of insulin. She said that electronic charting would not let her record a blood sugar greater than 600. She said the 390 was the second blood sugar. When LVN C asked about the 6 units of insulin on the MAR she said she did not give 6 units she gave 7.5 units and an additional 7.5 units. LVN C said regarding the 6 units it was" probably a typo". She said that the blood sugar was 398 and the electronic MAR had a time lock on it. She said that it would not let her alter the time. She said that the time recorded was the time it was done. When she was asked where was the order for the additional insulin, she said the doctor did give her an order and she remembered writing it. LVN C said that she remembered telling him the maximum the pump would administer was 7.5 units. She stated that she wrote the order on a telephone order sheet and put it in the chart. She stated "I hope it didn't fall off". She then looked through the medical record and did not find the order. LVN C stated "I am going to write an addendum to the note". Record review of CR # 1's physician's orders [REDACTED]. Record review of CR # 1's nursing notes revealed a [DATE] addendum to the [DATE] 10:34 AM note that read: "Notified (Dr. # 1) stated 'Give an additional 7.5 units' Administered 7.5 units to equal 15 units via insulin pump". In an interview with RN A on [DATE] she said that she was the only nurse on the station on [DATE] and she was caring for CR # 1. She said that the resident had vomited during the night. She further stated that the nurse's aide was with the resident. RN A said there was quite a bit of vomit and it had large food chunks in it. She stated that she asked the resident how she was feeling and how long she had been sick. RN A said that she gave a nonspecific answer and got up to the bedside commode. She stated that she administered the [MEDICATION NAME] and checked on the resident an hour later. At that time, RN A said that the resident was sleeping. RN A said that at 5:00 AM the CNA came and told her she was not comfortable with how the resident was looking. She stated she went and talked to the resident at that time. She said the resident was lethargic. RN A said that the day shift nurse came in at 6:30 AM and told her the resident's blood sugar was 600 and that was why she vomited. RN A stated "not likely, more likely - [MEDICAL CONDITION] was why blood sugar was high". She stated that she was off duty and the day shift nurse covered the resident's elevated blood sugar. She stated " hind sight , twenty/twenty, after I was told later that day that she coded, maybe I should have called the MD and sent her out ". She further stated she did not know if the doctor was called. RN A stated that blood sugar results over 400 were called to the doctor. When RN A was asked if she tested CR # 1's blood sugar during her shift that night she stated "again, another thing I regret". She further stated CR # 1 was very sensitive to her blood sugar and could usually tell that she needed to have her blood sugar checked. RN A said when the facility did not have a third nurse during the night shift, she did not have enough time to get everything done. She stated that the only thing she did not do was chart. She further stated that she felt like she had covered the charting with CR # 1 because the charting contained information about why she gave the medication. RN A stated that the only thing she did not chart was her "talk" with the resident at 5:00 AM. She said that the resident was coherent and she was not telling her she needed her blood sugar checked. RN A then said that the resident only told the staff that she needed her blood sugar checked when it was low, never when it was high. RN A said that she would call the doctor for a blood sugar of 600. She said that CR # 1's doctor would have probably sent her to the hospital. She stated that he was an advocate for sending out to the hospital for "something bad". When RN A was asked how often she would test blood sugar after giving extra insulin she said that she would check the blood sugar every 20 minutes. RN A stated "I have always been told you want to bring low blood sugar up fast and you don't want to bring high sugar down too fast". She said LVN C did recheck CR # 1's blood sugar and it was trending down. RN A was asked what she would consider too fast and she said if the blood sugar dropped to 300 within an hour. In an interview with the DON and the Administrator on [DATE] at 12:35 PM, the DON was asked if she normally went back and reviewed records of residents that had suddenly died . She said that she did not. The DON said on[DATE] the resident's blood sugar was elevated before her death. She said insulin was given and the resident was given breakfast which she did not eat. The DON said that LVN C tested the blood sugar at 6:30 AM and notified the charge nurse. She further stated that LVN C checked the blood sugar again in an hour and it was coming down. The DON said that the staff went to check on the resident again and found her not breathing. She further stated that was when they initiated CPR. At that time the DON and the Administrator were given CR # 1's MAR and nursing notes. They were then asked what the resident's blood sugar was based on the MAR. The DON said at 6:30 AM the blood sugar documented was 390 and 6 units of insulin were administered via pimp. She said the nursing notes say that she received 7.5 units via pump. She said on [DATE] LVN C told her the blood sugar was close to 500, and while they were coding the resident LVN C said that the blood sugar was 500. The DON stated that LVN C told her she rechecked the blood sugar and it was 390. The DON was asked what would be the facility standard for retesting the blood sugar when a resident had a reading of 600, she said every 20 to 30 minutes. When the DON was asked about the 15 units of insulin, she said the day it happened LVN C told her that she gave 7.5 units of insulin. When asked if the resident was given double that amount what should happen she said "that much insulin, probably should check" . The DON said that CR # 1 was a "brittle diabetic". She stated that the staff had received training on how to handle the insulin pump. Record review of CR # 1's Meal Intake Report revealed that the resident consumed 76 to 100 % of her meal on [DATE] Record review of CR # 1's [DATE] Discharge Summary revealed that her current plan of care read in part: " . . . Problem: Risk for hyper or hypoglycemic episodes secondary to diabetes, (CR # 1) has her own [DATE] Insulin pump that is maintained by staff. Goal # 1: Will maintain fasting blood sugar no less than 60 and not greater than 150 throughout review period. Goal # 2 Will have no unidentified S/S of hyper/[DIAGNOSES REDACTED] throughout review period . . . Approach #4: Observe for S/S of [DIAGNOSES REDACTED]: headache, sweating, weakness, decreased blood sugar; treat as ordered by MD. Approach # 5 Notify MD as needed. Approach #6: Monitor glucose as ordered and provide treatment as ordered. Approach # 7: Monitor for change in level of consciousness or mood. Approach # 8: Observe for S/S of [MEDICAL CONDITION]: increased thirst and/or voiding, N/V, fatigue, increased blood sugar . . . ". This care plan had an onset date of [DATE] Record review of CR #1's [DATE] Hemoglobin A1C% (a test that measures a person's average blood glucose level over the past 2 to 3 months) revealed that the result was 9.1 and the reference range was 4.5 - 5.7. There was note with hand written on the lab slip that read: "OK No new orders". Record review of the facility's [DATE] Change in Condition policy and procedure read in part: "Policy Resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely fashion . . . 2. The licensed nurse assesses the resident and notes signs and symptoms, including physical and mental changes in condition. 3. The resident's primary physician or designated alternative will be notified immediately of any change in resident's physical or mental condition. The resident's designated medical contact or guardian will also be notified . . . 4. Notification of physician and/or responsible parties shall be documented in the clinical record as well as on the 24 hour reports form . . . Essential Points . . .There are many signs and symptoms of a change of condition. It is the responsibility of the licensed nursing staff to monitor for these . . . Very often a change in resident condition is an indication that the current care and treatments of the resident are no longer appropriate. The physician and other members of the health care team must be consulted to deal with this and plan treatment alternatives. All changes of condition must be completely and objectively documented in the medical records . . . Appropriate follow through from shift to shift is imperative for all residents with a change in condition . . . ". Resident # 2 Record review of Resident # 2's face sheet revealed that he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 2's [DATE] MAR revealed the following orders: -[MEDICATION NAME] 100 units/ml, give 14 units subcutaneous every morning. -Blood glucose check twice a day. Further review revealed on [DATE] at 6:30 AM the resident's blood sugar result was 96. It also revealed that the resident did not receive any [MEDICATION NAME]. There were no parameters to hold the insulin on the MAR. The explanation read in part: " 7:24 AM, [DATE] (scheduled: 6:30 AM, [DATE] . . .) . . . [MEDICATION NAME] . . .scheduled for [DATE] 8:00 AM was held . . .". In an interview with the DON and the administrator on [DATE] at 12:35 PM, the DON stated with a blood sugar of 96 the insulin should not have been held for Resident # 2. She further stated that long acting insulin ([MEDICATION NAME]) should not be held. She said that she was not sure why it was held. She said that she that she did an in-service with the staff and told them they should not hold insulin when blood sugar was normal. The DON stated that is the reason to give [MEDICATION NAME] so the blood sugar does not go up and down. At that time the in-service documentationwas requested. It was not provided by the time of exit. Resident # 3 Record review of Resident # 3's face sheet revealed that she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 3's [DATE] MAR revealed the following blood sugars greater than 200 at 4:30 PM: [DATE] BG 262 [DATE] BG 267 [DATE] BG 318 [DATE] BG 272 [DATE] BG 258 [DATE] BG 257 [DATE] BG 230 [DATE] BG 232 [DATE] BG 354 [DATE] BG 253 [DATE] BG 223 [DATE] BG 286 [DATE] BG 212 [DATE] BG 225 [DATE] BG 207 [DATE] BG 278 [DATE] BG 206 [DATE] BG 309 [DATE] BG 326 [DATE] BG 243 [DATE] BG 211 [DATE] BG 207 Record review of Resident # 3's nursing notes revealed no notes that the physician had been notified that the resident's blood sugar was running consistently over 200 in the afternoon. In an interview with the DON and the administrator on [DATE] at 12:35 PM, the DON said when there was a pattern of elevated blood sugar it was to be given to the Nurse Practitioner to look at. The DON was given Resident # 3 MARs. She said "yeah, give it to the nurse practitioner, over 200 everyday". She said that the insulin needed to be adjusted. According to the American Diabetes Association at www.diabetes.org: What Are the Target Ranges? Blood glucose targets are individualized based on: ? duration of diabetes ? age/life expectancy ? comorbid conditions ? known CVD (cardiovascular disease) or advanced microvascular complications ? [DIAGNOSES REDACTED] unawareness ? individual patient considerations. The American Diabetes Association suggests the following targets for most nonpregnant adults with diabetes. More or less stringent glycemic goals may be appropriate for each individual. Glycemic control Preprandial plasma glucose (before a meal) ,[DATE] mg/dl Postprandial plasma glucose (after a meal)* <180 mg/dl According to a list provided by the facility (LVN A) there were 31 residents residing the facility with diabetes.

Based on record review and interview, the facility failed to ensure services provided by the facility staff met professional standards of quality for 3 of 7 sampled residents with a [DIAGNOSES REDACTED].# 3). As evidenced by: -CR # 1 had a blood glucose result of greater than 600 mg/dl (normal 70 to 110 mg/dl) on [DATE] at 6:30 AM and extra insulin was administered without a physician's orders [REDACTED]. CR # 1 coded (had no pulse or respirations) and died later that morning. -Resident # 2's insulin was held on [DATE] when there were no orders or parameters to hold the insulin. The blood glucose was in the normal range. -Resident # 3's blood glucose consistently ran greater than 200 in the afternoons during [DATE] and the physician was not notified. These failures affected 3 residents, one of whom died , and placed an additional 29 residents with diabetes at risk of not receiving the necessary care and services to prevent complications of diabetes and a decline in health status. Findings Include: Complaint # 7 Review of Standards of Nursing Practice put out by the Texas Board of Nursing (BON), Chapter 217 of 22 TAC. Section 217.11(1) revealed: (1) " Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; CR # 1 Record review of CR # 1's face sheet revealed that she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review was conducted of CR # 1's electronic nursing notes. The [DATE] at 11:03 PM read: "[MEDICATION NAME] 25 mg/ml (medication used to treat nausea/vomiting) was administered intramuscularly to right thigh for vomiting large quantity of orange fluid with large chunks of food in it". It revealed that the note was prepared by RN A. The [DATE] nursing note at 12:48 AM read in part: "Medication Follow-up . . . Medication was effective . . . no further vomiting or complaints of nausea, sleeping". It revealed that the note was prepared by RN A. The [DATE] nursing note at 10:34 AM read: "Late entry for 6:30 AM. Received report from night nurse that resident had vomited blood sugar checked meter reading stated 'Blood sugar over 600' administered 7.5 units via pump". It revealed that the note was prepared by LVN C. CR # 1's [DATE] nursing note at 10:35 AM read: "Late entry for 7:15 am rechecked blood sugar. Meter reading 398. Asked resident where her bag where she keeps her meter was and she stated 'its (sic) right there' resident responsive and still in bed". It revealed that the note was prepared by LVN C. CR # 1's [DATE] nursing note at 10:51 AM read: "Nurse went into resident's room to administer medication. Found resident lying in bed unresponsive. No pulse felt upon palpation. Nurse proceeded with chest compressions. Nurse delegated to CNA to announce code blue". CR # 1's [DATE] nursing note at 10:52 AM read in part: "summoned to resident's room, CNA stated that resident was unresponsive and not breathing. Upon assessment could not auscultate any breath sounds or palpate a pulse, unable to obtain a blood pressure. CPR initiated at 10:30 AM and 911/EMS response unit called and arrived at facility approximately 10:35. EMS team stated time of death approximately 10:45am, this am resident was alert verbalizing well, and had no complaints. CNA assigned to resident states she had seen resident about 9:45am and earlier resident had stated she wanted her breakfast later when it was brought to her . . . ". Record review of CR # 1's [DATE] physician's orders [REDACTED]. -Blood Glucose checks before meal and at bedtime daily. - Humalog 100 units/ml via pump according to accucheck indicated by [MEDICATION NAME] wizard. -Humalog 100 units/ml via pump at 1.35 units per hour form 6 AM to 9 PM daily. Document total dose at the end of shift. The MAR further revealed on the following dates and times the resident's blood glucose was greater than 300 or less than 60. It also revealed the amount of insulin administered when the blood glucose was greater than 300: -At 6:30 AM: --[DATE] BG 45 --[DATE] BG 592 Insulin administered: 7 units --[DATE] BG 57 --[DATE] BG 399 Insulin administered: 8 units --[DATE] BG 400 Insulin administered: 7 units --[DATE] BG 313 Insulin administered: 4 units --[DATE] BG 316 Insulin administered: 4.1 units --[DATE] BG 390 Insulin administered: 6 units (this amount and blood glucose were different than the amounts documented in the nursing notes). -At 11:30 AM --[DATE] BG 395 Insulin Administered: 6.1 units --[DATE] BG 545 Insulin administered: 7.5 units --[DATE] BG 323 Insulin administered: 4 units --[DATE] BG 434 Insulin administered: 7 units --[DATE] BG 387 Insulin administered: 5.1 units --[DATE] BG 386 Insulin administered: 7 units --[DATE] BG 311 Insulin administered: 4.7 units --[DATE] BG 411 Insulin administered: 6.5 units --[DATE] BG 414 Insulin administered: 6.6 units --[DATE] BG 492 Insulin administered: 7.2 units --[DATE] BG 390 Insulin administered: 6 units -At 4:30 PM --[DATE] BG 383 Insulin Administered: 5.8 units --[DATE] BG 382 Insulin Administered: 5.8 units --[DATE] BG 338 Insulin Administered: 3.8 units --[DATE] BG 364 Insulin Administered: 5.8 units --[DATE] BG 338 Insulin Administered: 4.7 units --[DATE] BG 438 Insulin Administered: 7.2 units --[DATE] BG 348 Insulin Administered: 4.9 units --[DATE] BG 385 Insulin Administered: 7.5 units --[DATE] BG 429 Insulin Administered: 6.5 units --[DATE] BG 390 Insulin Administered: 7.5 units --[DATE] BG 388 Insulin Administered: 7.5 units --[DATE] BG 308 Insulin Administered: 3.9 units --[DATE] BG 386 Insulin Administered: 7.5 units -At 8:00 PM --[DATE] BG 305 Insulin Administered: 3.6 units --[DATE] BG 514 Insulin Administered: 7.5 units --[DATE] BG 372 Insulin Administered: 5.7 units --[DATE] BG 354 Insulin Administered: 5.1 units --[DATE] BG 386 Insulin Administered: 7.5 units --[DATE] BG 315 Insulin Administered: 3.9 units --[DATE] BG 475 Insulin Administered: 7.5 units --[DATE] BG 365 Insulin Administered: 7.5 units --[DATE] BG 392 Insulin Administered: 7.5 units --[DATE] BG 327 Insulin Administered: 3.5 units --[DATE] BG 386 Insulin Administered: 5.9 units The MAR revealed no written explanation for the blood sugar of greater than 600 documented in the nursing note. The only explanation note for blood glucose was recorded and read in part: " 8:51 AM, [DATE] (Scheduled: 6:30 AM, [DATE]; BLOOD GLUCOSE CHECK BEFORE MEALS AND AT BEDTIME DAILY) Blood Glucose = 390.00 . . . " Record review of CR # 1's physician's orders [REDACTED]. According to www.diabetesnet.com <http://www.diabetesnet.com> "Humalog . . . begin working in about 10 minutes, peaks at one to one and a half hours and are gone in about three and a half to four hours. Record review of CR # 1's nursing notes revealed no calls to the doctor regarding increased blood sugar. Record review of 2006 Medtronic MiniMe Pardigm Real Time Insulin Pump provided by LVN B on [DATE] read in part: " . . . Unexplained high glucose levels . . . This can be an urgent situation. It is important to act quickly to know when to give insulin by syringe to prevent DKA (Diabetic Ketoacidosis). You should use the guidelines for high glucose levels and prevention of DKA given to you by your health care provider. Check urine [MEDICATION NAME] for all single reading over 200mg/dl or any two unexplained blood sugar above 250mg/dl. Preventing DKA If nausea or vomiting is present, immediately check your blood glucose and [MEDICATION NAME]. If your blood glucose is above 250 mg/dl . . . and/or [MEDICATION NAME] are present: Take a correction injection of insulin a syringe or insulin pen (NOT THROUGH THE PUMP). Call your healthcare provider. Change the infusion set, reservoir and use a new bottle of insulin. Drink 8 -12 ounces of liquids with no sugar every hour (for example water, broth, diet soda). Check your blood glucose and [MEDICATION NAME] in one hour and take insulin if required. Continue to take insulin as discussed with your healthcare provider. Contact your healthcare provider or call 911 if your blood glucose and [MEDICATION NAME] are not decreasing or you are vomiting. Continue to test blood glucose and [MEDICATION NAME] hourly, or as advised your healthcare provider. According to the American Diabetes Association [MEDICATION NAME] at www.diabetes.org is defined as a chemical produced when there is a shortage of insulin in the blood and the body breaks down body fat for energy. High levels of [MEDICATION NAME] can lead to diabetic ketoacidosis and coma. Sometimes referred to as [MEDICATION NAME] bodies. Record review of the other nursing notes revealed a nursing note on [DATE] that was related to changing the insulin pump and infusion set. There were no other nursing notes from that nursing note to the nursing note on [DATE]. In an interview with LVN B on [DATE] at 8:35 AM she said that she was called to CR # 1's room by the CNA A on the day CR #1 died . At that time she said the resident was sallow, grayish with her mouth open. She further stated she did not see any respirations. LVN B said that the resident skin's was clammy to touch, but not cold. She said that (CR # 1) was normally alert and oriented. She stated that the CNA had reported to her the resident did not want to go to breakfast. She further stated that she saw the breakfast tray in the room and knew that the CNA had seen the resident that morning. LVN B stated that CR # 1's glucometer (machine used to test blood glucose levels) was linked to her insulin pump. She further stated that the resident was able to take her own blood sugar and adjust the insulin pump. In a telephone interview with LVN C on [DATE] at 9:00 AM, she said was not assigned to care for CR #1 on [DATE], she was only assigned to do the blood sugar checks. She stated that night nurse (RN A) did not test CR # 1's blood sugar. LVN C stated that she did call the doctor regarding CR # 1's high blood glucose and gave additional insulin. LVN C stated that she went back an hour later tested the resident's blood sugar again. LVN C said that she had informed the day nurse of the blood sugar at 7:15 AM. She said that the charge nurse on that day was LVN B. In an interview with CNA A on [DATE] at 9:40 AM she said she was assigned to care for CR #1 on that day ([DATE]). She stated that she saw the resident for the first time that day between 6:00 and 6:30 AM and she was asleep. She further stated that she went in another time and the resident told her she was going to the bathroom. CNA A said that the resident refused her breakfast that morning. She further stated the resident never refused breakfast and always ate her food. CNA A said that CR # 1 did not tell her that she felt bad that morning and she looked " ok " . She stated that she left the breakfast tray in the resident's room. CNA A said that she either told the charge nurse that the resident did not eat or she put in on the ADL sheet. She stated she and another CNA went back to CR # 1 ' s room at about 10:00 AM to pick up her tray and " she was gone ". She further stated that she was a full code and they started a code (to attempt to restore respiration and heart beat) In an interview with LVN A and LVN B on [DATE] at 10:30 AM they were given CR # 1's notes and MAR. They were asked about the discrepancies between the Nurse's Notes and the MAR for CR #1. LVN B said if the blood sugar was greater than 600 the doctor should be called. She said she did not know what the blood sugar was at 6:30 AM and she would need the notes that LVN C wrote. In an interview with Dr. # 1 on [DATE] at 11:15 AM he said he had CR # 1 on sliding scale insulin. He said that he saw the resident three days before she died . Dr. # 1 said that he did not remember her having a blood sugar of over 600. He further stated that he did not take care of her insulin pump and if she had an elevated blood sugar he would order sliding scale insulin to be administered by injection, not by the insulin pump. He was informed there was not an order for [REDACTED]. At that time he looked through the medical record. Dr. # 1 said he thought she had sliding scale insulin. More than one time during the interview he said he never gave an order to give 7.5 units of insulin for CR # 1. He said that in this case he would have ordered the staff to do every two hour blood sugar checks. Record review of CR # 1's physician's orders [REDACTED]. There was only one order on [DATE] and that was to transfer the resident's remains to the mortuary. In an interview with LVN C on [DATE] at 1:40 PM she said that the first time she saw CR # 1 on [DATE] was between 6:15 AM and 6:30 AM. She further stated that at that time she was lethargic. LVN C said that the resident was awake but was slow to answer. She further stated the resident did open her eyes. She said that she called the doctor to inform him of the blood sugar greater than 600 and he asked what the pump would administer. LVN C said that she told him the maximum it would administer was 7.5 units. LVN C stated that he told her to give the 7.5 units and then give an additional 7.5 units for a total of 15 units. She said that she had to manually enter the 15 units, overriding the pump. She said that she administered a total of 15 units of insulin. She said she told the day shift nurse (LVN B) about the blood sugar but since she gave the insulin she went back to check the resident's blood sugar. LVN C stated that she went back on her own after an hour and the second time she saw the resident she was responding and had her eyes open. She said that the second time was between 7:15 AM and 7:30 AM. She said that the blood sugar had decreased but the resident had not eaten breakfast. At that time she was shown the MAR and asked about the 390 charted at 6:30 AM and the 6 units of insulin. She said that electronic charting would not let her record a blood sugar greater than 600. She said the 390 was the second blood sugar. When LVN C asked about the 6 units of insulin on the MAR she said she did not give 6 units she gave 7.5 units and an additional 7.5 units. LVN C said regarding the 6 units it was" probably a typo". She said that the blood sugar was 398 and the electronic MAR had a time lock on it. She said that it would not let her alter the time. She said that the time recorded was the time it was done. When she was asked where was the order for the additional insulin, she said the doctor did give her an order and she remembered writing it. LVN C said that she remembered telling him the maximum the pump would administer was 7.5 units. She stated that she wrote the order on a telephone order sheet and put it in the chart. She stated "I hope it didn't fall off". She then looked through the medical record and did not find the order. LVN C stated "I am going to write an addendum to the note". Record review of CR # 1's physician's orders [REDACTED]. Record review of CR # 1's nursing notes revealed a [DATE] addendum to the [DATE] 10:34 AM note that read: "Notified (Dr. # 1) stated 'Give an additional 7.5 units' Administered 7.5 units to equal 15 units via insulin pump". In an interview with RN A on [DATE] she said that she was the only nurse on the station on [DATE] and she was caring for CR # 1. She said that the resident had vomited during the night. She further stated that the nurse's aide was with the resident. RN A said there was quite a bit of vomit and it had large food chunks in it. She stated that she asked the resident how she was feeling and how long she had been sick. RN A said that she gave a nonspecific answer and got up to the bedside commode. She stated that she administered the [MEDICATION NAME] and checked on the resident an hour later. At that time, RN A said that the resident was sleeping. RN A said that at 5:00 AM the CNA came and told her she was not comfortable with how the resident was looking. She stated she went and talked to the resident at that time. She said the resident was lethargic. RN A said that the day shift nurse came in at 6:30 AM and told her the resident's blood sugar was 600 and that was why she vomited. RN A stated "not likely, more likely - [MEDICAL CONDITION] was why blood sugar was high". She stated that she was off duty and the day shift nurse covered the resident's elevated blood sugar. She stated " hind sight , twenty/twenty, after I was told later that day that she coded, maybe I should have called the MD and sent her out ". She further stated she did not know if the doctor was called. RN A stated that blood sugar results over 400 were called to the doctor. When RN A was asked if she tested CR # 1's blood sugar during her shift that night she stated "again, another thing I regret". She further stated CR # 1 was very sensitive to her blood sugar and could usually tell that she needed to have her blood sugar checked. RN A said when the facility did not have a third nurse during the night shift, she did not have enough time to get everything done. She stated that the only thing she did not do was chart. She further stated that she felt like she had covered the charting with CR # 1 because the charting contained information about why she gave the medication. RN A stated that the only thing she did not chart was her "talk" with the resident at 5:00 AM. She said that the resident was coherent and she was not telling her she needed her blood sugar checked. RN A then said that the resident only told the staff that she needed her blood sugar checked when it was low, never when it was high. RN A said that she would call the doctor for a blood sugar of 600. She said that CR # 1's doctor would have probably sent her to the hospital. She stated that he was an advocate for sending out to the hospital for "something bad". When RN A was asked how often she would test blood sugar after giving extra insulin she said that she would check the blood sugar every 20 minutes. RN A stated "I have always been told you want to bring low blood sugar up fast and you don't want to bring high sugar down too fast". She said LVN C did recheck CR # 1's blood sugar and it was trending down. RN A was asked what she would consider too fast and she said if the blood sugar dropped to 300 within an hour. In an interview with the DON and the Administrator on [DATE] at 12:35 PM, the DON was asked if she normally went back and reviewed records of residents that had suddenly died . She said that she did not. The DON said on [DATE] the resident's blood sugar was elevated before her death. She said insulin was given and the resident was given breakfast which she did not eat. The DON said that LVN C tested the blood sugar at 6:30 AM and notified the charge nurse. She further stated that LVN C checked the blood sugar again in an hour and it was coming down. The DON said that the staff went to check on the resident again and found her not breathing. She further stated that was when they initiated CPR. At that time the DON and the Administrator were given CR # 1's MAR and nursing notes. They were then asked what the resident's blood sugar was based on the MAR. The DON said at 6:30 AM the blood sugar documented was 390 and 6 units of insulin were administered via pimp. She said the nursing notes say that she received 7.5 units via pump. She said on [DATE] LVN C told her the blood sugar was close to 500 and while they were coding the resident LVN C said that the blood sugar was 500. The DON stated that LVN C told her she rechecked the blood sugar and it was 390. The DON was asked what would be the facility standard for retesting the blood sugar when a resident had a reading of 600, she said every 20 to 30 minutes. When the DON was asked about the 15 units of insulin, she said the day it happened LVN C told her that she gave 7.5 units of insulin. When asked if the resident was given double that amount what should happen she said "that much insulin, probably should check" . The DON said that CR # 1 was a "brittle diabetic". She stated that the staff had received training on how to handle the insulin pump. Record review of CR # 1's Meal Intake Report revealed that the resident consumed 76 to 100 % of her meal on [DATE] Record review of CR # 1's [DATE] Discharge Summary revealed that her current plan of care read in part: " . . . Problem: Risk for hyper or hypoglycemic episodes secondary to diabetes, (CR # 1) has her own [DATE] Insulin pump that is maintained by staff. Goal # 1: Will maintain fasting blood sugar no less than 60 and not greater than 150 throughout review period. Goal # 2 Will have no unidentified S/S of hyper/[DIAGNOSES REDACTED] throughout review period . . . Approach #4: Observe for S/S of [DIAGNOSES REDACTED]: headache, sweating, weakness, decreased blood sugar; treat as ordered by MD. Approach # 5 Notify MD as needed. Approach #6: Monitor glucose as ordered and provide treatment as ordered. Approach # 7: Monitor for change in level of consciousness or mood. Approach # 8: Observe for S/S of [MEDICAL CONDITION]: increased thirst and/or voiding, N/V, fatigue, increased blood sugar . . . ". This care plan had an onset date of [DATE] Record review of CR #1's [DATE] Hemoglobin A1C (a test that measures a person's average blood glucose level over the past 2 to 3 months) revealed that the result was 9.1 and the reference range was 4.5 - 5.7. There was note with hand written on the lab slip that read: "OK No new orders". Record review of the facility's [DATE] Change in Condition policy and procedure read in part: "Policy Resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely fashion . . . 2. The licensed nurse assesses the resident and notes signs and symptoms, including physical and mental changes in condition. 3. The resident's primary physician or designated alternative will be notified immediately of any change in resident's physical or mental condition. The resident's designated medical contact or guardian will also be notified . . . 4. Notification of physician and/or responsible parties shall be documented in the clinical record as well as on the 24 hour reports form . . . Essential Points . . .There are many signs and symptoms of a change of condition. It is the responsibility of the licensed nursing staff to monitor for these . . . Very often a change in resident condition is an indication that the current care and treatments of the resident are no longer appropriate. The physician and other members of the health care team must be consulted to deal with this and plan treatment alternatives. All changes of condition must be completely and objectively documented in the medical records . . . Appropriate follow through from shift to shift is imperative for all residents with a change in condition . . . ". Resident # 2 Record review of Resident # 2's face sheet revealed that he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 2's [DATE] MAR revealed the following orders: -[MEDICATION NAME] 100 units/ml, give 14 units subcutaneous every morning. -Blood glucose check twice a day. Further review revealed on [DATE] at 6:30 AM the resident's blood sugar result was 96. It also revealed that the resident did not receive any [MEDICATION NAME]. There were no parameters to hold the insulin on the MAR. The explanation read in part: " 7:24 AM, [DATE] (scheduled: 6:30 AM, [DATE] . . .) . . . [MEDICATION NAME] . . .scheduled for [DATE] 8:00 AM was held . . .". In an interview with the DON and the administrator on [DATE] at 12:35 PM, the DON stated with a blood sugar of 96 the insulin should not have been held for Resident # 2. She further stated that long acting insulin ([MEDICATION NAME]) should not be held. She said that she was not sure why it was held. She said that she that she did an in-service with the staff and told them they should not hold insulin when blood sugar was normal. The DON stated that is the reason to give [MEDICATION NAME] so the blood sugar does not go up and down. At that time the in-service documentationwas requested. It was not provided by the time of exit. Resident # 3 Record review of Resident # 3's face sheet revealed that she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 3's [DATE] MAR revealed the following blood sugars greater than 200 at 4:30 PM: [DATE] BG 262 [DATE] BG 267 [DATE] BG 318 [DATE] BG 272 [DATE] BG 258 [DATE] BG 257 [DATE] BG 230 [DATE] BG 232 [DATE] BG 354 [DATE] BG 253 [DATE] BG 223 [DATE] BG 286 [DATE] BG 212 [DATE] BG 225 [DATE] BG 207 [DATE] BG 278 [DATE] BG 206 [DATE] BG 309 [DATE] BG 326 [DATE] BG 243 [DATE] BG 211 [DATE] BG 207 Record review of Resident # 3's nursing notes revealed no notes that the physician had been notified that the resident's blood sugar was running consistently over 200 in the afternoon. In an interview with the DON and the administrator on [DATE] at 12:35 PM, the DON said when there was a pattern of elevated blood sugar it was to be given to the Nurse Practitioner to look at. The DON was given Resident # 3 MARs. She said "yeah, give it to the nurse practitioner, over 200 everyday". She said that the insulin needed to be adjusted. According to the American Diabetes Association at www.diabetes.org: What Are the Target Ranges? Blood glucose targets are individualized based on: ? duration of diabetes ? age/life expectancy ? comorbid conditions ? known CVD (cardiovascular disease) or advanced microvascular complications ? [DIAGNOSES REDACTED] unawareness ? individual patient considerations. The American Diabetes Association suggests the following targets for most nonpregnant adults with diabetes. More or less stringent glycemic goals may be appropriate for each individual. Glycemic control Preprandial plasma glucose (before a meal) ,[DATE] mg/dl Postprandial plasma glucose (after a meal)* <180 mg/dl According to a list provided by the facility (LVN A) there were 31 residents residing the facility with diabetes.