Every finding on record at Paradigm at Bay City

Based on observation, interview and record review the facility failed to ensure that residents were free of a med error rate of 5% or greater for 1 of 4 (Resident #15) residents reviewed for medication administration. The facility failed to ensure the medication error rate of 26.67% (30 opportunities with 8 medication errors) was less than 5%. This failure placed residents at risk of incorrect doses of medications and optimal therapeutic response.Findings included: Record review Resident #15's electronic face sheet, dated 07/23/2026, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. He had active diagnoses including: hypotension (low blood pressure), Acute Kidney Failure (inability of the kidneys to filter out toxins from the blood), esophagitis (inflammation of the tube that carries food and drink from the mouth to the stomach), dementia (condition where the brain gradually loses its ability to think, remember, and make decisions affecting daily life), major depressive disorder (persistent feeling of sadness and loss of interest in activities) and abdominal hernia (soft tissue that pushes through a weak spot in the muscle or connective tissue of that abdomen). Record review of Resident #15's electronic physician orders, dated 07/22/2026, reflected an order for: Aspirin EC tablet delayed release 81mg one time a day for heart health start date 02/26/2026; Ferrous Sulfate 325mg tablet one time a day for anemia (low iron level in blood) start date 02/26/2026; Multi-Vitamin with Minerals 1 tablet one time a day for supplement start date 02/26/2026; Protonix delayed release 40mg one time a day for GERD (when stomach contents regurgitate up into the tube that carries food and drink from the mouth to the stomach causing inflammation) start date 02/26/2026; Thiamine hcl 100mg table one time a day for supplement start date 02/26/2026; Vitamin B-12 1000mcg tablet one time a day for vitamin deficiency start date 04/07/2026; Risperdal 0.5mg tablet two times a day for brief psychotic disorder start date 06/23/2026; Carafate 1gm tablet before meals for ulcer start date 02/26/2026.Further review of physician orders revealed there was no order that medications could be crushed. During an observation and interview on 07/22/2026 at 9:40 a.m., MA B was performing medication pass for Resident #15. She took the tablets out of their packages and crushed the medications together. The Aspirin 81mg that was crushed was a chewable Aspirin and was not an Enteric Coated Aspirin. The crushed medications were mixed with vanilla pudding. MA B stated she had tried to give Resident #15's medications to him whole after he had first admitted into the facility, but he had requested for them to be crushed and she started crushing them for him after. Resident #15 took the medications mixed with vanilla pudding and drank some water after. MA B documented in the MAR that medications were given. During a follow-up interview on 07/22/2026 at 11:10 a.m., MA B stated she crushed Resident #15's medications because he wanted her to. She stated there should be an order to crush his medications before the medications were crushed. She stated she was unsure what medications could be crushed and stated she should have told the nurse he wanted the medications crushed so the nurse could have instructed her on if she could crush the medications or not. She stated that Carafate should have been given before meals if that was what the order stated. She stated she did not notice that the Aspirin was not coated per the order. She stated she did not know there was no physician order to crush Resident #15's medications and had not noticed that the Carafate was to be administered before meals until now. She stated Resident #15 has had difficulty in the past swallowing medications and that was why he requested her to crush them she thought.During an interview on 07/22/2026 at 11:39 a.m., RN A stated the MAs should not crush medications without an order to crush medications. She stated if she had been informed that Resident #15 did not have an order to crush medications, she would have called the physician to get his orders clarified. She stated she was unaware that MA B was crushing Resident #15's medications. She stated medications that have a delayed release should not be crushed including Protonix. She stated medications with an enteric coating should not be crushed including Aspirin. She stated if the order was for the resident to get Aspirin EC then a chewable Aspirin would not be the same. She stated crushing the Aspirin and Protonix could cause the medication to be absorbed in the body more rapidly than it would have otherwise. She stated Carafate should be given before meals to help it work more effectively in coating the stomach and could cause other medications to be absorbed if given with them. She stated the pharmacist was in the building monthly to watch medication pass and she knew that they watched the MA pass medications during that time. She stated the MA had been working for about a year and she needed more training on passing medications. She did not state any negative impact on a resident receiving crushed Ferrous Sulfate, Multi-vitamin with minerals, thiamine, B-12, or Risperdal.During an interview on 07/22/2026 at 12:50 p.m., the DON stated medications should not be crushed without an order. She stated usually there was an order put into the system when a resident could have medications crushed on admission. She stated EC medication should not be crushed because it could cause gastric distress by the coating being compromised. She stated DR medication should not be crushed because it could make the medication be absorbed more rapidly. She stated Carafate should not be administered in between meals because it needed to be given before meals to help coat the stomach to decrease gastric distress. She stated the orders needed to be reviewed, clarified about administration times, and if it was okay to crush medications by the charge nurse. She stated she expected the MA to tell the nurse prior to crushing medications for the nurse to get clarification from the physician. She stated she felt more education was needed on passing medications. She did not state any negative impact on a resident receiving crushed Ferrous Sulfate, Multi-vitamin with minerals, thiamine, B-12, or Risperdal. She stated she would have to review the Do Not Crush Medication guide that was provided to the facility by the pharmacy to see if those medications should be crushed.Record review of facility policy titled Oral Medication Administration, revised on 08/2020, reflected Medications will be administered in a safe and effective manner.Special Considerations 1. Refer to crushing guidelines prior to crushing any medication for confirmation that it can be pulverized.3. For solid medications:.b. Crush medication, if indicated by the prescriber's order for the resident, only after checking the Medication Crushing Guidelines.Record review of facility document, titled Medications Not To Be Crushed, revised on 03/21, revealed: Aspirin EC listed and Protonix listed. Review of drugs.com https://www.drugs.com/cdi/carafate-sucralfate-tablets.html accessed 07/23/2026 revealed: Carafate tablets Generic name: Sucralfate Tablets.Take on an empty stomach.Do not take antacids 30 minutes before or after taking Carafate (sucralfate tablets).Try to space other drugs from this one by 2 hours. This medicine stops many drugs from getting into the body.

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 4 of 26 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) resident rooms observed for environmental conditions. The facility failed to ensure rooms 150 bed A&B and 152 bed A&B had intact paint, no holes in drywall, and no dead bugs in shared restroom. The facility failed to ensure room [ROOM NUMBER] bed A&B had intact floor tiles. The facility failed to ensure room [ROOM NUMBER] bed A&B had running hot water in restroom sink.These failures could place residents at risk for diminished quality of life, discomfort, and safety.Findings included:During an observation and interview on 07/21/2026 at 12:15 p.m., adjoining jack and [NAME] restroom to rooms [ROOM NUMBERS] had peeling paint on both interior restroom doors and some paint chips were seen on the restroom floor. There was a whole in the drywall about 2 inches long and 1/4 inch wide where the drywall met the restroom vent in the ceiling. There was a sticky bug trap under the sink with different dead bugs in the trap. The resident in room [ROOM NUMBER] was lying in bed. There were visitors in the room who stated they did not like that the restroom was in disrepair. They stated the peeling paint on the doors and the dead bugs upset them when they came to visit the resident in room [ROOM NUMBER]. They stated it made them sad to see the resident in room [ROOM NUMBER] living in such an environment even though he did not get out of his bed.During an observation on 07/22/2026 at 8:25 a.m., room [ROOM NUMBER] had a missing tile in the floor and there were many cracked floor tiles in the room. The resident that resided in room [ROOM NUMBER] could not answer questions and she was sitting in a recliner in the room.During an observation and interview on 07/22/2026 at 9:51 a.m., room [ROOM NUMBER]'s restroom sink hot water knob would not move and no hot water came out of the faucet. The resident residing in room [ROOM NUMBER] stated the water was cold at first but would warm up when asked about hot water function in their restroom. They did not complain about not having access to hot water in restroom.During an interview on 07/22/2026 at 10:00 a.m., RN A stated she had worked in the facility for about two years. She stated that if there was something wrong in resident rooms, the staff notified the Maintenance Director through a computer program.During an interview on 07/23/2026 at 9:09 a.m., the Director of Support Services stated he was the Maintenance Director and had been working in the facility for about 2 months. The Maint D stated he had been working with the staff to make sure they used the computerized system to report maintenance issues to him. The Maint D stated room [ROOM NUMBER] should have hot water working in the restroom sink. He stated he had not been informed about the hot water part of the faucet not working prior to today. He stated room [ROOM NUMBER] should have tiles that were intact and not cracked. He stated room [ROOM NUMBER]'s air condition had been leaking and was recently fixed and could have caused the tiles to be loose and crack. He stated rooms [ROOM NUMBERS] should not have peeling paint on the bathroom doors, should not have a gap between the drywall and the restroom vent, and the bug trap should not have various bugs dead in it. He stated not having rooms repaired could make the residents feel that it was not homelike and could cause them to be upset about the appearance of the rooms. He stated tiles missing and cracked could make it difficult for the floor to be cleaned. He stated he would look at the maintenance log to see if any of the items were reported there to be fixed.During a follow-up interview on 07/23/2026 at 9:18 a.m., the Maint D brought in a copy of the computerized maintenance log report. He stated the peeling paint on the restroom door for room [ROOM NUMBER] was on the log dated 07/11/2026 and was waiting to be repaired. He stated the other issues were not reported to him. He stated the facility had a remodeling company repair several rooms in the last two weeks and the repairs were slow because they did not have more than one worker working on the rooms at a time. He stated Rooms 105, 134, 150, and 152 were not any of the rooms that were repaired. During an interview on 07/23/2026 at 11:25 a.m., the ADMN stated she expected for the shared restroom for rooms [ROOM NUMBERS] to be bug free, the paint to be intact and not peeling and the drywall to not have any holes in it. She stated she expected for the tiles in residents' rooms to be intact and not have missing / cracked tiles. She stated she expected for there to be working running hot water in residents' restrooms. She stated Maint D was responsible for making repairs and would be told about issues through the computerized system. She stated she did not know why there was no documentation about the concerns for the tiles, water, and gap in drywall on the computerized report. She stated the issues could make the residents feel the environment was not homelike and stated the residents had a right to a homelike environment.Record review of the facility document titled, Work Orders, reviewed on 07/23/2026, reflected open and in progress work orders of room [ROOM NUMBER] Bathroom walls need attention dated 07/11/2026. There was no evidence of any drywall repair, tile repair, or faucet repair in progress prior to 07/23/2026.Record review of facility policy titled, Resident Rights, Dignity and Privacy Handout, no date, reflected: 8. Right to Safe and Clean Environment Live in a facility that is safe, clean, and comfortable. Have accommodations that promote your quality of life and meet your needs.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:A. [NAME] C washed the food processor between use.B. Dietary Aide D and [NAME] E wore hair restraints properly covering all of their hair. C. The water machine used by the residents in the dining room was clean. These failures could place residents at risk for altered taste of food, foodborne illness and compromised health status and hair in food.The findings included:In the initial observation of the kitchen on 07/21/2026 at 9:30 am, Dietary Aide D was observed with his mustache exposed and not covered with a beard restraint or hair net. The water machine used by the residents in the dining room was soiled with water standing in the basin. In an observation on 07/21/2026 at 10:34 am, [NAME] C was preparing food for the 3 residents that received a puree diet. [NAME] C used the food processor to prepare the puree zucchini, placed the zucchini in a pan, failing to get all of the zucchini out of the food processor. [NAME] C did not wash the food processer between use. [NAME] C placed the main dish, beef macaroni casserole, in the food processor and pureed it with the remaining zucchini in the food processor together.In an observation on 07/21/2026 at 11:45 am, Dietary Aide D was observed with his mustache exposed and not covered with a beard restraint or hair net as he assisted preparing the food trays for the residents. In a follow-up observation of the kitchen on 07/22/2026 at 11:36 am, [NAME] E was observed with his mustache exposed and not covered with a beard restraint or hair net as he was assisting preparing the food trays for the residents. The water machine used by the residents in the dining room remained soiled with brown water standing in the basin. In an observation and interview on 07/22/2026 at 1:02 pm, [NAME] E was observed with his mustache exposed and not covered with a beard restraint. [NAME] E said he did not know if his moustache should be covered or not. He said a potential negative outcome could be hair in the residents' food. In an interview on 07/22/2026 at 1:04 pm, [NAME] C said she did not know why she did not clean the food processor between use but should have done so. She said a potential negative outcome is that it could alter the taste of the food. In an observation and interview on 07/22/2026 at 1:06 pm, Dietary Aide D said all hair should be covered by the hair net including his moustache. He did not know why his moustache was not covered. He said a potential negative outcome was the residents could have hair in their food. In an interview on 07/22/2026 at 1:30 pm, the Dietary Manager said all hair should be covered including moustaches. She said there was a potential negative outcome that there would be hair in the residents' food. The Dietary Manager said the food processor should be cleaned between each use. She said a potential negative outcome would be that it could alter the taste of the food. The Dietary Manager said she did not know who was responsible for cleaning the residents' water machine. In an interview on 07/22/2026 at 1:33 pm. The Administrator said any staff that goes into the kitchen should have hair nets that cover all hair, including moustaches. The Administrator said she was not sure who was responsible for cleaning the resident's water machine. Record review of the facility policy Kitchen Sanitation, dated as revised 5/2025, revealed the following [in part]:Policy: The facility will maintain a clean, sanitary, and safe dietary environment in accordance with federal, state, and local regulations. All food will be stored, prepared, and served in a manner that prevents contamination, foodborne illness, and environmental hazards.Procedure: General Sanitation Standards. Surfaces, shelves, and equipment will be kept free of food debris, grease, and liquids.Staff Hygiene & Infection Control: Dietary staff will wear hair restraints (e.g., hair nets or caps) and beard guards when applicable to prevent contamination.Record review of the Food and Drug Administration Food Code, dated 2022, specified [in part]: 2-402 Hair Restraints(A) Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from FDA Food Code 2022 Chapter 2. Management and Personnel Chapter 2 - 22 contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #41) of 13 residents reviewed for quality of care. The facility failed to ensure oxygen use orders were obtained prior to Resident #41 receiving oxygen therapy. The facility failed to ensure Resident #41's nasal canula was discarded when discoloration or contamination was present on 07/21/2026, 07/22/2026, and 07/23/2026. The facility failed to properly store Resident #41's nasal canula when oxygen was not in use on 07/21/2026, 07/22/2026, and 07/23/2026. The facility failed to ensure there was an oxygen in use sign posted on Resident #41's room door. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.Findings included:Record review of Resident #41's electronic face sheet, dated 07/23/2026, revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses including: COPD (a long-term lung disease that makes it hard to breathe because the airways and air sacs in the lungs are damaged or blocked).Record review of Resident #41's History and Physical, dated 11/19/2025, revealed Resident #41 had a history of COPD and would continue current respiratory medications and monitor oxygen saturation. There was no mention of oxygen therapy.Record review of Resident #41's Progress notes dated 06/23/2026 - 07/23/2026. There was no mention of oxygen therapy.Record review of Resident #41's Quarterly MDS assessment, dated 06/01/2026, revealed a BIMS score of 15 indicating he was cognitively intact. Further review of the MDS assessment revealed Resident #41 did not receive oxygen therapy.Record review of Resident #41's electronic physician orders reviewed on 07/23/2026 revealed no evidence for an order for oxygen therapy.Record review of Resident #41's comprehensive care plan reviewed on 07/23/2026 revealed Resident #41 had COPD related to smoking with interventions including Oxygen via nasal cannula at 3-4 L/min as needed for wheezing / SOB Date Initiated: 06/25/2026.During an observation on 07/21/2026 at 11:15 a.m., Resident #41 was not in his room. There was an oxygen concentrator in the room. The oxygen tubing was lying on top of the concentrator not in a bag and the n/c had brown discoloration with a crusty substance on it. There was no oxygen in use sign on the door entering the room.During an observation and interview on 07/21/2026 at 11:53 a.m., Resident #41 was lying in the bed in his room. Resident #41 was wearing the oxygen via n/c and the concentrator was set to 5 L/Min. He stated his oxygen tubing was changed out once a month by the nursing staff but could not state the last time it was changed. There was no date on the oxygen tubing. He stated he turned on the oxygen concentrator and put on his tubing when he came back into his room because he got short of breath. He stated he only wore oxygen when he needed it and he did not need it when he left his room. During an observation on 07/22/2026 at 9:53 a.m., Resident #41 was not in his room. The oxygen concentrator was turned off and the oxygen tubing was lying on top outside of the bag. The n/c continued to have a crusty substance and was discolored brown. There was no oxygen in use sign on his door.During an observation on 07/23/2026 at 10:00 a.m., Resident #41 was not in his room. The oxygen concentrator was turned off and the oxygen tubing was lying on top outside of the bag. The n/c continued to have a crusty substance and was discolored brown. There was no oxygen in use sign on his door.During an interview on 07/23/2026 at 10:45 a.m., the MDS nurse stated there should be an order for oxygen if a resident was receiving oxygen therapy. She stated she was not aware that Resident #41 received oxygen therapy because there was no order for oxygen therapy and no documentation from the nurses that he had received oxygen therapy. She stated the nurses would document oxygen therapy on the MAR, but an order would be needed for that documentation to be available. She stated the progress notes could have oxygen therapy documentation as well. She stated oxygen tubing should be stored in a bag when not in use. She stated she could not code oxygen use on the MDS unless she had evidence Resident #41 utilized oxygen therapy for at least 15 minutes. She stated she never knew he utilized oxygen therapy in the past and stated he had refused oxygen before. She stated the nurse who initiated the oxygen therapy or did an admission with oxygen orders was responsible for making sure there was a physician order for oxygen. She stated Resident #41 had been hospitalized recently and he did not come back with an order for oxygen therapy that she could see. She stated she developed comprehensive care plans and no one else updated her care plans. She did not know why the care plan had an intervention for Resident #41 to receive oxygen use when she had not coded the oxygen therapy on the MDS assessment. She stated the MDS assessment drove the items added on the care plans. She stated not putting the oxygen tubing in a bag when not used and changing the tubing out when discolored or contaminated could cause infection spread. She stated Resident #41 continued to smoke cigarettes which could have led to the n/c having brown discoloration. She stated there should be an oxygen in use sign posted when a resident utilized oxygen therapy.During an interview on 07/23/2026 at 11:22 a.m., the DON stated if a resident was utilizing oxygen there should be an order for the oxygen, there should be documentation of oxygen saturations and therapy dose, and there should be an oxygen in use sign on the door to the room. She stated the nurse should be documenting the oxygen administration in the MAR. She stated she did not know if Resident #41 ever came back from the hospital with an order for oxygen and he had refused oxygen in the past so did not know where the oxygen concentrator came from in his room. She stated if he did refuse care, it should be documented on the care plan. She stated she would look at care plans, but the MDS nurse was responsible for the care plans and had corporate oversite. She stated oxygen tubing should be stored in a bag when not in use and the tubing should be changed out when visibly soiled. She stated not storing or changing out the tubing could cause infection spread. She stated she monitored that nurses were documenting appropriately and did not know Resident #41 was using oxygen. She stated Resident #41 may have gotten the concentrator himself and put it in his room, but she did not know where he would have gotten it from.Review of the facility's policy, titled Respiratory Treatment, Care and Services, revised on 6/2019, revealed: 2. The facility has policies and procedures for the types of respiratory services provided, which may include but are not limited to: A. Oxygen therapy, including safe handling, humidification, cleaning, storage and dispensing.6. Infection control practices including standard and transmission-based precautions are followed during: A. Provision of respiratory care, treatment and services. B. Handling of equipment, including cleaning, storage and disposal of regular and biohazardous waste.7. Documentation for Respiratory Care, Treatment and Services: Depending on the type of respiratory services received, licensed independent practitioner orders and the individualized plan of care, documentation includes the following, as appropriate and necessary: A. Vital signs, including respiratory rate.Il Instructions for resident on how to participate or assist in respiratory care, treatment and services, if applicable.Review of the facility's policy, titled Oxygen Therapy: General Administration & Care, revised on 8/2019, revealed: Procedures: 1. Review physician's order on the chart for completeness: s. Modality, Liters, Frequency 2. Gather necessary equipment. 3. Follow relevant infection control procedures as appropriate. 4. Wash hands prior to setting up equipment. 5. Assess the resident. Establish baseline respiratory rate and heart rate. 6. Attach humidifier or nebulizer to flowmeter if indicated. A. Exchange Humidifier when empty i. Dating/Timing Humidifier not required as longevity varies according to multiple factors. 7. Attach administration device to flowmeter or humidifier/nebulizer outlet if indicated. 8. Start O2 flow rate at the prescribed liter flow or appropriate flow for administration device. 9. Place administration device on the resident. 10. Observe color, pulse rate, blood pressure, ventilatory rate/depth, and sensorium for any adverse reactions; remain with the patient/resident until they are accustomed to the therapy. 11. Monitor respiratory rate and heart rate. 12. Post Oxygen in Use sign on the patient/resident's room door. 13. Wash hands prior to leaving the resident's room. 14. Document initiation of therapy in medical record, per documentation standards. 15. Change O2 tubing with any discoloration or contamination.

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 of 6 (Resident #14) reviewed for ADL care. The facility failed to ensure Resident #14's nails were trimmed, cleaned, and filed on 07/21/2026, and 07/22/2026. This failure could place residents at risk of loss of dignity, at risk of infection, and a decreased quality of life. Findings included: Record review of Resident #14's face-sheet dated 07/23/2026 revealed the resident was an [AGE] year-old female with an admission date of 12/25/2025. The face-sheet listed the following diagnoses: Seizure disorder (a brain disorder characterized by recurrent, uncontrolled body movements caused by abnormal electrical activity in the brain), cerebral infarct (the death of brain tissue caused by a blocked blood vessel that cuts off oxygen and nutrient supplies), Atherosclerotic Heart Disease (a buildup of fats, cholesterol, and other substances on the artery walls which cause the arteries to narrow and harden resulting in blocked blood flow. The plaque that forms can break off and cause a blood clot), and Foot Drop to Right and Left foot (a condition caused by nerve impairment, and damage to brain regions controlling movement to the leg muscles that lift the feet). Record review of Resident #14's Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Under Section GG- Functional Abilities, the MDS revealed Resident #14 required supervision or touching assistance with personal hygiene, meaning the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently, and Resident #14 required substantial/maximal assistance to Shower/bathe self which means helper lifts or holds trunk or limbs and provides more than half the effort. Record review of Resident #14's care plan 01/19/2026 revealed Resident #14 required assistance with extensive assistance of one person with bathing and grooming and was bedbound. The goal was Resident #14 would be well dressed, groomed, clean, and her dignity maintained with no further decline in ADL functioning or injury. An observation and interview were done on 07/21/2026 at 10:55 AM of Resident #14's nails of both hands. The fingernails of both hands were observed to be approximately 1/4 inch long, the nails were jagged and a brown substance was noted underneath the third and fourth fingernails of her left hand. She stated it bothered her to have long nails. Resident #14 stated she would like to have her nails cut and filed, because she was going to get new dentures and she was afraid she would cut her gums with her fingernails when she put the teeth in her mouth. She stated she had asked staff to cut her nails, but they had not done it. She stated she could not remember the name of the staff that she asked. During an interview on 7/22/26 at 12:30 PM with CNA F she stated that nails should have been cut, filed, and trimmed when doing a resident's shower. She stated if a resident asked for their nails to be done an aide should have done it unless the resident was a diabetic, and then they should have told the Charge Nurse and she would have cut them. She stated if a CNA noticed unkempt nails or long nails, they should have asked the resident if they wanted them cut or cleaned and do it if the resident requested it be done regardless of whether it was their bath day or not. During an observation and interview on 07/22/2026 at 1:00 PM Resident #14 was in her bed. Resident #14 stated her fingernails had not been cut and she would like to have them cut and filed. She stated she had asked someone to cut them, and they said they would do it when they had time. She stated she could not remember the name of the staff that she asked. During an interview on 07/23/2026 at 10:20 AM with the DON, she stated the nurses were responsible for monitoring and maintaining residents' nails. The DON stated the CNAs provided nail trimming and grooming during shower days or as needed, such as residents being observed with long nails. She stated the potential risk of long and dirty fingernails included risk of injury from scratching selves or others, and it could be a potential portal of entry for bacteria which could place residents at risk for infections. During an interview on 07/23/2026 at 11:51 AM, the Administrator stated the charge nurses and staff providing care to residents were responsible for ensuring residents' fingernails remained trimmed and filed. The Administrator stated residents were at risk of infection if fingernails were not properly maintained. Record review of the facility's policy and procedure titled Nail Care, not dated, stated in part:Subject: Nail Care Policy: It is the policy of this facility that the facility staff will assist the residents with nail care as needed. Residents who are unable to care for their own finger or toenails require assistance in keeping nails clean and trimmed. Procedure: Before staff cares for any resident's nails, check with the nurse to be sure that cutting nails is within the scope of duties for a nurse's aide. (Note: Before you begin nail care, staff wash their hands and put gloves on. Ensure equipment such as scissors or trimmers are clean to prevent infection. Staff are to ensure there are no sharp or jagged edges. Sharp edges can cause cuts to the resident's skin, increasing the risk of infection transmission through breakage in the skin. Staff should inspect the resident's nail beds as you work to look for signs of inflammation or fungal growth. If facility staff observe discoloration or signs of infection, it should be reported to the nurse. Proper nail care can reduce the transmission of disease because the hands and feet are often exposed to many microorganisms which can grow quickly in the nail beds. This procedure will also help the patient to remain comfortable and allow facility staff to look for signs of infection that can lead to complications.) Steps to Perform Skill:Enters room and identifies self. Wash hands and put on disposable gloves. Explain procedure, respond to comments / questions. Assist to comfortable and safe position. Fill basin with warm water. Soaks nails. Clean under nails with orange stick. Groom nails with nail scissors, clippers or file. Avoid cutting or nicking resident's skin. Finishes with nails smooth and free of rough edges.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal care for 3 (Resident #32 Resident #19 and Resident #16) of 12 residents reviewed for ADL care, in that: - The facility failed to ensure Resident #32 was provided personal grooming (dry patches and flaky skin) by facility staff on 5/28/2025. - Resident #19 was not provided nail care. Resident #19's nails were long past the tips of his fingers with a dark substance on top and underneath his nail tips on 5/28/2025. - Resident #16 was not provided nail care. Resident #16's nails were long past the tips of her fingers with a dark substance underneath and dried substance on top the nails on 5/28/2025. This failure placed residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: Resident #32 Record review of Resident #32's face sheet dated 5/29/2025 revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident #32 had diagnoses included: Gastroenteritis and colitis (inflammation of the digestive tract), hemiplegia (weakness of one side of the body) and hemiparesis (one-sided weakness or inability to move) following cerebral infarction (blood vessel blockage in the brain) affecting left non dominant side, anxiety disorder, and glaucoma (damage the optic nerve). Record review of Resident #32's non-descript MDS assessment dated [DATE] revealed Resident BIMS score was 15 which indicated he was cognitively intact. Resident #32 depended on staff with ADL assistance with one staff for partial/moderate assistance. Record review of Resident #32's care plan revised on 1/10/2025 revealed Resident #32 had ADL self-care performance deficit and was at risk for further decline in ADL functioning and injury d/t functional impairments. Interventions: provide extensive assistance of 1 staff hygiene/grooming. Record review of Resident #32's personal hygiene history from POC dated 5/16/2025 - 5/29/2025 revealed the following was completed: Personal hygiene: The ability to maintain personal hygiene, including coming hair, shaving .washing/drying face and hands . Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of partially completed resident shower sheets undated revealed it was unable to determine who provided the personal hygiene (grooming, shaving, nail care) to the residents. During an observation on 5/28/2025 at 10:25 a.m., Resident #32 had dry patches and flaky skin on his forehead and sides of his face without facial hair. Also observed was a full beard (facial hair was approximately 1 ½ inches). During an observation and interview on 5/25/2025 at 12:42 a.m., Resident #32 said his face had not been washed that morning and he did not like his facial hair. He said he was not able to open the twist-off top on the toothpaste because of his paralysis. He said he had not told the staff he needed to be shaved and the staff had not asked if he needed assistance. He said he never liked facial hair. He said his face was itchy with the facial hair and he said, I can't stand it. Resident #32 had dried patches and flaky skin on his forehead and sides of his face without facial hair. Resident #32 had an unkept beard (2-3 inches - full beard). RESIDENT #19 Record review of Resident #19's face sheet dated 5/29/2025 revealed a [AGE] year-old male admitted to the facility originally on 10/15/2021 and current admission was on 2/15/2025. Resident diagnoses included: malignant neoplasm of prostate (prostate cancer), COPD (lung disease), heart failure, and mild cognitive impairment, Record review of Resident #19's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating that resident was cognitively intact. Further review section GG Functional Abilities reflected that resident required partial/moderate assistance from staff with showers. Record review of Resident #19's Comprehensive Care Plan date last reviewed 3/27/2025 reflected Resident #19 reflected the following: ADL self-care performance deficit: Resident #19 has ADL self care deficits and is a risk for further decline in ADL functioning and injury .Interventions: Anticipate needs - provide prompt assistance .Provide supervision assistance of 1 staff for personal hygiene/grooming . Observation and interview on 03/05/25 at 10:10 a.m. revealed Resident #19 in his room and his nails were long past the tips of her fingers with a dark substance underneath and on top the nails on both hands. Resident #19 said it had been a while since his nails were trimmed. He said he had not been offered to clean his hands. He said he was not sure why they were dirty. Observation and interview on 3/28/2024 at 12:10 p.m. revealed Resident #19 went to the dining room. He was sitting and breaking up saltine crackers into his bowl of chili. He continued to have the same dark substance underneath his nails and dried substance on top. Resident #19 said the staff did not offer him to wash or sanitize his hands before he ate. Resident #16 Record review of Resident #16's face sheet dated 5/29/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident diagnoses included: Type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by high blood sugar levels), major depressive disorder, post-viral fatigue syndrome, and generalized anxiety disorder. Record review of Resident #16's quarterly MDS dated [DATE] reflected a BIMS score of 99 indicating the resident could not complete the interview. Further review section GG Functional Abilities reflected that resident required partial/moderate assistance from staff with personal hygiene. Record review of Resident #16's Comprehensive Care Plan date last revised 5/14/2025 reflected Resident #16 reflected the following: ADL self-care performance deficit: Resident #16 has ADL self care deficits and is a risk for further decline in ADL functioning and injury .Interventions: Anticipate needs - provide prompt assistance .Provide extensive assistance of 1 staff for hygiene/grooming . Observation and interview on 5/28/2025 at 12:17 p.m. revealed Resident #16 was eating her food in her room. She was feeding herself and her fingernails were long past her tip. She was trying to grip the fork and it was slipping from her grip held by the fingernail tips. Resident #16 said she would like her fingernails to be trimmed down. She said the nails made it difficult to eat. Interview on 5/28/2025 at 12:58 p.m., LVN A said Resident #32 should be shaved during morning care or during his bath. She said a residents' face should be washed in the morning. She looked at Resident #32 and said his face had dry flaky skin and his beard was scruffy (not trimmed and overgrown). She said CNAs were responsible for shaving resident faces and cleaning residents' faces. She said Resident #32 could had suffered discomfort and skin irritation. LVN A said staff should shave residents upon request or ask residents if they wanted to be shaved. LVN A said we (staff) had to catch [Resident #19] in a good mood for him to accept nail care. She said she was not sure if he was offered nail care or if his hands had been washed. She said his hands should have been washed or sanitized before he ate his food to prevent cross-contamination. LVN A said nail care should have been offered to Resident #16. LVN A said Resident #16's nails were dirty underneath and the nails needed to be trimmed down. She said the resident's overgrown and dirty nails could have led to infection and the length could have been a barrier from Resident #16 holding her fork properly. She said CNAs and Nurses were responsible for nail care and ensuring resident's nails and hands were clean. She said the CNAs for the hall were currently on break. She said Resident #16's nails should have been cleaned before she ate to prevent cross-contamination. Interview on 5/28/2025 at 1:30 p.m., the DON said the resident's nails should have been cleaned daily or as needed. The DON said resident should be shaved upon request or offered during showers to provide dignity. She said CNAs should have documented on the shower sheets or in the POC. She said the shower sheets did not have dates and some did not have CNA names, so it could not be determined who assisted residents with grooming/personal hygiene. She said resident hands and nails should be cleaned and trimmed on shower days and cleaned or sanitized before meals. The DON said the nurses were supposed to make sure that the CNAs assisted residents with grooming and personal hygiene. Record review of the facility policy on AM Care (revised 6/2019) revealed the following: Policy: It is the policy of this facility that the nursing staff will assist the resident with their hygiene and self-care needs to prepare resident for morning activities and to observe resident's general condition . 17. Give resident moist cloth and towel for cleaning hands and face, assisting if necessary. Record review of the facility policy on Shaving (revised 6/2019) revealed the following: Subject: Shaving Policy: It is the policy of this facility that the facility staff will assist the residents with shaving to maintain appearance and self-esteem . Record review of the facility policy on Nail Care (not dated) revealed the following: Subject: Nail Care Policy: It is the policy of this facility that the facility staff will assist the residents with nail care as needed. Residents who are unable to care for their own finger or toe-nails require staff assistance in keeping nails clean and trimmed. Procedure: Before staff cares for any resident's nails, check with the nurse to be sure that cutting nails is within the scope of duties for a nurse's aide . (Note: Before you begin nail care, staff wash their hands and put gloves on. Ensure equipment such as scissors or trimmers are clean to prevent passing on infection Proper nail care can reduce the transmission of disease because the hands and feet are often exposed to many microorganisms which can grow quickly in the nail beds. This procedure will also help the patient to remain comfortable and allow facility staff to look for signs of infection that can lead to complications .)

Based on observation, interviews, and record reviews the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage rooms and 1 of 1 supply closets, reviewed for drug labeling and storage, in that: - The Medication Storage room had an inhaler that was open and in use, with no open date. It also had a TB vaccine vial and a Hepatitis B vaccine vial that was open with no opening date. - The Medication Supply closet had 4 expired bottles of liquid iron. These failures place residents at risk for receiving biologicals and medications which are ineffective and/or not safe. Findings included: In an observation and interview on 5/29/25 at 1:00pm with LVN A, an inhaler was found in the Medication Storage room behind the nurse's station, that did not have an open date on it. There was also a TB vaccine vial and a Hepatitis B vaccine vial found in the mini fridge that were open but did not have an open date on them. LVN A said the inhaler would not be as effective if it was old. She said the ADON handled the vaccines. In an interview with the ADON on 5/29/25 at 1:30pm, she said she was the one who gave the vaccines to new employees. She said she had not given any vaccines recently and did not know why the tops were removed from the TB and Hepatitis vials. She said she would have to throw them away because she did not know when they were opened and if they were still effective. In an observation and interview on 5/29/25 at 1:45pm with LVN A, 4 bottles of liquid iron were found in the Medication Supply closet by the front entrance. LVN A said there was a supply person who stocked the room, and she was the one who kept up with the expiration dates on the meds. She said expired medications would not be as effective. In an interview with the DON on 5/29/25 at 2:05pm, she said she expected staff to write the open date on any medication as soon as they opened it. She said an inhaler was good for 30 days after it was opened and then it would be less effective after that. The DON said the vaccines would be less effective if they were opened for longer than they should have been and there was no way of knowing since there was no open date on the bottle. She said the Supply closet (by the entrance) was run by a supply person, and she had not been trained yet on how to look for the expired meds, and it was her fault for not training her yet. She said she expected staff to check the med carts daily for expired medications since they worked with them all the time, but she did a check of all the carts once a month. Record review of the facility's policy and procedure on Storage of Medications (Revised August 2020) read in part: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists .Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics [eye drops], nitroglycerin tablets [for chest pain], and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating .All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining .

Based on record review and interview, the facility failed to maintain medical records on each resident that are in accordance with accepted professional standards and practices and that are accurately documented for 2 (Residents #55 and #89) of 10 residents reviewed for medical chart documentation. -Resident #89's hospital records were not in her medical chart and was in Resident #55's medical chart. This failure could put residents at risk of privacy issues with their personal health information not being uploaded to the correct chart and health decisions made based off another resident's information. Findings included: Record review of Resident #55's face sheet dated 05/29/2025, she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. She was discharged on 08/29/2025. Her medical diagnoses included acute kidney failure, hypertension (high blood pressure), bipolar disorder (mental health condition characterized by extreme mood swings), Type 2 Diabetes Mellitus, and Obstructive Sleep Apnea, Record review of Resident #89's face sheet dated 05/28/2025, she was an [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included Generalized Anxiety Disorder, Cauda Equina Syndrome (nerve roots at the end of your spinal cord become compressed), Hyperlipidemia (high fat in the blood), Hypertension (high blood pressure) and spinal stenosis (narrowing of the spinal cord). Record review of Resident #55's medical chart on 05/28/2025 at 11:23 am, revealed Resident #89's hospitalization dated 08/15/2024, prior to admission, was attached. Resident #89 did not have her hospitalization from 08/15/2024 uploaded to her medical chart. Interview with the DON on 5/29/2025 at 10:45 am, she said the survey team told her that Resident #89's hospital records were uploaded to Resident #55's medical chart. She said that it was a HIPAA violation (meaning it could violate the federal law protecting sensitive patient information from being disclosed with their consent), and that each resident's chart should only contain their records. Interview with the MDS Nurse on 5/29/2025 at 11:41 am, she said Corporate, the ADON, DON, Administrator, and MDS could upload files. She said a risk of a resident's health information being uploaded to another resident's medical chart would be that nursing got the wrong information and staff should be checking resident names when uploading. If the MDS Nurse uploaded a document to the wrong resident's medical chart, she would let the Administrator know right away and then they would inform Corporate so they can go in right away to delete it. Interview with the RSC on 5/29/2025 at 1:00 pm, she said that any staff could upload documents and the scanned documents would show up with the name of the person in the resident's file. The RSC said that nursing staff were told to upload resident records as they received them to decrease the risk of the wrong upload. She said that if one resident's documents were in another resident's medical chart, it would be a privacy issue, but only those staff members with access to medical charts could see the documents. Record review of the facility's Electronic Protected Health Information Security policy, last revised June 1, 2019, read in part, Purpose: To ensure the security and integrity of medical records of residents at the Facility . Residents' medical records will be maintained in the computerized system in a manner that protects the Electronic Protected Health Information) from unauthorized use, access .

Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #30) reviewed for infection control, in that: - LVN A failed to wear PPE for EBP, when giving Resident #30 his g-tube (tube into stomach for nutrition) medications. This deficient practice could place residents at-risk for infection due to improper care practices. Findings included: Record review of Resident #30's undated face sheet revealed he was a [AGE] year-old male with an admission date of 4/26/22, and a readmission date of 1/12/24. He had diagnoses which included: fracture of the right humerus (fracture of the right upper arm), hemoperitoneum (bleeding in the abdomen), aphonia (unable to speak due to damage to the voice box), aphasia (unable to process language), traumatic brain injury, and foreign body in respiratory tract causing asphyxiation (suffocation). Record review of Resident #30's annual MDS assessment, dated 1/1/2025, revealed a BIMS score could not be completed due to his medical condition. The MDS revealed he had severely impaired cognitive skills for daily decision making. The resident was dependent on staff with all ADLs. According to the MDS, the resident was using a feeding tube for all of his nutritional and fluid intake. Record review of Resident #30's care plan dated 5/11/25 had a Focus: The resident was receiving total nutrition/hydration through his feeding tube (Initiated: 8/4/23). The goal was to remain nourished and without aspiration (getting into the lungs) or dehydration (Initiated: 8/4/23, Revised: 5/11/25, Target: 8/11/25). Interventions included assessing the abdomen prior to feeding/flushing, checking placement of the tube, giving all feedings/water flushes via the feeding tube, and keeping his head of bed elevated at least 30 degrees. Focus: The resident required EBP's d/t his PEG tube (Initiated: 4/2/24). The goal was to not have any adverse effects r/t EBP's (Initiated: 4/30/24, Revised: 5/11/25, Target: 8/11/25). Interventions included PPE: gown/gloves during high contact resident care like dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, and wound care. Record review of Resident #30's Physician Orders revealed the following orders from MD L: - Enhanced Barrier Precautions (EBP): PPE Required- Hand hygiene, Gown, Gloves. Ordered on 4/2/24 at 10:30am. - Enteral Feeding- Order Jevity 1.5 (type of feeding) @ (60ml/hr) with (40ml/hr) free water flush via G-tube continuously x 22 hours. Ordered on 1/23/25 at 9:06pm. - Wound Care Abdominal Abrasion- Cleanse with Dakins (type of wound cleanser) and apply Mupirocin (antibiotic) and Calcium Alginate (wound dressing) and cover with dry dressing, every day. Ordered on 4/28/25 at 9:39am. Record review of Resident #30's Progress Note from 5/19/25 by NP O revealed the resident had an abdominal wound and a g-tube due to dysphagia (trouble swallowing). Record review of Resident #30's Wound Care note from 5/28/25 by NP B, revealed he had a midline, abdominal, surgical wound that was 6.4cm x 0.55cm x 0.2cm. The wound was acquired on 12/10/24 and was being treated by the Wound Care team. In an observation and interview on 5/29/25 at 10:00am, Resident #30 was observed lying in bed with his tube feeding running. LVN A paused the resident's feeding and gave him his morning medications through his g-tube. LVN A was wearing gloves but was not wearing a gown when she gave the resident his medications. She said EBP was like standard precautions which meant every resident was the same and they only wore gloves with them. LVN A said she had only been working at the facility for 2 weeks and had come from the hospital setting where they did not use EBP. She said she was going to find out for sure what EBP meant and get back with the Surveyor. In an interview on 5/29/25 at 10:17am, LVN A said EBP was for any resident that had a g-tube, foley (tube into bladder to drain urine), or open wound. She said she had to wear a gown and gloves for close contact, like giving g-tube meds and it was to prevent infection. In an interview with the DON on 5/29/25 at 2:00pm, she said EBP was for any resident with open wounds, IVs, foleys, or g-tubes. She said a gown and gloves should be worn when providing care. She said she expected staff to wear the proper PPE with every resident who was on EBP, and LVN A should have worn the PPE while she gave the g-tube meds to Resident #30. She said the EBP was to protect the residents and the staff from infection. Record review of the facility's policy and procedure on Enhanced Barrier Precautions (Revised March 2024) read in part: Enhanced Barrier Precautions is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDROs] and employs targeted gown and glove use during high-contact resident care activities for targeted residents. Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expands the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO .Examples of indwelling medical devices: central lines [flexible tube inserted into a large vein], urinary catheters, feeding tubes, and tracheostomies [opening into the windpipe for an airway] .When EBP are indicated, EBP should be employed for the following high-contact resident care activities: Dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, and wound care .

Based on observation interview and record review, the facility failed to ensure that each resident had a right to secure and confidential personal and medical records for two (Resident #3 and Resident #4) of five residents reviewed for privacy. 1. RN A walked away and left Resident #3's personal information unattended and in display in the resident data portal. 2. Resident #4's MAR was left unlocked and unattended on a laptop at the nurses station. This failure could place 55 residents who's personal information is stored in the resident data portal at risk of personal information being exposed to unauthorized individuals. Findings Included: Record review of Resident #3's face sheet revealed a sixty-eight-year-old man who was initially admitted on [DATE]. His admitting diagnoses were Type 2 Diabetes (chronic condition that happens when you have persistently high blood sugar levels), heart failure, chronic kidney disease (involves a gradual loss of kidney function), and gout (a type of inflammatory arthritis that causes pain and swelling in your joints). Record review of Resident #4's face sheet revealed a seventy-eight-year-old woman who was initially admitted on [DATE]. Her admitting diagnoses were cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dementia (memory loss), hypertension (high blood pressure), gout (a type of inflammatory arthritis that causes pain and swelling in your joints), and sepsis (occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body). In an interview on 05/15/24 at 11:53 am with RN A, she stated that she had been working at the facility since July 2023. She explained that as a nurse she did g- tubes, tracheostomy care, wound care, and change in conditions in patients. RN A was asked to pull up Resident #3's chart in the facility data portal. During the interview, a resident's call light went off at 11:54 am. She excused herself to answer the call light and returned to the interview at 11:57am. RN A and the investigator walked around inside the nurse's station and the computer screen was left unlocked and the face sheet for a Resident #3 was left exposed. She proceeded to go into Resident #3's profile. In a continued interview on 05/15/24 at 12:12 pm, The investigator began to walk away from the nurse's station to the dining room to observe residents during lunch. RN A also began to walk with the investigator to the dining room because she stated she was headed that way to help assist residents with lunch. In an observation on 05/15/24 at 12:15 pm, the investigator walked back to the nurse's station and observed the laptop had been left up and unlocked again on Resident #3's face sheet. Across from RN A's desk, there was another laptop that was folded down, but not closed. There was a blue light reflecting on the keyboard and when the investigator pulled the laptop screen up, it was observed that the laptop was left unlocked and was open on the page of Resident #4's MAR. In an interview on 05/19/24 at 12:19 pm with RN A, she is asked should the laptops be locked when the nurses are not at the station. She said that the laptops did not have to be locked when no one was at the nurse's station, but they did have to be flipped down, but not closed. She said that if there was no personal information on the screen and no one came behind the nurses station it would be ok. During an interview on 05/15/24 at 12:19 am with RN A, the DON walked up, and she was asked if it was appropriate for staff to have laptops unlocked with the MAR in view. She replied It was left like that? No, that is not acceptable. I will have to do a reeducation tomorrow. In an interview on 05/20/24 at 2:56 pm with the DON, she stated that the harm in leaving resident information exposed was a HIPAA violation (used to make sure that Personally Identifiable Information gathered in healthcare and insurance companies are protected against fraud and theft, and cannot be disclosed without consent). She explained that she completed an in-service on that incident and she reeducated RN A. Record review of the facility's policy and procedure titled Electronic Protected Health Information Security HIPAA Manual dated June 2019 stated: A. Physical Safeguards a. The facility will work to locate terminal for access to ePHI in secure locations to prevent unauthorized access. i. Computers or other electronic devices will be located in areas that limit access by residents and visitors. ii. When possible, monitors should face away from public view.

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #1 and Resident #2) whose care was reviewed for accidents and supervision. 1. Resident #1 was smoking unsupervised and housed his cigarettes inside of his room. 2. Resident #2 was observed taking a cigarette out of his room before he went outside during the designated smoking hour. These deficient practices could affect residents at the facility who smoked by contributing to burns or serious injuries. Findings Included: 1.Record review of Resident #1's face sheet revealed a sixty-seven-year-old man was admitted to the facility on [DATE]. An admitting diagnosis was acute B chronic obstructive pulmonary disease (COPD, lung disease),. Record review of Resident #1's care plan on 05/20/24 revealed he was a smoker and had the potential for injury related to smoking. Intervention dated on 03/04/24 stated that he was a supervised smoker and an intervention initiated on 04/25/23 (date listed) stated that smoking material was to be maintained by staff. Review of his ADL's dated 04/10/23 revealed he had an ADL self-care deficits and was at risk for further decline in ADL functioning and injury related to impaired cognition, weakness. Record review of Resident #1's MDS dated [DATE] Section C Cognitive patterns revealed a score 11 out of 15 (moderately impaired). 2.Record review of Resident #2's face sheet revealed a fifty-seven-year-old man who was originally admitted to the facility on [DATE]. His admitting diagnoses were acute kidney failure, atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), chronic obstructive pulmonary disease (COPD, lung disease), hypertension (high blood pressure), and Type 2 diabetes (chronic condition that happens when you have persistently high blood sugar levels). Record review of Resident #2's care plan on 05/20/24 revealed he was a smoker and had the potential for injury related to smoking. Intervention dated on 03/04/24 stated that he was a supervised smoker and that he was to be informed of the facility's smoking policy and potential consequences of noncompliance (dated 08/04/23). Review of his ADL's dated 08/03/23 revealed he an ADL self-care deficit and was at risk for further decline in ADL functioning and injury related to impaired cognition, Record review of Resident #1's MDS dated [DATE] Section C Cognitive patterns revealed a blank score (score was not accurately completed). In an observation on 05/20/24 at 11:00 am, Resident #1 was outside in the designated smoking area smoking a cigarette. There were no other residents outside with him and there were no staff supervising him. In an observation on 05/20/24 at 11:23 am, Resident #2 walked into his room and came out with a cigarette in his left hand. Resident #2 then used his walker to guide himself down the hall and out the door to the designated smoking area. In an observation on 05/20/24 at 11:30 am, Resident #1, Resident #2, and four other residents were observed smoking outside in the designated smoking area. Resident #1 left the smoking area and began to make his way down the hall using his walker back to his room. In an interview on 05/20/24 at 11:32 am with Resident #1, he walked into his room and grabbed his pack of cigarettes and placed one inside of his pocket. He stated that the facility does not let him keep his cigarettes on him, but they do not take them from him either. On the wall inside him room, the smoking times were listed on the wall and displayed that smoking was allowed at 11am, 3pm, and 7pm. When asked if he was supervised when smoking, he stated that he usually goes by himself, and he has never hurt himself while smoking. An interview was attempted in 05/20/24 at 2:16 pm with Resident #2. He was seen in the bed sleeping quietly. In an interview on 05/20/24 at 2:24 pm with CNA B, she stated that residents were not allowed to have cigarettes inside of their rooms. After residents were done smoking, a specified staff member from nursing, housekeeping, or maintenance would collect cigarettes and lighters and place them in a box. This box was secured inside of the nursing closet. She stated that residents were also not allowed to smoke by themselves, and they must be supervised at all times. In an interview on 05/20/24 at 2:56 pm with the DON, she stated she was not aware residents had access to cigarettes in their rooms. She was not sure where they were getting them from because the policy was to collect cigarettes and supplies after every smoke break. She suggested Resident #1 and Resident #2 may have gotten their cigarettes from pass (approved time to leave the facility). She stated staff have educated residents, preformed smoking assessments, and they discussed smoking policies during resident council. She explained that the harm in residents keeping their own cigarettes was a safety concern. Record review of the facilities Policies and Procedures subsection Safe Smoking, dated 03/24 stated: a. Staff members maintain all smoking materials as appropriate for the resident. Staff members will distribute smoking materials to residents at designated smoking times in the designated smoking area. b. Residents who require supervision while smoking will be supervised by an employee throughout the designated smoke break.

Based on interviews, and record review the facility failed to ensure clinical records were maintained in accordance with accepted professional standards and practices, were complete, and accurately documented for 1 (Resident #13) of 5 residents reviewed for clinical records. LVN B failed to document Insulin administration on the eMAR on 03/04/24, 03/11/24, 03/15/24,03/19/24, 03/20/24 and 03/27/24. This failure could place residents at risk inappropriate and inadequate medication administration and a decline in health status. Findings included: Review of Resident #13's revised face sheet dated 03/27/24 reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses including, type 2 diabetes mellitus with unspecified complications (high blood sugar), essential (primary) hypertension (high blood pressure), and cerebral infarction (disrupted blood flow to brain). Record review of Resident# 103's MDS assessment, dated 02/01/24, revealed that his BIMS score was a 09 (Moderate cognitive impairment). Record review of Resident #13's Physician's orders dated on 8/22/23 for Novolog Injection solution 100 unit/ml revealed, Inject sliding scale: if 150-200=3 units; 201-250=5 units; 251-300= 7 units; 301-350 =10 units; 351-400=12 units; If Blood sugar greater than 400, give 12 units and call MD immediately. Record review of Resident #13's March 2024 eMAR and eTAR revealed the following blood sugars without documented nursing interventions (medication administration and/or contact made to physician): 3/04/2024 at 0800: 463 mg/dl 3/04/2024 at 1600: 444 mg/dl 3/11/2024 at 1600: 463 mg/dl 3/15/2024 at 1600: 444 mg/dl 3/19/2024 at 1600: 440 mg/dL 3/20/2024 at 1600: 427 mg/dL 3/27/2024 at 0800: 540 mg/dl During an interview with the DON and the Regional nurse on 3/27/24 at 1:05 p.m., the DON and Regional Nurse were not aware of the elevated Blood glucose for Resident #13. They said that the expectation was to contact the MD immediately if the resident's blood glucose levels were outside the sliding scale parameters as ordered. The Regional nurse said, there was no risk because the nurse administered the 12 units of insulin and contacted the doctor; however, she just did not document her interventions . The DON stated that the risk of not documenting any interventions was that other nurses were not aware of what was going on with the resident and the need for proper follow-up by the staff. During an interview on 3/27/24 at 2:46 p.m. with LVN B, she stated, she checked the Sliding scale order for Resident #13 based on the eMAR, and the resident had a BS of 540 mg/dl which was on her personal notepad . She said she called the doctor and administered 12 units of Insulin but does not know the exact time. She said, if the resident's blood sugar reading was too high or too low, the system would not allow her to add the medication on the eMAR, and the progress notes would populate. LVN B said, she contacted the NP today and left a voicemail message. She rechecked resident A's blood sugar around 11:00 a.m. and it was down to 449 mg/dl. She said, she contacted the doctor because the NP had not called back. She said, when the MD called, he gave a new order for 15 units of Levemir between 1:45pm-200pm. LVN said, she should have documented in the nurse's notes that she contacted the physician and documented on the MAR that 12 units of insulin was administered. She said, if it isn't documented, it means that it wasn't done. LVN B said, the risk of not documenting was that someone else could have administered more medications because they would not have known that it was administered based on the MAR. During an interview on 3/28/24 at 2:46 p.m. with the Nurse Practitioner, she said that the initial contact with LVN B was on 03/27/24 at 1:11p.m. LVN B texted the resident's 540 mg/dl blood sugar reading. She stated the text was followed by a call at 1:40 p.m. and a new order was given for regular insulin and a nightly order for Levemir 15 Units. Requested policy for Medication administration from DON, and the policy had not been received by exit.

Based on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 resident (Resident #24) reviewed for incontinent care. -The facility failed to ensure CNA JJ and CNA RR properly cleaned Resident #24 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown, and a decreased quality of life. Findings include: Record review of the admission sheet (undated) for Resident #24 revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Record review of Resident #24's Quarterly MDS, dated [DATE], revealed the BIMS score was 14 out of 15, which indicated she was intact cognitively. The MDS revealed she was dependent from staff with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent. section H0400: Bowel Incontinence was coded (3) always incontinent. Record review of Resident #24's care plan, initiated 05/21/2021 and revised on 09/01/2023 revealed the following: Focus: Resident#24 has bowel and bladder incontinence and is at risk for skin break down AEB cognitive impairment. Goal: Resident#24 will remain clean, dry, odor free and no occurrence of skin breakdown will occur over the next 90 days. Interventions: Change promptly and apply a protective skin barrier to the skin as needed. Observation on 03/27/24 at 2:33p.m., revealed CNA RR and CNA JJ provided Resident #24 with incontinence care. CNA JJ removed Resident #24's brief and tucked it under the resident's buttocks. CNA JJ did not spread Resident #24's labia to thoroughly clean the area and the resident's urinary meatus. In an interview on 03/27/24 at 2:44p.m., with CNA JJ, she said she had been working at the facility for the last 7 years as a full-time employee. CNA JJ said she did not spread Resident's labia and clean the resident's meatus during incontinent care because I was nervous. She said the failure placed the resident at risk for infections. In an interview on 03/28/24 at 1:24 p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care. She said CNAs were provided training and competency check offs quarterly and as needed. At this time policy on perineal care was requested. No policy on Perineal Care was provided on exit. Record review of CNA JJ's Peri Care Competency Check off dated 01/26/23 and 01/8/24 revealed read in part: .FEMALE considerations: Helps to flex knees and spread legs apart. Observe limitations in positioning. Utilize bath towels or washcloths as indicated. Separate the labia, cleanse front to back with a disposable wipe using downward strokes. Discard soiled gloves, wash hands, and DON clean gloves. Apply barrier cream. Apply clean undergarment/brief as necessary. Remove gloves, wash hands, and dispose of linen properly .

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 infection for 1 of 4 residents (Resident #24) reviewed for infection. -The facility failed to ensure CNA JJ and CNA RR performed hand hygiene during incontinent care on Resident #24. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. Finding include: Record review of the admission sheet (undated) for Resident #24 revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Record review of Resident #24's Quarterly MDS, dated [DATE], revealed the BIMS score was 14 out of 15, which indicated she was intact cognitively. The MDS revealed she was dependent from staff with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent. section H0400: Bowel Incontinence was coded (3) always incontinent. Record review of Resident #24's care plan, initiated 05/21/2021 and revised on 09/01/2023 revealed the following: Focus: Resident#24 has bowel and bladder incontinence and is at risk for skin break down AEB cognitive impairment. Goal: Resident#24 will remain clean, dry, odor free and no occurrence of skin breakdown will occur over the next 90 days. Interventions: Change promptly and apply a protective skin barrier to the skin as needed. Observation on 03/27/24 at 2:33p.m., revealed CNA RR and CNA JJ provided Resident #24 with incontinence care. CNA JJ removed Resident #24's brief and tucked it under the resident's buttocks. CNA JJ did not spread Resident #24's labia to thoroughly clean the area and the resident's urinary meatus. CNA RR assisted Resident #24 to turn her onto her left side in order to clean her buttocks. Resident had a large bowel movement. CNA JJ without removing her soiled gloves, tucked the clean brief under the resident's buttocks. At this time CNA ZZ knocked on Resisdent#24's door. CNA JJ asked CNA ZZ for the barrier cream and gloves. CNA ZZ handed CNA JJ barrier cream packets and a pair of gloves. CNA JJ placed gloves in her pocket, closed the door and without sanitizing her hands placed gloves from her pocket and applied barrier cream on the resident's buttocks. CNA RR and CNA JJ completed perineal care and with the same soiled gloves on, touched the Resident's clean shirt, brief, sheet, and blanket. Both CNA JJ and CNA RR left the room without sanitizing or washing their hands. In an interview on 03/27/24 at 2:42p.m., with CNA RR, she said she did good assisting CNA JJ. She said CNA JJ should have changed her gloves, washed her hands, or used hand sanitizer before placing clean brief on. She said the failure placed the resident at risk for infections. In an interview on 03/27/24 at 2:44p.m., with CNA JJ, she said she had been working at the facility for the last 7 years as a full-time employee. CNA JJ said she did not spread Resident's labia and clean the resident's meatus during incontinent care because I was nervous. She said the failure placed the resident at risk for infections. She said she did not recall doing CNA competency checks for incontinent care. CNA JJ said she had performed hand hygiene during the delivery of incontinent care to Resident#24. CNA JJ said, I went across Resident#24's room and used the hand sanitizer that was sitting on the med cart. At this time the Surveyor shared her observation from earlier that the Surveyor did not observe her step out of Resident#24's room and observed CNA ZZ hand her packets of barrier cream and gloves. CNA JJ said her actions in not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-service on infection control last month and could not recall the exact date. In an interview on 03/27/24 at 2:48p.m., with CNA ZZ, she said she handed CNA JJ a pair of gloves and barrier cream packets when she came to check if CNA JJ and RR needed her assistance during incontinent care. In an interview on 03/28/24 at 1:24 p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care. She said CNAs should have either washed or sanitized their hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said these failures were risk for infection control. She said staff received training/in-service on infection control often. She said CNAs were provided training and competency check offs quarterly and as needed. At this time policy on perineal care was requested. Record review of the facility's Hand Hygiene policy (Revised 6/2019) revealed read in part: .It is the policy of this facility that proper hand hygiene/hand washing technique will be accomplished at all times that handwashing is indicated. Hand Hygiene/Hand washing is the most important component for preventing the spread of infection. Procedure: After: After removal of medical/surgical or utility gloves. NOTE: Wash hands at end of procedures where glove changes are not required. For procedures in which change of gloves, e.g., clean gloves to sterile gloves, is indicated follow the specific standard of practice. However, hand washing may not be necessary until completion of the procedure. If glove hands become contaminated as gloves are changed hands can be washed. Contact with a patient's/resident's intact skin (e.g. taking a pulse or blood pressure, performing physical examinations, lifting the patient/resident inn bed . Record review of the Infection Control Program (Revised 2/2022) revealed read in part: .Policy: Evidence-based policies and procedures are the foundation of a facility's infection control and prevention program. Goals: A Decrease the risk of infections and communicable diseases to residents, employees, volunteers, and visitors .

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation on 03/26/24 at 8:41 a.m., revealed the facility's dumpster area, which was in the lot on back side of the facility had a commercial size with top lid completely open. Interview on 03/26/24 at 8:45 a.m., with the Dietary Manager, she stated it was the dietary responsibility that the dumpster doors always must be closed to keep insects and trash out of the dumpster and from entering the facility. She stated housekeeping might have left it open because they throw night's trash out in the morning. In an interview on 03/26/2024 at 3:03p.m., with the Administrator and the DON, the Administrator said she expected the dumpster to be completely closed, and if it was found open, then it should be closed. She said failure to close the lid could cause trash coming out and infection control issue. The DON said the facility would re-educate and monitor that it stayed closed. Record review of the facility's waste Disposal policy (Revised 6-2019) revealed read in part: .Policy: Waste will be disposed of in a manner to prevent transmission of disease, nuisance or breeding place for insects and feeding places for rodents and other mammals. PROCEDURES: 5. Cover waste containers and close dumpsters at all times .

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 medication carts reviewed for pharmacy services in that: The facility failed to ensure LVN A did not leave 1 optic medication on top of the medication cart unsupervised. This failure placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications, misappropriation, and drug diversion. Findings included: Observation on 3/27/24 at 10:42 a.m. revealed LVN A's med cart unattended with optic (eye drops) medication located on top of medication cart. During an interview on 3/27/24 at 10:45 a.m. with LVN A, she said, all medications should be locked inside the carts. She said, the risk of leaving eye drops out, was that another resident could pick it up and start using it or drinking it. Record review of the facility's policy and procedure titled, Storage of Medications, not dated, read in part . Procedures: 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to excess medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Expiration dating (Beyond-use dating) .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, and disposing of expired medications) to meet the needs of each of resident for 1 (resident #27) of 5 residents reviewed for gastrostomy (G-tube) medication administration in that: LVN A's cart contained an insulin Glargine injection pen100 units/ML prefilled expired 03/26/24, and LVN B's Enoxaparin 40mg/.4ml prefilled syringes expired on 03/27/24. LVN A's cart contained expired low control glucose control solutions. expired 12/23 and the high control expired 01/24. These failures could place residents with G-tubes (Gastrostomy tube) at risk of g-tube replacement, medical complications, or a decline in health due to inappropriate G-tube care, management, and not following appropriate procedures. Findings Include: Observation on 3/27/24 at 9:30 a.m. of medication administration via g-tube , one (MiraLAX) medication cup with condensation noted and two additional medication cups for G-tube medication administration at bedside. LVN checked residual as ordered and administered 30 milliliters (mls) of water initial [NAME] via gravity but used plunger to initiate the 30mls of water flow. She removed the plunger and administered liquid medications with water flush in between each medication. The cup was noted to still be cool to touch after medication administration. In an interview 03/27/24 at 9:40 a.m. with the LVN A, she said, the cup was cold but has been sitting out for a while to do his g-tube medication. She said the risk of using the plunger and using cold fluids for g-tube was that the resident may feel discomfort . She said, I know I'm not supposed to use it, but it was going in too slow. Observation on 3/27/24 at 10:43 a.m. revealed an insulin Glargine injection pen100 units/ML prefilled with an opened date of 02/27/24; expired located inside of LVN A's cart. Observation on 3/27/24 at 10:44 a.m. revealed high and low glucose control solutions (used to perform Glucose Meter quality checks) expired inside the cart. The low control expired 12/23 and the high control expired 01/24. During an interview on 3/27/24 at 10:45 a.m. LVN A confirmed the insulin Glargine injection 100 units/ML prefilled pen had an expiration date of 3/27/24. She said, it should have been discarded. She said, the risk of having expired insulin was that the resident may not receive the correct amount needed. LVN A said, the evening shift checks controls for the blood glucose meters, and the risk of using expired control solutions to test the blood glucose meters was getting the incorrect reading. Observation and interview on 03/28/24 at 12:30 p.m. with the ADON, she accompanied this surveyor to LVN B's cart, and she confirmed there were three Enoxaparin 40mg/.4ml syringes with expiration date of 03/27/24. She said, the medications should have been removed from the cart as soon as they were expired, especially since the resident had not returned to the facility after his appointment. Record review of Resident # 27's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Displaced fracture of the right humerus (upper arm fracture), aphasia (a language disorder that makes it hard for you to read, write, and say what you mean to say), and aphonia (a loss of voice such as partial hoarseness or complete whisper). Record review of the MDS dated [DATE], revealed Resident #27 had no BIMS score documented. Record review of nurse notes dated 03/27/24 indicated the resident had a change of conditioned on 03/26/24 due to a weak g-tube after several attempts to unstop g-tube. Resident had a new 18 French g-tube exchanged by the physician on 03/26/24 at 1:46 p.m. Observation and interview on 03/28/24 at 12:30 p.m. with the ADON, she accompanied this surveyor to LVN B's cart, and she confirmed there were three Enoxaparin 40mg/.4ml syringes with expiration date of 03/27/24. She said, the medications should have been removed from the cart as soon as they were expired, especially since the resident had not returned to the facility after his appointment. Record review of the facility's policy and procedure titled, Storage of Medications, not dated, read in part . Medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations are those of the suppliers. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, our staff members lawfully authorized to administer medication. Procedures:2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to excess medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Expiration dating (Beyond-use dating):7. No expired medication will be administered to a resident. 8. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical and nursing needs for one (Resident #1) of four residents reviewed for care plans, in that: The facility failed to develop a care plan for Resident #1's foley catheter, recent severe dehydration and fecal impaction diagnoses, and his history of dehydration and constipation upon readmission to the facility after hospitalization . This failure could place residents at risk for not having their individual care needs met, errors in providing care, and poor/worsening condition. Findings Included: Record review of Resident #1's face sheet dated 01/11/24 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Displaced Fracture of Greater Tuberosity of Right Humerus (occurs due to trauma or shoulder dislocation, a boney disruption to the rotator cuff tendons around the shoulder); Cognitive Communication Deficit (difficulty with thinking and how a person uses language); Unspecified Foreign Body in other parts Respiratory Tract causing Asphyxiation (foreign bodies in the airway causing choking); Aphasia (loss of ability to understand or express speech, caused by brain damage); and, Traumatic Brain Injury without loss of consciousness (injury to the brain caused, at the moment of impact, by a blow or jolt to the head from blunt or penetrating trauma). Record Review of Resident #1's Care Plan, revised on 11/26/23, indicated the resident was on IV hydration therapy with a goal of no dehydration; at risk of dehydration related to Traumatic Brain injury and cognitive impairment and received total nutrition/hydration via feeding tube; he had a history of constipation and was at risk of impaction and bowel obstruction due to being bedbound. After three days without a bowel movement, a bowel assessment was to be performed and abnormal findings reported to the resident's doctor. Nurse's (LVNs and RNs) were to monitor the resident's bowel movements for amount and consistency. Record review of Resident #1's Quarterly MDS assessment dated [DATE], indicated the resident rarely/never had the ability to express ideas and wants. The resident rarely/never understood verbal content, as a result the Brief Interview for Mental Status was skipped; the resident was dependent or required the assistance of two or more persons to complete all functional abilities and goals; He was always urinary and bowel incontinent and not on a current toileting program to manage bowel continence. Record review of Resident #1's December 2023 Bowel and Bladder Elimination Record revealed the following: Bowel Elimination: 6 AM-6 PM - The resident was noted not to have a bowel movement on 12/1/23, 12/13/23 and 12/18/23; resident's bowel movement was constipated/hard/putty-like consistency noted on 12/2/23, 12/19/23 and 12/23/23; all other dates the resident was noted to have a normal bowel movement. Further review of the Bowel Elimination Record revealed, bowel elimination for Resident #1 was not documented 6 PM-6 AM on 12/5/23, 12/13, 12/15, 12/18, 12/20, and 12/22/23. The resident was noted not to have a bowel movement on 12/4/23, 12/6, 12/10, 12/11, 12/14, 12/19, 12/21 and 12/24/23; resident's bowel movement was constipated/hard/putty-like consistency noted on 12/8/23 and 12/9/23; resident was noted to have a normal bowel movements 12/1-12/3/23, 12/7/23, 12/12/23, 12/16-12/17/23 and 12/23/23. Record review of Resident #1's electronic health record indicated, the resident's MD was notified around 7:00 PM on 12/23/23, the resident was non-responsive to verbal touch or painful stimuli and had a temperature of 101.8 and O2 stats at 84%. The MD ordered for the resident to be sent to the hospital via emergency services. Further review of electronic record revealed an SBAR (Change in Condition Assessment) was documented, and the responsible party and DON were notified. Record review of Resident #1's electronic health record revealed the hospital faxed a 69-page clinical update on Resident #1 to the facility, on 12/25/23, after he was admitted to the hospital on 12/24/23. Further review of the clinical update revealed the following: Emergency Department Provider Documentation, dated 12/24/23 at 10:51 indicated, At 4:33 AM, Resident #1's vital signs were as follows: Temperature: 102.1, Pulse: 94, Resp.: 45, B/P: 134/91, Pulse Ox., 93, with oxygen delivery via nasal cannula .The Emergency Department Documentation revealed the following scheduled medications: .Valproic Acid 250 Mg/5 (Depakene Syrup*), 5 ML PO BID; Docusate Liquid, 10 MG PEG BID. Scheduled PRN: Acetaminophen, 1,000 MG PO Q8H PRN for pain; Docusate Liquid 100 MG/10 ML LIQ No Conflict Check, 100 MG PEG BID for Constipation, #100 M/L 0 Refills *Valproic Acid 250 MG/5 ML (Depakene Syrup)* 250 Mg/5 MI Solution, 5 ML PO, BID for Mood Stabilization . .History & Physical indicated, Resident #1 was intubated (insertion of tub to open the trachea for air) upon arrival due to respiratory rate. Labs showed elevated levels of sodium in the blood, elevated creatinine, decreased kidney function, and elevated lactic acid. Chest x-ray showed right perihilar airspace disease (Acute or chronic condition of alveolar airspaces filled by fluid, pus, blood, cells, or other material present consolidated opacity on chest imaging) in the right upper lobe, and mild left lower lobe atelectasis (mild collapse of the left lower part of the lung). The resident had a new or unexplained change in mental status. Sepsis (life threatening infection) without shock indicated by elevated white blood cell count, increased lactic acid, and white blood cell count on arrival to the ER, and new diagnosis of pneumonia; due to severe hypernatremia (sodium in the blood due to insufficient drinking of water) resident was started on D5W NS 100 ml/hr. Hyperosmolar Hyperglycemia State (life-threatening diabetic complication when blood glucose levels are too high for a long period, leading to severe dehydration and confusion) related to elevated blood sugar level (500) on arrival; the resident had no history of diabetes in the past. Hypernatremia (electrolyte problem caused by a decrease in total body water due to high levels of sodium in the blood) could be due to dehydration; Resident #1 had a water deficit around 7 liters; had past history of Hypernatremia probably related to TBI and placement, resident may not have been getting enough fluid. Acute Kidney Injury (sudden and often irreversible reduction in kidney function) likely due to dehydration; the resident's creatinine level was 2.14 and his baseline level was 1; and ordered to continue on D5W due to the hypernatremia diagnosis. The Treatments & Prophylaxis indicated, Resident #1 had a foley catheter inserted on 12/24/23. The History of Present Illness revealed, Resident #1 arrived in respiratory distress and was placed on a mechanical ventilator in the ER. He was noted to have severe electrolyte abnormalities including Hypernatremia and Acute Kidney Injury and was admitted to ICU for critical care management. Resident #1's MD consultation on 12/24/23 at 11:51 further revealed, History of Chief Complaint: .His sodium is extremely elevated with a reading at about 167 in the setting of his glucose being in the 500 range. Corrected sodium level is even further elevated perhaps close to 180 .D5W (Dextrose 5% in water is injected into a vein through an IV to replace lost fluids and provide carbohydrates to the body) at 100 mL an hour and repeat lab work in the afternoon. Patient seems very dehydrated .Assessment and Plan .acute hypoxic respiratory failure in the setting of pneumonia and severe hydration. Once patient is improved and discharged back, would need aggressive proper hydration given his traumatic brain injury. May not be able to get water or ask for water on a regular basis and this may need to be monitored with periodic BNP (blood test to measure the levels of a protein in the bloodstream) as well. A Radiology Report for Resident #1, dated 12/24/23 at 11:18, indicated the following: CT scan of the chest, abdomen, and pelvis was performed without contrast .Findings: .Gastrointestinal: Enteric tube (support device placed for feeding patients who cannot swallow or decompressing the GI tract) terminates in the stomach. Well-positioned percutaneous gastronomy tube (feeding tube often called PEG tube or G tube). Small catheter in the rectum. Very large amount of fecal material in the distal sigmoid colon and rectum (Fecal impaction or Fecaloma - A mass of hardened feces that remains in the colon or rectum; contractions that normally move feces along are not able to eject the hardened mass). Small to moderate amount throughout the rest of the colon. No evidence of small bowel obstruction or perienteric inflammation .Bladder/Reproductive: The urinary blader is decompressed by a balloon catheter .Impression: 2. Very large amount of fecal material in the distal sigmoid colon and rectum. Small to moderate amount throughout the rest of the colon. Correlate for constipation and potential fecal impaction. Record review of Resident #1's electronic health record revealed the hospital faxed a 66-page clinical update on Resident #1 to the facility, on 12/31/23, after he was transferred from one hospital, and admitted to another hospital on 12/28/23. Further review of the clinical update revealed, Resident #1 was .transfer from hospital with a diagnosis of fecal impaction with possible bowel obstruction with dilated sigmoid colon up to roughly 10 cm .He was extubated (removing endotracheal tube used for breathing) and now currently on room air. Also treated for Sepsis, hypernatremia due to severe dehydration with associated Acute Kidney Injury which has resolved .Physical Exam: . Gastrointestinal: slightly tender, distended, hypoactive bowel sounds, PEG tube capped. Further review of the Clinical Update revealed Recommendations, dated 12/28/23 as follows: .Transferred to hospital as there was a concern for an obstruction, severe impaction .likely has chronic fecal impaction .BID enemas ordered .Once complete should be able to resume tube feeds and Miralax BID .Chronic constipation and impaction. Low concern for stercoral ulcer at this point. However, need to prevent one from occurring. No need to repeat a CT abdomen/pelvis at this time. An MD Consultation, dated 12/29/23, revealed the resident's abdomen was soft and distended. Further review of the MD Consultation indicated, Assessment and Plan: 1 .Start patient on D5W at 125 cc/hour (cubic centimeters per hour)for water deficit of 3.3 L .2 .Continue IV fluid hydration. 3. Fecal impaction with suspected bowel obstruction. Surgery was consulted. Placed on enemas followed by General Surgery .5. Nutrition. Enteral tube feeds are currently on hold due to bowel obstruction . An MD Consultation, dated 12/30/23, revealed the resident had multiple stools overnight, was restarted on enteral tube feeds, and his abdomen was soft, nontender and mildly distended. Further review of the MD Consultation indicated, Assessment and Plan: 1 .Remains on D5W 125 mL/hour. We will start free water flushed 200 q.2 3. Fecal impaction with suspected bowel obstruction. Surgery was consulted. Treated with enemas and laxatives, improved. 4. Recent respiratory failure .Remains on antibiotic therapy. Further review of the clinical update revealed the following: Special Instructions, dated 12/31/23 at 4:17 PM indicated, .Discharge to SNF: Special Instructions: ok to d/c to SNF; meds per list; resume tube feed diet/aspiration precautions; PT/OT/ST: continue regular bowel regimen; follow up snf pcp; follow up nephrology and GI as per them. Discharge Medications: New medications to start taking Amoxicillin-potassium clavulanate oral tablet 875-125 mg - Take 1 EA orally twice daily; Ipratropium-Albuterol 0.5-2.5 Nebulization solution 0.5-2.5(3) mg/3ml - Take inhalation every 4 hours as needed for shortness of breath. Last dose given: 12/31/23 at 2:00 PM; Mineral Oil Oral - Take 30 ml tube once a day as needed for constipation. Last dose given: 12/31/23 at 3:17 AM .All medications must be taken as directed. Contact your physician before stopping medications. Record review of Resident #1's orders, dated as of 01/11/24, did not reveal orders to address the resident's foley catheter; past history of dehydration and recent diagnosis of severe dehydration; or monitoring/observations related the resident's past history of constipation and recent diagnosis of fecal impaction. Further review of Resident #1's electronic health records record revealed, the following orders, dated as of 01/11/24: Order Date: 1/04/24, Mineral Oil Give 30 ml via G-Tube every 24 hours as needed for Bowel Management Order Date: 1/04/24, MiraLax Oral Packet 17 GM (Polyethylene Glycol 3350) Give 1 packet via G-Tube every 24 hours as needed for Bowel Management Order Date: 1/04/24, Fleet Enema Rectal Enema (Sodium Phosphates) Insert 1 applicator rectally every 24 hours as needed for Bowel Management Order Date: 1/04/24, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 4 hours as needed for Wheezing Order Date: 1/04/24, *Enteral Feeding Site Care* every night shift for observations Cleanse with Normal saline, pat dry, apply fenestrated dressing daily and as needed. Order Date: 1/05/24, Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 5 ml via G-Tube two times a day related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION give 5ml to equal 250mg Order Date: 1/05/24, Amoxicillin-Pot Clavulanate Tablet 875-125 MG Give 1 tablet via G-Tube two times a day for bacterial infection for 7 Days. Order Date: 1/05/24, Docusate Sodium Liquid 50 MG/5ML Give 10 ml by mouth two times a day for Constipation give 10mg to equal 100mg Order Date: 1/05/24, Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) Give 1 tablet via G-Tube one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED Order Date: 1/09/24, NPO (Nothing by Mouth) diet NPO texture, NPO consistency Order Date: 1/09/24, *Enteral Order*- Monitor resident for signs/symptoms of misplacement of enteral tube: Difficulty with medication/feeding/water Order Date: 1/10/24, License nurse to monitor: *ABDOMINAL WOUND* for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site. Document plus (+) sign for no observed changes and a minus (-) sign for any observed changes, notify MD, and document findings in a progress note. every shift for observations. Record Review of Resident #1's Baseline Care Plan, dated 01/04/24, did not reveal goals or interventions to address the resident's foley catheter; history of dehydration and recent diagnosis of severe dehydration; or monitoring/observations related the resident's past history of constipation and recent diagnosis of fecal impaction. Further review of the baseline Care Plan indicated, Resident #1 required one-person physical assist for all ADLs; was to receive Physical and Occupational Therapy; always urinary and bowel incontinent, and had an indwelling catheter; and had a diet order for nothing by mouth, and Jevity 1.5 via his PEG tube. In an interview with LVN B on 01/11/24 at 4:52 PM, she said she worked at the facility for about 3 years and had worked all over the facility at different times. She said when she was assigned to her regular hall, she was the nurse responsible for providing care to Resident #1. She said Resident #1 was nonverbal, was good as long as he was kept dry and had a PEG tube. She said Resident #1 did not have a history of constipation, nor did he have a history of dehydration. LVN B said he did not have a history of dehydration because he received nutrition and fluids through his feeding tube. LVN B said she could not recall the last time she reviewed Resident #1's care plan. She said she did not know who was responsible for reviewing or updating a resident's care plan. She said she imagined it was the charge nurse or the DON's responsibility. She said she provided care to residents, based on the orders in the electronic health record. LVN B said she received updates on resident changes during report from nurses during shift change. LVN B said she was aware Resident #1 had been in the hospital and returned to the facility a few days ago. LVN B said she heard Resident #1 was hospitalized for an abscess, but LVN A was not sure who told her about the abscess. She said she was not aware Resident #1 was diagnosed with severe dehydration and fecal impaction. LVN B said Resident #1's recent diagnoses would not have changed the care the resident was currently receiving because it was standard to monitor Resident #1 for signs and symptoms of dehydration and constipation related to his PEG-tube. She said Resident #1 did not have a catheter before he went to the hospital but did have one in place now. She said the resident had orders in place for his catheter but did not know what diagnosis resulted in the catheter. She said now that Resident #1 had a catheter, it made it easier to track his urinary output. She said bowel movements and urinary output was documented in Resident #1's electronic health record by CNA's. She said she did not know who was responsible for reviewing Resident #1's bowel movements or urinary output. She said the CNA's were very good about verbally communicating with the nurses about issues with the residents. She said the CNA's were aware they were to notify a nurse when a resident went 48 hours without a bowel movement. She said she was not aware Resident #1 ever had orders for nurses to monitor his bowel movements. She said she had not reviewed Resident #1's bowel and bladder elimination records before, or since he had returned from the hospital. She said she was responsible for making sure residents with PEG-tubes did not aspirate and checked for residual air to make sure their stomachs were not full. LVN B said she performed those tasks for every resident that had a g-tube before LVN B administered every medication dose. She said all this information was documented on the resident's MAR. She said when completing the MAR for a resident with a PEG-tube, certain yes/no questions like did you assess bowel sounds, and did you assess lung sounds, were triggered and had to be answered before being allowed to move forward on the MAR. LVN B said if a resident went a full 8 hour shift without urinating, she would complete an assessment on the resident and notify the resident's MD. She said if a resident went two days without a bowel movement, they would also need to be assessed. LVN B said she would check for bowel distention and then contact the doctor to see if a catheter needed to be put in, or if x-rays needed to be ordered for the resident. She said she would check the resident's vital signs and ask the resident how much they had to eat or drink. She said she would also check with the CNA's and ask about their consumption. She said failure to document, assess or review Resident #1's changes in both urinary and bowel output put the resident at risk of bladder eruption, bowel obstruction, and pain and discomfort at the very least. She said information about residents like this and signs and symptoms to look out for were verbally discussed all throughout the shift with the necessary staff and during shift change. She said she would instruct CNA's to be mindful of the color, amount, or any odor related to urinary output. She said the CNA's knew to report issues like this to the nurse immediately. She said the CNA's know they could also report to the DON. She said all nurses could assist in the care of any resident and had access to review and document on any resident's electronic health record. An observation of Resident #1 on 01/11/24 at 6:28 PM revealed the following: The resident wore a gown that tied at the back of his neck. His face was clean in appearance, his lips were slightly chapped. The resident curled his body into a slight fetal position as LVN A removed the sheet that covered his body and raised his gown and exposed the resident's abdomen. He wore what appeared to be gown that tied at the back of his neck. He was clean in appearance; his lips were slightly chapped, and the resident wore a brief underneath the gown. Resident #1's PEG-tube site was clean and appeared to be operating appropriately. LVN A pulled the resident's gown down and placed the sheet back over his body. Plastic tubing containing what appeared to be urine, could be seen on the lower left side of the resident's bed after the sheet was placed back. In an interview with LVN A on 01/11/24 at 6:28 PM, she said she had worked for the facility for a few months and was typically the nurse on Resident #1's hall during the 6:00 PM to 6:00 AM shift, unless she was assigned to work a different hall. She said even though the resident was nonverbal, he still communicated with LVN A in his own way. LVN A said when she did her first round on Resident #1, she always asked him if he was doing okay, and he would usually give her a thumbs up. She said she had heard mention of the resident whispering words, but she never observed it for herself. LVN A said the resident had returned from the hospital a few days ago and had not fully returned to behaving like himself. She said the resident seemed as if he had even more of a cognitive decline since going to the hospital. LVN A said nothing had changed nor had she been made aware of changes or updates to the care or treatment for Resident #1. She said the resident was readmitted to the facility with a foley catheter in place. LVN A said she was not sure what diagnosis the resident returned with to have a catheter. She said she did not know whether Resident #1 had orders or care planned interventions for the foley catheter. She said it was standard for all residents with catheters to have their urinary intake and output monitored. LVN A said CNA's were responsible for documenting both urinary and bowel movements in the resident's electronic health record. She said the only time she would monitor or assess the resident for issues with the catheter or bowel movements, was if during her interaction with the resident, she noticed a problem or if a CNA notified her of an issue. She said the CNA's were very good about notifying the nurses of resident issues. LVN A said all the CNA's knew if a resident went longer than 3 days without having a bowel movement that a nurse needed to be notified. She said she did not specifically review the resident's Urinary and Bowel Elimination Record because that was something the CNA's documented. LVN A said as far as she knew, Resident #1 did not have a history of dehydration because he received fluids and nutrition via his PEG-tube. She said she did not know Resident #1 to have a history of constipation either. LVN A said she did not know Resident #1 was treated for severe dehydration or fecal impaction during his recent hospital stay. LVN A said the only update she received on Resident #1 when he returned to the facility, was report from the nurse she relieved the next time she cared for Resident #1 after he was readmitted . LVN A said she was the nurse in charge of Resident #1's care when he was sent out to the hospital in December. She said she never observed Resident #1 exhibiting signs or symptoms of dehydration, constipation or fecal impaction. She said if the resident was impacted, he would have had a distended stomach and likely expressed discomfort. She said she was never notified of any constipation issues either. LVN A said listening for bowel sounds was part of providing treatment to Resident #1 via PEG-tube before he went to the hospital. She said if she had noticed signs or symptoms of constipation or a distended stomach, she would have performed an assessment, completed an SBAR in the resident's electronic health record, notified the MD and followed any orders or directives, and notified the DON. In an interview with the DON on 01/11/24 at 7:41 PM, she said she worked at the facility since the week of Thanksgiving 2023. She said Resident #1 returned to the facility from the hospital on either 01/04/24 or 01/05/24. She said she could not recall off the top of her head the resident's medical history, or his recent diagnoses from the hospital. She said there were no changes or updates made to the care Resident #1 was receiving from staff. She said she was aware Resident #1 was readmitted to the facility with a foley catheter in place. She said she could not recall off the top of her head what diagnosis Resident #1 had been given for the insertion of the catheter. She said she would have to look at the resident's chart. She said she was waiting on an order from Resident #1's doctor to d/c his foley catheter. She said the nurses on duty at the time residents returned to the facility were responsible for completing readmission assessments and developing baseline care plans. She said she did not know who completed either when Resident #1 returned to the facility. She said she reviewed the resident's readmission assessment and baseline care plan but could not recall specifics of either. She said the only thing she remembered was Resident #1's readmission assessment did not include the resident's foley catheter. She said the resident's baseline care plan did include Resident #1's catheter She said she addressed the error on the readmission assessment with the staff to be corrected but did not document anything specific on the error or the conversation she had with the staff. She said other than the placement of the catheter, nothing had changed in the care and treatment Resident #1 was receiving since being readmitted to the facility. She said the facility was still within their timeframe for completing Resident #1's assessments and finalizing his care plan since being readmitted . She said she did not know off the top of her head what the facility's policy was on assessments or care plans, but that was what the facility was following. She said the ADON was typically responsible for reviewing readmission assessments and baseline care plans. She said the ADON's last day was 01/02/24, so ultimately, it was her responsibility to review assessments and care plans. She said she did not see an issue with the Resident #1's baseline care plan explicitly including his recent diagnoses of severe dehydration and bowel impaction because these are all things still being monitored by the staff. She said urinary output and bowel movements were being monitored for the resident. She said the only major change for Resident #1 was that he returned with a catheter and reiterated that nothing had changed in the care he was currently receiving. She said she did not know Resident #1 had a documented history of dehydration and constipation. She said she did not know prior to going to the hospital, Resident #1 was care planned for IV hydration therapy and for nurses to monitor his bowel movements. She said Resident #1's recent diagnoses of impaction and severe dehydration should have been care planned. She said the resident was put at risk of further impaction if his bowel movements were not appropriately monitored. She said Resident #1 was also at risk for constipation, impaction and Sepsis by not having his recent impaction care planned. She said the resident was at risk of further dehydration by not having his recent severe dehydration diagnosis care planned. In an interview with the DON on 01/12/24 at 11:10 AM, she said the third row of Resident #1's December 2023 Bowel and Bladder Elimination Record was not necessary for CNA's to complete, unless the resident had experienced additional urinary output or bowel movement after the initial one documented during a shift. She said the blank spaces that appeared within the first two rows of both the bowel and bladder record were times Resident #1's bowel or bladder elimination were not documented by staff in his electronic health record. In an interview with LVN C on 01/12/24 at 11:32 AM, she said she worked at the facility for four months and was promoted to the position of treatment nurse two weeks ago. She said prior to two weeks ago, she was regularly assigned to provide care to Resident #1. She said she was not completely familiar with Resident #1's care plan. She said she probably had, but could not say with 100% certainty that she had seen a resident care plan. She said she knew Resident #1 received tube feedings, needed a lot of mouth care, and that his lips got really dry. She said she was not sure, but believed Resident #1 did have a history of constipation. She said she did not ever review Resident #1's bowel movement records in his electronic health record because the CNA's took care of that. She said she did not know if the information entered by the CNA's was reviewed by nurses. She said for any resident, she relied on the CNA's to give her information about their bowel movements. She said the CNA's were very good about monitoring resident bowel movements and notifying nurses of any issues. She said she did not know of Resident #1 having a history of dehydration. She said she believed nurses were supposed to review resident care plans, but she was still learning how to navigate the electronic health records. She said she did not know the reason for Resident #1's recent hospitalization or if any changes had been made to the care he was currently receiving because she only handled wound treatments. She said Resident #1 was currently being monitored for a wound discovered prior to recent hospitalization . She said she did not know Resident #1 had been recently diagnosed with severe dehydration or constipation. She said dehydration could have affected an individual with wounds. She said the treatment nurse position was new and something the facility had just created. She said she did not know what risk Resident #1 could have been put at by not having dehydration appropriately care planned and monitored. She said no one gave nurses new information or updates on changes with residents. She said she relied on verbal communication with other nurses and CNA's, and doing her best to review resident electronic health records to stay up to date on the care she was to provide to residents. In an interview with CNA B on 01/12/24 at 1:28 PM, she said she worked at the facility for almost three years. She said CNA's were responsible for documenting bowel movements and bladder function for every resident. She said all the CNA's knew their residents well. Resident #1 had a bowel movement every day. She said sometimes his bowel movements were runny, sometimes formed, soft, but never hard. She said she did not know Resident #1 to have a history of constipation. She said the resident had a bowel movement every time she worked with him. She said the resident did not have a history of dehydration because he received hydration through his feeding tube. She said Resident #1 did receive a lot of mouth care. She said she would not let a resident go more than two days without having a bowel movement and letting a nurse know. She said she did not know if the nurses reviewed residents bowel and bladder information in their electronic health records. In an interview with the MD on 01/12/24 at 1:42 PM, he said he was Resident #1's primary care physician. He said he was aware Resident #1 had recently been hospitalized . He said he did not have access to previously entered information and could only see active orders for the resident. He said from what he could recall, prior to going to the hospital, Resident #1 should have been on an IV hydration therapy program. He said he was notified Resident #1 was returned to facility but did not remember the exact date. He said Resident #1 currently had an order for mineral oil every 24 hours and Miralax every 24 hours as needed for bowel management. He said the resident also had a PRN order for a fleet enema. He said he was notified today Resident #1 was readmitted to the facility with a foley

Based on observations, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to accurately modify interventions for Resident #1 when he was readmitted to the facility on [DATE] with a foley catheter, was recently hospitalized due to severe dehydration and fecal impaction, and a history of dehydration and constipation. These failures placed residents at risk for new development or worsening of existing infection, pain, and decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 01/11/24 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Displaced Fracture of Greater Tuberosity of Right Humerus (occurs due to trauma or shoulder dislocation, a boney disruption to the rotator cuff tendons around the shoulder); Cognitive Communication Deficit (difficulty with thinking and how a person uses language); Unspecified Foreign Body in other parts Respiratory Tract causing Asphyxiation (foreign bodies in the airway causing choking); Aphasia (loss of ability to understand or express speech, caused by brain damage); and, Traumatic Brain Injury without loss of consciousness (injury to the brain caused, at the moment of impact, by a blow or jolt to the head from blunt or penetrating trauma). Record review of Resident #1's Quarterly MDS assessment dated [DATE], indicated the resident rarely/never had the ability to express ideas and wants. The resident rarely/never understood verbal content, as a result the Brief Interview for Mental Status was skipped; the resident was dependent or required the assistance of two or more persons to complete all functional abilities and goals; He was always urinary and bowel incontinent and not on a current toileting program to manage bowel continence. Further review of the MDS did not reveal the resident had a foley catheter. Record Review of Resident #1's Care Plan, revised on 11/26/23, indicated the resident was on IV hydration therapy with a goal of no dehydration; at risk of dehydration related to Traumatic Brain injury and cognitive impairment and received total nutrition/hydration via feeding tube; he had a history of constipation and was at risk of impaction and bowel obstruction due to being bedbound. After three days without a bowel movement, a bowel assessment was to be performed and abnormal findings reported to the resident's doctor. Nurse's (LVNs and RNs) were to monitor the resident's bowel movements for amount and consistency. Record review of Resident #1's electronic health record indicated, the resident's MD was notified around 7:00 PM on 12/23/23, the resident was non-responsive to verbal touch or painful stimuli and had a temperature of 101.8 and O2 stats at 84%. The MD ordered for the resident to be sent to the hospital via emergency services. Further review of electronic record revealed an SBAR (Change in Condition Assessment) was documented, and the responsible party and DON were notified. Record review of Resident #1's electronic health record revealed the hospital faxed a 69-page clinical update on Resident #1 to the facility, on 12/25/23, after he was admitted to the hospital on 12/24/23. Further review of the clinical update revealed the following: Emergency Department Provider Documentation, dated 12/24/23 at 10:51 indicated, At 4:33 AM, Resident #1's vital signs were as follows: Temperature: 102.1, Pulse: 94, Resp.: 45, B/P: 134/91, Pulse Ox., 93, with oxygen delivery via nasal cannula .The Emergency Department Documentation revealed the following scheduled medications: .Valproic Acid 250 Mg/5 MI (Depakene Syrup*), 5 ML PO BID; Docusate Liquid, 10 MG PEG BID. Scheduled PRN: Acetaminophen, 1,000 MG PO Q8H PRN for pain; Docusate Liquid 100 MG/10 ML LIQ No Conflict Check, 100 MG PEG BID for Constipation, #100 M/L 0 Refills, Provider FNP-C 5/4/22; .*Valproic Acid 250 MG/5 ML (Depakene Syrup)* 250 Mg/5 MI Solution, 5 ML PO, BID for Mood Stabilization . .History & Physical indicated, Resident #1 was intubated upon arrival due to respiratory rate. Labs showed elevated levels of sodium in the blood, elevated creatinine, decreased kidney function, and elevated lactic acid. Chest x-ray showed right perihilar airspace disease (Acute or chronic condition of alveolar airspaces filled by fluid, pus, blood, cells, or other material present consolidated opacity on chest imaging) in the right upper lobe, and mild left lower lobe atelectasis (mild collapse of the left lower part of the lung). The resident had a new or unexplained change in mental status. The Diagnosis, Assessment & Treatment Plan of the clinical update, revealed the following: Resident #1 was diagnosed with Acute Hypoxic Respiratory Failure (air sacs of the lungs cannot release enough oxygen into the blood, likely due to conditions that affect lung function) due to pneumonia; intubated in the ER due to respiratory failure; Resident #1's elevated lactic acid level, white blood cell count and fever met sepsis criteria; he received 2 NS bolus in the ER; and, Critical Care was consulted. Sepsis without shock indicated by elevated white blood cell count, increased lactic acid, and white blood cell count on arrival to the ER, and new diagnosis of pneumonia; due to severe hypernatremia resident was started on D5W NS 100 ml/hr. Hyperosmolar Hyperglycemia State (life-threatening diabetic complication when blood glucose levels are too high for a long period, leading to severe dehydration and confusion) related to elevated blood sugar level (500) on arrival; the resident had no history of diabetes in the past. Hypernatremia (electrolyte problem caused by a decrease in total body water due to high levels of sodium in the blood) could be due to dehydration; Resident #1 had a water deficit around 7 liters; had past history of Hypernatremia probably related to TBI and placement, resident may not have been getting enough fluid. Acute Kidney Injury (sudden and often irreversible reduction in kidney function) likely due to dehydration; the resident's creatinine level was 2.14 and his baseline level was 1; and ordered to continue on D5W due to the hypernatremia diagnosis. Elevated Trops (signs of heart damage) likely due to type 2 NSTEMI (acute imbalance in the body's oxygen supply and demand, not related to an otherwise unstable coronary artery); cardiology was consulted. The Treatments & Prophylaxis indicated, Resident #1 had a foley catheter inserted on 12/24/23. The History of Present Illness revealed, Resident #1 arrived in respiratory distress and was placed on a mechanical ventilator in the ER. He was noted to have severe electrolyte abnormalities including Hypernatremia and Acute Kidney Injury and was admitted to ICU for critical care management. Resident #1's MD consultation on 12/24/23 at 11:51 further revealed, History of Chief Complaint: .His sodium is extremely elevated with a reading at about 167 in the setting of his glucose being in the 500 range. Corrected sodium level is even further elevated perhaps close to 180 .D5W (Dextrose 5% in water is injected into a vein through an IV to replace lost fluids and provide carbohydrates to the body) at 100 mL an hour and repeat lab work in the afternoon. Patient seems very dehydrated .Assessment and Plan .acute hypoxic respiratory failure in the setting of pneumonia and severe hydration. Once patient is improved and discharged back, would need aggressive proper hydration given his traumatic brain injury. May not be able to get water or ask for water on a regular basis and this may need to be monitored with periodic BNP (blood test to measure the levels of a protein in the bloodstream) as well. A Radiology Report for Resident #1, dated 12/24/23 at 11:18, indicated the following: CT scan of the chest, abdomen, and pelvis was performed without contrast .Findings: .Gastrointestinal: Enteric tube (support device placed for feeding patients who cannot swallow or decompressing the GI tract) terminates in the stomach. Well-positioned percutaneous gastronomy tube (feeding tube often called PEG tube or G tube). Small catheter in the rectum. Very large amount of fecal material in the distal sigmoid colon and rectum (Fecal impaction or Fecaloma - A mass of hardened feces that remains in the colon or rectum; contractions that normally move feces along are not able to eject the hardened mass). Small to moderate amount throughout the rest of the colon. No evidence of small bowel obstruction or perienteric inflammation .Bladder/Reproductive: The urinary blader is decompressed by a balloon catheter .Impression: 2. Very large amount of fecal material in the distal sigmoid colon and rectum. Small to moderate amount throughout the rest of the colon. Correlate for constipation and potential fecal impaction. Record review of Resident #1's electronic health record revealed, on 12/31/23, the hospital faxed a 66-page clinical update on Resident #1 to the facility after he was transferred from one hospital, and admitted to another hospital on 12/28/23. Further review of the clinical update revealed, Resident #1 was .transfer from hospital with a diagnosis of fecal impaction with possible bowel obstruction with dilated sigmoid colon up to roughly 10 cm .He was extubated and now currently on room air with Spo2 98%. Also treated for Sepsis, hypernatremia due to severe dehydration with associated Acute Kidney Injury which has resolved .Physical Exam: . Gastrointestinal: slightly tender, distended, hypoactive bowel sounds, PEG tube capped. Further review of the Clinical Update revealed Recommendations, dated 12/28/23 as follows: .Transferred to hospital as there was a concern for an obstruction, severe impaction .likely has chronic fecal impaction .BID enemas ordered .Once complete should be able to resume tube feeds and Miralax BID .Chronic constipation and impaction. Low concern for stercoral ulcer at this point. However, need to prevent one from occurring. No need to repeat a CT abdomen/pelvis at this time. An MD Consultation, dated 12/29/23, revealed the resident's abdomen was soft and distended. Further review of the MD Consultation indicated, Assessment and Plan: 1 .Start patient on D5W at 125 cc/hour for water deficit of 3.3 L .2 .Continue IV fluid hydration. 3. Fecal impaction with suspected bowel obstruction. Surgery was consulted. Placed on enemas followed by General Surgery .5. Nutrition. Enteral tube feeds are currently on hold due to bowel obstruction . An MD Consultation, dated 12/30/23, revealed the resident had multiple stools overnight, was restarted on enteral tube feeds, and his abdomen was soft, nontender and mildly distended. Further review of the MD Consultation indicated, Assessment and Plan: 1 .Remains on D5W 125 mL/hour. We will start free water flushed 200 q.2 3. Fecal impaction with suspected bowel obstruction. Surgery was consulted. Treated with enemas and laxatives, improved. 4. Recent respiratory failure .Remains on antibiotic therapy. Further review of the clinical update revealed the following: Special Instructions, dated 12/31/23 at 4:17 PM indicated, .Discharge to SNF: Special Instructions: ok to d/c to SNF; meds per list; resume tube feed diet/aspiration precautions; PT/OT/ST: continue regular bowel regimen; follow up snf pcp; follow up nephrology and GI as per them. Discharge Medications: New medications to start taking Amoxicillin-potassium clavulanate oral tablet 875-125 mg - Take 1 EA orally twice daily; Ipratropium-Albuterol 0.5-2.5 Nebulization solution 0.5-2.5(3) mg/3ml - Take inhalation every 4 hours as needed for shortness of breath. Last dose given: 12/31/23 at 2:00 PM; Mineral Oil Oral - Take 30 ml tube once a day as needed for constipation. Last dose given: 12/31/23 at 3:17 AM .All medications must be taken as directed. Contact your physician before stopping medications. Record Review of Resident #1's Baseline Care Plan, dated 01/04/24, revealed, Resident #1 required one-person physical assist for all ADLs; was to receive Physical and Occupational Therapy; always urinary and bowel incontinent, and had an indwelling catheter; and had a diet order for nothing by mouth, and Jevity 1.5 via his PEG tube. Further review of the care plan did not reveal goals or interventions to address the resident's foley catheter; past history of dehydration and recent diagnosis of severe dehydration; or monitoring/observations related the resident's past history of constipation and recent diagnosis of fecal impaction. Record review of Resident #1's orders, dated as of 01/11/24, did not reveal orders to address the resident's foley catheter; past history of dehydration and recent diagnosis of severe dehydration; or monitoring/observations related the resident's past history of constipation and recent diagnosis of fecal impaction. Further review of Resident #1's electronic health records record revealed, the following orders, dated as of 01/11/24: Order Date: 1/04/24, Mineral Oil Give 30 ml via G-Tube every 24 hours as needed for Bowel Management Order Date: 1/04/24, MiraLax Oral Packet 17 GM (Polyethylene Glycol 3350) Give 1 packet via G-Tube every 24 hours as needed for Bowel Management Order Date: 1/04/24, Fleet Enema Rectal Enema (Sodium Phosphates) Insert 1 applicator rectally every 24 hours as needed for Bowel Management Order Date: 1/04/24, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 4 hours as needed for Wheezing Order Date: 1/04/24, *Enteral Feeding Site Care* every night shift for observations Cleanse with Normal saline, pat dry, apply fenestrated dressing daily and as needed. Order Date: 1/05/24, Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 5 ml via G-Tube two times a day related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION give 5ml to equal 250mg Order Date: 1/05/24, Amoxicillin-Pot Clavulanate Tablet 875-125 MG Give 1 tablet via G-Tube two times a day for bacterial infection for 7 Days. Order Date: 1/05/24, Docusate Sodium Liquid 50 MG/5ML Give 10 ml by mouth two times a day for Constipation give 10mg to equal 100mg Order Date: 1/05/24, Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) Give 1 tablet via G-Tube one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED Order Date: 1/09/24, NPO (Nothing by Mouth) diet NPO texture, NPO consistency Order Date: 1/09/24, *Enteral Order*- Monitor resident for signs/symptoms of misplacement of enteral tube: Difficulty with medication/feeding/water Order Date: 1/10/24, License nurse to monitor: *ABDOMINAL WOUND* for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site. Document plus (+) sign for no observed changes and a minus (-) sign for any observed changes, notify MD, and document findings in a progress note. every shift for observations. In an interview with CNA A on 01/11/24 at 2:32 PM, she said she worked at the facility for about two years and mainly worked on Resident #1's hall during the 2:00 PM to 10:00 PM shift. She said sometimes she was assigned to work other halls. CNA A said she assisted residents with hygiene, incontinence care, and if they wanted water, she provided it. CNA A said Resident #1 did not talk, had a feeding tube, was bedbound and required total assistance. She said he only got fed through his feeding tube. CNA A said the resident required a lot of lip care due to g-tube feeding. She said she felt like the position of his mouth, due to metal plates put in after a car accident, was also why the resident's lip could have been dry and why he needed a lot of oral care. She said no changes had been made to the care Resident #1 received since he returned from the hospital. CNA A said the only difference was now the resident has a catheter. She said Resident #1 had issues with constipation in the past but did not recall when. She said even though he had issues with constipation, Resident #1 experienced way more issues with diarrhea. CNA A said she could not remember the last time the resident was constipated. CNA A said she got all the information she needed about her residents by accessing their electronic health records. She said she can find out things like the level of assistance residents required and the type of diet they were on in the electronic health record. CNA A said if a resident's bowel movements needed to be monitored, the nurses would let the CNA's know. She said Resident #1's bowel movements were documented by CNA's in his electronic health record. CNA A said the form asked for details like diarrhea, constipated, soft, small, medium large. She said the same form also had a place to complete when residents did not have bowel movements. She said she did not know if the nurses reviewed bowel movements documented in Resident #1's electronic health record. CNA A said she was not sure of the exact number of days a resident could go without having a bowel movement. She said if she noticed a resident did not have a bowel movement after 48 hours, she would let the nurse know. CNA A said she would notify a nurse about a possible issue with Resident #1's catheter if she noticed a different color urine, blood in his brief, or if she noticed a scratch or swelling and redness. In an interview with Med Aide A on 01/11/24 at 2:55 PM, she said she worked at the facility for a little over two years. She said she was a Med Aide but picked up extra shifts filling in as a CNA. Med Aide A said she was working as a CNA today. She said she was familiar with Resident #1 and had provided care to him as a CNA several times before he went to the hospital. Med Aide A said she had also cared for the resident since he was readmitted a few days ago. She said Resident #1 was a total care resident and needed help with everything. She said the resident was on a PEG tube and had a foley catheter now. Med Aide A said he did not talk, and she never knew the resident to be constipated. She said the resident's bowel movements were always pretty putty like. In an interview with LVN B on 01/11/24 at 4:52 PM, she said she worked at the facility for about 3 years and had worked all over the facility at different times. She said when she was assigned to her regular hall, she was the nurse responsible for providing care to Resident #1. She said Resident #1 was nonverbal, was good as long as he was kept dry and had a PEG tube. She said Resident #1 did not have a history of constipation, nor did he have a history of dehydration. LVN B said he did not have a history of dehydration because he received nutrition and fluids through his feeding tube. LVN B said she could not recall the last time she reviewed Resident #1's care plan. She said she did not know who responsible for reviewing or updating a resident's care plan. She said she imagined it was the charge nurse or the DON's responsibility. She said she provided care to residents, based on the orders in the electronic health record. LVN B said she received updates on resident changes during report from nurses during shift change. LVN B said she was aware Resident #1 had been in the hospital and returned to the facility a few days ago. LVN B said she heard Resident #1 was hospitalized for an abscess, but LVN A was not sure who told her about the abscess. She said she was not aware Resident #1 was diagnosed with severe hydration and fecal impaction. LVN B said Resident #1's recent diagnoses would not have changed the care the resident was currently receiving because it was standard to monitor Resident #1 for signs and symptoms of dehydration and constipation related to his PEG-tube. She said Resident #1 did not have a catheter before he went to the hospital but did have one in place now. She said the resident had orders in place for his catheter but did not know what diagnosis resulted in the catheter. She said now that Resident #1 had a catheter, it made it easier to track his urinary output. She said bowel movements and urinary output was documented in Resident #1's electronic health record by CNA's. She said she did not know who was responsible for reviewing Resident #1's bowel movements or urinary output. She said the CNA's were very good about verbally communicating with the nurses about issues with the residents. She said the CNA's were aware they were to notify a nurse when a resident went 48 hours without a bowel movement. She said she was not aware Resident #1 ever had orders for nurses to monitor his bowel movements. She said she had not reviewed Resident #1's bowel and bladder elimination records before, or since he had returned from the hospital. She said she was responsible for making sure residents with PEG-tubes did not aspirate and checked for residual air to make sure their stomachs were not full. LVN B said she performed those tasks for every resident that had a g-tube before LVN B administered every medication dose. She said all this information was documented on the resident's MAR. She said when completing the MAR for a resident with a PEG-tube, certain yes/no questions like did you assess bowel sounds, and did you assess lung sounds, were triggered and had to be answered before being allowed to move forward on the MAR. LVN B said if a resident went a full 8 hour shift without urinating, she would complete an assessment on the resident and notify the resident's MD. She said if a resident went two days without a bowel movement, they would also need to be assessed. LVN B said she would check for bowel distention and then contact the doctor to see if a catheter needed to be put in, or if x-rays needed to be ordered for the resident. She said she would check the resident's vital signs and ask the resident how much they had to eat or drink. She said she would also check with the CNA's and ask about their consumption. LVN B said all this information would be documented in a progress note or a change of condition in the resident's electronic health record. She said there was no distinction between a progress note and completing a change in condition assessment in a resident's electronic health record. She said completing a change in condition assessment in the electronic health record also triggered a progress note to appear with the change of condition information. She said she would notify the DON, the doctor and the family or responsible party. All this information should be documented in a progress note. LVN B said she checked if a tube feeding was not flowing freely; if LVN B could not hear placement of the tube; observed a distended abdomen; and, if the skin and site of the tube, itself appeared unhealthy. She said any of those scenarios with a resident who received tube feedings would be things to document on a change of condition assessment, notify the MD, family, and DON. She said if a resident was aspirating, she would contact emergency services and then make the necessary notifications. She said failure to document, assess or review Resident #1's changes in both urinary and bowel output put the resident at risk of bladder eruption, bowel obstruction, and pain and discomfort at the very least. She said information about residents like this and signs and symptoms to look out for were verbally discussed all throughout the shift with the necessary staff and during shift change. She said she would instruct CNA's to be mindful of the color, amount, or any odor related to urinary output. She said the CNA's knew to report issues like this to the nurse immediately. She said the CNAs know they could also report to the DON. She said all nurses could assist in the care of any resident and had access to review and document on any resident's electronic health record. In an interview with the DON on 01/11/24 at 7:41 PM, she said she worked at the facility since the week of Thanksgiving 2023. She said Resident #1 returned to the facility from the hospital on either 01/04/24 or 01/05/24. She said she could not recall off the top of her head Resident #1's medical history, or his recent diagnoses from the hospital. She said there were no changes or updates made to the care Resident #1 was receiving from staff. She said she was aware Resident #1 was readmitted to the facility with a foley catheter in place. She said she could not recall off the top of her head what diagnosis Resident #1 had been given for the insertion of the catheter. She said she would have to look at the resident's chart. She said she was waiting on an order from Resident #1's doctor to d/c his foley catheter. She said the nurses on duty at the time residents returned to the facility were responsible for completing readmission assessments and developing baseline care plans. She said she did not know who completed either when Resident #1 returned to the facility. She said she reviewed the resident's readmission assessment and baseline care plan but could not recall specifics of either. She said the only thing she remembered was Resident #1's readmission assessment did not include the resident's foley catheter. She said the resident's baseline care plan did include Resident #1's catheter. She said could not recall the staff that completed the readmission assessment or the baseline care plan. She said she addressed the error on the readmission assessment with the staff to be corrected but did not document anything specific on the error or the conversation she had with the staff. She said other than the placement of the catheter, nothing had changed in the care and treatment Resident #1 was receiving since being readmitted to the facility. She said the facility was still within their timeframe for completing Resident #1's assessments and finalizing his care plan since being readmitted . She said she did not know off the top of her head what the facility's policy was on assessments or care plans, but that was what the facility was following. She said the ADON was typically responsible for reviewing readmission assessments and baseline care plans. She said the ADON's last day was 01/02/24, so ultimately, it was her responsibility to review assessments and care plans. She said she did not see an issue with Resident #1's baseline care plan not explicitly including his recent diagnoses of severe dehydration and bowel impaction because these are all things still being monitored by the staff. She said urinary output and bowel movements were being monitored for the resident. She said the only major change for Resident #1 was that he returned with a catheter and reiterated that nothing had changed in the care he was currently receiving. She said she did not know Resident #1 had a documented history of dehydration and constipation. She said she did not know prior to going to the hospital, Resident #1 was care planned for IV hydration therapy and for nurses to monitor his bowel movements. She said Resident #1's recent diagnoses of impaction and severe dehydration should have been care planned. She said the resident was put at risk of further impaction if his bowel movements were not appropriately monitored. She said Resident #1 was also at risk for constipation, impaction, and Sepsis by not having his recent impaction care planned. She said the resident was at risk of further dehydration by not having his recent severe dehydration diagnosis care planned. An observation of Resident #1 on 01/11/24 at 6:28 PM revealed the following: The resident wore a gown that tied at the back of his neck. His face was clean in appearance, his lips were slightly chapped. The resident curled his body into a slight fetal position as LVN A removed the sheet that covered his body and raised his gown and exposed the resident's abdomen. He wore what appeared to be gown that tied at the back of his neck. He was clean in appearance; his lips were slightly chapped, and the resident wore a brief underneath the gown. Resident #1's PEG-tube sight was clean and appeared to be operating appropriately. LVN A pulled the resident's gown down and placed the sheet back over his body. Plastic tubing containing what appeared to be urine, could be seen on the lower left side of the resident's bed after the sheet was placed back. In an interview with LVN A on 01/11/24 at 6:28 PM, she said she had worked for the facility for a few months and was typically the nurse on Resident #1's hall during the 6:00 PM to 6:00 AM shift, unless she was assigned to work a different hall. She said even though the resident was nonverbal, he still communicated with LVN A in his own way. LVN A said when she did her first round on Resident #1, she always asked him if he was doing okay, and he would usually give her a thumbs up. She said she had heard mention of the resident whispering words, but she never observed it for herself. LVN A said the resident had returned from the hospital a few days ago and had not fully returned to behaving like himself. She said the resident seemed as if he had even more of a cognitive decline since going to the hospital. LVN A said nothing had changed nor had she been made aware of changes or updates to the care or treatment for Resident #1. She said the resident was readmitted to the facility with a foley catheter in place. LVN A said she was not sure what diagnosis the resident returned with to have a catheter. She said she did not know whether Resident #1 had orders or care planned interventions for the foley catheter. She said it was standard for all residents with catheters to have their urinary intake and output monitored. LVN A said CNA's were responsible for documenting both urinary and bowel movements in the resident's electronic health record. She said the only time she would monitor or assess the resident for issues with the catheter or bowel movements, was if during her interaction with the resident, she noticed a problem or if a CNA notified her of an issue. She said the CNA's were very good about notifying the nurses of resident issues. LVN A said all the CNA's knew if a resident went longer than 3 days without having a bowel movement that a nurse needed to be notified. She said she did not specifically review the resident's Urinary and Bowel Elimination Record because that was something the CNA's documented. LVN A said as far as she knew, Resident #1 did not have a history of dehydration because he received fluids and nutrition via his PEG-tube. She said she did not know Resident #1 to have a history of constipation either. LVN A said she did not know Resident #1 was treated for severe dehydration or fecal impaction during his recent hospital stay. LVN A said the only update she received on Resident #1 when he returned to the facility, was report from the nurse she relieved the next time she cared for Resident #1 after he was readmitted . LVN A said she was the nurse in charge of Resident #1's care when he was sent out to the hospital in December. She said she never observed Resident #1 exhibiting signs or symptoms of dehydration, constipation, or fecal impaction. She said if the resident was impacted, he would have had a distended stomach and likely expressed discomfort. She said she was never notified of any constipation issues either. LVN A said listening for bowel sounds was part of providing treatment to Resident #1 via PEG-tube before he went to the hospital. She said if she had noticed signs or symptoms of constipation or a distended stomach, she would have performed an assessment, completed an SBAR in the resident's electronic health record, notified the MD and followed any orders or directives, and notified the DON. In an interview with the DON on 01/12/24 at 11:10 AM, she said the third row of Resident #1's December 2023 Bowel and Bladder Elimination Record was not necessary for CNA's to complete, unless the resident had experienced additional urinary output or bowel movement after the initial one documented during a shift. She said the blank spaces that appeared within the first two rows of both the bowel and bladder record were times Resident #1's bowel or bladder elimination were not documented by staff in his electronic health record. In an

Based on observation, interview, and record review, the facility failed to notify the physician when there was a significant change of condition for one of four residents (CR #1) reviewed for notification of changes. -The facility failed to notify CR #1's physician when he was found with a bruise on his left arm. CR #1 was bed-bound and depended on staff for care when he was sent to the hospital for issues unrelated to the bruise, revealing CR#1 sustained a left humeral fracture and acute rib fractures. An IJ was identified on 7/29/23. The IJ template was provided to the facility on [DATE] at 6:16 p.m. While the IJ was removed on 8/3/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on reporting and assessing for changes of condition. These failures could place residents at risk for not receiving care and services to meet their needs. Findings include: Record review of CR #1's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia (loss of memory, language, problem -solving and other thinking ability), quadriplegia (paralysis below the neck that affect all of a person's limbs), sepsis (the body's extreme response to an infection), and acute respiratory failure with hypoxia (a serious condition that makes it difficult to breath on your own and a condition where you do not have enough oxygen in the tissues in the body). Record review of CR #1's quarterly MDS assessment, dated 05/12/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed he was always incontinent of bowel and bladder and required extensive assistance with two staff assist with bed mobility, transfers and toileting. Record review of CR #1's care plan initiated on 08/26/16 and revised on 10/04/22 revealed CR #1 required total assist by 2 staff for bed mobility and required total assistance of 1 staff for toileting. Record review of CR # 1's medication review report for July 2023 did not reflect any order for a x -ray. Record review of CR #1's skin observation reports dated from 06/15/23 to 07/06/23 did not reveal CR #1 had any bruises on his skin. Record review of CR #1's patient information sheet from a local hospital dated 7/10/23 revealed he was admitted on [DATE] at 10:03p.m. Record review of XR chest 1 view from a local hospital dated 07/10/23 read comminuted impacted left humeral fracture. Record review of the XR Chest 1VW portable from a local hospital dated 07/11/23 revealed acute fracture left humeral neck, acute right third - fifth rib fractures, and acute left fourth - sixth rib fractures. Interview on 07/12/23 at 10:59 a.m. with the ADON said she was not aware CR#1 had bruises on his left arm until the hospital called and asked her if she was aware CR#1 had bruises, fractured left humeral neck, and multiple ribs fracture. Interview on 07/12/23 at 11:12 a.m. 11:12 a.m. with the DON said she was unaware of CR #1 had any bruises on his left arm until the hospital called and notified the ADON on 07/11/23. Interview on 07/12/23 at 11:43 a.m. with the ADON said none of the nurses or aides told her CR #1 had bruises on his left arm or was in pain. She said she would have reported it to the administrator, resident doctor, and family member, initiated the incident report, documented it on the progress report, and followed the doctor's order. She said CR #1's injury of unknown origin was not assessed, reported, or treated. She said CR #1 would have been in pain, and care was not provided for CR #1. Observation and Interview on 07/13/23 at 9:25 a.m., CR #1 was lying on his back in a hospital bed. He responded to his name. CR #1's left arm was swollen around the elbow, and he had bruised left arm, which was dark purple with some yellow discoloration, and the inner arm was purple and red and had bruised areas on his left chest. The CR #1 nurse from the hospital was in the room when the surveyor asked him what had happened to his arm, and he said he had fallen. When asked how he fell , the surveyor could not understand what he was saying. Interview on 07/13/23 at 9:32 a.m. with HHSC Interpreter (6023), CR #1 told the interpreter that he fell from his chair, and when the interpreter asked him how he fell , the interpreter said he could not understand what CR #1 was saying. Interview on 07/13/23 at 12:24 p.m. with CNA A said she worked with CR #1 in the past, and CR #1 required assistance of two-staff with mechanical lift with transfers and required two-staff assistance bed mobility and during incontinent care. She said CR #1 could not do anything for himself; the staff had to do everything for CR #1. She said CR #1 had a bruise on his left arm for about four days before he went to the hospital. Interview on 07/13/23 at 1:42 p.m. with RN I, she said she was the MDS coordinator and she heard CR #1 threw up, aspirated, had spiked a fever, was having respiratory problems, and he was sent to the hospital. She said CR #1 was very stiff and could not turn himself even if he wiggled, he could not hurt himself on the side rails. During a telephone interview on 07/13/23 at 1:59 p.m., CNA E said she noticed the bruise on CR #1 left arm on 7/10/23, which was purple, and had some green to it, and it was on the inside of his left arm too. She said the bruised area was from the elbow to just below the shoulder, and the elbow area was swollen. She said she asked CNA S who was training her about the bruises, and CNA S said the Nurse was aware of the bruises and she left it at that. Interview on 07/13/23 at 2:21 p.m. with the Administrator , she said she was unaware of bruises on CR #1's left arm. The Administrator said none of the staff mentioned it during the morning meetings. Interview on 07/13/23 at 2:41 p.m. with CNA S, she said she saw the bruises on CR #1's left arm on 07/10/23. She said CNA E (the aide she was training) asked about the bruises on CR #1's left arm from below the shoulder to the elbow; his elbow was swollen, purple, and some of the area was yellow. She told CNA E that LVN D was aware of it because that was what the Nurse that told her. She said CNA E went and told LVN D again. She said they saw the bruise around 3:30 p.m., and that was when it was reported to LVN D. Interview on 07/13/23 at 3:09 p.m., the DON said the aide should let the Nurse know of any injury, and Nurses should report it directly to her, fill out the incident report, document it in CR #1's progress note, notified the physician, and provided care per the Physician's order. She said there was no documentation showing the doctor was notified, which meant care was not provided for the bruise on his left arm before he was sent to the hospital. The DON said the CR #1 doctor came in today and wrote on his progress report that an x-ray was done on 07/10/23 at the hospital, showing signs comparable with osteoporosis due to multiple morbid conditions, contractures, and complete immobility. She also said she had reports from an old x-ray showing CR #1 may have osteoporosis or osteopenia. When asked why the resident did not have the diagnosis, she said she was not a doctor. She did not respond when asked if any intervention was implemented since she knew that CR #1 may have osteoporosis or osteopenia. During a telephone interview on 07/13/23 at 4:36 p.m. LVN D said she worked with CR #1, and he had no health issues; he ate in the dining room, was doing fine, and was in his wheelchair. She said she noticed the bruises on his right arm, and if she was not mistaken, and it was on the upper arm. She said the bruised area was from his elbow up to just below his shoulder, but she did not assess the resident to see if it was on the inside of his arm. She said she asked the resident what happened, and he did not reply. She asked CNA R, and she said it may have happened the Friday or Thursday before this Monday (07/10/23), and she said it might have been already reported to LVN W. She said she asked the ADON about the bruise on CR #1, and the ADON said she would follow up on it. She said she did not document the bruise or follow up with it or called CR #1 doctor because it did not happen on her shift. During a telephone interview on 07/13/23 at 5:23 p.m., CNA R said she reported to LVN N on 07/05/23 that CR #1 had bruises on his left arm, and he said his arm was hurting. CNA R said when LVN D (07/06/23) came to work after 7:00 a.m., she reported that CR #1 was also complaining his left arm was hurting, which was bruised, and the Nurse said to leave him in bed, and she would call the x-ray company later. She said she left work at 2:30 p.m., and the x-ray company had not come. She said the color of the bruise was a big purple bruise and some green and yellow, and she said the bruise was from the elbow close to the shoulder, and she did not touch the arm because he said it was hurting in Spanish. Record review of the facility's policy on accident and incident - investigating and reporting created 09/19/21 read in part . all accidents or incidents involving residents . occurring on our premises shall be investigated and reported . policy interpretation and implementation . #1 . the charge nurse and /or the department director or supervisor shall promptly initiate and document investigation of the incident . #2g. the time the injured person's attending physician was notified as well as the time the physician responded and his instructions . This was determined to be an Immediate Jeopardy (IJ) on 7/29/23 at 6:16p.m. The ADON and Administrator were notified. The ADON was provide with the IJ template on 7/29/23 at 6:16p.m. The following Plan of Removal submitted by the facility was accepted on 8/1/23 at 9:48am: Plan of Removal CR # 1 was sent to theER on [DATE] and did not return to the facility. The Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. Ad Hoc QAPI was held on 7/29/23 with the Administrator, Director of Nursing, and Medical Director to review the IJ template and Plan of removal. MDS Coordinator conducted a 100% audit of ADL care plans on 7/29/23 to ensure it depicts the appropriate level of care the resident requires. Education The Director of Nursing initiated education with all staff on 7/13/23 on Reporting Changes in Resident Condition with a focus on following up on reports and notifying Administrator and DON if no interventions have been implemented, and reporting injuries of unknown origin. The Director of Nursing initiated education with all staff on 7/27/23 on Resident Rights; topics included- introducing self when entering resident's rooms, asking permission before providing care, and the resident's right to refuse care. The Director of Nursing initiated education with Licensed Nurses and CNAs on 7/29/23 with the following topics: reviewing the resident's Kardex prior to performing ADL care to provide the correct level of assistance. The Director of Nursing initiated education with CNAs on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA feels that the charge nurse does not address a concern that is brought to their attention, and reviewing the resident's Kardex prior to performing ADL care to provide the correct amount of assistance. Education will be completed by 7/30/23. Any staff member who did not receive the education will not be allowed to work their next shift until completed. Educational Packets/Training will be added to facility orientation. The facility does not currently utilize agency staff. Policy Review Change of Condition, Abuse/Neglect/Exploitation policy and procedure reviewed on 7/29/23 and required no changes. Monitoring The DON and ADON conducted grand rounds on 7/29/23 and 7/30/23 to ensure staff was providing the appropriate level of care, following the resident's Kardex, and compliant with observing resident's rights. Between 7/30/23 and 8/3/23, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interviews conducted on 7/30/23 with 4 staff revealed they had recently received training on abuse, change of condition, reporting of resident injuries, contacting supervisors, resident physicians, resident responsible parties, and completing documentation. They said if they were still concerned about the resident, they would talk to the Administrator or DON. Interviews and observations conducted on 7/30/23 with 4 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interviews conducted on 7/31/23 with 3 staff revealed they had recently received training on incontinence care, abuse/neglect, mechanical lifts, customer service, informing supervisors of resident condition concerns, and documentation. Interviews and observations conducted on 7/31/23 with 3 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interview on 8/3/23 at 10:55 a.m. with the Administrator, she said she was responsible for every operation in the facility. She said she had been at the facility since 2/23. She said when she was notified of the 3 IJs, she immediately began working on the PORs. She said once she got them approved, the facility began in-servicing on 7/11/23 and again on 7/13 for all staff for education on communication, reporting change of condition, injuries of unknown origin, who to report to, the important of reporting, bruising, swelling, injuries, policy (change in condition and ANE) and nursing staff on 7/29/23. She said the DON also in-serviced nursing staff on 7/29/23 for reviewing the clinical database prior to performing ADLs so they knew what services to provide to each resident. She said on 7/29/23, all staff were trained for Resident Rights. She said it was important to train all staff to ensure residents were protected. She said staff was trained to communicate with residents, informed them of care as they provide services, and the right to be free from abuse and neglect. She said all nursing staff on mechanical lift were trained on 7/29/23. The Administrator said nursing staff that worked closely with CR#1 were included in the mechanical lift training. She said all nursing staff from all three shifts were trained on in-services and the training was conducted by the Rehab Director. She said the DON conducted the other mentioned trainings. She said the DON continue to ensure the training were effective through frequent monitoring. She said the DON conducted competency testing and return demonstration to ensure staff had understanding. The Administrator said she shared the finding with the QAPI on 7/29/23. She said she notified CR#1's Physician and the Medical Director directly after being notified of the IJs. Interview on 8/3/23 at 11:25 am with the DON, she said she conducted 100% skin audits and there were no adverse findings on 7/13/23. She said on 7/29/23 in response to the IJ, she conducted a second 100% audit with ADON, and the MDS Nurse. She said the Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. She said she in-serviced all staff on Abuse and Neglect on 7/29/23. She said she also in-serviced nursing staff on reporting changes in resident condition with a focus on following up on reports of conditions to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt the charge nurse did not address a concern that was brought to their attention. She said staff were instructed to notify the Administrator and DON if no interventions had been implemented, and reporting injuries of unknown origin. Interview on 8/3/23 at 11:44 am with the RN I, she said she was responsible for MDS assessments for all resident in the facility. She said she updated care plans and coordinated drip drive (IV hydration/nutrition therapy). She said she had been at the facility about 7 years. She said she conducted 100% audit of the ADL care plans on 7/29/23 to ensure the appropriate level of care for each resident was accurate. She said it was a great experience for her because she was able to update about 3 or 4 care plans that required re-evaluation and the appropriate updates were made. She said communication improved between therapy staff and MDS Coordinator to ensure continuum of care was not interrupted. She said she completed all resident reviews by 8/2/23. Observation and Interview on 8/3/23 at 11:50 am with Resident #1 revealed a female resident that was well-groomed and well-dressed, playing a game on her iPad. She said a staff member (she could not recall who), had asked her if anyone had been rough with her during care and if she had ever been scared when nursing staff provided care. She said no one had ever been rough with her and she was not scared. She said she knew to tell the Administrator if someone ever mistreated her. Observation and Interview on 8/3/23 at 11:55 am with Resident #2 revealed a male resident, well-groomed and well-dressed conversing with his roommate while they both watch TV. He said a staff member (ADON) asked him if anyone had been rough with his during care and if he had any ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said she knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:05 pm with Resident #3 revealed a male resident, well-groomed and well-dressed having a conversation with his roommate. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:15 pm with Resident #4 revealed a male resident, well-groomed and dressed in shorts and a t-shirt. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he did not speak with the Administrator because she would tell him that she would return to speak with him but never would return. He said the Business Service Manager made rounds every morning to see how residents were doing. He said he would tell the Business Service Manager if anyone mistreated him. Observation and Interview on 8/3/23 at 12:20 pm with Resident #5 revealed a male resident, well-groomed and well-dressed watching TV. He said a staff member (ADON) asked him if anyone had been rough with his during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Interview on 8/3/23 at 1:11 pm with Med Tech A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with LVN C, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with Restorative Aide A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. Interview on 8/3/23 at 1:11 pm with CNA B, she said she worked the morning shift (6 a.m. to 2 p.m.). She said she provided care to CR#1. She said he required 2 persons assist for transfers with a Hoyer lift. She said he had a high level of care because he was dependent on assistance for all ADL's. She said she was trained due to the failure of reporting a change in condition for CR#1, so she was re-trained. She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. The Administrator was informed the Immediate Jeopardy was removed on 8/3/23 at 1:50pm. The facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

36918 Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from neglect for one (CR #1) of four residents reviewed for neglect. -The facility staff (LVN N and LVN D) failed to assess and treat CR #1, who was dependent on staff for all care, when he was discovered with injury of unknown origin that included a bruise on his arm. CR #1 was admitted to the hospital on 7/10/23 with a left humeral fracture and acute rib fractures. -facility failed to ensure CNA E did not provide incontinent care to CR #1 by herself when care required two staff. An IJ was identified on 7/29/23. The IJ template was provided to the facility on [DATE] at 6:16 p.m. While the IJ was removed on 8/3/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on reporting and assessing changes of condition. These failures could place residents at risk of neglect from facility staff. Findings include: Record review of CR #1's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia ( loss of memory, language, problem -solving and other thinking ability), quadriplegia (paralysis below the neck that affect all of a person's limbs), sepsis (the body's extreme response to an infection), and acute respiratory failure with hypoxia (a serious condition that makes it difficult to breath on your own and a condition where you do not have enough oxygen in the tissues in the body). Record review of CR #1's quarterly MDS assessment, dated 05/12/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed he was always incontinent of bowel and bladder and required extensive assistance with two staff assist with bed mobility, transfers and toileting. Record review of CR #1's care plan initiated on 08/26/16 and revised on 10/04/22 revealed CR #1 required total assist by 2 staff for bed mobility and required total assistance of 1 staff for toileting. Record review of CR # 1's medication review report for July 2023 did not reflect any order for x - ray. Record review of CR #1's skin observation report dated from 06/15/23 to 07/06/23 did not reveal CR #1 had any bruises on his skin. Record review of CR #1's patient information sheet from a local hospital dated 7/10/23 revealed he was admitted on [DATE] at 10:03p.m. Record review of CR #1's XR chest 1 view from a local hospital dated 07/10/23 read comminuted impacted left humeral fracture. Record review of CR # 1's XR Chest 1VW portable from a local hospital dated 07/11/23 revealed acute fracture left humeral neck, acute right third - fifth rib fractures, and acute left fourth - sixth rib fractures. Interview on 07/12/23 at 10:59 a.m., the ADON said she was not aware CR#1 had bruises on his left arm until the hospital called on 07/11/23 and asked her if she was aware CR#1 had bruises, fractured left humeral neck, and multiple ribs fracture. Interview on 07/12/23 at 11:12 a.m., the DON said she was unaware CR #1 had any bruises on his left arm until the hospital called and notified the ADON on 07/11/23. Interview on 07/12/23 at 11:43 a.m., the ADON said none of the nurses or aides told her CR #1 had bruises on his left arm or was in pain. She said she would have reported it to the administrator, resident doctor, and family member, initiated the incident report, documented it on the progress report, and followed the doctor's order. She said CR #1's injury of unknown origin was not assessed, reported, or treated. She said CR #1 would have been in pain, and care was not provided for CR #1. She said the floor nurse does weekly skin assessment and document if there were any issues with skin and report to her and the DON. Observation and Interview on 07/13/23 at 9:25 a.m., CR #1 was lying on his back in a hospital bed. He responded to his name. CR #1's left arm was swollen around the elbow, and he had bruise on his left arm, which was dark purple with some yellow discoloration. The inner arm was purple and red and had bruised areas on his left chest. When the surveyor asked him what had happened to his arm, he said he had fallen. When asked how he fell , the surveyor could not understand what he was saying. Surveyor conducted an interview with CR #1 using HHSC interpreter (6023) on 07/13/23 at 9:32 a.m. CR #1 told the interpreter in Spanish that he fell from his chair, and when the interpreter asked him how he fell , the interpreter said he could not understand what CR #1 was saying. Interview on 07/13/23 at 12:24 p.m., CNA A said she worked with CR #1 in the past. She said CR #1 required the assistance of two staff with a mechanical lift for transfers, and required the assistance of two staff for bed mobility and incontinent care. She said CR #1 could not do anything for himself; the staff had to do everything for him. She said CR #1 had a bruise on his left arm for about four days before he went to the hospital. She said she did not report the bruise on CR#1's arm because she was told it had been reported to LVN D. During a telephone interview on 07/13/23 at 1:07 p.m., LVN W said CNA E called and told her CR #1 was having a breathing problem on 07/10/23 at about 8:00p.m. When she saw CR #1, he was breathing shallow, and she checked his O2 sat, it was 85%, and she called 911 to take the resident to the hospital. She said the aide had just finished changing the resident by herself, but the resident required two-person assistance, and she did not tell her if the resident fell or hit any part of his body on the bed. She said she did not assess the resident's skin because the aide had cleaned him up, and he was good to go, and she sent him out and did not notice any bruise on his arm. She said she was concerned about his breathing, which was why she did not assess the resident. She said the resident does not speak too well, and you cannot really understand him, but he did not say anything about being in pain. Interview on 07/13/23 at 1:42 p.m., RN I said CR #1 was very stiff and could not turn himself even if he wiggled himself; he could not hurt himself on the side rails. She said the resident needed two people to assist with incontinent care in bed and for transfers. She said if one aide provided the care, she did not follow CR #1's plan of care which could cause an injury to CR #1. She said CR #1 went to the hospital on 7/10/23 because he threw up, aspirated, had spiked a fever, and was having respiratory problems. She said the administrator was the abuse coordinator and abuse/neglect should be reported immediately. She said the administrator and the DON does in service on abuse/neglect and she had in-service about two weeks ago. During a telephone interview on 07/13/23 at 1:59 p.m., CNA E said she went into CR #1's room, and he was not looking right (difficulty breathing) on 07/10/23 about 8:00 p.m. She called LVN W, and the nurse checked his oxygen, which was 85%. She said she provided incontinent care for CR #1 by herself because that was her first day of orientation on the floor, and she did not know he required two-person assistance. She said she transferred the resident to bed with CNA S earlier, around 3:30 p.m., because the resident vomited. CNA E said she noticed the bruise on CR #1 left arm, which was purple, and had some green to it, and it was on the inside of his left arm too. She said the bruised area was from the elbow to just below the shoulder, and the elbow area was swollen. She stated she asked CNA S who was training her about the bruises, and CNA S said the nurse was aware of the bruise and she left it at that. Interview on 07/13/23 at 2:21 p.m., the Administrator said she was unaware of bruises on CR #1's left arm. The administrator said none of the staff mentioned it during the morning meetings. Interview on 07/13/23 at 2:41 p.m. CNA S said she saw the bruise on CR #1's left arm on 07/10/23. She said CNA E (the aide she was training) asked about the bruise on CR #1's left arm from below the shoulder to the elbow; his elbow was swollen, purple, and some of the area was yellow. She told CNA E that LVN D was aware of it because that was what the person that told her said. She said CNA E went and told LVN D again. She said they saw the bruise around 3:30 p.m., and that was when it was reported to LVN D. CNA S said CNA E went and changed CR #1 by herself, but CR#1 needed two staff assistance. CNA S said she forgot to tell CNA E that CR #1 needed two-person assistance for incontinent care, and CNA E did not tell her she was going to provide incontinent for CR #1. She said CR #1 could get hurt if one person provided care. Interview on 07/13/23 at 3:05 p.m., the Administrator said she was the abuse coordinator for the facility, and her expectation was for the staff to notify her immediately if there was any incident. Still, they had to follow the chain of command. The Administrator said, she and the DON conducts in service on abuse/neglect and the staff were told to report to their immediate supervisor who would then report to her. She said if a resident had an injury and the staff did not report it to her, it was a deficient practice because she would only report if she were made aware of the incident. Interview on 07/13/23 at 3:09 p.m., the DON said the aide should let the nurse know of any injury, and nurses should report it directly to her, fill out the incident report, and document it in CR #1's progress note and notify the physician and provide care per his order. She said there was no documentation showing the doctor was notified, which meant care was not provided for the bruise on his left arm before he was sent to the hospital. The DON said the CR #1's doctor came in today and wrote on his progress report that an x-ray was done on 07/10/23 at the hospital, showing signs comparable with osteoporosis (decrease in the amount and thickness of bone tissue) due to multiple morbid conditions, contractures, and complete immobility. She also said she had reports from an old x-ray showing CR #1 may have osteoporosis or osteopenia (a loss of bone density that weakens the bones). When asked why the resident did not have the diagnosis, she said she was not a doctor. She did not respond when asked if any intervention was implemented since she knew that CR #1 may have osteoporosis or osteopenia. The DON said CR #1 needed two-person assistance with transfer and bed mobility, and two staff should have provided the incontinent care if it was care planned for two staff. During a telephone interview on 07/13/23 at 4:36 p.m. LVN D said she worked with CR #1, and he had no health issues; She said she noticed the bruises on his right arm, and if she was not mistaken, it was on the upper arm. She said the bruised area was from his elbow up to just below his shoulder, but she did not assess the resident to see if it was on the inside of his arm. She said she asked the resident what happened, and he did not reply. She asked CNA R, and she said it may have happened the Friday or Thursday (07/06/23 or 07/07/23) before this Monday (07/10/23), and she said it might have been reported to LVN W. She said she asked the ADON about the bruise on CR #1, and the ADON said she would follow up on it. She said she did not document the bruise or follow up with it or call CR #1's doctor because it did not happen on her shift. During a telephone interview on 07/13/23 at 5:23 p.m., CNA R said she reported to LVN N, the night nurse, on 07/05/23 that CR #1 had bruises on his left arm, and he stated his arm was hurting. CNA R said when her morning nurse LVN D (07/06/23) came to work after 7:00 a.m., she reported that CR #1 was also complaining his left arm which was bruised, was hurting, , and she said to leave him in bed, and she would call the x-ray company later. She said she left work at 2:30 p.m., and the x-ray company had not come. She said CR #1 said the bald white man pulled his arm hard to put his shirt on, which was painful. She said the color of the bruise was a big purple bruise and some green and yellow. She said the bruise was from the elbow close to the shoulder. She said she did not touch the arm because he said it was hurting in Spanish. She also said CR #1 said the aide with long nails and a big butt was rough when she transferred him to the bed last night (07/05/23), and she did not understand clearly if he meant she gave him a bear hug when she transferred him to bed. Interview on 07/13/23 at 5:50 p.m., the Administrator said she could not believe she was in the building on 07/04/23 and an incident (CR #1 bruise) happened, and she was not told about it. She said she could not believe the staff would not own up if they did something wrong (CR #1 bruise) instead, they would be calling other staff names. She said since the incident was not reported, CR #1 was not treated for the injury, and she did not report the incident until 07/11/23 after the hospital called and notified the facility about the injury. Record review of the facility's policy on accident and incident - investigating and reporting created 09/19/21 read in part . all accidents or incidents involving residents . occurring on our premises shall be investigated and reported . policy interpretation and implementation . #1 . the charge nurse and /or the department director or supervisor shall promptly initiate and document investigation of the incident . #2g. the time the injured person's attending physician was notified as well as the time the physician responded and his instructions . Record review of the facility policy on abuse/neglect revised 6/2019 read in part . it is the policy of this facility to provide professional care and services in an environment that is free from any type of . Neglect . definition of neglect . failure to react to a situation which may be harmful . neglect may be or may not be intentional . signs and symptoms of suspected abuse/neglect . #1 . prolonged interval between trauma/illness and seeking medical attention . This was determined to be an Immediate Jeopardy (IJ) on 7/29/23 at 6:16p.m. The ADON and Administrator were notified. The ADON was provide with the IJ template on 7/29/23 at 6:16p.m. The following Plan of Removal submitted by the facility was accepted on 8/1/23 at 9:48am: Facility Plan of Removal CR # 1 was sent to theER on [DATE] and did not return to the facility. The Facility Self-Reported CR #1s fractures on 7/11/23 with subsequent investigation. The investigation was inconclusive with discrepancies in the origin and location of resident fractures. The Director of Nursing conducted 1:1 training with staff members who were identified as failing to report changes in condition in CR #1 and were completed by 7/21/23. The Director of Nursing conducted a sample of resident questionnaires screening for abuse or neglect on 7/11/23 with no adverse findings. The Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. Ad Hoc QAPI was held on 7/14/23 with the Administrator, DON, and Medical Director with the following topics: Incident Reporting Process, Changes of Condition, Reporting Incidents and Accidents appropriately. Ad Hoc QAPI was held on 7/29/23 with the Administrator, Director of Nursing, and Medical Director to review the IJ template and Plan of removal. A 100% skin audit was completed 7/13/23 by the MDS Nurse and Charge Nurse. No adverse findings were noted. A 100% skin audit was repeated by the DON, ADON, and MDS Nurse on 7/29/23 in response to the IJ. Audits were conducted to ensure there was no bruising or injuries of unknown origin. No adverse findings were noted. DON reviewed Incidents and Accidents x 30 days to ensure any Injuries of Unknown Origin were communicated with the Physician, orders obtained, and Reported to HHSC as necessary. No adverse findings were noted. Education The Director of Nursing initiated education on 7/11/23 on Abuse and Neglect with all facility staff. The Director of Nursing initiated education with all staff on 7/13/23 on Reporting Changes in Resident Condition with a focus on following up on reports and notifying Administrator and DON if no interventions have been implemented, and reporting injuries of unknown origin. The Director of Nursing initiated education with Licensed Nurses on 7/29/23 with the following topics: Reporting changes of condition to include any injuries of unknown origin/bruising/swelling to the Physician, Changes of Condition Policy and Procedure, and Abuse/Neglect/Exploitation. The Director of Nursing initiated education with CNAs on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA feels that the charge nurse does not address a concern that is brought to their attention. Education will be completed by 7/30/23. Any staff member who did not receive the education will not be allowed to work their next shift until completed. Educational Packets/Training will be added to facility orientation. The facility does not currently utilize agency staff. Policy Review Change of Condition, Abuse/Neglect/Exploitation policy and procedure reviewed on 7/29/23 and required no changes. Between 7/30/23 and 8/3/23, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interviews conducted on 7/30/23 with 4 staff revealed they had recently received training on abuse, change of condition, reporting of resident injuries, contacting supervisors, resident physicians, resident responsible parties, and completing documentation. They said if they were still concerned about the resident, they would talk to the Administrator or DON. Interviews and observations conducted on 7/30/23 with 4 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interviews conducted on 7/31/23 with 3 staff revealed they had recently received training on incontinence care, abuse/neglect, mechanical lifts, customer service, informing supervisors of resident condition concerns, and documentation. Interviews and observations conducted on 7/31/23 with 3 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interview on 8/3/23 at 10:55 a.m. with the Administrator, she said she was responsible for every operation in the facility. She said she had been at the facility since 2/23. She said when she was notified of the immediate jeopardies, she immediately began working on the PORs. She said once she got them approved, the facility began in-servicing on 7/11/23 and again on 7/13 for all staff for education on communication, reporting change of condition, injuries of unknown origin, who to report to, the important of reporting, bruising, swelling, injuries, policy (change in condition and ANE) and nursing staff on 7/29/23. She said the DON also in-serviced nursing staff on 7/29/23 for reviewing the clinical database prior to performing ADLs so they knew what services to provide to each resident. She said on 7/29/23, all staff were trained for Resident Rights. She said it was important to train all staff to ensure residents were protected. She said staff was trained to communicate with residents, informed them of care as they provide services, and the right to be free from abuse and neglect. She said all nursing staff on mechanical lift were trained on 7/29/23. The Administrator said nursing staff that worked closely with CR#1 were included in the mechanical lift training. She said all nursing staff from all three shifts were trained on in-services and the training was conducted by the Rehab Director. She said the DON conducted the other mentioned trainings. She said the DON continue to ensure the training were effective through frequent monitoring. She said the DON conducted competency testing and return demonstration to ensure staff had understanding. The Administrator said she shared the finding with the QAPI on 7/29/23. She said she notified CR#1's Physician and the Medical Director directly after being notified of the IJs. Interview on 8/3/23 at 11:25 am with the DON, she said she conducted 100% skin audits and there were no adverse findings on 7/13/23. She said on 7/29/23 in response to the IJ, she conducted a second 100% audit with ADON, and the MDS Nurse. She said the Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. She said she in-serviced all staff on Abuse and Neglect on 7/29/23. She said she also in-serviced nursing staff on reporting changes in resident condition with a focus on following up on reports of conditions to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt the charge nurse did not address a concern that was brought to their attention. She said staff were instructed to notify the Administrator and DON if no interventions had been implemented, and reporting injuries of unknown origin. Interview on 8/3/23 at 11:44 am with the RN I, she said she was responsible for MDS assessments for all resident in the facility. She said she updated care plans and coordinated drip drive (IV hydration/nutrition therapy). She said she had been at the facility about 7 years. She said she conducted 100% audit of the ADL care plans on 7/29/23 to ensure the appropriate level of care for each resident was accurate. She said it was a great experience for her because she was able to update about 3 or 4 care plans that required re-evaluation and the appropriate updates were made. She said communication improved between therapy staff and MDS Coordinator to ensure continuum of care was not interrupted. She said she completed all resident reviews by 8/2/23. Observation and Interview on 8/3/23 at 11:50 am with Resident #1 revealed a female resident that was well-groomed and well-dressed, playing a game on her iPad. She said a staff member (she could not recall who), had asked her if anyone had been rough with her during care and if she had ever been scared when nursing staff provided care. She said no one had ever been rough with her and she was not scared. She said she knew to tell the Administrator if someone ever mistreated her. Observation and Interview on 8/3/23 at 11:55 am with Resident #2 revealed a male resident, well-groomed and well-dressed conversing with his roommate while they both watch TV. He said a staff member (ADON) asked him if anyone had been rough with his during care and if he had any ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said she knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:05 pm with Resident #3 revealed a male resident, well-groomed and well-dressed having a conversation with his roommate. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:15 pm with Resident #4 revealed a male resident, well-groomed and dressed in shorts and a t-shirt. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he did not speak with the Administrator because she would tell him that she would return to speak with him but never would return. He said the Business Service Manager made rounds every morning to see how residents were doing. He said he would tell the Business Service Manager if anyone mistreated him. Observation and Interview on 8/3/23 at 12:20 pm with Resident #5 revealed a male resident, well-groomed and well-dressed watching TV. He said a staff member (ADON) asked him if anyone had been rough with his during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Interview on 8/3/23 at 1:11 pm with Med Tech A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with LVN C, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with Restorative Aide A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. Interview on 8/3/23 at 1:11 pm with CNA B, she said she worked the morning shift (6 a.m. to 2 p.m.). She said she provided care to CR#1. She said he required 2 persons assist for transfers with a Hoyer lift. She said he had a high level of care because he was dependent on assistance for all ADL's. She said she was trained due to the failure of reporting a change in condition for CR#1, so she was re-trained. She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. The Administrator was informed the Immediate Jeopardy was removed on 8/3/23 at 1:50pm. The facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 41839

36918 Based on observation, interview and record review the facility failed, based on the comprehensive assessment, to ensure residents received the care and services in accordance with professional standards of practice for one of four residents (CR #1) reviewed for quality of care. -The facility failed to ensure nursing staff assessed and treated CR #1 when LVN D identified a bruise on his left arm. CR #1 was bed-bound and depended on staff for care when he sent to the hospital for issues unrelated to the bruise, revealing CR#1 sustained a left humeral fracture and multiple acute bilateral rib fractures. An IJ was identified on 7/29/23. The IJ template was provided to the facility on [DATE] at 6:16 p.m. While the IJ was removed on 8/3/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on reporting and assessing for changes of condition. This failure placed residents at risk of a delay in care and worsening of their medical condition. Findings include: Record review of CR #1's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia( loss of memory, language, problem -solving and other thinking ability), quadriplegia(paralysis below the neck that affect all of a person's limbs), sepsis(the body's extreme response to an infection), and acute respiratory failure with hypoxia(a serious condition that makes it difficult to breath on your own and a condition where you do not have enough oxygen in the tissues in the body). Record review of CR #1's quarterly MDS assessment, dated 05/12/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed he was always incontinent of bowel and bladder and required extensive assistance with two staff assist with bed mobility, transfers and toileting. Record review of CR #1's care plan initiated on 08/26/16 and revised on 10/04/22 revealed CR #1 required total assist by 2 staff for bed mobility and required total assistance of 1 staff for toileting. Record review of CR # 1's medication review report for July 2023 did not reflect any order for a x -ray. Record review of CR #1's skin observation reports dated from 06/15/23 to 07/06/23 did not reveal CR #1 had any bruises on his skin. Record review of CR #1's patient information sheet from a local hospital dated 7/10/23 revealed he was admitted on [DATE] at 10:03p.m. Record review of XR chest 1 view from a local hospital dated 07/10/23 read comminuted impacted left humeral fracture. Record review of the XR Chest 1VW portable from a local hospital dated 07/11/23 revealed acute fracture left humeral neck, acute right third - fifth rib fractures, and acute left fourth - sixth rib fractures. Interview on 07/12/23 at 10:59 a.m. with the ADON said she was not aware CR#1 had bruises on his left arm until the hospital called and asked her if she was aware CR#1 had bruises, fractured left humeral neck, and multiple ribs fracture. Interview on 07/12/23 at 11:12 a.m. 11:12 a.m. with the DON said she was unaware of CR #1 had any bruises on his left arm until the hospital called and notified the ADON on 07/11/23. Interview on 07/12/23 at 11:43 a.m. with the ADON said none of the nurses or aides told her CR #1 had bruises on his left arm or was in pain. She said she would have reported it to the administrator, resident doctor, and family member, initiated the incident report, documented it on the progress report, and followed the doctor's order. She said CR #1's injury of unknown origin was not assessed, reported, or treated. She said CR #1 would have been in pain, and care was not provided for CR #1. Observation and Interview on 07/13/23 at 9:25 a.m., CR #1 was lying on his back in a hospital bed. He responded to his name. CR #1's left arm was swollen around the elbow, and he had bruised left arm, which was dark purple with some yellow discoloration, and the inner arm was purple and red and had bruised areas on his left chest. The CR #1 nurse from the hospital was in the room when the surveyor asked him what had happened to his arm, and he said he had fallen. When asked how he fell , the surveyor could not understand what he was saying. Interview on 07/13/23 at 9:32 a.m. with HHSC Interpreter (6023), CR #1 told the interpreter that he fell from his chair, and when the interpreter asked him how he fell , the interpreter said he could not understand what CR #1 was saying. Interview on 07/13/23 at 12:24 p.m. with CNA A said she worked with CR #1 in the past, and CR #1 required assistance of two-staff with mechanical lift with transfers and required two-staff assistance bed mobility and during incontinent care. She said CR #1 could not do anything for himself; the staff had to do everything for CR #1. She said CR #1 had a bruise on his left arm for about four days before he went to the hospital. During a telephone interview on 07/13/23 at 1:07 p.m. with LVN W said CNA E called and told her CR #1 was having a breathing problem, and when she saw CR #1, he was breathing shallow, and she checked his O2 sat, it was 85%, and she called 911 to take the resident to the hospital. She said CNA E had just finished changing the resident by herself, and she did not tell her if the resident fell or hit any part of his body on the bed. She said she did not do any skin assessment on the resident because the CNA E had cleaned him up, and he was good to go to the hospital. She sent him out and did not notice any bruises on his arm. She said she was concerned about his breathing, which was why she did not assess the resident. She said the resident does not speak too well, you really cannot understand him, but he did not say anything about being in pain. Interview on 07/13/23 at 1:42 p.m. with RN I, she said she was the MDS coordinator and she heard CR #1 threw up, aspirated, had spiked a fever, was having respiratory problems, and he was sent to the hospital. She said CR #1 was very stiff and could not turn himself even if he wiggled, he could not hurt himself on the side rails. During a telephone interview on 07/13/23 at 1:59 p.m., CNA E revealed she went into CR #1's room, and he was not looking right. She called LVN W, and the nurse checked his oxygen, which was 85%. She said she provided incontinent care for CR #1 by herself because that was her first day of orientation on the floor, and she did not know he was two persons assist. She said she transferred the resident to bed with CNA S earlier, around 3:30 p.m., because the resident vomited. CNA E said she noticed the bruise on CR #1 left arm, which was purple, and had some green to it, and it was on the inside of his left arm too. She said the bruised area was from the elbow to just below the shoulder, and the elbow area was swollen. She said she asked CNA S who was training her about the bruises, and CNA S said the Nurse was aware of the bruises and she left it at that. Interview on 07/13/23 at 2:21 p.m. with the Administrator , she said she was unaware of bruises on CR #1's left arm. The Administrator said none of the staff mentioned it during the morning meetings. Interview on 07/13/23 at 2:41 p.m. with CNA S, she said she saw the bruises on CR #1's left arm on 07/10/23. She said CNA E (the aide she was training) asked about the bruises on CR #1's left arm from below the shoulder to the elbow; his elbow was swollen, purple, and some of the area was yellow. She told CNA E that LVN D was aware of it because that was what the Nurse that told her. She said CNA E went and told LVN D again. She said they saw the bruise around 3:30 p.m., and that was when it was reported to LVN D. CNA S said CNA E went and changed CR #1 by herself, but CR #1 needed two staff assistance. Interview on 07/13/23 at 3:05 p.m. with the Administrator, she said she was the Abuse Coordinator for the facility, and her expectation was for the staff to notify her immediately if there was any incident. She continued - still, they have to follow the chain of command. She said if a resident had an injury and the staff did not report it to her, it was a deficient practice because she would only report if she were made aware of the incident. Interview on 07/13/23 at 3:09 p.m., the DON said the aide should let the Nurse know of any injury, and Nurses should report it directly to her, fill out the incident report, document it in CR #1's progress note, notified the physician, and provided care per the Physician's order. She said there was no documentation showing the doctor was notified, which meant care was not provided for the bruise on his left arm before he was sent to the hospital. The DON said the CR #1 doctor came in today and wrote on his progress report that an x-ray was done on 07/10/23 at the hospital, showing signs comparable with osteoporosis due to multiple morbid conditions, contractures, and complete immobility. She also said she had reports from an old x-ray showing CR #1 may have osteoporosis or osteopenia. When asked why the resident did not have the diagnosis, she said she was not a doctor. She did not respond when asked if any intervention was implemented since she knew that CR #1 may have osteoporosis or osteopenia. The DON said CR #1 needed two-person assistance with transfer and bed mobility, and two staff should have provided the incontinent care if it was care planned for two staff. During a telephone interview on 07/13/23 at 4:36 p.m. LVN D said she worked with CR #1, and he had no health issues; he ate in the dining room, was doing fine, and was in his wheelchair. She said she noticed the bruises on his right arm, and if she was not mistaken, and it was on the upper arm. She said the bruised area was from his elbow up to just below his shoulder, but she did not assess the resident to see if it was on the inside of his arm. She said she asked the resident what happened, and he did not reply. She asked CNA R, and she said it may have happened the Friday or Thursday before this Monday (07/10/23), and she said it might have been already reported to LVN W. She said she asked the ADON about the bruise on CR #1, and the ADON said she would follow up on it. She said she did not document the bruise or follow up with it or called CR #1 doctor because it did not happen on her shift. During a telephone interview on 07/13/23 at 5:23 p.m., CNA R said she reported to LVN N on 07/05/23 that CR #1 had bruises on his left arm, and he said his arm was hurting. CNA R said when LVN D (07/06/23) came to work after 7:00 a.m., she reported that CR #1 was also complaining his left arm was hurting, which was bruised, and the Nurse said to leave him in bed, and she would call the x-ray company later. She said she left work at 2:30 p.m., and the x-ray company had not come. She said CR #1 told her, the bald white man pulled his arm hard to put his shirt on, which was painful. She said the color of the bruise was a big purple bruise and some green and yellow, and she said the bruise was from the elbow close to the shoulder, and she did not touch the arm because he said it was hurting in Spanish. She also said CR #1 said the aide with long nails and a big butt was rough when she put him in bed last night (07/05/23), and she did not understand clearly if he meant she gave him a bear hug when she transferred him to bed. Interview on 07/13/23 at 5:50 p.m. with the Administrator who said she could not believe she was in the building on 07/04/23 and had an incident and was not told about it. Instead, they would go and tell the people in the community. She also said she could not believe the staff would not own up if they did something wrong instead, they would be calling other staff names. Record review of the facility's policy on accident and incident - investigating and reporting created 09/19/21 read in part . all accidents or incidents involving residents . occurring on our premises shall be investigated and reported . policy interpretation and implementation . #1 . the charge nurse and /or the department director or supervisor shall promptly initiate and document investigation of the incident . #2g. the time the injured person's attending physician was notified as well as the time the physician responded and his instructions . This was determined to be an Immediate Jeopardy (IJ) on 7/29/23 at 6:16p.m. The ADON and Administrator were notified. The ADON was provide with the IJ template on 7/29/23 at 6:16p.m. The following Plan of Removal submitted by the facility was accepted on 8/1/23 at 9:48am: Plan of Removal CR # 1 was sent to theER on [DATE] and did not return to the facility. The Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. Ad Hoc QAPI was held on 7/29/23 with the Administrator, Director of Nursing, and Medical Director to review the IJ template and Plan of removal. MDS Coordinator conducted a 100% audit of ADL care plans on 7/29/23 to ensure it depicts the appropriate level of care the resident requires. Education The Director of Nursing initiated education with all staff on 7/13/23 on Reporting Changes in Resident Condition with a focus on following up on reports and notifying Administrator and DON if no interventions have been implemented, and reporting injuries of unknown origin. The Director of Nursing initiated education with all staff on 7/27/23 on Resident Rights; topics included- introducing self when entering resident's rooms, asking permission before providing care, and the resident's right to refuse care. The Director of Nursing initiated education with Licensed Nurses and CNAs on 7/29/23 with the following topics: reviewing the resident's Kardex prior to performing ADL care to provide the correct level of assistance. The Director of Nursing initiated education with CNAs on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA feels that the charge nurse does not address a concern that is brought to their attention, and reviewing the resident's Kardex prior to performing ADL care to provide the correct amount of assistance. Education will be completed by 7/30/23. Any staff member who did not receive the education will not be allowed to work their next shift until completed. Educational Packets/Training will be added to facility orientation. The facility does not currently utilize agency staff. Policy Review Change of Condition, Abuse/Neglect/Exploitation policy and procedure reviewed on 7/29/23 and required no changes. Monitoring The DON and ADON conducted grand rounds on 7/29/23 and 7/30/23 to ensure staff was providing the appropriate level of care, following the resident's Kardex, and compliant with observing resident's rights. On 7/30/23, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interviews conducted on 7/30/23 with 4 staff revealed they had recently received training on abuse, change of condition, reporting of resident injuries, contacting supervisors, resident physicians, resident responsible parties, and completing documentation. They said if they were still concerned about the resident, they would talk to the Administrator or DON. Interviews and observations conducted on 7/30/23 with 4 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interviews conducted on 7/31/23 with 3 staff revealed they had recently received training on incontinence care, abuse/neglect, mechanical lifts, customer service, informing supervisors of resident condition concerns, and documentation. Interviews and observations conducted on 7/31/23 with 3 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interview on 8/3/23 at 10:55 a.m. with the Administrator, she said she was responsible for every operation in the facility. She said she had been at the facility since 2/23. She said when she was notified of the 3 IJs, she immediately began working on the PORs. She said once she got them approved, the facility began in-servicing on 7/11/23 and again on 7/13 for all staff for education on communication, reporting change of condition, injuries of unknown origin, who to report to, the important of reporting, bruising, swelling, injuries, policy (change in condition and ANE) and nursing staff on 7/29/23. She said the DON also in-serviced nursing staff on 7/29/23 for reviewing the clinical database prior to performing ADLs so they knew what services to provide to each resident. She said on 7/29/23, all staff were trained for Resident Rights. She said it was important to train all staff to ensure residents were protected. She said staff was trained to communicate with residents, informed them of care as they provide services, and the right to be free from abuse and neglect. She said all nursing staff on mechanical lift were trained on 7/29/23. The Administrator said nursing staff that worked closely with CR#1 were included in the mechanical lift training. She said all nursing staff from all three shifts were trained on in-services and the training was conducted by the Rehab Director. She said the DON conducted the other mentioned trainings. She said the DON continue to ensure the training were effective through frequent monitoring. She said the DON conducted competency testing and return demonstration to ensure staff had understanding. The Administrator said she shared the finding with the QAPI on 7/29/23. She said she notified CR#1's Physician and the Medical Director directly after being notified of the IJs. Interview on 8/3/23 at 11:25 am with the DON, she said she conducted 100% skin audits and there were no adverse findings on 7/13/23. She said on 7/29/23 in response to the IJ, she conducted a second 100% audit with ADON, and the MDS Nurse. She said the Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. She said she in-serviced all staff on Abuse and Neglect on 7/29/23. She said she also in-serviced nursing staff on reporting changes in resident condition with a focus on following up on reports of conditions to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt the charge nurse did not address a concern that was brought to their attention. She said staff were instructed to notify the Administrator and DON if no interventions had been implemented, and reporting injuries of unknown origin. Interview on 8/3/23 at 11:44 am with the RN I, she said she was responsible for MDS assessments for all resident in the facility. She said she updated care plans and coordinated drip drive (IV hydration/nutrition therapy). She said she had been at the facility about 7 years. She said she conducted 100% audit of the ADL care plans on 7/29/23 to ensure the appropriate level of care for each resident was accurate. She said it was a great experience for her because she was able to update about 3 or 4 care plans that required re-evaluation and the appropriate updates were made. She said communication improved between therapy staff and MDS Coordinator to ensure continuum of care was not interrupted. She said she completed all resident reviews by 8/2/23. Observation and Interview on 8/3/23 at 11:50 am with Resident #1 revealed a female resident that was well-groomed and well-dressed, playing a game on her iPad. She said a staff member (she could not recall who), had asked her if anyone had been rough with her during care and if she had ever been scared when nursing staff provided care. She said no one had ever been rough with her and she was not scared. She said she knew to tell the Administrator if someone ever mistreated her. Observation and Interview on 8/3/23 at 11:55 am with Resident #2 revealed a male resident, well-groomed and well-dressed conversing with his roommate while they both watch TV. He said a staff member (ADON) asked him if anyone had been rough with his during care and if he had any ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said she knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:05 pm with Resident #3 revealed a male resident, well-groomed and well-dressed having a conversation with his roommate. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:15 pm with Resident #4 revealed a male resident, well-groomed and dressed in shorts and a t-shirt. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he did not speak with the Administrator because she would tell him that she would return to speak with him but never would return. He said the Business Service Manager made rounds every morning to see how residents were doing. He said he would tell the Business Service Manager if anyone mistreated him. Observation and Interview on 8/3/23 at 12:20 pm with Resident #5 revealed a male resident, well-groomed and well-dressed watching TV. He said a staff member (ADON) asked him if anyone had been rough with his during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Interview on 8/3/23 at 1:11 pm with Med Tech A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with LVN C, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with Restorative Aide A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. Interview on 8/3/23 at 1:11 pm with CNA B, she said she worked the morning shift (6 a.m. to 2 p.m.). She said she provided care to CR#1. She said he required 2 persons assist for transfers with a Hoyer lift. She said he had a high level of care because he was dependent on assistance for all ADL's. She said she was trained due to the failure of reporting a change in condition for CR#1, so she was re-trained. She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. The Administrator was informed the Immediate Jeopardy was removed on 8/3/23 at 1:50pm. The facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 41839

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one of three residents (CR #1) reviewed for accidents. The facility failed to ensure a mechanical lift sling used for Hoyer lift transfer was in good repair prior to staff using it to transfer CR #1 resulting in a fall . CR # 1 sustained Lumbar fracture and head injury . This failure could affect all residents who require a mechanical lift using a sling for transfer. Findings Included: CR #1 Record review of CR #1's admission record dated February 8, 2020 revealed she was a [AGE] year-old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Quarterly MDS assessment dated [DATE] revealed CR #1 was totally dependent on the help of two to three staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. CR #1 always incontinent of both bowel and bladder. CR #1 had a BI[CONDITION] of 00 which indicated severe cognitive impairment. Resident required enteral feeding for nutrition and has limitation in range in range of motion on both sides of upper and lower extremities. Record review of CR#1's care plan dated 2/10/2020 revealed CR#1 required mechanical lift with two staff assistance for transfer . goal was the resident will sustain no injuries related to the transfer through the next review date. intervention included: inspect slings for damage , utilize green full body sling for transfers and utilize two staff members for mechanical lifts transfers. Further review of CR#1's care plan dated 2/10/2020 revealed CR#1 was incontinent of bowel and bladder , had altered musculoskeletal status related to [MEDICAL CONDITION], had stroke affecting her left side , was dependent on staff for al activities of daily living , required tube feeding and was at high risk for falls related to paralysis. Record review of facility internal investigation statement and attestation dated 2/8/2020 and signed by the facility administrator revealed nurse stated she was notified RCS that CR#1 was on the ground. Nurse stated upon arrival to room , she noted the resident laying on the ground with his left side of her head laying on the leg of the Hoyer lift. She states that she assessed the resident and noticed some blood on the resident's head, so she applied pressure with gauze sponge too the resident's head on the left side. She stated that she notified the resident 's physician and then called Emergency medical services ( E[CONDITION]) to transfer resident to emergency room for evaluation per Phys vain orders. Nurse stated she stayed with resident until E[CONDITION] arrived and also notified the responsible party of the incident. Nurse stated that both CNA #A and CNA #C were present in the room at the time of incident. Record review of witness statement written by CNA #A dated 2/8/2020 revealed Aide states she and CNA #C were in CR#1's room to assist resident with transfer to bed . Aide states she inspected sling prior to use and there were no rips or frays noted. She states CNA #C lifted CR#1 up using Hoyer lift out of the Geri-chair approximately one foot above chair . She states the lower two straps broke simultaneously causing the resident's feet to come down towards the ground. As a result, the resident slid out of the sling onto the ground. Aide stated she attempted to break resident's fall , however unsuccessful. CNA # A Stated nurse was notified of the incident. Record review of witness statement written by CNA #C dated 2/8/2020 revealed Aide states she and CNA #A were in CR#1's room to assist resident with transfer to bed . Aide states she inspected sling prior to use and there were no tears or frays noted. She states she lifted CR#1 up using Hoyer lift out of the Geri-chair approximately one foot above chair . She states the lower two straps broke simultaneously causing the resident's feet to come down towards the ground. As a result, the resident slid out of the sling onto the ground. Aide stated she and the other aide attempted to break resident's fall , however unsuccessful. CNA #C sates she immediately notified the LVN assigned to the unit. Record review of CR#1's record revealed no incident reported for fall above fall on 2/8/2020. Record review of CR#1's hospital record dated 2/10/2020 revealed CR #1 who was bed down and non - ambulatory , was unable to communicate, unable to move her extremities , had a feeding tube to herself , was being moved on a Hoyer lift when apparently it broke, and she fell . She suffered acute T12 compression fracture ( Lumbar fracture) and acute traumatic hematoma of scalp ( bleeding in head) . Interview on 2/10/2020 at 2:00 p.m. with CNA # C, she said she started to raise CR #1 out of the chair using the mechanical lift when the straps snapped on the sling. She said the sling snapped as soon as she pulled the resident over the chair. She said she did not know who inspects the slings, she thought the maintenance man because the maintenance personnel were always near the linen closet. She said she had transferred resident once that day already with the same sling. The resident kept the same sling until they went back to bed. She said when she was finished with the sling she would put the sling in the linen barrel. She said each time they use a sling on a resident they put it in the linen barrel to be washed. She said she does not reuse a sling on another resident if it had not been washed. She said they have enough slings for the residents who need them. The slings are different trim colors depending on the resident's weight. CR #1 was a blue sling. She said the sling that was used for CR #1 was not nearly as worn down as some she had seen at the facility. She said CNA #A assisted her with the transfer. Interview on 2/10/2020 at 2:30 p.m. with CNA #A, she said the sling straps broke as soon as they tried to move CR #1 from her chair to the bed. She said the CNAs are responsible for looking at the slings to make sure they are in good shape. CR #1 was already in the chair when she clocked in, so she did not inspect the sling. She said CNA #F looked at the slings because she uses them for getting resident weights. She said, to her knowledge they do not have any other inspection of the slings other than the restorative aide and the CNAs before they get ready to use them. She said she assisted CNA #C with the transfer. Observation on 2/10/2020 at 2:40 p.m. revealed the sling that was used to transfer CR #1 was worn and the corners of the strap was torn thru the fabric on the straps that was still connected to the sling. The sling material was thin and worn. Interview on 2/10/2020 at 3:00 p.m. with the DON, she said the Maintenance Supervisor checks the Hoyer's and when he was done he would remind her. She said the ADON was to check the slings weekly. She said there was no documentation that the slings are checked regularly by the DON and ADON. A policy for mechanical (Hoyer) lifts use was requested at this time and the DON said the facility did not have a policy for Hoyer Lifts. The DON further said there were 7 residents in the facility who require mechanical lifts, after the incident the facility completed facility wide audit and removed all old Hoyer lift slings. She said new ones were ordered immediately and facility staff were educated on use and care of the slings. The DON said the facility had an emergency QAPI ( Quality assurance and performance program) on today 2/10/2020 and established new system for staff to closely monitor all slings used for resident transfers. Staff training on the new expectation was initiated 2/8/2020. Interview on 2/10/2020 at 3:30 p.m. with the Maintenance Supervisor, he said he inspects the Hoyer's weekly. He said if a sling was hanging on the Hoyer he might look at it but otherwise it was the nursing staff responsibility. He said he never told the DON or ADON to inspect the slings. He said he figured the nursing staff knew to inspect the slings before using them. Record received of the facility's Ad Hoc QAIP plan of correction agenda and summary dated 2/10/2020 (review was authorized by facility management) revealed systemic changes to include- staff education in inspection slings prior to use, competency evaluation , skill check off, monitoring , 100% of SLINGS in the facility assessed by DON/maintenance director , Scheduled inspection of facility lifts on 2/10/2020 etc. Record review of in-services for Mechanical Lifts revealed an in-service was initiated on 2/08/2020 and was ongoing for all direct care staff, and for facility laundry and maintenance staff. Record review of training log revealed the following training were provide 2/8/2020 and ongoing: Competency check on use of mechanical lift. Abuse and neglect . Staff should refer to Kardex when using a Hoyer lift and Mechanical lift sling audit. Record review of laundry in-service for laundering of slings and heat or chemical sensitive items in-service dated 2/10/2020 revealed all of the laundry staff had been in-serviced on how to inspect the sling and how to fill out inspection log for slings. Interview on 2/20/2020 at 11:30 a.m. with the Laundry Supervisor said they use what the manufacture recommended for washing the slings. She said the slings were air dried , they do not use chloride or bleach on the slings. She said any sling noted to worn out or frayed will immediately be removed from circulation and handed to the DON. Interview on 2/20/2020 at 1:43 p.m. with the DON said the facility did not have policy on washing the slings but followed the manufacturer's washing recommendations. She said the facility had the new invoices for the recently purchased slings and did not have the invoices for the slings purchased previously (including the sling that was torn). The DON said she started her job late 2017 and had not ordered slings until late 2019 and 2020. She said she was not sure how long the slings had been in use. The DON said the facility completed audit on all residents who required Hoyer lift for transfers, removed all old slings and replaced them with new ones, re-trained staff on use and on inspection of slings prior to use . the Son said the facility have initiated a new system and laundry staff log in inspection after every wash and notify her of any concerns. Record review of facility form labeled Residents using mechanical lifts undated revealed 7 residents that used slings. Observation/Record review of the facility slings on hand revealed the manufacture's wash recommendation read in part. Slings can suffer damage during washing and drying.Check sling before each use.torn.frayed slings are unsafe and could result in serious injury or death to patient.

Based on interview and record review the facility failed to ensure residents with a [DIAGNOSES REDACTED].#107) reviewed for quality of care. -The facility failed to call CR #107's physician for clarification and parameters on fasting blood sugars and use of prescribed medications. -The facility failed to ensure that CR #107 received medication prescribed by local hospital for 8 days. -The facility failed to obtain parameters on when to notify the physician on blood sugar results for CR #107. -The facility failed to have admission documentation and medication reconciliation for CR #107 for accuracy and consistency in care. This deficient practice affected one resident and placed him at risk for blood sugars not being adequately monitored, correct medication administered to prevent deterioration in health and wellness in the resident. Finding included: Intake Number Record review of CR #107's face sheet dated 12/14/18 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. CR #107's [DIAGNOSES REDACTED]. Record review of CR #107's admission MDS dated [DATE] identified a Brief Interview Mental Status (BIMS) score of 11 cognitively able to make decisions. Record review of CR #107's discharge MDS dated [DATE] revealed the discharge as a planned discharge. Record review of CR #107's undated care plan revealed no care plan related to diabetes mellitus, [DIAGNOSES REDACTED] or [MEDICAL CONDITION], and use of insulin and diabetic medications. Record review of Intake Investigation Worksheet created 10/29/18, reads . On 10/25/18, the complainant visited the resident and he told her that he hadn't been given his insulin shot since he arrived at the facility and that no one has given him any new medication . The complainant spoke to the administrator . Talk to nurse that was supposed to give the resident his insulin . There was no doctor's orders about administering insulin to the resident . Record review of CR #107's Medication Administration Record [REDACTED]. There were no parameters documents or when to notify the physician. Fasting blood sugars documented as follows for 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m. 10/18/18 - 273, 326, 436, 343 10/19/18 - 145,156, 132, 492 10/20/18 - 311, 455, 143, 338 10/21/18 - 342, 207, 325, 178 10/22/18 - 275, 346, 500, 465 10/23/18 - 157, 299, 320, 347 10/24/18 - 143, 203 289, 322 10/25/18 - 156, 176, no documentation, 381 10/26/18 - 176, 391, 382, 396 10/27/18 - 195, 87, 164, 185 10/28/18 - 64, no documentation Record review of CR #107's hospital Medication Administration Record [REDACTED]. Insulin Detemir 100 units/ml 42 units in the AM with a start date of 10/15/18 and end date of 11/14/18. Record review of consolidated physician orders [REDACTED].#107. Record review of CR #107's (MONTH) (YEAR) MAR indicated [REDACTED]. Interview on 12/13/18 at 12:20 p.m. with DON regarding CR #107, she said he was discharged home because his family member and CR #107 wanted his stay at the facility to be short. She said therapy talked with the physician for approval for CR #107 to leave early. DON said the family had no concerns with Resident #107's care, but the family member just wanted him home. She said there should have been a 72-hour care plan meeting. Surveyor requested for the documentation of the care plan meeting at that time and the care plan meeting notes were not given to the surveyor before exit. Interview on 12/14/18 8:29 a.m. with ADON, she said when a resident was admitted to the facility, the admitting nurse would reconcile medications by going through the form that the resident came with from the previous placement or the medications that they had brought with them. The nurse would contact the primary physician and reconcile the medications the resident would continue at the facility. She also said if a physician was called and no answer was received, the nurse should call the Medical Director or the DON. If it was an emergency, the nurse should call 911, and then let the physician know of the concern after the incident. The ADON said if a resident had multiple fasting blood sugars greater than 250 she should call the physician for guidance. She continued to say, if a resident was on insulin there should be parameters on the doses of insulin to give. She said if the resident does not have parameters on the MAR (medication administration record), the nurse should contact the physician for parameter clarification orders. She said if a resident does not have insulin parameters, she would give insulin to a resident she knows and knows that they will eat their meal and if it was a resident who would refuse the meal she would hold on the insulin if there were no parameters to give insulin. She said if the resident was a new admission she would not give insulin to the resident because she would not know how they react to the insulin. She said if any resident's blood sugar was below 70 she would give the resident a simple sugar like orange juice along with a meal. Interview on 12/14/18 at 9:12 a.m. with LVN C, she said if she was unable to get in touch with the physician she would contact the DON and follow her guidance. She also said she would contact the Medical Director if unable to get in touch with the primary physician. She said if a resident had a change in status there should be a note on the 24-hour report and also a change of status form should be written about the resident. LVN C said if a resident's fasting blood sugar was below 70, depending on parameters, she would give the resident something to eat to bring the sugar level up, and then recheck the blood sugar in 30 to 60 minutes. She said she would always contact the physician if the resident had a blood sugar less than 70 and would not give the resident insulin without physician guidance. LVN C said she was not sure what the policy is for this facility, but that was how she was trained at her previous placement. She said she had been working at the facility for a year. She said that residents on insulin should have parameters and if she found this a concern she would contact the physician. She also said new residents should have their medications reconciled on admission with the nurse reviewing the medication orders from the hospital and to go over them with the primary care physician. Interview on 12/14/18 at 10:56 a.m. with LVN B, she said if a resident has a change in status she would write it on the 24-hour report, do an SBAR (situation, background, assessment, recommendation) and notify the family and the primary physician. She explained this should be done by the nurse who noticed the change in the resident's condition. She said fasting blood sugars should have parameters, and if a resident did not have parameters on the MAR for fasting blood sugar, she would contact the physician for blood sugars 400 or greater and educate the resident. She said if a resident's fasting blood sugar was being monitored and no insulin or medications ordered then she typically would not contact the physician if unless the blood sugar was greater than 400. LVN B said she would not give insulin if a resident's fasting blood sugar is less than 70 and she would also notify the physician. She would also see if the resident has an order for [REDACTED]. She said she notified the next nurse on duty about not being able to contact the physician. Record review for CR #107's nurse notes dated 10/20/18 at 11:22 a.m. revealed the resident's fasting blood sugar at 11:10 a.m. was 455. The nurse educated the resident on [MEDICAL CONDITION] signs and symptoms. She called the MD and there was no answer, and she noted that she would continue to monitor the resident. Interview on 12/14/18 at 11:01 a.m. with DON, she said the nurse who admitted CR #107 should have gone over the discharge medication list from the hospital. The DON reviewed CR #107's record and said she did not find the discharge medication orders from the hospital and was unsure which form the admitting nurse used to reconcile the resident's medications with the physician. Interview on 12/14/18 at 11:57 a.m. with DON, she said there was no documentation for CR #107's reconciliation on admission. She said the resident was on insulin while in the hospital but the admitting primary care physician wanted to hold the insulin and monitor CR #107's fasting blood sugars. The DON said the nurse who completed CR #107's medication reconciliation did not write an admission note, but this information should have been added to the admission assessment note. She said she contacted the physician on 10/24/18 due to elevated blood sugars. Record review for CR #107's nurse notes dated 10/24/18 at 5:33 p.m. revealed the DON notified the MD of elevated blood sugar levels since admission to the facility. MD gave new orders for [MEDICATION NAME] 500 mg PO every day and [MEDICATION NAME] 5 mg PO every AM and PM. Resident and family member were notified of the new medication orders. The nurse note revealed the family member reported adverse reaction with use of [MEDICATION NAME] and the MD was notified of the adverse reaction. Record review of CR #107's Daily Skilled Nursing Assessments dated 10/18/18 through 10/27/18 revealed no documentation related to elevated blood sugars. Record review of CR #107's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of CR #107's (MONTH) (YEAR) MAR indicated [REDACTED] -Order date 10/26/18 for [MEDICATION NAME] Flex Touch Solution Pen Injector 100 unit/ ML (insulin detemir). Inject 45 unit subcutaneously two times a day (11:30 a.m. and 9:00 p.m.) related to type 2 diabetes mellitus without complications. No parameters were documented on when to notify the physician or hold insulin. -Order date 10/26/18 for [MEDICATION NAME] Mix 70/30 Flex Pen Suspension Pen injector (70/30) 100unit/ ML (insulin [MEDICATION NAME] prot and [MEDICATION NAME]). Inject 35 unit subcutaneously two times a day (6:30 a.m. and 4:30 p.m.) related to type 2 diabetes mellitus without complications. No parameters were documented on when to notify the physician or hold insulin. Record review of CR #107's (MONTH) (YEAR) MAR indicated [REDACTED] Record review of 24-hour report/change of condition report revealed: -10/18/18 CR #107 was admitted to the facility. The report revealed the physician was contacted regarding [MEDICATION NAME] order, the physician did not write a sliding scale order. -10/20/18 the 24-hour report revealed the MD was called at 1:00 p.m. when CR #107's fasting blood sugar was 455, but there was no answer. The documentation revealed CR #107 was educated on diet and signs and symptoms of [MEDICAL CONDITION]. -10/21/18 the 24-hour report revealed the night shift notified MD of CR #107's elevated blood sugars. -10/23/18 the 24-hour report revealed the night shift identified for CR #107 . fasting blood sugars are very elevated. Please contact the physician for order . -10/24/18 the 24-hour report revealed MD order received for CR #107's for [MEDICATION NAME] 5 mg by mouth in the a.m. and 5 mg at HS. [MEDICATION NAME] 500 mg by mouth every day. -10/26/18 the 24-hour report revealed a MD order to discontinue oral diabetic medications for CR #107's. Insulin was ordered. -10/27/18 the 24-hour report revealed the insulin flex pens delivered for CR #107's, 9:00 p.m. blood sugar was 396. Record review of CR #107's discharge plan under medication reconciliation revealed the pre-discharge and post discharge medications were reviewed with his family member. There was no documentation regarding physician orders [REDACTED]. The release of responsibility for medication identified no order for insulin or diabetic medications. Review of facility policy for Diabetic Management revised (MONTH) 2008 read in part Diabetic management involves both preventative measures and treatment of [REDACTED]. Assessment: Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: . Orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician . Routine Care: . Blood glucose measurements are taken per the physician order. Results outside of ordered parameters are communicated to the physician immediately . Residents are monitored for signs/ symptoms of complications . Acute Complication Management: . [MEDICAL CONDITION]-High Blood Sugar Levels . 4. Notify the physician of abnormal blood glucose test results and symptoms exhibited . 5. Follow physician orders [REDACTED]. 3. If blood glucose level is below 70 mg/dl, and the resident is presenting with signs/ symptoms of [DIAGNOSES REDACTED] and can swallow, administer: 4 ounces of fruit juice or Administer three 5 mg oral glucose tablets . 4. Reassess blood glucose level in 15 minutes . 7. Notify the physician of abnormal blood glucose test results, symptoms exhibited, and interventions implemented . 10. Repeat blood glucose level 15-30 minutes after food is consumed to ensure maintenance of acceptable range . Documentation: For acute complications, the clinical record should include the following information: Notification of physician and any new orders, Resident's signs and symptoms, Results of blood testing, Interventions initiated, Resident's response to treatment, and Notification of responsible party .

Based on interview, observation and record review the facility failed to ensure one of four residents (Resident #11) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident #11 had a history of [REDACTED]. Resident #11 had a fall and fracture of his right shoulder and cut on his chin. Nine days later he had another fall resulting in another x ray of the right shoulder. This failure affected one resident and has the potential to affect fourteen residents who require assistance for transfers per CMS form 672 dated 2/18/16. The findings included: Record review of Resident #11 ' s face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and his [DIAGNOSES REDACTED]. Record review of Resident #11 ' s most recent quarterly MDS dated [DATE] revealed Activities of Daily Living required extensive assistance with one person physical assist. Balancing during transitions and walking were coded as not steady, only able to stabilize with staff. Further review revealed Resident #11 was always incontinent of both bowel and bladder and had no falls since the prior assessment. Record review of Resident #11 ' s Care Plan dated 7/8/15 noted seven falls between January and May 2015 with approaches to include: falling star program, encourage assistance, PT/OT/restorative nursing/social services, assistive devices: geri-chair and hi-low bed, bed alarm, chair alarm, call light within reach, observe for patterns for falls, assist to toilet, observe for potential medication causes, and floor mat. Record review of Resident #11 ' s Care Plan dated 8/28/15 with review dates of 9/8/15 and 12/8/15 noted eight falls between September and December 2015 with approaches to include: falling star program, encourage assistance, PT/OT, assistive devices: geri-chair, bed alarm, chair alarm, call light within reach, neuro checks per protocol, notify MD of changes, Hi-Low beds every shift, floor mats every shift, check for incontinence episode every two hours, and change brief as needed. Observation and interview at 9:30 a.m. on 2/18/16 revealed Resident #11 in his bed in the high position with a pureed breakfast and nutritional shake on his bedside table. He had a sling on his right arm and an abrasion on his chin. There was no mat on the floor near his bed. Resident #11 stated that he fell and hurt his arm and did not like the breakfast but did drink the shake. Interview with the DON at 10:45 a.m. on 2/18/16 revealed that she was aware of Resident #11 ' s two recent falls. The DON stated that she was not familiar with Resident #11 ' s care plan but thought that at one time occupational therapy was trying a toileting program with the resident. The DON looked through Resident #11 ' s Care Plan and stated that the resident knows how to raise and lower his bed, can disconnect the bed alarm, and does not have the floor mat down when the staff performs transfers from the bed to the wheelchair. A request for any in-service documents for the past thirty days resulted in one in-service report titled: Facility/Responsible Party Communication (notification of transfer). The DON stated that there were no other in-service events conducted. Interview at 2:40 p.m. on 2/18/16 CNA A reported that she often cared for Resident #11 but was not working when he fell on [DATE]. CNA A stated that she recalled an in-service specifically for Resident #11 and signing the sign-in roster sheet. CNA A stated that she tried to check Resident #11 every hour when she is scheduled to work that hall. Record review of an investigation follow-up on 1/28/16 revealed CNA A found Resident #11 on the lying on the floor face down with a gash to his chin and complaint of shoulder pain. Resident #11 stated that he had fallen in the bathroom. The DON was notified at 7:30 p.m. with neurological checks started at 8:00 p.m. Resident #11 ' s hospital record for 1/28/16 revealed the patient received at 10:30 p.m. with a fracture of humerus and laceration of chin. Nurse ' s notes 1/29/16 at 12:15 a.m. revealed that Resident #11 returned to the facility with a fractured right humerus, sutures to chin, and [MEDICATION NAME] 10/325 PO QD PRN. Assist to bed with 1 aide. Record review of an investigation follow-up on 2/6/16 revealed LVN A reported Resident #11 found sitting on the bathroom floor with feces in his hands next to the toilet with his shoulder against the wall. The ' Resident Event ' document description revealed that the incident was: Incident Type 1, Fall/unattended - injury occurring at 3:30 p.m. on 02/06/2016 in the Bathroom with right shoulder pain. Phone Physician orders [REDACTED]. A written Physician order [REDACTED]. Record review revealed a Physician order [REDACTED]. The psychological assessment dated [DATE] at 4:08 p.m. revealed short term memory, long term memory, and judgment were moderately impaired with illogical and disorganized thought process. CMS form 672 dated 2/18/16 revealed 15 ressidents required assistance with transfers.

Based on observation, record review and interview the facility failed to follow interventions in the written plan of care and to ensure care plan approaches were performed and and revised as indicated based upon the resident's reponses to the care plan interventions for one of four residents (Resident #11) whose care plans were reviewed to ensure compliance. The facility failed to ensure Resident #11's care plan approaches for falls were performed and revised as indicated based upon the resident's response to the care plan interventions. This failure affected one resident and has the potential to affect fourteen residents who require assistance for transfers per CMS form 672 dated 2/18/16. The findings included: Record review of Resident #11 ' s face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and his [DIAGNOSES REDACTED]. Record review of Resident #11 ' s most recent quarterly MDS dated [DATE] revealed Activities of Daily Living required extensive assistance with one person physical assist. Balancing during transitions and walking were coded as not steady, only able to stabilize with staff. Further review revealed Resident #11 was always incontinent of both bowel and bladder and had no falls since the prior assessment. Record review of Resident #11 ' s Care Plan dated 7/8/15 noted seven falls between January and May 2015 with approaches to include: falling star program, encourage assistance, PT/OT/restorative nursing/social services, assistive devices: geri-chair and hi-low bed, bed alarm, chair alarm, call light within reach, observe for patterns for falls, assist to toilet, observe for potential medication causes, and floor mat. Record review of Resident #11 ' s Care Plan dated 8/28/15 with review dates of 9/8/15 and 12/8/15 noted eight falls between September and December 2015 with approaches to include: falling star program, encourage assistance, PT/OT, assistive devices: geri-chair, bed alarm, chair alarm, call light within reach, neuro checks per protocol, notify MD of changes, Hi-Low beds every shift, floor mats every shift, check for incontinence episode every two hours, and change brief as needed. Observation and interview at 9:30 a.m. on 2/18/16 revealed Resident #11 in his bed in the high position with a pureed breakfast and nutritional shake on his bedside table. He had a sling on his right arm and an abrasion on his chin. There was no mat on the floor near his bed. Resident #11 stated that he fell and hurt his arm and did not like the breakfast but did drink the shake. Interview with the DON at 10:45 a.m. on 2/18/16 revealed that she was aware of Resident #11 ' s two recent falls. The DON stated that she was not familiar with Resident #11 ' s care plan but thought that at one time occupational therapy was trying a toileting program with the resident. The DON looked through Resident #11 ' s Care Plan and stated that the resident knows how to raise and lower his bed, can disconnect the bed alarm, and does not have the floor mat down when the staff performs transfers from the bed to the wheelchair. A request for any in-service documents for the past thirty days resulted in one in-service report titled: Facility/Responsible Party Communication (notification of transfer). The DON stated that there were no other in-service events conducted. Interview at 2:40 p.m. on 2/18/16 CNA A reported that she often cared for Resident #11 but was not working when he fell on [DATE]. CNA A stated that she recalled an in-service specifically for Resident #11 and signing the sign-in roster sheet. CNA A stated that she tried to check Resident #11 every hour when she is scheduled to work that hall. Record review of an investigation follow-up on 1/28/16 revealed CNA A found Resident #11 on the lying on the floor face down with a gash to his chin and complaint of shoulder pain. Resident #11 stated that he had fallen in the bathroom. The DON was notified at 7:30 p.m. with neurological checks started at 8:00 p.m. Resident #11 ' s hospital record for 1/28/16 revealed the patient received at 10:30 p.m. with a fracture of humerus and laceration of chin. Nurse ' s notes 1/29/16 at 12:15 a.m. revealed that Resident #11 returned to the facility with a fractured right humerus, sutures to chin, and [MEDICATION NAME] 10/325 PO QD PRN. Assist to bed with 1 aide. Record review of an investigation follow-up on 2/6/16 revealed LVN A reported Resident #11 found sitting on the bathroom floor with feces in his hands next to the toilet with his shoulder against the wall. The ' Resident Event ' document description revealed that the incident was: Incident Type 1, Fall/unattended - injury occurring at 3:30 p.m. on 02/06/2016 in the Bathroom with right shoulder pain. Phone Physician orders [REDACTED]. A written Physician order [REDACTED]. Record review revealed a Physician order [REDACTED]. The psychological assessment dated [DATE] at 4:08 p.m. revealed short term memory, long term memory, and judgment were moderately impaired with illogical and disorganized thought process. CMS form 672 dated 2/18/16 revealed 15 ressidents required assistance with transfers.

Based on observation, interview and record review, the facility failed to ensure one of four residents (Resident #11) reviewed for falls received adequate supervision and assistance devices to prevent falls and/or accidents. Resident #11 had an unwitnessed fall where he sustained a fracture of the right shoulder. He had another unwitnessed fall nine days later and had another x-ray of the right shoulder. This failure affected one resident and has the potential to affect fourteen residents who require assistance for transfers per CMS form 672 dated 2/18/16. The findings included: Record review of Resident #11 ' s face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and his [DIAGNOSES REDACTED]. Record review of Resident #11 ' s most recent quarterly MDS dated [DATE] revealed Activities of Daily Living required extensive assistance with one person physical assist. Balancing during transitions and walking were coded as not steady, only able to stabilize with staff. Further review revealed Resident #11 was always incontinent of both bowel and bladder and had no falls since the prior assessment. Record review of Resident #11 ' s Care Plan dated 7/8/15 noted seven falls between January and May 2015 with approaches to include: falling star program, encourage assistance, PT/OT/restorative nursing/social services, assistive devices: geri-chair and hi-low bed, bed alarm, chair alarm, call light within reach, observe for patterns for falls, assist to toilet, observe for potential medication causes, and floor mat. Record review of Resident #11 ' s Care Plan dated 8/28/15 with review dates of 9/8/15 and 12/8/15 noted eight falls between September and December 2015 with approaches to include: falling star program, encourage assistance, PT/OT, assistive devices: geri-chair, bed alarm, chair alarm, call light within reach, neuro checks per protocol, notify MD of changes, Hi-Low beds every shift, floor mats every shift, check for incontinence episode every two hours, and change brief as needed. Observation and interview at 9:30 a.m. on 2/18/16 revealed Resident #11 in his bed in the high position with a pureed breakfast and nutritional shake on his bedside table. He had a sling on his right arm and an abrasion on his chin. There was no mat on the floor near his bed. Resident #11 stated that he fell and hurt his arm and did not like the breakfast but did drink the shake. Interview with the DON at 10:45 a.m. on 2/18/16 revealed that she was aware of Resident #11 ' s two recent falls. The DON stated that she was not familiar with Resident #11 ' s care plan but thought that at one time occupational therapy was trying a toileting program with the resident. The DON looked through Resident #11 ' s Care Plan and stated that the resident knows how to raise and lower his bed, can disconnect the bed alarm, and does not have the floor mat down when the staff performs transfers from the bed to the wheelchair. A request for any in-service documents for the past thirty days resulted in one in-service report titled: Facility/Responsible Party Communication (notification of transfer). The DON stated that there were no other in-service events conducted. Interview at 2:40 p.m. on 2/18/16 CNA A reported that she often cared for Resident #11 but was not working when he fell on [DATE]. CNA A stated that she recalled an in-service specifically for Resident #11 and signing the sign-in roster sheet. CNA A stated that she tried to check Resident #11 every hour when she is scheduled to work that hall. Record review of an investigation follow-up on 1/28/16 revealed CNA A found Resident #11 on the lying on the floor face down with a gash to his chin and complaint of shoulder pain. Resident #11 stated that he had fallen in the bathroom. The DON was notified at 7:30 p.m. with neurological checks started at 8:00 p.m. Resident #11 ' s hospital record for 1/28/16 revealed the patient received at 10:30 p.m. with a fracture of humerus and laceration of chin. Nurse ' s notes 1/29/16 at 12:15 a.m. revealed that Resident #11 returned to the facility with a fractured right humerus, sutures to chin, and Norco 10/325 PO QD PRN. Assist to bed with 1 aide. Record review of an investigation follow-up on 2/6/16 revealed LVN A reported Resident #11 found sitting on the bathroom floor with feces in his hands next to the toilet with his shoulder against the wall. The ' Resident Event ' document description revealed that the incident was: Incident Type 1, Fall/unattended - injury occurring at 3:30 p.m. on 02/06/2016 in the Bathroom with right shoulder pain. Phone Physician orders [REDACTED]. A written Physician order [REDACTED]. Record review revealed a Physician order [REDACTED]. The psychological assessment dated [DATE] at 4:08 p.m. revealed short term memory, long term memory, and judgment were moderately impaired with illogical and disorganized thought process. CMS form 672 dated 2/18/16 revealed 15 ressidents required assistance with transfers.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent development and worsening of pressure ulcers for 1 of 4 residents (Resident #32) reviewed for pressure ulcers. Resident #32 was admitted without pressure ulcers, but was at high risk for the development of pressure ulcers. She developed two Stage III facility-acquired pressure ulcers which were resolved on 8/6/15. Thereafter the facility failed to complete skin assessments and implement a care plan to address interventions to prevent another pressure ulcer. Facility acquired Stage III that resolved 8/6/15 was re-opened 11/11/15. This failure contributed to the re-opening of Resident #32's two stage III facility-acquired pressure ulcers in the sacral area and could place 3 residents with pressure ulcers and 22 others receiving preventive skin care at risk for developing new pressure ulcers or worsening of existing pressure ulcers. Findings included: Record review of Resident #32 ' s face sheet revealed a [AGE] year old, female resident who was admitted in the facility on 8/14/98 with [DIAGNOSES REDACTED]. Record review of Resident #32 ' s MDS assessment dated [DATE] revealed that she was cognitively impaired with short term memory loss. Resident # 32 required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. She was always incontinent of bowel and bladder. She had no behavioral symptoms or rejection of care. Further review of her MDS revealed she had one Stage III pressure ulcer measuring .8 cm X .3 cm X .1 cm and was at risk of developing pressure ulcers. Record review of Resident #32 ' s care plan dated 7/28/15 and reviewed 10/20/15 revealed that she needed assistance with all ADLs including bed mobility, transfers, toileting and hygiene. Further review of the care plan for pressure ulcers dated 7/28/15 and reviewed on 8/5/15 revealed a stage III to sacrum measuring 1.5 cm x 2.7 cm x 0.1 cm. with approaches including apply pressure reduction mattress, measure and stage wound weekly using the pressure ulcer healing assessment form and complete a full body check weekly and document. Review of the care plan for pressure ulcers dated 10/20/15 and reviewed on 10/27/15 revealed her Braden score was 13, putting her at risk for pressure ulcers related to moisture/incontinence, decreased activity and impaired mobility. Approaches included the following: low air mattress, turn and reposition while in bed frequently for comfort and pressure reduction, reposition in chair frequently for comfort and pressure reduction and complete a full body check weekly and document. Observation of Resident #32 on 11/18/15 at 10:00 am revealed she was lying in bed. Resident #32 was alert but not fully oriented. She was unable to speak but did make some noise in acknowledgement of entry into the room. Resident #32 was neat and well groomed. She was again observed at 12:30 pm of the same day, 11/18/15. Resident #32 was at this time being fed lunch on her bed by an aide. She ate all of her food. Observation of Resident #32 on 11/19/15 at 8:45 am revealed she was being fed breakfast in her bed by an aide. Record review of Resident #32 ' s Weekly Pressure Ulcer Record dated 11/11/15 revealed she had a 0.4 x 0.2 x 0.1cm stage III sacral ulcer greater than 3 days old. The progress note further stated, assessed by doctor; recurrent stage III to sacrum noted. Moisture associated [MEDICAL CONDITION] noted to bilateral buttocks. Will continue to monitor. Further review of the Resident #32 ' s clinical record revealed as follows: Resident had a stage III sacral ulcer which resolved on 8/6/15. A head to toe assessment was completed on 9/17/15 and indicated resident had no skin issues. An SBAR Communication Form signed and dated 11/6/15 revealed resident has a Stage II to right lower buttock. A Wound Care Specialist Evaluation signed by the physician and dated 11/11/15 revealed a Stage III pressure ulcer measuring 0.4 x 0.2 x 0.1 cm. Assessment and Plan revealed continue [MEDICATION NAME] every three days and off-load wound, reposition per facility protocol. A Nursing Weekly/Monthly Summary signed and dated 11/13/15 revealed a pressure ulcer on right buttock. A weekly skin assessment was completed on 11/17/15 and indicated resident had a stage III pressure ulcer in the sacral area that was identified on 11/11/15. A Wound Care Specialist Evaluation signed by the physician and dated 11/18/15 revealed a Stage III pressure ulcer measuring 0.4 x 0.2 x not measurable cm. Assessment and Plan reveal continue [MEDICATION NAME] every three days and off-load wound, reposition per facility protocol. Record review of the care plan revealed there was not an updated care plan after the pressure sore was identified on 11/11/15. In an interview with the DON on 11/19/15 at 10:30 am, she stated, I know Resident #32. She has a history of pressure sores. Presently she has a stage III sacral ulcer which is a re-opening of an old one. We do get her up, but only occasionally. We don ' t like to get her up because she gets over excited when she is up especially if taken to the dining room or activity. She yells and shakes herself and laughs a lot if she is up. But when she is in her room, she is calm. That is why we don ' t get her up except occasionally. When asked if the resident could turn herself in bed, the DON stated that the resident could not turn herself in bed without assistance from staff. Also when asked about getting the resident up and keeping her up in her room, the DON stated that it would be a good idea. In an interview with LVN 2 on 11/20/15 at 8:40 am she stated that she could not find any record of the weekly skin assessment on Resident #32 for the period between 8/6/15 and 11/14/15 except for 9/17/15. She also stated there were no nursing notes on the resident from 10/31/15 to 11/17/15. Observation of the wound care on 11/19/15 at 3:20 pm revealed the resident had open sores to both buttocks in the sacral area. The wound had small yellowish drainage. According to the facilitys ' form 672, 4 residents had pressure ulcers while 22 others were receiving preventive skin care.

Based on observation, interview and record review the facility failed to ensure 1 of 15 residents (#6) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: CNA E and CNA D failed to move Resident in a manner that avoid pain. During incontinent care, CNA E and CNA D were not aware that Resident #6 had a right pelvic fracture. Resident #6 cried in pain and held on to her right hip while CNA E grabbed her right hip to turn her to her left side and CNA D continued to do incontinent care. This failure affected 1 resident and placed 41 residents who were dependent on staff for incontinent care at risk of increased pain, discomfort and further injuries. Findings: Record review of Resident #6 ' s face sheet revealed a [AGE] year old, female resident who was admitted in the facility on 6/3/11 with [DIAGNOSES REDACTED]. Record review of Resident #6 ' s MDS assessment dated [DATE] revealed that she was cognition intact. Resident #6 required limited assistance for bed mobility and transfers. She required extensive assistance on dressing, toilet use, personal hygiene and bathing. Resident #6 was frequently incontinent of bowel and bladder. Observation and interview during Resident #6 ' s incontinent care on 10/9/14 at 10:02 am revealed that CNA D was assisted by CNA E. Resident #6 was lying flat on her back with her right leg straight and her left leg flexed. CNA D started by cleaning Resident #6 ' s pubis area and labia. After CNA D finished cleaning the vaginal area, CNA E grabbed Resident #6 ' s right hip and turned her to her left side. Resident #6 started crying in pain. She was crying out loud and her right hand was holding on to her right thigh. CNA E continued to hold on to her right hip. At this point, the surveyor asked CNA D and CNA E if they know the condition of Resident #6. CNA D said that she did not know which hip Resident #6 had a fracture on. CNA E said that she did not know that Resident #6 had a fracture. CNA E said that Resident #6 ' s pain was " maybe she fell or old age " . CNA E continued to say " may not be a [MEDICAL CONDITION] " . She said that she had taken care of Resident #6 in the last 2 weeks. She said that CNAs take turns in working different halls. CNA E said that nobody had explained to them about Resident #6 having a broken hip. She said that the rehab department did not show them how to handle Resident #6. CNA D continued to clean Resident #6 ' s sacral area. Resident #6 continued to cry when a clean brief was placed under her buttocks. In an interview with LVN X on 10/9/14 at 10:11 am she said she was the nurse for Resident #6 in the morning shift. LVN X pulled Resident #6 ' s chart and reviewed the x-ray result and told the surveyor that Resident #6 fractured the " right iliac " . In an interview with CNA D on 10/9/14 at 11:20 am she said that she knew that Resident #6 had a fracture but she did not know which side of the pelvis was fractured. She said that she had taken care of Resident #6 in the last 2 weeks since she had a fall. In an interview with the DON on 10/9/14 at 11:26 am she said that the CNAs have a " cardex " sytem that they refer to if they want to know the condition of a resident. The DON said that the cardex were updated with every change of condition. In an interview with CNA D on 10/9/14 at 11:34 am revealed that she did not know what a cardex was. She asked the surveyor what the cardex was. The surveyor told her that according to the DON, it was information for the CNAs about a resident. CNA D then showed the surveyor the resident ' s charts. In an interview with Restorative Aide G on 10/9/14 at 11:35 am she said that she knew where the cardex was. She went to get it out of the MDS office next to the nurse ' s station. She said that the cardex have information about the residents. She pulled Resident #6 ' s cardex and it was not updated. Restorative Aide G said that she did not know why it was not updated. She said that she was in the process of updating it. Record review of Resident #6 ' s "Resident care cardex worksheet" undated revealed that Resident #6 required total assistance with personal hygiene, assistance with toileting. There was no documentation that Resident #6 had a right pelvic fracture. In an interview with Resident #6 on 10/9/14 at 12:53 pm she said everytime that when staff came to help she would remind them to be easy on her. She said that she felt that staff " don ' t care " . She said that it was sad that old people like her had to go through the pain she had during incontinent care. She said, " They just don ' t care. All they care is to get it done and move to another person." When asked who was doing this, she said that it was "all of them, all the time". The resident said she was unable to identify the staff because she was legally blind. The resident continued to repeat that the staff did not care. In an interview with CNA K, who worked with Resident #6 on the 2-10 shift, on 10/9/14 at 2:07 pm she said that she was aware that Resident #6 had a fracture. She said tht a nurse told her to do care for Resident #6 with two people to make sure not to put too much pressure on the resident's hip. She said that it was a " left " [MEDICAL CONDITION]. She said that she did not know what a cardex was. She said that she had taken care of Resident #6 in the last 2 weeks. In an interview with CNA A (she worked with Resident #6 on the 2-10 shift) on 10/9/14 at 2:16 pm she said that she was aware that Resident #6 had a fracture. She said that she had taken care of Resident #6 in the last 2 weeks. She said that she would usually provide incontinent care to Resident #6 by herself. She said that she was not aware of the cardex. She said that " everything is in computer " . When the surveyor asked her to show the cardex in the computer, CNA A tried to log in the computer but was not able to get into the cardex in the computer. Record review of the facility 2014 Staffing Schedules for the last two weeks revealed CNA ' s K, D and E worked with Resident #6. In an interview with the DON on 10/9/14 at 4:00 pm revealed that she did not know that Resident #6 ' s cardex was not updated. She said that the cardex system was normally used to communicate with the CNAs. She said that Restorative Aide G helped to update the cardex with the assistance of the charge nurse. She said that the cardex were presented to the CNA ' s when they first got hired. She said that she had showed the cardex to the CNAs herself when they got hired. Record review of Resident #6 ' s incident and accident report dated 9/27/14 revealed that Resident #6 was found on the floor at 4:30 am on her left side " yelling out " . Record review of Resident #6 ' s x-ray dated 9/27/14 revealed under findings, " Evaluation of the bony pelvis raises concern for a comminuted fracture involving the medial aspect of the right iliac wing, particularly near the sacroiliac joint ... " Record review of Resident #6 ' s doctor ' s progress notes dated 10/1/14 revealed the following notes: 1. Pelvic (Ischium) comminuted fx (fracture) with a lot of pain. Start [MEDICATION NAME] (a [MEDICATION NAME] for management of moderate to severe pain) q week and PT slowly. 2. UTI on antibiotics 3. Debility and decline due to above 4. Hallucinations due to #2 Record review of Resident #6 ' s physician's order [REDACTED]. Further review of the physician order [REDACTED].#6 had orders for [MEDICATION NAME] 50 mg every 8 hrs, pain patch [MEDICATION NAME] 10 mg 1 patch per week and Tylenol 500 mg 2 tablets as needed for pain. Record review of Resident #6 ' s care plansdaed 08/27/14 revealed no care plan for right pelvic [MEDICAL CONDITION]. In an interview with LVN X on 10/10/14 at 9:00 am revealed that she would communicate with the CNAs to let them know of any of change of condition before the start of her shift. In an interview with the DON on 10/10/14 at 10:45 am she said that she was in the process of in-servicing the staff again on the use of the cardex system and also they were providng in-services on techniques to handle Resident #6 during care. She said that the therapy deparment would be involved in trasnfer or repositioning training to the staff. In an interview with the Physical therapist on 10/10/14 at 11:45 am revealed that she did not give training on bed mobility techniques and special precautions for Resident #6 because there was no request from the nursing staff. She said that the last time that she had given an in service on safe transfer and bed mobility techniques was in 03/2014. In an interview with the MDS Coordinator on 10/9/14 at 4:11 pm revealed that she was in charge of doing care plans for residents. She said that Resident #6 did not have a care plan for her pelvic fracture. She said that she went on leave right after Resident #6 had a fall and she was not able develop a care plan for her. She said that she should have updated Resident #6 ' s care plan or the nurses should have developed the care plan. Record review of the facility ' s policy and procedure on " Pain Management " dated August 2012 revealed, read in parts, " ...The facility will evaluate and identify residents experiencing pain; evaluate the existing pain and the cause; determine the type and severity of the pain; and develop a Care Plan for pain management ... Steps for Pain Management ...First Step: Evaluation for the Presence of Pain ...Second Step: In Depth Evaluation of Pain ...Third Step: Develop an individualized care plan and update the RCS Assignment sheet/Care Kardex ...Fourth Step: Putting the Plan into Action ...Fifth Step: Re-evaluate on Regular Basis. Record review of the facility ' s policy and procedure on " Resident Care Cardex Worksheet " undated, revealed, read in parts, " Purpose: To provide a means of communicating resident needs following admission and on-going basis. Who: Licensed Nurse with input from Interdisciplinary Team Members. The resident care specialist will use to review care needs of resident. When: Resident Care Cardex is to be completed upon admission and with each resident ' s change in plan of care in areas 1-14 ... " Record review of the facility ' s policy and procedure on " Comprehensive Plan of Care " dated June 2007, revealed, read in parts, " The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well being ...be periodically reviewed and revised by the interdisciplinary team as changes in the resident ' s care and treatment occur ... " Review of the facility ' s CMS 672 revealed 41 residents required assistance with incontinent care.