Every finding on record at Oasis Nursing & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral nutrition received appropriate treatment and services to prevent complications associated with eternal feedings and failed to maintain an effective infection prevention control program designed to prevent the development and transmission of infections for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 4 residents reviewed. -The facility failed to ensure Resident #1's external feeding bag was not dated in accordance with professional standards of practice.-The facility failed to ensure PEG/G-tube dressings were maintained clean, dry, dated, and changed as required when drainage or soiling was present for Residents #2, #3 and #4.These deficient practices could place residents at risk for infection, irritation and breakdown of the PEG/G tube site, and other adverse outcomes. Findings include: Resident #1 Record review of Resident #1 face sheet dated [DATE], revealed Resident #1, was a [AGE] year-old female who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #1's diagnoses included Stage 4 sacral pressure ulcer (a severe wound over the tailbone with full-thickness tissue loss), anemia (low red blood cells), Type 2 diabetes mellitus (high blood sugar), protein-calorie malnutrition (inadequate intake of protein and calories), hyperlipidemia (high cholesterol), hypernatremia (high sodium levels in the blood), , dysphagia (difficulty swallowing), hypotension (low blood pressure), chronic respiratory failure (long-term inability of the lungs to adequately exchange oxygen and carbon dioxide), gastroesophageal reflux disease (acid reflux), generalized muscle weakness (overall decreased muscle strength), sarcopenia (loss of muscle mass and strength), gastrostomy status (presence of a feeding tube into the stomach), and colostomy status (presence of a surgically created opening in the abdomen for stool elimination). Record review of Resident #1's Quarterly MDS dated [DATE], reflected a BIMS score of 00, which indicated severely impaired cognition. Record review of Resident #1's physician's orders revealed an order dated [DATE] for Peptamen 1.5 to be administered via gastrostomy tube at 55 milliliters (mL) per hour, with a water flush of 70 mL every two hours for 24 hours. The order indicated Vital AF 1.2 calorie formula could be substituted. Record review of Resident #1's [DATE] Medication/Treatment Administration Record (MAR/TAR) revealed a physician's order for Peptamen 1.5 to be administered via gastrostomy tube at 55 milliliters (mL) per hour, with a water flush of 70 mL every two hours for 24 hours. The order indicated Vital AF 1.2 calorie formula could be substituted. Further review of the MAR/TAR revealed nursing staff initials from night shift staff from day before were documented for the enteral feeding order on [DATE] and [DATE], indicating the ordered enteral feeding was documented as administered during the applicable shifts. The MAR/TAR did not contain documentation within the reviewed entry identifying the date and time the enteral feeding bag was changed. During observation on [DATE] at 1:50 PM, revealed Resident #1 was lying in bed with the head of the bed elevated. The resident demonstrated some facial expressions in response to surrounding noise but did not verbally communicate during the observation. Resident #1's enteral feeding remained actively infusing from a feeding bag labeled [DATE] at 1:00 PM, approximately 24 hours and 50 minutes after the date and time documented on the feeding bag. During an interview on [DATE] at 1:55 PM, ADON E stated she had served as the ADON for three years and had been employed at the facility since 2017. ADON E stated the nurse was responsible for changing Resident #1's enteral feeding when the nurse came in during the morning shift. She stated the nurse was responsible for ensuring the feeding was changed and for monitoring the enteral feeding. The ADON E stated the feeding had not been expired; however, it had not been changed as required. During an observation of Resident #1 and interview LVN D, conducted on [DATE] at 2:11 PM, the LVN D stated she had been employed at the facility for approximately three years. Regarding Resident #1's enteral feeding, LVN D stated she was aware the night shift was responsible for changing the feeding. LVN D stated to her understanding the feeding-related supplies were to be changed together. She further stated that if the feeding finished during her shift, she would address the feeding at that time. LVN D stated a new feeding was to be opened every 24 hours. LVN D stated that to her knowledge the feeding could result in diarrhea but did not believe it would otherwise affect the resident. LVN D further stated a bedbound resident could experience dehydration and that dehydration could contribute to wounds and other complications. LVN D described her rounding process as ensuring the resident was alive and breathing, ensuring the resident was okay, and ensuring the resident's feeding was in place. LVN D acknowledged monitoring the resident's feeding was part of her nursing rounds. During an interview on [DATE] at 12:49 PM, the DON stated Resident #1's enteral feeding should have been administered according to the provider-ordered rate. She stated that if the previous feeding remained in place beyond the expected duration based on the provider-ordered rate, the provider's order had not been followed. The DON stated failure to provide the resident with the ordered amount of enteral nutrition could result in adverse outcomes, including weight loss, hunger, weight gain, or abdominal distention. Resident #2Record review on of Resident #2's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE], with an original admission date of [DATE]. Diagnoses included anoxic brain damage, chronic respiratory failure with hypoxia, dysphagia, cognitive communication deficit, moderate protein-calorie malnutrition, dementia, other encephalopathy, and encounter for attention to gastrostomy. Record review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS), and a Staff Assessment for Mental Status was completed. The assessment identified short-term and long-term memory problems. The resident was unable to recall the current season, location of his room, staff names and faces, or that he was in a nursing home/hospital setting. The MDS further identified the resident's cognitive skills for daily decision-making as severely impaired. Record review of Resident #2's Care Plan, last reviewed [DATE], revealed the resident had a potential nutritional problem related to dysphagia and G-tube status and required tube feeding related to dysphagia and encephalopathy. The care plan directed staff to cleanse the G-tube site every shift, check G-tube placement prior to feeding and medication administration, and monitor, document, and report complications including infection at the tube site, tube dysfunction/malfunction, and tube dislodgement. Record review of Resident #2's Treatment Administration Record (TAR) for [DATE] revealed an active Enteral Feed Order directing staff to cleanse the G-tube site every shift and check G-tube placement every shift prior to feeding and medication administration.Observation on [DATE] at 2:10 PM revealed Resident #2's G-tube dressing was coming off and soiled with drainage. The dressing did not contain a date, time, or staff initials. Resident #3 Record review of Resident #3's admission Record/Face Sheet revealed the resident was a [AGE] year-old male with multiple medical diagnoses and conditions affecting his nutritional status, swallowing ability, cognition, communication, mobility, muscle strength, and need for enteral feeding. The diagnoses listed on the admission Record/Face Sheet included type 2 diabetes mellitus with hyperglycemia, severe protein-calorie malnutrition, cognitive communication deficit, muscle wasting and atrophy, dysphagia, generalized muscle weakness, dementia, and gastrostomy status. The diagnosis of type 2 diabetes mellitus with hyperglycemia indicated the resident had diabetes with elevated blood glucose levels, requiring ongoing monitoring and management. The diagnosis of severe protein-calorie malnutrition indicated the resident was at increased risk for inadequate nutritional intake, weight loss, impaired healing, and complications related to poor nutritional status. The diagnosis of dysphagia indicated the resident had difficulty swallowing and required an alternative method of receiving nutrition, hydration, and/or medications. The diagnosis of gastrostomy status indicated the resident had a gastrostomy tube in place for enteral feeding and related care. The admission Record/Face Sheet also identified muscle wasting and atrophy and generalized muscle weakness, which indicated the resident had decreased muscle mass and reduced physical strength. These conditions placed the resident at increased risk for functional decline, impaired mobility, and dependence on staff for activities of daily living and treatment-related care. The diagnosis of dementia, along with the diagnosis of cognitive communication deficit, indicated the resident had cognitive and communication-related impairments that could affect his ability to recognize, report, or communicate discomfort, drainage, pain, redness, or other changes involving the gastrostomy tube site. Record review of Resident #3's Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was able to participate in the interview and demonstrated generally intact cognition at the time of the assessment. Although the resident's BIMS score indicated generally intact cognition, the admission Record/Face Sheet continued to identify diagnoses of dementia and cognitive communication deficit. Therefore, staff were required to follow the resident's individualized care plan and monitor the resident's gastrostomy site rather than rely solely on the resident to identify or report a problem. Record review of Resident #3's Care Plan, last reviewed [DATE], revealed the resident required tube feeding related to dysphagia. The care plan identified the need for routine gastrostomy tube care and directed staff to cleanse the G-tube site every shift and clean the insertion site daily as ordered. The care plan further directed staff to monitor the insertion site for signs and symptoms of infection or skin breakdown, including redness, pain, drainage, swelling, and/or ulceration, and to report any identified symptoms to the physician. Record review of Resident #3's Treatment Administration Record (TAR) for [DATE] revealed an Enteral Feed Order directing staff to cleanse the G-tube site every shift. The TAR contained documentation indicating the ordered G-tube site care was administered through [DATE]. The documented order and TAR entries established that routine G-tube site cleansing was an active treatment requirement and was not optional or dependent on whether the site appeared visibly soiled at the time of care.Observation on [DATE] at 2:15 PM revealed Resident #3's PEG/G-tube dressing was dated [DATE] and not initialed was soiled with drainage. LVN B stated the dressing needed to be changed, was to be changed daily and as needed., and that failure to change a dressing when drainage was present could place the resident at risk for infection. Record review of Resident #3's Order Summary Report, generated [DATE] at 11:25 AM, revealed a new active Enteral Feed Order dated [DATE] directing staff to cleanse the G-tube site every shift and allowing T-drain gauze to be applied as needed. Resident #4Record review of Resident #4's admission Record/Face Sheet revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included lobar pneumonia (infection involving a section of the lung); encounter for attention to gastrostomy (required care and management of a surgically placed feeding tube into the stomach); dysphagia (difficulty swallowing); other feeding difficulties (problems safely or adequately eating or receiving nutrition); severe sepsis without septic shock (a serious body-wide response to infection without dangerously low blood pressure from septic shock); muscle wasting and atrophy (loss of muscle mass); generalized muscle weakness (overall decreased muscle strength); abnormalities of gait and mobility (difficulty with walking and movement); lack of coordination (difficulty controlling or coordinating body movements); type 2 diabetes mellitus with hyperglycemia (diabetes with elevated blood sugar); protein-calorie malnutrition (inadequate protein and calorie intake resulting in poor nutritional status.); chronic obstructive pulmonary disease [COPD] (chronic lung disease that makes breathing difficult); and acute systolic congestive heart failure (reduced ability of the heart to pump blood effectively, resulting in fluid buildup). Record review of Resident #4's Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Record review of Resident #4's Care Plan, last reviewed [DATE], revealed the resident had a potential fluid deficit related to dysphagia. The care plan directed staff to cleanse the G-tube site every shift and flush the tube with 30 mL of water before and after medications and feedings. Record review of order summary and MAR/TAR revealed physician orders required the G-tube site to be cleansed and checked every shift. Record review of Resident #4's Order Summary Report, generated [DATE] at 11:22 AM, revealed the previous order to cleanse the G-tube site every shift was discontinued and a new active verbal order dated [DATE] directed staff to cleanse the G-tube site every shift and allowed T-drain gauze Record review of Resident #4's Treatment Administration Record (TAR) for [DATE], printed [DATE] at 11:03 AM, revealed an Enteral Feed Order directing staff to cleanse the G-tube site every shift. The TAR contained direct care staff documentation indicating the ordered G-tube site care was administered through [DATE]. Observation on [DATE] at 2:16 PM revealed Resident #4's tube feeding was dated [DATE]; however, the G-tube dressing was dated [DATE]. RN O stated G-tube dressings should be changed every 24 hours or as ordered. During an interview on [DATE] at 2:25 PM, RN S stated dressing changes were to be completed according to provider orders, including every shift, daily, or as needed when drainage was present. RN S stated dressings were to contain the date and initials and acknowledged failure to follow these practices could place residents at risk. During an interview on [DATE] at 10:00 AM, LVN C described use of clean technique for dressing changes and stated PEG-tube dressings should be cleaned and changed daily. She stated failure to clean or change the dressings daily placed residents at risk for infection. During an interview on [DATE] at 3:38 PM, Charge Nurse G stated Resident #1's G-tube site was checked every shift for redness because the resident's colostomy was located below the PEG tube. He stated leakage from the colostomy could expose the PEG-tube area to moisture and bacteria and increase the risk for redness, skin deterioration, and infection. During an interview on [DATE] at 1:37 PM, the Administrator stated failure to change G-tube dressings could place residents at risk for infection. Record review of facility's policy named External Nutrition no date on policy, revealed, We will provide nutritional complete internal or private turtle feeding as bordered by the physician for the nourishment of residents who are unable to eat by mouth, The nursing services department is responsible for all feeding equipment and the administration of tooth feeding the dietary department has no involvement in tooth feeding administration is the physician and family opt for a feeding. Orders are written to include the following 2.) the volume to be given in 24 hours and the number of milliliters per cubed is not continuous drift 3.) number feedings per 24 hours is intermediate. Record review of facility's policy Infection Control Policy & Procedure Manual, policy titled Fundamentals of Infection Control Precautions, AD 03-8.0, revealed the facility established infection-control practices to decrease the risk of transmission of microorganisms and prevent infection during resident care. The policy identified hand hygiene as the primary means of preventing transmission of infection and required hand hygiene before and after handling invasive devices and before and after changing a dressing. The policy further required the use of gloves as a protective barrier when contact with body fluids, secretions, excretions, mucous membranes, or non-intact skin could occur and specified that wearing gloves did not replace the need for appropriate hand hygiene. The policy established infection-prevention practices applicable to the care of residents with invasive devices and dressings.

Based on observation , interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights 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 of 4 residents (Resident #1) reviewed for comprehensive person-centered care plans.-The facility failed to ensure Resident #1's behaviors related to removal of supplemental oxygen and required oxygen monitoring were addressed in the comprehensive care plan.-The facility failed to ensure Resident #1's care plan and Kardex accurately reflected the level of assistance required for bathing, transfers, and care following a change in condition and injury.-The facility failed to ensure care of the tracheostomy stoma (a small hole in the front of the neck that lead directly into the windpipe to help a person breath) was addressed after the resident removed the tracheostomy. These failures could place residents at risk for errors in treatment and services. Findings included :Record review of Resident #1 face sheet dated 08/19/2026, revealed Resident #1, was a [AGE] year-old female who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #1's diagnoses included Stage 4 sacral pressure ulcer (a severe wound over the tailbone with full-thickness tissue loss), anemia (low red blood cells), Type 2 diabetes mellitus (high blood sugar), protein-calorie malnutrition (inadequate intake of protein and calories), hyperlipidemia (high cholesterol), hypernatremia (high sodium levels in the blood), depression (a mood disorder causing persistent sadness or loss of interest), anxiety (excessive worry or nervousness), cerebrovascular disease (disease affecting blood flow to the brain), aphasia (difficulty speaking or understanding language), left-sided weakness and paralysis following a cerebrovascular accident (weakness and loss of movement on the left side following a stroke), dysphagia (difficulty swallowing), hypotension (low blood pressure), chronic respiratory failure (long-term impairment of the lungs' ability to adequately exchange oxygen and carbon dioxide), gastroesophageal reflux disease (acid reflux), generalized muscle weakness (overall decreased muscle strength), sarcopenia (loss of muscle mass and strength), urinary obstruction or reflux (blocked or backward flow of urine), cognitive and communication deficits (difficulty with thinking and communicating), functional quadriplegia (complete physical dependence due to severe weakness or disability), gastrostomy status (presence of a feeding tube into the stomach), and colostomy status (presence of a surgically created opening in the abdomen for stool elimination).Record review of Resident #1's Quarterly MDS dated [DATE], reflected a BIMS score of 00, which indicated Severely impaired cognition. Resident #1 had impairment to of both upper extremity (shoulder, elbow, wrist, hand), and impairment on both sides to lower extremities (hip, knee, ankle, foot).Record review of Resident #1's care plan dated 08/19/2026, revealed supplemental oxygen due to altered respiratory status was addressed; however, the care plan did not identify specific interventions for oxygen monitoring for behaviors. Observation of Resident #1 conducted on 08/17/2026 at 1:50 PM revealed the resident was lying in bed with the head of the bed elevated Resident #1 was observed to be nonverbal and demonstrated limited range of motion. The resident demonstrated some facial expressions in response to surrounding noise but did not verbally communicate during the observation.During an observation on Resident #1 on 08/17/2026 at 01:50 PM, revealed Resident #1 had a nasal cannula; however, the nasal cannula was not positioned in the resident's nostrils and was observed resting on the resident's chest. The resident remained in bed throughout the observation and did not exhibit observable signs or symptoms of respiratory or other acute distress at the time of the observation. During an interview on 08/18/2026 at 12:25 PM, LVN M stated the DON instructed her on 08/17/2026 to update Resident #1's care plan to include supplemental oxygen and the resident's behaviors related to oxygen use.During an interview on 08/18/2026 at 12:49 PM, the DON acknowledged Resident #1's stated the care plan was not person-centered because information was missing. The DON stated missing information could place the resident at risk for further injury. The DON further stated the oxygen order lacked specific instructions and that the resident's oxygen-related behaviors and monitoring should have been addressed. DON stated herself, both ADON, and both MDS nurses were in charge of monitoring updating careplan, quarterly,, and when there is a change in condition pertaining to resident. During an interview on 08/18/2026 at 1:15 PM, ADON E acknowledged Resident #1's care plan did not reflect the resident's current needs. She stated she would recommend a two-person assist for care, except bathing, she stated this was based on nursing and therapy assessment and acknowledged staff could not be expected to know the resident's needs when the care plan was not updated. She stated this could place the resident at risk for falls and injuries. She stated Record review of facility's policy named Comprehensive Care planning No date on policy, Revealed The facility will develop and implement a comprehensive person care plan centered care plan for each resident, consistent with the residents rights that includes, measurable objectives and timeframes to meet a residents medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment. Each Resident will have a person centered comprehensive care plan developed and implemented to meet his other purposes and goals and address the residents medical physical mental and psychosocial needs. The comprehensive care plan will reflect interventions to enable each resident to meet his her objective interventions are the specific care and services that will be implemented. The Residents care plan will be reviewed after each Admission, Quarterly, Annual and/ or Significant changes MDS assessment, and Revised based on changing Goals, Preferences and needs of the residents and in response to current interventions.

Based on observation, interview, and record review, the facility failed to ensure a resident who required respiratory care received such care consistent with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for oxygen management.The facility failed to ensure Resident #1's supplemental oxygen was maintained as ordered and that the resident's repeated removal of the nasal cannula was monitored and addressed.This failure could place residents at risk for inadequate oxygen support, decreased oxygen saturation, respiratory decline, and becoming clinically unstable.Findings included:Record review of Resident #1 face sheet dated 08/19/2026, revealed Resident #1, was a [AGE] year-old female who was admitted to the facility on [DATE], and readmitted on [DATE]. Type 2 diabetes mellitus (high blood sugar), protein-calorie malnutrition (inadequate intake of protein and calories), dysphagia (difficulty swallowing), hypotension (low blood pressure), chronic respiratory failure (long-term impairment of the lungs' ability to adequately exchange oxygen and carbon dioxide), gastroesophageal reflux disease (acid reflux), generalized muscle weakness (overall decreased muscle strength), sarcopenia (loss of muscle mass and strength), urinary obstruction or reflux (blocked or backward flow of urine), cognitive and communication deficits (difficulty with thinking and communicating), functional quadriplegia (complete physical dependence due to severe weakness or disability), gastrostomy status (presence of a feeding tube into the stomach), and colostomy status (presence of a surgically created opening in the abdomen for stool elimination). Record review of Resident #1's Quarterly MDS dated [DATE], reflected a BIMS score of 00, which indicated severely impaired cognition. Resident #1 had impairment to of both upper extremity (shoulder, elbow, wrist, hand), and impairment on both sides to lower extremities (hip, knee, ankle, foot), and had no oxygen monitoring administration or monitoring. Observation of Resident #1 on 08/17/2026 at 1:50 PM revealed a nasal cannula resting on the resident's chest and not positioned in the resident's nostrils. The resident did not exhibit observable signs or symptoms of acute respiratory distress at the time of the observation.Record review of Resident #1's care plan dated 08/19/2026, revealed no documented interventions addressing the administration and monitoring of supplemental oxygen via nasal cannula. Further review revealed the care plan did not address Resident #1's known behavior of removing the nasal cannula or identifying interventions for staff to monitor and respond when the resident removed the oxygen. During an interview on 08/17/2026 at 1:55 PM, ADON E stated Resident #1's oxygen was scheduled and the resident had a tendency to remove the oxygen. ADON E stated the resident's oxygen saturation could decrease and affect the resident and stated the resident's behavior of removing the oxygen should have been documented , in progress notes or as a behavior in careplan for monitoring. During an interview on 08/17/2026 at 3:38 PM, Charge Nurse G stated Resident #1 had received continuous oxygen since admission and that only the tracheostomy, not the oxygen, had been discontinued.During an interview on 08/18/2026 at 10:15 AM, CNA L stated Resident #1 had behaviors of removing the oxygen and stated she did not know how often the oxygen was checked to ensure it remained in place.During an interview on 08/18/2026 at 10:48 AM, Doctor A stated Resident #1 required supplemental oxygen because of her respiratory condition and the remaining open tracheostomy site that was not in use and was healing since removal. During an interview on 08/18/2026 at 12:49 PM, the DON stated the oxygen order dated 12/09/2025 that had did not contain specific oxygen instructions pertaining oxygen administration liter per minute to be given and how often, and was updated after oxygen administration concern was identified. The DON stated the resident's behaviors and oxygen monitoring should have been addressed.During an interview on 08/18/2026 at 1:15 PM, ADON E acknowledged she was aware Resident #1 removed the nasal cannula and had observed the behavior. She stated failure to address the resident's oxygen needs could place the resident at risk for becoming clinically unstable.Record review of facility's policy named Oxygen administration no dated conducted on 08/17/2026 , revealed oxygen therapy included the administration of oxygen by nasal cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac disease and to ensure adequate oxygenation of the resident's body organs and systems. The policy stated the amount of oxygen, concentration, or liters per minute (L/min), and method of administration were to be ordered by the physician. The policy further identified that administration of oxygen, monitoring of the resident's response, and implementation of associated safety precautions were the responsibility of the nurse. The policy identified the goal that the resident would maintain adequate oxygenation through the safe and effective delivery of the prescribed oxygen and maintain an effective breathing pattern during oxygen administration. The policy directed nursing staff to become familiar with the resident's medical diagnosis, reason for oxygen therapy, whether oxygen was ordered intermittently or continuously, and the prescribed amount to be delivered. Staff were further directed to properly set the oxygen flow to the desired rate, verify that oxygen was flowing through the delivery device, appropriately position and secure the nasal cannula or mask, and replace oxygen tubing or the delivery device if it malfunctioned or became visibly contaminated. The policy established that nursing staff were responsible for ensuring oxygen was administered in accordance with the physician's prescribed rate and method and for monitoring the resident's response to ensure safe and effective oxygen delivery.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards and practices for 2 of 4 residents (Resident #2 and Resident #3) reviewed for gastro enteral feeding tube dressing care.The facility failed to ensure documentation of gastro enteral feeding tube dressing changes accurately reflected the care provided for Resident #2 and Resident #3.This deficient practice could place residents at risk for not receiving required treatment and services when the clinical record indicated the care had been completed.Findings included:Resident #2Record review of Resident #2's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE], with an original admission date of 07/01/2025. Diagnoses included chronic respiratory failure with hypoxia, dysphagia, cognitive communication deficit, moderate protein-calorie malnutrition, dementia, , and encounter for attention to gastrostomy. Record review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS), and a Staff Assessment for Mental Status was completed. The assessment identified short-term and long-term memory problems. The resident was unable to recall the current season, location of his room, staff names and faces, or that he was in a nursing home/hospital setting. The MDS further identified the resident's cognitive skills for daily decision-making as severely impaired.Record review of Resident #2's Care Plan, last reviewed 08/13/2026, revealed the resident had a potential nutritional problem related to dysphagia and G-tube status and required tube feeding related to dysphagia and encephalopathy. The care plan directed staff to cleanse the G-tube site every shift, check G-tube placement prior to feeding and medication administration, and monitor, document, and report complications including infection at the tube site, tube dysfunction/malfunction, and tube dislodgement.Record review of Resident #2's Treatment Administration Record (TAR) for August 2026 revealed an active Enteral Feed Order directing staff to cleanse the G-tube site every shift and check G-tube placement every shift prior to feeding and medication administration .Observation on 08/17/2026 at 2:10 PM revealed Resident #2's G-tube dressing was coming off and soiled with drainage. The dressing did not contain a date, time, or staff initials. When the gauze was removed , by LVN the dressing was observed to be soiled and drainage was present from the G-tube site. The CNA stated she did not know whether the nurse had changed the dressing.Resident #3Record review of Resident #3's admission Record/Face Sheet revealed the resident was a [AGE] year-old male with multiple medical diagnoses and conditions affecting his nutritional status, swallowing ability, cognition, communication, mobility, muscle strength, and need for enteral feeding. The diagnoses listed on the admission Record/Face Sheet included type 2 diabetes mellitus with hyperglycemia, severe protein-calorie malnutrition, cognitive communication deficit, muscle wasting and atrophy, dysphagia, generalized muscle weakness, dementia, and gastrostomy status. The diagnosis of type 2 diabetes mellitus with hyperglycemia indicated the resident had diabetes with elevated blood glucose levels, requiring ongoing monitoring and management. The diagnosis of severe protein-calorie malnutrition indicated the resident was at increased risk for inadequate nutritional intake, weight loss, impaired healing, and complications related to poor nutritional status. Record review on 08/16/2026 of Resident #3's Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was able to participate in the interview and demonstrated generally intact cognition at the time of the assessment. Record review of Resident #3's Care Plan, last reviewed 05/27/2026, revealed the resident required tube feeding related to dysphagia. The care plan identified the need for routine gastrostomy tube care and directed staff to cleanse the G-tube site every shift and clean the insertion site daily as ordered. The care plan further reflected staff to monitor the insertion site for signs and symptoms of infection or skin breakdown, including redness, pain, drainage, swelling, and/or ulceration, and to report any identified symptoms to the physician.Record review of order summay and MAR/TAR re vealed physician orders required G-tube site cleansing and checks each shift to be documented by direct staff to Resident #3. Record review of Resident #3's Treatment Administration Record (TAR) for August 2026 revealed an Enteral Feed Order directing staff to cleanse the G-tube site every shift. The TAR contained documentation indicating the ordered G-tube site care was administered through 08/17/2026. The documented order and TAR entries established that routine G-tube site cleansing was an active treatment requirement and was not optional or dependent on whether the site appeared visibly soiled at the time of care. Observation and interview on 08/17/2026 at 2:15 PM revealed Resident #3's PEG-tube dressing was dated 08/16/2026 and was soiled with drainage. , stated the dressing needed to be changed and stated dressings were to be changed daily and as needed. During an interview on 08/18/2026 at 12:49 PM, the DON stated PEG-tube orders had been updated to address cleansing and dressing changes. The DON stated that if staff documented dressing changes as completed when the dressing changes had not actually been performed, the documentation would be considered false documentation.Record review of Resident #3's Order Summary Report, generated 08/18/2026 at 11:25 AM, revealed a new active Enteral Feed Order dated 08/18/2026 directing staff to cleanse the G-tube site every shift and allowing T-drain gauze to be applied as needed. Record review of facility's policy named Documentation no date on policy conducted on 08/17/2026, revealed documentation was defined as the recording of objective and subjective information in the resident's clinical record, including observations, investigations, communications, care, and treatments. The policy identified requirements related to the accuracy, completeness, legibility, and timing of documentation and included documentation maintained within the facility's electronic clinical software. The policy stated the facility would maintain complete and accurate documentation for each resident on all appropriate clinical record forms and would ensure information was comprehensive, timely, and properly signed. The policy further directed staff to document completed assessments in a timely manner and according to policy and to complete documentation as needed in a timely manner. Each entry was required to be dated, timed, and signed with the appropriate signature and title. The policy also required staff to document or check information on flow sheets each shift, or as appropriate, for the care or treatment being monitored. The policy required documentation for each shift for at least 72 hours for new admissions, during and following an acute episode, following an incident, and during physiological, mental, or emotional changes or instability. The policy established the facility's expectation that resident assessments, monitoring, care, and treatments were to be accurately, completely, and timely documented in the clinical record.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 2 (Resident #32 and Resident #12) of 11 residents observed for oxygen management.The facility failed to maintain the oxygen concentrator filter for Resident #12.The facility failed on 06/23/2026 to ensure an oxygen warning sign was posted outside the room of Resident #32 while the resident was receiving oxygen therapy.These failures had the potential to expose residents receiving oxygen therapy delayed identification of oxygen-related needs, increase the risk of fire hazards associated with oxygen use, reduce airflow, decrease equipment efficiency, and potentially affect oxygen delivery to the resident.Findings included: Resident #32 Record review of the face sheet dated 06/23/2026 revealed Resident #32 was an [AGE] year-old male who was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnosis list revealed Resident #32 had chronic obstructive pulmonary disease (COPD - chronic lung disease that makes breathing difficult) as the primary diagnosis with an onset date of 12/01/2025. Additional respiratory-related diagnoses included chronic respiratory failure with hypoxia (long-term breathing failure causing low oxygen levels) with an onset date of 04/22/2026, pan lobular emphysema (lung disease causing damaged air sacs and shortness of breath) with an onset date of 01/21/2026, and solitary pulmonary nodule (a spot or growth in the lung) with an onset date of 01/21/2026. Record review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 7, indicating moderate cognitive impairment. Section O for special treatments, procedures and programs included a respiratory treatments section that listed oxygen therapy as a treatment item. Record review of the care plan dated 06/24/2026 revealed the Resident #32 continued to require oxygen therapy. The care plan instructed staff to administer oxygen as ordered with oxygen 2 liters per minute, monitor oxygen use and respiratory status, ensure oxygen equipment remained in safe working condition, implement oxygen safety precautions, and provide ongoing observation and interventions to promote respiratory stability and resident safety. During an observation on 06/23/2026 at 9:16 a.m., at Resident #32's room, he was sitting on his wheelchair having breakfast; Resident #32 was wearing his nasal canula and receiving oxygen. There was on oxygen sign posted outside his room. During an interview on 06/24/2026 at 2:38 p.m., LVN C stated that any resident receiving oxygen therapy or who had an oxygen concentrator in the room was required to have an oxygen-in-use sign posted outside the room. LVN C stated the sign alerted staff, residents, and visitors that oxygen was in use so appropriate safety precautions could be followed. LVN C stated that all nurses, CNAs, ADONs, the DON, and other staff making rounds were responsible for ensuring the signs remained posted. LVN C stated that if an oxygen-in-use sign was not posted, staff or visitors could unknowingly create a fire hazard, and staff who were unaware the resident was receiving oxygen might fail to perform appropriate monitoring or oxygen-related safety checks. During an interview on 06/24/2026 at 2:42 p.m., LVN D stated that residents receiving oxygen therapy were required to have an oxygen-in-use sign posted outside their room. LVN D stated the sign warned anyone entering the room that oxygen was present and reminded staff to follow oxygen safety precautions. LVN D stated that without the sign, a visitor could unknowingly bring an ignition source or flammable product into the room, creating a fire hazard. LVN D stated staff who did not know a resident was receiving oxygen therapy could also fail to check the resident or ensure oxygen was being used safely and as ordered. During an interview on 06/24/2026 at 2:55 p.m., CNA E stated that oxygen-in-use signs were required outside the rooms of residents receiving oxygen therapy. CNA E stated the signs notified staff, residents, and visitors that oxygen was in use, and that smoking or other ignition sources were not permitted near the room. CNA E stated that if the signs were missing, there was a potential for a fire hazard. CNA E also stated staff who were unaware a resident was receiving oxygen therapy might not perform appropriate oxygen-related observations or verify the resident was receiving oxygen as prescribed. During an interview on 06/25/2026 at 1:52 p.m., the DON stated that oxygen-in-use signs were required to be posted outside the rooms of residents receiving oxygen therapy or who had oxygen equipment in their rooms. The DON stated the purpose of the signs was to alert staff, visitors, and anyone entering the room that oxygen was in use so appropriate safety precautions could be followed. The DON stated all staff who cared for residents, including CNAs, LVNs, RNs, and supervisory staff, were responsible for ensuring the oxygen-in-use signs were properly displayed. The DON stated that failing to post the signs created the potential for a fire hazard if staff or visitors unknowingly brought ignition sources or other combustible items into the room. The DON stated that staff who were unaware of a resident receiving oxygen therapy might fail to perform appropriate monitoring or safety checks related to the resident's oxygen use. During an interview on 06/25/2026 at 2:33 p.m., the Administrator stated that oxygen-in-use signs should be posted outside the rooms of all residents receiving oxygen therapy to provide a clear visual warning that oxygen was present. The Administrator stated that every staff member working with residents shared the responsibility of ensuring the signs remained posted when oxygen equipment was in the room. The Administrator stated that without the required signage, visitors or staff could unknowingly bring items capable of producing sparks or flames into the room, creating a potential fire hazard in an oxygen-enriched environment. The Administrator also stated that staff who were unaware a resident was receiving oxygen therapy might not recognize the need for oxygen-related monitoring, safety precautions, or routine checks, which could delay appropriate care and place the resident at risk. Record review of the facility's policy and procedures titled Oxygen Administration, not dated, read in part: Oxygen Administration. 11. Place NO SMOKING signs in area when oxygen is administered and stored. Store oxygen cannister in an area free of flammable substances. Avoid the use of electrical appliances in the rea of oxygen use as well. If the facility is non-smoking, oxygen in use signs are not required on individual resident rooms. Record review of Resident 12's face-sheet dated 6/25/2026 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12s diagnoses included End Stage Renal Disease (ESRD) (Permanent kidney failure requiring dialysis to perform the kidneys' function.) Dependence on Renal Dialysis (Requires regular dialysis treatments to filter waste and excess fluid from the blood.) Other Seasonal Allergic Rhinitis (Seasonal allergies causing nasal congestion, sneezing, and runny nose.) Cognitive Communication Deficit (Difficulty with thinking, processing information, and communicating effectively.) Other Symbolic Dysfunctions (Difficulty understanding or using language, numbers, or symbols.) Unspecified Dementia Without Behavioral Disturbance (Progressive decline in memory and cognitive function without significant behavioral symptoms.) and Other Specified Anxiety Disorders (An anxiety disorder causing excessive worry or nervousness.) Record review of Resident 12's Quarterly MDS dated [DATE] reflected a BIMS score of 07 indicated he was moderately cognitive impaired. Record review or Resident # 12' care plan dated 05/20/26 revealed there was no documentation to address oxygen concentrator filter maintenance An observation on 06/23/26 at 8:51 AM Resident #12 was observed with dirty, dusty, lint on oxygen filter. In an interview with CNA A on 06/24/2026 at 11:12 AM stated that she observed Resident #12's the oxygen concentrator air filter to be dirty and full of dust. CNA A reported that she did not know who was responsible for cleaning the filter and assumed it was the responsibility of housekeeping. CNA A further stated that, when she observed concerns within the facility, she reported them to the nurses, and the appropriate action could be taken. In an interview with RN F on 06/24/2026 at 2:08pm stated that Resident #12's oxygen concentrator air filter was dirty and that in that condition was not acceptable. RN F reported that maintaining a clean filter was everyone's responsibility to help ensure the equipment functioned properly. RN F stated that a dirty filter could interfere with the machine's operation, potentially affecting airflow and creating a risk for the resident who relied on the equipment for oxygen therapy. In an interview with ADON on 06/24/2026 at 2:13pm stated that the oxygen concentrator air filter appeared dirty. ADON reported that the facility did not have a specific policy addressing the cleaning or maintenance of oxygen concentrator filters, and that staff were instructed to follow the manufacturer's recommendations. She stated that, to her knowledge, central supply was responsible for cleaning and sanitizing the filters but was unsure how often the cleaning was performed. She further reported that the facility did not maintain documentation identifying when the filters were cleaned or who completed the cleaning. The ADON stated that a dirty filter could restrict airflow, affect the oxygen concentrator's performance, and potentially impact the resident's oxygen therapy. ADON also reported that staff had not received in-service training regarding oxygen filter maintenance and that there was no documentation outlining the frequency of filter cleaning or staff responsibility for the task. In an interview with DON on 06/24/2026 at 2:35pm stated that the oxygen concentrator air filter was dirty and required cleaning and replacement. She reported that central supply was responsible for cleaning the filters, while nursing staff were responsible for cleaning the oxygen concentrators. She stated that the inner filters should be changed approximately every two weeks and replaced annually or as needed, in accordance with manufacturer recommendations. The DON further reported that all concentrator filters had recently been cleaned and replaced and that additional replacement filters had been obtained from the manufacturer. She stated that a dirty or contaminated filter could interfere with proper oxygen delivery and place residents at risk. She also reported that the facility had not provided in-service education regarding oxygen concentrator filter maintenance. In an interview with administrator on 06/24/2026 at 3:08pm the Administrator stated that Resident #12's oxygen concentrator filter appeared dirty and believed it had not been cleaned for several weeks. He reported that responsibility for cleaning the filter likely belonged to central supply or nursing staff but was unsure whether the facility-maintained documentation identified how often the filters were cleaned. The administrator stated that central supply personnel were currently available on a daily basis. The Administrator further reported that a dirty filter could prevent the oxygen concentrator from operating at maximum efficiency and could potentially result in a resident not receiving the prescribed amount of oxygen. He stated that he assumed the staff member responsible for oxygen concentrator maintenance had received the appropriate training.

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 in 1 of 1 kitchen reviewed for kitchen sanitation and food storage.1. - The facility failed to store food in the dry storage room in sealed containers. 2. - The facility failed to label and date food containers stored in the refrigerator.3. - The facility failed to keep 21 spice bottles stored on a rack directly above food preparation sink free of grease build-up and residual around the tops and sides of the bottles; failed to label a spice bottle that contained white powder.4. - The facility failed to keep the bottom shelf in the freezer free of food particles.5. - The facility failed to store food in the freezer in sealed containers.These failures could place residents at risk of foodborne illnesses. Findings include: During an observation and interview on 06/23/2026 8:38 a.m. with Dietary Supervisor H in the Dry Storage Room revealed the following:-four bowls of cereal stored on a meal tray on the metal rack that were wrapped in plastic wrap and were not dated.-a large, uncovered plastic container that was labeled Yellow Corn Meal, that was stored on the metal rack that had a large plastic bag that contained yellow corn meal that was not sealed and there was yellow corn meal residual around the sides of the plastic container.The Dietary Supervisor said the dietary staff had been trained to store food in sealed containers.During an observation and interview on 06/23/2026 8:39 a.m. with Dietary Supervisor H in the Food Preparation Area and refrigerator revealed the following:- two large opened plastic bags that contained corn tortillas that had been removed from the original packages were stored in the refrigerator and were not sealed or dated.-a sealed plastic container that contained pink dessert topping that was not labeled or dated.-21 spice bottles stored on a metal rack directly above the food preparation sink with grease build-up and residual around the tops and sides of the bottles-a glass spice bottle that contained a white powdered substance that was not labeled stored on another spice rack directly above the food preparation sink.The Dietary Supervisor said the dietary staff had been trained to label and date food containers when foods were removed from the original containers.During an observation and interview on 06/23/2026 8:49 a.m. with Dietary Supervisor H revealed there was an opened box stored in the freezer that contained pasta with cheese that was stored in a plastic bag that was not sealed. During an interview on 06/23/26 at 9:30 a.m. with Dietary Manager K said the Dietary staff had been trained to label and store food in sealed containers when foods were removed from the original containers. Review of the facility's policy and procedure on Food Storage and Supplies dated 2012 provide by facility's Regional Compliance Nurse revealed: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin, and insects. Procedure: Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Containers are cleaned regularly. Open packages of food are stored in closed containers with covers or sealed bags and dated as to when opened.Food Code 2022(C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18.3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants.

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #22 and Resident #89) of 9 residents reviewed for call light placement.The facility failed to ensure call lights were within reach for Residents #22 and #89.This failure could affect residents by not having access to call for assistance resulting in needs not being met.Findings included:Resident #22Record review of the face sheet dated 06/23/2026 revealed Resident #22 was a [AGE] year-old female who was originally admitted to the facility on [DATE] and was readmitted on [DATE].Record review of the history and physical dated 05/12/2026 revealed Resident #22 was diagnosed with generalized muscle weakness (decreased strength), other abnormalities of gait and mobility (problems walking or moving safely), lack of coordination (difficulty controlling body movements), unspecified dementia (memory/thinking impairment) and cognitive communication deficit (difficulty understanding or communicating).Record review of Resident #22's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 3, indicating severe cognitive impairment. The MDS Section J1800 revealed the resident had falls since admission/entry or the prior assessment. Review of section GG for functional abilities revealed the resident required assistance with multiple mobility-related tasks. The MDS documented code 03 for sit-to-lying and lying-to-sitting on the side of the bed, meaning the resident required partial/moderate assistance. The MDS documented code 02 for sit-to-stand and chair/bed-to-chair transfer, meaning the resident required substantial/maximal assistance. The MDS documented code 09 for toilet transfer and walk 10 feet, meaning the activity was not applicable and the resident did not perform the activity prior to the current illness, exacerbation, or injury.Record review of Resident #22's care plan last revised on 06/15/2024 revealed the resident had a communication problem related to moderate difficulty in hearing and called for staff intervention of ensuring to provide a safe environment for the resident by having the call light within reach, adequate log glare light, bed in lowest position and wheels looked. Resident #22's care plan revealed the resident had an ADL self-care performance deficit and called for staff intervention by encouraging the resident to use the bell to call for assistance.During an observation and interview on 06/23/2026 at 9:00 a.m., with CNA A, Resident #22's call light was observed underneath the resident's bed and not within the resident's reach. CNA A stated that the resident frequently repositioned herself in bed and, at times, the call light could fall to the floor. CNA A stated that despite this occurring, the call light was expected to always remain within the resident's reach. CNA A stated that all staff who provided care to the residents were responsible for ensuring the call light remained accessible. CNA A stated that if the residents were unable to reach the call light, they could attempt to get up without assistance and experience a fall or experience delays in receiving needed assistance and services.During an observation and interview on 06/23/2026 at 9:02 p.m., CNA B stated that Resident #22's call light was observed underneath the resident's bed. CNA B stated that all staff members who worked with residents were responsible for checking and ensuring the call lights were placed within the residents reach. CNA B stated that residents relied on the call light to request assistance and communicate their needs. CNA B stated that when a call light was not readily accessible, there was a risk that the residents could try to obtain assistance independently and sustain an injury, including a fall. CNA B stated that an inaccessible call light could also result in delays in care because staff would not be alerted when the resident required assistance. During an observation and interview on 06/23/2026 at 9:38 a.m., Resident #22 was in bed. Her call light was observed on the floor underneath her bed. The surveyor asked Resident #22 if she was able to locate her call light, but the resident was confused and did not answer the surveyor's questions. CNA A was present at the time and stated the resident knew how to use her call light. CNA A stated the call light must have fallen from the resident's bed, and it was likely not properly clipped to the bed sheet.During an interview on 06/24/2026 at 2:25 p.m., with LVN C, stated that call lights were used by residents whenever they needed assistance with water, ADLs, ask for assistance with showers and transfers. LVN C stated that call lights needed to be located within reach of the residents and that it was the responsibility of CNAs, LVNs, RNs or DON to make sure that call lights were within reach of the residents while they were in their room. LVN C stated that rounds were conducted every two hours to make sure call lights were within the resident's reach. LVN C stated that potential negative outcome for call lights not being within reach and beneath Resident #22's bed, could be the resident could fall if she tried to reach the call light for assistance or getting up on her own and also potentially delaying services by Resident #22 not being able to call for help. Resident #89Record review of the face sheet dated 06/23/2026 revealed Resident #89 was an [AGE] year-old female who was originally admitted to the facility on [DATE] and was readmitted on [DATE].Record review of the history and physical dated 09/11/2024 revealed Resident #89 was admitted after a ground-level fall after tripping over an object. The record revealed the resident reported mild head pain after a possible head strike, back pain, groin pain, and a fall earlier in the week. Injuries included a subgaleal hematoma to the right frontal scalp (bleeding/swelling under the scalp), subacute fractures of the left superior pubic ramus, right suprapubic ramus, bilateral inferior pubic rami (pelvic fractures), nondisplaced fracture of the right sacral ala extending to the sacral foramen (lower spine/pelvic area fracture), and burst/compression fracture of L2 causing mild central stenosis (a broken lower-back bone causing narrowing around the spinal canal).Record review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 3, indicating severe cognitive impairment. MDS Section GG for functional abilities revealed the resident had a code 06 for sit-to-lying, lying-to-sitting on the side of the bed, sit-to-stand, chair/bed-to-chair transfer, and walking 10 feet, meaning independent performance for those specific coded activities during the assessment period. The MDS documented code 05 for toilet transfer, meaning setup or clean-up assistance was required.Record review of the care plan revised on 05/27/2026 revealed an ADL self-care performance deficit related to multiple lumbar fractures, pubis and sacral fractures, muscle weakness, lack of coordination, and history of falls. Record review of the fall risk care plan revealed Resident #89 was at risk for falls related to confusion, gait/balance problems, incontinence, and noncompliance with the use of a walker. Interventions included anticipating and meeting the resident's needs; ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed; ensuring a safe environment with a working and reachable call light, bed in low position at night, and personal items within reach.During an observation and interview on 06/23/2026 at 8:50 a.m., with Resident #89, the resident was observed laying in bed in her room. The surveyor observed the resident's call light on the floor underneath the bed and not within the resident's reach. Resident #89 looked around her bed for her call light but stated she could not locate it. The Resident #89 stated, I would just pray to God I don't need to call for help because I wouldn't be able to reach it if I needed assistance.During an interview on 06/25/2026 at 1:48 p.m., the DON stated the facility did not have a written policy specific to call light placement. The DON stated the purpose of a call light was to allow residents to call staff for assistance whenever they needed help. The DON stated that all staff who provided care to residents, including CNAs, LVNs, RNs, and supervisory staff, were responsible for ensuring residents' call lights remained within reach while residents were in their rooms. The DON stated that if a call light was not within a resident's reach, there was a potential for a delay in care because the resident might be unable to request assistance in a timely manner. The DON stated there was also a potential for injury if a resident attempted to get out of bed or transfer independently without staff assistance because they could not access the call light. During an interview on 06/25/2026 at 2:22 p.m., the Administrator stated that the purpose of the call light system was to ensure residents could immediately notify staff when assistance was needed. The Administrator stated every staff member working with residents was responsible for making sure call lights were left within residents' reach before leaving the room. The Administrator stated that when a call light was out of reach, residents could experience a delay in receiving needed services because they would be unable to notify staff. The Administrator stated residents might attempt tasks such as getting out of bed, transferring, or walking without assistance, which could increase the potential for falls or other injuries.

Based on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene, for 1 of 19 residents ( Resident #92) reviewed for ADL care.The facility failed to ensure Resident #92 had trimmed and clean nails on 06/23/2026 and 06/24/2026.This failure could place residents who required assistance with ADL's at risk for unmet care needs.Findings included:Record review of Resident #92's face-sheet dated 06/24/26 revealed a [AGE] year-old male with admission date 04/20/22.Record review of Resident #92's history and physical dated 06/24/26 revealed a medical history of Diabetes Mellitus type 2 (a chronic condition when the body becomes resistant to insulin or does not produce enough insulin causing high blood sugar levels), Cerebral Infarction (disruption in blood flow to the brain causing cell death), and hemiplegia (one-sided weakness or paralysis of the face, arm, and leg).Record review of Resident #92's quarterly MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment.Record review of Resident #92's care plan dated 04/25/22 , revealed resident had ADL Self Care Performance Deficit related to Cerebral Infarction with hemiplegia to left non dominant side, and interventions included for staff to provide x1 staff participation with Personal hygiene.On an observation and interview on 06/23/26 at 10:26 AM Resident #92 revealed the his right hand's fingernails were jagged and had black debris underneath. Resident #92 stated he had his fingernails cleaned last week and wanted them to clean and trim. Resident #92 did not want to answer any more questions regarding his nails.An observation on 06/24/26 at 11:38 AM Resident #92 revealed his right hand's fingernails were still jagged, and black debris was observed underneath his fingernails. Resident #92 stated he had not told staff he wanted them cleaned or trimmed, but they had not offered the service since last week.In an interview on 06/25/26 at 11:14 AM with CNA J revealed the nursing assistants and staff were responsible for residents' nail care. She stated CNAs provide nail care and grooming every Sunday to residents. CNA J stated the risk of having dirty and jagged nails including illness since the residents touch their face or mouth when they eat their food, for example. CNA J stated the ADONs and DON monitor residents' appearance and fingernails as needed but was unsure how often.In an interview on 06/25/26 at 12:28 PM with LVN I, she stated CNAs were responsible for providing nail care and grooming to residents which was every Sunday. LVN I stated that nursing staff was responsible for monitoring the CNAs and ensuring residents' nails were groomed. LVN I stated the DON monitors and rounds on residents including their fingernails, but was not sure how often. LVN I stated the risk of jagged and dirty fingernails was injury and an infection control issue. LVN I stated Resident #92 was able to verbalize his needs and was vocal about it.In an interview on 06/25/26 at 2:23 PM with the DON revealed the CNAs were responsible for grooming resident nails. The DON stated that the CNAs provided nail grooming services every Sunday, or as needed, such as if the resident was observed with long or dirty fingernails. The DON stated the risks of jagged nails was injury to the resident or others, and dirty fingernails were an infection control issue.In an interview on 06/25/26 at 3:19 PM with the Administrator, he stated that the nursing staff was responsible for nail care. The Administrator stated that the CNAs provided nail grooming to residents as needed. He stated the ADON and DON monitor residents daily including their fingernails, which was also monitored through Champion rounds, which consisted of Department Supervisors rounding on residents daily. The Administrator stated during Champion rounds, the residents' appearance and fingernails were looked at and addressed if needed. The Administrator stated the risk of having jagged nails was the resident cutting themselves or others, and dirty fingernails was an infection control concern.Record review of the Nursing Faciilty's Nail Care policy, with no date, read in part: Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin cintegrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath. It continued to read, in part, under Goals, 1. Nail care will be performed regularly and safely.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was as free from accident hazards as possible for 1 of 15 rooms (room # 7) reviewed for accidents.The facility failed to ensure Resident #12 did not have a white unlabeled medication bottle in room on 06/23/26.This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: Record review of Resident 12's face-sheet dated 6/25/2026 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident 12's history and physical dated 05/20/26 revealed diagnoses of cognitive communication deficit (is when someone has trouble communicating effectively because of problems with the mental skills that go along with talking), dysphasia (is a condition that results from damage to the areas of the brain responsible for language, it leads to difficulties in speaking), and unspecified dementia (a diagnosis given when a person has clear signs of dementia (memory loss, confusion, and difficulty with everyday tasks), but the exact type hasn't been identified). Record review of Resident 12's Quarterly MDS dated [DATE] reflected a BIMS score of 07 indicated he was moderately cognitive impaired.Record review or Resident # 12' care plan dated 05/20/26 revealed there was no indication she was assessed and/or capable of self-administering ointment on her own without assistance.An observation on 06/23/26 at 8:51 AM Resident #12 was sitting down eating her breakfast; Observed an unlabeled medication bottle on top of the drawer. Resident #12 stated it was an ointment for pain that she used sometimes.In an interview with CNA A on 06/24/2026 at 11:12 AM stated she observed unlabeled medication in the facility but did not know what the medication was. CNA A stated when she identified concerns such as unlabeled medication, she reported them to the nursing staff because, as a CNA A, she considered herself the eyes in the halls. CNA A stated if her concerns were not addressed, she would report them to someone else. CNA A stated unlabeled medication created a risk because residents could potentially take the medication without knowing what it was and could experience an adverse reaction. CNA A stated staff were expected to report any unlabeled medication to the nurses for follow-up. CNA A stated the facility provided trainings at least once per month. CNA A stated she could not recall the subjects covered during the most recent trainings but confirmed that regular training sessions were conducted by the facility.In an interview with Medication Aide on 06/24/2026 at 1:56 PM stated he has been employed at the facility for about 3 to 4 years. Medication Aide stated that family members sometimes bring medications to the facility without labels. Medication aide reported that unlabeled medications create a safety concern because staff cannot verify the contents in the bottle and residents could accidently receive medication that is not prescribed to them, potentially resulting in adverse effects or toxicity. We will report everything to the nurse, admin and DON, we have trainings every month, especially infection control.In an interview with RN F on 06/24/2026 at 2:08 PM stated he has been employed with the facility for about one year. RN F stated that unlabeled medications are unacceptable because staff cannot verify what was inside the unlabeled medication. RN F reported that family members occasionally bring medications to the facility without labels, and staff remove them when identified. RN F expressed concern that if an unlabeled medication were accessible, a resident could mistakenly ingest it, potentially resulting in an allergic reaction or other serious adverse events due to unknown contents.In an interview with ADON 06/24/2026 2:13 PM stated that the medication appeared to be in a medication bottle; however, because the bottle did not have a label, they were unable to identify what is exactly in the bottle. ADON expressed concern that administering or ingesting an unidentified medication could result in adverse reactions or other harmful side effects. ADON stated that medications are not permitted to be kept at the resident's bedside. ADON explained that if an unlabeled medication was discovered, the physician and the supervisor should be notified, and an incident report should be completed, and the facility should follow the physician's orders if the resident has ingested the medication. ADON stated they do not recall receiving a formal in-service regarding the handling of unlabeled medications. ADON stated during orientation, they were instructed to remove or discard unlabeled medications and notify the resident's family to retrieve the medication.In an interview with DON on 06/25/2026 at 2:35 PM the DON stated that the medication bottle appeared empty and unlabeled, making it impossible to determine what medication it previously contained. DON stated that the resident's family member frequently brings personal items for the resident but could not confirm whether the bottle had been brought by the family. DON stated that nursing staff or certified nursing assistants (CNAs) are responsible for notifying other staff when an unlabeled medication was identified, including during champion rounds. DON stated concern that an unlabeled medication presents a safety risk because a resident could mistakenly take it without knowing what it was, potentially resulting in an adverse or allergic reaction if it was not prescribed for that resident. DON stated that the facility has not recently provided an in-service regarding the management of unlabeled medications. She stated if an unlabeled medication was found, staff would notify the resident's family and the physician to determine whether an order should be obtained. DON stated that families are educated not to bring unlabeled medications into the facility. If a medication is identified, staff assess whether the resident is authorized to keep it at the bedside and whether the resident has been approved to self-administer the medication.In an interview with Administrator 06/25/2026 3:08 PM administrator stated they were unable to identify the contents of the unlabeled medication bottle because it did not have a label. Although the bottle appeared to be empty, the administrator stated that all medication containers should be properly labeled regardless of their contents. The administrator expressed concern that an unlabeled medication could pose a risk of an adverse reaction because staff cannot verify the medication or its potential side effects. The administrator stated that residents should not have unlabeled medications at their bedside. Although some residents are authorized to self-administer their medications, those medications must be properly identified and labeled. If an unlabeled medication was found, staff would remove it from the resident's room, determine what the medication is, and document the findings in the resident's medical record. Administrator stated they were unsure whether the facility provides formal in-service training regarding the management of unlabeled medications but reported that family members are educated upon admission regarding the facility's expectations for bringing medications into the facility.

Based on observations, and interviews, the facility failed ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one (South Low Side Medication Cart) of five medication carts viewed for medication storage. -The facility failed to store eye drop bottles separately for multiple residents when eye drops bottles were removed from the manufacture's containers and were stored together in one plastic bin in the medication cart.This failure could affect residents that received medications from the facility by placing them at risk of cross contamination and infection.The findings include:Observation 06/24/26 at 11:15 a.m. with LVN I revealed Medication Cart South Low Side, Multiple Eye drops bottles removed from the manufacture's containers were labeled with multiple resident's names were stored together in a plastic bin in one of the drawers in the medication cart. She said that she was not aware that eye drop bottles removed from the manufacture's containers needed to be stored in a container with dividers to prevent cross contamination. During an interview 06/24/26 at 3:00 p.m. the Regional Compliance Nurse said the nurses had been trained to store the eye drop bottles in plastic bins with dividers if the eye bottles had been removed from the original boxes to prevent cross contamination. The state surveyor requested a copy of the facility's policy and procedure on Medication Storage. The facility's policy on Medication Storage was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one treatment cart checked for cross contamination, and for one (South Side) of two Crash Carts reviewed for infection control. -The facility failed to ensure an opened package of 4 x 4 gauze pads was stored in a sealed container in the crash cart on the South Side of the facility. -The facility failed to ensure an opened package of 4 x 4 gauze pads was stored in a sealed container in the treatment cart. These failures could result in increased risk of infection to residents. Findings include: During an observation and interview on 06/24/26 at 10:00 a.m. in the South Side with the DON revealed there was an open paper package of 4 x 4 gauze pads that was not stored in sealed container in the crash cart. The DON said the opened packages of 4 x 4 gauze pads needed to be stored in sealed containers to prevent cross contamination. During an observation and interview on 06/24/26 at 10:37 a.m. with LVN G Wound Care Nurse revealed there was an opened bag of 4 x 4 gauze pads that was opened and stored in a plastic bag that was not sealed in the treatment cart. The Wound Care Nurse said they had been trained to store the opened bags of 4 x 4 gauze pads in sealed containers to prevent cross contamination. Review of facility's undated policy and procedures on Fundamentals of Infection Control Precautions revealed: A variety of Infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions to prevent the transmission of infection: Hand Hygiene, Gloving, Resident care equipment and articles. It is important that practices reflect the most current CDC guidelines.

Based on observation, interview, and record review the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #52 and Resident #88) of 9 residents reviewed for call light placement. The facility failed to ensure call lights were at reach for Residents #52 and #88. This failure could affect residents by not having access to call for assistance resulting in needs not being met. Findings included: Resident #58 Review of Resident #52's face sheet dated 04/17/2025 reflected an [AGE] year-old female with an admitted [DATE] and a re-admitted [DATE] with diagnoses of a fracture of unspecified part of the neck of right femur, pain on right hip, muscle wasting and atrophy, difficulty in walking, unsteadiness on feet, muscle weakness generalized and other lack of coordination. Review of Resident #52's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 indicating a moderate cognitive impairment. Review of Resident #52's Functional Abilities revealed she had limitation in range of motion in upper and lower extremities. It revealed Resident #52 required substantial to maximal assistance with upper body dressing, sit to lying position, sit to stand, chair to bed transfer, toilet transfer and shower transfer. She was dependent for toileting hygiene, shower, lower body dressing and for putting and taking off footwear. Review of Resident #52's Comprehensive Care Plan revised on 11/13/2024 reflected that Resident #52 was at fall risk due to a personal history of falls and a hip fracture related to a fall. The plan called for intervention to anticipate and meet the needs of the resident, ensuring the call light was within reach and for staff to respond promptly to all requests for assistance. In an observation and interview on 04/15/25 at 11:01 AM, Resident #52 was lying in bed watching TV. Her call light was clipped to her bed sheet towards her right side, hanging behind in between the mattress and the headboard and out of her reach of the Resident. When asked if she could reach the call light, she said no. When asked what she would do if she needed help and couldn't reach it, she stated she did not know and would probably wait for a staff member to check on her in her room. Resident #88 Review of Resident #88's face sheet dated 04/16/2025 reflected a [AGE] year-old female with an admitted [DATE] with diagnoses of non-pressure chronic ulcer of back with unspecified severity, pain in unspecified joint, contracture of muscles in multiple sites, muscle wasting and atrophy, unspecified lack of coordination, muscle weakness generalized, unsteadiness on feet and lack of coordination. Review of Resident #88's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 indicating a moderate cognitive impairment. Review of Resident #88's Functional Abilities revealed she had limitation in range of motion in upper and lower extremities. It revealed Resident #88 required substantial to maximal assistance with eating, oral hygiene, upper body dressing and personal hygiene and she was dependent for toileting hygiene, shower, lower body dressing and for putting and taking off footwear. Review of Resident #88's Comprehensive Care Plan revised on 01/02/2025 reflected that Resident #88 was at risk of falls related to Cerebrovascular Accident (medical term for a stroke that occurs when the blood supply to part of the brain sin interrupted depriving brain tissue of oxygen) and required assistance with transfers and bed mobility. The Care Plan stated staff needed to ensure the residents' call light was within reach and to encourage the resident to use it for assistance as needed. In an observation on 04/16/25 at 10:43 AM Resident # 88 voiced to the surveyor that she was in pain, had a bowel movement, felt a burning sensation, and needed assistance from staff. The cable of her call light was located to her left side, clipped to her bed sheet towards the headboard, and the call light was lying between the mattress and the bed rail, out of her reach. Resident #88 stated she had not been able to call for help because she couldn't reach her call light and never knew where it was. The LVN was contacted to assist the resident. In an interview on 04/16/25 at 11:08 AM with CNA A she stated staff went to Resident's to rooms with the call light on to assist and consistently made rounds to ask residents if they needed something. She stated the call lights needed to be within reach of a resident so they could receive assistance, and if a resident couldn't use their call light, their condition could worsen, and they could get desperate. CNA A reviewed the pictures taken at Resident #55 and Resident #88 rooms and stated both call lights were not within the reach of the Residents. In an interview on 04/16/25 at 11:19 AM with LVN B reported that the call light was supposed to be within reach of residents. She noted that Resident #88's call light was not within reach when she went to assist her with a bowel movement, and the resident felt like it was burning. LVN B said rounds were made within 2 hours or as needed to ensure the Resident receive assistance in a timely manner. LVN B added that the risk for a resident not having their call lights within reach could result in them feeling distraught or ignored and if they had a fall and didn't receive assistance, their health could worsen by not receiving help in a timely manner. In an interview on 04/17/25 at 09:25 AM with the Social Worker she stated that call lights needed to be next to the residents and within reach. She mentioned a possible negative outcome of a resident not having a call light within reach could result in them not being assisted in time and could lead to worsening situations and their health. When the Social Worker was shown the pictures of Resident # 55 and Resident # 88 call lights, she agreed both call lights for the residents were not within reach. In an interview on 04/17/25 at 09:52 AM with the Corporate Nurse, she stated that call lights need to be always placed within reach of the residents. She stated that for both Resident # 55 and Resident # 88, the lights were not within reach. She added that staff needed to be making rounds to ensure call lights were within reach and that rounds should be done every two hours or as needed. She said that if a resident couldn't access a call light to request assistance, it could lead to health complications from the resident not being assisted on time. In an interview on 04/17/25 at 11:25 AM with the DON stated that call lights needed to be placed within reach of every resident so they could push the button to receive assistance. The DON noted that for residents who prefer the call light placed elsewhere, the preference needed to be care-planned. Regarding Resident #55 and Resident #88, DON stated the call lights were not within reach of the residents. The DON emphasized that not receiving care they needed in a timely manner and not being able to get assistance from staff were concerns and could possibly lead to health complications or, in the case of a resident fall, the potential negative outcome was they would not receive the assistance they needed in a timely manner. On 04/17/25 at 03:52 PM the DON entered the conference room and stated the facility did not have a specific policy addressing call lights.

Based on observation, interview, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature, for one test tray reviewed. A test tray of the food served at lunch on 04/16/25 on hall revealed the ribs were not hot and at an appetizing temperature. This failure could place residents who ate in their rooms at-risk of poor intake and/or foodborne illness. The findings included: Observation of test tray provided to this surveyor on 04/16/25 at 12:32 PM, revealed temperature reading of lunch entree alternative ribs were 120F degrees. In an interview on 04/17/25 at 3:10 PM with Dietary [NAME] F revealed that hot food temperature readings should be 140F or 150F degrees at time of the resident is served. She stated the purpose for hot foods to be at that temperature was to satisfy the resident as they can become upset being served a cold meal when it was meant to be a warm meal. She stated the risks of hot food being below the required temperature included residents not eating their meals or harm such as illness. In an interview on 04/18/25 at 10:30 AM with the Director of Food and Nutrition revealed that food temperature when served to a resident should be 140F. She stated the food was to come out hot from the kitchen, but it does cool down when being transported in the cart to the resident. She stated the risks to residents of food being served below 140F degrees included the risk for infection or illness. She stated that all kitchen staff were responsible for ensuring food was served hot to the residents of the facility. In an interview on 04/18/25 at 12:45PM with CNA G revealed she was unsure of the required serving temperature per the facility policy, but stated it was to be hot, so the resident was encouraged to eat their meal. She stated the process of passing out meal trays included nurses confirming meal tickets with the tray and they wereare to be passed out to the resident. She stated lids wereare removed from trays when in front of the resident to maintain their temperature. She stated if meal entrees were lower than the required temperature per policy, the risk for the resident could include illness. CNA G stated the responsibility of serving hot food to residents included the CNA's as they helped serve the residents. CNA G stated the kitchen staff were responsible for monitoring meal trays maintaining the required temperature per policy. In an interview on 04/18/25 at 2:45PM with the DON revealed that all hot meal entrees were to be 140F degrees or above. She stated the kitchen staff were responsible to check the temperature of meal entrees at the steamtable and nursing staff were responsible to pass out trays in a timely manner. She stated supervisors or managers from different departments rotate on rounding on meal tray pass to make sure trays were passed out to residents in a timely manner. She stated that nurses were also responsible for ensuring CNA's pass out meal trays to residents in a timely manner. She stated the risk for the resident not being served meals of the required 140F degree temperature included resident dissatisfaction. The DON stated the Director of Food and Nutrition or the Kitchen Supervisor was responsible for monitoring meal temperatures to make sure they were the temperature required per their policy. Record review of the Facility's Dietary Services Policy and Procedure Manual titled Daily Food Temperature Control, dated 2012, revealed in part: We will assure that food is served at a safe temperature. All hot foods shall be cooked and held for service at temperatures of 140 degrees F or above.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. The facility failed to date 04/15/25 and label the contents of the disposable plastic cups that contained syrup located in the fridge in the facility's main kitchen. The facility failed to maintain corn dogs and red onions free from visible freezer burn. The facility failed to maintain the water temperature for 2 of 3 compartment sink per their policy. The facility failed to maintain the kitchen area free from staff personal belongings. The facility failed to cover and seal a meal cart containing the residents' meal trays while transporting them through zone/hallway # 6. These failures could place all residents who received meals from the main kitchen and place them at risk for food borne illness. The findings were: In an observation on 04/15/25 at 07:09 AM during the initial kitchen tour, the fridge located in the main kitchen had disposable plastic cups that contained syrup that was placed in a plastic bin and was sealed with plastic wrapping. The disposable plastic cups were not dated when prepared 04/15/25 or labeled with contents of the container. At 07:14 AM, corn dogs in a ziplock bag sealed and red onion in a plastic container, not sealed, placed in the freezer were observed with freezer burn. In an Observation on 04/15/2025 at 8:00 AM in zone # 6, CNA A was observed delivering meal trays for residents who ate breakfast in their rooms. The food cart containing the meal trays for the residents was observed to be left uncovered at 8:03 AM. Three of the plates in the meal cart were observed to not be properly covered and sealed with the heat-retaining lid. CNA A was observed rolling the uncovered meal cart down the hallway and covering the meal cart at 8:15 AM. CNA A was observed placing dirty meal trays with food leftover from other residents who had already finished their meals on the lower racks of the meal cart in near proximity to undelivered meal trays that were to be served to residents down the hall. CNA A moved the meal cart down the hall and uncovered the meal cart at 8:16 AM and it was left uncovered until the last tray was taken out of the cart and delivered at 8:35 AM. The cart rolled back to the kitchen at 8:38 AM. In an Observation and Interview on 4/16/2025 at 08:15 AM with CNA C, she looked at the food cart and stated it was wrong to place soiled trays in close proximity to the trays with food that had not yet been delivered because there was a risk of cross-contamination. CNA C said the proper procedure was to place the soiled trays with the leftover food in the meal cart until all the food had been delivered to the rest of the residents in the hallway. CNA C said the possible outcome of leaving the cart uncovered for extended periods of time and placing soiled trays near other residents' food could result in cross-contamination potentially leading for residents to get sick, as well as the food for the residents getting cold. CNA C said if the food got cold, the resident might refuse to eat it, potentially leading to weight loss impacting the resident's health. In an observation on 04/17/25 at 10:00 AM, dietary cook used sink to wash kitchen utensils and this surveyor requested for temperature reading. Temperature readings for the Rinse compartment were 110F and the Wash compartment was 95F. In an interview on 04/16/25 at 10:55 AM CNA A stated she had been trained that all trays needed to be covered, and in between each delivery to every room, they needed to open and close the plastic from the carts. CNA A said she believed the bag served the purpose of insulating the cart to keep the resident's food warm and keeping the food free of cross-contamination. CNA A stated that leaving the cart uncovered could lead to cross-contamination and the food getting cold. CNA A said if the residents ate food that had been exposed to cross-contamination, there was a possibility for the residents to get sick. CNA A said she did not know what kind of sickness could result out of cross-contamination. CNA A said if the resident received cold food and refused to eat, she would ask if the resident wanted a substitution and offer it to the resident. CNA A said the potential outcome of a resident constantly refusing to eat a cold meal could result in poor satisfaction and create an uncomfortable environment for the resident In an Interview on 04/16/25 at 11:29 AM with LVN B, she said the cart should not have been left uncovered because there was a risk for infection control and also the food might not hold the correct temperature. LVN B said that if a resident ate a meal contaminated by cross-contamination, it might result in them getting sick or aggravating their condition. LVN B said delivering cold meals to residents could lead to them not feeling satisfied with the services they are provided by the facility. In an Interview on 04/16/25 at 2:26 PM with the Social Worker, she stated the plastic bag needed to be covering the cart all the way down to avoid leaving the resident's meals exposed to cross contamination. The Social Worker explained the reason for covering the cart with the bag all the way down was for infection control purposes. The Social Worker said the bag also served the purpose of keeping the food hot, and if it's left uncovered it could potentially make the resident decline their meal when they received it if it was cold, and if they request another meal, it creates delays on their times to eat, and if they were non-verbal and started refusing to eat, it could lead to weight loss and maybe sickness. The Social Worker stated that by leaving the meal cart uncovered, it could potentially result in cross-contamination and making the residents sick or worsening a pre-existing health condition. In an Interview on 04/16/25 at 2:58 PM with the Corporate Nurse, she stated the plastic bag covering the meal carts was to keep the food retaining their temperature and for infection prevention control. She stated that the plates were covered and that should help retain the food temperature, and the bag acted as a second barrier to prevent infection and to have the food retain the heat. She stated that those plates that were not covered and sealed correctly with the heat retaining lid could potentially be contaminated and make the residents sick, and by not covering the cart with the plastic bag in between distribution, it could lead for the rest of the trays getting contaminated and the food not retaining their temperature. In an interview on 04/17/2025 at 11:18 AM with the DON said the purpose of the plastic bags were to keep the meal trays covered for infection control as a second protection and also to keep the food warm. The DON stated that the food in the meal cart was exposed because it was not properly covered by the heat retaining lids nor by the plastic cover. The DON said the potential outcome for not covering the meal carts could result in the residents receiving contaminated food and getting sick depending on what gets to the food. The DON noted the potential outcome for serving food that was cold for a resident was that they were not satisfied. In an interview on 04/17/25 at 3:14 PM with Dietary [NAME] F revealed the process of preparing individual packets included dating them. She stated kitchen staff were to date individual packages of food to ensure they were not to be used after expiration timeframe. She stated if any food items were not observed with a date, kitchen staff was to dispose of it as it was not confirmed when it was packaged or received by kitchen staff. She stated the risks of not dating food items in the kitchen included illness caused by bacteria. She stated all kitchen staff wereare responsible for ensuring all food items were dated and labeled. In an interview on 04/18/25 at 10:33 AM with the Director of Food and Nutrition revealed that the plastic seal on the container with individually packed syrups were to be labeled and dated. She stated the protocol for food preparation and packaging included for kitchen staff to date it after preparing it. She stated this was to prevent disposing of unlabeled food items. She stated all kitchen staff were responsible for monitoring food items that were labeled on a daily basis. She stated she was also responsible, and she reviewed food items every 13 days to confirm they were dated and labeled. She stated she did not there wasis not a lot of risk for the residents as the unlabeled food item was syrup. In an interview on 04/17/25 at 3:16 PM with Dietary [NAME] F revealed kitchen staff were responsible for confirming food in the freezer was sealed properly and dated. She stated the red onions in their original container were not sealed correctly and should have been placed in another plastic Ziplock bag. She stated the red onions, and the corn dogs had visible freezer burn and should be disposed of. She stated the purpose of sealed food items in the freezer was to prevent the food from hitting the air which can cause a risk for bacteria and illnesses for the residents. Dietary [NAME] G stated the Director of Food and Nutrition was responsible for monitoring all food items in the freezer are properly sealed. In an interview on 04/18/25 at 10:35 AM with the Director of Food and Nutrition revealed that the kitchen staff were to repackage food in a Ziplock bag as it cannot be resealed in its' original packaging. She stated the red onion and corn dogs were not to be used because of the visible freezer burn and was contaminated. She stated the risks for residents eating food with freezer burn or were not sealed properly can cause illness as it is contaminated by bacteria. She stated the residents could have possibly experienced diarrhea, or vomiting. She stated the responsibility was the kitchen staff and they were to monitor food items being properly sealed or not contaminated on a daily basis. In an interview on 04/17/25 at 3:18 PM with Dietary [NAME] F revealed that the water temperature of the three compartments sink varied depending on the compartment. She stated the purpose of the water temperature maintenance per their policy was to ensure the dishes were properly cleaned. She stated the risks for residents being served on dishes not properly washed or sanitized included cross contamination which could cause illness. She stated the responsibility belonged to all kitchen staff. In an interview on 04/18/25 at 10:40 AM with the Director of Food and Nutrition revealed the water temperature of the three-compartment sink should be hot or per the facility policy. She stated if temperatures were not per policy, the kitchen staff were to drain and fill it as necessary. She stated the kitchen staff using the sink at that time were responsible for confirming temperatures reflected per the facility policy. She stated the risks for residents of having lower water temperatures for the three-compartment sink included infections or illness, including symptoms such as diarrhea. She stated she was also responsible for confirming kitchen staff washing and sanitizing dishes per their policy. In an interview on 04/17/25 at 3:22 PM with Dietary [NAME] F revealed that there were no designated areas for personal belongings in the kitchen. She stated the water bottles, and the chocolate were in fact staff personal belongings, and they should not be there behind the mixer. She stated it was a cross-contamination issue as it was items coming from outside the facility. She stated the risk for the residents being served food from a kitchen with staff personal belongings including illness. She stated all kitchen staff were responsible for making sure the kitchen was free from staff personal belongings, and the Director of Food and Nutrition was responsible for monitoring that kitchen staff comply. In an interview on 04/18/25 at 10:49 AM with the Director of Food and Nutrition revealed there should not be any staff personal belongings in the kitchen. She stated personal belongings in the kitchen can pose a risk to residents by exposing them to outside items as it was a cross-contamination issue. She stated the risk of personal belongings in a kitchen was infection or illness for residents. In an interview on 04/18/25 at 02:50 PM with the DON revealed that their staff were not to have their personal belongings in the kitchen. The DON stated all personal items were to be kept out of the kitchen preparatory area because food was being handled to be served to the resident, and it posed as a risk for contamination. She stated possible risk included residents becoming ill. She stated that all kitchen staff were responsible for ensuring they placed their personal belongings outside of the kitchen preparation area. The DON stated the Director of Food and Nutrition was responsible for monitoring the kitchen for staff personal belongings. Record review of the Facility's Dietary Policy and Procedure Manual titled Food Storage and Supplies, dated 2012, revealed in part: Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened. These non-perishable foods are still dated when received if they do not have an expiration date and once opened, but do not need to be discarded within 7 days after opening. Perishable items that are refrigerated are dated once opened and used within 7 days. The policy did not address freezer burn on food items. Record Review of sign posted above the three-compartment sink labeled Three-Compartment Sink Procedures, no date, revealed in part: the Rinse Compartment Sink was to 120F +, and the Wash compartment sink was to be 110F +. Record review of the Facility's Dietary Policy and Procedure Manual titled Dietary Food Service Personnel Policy and Procedures, dated 2012, revealed in part: All personal belongings must be kept out of the food preparation area. Record Review of the Facility's Policy and Procedures Manual titled Nursing Responsibilities at Meal Service, dated 2012 stated in part: Trays will be passed in a timely manner. Food must remain covered while being distributed through the hallways. Pick up food trays from resident rooms and return them to the Dietary department. Soiled trays cannot be placed in food carts with undelivered trays. All food transferred to resident rooms will be covered. The eating surface of utensils will be covered.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date for one of three medications carts reviewed. - The high north hall nurse's cart had a smeared (illegible) dated insulin pen for Resident # 58 This failure could place residents at risk for harm by receiving ineffective insulin therapy. Finding included: Review of Resident 58's face sheet dated [DATE] revealed a [AGE] year-old male with an original admitted [DATE] and a readmitted [DATE]. Review of Resident #58's medical diagnoses revealed Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema unspecified eye. Review of Resident #58's quarterly MDS assessment dated [DATE] revealed a BIMS score of 07, indicating severe cognitive impairment. Review of Resident #58's Care Plan dated [DATE] revealed resident has Diabetes Mellitus and was at risk for hyper/hypoglycemia (high/low blood sugar). Record review of Resident #58's physician orders reflected the following order: NovoLOG Injection Solution 100 UNIT/ML (Insulin Aspart) Inject 3 unit subcutaneously three times a day for DM related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA. In an observation on [DATE] at 10:07 AM, while checking the north high side hall nurse's cart with LVN D, revealed a smeared (illegible) insulin pen date for Resident # 58. In an interview with LVN D on [DATE] at 10:07 AM revealed that all insulin pens were dated upon opening. She stated that the date was placed on the barrel of the pen, avoiding the plastic label portion of the pen because it could smear, preferably it should be dated on the paper label. In an interview with LVN E on [DATE] at 1:24 pm revealed that insulin pens should be dated as soon as they were opened for first use. Nurses were responsible to make sure that all pens were dated and to ensure that all dates were legible and not smeared off. A negative outcome for the resident would be using an old pen that was out of the range of the 28 days. In an interview with LVN B on [DATE] at 1:50 pm revealed that the insulin pens were dated as soon as they were opened, the date could be placed on the barrel but preferably on the paper tag to prevent smearing. She stated that all nurses were responsible to make sure all dates were printed clearly on the insulin pen. A negative outcome of an illegible date would be not knowing how long ago it was opened thus leading to medication being less effective. In an interview with the DON on [DATE] at 3:03 pm revealed that insulin pens were dated when opened, the date was placed on the label or on the barrel of the pen. She stated that the date was supposed to be placed on a spot where it would not smudge off. She stated that it was every nurse's responsibility to make sure pens were dated. A smudged off date could lead to medication being expired because it was unclear when it was opened, and medication could be less effective. Review of facility's policy titled Recommended Medication Storage revised in [DATE] revealed, Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened.

Based on interviews and record review, the facility failed to maintain medical records that were complete and accurately documented for 5 (Resident #1, #2, #3, #4, and #5) of 5 residents reviewed for accurate medical records. 1. The facility failed to ensure LVN ADON C signed the Initial Skin Assessment when completed for Resident #1 on [DATE]. 2. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #2 on [DATE]. 3. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #3 on [DATE]. 4. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #4 on [DATE]. 5. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #5 on [DATE]. This failure could place residents at risk for misinformation about professional care provided. Findings included: Resident #1 Closed record review Admission Record dated [DATE] at 11:45 PM for Resident #1 revealed original admitted [DATE]. Resident #1 expired at nursing facility on [DATE] at 3:00 PM. Review of New Admission History and Physical dated [DATE] at 9:39 AM for Resident #1, revealed [AGE] year-old male with past medical history of hypertension, hyperlipidemia, coronary artery disease (a disease in which there is narrowing or blockage of the coronary artery) with history of Myocardial infarction (heart attack), diabetes mellitus type 2, GERD, BPH, obstructive sleep apnea, dementia, insomnia, hallucinations, anxiety, depression, bipolar disorder, acute respiratory failure (serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues) , pneumonia, metabolic encephalopathy (is a problem in the brain caused by chemical imbalance in the blood caused by an illness or organs that are not working as well as they should), stroke, rectal bleeding, and vertigo (is a sensation of motion or spinning that is often described as dizziness). Review of Admission Minimum Data Set (MDS) assessment (is a standardized assessment tool that measures health status in nursing home residents) dated [DATE] for Resident #1 revealed hearing adequate; clear speech ; understood; understands; vision adequate; BIMS Score 7 cognitively severely impaired; functional status - requires extensive assistance of two persons with bed mobility, transfer, and toilet use; extensive assistance of one person with locomotion on and off unit, dressing, and personal hygiene; supervision with eating; total assistance of one person with bathing; wheelchair; incontinent of bowel & bladder; Review of Care Plan for Resident #1 revealed, Resident is a diabetic initiated [DATE]. Resident required antipsychotic/antianxiety/antidepressant medication initiated [DATE]. Resident incontinent of bladder initiated [DATE]. Resident was on thickened liquids initiated [DATE]. Resident has a bruise initiated [DATE]. Impaired cognitive function r/t dementia. At risk for altered respiratory status r/t pneumonia. Self-Care deficit r/t muscle weakness. Undated Care Plan revealed resident #1 has stage IV pressure ulcer to coccyx. At risk for falls r/t poor safety awareness; resident is incontinent of bowel and bladder. Review of Care Plan Conference Form, for Resident #1 revealed Effective Date: [DATE] at 4:39 PM. Care Plan Conference Form was signed [DATE] by social worker. Review of Initial Skin Assessment Form dated [DATE] at 6:00 PM, for Resident #1 revealed form was not signed or dated. In an interview on [DATE] at 10:17 AM, with LVN ADON C revealed she had completed the Skin Assessment Form dated [DATE] at 6:00 PM, for Resident #1 and could not remember why she had not signed the assessment form. LVN ADON E stated she had been trained to sign the resident assessment form in the computer on the date that the assessment was completed . LVN ADON C reported DON and ADON are responsible for checking that assessment forms are signed and dated by licensed staff when assessments are completed to ensure electronic records are accurate, and complete. Resident #2 Review of Admission Record dated [DATE] at 12:31 PM for Resident #2 revealed original admitted [DATE] and re-admitted [DATE]. Review of New Admission History and Physical dated [DATE] at 9:11 AM, for Resident #2 revealed [AGE] year-old male with past medical history of BPH, chronic kidney disease, dysphagia (swallowing difficulties), diabetes mellitus type 2, UTI, atherosclerotic heart disease, hypertension, gastritis, moderate protein malnutrition, cardiac pacemaker, thrombocytopenia (a condition that occurs when the platelet count in the blood is too low) , Left heel wound, left foot amputation of 4th and 5th toes, and coccyx stage III. Review of Quarterly Minimum Data Set (MDS) dated [DATE], for Resident #2 revealed hearing adequate; clear speech; understood; understands; vision adequate; BIMS Score 9 cognitive moderately impaired; wheelchair; Functional Ability: eating partial/moderate assistance; oral hygiene partial/moderate assistance; toileting hygiene partial/moderate assistance; shower partial/moderate assistance ; upper body dressing supervision; lower body dressing partial/moderate assistance; personal hygiene partial/moderate assistance; roll left and right supervision; Review of undated Care Plan for Resident #2 revealed Pacemaker r/t Atrial Fibrillation ; (an irregular heartbeat that occurs when the electrical signals in the atria (the two upper chambers of the heart) fire rapidly at the same time. This causes the heart to beat faster than normal.) Resident has hypertension; Resident has Diabetes Mellitus; Resident has renal failure r/t chronic kidney disease; Resident is on anticoagulant therapy; Resident has gastritis; Resident has diabetic ulcer right and left foot r/t diabetes; Self-Care deficit r/t muscle weakness. Record review Care Plan Conference Form for Resident #2 revealed effective Date: [DATE] at 11:53 AM. Care Plan Conference Form was signed [DATE] by social worker. Resident #3 Review of Admission Record dated [DATE] at 9:59 AM, for Resident #3 revealed original admitted [DATE] and readmitted on [DATE]. Record review of Annual History and Physical dated [DATE] at 9:22 AM, for Resident #3 revealed [AGE] year-old female with past medical history of anemia, cardiac arrest, diabetes mellitus type 2, hypertension, osteoarthritis , major depressive disorder, dementia w/o behaviors, vitamin D deficiency, vitamin B 12 deficiency, dysphagia , constipation, hyperlipidemia, osteoporosis (a bone disease that develops when bone material density and bone mass decreases, or when the structure and strength of bone changes.), and abnormalities with gait and mobility. Record review of Resident #3's Reentry Minimum Data Set (MDS) dated [DATE] revealed hearing adequate; clear speech; understood; usually understands; vision adequate; BIMS Score cognitive severely impaired; wheelchair; Functional Ability: eating supervision; oral hygiene partial/moderate assistance; toileting dependent; shower dependent; upper body dressing substantial/maximal assistance; lower body dressing dependent; personal hygiene substantial/maximal assistance; Record review of Care Plan for Resident #3 revealed Risk for skin impairment r/t incontinence revised on [DATE]; impaired decision-making r/t dementia revised [DATE]; risk for fall r/t unaware of safety needs, confusion, requires physical assistance with bed mobility and transfers revised [DATE]; able to self-proper in wheelchair revised [DATE]; impaired vision r/t cataracts revised [DATE]; communication problem r/t unclear speech revised [DATE]; Risk for altered mood problem r/t was found in male room in bed with male resident revised [DATE].; Record review Care Plan Conference Form for Resident #3 revealed effective Date: [DATE] at 11:53 AM. Care Plan Conference Form was signed [DATE] by social worker. Resident #4 Review of Admission Record dated [DATE] at 11:04 AM, for Resident #4 revealed original admitted [DATE]. Record review Annual History and Physical dated [DATE] at 9:07 AM, of Resident #4 revealed [AGE] year-old male with past medical history dementia without behavioral disturbances, diabetes mellitus type II, hypertension, Peripheral Vascular Disease (the reduced circulation of blood to a body part other than the brain or heart), chronic kidney disease stage III, osteoarthritis, major depression, BPH, vitamin D deficiency. Alert oriented X 1. He is pleasant and cooperative. Record review of Quarterly Minimum Data Set (MDS) dated [DATE], for Resident #4 revealed hearing adequate; clear speech; understood; understands; vision adequate; BIMS Score 4 cognitive severely impaired; Functional Ability: eating independent; oral hygiene setup or clean-up assistance; toileting hygiene independent; shower supervision; upper and lower body dressing independent; personal hygiene independent. Record review of Care Plan for Resident #4 revealed Diabetes Mellitus revised on [DATE]. Resident has potential to demonstrate verbally abusive behaviors. He talks ugly to the employees and makes false accusations revised [DATE]. Record review Care Plan Conference Form for Resident #4 revealed effective Date: [DATE] at 10:10 AM. Care Plan Conference Form was signed [DATE] by social worker. Resident #5 Review of Admission Record dated [DATE] at 12:39 PM, for Resident #5 revealed original admitted [DATE] and readmitted [DATE]. Record review of Annual History and Physical dated [DATE] at 9:48 AM, for Resident #5 revealed [AGE] year-old male with past medical history of respiratory failure (a condition that makes it difficult to breather on your own), vitamin D deficiency, hypertension, neuromuscular dysfunction (affect the function of muscles due to problems with the nerves and muscles in your body), benign prostatic hyperplasia (overgrowth of prostate tissue pushes against the urethra and the bladder , blocking the flow of urine), retention of urine, paraplegia (paralysis that affects your legs, but not your arms), amputation of left leg above the knee, GERD (gastroesophageal reflux disease). Resident has a suprapubic catheter (the placement of a drainage tube into the urinary bladder just above the pubic symphysis). He is oxygen dependent. He also has a history of behavior episodes. Baseline dementia. Plan: Turn every 2 hours while in bed. Wound care evaluates and treat. Review of Quarterly Minimum Data Set (MDS) dated [DATE], for Resident #5 revealed hearing adequate; clear speech; understood; understands; vision impaired; BIMS Score 13 cognitively intact; Behavior-verbal behavioral symptoms directed at others (e.g., screaming at others, cursing at others) occurred 1 to 3 days; Rejection of Care-occurred 1 to 3 days; functional limitation of range of motion impairment on one side to lower extremity; wheelchair; Functional Ability: eating setup or clean-up assistance; oral hygiene partial/moderate assistance; toileting hygiene substantial/maximal assistance; shower substantial/maximal assistance; upper and lower body dressing substantial/maximal assistance; personal hygiene partial/moderate assistance; Review of Care Plan for Resident #5 revealed has stage IV pressure ulcer right lateral foot revised on [DATE]. Interventions: administer treatment as ordered and monitor for effectiveness. Replace loose or missing dressing PRN to right lateral foot stage IV pressure injury. Cleanse with wound cleanser, pat dry, apply TheraHoney gel (is used on wounds to provide moist wound healing environment and helps rapidly reduce wound odor), cover with bordered island dressing and change every M-W-F. Air mattress in place. Record review of Care Plan Conference Form dated [DATE] for Resident #5 revealed Social Worker had had only provided the state surveyor page 1 of document on [DATE]. In an interview and record review on [DATE] at 1:00 PM, with the DON revealed the Social Worker had not provided the state surveyor page 2 of the Care Plan Conference Form dated [DATE] for Resident #5. The DON provided the state surveyor page 2 of Care Plan Conference Form dated [DATE] for Resident #5. The DON confirmed the Care Plan Conference Form documented Effective Date: [DATE] at 11:39 AM and was signed by the Social Worker on [DATE]. The DON stated, I don't know why the form is dated [DATE], if the form was completed on [DATE]. Sometimes the staff will complete the forms and sign the forms later. The computer will stamp date the form when the form is signed. DON stated the staff should sign the electronic forms on the date that the forms are completed . DON reported that she and the ADON were responsible for checking that all documents in the clinical electronic records were signed by the staff on the date that the forms were completed to ensure records were accurate and complete. In an interview and record review on [DATE] at 1:20 PM, with the Social Worker confirmed she had completed the Care Plan Conference Form for Resident #5 on [DATE] and had signed the form on [DATE]. The Social Worker reported that she sometimes signs the forms later. The Social Worker stated that she was not aware if there was a facility policy that stated forms completed in the resident's electronic medical record needed to be signed on the date that the forms were completed . Review of facility policy on Documentation revised [DATE], provided by DON revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It has legal requirements regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medications sheets, incident reports, and summary sheet (daily, weekly, monthly, discharge.) Documentation also occurs in the electronic clinical software. Goal: 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed. Procedure: Place all required and appropriate signed forms in the clinical record. Document completed assessments in a timely manner and per policy. Each entry will be dated and timed. Each entry will be signed with proper signature and title. If electronic clinical record is used for the assessment the signature and title of the person entering the information will be signed by entering their password. In computerized documentation is used, safeguards and controls to protect the data from changes should be present; each authorized person must have a personal identifier and electronic signature based on qualifications to access and enter data.

Based on observations, record review, and interviews, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #5) of 5 residents reviewed for quality of care. The facility failed on 03/29/2024 to ensure the pressure ulcer on Resident #5's right lateral foot was covered with a dressing as ordered. This failure could result in increased pain, infections, development of new pressure ulcers, and decline in quality of life for residents. Findings included: Review of Admission Record dated 03/29/24 at 12:39 PM, for Resident #5 revealed initial admitted d 11/02/2016 and re-admitted [DATE]. Record review of Annual History and Physical dated 07/20/2023 at 9:48 AM, for Resident #5 revealed [AGE] year-old male with past medical history of respiratory failure (a condition that makes it difficult to breathe on your own), vitamin D deficiency, hypertension, neuromuscular dysfunction (affect the function of muscles due to problems with the nerves and muscles in your body), benign prostatic hyperplasia (overgrowth of prostate tissue pushes against the urethra and the bladder , blocking the flow of urine), retention of urine, paraplegia (paralysis that affects your legs, but not your arms), amputation of left leg above the knee, and GERD (gastroesophageal reflux disease). Resident has a suprapubic catheter (the placement of a drainage tube into the urinary bladder just above the pubic symphysis). He was oxygen dependent. He also had a history of behavior episodes. Baseline dementia. Plan: Turn every 2 hours while in bed. Wound care evaluates and treat. Review of Quarterly Minimum Data Set (MDS) dated [DATE], for Resident #5 clear speech; understood; understands; BIMS Score 13 cognitively intact; Behavior-verbal behavioral symptoms directed at others (e.g., screaming at others, cursing at others) occurred 1 to 3 days; Rejection of Care-occurred 1 to 3 days; functional limitation of range of motion impairment on one side to lower extremity; wheelchair; Functional Ability: eating setup or clean-up assistance; oral hygiene partial/moderate assistance; toileting hygiene substantial/maximal assistance; shower substantial/maximal assistance; upper and lower body dressing substantial/maximal assistance; personal hygiene partial/moderate assistance; indwelling catheter; always incontinent of bowel; resident has a pressure ulcer; risk for development of pressure ulcer; 1 stage IV pressure ulcer; pressure reducing device for bed; antibiotic; Review of Care Plan revised on 01/19/2024, for Resident #5 revealed stage IV pressure ulcer right lateral foot. Revisions on: 01/08/2024. Interventions: Administer treatment as ordered and monitor for effectiveness. Replace loose or missing dressing PRN to right lateral foot stage IV pressure injury. Cleanse with wound cleanser, pat dry, apply TheraHoney gel (used on wounds to provide moist wound healing environment and helps rapidly reduce wound odor), cover with bordered island dressing, and change every M-W-F. Air mattress in place. Review of Physician Order Summary Report dated 03/29/24 at 12:39 PM, for Resident #5 revealed Consult with wound care physician to evaluate and treat wounds as needed. Stage IV pressure injury to the right lateral foot. Cleanse with wound cleanser, pat dry, apply TheraHoney gel, protect with bordered island dressing, and change every M-W-F. Wound care to evaluate and treat as warranted. Review of Medication Administration Record (MAR) dated March 2024, for Resident #5 revealed Stage IV pressure ulcer to right lateral foot: cleanse with wound cleanser, pat dry, apply TheraHoney gel, protect with bordered island dressing, and change every M-W-F. Record review of Wound Evaluation & Management Summary dated 03/25/24, for Resident #5 signed by wound care physician revealed Chief Complaint: Wound on his right lateral foot. Focused Wound Exam: Pressure Stage 4 0.2 x 0.2 x 0.1 cm. Plan of Care Reviewed and addressed: Dressing Treatment Plan: Leptosperum honey (Medihoney) apply three times per week for 23 days. Gauze island with border apply three times per week for 23 days. Observation 03/29/24 at 12:41 PM, with Wound Care Nurse A, revealed Resident #5 was lying in bed on his side. Resident was alert and oriented of person, place, and time. It was observed resident had an air mattress, sheets were clean, and dry. Resident #5 had an amputation of the left lower extremity above the knee, right lower extremity was constructed at the knee, and: stage IV pressure ulcer on the right lateral foot. It was observed Resident #5 did not have a wound dressing on right lateral foot. Wound Care Nurse A stated, Resident #5 should have a Bordered Island dressing on stage IV pressure ulcer on the right lateral foot as ordered by wound care physician. Wound Care Nurse B that works on the weekends is doing treatments today, and I do not know if the treatment has been done today . An observation and interview on 03/29/24 at 12:51 PM, the Wound Care Nurse A and LVN ADON C revealed Resident #5 had a stage IV pressure ulcer on right lateral foot and did not have a dressing on the wound. LVN ADON C stated, The weekend Wound Care Nurse B is doing treatments today and I will let her know that she needs to do the treatment on Resident #5's right lateral foot. The weekend Wound Care Nurse B is still in training, so she had not done the treatment yet for Resident #5. LVN ADON C and Wound Care Nurse A reported CNAs had been trained to immediately report to the charge nurses when the residents do not have the wound dressing in place to prevent injury to wound and/or infection. The Wound Care Nurse A stated, The CNAs usually are good about reporting this to the charge nurses. I will check and see if they reported this to his charge nurse . In an interview on 03/29/24 at 1:00 PM, Weekend Wound Care Nurse B reported she was covering for LVN Wound Care Nurse A today. She stated she was doing treatments and still had not done the treatment for Resident #5. Wound Care Nurse B stated, The CNAs have been trained to immediately report to the charge nurses when the residents do not have the dressings to the wounds to prevent injury and/or infection to the wound. In an interview on 03/29/24 at 1:12 PM, the DON reported CNAs had been trained to immediately report to the charge nurses when the residents do not have the dressings to the wounds, to prevent injury to wound and/or infection. The DON stated The ADONs just started re-training the staff today on immediately reporting to the nurses if the residents do not have the wound dressing in place to prevent injury and/or infection to the wound. In an interview on 03/29/24 at 1:12 PM, LVN Charge Nurse D reported CNAs had been trained to immediately report to the charge nurses when the residents did not have the dressings on the wounds, to prevent injury to wound and/or infection. In an interview on 04/01/24 at 12:59 PM, CNA E reported she had been assigned to Resident #5 on Friday March 29, 2024, on the 6:00 AM - 2:00 PM shift. CNA E stated Resident #5 has a pressure ulcer on the right lateral foot. On that day, I noted Resident #5 did not have the dressing on the pressure ulcer on the right outer foot. I was going to report it to the charge nurse, but I got busy with another resident and forgot to report it to the charge nurse. I re-checked Resident #5 at 7:00 AM but did not notice if the dressing was in place on the right lateral foot, because I did not lift the sheet to check the resident. Resident #5 did not allow me to check him for incontinence. It was just before lunch when I went to check Resident #5 for incontinence and that is when I noted the wound dressing to the right lateral foot was still not in place. We have been trained to immediately report to the charge nurses when the residents do not have the dressings to the wounds, to prevent injury to the wound and/or infection. In an interview on 04/01/24 at 3:01 PM, Medication Aide F revealed CNAs and Med Aides had been trained to immediately report to the charge nurses when the residents do not have the dressings to the wounds, to prevent injury and/or infection. In a telephone interview on 04/02/24 at 12:14 PM, with Hospice CNA revealed Resident #5 had refused to shower on Thursday 03/28/24. Hospice CNA stated, I did not notice if Resident #5 had a wound dressing to the right lateral foot because he did not allow me to change his brief, so I did not pull the sheets down. Resident #5 became very angry when I attempted to pull the sheet down and started to cuss and yell at me. He kept asking me why I came every day to try to care for him. He stated, he could do whatever the Fuck he wanted. I reported the refusal of care to the LVN assigned to the resident. Record review of facility's policy on Pressure Injury: Prevention, Assessment and Treatment revised 08/12/16 revealed 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.

Based on interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and the facility failed to ensure the baseline care plan was developed within 48 hours of a resident's admission for 2 of 8 residents (Resident #294 and Resident # 241) reviewed for baseline care plans. The facility failed to ensure Resident #294 had a baseline care plan that addressed her fracture of left femur (longest, strongest, thigh bone), pain management, wound care for surgical wound, Type 2 Diabetes Mellitus, Hypertension (high blood pressure), and Malignant neoplasm of lung (lung cancer). The facility failed to ensure Resident #241 had a baseline care plan that addressed his use of a feeding tube. This failure could place residents at risk of not receiving needed care and services or continuity of care. Findings include: Record review of Resident #294's face sheet, dated 02/08/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included fracture of left femur, Type 2 Diabetes Mellitus, Hypertension, and Malignant neoplasm of lung. Review of Resident #294's MDS section dated 02/05/24 showed her admission MDS was not completed yet. Review of Resident #294's Order Summary Report, dated 02/02/24, revealed orders: Fracture left femur with routine healing; Physical Therapy /Occupational Therapy /Speech Therapy and wound care to evaluate and treat as warranted. Baclofen Oral Tablet, give 10 mg by mouth three times a day for Pain. Acetaminophen Tablet, give 650 mg by mouth every 6 hours for Pain. Lantus SoloStar Subcutaneous Solution Pen-injector, Inject 20 unit subcutaneously one time a day for Diabetes Mellitus. Metformin Oral Tablet 850 MG, Give 1 tablet by mouth two times a day for Diabetes Mellitus. Review of Resident #294's care plan dated 02/06/24 showed no care plan for fracture of left femur, pain management, wound care for surgical wound or Type 2 Diabetes Mellitus. Record review of Resident #241's face sheet, dated 2/8/2024 revealed he was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. Record review of Resident #241's electronic census listing revealed he was discharged on [DATE] and readmitted on [DATE]. Review of Resident #241's electronic diagnosis listing accessed 02/08/2024 revealed he had diagnoses including dysphagia (problems with swallowing). Review of Resident #241's MDS assessment (discharge - return anticipated) dated 01/22/2024 revealed he was unable to participate in an interview to determine his cognitive status. Staff assessed him as having problems with short-term memory and severely impaired cognitive skills for daily decision making. He required assistance with setup for eating, and moderate assistance with oral hygiene, toileting, upper body dressing and personal hygiene. He required maximal assistance with showering, lower body dressing and putting on/taking off footwear. He had not had a significant weight loss over the past month. He was receiving a mechanically altered therapeutic diet. Review of Resident #241's order dated 02/01/2024 revealed he was to receive 60 ml of FiberSource HN (tube feeding formula) per hour with 250 ml of water every shift. His order dated 02/01/2024 revealed his g-tube site (where the feeding tube enters the body) was to be cleaned every shift. Record review of Resident #241's History and Physical dated 02/06/2024 for admission 02/01/2024 revealed that during his admission to a local hospital beginning on 01/22/2024 he underwent a PEG tube (a feeding tube into the stomach to deliver nutritional liquid) placement. Review of Resident #241's entire care plan with a last review date of 01/19/2024 revealed no active care plan addressing the care of his feeding tube or care related to him receiving his nutrition and hydration though a feeding tube. In an interview on 02/08/24 at 10:38 AM the MDS LVN revealed that when a resident was discharged to the hospital and returned, the old care plan should be locked, and a new care plan started. She said that Resident #241's care plan should have been locked and restarted to include his use of a feeding tube for nutrition. Interview on 02/08/24 at 10:55 AM DON stated that the admitting nurse should add baseline care plan based on the resident's diagnosis at the time of admission for all newly admitted residents. The residents record shows that the baseline care plan only includes resident wishes to be discharged to her home, resident needs in room socialization and sensory stimulation, and has an order for do not resuscitate. DON stated that when the facility admits a new resident, the admitting nurse is responsible for creating the baseline care plan. Unfortunately, the admitting nurse had several admissions that day and it was overlooked. The ADON is responsible for auditing all new admissions and she probably missed it as well. Interview on 02/08/24 at 09:26 AM with MDS nurse stated that nursing department is responsible for the baseline care plan. MDS nurse stated that the admitting nurse should initiate the baseline care plan within 48 hours and it should include diagnosis, medications, and referrals. Record review of the facility's Baseline Care Plans policy, undated, revealed: Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission, and to ensure resident is informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will: - be developed within 48 hours of a resident admission. - include the minimum healthcare information necessary to properly care for a resident, including but not limited to: *Initial goals based on admission orders. *Physician orders. *Dietary orders. *Therapy services. *Social services. *PASARR recommendations. The baseline care plan will reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It will be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident. Facility staff will implement the interventions to assist the resident to achieve care plan goals and objectives.

Based on observation, interview and record review the facility failed to ensure that residents who receive enteral nutrition received treatment to prevent complications of enteral feeding for one (Resident #241) of six residents reviewed for tube feeding. Resident #241 was receiving hydration through a g-tube (a tube into the stomach for nutrition and liquids) from a plastic bag which had been labeled using a marking pen. This failure could place residents who receive liquids through a g-tube at increased risk of having marking pen chemicals in the liquid. Findings included: Record review of Resident #241's face sheet, dated 2/8/2024 revealed he was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. Record review of Resident #241 ' s electronic census listing revealed he was discharged on [DATE] and readmitted on [DATE]. Review of Resident #241 ' s electronic diagnoses listing accessed 02/08/2024 revealed he had diagnoses including dysphagia (problems with swallowing). Review of Resident #241's MDS assessment (discharge - return anticipated) dated 01/22/2024 revealed he was unable to participate in an interview to determine his cognitive status. Staff assessed him as having problems with short-term memory and severely impaired cognitive skills for daily decision making. He required assistance with setup for eating, and moderate assistance with oral hygiene, toileting, upper body dressing and personal hygiene. He required maximal assistance with showering, lower body dressing and putting on/taking off footwear. He had not had a significant weight loss over the past month. He was receiving a mechanically altered therapeutic diet. Review of Resident #241's order dated 02/01/2024 revealed he was to receive 60 ml of FiberSource HN (tube feeding formula) per hour with 250 ml of water every shift. His order dated 02/01/2024 revealed his g-tube site (where the feeding tube enters the body) was to be cleaned every shift. Record review of Resident #241 ' s History and Physical dated 02/06/2024 for admission 02/01/2024 revealed that during his admission to a local hospital beginning on 01/22/2024 he underwent a PEG tube (a feeding tube into the stomach to deliver nutritional liquid) placement. Observation on 02/06/2023 at 3:37 PM of the water bag attached to Resident #241 ' s feeding pump had been written on with a marking pen. In an interview on 02/06/2024 at 03:44 PM LVN D revealed that the rate of flow for the water for Resident #241 ' s tube feedings had been written on the water bag with a marking pen. She said a marking pen should not be used to write directly on the water bag because the ink could leach through into the water. In an interview on 02/08/24 at 7:41 AM the DON revealed some tube feeding water bags should not be written on with a marker because it could go through the plastic into the water. The DON stated she was not sure which bags this would apply to and would need to check on it. The DON did not provide any additional information regarding Resident #241 ' s water bag prior to exit. Record review of the facility policy Gastrostomy Tube Care dated 02/13/2007 revealed that the formula and/or feedings should be labeled but did not outline what types of labels were to be used. Record review of the facility policy Hydration dated 10/05/2016 revealed that the facility was to provide each resident with sufficient fluid intake but did not address hydration for residents receiving tube feeding.

Based on observations, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 2 residents (Residents #27) by 1 of 3 certified staff (CNA A) reviewed for competent staff, in that: CNA A failed to change his gloves once they became contaminated during incontinent care for Resident #27. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection. The findings were: Record review of Resident #27s admission record dated 02/06/2024 indicated she was admitted to the facility on [DATE] with diagnoses of dementia, muscle wasting and atrophy (waste away). She was [AGE] years of age. Record review of Resident #27's care plan revised date 10/19/21 indicated in part: Focus: The resident has bladder incontinence r/t related to) Alzheimer's Disease and Dementia. The resident has bowel incontinence r/t Alzheimer's Disease and Dementia. Goals: The resident will not have any complications r/t incontinence. Interventions: Provide pericare after each incontinent episode. Record review of Resident #27's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. Urinary and Bowel continence = Always incontinent. During an observation on 02/06/24 at 09:34 AM CNA A performed incontinent care for Resident #27. CNA A sanitized his hands and then put some gloves on. CNA A then undid the resident's brief and it was noted to be wet with urine. The CNA wiped the resident's vaginal and rectal area with some wet wipes. Resident #27 had urinated and had a bowel movement. After the CNA finished wiping the resident's urine and bowel movement, he removed the soiled brief. While still wearing the same gloves, CNA A then applied the clean brief on the resident and dressed the resident. Lastly CNA A placed a mechanical lift sling under the resident then pulled the privacy curtain out of the way while still wearing the same gloves then after that he removed his gloves. During an interview on 02/08/24 at 10:40 AM ADON C said there were no designated trainers for CNAs when hired on or afterwards. The ADON said the new CNAs were placed with other CNAs at first during their orientation to get trained by the CNAs that were already working there. During a telephone interview on 02/08/24 at 02:24 PM CNA A said he usually changed his gloves once they became contaminated. The CNA said he had gotten nervous and had not changed his gloves after they became contaminated when he had performed incontinent care for Resident #27. CNA A said if he did not change his gloves that could lead to cross contamination and the spread of germs. CNA A said he had received training on infection control and glove use but that he had just gotten nervous and had not done the steps correctly. During an interview on 02/08/24 at 02:40 PM the DON said the expectation was for CNAs to change their gloves if they became contaminated during personal care. The DON said the staff were supposed to change their gloves to prevent the spread of infections. The DON was made aware of the incontinent care performed by CNA A. The DON said the CNA should have changed his gloves prior to placing the new brief and doing the other things while still wearing the same gloves. The DON said the CNA was supposed to change his gloves to prevent cross contamination. The DON said they did on-going training with staff and did CNA proficiencies upon hire and yearly. During an interview on 02/08/24 at 02:52 PM the Administrator was made aware of the incontinent care performed by CNA A. The Administrator said the staff were expected to change their gloves when contaminated and that they did training and training over and over about glove changes at proper times. The Administrator acknowledged the issue and would continue with staff training. The Administrator agreed that staff would get nervous and forget the steps. Record review of the facility's document titled CNA proficiency audit dated 01/16/2024 and signed by CNA A indicated in part: Skills checked on were hand washing, perineal care female and infection control awareness. Record review of the facility's document titled Job description certified nursing assistant dated 2014 indicated in part: The following is a non-exhaustive criteria that relates to the job of a certified nursing assistant and it is consistent with the business needs of the facility. These are legitimate measure of the qualifications for a certified nursing assistant and are related to the functions that are essential to the job of a certified nursing assistant. Accountable for personal care (i.e., grooming, bathing, catheter care, pericare and dressing) and observation of residents within patient care policy guidelines Identify and report any condition requiring management attention. Record review of the facility's document titled Nursing personal care- perineal care dated 05/11/2022 indicated in part: It is essential that residents using various devices, absorbent products, external collection devices etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice and the manufacturer's recommendations. Purpose- this procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation and observing the resident's skin condition. Start: Perform hand hygiene- Put on gloves and all other PPE per standard precautions, chose your PPE (Personal Protective Equipment) by considering the type of exposure, the durability and appropriateness for the task. Limit resident exposure to the perineal care-provide privacy at all times. Back: Reposition the resident to their side, gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area, remove gloves and PPE, perform hand hygiene. Important points: Do not wipe more than once with the same surface, removing and discarding of gloves are required if visibly soiled, always perform hand hygiene before and after gloves use. Record review of the facility's document titled Infection control policy and procedure manual 2019 updated 3/2022 indicated in part: Gloving- gloves are worn for three important reasons - To the likelihood that hands of personnel contaminated microorganisms from a resident or a fomite (materials which are likely to carry infection, such as clothes, utensils, and furniture) can transmit these microorganisms to another resident in this situation gloves must be changed between resident contacts and hands washed after gloves are removed. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between resident contact is an infection control hazard.

Based on observation, interviews and record review, the facility failed to ensure that all alleged violations of abuse were thoroughly investigated and to prevent further abuse while the investigation is in progress for 1 (Residents #2) of 7 residents reviewed for abuse/neglect, in that: 1) The facility failed to investigate an allegation of physical abuse to Resident #2. 2) The facility failed to prevent further potential abuse and mistreatment by allowing the alleged perpetrator to remain in the facility and to have direct contact with the residents. An Immediate Jeopardy (IJ) situation was identified on 4/20/2022 at 4:20 p.m. While the IJ was removed on 4/21/2022, the facility remained out of compliance at a potential for no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to facility continuation of in-servicing and monitoring the plan of removal. These failures could place residents at risk for continued abuse and or unrecognized abuse and emotional distress. The findings include: Review of Resident #2's electronic Face Sheet dated 4/20/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's Quarterly Minimum Data Set (MDS) dated [DATE] reflected that resident was not able to answer questions for brief interview on mental status. Resident #2 uses mobility device of a wheelchair and requires limited assistance with locomotion on and off the unit. Review of Resident #2's Care Plan dated 1/12/2022 reflected that Resident #2 has Intellectual Disability and is PASRR positive related to intellectual disability. Review of Resident #2's Progress Notes dated 4/15/2022 at 9:40 p.m., reflected that Resident #2 wanders throughout the facility throughout the day and he was brought back multiple times from the North side of the building to the South side. The final time he was brought back Resident #2 complained of pain to his back. Resident #2 complained of left shoulder, left flank, and mid low back pain. On assessment Resident #2 yelled out in pain from palpation of his back. Resident #2 said he was punched on his back by a staff member. Resident #2 pointed to his back and then back towards where he was brought back from. No other marks were observed or reported. Resident #2 was asked who punched him and he pointed out a male staff member from the North side of the building. This was reported to the ADON, DON, and Facility Administrator. Review of Resident #2's skin assessment dated [DATE] at 10:24 p.m., reflected that Resident #2's left shoulder, left flank and mid back had red splotches. Resident #2 stated he is hurting from being hit on his back by a staff member. During an interview on 4/20/2022 at 9:28 a.m., LVN A said that on Friday 4/15/22 during the evening, Resident #2 had been wandering around in the facility on his wheelchair. LVN A said that CNA C brought Resident #2 back three times. LVN A said on the third time Resident #2 said in Spanish that someone hit him. LVN A said that this was not usual for Resident #2 to make allegations of being hit. LVN A said she assessed Resident #2 and it looked like someone grabbed him on his left shoulder and squished him on the back because there was a red mark like a scratch from a handprint. LVN A said on Resident #2's mid back there was a round red splotch and Resident #2 said it was hurting him and kept saying he hit me. LVN A said she asked Resident #2 to show her who hit him, and Resident #2 rolled himself to the Northside of the building and he pointed towards CNA C and said he hit him. LVN A said she reported the information to the ADON who in turn notified the DON and the Facility Administrator (FA) who is the Abuse Preventionist for the facility. LVN A said that FA did not do anything about the incident as CNA C continued working the floor. LVN A said the ADON relayed to her that FA said there was no hard evidence and no witnesses to support the allegation. LVN A said that CNA C worked the rest of the shift on Friday (4/15/2022) and Saturday (4/16/2022). During an interview on 4/20/2022 at 10:13 a.m., ADON said that on 4/15/2022 sometime during the evening shift, Resident #2 told LVN A that someone hit him. ADON said that LVN A brought this to her attention. ADON said that it was sometime after dinner around 7:00 to 8:00 p.m. when she first learned of the allegation. ADON said that she reported the allegation to Facility Administrator (FA) and Regional Nurse DON. ADON said that FA is the facility Abuse Preventionist. ADON said that FA instructed ADON to complete a head-to-toe assessment of Resident #2 and document findings in the progress notes. ADON said that Resident #2 had redness to his left shoulder . ADON said that Resident #2 did not complain of any pain. ADON said that she called FA back with assessment findings and FA instructed ADON to monitor. ADON said that she thinks that the FA reported the allegation to the State on 4/15/2022. ADON said that FA was not at the facility at the time the allegation was reported. During an interview on 4/20/2022 at 10:36 a.m., Facility Administrator (FA) said that he is the facility Abuse Preventionist. FA said that he is responsible for ensuring investigation of allegations and determines if the allegation is reportable or not reportable to the State. FA said that staff are in-serviced to report allegations to Abuse Preventionist. FA said he conducts investigations by interviewing staff and asking the facility nurses to conduct skin assessments and if there is any type of evidence found then it is reported to the State. FA said that the process for protecting residents when an allegation is made is the facility will suspend the suspected staff member or members until the investigation is completed. FA said on Friday 4/15/2022, during the evening time he was not at the facility and he received a phone call report from the ADON that one of the CNA's pushed or hit Resident #2. FA said he asked the ADON to perform a skin assessment and ADON called him back and said there were no abrasions, no bruising, or any marks of any kind. FA said he did not receive any report of any redness that he could recall. FA said that he knows the ADON did some interviews, and it was determined that Resident #2 was not hit, slapped, or pushed based on assessment and interviews. FA said that Resident #2 does not have any history of making false allegations. FA said that he did not document anything related to the conversation he had with the ADON on 4/15/2022. FA said that he did not complete a comprehensive investigation on the allegation. FA said that CNA C works on the Northside of the building and Resident #2 resides in the Southside of the building. FA said that Resident #2 does wander into the Northside of the building throughout the day and evening, which is his right to do so. FA said he did not suspend CNA C pending investigation on 4/15/2022. FA said that CNA C has not been suspended as of this interview on 04/20/2022 at 10:36 a.m. FA said that he handled the report like a grievance and on 4/18/2022 he met with CNA C regarding poor customer service and that the residents have the right to go around the facility. FA said this meeting with CNA C on 4/18/2022 was documented on a Coaching Form. FA said during the meeting CNA C denied pushing or hitting Resident #2. In an observation on 4/20/2022 at 11:10 a.m., it revealed that the northside and southside of the building had an open hallway that connected the two sides. Resident #2 was observed self-propelling on a wheelchair through the hallway from the northside into the southside. Resident #2 placed his arm up towards his face and grunted when he was asked if HHS Investigator could meet with him. Record review of CNA Hall Assignment Sheet on 4/20/2022 at 11:30 a.m., revealed that on 4/15/2022 during the 2:00 p.m. to 10:00 p.m. shift, CNA C worked on the northside unit. During an interview on 4/20/2022 at 12:23 p.m., FA said that he may not have done the right thing for Resident #2 in failing to report the allegation to the State, and that he had corrected his mistake by making a self-report a few minutes before speaking with HHS Investigator and started the investigation into the allegation. FA said another update is CNA C has been suspended pending investigation. During a phone interview on 4/21/2022 at 12:36 p.m., CNA C said that he was assigned to work the northside of the building. CNA C said that Resident #2 lives in the southside of the building but routinely self-propelled into the northside of the building. CNA C said that he was not assigned to Resident #2 on 4/15/2022 but did assist Resident #2 back to the southside of the building. CNA C said that he did not hit, push, or grab Resident #2 at any time. Record review of CNA C's Timesheet from 4/14/2022 through 4/19/2022, revealed that CNA C worked the evening shift at the facility on 4/15/2022, 4/16/2022, 4/18/2022, and 4/19/2022. Record review of facility's Abuse/Neglect policy with revision date 3/29/2018, was provided by FA. Policy read in part that Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff Under section titled Prevention, reads the following: All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. Under the section titled Investigation, reads the following: Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. With allegations of abuse, the employee(s) will immediately be suspended pending an investigation. Under section titled Protection, reads the following: The facility will take necessary measures to protect residents . during an abuse investigation. The Administrator was notified of the Immediate Jeopardy on 4/20/2022 at 4:20 p.m., and the administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 4/21/2022 at 8:00 a.m., and reflected the following: Interventions: -One on One in-service on Abuse Investigation with the Administrator/DON by Area Director (AD) on 4-20-22 4:30 pm. -Staff working with Alleged perpetrator have been interviewed by administrator and there were customer service issues noted and including raising his voice with a resident. Resident is doing ok and not able to answer. -Alleged perpetrator was suspended on 4/20/22 pending outcome of investigation. -Resident safe surveys have been initiated by Social Worker/Dietary Manger/ Administrator on 4-20-22 and no abuse incidents have been reported. -The following in-services were initiated on 4/20/22 by DON/Administrator/ADON: Any staff member not present or in-serviced on 4/20/22, will not be allowed to assume their duties until in-serviced by Admin/DON/ADON. All Staff; Abuse/Neglect; Abuse/Neglect Reporting, and Who to Report Abuse/Neglect to. -All staff will need to be able to articulate back on reporting any type of abuse allegation and to whom to report. -Any employees that are reported of any abuse will be suspended pending investigation. -The medical director was notified of the immediate jeopardy situation on 4/20/22 at 4:40, family was notified at what (sic) time 7:48 pm. Monitoring -Administrator will report any abuse allegations, investigate, and submit findings to Area Director and Risk Management for review. -Administrator will submit documentation of investigation with Resident and Staff interviews, as well as weekly follow up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with outcome of investigation -Area Director will monitor abuse allegations reported and check Real Time system which monitors key word like abuse x 4 weeks documentation and PCC for any incident and accidents -The QA committee will review findings of any abuse allegation and investigations monthly and makes changes as needed to system. Monitoring of the facilities plan and removal occurred on 4/21/2022 and included the following: During an interview on 4/21/2022 at 8:25 a.m., FA said he was in-serviced on 4/20/22 by the Area Director (AD) regarding reporting allegations of abuse and other reportable incidents. FA said that when abuse is reported or suspected that the facility will suspend the alleged perpetrator, complete a physical assessment of the resident, and report within 2 hours of the allegation of abuse being reported. FA said that he interviewed staff members who worked with the alleged perpetrator. FA said that an addendum to the allegation of abuse was called in to the State following interviews, as facility investigation revealed that AP CNA C was overheard yelling at a resident something like No! or Stop It!. FA said no other concerns related to CNA C were noted. FA said that Resident #2 was asked about any incidents involving CNA C and he did not provide any information. FA said that on 4/20/22, CNA C was suspended pending an investigation into the allegation of abuse. FA said that any time there is an allegation of any kind, the employee who is named the alleged perpetrator will be suspended until the investigation is complete. Any further disciplinary actions with the employee may be taken after the investigation is complete. FA said that in-services of all staff at the facility had been started 4/20/22 on identifying abuse/neglect, reporting abuse/neglect, and who to report abuse/neglect to. FA said that he, the DON, and ADON are conducting facility wide in-services. FA said that staff on all shifts must be in-serviced on all areas before they are allowed to work. FA said that verification of completion of in-services are documented on signature sheets. Review of Facility In-Service Training records were conducted on 4/21/2022. The in-services were dated 4/20/2022 and included the topics of abuse/neglect, abuse/neglect reporting, and who to report allegations of abuse/neglect to. Sixty-four (64) of one hundred and ten (110) staff had signed the in-service training forms. During an interview on 4/21/2022 at 9:00 a.m., ADON said on 4/20/22 she was in-serviced by the AD regarding reporting allegations of abuse and other incidents. ADON said that all allegations of abuse are reported to the facility Abuse Preventionist and State within two hours. ADON said the alleged perpetrator will be suspended pending investigation and a physical assessment will be completed on the resident. During an interview on 4/21/22 at 9:16 a.m., Dietary Manager (DM) said he was in-serviced yesterday afternoon by the FA. DM said the topics of the in-service how to identify abuse/neglect, abuse/neglect reporting, and who to report to. DM said that allegations of abuse and other incidents are to be reported to the Abuse Preventionist who is the FA. During an interview on 4/21/22 at 9:21 a.m., LVN B said yesterday during the afternoon she was trained by DON regarding abuse/neglect, reporting and how to identify. LVN B said she signed a document to verify that she was trained. LVN B said that any time abuse allegation is made it must be reported to the FA who is the Abuse Preventionist of the facility. During an interview on 4/21/22 at 9:49 a.m., ADON said she was in-serviced yesterday on abuse/neglect, identifiers of abuse/neglect and reporting abuse/neglect. ADON said that FA and Regional Compliance Nurse did the in-service with her. ADON said she signed the in-services. ADON said that FA, DON, and ADON are conducting the in-services with staff members before they are allowed to report to their work area. During an interview on 4/21/22 at 10:15 a.m., HK A said that she was in-serviced yesterday by DON. HK A said that the in-service was over abuse/neglect, reporting abuse/neglect and identifying signs of abuse. She said that if abuse is reported or suspected then the allegation is reported to the FA who is the Abuse Preventionist. During an interview on 4/21/22 at 11:20 a.m., HRC said that she was in-serviced yesterday by FA. HRC said she was in-serviced on who to report abuse/neglect to, when to report it, and who the Abuse Preventionist is. HRC said that any type of abuse must be reported to Abuse Preventionist immediately. HRC said that in-service also covered definition of abuse/neglect to identify signs of possible abuse. During an interview on 4/21/22 at 11:30 a.m., LVN C said that she was in-serviced yesterday by DON. LVN C said the in-service was on identifying abuse/neglect, and who to report allegations of abuse/neglect to. LVN C said that all allegations are to be reported to the Abuse Preventionist who is the FA immediately. During an interview on 4/21/22 at 11:49 a.m., CNA A said that she was in-serviced on 4/20/22 by DON. CNA A said that she was trained on abuse/neglect, and who to report allegations of abuse/neglect to. CNA A said that if she suspected or witnessed any abuse, she would report it immediately to the FA who is the Abuse Coordinator of the facility. During an interview on 4/21/22 at 11:55 a.m., HK B said that she was in-serviced this morning before reporting to her work area. HK B said that she was in-serviced on abuse/neglect and who to report allegations of abuse/neglect to. HK B said that allegations are reported to FA immediately. During an interview on 4/21/22 at 1:15 p.m., CNA D said that on 4/20/22 she was in-serviced on reporting abuse/neglect. CNA D said that if there are any reports of abuse or other allegations then she is to report to FA immediately. CNA D said she was trained on possible abuse and neglect scenarios. CNA D said the DON trained her on abuse/neglect and reporting. During an interview on 4/21/22 at 1:25 p.m., CNA E said that she was in-serviced by the DON on abuse/neglect on 4/20/22. CNA E said that the in-service covered reporting suspected or witnessed abuse/neglect along with other incidents. CNA E said that reports are made to the Abuse Preventionist who is the FA. CNA E said reports must be made immediately. Review of document titled In-Service Training Attendance Roster dated 4/20/2022 at 4:30 p.m., reflected that Area Director (AD) conducted one-on-one in-services with FA, DON, and ADON on training topic of reporting guidelines. Review of Resident Safe Surveys dated 4/20/2022, reflected that 75 resident surveys were conducted. The document covered the areas of 1) if there were any negative responses from residents; 2) any evidence of potential abuse/neglect; and 3) during rounds were there any signs of staff acting rudely or inappropriate with residents. No potential abuse noted. Review of Oasis Nursing and Rehabilitation Employee Disciplinary Report dated 4/21/2022, reflected that CNA C was placed on unpaid investigatory suspension due to the allegation. CNA C will remain on investigatory suspension until the investigation is completed. CNA C signed the document on 4/21/2022. On 4/21/2022 at 2:16 p.m., the FA was informed that the IJ was removed. However, the facility remained out of compliance at a severity of potential for no actual harm with the potential for more than minimal harm, and a scope of isolated. The facility was continuing to monitor its plan for effectiveness.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free from accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 (Resident #15) of 8 residents on continuous oxygen. The facility failed to secure Resident #15's portable oxygen cylinder when she walked in the hallway. The cylinder either stood up in or laid in the seat of her wheelchair. The staff were not aware of the potential hazard if the oxygen cylinder fell to the floor and the valve post was to break off. On 10/24/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 10/25/17 the facility remained out of compliance at potential for more than minimal harm pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could affect 15 residents with orders for oxygen administration at risk of injury or death related to unsecured oxygen tanks. The findings included: Review of the face sheet dated 6/06/17 documented Resident #1 was a [AGE] year old woman admitted on [DATE]. Review of the facility History and Physical dated 3/15/17 documented [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] documented Resident #15 had clear comprehension of verbal content, had a BIMS (Basic Interview of Mental Status) score of 14 out of 15 (intact cognition), no behaviors, required 1 person limited assistance to move herself around the facility and was on oxygen therapy. Review of Resident #15's care plan initiated on 5/06/14 documented she was on oxygen therapy due to COPD (Chronic Obstructive Pulmonary Disease). The Intervention/Tasks, reviewed on 5/25/15 and again on 10/24/17, documented Resident #15 has paranoid behaviors r/t (related to) oxygen; always thinks oxygen tank is empty, and/or nasal cannula is not working properly or at all. Resident #15 refuses to have O2 (oxygen) portable cylinder in place behind (wheelchair) on the rack. Frequently redirected, resident becomes agitated and states she knows what she's doing. Family is aware of behavior. Review of Resident #15's Physician Orders dated October 2017 documented in part oxygen at 2 liters/minute via nasal canula continuous. Observation on 10/24/17 at 2:15 PM, Resident #15 was standing on the South side hallway with her wheelchair in front of her. Resident #15 had a nasal cannula connected to a portable oxygen cylinder. The portable oxygen (O2) cylinder in the resident's wheelchair seat leaned, unsecured, against the side of the wheelchair on top of a gray gel cushion. Resident #15 pushed the wheelchair with the unsecured O2 cylinder while she walked behind it down the South side hallway. Observation on 10/24/17 at 2:25 PM, Certified Nurse Aide (CNA) E was filling water pitchers with ice. Resident #15 stood in front of CNA E with the O2 cylinder unsecured on the seat of her wheelchair. CNA E completed her task and left, and did not ask Resident #15 to secure the O2 cylinder. Observation on 10/24/17 at 2:30 PM, Licensed Vocational Nurse (LVN) J entered a room by the nurse's station on the south side. Resident #15 was standing in front of the room with the O2 cylinder placed on the seat of her wheel chair, unsecured. LVN J did not approach Resident #15. Observation on 10/24/17 at 3:35 PM, Resident #15 stood behind her wheelchair in front of the South side nurses station. Her portable O2 cylinder leaned against the left rear corner of the seat of the wheelchair. The O2 cylinder was not secured in any way. Observation on 10/24/17 at 3:40 PM, Assistant Director of Nurses (ADON) D stood in the South side nurses station. Resident #15 stood in front of the nurses station with the O2 cylinder unsecured and propped in the seat of the wheelchair. ADON D did not approach Resident #15 or speak to her. In an interview on 10/24/17 at 2:20 PM, Resident #15 said she liked to have the portable O2 cylinder on top of the wheelchair seat because she could access it better. She said the staff puts it down there (metal cylinder holder) and I don't like it there so I pull it out. In an interview on 10/24/17 at 2:35 PM, LVN J said Resident #15 was stubborn and set in her ways, We put the O2 in a bag and she takes it out and puts it on the seat of the wheelchair. LVN J stated now that I'm thinking of it, if it falls it can explode, for the other residents it's dangerous. In an interview on 10/24/17 at 3:45 PM, ADON D said it was everyone's responsibility to assure portable O2 cylinders were secured. She said the facility did not conduct audits to ensure all residents had their portable O2 cylinders secured. She said Resident #15 did not need a wheelchair to ambulate and used the wheel chair to place the portable O2 cylinder on the seat. ADON D said she had seen Resident #15's portable O2 cylinder unsecured on the seat of the wheelchair for 1 year. ADON D said the staff's interventions to address this was to redirect the resident when they saw the O2 unsecured and to refer it to the social worker. ADON D stated, I don't know what could happen if the 02 tank fell to the ground, I really don't know. An immediate Jeopardy was identified on 10/24/17 and the Nursing Home Administrator (NHA) was informed at 5:25 PM. In an interview on 10/25/17 at 8:07 AM, the Regional Clinical Coordinator said he did not understand why an IJ was called because of an unsecured oxygen cylinder. When asked what were the consequences of an unsecured O2 cylinder, he said, Well, it could fall on your foot. The Regional Clinical Coordinator said they became aware of the problem and fixed it immediately. In an interview on 10/25/17 at 11:11 AM, Minimum Data Set (MDS) Nurse G said, according to the care plan, Resident #15 has been ambulating in the facility with her portable oxygen cylinder unsecured since 5/25/15. In an interview on 10/25/17 at 12:08 PM, CNA E said, I tell her and tell her that is not supposed to be there (the O2 cylinder), but she does whatever she wants. CNA E said Resident #15 was independent in transfer but needed assistance with the oxygen cylinder. CNA E said the nurse will put the portable oxygen cylinder in the black sack on the back of her wheelchair, but she takes it out because she does not want it there. If it is put back, Resident's #15 gets real mad. CNA E said when the resident takes the oxygen cylinder out of the sack, she tells the nurse. When asked how long Resident #15 had been putting the portable oxygen O2 cylinder in her wheelchair seat, CNA E said everyday since she started using the oxygen. CNA E said she could not remember exactly when, but it had been for a long time. She said Resident #15 had been in the south hallway for at least 2 years. In an interview on 10/25/17 at 12:12 PM, LVN F said Resident #15 had been on oxygen for about 2 years. She said Resident #15's putting the portable oxygen cylinder on her wheelchair seat had been an ongoing problem. Resident #15 gets mad when the cylinder is put in the bag provided to carry the oxygen cylinder on her wheelchair . LVN F said the family was aware of the problem. The family said, You know how she is. We know how she is. Deal with it the best you can. In a telephone interview on 10/26/17 at 11:06 AM, Resident #15's daughter said she had been attending the care plan meetings at the facility throughout her mother's stay. Resident #15's daughter said she had not been notified Resident #15 was refusing to secure her portable O2 cylinder at any of the care plan meetings. She said the first time she received a call notifying her of the issue was on 10/24/17. In an interview on 10/26/17 at 3:55 PM, the Director of Nursing (DON) said the problem with Resident #15 and her O2 cylinder was an ongoing problem. All staff should be monitoring Resident #15 and working on securing the portable 02. The DON said the interventions Resident #15 received to keep her and the rest of the facility safe were: close supervision when she was ambulating with her O2 cylinder unsecured on the seat of her wheelchair and redirection. The DON said this issue had been care planned with Resident #15's family. When asked if the resident had the cognitive function to be aware of safety concerns, the DON said if you were to initially speak with her you would think she was able to understand, but if the conversation continued you would see she was not able to understand safety issues. The DON said all staff were aware if they witnessed Resident #15 and her O2 was not secured they needed to stop and address it. The DON stated, We have tried and tried and she continues to take it out of the holder and the pouch because she does not like it there. The DON said the portable O2 cylinder was on the seat of the wheel chair on top of the gel cushion. It's not unsecured; the gel cushion is holding it in place. The DON said she had not looked at what could happen if the O2 cylinder fell to the floor from the seat of the wheelchair. Review of the facility policy Compressed Gases, Safe Handling Of revised 12/10/15 stated in part: 9. Never drop cylinders or permit them to strike against each other or against other surfaces violently. 10. When cylinders are used for transport, they should be secured properly in the transport vehicle. Methods to secure the cylinders are listed below: In a cylinder pouch attached to a wheelchair or Geri-chair In a cylinder cart that has been stabilized in the vehicle to prevent unnecessary movement Any other method to prevent movement of the cylinder and protect the stem/regulator Pressurized cylinders, used to store various flammable and nonflammable gases, are likely to fall over if left unsecured .Such a fall could cause damage to the cylinder's valve or the cylinder itself, resulting in a gas leak. A rapid loss of pressure can turn a cylinder into an unguided missile powerful enough to break through a concrete wall. (https://www.compliance.gov/sites/default/files/wp-content/uploads/2010/03/fastfacts_pressurizedcylinders.pdf accessed 11/6/17) On 10/26/17 at 4:47 PM, the Plan of Removal was accepted. I. Interventions: - Resident identified without O2 holder has had an O2 pouch placed on wheelchair on 10/24/17 - Care plan meeting with resident regarding past behaviors of refusing to use cylinder holder/pouch held on 10/24/17. -Resident agreed to use holder/pouch to secure O2 tank (resident BIMS score 14), however, if resident does not comply resident family member and ombudsman will be notified to assist with compliance concerns, and if still unsuccessful, a 30-day discharge notice will be issued, or sooner if other residents are put in danger due to unsecured O2 tank. - On 10/24/17 began in-servicing all staff on the following: 1. P&P on Compressed Gases, Safe Handling Of - which includes that oxygen tanks should be secured in an appropriate device at all times. - In-service all staff regarding Notification of Potential Safety Hazards. If any staff member recognizes a situation where a resident places other residents in harm or danger the staff member must immediately notify charge nurse, DON and Administrator. Examples include: if an O2 tank is leaking, an O2 tank is not secured in a pouch, sleeve, carrier or other appropriate device. If someone is in immediate danger or harm you need to intervene immediately. Examples include: a resident's using a portable O2 tank without a holder you should immediately secure O2 tank with holder or device. It you have questions if any resident practices could potentially harm the resident, other residents, staff or visitors, immediately notify the administrator and/or DON. - Assessed all residents who use portable O2 tanks on 10/24/17 to ensure they are using cylinder holder/pouch. - The medical director was notified of this plan on 10/24/17. II. Monitoring: - The resident without the O2 holder is being monitored Q-30 minutes to ensure O2 pouch/holder remains in place initiated on 10/24/17. - The DON and/or designee will monitor all residents with O2 cylinders to ensure the cylinder is secured with an appropriate device daily for 4 weeks and randomly once a week to ensure compliance, and will address with re-education of staff. - Any findings related with residents on O2 will be discussed weekly during standards of care meetings and addressed with a 30-day notice, or sooner if other residents are put in danger due to unsecured O2 tank. - The Nursing Home Administrator will randomly check residents on oxygen once a week if the O2 tank is secured for any resident using O2 holder/pouch. - The QA committee will review the findings and make changes to this plan as needed. Interviews on 10/25/17 and 10/26/17 with Licensed Staff, CNAs, CMAs and Housekeeping revealed they had been trained on ensuring portable O2 cylinders were secure and what to do if they identify hazards that could affect residents. The DON had started daily monitoring of residents on oxygen checking for secured tanks. The Plan of Removal was verified as having been implemented through observations of residents with portable oxygen cylinders for secured cylinders on 10/25-27/17, interviews with staff on 10/25/17-27/17 and record review of in-services held on 10/24-25/17 and monitoring tools dated 10/24-25/17. Resident #15's oxygen cylinder was secured in a metal cylinder holder on the back of her wheelchair. The Nursing Home Administrator was informed the IJ had been lifted on 10/25/17 at 2:00 PM. While the Immediate Jeopardy was lifted, the facility remained out of compliance at potential for more than minimal harm pattern due to the facility need to evaluate and monitor their corrective action system. The list of 10 residents on continuous oxygen and 5 residents on oxygen as needed was provided by the DON on 10/26/17.

Based on observation, interview and record review the facility failed to consult with the physician when there was a significant change in condition for 2 of 9 residents (Resident #1, and #2) reviewed for change of condition. A. On [DATE] at 6:30 PM, resident #1's daughter reported to Licensed Vocational Nurse (LVN A) that her mother did not look right and asked her to send her mother to the hospital. LVN A called the physician at 10:00 PM, and reported that resident #1 did not look like her usual self and orders were received for stat (immediately) labs and UA (urine analysis). LVN A and LVN B failed to immediately notify the attending physician that it was going to take more than five hours for stat labs and UA to be done as ordered. On [DATE] at 5:08 AM, lab collected specimens. The Lab faxed lab results to the facility on [DATE] at 10:10 AM. Resident #1 arrived to the hospital on [DATE] at 10:26 AM and died on [DATE] at 11:35 PM. B. On [DATE] at 7:00 AM, resident #2 reported to LVN A that she had fell down in her room four days prior and did not want to get out of bed for meals like she usually did because she was having pain to right leg with movement and cramping to the right thigh. LVN A did not immediately report to the attending physician on [DATE] that scheduling of the Venous Doppler could not be done on the weekend. Resident #2 continued to have swelling and pain to the right leg with movement. On [DATE] on the morning shift LVN I failed to immediately report to the attending physician resident #2 had swelling and pain on the right knee with movement and that they were having problems with making arrangements to schedule the Venous Doppler as ordered. On [DATE] at 12:53 PM, physician gave orders for an x-ray of the right knee. X-ray was done [DATE] at 3:51 PM. X-ray results were received at 4:52 PM, documented an Acute [MEDICAL CONDITION] femur with posterior displacement. Physician was notified at 4:45 PM, and resident was sent resident to hospital. On [DATE] an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at actual harm, pattern due to the facility's need to evaluate and monitor their corrective action system. This failure placed 62 residents at the facility in the North side at risk of not promptly receiving the necessary medical care by not consulting with the physicians were there was a change in condition. Findings include: Resident #1 Closed record review of the Resident Face Sheet dated [DATE] documented resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted back to the facility on [DATE] had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #1 documented in part: Unclear speech, Sometimes understood, Sometimes understands, Cognitive skills severely impaired, extensive assistance of one to two persons with Activities of Daily Living, and incontinent of bowel & bladder. Review of the Care Plan revised on [DATE] for resident #1 documented in part: Resident is incontinent of bowel & bladder. Resident has cognitive loss related to Dementia. Monitor/record/report to physician new on-set of [MEDICAL CONDITION], changes in behavior, altered mental status, wide variation in cognitive function through the day, communication decline, disorientation, lethargy, restlessness, agitation, dehydration and infection. Resident sometimes understood/understands. Requires extensive assistance of ,[DATE] persons with Activities of Daily Living. Review of Hospital emergency room report dated [DATE] documented in part: Resident #1 arrived via EMS (Emergency Medical Services) at 10:24 AM in respiratory distress. Chief Complaint: Onset of respiratory distress yesterday evening. Altered Mental Status. Nursing Home reported resident [MEDICAL CONDITION], patient currently tachy. Not responding, Hypoxic breaths/min on 15 liters per minute of oxygen. Review of the Hospital History & Physical dated [DATE] documented in part: Chief Complaint: Lethargy. Onset of respiratory distress yesterday evening. Altered Mental Status. Not responding. Hypoxic. History of present illness: Resident #1 is a [AGE] year old female with past medical history of [REDACTED]. The patient was found to be less responsive with poor oral intake about a day ago in the nursing home. This morning, patient's condition continues to worsen, therefore, patient was transferred to the ER (emergency room ). In ER, patient was found to be septic and also have pancreatitis. Patient was admitted . Patient is nonviable, therefore could not get information from her. Physical examination: Temperature 99.6, on arrival to the ER, heart rate of 119, respiratory rate of 32, blood pressure ,[DATE], patient is on 15 Liters of oxygen on non-rebreather mask. Mucosa is dry. Positive bilateral sounds with occasional coarse breath sounds. Patient is lethargic.[MEDICAL CONDITION] Screening: Altered Mental Status, decreased urine output, [MEDICAL CONDITION]> 90 BPM (beats per minute. Diagnoses: [REDACTED]. Treated with IV (intravenous hydration). 2)[MEDICAL CONDITION] secondary to acute infectious process. Has been given several boluses of IV fluids in the ER. 3) Hypernatremic dehydration. 4) Urinary Tract Infection. Started on IV antibiotic. 5) Leukocytosis secondary to acute infectious process. Review of the Hospital Lab results dated [DATE] at 11:07 AM, for resident #1 documented in part: White blood cell of 15.10 (High), BUN 39 (High), Hemoglobin 15.9 (High), Sodium 146 (High); Urinalysis (UA) results dated [DATE] at 11:07 AM, Urine color-cloudy, UA Protein 1+, Leuk Est 2+, UA blood 2+, WBC Urine 16 (high). Review of the Hospital Discharge Summary dated [DATE] documented at around 11:35 PM, on [DATE] resident #1 was pronounced dead by 2 RNs (registered nurses). Review of the Grievance Form dated [DATE] written by the (Business Office Manager) BOM documented in part: BOM received telephone call from resident #1's daughter. Daughter reported that she was upset because she came in on Saturday [DATE] to feed her mother and told LVN A that her mother did not look good and asked her to send her mother to the hospital. She reported that her mother was unresponsive, and had a pale/ashy skin color to her face. LVN A told her that her mother was probably just tired because of the event that was held on Friday to celebrate mother's day. LVN A told the daughter that she had called the doctor and got an order for [REDACTED]. The doctors did not know that her mother was in the nursing home. The attending physician told the daughter that LVN A had only reported to her that her mother was not eating and that is why she had only given orders for labs. The daughter also reported that her mother had not voided for one day and that should have been a big flag for nurses to send her mother to the hospital. Review of the Provider Investigation Report dated [DATE] documented in part: Date of incident [DATE] at 6:00 PM. Allegation: Neglect. Description of Allegation: Resident's daughter came in to visit with Business Office Manager (BOM) and Director of Nurses on [DATE] at 11:00 AM, to discuss why her mother was not sent to the hospital on the evening of [DATE] instead of the morning on [DATE]. She alleged that if her mother had been sent out on the 13th instead of putting her to bed it would have been different. She made reference to the hospital nurses making comments about why she did not get her to the hospital sooner. Resident was sent to hospital on the morning of [DATE] due to signs and symptoms of respiratory distress. Allegation of Neglect: Unconfirmed. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by LVN A documented in part: Assigned to resident #1 on [DATE] and [DATE]. At 6:30 PM, resident's daughter was visiting and reported that her mom was not responding to her. I told the daughter that I would be calling the doctor to ask for labs. Received new order for labs on change of shift when giving report to LVN B on the night shift. This nurse next workday (Sunday [DATE]). After breakfast noted resident #1 at Nurses station with shortness of breath, labored breathing. Asked (Certified Nurse Aide) CNA to lay her down and to take vitals. Vital signs abnormal. Called physician and gave orders to send her out. Review of a hand written statement attached to the Provider Investigation Report dated [DATE] written by CNA D documented in part: On [DATE] at 3:00 PM, got resident #1 up and took to dining room. The daughter brought the resident to Nurses station and was telling LVN A, that her mother was not responding LVN A told the daughter that the resident looked tired and asked me to put the resident to bed. The resident looked pale and was incontinent of urine. Not as wet as usual. The daughter told me that her mother didn't want to eat. Went to check resident again, had a small amount of urine on brief. Reported to LVN A. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by CNA (F) documented in part: Assigned to resident #1 on [DATE] and [DATE] on the 6:00 AM to 2:00 PM shift. On Saturday [DATE] resident #1 did not eat breakfast or lunch. Resident was holding food in her mouth. Resident appeared tired. Notified LVN A. Resident was incontinent of urine x 2 on this shift. On Sunday [DATE] at 6:00 AM, resident seemed tired. Sat resident in wheelchair and took her to the dining room. At breakfast resident was breathing hard with mouth opened, eyes rolled back. Resident did not eat breakfast. LVN A was notified. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by CNA E documented in part: I worked on the night shift on [DATE]. When I got there at start of shift LVN B asked me to try and offer water to resident #1. When I attempted to give her water she would not open her mouth. I tried to give her a spoonful of water every hour, but the resident would not open her mouth. I reported this to LVN B. Telephone interview on [DATE] at 4:35 PM, resident's daughter said, On Saturday [DATE] at approximately 5:00 PM to 5:30 PM, I found my mother sitting in her wheelchair in the dining room with her head hanging down and was not responding when I talked to her. My mother looked dead. I asked LVN A to send my mother to the hospital. LVN A told me that my mother was probably just sleepy and asked one of the aides to put my mother to bed. I asked the CNAs on that day, why they had not noted that my mother was unconscious. I tried to feed my mother on that day, she opened her mouth once but could not swallow her pureed food. She was just holding the food in her mouth. I also noted that my mother's disposable brief was dry when I got there and was still dry when I left that day at approximately 7:00 PM to 8:00 PM. I called LVN A later that night and LVN A told me that she had called the doctor and got orders for labs. LVN A told me my mother was ok and resting. My brother was with my mother the day before on Friday during the mother's day celebration and she was fine. My mother could not talk, but was able to answer simple questions by nodding yes and no with her head. On Sunday morning [DATE] LVN A called my brother to tell him that she was sending my mother to the hospital because she was lethargic. I met my brother at the hospital. My mother was almost dead when she got to the hospital. I don't know why LVN A did not call the doctor right away on Saturday to send my mother to the hospital. Maybe she would still be alive. I did call the BOM to tell her that I could not understand, how the LVN A and CNAs did not see that my mother was unconscious. She was rigid and was not her usual self. Telephone interview on [DATE] at 12:45 PM, attending physician reported that LVN A had called her at night on [DATE] to report resident #1 was not looking good and her vital signs were stable. When I talked to LVN A, she did not tell me that the resident was very sick. LVN A never reported to me when she called me on that day that resident #1 had not been eating or drinking fluids, on that day. She never told me that the daughter had reported to her that the resident was not responding and wanted her mother to be sent to the hospital. LVN A did not report to me that the CNAs had reported to her that the resident #1's eyes were rolling, and had decreased urine output. Based on what LVN A reported to me, I just gave orders for stat labs. I depend on the Nurses to accurately assess the residents and immediately report to me any change in condition. LVN A should have called me back right away if she knew that it was going to take several hours before the lab work could be done. On Sunday [DATE] at 9:45 AM, LVN A called me to report that resident #1 was having rapid, labored respirations and lab results had been received. I told LVN A that I was on my way to the nursing home and gave orders to send the resident to the hospital for evaluation. I treated resident #1 at the hospital. When the resident arrived she was almost dead. She was hyperventilating and was septic. This was not an immediate change in condition. The resident most likely had been sick for approximately two days prior to Saturday [DATE] for her to be septic. I'm concerned of how accurately the nurses are assessing the residents when they have a change in condition. Telephone interview on [DATE] at 3:51 PM, with CNA F reported resident #1 was alert, oriented to person, was able to answer simple questions with yes and no, required total assistance of one person with Activities of Daily Living, spoon fed, incontinent of bowel & bladder, and usually ate ,[DATE] percent of her meals. CNA F reported that she had been assigned to resident #1 on Saturday [DATE] on the morning shift. On that day, I got resident out of bed for breakfast at approximately 6:15 AM. I always do her first at the start of the shift. Resident #1 was very weak, and kept her eyes closed all day. Resident #1 was spoon fed. On that day I noted that she just kept the food in her mouth and was not swallowing her food. I tried to give her the shake, but it would roll down the sides of her mouth. I also noted that she was not urinating as much as she usually did. Usually the incontinent brief would be soaked with urine, but on that day not even half a brief was wet. I immediately reported this to LVN A and she asked me to put the resident #1 back to bed. CNA F reported that she had also been assigned to resident #1 on Sunday [DATE] on the morning shift. On that day at approximately 6:15 AM, when got the resident #1 out of bed and sat her in her wheelchair, I noted that the resident appeared to be very weak, and was breathing very rapidly. I wheeled the resident to the dining room and immediately reported the resident's condition to LVN A. Resident #1 refused to eat breakfast on that day. When I tried to give her the shake, it rolled out the sides of her mouth. I immediately reported this to LVN A and she instructed me to put the resident in bed. CNA F reported that they had been trained to immediately report to the charge nurse any changes of condition. In an interview on [DATE] at 1:38 PM, LVN A said, On Saturday [DATE] at approximately 5:30 PM - 6:15 PM, I was at the Nurses station when resident #1's daughter came to tell me that her mother looked different and was not her usual self. When I checked the resident at the Nurses Station, the resident was rigid, clenching teeth, and was able to answer simple questions. I checked her lungs and lung sounds were clear. The resident appeared to be very sleepy but was not lethargic. Based on my assessment the resident just looked tired and was not lethargic. I asked the CNA to put the resident back to bed. I called the doctor and she gave orders for stat labs and UA like 15 minutes before the start of the night shift. I was very busy doing other stuff so I asked LVN B to write the Telephone Order for the lab work. I don't remember who called the lab. On Sunday [DATE] I made walking rounds at approximately 6:30 AM - 7:30 AM, and noted resident #1 was in her bed asleep. LVN B reported to me at the change of shift that lab results were still pending. I don't remember what time I followed up with the lab because I was busy supervising the breakfast meal in the dining room and taking care of other residents. I don't recall the CNAs reporting to me on [DATE] and [DATE] that resident #1 was not eating/drinking, or that resident had a change in condition. On Sunday at approximately 9:45 AM, resident #1 was sitting in front of the Nurses station and I noted resident #1 had rapid, and labored respirations. I called the physician and got orders to send the resident to the emergency room . LVN A said that they had been trained to immediately report any change of condition to the attending physician and to immediately send the resident to the hospital upon family's request. LVN A reported that CNAs had been trained to immediately report changes in condition to the nurse. Review of the Nurses Notes dated [DATE] written by LVN A documented in part: At 6:30 PM, Daughter at bedside, resident up in wheelchair. Daughter stating mother does not look right and she's not responding. Clenching jaw and teeth, response was a whisper, unable to understand. Vital Signs-Blood pressure ,[DATE], Oxygen Saturation 98%, Pulse 100, respirations 20, and Temperature 98.4. Placed call to attending physician new orders for labs and urine analysis received via text at 10:00 PM. Will continue to monitor. Review of SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] for resident #1 written by LVN A documented in part: Situation: Shortness of breath and drop in pulse rate started on [DATE]. Since this started it has gotten worse. Date of transfer [DATE]. Acute change in condition. Vital signs blood pressure ,[DATE], heart rate 44, respirations 32, temperature 97.4; oxygen at 2 liters by nasal cannula. Resident with decreased food and water intake, shortness of breath, labored breathing and drop in pulse rate. Nurses Note: This nurse (LVN A) noted resident with labored breathing, low pulse, and lethargic. Physician called orders given to send resident to emergency room . Review of the Meal Intake Record dated [DATE] through [DATE] documented resident #1 ate 75% to 100% of her meals. Meal Intake Record dated [DATE] documented resident #1 ate 50% of breakfast, 25% of lunch, and refused dinner. Meal Intake Record dated [DATE] documented resident #1 refused breakfast. Review of the Physician's Telephone Order dated [DATE] at 10:00 PM, written by LVN B documented UA (urine analysis), CBC (complete blood count), CMP (comprehensive metabolic panel) stat (immediately). Review of the Nurses Notes dated [DATE] written by LVN B documented in part: At 10:10 PM, called Lab for stat orders for CBC, CMP and urine analysis. Dispatcher notified nurse that the soonest labs can be done will be at 3:00 AM. Vital Signs-Blood pressure ,[DATE], Oxygen Saturation 97%, Pulse 94, respirations 18, and Temperature 98.2. At 10:40 PM, Resident resting in bed with eyes closed, no signs of distress. Review of the Nurses Notes dated [DATE] written by LVN B documented [DATE] at 3:40 AM, labs were drawn, resident with no complaints. Review of the Lab Results dated [DATE] for resident #1 documented in part: Specimens collected at 5:08 AM. UA report: Urine slightly cloudy, [MEDICATION NAME]-Trace, Blood-Moderate, LEUK - EST-Moderate, WBC Urine TNTC-Abnormal, Bacteria-2+, [MEDICATION NAME]-2+. General Chemistry report: Potassium 5.2 High, Chloride 109 High, Carbon [MEDICATION NAME] 13 Low, Glucose 128 High, BUN 43 High, Creatinine 2.37 High, Bilirubin 1.3 High. Hematology report: White Blood Count 25.08 High, Red Blood Cell 5.66 High, Hemoglobin 16.8 High, Hematocrit 50.0 High. Review of the Nurses Notes dated [DATE] by LVN B documented, Late entry on [DATE] at 11:30 PM, resident's daughter called to report that mother had passed away at the hospital. Telephone Interview on [DATE] at 11:09 AM, LVN B confirmed that he had worked on the night shift on Saturday [DATE]. LVN B said I honestly do not remember if LVN A reported to me at the change of shift that resident #1 was not eating, drinking or that the resident was lethargic on her shift. I called the lab on [DATE] at 10:40 PM, to order the Stat labs and UA at 10:40 PM. I did not notify the attending physician that it was going to take several hours before the lab work could be done. I checked the resident's vital signs at approximately 10:30 PM on that day and I think that the CNA gave her some water. I don't remember too well what happened. I checked the resident at 2:00 AM on [DATE] and she was sleeping. I do not remember the last time that I checked her before the end of the shift. LVN B denied that CNA E had reported to him during his shift that the resident #1 was not drinking water. LVN B said that they had been trained to immediately report any change of condition to the attending physician. LVN B said that CNAs had been trained to immediately report changes in condition to the nurse. In an interview on [DATE] at 7:56 AM, BOM reported that on Monday [DATE] she had received a telephone call from resident #'s daughter to inform her that her mother had passed away at the hospital on [DATE]. She was very upset because she had come to visit her mother on Saturday and she did not look good. The resident was pale, had an ashy skin color to her face, and was unresponsive. She went to look for LVN A and LVN A said that maybe her mother was just tired because they had stayed up late the day before for the mother's day celebration. The daughter reported that she had asked LVN A to send her mother to the hospital because she was very concerned about the way that her mom looked. The daughter reported that one of the CNAs had told her that her mother was not urinating like usual. The BOM stated that later that day [DATE] the daughter for resident #1 came to her office and said, I think it was neglect. The BOM reported that she had written the Grievance form and immediately reported this to the Administrator and Director of Nurses on [DATE]. In an interview on [DATE] at 2:43 PM, CNA D reported that she had been assigned to resident #1 on Saturday [DATE] on the evening shift. CNA D, said I reported to LVN A on [DATE] that the resident #1 did not want to eat or drink liquids and was urinating very small amounts of urine. CNA D reported that they had been trained to immediately report any change of condition to the nurse. Telephone interview on [DATE] at 11:41 AM, CNA E reported that she had been assigned to resident #1 on Saturday [DATE] on the night shift from 10:00 PM to 6:00 AM. CNA E said, LVN B told me at the beginning of the shift on that day, to try and give water to the resident as tolerated. LVN B did not tell me why. I tried to give her water, but the resident would not open her mouth. I finally was able to give her a teaspoon of water and it rolled down the sides of her mouth. I continued to try and give water to resident #1 throughout the night but she would not open her mouth. The resident kept her eyes closed when I talked to her. I reported this to LVN B, and he said that he would go and check the resident. CNA E reported that they had been trained to immediately report any change of condition to the nurse. In an interview on [DATE] 9:27 AM, Director of Nurses (DON) said, We had a mother's celebration at the facility on Friday [DATE] that was over at 8:00 PM to 8:30 PM, and the residents were tired the next day because they usually go to bed at 6:00 PM to 6:30 PM. LVN A called me on [DATE] to report the daughter for resident #1 was at the facility and was concerned about how her mother looked. LVN A reported that she had checked resident #1 and reported that the resident just looked tired and her vital signs were stable. LVN A reported that the doctor had returned her call at 10:00 PM, and gave orders for stat labs and UA. Keep in mind that it was the weekend, so it takes longer for the labs to be done. I don't know if LVN A or LVN B called the doctor to let her know that it was going to be several hours before the lab work was done. If it was me, I would have called the physician right away to let her know that it was going to take several hours to get the labs done. LVN A reported that the resident remained stable throughout the day and evening shift on that day. The DON stated that the BOM wrote a Grievance Report on Monday [DATE] when resident #1's daughter came to report that she was upset because LVN A had not sent her mother to the hospital on Saturday [DATE]. The daughter reported that her mother was not responding and did not look like her usual self. The daughter said, LVN A checked my mother and said that my mother was just tired and asked one of the CNAs to put her back to bed. My mother did not eat her dinner on that day. LVN A my brother on Sunday [DATE] to report that my mother had labored breathing, was lethargic, and did not eat on that day. LVN A told my brother that she was going to send my mother to the hospital for evaluation. In an interview on [DATE] at 5:04 PM, DON reported that they had been having problems with the Lab not doing stat orders within two hours of receiving the physician's orders [REDACTED].#1, and agreed to allow the lab a maximum of two hours to do stat labs. If the Lab cannot draw the labs within the two hour time frame, the nurse needs to immediately report this to the attending physician. Resident #2 Closed record review of the Resident Face Sheet dated [DATE] documented resident #2 was a [AGE] year old female admitted to the facility on [DATE]. Review of the History & Physical dated [DATE] for resident #2 documented in part: [AGE] year old female with a past medical history of [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #2 documented in part: Clear speech, usually understood, usually understands, vision moderately impaired, Brief Interview for Mental Status (BIMS) 13-cognitively intact, extensive assistance of two persons with bed mobility, transfers, and toileting, unsteady when moving from seated to standing position, unsteady moving on and off toilet, and unsteady transfer from surface to surface, Functional Limitation in Range of Motion - no impairment to upper and lower extremities, chair bound, incontinent of bowel and bladder. No pain, receiving scheduled pain medication, No history of falls. Review of the Care Plan revised on [DATE] for resident #2 documented in part: Resident has impaired cognition related to Dementia; Resident on pain medication for neuropathic pain. Administer [MEDICATION NAME] and Tylenol as ordered for pain. Review for pain medication efficacy, assess whether pain intensity acceptable to resident. Activities of Daily Living (ADLs) deficit related to Alzheimer's and Chronic Pain. Resident requires maximum assistance of two persons with transfers; Use a Hoyer Lift and/or Sit to Stand Device for safety. Requires extensive assistance of two persons with ADLs. Review of the Hospital History of Present Illness dated [DATE] at 6:38 PM for resident #2 documented in part: Chief Complaint: Right Femur Fracture. Onset occurred three days ago. Symptom Duration: Since onset. Progression since Onset: Constant. No trauma by history. [AGE] year old female presented to emergency department via EMS accompanied by niece complain of right femur fracture from unknown injury onset 3 days ago. Niece states the patient does not usually walk, and patient states someone was trying to help her into bed when she fell . Nursing home states they do not know of any fall. Niece also reports pallor. Patient was not initially answering questions. Musculoskeletal: Extremity pain to right leg. Neurologic; Oriented X 3. Review of hospital x-ray report dated [DATE] at 8:12 PM, Right Femur Mildly displaced oblique [MEDICAL CONDITION] femur. Due to significant osteopenia it is difficult to ascertain whether this fracture is pathologic. Review of hospital Operative Report dated [DATE] for resident #2 documented in part: Fracture Right Femur fracture closed, supracondylar femur; Procedure Performed: ORIF (open reduction internal fixation). Review of the Event report dated [DATE] at 7:00 AM, written by LVN A documented in part: Resident #2 alleged she fell four days ago. CNA came to report resident #2 did not want to get out of bed because she had pain to the right leg. Resident reported that she fell down four days in her room and a man picked her up and put her to bed. Head to toe assessment done, no bruising, swelling, or redness noted. An abrasion to the left knee measuring 0.5 x 0.5 CM, area light pink. ROM (range of motion) to all extremities moving arms and legs up and down, and side to side. Resident stating she has pain to the right leg but more cramping on right thigh. Nurse Practitioner gave orders for Venous Doppler on [DATE] on the day shift. Telephone interview on [DATE] at 8:26 AM with the niece for resident #2 stated that her aunt, had called her (not able to give specific date) and said that on Friday two women had dropped her and that they had to get a man to come and pick her up. The Niece stated that she visited resident #2 the Monday after she received the phone call and at that point her aunt was yelling with pain from her right knee. She stated that when she touched her knee it was like her aunt was going to faint because of the pain. The niece reported that the facility had sent her aunt to the hospital. Review of the Provider Investigation Report dated [DATE] documented in part: Date of incident [DATE] at 7:00 AM. Allegation: Neglect. Description of Allegation: CNA reported to staff nurse at 7:00 AM, resident #2 did not want to get out of bed because she had sustained a fall four days ago and her legs hurt. A call was placed to the physician and the responsible party on [DATE]. The NP (nurse practitioner) called back and gave orders for a Venous Doppler. Scheduling was not done on Sunday. Monday morning charge nurse could not make arrangements for the venous Doppler to be made as soon as possible and called for an order to do an x-ray. X-ray was done on [DATE] at 3:51 PM, at approximately 5:00 PM, received x-ray results that revealed an acute [MEDICAL CONDITION] femur with posterior displacement. Resident was sent to the hospital. The responsible party for resident #2 called on [DATE] to voice a concern about the care provided to resident #2 while at the nursing facility. The niece reported that her aunt had told her that on [DATE] two female staff members had dropped her when they were placing her on the bed. The niece was upset because the fall had not been reported to her until Sunday [DATE] when the staff c(TRUNCATED)

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibited neglect for 2 of 9 (ID #1 and #2) residents reviewed for neglect. A. On [DATE] at 6:30 PM, resident #1's daughter reported to Licensed Vocational Nurse (LVN A) that her mother did not look right and asked her to send her mother to the hospital. LVN A called the physician at 10:00 PM, and reported that resident #1 did not look like her usual self and orders were received for stat (immediately) labs and UA (urine analysis). LVN A and LVN B failed to immediately notify the attending physician that it was going to take more than five hours for stat labs and UA to be done as ordered. On [DATE] at 5:08 AM, lab collected specimens. The Lab faxed lab results to the facility on [DATE] at 10:10 AM. Resident #1 arrived to the hospital on [DATE] at 10:26 AM and died on [DATE] at 11:35 PM. B. On [DATE] at 7:00 AM, resident #2 reported to LVN A that she had fell down in her room four days and did not want to get out of bed for meals like she usually did because she was having pain to right leg with movement and cramping to the right thigh. LVN A did not immediately report to the attending physician on [DATE] that scheduling of the Venous Doppler could not be done on the weekend. Resident #2 continued to have swelling and pain to the right leg with movement. On [DATE] on the morning shift LVN I failed to immediately report to the attending physician resident #2 had swelling and pain on the right knee with movement and that they were having problems with making arrangements to schedule the Venous Doppler as ordered. On [DATE] at 12:53 PM, physician gave orders for an x-ray of the right knee. X-ray was done [DATE] at 3:51 PM. X-ray results were received at 4:52 PM, documented an Acute [MEDICAL CONDITION] femur with posterior displacement. Physician was notified at 4:45 PM, and resident was sent resident to hospital. On [DATE] an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at actual harm, pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could affect 62 residents that reside on the North side of the facility by placing them at risk of being neglected. The findings include: Resident #1 Closed record review of the Resident Face Sheet dated [DATE] documented resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted back to the facility on [DATE] had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #1 documented in part: Unclear speech, Sometimes understood, Sometimes understands, Cognitive skills severely impaired, extensive assistance of one to two persons with Activities of Daily Living, and incontinent of bowel & bladder. Review of the Care Plan revised on [DATE] for resident #1 documented in part: Resident is incontinent of bowel & bladder. Resident has cognitive loss related to Dementia. Monitor/record/report to physician new on-set of [MEDICAL CONDITION], changes in behavior, altered mental status, wide variation in cognitive function through the day, communication decline, disorientation, lethargy, restlessness, agitation, dehydration and infection. Resident sometimes understood/understands. Requires extensive assistance of ,[DATE] persons with Activities of Daily Living. Review of Hospital emergency room report dated [DATE] documented in part: Resident #1 arrived via EMS (Emergency Medical Services) at 10:24 AM in respiratory distress. Chief Complaint: Onset of respiratory distress yesterday evening. Altered Mental Status. Nursing Home reported resident [MEDICAL CONDITION], patient currently tachy. Not responding, Hypoxic breaths/min on 15 liters per minute of oxygen. Review of the Hospital History & Physical dated [DATE] documented in part: Chief Complaint: Lethargy. Onset of respiratory distress yesterday evening. Altered Mental Status. Not responding. Hypoxic. History of present illness: Resident #1 is a [AGE] year old female with past medical history of [REDACTED]. The patient was found to be less responsive with poor oral intake about a day ago in the nursing home. This morning, patient's condition continues to worsen, therefore, patient was transferred to the ER (emergency room ). In ER, patient was found to be septic and also have pancreatitis. Patient was admitted . Patient is nonviable, therefore could not get information from her. Physical examination: Temperature 99.6, on arrival to the ER, heart rate of 119, respiratory rate of 32, blood pressure ,[DATE], patient is on 15 Liters of oxygen on non-rebreather mask. Mucosa is dry. Positive bilateral sounds with occasional coarse breath sounds. Patient is lethargic.[MEDICAL CONDITION] Screening: Altered Mental Status, decreased urine output, [MEDICAL CONDITION]> 90 BPM (beats per minute. Diagnoses: [REDACTED]. Treated with IV (intravenous hydration). 2)[MEDICAL CONDITION] secondary to acute infectious process. Has been given several boluses of IV fluids in the ER. 3) Hypernatremic dehydration. 4) Urinary Tract Infection. Started on IV antibiotic. 5) Leukocytosis secondary to acute infectious process. Review of the Hospital Lab results dated [DATE] at 11:07 AM, for resident #1 documented in part: White blood cell of 15.10 (High), BUN 39 (High), Hemoglobin 15.9 (High), Sodium 146 (High); Urinalysis (UA) results dated [DATE] at 11:07 AM, Urine color-cloudy, UA Protein 1+, Leuk Est 2+, UA blood 2+, WBC Urine 16 (high). Review of the Hospital Discharge Summary dated [DATE] documented at around 11:35 PM, on [DATE] resident #1 was pronounced dead by 2 RNs (registered nurses). Review of the Grievance Form dated [DATE] written by the (Business Office Manager) BOM documented in part: BOM received telephone call from resident #1's daughter. Daughter reported that she was upset because she came in on Saturday [DATE] to feed her mother and told LVN A that her mother did not look good and asked her to send her mother to the hospital. She reported that her mother was unresponsive, and had a pale/ashy skin color to her face. LVN A told her that her mother was probably just tired because of the event that was held on Friday to celebrate mother's day. LVN A told the daughter that she had called the doctor and got an order for [REDACTED]. The doctors did not know that her mother was in the nursing home. The attending physician told the daughter that LVN A had only reported to her that her mother was not eating and that is why she had only given orders for labs. The daughter also reported that her mother had not voided for one day and that should have been a big flag for nurses to send her mother to the hospital. Review of the Provider Investigation Report dated [DATE] documented in part: Date of incident [DATE] at 6:00 PM. Allegation: Neglect. Description of Allegation: Resident's daughter came in to visit with Business Office Manager (BOM) and Director of Nurses on [DATE] at 11:00 AM, to discuss why her mother was not sent to the hospital on the evening of [DATE] instead of the morning on [DATE]. She alleged that if her mother had been sent out on the 13th instead of putting her to bed it would have been different. She made reference to the hospital nurses making comments about why she did not get her to the hospital sooner. Resident was sent to hospital on the morning of [DATE] due to signs and symptoms of respiratory distress. Allegation of Neglect: Unconfirmed. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by LVN A documented in part: Assigned to resident #1 on [DATE] and [DATE]. At 6:30 PM, resident's daughter was visiting and reported that her mom was not responding to her. I told the daughter that I would be calling the doctor to ask for labs. Received new order for labs on change of shift when giving report to LVN B on the night shift. This nurse next workday (Sunday [DATE]). After breakfast noted resident #1 at Nurses station with shortness of breath, labored breathing. Asked (Certified Nurse Aide) CNA to lay her down and to take vitals. Vital signs abnormal. Called physician and gave orders to send her out. Review of a hand written statement attached to the Provider Investigation Report dated [DATE] written by CNA D documented in part: On [DATE] at 3:00 PM, got resident #1 up and took to dining room. The daughter brought the resident to Nurses station and was telling LVN A, that her mother was not responding LVN A told the daughter that the resident looked tired and asked me to put the resident to bed. The resident looked pale and was incontinent of urine. Not as wet as usual. The daughter told me that her mother didn't want to eat. Went to check resident again, had a small amount of urine on brief. Reported to LVN A. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by CNA (F) documented in part: Assigned to resident #1 on [DATE] and [DATE] on the 6:00 AM to 2:00 PM shift. On Saturday [DATE] resident #1 did not eat breakfast or lunch. Resident was holding food in her mouth. Resident appeared tired. Notified LVN A. Resident was incontinent of urine x 2 on this shift. On Sunday [DATE] at 6:00 AM, resident seemed tired. Sat resident in wheelchair and took her to the dining room. At breakfast resident was breathing hard with mouth opened, eyes rolled back. Resident did not eat breakfast. LVN A was notified. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by CNA E documented in part: I worked on the night shift on [DATE]. When I got there at start of shift LVN B asked me to try and offer water to resident #1. When I attempted to give her water she would not open her mouth. I tried to give her a spoonful of water every hour, but the resident would not open her mouth. I reported this to LVN B. Telephone interview on [DATE] at 4:35 PM, resident's daughter said, On Saturday [DATE] at approximately 5:00 PM to 5:30 PM, I found my mother sitting in her wheelchair in the dining room with her head hanging down and was not responding when I talked to her. My mother looked dead. I asked LVN A to send my mother to the hospital. LVN A told me that my mother was probably just sleepy and asked one of the aides to put my mother to bed. I asked the CNAs on that day, why they had not noted that my mother was unconscious. I tried to feed my mother on that day, she opened her mouth once but could not swallow her pureed food. She was just holding the food in her mouth. I also noted that my mother's disposable brief was dry when I got there and was still dry when I left that day at approximately 7:00 PM to 8:00 PM. I called LVN A later that night and LVN A told me that she had called the doctor and got orders for labs. LVN A told me my mother was ok and resting. My brother was with my mother the day before on Friday during the mother's day celebration and she was fine. My mother could not talk, but was able to answer simple questions by nodding yes and no with her head. On Sunday morning [DATE] LVN A called my brother to tell him that she was sending my mother to the hospital because she was lethargic. I met my brother at the hospital. My mother was almost dead when she got to the hospital. I don't know why LVN A did not call the doctor right away on Saturday to send my mother to the hospital. Maybe she would still be alive. I did call the BOM to tell her that I could not understand, how the LVN A and CNAs did not see that my mother was unconscious. She was rigid and was not her usual self. Telephone interview on [DATE] at 12:45 PM, attending physician reported that LVN A had called her at night on [DATE] to report resident #1 was not looking good and her vital signs were stable. When I talked to LVN A, she did not tell me that the resident was very sick. LVN A never reported to me when she called me on that day that resident #1 had not been eating or drinking fluids, on that day. She never told me that the daughter had reported to her that the resident was not responding and wanted her mother to be sent to the hospital. LVN A did not report to me that the CNAs had reported to her that the resident #1's eyes were rolling, and had decreased urine output. Based on what LVN A reported to me, I just gave orders for stat labs. I depend on the Nurses to accurately assess the residents and immediately report to me any change in condition. LVN A should have called me back right away if she knew that it was going to take several hours before the lab work could be done. On Sunday [DATE] at 9:45 AM, LVN A called me to report that resident #1 was having rapid, labored respirations and lab results had been received. I told LVN A that I was on my way to the nursing home and gave orders to send the resident to the hospital for evaluation. I treated resident #1 at the hospital. When the resident arrived she was almost dead. She was hyperventilating and was septic. This was not an immediate change in condition. The resident most likely had been sick for approximately two days prior to Saturday [DATE] for her to be septic. I'm concerned of how accurately the nurses are assessing the residents when they have a change in condition. Telephone interview on [DATE] at 3:51 PM, with CNA F reported resident #1 was alert, oriented to person, was able to answer simple questions with yes and no, required total assistance of one person with Activities of Daily Living, spoon fed, incontinent of bowel & bladder, and usually ate ,[DATE] percent of her meals. CNA F reported that she had been assigned to resident #1 on Saturday [DATE] on the morning shift. On that day, I got resident out of bed for breakfast at approximately 6:15 AM. I always do her first at the start of the shift. Resident #1 was very weak, and kept her eyes closed all day. Resident #1 was spoon fed. On that day I noted that she just kept the food in her mouth and was not swallowing her food. I tried to give her the shake, but it would roll down the sides of her mouth. I also noted that she was not urinating as much as she usually did. Usually the incontinent brief would be soaked with urine, but on that day not even half a brief was wet. I immediately reported this to LVN A and she asked me to put the resident #1 back to bed. CNA F reported that she had also been assigned to resident #1 on Sunday [DATE] on the morning shift. On that day at approximately 6:15 AM, when got the resident #1 out of bed and sat her in her wheelchair, I noted that the resident appeared to be very weak, and was breathing very rapidly. I wheeled the resident to the dining room and immediately reported the resident's condition to LVN A. Resident #1 refused to eat breakfast on that day. When I tried to give her the shake, it rolled out the sides of her mouth. I immediately reported this to LVN A and she instructed me to put the resident in bed. CNA F reported that they had been trained to immediately report to the charge nurse any changes of condition. In an interview on [DATE] at 1:38 PM, LVN A said, On Saturday [DATE] at approximately 5:30 PM - 6:15 PM, I was at the Nurses station when resident #1's daughter came to tell me that her mother looked different and was not her usual self. When I checked the resident at the Nurses Station, the resident was rigid, clenching teeth, and was able to answer simple questions. I checked her lungs and lung sounds were clear. The resident appeared to be very sleepy but was not lethargic. Based on my assessment the resident just looked tired and was not lethargic. I asked the CNA to put the resident back to bed. I called the doctor and she gave orders for stat labs and UA like 15 minutes before the start of the night shift. I was very busy doing other stuff so I asked LVN B to write the Telephone Order for the lab work. I don't remember who called the lab. On Sunday [DATE] I made walking rounds at approximately 6:30 AM - 7:30 AM, and noted resident #1 was in her bed asleep. LVN B reported to me at the change of shift that lab results were still pending. I don't remember what time I followed up with the lab because I was busy supervising the breakfast meal in the dining room and taking care of other residents. I don't recall the CNAs reporting to me on [DATE] and [DATE] that resident #1 was not eating/drinking, or that resident had a change in condition. On Sunday at approximately 9:45 AM, resident #1 was sitting in front of the Nurses station and I noted resident #1 had rapid, and labored respirations. I called the physician and got orders to send the resident to the emergency room . LVN A said that they had been trained to immediately report any change of condition to the attending physician and to immediately send the resident to the hospital upon family's request. LVN A reported that CNAs had been trained to immediately report changes in condition to the nurse. Review of the Nurses Notes dated [DATE] written by LVN A documented in part: At 6:30 PM, Daughter at bedside, resident up in wheelchair. Daughter stating mother does not look right and she's not responding. Clenching jaw and teeth, response was a whisper, unable to understand. Vital Signs-Blood pressure ,[DATE], Oxygen Saturation 98%, Pulse 100, respirations 20, and Temperature 98.4. Placed call to attending physician new orders for labs and urine analysis received via text at 10:00 PM. Will continue to monitor. Review of SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] for resident #1 written by LVN A documented in part: Situation: Shortness of breath and drop in pulse rate started on [DATE]. Since this started it has gotten worse. Date of transfer [DATE]. Acute change in condition. Vital signs blood pressure ,[DATE], heart rate 44, respirations 32, temperature 97.4; oxygen at 2 liters by nasal cannula. Resident with decreased food and water intake, shortness of breath, labored breathing and drop in pulse rate. Nurses Note: This nurse (LVN A) noted resident with labored breathing, low pulse, and lethargic. Physician called orders given to send resident to emergency room . Review of the Meal Intake Record dated [DATE] through [DATE] documented resident #1 ate 75% to 100% of her meals. Meal Intake Record dated [DATE] documented resident #1 ate 50% of breakfast, 25% of lunch, and refused dinner. Meal Intake Record dated [DATE] documented resident #1 refused breakfast. Review of the Physician's Telephone Order dated [DATE] at 10:00 PM, written by LVN B documented UA (urine analysis), CBC (complete blood count), CMP (comprehensive metabolic panel) stat (immediately). Review of the Nurses Notes dated [DATE] written by LVN B documented in part: At 10:10 PM, called Lab for stat orders for CBC, CMP and urine analysis. Dispatcher notified nurse that the soonest labs can be done will be at 3:00 AM. Vital Signs-Blood pressure ,[DATE], Oxygen Saturation 97%, Pulse 94, respirations 18, and Temperature 98.2. At 10:40 PM, Resident resting in bed with eyes closed, no signs of distress. Review of the Nurses Notes dated [DATE] written by LVN B documented [DATE] at 3:40 AM, labs were drawn, resident with no complaints. Review of the Lab Results dated [DATE] for resident #1 documented in part: Specimens collected at 5:08 AM. UA report: Urine slightly cloudy, [MEDICATION NAME]-Trace, Blood-Moderate, LEUK - EST-Moderate, WBC Urine TNTC-Abnormal, Bacteria-2+, [MEDICATION NAME]-2+. General Chemistry report: Potassium 5.2 High, Chloride 109 High, Carbon [MEDICATION NAME] 13 Low, Glucose 128 High, BUN 43 High, Creatinine 2.37 High, Bilirubin 1.3 High. Hematology report: White Blood Count 25.08 High, Red Blood Cell 5.66 High, Hemoglobin 16.8 High, Hematocrit 50.0 High. Review of the Nurses Notes dated [DATE] by LVN B documented, Late entry on [DATE] at 11:30 PM, resident's daughter called to report that mother had passed away at the hospital. Telephone Interview on [DATE] at 11:09 AM, LVN B confirmed that he had worked on the night shift on Saturday [DATE]. LVN B said I honestly do not remember if LVN A reported to me at the change of shift that resident #1 was not eating, drinking or that the resident was lethargic on her shift. I called the lab on [DATE] at 10:40 PM, to order the Stat labs and UA at 10:40 PM. I did not notify the attending physician that it was going to take several hours before the lab work could be done. I checked the resident's vital signs at approximately 10:30 PM on that day and I think that the CNA gave her some water. I don't remember too well what happened. I checked the resident at 2:00 AM on [DATE] and she was sleeping. I do not remember the last time that I checked her before the end of the shift. LVN B denied that CNA E had reported to him during his shift that the resident #1 was not drinking water. LVN B said that they had been trained to immediately report any change of condition to the attending physician. LVN B said that CNAs had been trained to immediately report changes in condition to the nurse. In an interview on [DATE] at 7:56 AM, BOM reported that on Monday [DATE] she had received a telephone call from resident #'s daughter to inform her that her mother had passed away at the hospital on [DATE]. She was very upset because she had come to visit her mother on Saturday and she did not look good. The resident was pale, had an ashy skin color to her face, and was unresponsive. She went to look for LVN A and LVN A said that maybe her mother was just tired because they had stayed up late the day before for the mother's day celebration. The daughter reported that she had asked LVN A to send her mother to the hospital because she was very concerned about the way that her mom looked. The daughter reported that one of the CNAs had told her that her mother was not urinating like usual. The BOM stated that later that day [DATE] the daughter for resident #1 came to her office and said, I think it was neglect. The BOM reported that she had written the Grievance form and immediately reported this to the Administrator and Director of Nurses on [DATE]. In an interview on [DATE] at 2:43 PM, CNA D reported that she had been assigned to resident #1 on Saturday [DATE] on the evening shift. CNA D, said I reported to LVN A on [DATE] that the resident #1 did not want to eat or drink liquids and was urinating very small amounts of urine. CNA D reported that they had been trained to immediately report any change of condition to the nurse. Telephone interview on [DATE] at 11:41 AM, CNA E reported that she had been assigned to resident #1 on Saturday [DATE] on the night shift from 10:00 PM to 6:00 AM. CNA E said, LVN B told me at the beginning of the shift on that day, to try and give water to the resident as tolerated. LVN B did not tell me why. I tried to give her water, but the resident would not open her mouth. I finally was able to give her a teaspoon of water and it rolled down the sides of her mouth. I continued to try and give water to resident #1 throughout the night but she would not open her mouth. The resident kept her eyes closed when I talked to her. I reported this to LVN B, and he said that he would go and check the resident. CNA E reported that they had been trained to immediately report any change of condition to the nurse. In an interview on [DATE] 9:27 AM, Director of Nurses (DON) said, We had a mother's celebration at the facility on Friday [DATE] that was over at 8:00 PM to 8:30 PM, and the residents were tired the next day because they usually go to bed at 6:00 PM to 6:30 PM. LVN A called me on [DATE] to report the daughter for resident #1 was at the facility and was concerned about how her mother looked. LVN A reported that she had checked resident #1 and reported that the resident just looked tired and her vital signs were stable. LVN A reported that the doctor had returned her call at 10:00 PM, and gave orders for stat labs and UA. Keep in mind that it was the weekend, so it takes longer for the labs to be done. I don't know if LVN A or LVN B called the doctor to let her know that it was going to be several hours before the lab work was done. If it was me, I would have called the physician right away to let her know that it was going to take several hours to get the labs done. LVN A reported that the resident remained stable throughout the day and evening shift on that day. The DON stated that the BOM wrote a Grievance Report on Monday [DATE] when resident #1's daughter came to report that she was upset because LVN A had not sent her mother to the hospital on Saturday [DATE]. The daughter reported that her mother was not responding and did not look like her usual self. The daughter said, LVN A checked my mother and said that my mother was just tired and asked one of the CNAs to put her back to bed. My mother did not eat her dinner on that day. LVN A my brother on Sunday [DATE] to report that my mother had labored breathing, was lethargic, and did not eat on that day. LVN A told my brother that she was going to send my mother to the hospital for evaluation. In an interview on [DATE] at 5:04 PM, DON reported that they had been having problems with the Lab not doing stat orders within two hours of receiving the physician's orders [REDACTED].#1, and agreed to allow the lab a maximum of two hours to do stat labs. If the Lab cannot draw the labs within the two hour time frame, the nurse needs to immediately report this to the attending physician. Resident #2 Closed record review of the Resident Face Sheet dated [DATE] documented resident #2 was a [AGE] year old female admitted to the facility on [DATE]. Review of the History & Physical dated [DATE] for resident #2 documented in part: [AGE] year old female with a past medical history of [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #2 documented in part: Clear speech, usually understood, usually understands, vision moderately impaired, Brief Interview for Mental Status (BIMS) 13-cognitively intact, extensive assistance of two persons with bed mobility, transfers, and toileting, unsteady when moving from seated to standing position, unsteady moving on and off toilet, and unsteady transfer from surface to surface, Functional Limitation in Range of Motion - no impairment to upper and lower extremities, chair bound, incontinent of bowel and bladder. No pain, receiving scheduled pain medication, No history of falls. Review of the Care Plan revised on [DATE] for resident #2 documented in part: Resident has impaired cognition related to Dementia; Resident on pain medication for neuropathic pain. Administer [MEDICATION NAME] and Tylenol as ordered for pain. Review for pain medication efficacy, assess whether pain intensity acceptable to resident. Activities of Daily Living (ADLs) deficit related to Alzheimer's and Chronic Pain. Resident requires maximum assistance of two persons with transfers; Use a Hoyer Lift and/or Sit to Stand Device for safety. Requires extensive assistance of two persons with ADLs. Review of the Hospital History of Present Illness dated [DATE] at 6:38 PM for resident #2 documented in part: Chief Complaint: Right Femur Fracture. Onset occurred three days ago. Symptom Duration: Since onset. Progression since Onset: Constant. No trauma by history. [AGE] year old female presented to emergency department via EMS accompanied by niece complain of right femur fracture from unknown injury onset 3 days ago. Niece states the patient does not usually walk, and patient states someone was trying to help her into bed when she fell . Nursing home states they do not know of any fall. Niece also reports pallor. Patient was not initially answering questions. Muscoloskeletal: Extremity pain to right leg. Neurologic; Oriented X 3. Review of hospital x-ray report dated [DATE] at 8:12 PM, Right Femur Mildly displaced oblique [MEDICAL CONDITION] femur. Due to significant osteopenia it is difficult to ascertain whether this fracture is pathologic. Review of hospital Operative Report dated [DATE] for resident #2 documented in part: Fracture Right Femur fracture closed, supracondylar femur; Procedure Performed: ORIF (open reduction internal fixation). Review of the Event report dated [DATE] at 7:00 AM, written by LVN A documented in part: Resident #2 alleged she fell four days ago. CNA came to report resident #2 did not want to get out of bed because she had pain to the right leg. Resident reported that she fell down four days in her room and a man picked her up and put her to bed. Head to toe assessment done, no bruising, swelling, or redness noted. An abrasion to the left knee measuring 0.5 x 0.5 CM, area light pink. ROM (range of motion) to all extremities moving arms and legs up and down, and side to side. Resident stating she has pain to the right leg but more cramping on right thigh. Nurse Practitioner gave orders for Venous Doppler on [DATE] on the day shift. Telephone interview on [DATE] at 8:26 AM with the niece for resident #2 stated that her aunt, had called her (not able to give specific date) and said that on Friday two women had dropped her and that they had to get a man to come and pick her up. The Niece stated that she visited resident #2 the Monday after she received the phone call and at that point her aunt was yelling with pain from her right knee. She stated that when she touched her knee it was like her aunt was going to faint because of the pain. The niece reported that the facility had sent her aunt to the hospital. Review of the Provider Investigation Report dated [DATE] documented in part: Date of incident [DATE] at 7:00 AM. Allegation: Neglect. Description of Allegation: CNA reported to staff nurse at 7:00 AM, resident #2 did not want to get out of bed because she had sustained a fall four days ago and her legs hurt. A call was placed to the physician and the responsible party on [DATE]. The NP (nurse practitioner) called back and gave orders for a Venous Doppler. Scheduling was not done on Sunday. Monday morning charge nurse could not make arrangements for the venous Doppler to be made as soon as possible and called for an order to do an x-ray. X-ray was done on [DATE] at 3:51 PM, at approximately 5:00 PM, received x-ray results that revealed an acute [MEDICAL CONDITION] femur with posterior displacement. Resident was sent to the hospital. The responsible party for resident #2 called on [DATE] to voice a concern about the care provided to resident #2 while at the nursing facility. The niece reported that her aunt had told her that on [DATE] two female staff members had dropped her when they were placing her on the bed. The niece was upset because the fall had not been reported to her until Sunday [DATE] when the staff called to report that her aunt had been complaining of leg pain. Allegation of Neglect: Unconfirmed. Review(TRUNCATED)

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibited mistreatment, neglect, and abuse for 2 of 9 (ID #1 and #2) residents reviewed for neglect. A. On [DATE] at 6:30 PM, resident #1's daughter reported to Licensed Vocational Nurse (LVN A) that her mother did not look right and asked her to send her mother to the hospital. LVN A called the physician at 10:00 PM, and reported that resident #1 did not look like her usual self and orders were received for stat (immediately) labs and UA (urine analysis). LVN A and LVN B failed to immediately notify the attending physician that it was going to take more than five hours for stat labs and UA to be done as ordered. On [DATE] at 5:08 AM, lab collected specimens. The Lab faxed lab results to the facility on [DATE] at 10:10 AM. Resident #1 arrived to the hospital on [DATE] at 10:26 AM and died on [DATE] at 11:35 PM. B. On [DATE] at 7:00 AM, resident #2 reported to LVN A that she had fell down in her room four days prior and did not want to get out of bed for meals like she usually did because she was having pain to right leg with movement and cramping to the right thigh. LVN A did not immediately report to the attending physician on [DATE] that scheduling of the Venous Doppler could not be done on the weekend. Resident #2 continued to have swelling and pain to the right leg with movement. On [DATE] on the morning shift LVN I failed to immediately report to the attending physician resident #2 had swelling and pain on the right knee with movement and that they were having problems with making arrangements to schedule the Venous Doppler as ordered. On [DATE] at 12:53 PM, physician gave orders for an x-ray of the right knee. X-ray was done [DATE] at 3:51 PM. X-ray results were received at 4:52 PM, documented an Acute [MEDICAL CONDITION] femur with posterior displacement. Physician was notified at 4:45 PM, and resident was sent resident to hospital. On [DATE] an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at actual harm, pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could affect 62 residents that reside on the North side of the facility by placing them at risk of being neglected. The findings include: Review of the facility's policy on Abuse/Neglect revised [DATE] provided by the DON on [DATE] documented in part: The resident has the right to be free of neglect. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged neglect and situations that may constitute neglect to any resident in the facility. All reports of abuse or suspicion of neglect will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. The facility will be responsible to identify, correct, and intervene in situations of possible neglect. Review of the facility's policy on Notifying the Physician of Significant Change in Condition in Status revised on [DATE] provided by the DON on [DATE] documented in part: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change is status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The nurse is responsible, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 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 resident's status, and response to interventions. Review of the facility's undated policy on SBAR/Progress Notes provided by the DON on [DATE] documented in part: For use by nursing home licensed staff for evaluation and communication of acute changes in condition to MD (physician), NP (nurse practitioner), and/or PA (physician assistant). Upon discovery of a resident change in condition you must assess the resident. Notify the Physician/NP/PA of your assessment findings. Document any new orders and responsible party notification on this form. This is your documentation for this change in condition. Change in condition: Immediate Notification of any symptoms, sign or apparent discomfort that is: Acute or Sudden in onset, and a Marked Change in relation to usual symptoms and signs, or unrelieved pain by measures already prescribed. Any STAT orders for labs, x-ray etc. must be initiated within ,[DATE] hour window. For any reason STAT orders cannot be initiated within ,[DATE] hour window notify supervisor and MD/NP/PA/Supervisor. Follow up with results. Document chain of events and communication process in the Nurses Notes. Resident #1 Closed record review of the Resident Face Sheet dated [DATE] documented resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted back to the facility on [DATE] had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #1 documented in part: Unclear speech, Sometimes understood, Sometimes understands, Cognitive skills severely impaired, extensive assistance of one to two persons with Activities of Daily Living, and incontinent of bowel & bladder. Review of the Care Plan revised on [DATE] for resident #1 documented in part: Resident is incontinent of bowel & bladder. Resident has cognitive loss related to Dementia. Monitor/record/report to physician new on-set of [MEDICAL CONDITION], changes in behavior, altered mental status, wide variation in cognitive function through the day, communication decline, disorientation, lethargy, restlessness, agitation, dehydration and infection. Resident sometimes understood/understands. Requires extensive assistance of ,[DATE] persons with Activities of Daily Living. Review of Hospital emergency room report dated [DATE] documented in part: Resident #1 arrived via EMS (Emergency Medical Services) at 10:24 AM in respiratory distress. Chief Complaint: Onset of respiratory distress yesterday evening. Altered Mental Status. Nursing Home reported resident [MEDICAL CONDITION], patient currently tachy. Not responding, Hypoxic breaths/min on 15 liters per minute of oxygen. Review of the Hospital History & Physical dated [DATE] documented in part: Chief Complaint: Lethargy. Onset of respiratory distress yesterday evening. Altered Mental Status. Not responding. Hypoxic. History of present illness: Resident #1 is a [AGE] year old female with past medical history of [REDACTED]. The patient was found to be less responsive with poor oral intake about a day ago in the nursing home. This morning, patient's condition continues to worsen, therefore, patient was transferred to the ER (emergency room ). In ER, patient was found to be septic and also have pancreatitis. Patient was admitted . Patient is nonviable, therefore could not get information from her. Physical examination: Temperature 99.6, on arrival to the ER, heart rate of 119, respiratory rate of 32, blood pressure ,[DATE], patient is on 15 Liters of oxygen on non-rebreather mask. Mucosa is dry. Positive bilateral sounds with occasional coarse breath sounds. Patient is lethargic.[MEDICAL CONDITION] Screening: Altered Mental Status, decreased urine output, [MEDICAL CONDITION]> 90 BPM (beats per minute. Diagnoses: [REDACTED]. Treated with IV (intravenous hydration). 2)[MEDICAL CONDITION] secondary to acute infectious process. Has been given several boluses of IV fluids in the ER. 3) Hypernatremic dehydration. 4) Urinary Tract Infection. Started on IV antibiotic. 5) Leukocytosis secondary to acute infectious process. Review of the Hospital Lab results dated [DATE] at 11:07 AM, for resident #1 documented in part: White blood cell of 15.10 (High), BUN 39 (High), Hemoglobin 15.9 (High), Sodium 146 (High); Urinalysis (UA) results dated [DATE] at 11:07 AM, Urine color-cloudy, UA Protein 1+, Leuk Est 2+, UA blood 2+, WBC Urine 16 (high). Review of the Hospital Discharge Summary dated [DATE] documented at around 11:35 PM, on [DATE] resident #1 was pronounced dead by 2 RNs (registered nurses). Review of the Grievance Form dated [DATE] written by the (Business Office Manager) BOM documented in part: BOM received telephone call from resident #1's daughter. Daughter reported that she was upset because she came in on Saturday [DATE] to feed her mother and told LVN A that her mother did not look good and asked her to send her mother to the hospital. She reported that her mother was unresponsive, and had a pale/ashy skin color to her face. LVN A told her that her mother was probably just tired because of the event that was held on Friday to celebrate mother's day. LVN A told the daughter that she had called the doctor and got an order for [REDACTED]. The doctors did not know that her mother was in the nursing home. The attending physician told the daughter that LVN A had only reported to her that her mother was not eating and that is why she had only given orders for labs. The daughter also reported that her mother had not voided for one day and that should have been a big flag for nurses to send her mother to the hospital. Review of the Provider Investigation Report dated [DATE] documented in part: Date of incident [DATE] at 6:00 PM. Allegation: Neglect. Description of Allegation: Resident's daughter came in to visit with Business Office Manager (BOM) and Director of Nurses on [DATE] at 11:00 AM, to discuss why her mother was not sent to the hospital on the evening of [DATE] instead of the morning on [DATE]. She alleged that if her mother had been sent out on the 13th instead of putting her to bed it would have been different. She made reference to the hospital nurses making comments about why she did not get her to the hospital sooner. Resident was sent to hospital on the morning of [DATE] due to signs and symptoms of respiratory distress. Allegation of Neglect: Unconfirmed. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by LVN A documented in part: Assigned to resident #1 on [DATE] and [DATE]. At 6:30 PM, resident's daughter was visiting and reported that her mom was not responding to her. I told the daughter that I would be calling the doctor to ask for labs. Received new order for labs on change of shift when giving report to LVN B on the night shift. This nurse next workday (Sunday [DATE]). After breakfast noted resident #1 at Nurses station with shortness of breath, labored breathing. Asked (Certified Nurse Aide) CNA to lay her down and to take vitals. Vital signs abnormal. Called physician and gave orders to send her out. Review of a hand written statement attached to the Provider Investigation Report dated [DATE] written by CNA D documented in part: On [DATE] at 3:00 PM, got resident #1 up and took to dining room. The daughter brought the resident to Nurses station and was telling LVN A, that her mother was not responding LVN A told the daughter that the resident looked tired and asked me to put the resident to bed. The resident looked pale and was incontinent of urine. Not as wet as usual. The daughter told me that her mother didn't want to eat. Went to check resident again, had a small amount of urine on brief. Reported to LVN A. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by CNA (F) documented in part: Assigned to resident #1 on [DATE] and [DATE] on the 6:00 AM to 2:00 PM shift. On Saturday [DATE] resident #1 did not eat breakfast or lunch. Resident was holding food in her mouth. Resident appeared tired. Notified LVN A. Resident was incontinent of urine x 2 on this shift. On Sunday [DATE] at 6:00 AM, resident seemed tired. Sat resident in wheelchair and took her to the dining room. At breakfast resident was breathing hard with mouth opened, eyes rolled back. Resident did not eat breakfast. LVN A was notified. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by CNA E documented in part: I worked on the night shift on [DATE]. When I got there at start of shift LVN B asked me to try and offer water to resident #1. When I attempted to give her water she would not open her mouth. I tried to give her a spoonful of water every hour, but the resident would not open her mouth. I reported this to LVN B. Telephone interview on [DATE] at 4:35 PM, resident's daughter said, On Saturday [DATE] at approximately 5:00 PM to 5:30 PM, I found my mother sitting in her wheelchair in the dining room with her head hanging down and was not responding when I talked to her. My mother looked dead. I asked LVN A to send my mother to the hospital. LVN A told me that my mother was probably just sleepy and asked one of the aides to put my mother to bed. I asked the CNAs on that day, why they had not noted that my mother was unconscious. I tried to feed my mother on that day, she opened her mouth once but could not swallow her pureed food. She was just holding the food in her mouth. I also noted that my mother's disposable brief was dry when I got there and was still dry when I left that day at approximately 7:00 PM to 8:00 PM. I called LVN A later that night and LVN A told me that she had called the doctor and got orders for labs. LVN A told me my mother was ok and resting. My brother was with my mother the day before on Friday during the mother's day celebration and she was fine. My mother could not talk, but was able to answer simple questions by nodding yes and no with her head. On Sunday morning [DATE] LVN A called my brother to tell him that she was sending my mother to the hospital because she was lethargic. I met my brother at the hospital. My mother was almost dead when she got to the hospital. I don't know why LVN A did not call the doctor right away on Saturday to send my mother to the hospital. Maybe she would still be alive. I did call the BOM to tell her that I could not understand, how the LVN A and CNAs did not see that my mother was unconscious. She was rigid and was not her usual self. Telephone interview on [DATE] at 12:45 PM, attending physician reported that LVN A had called her at night on [DATE] to report resident #1 was not looking good and her vital signs were stable. When I talked to LVN A, she did not tell me that the resident was very sick. LVN A never reported to me when she called me on that day that resident #1 had not been eating or drinking fluids, on that day. She never told me that the daughter had reported to her that the resident was not responding and wanted her mother to be sent to the hospital. LVN A did not report to me that the CNAs had reported to her that the resident #1's eyes were rolling, and had decreased urine output. Based on what LVN A reported to me, I just gave orders for stat labs. I depend on the Nurses to accurately assess the residents and immediately report to me any change in condition. LVN A should have called me back right away if she knew that it was going to take several hours before the lab work could be done. On Sunday [DATE] at 9:45 AM, LVN A called me to report that resident #1 was having rapid, labored respirations and lab results had been received. I told LVN A that I was on my way to the nursing home and gave orders to send the resident to the hospital for evaluation. I treated resident #1 at the hospital. When the resident arrived she was almost dead. She was hyperventilating and was septic. This was not an immediate change in condition. The resident most likely had been sick for approximately two days prior to Saturday [DATE] for her to be septic. I'm concerned of how accurately the nurses are assessing the residents when they have a change in condition. Telephone interview on [DATE] at 3:51 PM, with CNA F reported resident #1 was alert, oriented to person, was able to answer simple questions with yes and no, required total assistance of one person with Activities of Daily Living, spoon fed, incontinent of bowel & bladder, and usually ate ,[DATE] percent of her meals. CNA F reported that she had been assigned to resident #1 on Saturday [DATE] on the morning shift. On that day, I got resident out of bed for breakfast at approximately 6:15 AM. I always do her first at the start of the shift. Resident #1 was very weak, and kept her eyes closed all day. Resident #1 was spoon fed. On that day I noted that she just kept the food in her mouth and was not swallowing her food. I tried to give her the shake, but it would roll down the sides of her mouth. I also noted that she was not urinating as much as she usually did. Usually the incontinent brief would be soaked with urine, but on that day not even half a brief was wet. I immediately reported this to LVN A and she asked me to put the resident #1 back to bed. CNA F reported that she had also been assigned to resident #1 on Sunday [DATE] on the morning shift. On that day at approximately 6:15 AM, when got the resident #1 out of bed and sat her in her wheelchair, I noted that the resident appeared to be very weak, and was breathing very rapidly. I wheeled the resident to the dining room and immediately reported the resident's condition to LVN A. Resident #1 refused to eat breakfast on that day. When I tried to give her the shake, it rolled out the sides of her mouth. I immediately reported this to LVN A and she instructed me to put the resident in bed. CNA F reported that they had been trained to immediately report to the charge nurse any changes of condition. In an interview on [DATE] at 1:38 PM, LVN A said, On Saturday [DATE] at approximately 5:30 PM - 6:15 PM, I was at the Nurses station when resident #1's daughter came to tell me that her mother looked different and was not her usual self. When I checked the resident at the Nurses Station, the resident was rigid, clenching teeth, and was able to answer simple questions. I checked her lungs and lung sounds were clear. The resident appeared to be very sleepy but was not lethargic. Based on my assessment the resident just looked tired and was not lethargic. I asked the CNA to put the resident back to bed. I called the doctor and she gave orders for stat labs and UA like 15 minutes before the start of the night shift. I was very busy doing other stuff so I asked LVN B to write the Telephone Order for the lab work. I don't remember who called the lab. On Sunday [DATE] I made walking rounds at approximately 6:30 AM - 7:30 AM, and noted resident #1 was in her bed asleep. LVN B reported to me at the change of shift that lab results were still pending. I don't remember what time I followed up with the lab because I was busy supervising the breakfast meal in the dining room and taking care of other residents. I don't recall the CNAs reporting to me on [DATE] and [DATE] that resident #1 was not eating/drinking, or that resident had a change in condition. On Sunday at approximately 9:45 AM, resident #1 was sitting in front of the Nurses station and I noted resident #1 had rapid, and labored respirations. I called the physician and got orders to send the resident to the emergency room . LVN A said that they had been trained to immediately report any change of condition to the attending physician and to immediately send the resident to the hospital upon family's request. LVN A reported that CNAs had been trained to immediately report changes in condition to the nurse. Review of the Nurses Notes dated [DATE] written by LVN A documented in part: At 6:30 PM, Daughter at bedside, resident up in wheelchair. Daughter stating mother does not look right and she's not responding. Clenching jaw and teeth, response was a whisper, unable to understand. Vital Signs-Blood pressure ,[DATE], Oxygen Saturation 98%, Pulse 100, respirations 20, and Temperature 98.4. Placed call to attending physician new orders for labs and urine analysis received via text at 10:00 PM. Will continue to monitor. Review of SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] for resident #1 written by LVN A documented in part: Situation: Shortness of breath and drop in pulse rate started on [DATE]. Since this started it has gotten worse. Date of transfer [DATE]. Acute change in condition. Vital signs blood pressure ,[DATE], heart rate 44, respirations 32, temperature 97.4; oxygen at 2 liters by nasal cannula. Resident with decreased food and water intake, shortness of breath, labored breathing and drop in pulse rate. Nurses Note: This nurse (LVN A) noted resident with labored breathing, low pulse, and lethargic. Physician called orders given to send resident to emergency room . Review of the Meal Intake Record dated [DATE] through [DATE] documented resident #1 ate 75% to 100% of her meals. Meal Intake Record dated [DATE] documented resident #1 ate 50% of breakfast, 25% of lunch, and refused dinner. Meal Intake Record dated [DATE] documented resident #1 refused breakfast. Review of the Physician's Telephone Order dated [DATE] at 10:00 PM, written by LVN B documented UA (urine analysis), CBC (complete blood count), CMP (comprehensive metabolic panel) stat (immediately). Review of the Nurses Notes dated [DATE] written by LVN B documented in part: At 10:10 PM, called Lab for stat orders for CBC, CMP and urine analysis. Dispatcher notified nurse that the soonest labs can be done will be at 3:00 AM. Vital Signs-Blood pressure ,[DATE], Oxygen Saturation 97%, Pulse 94, respirations 18, and Temperature 98.2. At 10:40 PM, Resident resting in bed with eyes closed, no signs of distress. Review of the Nurses Notes dated [DATE] written by LVN B documented [DATE] at 3:40 AM, labs were drawn, resident with no complaints. Review of the Lab Results dated [DATE] for resident #1 documented in part: Specimens collected at 5:08 AM. UA report: Urine slightly cloudy, [MEDICATION NAME]-Trace, Blood-Moderate, LEUK - EST-Moderate, WBC Urine TNTC-Abnormal, Bacteria-2+, [MEDICATION NAME]-2+. General Chemistry report: Potassium 5.2 High, Chloride 109 High, Carbon [MEDICATION NAME] 13 Low, Glucose 128 High, BUN 43 High, Creatinine 2.37 High, Bilirubin 1.3 High. Hematology report: White Blood Count 25.08 High, Red Blood Cell 5.66 High, Hemoglobin 16.8 High, Hematocrit 50.0 High. Review of the Nurses Notes dated [DATE] by LVN B documented, Late entry on [DATE] at 11:30 PM, resident's daughter called to report that mother had passed away at the hospital. Telephone Interview on [DATE] at 11:09 AM, LVN B confirmed that he had worked on the night shift on Saturday [DATE]. LVN B said I honestly do not remember if LVN A reported to me at the change of shift that resident #1 was not eating, drinking or that the resident was lethargic on her shift. I called the lab on [DATE] at 10:40 PM, to order the Stat labs and UA at 10:40 PM. I did not notify the attending physician that it was going to take several hours before the lab work could be done. I checked the resident's vital signs at approximately 10:30 PM on that day and I think that the CNA gave her some water. I don't remember too well what happened. I checked the resident at 2:00 AM on [DATE] and she was sleeping. I do not remember the last time that I checked her before the end of the shift. LVN B denied that CNA E had reported to him during his shift that the resident #1 was not drinking water. LVN B said that they had been trained to immediately report any change of condition to the attending physician. LVN B said that CNAs had been trained to immediately report changes in condition to the nurse. In an interview on [DATE] at 7:56 AM, BOM reported that on Monday [DATE] she had received a telephone call from resident #'s daughter to inform her that her mother had passed away at the hospital on [DATE]. She was very upset because she had come to visit her mother on Saturday and she did not look good. The resident was pale, had an ashy skin color to her face, and was unresponsive. She went to look for LVN A and LVN A said that maybe her mother was just tired because they had stayed up late the day before for the mother's day celebration. The daughter reported that she had asked LVN A to send her mother to the hospital because she was very concerned about the way that her mom looked. The daughter reported that one of the CNAs had told her that her mother was not urinating like usual. The BOM stated that later that day [DATE] the daughter for resident #1 came to her office and said, I think it was neglect. The BOM reported that she had written the Grievance form and immediately reported this to the Administrator and Director of Nurses on [DATE]. In an interview on [DATE] at 2:43 PM, CNA D reported that she had been assigned to resident #1 on Saturday [DATE] on the evening shift. CNA D, said I reported to LVN A on [DATE] that the resident #1 did not want to eat or drink liquids and was urinating very small amounts of urine. CNA D reported that they had been trained to immediately report any change of condition to the nurse. Telephone interview on [DATE] at 11:41 AM, CNA E reported that she had been assigned to resident #1 on Saturday [DATE] on the night shift from 10:00 PM to 6:00 AM. CNA E said, LVN B told me at the beginning of the shift on that day, to try and give water to the resident as tolerated. LVN B did not tell me why. I tried to give her water, but the resident would not open her mouth. I finally was able to give her a teaspoon of water and it rolled down the sides of her mouth. I continued to try and give water to resident #1 throughout the night but she would not open her mouth. The resident kept her eyes closed when I talked to her. I reported this to LVN B, and he said that he would go and check the resident. CNA E reported that they had been trained to immediately report any change of condition to the nurse. In an interview on [DATE] 9:27 AM, Director of Nurses (DON) said, We had a mother's celebration at the facility on Friday [DATE] that was over at 8:00 PM to 8:30 PM, and the residents were tired the next day because they usually go to bed at 6:00 PM to 6:30 PM. LVN A called me on [DATE] to report the daughter for resident #1 was at the facility and was concerned about how her mother looked. LVN A reported that she had checked resident #1 and reported that the resident just looked tired and her vital signs were stable. LVN A reported that the doctor had returned her call at 10:00 PM, and gave orders for stat labs and UA. Keep in mind that it was the weekend, so it takes longer for the labs to be done. I don't know if LVN A or LVN B called the doctor to let her know that it was going to be several hours before the lab work was done. If it was me, I would have called the physician right away to let her know that it was going to take several hours to get the labs done. LVN A reported that the resident remained stable throughout the day and evening shift on that day. The DON stated that the BOM wrote a Grievance Report on Monday [DATE] when resident #1's daughter came to report that she was upset because LVN A had not sent her mother to the hospital on Saturday [DATE]. The daughter reported that her mother was not responding and did not look like her usual self. The daughter said, LVN A checked my mother and said that my mother was just tired and asked one of the CNAs to put her back to bed. My mother did not eat her dinner on that day. LVN A my brother on Sunday [DATE] to report that my mother had labored breathing, was lethargic, and did not eat on that day. LVN A told my brother that she was going to send my mother to the hospital for evaluation. In an interview on [DATE] at 5:04 PM, DON reported that they had been having problems with the Lab not doing stat orders within two hours of receiving the physician's orders [REDACTED].#1, and agreed to allow the lab a maximum of two hours to do stat labs. If the Lab cannot draw the labs within the two hour time frame, the nurse needs to immediately report this to the attending physician. Resident #2 Closed record review of the Resident Face Sheet dated [DATE] documented resident #2 was a [AGE] year old female admitted to the facility on [DATE]. Review of the History & Physical dated [DATE] for resident #2 documented in part: [AGE] year old female with a past medical history of [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #2 documented in part: Clear speech, usually understood, usually understands, vision moderately impaired, Brief Interview for Mental Status (BIMS) 13-cognitively intact, extensive assistance of two persons with bed mobility, transfers, and toileting, unsteady when moving from seated to standing position, unsteady moving on and off toilet, and unsteady transfer from surface to surface, Functional Limitation in Range of Motion - no impairment to upper and lower extremities, chair bound, incontinent of bowel and bladder. No pain, receiving scheduled pain medication, No history of falls. Review of the Care Plan revised on [DATE] for resident #2 documented in part: Resident has impaired cognition related to Dementia; Resident on pain medication for neuropathic pain. Administer [MEDICATION NAME] and Tylenol as ordered for pain. Review for pain medication efficacy, assess whether pain intensity acceptable to resident. Activities of Daily Living (ADLs) deficit related to Alzheimer's and Chronic Pain. Resident requires maximum assistance of two persons with transfers; Use a Hoyer Lift and/or Sit to Stand Device for safety. Requires extensive assistance of two persons with ADLs. Review of the Hospital History of Present Illness dated [DATE] at 6:38 PM for resident #2 documented in part: Chief Complaint: Right Femur Fracture. Onset occurred three days ago. Symptom Duration: Since onset. Progression since Onset: Constant. No trauma by history. [AGE] year old female presented to emergency department via EMS accompanied by niece complain of right femur fracture from unknown injury onset 3 days ago. Niece states the patient does not usually walk, and patient states someone was trying to help her into bed when she fell . Nursing home states they do not know of any fall. Niece also reports pallor. Patient was not initially answ(TRUNCATED)

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being consistent with the comprehensive assessment and plan of care by failing to consult with the physician when there was a significant change in condition for 2 of 9 residents (Resident #1, and #2) reviewed for change of condition. A. On [DATE] at 6:30 PM, resident #1's daughter reported to Licensed Vocational Nurse (LVN A) that her mother did not look right and asked her to send her mother to the hospital. LVN A called the physician at 10:00 PM, and reported that resident #1 did not look like her usual self and orders were received for stat (immediately) labs and UA (urine analysis). LVN A and LVN B failed to immediately notify the attending physician that it was going to take more than five hours for stat labs and UA to be done as ordered. On [DATE] at 5:08 AM, lab collected specimens (7 hours after nurse received order for stat lab) . The Lab faxed lab results to the facility on [DATE] at 10:10 AM. Resident #1 arrived to the hospital on [DATE] at 10:26 AM and died on [DATE] at 11:35 PM. B. On [DATE] at 7:00 AM, resident #2 reported to LVN A that she had fell down in her room four days prior and did not want to get out of bed for meals like she usually did because she was having pain to right leg with movement and cramping to the right thigh. LVN A did not immediately report to the attending physician on [DATE] that the scheduling of the Venous Doppler could not be done on the weekend. Resident #2 continued to have swelling and pain to the right leg with movement. On [DATE] on the morning shift LVN I failed to immediately report to the attending physician resident #2 had swelling and pain on the right knee with movement and that they were having problems with making arrangements to schedule the Venous Doppler as ordered. On [DATE] at 12:53 PM, physician gave orders for an x-ray of the right knee. X-ray was done [DATE] at 3:51 PM. X-ray results were received at 4:52 PM, documented an Acute [MEDICAL CONDITION] femur with posterior displacement. Physician was notified at 4:45 PM, and resident was sent resident to hospital. On [DATE] an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at actual harm, pattern due to the facility's need to evaluate and monitor their corrective action system. This failure placed 62 residents at the facility in the North side at risk of not promptly receiving the necessary medical care by not consulting with the physicians were there was a change in condition. Findings include: Resident #1 Closed record review of the Resident Face Sheet dated [DATE] documented resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted back to the facility on [DATE] had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #1 documented in part: Unclear speech, Sometimes understood, Sometimes understands, Cognitive skills severely impaired, extensive assistance of one to two persons with Activities of Daily Living, and incontinent of bowel & bladder. Review of the Care Plan revised on [DATE] for resident #1 documented in part: Resident is incontinent of bowel & bladder. Resident has cognitive loss related to Dementia. Monitor/record/report to physician new on-set of [MEDICAL CONDITION], changes in behavior, altered mental status, wide variation in cognitive function through the day, communication decline, disorientation, lethargy, restlessness, agitation, dehydration and infection. Resident sometimes understood/understands. Requires extensive assistance of ,[DATE] persons with Activities of Daily Living. Review of Hospital emergency room report dated [DATE] documented in part: Resident #1 arrived via EMS (Emergency Medical Services) at 10:24 AM in respiratory distress. Chief Complaint: Onset of respiratory distress yesterday evening. Altered Mental Status. Nursing Home reported resident [MEDICAL CONDITION], patient currently tachy. Not responding, Hypoxic breaths/min on 15 liters per minute of oxygen. Review of the Hospital History & Physical dated [DATE] documented in part: Chief Complaint: Lethargy. Onset of respiratory distress yesterday evening. Altered Mental Status. Not responding. Hypoxic. History of present illness: Resident #1 is a [AGE] year old female with past medical history of [REDACTED]. The patient was found to be less responsive with poor oral intake about a day ago in the nursing home. This morning, patient's condition continues to worsen, therefore, patient was transferred to the ER (emergency room ). In ER, patient was found to be septic and also have pancreatitis. Patient was admitted . Patient is nonviable, therefore could not get information from her. Physical examination: Temperature 99.6, on arrival to the ER, heart rate of 119, respiratory rate of 32, blood pressure ,[DATE], patient is on 15 Liters of oxygen on non-rebreather mask. Mucosa is dry. Positive bilateral sounds with occasional coarse breath sounds. Patient is lethargic.[MEDICAL CONDITION] Screening: Altered Mental Status, decreased urine output, [MEDICAL CONDITION]> 90 BPM (beats per minute. Diagnoses: [REDACTED]. Treated with IV (intravenous hydration). 2)[MEDICAL CONDITION] secondary to acute infectious process. Has been given several boluses of IV fluids in the ER. 3) Hypernatremic dehydration. 4) Urinary Tract Infection. Started on IV antibiotic. 5) Leukocytosis secondary to acute infectious process. Review of the Hospital Lab results dated [DATE] at 11:07 AM, for resident #1 documented in part: White blood cell of 15.10 (High), BUN 39 (High), Hemoglobin 15.9 (High), Sodium 146 (High); Urinalysis (UA) results dated [DATE] at 11:07 AM, Urine color-cloudy, UA Protein 1+, Leuk Est 2+, UA blood 2+, WBC Urine 16 (high). Review of the Hospital Discharge Summary dated [DATE] documented at around 11:35 PM, on [DATE] resident #1 was pronounced dead by 2 RNs (registered nurses). Review of the Grievance Form dated [DATE] written by the (Business Office Manager) BOM documented in part: BOM received telephone call from resident #1's daughter. Daughter reported that she was upset because she came in on Saturday [DATE] to feed her mother and told LVN A that her mother did not look good and asked her to send her mother to the hospital. She reported that her mother was unresponsive, and had a pale/ashy skin color to her face. LVN A told her that her mother was probably just tired because of the event that was held on Friday to celebrate mother's day. LVN A told the daughter that she had called the doctor and got an order for [REDACTED]. The doctors did not know that her mother was in the nursing home. The attending physician told the daughter that LVN A had only reported to her that her mother was not eating and that is why she had only given orders for labs. The daughter also reported that her mother had not voided for one day and that should have been a big flag for nurses to send her mother to the hospital. Review of the Provider Investigation Report dated [DATE] documented in part: Date of incident [DATE] at 6:00 PM. Allegation: Neglect. Description of Allegation: Resident's daughter came in to visit with Business Office Manager (BOM) and Director of Nurses on [DATE] at 11:00 AM, to discuss why her mother was not sent to the hospital on the evening of [DATE] instead of the morning on [DATE]. She alleged that if her mother had been sent out on the 13th instead of putting her to bed it would have been different. She made reference to the hospital nurses making comments about why she did not get her to the hospital sooner. Resident was sent to hospital on the morning of [DATE] due to signs and symptoms of respiratory distress. Allegation of Neglect: Unconfirmed. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by LVN A documented in part: Assigned to resident #1 on [DATE] and [DATE]. At 6:30 PM, resident's daughter was visiting and reported that her mom was not responding to her. I told the daughter that I would be calling the doctor to ask for labs. Received new order for labs on change of shift when giving report to LVN B on the night shift. This nurse next workday (Sunday [DATE]). After breakfast noted resident #1 at Nurses station with shortness of breath, labored breathing. Asked (Certified Nurse Aide) CNA to lay her down and to take vitals. Vital signs abnormal. Called physician and gave orders to send her out. Review of a hand written statement attached to the Provider Investigation Report dated [DATE] written by CNA D documented in part: On [DATE] at 3:00 PM, got resident #1 up and took to dining room. The daughter brought the resident to Nurses station and was telling LVN A, that her mother was not responding LVN A told the daughter that the resident looked tired and asked me to put the resident to bed. The resident looked pale and was incontinent of urine. Not as wet as usual. The daughter told me that her mother didn't want to eat. Went to check resident again, had a small amount of urine on brief. Reported to LVN A. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by CNA (F) documented in part: Assigned to resident #1 on [DATE] and [DATE] on the 6:00 AM to 2:00 PM shift. On Saturday [DATE] resident #1 did not eat breakfast or lunch. Resident was holding food in her mouth. Resident appeared tired. Notified LVN A. Resident was incontinent of urine x 2 on this shift. On Sunday [DATE] at 6:00 AM, resident seemed tired. Sat resident in wheelchair and took her to the dining room. At breakfast resident was breathing hard with mouth opened, eyes rolled back. Resident did not eat breakfast. LVN A was notified. Review of a hand written Witness Statement attached to the Provider Investigation Report dated [DATE] written by CNA E documented in part: I worked on the night shift on [DATE]. When I got there at start of shift LVN B asked me to try and offer water to resident #1. When I attempted to give her water she would not open her mouth. I tried to give her a spoonful of water every hour, but the resident would not open her mouth. I reported this to LVN B. Telephone interview on [DATE] at 4:35 PM, resident's daughter said, On Saturday [DATE] at approximately 5:00 PM to 5:30 PM, I found my mother sitting in her wheelchair in the dining room with her head hanging down and was not responding when I talked to her. My mother looked dead. I asked LVN A to send my mother to the hospital. LVN A told me that my mother was probably just sleepy and asked one of the aides to put my mother to bed. I asked the CNAs on that day, why they had not noted that my mother was unconscious. I tried to feed my mother on that day, she opened her mouth once but could not swallow her pureed food. She was just holding the food in her mouth. I also noted that my mother's disposable brief was dry when I got there and was still dry when I left that day at approximately 7:00 PM to 8:00 PM. I called LVN A later that night and LVN A told me that she had called the doctor and got orders for labs. LVN A told me my mother was ok and resting. My brother was with my mother the day before on Friday during the mother's day celebration and she was fine. My mother could not talk, but was able to answer simple questions by nodding yes and no with her head. On Sunday morning [DATE] LVN A called my brother to tell him that she was sending my mother to the hospital because she was lethargic. I met my brother at the hospital. My mother was almost dead when she got to the hospital. I don't know why LVN A did not call the doctor right away on Saturday to send my mother to the hospital. Maybe she would still be alive. I did call the BOM to tell her that I could not understand, how the LVN A and CNAs did not see that my mother was unconscious. She was rigid and was not her usual self. Telephone interview on [DATE] at 12:45 PM, attending physician reported that LVN A had called her at night on [DATE] to report resident #1 was not looking good and her vital signs were stable. When I talked to LVN A, she did not tell me that the resident was very sick. LVN A never reported to me when she called me on that day that resident #1 had not been eating or drinking fluids, on that day. She never told me that the daughter had reported to her that the resident was not responding and wanted her mother to be sent to the hospital. LVN A did not report to me that the CNAs had reported to her that the resident #1's eyes were rolling, and had decreased urine output. Based on what LVN A reported to me, I just gave orders for stat labs. I depend on the Nurses to accurately assess the residents and immediately report to me any change in condition. LVN A should have called me back right away if she knew that it was going to take several hours before the lab work could be done. On Sunday [DATE] at 9:45 AM, LVN A called me to report that resident #1 was having rapid, labored respirations and lab results had been received. I told LVN A that I was on my way to the nursing home and gave orders to send the resident to the hospital for evaluation. I treated resident #1 at the hospital. When the resident arrived she was almost dead. She was hyperventilating and was septic. This was not an immediate change in condition. The resident most likely had been sick for approximately two days prior to Saturday [DATE] for her to be septic. I'm concerned of how accurately the nurses are assessing the residents when they have a change in condition. Telephone interview on [DATE] at 3:51 PM, with CNA F reported resident #1 was alert, oriented to person, was able to answer simple questions with yes and no, required total assistance of one person with Activities of Daily Living, spoon fed, incontinent of bowel & bladder, and usually ate ,[DATE] percent of her meals. CNA F reported that she had been assigned to resident #1 on Saturday [DATE] on the morning shift. On that day, I got resident out of bed for breakfast at approximately 6:15 AM. I always do her first at the start of the shift. Resident #1 was very weak, and kept her eyes closed all day. Resident #1 was spoon fed. On that day I noted that she just kept the food in her mouth and was not swallowing her food. I tried to give her the shake, but it would roll down the sides of her mouth. I also noted that she was not urinating as much as she usually did. Usually the incontinent brief would be soaked with urine, but on that day not even half a brief was wet. I immediately reported this to LVN A and she asked me to put the resident #1 back to bed. CNA F reported that she had also been assigned to resident #1 on Sunday [DATE] on the morning shift. On that day at approximately 6:15 AM, when got the resident #1 out of bed and sat her in her wheelchair, I noted that the resident appeared to be very weak, and was breathing very rapidly. I wheeled the resident to the dining room and immediately reported the resident's condition to LVN A. Resident #1 refused to eat breakfast on that day. When I tried to give her the shake, it rolled out the sides of her mouth. I immediately reported this to LVN A and she instructed me to put the resident in bed. CNA F reported that they had been trained to immediately report to the charge nurse any changes of condition. In an interview on [DATE] at 1:38 PM, LVN A said, On Saturday [DATE] at approximately 5:30 PM - 6:15 PM, I was at the Nurses station when resident #1's daughter came to tell me that her mother looked different and was not her usual self. When I checked the resident at the Nurses Station, the resident was rigid, clenching teeth, and was able to answer simple questions. I checked her lungs and lung sounds were clear. The resident appeared to be very sleepy but was not lethargic. Based on my assessment the resident just looked tired and was not lethargic. I asked the CNA to put the resident back to bed. I called the doctor and she gave orders for stat labs and UA like 15 minutes before the start of the night shift. I was very busy doing other stuff so I asked LVN B to write the Telephone Order for the lab work. I don't remember who called the lab. On Sunday [DATE] I made walking rounds at approximately 6:30 AM - 7:30 AM, and noted resident #1 was in her bed asleep. LVN B reported to me at the change of shift that lab results were still pending. I don't remember what time I followed up with the lab because I was busy supervising the breakfast meal in the dining room and taking care of other residents. I don't recall the CNAs reporting to me on [DATE] and [DATE] that resident #1 was not eating/drinking, or that resident had a change in condition. On Sunday at approximately 9:45 AM, resident #1 was sitting in front of the Nurses station and I noted resident #1 had rapid, and labored respirations. I called the physician and got orders to send the resident to the emergency room . LVN A said that they had been trained to immediately report any change of condition to the attending physician and to immediately send the resident to the hospital upon family's request. LVN A reported that CNAs had been trained to immediately report changes in condition to the nurse. Review of the Nurses Notes dated [DATE] written by LVN A documented in part: At 6:30 PM, Daughter at bedside, resident up in wheelchair. Daughter stating mother does not look right and she's not responding. Clenching jaw and teeth, response was a whisper, unable to understand. Vital Signs-Blood pressure ,[DATE], Oxygen Saturation 98%, Pulse 100, respirations 20, and Temperature 98.4. Placed call to attending physician new orders for labs and urine analysis received via text at 10:00 PM. Will continue to monitor. Review of SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] for resident #1 written by LVN A documented in part: Situation: Shortness of breath and drop in pulse rate started on [DATE]. Since this started it has gotten worse. Date of transfer [DATE]. Acute change in condition. Vital signs blood pressure ,[DATE], heart rate 44, respirations 32, temperature 97.4; oxygen at 2 liters by nasal cannula. Resident with decreased food and water intake, shortness of breath, labored breathing and drop in pulse rate. Nurses Note: This nurse (LVN A) noted resident with labored breathing, low pulse, and lethargic. Physician called orders given to send resident to emergency room . Review of the Meal Intake Record dated [DATE] through [DATE] documented resident #1 ate 75% to 100% of her meals. Meal Intake Record dated [DATE] documented resident #1 ate 50% of breakfast, 25% of lunch, and refused dinner. Meal Intake Record dated [DATE] documented resident #1 refused breakfast. Review of the Physician's Telephone Order dated [DATE] at 10:00 PM, written by LVN B documented UA (urine analysis), CBC (complete blood count), CMP (comprehensive metabolic panel) stat (immediately). Review of the Nurses Notes dated [DATE] written by LVN B documented in part: At 10:10 PM, called Lab for stat orders for CBC, CMP and urine analysis. Dispatcher notified nurse that the soonest labs can be done will be at 3:00 AM. Vital Signs-Blood pressure ,[DATE], Oxygen Saturation 97%, Pulse 94, respirations 18, and Temperature 98.2. At 10:40 PM, Resident resting in bed with eyes closed, no signs of distress. Review of the Nurses Notes dated [DATE] written by LVN B documented [DATE] at 3:40 AM, labs were drawn, resident with no complaints. Review of the Lab Results dated [DATE] for resident #1 documented in part: Specimens collected at 5:08 AM. UA report: Urine slightly cloudy, [MEDICATION NAME]-Trace, Blood-Moderate, LEUK - EST-Moderate, WBC Urine TNTC-Abnormal, Bacteria-2+, [MEDICATION NAME]-2+. General Chemistry report: Potassium 5.2 High, Chloride 109 High, Carbon [MEDICATION NAME] 13 Low, Glucose 128 High, BUN 43 High, Creatinine 2.37 High, Bilirubin 1.3 High. Hematology report: White Blood Count 25.08 High, Red Blood Cell 5.66 High, Hemoglobin 16.8 High, Hematocrit 50.0 High. Review of the Nurses Notes dated [DATE] by LVN B documented, Late entry on [DATE] at 11:30 PM, resident's daughter called to report that mother had passed away at the hospital. Telephone Interview on [DATE] at 11:09 AM, LVN B confirmed that he had worked on the night shift on Saturday [DATE]. LVN B said I honestly do not remember if LVN A reported to me at the change of shift that resident #1 was not eating, drinking or that the resident was lethargic on her shift. I called the lab on [DATE] at 10:40 PM, to order the Stat labs and UA at 10:40 PM. I did not notify the attending physician that it was going to take several hours before the lab work could be done. I checked the resident's vital signs at approximately 10:30 PM on that day and I think that the CNA gave her some water. I don't remember too well what happened. I checked the resident at 2:00 AM on [DATE] and she was sleeping. I do not remember the last time that I checked her before the end of the shift. LVN B denied that CNA E had reported to him during his shift that the resident #1 was not drinking water. LVN B said that they had been trained to immediately report any change of condition to the attending physician. LVN B said that CNAs had been trained to immediately report changes in condition to the nurse. In an interview on [DATE] at 7:56 AM, BOM reported that on Monday [DATE] she had received a telephone call from resident #'s daughter to inform her that her mother had passed away at the hospital on [DATE]. She was very upset because she had come to visit her mother on Saturday and she did not look good. The resident was pale, had an ashy skin color to her face, and was unresponsive. She went to look for LVN A and LVN A said that maybe her mother was just tired because they had stayed up late the day before for the mother's day celebration. The daughter reported that she had asked LVN A to send her mother to the hospital because she was very concerned about the way that her mom looked. The daughter reported that one of the CNAs had told her that her mother was not urinating like usual. The BOM stated that later that day [DATE] the daughter for resident #1 came to her office and said, I think it was neglect. The BOM reported that she had written the Grievance form and immediately reported this to the Administrator and Director of Nurses on [DATE]. In an interview on [DATE] at 2:43 PM, CNA D reported that she had been assigned to resident #1 on Saturday [DATE] on the evening shift. CNA D, said I reported to LVN A on [DATE] that the resident #1 did not want to eat or drink liquids and was urinating very small amounts of urine. CNA D reported that they had been trained to immediately report any change of condition to the nurse. Telephone interview on [DATE] at 11:41 AM, CNA E reported that she had been assigned to resident #1 on Saturday [DATE] on the night shift from 10:00 PM to 6:00 AM. CNA E said, LVN B told me at the beginning of the shift on that day, to try and give water to the resident as tolerated. LVN B did not tell me why. I tried to give her water, but the resident would not open her mouth. I finally was able to give her a teaspoon of water and it rolled down the sides of her mouth. I continued to try and give water to resident #1 throughout the night but she would not open her mouth. The resident kept her eyes closed when I talked to her. I reported this to LVN B, and he said that he would go and check the resident. CNA E reported that they had been trained to immediately report any change of condition to the nurse. In an interview on [DATE] 9:27 AM, Director of Nurses (DON) said, We had a mother's celebration at the facility on Friday [DATE] that was over at 8:00 PM to 8:30 PM, and the residents were tired the next day because they usually go to bed at 6:00 PM to 6:30 PM. LVN A called me on [DATE] to report the daughter for resident #1 was at the facility and was concerned about how her mother looked. LVN A reported that she had checked resident #1 and reported that the resident just looked tired and her vital signs were stable. LVN A reported that the doctor had returned her call at 10:00 PM, and gave orders for stat labs and UA. Keep in mind that it was the weekend, so it takes longer for the labs to be done. I don't know if LVN A or LVN B called the doctor to let her know that it was going to be several hours before the lab work was done. If it was me, I would have called the physician right away to let her know that it was going to take several hours to get the labs done. LVN A reported that the resident remained stable throughout the day and evening shift on that day. The DON stated that the BOM wrote a Grievance Report on Monday [DATE] when resident #1's daughter came to report that she was upset because LVN A had not sent her mother to the hospital on Saturday [DATE]. The daughter reported that her mother was not responding and did not look like her usual self. The daughter said, LVN A checked my mother and said that my mother was just tired and asked one of the CNAs to put her back to bed. My mother did not eat her dinner on that day. LVN A my brother on Sunday [DATE] to report that my mother had labored breathing, was lethargic, and did not eat on that day. LVN A told my brother that she was going to send my mother to the hospital for evaluation. In an interview on [DATE] at 5:04 PM, DON reported that they had been having problems with the Lab not doing stat orders within two hours of receiving the physician's orders [REDACTED].#1, and agreed to allow the lab a maximum of two hours to do stat labs. If the Lab cannot draw the labs within the two hour time frame, the nurse needs to immediately report this to the attending physician. Resident #2 Closed record review of the Resident Face Sheet dated [DATE] documented resident #2 was a [AGE] year old female admitted to the facility on [DATE]. Review of the History & Physical dated [DATE] for resident #2 documented in part: [AGE] year old female with a past medical history of [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #2 documented in part: Clear speech, usually understood, usually understands, vision moderately impaired, Brief Interview for Mental Status (BIMS) 13-cognitively intact, extensive assistance of two persons with bed mobility, transfers, and toileting, unsteady when moving from seated to standing position, unsteady moving on and off toilet, and unsteady transfer from surface to surface, Functional Limitation in Range of Motion - no impairment to upper and lower extremities, chair bound, incontinent of bowel and bladder. No pain, receiving scheduled pain medication, No history of falls. Review of the Care Plan revised on [DATE] for resident #2 documented in part: Resident has impaired cognition related to Dementia; Resident on pain medication for neuropathic pain. Administer [MEDICATION NAME] and Tylenol as ordered for pain. Review for pain medication efficacy, assess whether pain intensity acceptable to resident. Activities of Daily Living (ADLs) deficit related to Alzheimer's and Chronic Pain. Resident requires maximum assistance of two persons with transfers; Use a Hoyer Lift and/or Sit to Stand Device for safety. Requires extensive assistance of two persons with ADLs. Review of the Hospital History of Present Illness dated [DATE] at 6:38 PM for resident #2 documented in part: Chief Complaint: Right Femur Fracture. Onset occurred three days ago. Symptom Duration: Since onset. Progression since Onset: Constant. No trauma by history. [AGE] year old female presented to emergency department via EMS accompanied by niece complain of right femur fracture from unknown injury onset 3 days ago. Niece states the patient does not usually walk, and patient states someone was trying to help her into bed when she fell . Nursing home states they do not know of any fall. Niece also reports pallor. Patient was not initially answering questions. Muscoloskeletal: Extremity pain to right leg. Neurologic; Oriented X 3. Review of hospital x-ray report dated [DATE] at 8:12 PM, Right Femur Mildly displaced oblique [MEDICAL CONDITION] femur. Due to significant osteopenia it is difficult to ascertain whether this fracture is pathologic. Review of hospital Operative Report dated [DATE] for resident #2 documented in part: Fracture Right Femur fracture closed, supracondylar femur; Procedure Performed: ORIF (open reduction internal fixation). Review of the Event report dated [DATE] at 7:00 AM, written by LVN A documented in part: Resident #2 alleged she fell four days ago. CNA came to report resident #2 did not want to get out of bed because she had pain to the right leg. Resident reported that she fell down four days in her room and a man picked her up and put her to bed. Head to toe assessment done, no bruising, swelling, or redness noted. An abrasion to the left knee measuring 0.5 x 0.5 CM, area light pink. ROM (range of motion) to all extremities moving arms and legs up and down, and side to side. Resident stating she has pain to the right leg but more cramping on right thigh. Nurse Practitioner gave orders for Venous Doppler on [DATE] on the day shift. Telephone interview on [DATE] at 8:26 AM with the niece for resident #2 stated that her aunt, had called her (not able to give specific date) and said that on Friday two women had dropped her and that they had to get a man to come and pick her up. The Niece stated that she visited resident #2 the Monday after she received the phone call and at that point her aunt was yelling with pain from her right knee. She stated that when she touched her knee it was like her aunt was going to faint because of the pain. The niece reported that the facility had sent her aunt to the hospital. Review of the Provider Investigation Report dated [DATE] documented in part: Date of incident [DATE] at 7:00 AM. Allegation: Neglect. Description of Allegation: CNA reported to staff nurse at 7:00 AM, resident #2 did not want to get out of bed because she had sustained a fall four days ago and her legs hurt. A call was placed to the physician and the responsible party on [DATE]. The NP (nurse practitioner) called back and gave orders for a Venous Doppler. Scheduling was not done on Sunday. Monday morning charge nurse could not make arrangements for the venous Doppler to be made as soon as possible and called for an order to do an x-ray. X-ray was done on [DATE] at 3:51 PM, at approximately 5:00 PM, received x-ray results that revealed an acute [MEDICAL CONDITION] femur with posterior displacement. Resident was sent to the hospital. The responsible party for resident #2 called on [DATE] to voice a concern about the care provided to resident #2 while at the nursing facility. The niece re(TRUNCATED)

Based on interview and record review, the facility failed to permit a resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for one (Resident #1) of one resident reviewed for 30 day discharge letters. The facility initiated Resident #1's discharge without an appropriate justification and locked Resident #1 out of the facility prior to his appeal hearing without justification causing psychological harm. These failures could affect 1 resident by placing him at risk for a sudden discharge without reason. Findings included: Review of closed record face sheet dated 10/8/15 revealed Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 30 day discharge date d June 16, 2015 documented the reason for discharge was the facility could not meet Resident #1 ' s needs as he was a danger to himself. In an interview on 10/13/15 at 4:00 PM Assistant Director of Nursing (ADON) E said Resident #1 had been given a 30 day discharge letter and had an appeal scheduled for October 14, 2015. ADON E said Resident #1 was given a 30 day discharge letter because of his non-compliance with using the sit to stand machine. ADON E said Resident #1 did not want to use the sit to stand machine he said it bothered his back and shoulder so he wanted to transfer with the assistance of Certified Nursing Assistants (CNA). ADON E said the facility did continue to use the sit to stand machine and had some refusals. In an interview on 10/15/15 at 3:33 PM the Director of Rehabilitation (DOR) said on 7/24/15 he was asked to re-evaluate Resident #1 using the sit to stand machine because Resident #1 did not want to use it. DOR said he was never told Resident #1 complained of pain or discomfort in his back and shoulder when using the machine. DOR said a 2 person transfer has always been safe with Resident #1, the sit to stand machine was not something that had to be used. In an interview on 10/8/15 at 8:30 PM Nursing Home Administrator (NHA) said she received a call early that morning, 10/8/15, from the corporate attorney who told her Physician A was no longer going to see Resident #1 because Resident #1 had sent a complaint to the medical board about Physician A. NHA said that according to what the SW found in the regulations if he did not have a physician it meant Resident #1 could not get medications, treatments, food or anything else because he no longer had a physician. NHA said she did not call Physician A to ask if he was or was not going to continue to provide care to Resident #1. The NHA said she didn ' t know what to do and she was in constant contact with the corporate attorney and the Regional Director of Operations (RDO) all day by email. The NHA said she locked the resident out of the facility and told him he could not come in because he did not have a physician. The NHA said Resident #1 and his sister stayed at the front door for several hours wanting to come in but she would not let them in. The NHA said finally an ambulance and fire truck pulled up out front and put Resident #1 onto the stretcher and left. The NHA said she assumed Resident #1 or his sister had called 911 when they gave up on getting back into the facility. The NHA said the hospital called to say Resident #1 was in the emergency room and they were going to send Resident #1 back to the facility but she told them no they would not accept him back. In an interview on 10/13/15 at 4:47 PM Director of Nursing (DON) said Resident #1 had been given a 30 day discharge letter last June and was in the process of appealing. DON said Resident #1 was given the 30 day letter for non-compliance. DON said off and on certain Certified Nursing Assistant (CNA) could not go into his room because he accused them of poor treatment, he didn ' t want to use the sit to stand machine he wanted 2 CNA's to transfer him. The DON said Resident #1 would use the machine but he didn ' t want to and he would give the CNA's a hard time about using it. DON said Resident #1 was also non-complaint with the smoking times, he wanted to smoke and it wasn ' t smoking time. The DON said if smoking time was at 10:00 AM Resident #1 would come at 10:15 AM and want to smoke and it wasn ' t the right time. In an interview on 10/14/15 at 6:11 PM Director of Nursing (DON) said on 10/8/15 after the morning meeting the NHA told her Physician A was no longer going to be Resident #1 ' s physician. DON said she did not call Physician A to ask if he was or was not going to continue to provide care to Resident #1. In an interview on 10/14/15 at 8:30 AM Physician A said he is the Medical Director so he would never say he would not see a resident. Physician A said he did not speak to any attorney and he did not talk to the NHA to say he would not be the physician covering Resident #1. In an interview on 10/13/15 at 11:00 AM the Social Worker (SW) said he came in at 7:30 AM on 10/8/15 because he was told Physician A was not going to see Resident #1 anymore because Resident #1 had made a complaint to the medical board about Physician A. SW said he was asked by the NHA to research if Resident #1 could remain in the facility without a physician. SW said he found a state regulation that said Resident #1 could not remain in the facility without a physician. SW said he went to the nursing station in the afternoon on 10/8/15 and overheard Resident #1 asking for pain medication and the nurse telling him she didn ' t have orders for meds but she could call 911 for pain control. SW said he overheard Resident #1 refusing to leave with 911 but asking for a smoking pass to go to the front parking lot to smoke a cigarette. SW said at that time the NHA, DON, ADON E and himself were in the nursing station and had a discussion if Resident #1 could come back into the building if he went out front to smoke on a smoking pass because Resident #1 did not have a doctor. SW said they discussed the regulations that said a resident cannot stay without physicians order. SW said he went out front with the NHA on 10/8/15and they told Resident #1 he could not come back into the building. SW said they called the police department to come to watch the staff pack Resident #1 ' s clothes. SW said he inventoried the clothes and multiple people put the clothes in trash bags. SW said they put everything on carts and took it out the side door. In an interview on 10/8/15 at 9:00 PM Resident #1's sister said on 10/8/15 she happened to go to the nursing facility to take paperwork and while she was there the facility would not give Resident #1 his pain medication. Resident #1 ' s sister said she requested the facility give her the medication and she would give it to her brother but the facility refused. Resident #1 ' s sister said she called the physicians on the list provided by the insurance company but none of the physicians went to nursing facilities. Resident #1 ' s sister said on 10/8/15 in the afternoon her brother went out front to smoke and she stayed in the room, after a while she wondered why he was not back yet and she went out front to check on him. Resident #1 ' s sister said when she got out there Resident #1 said the facility was not letting him back into the facility. Resident #1 ' s sister said she attempted to get into the facility and she couldn ' t. Resident #1 ' s sister said she and her brother called the facility multiple times but they would not answer the phone. Resident #1 ' s sister said the facility management staff put all of her brother ' s belongings out the side door of the facility onto the parking lot in trash bags. Resident #1 ' s sister said she is also disabled and could not move her brothers belongings so she asked staff, who were watching, if they would help and they told her they were not allowed to help. Resident #1 ' s sister said it was dark and only about 60 degrees, her brother had been locked out wearing shorts and a tee shirt, they were both cold and upset because they didn ' t know what to do. Resident #1 ' s sister said they kept trying to get the facility to let Resident #1 in but after about three hours of trying she called 911 to come and pick Resident #1 up. Resident #1 ' s sister said both she and her brother were very upset, they could not believe what happened. In an interview on 10/15/15 at 11:20 AM, in his hospital room, Resident #1 said 10/8/15 started out like any other day but then about 2:00 PM it started turning strange. Resident #1 said he requested pain medicine and was told he couldn ' t have any because he didn ' t have a doctor. Resident #1 said later he was rolling down the hallway in his wheelchair to get a smoking pass to go in front of the building to smoke when at the corner by the nursing station he was asked by Emergency Medical Technicians (EMT) if he was Resident #1. Resident #1 said he replied yes he was Resident #1 and the EMT ' s told him they were there to take him to the hospital. Resident #1 said he told the EMT ' s he was not going anywhere. Resident #1 said he got his smoking pass and cigarettes from the nurse and went out the front door to the parking lot to smoke. Resident #1 said when he finished smoking and started back into the facility the gates at the front door were closed and the NHA was on the other side of the gates. Resident #1 said he was pulling on the gates trying to open them and the NHA was trying to hold them closed. Resident #1 said he was surprised, stunned, dazed and confused he had no idea what was happening, he was trying to get into his home and the NHA was telling him you are not coming in. Resident #1 said the NHA could not hold the gates closed, he got the gates open and the NHA ran into the facility and locked the front door. Resident #1 said he pounded on the door pleading for someone to let him in, but no one did. Resident #1 said his sister came and asked What Happened? Resident #1 said his sister said, they can ' t do that to you and she tried to get in but the staff would not let her in either. Resident #1 said another family came to the front door and tried to get in, the door was locked but the NHA and her group of Department Heads came out and blocked Resident #1 and his sister and allowed the other family into the building. Resident #1 said he felt helpless he could not believe he was locked out of his home in shorts and a tee shirt in his wheelchair and there was nothing he could do. Resident #1 said he felt like an animal like he was trash. Resident #1 said he had nowhere to go, he couldn ' t even get into his sisters car because he has to be transferred into and out of his wheelchair and his sister can ' t do that. Resident #1 said they just kept waiting and waiting to be let back into the facility, it was cold and he felt helpless, they waited for 3 hours then decided to call 911. Resident #1 said 911 came picked him up took him to the hospital emergency room and when the emergency room called the facility to tell them they were bringing him back, the facility said no, we will not take him. Resident #1 said he was in a lot of pain and felt horrible because he had just lost his home, it was unbelievable. The facility did not provide a Policy/Procedure on Notice of Transfer and/or Discharge. The facility ' s policy/procedure dated 2003, Discharge Planning reflected, Objective: To evaluate the resident ' s health status and formulate the best plan of discharge for each resident. In an interview on 10/15/15 the Business Office Manager said only 1 resident had been given a 30 day discharge notice.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for one (Resident #1) of one resident reviewed for 30 day discharge letters. The facility locked Resident #1 out of the facility and put all of his property out of a side door onto the parking lot without justification causing psychological harm. These failures could affect 1 resident by placing him at risk of getting locked out of the facility in his wheelchair and having his property put out onto the parking lot without reason. Findings included: Review of closed record face sheet dated 10/8/15 revealed Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 10/8/15 at 8:30 PM Nursing Home Administrator (NHA) said she received a call early that morning, 10/8/15, from the corporate attorney who told her Physician A was no longer going to see Resident #1 because Resident #1 had sent a complaint to the medical board about Physician A. NHA said that according to what the SW found in the regulations if he did not have a physician meant Resident #1 could not get medications, treatments, food or anything else because he no longer had a physician. NHA said she did not call Physician A to ask if he was or was not going to continue to provide care to Resident #1. The NHA said she didn ' t know what to do and she was in constant contact with the corporate attorney and the Regional Director of Operations (RDO) all day by email. The NHA said she locked the resident out of the facility and told him he could not come in because he did not have a physician. The NHA said Resident #1 and his sister stayed at the front door for several hours wanting to come in but she would not let them in. The NHA said finally an ambulance and fire truck pulled up out front and put Resident #1 onto the stretcher and left. The NHA said she assumed Resident #1 or his sister had called 911 when they gave up on getting back into the facility. The NHA said the hospital called to say Resident #1 was in the emergency room and they were going to send Resident #1 back to the facility but she told them no they would not accept him back. In an interview on 10/13/15 at 11:00 AM the Social Worker (SW) said he came in at 7:30 AM on 10/8/15 because he was told Physician A was not going to see Resident #1 anymore because Resident #1 had made a complaint to the medical board about Physician A. SW said he was asked by the NHA to research if Resident #1 could remain in the facility without a physician. SW said he found a state regulation that said Resident #1 could not remain in the facility without a physician. SW said he went to the nursing station in the afternoon on 10/8/15 and overheard Resident #1 asking for pain medication and the nurse telling him she didn ' t have orders for meds but she could call 911 for pain control. SW said he overheard Resident #1 refusing to leave with 911 but asking for a smoking pass to go to the front parking lot to smoke a cigarette. SW said at that time the NHA, DON, ADON E and himself were in the nursing station and had a discussion if Resident #1 could come back into the building if he went out front to smoke on a smoking pass because Resident #1 did not have a doctor. SW said they discussed the regulations that said a resident cannot stay without physicians order. SW said he went out front with the NHA on 10/8/15and they told Resident #1 he could not come back into the building. SW said they called the police department to come to watch the staff pack Resident #1 ' s clothes. SW said he inventoried the clothes and multiple people put the clothes in trash bags. SW said they put everything on carts and took it out the side door. In an interview on 10/8/15 at 9:00 PM Resident #1 ' s sister said on 10/8/15, she happened to go to the nursing facility to take paperwork and while she was there the facility would not give Resident #1 his pain medication. Resident #1 ' s sister said she requested the facility give her the medication and she would give it to her brother but the facility refused. Resident #1 ' s sister said she called the physicians on the list provided by the insurance company but none of the physicians went to nursing facilities. Resident #1 ' s sister said her brother went out front to smoke on 10/8/15 in the afternoon, and she stayed in the room, after a while she wondered why he was not back yet and she went out front to check on him. Resident #1 ' s sister said when she got out there Resident #1 said the facility was not letting him back into the facility. Resident #1 ' s sister said she attempted to get into the facility and she couldn ' t. Resident #1 ' s sister said she and her brother called the facility multiple times but they would not answer the phone. Resident #1 ' s sister said the facility management staff put all of her brother ' s belongings out the side door of the facility onto the parking lot in trash bags. Resident #1 ' s sister said she is also disabled and could not move her brothers belongings so she asked staff, who were watching, if they would help and they told her they were not allowed to help. Resident #1 ' s sister said it was dark and only about 60 degrees, her brother had been locked out wearing shorts and a tee shirt, they were both cold and upset because they didn ' t know what to do. Resident #1 ' s sister said they kept trying to get the facility to let Resident #1 in but after about three hours of trying she called 911 to come and pick Resident #1 up. Resident #1 ' s sister said both she and her brother were very upset, they could not believe what happened. In an interview on 10/15/15 at 11:20 AM, in his hospital room, Resident #1 said 10/8/15 started out like any other day but then about 2:00 PM it started turning strange. Resident #1 said he requested pain medicine and was told he couldn ' t have any because he didn ' t have a doctor. Resident #1 said later he was rolling down the hallway in his wheelchair to get a smoking pass to go in front of the building to smoke when at the corner by the nursing station he was asked by Emergency Medical Technicians (EMT) if he was Resident #1. Resident #1 said he replied yes he was Resident #1 and the EMT ' s told him they were there to take him to the hospital. Resident #1 said he told the EMT ' s he was not going anywhere. Resident #1 said he got his smoking pass and cigarettes from the nurse and went out the front door to the parking lot to smoke. Resident #1 said when he finished smoking and started back into the facility the gates at the front door were closed and the NHA was on the other side of the gates. Resident #1 said he was pulling on the gates trying to open them and the NHA was trying to hold them closed. Resident #1 said he was surprised, stunned, dazed and confused he had no idea what was happening, he was trying to get into his home and the NHA was telling him you are not coming in. Resident #1 said the NHA could not hold the gates closed, he got the gates open and the NHA ran into the facility and locked the front door. Resident #1 said he pounded on the door pleading for someone to let him in, but no one did. Resident #1 said his sister came and asked What Happened? Resident #1 said his sister said, they can ' t do that to you and she tried to get in but the staff would not let her in either. Resident #1 said another family came to the front door and tried to get in, the door was locked but the NHA and her group of Department Heads came out and blocked Resident #1 and his sister and allowed the other family into the building. Resident #1 said he felt helpless he could not believe he was locked out of his home in shorts and a tee shirt in his wheelchair and there was nothing he could do. Resident #1 said a department head came to the window at the front door and was pointing to the side of the building. Resident #1 said he went slowly in his wheelchair around to the side of the facility and his clothes, television, computer, bookcase and all of his belongings were in the parking lot, his belongings were in trash bags. Resident #1 said he felt like an animal like he was trash; all of his belongings were just thrown out like he was nothing. Resident #1 said he didn ' t know what to do, he asked the facility employees who were guarding the gate if they could watch it until he could hire a moving company to pick it up but they said no. Resident #1 said he had nowhere to go, he couldn ' t even get into his sisters car because he has to be transferred into and out of his wheelchair and his sister can ' t do that. Resident #1 said they just kept waiting and waiting to be let back into the facility, it was cold and he felt helpless, they waited for 3 hours then decided to call 911. Resident #1 said 911 came picked him up took him to the hospital emergency room and when the emergency room called the facility to tell them they were bringing him back, the facility said no, we will not take him. Resident #1 said he was in a lot of pain and felt horrible because he had just lost his home, it was unbelievable. The facility ' s policy/procedure dated as REVISED January 8, 2003, Abuse/Neglect , documented in part: The facility will provide and ensure the promotion and protection of resident rights. It is each individuals responsibility to recognize, report and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect and situations that may constitute abuse or neglect to any resident in the facility. The facility will provide the residents, families and staff an environment free from abuse and neglect. The facility's policy/procedure dated 2003, Resident Rights, documented in part: We believe each resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside our facility. We protect and promote the rights of each resident. In an interview on 10/15/15 the Business Office Manager said only 1 resident had been given a 30 day discharge notice.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for one (Resident #1) of one resident reviewed for 30 day discharge letters. The facility locked Resident #1 out of the facility and put all of his property out of a side door onto the parking lot without justification causing psychological harm. These failures could affect 1 resident by placing him at risk of getting locked out of the facility in his wheelchair and having his property put out onto the parking lot without reason. Findings included: Review of closed record face sheet dated 10/8/15 revealed Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 10/8/15 at 8:30 PM Nursing Home Administrator (NHA) said she received a call early that morning, 10/8/15, from the corporate attorney who told her Physician A was no longer going to see Resident #1 because Resident #1 had sent a complaint to the medical board about Physician A. NHA said that according to what the SW found in the regulations if he did not have a physician meant Resident #1 could not get medications, treatments, food or anything else because he no longer had a physician. NHA said she did not call Physician A to ask if he was or was not going to continue to provide care to Resident #1. The NHA said she didn ' t know what to do and she was in constant contact with the corporate attorney and the Regional Director of Operations (RDO) all day by email. The NHA said she locked the resident out of the facility and told him he could not come in because he did not have a physician. The NHA said Resident #1 and his sister stayed at the front door for several hours wanting to come in but she would not let them in. The NHA said finally an ambulance and fire truck pulled up out front and put Resident #1 onto the stretcher and left. The NHA said she assumed Resident #1 or his sister had called 911 when they gave up on getting back into the facility. The NHA said the hospital called to say Resident #1 was in the emergency room and they were going to send Resident #1 back to the facility but she told them no they would not accept him back. In an interview on 10/13/15 at 11:00 AM the Social Worker (SW) said he came in at 7:30 AM on 10/8/15 because he was told Physician A was not going to see Resident #1 anymore because Resident #1 had made a complaint to the medical board about Physician A. SW said he was asked by the NHA to research if Resident #1 could remain in the facility without a physician. SW said he found a state regulation that said Resident #1 could not remain in the facility without a physician. SW said he went to the nursing station in the afternoon on 10/8/15 and overheard Resident #1 asking for pain medication and the nurse telling him she didn ' t have orders for meds but she could call 911 for pain control. SW said he overheard Resident #1 refusing to leave with 911 but asking for a smoking pass to go to the front parking lot to smoke a cigarette. SW said at that time the NHA, DON, ADON E and himself were in the nursing station and had a discussion if Resident #1 could come back into the building if he went out front to smoke on a smoking pass because Resident #1 did not have a doctor. SW said they discussed the regulations that said a resident cannot stay without physicians order. SW said he went out front with the NHA on 10/8/15and they told Resident #1 he could not come back into the building. SW said they called the police department to come to watch the staff pack Resident #1 ' s clothes. SW said he inventoried the clothes and multiple people put the clothes in trash bags. SW said they put everything on carts and took it out the side door. In an interview on 10/8/15 at 9:00 PM Resident #1 ' s sister said on 10/8/15, she happened to go to the nursing facility to take paperwork and while she was there the facility would not give Resident #1 his pain medication. Resident #1 ' s sister said she requested the facility give her the medication and she would give it to her brother but the facility refused. Resident #1 ' s sister said she called the physicians on the list provided by the insurance company but none of the physicians went to nursing facilities. Resident #1 ' s sister said her brother went out front to smoke on 10/8/15 in the afternoon, and she stayed in the room, after a while she wondered why he was not back yet and she went out front to check on him. Resident #1 ' s sister said when she got out there Resident #1 said the facility was not letting him back into the facility. Resident #1 ' s sister said she attempted to get into the facility and she couldn ' t. Resident #1 ' s sister said she and her brother called the facility multiple times but they would not answer the phone. Resident #1 ' s sister said the facility management staff put all of her brother ' s belongings out the side door of the facility onto the parking lot in trash bags. Resident #1 ' s sister said she is also disabled and could not move her brothers belongings so she asked staff, who were watching, if they would help and they told her they were not allowed to help. Resident #1 ' s sister said it was dark and only about 60 degrees, her brother had been locked out wearing shorts and a tee shirt, they were both cold and upset because they didn ' t know what to do. Resident #1 ' s sister said they kept trying to get the facility to let Resident #1 in but after about three hours of trying she called 911 to come and pick Resident #1 up. Resident #1 ' s sister said both she and her brother were very upset, they could not believe what happened. In an interview on 10/15/15 at 11:20 AM, in his hospital room, Resident #1 said 10/8/15 started out like any other day but then about 2:00 PM it started turning strange. Resident #1 said he requested pain medicine and was told he couldn ' t have any because he didn ' t have a doctor. Resident #1 said later he was rolling down the hallway in his wheelchair to get a smoking pass to go in front of the building to smoke when at the corner by the nursing station he was asked by Emergency Medical Technicians (EMT) if he was Resident #1. Resident #1 said he replied yes he was Resident #1 and the EMT ' s told him they were there to take him to the hospital. Resident #1 said he told the EMT ' s he was not going anywhere. Resident #1 said he got his smoking pass and cigarettes from the nurse and went out the front door to the parking lot to smoke. Resident #1 said when he finished smoking and started back into the facility the gates at the front door were closed and the NHA was on the other side of the gates. Resident #1 said he was pulling on the gates trying to open them and the NHA was trying to hold them closed. Resident #1 said he was surprised, stunned, dazed and confused he had no idea what was happening, he was trying to get into his home and the NHA was telling him you are not coming in. Resident #1 said the NHA could not hold the gates closed, he got the gates open and the NHA ran into the facility and locked the front door. Resident #1 said he pounded on the door pleading for someone to let him in, but no one did. Resident #1 said his sister came and asked What Happened? Resident #1 said his sister said, they can ' t do that to you and she tried to get in but the staff would not let her in either. Resident #1 said another family came to the front door and tried to get in, the door was locked but the NHA and her group of Department Heads came out and blocked Resident #1 and his sister and allowed the other family into the building. Resident #1 said he felt helpless he could not believe he was locked out of his home in shorts and a tee shirt in his wheelchair and there was nothing he could do. Resident #1 said a department head came to the window at the front door and was pointing to the side of the building. Resident #1 said he went slowly in his wheelchair around to the side of the facility and his clothes, television, computer, bookcase and all of his belongings were in the parking lot, his belongings were in trash bags. Resident #1 said he felt like an animal like he was trash; all of his belongings were just thrown out like he was nothing. Resident #1 said he didn ' t know what to do, he asked the facility employees who were guarding the gate if they could watch it until he could hire a moving company to pick it up but they said no. Resident #1 said he had nowhere to go, he couldn ' t even get into his sisters car because he has to be transferred into and out of his wheelchair and his sister can ' t do that. Resident #1 said they just kept waiting and waiting to be let back into the facility, it was cold and he felt helpless, they waited for 3 hours then decided to call 911. Resident #1 said 911 came picked him up took him to the hospital emergency room and when the emergency room called the facility to tell them they were bringing him back, the facility said no, we will not take him. Resident #1 said he was in a lot of pain and felt horrible because he had just lost his home, it was unbelievable. The facility ' s policy/procedure dated as REVISED January 8, 2003, Abuse/Neglect , documented in part: The facility will provide and ensure the promotion and protection of resident rights. It is each individuals responsibility to recognize, report and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect and situations that may constitute abuse or neglect to any resident in the facility. The facility will provide the residents, families and staff an environment free from abuse and neglect. The facility's policy/procedure dated 2003, Resident Rights, documented in part: We believe each resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside our facility. We protect and promote the rights of each resident. In an interview on 10/15/15 the Business Office Manager said only 1 resident had been given a 30 day discharge notice.

Based on interview and record review corporate and facility Administration failed to ensure the facility was administered in a manner which enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (Resident #1) of one resident reviewed for 30 day discharge letters. The facility initiated Resident #1's discharge without an appropriate justification and locked Resident #1 out of the facility and put all of his property out of a side door onto the parking lot prior to his appeal hearing without justification causing psychological harm. These failures could affect 1 resident by placing him at risk for a sudden discharge without reason. The findings included: In an interview on 10/8/15 at 8:30 PM Nursing Home Administrator (NHA) said she received a call early that morning, 10/8/15, from the corporate attorney who told her Physician A was no longer going to see Resident #1 because Resident #1 had sent a complaint to the medical board about Physician A. NHA said that according to what the SW found in the regulations if he did not have a physician it meant Resident #1 could not get medications, treatments, food or anything else because he no longer had a physician. NHA said she did not call Physician A to ask if he was or was not going to continue to provide care to Resident #1. The NHA said she didn ' t know what to do and she was in constant contact with the corporate attorney and the Regional Director of Operations (RDO) all day by email. The NHA said she locked the resident out of the facility and told him he could not come in because he did not have a physician. The NHA said Resident #1 and his sister stayed at the front door for several hours wanting to come in but she would not let them in. The NHA said finally an ambulance and fire truck pulled up out front and put Resident #1 onto the stretcher and left. The NHA said she assumed Resident #1 or his sister had called 911 when they gave up on getting back into the facility. The NHA said the hospital called to say Resident #1 was in the emergency room and they were going to send Resident #1 back to the facility but she told them no they would not accept him back. In an interview on 10/15/15 at 2:47 PM the NHA said Resident #1 complained of pain and the DON said the nurses couldn ' t give him anything without orders. The NHA said she and the DON called the Vice President of Clinical and he told them if Resident #1 complains of pain call 911. The NHA said they called 911 but the resident refused to go. NHA said the SW came and told her Resident #1 was going to sign himself out to go smoke. NHA said she called the attorney and he said it was great that Resident #1 could not stay in the facility without a physician, NHA then called the Regional Director of Operations (RDO) who said how are we going to let him back in without a physician. NHA said Resident #1 was coming back in from his smoke break so she went outside and told him, we need a doctor to let you back in and she locked the gates. NHA said the corporate attorney told her to call the police to watch them pack Resident #1 ' s belongings and that is what she did. NHA said she told the staff not to let Resident #1 or his family into the facility. Review of closed record face sheet dated 10/8/15 revealed Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's 30 day discharge date d June 16, 2015 documented the reason for discharge was the facility could not meet Resident #1 ' s needs as he was a danger to himself. In an interview on 10/13/15 at 4:00 PM Assistant Director of Nursing (ADON) E said Resident #1 had been given a 30 day discharge letter and had an appeal scheduled for October 14, 2015. ADON E said Resident #1 was given a 30 day discharge letter because of his non-compliance with using the sit to stand machine. ADON E said Resident #1 did not want to use the sit to stand machine he said it bothered his back and shoulder so he wanted to transfer with the assistance of Certified Nursing Assistants (CNA). ADON E said the facility did continue to use the sit to stand machine and had some refusals. In an interview on 10/15/15 at 3:33 PM the Director of Rehabilitation (DOR) said on 7/24/15 he was asked to re-evaluate Resident #1 using the sit to stand machine because Resident #1 did not want to use it. DOR said he was never told Resident #1 complained of pain or discomfort in his back and shoulder when using the machine. DOR said a 2 person transfer has always been safe with Resident #1, the sit to stand machine was not something that had to be used. In an interview on 10/13/15 at 4:47 PM Director of Nursing (DON) said Resident #1 had been given a 30 day discharge letter last June and was in the process of appealing. DON said Resident #1 was given the 30 day letter for non-compliance. DON said off and on certain Certified Nursing Assistant (CNA) could not go into his room because he accused them of poor treatment, he didn ' t want to use the sit to stand machine he wanted 2 CNA ' s to transfer him. The DON said Resident #1 could use the machine but he didn ' t want to and he would give the CNA ' s a hard time about using it. DON said Resident #1 was also non-complaint with the smoking times, he wanted to smoke and it wasn ' t smoking time. The DON said if smoking time was at 10:00 AM Resident #1 would come at 10:15 AM and want to smoke and it wasn ' t the right time. In an interview on 10/14/15 at 6:11 PM Director of Nursing (DON) said on 10/8/15 after the morning meeting the NHA told her Physician A was no longer going to be Resident #1 ' s physician. DON said she did not call Physician A to ask if he was or was not going to continue to provide care to Resident #1. In an interview on 10/14/15 at 8:30 AM Physician A said he was the Medical Director so he would never say he would not see a resident. Physician A said he did not speak to any attorney and he did not talk to the NHA to say he would not be the physician covering Resident #1. In an interview on 10/13/15 at 11:00 AM the Social Worker (SW) said he came in at 7:30 AM on 10/8/15 because he was told Physician A was not going to see Resident #1 anymore because Resident #1 had made a complaint to the medical board about Physician A. SW said he was asked by the NHA to research if Resident #1 could remain in the facility without a physician. SW said he found a state regulation that said Resident #1 could not remain in the facility without a physician. SW said he went to the nursing station in the afternoon on 10/8/15 and overheard Resident #1 asking for pain medication and the nurse telling him she didn ' t have orders for meds but she could call 911 for pain control. SW said he overheard Resident #1 refusing to leave with 911 but asking for a smoking pass to go to the front parking lot to smoke a cigarette. SW said at that time the NHA, DON, ADON E and himself were in the nursing station and had a discussion if Resident #1 could come back into the building if he went out front to smoke on a smoking pass because Resident #1 did not have a doctor. SW said they discussed the regulations that said a resident cannot stay without physicians order. SW said he went out front with the NHA on 10/8/15and they told Resident #1 he could not come back into the building. SW said they called the police department to come to watch the staff pack Resident #1 ' s clothes. SW said he inventoried the clothes and multiple people put the clothes in trash bags. SW said they put everything on carts and took it out the side door. In an interview on 10/8/15 at 9:00 PM Resident #1 ' s sister said she happened to go to the nursing facility to take paperwork and while she was there the facility would not give Resident #1 his pain medication. Resident #1 ' s sister said she requested the facility give her the medication and she would give it to her brother but the facility refused. Resident #1 ' s sister said she called the physicians on the list provided by the insurance company but none of the physicians went to nursing facilities. Resident #1 ' s sister said her brother went out front to smoke and she stayed in the room, after a while she wondered why he was not back yet and she went out front to check on him. Resident #1 ' s sister said when she got out there Resident #1 said the facility was not letting him back into the facility. Resident #1 ' s sister said she attempted to get into the facility and she couldn ' t. Resident #1 ' s sister said her and her brother called the facility multiple times but they would not answer the phone. Resident #1 ' s sister said the facility management staff put all of her brother ' s belongings out the side door of the facility onto the parking lot in trash bags. Resident #1 ' s sister said she is also disabled and could not move her brothers belongings so she asked staff, who were watching, if they would help and they told her they were not allowed to help. Resident #1 ' s sister said it was dark and only about 60 degrees, her brother had been locked out wearing shorts and a tee shirt, they were both cold and upset because they didn ' t know what to do. Resident #1 ' s sister said they kept trying to get the facility to let Resident #1 in but after about three hours of trying she called 911 to come and pick Resident #1 up. Resident #1 ' s sister said both her and her brother were very upset, they could not believe what happened. In an interview on 10/15/15 at 11:20 AM, in his hospital room, Resident #1 said 10/8/15 started out like any other day but then about 2:00 PM it started turning strange. Resident #1 said he requested pain medicine and was told he couldn ' t have any because he didn ' t have a doctor. Resident #1 said later he was rolling down the hallway in his wheelchair to get a smoking pass to go in front of the building to smoke when at the corner by the nursing station he was asked by Emergency Medical Technicians (EMT) if he was Resident #1. Resident #1 said he replied yes he was Resident #1 and the EMT ' s told him they were there to take him to the hospital. Resident #1 said he told the EMT ' s he was not going anywhere. Resident #1 said he got his smoking pass and cigarettes from the nurse and went out the front door to the parking lot to smoke. Resident #1 said when he finished smoking and started back into the facility the gates at the front door were closed and the NHA was on the other side of the gates. Resident #1 said he was pulling on the gates trying to open them and the NHA was trying to hold them closed. Resident #1 said he was surprised, stunned, dazed and confused he had no idea what was happening, he was trying to get into his home and the NHA was telling him you are not coming in. Resident #1 said the NHA could not hold the gates closed, he got the gates open and the NHA ran into the facility and locked the front door. Resident #1 said he pounded on the door pleading for someone to let him in, but no one did. Resident #1 said his sister came and asked What Happened? Resident #1 said his sister said, they can ' t do that to you and she tried to get in but the staff would not let her in either. Resident #1 said another family came to the front door and tried to get in, the door was locked but the NHA and her group of Department Heads came out and blocked Resident #1 and his sister and allowed the other family into the building. Resident #1 said he felt helpless he could not believe he was locked out of his home in shorts and a tee shirt in his wheelchair and there was nothing he could do. Resident #1 said a department head came to the window at the front door and was pointing to the side of the building. Resident #1 said he went slowly in his wheelchair around to the side of the facility and his clothes, television, computer, bookcase and all of his belongings were in the parking lot, his belongings were in trash bags! Resident #1 said he felt like an animal like he was trash; all of his belongings were just thrown out like he was nothing. Resident #1 said he didn ' t know what to do, he asked the facility employees who were guarding the gate if they could watch it until he could hire a moving company to pick it up but they said no. Resident #1 said he had nowhere to go, he couldn ' t even get into his sisters car because he has to be transferred into and out of his wheelchair and his sister can ' t do that. Resident #1 said they just kept waiting and waiting to be let back into the facility, it was cold and he felt helpless, they waited for 3 hours then decided to call 911. Resident #1 said 911 came picked him up took him to the hospital emergency room and when the emergency room called the facility to tell them they were bringing him back, the facility said no, we will not take him. Resident #1 said he was in a lot of pain and felt horrible because he had just lost his home, it was unbelievable. In an interview on 10/14/15 at 11:16 AM Licensed Vocational Nurse (LVN) D said about a year ago administration told staff to be stern and strict with Resident #1. LVN D said previously the staff would satisfy Resident #1 with what time he wanted to get up, when he wanted his shower and when he wanted to go smoke. LVN D said the ADON gave an in-service just on Resident #1 to follow all rules be stern and strict and document more on every behavior. LVN D said on 10/8/15 at about 10:00 AM the Director of Nursing (DON) and the Social Worker (SW) told her Resident #1 did not have a physician and could not receive medications. LVN D said at 1:00 PM Resident #1 requested pain medications, LVN D explained to him she could not give him any medications because she was told by DON he did not have a doctor. LVN D said Resident #1 waited about 20 minutes then got agitated and called his sister. LVN D said when Resident #1 ' s sister arrived she directed both of them to the DON ' s office but the DON, ADON E and SW were all in ADON E ' s office having a meeting. In an interview on 10/12/15 at 2:45 PM LVN F said since May 2015 when she started working with Resident #1, he was calm and then agitated, back and forth, she would try to re-direct. LVN F said the staff were never given any training on dealing with his behaviors. LVN F said on 10/8/15 she was told Resident #1 did not have a physician and he could not be treated. LVN F said the DON, ADON and the SW were at the nursing station and called 911 to come and get Resident #1 but when 911 arrived Resident #1 said he did not want to go to the hospital and he went out to smoke. LVN F said the NHA, DON, ADON and SW were all at the nursing station talking about Resident #1. Policy and Procedure dated 2003 titled Discharge Planning documented in part: Objective: To evaluate the resident's health status and formulate the best plan of discharge for each resident. In an interview on 10/15/15 the Business Office Manager said only 1 resident had been given a 30 day discharge notice.

Based on observation, record review and interview, it was determined the facility failed to provide adequate supervision and assistance devices for 3 of 5 residents (Resident ID#1, #2 and #4) with a known risk of elopement who wore wanderguard ankle bracelets (code alert monitors), to prevent the residents from eloping from the facility. A. Residents #1 and #2, who had a history of [REDACTED]. The wanderguard door alarm system had not been working since April 2010 and the facility failed to implement interventions to monitor the residents and exit doors to prevent resident elopement. Both residents were observed at 2:15 PM by a family member while driving her car, to be wearing yellow vests and to be headed West on North Loop, a highly traffic street with 4 lanes and a divided road, approximately 1.25 miles away from the facility. The temperature on that day was 95 degrees Fahrenheit (F). Resident #1 and #2 were later found at 2:45 PM, approximately 0.93 miles from the facility. The residents were known to be missing for at least 1.25 hours. B. Residents #1 and #2 eloped again on 09/05/10 and were found wandering outside the drug store on North Loop next door to the nursing facility approximately 450 feet away. The drug store is located at the busy intersection of North Loop and Zaragoza both heavily trafficked streets. The temperature at that time was 95 degrees F. The wanderguard door alarm system continued malfunctioning and no interventions had been implemented to monitor the exit doors to prevent continued resident elopements. C. Resident #4, who had a history of [REDACTED]. This entrance exits to North Loop, a heavily trafficked street with four lanes and a divided road. Resident #4 was brought back inside the facility. The wanderguard door alarm system had not been working since April 2010 and the facility failed to implement interventions to monitor the exit doors to prevent continued resident elopement. An Immediate Jeopardy was identified and the Acting Administrator #A and Director of Nursing #B were informed on 09/08/10 at 2:52 PM. While the Immediate Jeopardy was removed on 09/13/10 at 5:00 PM, the facility remained out of compliance at a level of potential for more than minimal harm at a pattern, because the facility had not yet monitored the effectiveness of their plan. These failures could affect 5 residents identified as being exit-seeking wanderers. These failures could result in residents exiting the building undetected, placing them at risk of serious harm or death due to severe weather conditions or other hazards. The findings include: 1) Confidential interview #A on 09/07/10 at 8:40 AM, revealed two female residents who had Alzheimer's Disease "eloped again" on Sunday 09/05/10 and were found at the drug store next door to the nursing facility. The two residents were identified as resident #1 and #2. The interviewee stated that resident's #1 & #2 had also eloped on 8/10/10. The following day 08/11/10 the interviewee had been informed by the staff, that on 08/10/10 resident #1 and #2 had eloped from the facility at 1:00 PM. The interviewee was informed by staff that when LVN #C was getting ready to give resident's #1 and #2 their medications, they found out both residents were missing from the nursing facility. The interviewee stated that administration was aware that the alarms had not been working properly since April 2010 and has done nothing to fix them. The interviewee stated that the alarms to the exit doors will sometimes sound off when exiting the facility and there are times when the alarms will not sound off. According to MapQuest, The drug store next door to the nursing facility was approximately 450 feet away. 2) Resident #1 Record review of clinical record face sheet revealed resident #1 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of care plan dated 03/30/10, revealed resident #1 to have a short attention span and an increase in periods of wandering and exit seeking behavior. Interventions included, in part, keep resident occupied while in activities to decrease wandering episodes. Review of Psychiatry Progress Note dated 04/21/10 revealed resident #1 is anxious, wants to go out of facility, doesn't sleep, keeps her clothes, always says she wants to go to Juarez, Mexico and cries for her son. Review of Psychiatry Progress Note dated 06/16/10 revealed resident #1 paces and continues exit seeking. Review of resident #1's nurses notes revealed on 06/21/10 at 1:30 PM Resident walking with difficulty noted grabbing left knee. Continue on scheduled pain medication. New Order for Physical Therapy to evaluate and treat as warranted. On 06/26/10 at 1:30 PM nurses notes documented Resident #1 exited the building and within premises. Resident escorted into building. Responsible party notified. Will continue to monitor as ordered. Review of Elopement Risk assessment dated [DATE] revealed a score of 23, 10 and above represents high risk for elopement. Review of resident #1's most recent Minimum Data Set (MDS) Quarterly Review dated 06/28/10 revealed resident #1 measured 56 inches and weight 184 pounds, had short term and long term memory problems, had moderately impaired cognitive status for decision making - decisions poor, cues/supervision required, her mental function varies over the course of the day - sometimes better, sometimes worse - behaviors sometimes present, sometimes not, usually understood, usually understands, unsteady gait, wandering behavior occurred 1 to 3 days in last 7 days and behavior was not easily altered, walk in room and corridor independent with setup help only, locomotion on and off unit independent with one person physical assist, continent of bowel and bladder. On 07/08/10 nurses notes documented a Quarterly Care Plan review was held with care plan team in attendance. Continues to require minimal to moderate assist to complete ADL (activities of daily living ) tasks secondary to decrease awareness and forgetfulness. Ambulates independently wears yellow alert vest, monitored frequently due to wanders up and down hallways to both side of facility. Encouraged to participate in special care program. Enjoys time in special events, religious services and special care. Currently on Therapy Part B services to assist with ambulation and complaints of pain to knee. Will continue with P.O.C. (Plan of Care) Review of care plan dated 07/08/10 revealed resident #1 was at risk for injuries due to exit-seeking behavior, attempts to exit building unattended. Approaches included, in part, check resident's whereabouts. Wanderguard in place at all times. Re-direct as needed/cues. Notify all staff of resident's tendency to seek exit, on wander list at nurses station, Yellow Alert Vest to be worn while up and wandering. Review of care plan for resident #1 dated 07/08/10 revealed the following: - Presenting with sad mood as seen by sad facial expressions and exit seeking. Approaches included, in part, Yellow Alert Vest while up. - At risk for pain related to history of knee pain. Approaches included, in part, rest periods as needed. - Episodes of long/short term memory impairment, episodes of confusion and forgetfulness, needs assistance to make decisions. Approaches included, in part, Reorient/redirect during episodes of confusion/forgetfulness, Yellow Alert Vest while up, use monitor log frequently, ensure staff aware of wander and elopement risk. - At risk for injuries related to history of falls secondary to knee. 3) Resident #2 Record review revealed resident #2 was an [AGE] year old female with [DIAGNOSES REDACTED]. Airway Obstruction. Record review of Elopement Risk assessment dated [DATE] documented: resident cognitively impaired with poor decision making skills ambulates independently resident has a history of elopement while at home resident wanders aimlessly the family has voiced concerns that would indicate the resident may have wandering tendencies or try to leave. Summary of Assessment: Resident is at risk of elopement - wonders/monitor Appropriate interventions have been initiated Wanderguard in place Review of resident #2's most recent Comprehensive MDS assessment dated [DATE], documented resident #2 measured 62 inches and weight 126 pounds, had short term memory problems, had moderately impaired cognitive status for decision making, Usually understands others, asked repetitive questions such as; "Where do I go? What do I do?" Wandering behavior, Activities of Daily Living (ADL) had deteriorated, Moderate pain less than daily, joint pain, conditions/diseases make resident's cognitive, ADL, and mood or behavior patterns unstable (fluctuating, precarious, or deteriorating). Review of care plan dated 04/05/10, revealed resident #2 to be at risk for elopement secondary to episodes of wandering and/or exit-seeking behaviors. Interventions included, in part, attempt to determine times of wandering/exit-seeking and watch for signs during those times to deter resident from leaving the facility, alert staff to monitor this resident's location more closely, provide elopement precautions i.e. educating staff, monitor wanderguard bracelet and make sure it is in place, fits comfortably and functions properly. Review of Psychiatry Progress Note dated 04/21/10 revealed resident #2 is not sleeping during nights or days and is always exit seeking. Record review revealed Elopement Alertness memo dated 5/4/10 from Social Services Department with the following directions: Please Monitor the where abouts, Make sure to redirect when approaching exit doors, Make sure she is dressed appropriately, Make sure to keep her occupied, offer daily activities, Report any unusual behaviors, Report any comments or attempts of eloping, Make sure wanderguard is in place at all times, make sure resident wears ID. Review of Psychiatry Progress Note dated 06/16/10 revealed resident #2 paces, is very disoriented, wanders in and out of room and asks for her children alot and had a fall two weeks ago. 4) 8/10/10 Elopement of Resident #1 & 2 Review of Incident Report dated 08/10/10 at 2:45 PM revealed residents #1 and #2 had eloped from the facility and were both found sitting on a bench outside the police station on Zaragoza and Escobar. Past Interventions Attempted revealed Alarms on doors (Door alarm system not functioning since April 2010) and Q (every) 1 hour monitoring of the resident. Recommendations/New Interventions revealed Q (every) 30 minute monitoring. On 08/10/10 at 2:45 PM Resident #1 ' s nurses notes documented Resident #1 eloped from facility with another resident. Resident found sitting on a bench outside the police station on Escobar Street. Resident was transported back to the facility. Upon arrival head to toe assessment completed. VS 98/66, 94, 20, 98.3 and fluids were offered, no bruises or injuries noted. Family and physician were notified. Resident on 30 minute monitoring for elopement. 08/10/10 at 5:55 PM Resident #2 ' s nurses notes documented resident #2 eloped from facility with another resident (female). Resident found at police station on Zaragoza and Escobar sitting down on a bench. Resident was transported back to facility. Upon arrival head to toe assessment completed. Vital Signs 102/58, 76, 18, 97.0 and fluids were offered. No bruises or injuries were noted, family and physician notified. Resident will be monitored every 15 minutes for elopement and employee will be watching her throughout the evening and night. Will continue to monitor. In an interview on 09/08/10 at 11:30 AM the daughter of another resident stated that on 8/10/10, as she was driving east on North Loop near the Pecan Orchid passing Pendale Street at 2:15 PM, the yellow vests had caught her eye. She stated she glanced quickly and saw 2 female elderly residents wearing yellow vests, walking side by side as one was holding the other resident's elbow. The family member said it was a hot day and there was a lot of traffic behind her along with a police officer. She finally was able to pull out to the side of the road to use her cell phone to call the nursing facility. In an interview on 09/07/10 at 11:17 AM with Business Office Assistant (BOA) #D stated she had received a telephone call after lunch from a family member of another resident on 08/10/10 at around 2:00 PM asking what it meant when the residents wear yellow vests. The family member said that she had seen 2 female residents wearing yellow vests headed West on North Loop close to Pendale as she was driving East. The BOA #D said that she informed the Business Office Manager #E about residents #1 and #2 being seen by the family member. All the staff went on separate vehicles to look for resident #1 and #2 and she was informed that the Assistant Activities Director #F had found both residents outside the Police Department on Zaragoza Street (0.5 miles away from the Interstate 10 Highway according to NAVTEQ). BOA #D stated that shortly after another family member who had arrived to the nursing facility that same day after the first family member had called, reported that he had seen 2 females wearing yellow vests at the Grocery Store (0.2 miles away from nursing facility according to NAVTEQ). He stated that he had recognized them because his wife had been in the same wing where both residents lived. The BOA #D stated that a lot of CNAs went to the market to look for the residents and did not find them. She stated that when both residents were brought back to the nursing facility, resident #2 was complaining from one of her knees hurting. Resident #2 who is ambulatory, had to be put on a wheelchair because her knee was hurting. Both resident #1 and #2 were observed to be tired, their faces looked flushed and were red. BOA #D identified resident #1 and #2 as being confused. In an interview on 09/10/10 at 8:40 AM Activities Assistant #F (AA) stated that on the day of the incident 08/10/10, at about 1:00 PM she was gathering residents for an actvity that was scheduled for 1:30 PM. She stated the Business Office Manager (BOM) #E came out of her office saying "Andale, ya se salio" resident #1 and #2. (Hurry up, resident #1 and #2 left). She turned around to look outside and ran to the drugstore, to the gas station which is across the drug store, to the carwash next to the gas station and then to the shopping center next to the gas station and did not see either resident #1 or 2. She caught up with Licensed Vocational Nurse (LVN) #N and both went to the Grocery Store. Both LVN #N and she were very tired and got into the Treatment Nurse's (TN) #O vehicle. All 3 drove to the another shopping center across from the Grocery Store. LVN #N checked inside one of the stores and did not see resident #1 or 2. They saw other staff in a vehicle headed West on North Loop. We decided to go North on Zaragoza towards I-10 (Interstate). We found them outside the Police Station sitting on a rockwall bench. (Police Station 0.5 miles away from I-10 Highway according to NAVTEQ) Resident #1 and 2 looked tired and their faces were red. AA #F stated that resident #1 complains alot of left knee pain, will hold her left knee with her hand when she walks and will hold onto the handrails out on hall when her left knee pain is very strong. There are times where she has seen her limping as she ambulates down the hall. In an interview on 9/10/10 at 10:30 AM Activity Director (AD) #P stated, on the day of the incident 8/10/10, Wii Bowling was scheduled for 1:30 PM. My assistant and I were gathering residents for the activity at about 1:00 PM, when the Social Worker informed me that resident's #1 & #2 were missing and to start a search. On 8/10/10 the temperature was 97 degrees Fahrenheit (F), according to Weather History for El Paso, Tx printed and provided by ADM #A. Resident #1 ' s nurses notes dated 08/11/10 at 4:00 PM documented met with family and son to discuss occurrence from 08/10 -- Resident exit seeker continues wanting to go to Juarez, Mexico to go check on her mom. Resident wanders within facility. Explained to family that facility doesn't have a wanderguard system. Options given for possible transfer to another facility that has wanderguard system. Family agreed to transfer resident to another facility. Explained to family that facility cannot provide 1:1. Currently resident Q (every) 15 minutes. Monitoring resident whereabouts. Social Worker placed calls to different facilities to find placement. Daughter agreed to come visit and sit with resident 6:00 PM to 8:00 PM to assist with 1:1 starting today. Review of Resident #1 ' s Care Plan Family Conference dated 08/11/10 revealed meeting was held to discuss resident's wandering and exit seeking behavior. Resident exited yesterday from this facility. Family informed about wanderguard system not working at this time and resident might be at risk for elopement. Temporary placement recommended at another facility that could meet residents needs. Record review of Resident #1 ' s Care Plan; Short Attention and Increase Periods of Wandering and Exit Seeking Behavior revealed it was updated on 8/10/10 with: Every 15 minute monitoring, Have family conference, Inservice staff re: alarms. Record review of Social Services Note dated 8/12-8/13/10 revealed Social Services Director (SSD) has been looking for adequate placement for Resident ' s #1 and #2 due to both residents continue to wander and in need of a closed unit, or a facility with wander alarm system or a smaller setting where they could receive 1:1 monitoring. SSD contacted the following places; however none of them had vacancies. SSD then listed names of 5 Nursing Homes and 14 Foster Homes. 5) 9/05/10 (Sunday) Elopement of Resident #1 & 2 Interview on 09/08/10 at Noon with resident #1's son who had visited on 09/05/10 after church around 1:30 PM. Resident #1's son stated "my mother was not wearing a yellow vest at the time of his visit. Sometimes my mother doesn't recognize me and at other times she is very oriented." Review of Incident Report dated 09/05/10 at 7:00 PM revealed resident #1 was found walking outside the facility by a family member. Nurses notes dated 09/06/10 at 2:30 PM documented resident #1 was found wandering outside the facility by a family member. (Incident occurred 9/5/10, no note on 9/5/10) Record review of Resident #1 ' s Care Plan; Resident is at Risk for Injuries due to Exit Seeking Behavior; Attempts to Exit Building Unattended was updated on 9/6/10 with: Every 15 minute monitoring, Encourage Family to Take Out on Pass. Review of Resident #1 ' s Elopement Risk assessment dated [DATE] revealed a score of 23, 10 and above represents high risk for elopement. Review of Incident Report dated 9/5/10 at 7:00 PM revealed resident #2 was found walking outside the facility by a family member. Resident #2's nurses notes documented 09/06/10 at 2:35 PM resident found by a family member wandering outside of the facility. (Incident occurred 9/5/10) Review of resident #2's physician orders [REDACTED]. Observation on 09/07/10 at 10:12 AM revealed resident #1 and #2 to be sitting in chairs in a small table, coloring in color books, in the therapy room with the Speech Language Pathologist (SLP) #G. Resident #1 was observed to be wearing a yellow vest with the facility's name and address embroidered on the back of the vest and with resident #1's name embroidered on the front that read "My name is ....." Resident #1 was observed to be wearing a wanderguard bracelet on her left ankle. Resident #2 was observed to be wearing a yellow vest with the facility's name and address embroidered on the back of the vest and with resident #2's name written in black marker right above the facility's name. Resident #2 was observed to be wearing a wanderguard bracelet on her right ankle. In an interview on 09/07/10 at 10:12 AM SLP #G stated that both resident #1 and #2 attend speech therapy daily. The yellow vests were both given to resident #1 and #2 for safety measures for those residents that are not cognitive. She goes over safety issues, which she has gone over "a million times" with both resident #1 and #2. She identified both residents to be ambulatory and disoriented. She stated that resident #1 verbalizes understanding, knows staff and is working on her memory. She stated that she had heard from staff that both residents had eloped from the facility this past weekend, 09/05/10. Observation on 09/07/10 at 10:29 AM revealed resident #1 and resident #2 not to be in their rooms. Resident #1 and #2 lived in rooms across from each other at the very end of the hallway at the Exit door in Zone 3 on the South side. Both residents were observed to be ambulating up and down the hallway together. In an interview on 09/07/10 at 10:34 AM Licensed Vocational Nurse (LVN) #C identified resident #1 and #2 as being at high risk for elopement, both to wear a yellow vest to indicate at high risk for elopement and both residents wear wanderguard ankle bracelets. LVN #C stated that both residents had eloped together one month ago during the 6-2 shift but were found by another nurse. She said that the nurses and certified nurse aides (CNA) both are to check that they have wanderguard bracelet on and that it is working by taking them to the North Side dining room entrance and the alarm should sound off. Both residents are being monitored every 15 minutes and documentation location of resident on the monitoring sheet. Both residents used to be monitored every hour. LVN #C identified both residents to be oriented to self, to ambulate on own and has observed both residents #1 and #2 wandering up and down the hall. She said that resident #1 always follows resident #2. In an interview on 09/09/10 at 3:35 PM CNA #J stated that both residents #1 and #2 are always walking together, wander throughout the facility, identified them both as exit seeking and had seen them once attempt to leave the facility. 6) Door alarms Confidential interview #B on 9/8/10 at 12:18 PM revealed, "Since March 2010 I was told there was no Wanderguard system in place but they had an alarm. At times I come to the facility and the doors are open without alarm sounds in the North Side dining room". Interview on 9/8/10 at 9:50 AM ADM #A stated, "The south side front entrance door alarm has not worked since April or May. I have been getting bids for replacing the whole system (wanderguard alarms, keypad alarms and the delayed release alarms). We started Q (every) 1 hour monitoring for all wanderers and after 8/10/10 we started every 15 minute monitoring for all wanderers. We had gates placed and we tried to get a company to install key pads on the gates with a code to get into and out of the facility. Several companies came in to give bids. Interview on 9/8/10 at 4:54 PM ADM #A stated, "We started having issues with all alarm systems June 2010 and at that time I had the Maintenance Director start keeping logs. We do not have a Policy and Procedure for the Wanderguard system. The Yellow Vests for wanderers was started in January 2010 just as an added precaution. Interview on 09/07/10 at 3:00 PM Maintenance Assistant Supervisor # H stated "The Maintenance Director checks the door alarms each morning, Monday through Friday, when he arrives. I check each day, Monday through Friday at Noon and again before I leave in the evening. Neither one of us check door alarms on the weekend, Saturday and Sunday. The South Entrance doors have a code. The North Dining Room Exit has a wanderguard system it detects a wanderguard at about 5 feet before it gets to the door. The doors at the end of the hallways are alarmed, they are emergency exits. The Maintenance Director checks the batteries in the wanderguard system. No one checks the doors on the weekend. If there is a problem with a door the staff will call to report it to either the Maintenance Director or Assistant depending on who is on call. I am also working on alarms on the outside gates. Monday or Tuesday they should be installed. On 9/07/10 at 3:19 PM, accompanied by the Activities Assistant #F, observation revealed the North Dining Room Entrance wanderguard alarm door sounded but did not automatically lock when resident #1 approached the door and walked outside to the patio. In an interview on 9/7/10 at 4:20 PM with the Maintenance Director (MD) #Q revealed that no door checks are done on the weekend unless staff suspect that the alarm is not working. The nurses checked the wanderguard system by taking a resident with a wanderguard on close to the door and it should alarm and lock. We started checking all doors 8/9/10. The wanderguard system is shutting down completely, we used to have it on every door. We started replacing the wanderguard system before 8/9/10. Zone 5 North was the one that worked. The others were shutting down, the alarm would not respond right away to wanderguard transmitter. If functioning properly the door will lock, after 15 seconds of trying to open it, it will open. He reported that on the day of the 08/10/10 incident involving resident #1 and #2, he checked the Exit door Zone 3 beside Resident #1 and #2's room and found the alarm would not work. The lid was popped open and the batteries were missing. The alarm was at eye level so he moved it higher on the wall and stated Zone 7 & 8 were not hooked up to the code lock system. It is on a 9 volt battery door alarm. Zone 7 & 8 have never been hooked up to wanderguard system. Observation on 9/12/10 at 10:50 AM with Maintenance Director #Q revealed gate door from the laundry room to the parking lot alarm did not sound when opened. Interview on 9/12/10 at 10:55 AM Registered Nurse (RN) ##L stated, "The gate door from the laundry room to the parking lot alarm requires a remote control. I have armed it 4 times using the remote control and the alarm did not sound." Observation on 9/12/10 at 11:05 AM with Maintenance Director #Q revealed North Side double door motion sensor did not alarm when a staff member went out of door. Observation of motion sensor revealed sensor was not facing the door. During an interview on 9/12/10 at 11:10 AM Maintenance Assistant Supervisor (MAS) # H stated, "I have been told by facility staff that when they are feeding residents at the tables and the half moon table that they turn the alarm off because the sensor catches them and the alarm will sound. I have noticed the alarm turned off at noon and at dinner on occasion the sensor has been facing in a direction other than towards the door and it will not sound off. Observation and interview on 9/12/10 at 11:15 AM with Maintenance Director #Q revealed, double doors in Zone 2 to patio, door opened and alarm did not sound. Maintenance Director stated, "The alarm will only work if the right door top barrel lock is locked so it will not open then the left door will alarm if opened. The right door top barrel lock is not locked and it must be locked. Staff have been inserviced to put the barrel lock on the top of the right door." Observation on 9/12/10 at 11:20 AM with Maintenance Director #Q revealed Food Service Office door to the parking lot had a pad lock on it but the pad lock was not locked. Interview on 9/9/10 at 2:39 PM the Medical Director stated, "I am not aware that the Wanderguard Alarm System has not been functioning properly. The nursing facility did not inform me. It is not safe for resident's #1 and #2 to be out of the nursing facility and out in the community due to Alzheimer's [DIAGNOSES REDACTED]. I was informed all three residents have been transferred to another nursing facility until the alarm system can be fixed and then all three residents will return. 7) Resident #4 Record review revealed resident #4 was [AGE] years old with [DIAGNOSES REDACTED]. Review of resident #4's physician orders [REDACTED]. Review of resident #4's most recent MDS dated [DATE] revealed resident #4 measured 63 inches and weighed 165 pounds, had short term memory problems, moderately impaired cognitive status for decision making, mental function varies over the course of the day, sometimes understood ability is limited to making concrete requests, usually understands others, wandering behavior, walk in room - walk in corridors - locomotion on unit - locomotion off unit --supervision with set up help only, incontinent of bladder. Review of care plan dated 04/20/10 revealed resident #4 was at risk for elopement and had episodes long/short term memory impairment, episodes of confusion and forgetfulness. Needs assistance to make decisions. Interventions revealed to be in part, monitor frequently for needs, monitor everyday for cognitive changes with care, reorient/redirect during episodes of confusion/forgetfulness, yellow alert vest while up. Review of care plan dated 04/20/10 and updated 08/25/10 revealed resident #4 was cognitively impaired due to [DIAGNOSES REDACTED]. Approaches included in part, observe whereabouts, wanderguard as needed, use yellow alert vest while awake, changed to every 15 minutes, monitor and encourage to wear vest. Review of care plan dated 04/20/10 and updated 06/23/10 revealed resident #4 was exhibiting wandering behaviors and was at risk for injury related to impaired safety awareness. Approaches include in part, yellow alert vest while up. Review of Psychiatry Progress Note dated 04/21/10 revealed resident #4 identified as wandering. Review of Psychiatry Progress Note dated 06/16/10 revealed resident #4 stating she wants to go, exit seeking at least once a day. Review of Psychiatry Progress Note dated 07/11/10 revealed resident #4 exit seeking at times. Review of Psychiatry Progress Note dated 08/13/10 revealed resident #4 was physically aggressive and hit staff, exit seeking. On 09/07/10 at 2:00 PM resident #4 was observed to be watching television on the north side dining room. Resident was observed to have a wanderguard on his right ankle. Interview on 9/08/10 at 8:35 AM CNA # H stated he has seen resident #4 opening and trying to leave thru the exit door near his room. The nursing facility has been having trouble with the door alarms not always working. Resident #4 used to have a yellow vest but I haven't seen it for about a week and a half. Last Sunday, 09/05/10, resident #4 was trying to leave the building. Sometimes when I am doing my paperwork I see him open the exit door, I catch him, he has a wanderguard. Interview on 9/9/10 at 3:45 PM LVN #K revealed resident #4 was very confused, exit seeking, wore a yellow vest. He wants to go to his daughter ' s house. Resident #4 is oriented to himself, his gait is steady and he walks fast. He is not able to identify or detect danger. If he sees an opened door he would leave the facility. He was checked Q (every) 15 minutes. Interview on 9/9/10 at 3:35 PM CNA # J revealed, resident #4 did wander and he was exit seeking, he was oriented to his name. He was very confused and walked slowly. Review of resident #4's nurses notes documented a previous history of attempts to elope during the time the wanderguard and door alarm systems were known to not be functioning: - 7/14/10 Resident brought into facility per kitchen staff due to elopement. - 7/15/10 Elopement X 1 this am, confused and crying I'd rather be dead than here. I'm going home. - 7/16/10 Alerted resident attempted to exit facility - 7/17/10 Exit seeking continues with Q (every) 1 hour monitoring - 8/19/10 resident noted with 2 attempts to exit facility through

Based on observation, interview, and record review, it was determined the Administrator (ADM) #A and Director of Nurses (DON) #B failed to effectively and efficiently use its resources to maintain the highest practicable physical well-being for 3 (Resident ' s ID#1, #2 and #4) of 5 residents reviewed for elopement by not maintaining facility door alarm system and not supervising facility staff to ensure Resident ' s who were known elopement risks, did not exit the facility undetected. The ADM #A and DON #B failed to supervise nursing staff, and ensure a system was implemented so residents with a known risk of elopement, who wore wanderguard ankle bracelets (code alert monitors), were prevented from eloping from the facility. The Wanderguard system stopped working April 2010. On 8/10/10 Residents # 1 and 2 exited the facility at an undetermined time of early afternoon hours unknown to facility staff. The residents were found after having been known to be missing for at least 1.25 hours. The residents had travelled approximately 3 miles along heavily trafficked streets, while the temperature was 97 degrees Fahrenheit (F). On 9/5/10 Resident ' s #1 and 2 again exited the facility and were found at 7:00 PM wandering outside the building. The temperature on that day was 95 degrees F. The facility failed to accurately identify, evaluate, implement interventions, monitor the wanderguard door alarm system, and immediately repair the door alarm system to prevent any of the 5 residents with known elopement risks from eloping again from the facility. An Immediate Jeopardy was identified and the Administrator #A and Director of Nursing #B were informed on 09/08/10 at 2:52 PM. While the Immediate Jeopardy was removed on 09/13/10 at 5:00 PM, the facility remained out of compliance at a level of potential for more than minimal harm. These failures could affect 5 residents identified as being wanderers. These failures could result in residents exiting the building undetected, placing them at risk of serious harm or death due to severe weather conditions or other hazards. The findings include: 1) Confidential interview #A on 09/07/10 at 8:40 AM, revealed two female residents who had [MEDICAL CONDITION] "eloped again" on Sunday 09/05/10 and were found at the drug store next door to the nursing facility. The two residents were identified as resident #1 and #2. The interviewee stated that resident's #1 & #2 had also eloped on 8/10/10. The following day 08/11/10 the interviewee had been informed by the staff, that on 08/10/10 resident #1 and #2 had eloped from the facility at 1:00 PM. The interviewee was informed by staff that when LVN #C was getting ready to give resident's #1 and #2 their medications, they found out both residents were missing from the nursing facility. The interviewee stated that administration was aware that the alarms had not been working properly since April 2010 and has done nothing to fix them. The interviewee stated that the alarms to the exit doors will sometimes sound off when exiting the facility and there are times when the alarms will not sound off. According to MapQuest, The drug store next door to the nursing facility was approximately 450 feet away. 2) Resident #1 Record review of clinical record face sheet revealed resident #1 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of care plan dated 03/30/10, revealed resident #1 to have a short attention span and an increase in periods of wandering and exit seeking behavior. Interventions included, in part, keep resident occupied while in activities to decrease wandering episodes. Review of Psychiatry Progress Note dated 04/21/10 revealed resident #1 is anxious, wants to go out of facility, doesn't sleep, keeps her clothes, always says she wants to go to Juarez, Mexico and cries for her son. Review of Psychiatry Progress Note dated 06/16/10 revealed resident #1 paces and continues exit seeking. Review of resident #1's nurses notes revealed on 06/21/10 at 1:30 PM Resident walking with difficulty noted grabbing left knee. Continue on scheduled pain medication. New Order for Physical Therapy to evaluate and treat as warranted. On 06/26/10 at 1:30 PM nurses notes documented Resident #1 exited the building and within premises. Resident escorted into building. Responsible party notified. Will continue to monitor as ordered. Review of Elopement Risk assessment dated [DATE] revealed a score of 23, 10 and above represents high risk for elopement. Review of resident #1's most recent Minimum Data Set (MDS) Quarterly Review dated 06/28/10 revealed resident #1 measured 56 inches and weight 184 pounds, had short term and long term memory problems, had moderately impaired cognitive status for decision making - decisions poor, cues/supervision required, her mental function varies over the course of the day - sometimes better, sometimes worse - behaviors sometimes present, sometimes not, usually understood, usually understands, unsteady gait, wandering behavior occurred 1 to 3 days in last 7 days and behavior was not easily altered, walk in room and corridor independent with setup help only, locomotion on and off unit independent with one person physical assist, continent of bowel and bladder. On 07/08/10 nurses notes documented a Quarterly Care Plan review was held with care plan team in attendance. Continues to require minimal to moderate assist to complete ADL (activities of daily living ) tasks secondary to decrease awareness and forgetfulness. Ambulates independently wears yellow alert vest, monitored frequently due to wanders up and down hallways to both side of facility. Encouraged to participate in special care program. Enjoys time in special events, religious services and special care. Currently on Therapy Part B services to assist with ambulation and complaints of pain to knee. Will continue with P.O.C. (Plan of Care) Review of care plan dated 07/08/10 revealed resident #1 was at risk for injuries due to exit-seeking behavior, attempts to exit building unattended. Approaches included, in part, check resident's whereabouts. Wanderguard in place at all times. Re-direct as needed/cues. Notify all staff of resident's tendency to seek exit, on wander list at nurses station, Yellow Alert Vest to be worn while up and wandering. Review of care plan for resident #1 dated 07/08/10 revealed the following: - Presenting with sad mood as seen by sad facial expressions and exit seeking. Approaches included, in part, Yellow Alert Vest while up. - At risk for pain related to history of knee pain. Approaches included, in part, rest periods as needed. - Episodes of long/short term memory impairment, episodes of confusion and forgetfulness, needs assistance to make decisions. Approaches included, in part, Reorient/redirect during episodes of confusion/forgetfulness, Yellow Alert Vest while up, use monitor log frequently, ensure staff aware of wander and elopement risk. - At risk for injuries related to history of falls secondary to knee. 3) Resident #2 Record review revealed resident #2 was an [AGE] year old female with [DIAGNOSES REDACTED]. Airway Obstruction. Record review of Elopement Risk assessment dated [DATE] documented: resident cognitively impaired with poor decision making skills ambulates independently resident has a history of elopement while at home resident wanders aimlessly the family has voiced concerns that would indicate the resident may have wandering tendencies or try to leave. Summary of Assessment: Resident is at risk of elopement - wonders/monitor Appropriate interventions have been initiated Wanderguard in place Review of resident #2's most recent Comprehensive MDS assessment dated [DATE], documented resident #2 measured 62 inches and weight 126 pounds, had short term memory problems, had moderately impaired cognitive status for decision making, Usually understands others, asked repetitive questions such as; "Where do I go? What do I do?" Wandering behavior, Activities of Daily Living (ADL) had deteriorated, Moderate pain less than daily, joint pain, conditions/diseases make resident's cognitive, ADL, and mood or behavior patterns unstable (fluctuating, precarious, or deteriorating). Review of care plan dated 04/05/10, revealed resident #2 to be at risk for elopement secondary to episodes of wandering and/or exit-seeking behaviors. Interventions included, in part, attempt to determine times of wandering/exit-seeking and watch for signs during those times to deter resident from leaving the facility, alert staff to monitor this resident's location more closely, provide elopement precautions i.e. educating staff, monitor wanderguard bracelet and make sure it is in place, fits comfortably and functions properly. Review of Psychiatry Progress Note dated 04/21/10 revealed resident #2 is not sleeping during nights or days and is always exit seeking. Record review revealed Elopement Alertness memo dated 5/4/10 from Social Services Department with the following directions: Please Monitor the where abouts, Make sure to redirect when approaching exit doors, Make sure she is dressed appropriately, Make sure to keep her occupied, offer daily activities, Report any unusual behaviors, Report any comments or attempts of eloping, Make sure wanderguard is in place at all times, make sure resident wears ID. Review of Psychiatry Progress Note dated 06/16/10 revealed resident #2 paces, is very disoriented, wanders in and out of room and asks for her children alot and had a fall two weeks ago. 4) 8/10/10 Elopement of Resident #1 & 2 Review of Incident Report dated 08/10/10 at 2:45 PM revealed residents #1 and #2 had eloped from the facility and were both found sitting on a bench outside the police station on Zaragoza and Escobar. Past Interventions Attempted revealed Alarms on doors (Door alarm system not functioning since April 2010) and Q (every) 1 hour monitoring of the resident. Recommendations/New Interventions revealed Q (every) 30 minute monitoring. On 08/10/10 at 2:45 PM Resident #1 ' s nurses notes documented Resident #1 eloped from facility with another resident. Resident found sitting on a bench outside the police station on Escobar Street. Resident was transported back to the facility. Upon arrival head to toe assessment completed. VS 98/66, 94, 20, 98.3 and fluids were offered, no bruises or injuries noted. Family and physician were notified. Resident on 30 minute monitoring for elopement. 08/10/10 at 5:55 PM Resident #2 ' s nurses notes documented resident #2 eloped from facility with another resident (female). Resident found at police station on Zaragoza and Escobar sitting down on a bench. Resident was transported back to facility. Upon arrival head to toe assessment completed. Vital Signs 102/58, 76, 18, 97.0 and fluids were offered. No bruises or injuries were noted, family and physician notified. Resident will be monitored every 15 minutes for elopement and employee will be watching her throughout the evening and night. Will continue to monitor. In an interview on 09/08/10 at 11:30 AM the daughter of another resident stated that on 8/10/10, as she was driving east on North Loop near the Pecan Orchid passing Pendale Street at 2:15 PM, the yellow vests had caught her eye. She stated she glanced quickly and saw 2 female elderly residents wearing yellow vests, walking side by side as one was holding the other resident's elbow. The family member said it was a hot day and there was a lot of traffic behind her along with a police officer. She finally was able to pull out to the side of the road to use her cell phone to call the nursing facility. In an interview on 09/07/10 at 11:17 AM with Business Office Assistant (BOA) #D stated she had received a telephone call after lunch from a family member of another resident on 08/10/10 at around 2:00 PM asking what it meant when the residents wear yellow vests. The family member said that she had seen 2 female residents wearing yellow vests headed West on North Loop close to Pendale as she was driving East. The BOA #D said that she informed the Business Office Manager #E about residents #1 and #2 being seen by the family member. All the staff went on separate vehicles to look for resident #1 and #2 and she was informed that the Assistant Activities Director #F had found both residents outside the Police Department on Zaragoza Street (0.5 miles away from the Interstate 10 Highway according to NAVTEQ). BOA #D stated that shortly after another family member who had arrived to the nursing facility that same day after the first family member had called, reported that he had seen 2 females wearing yellow vests at the Grocery Store (0.2 miles away from nursing facility according to NAVTEQ). He stated that he had recognized them because his wife had been in the same wing where both residents lived. The BOA #D stated that a lot of CNAs went to the market to look for the residents and did not find them. She stated that when both residents were brought back to the nursing facility, resident #2 was complaining from one of her knees hurting. Resident #2 who is ambulatory, had to be put on a wheelchair because her knee was hurting. Both resident #1 and #2 were observed to be tired, their faces looked flushed and were red. BOA #D identified resident #1 and #2 as being confused. In an interview on 09/10/10 at 8:40 AM Activities Assistant #F (AA) stated that on the day of the incident 08/10/10, at about 1:00 PM she was gathering residents for an actvity that was scheduled for 1:30 PM. She stated the Business Office Manager (BOM) #E came out of her office saying "Andale, ya se salio" resident #1 and #2. (Hurry up, resident #1 and #2 left). She turned around to look outside and ran to the drugstore, to the gas station which is across the drug store, to the carwash next to the gas station and then to the shopping center next to the gas station and did not see either resident #1 or 2. She caught up with Licensed Vocational Nurse (LVN) #N and both went to the Grocery Store. Both LVN #N and she were very tired and got into the Treatment Nurse's (TN) #O vehicle. All 3 drove to the another shopping center across from the Grocery Store. LVN #N checked inside one of the stores and did not see resident #1 or 2. They saw other staff in a vehicle headed West on North Loop. We decided to go North on Zaragoza towards I-10 (Interstate). We found them outside the Police Station sitting on a rockwall bench. (Police Station 0.5 miles away from I-10 Highway according to NAVTEQ) Resident #1 and 2 looked tired and their faces were red. AA #F stated that resident #1 complains alot of left knee pain, will hold her left knee with her hand when she walks and will hold onto the handrails out on hall when her left knee pain is very strong. There are times where she has seen her limping as she ambulates down the hall. In an interview on 9/10/10 at 10:30 AM Activity Director (AD) #P stated, on the day of the incident 8/10/10, Wii Bowling was scheduled for 1:30 PM. My assistant and I were gathering residents for the activity at about 1:00 PM, when the Social Worker informed me that resident's #1 & #2 were missing and to start a search. On 8/10/10 the temperature was 97 degrees Fahrenheit (F), according to Weather History for El Paso, Tx printed and provided by ADM #A. Resident #1 ' s nurses notes dated 08/11/10 at 4:00 PM documented met with family and son to discuss occurrence from 08/10 -- Resident exit seeker continues wanting to go to Juarez, Mexico to go check on her mom. Resident wanders within facility. Explained to family that facility doesn't have a wanderguard system. Options given for possible transfer to another facility that has wanderguard system. Family agreed to transfer resident to another facility. Explained to family that facility cannot provide 1:1. Currently resident Q (every) 15 minutes. Monitoring resident whereabouts. Social Worker placed calls to different facilities to find placement. Daughter agreed to come visit and sit with resident 6:00 PM to 8:00 PM to assist with 1:1 starting today. Review of Resident #1 ' s Care Plan Family Conference dated 08/11/10 revealed meeting was held to discuss resident's wandering and exit seeking behavior. Resident exited yesterday from this facility. Family informed about wanderguard system not working at this time and resident might be at risk for elopement. Temporary placement recommended at another facility that could meet residents needs. Record review of Resident #1 ' s Care Plan; Short Attention and Increase Periods of Wandering and Exit Seeking Behavior revealed it was updated on 8/10/10 with: Every 15 minute monitoring, Have family conference, Inservice staff re: alarms. Record review of Social Services Note dated 8/12-8/13/10 revealed Social Services Director (SSD) has been looking for adequate placement for Resident ' s #1 and #2 due to both residents continue to wander and in need of a closed unit, or a facility with wander alarm system or a smaller setting where they could receive 1:1 monitoring. SSD contacted the following places; however none of them had vacancies. SSD then listed names of 5 Nursing Homes and 14 Foster Homes. 5) 9/05/10 (Sunday) Elopement of Resident #1 & 2 Interview on 09/08/10 at Noon with resident #1's son who had visited on 09/05/10 after church around 1:30 PM. Resident #1's son stated "my mother was not wearing a yellow vest at the time of his visit. Sometimes my mother doesn't recognize me and at other times she is very oriented." Review of Incident Report dated 09/05/10 at 7:00 PM revealed resident #1 was found walking outside the facility by a family member. Nurses notes dated 09/06/10 at 2:30 PM documented resident #1 was found wandering outside the facility by a family member. (Incident occurred 9/5/10, no note on 9/5/10) Record review of Resident #1 ' s Care Plan; Resident is at Risk for Injuries due to Exit Seeking Behavior; Attempts to Exit Building Unattended was updated on 9/6/10 with: Every 15 minute monitoring, Encourage Family to Take Out on Pass. Review of Resident #1 ' s Elopement Risk assessment dated [DATE] revealed a score of 23, 10 and above represents high risk for elopement. Review of Incident Report dated 9/5/10 at 7:00 PM revealed resident #2 was found walking outside the facility by a family member. Resident #2's nurses notes documented 09/06/10 at 2:35 PM resident found by a family member wandering outside of the facility. (Incident occurred 9/5/10) Review of resident #2's physician orders [REDACTED]. Observation on 09/07/10 at 10:12 AM revealed resident #1 and #2 to be sitting in chairs in a small table, coloring in color books, in the therapy room with the Speech Language Pathologist (SLP) #G. Resident #1 was observed to be wearing a yellow vest with the facility's name and address embroidered on the back of the vest and with resident #1's name embroidered on the front that read "My name is ....." Resident #1 was observed to be wearing a wanderguard bracelet on her left ankle. Resident #2 was observed to be wearing a yellow vest with the facility's name and address embroidered on the back of the vest and with resident #2's name written in black marker right above the facility's name. Resident #2 was observed to be wearing a wanderguard bracelet on her right ankle. In an interview on 09/07/10 at 10:12 AM SLP #G stated that both resident #1 and #2 attend speech therapy daily. The yellow vests were both given to resident #1 and #2 for safety measures for those residents that are not cognitive. She goes over safety issues, which she has gone over "a million times" with both resident #1 and #2. She identified both residents to be ambulatory and disoriented. She stated that resident #1 verbalizes understanding, knows staff and is working on her memory. She stated that she had heard from staff that both residents had eloped from the facility this past weekend, 09/05/10. Observation on 09/07/10 at 10:29 AM revealed resident #1 and resident #2 not to be in their rooms. Resident #1 and #2 lived in rooms across from each other at the very end of the hallway at the Exit door in Zone 3 on the South side. Both residents were observed to be ambulating up and down the hallway together. In an interview on 09/07/10 at 10:34 AM Licensed Vocational Nurse (LVN) #C identified resident #1 and #2 as being at high risk for elopement, both to wear a yellow vest to indicate at high risk for elopement and both residents wear wanderguard ankle bracelets. LVN #C stated that both residents had eloped together one month ago during the 6-2 shift but were found by another nurse. She said that the nurses and certified nurse aides (CNA) both are to check that they have wanderguard bracelet on and that it is working by taking them to the North Side dining room entrance and the alarm should sound off. Both residents are being monitored every 15 minutes and documentation location of resident on the monitoring sheet. Both residents used to be monitored every hour. LVN #C identified both residents to be oriented to self, to ambulate on own and has observed both residents #1 and #2 wandering up and down the hall. She said that resident #1 always follows resident #2. In an interview on 09/09/10 at 3:35 PM CNA #J stated that both residents #1 and #2 are always walking together, wander throughout the facility, identified them both as exit seeking and had seen them once attempt to leave the facility. 6) Door alarms Confidential interview #B on 9/8/10 at 12:18 PM revealed, "Since March 2010 I was told there was no Wanderguard system in place but they had an alarm. At times I come to the facility and the doors are open without alarm sounds in the North Side dining room". Interview on 9/8/10 at 9:50 AM ADM #A stated, "The south side front entrance door alarm has not worked since April or May. I have been getting bids for replacing the whole system (wanderguard alarms, keypad alarms and the delayed release alarms). We started Q (every) 1 hour monitoring for all wanderers and after 8/10/10 we started every 15 minute monitoring for all wanderers. We had gates placed and we tried to get a company to install key pads on the gates with a code to get into and out of the facility. Several companies came in to give bids. Interview on 9/8/10 at 4:54 PM ADM #A stated, "We started having issues with all alarm systems June 2010 and at that time I had the Maintenance Director start keeping logs. We do not have a Policy and Procedure for the Wanderguard system. The Yellow Vests for wanderers was started in January 2010 just as an added precaution. Interview on 09/07/10 at 3:00 PM Maintenance Assistant Supervisor # H stated "The Maintenance Director checks the door alarms each morning, Monday through Friday, when he arrives. I check each day, Monday through Friday at Noon and again before I leave in the evening. Neither one of us check door alarms on the weekend, Saturday and Sunday. The South Entrance doors have a code. The North Dining Room Exit has a wanderguard system it detects a wanderguard at about 5 feet before it gets to the door. The doors at the end of the hallways are alarmed, they are emergency exits. The Maintenance Director checks the batteries in the wanderguard system. No one checks the doors on the weekend. If there is a problem with a door the staff will call to report it to either the Maintenance Director or Assistant depending on who is on call. I am also working on alarms on the outside gates. Monday or Tuesday they should be installed. On 9/07/10 at 3:19 PM, accompanied by the Activities Assistant #F, observation revealed the North Dining Room Entrance wanderguard alarm door sounded but did not automatically lock when resident #1 approached the door and walked outside to the patio. In an interview on 9/7/10 at 4:20 PM with the Maintenance Director (MD) #Q revealed that no door checks are done on the weekend unless staff suspect that the alarm is not working. The nurses checked the wanderguard system by taking a resident with a wanderguard on close to the door and it should alarm and lock. We started checking all doors 8/9/10. The wanderguard system is shutting down completely, we used to have it on every door. We started replacing the wanderguard system before 8/9/10. Zone 5 North was the one that worked. The others were shutting down, the alarm would not respond right away to wanderguard transmitter. If functioning properly the door will lock, after 15 seconds of trying to open it, it will open. He reported that on the day of the 08/10/10 incident involving resident #1 and #2, he checked the Exit door Zone 3 beside Resident #1 and #2's room and found the alarm would not work. The lid was popped open and the batteries were missing. The alarm was at eye level so he moved it higher on the wall and stated Zone 7 & 8 were not hooked up to the code lock system. It is on a 9 volt battery door alarm. Zone 7 & 8 have never been hooked up to wanderguard system. Observation on 9/12/10 at 10:50 AM with Maintenance Director #Q revealed gate door from the laundry room to the parking lot alarm did not sound when opened. Interview on 9/12/10 at 10:55 AM Registered Nurse (RN) ##L stated, "The gate door from the laundry room to the parking lot alarm requires a remote control. I have armed it 4 times using the remote control and the alarm did not sound." Observation on 9/12/10 at 11:05 AM with Maintenance Director #Q revealed North Side double door motion sensor did not alarm when a staff member went out of door. Observation of motion sensor revealed sensor was not facing the door. During an interview on 9/12/10 at 11:10 AM Maintenance Assistant Supervisor (MAS) # H stated, "I have been told by facility staff that when they are feeding residents at the tables and the half moon table that they turn the alarm off because the sensor catches them and the alarm will sound. I have noticed the alarm turned off at noon and at dinner on occasion the sensor has been facing in a direction other than towards the door and it will not sound off. Observation and interview on 9/12/10 at 11:15 AM with Maintenance Director #Q revealed, double doors in Zone 2 to patio, door opened and alarm did not sound. Maintenance Director stated, "The alarm will only work if the right door top barrel lock is locked so it will not open then the left door will alarm if opened. The right door top barrel lock is not locked and it must be locked. Staff have been inserviced to put the barrel lock on the top of the right door." Observation on 9/12/10 at 11:20 AM with Maintenance Director #Q revealed Food Service Office door to the parking lot had a pad lock on it but the pad lock was not locked. Interview on 9/9/10 at 2:39 PM the Medical Director stated, "I am not aware that the Wanderguard Alarm System has not been functioning properly. The nursing facility did not inform me. It is not safe for resident's #1 and #2 to be out of the nursing facility and out in the community due to Alzheimer's [DIAGNOSES REDACTED]. I was informed all three residents have been transferred to another nursing facility until the alarm system can be fixed and then all three residents will return. 7) Resident #4 Record review revealed resident #4 was [AGE] years old with [DIAGNOSES REDACTED]. Review of resident #4's physician orders [REDACTED]. Review of resident #4's most recent MDS dated [DATE] revealed resident #4 measured 63 inches and weighed 165 pounds, had short term memory problems, moderately impaired cognitive status for decision making, mental function varies over the course of the day, sometimes understood ability is limited to making concrete requests, usually understands others, wandering behavior, walk in room - walk in corridors - locomotion on unit - locomotion off unit --supervision with set up help only, incontinent of bladder. Review of care plan dated 04/20/10 revealed resident #4 was at risk for elopement and had episodes long/short term memory impairment, episodes of confusion and forgetfulness. Needs assistance to make decisions. Interventions revealed to be in part, monitor frequently for needs, monitor everyday for cognitive changes with care, reorient/redirect during episodes of confusion/forgetfulness, yellow alert vest while up. Review of care plan dated 04/20/10 and updated 08/25/10 revealed resident #4 was cognitively impaired due to [DIAGNOSES REDACTED]. Approaches included in part, observe whereabouts, wanderguard as needed, use yellow alert vest while awake, changed to every 15 minutes, monitor and encourage to wear vest. Review of care plan dated 04/20/10 and updated 06/23/10 revealed resident #4 was exhibiting wandering behaviors and was at risk for injury related to impaired safety awareness. Approaches include in part, yellow alert vest while up. Review of Psychiatry Progress Note dated 04/21/10 revealed resident #4 identified as wandering. Review of Psychiatry Progress Note dated 06/16/10 revealed resident #4 stating she wants to go, exit seeking at least once a day. Review of Psychiatry Progress Note dated 07/11/10 revealed resident #4 exit seeking at times. Review of Psychiatry Progress Note dated 08/13/10 revealed resident #4 was physically aggressive and hit staff, exit seeking. On 09/07/10 at 2:00 PM resident #4 was observed to be watching television on the north side dining room. Resident was observed to have a wanderguard on his right ankle. Interview on 9/08/10 at 8:35 AM CNA # H stated he has seen resident #4 opening and trying to leave thru the exit door near his room. The nursing facility has been having trouble with the door alarms not always working. Resident #4 used to have a yellow vest but I haven't seen it for about a week and a half. Last Sunday, 09/05/10, resident #4 was trying to leave the building. Sometimes when I am doing my paperwork I see him open the exit door, I catch him, he has a wanderguard. Interview on 9/9/10 at 3:45 PM LVN #K revealed resident #4 was very confused, exit seeking, wore a yellow vest. He wants to go to his daughter ' s house. Resident #4 is oriented to himself, his gait is steady and he walks fast. He is not able to identify or detect danger. If he sees an opened door he would leave the facility. He was checked Q (every) 15 minutes. Interview on 9/9/10 at 3:35 PM CNA # J revealed, resident #4 did wander and he was exit seeking, he was oriented to his name. He was very confused and walked slowly. Review of resident #4's nurses notes documented a previous history of attempts to elope during the time the wanderguard and door alarm systems were known to not be functioning: - 7/14/10 Resident brought into facility per kitchen staff due to elopement. - 7/15/10 Elopement X 1 this am, confused and crying I'd rather be dead than here. I'm going home. - 7/16/10 Alerted resident attempted to exit facility - 7/17/10 Exit seeking continues with Q (every) 1 hour monitoring - 8/19/10 resident noted with 2 attempts to exit facility through north side doors at the end of the hallway - 8/24/10 resident attempted to exit the building through front - 8/25/10 resident exited facility through side door on north side, resident brought back into the facility - 8/26/10 phone conference with family - increased behaviors and exit seeking, very lonely - 9/6/10 resident noted crying, ambulating throughout the facility attempting to exit facility - 9/7/10 resident noted exiting facility through side door. Resident brought back into the facility, resident crying and upset. - 9/8/10 discharged to Facility B at 10:20 AM An Immediate Jeopardy was identified and the Administrator #A and Director of Nursing #B were informed on 09/08/10 at 2:52 PM. The Action Plan (the third draft) submitted by the facility was accepted