Every finding on record at Paradigm at Katy

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for three of four residents (Resident #36, Resident #22, and Resident #66) reviewed for ADLs.1. The facility failed to provide nail care to Resident #36.2. The facility failed to apply lotion to Resident #22 skin.3. The facility failed to shave Resident #66's chin hairThese deficient practices could place residents at risk of skin breakdown and reduced feelings of self-worth.Findings include: 1. Record review of Resident #36's face sheet, dated 05/21/26, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Resident #36 had diagnoses which included: hyperkalemia (too much potassium in the blood), heart failure (heart is too weak or stiff to pump blood efficiently), and tracheostomy (presence of artificial opening into windpipes).Record review of Resident #36's quarterly MDS assessment, dated 04/06/26, revealed a BIMS of 07, which indicated severely impaired cognition. The resident was dependent on staff for all ADL care.Record review of Resident #36's care plan, initiated on 01/28/26, revealed the resident had an ADL self-care performance deficit related to respiratory failure, on vent and tracheostomy. Intervention: bathing/showering; check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.Record review of Resident #36's Point of Caer report for ADL care for May 2026 revealed Resident #36 had not missed any showers or bed baths, and there was no documentation of fingernail care for the month of May 2026.During an observation and interview on 05/19/26 at 12:20 a.m., Resident #36's ten fingernails were about 1.5CM(centimeter)long. Resident #36 said he wanted his fingernails cut, and he could not remember if he had asked the staff to cut his fingernails.During an observation and interview on 05/20/26 at 12:01 p.m., RN F said Resident #36's ten fingernails were long, and Resident #36 said he wanted his fingernails cut. She said the aides were supposed to cut the resident's fingernails on shower days and as needed. RN F said she saw Resident #36 when she made rounds that morning and did not notice the resident's fingernails were long. RN F said Resident #36 could scratch his skin and/or get an infection.During an interview on 05/20/26 at 3:21 p.m., the DON said fingernail care was part of the ADL care which the aides should have provided for the residents during daily care. He said residents' fingernails were cut on Saturday and as needed. He said the fingernails were not officially done on shower days, but they could had been cut on shower days. The DON said the residents did not have to request for nails to be cut before the staff would cut the resident's nails. The DON said he did not think Resident #36 had refused to have his fingernails cut. He said Resident #36 would have been at risk for ingrown fingernails, scratching his skin, and infection control issues.2. Record review of Resident #22's face sheet, dated 05/21/26, revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Resident #22 had diagnoses which included tracheostomy status (presence of artificial opening into windpipe), cerebrovascular disease (condition affecting the heart and blood vessel), and hypertension (blood pressure is too high).Record review of Resident #22's 5-day MDS assessment, dated 05/01/26, revealed a BIMS of 15, which indicated intact cognition. The resident was dependent on staff for all ADL care.Record review of Resident #22's care plan, dated 04/22/26, revealed the resident had ADL self-care deficits and was at risk for further decline in ADL functioning and injury AEB complex health conditions. Interventions: provide total care of 1 support person for personal hygiene/grooming. Provide total care of 1 support person for bathing.Record review of Resident #22's admission and weekly skin assessments (04/21/26, 04/29/26, 05/06/26, 05/13/26, and 05/20/26) did not reveal the resident's skin was patchy, dry, and flaky.During an observation on 05/19/26 at 2:45 p.m., with the Wound Care Nurse, it was revealed Resident #22 had dry, patchy, flaky skin from below the knee to the sole of the foot.During an interview on 05/19/26 at 3:05 p.m., the Wound Care Nurse said Resident #22 had dry, patchy, and flaky skin from below the knee to his foot. She said the aides were responsible for applying lotion on shower days and as needed. She said if Resident #22's skin continued to be dry, it could cause skin tear.During an interview on 05/19/26 at 3:15 p.m., LVN E said Resident #22's skin assessment was done on Wednesdays by the charge nurse, and she reviewed Resident #22's skin assessment and said it did not show his skin was dry or flaky. LVN E said it was the aides' responsibility to apply cream or lotion on the resident's skin on shower days and as needed. She said Resident #22's skin could crack or get infected.During an interview on 05/20/26 at 5:16 p.m., the ADON said the aide should apply lotion on the resident's skin on shower days and as needed. She said the nurse did skin assessments on Resident #22 weekly. The ADON said none of the staff told her Resident #22 had refused showers or lotion being applied to his skin. She said Resident #22 could develop skin breakdown because the skin would become flaky and could get infected.3. Record review of Resident #66's face sheet, dated 05/21/26, revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Resident #66 had diagnoses which included chronic respiratory failure (a long-term lung condition that struggles to get fresh oxygen into the blood), hypertension (high blood pressure), and diabetes mellitus (high blood sugar).Record review of Resident #66's admission MDS assessment, dated 04/16/26, revealed under section C1000 the resident was severely impaired. The resident was dependent on staff for all ADL care. The resident had a Foley.Record review of Resident #66's care plan, initiated on 04/14/26 and revised on 05/12/26, revealed the resident had ADL self-care deficits and was at risk for further decline in ADL functioning and injury AEB complex health conditions. Interventions: provide total care of 1 support person for bathing. Intervention: provide total care of 1 person for personal hygiene/grooming. Record review of Resident #66's Point of Care report for ADL care for May 2026 revealed Resident #66 had not missed any showers or bed baths, and there was no documentation of shaving for the month of May 2026.During an observation on 05/20/26 at 11:11 a.m., Resident #66 had black and white hair covering her chin, and Resident #66 was not able to verbalize her needs.During an observation and interview on 05/20/26 at 12:29 a.m., CNA Q said residents were shaved on shower days and when a family member asked. She said the resident could be shaved as needed. She said Resident #66 had not refused to be shaved. CNA Q said she worked with Resident #66 the previous day, and she noted the facial hair. CNA Q said she did not shave Resident #66 the previous day because it was not her shower day. CNA Q said Resident #66 would have felt bad if she had been able to voice her needs.During an interview on 05/20/26 at 11:41 a.m., LVN F said she observed Resident #66's whole chin was covered with white and black hair. LVN F said shaving was part of ADL care and was the aides' responsibility. She said if the aide was not available, she would shave the resident. She said the residents were shaved on shower days and as needed. She said Resident #66 would not have been happy if she could express herself and it was a dignity issue.During an interview on 05/20/26 at 3:38 p.m., the DON said the aides were responsible for shaving the residents. He said residents were shaved on weekends and as needed and were not required to be shaved on shower days. He said Resident #66 was not alert and oriented enough to refuse care. He said Resident #66 would not have liked not being shaved and it was a dignity issue. Record review of the facility's, undated, policy on shaving read, in part, . 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's, undated, policy on nail care read, in part, . 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. require staff assistance in keeping clean and trimmed.

Based on observation, interview and record review the facility failed to ensure that food was prepared by a method that conserved nutritive value, flavor, and apperance in one of one kitchen. The facility failed to ensure that California blend vegetables and Parmesan chicken for dinner were not cooked 5 hours prior to dinner service. This failure places all residents who ate meals prepared by the kitchen at risk of not getting the nutrients needed to prevent malnutrition and weight loss. Observation on 5/20/2026 at 11:45am of the kitchen revealed California vegetables (carrots, broccoli and cauliflower) on the stove top cooking. In the oven there was parmesan chicken cooking. In an interview on 5/20/2026 at 11:47 am with [NAME] F she said the vegetables and chicken were for dinner. She said dinner starts serving around 4:45pm. In an interview on 5/20/2026 at 11:50 am with the Dietary Manager he said the vegetables were in the freezer and he was just letting it cook for a few minutes and he was going to put them in the oven to finish cooking. Further interview revealed the menu items on the stove and in the oven were for dinner. Observation and test tray done during dinner on 5/20/2026 at 5:45 pm revealed the broccoli was olive green in color. The vegetables tasted bland (they had no flavor) and the carrots tasted like they were water soaked. In an interview with the Dietary Manager on 5/20/2026 at 5.45pm he said that vegetables tasted bland and the broccoli was olive green in color. Further interview on 5/21/2026 at 1:50pm with the Dietary Manager he said he started cooking dinner early on 5/20/2026 because he did not want dinner to be late. He said starting to cook too early could cause food to be overcooked and lose it's nutritive values. He said he was going to in-service the dietary staff on meal preparation and cooking to conserve nutritive value. He said he was going to ensure that vegetables were cooked a few minutes before meals service. Record review of the recipe for California Blend Vegetables dated 4/9/2026 read in part.Steaming Instruction:Place California vegetable blends in full perforated pans.Place California vegetable blend in the steamer for 5-9 minutes or until an internal temperature of 135 degrees F is reached.Do not overcook. Boiling InstructionsAdd California vegetable blend to boiling water.Cook in boiling water for 10 - 15 minutes, or until an internal temperature of 135 degrees F is reached.Do not overcook.Drain liquid.After California vegetable blend is cooked, add margarine and seasonings. Mix wellPlace prepared vegetables in steam table pan and hold for service at 135 degrees

Based on interview and record review the facility failed to ensure residents are free of any significant medication error for 2 of 8 residents (Resident #49& #86) reviewed/observed for medication. The facility failed to ensure that Resident #86's blood pressure medication Midodrine was held within the parameter the physician ordered. LVN A failed to follow on 05/21/26 the parameters ordered for Resident # 46's medication metoprolol 50mg ER (extended release) 1 tablet by mouth BID to hold if systolic blood pressure was less than 110 and heart rate less than 60. Resident #46's systolic blood pressure was 108/52. This failure could have placed Residents # 46 and Resident #86 at risk for elevated blood pressure at risk of fainting or a stroke due to not getting their blood pressure medication as ordered by their physician. Record review of Resident #46's face sheet dated 05/25/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident diagnoses included the following: heart failure, type 2 diabetes mellitus (when the body cannot properly process sugar in the body for energy), heart disease, hypertension (high blood pressure), and acute kidney failure. Record review of Resident #46's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 indicating that resident cognition was moderately impaired. Record review of Resident #46's Comprehensive Care Plan dated 03/06/26 and revised 03/19/26 revealed that resident was care planned for hypertension and being at risk fluctuations in blood pressure values, hypo (low)/hypertension (high blood pressure). An intervention included medication as ordered-monitor labs and reporting results to MD. Record review of Resident #46's Physician Order Summary Report included the following order: -Dated 05/21/26 Metoprolol ER (extended release) 50mg give 1 tablet by mouth twice a day related to hypertension. Hold for SBP < 110 and HR < 60. Observation on 05/21/26 at 9:30AM of medication pass for Resident #46 by LVN E . LVN E obtained vitals on Resident #46 for a blood pressure of 108/52 and heart rate of 76. LVN E was preparing to administer medication metoprolol 50mg ER 1 tablet by mouth to Resident # 46. The survey intervened and asked LVN E to pause from administering the medication. LVN E told the surveyor that it was okay to administer the medication metoprolol 50 mg 1 tablet by mouth because Resident #46's heart rate was okay. The survey asked LVN E to not administer the medication until further confirmed with the DON as well as the NP since the SBP was out of parameters. Interview on 05/21/26 at 9:35AM with the DON said LVN E should not administer the medication due to SBP being out of the parameters. The DON said if LVN E administered the medication with SBP of 108, it placed Resident #46 at risk of his blood pressure further decreasing. The DON said the nurses were checked off on medication pass every year by himself and the ADON during their yearly competency skills. Interview on 05/21/26 at 9: 36AM with LVN E said she had spoken with the NP about parameters on blood pressure medications and the NP said it would be okay to administer medication[. LVN E said administering blood pressure medications outside the ordered parameters placed the resident (s) at risk of blood pressure problems] headache, and so many other things. LVN E did not elaborate on what she meant by other things. LVN E said the NF had done a medication pass competency check off with her every other month and that her last medication pass was done with a weekend supervisor (did not remember their name) that came to the facility on the weekday. LVN E said she had never done medication pass with ADON but had done it with the Regional Corporate Nurse. LVN E said there were 8 rights to follow when administering medication to a resident and provided the following: right name, right medication, right dosage, right time, right order, right feedback, and right to refuse. LVN E said she could not remember the last one. Interview on 05/21/26 at 9:43AM with LVN N said she worked at the facility from 6AM-6PM full time. LVN N said for a resident that was on blood pressure medication, if their blood pressure and heart rate were out of the ordered parameters given by the physician, she would hold the medication because it could affect their blood pressure[KS15] . Interview on 05/21/26 at 11:50AM with the NP said medication parameters were put in place to help guide the nurses when administering certain medications like blood pressure or heart medications. The NP said the medication metoprolol worked on the heart as well as the blood pressure. The NP said if the nurse is ever in doubt whether she should give a medication or not, she preferred that they call her. The NP said if she is at the facility and a resident was out of the prescribed parameters; she could assess the resident to see if she wanted the medication to be still administered. The NP said the nurses should not administer blood pressure medication if the ordered parameters said to hold for a SBP less than 110 and just follow the ordered parameters. The NP said if a blood pressure medication is given out of the ordered parameters, it placed the resident at risk for abnormal vital signs causing the resident to become sick and lead to other issues . Record review of Resident #86's admission face sheet dated 5/20/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hypertension (high blood pressure), depression (a mental health disorder characterized by persistent sadness and low energy), protein calorie malnutrition ( a severe nutritional deficiency resulting from inadequate intake of protein and calories leading to reduced body weight), respiratory failure (is a condition where lungs cannot adequately transfer oxygen to the blood and remove carbon dioxide from the blood), and Chronic obstructive pulmonary disease ( a condition where the air flow is obstructed making it difficult to breathe). Record review of Resident #86's quarterly MDS dated [DATE] Section C:500 revealed a BIMS score of 10 which indicated the resident was moderately cognitively impaired for decision making. Record review of Resident #86's physician's order dated 5/2/2026 revealed an order for Midodrine 5mg three times a day at 9:00am, 3:00pm and 8:00pm. Hold for SBP was greater than 130. HYPOTENSION. Record review of Resident #86's MARs for May 2026 revealed on 5/4/2026 at 8:00am Midodrine 5mg was not held when the blood pressure was 140/90. Record review of Resident #86's clinical record for May 2026 revealed no documentation that the doctor was notified of the result of the blood pressure reading and why the medication was not held. In an interview on 5/22/2026 at 5:50 pm with the DON he said if there was an order for blood pressure medication to be held with a certain parameter then it should be held as ordered. He said if the medication was held as ordered it should be coded with a number which should indicate if the resident refuses medication or was not in the facility. He said if the medication was not held as ordered the blood pressure could get higher and it could cause the resident to have a stroke. He said his expectation of the nurses is that they should administrator medication as ordered. He said they were in-servicing staff on ensuring medications were administered as ordered and checking vital signs to ensure they were not within the parameter they should be held before medications were given. Record review of Resident #46's face sheet dated 05/25/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident diagnoses included the following: heart failure, type 2 diabetes mellitus (when the body cannot properly process sugar in the body for energy), heart disease, hypertension (high blood pressure), and acute kidney failure. Record review of Resident #46's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 indicating that resident cognition was moderately impaired. Record review of Resident #46's Comprehensive Care Plan dated 03/06/26 and revised 03/19/26 revealed that resident was care planned for hypertension and being at risk [fluctuations in blood pressure values, hypo (low)/hypertension (high blood pressure). An intervention included medication as ordered-monitor labs and reporting results to MD. Record review of Resident #46's Physician Order Summary Report included the following order: -Dated 05/21/26 Metoprolol ER (extended release) 50mg give 1 tablet by mouth twice a day related to hypertension. Hold for SBP < 110 and HR < 60. Observation on 05/21/26 at 9:30AM of medication pass for Resident #46 by LVN E. LVN E obtained vitals on Resident #46 for a blood pressure of 108/52 and heart rate of 76. LVN E was preparing to administer medication metoprolol 50mg ER 1 tablet by mouth to Resident # 46. The survey intervened and asked LVN E to pause from administering the medication. LVN E told the surveyor that it was okay to administer the medication metoprolol 50 mg 1 tablet by mouth because Resident #46's heart rate was okay. The survey asked LVN E to not administer the medication until further confirmed with the DON as well as the NP since the SBP was out of parameters. Interview on 05/21/26 at 9:35AM with the DON said LVN E should not administer the medication due to SBP being out of the parameters. The DON said if LVN E administered the medication with SBP of 108, it placed Resident #46 at risk of his blood pressure further decreasing. The DON said the nurses were checked off on medication pass every year by himself and the ADON during their yearly competency skills. Interview on 05/21/26 at 9: 36AM with LVN E said she had spoken with the NP about parameters on blood pressure medications and the NP said it would be okay to administer medications. LVN E said administering blood pressure medications outside the ordered parameters placed the resident (s) at risk of blood pressure problems, headache, and so many other things. LVN E did not elaborate on what she meant by other things. LVN E said the NF had done a medication pass competency check off with her every other month and that her last medication pass was done with a weekend supervisor (did not remember their name) that came to the facility on the weekday. LVN E said she had never done medication pass with ADON but had done it with the Regional Corporate Nurse. LVN E said there were 8 rights to follow when administering medication to a resident and provided the following: right name, right medication, right dosage, right time, right order, right feedback, and right to refuse. LVN E said she could not remember the last one. Interview on 05/21/26 at 9:43AM with LVN N said she worked at the facility from 6AM-6PM full time. LVN N said for a resident that was on blood pressure medication, if their blood pressure and heart rate were out of the ordered parameters given by the physician, she would hold the medication because it could affect their blood pressure. Interview on 05/21/26 at 11:50AM with the NP said medication parameters were put in place to help guide the nurses when administering certain medications like blood pressure or heart medications. The NP said the medication metoprolol worked on the heart as well as the blood pressure. The NP said if the nurse is ever in doubt whether she should give a medication or not, she preferred that they call her. The NP said if she is at the facility and a resident was out of the prescribed parameters; she could assess the resident to see if she wanted the medication to be still administered. The NP said the nurses should not administer blood pressure medication if the ordered parameters said to hold for a SBP less than 110 and just follow the ordered parameters. The NP said if a blood pressure medication is given out of the ordered parameters, it placed the resident at risk for abnormal vital signs causing the resident to become sick and lead to other issues. Record review of the facility policy on Physician Orders revised December 2024 reflected in part: Following Physician Orders.Facility staff are responsible for: reviewing the order promptly, ensuring that all orders are correctly implemented within the timeframe specified.Communicating any barriers to implementation to the prescribing practitioner.The staff must: contact the prescribing practitioner for clarification.Document the clarification conversation and any modifications in the medical record. Record review of the facility's policies and procedure titled Medication Administration Management dated June 2019 read in part. Nursing Policies and Procedures Subject: Medication Administration and Management Policy: It is the policy of this facility that the facility will implement a Medication Management Program that incorporates systems with established goals to meet each resident's needs as well as regulatory requirements. Procedures: Step III: Administering the Medication Pass 3. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member follows the MAR prepared for the patient/resident by identifying the: 8. Medications are prepared, administered and recorded by the same authorized medical/licensed staff 10. Initials and signature verification of licensed or certified/permitted medication aide or by state regulatory guidelines staff administering medication are documented according to regulations. L. If the patient/resident is unable to take the medication or refuses it, the authorized licensed/certified staff member circles his/her initials on the MAR, and documents the reason refused or not given on the designated area of the MAR (physician is notified as necessary). Record review of the facility policy on Medication Administration & Management revised June 2019 reflected in part: It is the policy of this facility that the facility will implement a medication management program that incorporates systems with established goals to meet each resident's needs as well as regulatory requirements.Authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff must understand: The 8 rights for administering medication: -Right Patient/Resident -Right Drug -Right Dosage -Right Time -Right Route -Right Charting -Right Results -Right Reason.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections that included, at a minimum, a system for preventing and controlling infections for 1 of 8 residents (Resident #6) and 1 of 2 staff (CNA PP) reviewed for infection control. - The facility failed to ensure CNA PP washed or sanitized her hands and performed glove changes appropriately while providing incontinence care to Resident #6 on 05/20/26. This deficient practice placed residents at risk for cross contamination and the spread of infection. Finding included: Review of Resident #6's face sheet dated 05/20/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: tracheostomy (a surgically created hole in the front of the neck that leads directly into the windpipe Trachea), anoxic brain damage (caused by a complete lack of oxygen to the brain), Pressure ulcer to buttock, stage 4 (Full thickness tissue loss with exposed bone, tendon muscle), cognitive communication deficit, gastrostomy tube ( or G-tube is a soft flexible tube inserted directly into the stomach through a small incision in the abdomen), Parkinson's disease without dyskinesia (a brain disorder that affects movement), sepsis (a life-threatening medical emergency that occurs when the body's immune system overreacts to an infection, causing it to damage its own tissues and organs). Review of Resident #6's admission MDS assessment dated [DATE] reflected Resident #6's BIMS score was 13 indicating intact cognition. Resident #6 was assessed to require dependent assistance for all ADLs and pressure ulcer treatment. Resident #6 was further assessed to have functional limitations in range of motion for bilateral upper and lower extremities. Observation during incontinent care on 5/20/26 at 3:15 PM performed by CNA PP and CNA K assisting, revealed Resident #6 was soaked with urine and feces to the mattress, and the pressure ulcer was soiled with urine and fecal matter. CNA PP donned 2 pairs of gloves, stating she always double gloved. CNA PP did not wash her hands before donning clean gloves CNA PP poured perineal lotion on wet wipes used to cleaned Resident #6 perineal area. CNA PP changed gloves 3 times, removing the top gloves then donning another pair of clean gloves without washing her hands or using hand sanitizer. At 3:26 PM she then went to the clean packed linen cart by the hallway to get clean bedding sheets with dirty gloves. The bedding was soiled to the mattress. She removed the soiled fitted, draw and cover sheets without cleaning the mattress to disinfect it. She placed the clean sheet on the soiled mattress and placed a clean brief on Resident #6.Interview with CNA PP on 5/20/26 at 5:49 PM, she said she worked with the facility since December 2025, on the 2:00 PM -10:00 PM shift. CNA PP said she had 3 days orientation with returned demonstration for incontinent care and hand washing with the former DON. CNA PP said she was very nervous and she was not taught to wear double gloves. She knew not washing hands after changing gloves could lead to spreading infections. CNA PP stated if she did not wash or sanitize her hands when going from a dirty to clean surface, it could cause cross contamination and a risk of transferring infection.Interview with DON on 5/22/26 at 3:35 PM, who stated it was the facility's policy for staff to wash or sanitize hands when going from a dirty to clean surface. He stated staff had been in-serviced on infection control and hand hygiene. He stated if hand hygiene or sanitizing was not performed when going from a dirty to clean surface, it could cause an infection.Record review of the facility policy titled Hand Hygiene dated 12/2024 revealed: Policy It is the policy of The Facility to prioritize hand hygiene as a fundamental practice in preventing the spread of infections. All staff must perform hand hygiene. Procedure When to Utilize Hand Hygiene Before/after resident contact After removing gloves or PPE After contact with bodily fluids, surface, or contaminated equipment Before eating and after using the restroom Soap and Water (Preferred Method for Visibly Soiled Hands & CDIFF Care) Prep hands for handwashing: maneuver clothing and jewelry for optimization Wet hand with water Apply an adequate amount of soap Lather the backs of hands, fingers, and under fingernails; scrubbing for at least 20 seconds Rinse hands well under clean, running water Dry hands using a clean towel or air dryer Discard towel in trash receptacle Alcohol-Based Hand Rub (Preferred Method w/o Visibly Soiled Hands)

Based on observation, interview and record review, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 5 residents (Resident #73) reviewed for call lights.The facility failed to have a call light within reach for Resident #73.This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life.Findings include:Record review of Resident #73's face sheet, dated 05/21/26, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Resident #73 had diagnoses which included: tracheostomy (a small opening directly through the front of the neck into the windpipe), acute and chronic respiratory (breathing and lung problem ), heart failure (heart muscle is too weak or too stiff to pump blood efficiently), and diabetes mellitus (a disease of inadequate control of blood levels of glucose).Record review of Resident #73's admission MDS assessment, dated 04/29/26, revealed under Section C the resident was severely impaired. The resident dependent on staff for all ADL care.Record review of Resident #73's care plan on 05/13/26 revealed the resident had an ADL self-care deficit and was at risk for further decline in ADL functioning and injury. Intervention: ensure call light was within reach and answered in a timely manner.During an observation and interview on 05/19/26 at 10:55 a.m., Resident #73 moved his right hand on the mattress when he was asked if he could reach his call light, and he shook his head from side to side when he could not reach the call light. Resident #73 could not reach the call light because his call light was hung on the G-tube feeding pump.During an interview on 05/19/26 at 11:08 a.m., the Wound Care Nurse said she had placed the call light on top of the G-tube pump when she provided wound care for the resident and forgot to place it back where Resident #73 could reach the call light. The Wound Care Nurse said Resident #73 could not reach the call light. The Wound Care Nurse said Resident #73's call light should have been within reach at all times. She said if the resident could not reach the call light, he could not get the care he needed, and this could have been critical for Resident #73's health because he was a tracheostomy and ventilator resident.During an interview on 05/20/26 at 3:37 p.m., the DON said Resident #73's call light should have been placed within reach in case the resident needed assistance. The DON said if Resident #73 could not reach the call light and the resident needed help, then the help would not have been provided in a timely manner. He said if Resident #73 needed immediate assistance, the resident would not have received assistance immediately, and an injury could have occurred or worse health issues could have resulted.Record review of the facility's, undated, policy for call light revealed, . the facility will provide a call light system that is accessible, functional, responsive to meet the needs of the residents. procedure. call light will be placed within reach of the resident's bed.

Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of six residents reviewed (Resident #6) for pressure ulcers. 1. The facility failed to ensure Resident #6 received treatment as ordered to promote healing of sacral and ischial pressure ulcers on 5/20/26These failures could place residents at risk for worsening existing wounds or development of new pressure ulcers. Review of Resident #6's face sheet dated 05/20/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: tracheostomy (a surgically created hole in the front of the neck that leads directly into the windpipe Trachea), anoxic brain damage (caused by a complete lack of oxygen to the brain), Pressure ulcer to buttock, stage 4 (Full thickness tissue loss with exposed bone, tendon muscle), cognitive communication deficit, gastrostomy tube (or G-tube is a soft flexible tube inserted directly into the stomach through a small incision in the abdomen), Parkinson's disease without dyskinesia (a brain disorder that affects movement), sepsis (a life-threatening medical emergency that occurs when the body's immune system overreacts to an infection, causing it to damage its own tissues and organs). Review of Resident #6's admission MDS assessment dated [DATE] reflected Resident #6's BIMS score was 13 indicating intact cognition. Resident #6 was assessed to require dependent assistance for all ADLs and pressure ulcer treatment. Resident #6 was further assessed to have functional limitations in range of motion for bilateral upper and lower extremities.Record review of Resident #6's wound order summary dated 4/12/26, reflected Wound Care: stage 3 pressure injury to right ischial (anything related to the ischium, which is the and back part of the hip bone) cleanse with (normal saline / wound cleanser), pat dry, apply calcium alginate with silver and cover with dry dressing every day and as needed every day shift AND every 6 hours as needed.Record review of the facility care plan dated 4/12/26 reflected PRESSURE INJURY: Resident #6 has a pressure injury/injuries and is at risk for further skin break down, infection, worsening of existing pressure injury, new pressure injury formation Stage 3 Pressure Injury Right ischial and Stage 4 Pressure Injury sacrum( a large, triangular bone at the base at the of the spine that connects the vertebral column to pelvis), the goal pressure injury/injuries will show signs and symptom of improvement through the review date and intervention was to . Perform treatments per order by the physician.Record review of Resident #6's wound culture result on 4/15/26, reflected enterococcus faecalis (often abbreviated as E.faecalis and E. coli) a type of bacteria that normally lives in the human intestines, mouth and female genital tract, while E.coli is often the primary invader , these two resilient microbes frequently team up in hospital to create difficult -to- treat dual - species infections. Record review of Resident #6's physician's orders summary dated 5/15/26 reflected: Doxycycline Hyclate Tablet 100 MG Give 1 tablet enterally two times a day for positive wound culture for 14 DaysRecord review of physician's wound measurement dated 5/21/26 revealed sacral pressure ulcer which measured length 7.3 CM, width 7.9 CM and depth 2.3cm right ischial length 6.3 cm, width 4.3cm depth 0.5cm. Observation during incontinent care on 5/20/26 at 3:15 PM performed by CNA PP and CNA K assisting, revealed Resident #6 was soaked with urine and feces to the mattress, and the pressure ulcer was soiled with urine and fecal matter and discarded it. Resident #6 was repositioned to his right side, and the dressing to the sacral and ischial area was soiled with urine and fecal matter. C NA PP cleaned in-between the buttocks, and CNA PP removed the soiled dressing and discarded it in the trash bag. CNA PP did not inform RN F about the pressure ulcer soiled dressing with fecal matter and urine that needed to be changed. Interview with the charge nurse, RN F on 5/20/26 at 5:28 PM, she said she works the 6:00AM to 6:00 PM shift. She said she had been working since April 2025, and she was not told about the pressure ulcer to Resident #6's sacral and ischial being soiled. She said the treatment nurse works 6:00AM to 2:00PM. RN F said I will be the one to change the pressure ulcer soiled dressing. RN F said she was going to change the dressing to Resident #6's sacral and ischial pressure ulcer. RN F was observed changing the dressing.Interview with CNA PP on 5/20/26 at 5:49 PM, she said she worked with the facility since December 2025, on the 2:00 PM -10:00 PM shift. CNA PP said she forgot to tell the charge nurse (RN F) about the soiled pressure ulcer. She said she got busy and knew that the pressure ulcer could become more infected.Interview with RN wound care nurse on 5/21/26 at 8:59AM, she said she had been working with the facility since 2020, on the 6:00 AM to 2:00PM shift. She said Resident #6 was admitted to the sacral and ischial pressure ulcer. She said she changed his pressure ulcer dressing daily and when the wound got soiled, the charge nurse would change the dressing.Interview on 5/22/26 at 3:35 PM with the DON, he said the CNAs were supposed to report to the charge nurse if Resident #6's dressing got soiled, so it can be changed. DON stated his expectation was for the nurses to follow Dr's orders. He stated not following orders could potentially affect the resident's health. He would have an in-service and monitor the staff.Record review of the facility Nursing Policies and Procedures dated 6/2019:Subject: Dressing Change: Wound: Policy reflected: It is the policy of this facility that dressing changes will follow specific manufacture's guidelines and general infection control principles. Procedures: 11) Apply a cover dressing - date and initial cover dressing, place time reference on it.15) The clinician documents all procedures performed as well as the resident's/caregiver's response. 16) Follow manufacturer's guidelines (available on the wound care product's package insert) and physician orders when using any wound care product

Based on observations, interviews, and record reviews, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for one (Resident #22) of five residents reviewed for podiatrist services.The facility failed to ensure Resident #22 was seen by a podiatrist for fourth and fifth discolored long toenails. The facility failed to ensure Resident #22's big toenail, which was 75% separated from the nail bed, was addressed.This failure could have placed residents at risk for skin tears and infection because of not receiving foot care.Findings included:Record review of Resident #22's face sheet dated 05/21/26 revealed he was initially admitted to the facility on [DATE] and was readmitted on [DATE] from the hospital. Resident #22 had diagnoses which included tracheostomy status (presence of artificial opening into windpipe), cerebrovascular disease (condition affecting the heart and blood vessels), and hypertension (blood pressure was too high).Record review of Resident #22's 5-day MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review of the MDS revealed the resident was dependent on staff for all ADL care.Record review of Resident #22's care plan dated 04/22/26 revealed the resident had ADL self-care deficits and was at risk for further decline in ADL functioning and injury AEB complex health conditions. Interventions included providing total care of one support person for personal hygiene/grooming and providing total care of one support person for bathing.Record review of Resident #22's admission and weekly skin assessments 04/21/26, 04/29/26, 05/06/26, 05/13/26, and 05/20/26 did not reveal the resident's skin was dry, that he had long toenails, or that the big toenail was separating from the nail bed.Record review of Resident #22's physician orders for May 2026 revealed an order dated 05/20/26 for a podiatry consult.During an observation and interview on 05/19/26 at 2:45 p.m., it revealed Resident #22 had a dressing on his big toenail. When the FM #1removed the dressing, it revealed the toenail was discolored and was 75% pulled off the skin. It also revealed the skin around the big toenail and the nail bed was red. Resident #22 said he needed his toenails cut and could not remember if he had asked the staff to cut his toenails.During an interview on 05/19/26 at 2:55 p.m., Wound Care Nurse said she had not put the dressing on Resident #22's toenail. She said the nail on Resident #22's big toe was almost detached from the toe, was discolored, and the skin around the big toe was red. Wound Care Nurse said the fourth and fifth toenails were long and the fifth toenail was curved and touching the top of the fourth toe. She said the nurse and aides cut residents' toenails, and if staff could not cut the toenails, the nurse would tell the social worker, and the social worker would notify the podiatrist. She said the resident's long toenails could get caught on the linen, cause skin tears, or become infected.During an interview on 05/19/26 at 3:00 p.m., FM #1said FM #2 saw the toenail on the big toe was coming off and told the NP (Nurse Practitioner) the previous week, but the facility had not done anything about it and Resident #22 had not seen a podiatrist. She said the fourth and fifth toenails were longer than they were that day because FM #2 had cut down the toenails as much as she could to prevent the long toenails from cutting into the skin.During an interview on 05/19/26 at 3:20 p.m., LVN E said it was her first day working with Resident #22 and she had not noticed the dressing on his big toe or the two long nails on his fourth and fifth toes. She said the nurse cut the resident's toenails if the resident was not diabetic, and if the resident was diabetic, the nurse would tell the social worker and the social worker would place the resident's name on the podiatrist list. She said Resident #22's skin assessment did not show the resident had long toenails or that the big toenail was separating from the toe. She said Resident #22's toenails could become infected or cause skin breakdown.During an interview on 05/19/26 at 3:25 p.m., Resident #22 said he would like to see a podiatrist but had not seen one yet. He said FM #2 had told him the nail on his big toe was coming off about a week ago, and she had told the nurse, and the nurse had given a dressing to apply on his toe. He said he could not remember what had happened to his big toenail and why it was detaching from the nail bed. During an interview on 05/20/26 at 3:26 p.m., the DON said aides were responsible for cutting Resident #22's toenails. He said when residents' toenails were calcified, the family or resident would request to see a podiatrist. He said the podiatrist made rounds every 60 days and saw residents on the list and residents who requested to see the podiatrist. The DON said the SW(Social worker) was the staff member responsible for communicating with the podiatrist. He said the nurse would tell the SW when a resident requested to see a podiatrist, but since they did not have a SW until a few days earlier, the ADON or he oversaw notification to the podiatrist. He said he had not been made aware that Resident #22 needed his toenails cut. He said the resident's family was actively involved in his care.The DON said he had not been made aware that Resident #22's big toenail was coming off his toe. He said the nurses performed head-to-toe assessments on admission and weekly thereafter. He said the big toe could become infected or, worse, could lead to amputation. He said the fourth and fifth toenails could get caught on socks or linen, causing skin tears or pulling the toenails away from Resident #22's nail bed, which would cause trauma for Resident #22.During an interview on 05/21/26 at 2:55 p.m., NP said the nurse told her Resident #22's toenail was separating from the big toe on Tuesday(05/21/26), and she gave an order for bacitracin and wound care. NP said Resident #22's big toe was red, and she cleaned the big toe with betadine and called the WCN to treat Resident #22's toenail. NP said she saw the fourth and fifth toenails were long and wrote an order for a podiatrist consult. She said Resident #22's toenails could get caught on a sock or become infected.Record review of the undated facility policy revealed, It was the policy of this facility that facility staff would assist residents with nail care as needed. Residents who were unable to care for their own fingernails or toenails required staff assistance in keeping nails clean and trimmed .

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 2 of 5 residents (Resident #66, and Resident #6) reviewed for incontinent care. The facility failed to ensure CNA J provided peri care during foley catheter care for Resident #66.The facility failed to ensure CNA PP properly cleaned Resident #6 during incontinent care when CNA PP did not clean around Resident #6's buttocks on 05/20/2026.These failures could place residents at risk for pain, infection, injury, and hospitalization.Findings IncludedRecord review of Resident #66's face sheet dated 05/21/26 revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Resident #66 had diagnoses which included chronic respiratory failure (a long-term lung struggle getting fresh oxygen into the blood), hypertension (high blood pressure), and diabetes mellitus (high blood sugar).Record review of Resident #66's admission MDS assessment dated [DATE] revealed under section C1000 that he was severely cognitively impaired. Further review of the MDS revealed the resident was dependent on staff for all ADL care. It also revealed the resident had a foley catheter.Record review of Resident #66's care plan initiated on 04/09/26 revealed the resident had an indwelling/suprapubic foley catheter and was at risk for infection and skin breakdown related to obstructive uropathy(blockage in the urinary system that stop pee from leaving the body). Intervention: provide catheter care and perineal care and monitor the site for s/sx of infection or skin breakdown.During an observation on 05/20/26 at 11:11 a.m., revealed foley care for Resident #66 was provided by CNA Q and assisted by CNA L. CNA Q wiped the foley tubing close to the insertion site downward four times and said she had completed foley care and did not clean the insertion site and sin skin around the site.During an interview on 05/20/26 at 11:28 a.m., CNA Q said during foley care you just cleaned the tubing. She said the foley care was provided to prevent infection. She said she had received in-service training on foley care before she started working and could not remember if she was supposed to provide peri care(the washing and cleaning of the genital and anal area) during foley care(cleaning the skin where the tube enters the body and the tubing). CNA Q said she did not provide peri care when she provided foley care.During an interview on 05/20/26 at 11:48 a.m., LVN F said peri care was part of foley care. LVN F said CNA Q was supposed to clean the peri area(is a small, sensitive patch od skin and tissue located between genitals, vaginal opening or scrotum) from one side to the other side, middle, and then the tubing from the insertion site downward when she provided foley care for Resident #66. LVN F said foley care was provided for Resident #66 for infection control.During an interview on 05/20/26 at 12:00 p.m., the Corporate Nurse said CNA Q should have provided complete peri care with each foley care and that was the facility protocol for foley care. She said foley care was provided to prevent infections such as UTI(urinary tract infection).During an interview on 05/21/26 at 11:13 a.m., the DON said CNA Q or the nurse should have provided foley care for the resident. He said foley care was provided to residents to prevent infections such as UTIs. He said when CNA Q provided foley care for Resident #66, she should have provided peri care. He said when CNA Q wiped only the tubing and said that was foley care, it did not meet the facility protocol for foley care.Review of Resident #6's face sheet dated 05/20/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: tracheostomy (a surgically created hole in the front of the neck that leads directly into the windpipe Trachea), anoxic brain damage (caused by a complete lack of oxygen to the brain), Pressure ulcer to buttock, stage 4 (Full thickness tissue loss with exposed bone, tendon muscle), cognitive communication deficit, gastrostomy tube (or G-tube is a soft flexible tube inserted directly into the stomach through a small incision in the abdomen), Parkinson's disease without dyskinesia (a brain disorder that affects movement), sepsis (a life-threatening medical emergency that occurs when the body's immune system overreacts to an infection, causing it to damage its own tissues and organs). Review of Resident #6's admission MDS assessment dated [DATE] reflected Resident #6's BIMS score was 13 indicating intact cognition. Resident #6 was assessed to require dependent assistance for all ADLs and pressure ulcer treatment. Resident #6 was further assessed to have functional limitations in range of motion for bilateral upper and lower extremities. Further review revealed Resident #6 required substantiation assistance with ADL care with two staff assist.Record review of Resident #6's care plan dated 04/13/26 revealed Resident #6 had incontinent bowel and bladder. Interventions: perform routine rounding to include incontinence care and brief changes. Observation during incontinent care on 5/20/26 at 3:15 PM performed by CNA PP and CNA K assisting, revealed Resident #6 was soaked with urine and feces to the mattress, and the pressure ulcer was soiled with urine and fecal matter. Resident #6 was repositioned to his right side. C NA PP cleaned in-between the buttocks, and CNA PP removed the soiled pressure ulcer dressing and discarded it in the trash bag. C NA PP did not clean around the buttocks before placing a clean brief on it.Interview with CNA PP on 5/20/26 at 5:49 PM, she said she worked with the facility since December 2025, on the 2:00 PM -10:00 PM shift. CNA PP said she was very nervous and she forgot to clean around the buttocks. She said she had 3 days orientation with returned demonstration for incontinent care and hand washing with the former DON. CNA PP knew not cleaning the buttocks could cause more skin break down and odors.Interview on 5/22/26 at 3:35 PM with the DON, he said the CNAs were supposed to perform incontinent care in a manner to keep residents cleaned without any odors. DON stated his expectation was for the CNAs to clean around resident buttocks and perineal area. He said the aides should have a skilled check-off before working on the floor. They also had in-service on ADL rounding and incontinent care. He stated not performing incontinent care properly could potentially cause resident's skin breakdown and infections. He would have an in-service and monitor the staff.Review of the facility's Policies and Procedures Revised 12/23 titled: Perineal Care reflected- POLICY The Facility will provide perineal care in a manner that maintains privacy, reduces the risk of infection, and promotes skin integrity.-Cleaning. For male residents, retract the foreskin (if applicable), and clean the penis from the tip down to the base, clean the scrotum. Pat the area dry with a clean towel. Record review of the undated facility policy for foley care revealed in part, .to ensure proper hygiene, minimize infection risk, and maintain resident comfort during catheter care. exposure of catheter site. female site. gently retract the labia with non-dominant hand to fully expose the urethral meatus and catheter site. maintain this position throughout the procedure. perineal care. provide routine perineal care using pre-moistened wipes.

Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1of 6 residents (Resident # 6) reviewed for continuous gastrostomy tube feedings. The facility failed to keep Resident #6's head of bed elevated while receiving continuous gastrostomy feedings. This failure could place residents at risk for aspiration pneumonia (lung infection caused by inhaling liquids or vomiting into airway) and unwanted hospitalization.Findings include: Record review of Resident #6 face sheet, dated 05/20/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and 03/27/26. Resident #6 had diagnoses which included: cerebral infarction (when blood vessel in the brain is blocked or restricted) due to embolism (blockage in a blood vessel caused by foreign substance like a blood clot, etc.), gastrostomy (surgical procedure that creates an opening into the stomach to allow the insertion of a feeding tube that is used to deliver fluids, nutrition, or medications), muscle weakness, aphasia (language disorder caused by brain damage that impairs a person ability to speak, write, and understand both written and spoken language) hemiplegia (a form of paralysis that affects one entire side of the body), and hemiparesis (partial weakness affecting one entire side of the body). Record review of Resident #6's quarterly MDS, dated [DATE], reflected a BIMS score 0f 3, which indicated the resident cognition was severely impaired. Section GG-Functional Abilities revealed Resident #6 had impairment to the upper and lower extremities on both sides. Record review of Resident #6 Comprehensive Care Plan, dated 02/22/26 and revised on 03/27/26, reflected the resident was care planned for requiring a feeding tube for nutrition and was at risk for aspiration. An intervention included to encourage the resident to keep HOB elevated at 30 degrees or higher with active feeding administration. Record review of Resident #6's Physician Order Summary Report for the month of May 2026 reflected the following order:-Dated 02/22/26 Enteral Feeding (delivers liquid nutrition directly into the stomach or small intestine) -head of bed every shift to keep HOB elevated at 30 degrees or higher with active feeding administration.-Dated 03/28/26 Novasource Renal (calorie-dense [high number of calories], nutrition developed for individuals with chronic kidney disease or on dialysis) at 50ml/hr with 10ml/hr free water flush via G-tube continuous times 22 hours every shift. Record review of Resident #6's TAR for the month of May 2026 reflected the facility administered enteral feedings as ordered by the physician. Observation on 05/19/26 at 9:35AM revealed Resident #6 resting in bed on an air mattress. Resident #6 was receiving continuous gastrostomy feeding, Novasource Renal feedings, along with a water flush. The feeding was infusing at 50ml/hr. The resident's head of bed was not elevated but in a low position. Resident #6 was not showing any signs of distress such as labored breathing or vomiting. Observation on 05/19/26 at 9:38 AM revealed RN J was requested to come to Resident #6's room. When RN J entered the room and saw Resident #6's head of bed was lower than 30 degrees. RN J immediately raised resident head of the bed. Interview on 05/19/26 at 9:39AM, RN J said Resident #6's head of bed was not elevated to 30 degrees which placed the resident at risk for aspirating. RN J said she was in Resident #6 room approximately 30 minutes prior and the resident's head was elevated to 30 degrees. RN J said she did not know who lowered the resident's head of bed, but they knew better not to do this. RN J said when residents were receiving continuous gastrotomy feedings the head of bed was to be elevated 30 degrees to prevent the resident from developing aspirating pneumonia. Interview on 05/20/26 at 5:30 PM, the DON said residents who received continuous gastrostomy feedings, the head of bed should be elevated to prevent aspiration. Interview on 05/23/26 at 4:05 PM, CNA JJ said she worked full time from 6AM-10PM. CNA JJ said she had been working at the facility for more than 16 years. CNA JJ said she worked the 400-Hall and when providing care for a resident who was receiving continuous gastrostomy feedings, before providing care, she had to call the nurse to stop the feeding. CNA JJ said the head of bed was to be raised when the resident received feedings to prevent the resident from choking. Record review of the facility's policy on Enteral Feedings, revised September 2023, reflected in part: .The facility will provide adequate care for residents with enteral feeding tubes to prevent complications.Encourage resident to keep HOB elevated at 30 degrees or higher with active feeding administration.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 5 residents (Resident #17) reviewed for respiratory care. The facility failed to ensure Resident #17's oxygen humidifier bottle on the oxygen concentrator had water to function properly. This failure could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health. Record review of Resident #17's face sheet dated 5/19/2026 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), Cerebrovascular accident (when blood flow to the brain is interrupted or reduced), seizure disorder (neurological condition characterized by involuntary movement), nontraumatic intracranial hemorrhage (life threatening medical emergency where bleeding occurs without any head injury), Multiple subsegmental thrombosis pulmonary embolism (multiple blood clots in the arteries of the lungs) and long-term use of anticoagulant (an intervention to prevent strokes). Record review of Resident #17's quarterly MDS dated [DATE] Section CO1000 revealed he was severely impaired for cognition for decision making. Section: O 0110 reflected the resident was coded as having oxygen therapy. Record review of the physician's orders dated 2/27/2026 revealed Resident #17 was to receive Oxygen via nasal cannula as needed for shortness of breath or decreased O2 saturation. Titrate between 1-6 lpm, 02 to keep stats > 90% every 12 hours as needed. Record review of Resident #17's care plan dated 09/05/2025 revealed:Focus: OXYGEN USE: Resident #17 requires supplemental oxygen via (select interface: nasal cannula, mask, trach, vent) related.Goal: Resident #17 will maintain adequate oxygen saturation levels and respiratory comfortIntervention: Assess for signs of hypoxia (cyanosis, confusion, restlessness) and respiratory distress and report to MD as needed. Observation on 5/19/2026 at 10:15 am revealed Resident #17 was in bed and his O2 was infusing at 4 ml per minute. The humidifier bottle was dated 5/12/2026 and the bottle was empty. In an interview on 5/19/2026 at 10:pm RN C said she was supposed to check the bottle at the beginning of her shift but forgot to check the water at the beginning of her shift. She looked at the bottle and said the bottle was empty and she was going to change the bottle. Further interview at that time RN C said the water on the humidifier was changed weekly and as needed. She said anytime the bottle was empty or below a certain level, it should be changed. She said the water should be checked at the beginning of the shift to ensure everything was working properly, but she forgot to check it that morning. She said if there was no water in the bottle it could cause dryness in the nose and nosebleed. In an interview on 5/21/2026 at 3:45pm with the DON, he said the expectations of the nurses were to make rounds and check the humidifier. He said the nurses should check the water and when the water bottle was empty, they are required to replace it. The DON stated the oxygen flow without water could lead to resident nose bleeding, and cause nose dryness. Record review of the undated Nursing Policies and Procedures revised 8/2019, revealed: Subject: Oxygen Therapy: General Administration & CarePolicy:It is the policy of this facility that the facility will provide oxygen therapy by means of various administration devices.Procedures:1. Review physician's order on the chart for completeness:5. Assess the resident. Establish baseline respiratory rate and heart rate.6. Attach humidifier or nebulizer to flowmeter if indicated.a. Exchange Humidifier when empty7. 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.12. Post Oxygen in Use sign on the patient/resident's room door.13. Wash hands prior to leaving the resident's room.15. Change O2 tubing with any discoloration or contamination.(Note: For oxygen saturation below 89% emergency use of oxygen from 2-4L is appropriate to prevent worsening of hypoxemia and negative outcomes. The physician should be notified, and an order obtained for continued use of oxygen as soon as medically practicable.)

Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 1 call light systems reviewed for resident call system in that: The facility failed to provide a reliable and effective nurse call system and timely staff response.This failure could result in delayed staff response and placed residents at risk of respiratory compromise and injury related to delayed call light response. Interviews on 12/13/2025 at varies time between 1:00PM - 3:00PM with direct care staff (CNA D, Staff J, Nurse A, RT A) stated that the facility nurse call system does not provide audible alerts which could be heard and relied on staff visually monitoring hallway lights. Staff stated that if they were in resident rooms or other areas, they might not see the activated call lights promptly. Staff stated that the residents and staff had previously complained about the call light system and the system had been repaired (September/2025) but audible alerts could not be heard. Staff stated this limited staff ability to monitor and respond to resident calls for assistance and could have placed residents at risk for delayed response to care needs. Staff denied notifying the administrator and DON of the inability to hear audible alerts. Staff denied having knowledge of any residents who had sustained injury related to delayed call light response times. Interview on 12/13/2025 at 3:30PM, the Maintenance staff stated he was not informed of ongoing concerns or complaints related to the nurse call system's effectiveness or delayed response times reported by residents.Interview on 12/13/2025 at 3:40PM, the DON stated she was not aware of resident or staff concerns regarding delayed nurse call light response times or ineffectiveness of the nurse call system.Interview on 12/13/2025 at 12:53PM, the Administrator stated he was not informed of staff or resident concerns related to the nurse call system. The Administrator further stated the nurse call system had been repaired in September 2025 and indicated he believed the system was functioning as intended at that time.Observation on 12/13/2025, the surveyor tested the nurse call system in residents (Resident #1 and Resident #2) rooms, and the system activated a visual hallway light, with no audible alert in the hallway, and a low audible alert at the nurse station. The activated 400 hallway light for Resident #2 was not visible from the nurse station. Record review of maintenance log, revealed no repairs made to call light system during the 30-day look back period. Record review on of repair invoice on 12/16/2025 revealed call light system had been repaired with audible sound on 12/16/2025. Interviews on 12/16/2025 at varies time between 2:00PM - 4:00PM with direct care staff (Nurse B, RT E) stated that the facility nurse call system provided audible alerts which could be heard and relied on by staff. Record review revealed in-service and training documentation related to abuse and neglect, and call light response had been provided by the facility 12/2025. Review of the facility's current policy not dated, titled Call Lights reflected:The Facility will provide a call light system that is accessible, functional, and responsive to meet the needs of the residents. Call lights will be placed within reach of the resident's bed or sitting area in the resident's room. Response Staff are required to respond to activated call lights in a timely manner. While the specific response time will vary, staff will respond in a manner to address the residents' needs. Once needs are addressed, turn the call light off. Functionality Call lights will be in working order. Call lights will be monitored routinely to assess functionality. Accommodations The Facility will evaluate residents for potential accommodation for alternative call light systems when they have any limitations that affect their ability to use a standard call light.

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Hallway A) of four hallways observed for infection control. -CNA K left her hooded jacket and eyeglass case of the clean linen cart in Hallway A.This failure could place the residents at risk of cross-contamination and development of infection. During an observation and interview with RN C of a clean linen cart on Hallway A on 11/19/2025 at 12;19pm, there was an eyeglass case laying directly on top of a black zip-up jacket which was laying on top of the green mesh covering of the clean linen cart. The wheeled cart contained folded linen sheets and briefs inside the mesh cover. RN C said those items should not have been there and that it was an infection control issue. Interview with CNA B on 11/19/2025 at 1:55pm, she said she was one of the CNAs working on Hallway A but was not the person who put the jacket on the cart. CNA B said the jacket and eyeglass case should not have been there and that could be an infection control issue. Personal items could be placed in a locker or purse. Interview with CNA K on 11/19/2025 at 2:00pm, she said she was giving a resident a bed bath and then her sleeves of her jacket got wet, so she took it off and placed it along with her eyeglass case on the clean linen cart because she had to get back to the resident. CNA K apologized and said she shouldn't have done that and that it was an infection control issue. CNA K said she should have put it up somewhere else. Interview with the ADON on 11/20/2025 at 1:39pm, he said he was also the Infection Preventionist at the facility. The ADON said everything in the cart was for residents and that staff items like the jacket and eyeglass case should not have been on the cart. The facility had halls with major infections and if those items came into contact with staff, infections could spread to residents and vice versa. Interview with the Administrator on 11/20/2025 at 1:44pm, he said that the staff personal items should not have been on the cart. He said it would have been hard to say if the jacket would have caused an infection control issue. If the jacket was wet, then it might be an infection control issue, but he did not know the state of the jacket on the linen cart.Interview with the DON on 11/20/2025 at 3:01pm, she said the clothing items should not have been on the cart. She was going to do another audit on CNA K and do some re-training. The DON said a negative outcome of the clothing item on the clean linen cart could be infection control and that the facility needed to maintain their isolation protocol.Record review of the facility's policy on Infection Control last revised on 6/2024 read in part, The Facility is dedicated to maintaining a safe and healthy environment by implementing an effective infection control program that adheres to state and federal regulations . Environmental Safety .The cleanliness and hygiene standards within The Facility are paramount for effective infection control practices .Includes: regular disinfection of high-touch surfaces, proper handling and disposal of contaminated materials, and maintenance of optimal ventilation and air quality.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment which included injuries of unknown sources and misappropriation of resident property in accordance with state law through established procedures and the facility failed to report the results of all the investigations to the administrator or his or her designated representative and to other officials in accordance with the state law which included to the survey agency within 5 working days of the incident and if the alleged violation was verified appropriate corrective action must be taken for 1 of 4 residents (CR #1) reviewed for abuse and neglect. -The facility failed to report results of a self-reported incident when CR #1 had a fall with injury and was sent to the hospital on [DATE].This failure could place residents involved in abuse incidents at risk of continued abuse, further injury, pain, and physical and emotional distress. Record review of CR#1's face sheet dated 11/20/2025 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Record review CR#1's face sheet had diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, muscle weakness, hypertension (high blood pressure), insomnia (difficulty with sleeping), hyperlipidemia (high fat content in the blood), abnormal findings of blood chemistry, anxiety disorder (chronic excessive worry), Alzheimer's disease (a progressive brain disease causing memory loss), acute kidney failure and unspecified anemia (low iron in the blood).Record review of CR#1's Comprehensive Care Plan dated 11/20/2025 reflected that on 7/28/25 CR#1 had an unwitnessed fall with left hip intertrochanteric fracture of left femur.Record review of CR#1's clinical record during her stay in the facility reflected there was not a provider investigation report sent to the state survey agency.Record review of CR #1's progress notes for July 2025:-07/28/2025 at 2:48am, CR#1 was noted wandering along the corridor and night staff attempted to redirect her. CR #1 was given Hydroxyzine 25 mg for anxiety and pain medication for pain. CR #1 laid in bed afterward.-07/28/2025 at 8:36am, CR #1 was noted as having a fall on at 4:30am, witnessed and without head injury. CR #1's medication was reviewed and RP was notified.-0728/2025 at 10:50am, CR #1 had 2 x-rays completed which came back with acute left hip fracture. CR #1's MD notified and the MD gave orders for CR#1 to be sent out to the hospital.Record review of CR #1's x-rays dated 07/28/2025, she had acute left hip fracture at the intertrochanteric region (upper leg).Record review of CR #1's hospital visit dated 07/28/2025, she was admitted with leg pain and unable to walk after the fall. Imaging showed CR#1 had a fracture with a negative brain scan. CR #1 was admitted for further evaluation and medication.Interview on 11/29/2025 at 10:58am, the DON said the facility had taken steps before the fall on 07/28/2025 to transfer CR #1 to another facility with a locked unit due to wandering. The DON said that was when the new Administrator was taking over and was getting orientation, so she did not know if the previous Administrator had sent the 5-day investigation in or not. But the new Administrator will include the DON in submissions so that the Administrator and DON will be on the same page. Interview with the Administrator on 11/20/ 2025 at 1:44pm, he said he was not the Administrator at the time and was not notified or aware about the fall on 07/28/2025. He found the initial report and facility investigation but could not find the 5-day investigation. The Administrator said if the investigation report was not sent in, there was a possibility that the investigation would not be completed. If the investigation was not done, then an issue related to CR #1's fall could have remained unaddressed. The Administrator said the goal was to focus on taking care of residents.Record review of facility's Abuse/ Neglect & Exploitation Policy dated 04/2024 reflected the facility will report all alleged violations, involving abuse, neglect, exploitation or mistreatment including injuries of unknown source to the administrator or a designee and reports any alleged abuse, neglect, exploitation or mistreatment including injuries of unknown source should also be reported to other officials including to the state agency in accordance with applicable state law.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 3 of 4 residents (Resident #33and Resident #56, and Resident #15) reviewed for ADLs. - The facility failed to ensure Resident #33, and Resident #56 were provided incontinent care in a timely manner by facility staff. - The facility failed to ensure Resident #15 was provided personal grooming (cut resident long classified toenails) by facility staff. These failures placed residents a risk for skin break down, offensive odors, and decrease in quality of life. Findings included: Resident #33 Record review of Resident #33's face sheet dated 04/30/25 revealed a [AGE] year-old male was admitted the facility on 10/24/24. Resident #33 diagnosis included: dependence on respirator (ventilator: a device for maintaining artificial respiration), hypertension (force of blood against the walls of the arteries is consistently too high), and gastrostomy (a surgical procedure used to insert a tube, often through the abdomen and into the stomach) Record review of Resident #33's quarterly assessment dated [DATE] revealed on section C0700 Resident #33 had memory problem. Further review revealed Resident #33 dependent on staff for ADL care with one to two staff assist and the resident was incontinent of bowel and bladder. Record review of Resident #33's care plan initiated 01/29/25 revealed Resident #33 had ADL self-care deficits and is at risk for further decline in ADL functioning and injury AEB weakness. Intervention: Provide (Extensive/) assistance of (1 of support persons) for toileting/incontinent care. During an observation on 04/27/24 at 3:30 p.m., the incontinent care for Resident #33 provided by CNA E revealed that the incontinent brief was saturated with urine, the inside of the brief was dark brown, and the cotton stuffing was broken apart. Resident #33's room has a very strong ammonia odor. The draw sheet under Resident #33 was saturated with urine and it had brown defined bordered line. During an interview on 04/27/25 at 3:43 p.m., RN S said she came to work at 6:00 a.m. today. RN S said she did not notice Resident #33 was wet when she saw CNA E in Resident #33's room at 11:00 a.m. She said the aides and the nurses were supposed to make rounds every two hours for incontinent care. RN S said the aide and the nurse should check the resident's brief during the round because the resident could not talk. She said she did not check the brief. RN S said Resident #3 skin would start to break down if Resident #33 was left on a wet incontinent for extended time. RN S said she had skills check-off, which included incontinent care and rounding. She said the staff must make rounds every two hours and change the resident. She said the nurses monitored the aides throughout the shift. RN S said the nurse managers monitors the nurse during rounding. During an interview on 04/27/25 at 3:58 p.m., CNA E said she came to work at 6:00 a.m. and changed Resident #33 around 6:30 a.m. CNA E said that she had not changed the resident before now because she was working alone and had to change other residents. CNA E said Resident #33's incontinent brief was soaked with urine and the draw sheet was also soaked with urine and had brown ring. CNA E said she was supposed to make rounds every 2 to 3 hours and change the resident, but she did not today because she had a lot of residents (12). CNA E said Resident #33 could develop blister and skin break down when Resident #33 was left on a wet incontinent brief. CNA E said that she had a skill check-off and in-service on rounding and providing incontinent care, and the trainer educated the aides to check on the resident every two hours. She said he did not check on the resident every two hours because she got busy, had to feed other residents, and had to go on break, too. She said the nurse monitored the aides throughout the shift. During an interview on 04/28/25 at 1:54 p.m., the Unit Manager said the aides should make rounds every two hours and as needed. She said if the resident could not make needs known, the aides had to check the resident's brief. The Unit Manager said the aides have skills check-off on ADL with another staff before the aide would work on the floor by herself, and they also have in-services. She stated the DON taught the aides to make rounds every two hours, see if the resident was wet, and check skin condition. The Unit Manager said Resident #33 could develop a skin breakdown if CNA E had not provided incontinent care for #33 promptly. She said the charge nurse and the lead CNA monitor the aide throughout the shift. Resident #56 Record review of Resident #56's face sheet dated 04/30/25 revealed a [AGE] year-old female was admitted to the facility on [DATE]. Resident #56 diagnosis included: malignant neoplasm of colon (cancerous growth in the colon), hypertension (force of blood against the walls of the arteries is consistently too high), atrial fibrillation (an irregular heartbeat) and cognitive communication deficit (someone has difficulty communicating because their thinking processes, like memory, attention, and reasoning). Record review of Resident #56's admission assessment dated [DATE] revealed on BIMS of 13 indicating intact cognition. Further review revealed Resident #56 required substantiation assistance with ADL care with one to two staff assist. Record review of Resident #56's care plan dated 04/09/25 revealed Resident #56 had incontinent of bowel and bladder. Interventions: perform routine rounding to include incontinence care and brief changes. During an interview on 04/2/25 at 4:38 p.m., Resident #56 said CNA V changed her last around 11:00 a.m., and she is wet now and needs to be changed. Resident #56 said the staff had not come to ask if she needed to be changed. Resident#56 said she felt neglected, bad, and dirty. Then she stated What could she do but endure because she could not care for herself Then, she lowered her head and would not talk again. During an interview on 04/27/25 at 4:46 p.m., CNA V said she had changed Resident #56 around 11:00 a.m. or 12:00 p.m., since she came to work at 6:15 a.m. CNA C said she has a lot of residents, and she was doing the best she could. During an observation on 04/27/25 at 5:00 p.m., incontinent care for Resident #56 provided by CNA V and CNA E revealed the resident's incontinence brief was saturated with urine and bowel movement from the resident's lower back up to the resident's pubic area. The draw sheet under Resident #56 was soaked with urine and stained with bowel movement. The draw sheet was also had dry brown ring. During an interview on 04/27/25 at 5:16 p.m., CNA V said Resident #56's incontinent brief was dirty and saturated with urine and bowel movement and the bowel movement was inside Resident #56's private area. CNA V said the pad on Resident #56's bead was soaked with urine and bowel movement, and it had brown ring which meant Resident #56 had been wet for more than two hours. During an interview on 04/28/25 at 12:01 p.m., the Medical Director said if CNA V did not change Resident #56's incontinent brief timely, the resident's skin could become macerated. During an interview on 04/28/25 at 3:05 p.m., the DON said staff should make rounds every 2 hours as needed. She said the aides should check the incontinent brief and see if it was wet. The DON said Resident #56 would be at risk for skin breakdown if CNA V did not change Resident #56 promptly. The DON said the lead CNA and nurse check if the aides provide care to the resident, and the nurse managers monitor the nurses during random rounds. The DON said the aides are trained upon hire and in services are provided on intervals throughout the year. The DON said the aides are told to make round for incontinent every two to three hours during in -service. Resident #15 Record review of Resident #15's face sheet dated 04/30/25 revealed a [AGE] year-old female was initial admitted to the facility on [DATE]and readmitted on [DATE]. Resident #15 diagnosis included: dependence on respirator (ventilator: a device for maintaining artificial respiration), tracheostomy(an opening surgically created through the neck into the trachea(windpipe) to allow air to fill the lungs), hypotension (force of blood against the walls of the arteries is consistently too low), and cognitive communication deficit (someone has difficulty communicating because their thinking processes, like memory, attention, and reasoning) Record review of Resident #15's quarterly assessment dated [DATE] revealed on section C0700 Resident #15 had memory problem. Further review revealed Resident #1 dependent on staff for ADL care with one to two staff assist. Record review of Resident #15's care plan initiated on 02/02/25 revealed Resident #1 had ADL self - care deficit and is at risk for further deficits in ADL and injury. Interventions: Provide (Total) assistance of (# of support persons) for personal hygiene/grooming. Record review of Resident #15's physician ordered for April 2025 revealed don not resuscitate, do not hospitalize, no labs, hospice care dated 04/25/25. Record review of Resident #15's physician ordered for April 2025 revealed the resident was admitted to hospice care on 04/28/25. During an observation and interview on04/27/25 at 5:25 p.m., Resident #15's long toenails were observed. CNA V said Resident #15 had 10 long and classified toenails, and she told the nurse 3 weeks ago about Resident #15's toenails. She said the nurse, or the podiatrist, cuts the resident's toenails. During an observation and interview on 04/27/25 at 5:29 p.m., RN S said she saw Resident #15's toenails were long and needed to be cut down. She said the aides are responsible for cutting the residents toenails but if the resident were diabetic then the podiatrist would cut the resident toenails. She said Resident #15's toenails were long on Saturday and Sunday, but did not tell the DON. RN S said the nurses monitored the aides throughout the shift, and the nurse managers monitored the nurses during random rounds. RN S said Resident #15's long toenails could cut Resident #15's skin or get infected. During an Interview on 04/28/25 at 2:23 p.m., the Unit Manager said the aides were responsible for cutting the resident toenails and if the resident had diabetes, then the podiatrist cuts the resident toenails. The Unit Manager said the nurse would tell her, and she would put in the order, and the social worker would contact the podiatrist. She said if Resident #15 had long toenails, she could cut her skin open, and it could lead to gangrene. During an interview on 04/28/25 at 2:34 p.m., SW said the podiatrist emails the list of residents he would see when he made rounds to her, and the residents are from the referrals she sent to the podiatrist. SW said the podiatrist saw the residents on 04/16/25. SW said Resident #15 was put on hospice on Friday (04/25/25) when Resident #15 came back from the hospital, and her family member told her she did not want Resident #15 on any services. Still, she did not document what family member told her. During an interview on 04/28/25 at 3:18 p.m., the DON said Resident #15, who was on hospice, should still have her toenails cut. She said she was told yesterday (04/27/25) by RN S after the surveyor showered Resident #15's toenails to RN S. The DON said she told the Unit Manager to call hospice and did not know if she had called hospice. The DON said Resident #15's skin could break down, and she could develop an infection under her toenails. During an interview on 04/29/25 at 5:00 p.m., the ADON said she was unaware Resident #15 had long toenails and was unsure if Resident #15 was admitted to hospice. She said if the resident were on hospice, they would call the hospice nurse and let the nurse know that the resident had long toenails, then the facility would wait for the hospice nurse to respond before contacting the podiatrist. She said if the resident did not have diabetes, the aides would cut the resident's toenails. The DON said If the resident had diabetes the nurses would cut it and also use nursing judgment to determine if Resident #15 was at risk and if Resident #15 was at risk, then the SW would call the podiatrist would be called. The ADON said she did not know what was done about Resident #15's long toenails. She said Resident #15, who had long, calcified toenails, could be injured if her nails got caught on the sheets and even infected. The DON said the aides and the nurse went to school and should know how to provide toenail care. The ADON said she did not know the facility's policy on toenail care and would check and get back to the surveyor. The ADON said the nurses monitored the aides throughout the shift, and the nurse managers monitored the nurse nurses during random rounding. Record review of the facility on activities of daily living revised 3/2019 read in part . the facility is responsible to provide necessary care to all residents who are not able to carry out activities of daily living on their own to ensure they maintain proper . grooming and hygiene .

Based on observation, interviews, and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 5 of 5 confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on Saturdays and Sundays for 5 confidential residents. These failures placed residents at risk for decline in quality of life, social and mental psychosocial wellbeing. Findings Include: Observation on Sunday, 04/27/2025 from 01:00 p.m. to 06:00 p.m. revealed there were no activities visible provided for residents in the activity area. Later observation on 04/28/2025 from 8:00 a.m. to 1:00 p.m. revealed there were no activities visible provided for residents in the activity area. Interview on 04/27/2025 at 02:38 p.m. with the Activity Director, she said that she would arrange Resident Council tomorrow 04/48/2025 at 10:30 a.m. During a confidential group interview on 04/28/2025 at 10:30 a.m., with 5 confidential residents, all residents stated that there were no weekend activities. 3 of 5 said that the Activity Director came in on Sunday's and would sit in her office, and they were on their own. While displaying a printed calendar for April 2025, they all agreed that the calendars were not really for the residents, but for others (visitors) to see. All said that they have never done a lot of the activities printed on the calendar. 3 out of 5 saying, and all agreeing that this makes us feel tired, like banging our heads against the wall. 3 out of 5 said that they Never even had coffee and a donut for an activity. 2 said, all agreed that watching tv in your room was not an activity and that one resident was so bored that he used to watch cars passing by and count them, so they (The facility) put in on the calendar as an activity for bird watching. Interview on 04/28/2025 at 01:21 p.m. with the Activity Director, w [NAME] reviewing the Activities calendar for April 2025, she said that the residents attend about 90 % of the activities on the calendar. When informed that no activities on the calendar were observed or done since the survey began on 04/27/2025, she said many times she would go and check the residents to see if they had taken medication, were drowsy, in pain or if they wanted to attend an activity and a lot of residents said no, they did not want to attend. She said that she would have worksheets, coloring books and other items sitting out if the residents chose to do any activity at times if the activity staff were not there on the weekend. The Activity Director said activities posted were not done because residents refused to go. During an interview on 04/29/2025 at 06:07 pm with the Administrator he said that not having activities could cause the resident to get bored and have a negative impact on the resident's quality of life. During an interview on 04/30/2025 at 10:22 a.m. with the DON, she said that residents not having activities could cause psychological and mental health could develop. She said that the responsibility of the activity program was the Activity Director's and they all worked together as a team. During an interview on 05/01/2025 at 11:19 a.m. with the Activity Director Assistant, she said she had been the Activity Director Assistant for about a year, she said that activities were important to residents because they could feel isolated or become depressed and affect their quality of life. Record Review of the Activities Calendar for April 2025, the following Saturday dates 04/12/25, 04/26/2025 had family visits, individual Activity Sheets, and watching tv. On the following Sunday dates 04/06/2025, 04/13/2025, 4/20/2025, and 04/27/2025 had 009:30 a.m. Bible Study Rounds, 01:30 p.m. Puzzles and Coloring Sheets and 02:30 p.m. watching tv. Record review of the policy and procedure entitled Activities dated revised 5/24 read in part .The Facility's activity program shall provide meaningful, person-centered activities to meet each resident's physical, mental, and psychosocial well-being, per their comprehensive care plan .offer a variety of activities that promote engagement and meet the diverse needs of the resident population, including: Group and individual activities .physical, intellectual, spiritual, emotional, and social activities.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #19) of 4 residents reviewed for resident rights. - The facility failed to place Resident #19's foley catheter bag inside of a privacy bag. This failure could affect the residents who require assistance with their ADLs from facility staff by placing them at risk for social isolation, loss of dignity, and self-worth. The findings include: Record of Resident #19's Facesheet dated 04/30/2025 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included but were not limited to functional quadriplegia (complete inability to move due to sever disability or medical condition), benign prostatic hyperplasia (enlarged prostate (male gland below the bladder responsible for reproduction and fluid flow including urine) causing frequent urination) without lower urinary tract symptoms, dementia (group of symptoms affecting memory, thinking and social abilities), without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, bipolar disorder (extreme high/low mood swings), gastro-esophageal reflux disease without esophagitis (stomach acid backing up into the esophagus (muscle tube that connects throat to the stomach) causing visible damage to the esophageal (tube that connects the throat to the stomach) lining), gastrostomy status (presence of a surgical opening into the stomach for nutritional support or gastric decompression), and tracheostomy status (surgical hole in the windpipe that helps with breathing when the usual way is blocked or reduced). Record review of Resident #19's Minimum Data Set (MDS) dated [DATE] revealed that the resident had no Brief Interview for Mental Status (BIMS) indicating he was not able to answer or respond to the BIMS questions. Section H: Bladder and bowel: Resident noted to have an indwelling catheter (including suprapubic catheter and nephrostomy tube). Record review of Resident #19's Nursing Progress Notes dated 04/26/2025 at 03:13 p.m. reflected, Licensed Vocation Nurse (LVN) A provided foley catheter care and noted: dark yellow urine recorded a.m. shift. Incontinent care provided. No acute distress noted this far. In an observation on 04/27/2025 at 03:10 p.m., Resident #19 laid in his room bed. Resident's foley catheter bag was exposed, and urine within was visible. The resident did not arouse to sound or voice. In an interview on 04/27/2025 at 03:13 p.m., LVN A stated that Resident #19's foley catheter bag was not to have been exposed and should have been placed into a privacy bag for his dignity. She stated that catheters were changed twice a month, and the foley once a month and after those changes, his privacy cover must have been thrown away and not replaced. She stated it had been her responsibility to ensure that the resident's catheter bag was in a privacy bag. She stated that the staff received in-services on foley catheter care monthly. In an interview on 04/27/2025 at 05:35 p.m., Registered Nurse (RN) A stated that it was everyone's responsibility to ensure that resident's catheters were within privacy bags to preserve a resident's privacy. He stated that if he had seen a foley bag without a privacy bag he would cover it immediately with a new privacy bag cover. He stated that they received in-service on foley catheter care monthly. In an interview on 04/28/2025 at 01:56 p.m., LVN C stated that the Director of Nursing (DON) performed in-services on foley catheter care routinely. She stated that the Certified Nursing Assistants (CNA) were responsible for emptying resident's foley catheters and reporting any changes in a resident's condition to the charge nurses immediately, including notifying them if a foley bag had not been within a privacy bag. She stated it had been the responsibility of the nurses to change foley catheters and ensure that foley bags were covered in a privacy bag. In an interview on 04/28/2025 at 02:47 p.m., the DON stated that residents with a foley bag should have a privacy cover over the bag to preserve dignity. She stated it had been the responsibility of the CNAs and the nursing staff to ensure that the foley bag was covered with a privacy bag. She stated she performed in-services all the time on foley care to include placing the bag in a privacy bag. Record review of facility Education In-service Attendance Record dated 02/01/2025 and titled . Foley Catheter . Summary of Training: Date and cover urine foley catheter bag, check proper placement of foley, drain by gravity, and below the bladder. Presented by DON and signed by LVN A and other nursing staff. Record review of facility policy revised dated: 02/2024 and titled: Policy Policies and Procedures. Catheter Care Policy . Catheter Management: Privacy: Store the catheter bag in a privacy bag to maintain dignity.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #34) reviewed. -The facility failed to ensure that Resident #34's status of oxygen was a focus area in the resident's comprehensive care plan and no intervention was in place. This deficient practice could affect residents by contributing to inadequate care. The findings included: Resident #34 Record review of Resident #34's facility admission record dated 4/28/25 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included sepsis (sepsis is a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to organ damage) and heart failure (a condition where the heart muscle is unable to pump blood effectively enough to meet the body's needs. This results in the accumulation of fluid in the lungs and other parts of the body, leading to symptoms such as shortness of breath, fatigue, and swelling). Record review of Resident #34's Admission Minimum MDS dated [DATE] revealed Resident #34 had a BIM score of 15 out of 15 indicating she was cognitively intact. Resident #34 required substantial/maximal assistance with ADL's. She was occasionally incontinent of bladder bowel. Record review of section O (special treatments) revealed that she used oxygen. Record review of Resident #34's comprehensive care plan revealed there were no care plans to address oxygen use. Interview and record review on 4/29/25 at time unknown, with the MDS Coordinator, said she is the one that performs the care plans and confirmed no comprehensive care plan for Resident# 34 in either EMR systems, she also said that the care plan for oxygen was added on 4/28/25. She said that the RAI manual was used to complete assessments. During an interview on 4/30/25 at 10:22 a.m. with the DON, she said that Comprehensive care plans and MDS assessments were important because they all addressed goals and interventions, helped carry orders correctly and safely. The risk of not having them in place was that staff could make a mistake in performing duties correctly. Record review of the facility policy and procedure entitled Care Planning dated revised 6/2019 read in part . It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident .Procedure: A comprehensive care plan is developed within seven (7) days of completion of the comprehensive assessment .

Based on observation, interview and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible for 1 of 6 (Resident #13) resident rooms observed for accident hazards. -Resident #13's room had two bottles of hair products on their dresser not stored in a safe manner on 4/27/2025. This failure could place residents at risk of injury due to unnecessary access to potentially harmful substances. Findings included: Record review of Resident #13's face sheet captured 04/27/2025, she was a [AGE] year-old female originally admitted to the facility on [DATE]. Her medical diagnoses included Type 2 Diabetes Mellitus (high blood sugar), Dementia, Dysphagia, Traumatic Subdural hemorrhage with loss of Consciousness of Unspecified Duration (brain bleed) and Tracheostomy. Record review of Resident #13's Quarterly MDS dated [DATE] revealed, she did not have a BIMS completed and did not have a mood interview done due to her being rarely or never understood. She was totally dependent on staff for ADLs, including toileting, oral and personal hygiene, dressing and showering/bathing self. Record review of Resident #13's care plan last updated 02/12/2025 revealed, she had ADL self-care deficits and required total assistance for bathing, personal hygiene/grooming. and toileting/incontinent care. Record review of the facility's census revealed, the facility marked five residents as being ambulatory, meaning they were able to independently move around the facility. Observation on 4/27/2025 at 3:25pm in Resident #13's room, Resident #13 was resting in bed and appeared well-groomed, comfortable with no grimacing. She was unresponsive to questions. There were two bottles of hair product on top of the resident's dresser. The first was a 300 mL quarter-full clear shampoo bottle. On the back, the bottle read in part, Safety Tip: Keep out of reach of children. The second was a 778 mL purple opaque conditioner bottle. Both bottles had names of other residents who were no longer at the facility. Interview on 4/27/2025 at 3:25pm with LVN B, he said the two bottles should not have been there, it could have been cross-contamination between resident personal items. He called the aide into the room and told him to remove the bottles. Interview on 4/27/2025 at 3:30pm with CNA B, he said he was the aide on the hall, and he did not know the bottles were there or who put it there. He put gloves on and said he was going to remove the bottles. Interview on 4/28/2025 at 2:43pm with CNA E, she said that toiletries should be ziplocked and put away in residents' drawers. They should be sealed and labelled to avoid infection control issues from using other residents' items. Wandering residents could be at risk if they have access to these items. CNA E said she was the one responsible for checking resident rooms for making sure items were ziplocked and put away once a week. Interview with the DON on 4/28/25 at 2:42pm, she said that personal hygiene products should be labelled with the resident's name and placed in a bag or placed inside a drawer so that residents were not using someone else's items. A risk to residents would also be infection control and could be a risk to wandering residents. The DON said that CNA E was responsible for checking resident rooms once a week to ensure personal hygiene products were ziplocked and put away in residents' drawers. Record review of the facility's Resident Rights policy last revised 04/2024, it read it part, The facility provides a clean, safe, comfortable and home-like environment .Resident rights may be restricted only to the extent necessary to protect the resident and others. Request for an Accident/Hazards policy was made on 4/29/2025 at 10:34am to the DON and Administrator, the DON later stated they did not have a specific policy on that.

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 3 residents (Resident #56) reviewed for incontinent care. The facility failed to ensure CNA V properly cleaned Resident #56 during incontinent care when CNA V did not separate Resident #56's labia on 04/27/2025. This failure could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Record review of Resident #56's face sheet dated 04/30/25 revealed a [AGE] year-old female was admitted to the facility on [DATE]. Resident #56 diagnosis included: malignant neoplasm of colon (cancerous growth in the colon), hypertension (force of blood against the walls of the arteries is consistently too high), atrial fibrillation (an irregular heartbeat) and cognitive communication deficit (someone has difficulty communicating because their thinking processes, like memory, attention, and reasoning). During an observation on 04/27/25 at 5:00 p.m., CNA V did not separate Resident #65's labia during incontinent care for Resident #3. The surveyor intervened when CNA V was about to close the strips on the clean incontinent brief. CNA V reseparated the resident's labia and wiped the resident's labia four additional times, and from the labia area exposed feces on the wipes, and on the fifth wiping/wipe the area appeared to be cleaned. Record review of Resident #56's admission assessment dated [DATE] revealed on BIMS of 13 indicating intact cognition. Further review revealed Resident #56 required substantiation assistance with ADL care with one to two staff assist. Record review of Resident #56's care plan dated 04/09/25 revealed Resident #56 had incontinent bowel and bladder. Interventions: perform routine rounding to include incontinence care and brief changes. During an interview on 04/27/25 at 5:16 p.m., CNA V said if the surveyor did not intervene, she would not have separated Resident #56's labia and cleaned the labia well before applying the clean incontinent brief. CNA V said if she did not clean Resident #56 well, she could develop an infection (UTI). CNA V said she had skills check off and in service on ADL, including rounding and incontinent care. She stated that the nurse monitored the aide throughout the shift. During an interview on 04/28/25 at 2:02 p.m., the Unit Manager said CNA V should have separated Resident #56's labia and cleaned side, side and middle to ensure the resident was clean properly to prevent Resident #56 from getting UTI. She said the aide had training on providing incontinent care before they started to work on the floor. The Unit Manager said the aides were tough to wipe from front to back to prevent infection. She said the nurse and lead CNA monitor the aides throughout the shift, and the nurse manager monitors the nurses during random rounds. During an interview on 04/28/25 at 3:16 p.m., the DON said CNA V should have cleaned Resident #56 from front to back and should have separated Resident #56's labia and cleaned three times, side, side, and middle each time with a different wipe. The DON said the resident's labia are separated and cleaned to avoid redness or the development of infection. She stated that the nurses and lead CNA monitored the aides throughout the shift, and the nurse managers monitored the nurses during random rounds. She said the aides should have a skilled check-off before working on the floor. They also had in-service on ADL rounding and incontinent care. Record review of the facility's policy on perineal care revised 12/23 read in part . the facility will provide perineal care in a manner that . reduce the risk of infection, and promotes skin integrity .procedure: . cleaning . for female residents, separate the labia and clean from front to back using a clean wipe for each stroke .

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #11) of 7 residents reviewed for enteral nutrition. The facility failed to follow physician orders for Resident #11 enteral feeding tube to be administer 55ml (milliliters) high-protein tube-feeding formula 1.5 calories (cal) every hour (hr). This failure could place residents who had gastrostomy tube at risk for fluid overload. Findings included: Record of Resident #11's Facesheet dated 05/05/2025 revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included but were not limited to acute and chronic respiratory failure (lungs are unable to adequately exchange oxygen and carbon dioxide), moderate protein- calorie malnutrition (deficiency in both protein and calories, leading to a weight loss or a lack of weight gain), and encounter for attention to gastrostomy (a surgical procedure that creates an opening in the stomach through the abdominal wall for receiving nutrition), and dehydration (body losing too much fluid). Record review of Resident #11's Comprehensive MDS dated [DATE] revealed that the resident had no BIMS indicating he was not able to answer or respond to the BIMS questions. Section K: Swallowing/Nutritional Status. Feeding tube (e.g., nasogastric or abdominal (PEG). The percent (%) Intake by Artificial Route: The proportion of total calories the resident received through parenteral, or tube feeding was 51% or more. The average fluid intake per day by IV or tube feeding 501 cc (cubic centimeter)/day or more. Record review of Resident #11's undated Care Plan reflected FOCUS: FEEDING TUBE: Resident required the use of a feeding tube for nutrition and was at risk for aspiration, unplanned weight loss, dehydration and nutritional complications. GOAL: Resident's feeding tube would remain patent and resident would receive nutrition as ordered without evidence of aspiration, dehydration, or nutritional compromise through the review date. INTERVENTIONS: Follow Physician orders for feedings. Record review of Resident #11's Physician Order dated 02/26/2025, reflected, Enteral Feeding- Order: High-protein tube-feeding formula 1.5 cal 55ml/hr . preposition (via) gastrostomy tube (G-tube) continuously times (x) 22 hours. 22 hours accounts for activities of daily living (ADL) Care. Every shift for feeding. Record review of Resident #11's 04/29/2025 at 04:53 p.m. Medication Administration Record (MAR) dated 04/01/2025 to 04/29/2025 reflected, on 04/26/2025 into 04/27/2025 RN A administered the resident's enteral feeding - order high-protein tube-feeding formula 1 .5 cal. at 06:00 a.m., 55ml/hr . via G-tube continuously x 22 hours. Observation on 04/27/2025 at 02:29 p.m., reflected Resident #11 laid in bed and had not aroused to voice or sound. Feeding machine reflected, high-protein tube-feeding formula 1.5 cal at a continuous rate of 56 ml/hr. Total feed 1385 ml. Interview on 04/28/2025 at 02:47 p.m., DON stated that not following Resident #11's high-protein tube-feeding formula of 55ml/hr rather that the feeding machines setting of 56 ml/hr could result in an overload of weight gain for the resident resulting in an undesired maintains of weight. She stated that nursing staff were responsible for verifying each order, every shift, every time the resident's feeding was administered. Interview on 04/29/2025 at 06:01 p.m., the Administrator (ADM) stated that Resident #11 feeding order should be followed and received as ordered. He stated that the resident receiving 56mls verse 55mls of high protein feeding formula would result in overfeeding and unplanned and undesired weight gain. Interview on 05/01/2025 at 09:30 a.m., RN A stated he had been responsible MAR for Resident #11's high-protein tube-feeding formula at 55ml/hr on 04/26/2025 into 04/27/2025. He stated he was not aware that Resident #11's feeding entered at 56ml/hr verses the physician ordered 55ml/hr. He stated that the CNAs start and stop the feeding machines to provide incontinence care and maybe the feeding was changed inadvertently during the stopping and starting. He stated that CNAs were not to stop and start the machine and it was ultimately his responsibility as the resident's nurse to ensure that the amount of formula was correctly administered per hr by confirming with the actual order each time the formula was administered. He stated that the consequences of residents receiving too much feeding could result in side effects such as weakness, abdominal distention, shortness breath and cause pulmonary destress, and circulatory overload. He stated he received his training on how to administer feeding in college as a student. He stated he also received 3-days of training on how to enter and follow physician orders from LVN B and LVN C when he began working with the facility nearly a year ago. He stated that the facility provides in-services on how to stop and start the feeding machines routinely. Record review of facility policy dated title: Policy Policies and Procedures Physician Orders Policy All physician orders must be accurate, timely, and documented in the resident's medical record. Only authorized individuals (e.g., physicians, nurse practitioners, or physician assistants) may write or verbally provide orders. Verbal orders must be promptly documented, signed, and authenticated by the prescribing practitioner within the timeframe. The facility staff must ensure that all orders are obtained, clarified, and carried out promptly, with documentation . Following Physician Orders 1. Facility staff are responsible for: Reviewing the order promptly. Ensuring that all orders are correctly implemented within the timeframe specified. Communicating any barriers to implementation to the prescribing practitioner. 2. Documentation of implementation must include: Date and time the order was carried out. Name and credentials of the staff member completing the task. Any resident responses or outcomes, as applicable. 3. If clarification is required, the staff member must: Contact the prescribing practitioner for clarification. Document the clarification conversation and any modifications in the medical record.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 13 of 28 residents (Resident #1, #2, #3, #4, #5, #6, #8, #9, # 10, #11 #12, #13, and #14) reviewed for infection control. The facility failed to ensure residents (Resident #1, #2, #3, #4, #6, #7 #8, #9, # 10, #11, #12, #13, #14) did not acquire Candida auris (Candida auris is a fungal infection that can cause serious illness) infection at the facility. The facility failed to ensure staff (CNA B and LVN M) wash or sanitize hands after providing care to Residents (Resident #2, #3, #4, #5, #6 and #7) rooms. The facility failed to ensure that staff (CNA B and LVN M) implemented appropriate use of PPE and transmission-based precautions prior to enter and exiting residents' (Resident #2, #3, #4, #5, #6 and #7) rooms. The facility failed to ensure that staff (CNA B) clean and disinfect equipment (pulse ox and thermometer) used to obtain residents' (Resident #2, #3, #4, #5, and #6) vitals before and after use. The facility failed to show proof that the facility had established and implemented a surveillance plan for mitigating the spread of Candida auris infection. An Immediate Jeopardy (IJ) situation was identified on 02/15/25. While the IJ was removed on 02/18/25 at 1:30p.m, the facility remained out of compliance at a scope of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures have the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings include: Record review of Resident #1's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 02/02/2025. Record review of Resident #2's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 02/23/2025. Record review of Resident #3's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 12/13/2024. Record review of Resident #4's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 12/11/2024. Record review of Resident #5's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris present on admission. Record review of Resident #6's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 11/18/2024. Record review of Resident #7's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 11/06/2024. Record review of Resident #8's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 01/30/2025. Record review of Resident #9's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], 41 age years old; Resident tested positive for Candida auris dated 07/31/2024. Record review of Resident #10's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 04/08/2024. Record review of Resident #11's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 12/11/2024. Record review of Resident #12's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident tested positive for Candida auris dated 12/04/2024. Record review of Resident #13's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 11/06/2024. Record review of Resident #14's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 05/21/2024. Record review of infection control binder provided by IP B revealed the facility was not able to show evidence the facility established/implemented a surveillance plan, for identifying, tracking, monitoring and/or reporting of infections, communicable diseases, and outbreaks. Record review of the facility furnished list, indicating positive Candida Auris results for 28 residents. List reflected there was 12 facility acquired candida auris positive residents and 28 total positive residents on the 3 of 4 hallways. Observation on 02/14/2025 at 11:40 AM, LVN M was observed entering contact precaution room [ROOM NUMBER]. without the appropriate Personal Protective Equipment, which included gloves and gowns while administering medication to Resident #7. Upon exiting Resident #7 room, proper hand hygiene measures were not implemented. Observation on 02/14/2025 at 11:50 AM, CNA B was observed inside contact precaution room [ROOM NUMBER] with Personal Protective Equipment obtaining Resident #2 vitals while wearing gloves and a gown. After obtaining vitals, CNA B did not remove the gloves, sanitize or wash her hands or clean equipment prior to exiting Resident #2's room. CNA B proceeded to enter room [ROOM NUMBER] and did not remove the gloves, gown, sanitize or wash her hands, and clean equipment before attending to Resident #3. CNA B obtained Resident #3 and Resident #4 omitting proper hand hygiene, cleaning equipment, and changing PPE between obtaining Resident #3 and Resident #4 vitals. Using the same contaminated gloves and gown, CNA B entered room [ROOM NUMBER] and proceeded to obtain Resident #5 and Resident #6 vitals without washing and sanitizing hands, cleaning equipment, and changing PPE between obtaining Resident #5 and Resident #6. Interview conducted on 02/14/2025 at 11:13 AM, IP B stated the presence of active C. auris cases within the facility, initially detected in April 2024. IP B expressed uncertainty regarding the number of residents who tested positive for C. auris and was also unsure about the total number of residents tested for the infection. She stated she recently was hired as the facility's IP. She stated the pervious IP was terminated approximately a week prior. She stated the DON and pervious IP (IP A) worked with the health department in testing residents monthly. She stated she was made aware of the Candida auris outbreak when she onboarded approximately a week ago. She stated she was not sure of the health department's recommendations. She stated the DON received the health department's recommendations and reports after each. She stated she was not provided with the plan of correction and recommendation from the health department. She could not articulate a plan to mitigate the risk at the time of the interview. She could not provide proof the facility established and implemented a surveillance plan. She stated when she stepped into the role, she was informed by the DON there were many gaps in the tracking and monitoring of infection within the facility. She did not explain the gaps when asked. She could not explain what actions she had taken to close the gaps. She stated she would follow up with the DON regarding the health departments recommendations. Interview on 02/14/2023 at 11:55am, LVN M verablized the error of failing to don PPE and wash hands. LVN M stated that Resident #7 was on Contact Precautions due to testing positive for Candida auris. She verbalized an understanding that the transmission of infection can occur when PPE and hand hygiene protocols were not followed. She stated that such error put residents and staff at risk for infection. LVN M mentioned receiving infection control training, some time ago. She stated that contact precaution required her to put wear a glow and gloves and wash or sanitize her hands before and after enter contact isolated rooms. She stated that the facility supplied adequate PPE. She stated that that the facility had not provided training on Candida auris, but she had knowledge of the infection. She did not identify why she failed to implement proper transmission precautions. She stated by failing to don PPE and wash hands she placed residents at risk for being exposed to the infection and the infection could rapidly spread. Interview on 02/14/2025 at 12:10, CNA B expressed uncertainty regarding why proper PPE measures was not utilized, hand hygiene practices were neglected, and disinfectant measures were not implemented. CNA B stated Residents #1, #2, #3, #4, #5, and #6 were on Contact Precautions due to testing positive for Candida auris. CNA B also acknowledged the risk of infection transmission in the absence of proper PPE, hand hygiene and disinfectant measures. CNA B mentioned undergoing training previously but was unable to articulate the specifics or content of the training provided. CNA B stated that she had not received training on caring for Residents with Candida auris. Interview on 02/14/2025 at 12:20 PM, Local Health Department Epidemiologist A stated the health department began working with the facility in April 2024. Epidemiologist A stated the facility initially (April 2024) had approximately 4 residents who tested positive for Candida auris. Epidemiologist A stated she was not aware of the current number of residents who were positive at the facility. She stated a plan of correction along with recommendations was provided by the local health department to the facility in April 2024, in the effort to mitigate the spread of the infection. She stated when visiting the facility monthly, the Local Health Department tested residents who had not been previously tested and identified as positive residents. She stated results were then provided the facility. She stated the facility continued to have positive test results during each visit and there was a continued outbreak at the facility. She stated the Health Department witnessed staff entering and exiting contact precaution rooms with implement PPE and proper hand hygiene. Epidemiologist A stated she had been working with the DON and the Infection Preventionist (IP) for several months. She stated the continued outbreak could be a result of the facility staff not implementing TBPs. She stated not implementing PPE and hand hygiene put all residents at risk of being exposed to the infection. Interview attempt on 02/14/2025 at 12:26 PM, to the DON by telephone was unsuccessful. Interview attempt on 02/14/2025 at 12:40 PM, to IP A by telephone was unsuccessful. Interview conducted on 02/14/2025 at 5:00 PM, the Administrator could not articulate a structured system designed to effectively mitigate the risk of C. auris transmission. He stated the DON was working with the health department and was aware of the health department's recommendation. He could not explain who was monitoring to ensure the plan and recommendations were being followed. The Administrator stated he was not aware of the number of residents effected with C. auris. Interview conducted on 02/14/2025 at 5:30 PM, the Regional Corporate Nurse stated staff were expected to follow contact precautions when dealing with residents with Candida auris to prevent its spread. This included using personal protective equipment (PPE) such as gloves and gowns, hand washing, properly disinfecting surfaces, and isolating infected or colonized patients when necessary. He stated when failure to use proper TBP placed other residents at risk for being exposed to the infection. Interview conducted on 02/15/2025 at 10:00 AM, IP B was not able to articulate how staff were monitored for compliance. Infection Preventionist B (IP B) stated the DON resigned after being contacted on 02/14/2025 regarding the health department's recommendation and plan of correction. IP B stated she reached out to the health department's Epidemiologist A to request the plan of correction on 02/14/2025, after the state surveyor requested the information. Infection Preventionist B (IP B) stated she was working with the Regional Corporate Nurse and weekend Supervisor to complete an audit of residents who had acquired the infection at the facility. Interview conducted on 02/15/2025 at 12:00 PM, the Administrator said staff were notified of the Candida auris outbreak when he onboarded in 11/2024. The Administrator could not provide a plan to mitigate the risk at the time of the meeting. The Administrator stated the facility would adhere to infection control policy moving forward. The Administrator did not have knowledge of what the infection control policy indicated. The Administrator stated the DON resigned yesterday, 02/14/2024, after she was notified a state surveyor was in the facility. Interview conducted on 02/15/25 at 1:00 PM with Administrator who stated the facility IP A and IP B were training on transmission-based precautions and were responsible for the tracking a trending of communicable diseases within the facility. He stated he was notified by the DON of concerns related to IP A's performance and ability to maintain the infection control responsibilities, a couple of weeks back (could not recall the specific date). He stated approximately a week ago Infection Preventionist B assumed the role of the facility's Infection Preventionist. He was unable to explain IP A's failures and what action were implemented to correct the failures since identified. He stated the Infection Preventionist role was to prevent and contain the spread of infections. He stated the DON was responsible for overseeing the Infection Preventionist duties and responsibilities were being implemented. The Administrator did not explain his active role of preventing and mitigating the spread of Candida auris and communicable diseases within the facility. The Administrator stated IP A was terminated from the facility this week but could not recall the date. The Administrator stated IP B assumed the role as the Infection Preventionist last week. The Administrator stated the DON was responsible for ensuring the tracking and trending was completed by the Infection Preventionist. He stated the Infection Preventionist and the DON had been working with the local health department epidemiologist, but he was not knowledgeable of the current recommendations. Interview conducted on 02/15/2025 at 6:00 PM, the DNP (medical provider) stated failure to properly monitor and mitigate the spread of Candida auris could lead to severe adverse outcomes. Initially, infections may cause serious complications, particularly in immunocompromised individuals, leading to increased mortality rates and death. She stated staff were expected to follow contact precautions when dealing with Candida auris to prevent its spread. This included using personal protective equipment such as gloves and gowns, practicing strict hand hygiene. Failure to adhere to these precautions could further exacerbate the outbreak. She stated she was aware of the spread through the facility. She was not able to identify the total number of residents infected. She stated she believed staff implemented the appropriate contact precautions when dealing with resident Candida auris. She stated she could not attest to how often staff washed their hands or entered a contact isolation room without PPE. She could not explain why the facility had such an increase in residents who acquired the infection while admitted at the facility. Record review of local health department plan of correction, 04/2024 read advised to take the corrective actions listed in the recommendations below: 1. PPE: a. Patient should be on contact precautions. Staff should be using gowns and gloves upon entering the patients room. b. Clear signage to indicate patients are on TBPs with proper indications for precautions and PPE requirements. c. Follow transmission-based precautions, including the use of personal protective equipment by personnel and prefer single patient- use items. e. Making sure PPE, gowns, and gloves are accessible and used appropriately. 2. Handwashing: a. Appropriate hand decontamination following cleaning of C. auris - exposed body fluids/areas. b. Frequent handwashing by staff with soap and water, followed by alcohol-based hand rub. c. Monitor adherence of staff to hand hygiene practices. 3. Cleaning: Shared medical equipment should be cleaned and disinfected thoroughly . Thes was determined to be an immediate jeopardy (IJ) on 02/15/23 due to the above failures. The administrator was notified and provided the IJ template on 02/15/23 at 6:45p.m. The immediacy was lowered on Tuesday, 02/18/2025 at 2:05p.m. with the facility Administrator and DON, the facility remained out of compliance at a scope of no actual harm with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal - Infection Prevention and Control - Accepted 02/16/2025 at 11:00am 1. Candida auris Education The Regional Nurse Consultant initiated education on 02/15/2025 provided to all staff on Candida auris (including background/definition, PPE & isolation protocols (including co-horting), disinfectant protocols, equipment/clothes/linen handling, meal service, and methods to prevent the spread of Candida auris). Staff will be educated prior to initiating their next shift. Staff will show competency and understanding of education through testing. Education on Candida auris, including testing will occur in Facility Orientation. Education and Testing will be completed by 02/16/2025 2. Environmental Cleaning Education On 2/14/25 the Regional Nurse Consultant initiated education provided to housekeeping staff on cleaning schedules for residents affected by Candida auris and the requirement to clean/disinfect twice a day and using EPA-approved disinfectants effective against Candida auris per the county health department recommendations. Housekeeping staff will be educated prior to initiating their next shift. Education will be completed on 02/16/2025. The Administrator will ensure compliance. 3. Infection Control Education The Regional Nurse Consultant initiated education on 02/14/2025 with all staff on Handwashing and Equipment Disinfection between resident rooms. Staff will be educated prior to initiating their next shift. Education will be completed by 02/16/2025 4. 1:1 Education The Regional Nurse Consultant provided 1:1 education with the Infection Preventionist, Weekend RN Supervisor, and Administrator on 2/15/25 on Candida auris, Infection Prevention Program Policy to include surveillance. 5. Medical Director Notification The Administrator notified the Medical Director on 02/15/2025 of the IJ template and will be updated on the POR as indicated. 6. Surveillance The Regional Nurse Consultant audited 100% of resident's charts on 02/15/2025 to identify residents with a presence of Candida auris and whether the infection was facility or community acquired. Outcome: (12) facility acquired & (16) Community acquired. Active surveillance listing will be maintained by the Facility Infection Preventionist from 02/15/2025 forward to include Infection Type and acquired status (Facility vs Community). 7. Sustainability The Administrator is responsible for reviewing all compliance reports (including health department recommendations) and taking immediate corrective action where needed. The Infection Preventionist or Weekend RN Supervisor will conduct Daily audits for PPE compliance and environmental cleaning logs will continue for 30 days and then as needed. The Infection Preventionist will collaborate with the health department as directed and will ensure recommendations are carried out timely. 8. Policy / Recommendation Review The Administrator reviewed the Infection Control Program Policy and Procedure and the Candida auris policy and procedure on 02/15/2025 and no updates were required. The Regional Nurse Consultant, IP, and Administrator reviewed the current Health Department recommendations on 02/14/2025 and initiated Candida auris training (see number 1) and increased environmental cleaning (see number 2). Completion date 2/16/2025. Monitoring of the plan of removal included the following: Observation on 02/17/2025 at varies times, between 9:00am and 5:00am on the 100, 300 and 400 halls during rounds revealed contact precaution signs posted, bins were placed on outside their room doors, and bio-hazard box (boxes used to discard PPE) in the room. Staff were seen donning and doffing PPE, washing hands, and using hand sanitizer. Observation on 02/18/2025 at varies times, between 9:00am and 5:00am on the 100, 300 and 400 halls during rounds revealed all residents identified with Candida Auris were on isolations, with contact precaution signs posted, bins were placed on outside their room doors, and bio-hazard box in the rooms. Staff were seen donning and doffing PPE, washing hands and using hand sanitizer. Observation on 02/18/2025 at 11:45 AM, revealed disposable trays we're being used to serve residents who were on contact isolation precaution. Trays were discarded bio-hazard box after use. Interview conducted on 02/17/2025 at 11:04 AM, RN E stated a resident with Candida Auris families were called and educated about the disease process. He said the nurses, CNAs, housekeeping, central supply, Respiratory Therapist were educated, about Candida Auris and TBPs. He staff knowledge and understanding was verified by taking and passing a facility provided test competency test. Interview conducted 02/17/2025 at 11:15 AM, the Housekeeping Supervisor stated she worked 6:00 AM to 3:00 PM and as needed. She said she was in-serviced on 02/15/2025 about Candida Auris, how it spread, hand washing, cleaning the equipment's, donning, and doffing PPE's. Identifying residents with Candida Auris with the sign posted. She said the facility had adequate bio-hazard box and bags. Interview conducted on 02/17/2025 at 11:25 AM, LVN M said residents' family were called and educated about Candida Auris disease process, contact isolation for Candida Auris, hand washing, cleaning the equipment's, donning and doffing PPE's and she care planned resident isolation with Candida Auris. Interview conducted on 02/17/2025 at 11:27 AM, revealed RT worked 6:30 AM to 7:00 PM, she had in-services on Candida Auris disease process, contact isolation for Candida Auris, hand washing, cleaning the blood pressure cuff, Accu checks equipment, donning and doffing PPE's. Interview conducted on 02/17/2025 at 11:33 AM, revealed LVN C worked 6:00 AM -2:00 PM for one year, had in-services on Candida Auris disease process, spray, contact isolation for Candida Auris, hand washing, cleaning the blood pressure cuff, Accu checks equipment , donning and doffing PPE's. Interview conducted on 02/17/2025 at 11:47 AM, CNA R stated she worked 6:00 AM to 2:00 PM and had in-services on Candida Auris disease process, spray, contact isolation for Candida Auris, hand washing, donning, doffing PPE's. CNA R was observed to don gloves and a gown to feed Resident #4 on contact isolation. In an interview with the Regional Nurse Consultant and the Facility Administrator on 02/18/2025 at 12:30 PM, the Administrator said the Medical Director was informed of the outbreak. Interview attempt on 02/18/2025 at 1:40 PM with the Medical Director by telephone was unsuccessful. Interview conducted on 02/18/2025 at various times, 9:00am - 5:00pm, with (LVN S, CNA Y, CNA D, CAN S, RT O) revealed they were able to verbalize understanding of all in-services provided on hand hygiene, donning and doffing PPE, contact precaution and transmission-based precautions, and verified knowledge of systems in place as of 02/18/2025. Interview conducted on 02/18/2025 at various time, the Housekeeping Supervisor and Housekeeping staff verbalized TBPs to prevent the spread of Candida auris. All were verbalized knowledge of cleaning schedules for residents affected by Candida auris and the requirement to clean and disinfect twice a day using EPA-approved disinfectants effective against Candida auris per the county health department recommendations. Record review revealed Regional Nurse Consultant provided education on 02/15/2025, 02/16/2025, 02/17/2025, and 02/18/2025 provided to all staff on Candida auris (including background/definition, PPE & isolation protocols (including co-horting), disinfectant protocols, equipment/clothes/linen handling, meal service, and methods to prevent the spread of Candida auris). Record review revealed daily cleaning audits logs were being conducted as of 02/17/2025, by Housekeeping Supervisor. Record review of trainings revealed Regional Nurse Consultant provided 1:1 education with the IP B, Weekend RN Supervisor, and Administrator on 2/15/2025 on Candida auris, Infection Prevention Program Policy to include surveillance. Record review of clinical documentation revealed the Regional Nurse randomly selected residents revealed the families was educated on Candida auris and the prevention measures to be used when entering and exiting residents isolation rooms. The Facility Administrator and Regional Nurse Consultant was informed the Immediate Jeopardy was removed on 02/18/2025 at 1:30 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, record review, and interview, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities for 4 of 4 halls (100 Hall, 200 Hall, 300 Hall, and 400 Hall) reviewed for call light systems. 1. The facility failed to repair or replace the call light system for the entire building after five months when inclement weather caused the system to fail on 05/02/2024 through 10/09/2024. Resident #2, Resident #3, and Resident #4, who were all physically and cognitively capable of using a call light system had no means to call for staff assistance. 2. The facility failed to have adequate interventions in place for CR #1, who was alert, oriented, and quadriplegic (a condition that causes a person to lose the ability to move all four limbs and the body from the neck down), to call for staff assistance and resulted in family members calling 911 after attempting to call the facility 45 times when CR #1 experienced a change of condition (shortness of breath). EMS noted CR #1 was tachycardic (134 BPM) (when the heart beats faster than normal, usually more than 100 beats per minute while resting), diaphoretic (sweating profusely), and febrile (103 degrees F) (with fever) with an oxygen saturation (the percentage of oxygen-saturated hemoglobin in the blood) of 89% (normal range is between 95% and 100 %) on 09/10/2024. An IJ was identified on 11/14/2024 at 11:49 a.m. The IJ template was provided to the facility on [DATE] at 11:49 a.m. While the IJ was removed on 11/15/2024, the facility remained out of compliance at a scope of pattern with severity level at a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on 11/14/2024. These failures could place residents capable of operating a call light system or adaptive call buttons at risk of experiencing a delay in receiving urgent medical care in emergency situations and delayed assistance with activities of daily living. Findings include: Record review of CR #1's face sheet dated 09/10/2024 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 was diagnosed with non-pressure chronic ulcer (a non-healing wound) of the skin, acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), and pressure ulcer of the sacral region (the triangular bone that connects the spine to the pelvis and forms the back wall of the pelvis), stage 4 (the most severe type of pressure ulcer and involves full thickness tissue loss with exposed bone, tendon, or muscle). He was discharged to an acute care hospital on 09/10/2024. Record review of CR #1's electronic health record revealed he did not have a completed MDS. Record review of CR #1's Observation Detail List Report dated 09/04/2024 revealed CR #1 could make himself understood, he understood others, and he had no short-term or long-term memory concerns. Record review of CR #1's care plan revised on 09/05/2024 revealed the following care areas: * Baseline Care Plan: will identify my care needs, risks, strengths, and goals for the first 48 hours. Goal included: My initial goal is to have access of services to promote adjustment to my new living environment. Approach included: * Activities and Functional Level for daily Care: I will receive the necessary setup, cueing, support and assistance level for activities of daily living. * Anticoagulation therapy will be administered as ordered by the physician. * Behavioral need will be evaluated for impact on quality of life, safety, and safety of others. * I will be receiving skilled care and my discharge planning, goals, community referrals, transportation, health knowledge deficits, and follow-up will be discussed and planned with me and as needed with selected representatives. I will remain in place for long-term or hospice care. A comprehensive plan of care will be developed following a complete evaluation of my needs, strengths, and personal preferences. * Pressure Ulcer/Injury. Trauma wound to back of head related to immobility. Goal included: Trauma wound to back of head will heal without complications. Approach included: Avoid shearing resident's skin during positioning, transferring, and turning; Conduct systematic skin inspection weekly; Treat area per doctor orders. * Pressure Ulcer/Injury. Stage 4 Pressure injury/ulcer wound to sacrum related to immobility. Goal included: Resident's ulcer will heal without complications. Approach included: Apply dressings per doctor orders; Assess the pressure ulcer for stage, size, granulation tissue (a new connective tissue that forms in a wound during the healing process), and condition of surrounding skin weekly; Keep resident off load wound; Turn and reposition as needed, and as tolerated. Record review of CR #1's Physician's Progress Note dated 09/09/2024 revealed, . [CR #1] is an [AGE] year-old male with no previous medical history whose hospitalization started with a gunshot wound to his right neck in 05/2024. He sustained a transection of right ICA and right vertebral artery with blast injury (physical trauma resulting from direct or indirect exposure to an explosion) of C2 (the second cervical vertebra) and involvement of spinal canal. This has resulted in quadriplegia (a condition that causes a person to lose the ability to move all four limbs and the body from the neck down), tracheostomy placement (a surgical procedure that creates an opening in the neck and into the windpipe, or trachea to provide an airway for breathing), and chronic respiratory failure requiring continuous invasive mechanical ventilation. His course was complicated by a pneumothorax (when air leaks into the space between the lungs and chest wall) s/p chest tube placement and removal, multi-drug resistant pneumonia, multi-drug resistant urinary tract infection, and a significant sacral wound requiring I&D (minor surgical procedures to release pus or pressure built up under the skin) on 08/19/2024. He has been treated with multiple antibiotics, however, most recently was placed on Ceftazidime for a 4-week course due to his sacral wound, which per the infectious disease team that was seeing him, should continue until 09/20/2024 . [CR #1] is awake and alert and in no distress . Vital Signs: Pulse - 99 BMP, Blood Pressure - 122/67, O2 Saturation - 99 Room Air, Respiratory Rate - 18 Breaths per minute . Record review of CR #1's nursing progress notes for September 2024 revealed: * On 09/09/2024, at 1:45 p.m., LVN C wrote, Resident on day 5 of Ceftazidime 1 gram IV for Pneumonia. Indwelling Catheter intact, patent (open and functioning properly, with minimal blockage), and draining . * On 09/11/2024, at 3:17 p.m. (this entry was recorded as a late entry for 09/09/2024 at 11:13 p.m.), LVN A wrote, Resident is alert and oriented x 4 (a medical term that indicates a patient is awake, alert, and oriented to person, place, time, and event), was asked if he needed any PRNs or anything during this nurse first round, resident denied needing anything. Vital signs were taken by nighttime CNAs. IV line was flushed after antibiotic therapy finished. No s/s of distress or pain noted during this round. * On 09/10/2024, at 3:40 a.m., LVN A wrote, 911 showed up to facility for patient by [family member] request. Paramedic suctioned the patient, there was no secretions coming out. He repeatedly kept suctioning and bleeding was observed on the tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck). Vital signs were taken - BP: 114/68, HR: 137, RR: 20, T: 97.9 [degrees Fahrenheit], O2 Sat: 99%. Resident had complained of SOB, RT assessed and O2 Sats were WNL for this patient. Resident is A&O x 4 and requested to be transported to the hospital. Resident will be taken to a local acute care hospital. RP notified of transfer. DON was notified. * On 09/10/2024, at 5:38 a.m., RT B wrote, Lung Sounds: Diminished; Respirations Rhythm/Pattern: Regular/Unlabored. Cough Present? No. Shortness of Breath present? No. Shortness of Breath (dyspnea): None of the above. Oxygen in use? Yes (Liter Flow) 5. Use of vent: Yes . Restlessness present? No. Anxiety present? No . Resident's [family member] called 911 to take resident to the hospital. Resident complaining that he cannot breathe. SPO2 WNL at 99%. Paramedic immediately began suctioning resident's tracheostomy, no secretions noted. Paramedic repeatedly suctioned and bleeding through the tracheostomy started. RT suctioned small amount of secretion through nose and mouth. Resident alert and oriented. No respiratory distress noted. RT has provided respiratory care. EMS left at 4:00 a.m. * On 09/10/2024, at 2:30 p.m., the DON wrote, This writer spoke with RP regarding concerns about phone calls last night. She expressed her concerns. Provided RP with this writer's phone number to call. Explained that new cordless phones are being provided. RP stated she will be bringing [CR #1] back. She stated he has a low fever and will be getting a supra pubic catheter while at the hospital and the return to the facility. * On 09/10/2024, at 3:35 p.m., the Administrator wrote, Spoke to family member and apologized of the phone not being answered timely and gave her my cell phone number to reach out with any questions or concerns . Record review of CR #1's EMS record dated 09/10/2024 revealed, . Last known well - 09/10/2024 at 1:00 a.m. Signs and Symptoms: Shortness of Breath (Primary) . Call Received: 3:23 a.m. Dispatched: 3:25 a.m. On Scene: 3:33 a.m. At Patient: 3:36 a.m. Depart Scene: 4:13 a.m. 3:41 a.m. - Pulse: 134, RR: 22, Temperature: 103.5 [degrees Fahrenheit] . Was dispatched to facility for a breathing problem. We responded emergency traffic and arrived on location without incident or delay. Dispatch advised that the patient's family member called 911 but was not on location. We entered the facility and found the patient lying in bed. Patient contact was made an initial assessment was performed . Patient was A&O x 4. Patient tracheostomy tube was occluded with mucus and was immediately suctioned and cleared. Patient breathing was accelerated with equal chest rise and fall, clear lung sounds, denied any chest pain but was in moderate distress. Patient skin was hot to touch and diaphoretic (sweating profusely), strong and rapid pulses, and no obvious signs of injury or bleeding noted. Further assessment showed patient was running a fever and had increased capnometry (amount of carbon dioxide in exhaled air). Patient family member was contacted at this time. She advised that she had called the facility multiple times since 1:00 a.m. to find out why [CR #1] was having difficulty breathing but eventually called 911 after getting no response. Patient vitals were obtained at this time and are as noted in report. EMS requested additional staff to make location for additional manpower to assist in moving the patient and assisting ventilations during transport . Patient tracheostomy tube was flushed and suctioned . Patient showed sinus tachycardia that would gradually increase in rate during patient care . Record review of CR #1's hospital records revealed on 09/10/2024, at 4:29 a.m. his temperature was 103.5 degrees Fahrenheit, and his heart rate was 158. IV fluids and acetaminophen were ordered. The document read in part, . 09/10/2024, at 9:42 a.m. History and Physical . Today 09/10/2024 brought by EMS with worsening shortness of breath. According to his family member, he has been 'feeling hot' for the past two days, having shortness of breath since last night. According to her, he has been with a lot of respiratory secretions. He reports no symptoms at the time of my interview, only asking for ice chips. He reports no chest pain, no nausea, no vomiting, or diarrhea. ED course: Mild hypernatremia (high concentration of sodium in the blood) with slight leukocytosis (high white blood cell count) with mild anemia. Calcium slightly elevated with mild liver enzymes elevation. Chest x-ray was consistent with right lower lobe pneumonia versus atelectasis (complete or partial collapse of a lung). EKG with sinus tachycardia. Patient was treated with IV Meropenem (antibiotic used to treat infection) in the ED and admitted for further evaluation and treatment . Impression and Plan Diagnosis: acute on chronic respiratory failure, acute sepsis (a life-threatening complication of an infection), anemia, aspiration pneumonia (a lung infection due to a relatively large amount of material from the stomach or mouth entering the lungs) . Record review of Resident #2's face sheet dated 09/17/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with acute respiratory failure with hypoxia, cerebral palsy (a congenital disorder of movement, muscle tone, or posture), chronic obstructive pulmonary disease (a group of lung diseases that make it hard to breathe), history of tracheostomy, and dependence on respirator. Record review of Resident #2's MDS dated [DATE] revealed he could make himself understood; he had a BIMS score of 15 (cognitively intact); and he required extensive assistance from one staff member with bed mobility, transfers, eating, and toilet use. Record review of Resident #2's care plan revised 06/20/2024 revealed the following care areas: * Resident is at risk for falls due to weakness. Goal included: Resident will be free of falls. Approaches included: Implement exercise program that targets strength, gait, and balance. Place call light/ call bell within reach all the time and respond to call light/ call bell promptly. * Resident has a chronic established contractures of bilateral (both sides) upper extremities due to cerebral palsy (upon admission). Goal included: Resident will receive measures to correct or prevent further progression of current contractures from developing to allow for proper positioning and adequate hygiene of extremities. Approach included: PT/OT to establish most appropriate contracture management program and work on compensatory strategies to improve independence with functional tasks. * Resident able to communicate well with the staff: alert and oriented x 3-4 (3: person is alert and oriented to person, place, and time, but not what is happening to them. 4: fully alert), verbal, speaks and understands English, understood and able to understand other. Goal included: Resident needs will be communicated to the staff and will ensure that they are met. Approaches included: Allow resident time to speak. Avoid interrupting. Encourage verbalization. Record review of Resident #3's face sheet dated 09/17/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with metabolic encephalopathy (a group of neurological disorders that occur when the brain is affected by chemical imbalance in the blood), cognitive communication deficit (difficulty with communication that is caused by a disruption in cognition) , aphonia (loss of voice), dysphagia (difficulty swallowing), tracheostomy status, and dependence on a respirator, acute and chronic respiratory failure, cerebral infarction (when blood flow to the brain is blocked, resulting in brain tissue death), and end-stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). Record review of Resident #3's MDS dated [DATE] revealed he was usually understood by others; he had a BIMS score of 15 (cognitively intact); and he required substantial/maximal assistance from staff with eating, oral hygiene, and toileting. Record review of Resident #3's care plan revised 10/03/2024 revealed the following care areas: * Resident has impaired communication related to unclear speech and aphonia (loss of voice). Resident is usually understood and understands other. Goal included: Resident will be able to make basic needs known daily. Approaches included: Allow adequate time to respond, repeat as necessary. Anticipate and meet needs. Ensure/provide a safe environment: call light in reach, adequate low glare light. * Resident is at risk for falls due to muscle weakness, decreased coordination, and impaired physical and functional mobility. Goal included: Resident will be free from minor/major fall related injuries. Approaches included: Implement exercise program that targets strength, gait, and balance. Keep call light/call bell within easy reach. Ensure prompt staff response. Record review of Resident #4's face sheet dated 11/19/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with acute and chronic respiratory failure with hypoxia, anemia (when the blood does not have enough healthy red blood cells and hemoglobin to carry oxygen all through the body), pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus), dysphagia, history of transient ischemic attack (a brief stroke-like attack) and cerebral infarction, aphonia, cognitive communication deficit, and history of tracheostomy. Record review of Resident #4's quarterly MDS dated [DATE] revealed she understood others and made herself understood; she had a BIMS of 8 (moderate cognitive impairment); and she was dependent on staff for eating, hygiene and bathing. Record review of Resident #4's care plan revised 10/23/2024 revealed the following care area: * Resident is at risk for falls due to weakness. Goal included: Resident will be free of falls. Approaches included: Increased staff supervision with intensity based on resident need. Place call light/call bell within reach all the time and respond to call light/call bell promptly. Observation of all four of the facility's halls (100 Hall, 200 Hall, 300 Halls, and 400 Hall) and random rooms on all four halls inside the facility (101, 103 - 100 Hall, 204 - 200 Hall, 306 - 300 Hall, and 402, 413, 414 - 400 Hall) on 09/10/2024, starting at 12:45 p.m. until 3:15 p.m. revealed residents had cowbells (a hand percussion instrument), squeeze toys, and buzzers to use at beside and in bathrooms when they needed staff assistance. Further observation of the facility during this timeframe revealed there were multiple bedside tables placed haphazardly on each hall with chairs. Facility staff were observed sitting in the chairs at random times. Observation and interview of Resident #2 in room [ROOM NUMBER] (on the 100 Hall) on 09/10/2024, at 1:16 p.m. revealed he was alert and oriented. He stated his family supplied him with a buzzer which played a musical sound to use when he needed staff assistance. He stated because of his hands, he would not be able to operate a regular call button and would require an adaptive call button. The sound from the buzzer was loud inside the resident's room and could be heard from outside the resident's room. The sound of the buzzer became more and more faint further down the hall. Resident #2 stated he pushed the buzzer multiple times, depending on the urgency of what he needed. He stated staff responded timely most of the time, but sometimes, staff took longer to respond, just as they did when the call light system was in working order. He said he had not experienced any negative outcomes because of the broken call light system. Observation and interview with CR #1 on 09/10/2024 at 3:30 p.m. revealed he was in a room in the ER of a local acute care hospital. CR #1 was alert and had a tracheostomy connected to a ventilator. CR #1 also had on a neck brace. CR #1 was sweating heavily. CR #1 did not initially verbalize words. He blinked once for yes answers and twice for no answers. CR #1 indicated no facility staff went to his room early that morning (09/10/2024) until EMS arrived. He indicated he did not know what time facility staff last checked on him. He indicated he felt hot and sick while waiting for staff to reposition him. CR #1 indicated he had trouble breathing and needed to be suctioned that morning, but he did not have a way to call the staff directly for help. He indicated he was sweating that morning and then he said, Help. CR #1 indicated he wanted a nurse. While waiting for a hospital nurse to come, CR #1 said, Ice chips. CR #1's hospital nurse stated CR #1 was febrile (had a fever) with a temperature of 103.5 degrees Fahrenheit when he arrived in the ER, and he was being admitted for sepsis. The nurse took CR #1's temperature and stated it was 99.9 degrees Fahrenheit. The nurse stated CR #1 was tachycardic upon arrival to the ER at 158 BPM. Observation and interview of Resident #3 in room [ROOM NUMBER] (on the 400 Hall) on 09/17/2024 at 1:18 p.m. revealed he was alert but had a tracheostomy connected to a ventilator and could not communicate verbally. There was a red cowbell on a bedside table in the space between Resident #3 and his roommate's bed. The bell was not within reach of Resident #3. Resident #3 could answer questions with gestures and head nods. He indicated he did not have a bell to ring if he needed help from staff because the call light system did not work. He indicated the red bell on the table was not his. He indicated he was new to the facility, and nobody ever gave him a bell or device to use when he needed help from staff. He indicated he could move both of his hands and arms. Observation of Resident #3, at that time, revealed he could move both arms and hands. He shrugged his shoulders to indicate he did not know how he would let staff know he needed help. At that time, RT E was in the hallway outside of Resident #3's room. RT E stated Resident #3 was alert and oriented. RT E stated the red bell on the table belonged to Resident #3 because his roommate was unable to operate the bell. Resident #3 indicated nobody ever told him the red bell was his to ring when he needed help from staff. RT E asked Resident #3 to demonstrate his ability to ring the bell. Resident #3 placed his hand around the bell and attempted to ring it, but the sound was slightly muffled. RT E provided Resident #3 with a buzzer, and he demonstrated he could operate it successfully. Observation and interview with a Resident #4 in room [ROOM NUMBER] (100 Hall) on 09/17/2024 1:40 p.m. revealed she was alert with a tracheostomy and could not communicate verbally. Observation of Resident #4's room revealed she did not have a bell or other device to operate if she needed help from staff. She could answer questions with gestures and head nods. She indicated she did not know where her bell was, and she did not know how long it had been missing. Observation of Resident #4 at that time revealed she could move her arms and hands. She indicated she did have a bell at one time, but she had not seen it in a while. She indicated she had not had the bell for at least multiple days. She shrugged her shoulders to indicate she did not know how she would alert staff if she needed help. In a telephone interview with CR #1's RP on 09/10/2024 at 11:35 a.m., she stated EMS told her that CR #1 had a high temperature when he was admitted to the hospital on 09/10/2024. She stated CR #1 was able to communicate with an eye tracker system on his tablet which allowed him to text (which turned the text to voice) with his eyes since he could not move his limbs and the facility did not have a call light he could use. She said the device allowed CR #1 to call phone numbers when he needed help. She said she let the staff know when he was admitted on [DATE] to keep an eye on him because he had problems with his breathing between the hours of 2:00 a.m. - 3:00 a.m. and 6:00 a.m. - 7:00 a.m. She said she had not been able to reach the staff by phone during those hours. She said CR #1 was able to tell her he had snot all over his face on the morning of 09/10/2024. She said CR #1 knew when he needed to be repositioned and suctioned and he recalled everything perfectly. She said he was nonverbal now, but he was very aware and alert. She said she had to call 911 on 09/10/2024 because nobody answered the phone and staff only called her to let her know CR #1 was going to the hospital. She said earlier during the night shift, (on 09/09/2024) at 9:31 p.m., CR #1 contacted her and said he had not been repositioned. She said he could not recall what time he was last repositioned, before then, but he said it had been a long time. She said she called the facility at 9:34 p.m. and someone answered the phone and went to assist CR #1. She said on 09/10/2024, the problem started at 1:45 a.m. when CR #1 called another family member and indicated he could not breath, he had mucus coming out of his nose, and he needed to be repositioned. She said that family member called her at 1:53 a.m. She said she called the facility at 1:53 a.m., but nobody ever answered the phone. She said on at 2:38 a.m., she asked CR #1 if anybody came to assist him and he texted No, please call the facility. She said she told CR #1 she was calling right then. She said at 2:40 a.m., she called the facility more times and CR #1 indicated that he was hot, he needed a breathing treatment, and he need to be repositioned. She said at 2:49 a.m., CR #1 indicated nobody came to assist him yet and he had a lot of snot on his face. She said at 2:50 a.m., CR #1 got anxious and texted, Help! She said two other family members got involved and started calling the facility. She said at 3:00 a.m., CR #1 indicated that nobody had went to assist him. She said CR #1 stopped texting at 3:05 a.m., but she was still calling the facility over and over from 3:03 a.m. - 3:19 a.m. She said she called 911 at 3:21 a.m. She said EMS called her from their personal cell phone at 3:47 a.m. and said CR #1 had a face full of snot and needed to be suctioned. She said EMS told her CR #1's other vital signs were fine, but he had a high temperature. She said EMS took CR #1 to the hospital because he wanted to go. She said the facility's staff called her at 4:30 a.m. to let her know CR #1 was being transported to the hospital. She said another family member called the facility 28 times and she called 17 times. She stated she previously told facility staff (she could not recall the names of staff she talked to) that CR #1 experienced anxiety at certain times during the night. In an interview with RT B on 09/12/2024 at 3:15 a.m., he stated he worked with CR #1 on Saturday (09/07/2024), Sunday (09/08/2024), and Monday 09/09/2024) (respiratory therapists work 12-hour shifts, so RT B was on shift the morning of 09/10/2024). He stated CR #1 complained of shortness of breath a few times during his shift, but his oxygen saturation was good at 99% and he was not in distress. He said he thought CR #1 experienced anxiety because his vital signs were fine, he was breathing fine, and it was common for residents with new tracheostomies to have anxiety. RT B said he checked on CR #1 every two hours, and he was called to CR #1's room a lot to suction secretions from his nose and mouth. RT B said CR #1 always called his RP and she called them at the facility. He said CR #1 often had a lot of secretions from his nose and mouth. He said CR #1 was uncomfortable with the secretions, so he suctioned him, but CR #1 was not in an emergency. He said he heard the phone ring a lot on Tuesday morning (09/10/2024) and the nurse (he could not recall which nurse answered the phone) answered a few times. RT B said LVN A told him CR #1's RP wanted them to check him to see if was ok, so they went to check him immediately after his RP called. He said CR #1's vital signs were perfect. He said CR #1 made sounds with his mouth and grimaced, so he suctioned his nose, mouth, and tracheostomy. He said CR #1 had some snot (secretions from his nose) on his face, but not a lot. He said LVN A was CR #1's nurse, and she was assigned to work half of two halls, so she was not on CR #1's hall the whole shift. RT B said CR #1 was not sweating when he checked him. He said between 1:45 a.m. and when EMS arrived, he had been in CR #1's room three times. He said he went in when EMS came, so that was his 4th round into CR #1's room. He said he was surprised when he saw EMS in the building, and they immediately suctioned CR #1 because of SOB. He said nothing came from CR #1's tracheostomy and EMS went in again and again until CR #1 started bleeding. RT B said he told EMS to stop. He said when EMS arrived, CR #1 had a medium amount of nose and mouth secretions. He said he called LVN A to come when EMS arrived because she was on another hall. He said he saw LVN A check CR #1's vital signs, including his temperature when EMS arrived. He said CR #1's heart rate was a little high, but he thought it was from anxiety. RT B said CR #1's temperature was fine at that time and he was not sweating. He said CR #1's RP insisted EMS take him to the hospital. In an interview with the Administrator on 09/12/2024, at 12:45 p.m., she stated the call light system was still broken and had been broken for several months since a thunderstorm caused it to go out in April 2024, or May 2024. She stated lightning struck the whole panel during the storm and the system could not be fixed. She stated she went out and bought bells and squeeze toys because the bells were too heavy for some residents to use. She said they also placed tables and chairs for nursing staff to sit out on each hall and check residents more frequently. She said she also implemented the use of walkie-talkies, so if an RT needed a nurse quickly, they could call on the walkie-talkie. She said contractors tried to replace the system and said they would come back when they were paid. She stated she did not know when the contractors would be paid by corporate. She said residents asked for updates every month during resident council meetings, but she had to tell them she did not have answers. She said she heard residents say it took too long for staff to come when they rang the bells/buzzers, but some residents also had that complaint before the call light system broke. In an interview with the DON on 09/12/2024, at 2:15 p.m., she stated she was familiar with CR #1, and she had just spoken to his RP. She said CR #1's RP said she called the facility multiple times that morning (09/10/2024) and felt CR #1 did not get adequate care. She said the RP said she and other family members called over 50 times. She said a nurse only answered once and went in to help CR #1, but nobody answered the other times. The DON said she investigated, and the nurse (LVN A) verified she went in and checked on CR #1. She said the nurse told her the phone probably did ring that many times, but she was in another room at the time. The DON said that was probably why CR #1's RP called 911. She said since that incident, they had gotten cordless phones for the nurses on each hall. The DON said CR #1 was already gone to the hospital when she arrived on 09/10/2024, so she could not assess him. She stated CNAs, nurses, and respiratory therapists had to go in every two hours and anticipate CR #1's needs because he could not utilize the bells/buzzers as other residents. She said the nurses usually did visual head-to-toe checks and did not check vitals with each round. In an interview with LVN A on 09/12/2024, at 2:40 p.m., she stated her normal shift was 2:00 p.m. - 10:00 p.m. but she picked up a 10:00 p.m. - 6:00 a.m. shift on Monday 09/09/2024. She stated that was her first time working with CR #1. She said her first encounter with CR #1 was at 10:15 p.m., at the beginning of her shift. She said CR #1 was watching a movie on his tablet and could mouth words. She said CR #1 indicated he was ok. She state [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care on accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 residents (CR #1) reviewed for quality of care. The facility failed to ensure the night shift staff (10:00 p.m. - 6:00 a.m.) recognized and provided clinical interventions when CR #1 experienced a change of condition (shortness of breath, fever of 103.5 degrees Fahrenheit, tachycardia (134 BPM) (when the heart beats faster than normal, usually more than 100 beats per minute while resting), and diaphoresis (sweating profusely), with an oxygen saturation (the percentage of oxygen-saturated hemoglobin in the blood) of 89% (normal range is between 95% and 100 %) on 09/10/2024 after family members attempted to report his concerns by calling the facility approximately 45 times between 1:53 a.m. and 3:47 a.m. This resulted in a delay in CR #1 receiving urgent medical treatment. This failure could place residents at risk of further deterioration of their condition and pain. Findings include: Record review of CR #1's face sheet dated 09/10/2024 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 was diagnosed with non-pressure chronic ulcer (a non-healing wound) of the skin, acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), and pressure ulcer of the sacral region (the triangular bone that connects the spine to the pelvis and forms the back wall of the pelvis), stage 4 (the most severe type of pressure ulcer and involves full thickness tissue loss with exposed bone, tendon, or muscle). He was discharged to an acute care hospital on 09/10/2024. Record review of CR #1's electronic health record revealed he did not have a completed MDS. Record review of CR #1's Observation Detail List Report dated 09/04/2024 revealed CR #1 could make himself understood, he understood others, and he had no short-term or long-term memory concerns. Record review of CR #1's care plan revised on 09/05/2024 revealed the following care areas: * Baseline Care Plan: will identify my care needs, risks, strengths, and goals for the first 48 hours. Goal included: My initial goal is to have access of services to promote adjustment to my new living environment. Approach included: * Activities and Functional Level for daily Care: I will receive the necessary setup, cueing, support and assistance level for activities of daily living. * Anticoagulation therapy will be administered as ordered by the physician. * Behavioral need will be evaluated for impact on quality of life, safety, and safety of others. * I will be receiving skilled care and my discharge planning, goals, community referrals, transportation, health knowledge deficits, and follow-up will be discussed and planned with me and as needed with selected representatives. I will remain in place for long-term or hospice care. A comprehensive plan of care will be developed following a complete evaluation of my needs, strengths, and personal preferences. * Pressure Ulcer/Injury. Trauma wound to back of head related to immobility. Goal included: Trauma wound to back of head will heal without complications. Approach included: Avoid shearing resident's skin during positioning, transferring, and turning; Conduct systematic skin inspection weekly; Treat area per doctor orders. * Pressure Ulcer/Injury. Stage 4 Pressure injury/ulcer wound to sacrum related to immobility. Goal included: Resident's ulcer will heal without complications. Approach included: Apply dressings per doctor orders; Assess the pressure ulcer for stage, size, granulation tissue (a new connective tissue that forms in a wound during the healing process), and condition of surrounding skin weekly; Keep resident off load wound; Turn and reposition as needed, and as tolerated. Record review of CR #1's undated pre-admission hospital records revealed he was admitted to a specialty hospital on 07/10/2024 and was discharged to the facility on [DATE]. The document revealed CR #1 was diagnosed with the following: *Sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, damaging the body's own tissues and organs), *Aspiration pneumonia (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs), *Leukocytosis (a high level of white blood cells in the blood), *Fever, *Complicated UTI (a UTI that has a higher risk of treatment failure than a simple UTI), *Acute on chronic respiratory failure (when a patient with chronic respiratory insufficiency experiences a sudden decline in health) *s/p tracheostomy, *Peg (a feeding tube) placements with ventilator dependency, *Sacral and posterior head wounds, and *New sepsis of sacral wound (unstageable) with infection/cellulitis (bacterial skin infection). Further review read in part, Plan: Presented from an acute care hospital on 07/11/2024 with infiltrates in right upper lobe (lung) and right middle lobe. Began having intermittent fevers on 7/28/2024 (highest temperature seen in records is 102.9 degrees Fahrenheit on 07/31/2024) . Date of Service: 09/03/2024. Subjective Progress Notes: . The patient remains on ventilator with catheter in place . He continues to have intermittent low-grade fevers (a body temperature that is slightly higher than normal, usually between 99.5 and 100.3- degrees Fahrenheit) and remains with leukocytosis . Record review of CR #1's Physician's Progress Note dated 09/09/2024 revealed, . [CR #1] is an [AGE] year-old male with no previous medical history whose hospitalization started with a gunshot wound to his right neck in 05/2024. He sustained a transection of right ICA and right vertebral artery with blast injury (physical trauma resulting from direct or indirect exposure to an explosion) of C2 (the second cervical vertebra) and involvement of spinal canal. This has resulted in quadriplegia (a condition that causes a person to lose the ability to move all four limbs and the body from the neck down), tracheostomy placement, and chronic respiratory failure requiring continuous invasive mechanical ventilation. His course was complicated by a pneumothorax (when air leaks into the space between the lungs and chest wall) s/p chest tube placement and removal, multi-drug resistant pneumonia, multi-drug resistant urinary tract infection, and a significant sacral wound requiring I&D (minor surgical procedures to release pus or pressure built up under the skin) on 08/19/2024. He has been treated with multiple antibiotics, however, most recently was placed on Ceftazidime for a 4-week course due to his sacral wound, which per the infectious disease team that was seeing him, should continue until 09/20/2024 . [CR #1] is awake and alert and in no distress . Vital Signs: Pulse - 99 BMP, Blood Pressure - 122/67, O2 Saturation - 99 degrees Fahrenheit Room Air, Respiratory Rate - 18 Breaths per minute . Record review of CR #1's physician's orders for September 2024 revealed: * Ceftazidime Reconstitution solution (used to treat or prevent a variety of bacterial infections); 1 gram; 1000 mg; Intravenous (within or into a vein). Frequency: Every 8 hours (5:00 a.m., 1:00 p.m., and 9:00 p.m.). Special Instructions: Pneumonia (an infection that inflames air sacs in one or both lungs). Start/End Date: 09/04/2024 - 09/05/2024 (Discontinued date). * Ceftazidime Reconstitution solution; 1 gram; 1000 mg; Intravenous (within or into a vein). Frequency: Every 8 hours (5:00 a.m., 1:00 p.m., and 9:00 p.m.). Special Instructions: Sacral Wound. Start/End Date: 09/05/2024 - 09/20/2024. * Anti-Anxiety Medication Use - Observe resident closely for significant side effects. Every Shift. Start Date: 09/05/2024. * Check vital signs once every shift. Every Shift. Start Date: 09/05/2024. * Respiratory: Suction Every Shift. Start Date: 09/04/2024. * Respiratory: Suction every two hours or as needed for increased secretions. Every two hours - PRN. Start Date: 09/04/2024. * Respiratory: Tracheostomy Care (Even Rooms) Once per day. 7:00 p.m. - 7:00 a.m. Start Date: 09/04/2024. Record review of CR #1's MAR for September 2024 revealed Ceftazidime was administered as ordered from 09/05/2024 until 09/09/2024. Record review of CR #1's nursing progress notes for September 2024 revealed: * On 09/09/2024, at 1:45 p.m., LVN C wrote, Resident on day 5 of Ceftazidime 1 gram IV for Pneumonia. Indwelling Catheter intact, patent, and draining . * On 09/11/2024, at 3:17 p.m. (this entry was recorded as a late entry for 09/09/2024 at 11:13 p.m.), LVN A wrote, Resident is alert and oriented x 4 (a medical term that indicates a patient is awake, alert, and oriented to person, place, time, and event), was asked if he needed any PRNs or anything during this nurse first round, resident denied needing anything. Vital signs were taken by nighttime CNAs. IV line was flushed after antibiotic therapy finished. No s/s of distress or pain noted during this round. * On 09/10/2024, at 3:40 a.m., LVN A wrote, 911 showed up to facility for patient by [family member] request. Paramedic suctioned the patient, there was no secretions coming out. He repeatedly kept suctioning and bleeding was observed on the tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck). Vital signs were taken - BP: 114/68, HR: 137, RR: 20, T: 97.9, O2 Sat: 99%. Resident had complained of SOB, RT assessed and O2 Sats were WNL for this patient. Resident is A&O x 4 and requested to be transported to the hospital. Resident will be taken to a local acute care hospital. RP notified of transfer. DON was notified. * On 09/10/2024, at 5:38 a.m., RT B wrote, Lung Sounds: Diminished; Respirations Rhythm/Pattern: Regular/Unlabored. Cough Present? No. Shortness of Breath present? No. Shortness of Breath (dyspnea): None of the above. Oxygen in use? Yes (Liter Flow) 5. Use of vent: Yes . Restlessness present? No. Anxiety present? No . Resident's [family member] called 911 to take resident to the hospital. Resident complaining that he cannot breathe. SPO2 WNL at 99%. Paramedic immediately began suctioning resident's tracheostomy, no secretions noted. Paramedic repeatedly suctioned and bleeding through the tracheostomy started. RT suctioned small amount of secretion through nose and mouth. Resident alert and oriented. No respiratory distress noted. RT has provided respiratory care. EMS left at 4:00 a.m. * On 09/10/2024, at 2:30 p.m., the DON wrote, This writer spoke with RP regarding concerns about phone calls last night. She expressed her concerns. Provided RP with this writer's phone number to call. Explained that new cordless phones are being provided. RP stated she will be bringing [CR #1] back. She stated he has a low fever and will be getting a supra pubic catheter while at the hospital and the return to the facility. * On 09/10/2024, at 3:35 p.m., the Administrator wrote, Spoke to family member and apologized of the phone not being answered timely and gave her my cell phone number to reach out with any questions or concerns . Record review of CR #1's EMS record dated 09/10/2024 revealed, . Last known well - 09/10/2024 at 1:00 a.m. Signs and Symptoms: Shortness of Breath (Primary) . Call Received: 3:23 a.m. Dispatched: 3:25 a.m. On Scene: 3:33 a.m. At Patient: 3:36 a.m. Depart Scene: 4:13 a.m. 3:41 a.m. - Pulse: 134, RR: 22, Temperature: 103.5 degrees Fahrenheit . Was dispatched to facility for a breathing problem. We responded emergency traffic and arrived on location without incident or delay. Dispatch advised that the patient's family member called 911 but was not on location. We entered the facility and found the patient lying in bed. Patient contact was made an initial assessment was performed . Patient was A&O x 4. Patient tracheostomy tube was occluded with mucus and was immediately suctioned and cleared. Patient breathing was accelerated with equal chest rise and fall, clear lung sounds, denied any chest pain but was in moderate distress. Patient skin was hot to touch and diaphoretic (sweating profusely), strong and rapid pulses, and no obvious signs of injury or bleeding noted. Further assessment showed patient was running a fever and had increased capnometry (amount of carbon dioxide in exhaled air). Patient family member was contacted at this time. She advised that she had called the facility multiple times since 1:00 a.m. to find out why [CR #1] was having difficulty breathing but eventually called 911 after getting no response. Patient vitals were obtained at this time and are as noted in report. EMS requested additional staff to make location for additional manpower to assist in moving the patient and assisting ventilations during transport . Patient tracheostomy tube was flushed and suctioned . Patient showed sinus tachycardia that would gradually increase in rate during patient care . Record review of CR #1's hospital records revealed on 09/10/2024, at 4:29 a.m. his temperature was 103.5 degrees Fahrenheit, and his heart rate was 158. IV fluids and acetaminophen were ordered. The document read in part, . 09/10/2024, at 9:42 a.m. History and Physical . Today 09/10/2024 brought by EMS with worsening shortness of breath. According to his family member, he has been 'feeling hot' for the past two days, having shortness of breath since last night. According to her, he has been with a lot of respiratory secretions. He reports no symptoms at the time of my interview, only asking for ice chips. He reports no chest pain, no nausea, no vomiting or diarrhea. ED course: Mild hypernatremia (high concentration of sodium in the blood) with slight leukocytosis with mild anemia. Calcium slightly elevated with mild liver enzymes elevation. Chest x-ray was consistent with right lower lobe pneumonia versus atelectasis (complete or partial collapse of a lung). EKG with sinus tachycardia. Patient was treated with IV Meropenem (antibiotic used to treat infection) in the ED and admitted for further evaluation and treatment . Impression and Plan Diagnosis: acute on chronic respiratory failure, acute sepsis, anemia, aspiration pneumonia . In a telephone interview with CR #1's RP on 09/10/2024 at 11:35 a.m., she stated EMS told her that CR #1 had a high temperature when he was admitted to the hospital on 09/10/2024. She stated CR #1 was able to communicate with an eye tracker system on his tablet which allowed him to text (which turned the text to voice) with his eyes since he could not move his limbs. She said the device allowed CR #1 to call phone numbers when he needed help. She said she let the staff know when he was admitted on [DATE] to keep an eye on him because he had problems with his breathing between the hours of 2:00 a.m. - 3:00 a.m. and 6:00 a.m. - 7:00 a.m. She said she had not been able to reach the staff by phone during those hours. She said CR #1 was able to tell her he had snot all over his face on the morning of 09/10/2024. She said CR #1 knew when he needed to be repositioned and suctioned and he recalled everything perfectly. She said he was nonverbal now, but he was very aware and alert. She said she had to call 911 on 09/04/2024 because nobody answered the phone and staff only called her to let her know CR #1 was going to the hospital. She said earlier during the night shift, (on 09/09/2024) at 9:31 p.m., CR #1 contacted her and said he had not been repositioned. She said he could not recall what time he was last repositioned, before then, but he said it had been a long time. She said she called the facility at 9:34 p.m. and someone answered the phone and went to assist CR #1. She said on 09/10/2024, the problem started at 1:45 a.m. when CR #1 called another family member and indicated he could not breath, he had mucus coming out of his nose, and he needed to be repositioned. She said that family member called her at 1:53 a.m. She said she called the facility at 1:53 a.m., but nobody ever answered the phone. She said on at 2:38 a.m., she asked CR #1 if anybody came to assist him and he texted No, please call the facility. She said she told CR #1 she was calling right then. She said at 2:40 a.m., she called the facility more times and CR #1 indicated that he was hot, he needed a breathing treatment, and he need to be repositioned. She said at 2:49 a.m., CR #1 indicated nobody came to assist him yet and he had a lot of snot on his face. She said at 2:50 a.m., CR #1 got anxious and texted, Help! She said two other family members got involved and started calling the facility. She said at 3:00 a.m., CR #1 indicated that nobody had come to assist him. She said CR #1 stopped texting at 3:05 a.m., but she was still calling the facility over and over from 3:03 a.m. - 3:19 a.m. She said she called 911 at 3:21 a.m. She said EMS called her from their personal cell phone at 3:47 a.m. and said CR #1 had a face full of snot and needed to be suctioned. She said EMS told her CR #1's other vital signs were fine, but he had a high temperature. She said EMS asked her why they were there (at the facility). She said EMS took CR #1 to the hospital because he wanted to go. She said the facility's staff called her at 4:30 a.m. to let her know CR #1 was being transported to the hospital. She said another family member called the facility 28 times and she called 17 times. She stated she previously told facility staff (she could not recall the names of staff she talked to) that CR #1 experienced anxiety at certain times during the night. Observation and interview with CR #1 on 09/10/2024 at 3:30 p.m. revealed he was in a room in the ER of a local acute care hospital. CR #1 was alert and had a tracheostomy connected to a ventilator. CR #1 also had on a neck brace. CR #1 was sweating heavily. CR #1 did not initially verbalize words. He blinked once for yes answers and twice for no answers. CR #1 indicated no facility staff went to his room early that morning (09/10/2024) until EMS arrived. He indicated he did not know what time facility staff last checked on him. He indicated he felt hot and sick while waiting for staff to reposition him. CR #1 indicated he had trouble breathing and needed to be suctioned that morning. He indicated he was sweating that morning and then he said, Help. CR #1 indicated he wanted a nurse. While waiting for a hospital nurse to come, CR #1 said, Ice chips. CR #1's hospital nurse stated CR #1 was febrile (had a fever) with a temperature of 103.5 when he arrived in the ER, and he was being admitted for sepsis. The nurse took CR #1's temperature and stated it was 99.9. The nurse stated CR #1 was tachycardic upon arrival to the ER at 158 BPM. In an interview with RT B on 09/12/2024 at 3:15 a.m., he stated he worked with CR #1 on Saturday (09/07/2024), Sunday (09/08/2024), and Monday 09/09/2024) (respiratory therapist work 12-hour shifts, so RT B was on shift the morning of 09/10/2024). He stated CR #1 complained of shortness of breath a few times during his shift, but his oxygen saturation was good at 99% and he was not in distress. He said he thought CR #1 experienced anxiety because his vital signs were fine, he was breathing fine, and it was common for residents with new tracheostomies to have anxiety. RT B said he checked on CR #1 every two hours, and he was called to CR #1's room a lot to suction secretions from his nose and mouth. RT B said CR #1 called his RP and she called them at the facility. He said CR #1 often had a lot of secretions from his nose and mouth. He said CR #1 was uncomfortable with the secretions, so he suctioned him, but CR #1 was not in an emergency. He said he heard the phone ring a lot on Tuesday morning (09/10/2024) and the nurse (he could not recall which nurse answered the phone) answered a few times. RT B said LVN A told him CR #1's RP wanted them to check him to see if was ok, so they went to check him immediately after his RP called. He said CR #1's vital signs were perfect. He said as the respiratory therapist, he checked oxygen saturation, respiratory rate, and pulse. He said the nurse would have checked CR #1's blood pressure and temperature. He said he went into CR #1's room once with LVN A (when CR #1's RP called), but he went in alone all the other times during his shift. He said LVN A only did a visual check of CR #1 and did not check his temperature when they went into his room together. He said CR #1 made sounds with his mouth and grimaced, so he suctioned his nose, mouth, and tracheostomy. He said CR #1 had some snot (secretions from his nose) on his face, but not a lot. He said LVN A was CR #1's nurse, and she was assigned to work half of two halls, so she was not on CR #1's hall the whole shift. RT B said CR #1 was not sweating when he checked him. He said between 1:45 a.m. and when EMS arrived, he had been in CR #1's room three times. He said he went in when EMS came, so that was his 4th round into CR #1's room. He said he was surprised when he saw EMS in the building, and they immediately suctioned CR #1 because he of SOB. He said nothing came from CR #1's tracheostomy and EMS went in again and again until CR #1 started bleeding. RT B said he told EMS to stop. He said when EMS arrived, CR #1 had a medium amount of nose and mouth secretions. He said he called LVN A to come when EMS arrived because she was on another hall. He said he saw LVN A check CR #1's vital signs, including his temperature when EMS arrived. He said CR #1's heart rate was a little high, but he thought it was from anxiety. RT B said CR #1's temperature was fine at that time and he was not sweating. He said CR #1's RP insisted EMS take him to the hospital. In an interview with the DON on 09/12/2024, at 2:15 p.m., she stated she was familiar with CR #1, and she had just spoken to his RP. She said CR #1's RP said she called the facility multiple times that morning (09/10/2024) and felt CR #1 did not get adequate care. She said the RP said she and other family members called over 50 times. She said a nurse only answered once and went in to help CR #1, but nobody answered the other times. The DON said she investigated, and the nurse verified she went in and checked on CR #1. She said the nurse told her the phone probably did ring that many times, but she was in another room at the time. The DON said that was probably why CR #1's RP called 911. She said since that incident, they have gotten cordless phones for the nurses on each hall. The DON said CR #1 was already gone to the hospital when she arrived on 09/10/2024, so she could not assess him. She stated CNAs, nurses, and respiratory therapists had to go in every two hours and anticipate CR #1's needs because he could not utilize the bells/buzzers as other residents. She said the nurses usually did visual head-to-toe checks and did not check vitals with each round. She said vital signs were taken every shift unless there was a change of condition. The DON said a person's temperature could change fast depending on where they checked it. She said the thermometer the staff used could have been defective. She said if CR #1 did not appear to be abnormal (experiencing a change of condition) and the nurse did not see a need for a hands-on check, she would not have done one. In an interview with LVN A on 09/12/2024, at 2:40 p.m., she stated her normal shift was 2:00 p.m. - 10:00 p.m. but she picked up a 10:00 p.m. - 6:00 a.m. shift on Monday 09/09/2024. She stated that was her first time working with CR #1. She said her first encounter with CR #1 was at 10:15 p.m., at the beginning of her shift. She said CR #1 was watching a movie on his tablet and could mouth words. She said CR #1 indicated he was ok. She stated CR #1 did not have any secretions. She said she could not recall what time she saw CR #1 after that initial encounter. She said the second time she checked on CR #1, he indicated he was fine and did not need anything. She said he did not have any secretions. She said she could not recall what time it was, but she flushed IV line and gastrostomy tube (feeding tube) and placed a new feed bottle. She said CR #1 was asleep at that time and he did not have any secretions. She said the next time she saw CR #1 was when EMS arrived. She said she did not take any calls from CR #1's family because she was busy with other residents. She said nobody ever told her CR #1's family called, and she did not know his family called. She said she was the only nurse responding to CR #1 that night and no other nurses helped her with him that night. She said she never observed CR #1 with snot around his nose or face. She said CR #1 did not have any secretions and there were no signs of discomfort. She said she saw CR #1 twice before EMS came into the building. She said when EMS arrived, she went to CR #1's room. She said when EMS tried to suction CR #1, nothing came out. She said after the 3rd or 4th time; a small amount of blood came out. She said there was no snot on CR #1's face when she went in, but RT B was there before her. She said EMS did everything (suctioning and vital signs) and she just printed CR #1's paperwork for his transfer. She said EMS handed her a sheet of paper with CR #1's vital signs that they took. She said the CNAs took residents' vital signs at the beginning of the shift. She said she asked EMS if she could take CR #1's vitals and they said they already took them. She said the only abnormal vital sign she saw on 09/10/2024 was his heart rate at 130-something. She said CR #1's temperature was good, but she could not recall what it was, and she did not keep the paper EMS gave her. She said 103.5 degrees Fahrenheit was not what EMS handed her for CR #1's temperature. She said the vital signs she documented in her progress note on 09/10/2024 were from the beginning of the shift when the CNA checked them. She said when she did her rounds, she had to put her hands on CR #1's skin to flush his IV. She said she had to uncovered CR #1. She said CR #1's face just looked shiny, like he had oil built up. She said CR #1 never expressed that he was not feeling well to her. She said EMS did not really want to talk to her, but she heard him talking to someone on the phone. She said it seemed like the EMT was very upset, but she did not know what he was talking about on the phone. She said she heard the EMT describe the resident to the person on the phone. She said she heard them discuss if they were going to take CR #1 or not. She said the EMT told her they were taking CR #1 because his heart rate was 136. She said EMS asked CR #1 if he wanted to go and he said yes. She said CR #1 was alert and oriented x 4. She said the CNAs checked residents' vitals at the beginning of the shift but if the nurses notice anything usual, they took them again. In a telephone interview with CNA D on 09/12/2024 at 3:30 p.m., she stated she worked the 10:00 p.m. - 6:00 a.m. shift and CR #1 was new to the facility. She said CR #1 could answer yes and no questions when asked if he needed something. She said CR #1 was able to make his needs known and could verbally express when he needed to be suctioned. She said her first encounter with CR #1 on 09/09/2024 was between 11:30 p.m. and 12:00 a.m. when she took his vital signs. She said she asked CR #1 if he needed to be repositioned and he said he was ok. She said CR #1's vital signs were normal. She said he was not sweating at that time. She said the next time she checked on CR #1 was around 2:00 a.m. during normal rounds. She said she rounded every two hours. She said she checked to see if CR #1 needed incontinent care or repositioning, but he was ok. She said she asked if he needed anything, and he said he was ok. She said CR #1 did not have any snot around his face or nose at that time. She said she started her next rounds around 3:00 a.m. She said she saw EMS arrive between 3:00 a.m. - 4:00 a.m. She said she did not go into CR #1's room after EMS arrived. She said she was never informed that CR #1's family members were calling the facility and she never observed him sweating. She said she never touched CR #1's skin after checking his vital signs at the beginning of the shift because he had a catheter and CR #1 did not ask for incontinent care. She said she did check to see if CR #1 had a bowel movement and she touched him to check, but his skin was normal. She said she saw CR #1 twice that night. She said CR #1 was alert and oriented. In a follow up interview with the DON on 09/17/2024, at 1:48 p.m., she said a resident's condition could change very quickly. She said they could look fine and then need to go to the hospital fast. She said she had seen quick temperature changes a few times. She said when residents had elevated white blood cells and were being treated with antibiotics, their temperatures could go up and down. She said she could not say that was what happened in CR #1's case, and she could not say what happened that night because she was not there. She stated she expected the nurses to do head to toe assessments when they rounded, including touching the resident. The DON then said she could not say the nurses would physically touch the residents' skin. She said the nurses should go into the room and look to make sure the resident was at baseline, but they would not wake the resident up or be invasive. She said each nurse did their clinical assessments based on what they thought the resident needed. She stated some residents required touch, and some did not. She said she did not know if it was fair to say staff missed CR #1's change of condition. She said if the staff observed CR #1 sweating, it would be considered a change of condition, but it was possible the sweating happened just prior to when EMS arrived. She stated CR #1 had some anxiety between certain hours and started calling his family members at certain times. She said CR #1's family member said she anticipated those calls from CR #1 in the middle of the night. She said she could not speak on what happened, but when nurses saw changes, they responded immediately, and a lot of things could factor that. Record review of the facility's undated job description for LVN's revealed, The primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents' attending physician and within the scope of nursing practice for the state. Essential Functions: Observe patients, charting and reporting changes in conditions such as adverse reactions to medication or treatment and takes necessary actions. Answers patients' calls and determines how to assist them. Measures and records patients' vital signs such as height, weight, temperature, blood pressure, pulse, and respiration. Works as part of a health care team to assess patient needs, plans and modifies care, and implements interventions . Provide nursing services to residents in accordance with scope pf practice, facility policies, and professional standards of care. Monitor residents for developments of acute changes of condition including confusion, fever, difficulty breathing, increased pain .; conduct assessments and notify the provider as needed . Record review of the facility's policy, Change in a Resident's Condition or Status revised February 2021 revealed, Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . Policy Interpretation and Implementation . 2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without inte [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure that residents who required dialysis received such services, consistent with the professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (CR # 1) reviewed for dialysis. The facility failed to ensure CR # 1 received hemodialysis treatments as ordered by his physician. CR # 1 exhibited symptoms of fluid overload and required emergency medical care. In addition, Resident #1's dialysis access port malfunctioned, and Resident # 1 did not receive dialysis for 4 days.CR # 2 missed dialysys treatments on [DATE] and [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:50 pm. While the IJ was removed on [DATE] at 11:41 am, the facility remained out of compliance at scope of isolated with the potential of more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of missing vital treatment, serious health side effects and death. Finding include: Record review of CR # 1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. CR # 1 had diagnoses which included Acute and chronic respiratory failure with hypoxia (absence of oxygen in the tissue to sustain bodily functions), Hypokalemia (low potassium), End stage renal disease (the kidney can no longer function properly) , and Hypertensive heart disease without heart failure (a condition that happens when chronic blood pressure causes changes in the heart left ventricle, left atrium, and coronary arteries. Record review of CR #1's orders, start date [DATE], reflected dialysis catheter dressing change to be done by dialysis nurse only (Monday, Wednesday and Friday (start date [DATE]), Dialysis: Monday, Wednesday, and Friday (once a day at 6:00 am) (start date [DATE]), If the dialysis center is unable to perform hemodialysis as scheduled transfer resident to nearest hospital. As needed (prn1, prn2, and prn 3), monitor catheter site for s/s infection (every shift). Notify MD/NP. Record review of CR#1's MDS, dated [DATE], reflected no BIMS (severe cognitive impairment), partial/moderate assistance with eating, oral hygiene, showering /bath, and personal hygiene and he required dialysis. Record review of Resident # 1's Care plan, start date [DATE], reflected Resident #1 had a risk of falling related to weakness and impaired mobility. Record review of CR#1's Treatment Details Report from the dialysis center, dated [DATE], reflected Treatment Type: In-Center Hemodialysis Treatment. No data available for the following: machine setup nurse prescription verification pre-treatment verification, pre-treatment fluid calculation treatment nurse assessment, access, labs, Intradialytic/vitals stat line. Record review of CR#1's Treatment Details Report from dialysis center, dated [DATE] reflected, Treatment Type: In-Center Hemodialysis Treatment). Pre-Treatment Vitals on [DATE] at 6:04 AM-(1) Comments (Pre) Patient has new CVC placed faint blood noted to CVC exit site. No s/s trauma or infection present. Patient denies pain CVC dressing changed prior to treatment initiation. Comments (Post) Staff will receive Cathflo this evening and indwelling it for next treatment. No time notated. (2) Comments (Pre) Patient received alert and in stable condition. Patient denies pain or discomfort. Comments (Post) Patient treatment was not performed because of catheter malfunction. The MD would like for to have Cathflo instilled into the catheter over the weekend. The staff will go pick up over the weekend and come back to instill it. (3) Comment- Arterial lumen (allows for the free flow of oxygenated blood from the heart to the veins and capillaries) is not pushing on pulling. MD is aware he orders Cathflo but there is not in the Den. Attempting to get Cathflo from SNF. Record review of CR#1's Treatment Detail Report from dialysis center, dated [DATE], reflected Treatment Nurse Assessment: Time: Pre-6:42 AM and Post: 10:31 AM-Comment: Patient Treatment terminated early due to problematic. Record review of CR#1's progress notes, dated [DATE] at 12:06 PM, reflected CR#1 was found unresponsive at 11:25 AM. Nurse called out to resident, no response, sternal rub performed, no response. Pulse checked, undetected. Nurse immediately called code blue and began ambu(a bag valve mask used to provide respiratory support) bagging resident. When RT Aide walked in to assist with bagging, nurse began compressions. No blood pressure reading obtained due to condition, blood glucose 215 at time on first round of compressions. 11:30 AM AED pads placed on resident no shock advised. 911 was called and CPR continued until arrival of EMS. Multiple rounds of CPR done, when EMS arrived monitor placed, and no pulse detected. EMS called of death 11:45 AM. Dialysis nurse verbalized concerns for fluid overload due to inability to perform dialysis Saturday and today [DATE]. CR#1 received orders to be sent out to the ER to restores function to port and receive dialysis in hospital. Transport scheduled to pick up resident with 2 hours. Resident in bed resting, no distress noted at this time vs WNL, no c/o pain or discomfort at this time. CVC. MD notified. Record review of CR#1's dialysis center patient notes, dated [DATE], reflected, CR#1 returned from hospital unable to treat on scheduled day due to watery stool noticed in den at treatment time. Per hospital discharge documents patient tested positive for C. diff and is receiving PO ABX. In addition, the patient was admitted due to malfunction of gastrostomy tube diarrhea, and GI/PEG tube exchange. At the time of exchange the patient was also noted to have an ileus (inability of the intestine to contract normally and move waste out of the body). The dialysis MD updated about pa record review of CR#1's dialysis center patient notes, dated [DATE], reflected, Resident #1 patient status and ok with schedule adjustment. Record review of CR#1's dialysis center patient notes, dated [DATE], reflected, [CR#1] treatment terminated early due to problematic access. Patient had 118 minutes remaining at the time of treatment was discontinued. Notified Dialysis MD, ordered the patient be sent out to the hospital to treat and evaluate catheter. Venous pressure continuously high causing the machine to alarm often Cathflo was previously tried prior to being sent out. Record review of CR#1's orders form SNF dialysis, dated [DATE], reflected Please place Cathflo in Arterial Lumen for 45 minutes. Today DX: Dysfunction/clotted Lumen. If patient cannot receive Cathflo today, he will have to wait until Monday for treatment when Cathflo is available. Record review of CR#1's orders form SNF dialysis, dated [DATE], reflected Please send patient out to the hospital to dialyze. Unable to treat due to problematic CVC, Venous pressure continuously elevated. Record review of CR#1's dialysis SNF Services Communication form, dated [DATE], reflected Pre-Treatment Report Nurse-isolation reason: C. Diff, fall precaution - yes, Mental status- alert, pain assessment-none, VS: BP ,d+[DATE], Pulse 78, R 20, Temperature 97.2, Fo2 Sat 99%, O,d+[DATE]/Vent- time vital and weight obtained 5:38 AM. Dialysis Access Notes problematic, alarmed throughout treatment, catheter problematic treatment terminated early. MD notified There were no dialysis SNF Services Communication form for [DATE] and [DATE]. During an interview on [DATE] at 1:00 PM Dialysis RN A she stated CR#1 had a CVC catheter (central venous catheter). CR#1' was sent out to the hospital on [DATE] because he had a loose stool, peg tube malfunction, vomiting. CR#1 returned to the facility last Wednesday ([DATE]) or Thursday ([DATE]). She stated on [DATE] she was not aware Resident # 1 returned to the facility. She stated the SNF staff did not inform the dialysis center CR#1 returned. She stated after realizing CR#1 returned she stayed late for him to dialyzed. She stated when she attempted to get CR#1's weight she noticed he had loose stool on him. He tested positive for C-DIFF (loose stool and you have to use bleach). She stated she contacted the MD and informed him as to the situation. She stated the MD gave approval for CR#1 to receive dialysis on [DATE]. She stated Dialysis RN B attempted to dialyze CR#1 on [DATE]. CR#1was not dialyzed on [DATE] because CR#1's catheter did not work. She stated Dialysis notified the Dialysis MD. The Dialysis MD gave an order to put Activase in the catheter. She stated Activase breaks up the clot and allow the blood to flow. She stated CR#1's port continued to malfunction. She stated the Dialysis MD gave an order to have the resident dialyzed on Monday. She stated on [DATE] CR#1 received dialysis. She stated he was unable to complete dialysis due the malfunction of CR # 1's port. She stated he received dialysis for 3 hours and 30 minutes, however, he only received 1 hour and 30 minutes of treatment. She stated the dialysis machine kept beeping. She stated CR#1 received a new catheter, and the catheter was not working. She contacted the Dialysis MD and was informed to have the resident transferred to the hospital. Dialysis RN B stated CR#1 was taken back to the SNF. She stated she informed CR#1's Nurse the resident needed to be transferred to the hospital to have his catheter assessed and dialysis RN A stated she was going to call an ambulance to have the resident transferred. She stated this occurred around 8:30 AM. She stated hours later she heard a code blue (code that indicates a patient needs immediate medical attention). She stated if an ESRD patient went without dialysis for three to four days they could have confusion, fluid overload, and septic. During an interview with Dialysis RN B on [DATE] at 2:30 PM, she stated on [DATE] CR#1 came to the den for dialysis treatment. She stated CR # 1's arterial was not pushing and pulling. She stated the reversed the venous pressure and it was high, and it kept alarming. She stated it would start at two hundred and the dialysis machine kept cutting off. She stated she contacted the Dialysis MD, and she told him CR#1 had a new catheter from the hospital. The Dialysis MD asked if the facility had any Cathflo and they did not. She stated later that day she went to the clinic and got Cathflo. She stated she returned to the facility. She stated Cathflo was administered to CR#1. She stated once the Cathflo was administered there was a 45-minute wait. She stated she informed the Dialysis MD, and she was given an order that CR#1 could be dialyzed on Monday. During a telephone interview on [DATE] at 3:00 PM with RN A, she stated CR#1 was on Dialysis. She stated protocol for resident's who received in-house dialysis was the resident's vital signs were taken prior to being transported to dialysis. She stated the resident was transported the in-house dialysis center with the Nurse, RT, CNA, and Transporter. She stated the SNF and Dialysis communicated verbally. She stated there was a communication form which consisted of pre and post dialysis information. She stated that when she arrived CR#1 was in dialysis. She stated on [DATE] around 8:30 am the Dialysis RN A stated CR#1 could not be dialyzed, and CR# 1 needed to be sent to the hospital. She stated Dialysis RN A informed her that CR#1's port was malfunctioning, and CR#1 had fluid overload. She stated she scheduled non-emergency transport for CR#1 to be transported to the hospital. She stated the transport service informed her that it would be 2 hours before the transport would arrive. She stated she did not call 911. She stated she assessed CR#1 to include checking blood pressure and pulse rate and there were signs of distress. She stated CR#1 verbalized he was tired which was a common side effect after dialysis. She stated she checked on CR #1 at 11:15 AM and went to check on CR#1 and he was unresponsive. She stated she called a code blue. She stated they began CPR and EMS arrived, and CR# 1 was pronounced deceased at 11:45 AM. She stated if a resident did not have dialysis for three to four day they could have fluid overload, septic, and other serious injuries to include death. Record Review of The National Kidney Foundation website, undated, reflected if you miss your dialysis treatment, you may feel the effects of fluid overload, which include shortness of breath due to fluid in your lungs. If this happens, you may need to go to your hospital's emergency department for dialysis. During an interview with the DON on [DATE] at 9:55 AM, she stated CR#1 received dialysis on Monday, Wednesday and Friday. She stated CR#1 was in the hospital from [DATE]-[DATE]. She stated she did not why the Dialysis nurse did not know CR#1 returned to the facility. She stated Dialysis had access to the Matrix. She stated CR#1 staff was aware his port was not working. She stated Resident #1 had C-DIFF, however, this would not prevent him or any resident from having dialysis. She stated when a resident had C-DIFF the stool was continuous. She stated if a resident's port was clogged the resident would be scheduled to go out and looked at by a vascular doctor. She stated a clogged port was not a reason to send a resident out to the hospital by 911. She stated CR#1 was assessed by RN A and there were no signs of distress, therefore, the contracted ambulance service was contacted and not 911. . During an interview on [DATE] at 10:50 AM, RN C stated when a resident was on dialysis they must be placed on the dialysis schedule. She stated when a resident returned from dialysis the nurse should assess the resident to include vital signs. She stated if a resident's dialysis port was malfunctioning, she would call the doctor. She stated that if the MD ordered the resident be transferred to the hospital, she would call 911. She stated because the resident had not had dialysis for days she would call 911. She stated when a resident was not dialyzed the resident was prone to fluid overload, electrolytes would not be good, the resident would be confused and the level of consciousness would be affected. Record review of the facility's Abnormal Findings Job Aid policy, dated [DATE], reflected any abnormal findings or findings outside of any patient specific physician ordered parameters discovered pre, intra or post treatment data collection will be discontinued and immediately reported to the licensure nurse. An assessment by the nurse prior to initiation of dialysis, during dialysis, and/or prior to discharge will be triggered by an abnormal finding. The medical record should indicate the finding, the intervention, physician notification, physician orders and the patient response. Record review of the facility's Hemodialysis policies and procedures, dated [DATE], reflected the following: patient data the nursing assessment, patient identity, prescription and machine settings, Pre-treatment data collection/ assessment, Intradialytic data collection assessment, post treatment data collection/assessment and abnormal findings. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:50 PM. The Administrator was notified. The Administrator was provided the IJ template on [DATE] at 2:50 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 2:23 PM: PLAN OF REMOVAL Name of facility: Date: [DATE] The Texas Department of Health and Human Services entered the facility on [DATE] for a P1 Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F698 and F684 as stated below: F698 Dialysis Services CR#1 Passed away on [DATE] Immediate action: On [DATE] DON under the guidance of the Regional Nurse Consultant initiated an in-service with all direct care staff training will be completed by [DATE]. o Notifying Physician and Family of Resident Change of Condition/or have not receive their full dialysis. The physician should be notified as soon as possible after identifying a change of condition/or have not received their full dialysis, assessed resident needs, and provided necessary services. If the physician is unable to be reached, the DON and/or designee should be notified and the Medical Director contacted for treatment plan. o Recognizing and Reporting Acute Changes of Condition. Changes of condition include, but are not limited to SOB, vital signs, mental status changes, functional decline, desaturation, etc. o Symptoms include the need for emergency ambulance services. o Documentation of events (Change of Condition), SBAR and Stop & Watch. o Change of Condition and policy was reviewed, no changes were made. Staff in-service on current policy. o Staff in-service to pre-dialysis assessment and post assessment documentation in Matrix. o Communications between dialysis and nursing will be documented in Matrix. o Continue weekly core team meetings with dialysis. o Location where dialysis schedule is at. o Nurses will review dialysis schedules with transport daily. o How codes should be run. o Location where the AED is at. o Shift report will go over admits and discharges. o Review all new orders daily by management. o [DATE] In-service on dialysis policy to all direct care staff and completion date [DATE]. o 100% audit on all residents to ensure anyone who was unable to do dialysis has been identified and MD notified completion date [DATE]. On going dialysis audit will be done in IDT morning clinical meeting. o DON/Designee will audit all residents who have dialysis in IDT morning clinical meeting to make sure they have received their dialysis or if unable to do dialysis then MD/DON was notified. Facility Plan to ensure compliance quickly: o All nursing staff will be in-service on the above-listed topics prior to beginning their next scheduled work shift. o The DON and/or designee will conduct audits of the 24-hour report to include review of progress notes to ensure that all changes of conditions/ or have not fully received dialysis will be identified and physician notification has been made. This audit began [DATE]. Demonstration of and acknowledgement that all licensed nurses are aware of the above: o The DON/ADON and/or designee will contact all licensed nurse staff and get a verbal acknowledgement as a return demonstration of understanding that: o A physician is to be notified immediately of changes of condition or have not received dialysis. o This in-service began [DATE] and will be completed by [DATE]. On [DATE] The facility Administrator, ADON, and Regional Nurse Consultant held an ad hoc QAPI meeting with the Medical Director, via phone, to discuss: o F698 - Dialysis Services - IJ Cited o Plan of Removal and actions taken to ensure continued compliance. QAPI: o The above actions will be reviewed monthly in QAPI to ensure continued compliance. Monitoring of the plan of removal included: During interviews on [DATE] from 10:30 AM - 4:00 PM - three CNA's, five RN's, four LVN's and six RT's stated they were in-serviced before their shifts in: Change of Condition, Recognizing and Reporting Acute Change of Condition, Symptoms included for the need for emergency ambulance services, Documentation of events ( Change of Conditions), SBAR and Stop and Watch, Staff in-service to pre and post dialysis assessment documentation, communications between dialysis and nursing will be documented in Matrix, Nurses will review dialysis schedule with transport daily, shift reports will go over admits and discharges. Staff stated they were competent in all trainings. Record review of General In-Service for All Direct Care Staff and RT, dated [DATE], reflected the following in-services: Change of Condition, Recognizing and Reporting Acute Change of Condition, Symptoms included for the need for emergency ambulance services, Documentation of events ( Change of Conditions), SBAR and Stop and Watch, Staff in-service to pre and post dialysis assessment documentation, communications between dialysis and nursing will be documented in Matrix, Nurses will review dialysis schedule with transport daily, shift reports will go over admits and discharges, MD/NP/DON or designee will determine if resident needs to go by 911 or non-emergency transport and will be documented in resident chart. Record review of In-services for DON, dated [DATE], reflected: Change of Condition, Recognizing and Reporting Acute Changes of Condition, Symptoms include the need of emergency ambulance services, Documentation of events (change of condition, SBAR, and Stop & Watch, Pre and Post dialysis assessment documentation in Matrix, Communication between dialysis and nursing , continue weekly core team meetings with dialysis, nurses will review dialysis schedules with transport daily, shift reports will go over admits and discharges, review all orders daily by management, Education provided to 100% nursing staff on monitoring of residents who experience change in condition while waiting on emergency services, and MD/NP/DON or designee will determine if resident needs to go by 911 or non-emergency transport and will be documented in resident chart. The Administrator was informed the Immediate Jeopardy (IJ) was removed on [DATE] at 11:41 AM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal arm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place that is not immediate.

Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 2 of 2 residents (CR#1 and CR#2) reviewed for quality of care. 1. The facility failed to ensure emergency medical treatment was provided in a timely manner to CR #1, after he missed 3 to 4 days of dialysis, his doctor gave orders for hospital evaluation and treatment, and the Dialysis Nurse expressed concerns of fluid overload. 2. The facility failed to ensure emergency medical treatment was provided in a timely manner to CR#2, after his doctor gave orders for a blood transfusion, which was an emergency situation. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs. Findings include: 1. Record review of CR#1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia (not enough oxygen in the body all at once-acute, or over time-chronic); hypokalemia (low blood potassium levels); End-Stage Renal Disease (an individual's kidneys no longer function and require a regular course of long-term dialysis or a kidney transplant to maintain life); and hypertensive heart disease without heart failure (changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). Record review of CR#1's care plan, dated [DATE], reflected CR#1 was at risk of falls related to weakness and impaired mobility. Record review of CR#1's progress notes, dated [DATE], reflected the following: at 12:06 PM, CR#1 was found unresponsive at 11:25 AM. Nurse called out to resident, no response, sternal rub performed, no response. Pulse checked, undetected. Nurse immediately called code blue and began ambu (provides respiratory support to patients in emergency and non-emergency situations) bagging resident. When RT Aide walked in to assist with bagging, nurse began compressions. No blood pressure reading obtained due to condition, blood glucose 215 at time of first round of compressions. 11:30 AM AED pads placed on resident no shock advised. 911 was called and CPR continued until arrival of EMS. Multiple rounds of CPR done, when EMS arrived monitor placed, and no pulse detected. EMS called of death 11:45 AM. Further review of CR#1's progress notes, dated [DATE], reflected the following: Dialysis nurse verbalized concerns for fluid overload due to inability to perform dialysis Saturday and today [DATE]. CR#1 received orders to be sent out to the ER do restores function to port and receive dialysis in hospital. Transport scheduled to pick up resident with 2 hours. Resident in bed resting, no distress noted at this time vs WNL, no c/o pain or discomfort at this time. Record review of CR#1's Dialysis Center Treatment Detail Report, reflected the following: [DATE], Treatment Nurse Assessment: Time: Pre-6:42 AM and Post: 10:31 AM-Comment: Patient Treatment terminated early due to problematic CVC. MD notified. Record review of CR#1's dialysis center patient notes, reflected the following: CR#1 treatment terminated early due to problematic access . Patient had 118 minutes remaining at the time of treatment was discontinued. Notified Dialysis MD, ordered the patient be sent out to the hospital to treat and evaluate catheter. Record review of CR#1's Dialysis Communication form, reflected the following: [DATE], Dialysis Access Notes: problematic, alarmed throughout treatment, catheter problematic treatment terminated early. MD notified. 2. Record review of CR#2's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. CR #2 had diagnoses which included diagnoses of Metabolic Encephalopathy (problems with your metabolism, like low blood sugar or excess brain fluid, cause brain dysfunction); Dysphagia (difficulty swallowing); End-Stage Renal Disease (an individual's kidneys no longer function and require a regular course of long-term dialysis or a kidney transplant to maintain life); Type 2 Diabetes (a chronic condition that happens when an individual has persistent high blood sugar levels, due to their pancreas' inability to produce enough insulin, or their body not utilizing insulin properly, or both); Chronic Obstructive Pulmonary Disease (chronic inflammatory lung disease causing restricted or obstructed airflow and breathing problems); and, Unspecified Acute Myocardial Infarction (also known as a heart attack, which occurs when blood flow to the heart muscle is abruptly cut off, causing permanent damage to the heart muscle). Record review of CR#2's admission MDS, dated [DATE], reflected the resident's BIMS score was 8, which indicated moderate cognitive impairment. The resident had minimal difficulty in hearing, unclear speech pattern, was able to make himself understood sometimes and usually understood verbal content. The resident was dependent on staff for all ADL's and maximal assistance with oral hygiene. The resident was receiving oxygen therapy, scheduled suctioning, ventilator, dialysis, and speech therapy five days a week for 45 minutes. Record review of CR#2's care plan, last revised on [DATE], did not reflect goals or interventions related to dialysis. Further review of the care plan reflected the resident was dependent on staff for all activities of daily living, had some confusion, needed assistance with communication. The resident also received tube feedings via enteral pumps and was at risk for swallowing problems and weight loss. Interventions included monitoring by aides and nursing staff for choking/aspiration hazard. Record review of CR#2's progress notes, dated [DATE] at 9:43 AM, reflected the following: At 6:30 AM, the dialysis nurse reported CR#2 had low hemoglobin of 6.7 and received orders from the doctor to be transported to the nearest hospital for a blood transfusion via non-emergency medical services. Non-emergency services arrived at 9:45 AM, CR#2 was stable, transported to the hospital, RP and MD/NP notified . During an interview on [DATE] at 1:00 PM, Dialysis Nurse A said CR#1 had a Central Venous Catheter. She said on [DATE], CR#1 started dialysis, but CR#1 was not able to complete the full treatment. She said his ordered treatment for dialysis was for three hours and 30 minutes . She said he only completed one hour and 30 minutes of treatment . She said the resident's dialysis machine kept beeping. She said CR#1 recently received a new catheter, and the catheter was not working on [DATE]. She said she contacted the Dialysis MD who gave an order to transfer CR#2 to the hospital to have his catheter assessed and to receive further dialysis treatment. Dialysis Nurse A said CR#2 was taken back to his room. She said she verbally informed CR#1's assigned nurse, RN A , the resident needed to be transferred to the hospital to have his catheter assessed and receive further dialysis treatment. She said RN A verbally told her that RN A was going to call an ambulance to have CR#2 transferred to the hospital. She said this conversation occurred around 8:30 AM on [DATE]. She said hours later she heard a code blue being called. She said if an ESRD patient went without dialysis treatment they were at risk for experiencing confusion, fluid overload, and sepsis . In an interview with RN A on [DATE] at 3:00 PM, she said CR#1 was on Dialysis. She said the protocol for residents on in-house dialysis was to check their vital signs prior to being transported to dialysis. She said the facility nurses assigned to dialysis residents and the dialysis nurses communicated verbally. She said there was also a communication form that consisted of information on the resident, pre and post dialysis treatment. She said when she arrived at work on [DATE], CR#1 was already in dialysis. She said around 8:30 AM, Dialysis Nurse A informed RN A, CR#1 could not be dialyzed, and the Dialysis MD ordered CR#1 to be sent to the hospital. She said Dialysis Nurse A told RN A, CR#1's port was malfunctioning. She said she scheduled non-emergency medical transportation for CR#1 to be transferred to the hospital. She said the transportation service told RN A it would be 2 hours before non-emergency medical transportation would arrive at the facility. She said she did not call 911. She said she assessed CR#1 and the resident did not show any signs of distress. She said CR#1 verbalized to RN A he was tired. She said being tired was a common side effect after dialysis. She said she checked on CR#1 at 11:15 AM, and RN A found CR#1 unresponsive in his bed. She said she called a code blue throughout the facility. She said CPR was started on CR#1, EMS arrived, and CR#1 was pronounced deceased at 11:45 AM. She said if a resident did not have dialysis treatment, the resident was at risk for fluid overload, sepsis, and other serious injuries, which included death . In an interview with LVN C on [DATE] at 2:42 PM, she said one of the things she was responsible for was getting report from the nurses on which residents were sent out to the hospital that day and why, so she knew what beds in the facility remained empty and available. She said she was familiar with CR#2. She said the resident would open his eyes if you spoke to him, but he was difficult to understand. She said from what she could remember CR#2 was sent to the hospital on [DATE] for respiratory distress and hypoxia. She said that day, before the dialysis center began the resident's treatment, his bloodwork results showed his hemoglobin levels were low. She said she could not remember if it was nurse on the 300 hall or the DON who informed her about CR#2. She said the dialysis center was not able to perform dialysis due to CR#2's low hemoglobin. She said dialysis informed the facility nurse, and the facility set up transportation for him to be sent to the hospital. She said the facility had contracts with transportation companies set up. She said she reviewed the information entered into CR#2's electronic health record that day but could not recall all of the documentation off the top of her head. She said if the resident's pulse oximeter was good, 90 and above, it was not an emergency and 911 did not need to be call for the resident. She said she did not know how long it took non-emergency medical transportation to arrive at the facility to take CR#2 to the hospital. She said she did not know what care CR#2 received after the doctor gave the order for the resident to be sent to the hospital and the time the transportation company arrived. She said a nurse assessment of a resident consisted of checking vital signs, capillary refill, and checking whether the resident was at their baseline or not. She said the resident was opening his eyes, which was his baseline. She said the DON was responsible for reviewing nursing documentation in the resident's electronic health records. She said nurses should document their assessment information underneath the progress notes or events within the resident's electronic health record. She said she did not review the documentation entered by the nurse on [DATE] for CR#2. She said she only checked the vital signs entered into CR#2's electronic health record because she wanted to know why the resident was sent out to the hospital. She said she always checked the vital signs in a resident's electronic health record when she was notified a resident was being sent out to the hospital. She said she did not review whether the nurse completed an assessment on CR#2 on [DATE]. She said she did not remember which nurse was working with CR#2 at the time because this all occurred before her shift started that day. She said CR#2 was ordered to be sent to the hospital for low hemoglobin and he needed a blood transfusion. She said the dialysis notified the nurse on the floor that the resident was ordered to be sent to the hospital for treatment. She said this was not an emergency. She said if the resident experienced a change in condition after coming back from dialysis, and the resident's doctor said the resident needed to be sent out immediately, they would have done that. She said the nurses received their orders directly from doctors and the doctor never specified the resident needed to be sent out immediately. She said if a resident became synoptic, their lips were turning blue, had low 02 saturation, had shortness of breath, then the resident would have been considered as having an emergency. She said she was not on the floor at the time, so she would not be able to say what sort of care would have been provided to between 6:30 AM and 9:45 AM. She said the aides and nurses were at least responsible for making sure the resident was ready and prepared to be sent out to the hospital before non-emergency medical transportation arrived at the facility. She said if the facility received confirmation of a critical lab result, the nurses were going to call the doctor for further instruction. She said CR#2's order to be sent out came directly from the nephrologist. She said it would have depended on what the residents baseline was, and what the nurse saw at the time to determine whether a situation was critical. In an interview with the DON on [DATE] at 9:55 AM, she said CR#1 received dialysis treatment on Mondays, Wednesdays and Fridays. She said she reviewed all the information regarding the situation with CR#1 on [DATE] but could not recall details. She said she reviewed the 24-hour report every morning. She said because she reviewed so much information daily, it was difficult to recall specifics about what exactly occurred with CR#1 on [DATE]. She said in reviewing the documentation nothing stuck out to her. She said the situation was handled properly. She said CR#1's assigned nurse was aware his port was not working. She said a clogged port was not a reason to send a resident out to the hospital by 911, unless there was a significant change in condition , or the doctor gave a STAT order. She said she was aware transportation services were scheduled for CR#1 but did not know the length of time between the order given by the physician and the resident being found unresponsive. She said CR#1 was assessed by RN A and CR#1 did not exhibit signs of distress. She said that was the reason the contracted non-emergency medical transportation service was contacted and not 911.She said she believed CR#1's nurse used their best judgement after receiving orders from the physician for CR#1. She said she would have to review the details again to determine whether the length of time was an issue. In an interview with the DON on [DATE] at 4:42 PM, she said she reviewed documentation in CR#2's electronic health record on [DATE] but was not aware of what care was provided to the resident between 6:30 AM and 9:45 AM. She said nurses were trained to use their best judgment in knowing when to contact emergency services for residents. She said she did not know how long CR#2 remained at the facility after an order for CR#2 was given by his nephrologist. She said if the nephrologist would have given a STAT order or the nurse observed a change in condition or signs of distress, 911 would be contacted for emergency medical treatment. She said CR#2's baseline hemoglobin level was low and CR#2 never showed any signs or symptoms of distress on [DATE]. She said there was no standard timeframe for the contracted medical transportation company to arrive at the facility. She said the facility contracted with a particular company that had necessary equipment to provide life saving measures to individuals on ventilators and trachs. She said using the transportation company was a way of ensuring the safety of the residents. She reiterated that nurses would need to use their best judgement to utilize emergency services to send residents to the hospital after scheduling and waiting for the contracted transportation. She said the nurses knew to call 911 when residents were experiencing a medical emergency. She said she was not aware of the length of time between the physician's order was given and the time the transportation company arrived to take the resident to the hospital. She said based on CR#2's history; she did not see an issue with CR#2 waiting three hours to be transported to the hospital for a blood transfusion. She stated CR#2 was pronounced deceased at the hospital much later than [DATE]. Interview with Regional Nurse Consultant A and the DON on [DATE] at 3:10 PM, the Regional Nurse Consultant said the nurses who provided care to dialysis residents were going to be looking for desaturation and the ventilator machine was going to alarm which allowed them to know there was something malfunctioning. The nurses were going to be looking at vital signs and oxygen levels. She said if there was an issue with the port, the dialysis center would set up an appointment at the hospital to have the shunt replaced. She said it was not a guarantee or a proficient tool to visually assess how much fluid a resident on dialysis retained. She said where the fluid was going to go in the body, was going to be around the organs because the fluid had nowhere else to go. That was the reason why the nurses monitored for the vital signs and oxygen levels as signs and symptoms of distress in residents on dialysis . She said there was no way of seeing fluid overload during a visual assessment. She said the best practice was for nurses to go by the residents' blood pressure standards and airway standards. She said the best practice for contacting emergency services was for residents experiencing chest pain or a GI bleed, which was an automatic call to 911. She said the dialysis residents were just like any other residents when it came to acute situations. The nurses were trained to monitor the same vital signs for residents whether they were on dialysis, or not. Both the regional nurse and the DON agreed that most individuals on dialysis that might have experienced fluid overload did not experience pain. The regional nurse said they would more so experience shortness of breath. The DON said CR#1 was not showing any signs of distress or any signs or symptoms prior to beginning dialysis, because if he had, they would not have begun dialysis. She said the dialysis center ran labs and checked vital signs before starting a resident's dialysis, and CR#1's labs came back normal. She said it was part of the protocol for the dialysis center to check vital signs again at the end of dialysis treatment. The DON said the dialysis enter checked CR#1's vitals, and he was stable at that point. The DON said when CR#2 came from dialysis there was no indication the resident was experiencing any sort of symptoms or distress of any kind. Regional Nurse Consultant A said she reviewed CR#1's doctor orders, and he was only being sent to the hospital to have his shunt replaced. Regional Nurse Consultant A said there would have had to be a break, possibly a day or two, between the resident receiving dialysis treatment and having a shunt replaced. She said an individual would have to be NPO for a certain amount of time, a surgeon had to be available for, and schedule the surgical procedure to replace a shunt. The DON said having a shunt replaced would take some time to set up and was not an immediate kind of thing anyway. She said the nephrologist decided whether, a resident moved forward with dialysis treatment based on their assessment of the resident's weight and labs drawn the morning of the scheduled treatments. She said the results of the BUN/Creatinine ratio indicated to the nephrologist whether the resident was experiencing fluid overload. She said CR#1 was not examined by the coroner's office. She said if there was no coroner's examination completed on a body, no definitive cause of death was provided. She said the coroner would look at a resident's medical history and decide the cause of death, based on their history. The DON said when CR#2 came from dialysis there was no indication the resident was in any sort of distress, based on his vital signs. She said there was a dialysis information sheet with data documented before and after dialysis. The DON said the form listed how much fluid in liters were pulled off the resident during dialysis. She said any pertinent information, like vital signs, pre and post weight, and issues or concerns were documented by the dialysis center nurse on the information sheet. The DON said if there was something that went on or was noticed during dialysis, the dialysis nurse would bring the information sheet directly to the nurse assigned to the resident on the hall. She said if there was an emergency during dialysis, they would call 911 immediately from the dialysis center. She said if there was no issue, once dialysis was closed for the day, the dialysis nurse placed the information sheet in a folder on the medication cart of the nurse assigned to the resident's hall. She said the nurse assigned to the resident was responsible for reviewing the information sheet by the end of their shift. The DON said after the information sheet was reviewed it went to the nurses' station for filing with medical records. The DON said none of the residents' primary doctors were responsible for monitoring dialysis care. She said dialysis was monitored specifically by the residents' Nephrologist and Urologist. She said if it was not anything that was critical or acute going on with a resident on dialysis the nurses were not going to contact the residents' physicians. The DON said there was no special sort of care, monitoring or assessments done on residents who were on dialysis. Regional Nurse Consultant A said people who lived out in the community and were on dialysis were able to go home all the time after treatment, with no special monitoring. She said the residents at the facility who received dialysis were no different. The Regional Nurse said the special care that differentiated residents who were on dialysis was, on each shift the nurses checked the dialysis residents' shunt for bleeding. The DON said the only follow up done by the nurse once a resident was ordered to be sent to the hospital by the nephrologist or urologist due to concerns during dialysis, was to keep an eye on the resident until transport arrived. She said then, the nurse would document in the resident's electronic health record what time transport arrived to pick the resident up, what hospital they were taken to, and the notifications made to herself, the doctor and the family. The DON said there was no set timeframe for when a resident who returned from dialysis needed to be checked on by any staff. She said she could not say the resident would be checked on within 5 minutes of returning from dialysis, but at some point, after returning from dialysis either the nurse, CNA or RT would check on the resident. She said most times, it was RT who saw the resident first because they had to hook the residents back up to their ventilators and/or trachs. Regional Nurse Consultant A and the DON agreed that there was no standard to checking on a resident or performing any sort of assessment once they returned from dialysis. They both stated that staff were simply laying their eyes on the resident. In an interview with RN C on [DATE] at 10:50 AM, she said if a resident's dialysis port was malfunctioning, she would call the doctor. She said if the MD ordered the resident be transferred to the hospital, she would call 911. She said because the resident had not had dialysis for days she would call 911. She stated when a resident was not dialyzed the resident was prone to fluid overload, electrolytes would not be good, the resident would be confused and the level of consciousness would be affected. In an interview with the Administrator on [DATE] at 8:38 AM, she said she became aware of the timeframe between the orders for CR#1 and CR#2 to be sent to the hospital and non-emergency transportation arriving at the facility when the facility received the IJ on [DATE]. She said it was her expectation of the DON to review the 24-hour report on a daily basis and discuss things like this during their afternoon daily call. She said it was her expectation of the nurses to be able to exercise good judgment and follow best practices when they provided care to residents. She said CR#2 should have been assessed after he returned from dialysis. She said after the IJ was called; the facility reviewed information they collected as part of an audit of residents on dialysis. She said she became aware of communication issues between the dialysis center staff and nursing staff, and a lot of the information required on the communication form between the center and nursing were not completed by nursing staff prior to residents being sent to dialysis. She said she did not think three hours was an appropriate amount of time for any resident who needed emergency medical treatment to wait for transportation, even if a doctor did not explicitly give an emergency order. She said any resident was put at high clinical risk in a situation like that. She said all staff were currently being trained and in-serviced. She said the nurses were being trained to recognize that an order for a resident not being dialyzed, even with notification to the doctor was an emergency and residents could be sent out via emergency services to receive the needed treatment at the hospital. She said the nurses could still utilize the non-emergency transportation, but only for things like routine visits, or when the timeframe of arrival was within reason, based on the resident's condition. She said three hours was not an acceptable timeframe for CR#2 or any other resident on dialysis that needed emergency medical treatment. She said nurses were also being trained to conduct full assessments on residents every 15 minutes, document their findings in the resident's chart, contact the doctor if a change in condition was noted, or call 911 and notify the doctor, the DON, and the RP after. In an interview with Regional Nurse Consultant B on [DATE] at 4:23 PM, she said she was made aware of the delays in transportation for emergency medical treatment for CR#1 and CR#2, understood and agreed they were cause for concern. She said she was working with the Administrator to get the DON and Regional Nurse Consultant A trained on facility expectations. She said she was also working with the DON and Regional Nurse Consultant A to ensure the rest of the staff were trained and exhibited competency in communication expectations, recognizing signs and symptoms in residents, conducting thorough assessments, documenting those assessments, and making proper notifications. In an interview with Regional Nurse Consultant B on [DATE] at 12:58 PM, she said if there was any delay in non-emergency medical transportation for any reason, the nursing staff were aware they needed to contact the DON for further directives. She said if transportation was delayed for a doctor's appointment or a routine procedure, they could contact the doctor for further directives. She said however, if the resident was dealing with something that could cause an infection or worsening of their condition, the staff were aware they needed to contact 911 immediately. She said the staff also understood they were not doctors and could not determine how a delay in transportation would affect a resident. So, to air on the side of caution, the staff knew they would call 911 in those instances. She said they would still notify the doctor, but they were not going to wait on non-emergency medical transportation. She said identifying the IJ situations highlighted the fact that there was a missing piece of the puzzle with nursing staff. She said all the tools were there for all staff to use, they were not utilizing them. She said the DON was completing in-services and trainings with staff, but she was not requiring nursing staff to show competency. She said the DON was not following up or doing thorough reviews of nursing documentation enough to identify situations that needed to be addressed or improved. She said now, the staff were clear they were going to be required to show competency of their skills. She said the nursing staff were re-trained and re-in-serviced on change of condition, SBAR, completing a proper shift change with oncoming staff, communication, assessments, reporting, making the necessary notifications, and follow through. She said they were continuing to work through educating the entire staff. She said another big takeaway was the lack of communication, internally, when it came to nursing and the dialysis center staff. The staff were now clear that while the dialysis center functioned separately from the facility, there was overlap in work. She said the facility nurses and the dialysis nurses now understood they were all intertwined, and not separate. She said they were all essentially part of the same team and communication from dialysis was also to be shared with residents' primary physicians. Record review of the facility's Charting and Documentation policy, revised [DATE], reflected the following: All services provided the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident's medical record: a. objective observations; b. medications administered; c. treatments or services performed; d. changes in the resident's condition; e. events, incidents or accidents involving the resident; and f. progress toward or changes in the care plan goals and objectives .7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individuals who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. Record review of the facility's Change in a Resident's Condition or Status policy, revised February 2021, reflected the following: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .d. significant change in the resident's physical/emotional/mental condition .g. need to transfer the resident to a hospital/treatment center; i. specific instruction to notify the physician of changes in the resident's condition .2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. impacts more than one area of the resident's health status; c. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR Communication Form .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resid [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (CR #1) out of 3 residents reviewed for quality of care in that: The facility failed to recognize a change in condition for CR#1 when she began throwing up on [DATE] and some days after, and continuously having extremely high blood glucose levels for 6 days ([DATE] - [DATE]). CR#1 was sent out to the hospital on [DATE] and died in the hospital on [DATE]. The facility delayed in sending CR#1 to the hospital by calling the non-emergency line taking the ambulance over an hour to come when CR#1 was nonresponsive, blood sugar was 598, and O2 Saturation was 88% while on nonrebreather mask with 10 liters oxygen on [DATE]. The facility failed to monitor blood glucose levels adequately when CR#1's blood glucose level continued to spike with numbers above 600. An Immediate Jeopardy (IJ) situation was identified on [DATE] while the IJ was removed on [DATE] at 3:58pm, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures could expose residents to low quality of care, worsening of condition, hospitalization , and death. Findings included: Record review of CR#1's face sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE]. Current admission was on [DATE] with diagnoses of type 2 diabetes (A chronic condition that affects the way the body processes blood sugar, resulting in too much sugar in the body), kidney failure, cerebral infarction (cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), malnutrition, hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), high blood pressure, sepsis (Sepsis is a serious condition in which the body responds improperly to an infection, causing a cascade of changes that damage multiple organ systems, leading them to system failure, sometimes even death), and heart disease. Review of CR #1's MDS (Minimum Data Set) dated [DATE] revealed CR #1 was diagnosed with Diabetes Mellitus, high blood pressure, cerebral infarction, and hemiplegia. MDS also revealed CR #1 was on insulin medication, oxygen therapy treatment, suctioning, and tracheostomy care. Review of CR #1's care plan revealed CR #1 was at risk hypoglycemia / hyperglycemia episodes due to diabetes mellitus. The care plan goal was that CR #1's blood sugar will be managed effectively, and the careplan intervention was to do accu checks as ordered and report any abnormal findings to the Physician and family members. Record review of CR #1's Physician order dated [DATE] revealed insulin NPH and insulin Lispro was discontinued by LVN D on [DATE]. Record review of CR #1's physician orders revealed there was no order for insulin NPH from [DATE] through [DATE]. Review of CR #1's Physician order dated [DATE] revealed the following: Accu check with insulin Lispro (AdmeLOG) sliding scale SQ 142 - 180 = 2 units 181 - 220 = 4 units 221 - 240 = 5 units 241 - 260 = 7 units 261 - 280 = 9 units 281 - 300 = 10 units >300 = 12 units and call MD Four Times A Day 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM Record review of CR #1's [DATE] MAR revealed there was no insulin NPH administered to CR #1 from [DATE] through [DATE]. Further review revealed there was no documentation of blood sugar checked and no insulin administered to CR #1 on the 9pm accu check schedule on [DATE] when LVN A worked. Record review of CR#1's blood sugar vitals from (date) to (date) revealed no continued follow up on CR #1's blood sugar when the blood sugar was high: [DATE]: 5:34 am 598 mg/dL On [DATE] 11:28 pm 319 mg/dL 11:28 pm 283 mg/dL 1:01 pm 381 mg/dL 10:57 am 468 mg/dL 8:15 am 556 mg/dL 8:02 am 468 mg/dL [DATE] 7:01 pm 300 mg/dL 11:33 am 386 mg/dL 9:31 am High (above 600) 8:24 am High (above 600) 1 pm 414 mg/dL [DATE] 9:27 pm 250 mg/dL 5:52 pm 289 mg/dL 1:16 pm 365 mg/dL [DATE] 5:32 pm 313 mg/dL 12:04 pm 398 mg/dL 9:24 am 388 mg/dL [DATE] 8:43 pm 382 mg/dL 10:42 am 320 mg/dL 10:24 am 365 mg/dL [DATE] 7:24 pm 269 mg/dL 1:55 pm 139 mg/dL 8:39 am 139 mg/dL [DATE] 10:36 pm 159 mg/dL 11:57 am 300 mg/dL Record review of CR #1's progress note documented by LVN A on [DATE] revealed Rsd breathing but non-responsive. bs 598 per Dr order gave 15units of lispro @05am and to send rsd out to hospital v/s ,d+[DATE], hr 128, t-97.4, O2 88% w/ non-breather mask on 10L oxygen. Non-emergent line contacted eta 0600 . On [DATE] at 11:25am in an interview with CR#1's family member, she stated CR#1 had an infection that was not treated and by the time CR #1 got to the ER she was septic and dies the [DATE]. CR#1's family member stated there were instances where the Physician stated he did not know about CR#1 and admitted that he did not know CR#1. CR#1's family member stated she went to check CR#1 out of the facility on thanksgiving day, but CR#1 was throwing up that day and no one knew why she was throwing up. CR#1's family member stated she did not want to take CR#1 out of the facility not knowing what was happening. CR#1's family member stated no one knew why CR#1 was throwing up and it was odd for CR#1 to be throwing up so something must have been wrong with CR #1 on that day ([DATE]). CR#1's family member stated the staff (unknown) said CR#1 threw up twice that morning. On [DATE] at 12:24pm in an interview with CNA A, she stated she remembered CR#1 threw up on [DATE] on thanksgiving day. CNA A stated they noticed CR#1 threw up and she (CNA A) went to tell the Nurse (unknown). CNA A stated CR#1's emesis was brown and it was a lot. CNA A stated she told the nurse and she went to check CR#1. CNA A stated she did not recognize any other changes in condition for CR #1 on that day. On [DATE] at 10:21am in an interview with CNA B she stated CR#1 came from the 100 hall doing well and moved to the 200 Hall and after CR#1 stopped eating well the staff had to feed her and she refused sometimes. CNA B stated CR#1 was not really eating enough by mouth when she came to the 200 hall and she had a feeding tube. CNA B stated the day she went with her family member for Thanksgiving on [DATE] CR#1 was throwing up a lot on that day. CNA B stated she told the nurse on the floor and CR#1's family member that CR#1 was throwing up. She stated the nurse came to the room to speak with the family member and they decided with the family member whether to take CR#1 home for the day or not because of her throwing up. CNA B stated she remembered the day they sent CR#1 to the hospital she was throwing up also. On [DATE] at 11:21 am with RN C, she stated she took care of CR #1 on 100 hall on [DATE], and on 200 hall on [DATE]. She stated when she took care of CR #1 100 hall on [DATE] she checked CR#1's blood sugar and it was very high and that was the only thing she knew that happened that day. She stated she called the Physician, and he told her to give CR#1 a dose of insulin, but she could not remember the units. When they call Physician's number usually they would speak with anyone who picked the line, it could be one of the nurse practitioners working with the physician, but she did not know who specifically she spoke with on that day ([DATE]) on thanksgiving day. CR#1 used to have insulin scheduled for her blood sugar, she stated she was shocked that CR#1 was not on insulin when she took care of her on that day because CR#1's blood sugar was so high, 402 mg/dL, that she had to call the Physician. She stated CR#1 used to have insulin NPH and sliding scale. RN C stated CR#1's family member wanted to take her out to eat on the thanksgiving day, but she (RN C) told the family member that they had to take care of CR#1's blood sugar before the family member could take CR #1 out. RN C stated she followed up and rechecked the blood sugar and it was lower than what it was before, but she did not remember what the value was and she was not sure if she documented it. She stated she should have put what the blood sugar came down to. She stated she could not remember if CR#1 was throwing up. She stated there were so many things that happened that day and many families came to pick their family up so she did not recall if she wrote any notes or any assessments. On [DATE] at 1:58pm with former ADON C she stated she could not remember what happened with CR#1. She stated CR#1 did get sent out to the hospital on the night shift. She stated if someone was throwing up, it was a change in condition, and they needed to do something about that. She stated they needed to call the Nurse Practitioner, Responsible Party, and everyone that needed to be called. On [DATE] at 2:12pm in an interview with RN B, she stated she walked in on [DATE] and CR#1 did not have any signs and symptoms, CR #1 was acting normal, the blood pressure was normal and then she checked CR#1's blood sugar and CR#1's blood sugar was pretty high in the 491mg/dl, so she called the physician. RN B stated she looked through CR#1's physician orders and saw that her orders for insulin had been discontinued by the physician and she did not know why it was discontinued. RN B stated on the weekend of [DATE] and [DATE], CR#1's blood sugar was in the 300's and they did not document any interventions from the nurses. RN B stated she worked at the facility on [DATE] and [DATE], and it was her first-time taking care of with CR#1. RN B stated she knew that blood glucose of 300 was not a normal thing. RN B stated no one informed her that CR#1 had been throwing up on [DATE] on the thanksgiving day. On [DATE] at 12: 38pm in an interview and record review of CR#1's clinical record with the DON, she stated CR#1 came to them from home with dementia, old CVA history, sepsis with shock, malnutrition, diabetes, High blood pressure, and pressure ulcers when admitted . The DON stated CR#1's blood sugars were in the 400's and 500's. She stated CR#1 could spike and go up to 402 within 30 minutes of each other and then went back down to 126. She stated CR#1's blood sugars started going consistently higher on [DATE]. She stated they were holding CR#1's tube feeding, and administered the insulin sliding scale. The DON stated in CR#1's clinical record, the physician noted dated [DATE] revealed CR#1's Pt's diabetes is controlled at this time. Will continue to monitor for stability. BS: 557mg/dL, the Physician wrote that it was controlled and will continue to monitor. The DON stated she was not going to second guess a physician when he stated the blood sugar was 557 and that it was controlled. On [DATE] at 3:05pm with LVN B, she stated she worked on [DATE] and [DATE] in the hall where CR #1 was. She stated on [DATE], she went to assess CR#1 and she called CR#1's Physician and told the NP that CR#1 was not doing well. LVN B stated CR#1's O2 Saturation was still okay at the time she came to the shift. She stated when she assessed CR#1 she was just quietly looking, and CR #1 was a quiet person. LVN B stated when she was handing over to the night nurse (LVN A), she and the nurse they checked CR #1's O2 saturation it was below 90. LVN B stated CR#1's O2 saturation was the problem, and she called the RT, and the Respiratory Therapist came to check CR#1's oxygen and it was low so they sent CR#1 out to the hospital on [DATE]. LVN B stated she reported to LVN A because she (LVN A) worked that night. On [DATE] at 12:33pm in an interview with RN A she stated she was on orientation with LVN C on that day on [DATE]. She said it seemed the problem started during the night shift, but they were waiting for Physician because they were trying to reach the Physician during the night. She said if resident was having change in condition and Physician was not answering the call, the expectation was to call 911 and inform her supervisors that she was going to send the patience to hospital. She said on that day they were calling the Physician back and forth. She stated when she came to the shift on that morning they got reports that the resident's blood sugar was spiking. They discontinued CR #1 feeding tube and flush her tube with water, she said she was not used to that patient so she did not know if the patient was having a change in condition, if it was a patient she was used to she would know if CR#1 was having even any slight changes in her condition. RN A stated on [DATE] she was a PRN staff and she took care of CR#1 and she did not think CR#1's blood sugar was high that day at 6:30pm, but on [DATE] RN A stated she was coming on-board as a full time staff and was on orientation with LVN C. RN A stated on [DATE] the night duty nurse reported CR#1's blood sugar was spiking and CR#1 continued having high blood sugar. RN A stated she called the Physician and they did not respond. RN A stated CR#1's blood sugar was high on [DATE], and the Physician (she was not sure if it was a Physician or the NP) got back to them at around 10:00am but before the MD got back to them they applied the sliding scale and they also gave CR#1 bolus fluid. RN A stated to be very honest, she did not notice if the resident (CR#1) was having any change in condition, if it was a patient that she was used to she would be able to say if the patient had a change of condition. She stated that same CR#1 was sent out to the hospital. RN A stated the resident (CR#1) had a lot of health issues going on with her, she said to be very [NAME], when the woman started having hyperglycemia they (nurses) should have given her insulin, but they delayed. RN A stated she was not able to make notes because she was doing orientation and was not used to the documentation system, and she could not find a place to make the notes and the intervention. She stated making the notes was not easy because she was trying to know the patient at the same time. On [DATE] at 1:00pm in an interview with LVN C, she stated she worked the morning shift on [DATE], but she no longer worked at the facility. She stated if she did a blood sugar and it was 500 she would call the Physician and she would reassess the resident to make sure it was the right reading. She stated if the resident had a sliding scale she would administer the insulin and she would check if they were on continuous feeding and they would pause the feeding. She stated she would also do a water flush for the tube feeding and call the physician. She stated the first thing she would do was to administer the insulin sliding scale and go from there. She stated if the blood sugar was that high in the 500s, she would check it every 30 min and keep rechecking it. She stated if she was able to get the blood sugar down from 500 to 380 within an hour she would still alert the physician and would continue to follow up with the blood sugar. She said she could not remember the patient specifically because she always working with a lot of nurses and orienting them, and that she was not a primary nurse on the floor. She stated she could not recall anything about CR #1, and she could not recall anything happening to CR #1 on ,d+[DATE] 2023. On [DATE] at 2:39pm in an interview with the Lead NP, she stated she knew all the residents in the facility because she comes to the building everyday. The Lead NP stated CR#1 was on 2 different insulins (NPH and Lispro) when she was admitted to the facility. She stated on [DATE] a nurse (she did not remember the nurse) told her that the resident's blood sugar was running too low, and she gave verbal order to the nurse to discontinue the insulin lispro for CR#1 because her blood sugar was low at that time. The Lead NP stated she did not give any order to discontinue the NPH. She stated CR#1 was on NPH 40 units 3 times a day, the nurse was to discontinue only the insulin Lispro, and leave the NPH insulin without any changes. She stated that the nurse discontinued both insulin (NPH and Lispro) by error. The NP stated if blood sugar was high the nurse was supposed to call and let them know that the resident's insulin was discontinued, because the resident (CR #1) was supposed to be on the NPH as a basal coverage for the resident. She stated insulin lispro was not meant for treating residents with hyperglycemia, she stated the lispro was a short acting insulin which was in place to bring the blood sugar down in case the resident's blood sugar spiked. She stated there should be a scheduled insulin NPH which would be covering the resident for up to 12 hours. The lead NP stated she did not know the insulin NPH was discontinued, she did not check the resident's record, because she believed when they gave an order to the nurses, they were supposed to carry out the order accordingly. She stated she was always in the building and most nurses would come to her to get order for anything happening with any resident and she would give verbal order at times. She stated whenever she or any other team member give an order, they would always communicate with other team members, so they all be on the same page. The Lead NP stated if a patient started throwing up, she would expect the staff to call them for any change in condition. The Lead NP stated she was at the building on the [DATE] and the resident's vital signs were all good and there was no need to send the resident to hospital. On [DATE] at 4:38pm in an interview with LVN D who discontinued the insulin NPH and Lispro for CR #1, she stated the NP gave her order on the [DATE] to discontinue the lispro and that was the only insulin she discontinued, she stated she only discontinued the sliding scale according to what the nurse practitioner (Lead NP) told her. She stated she did not recall discontinuing the insulin NPH for CR #1. On [DATE] at 2:43pm in an interview with LVN A she said CR#1's blood sugar on [DATE] at 11:28pm was 319. LVN A stated CR#1 was sent out because she was declining compared to the last time she took care of CR #1 on the 100 hall. LVN A said CR#1's oxygen saturation was what they were mainly worried about, her oxygen was low in the 80s so they got orders to put CR #1 on oxygen. LVN A said CR#1 was not acting the same as when she was on 100 Hall. She said on [DATE] at 5:34 am CR#1's blood sugar was up to 598 so they gave CR#1 some insulin. LVN A said with CR#1 was declining oxygen saturation was 88% and resident was placed on non-rebreather with oxygen at 10 liters, but they still could not get CR #1's oxygen level up, the resident (CR #1) was not looking good, and her blood sugar was high, so she got orders to send the CR#1 out to hospital. LVN A stated when she took care of CR#1 on the 100 hall CR #1 was getting insulin NPH in the morning but it was discontinued on [DATE] and she did not know why it was discontinued. LVN A stated she also took care of CR #1 on [DATE] and checked CR #1's blood sugar on [DATE] but could not recall what it was and whether she gave insulin or not. She stated on [DATE] during the night shift, she tried to call the physician, but they don't really respond in the middle of the night. She said the physician did respond early in the morning around 5:00am. She said CR #1 was barely trying to open her eyes and that was a big difference from CR#1's normal self, CR #1 appeared lethargic, she knew CR #1 to be more alert than how she appeared on [DATE]. LVN A said EMS came at 6:20 am. LVN A said she did not recheck CR#1's blood sugar or the oxygen saturation. She stated everything during the shift was going so fast I guess I did not recheck. LVN A said she called the non-emergency line because 911 was called if the resident was not stable. She said CR#1 was still trying to open her eyes, so she thought it was not an emergency, she did not think she needed 911. LVN A stated if a resident was coding and not breathing she would call 911 but CR #1 was still breathing only that she appeared lethargic, O2 low, and blood sugar high. LVN A stated she did not realize the situation with the resident was an emergency because the resident was not in comatose, she stated, I felt it was getting to that point and she had to send her out. On [DATE] at 3:13pm in an interview with LVN B, she stated CR#1 had elevated blood sugar at 313 on [DATE]. She stated CR#1 was on insulin sliding scale and every time blood sugar was beyond the normal she would give the insulin. She stated on [DATE] she handed CR #1's care over to LVN A to send CR#1 out because the oxygen saturation was low even after they placed CR#1 on oxygen and it was still low. LVN B stated she worked the 2 to 10 pm shift and LVN A worked the 10pm to 6am. LVN B stated she could not remember the date, but the time she charted was 11:28pm and she was still at the facility even after she finished her schedule at 10pm. She stated she was still doing her charting before leaving for the night. LVN B stated she did not write notes on the resident (CR #1), but she told LVN A that CR#1's oxygen saturation was not okay and she kept following up with the nurse until she (LVN B) left the facility. LVN B stated she gave CR#1 insulin sliding scale and rechecked, she stated if she did not write it down she must have missed it to document because she was overwhelmed, because their new system where they document was not user-friendly. She stated she took CR#1's blood sugar earlier during the shift on [DATE] and the blood sugar value was 313, but she documented it late at 11:28pm. She did not recall if she followed up to recheck the blood sugar again, she only documented it into the system at 11:28pm when she had the chance to document. She stated if the blood sugar was that high she was supposed to continue to recheck the blood sugar to make sure it was coming down because high blood sugar could affect the resident negatively if not treated. on [DATE] at 3:57pm in an interview with the DON, she said if CR#1 has a blood sugar above 300 the nurses were to call the Physician to get order. The DON said besides the Physician's order, the nurses were to use nursing judgement and check the blood sugar every 30 minutes to an hour if the resident's blood sugar was still high, and if there are further orders they check with the physician again. She stated in 30 minutes to an hour they would be able to identify if the blood sugar was going down, but they do not want to give more insulin because the insulin was still working. The DON stated CR#1's blood sugar was coming down, but then she had a meal in between which could have brought her blood sugar up again. The DON stated blood sugar was a patient specific thing and 300 was high for CR#1 and the nurses were expected to use their nursing judgement to recheck CR #1's blood sugar more frequently to see the blood sugar trending down. The DON said based on the CR#1's blood sugar level and overall change in condition, CR #1 should have been sent by emergency 911 and not non-emergency ambulance. She said the situation with CR #1, high blood sugar and low O2 saturation while on non-rebreather mask with 10liters oxygen, was a change in condition and needed prompt interventions. She said when the nurses are given orders by the physician, nurses were supposed to carry them out, and in this situation she would have implemented the order to send resident out rapidly. The DON stated she was not sure if CR #1 was throwing up on the [DATE]. She stated if a resident threw up only once then she would watch it because it could have been something they ate that did not agree with them, but if it was something happening consistently it was a change in condition. The DON said she was not aware CR#1 vomited multiple times at the facility on Thanksgiving morning. On [DATE] at 4:21pm in an interview with the Primary physician, he stated he was the primary physician for CR #1, but he was not the physician who was called on the day ([DATE]) when resident was sent to the hospital, he said the facility could have called the medical director. He stated he was not aware and could not recall anyone called him for CR #1 throwing up on any day. He stated it was an emergency if a resident was having a change in condition, becoming lethargic with low oxygen level at 88% while on non-rebreather with 10 liters of oxygen and high blood sugar in the 500s. The Primary physician stated it is a possibility that the high blood sugar could have caused the resident to throw up. He stated when a sliding scale was given and residents blood spiked, the goal was to administer insulin so as to bring the resident's blood sugar down to the lowest level on the slightly scale. On [DATE] at 4:23pm in an interview with the facility Medical Director, he stated I won't remember that patient at all he stated he was not the Physician for the patient and he stated the Primary physician was the primary physician. He said the protocol was that the facility would only reach out to him if the nurses were not able to reach to the NPs that worked with him or not able to reach another physician s, they would call him. He stated he received a lot of calls all the time with a lot of things, he said the residents at the facility had very high acuity, and they were doing their best to care for the residents. He stated he could not recall anyone calling him about CR #1 throwing up or having extremely high blood sugar of having any change in condition. He stated the nurses must have reached out to the primary care Physician and not him. Review of facility policy titled 'Blood Sugar Checks' undated revealed in part, residents receiving insulin should be monitored according to the ordered sliding scale and as needed. Review of facility policy titled 'Pulse Oximetry (Assessing Oxygen Saturation)' dated 'revised [DATE]' revealed in part, normally SpO2 is between 90 and 100 percent .if SpO2 is less than acceptable level for resident's condition, notify the physician. Review of facility policy titled Change in a Residence Condition or Status Dated Revised February 2021 revealed, in part, a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions .A nurse will notify the residence representative when there is a significant change in the resident physical mental or psychosocial status .The nurse will record in the residence medical record information relative to changes in the resident medical or mental condition or status This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 2:57pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 8:17pm. The plan of removal reflected the following: PLAN OF REMOVAL Name of facility: Date: [DATE] The Texas Department of Health and Human Services entered [facility] on [DATE], for a P1 Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F684 as stated below: F684: Quality of Care Resident Status: The resident was discharged to an acute care hospital on [DATE] and did not return. Immediate action: On [DATE] DON, under the guidance of the Regional Nurse Consultant initiated an in-service with all nursing staff (all nursing staff to include CNAs) on duty to cover the following topics, this training will be completed on [DATE]. o Notifying Physician and Family of Resident Change of Condition. The physician should be notified as soon as possible after identifying a change of condition, assessing resident needs and providing necessary services. If the physician is unable to be reached, the DON and/or designee should be notified and the Medical Director contact for treatment plan. o Recognizing and Reporting Acute Changes of Condition. Changes of condition include, but are not limited to vomiting, vital signs, mental status changes, functional decline, hyperglycemia, etc. o Notification of physician upon identifying a high blood sugar level. o Monitoring and follow-up of changes of conditions. o Symptoms that include the need for emergency ambulance services. o Documentation of events (Change of Condition), SBAR and Stop & Watch. o Change of Condition policy was reviewed, no changes were made. Staff in-serviced on current policy. o Residents receive treatment as per physician orders. o Documentation of events (Change of Condition), SBAR and Stop & Watch. o Residents receive treatment as per physician orders. o An audit will be conducted of all residents receiving insulin to ensure orders are correct. This audit will be completed by [DATE]. o An audit will be conducted of all residents receiving blood sugar checks to ensure parameters are set. This audit will be completed by [DATE]. o An audit was completed of residents with changes of conditions, within the last 30 days, to ensure the resident physician was notified. This audit will be completed [DATE]. o An audit of residents with diabetes was done to assess for high blood sugar levels or change of condition. This audit was started on [DATE] and will be completed [DATE]. o The nurse referenced in the IJ narrative was identified and in-serviced on following physician orders and discontinuation of medications. In-service completed on [DATE]. o 1:1 in-service was completed with LVN-A on assessing and monitoring resident who experience a change of condition; residents receive treatment as per physician orders; and residents receive emergency services timely, if required. Inservice completed on [DATE]. Facility Plan to ensure compliance quickly: o All nursing staff will be in-serviced on the above-listed topics prior to beginning their next scheduled work shift. o The DON and/or designee will conduct audits of the 24-hour report to include review of progress notes to ensure that all changes of conditions have been identified and physician notification has been made; physician orders written in the previous 24 hours; and any resident hospital transfer to ensure emergency services were utilized, when appropriate. This audit began on [DATE]. Demonstration of and acknowledgement that all licensed nurses are aware of the above: o The DON/ADON and/or designee will contact all licensed nurse staff and get a verbal acknowledgement as a return demonstration of understanding of the above listed training topics. o This in-servicing began [DATE] and will be completed by [DATE]. On [DATE] The facility Administrator, ADON, and Regional Nurse Consultant held an ad hoc QAPI meeting with the Medical Director, via phone, to discuss: o F684 - Quality of Care - IJ Cited o Plan of Removal and actions taken to ensure continued compliance. QAPI: o The above actions will be reviewed monthly in QAPI to ensure continued compliance. The State Surveyor confirmed the facility implemented their Plan of Removal for the IJ to be removed by monitoring from [DATE] through [DATE] as follows: On [DATE] at 3:09pm interview with LVN E, she stated she only worked on weekends, she had not been trained in

Based on interview and record review, the facility failed to consult with the resident's physician; and notify the resident representative for 1 of 3 residents (CR #1) reviewed for change of condition, in that, The facility staff failed to immediately notify the physician when CR#1 started vomiting up a brown substance repeatedly on [DATE]. The facility failed to notify the physician that CR #1 insulin NPH was discontinued when CR#1 was having high glucose readings for 6 days. CR#1 was sent out to the hospital on [DATE] and died in the hospital on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] while the IJ was removed on [DATE] at 3:58pm, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures could expose residents to low quality of care, worsening of condition, hospitalization , and death. Findings included: Record review of CR#1's face sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE]. Current admission was on [DATE] with diagnoses of type 2 diabetes (A chronic condition that affects the way the body processes blood sugar, resulting in too much sugar in the body), kidney failure, cerebral infarction (cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), malnutrition, hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), high blood pressure, sepsis (Sepsis is a serious condition in which the body responds improperly to an infection, causing a cascade of changes that damage multiple organ systems, leading them to system failure, sometimes even death), and heart disease. Review of CR #1's MDS dated [DATE] revealed CR #1 was diagnosed with Diabetes Mellitus, high blood pressure, cerebral infarction, and hemiplegia. MDS also revealed CR #1 was on insulin medication, oxygen therapy treatment, suctioning, and tracheostomy care. Review of CR #1's care plan revealed CR #1 was at risk hypoglycemia / hyperglycemia episodes due to diabetes mellitus. The care plan goal was that CR #1's blood sugar will be managed effectively, and the care plan intervention was to do a quick check as ordered and report any abnormal findings to the Physician and family members. Review of Physician order dated [DATE] revealed Accu check with insulin Lispro (AdmeLOG) sliding scale SQ 142 - 180 = 2 units 181 - 220 = 4 units 221 - 240 = 5 units 241 - 260 = 7 units 262 - 280 = 9 units 282 - 300 = 10 units >300 = 12 units and call MD Four Times A Day 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM Record review of CR#1's blood sugar vitals revealed: [DATE] at 5:34 am 598 mg/dL [DATE] at 11:28 pm 319 mg/dL [DATE] at 11:28 pm 283 mg/dL [DATE] at 1:01 pm 381 mg/dL [DATE] at 10:57 am 468 mg/dL [DATE] at 8:15 am 556 mg/dL [DATE] at 8:02 am 468 mg/dL [DATE] at 7:01 pm 300 mg/dL [DATE] at 11:33 am 386 mg/dL [DATE] at 9:31 am High (above 600) [DATE] at 8:24 am High (above 600) [DATE] at 1 pm 414 mg/dL [DATE] at 9:27 pm 250 mg/dL [DATE] at 5:52 pm 289 mg/dL [DATE] at 1:16 pm 365 mg/dL [DATE] at 5:32 pm 313 mg/dL [DATE] at 12:04 pm 398 mg/dL [DATE] at 9:24 am 388 mg/dL [DATE] at 8:43 pm 382 mg/dL [DATE] at 10:42 am 320 mg/dL [DATE] at 10:24 am 365 mg/dL [DATE] at 7:24 pm 269 mg/dL [DATE] at 1:55 pm 139 mg/dL [DATE] at 8:39 am 139 mg/dL [DATE] at 10:36 pm 159 mg/dL [DATE]at 11:57 am 300 mg/dL On [DATE] at 11:25am in an interview with CR#1's family member, she stated CR#1 had an infection that was not treated and by the time CR #1 got to the ER she was septic and died on [DATE] at the hospital. CR#1's family member stated there were instances where the Physician stated he did not know about CR#1 and admitted that he did not know CR#1. CR#1's family member stated she went to check CR#1 out of the facility on thanksgiving day, but CR#1 was throwing up that day and no one knew why she was throwing up. CR#1's family member stated she did not want to take CR#1 out of the facility not knowing what was happening. CR#1's family member stated no one knew why CR#1 was throwing up and it was odd for CR#1 to be throwing up so something must have been wrong with CR #1 on that day ([DATE]). CR#1's family member stated the staff (unknown) said CR#1 threw up twice that morning. On [DATE] at 1:58pm with former ADON C she stated she could not remember what happened with CR#1. She stated CR#1 did get sent out to the hospital on the night shift. She stated if someone was throwing up, it is a change in condition, and they needed to do something about that. She stated they needed to call the Nurse Practitioner, Responsible Party, and everyone that needed to be called. On [DATE] at 12:24pm in an interview with CNA A, she stated she remembered CR#1 threw up on [DATE] on thanksgiving day. CNA A stated they noticed CR#1 threw up and she (CNA A) went to tell the Nurse (did not remember who the nurse was). CNA A stated CR#1's emesis was brown and it was a lot. CNA A stated she told the nurse and she went to check CR#1. CNA A stated she did not recognize any other changes in condition for CR #1 on that day. On [DATE] at 12: 38pm in an interview and record review of CR#1's clinical record with the DON, she stated CR#1 came to them from home with dementia, old CVA history, sepsis with shock, malnutrition, diabetes, High blood pressure, and pressure ulcers when admitted . The DON stated CR#1's blood sugars were in the 400's and 500's. She stated CR#1 could spike and go up to 402 within 30 minutes of each other and then went back down to 126. She stated CR#1's blood sugars started going consistently higher on [DATE]. She stated they were holding CR#1's tube feeding, and administered the insulin sliding scale. The DON stated in CR#1's clinical record, the physician note dated [DATE] revealed CR#1's Pt's diabetes is controlled at this time. Will continue to monitor for stability. BS: 557mg/dL, the Physician wrote that it was controlled and will continue to monitor. The DON stated she was not going to second guess a physician when he stated the blood sugar was 557 and that it was controlled. On [DATE] at 3:05pm with LVN B, she stated she worked on [DATE] and [DATE] in the hall where CR #1 was. She stated on [DATE], she went to assess CR#1 and she called CR#1's Physician and told the NP that CR#1 was not doing well. LVN B stated CR#1's O2 Saturation was still okay at the time she came to the shift. She stated when she assessed CR#1 she was just quietly looking, and CR #1 was a quiet person. LVN B stated when she was handing over to the night nurse (LVN A), she and the nurse they checked CR #1's O2 saturation it was below 90. LVN B stated CR#1's O2 saturation was the problem, and she called the RT, and the Respiratory Therapist came to check CR#1's oxygen and it was low so they sent CR#1 out to the hospital on [DATE]. LVN B stated she reported to LVN A because she (LVN A) worked that night. Review of progress note revealed no documentation by LVN B of notification to physician regarding CR #1's condition on [DATE]. On [DATE] at 10:21am in an interview with CNA B she stated CR#1 came from the 100 hall doing well and moved to the 200 Hall and after some time, CR#1 stopped eating well the staff had to feed her and she refused sometimes. CNA B stated CR#1 was not really eating enough by mouth when she came to the 200 hall and she had a feeding tube. CNA B stated the day she went with her daughter for Thanksgiving on [DATE] CR#1 was throwing up a lot on that day. CNA B stated she told the nurse on the floor and CR#1's family member that CR#1 was throwing up. She stated the nurse came to the room to speak with the family member and they decided with the family member whether to take CR#1 home for the day or not because of her throwing up. CNA B stated she remembered the day they sent CR#1 to the hospital she was throwing up also. On [DATE] at 11:21 am with RN C, she stated she took care of CR #1 on 100 hall on [DATE], and on 200 hall on [DATE]. She stated when she took care of CR #1 on 100 hall on [DATE] she checked CR#1's blood sugar and it was very high and that was the only thing she knew that happened that day. She stated she called the Physician, and he told her to give CR#1 a dose of insulin, but she could not remember the units. She stated when they call Physician's number usually they would speak with anyone who picked the line, it could be one of the nurse practitioners working with the physician, but she did not know who specifically she spoke with on that day ([DATE]) on thanksgiving day. RN C stated CR#1's family member wanted to take her out to eat on the thanksgiving day, but she (RN C) told the family member that they had to take care of CR#1's blood sugar before the family member could take CR #1 out. She stated she could not remember if CR#1 was throwing up. She stated there were so many things that happened that day and many families came to pick their family up so she did not recall if she wrote any notes or any assessments. Record review of CR #1's Medication Administration Record (MAR) for the month of [DATE] revealed there was no documentation of blood sugar checked and no insulin administered to CR #1 on the 9pm check schedule on [DATE] when LVN A worked. On [DATE] at 1:00pm in an interview with LVN C, she stated she worked the morning shift on [DATE], but she no longer worked at the facility. She stated if she did a blood sugar and it was 500 she would call the Physician and she would reassess the resident to make sure it's the right reading. She stated if the resident had a sliding scale she would administer the insulin and she would check if they were on continuous feeding and they would pause the feeding. She stated she would also do a water flush for the tube feeding and call the physician. She stated the first thing she would do was to administer the insulin sliding scale and go from there. She stated if the blood sugar was that high in the 500s, she would check it every 30 min and keep rechecking it. She stated if she was able to get the blood sugar down from 500 to 380 within an hour she would still alert the physician and would continue to follow up with the blood sugar. She said she could not remember the patient specifically because she always working with a lot of nurses and orienting them, and that she was not a primary nurse on the floor. She stated she could not recall anything about CR #1, and she could not recall anything happening to CR #1 on ,d+[DATE] 2023. On [DATE] at 2:39pm in an interview with the Lead NP, she stated she knew all the residents in the facility because she comes to the building everyday. NP stated CR#1 was on 2 different insulins (NPH and Lispro) when she was admitted to the facility. She stated on [DATE] a nurse (she did not remember the nurse) told her that the resident's blood sugar was running too low, and she gave verbal order to the nurse to discontinue the insulin lispro for CR#1 because her blood sugar was low at that time. The Lead NP stated she did not give any order to discontinue the NPH. She stated CR#1 was on NPH 40 units 3 times a day, the nurse was to discontinue only the insulin Lispro, and leave the NPH insulin without any changes. She stated that the nurse erroneously discontinued both insulin (NPH and Lispro). The NP stated if blood sugar was high the nurse was supposed to call and let them know that the resident's insulin was discontinued, because the resident (CR #1) was supposed to be on the NPH as a basal coverage for the resident. She stated insulin lispro was not meant for treating residents with hyperglycemia, she stated the lispro is a short acting insulin which was in place to bring the blood sugar down in case the resident's blood sugar spiked. She stated there should be a scheduled insulin NPH which would be covering the resident for up to 12 hours, The lead NP stated she did not know the insulin NPH was discontinued, she did not check the resident's record, because she believed when they gave order to the nurses, they were supposed to carry out the order accordingly. She stated she was always in the building and most nurses would come to her to get order for anything happening with any resident and she would give verbal order at times. She stated whenever she or any other team members give order, they would always communicate with other team members, so they all be on the same page. The NP stated if a patient started throwing up, she would expect the staff to call them for any change in condition. The Lead NP stated she was at the building on the [DATE] and the resident's vital signs were all good and there was no need to send the resident to hospital. On [DATE] at 2:43pm in an interview with LVN A she said CR#1's blood sugar on [DATE] at 11:28pm was 319. LVN A stated CR#1 was sent out because she was declining compared to the last time she took care of CR #1 on the 100 hall. She stated she got shift report from thee day/evening shift nurse and she took over CR #1's care. She stated on [DATE] during the night shift, she tried to call the physician, but they don't really respond in the middle of the night. She said the physician did respond early in the morning around 5:00am. LVN A said CR#1's oxygen sat was what they were mainly worried about, her oxygen was low in the 80s so they got orders to put CR #1 on oxygen. LVN A said CR#1 was not acting the same like when she was on 100 Hall. She said on [DATE] at 5:34 am CR#1's blood sugar was up to 598 so they gave CR#1 some insulin. LVN A said with CR#1 was declining - oxygen saturation was 88% and resident was placed on non-rebreather with oxygen at 10 liters, but they still could not get CR #1's oxygen level up, the resident (CR #1) was not looking good, and her blood sugar was high, so she got orders to send the CR#1 out to hospital at around 5:00am when she got through to the physician. She said CR #1 was barely trying to open her eyes and that was a big difference from CR#1's normal self, CR #1 appeared lethargic, she knew CR #1 to be more alert than how she appeared on [DATE]. LVN A said EMS came at 6:20 am. Record review of CR #1's progress note documented by LVN A on [DATE] revealed Rsd breathing but non-responsive. bs 598 per Dr order gave 15units of lispro @05am and to send rsd out to hospital v/s ,d+[DATE], hr 128, t-97.4, O2 88% w/ non-breather mask on 10L oxygen. Non-emergent line contacted eta 0600 . On [DATE] at 3:13pm in an interview with LVN B she stated on [DATE] CR#1 had elevated blood sugar at 313. She stated CR#1 was on insulin sliding scale and every time blood sugar was beyond the normal she would give the insulin. She stated on [DATE] she handed CR #1's care over to LVN A to send CR#1 out because the oxygen saturation was low even after they placed CR#1 on oxygen and it was still low. LVN B stated she worked the 2 to 10 pm shift and LVN A worked the 10pm to 6am. She stated before giving CR#1 oxygen it was low and her O2 saturation remained low. LVN B stated she could not remember the date, but the time she charted at 11:28pm she was still at the facility even after she finished her schedule at 10pm she was still doing her chart before leaving for the night. LVN B stated she did not write notes on the resident (CR #1), but she told LVN A that CR#1's oxygen saturation was not ok and she kept following up with the nurse until she (LVN B) left the facility. LVN B stated she gave CR#1 insulin sliding scale. She stated if she did not write it down she must have missed it to document because she was overwhelmed, because their new system where they document was not user-friendly. She stated she took CR#1's blood sugar earlier during the shift and the value was 313, but she documented it at 11:28pm . She did not recall if she followed up to recheck the blood sugar again, she only documented it into the system at 11:28pm when she had the chance to document. She stated if the blood sugar was that high she was supposed to continue to recheck the blood sugar to make sure it was coming down because high blood sugar could affect the resident negatively if not treated. On [DATE] at 3:57pm in an interview with the DON, she said if CR#1 has a blood sugar above 300 the nurses were to call the Physician to get order. The DON said besides the Physician's order, the nurses were to use nursing judgement and check the blood sugar every 30 minutes to an hour if the resident's blood sugar was still high, and if there are further orders they check with the Physician again. She stated in 30 min to an hour they would be able to identify if the blood sugar was going down, but they don't want to give more insulin because the insulin was still working. The DON stated CR#1's blood sugar was coming down, but then she had a meal in between which could have brought her blood sugar up again. The DON stated blood sugar is a patient specific thing and 300 was high for CR#1 and the nurses were expected to use their nursing judgement to recheck CR #1's blood sugar more frequently to see the blood sugar trending down. The DON said based on the CR#1's blood sugar level and overall change in condition, CR #1 should have been sent by emergency 911 and not non-emergency ambulance. She said the situation with CR #1, high blood sugar and low O2 sat while on non-rebreather mask with 10liters oxygen, was a change in condition and needed prompt interventions. She said when the nurses are given orders by the Physician, nurses were supposed to carry them out, and in this situation she would have implemented the order to send resident out rapidly. The DON stated she was not sure of CR #1 was throwing up on the [DATE]. She stated if a resident throws up only once then she would watch it because it could have been something they ate that did not agree with them, but if it is something that is happening consistently it is a change in condition. The DON said she was not aware that CR#1 vomited multiple times at the facility on Thanksgiving morning. On [DATE] at 4:21pm in an interview with the Primary Physician, he stated he was the primary Physician for CR #1, but he was not the one who was called on the day ([DATE]) when resident was sent to the hospital, he said probably they called the medical director. He stated he was not aware and could not recall anyone called him for CR #1 throwing up on any day. He stated it was an emergency if a resident was having a change in condition, becoming lethargic with low oxygen level at 88% while on non-rebreather with 10 liters of oxygen and high blood sugar in the 500s. The Primary Physician also stated it is a possibility that the high blood sugar could have caused the resident to throw up. He stated when a sliding scale is given and residents blood spiked, the goal was to administer insulin so as to bring the resident's blood sugar down to the lowest level on the slightly scale. On [DATE] at 4:38pm in an interview with LVN D who discontinued the insulin NPH and Lispro for CR #1, she stated the NP gave her order on the [DATE] to discontinue the lispro and that was the only insulin she discontinued, she stated she only discontinued the sliding scale according to what the nurse practitioner (Lead NP) told her. She stated she did not recall discontinuing the insulin NPH for CR #1. Record review of CR #1's Physician order revealed insulin NPH and insulin Lispro was discontinued by LVN D on [DATE]. On [DATE] at 4:23pm in an interview with the facility Medical Director, the Medical Director he state I won't remember that patient at all he stated he was not the Physician for the patient and he stated the Primary Physician was the primary Dr. He said the protocol was that the facility would only reach out to him if the nurses were not able to reach to the NPs that worked with him or not able to reach other Physicians, they would call him. He stated he gets a lot of calls all the time with a lot of things, he said the resident there at the facility their acuity is very high, and they were doing their best to care for the residents. He stated he could not recall anyone calling him about CR #1 throwing up or having extremely high blood sugar of having any change in condition. He stated the nurses must have reached out to the primary care Physician and not him. Review of facility policy titled Change in a Residence Condition or Status Dated Revised February 2021 revealed, in part, The nurse will notify the resident's attending physician or physician on call where there has been it's significant change in residence physical emotional mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions .A nurse will notify the residence representative when there is a significant change in the resident physical mental or psychosocial status .The nurse will record in the residence medical record information relative to changes in the resident medical or mental condition or status This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 2:57pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 8:17pm. PLAN OF REMOVAL Name of facility: Date: [DATE] The Texas Department of Health and Human Services entered [facility] on [DATE], for a P1 Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F580 as stated below: F580: Notify of Change in Condition Resident Status: The resident was discharged to an acute care hospital on [DATE] and did not return. Immediate action: On [DATE] DON under the guidance of the Regional Nurse Consultant initiated an in-service with all nursing staff (all nursing staff to include CNAs) on duty to cover the following topics, this training will be completed by [DATE]. o Notifying Physician and Family of Resident Change of Condition. The physician should be notified as soon as possible after identifying a change of condition, assessing resident needs and providing necessary services. If the physician is unable to be reached, the DON and/or designee should be notified and the Medical Director contact for treatment plan. o Recognizing and Reporting Acute Changes of Condition. Changes of condition include, but are not limited to vomiting, vital signs, mental status changes, functional decline, etc. o Symptoms that include the need for emergency ambulance services. o Documentation of events (Change of Condition), SBAR and Stop & Watch. o Notification of physician upon identifying a high blood sugar level. o Change of Condition policy was reviewed, no changes were made. Staff in-serviced on current policy. o An audit will be conducted of all residents receiving insulin to ensure orders are correct. This audit will be completed by [DATE]. o An audit will be conducted of all residents receiving blood sugar checks to ensure parameters are set. This audit will be completed by [DATE]. o An audit was completed of residents with changes of conditions, within the last 30 days, to ensure the resident physician was notified. This audit will be completed [DATE]. o An audit of residents with diabetes was done to assess for high blood sugar levels or change of condition. This audit was started on [DATE] and will be completed [DATE]. Facility Plan to ensure compliance quickly: o All nursing staff will be in-serviced on the above listed topics prior to beginning their next scheduled work shift. o The DON and/or designee will conduct audits of the 24-hour report to include review of progress notes to ensure that all changes of conditions have been identified and physician notification has been made. This audit began [DATE]. Demonstration of and acknowledgement that all licensed nurses are aware of the above: o The DON/ADON and/or designee will contact all licensed nurse staff and get a verbal acknowledgement as a return demonstration of understanding that: o A physician is to be notified immediately of changes of condition. o This in-servicing began [DATE] and will be completed by [DATE]. On [DATE] The facility Administrator, ADON, and Regional Nurse Consultant held an ad hoc QAPI meeting with the Medical Director, via phone, to discuss: o F580 - Notify of Change of Condition - IJ Cited o Plan of Removal and actions taken to ensure continued compliance. QAPI: o The above actions will be reviewed monthly The State Surveyor confirmed the Plan of Removal for the IJ by monitoring from [DATE] through [DATE] as follows: On [DATE] at 3:09pm interview with LVN E, she stated she only worked on weekends, she had not been trained in an in-service today, she said she saw some pieces of paper at the nurses station but nobody has told her anything. On [DATE] at 3:10pm in an interview with CNA C, he stated he had received in-service training when he came to the shift today, the training was about reporting to the nurse and DON immediately if they saw any changes in resident and to complete the Stop & Watch form. On [DATE] at 3:12pm in an interview with LVN F, he stated he was in-serviced today regarding abuse and neglect, documentation of SBAR when resident have change in condition and to document all intervention, he provided to his residents in the nurses note. He stated he was also trained about medication administration medications such as antibiotic insulin and other meds and to monitor blood sugar after administration of insulin to residents and to notify the Physician, the DON and the supervisors if there is any change in condition for his residents. He stated monitoring blood sugar for residents should be done every 30 to 40 minutes for every resident with high blood sugar and to continue to monitor the blood sugar until the blood sugar gets down to the level you don't need to give insulin. On [DATE] at 3:19pm in an interview with RT A, she said she had in-service training yesterday and today they were taught to make sure they document if any patient have change in condition and pay attention to abnormal changes in patient. and they have to communicate with the nurse Physician, NP, DON, and resident's family members. On [DATE] at 3:21pm in an interview with CNA D, she stated she had in service training yesterday about reporting any changes in resident at any point in time to the nurse immediately, she said changes could be if patient is not eating as they used to eat, not talking as they used to talk, not opening their eyes, not having enough bowel movement, not having enough urine, or patient is vomiting, patient has any skin issue, she said anything different in the normal condition of the patient she would report immediately to the nurse and to the DON so they can follow up with the necessary intervention. On [DATE] 3:13pm in an interview with CNA E she stated that she was trained this morning and few days ago about changes in condition of a patient to let the nurse know immediately if the CNA's notice any little change in the situation of the patient and to complete the stop and watch form. On [DATE] at 3:15pm in an interview with LVN G, he said he received an in service on Friday [DATE] and the training was about documentation reporting of changes in condition and sending patient out on emergency and completion of SBAR. he said he would send a patient out on emergency if the patient was having a serious change in condition or a life threatening condition, or if it is a situation with ABC (Airway Breathing Circulation) and the vitals like oxygen saturation was low and not able to get the oxygen up, or if the patient is having active bleeding that is uncontrollable, or if the patient stop breathing. He said he would also contact the Physician the DON and the family member if there's any changes in resident condition. On [DATE] at 3:20pm in an interview with RN D, she stated she had training yesterday Sunday ([DATE]), he said the training was about monitoring residents blood sugar, when resident had high blood sugar the nurses have to call the Physician to get order and continue to monitor the patient after administering insulin. RN D said the training also include monitoring patient for any change in condition, she stated clinically when your patient is not looking good to you must call Physician to let him or her know your findings and promptly carry out the order given by the Physician. On [DATE] at 3:37pm, in an interview with RT C, she said she received training on Friday about changes in condition of resident and to report to the nurse who was assigned to the resident, and to report to her manager the respiratory therapy manager and the DON and the Physician about whatever changes she found in her resident. She said she was also trained to check vital sign and documenting her findings or evaluation and what was done for the resident and who she told about the resident's condition. On [DATE] at 3:52pm in an interview with LVN H, she said she received training on Friday ([DATE]) about changes in condition if she noticed any changes in any resident she will call the Physician and also informed the DON. she said it depend on the degree of change if patient was having high temperature, or high blood sugar she will continue to monitor the patient and keep the Physician informed. She said if a resident have high blood sugar in the 500s she will call the Physician and get order and she will continue to recheck resident's blood sugar every 30 minutes to 1 hour. On [DATE] at 3:57pm in an interview with Weekend Supervisor, she stated she had received in-service training from the DON on Friday ([DATE]) about changes in condition of resident blood sugar check and follow up notify family members Physician and Don whenever a resident had a change in condition or any abnormal love values abnormal vital sign. she said the training also included documentation of SBAR and documenting in progress notes in detail about every intervention performed for residents. Record review of the plan of removal was completed: - In-service training documentations were reviewed. - An audit of residents with changes of conditions, within the last 30 days, to ensure the resident physician was notified. - Documentation of the Audit of current residents. - Impromptu QAPI meeting of the Administrator with the medical Director. - An audit of all residents receiving insulin to ensure orders are correct.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being by not assessing and treating the pain of 1 of 19 residents (Resident #74) reviewed for receiving necessary care and services. Resident # 74 ' s pain assessments revealed the resident was not having pain and interventions were not necessary. Resident #74 consistantly complained of pain to her lower back and right knee which prevented her for getting out of bed, participating in her ADLs, and socializing with other residents. Resident #74 ' s was not assessed and appropriately treated for [REDACTED]. This failure affected 1 resident by limiting her independence with her care and her socializatin with others due to unmanaged pain and placed 39 other residents on pain management at risk of unmanaged pain which could result in a decline in their psychosocial and physical well-being. Findings include: Resident # 74 Record review of Resident # 74 ' s face sheet revealed a [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #74's MDS dated [DATE] revealed the resident required assistance with transfers and with ADLs and the resident was being assisted with transfers out of bed. Record review of Resident #74 ' s MDS dated [DATE] revealed Resident # 74's cognitive skills for daily decision making were moderately impaired. The MDS revealed Resident # 74 was continent of bowel and had an indwelling urinary catheter. The resident had impairment on both sides of her lower extremities and the resident had a stage IV sacral pressure ulcer. The MDS also revealed the resident had not been transfered out of the bed anytime during the 7 days prior to the assessment. Further review of Resident # 74 ' s MDS dated [DATE] revealed Resident #74 received scheduled and as needed pain medication in the last five days with the pain intensity documented as " rarely " . Record review of Resident # 74 ' s form titled nursing rehabilitation /restorative plan of care dated April 2013 revealed a note dated 4/26/13 " patient has stated that all month long, her extremities hurt too much to get exercise or get into a Geri-chair. Patient says upper extremities hurt as well so no activity was done with upper extremities either " . Record review of Resident #74 ' s care plan updated 5/24/13 revealed Resident # 74 was at risk for pain secondary to her [DIAGNOSES REDACTED]. Goal was resident would have no pain for the next 90 days. Approaches included: "...assess for signs and symptoms of pain i.e. grimacing, moaning etc., staff to ensure she is properly and comfortably positioned at all times, provide medications for pain as ordered, assess for efficacy of pain medication." Record review of Resident # 74 ' s pain assessment form dated 6/8/13 revealed Resident # 74 experienced aching pain from sacral ulcer increased by movement and positioning. Resident # 74 ' s acceptable pain level was documented as a 5 on a scale of 1 to 10 with 1 being the least pain. The assessment documented the resident's pain was relieved by medication and frequent position changes. Conclusion of assessment was " no pain, intervention is not necessary. Re-assess quarterly or with onset of pain " . Record review of Resident # 74 ' s MAR indicated [REDACTED]. Record review of Resident # 74 ' s MAR indicated [REDACTED]. None was documented administered in the month of June. Further review of the June 2013 MAR indicated [REDACTED]. Ordered 9/7/12. None was documented as being administered in the month of June. Observation and interview on 6/13/13 at 12:17 A.M., revealed Resident # 74 in bed. She stated she had pain to her back and right leg, particularly her right knee. The resident was very concerned and moaned when the aide attempted to move her right leg. She said the pain to her right leg was constant and her medication did not relieve the pain. She reported she has requested more pain medication but staff would not give her any. Resident # 74 said she remained in bed because it hurt to much to get in and out of bed. She said she would love to go out of the room and socialize with other residents or to go eat in the dining room with the other residents. She said if given some medication that would relieve her pain, she would get up. Observation and interview on 6/14/13 at 8:50 A.M., Resident # 74 reported a constant pain to her right leg. She said the pain had been there for a long time. She said she believed she had Arthritis and had been asking staff for a pain medication that would work . The resident said she did not recall anyone asking her about her pain recently. She was told by the staff she received medication for pain daily. She said she was unable to move her right leg due to the pain. Resident # 74 ' s right knee was swollen and painful to touch. Interview on 6/14/13 following the above observation, LVN # 7 said she spoke to Resident # 74 last week when conducting a pain assessment and the resident did not have any pain. Resident # 74 interjected she had been having knee pain and had reported this to the staff. LVN# 7 said Resident # 74 had as needed pain medication as well as the scheduled pain medication which she received three times daily. Resident # 74 responded " no, it does not help me, I still have a lot pain to my right knee and I can ' t move it because it hurts a lot, I did not know that I had to ask for another pain medication,but I have been telling staff and no one gave me anything for my pain " . Observation and interview on 6/14/13 at 4:50 P.M., Resident # 74 reported pain in her right knee to the Nurse Practitioner ( NP ) who was assessing her. The NP touched her knee and Resident # 74 moaned in pain. The resident again expressed she desired to be out of bed and could do more if the pain was controlled. She said it hurt to much to get out of bed. Interview on 6/14/13 immediately following the above encounter, the NP said she had been working with Resident # 74 for years now. She said she had not been made aware of Resident # 74 ' s knee issues. She said she was aware Resident # 74 had Osteo[DIAGNOSES REDACTED] and would send her for a consult. Record review of facility ' s policy concerning pain assessments revised August 2001 revealed purpose of the policy was " to assess the resident pain level and provide optimal comfort through a pain control plan which is mutually established with the resident family and members of the health care team. General guidelines # 1: pain assessment will be completed as part of the initial nursing assessment on admission, re-admission, change in condition, self/observed signs of pain and quarterly thereafter. # 2; assessment will occur every shift and will focus on identifying the cause of pain and developing a pain management plan. # 3; Pain will be reassessed and documented. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident will occur within 2 hours of administration." Facility 672 listed 40 residents in the facility who were on pain management.

Based on observation, interview and record review the facility failed to ensure that 1 of 21 Residents (#3) reviewed for neglect, was free from neglect when the facility did not intervene and failed to put an effective plan in place to prevent more falls. Resident # 3 had two falls in 8 days and the facility failed to investigate and re-evaluate the interventions to prevent further falls. Resident fell on [DATE], [DATE] at [DATE]. The last fall on [DATE] resulted in the resident's [MEDICAL CONDITION] being dislodged and subsequent brain damage. Resident # 3 had fallen twice in the early hours of the day between 3:30 and 7:00 A.M on [DATE], [DATE] and [DATE]. No interventions were put into place concerning early morning monitoring of Resident # 3. Resident # 3 had physician's orders [REDACTED]. When the resident fell the third time on [DATE] the mittens were attached to both sides of the bed and there was no documentation of any mats being present. This failure caused one Resident, who had been alert and oriented, to be hospitalized with a [DIAGNOSES REDACTED]. The failure placed 38 residents at risk of their care needs being neglected by staff which could result in a decline in their health. Findings include: Record review of Resident #3 ' s information sheet revealed she was a [AGE] year old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. further record review of admission records revealed Resident #3 was readmitted to facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident # 3 ' s admission MDS assessment dated [DATE] revealed Resident # 3 ' s cognition was 14 of 15, which meant she was cognitively intact. This MDS also revealed Resident # 3 had physical behavior symptoms directed towards others. The assessment revealed this behavior put the Resident at significant risk for physical illness or injury. Resident # 3 required extensive assistance with two people ' s physical help with ADLs, was incontinent of both bowel and bladder, required [MEDICAL CONDITION] care, suctioning and used bed rails less than daily. Record review of Resident # 3 ' s care plan dated [DATE] revealed the resident was at risk for falls/injury due to she had attempted to get out of bed. Goal was documented that the "...Resident will have no further complications from condition during the next 14 days..." Approaches included: "...monitor closely, call light within reach, keep clean, monitor for pain every shift, physical therapy, low bed/lowest position with mat on the floor. There was documentation that revealed the resident refused a low bed and the family was aware of Resident # 3 ' s refusal of low bed and agreed. Record review of Resident # 3 ' s care plan dated [DATE] revealed Resident # 3 had Altered behavior pattern related to chronic condition - striking out, attempting to get out of bed. Goal was "...Resident will have no further complications from condition during the next 14 days..." Approaches outlined included: "... assess behavior and mental status every shift and as needed. Approach in a calm and non-threatening manner, re-orient every shift and as needed, provide calm quiet environment, place in a low bed, keep clean and dry and give meds as ordered." Record review of Resident # 3 ' s nurse ' s notes dated [DATE] at 3:30 A.M., revealed Resident was noted on the floor lying on her side. Resident # 3 was assessed, and no visual injury was noted. The resident was able to move all extremities without any discomfort, was transferred to bed and placed in a comfortable position. The resident's vital signs were documented within normal limits. Record review of Resident # 3's temporary care plan dated [DATE] revealed a problem of a recent fall. The goal documented was the Resident would have no further falls during the next 14 days. Approaches included :"... two person assist, encourage Resident to use call light ,monitor and report to physician and family for any injury from fall, vital signs, head to toe assessment ,call physician and family for any changes in condition." There was no documentation concerning supervision or bed alarms. There was no incident report provided for review for this unwitnessed fall. The investigation of this fall was requested but was not provided for review concerning this unwitnessed fall. Record review of the facility ' s form titled unusual occurrence report dated [DATE] for Resident # 3 revealed at 7:00 A.M. on the flooe, Resident was noted sitting beside the bed on the floor. Record review of Resident # 3 ' s nurses ' notes dated [DATE] revealed at 7:00 A.M., Resident # 3 was noted on the floor in a sitting position. Assessment was completed and no injuries were noted and Resident # 3 denied any pain. The note goes on to read "... two person transferred residents into bed, bed placed in lowest position..." Further record review of Resident # 3 ' s record revealed no care plan developed/updated for the fall on [DATE]. The care plan dated on [DATE] had no new interventions or no updated information concerning the new fall. Record review of Resident # 3 ' s monthly physician's order [REDACTED]." The Order was dated [DATE]. Record review of Resident # 3 ' s nurse ' s noted dated [DATE] at 10:15 P.M., revealed Resident # 3 was lying in bed alert and oriented with mitten restraints on and T-piece on and intact. At 4:30 A.M., the nurse's notes read that CNA went to resident room to turn Resident and check for brief change. The CNA found the Resident on the floor lying on the far side of the bed, by the window with her head beside the foot of bed and her feet towards the head of bed. The side rails were up on both sides with right mitten restraint and call bell on the right side rail of the bed. The other mitten (left) restraint was hanging on the left side of bed. The CNA notified the Respiratory Therapist then summoned the Registered Nurse to Resident # 3 ' s room. The RN went to Resident #3 ' s room, found Resident # 3 was unresponsive with no pulse or respirations and stated CPR with the Respiratory Therapist while the CNA called 911. The Respiratory Therapist re-inserted the decannulated [MEDICAL CONDITION] and continued CPR for about 10 minutes before EMS arrival. Resident # 3 regained pulse and breathing. EMS continued CPR and the resident was transferred to the hospital. Record review of facility ' s form titled unusual occurrence report dated [DATE] for Resident # 3 revealed at 4:35 A.M., Resident # 3 was found on the floor in her room. Injury documented was loss of consciousness. The fall was not witnessed. Record review of Resident # 3 care plan revealed a temporary care plan dated [DATE]. It was documented "...Problem recent fall. Goal was Resident "... will have no further falls during the next 14 days." Approaches included : "...two person assist, encourage Resident to use call light ,monitor and report to physician and family for any injury from fall, vital signs, head to toe assessment ,call physician and family for any changes in condition and neuro-checks." Record review of Resident # 3 ' s hospital record titled preliminary report dated [DATE] revealed Resident # 3 was transferred from a nursing facility. She was found with high lactic acid, Urinary tract Infection and [MEDICAL CONDITIONS] post cardiopulmonary arrest due to Tracheal dislodgement. Record review of Resident # 3 ' s nurse ' s notes dated [DATE] revealed Resident was readmitted to facility with the [DIAGNOSES REDACTED]. Record review of Resident # 3 ' s significant change MDS assessment dated [DATE] revealed Resident # 3's cognitive status was now severely impaired. She was assessed as being totally dependent on staff for all ADLs and dependent on a Ventilator for breathing. Observation and interview on [DATE] at 9:37 A.M., revealed Resident # 3 in bed. She was dependent on a ventilator, had a [MEDICAL CONDITION] and Gastrostomy Tube with the feeding on at this time. She was non-verbal and comatose with eyes closed. LVN # 2 reported the resident was alert and oriented a couple of weeks prior, before a fall at which time she pulled out her [MEDICAL CONDITION] and was found unresponsive at her bed side. LVN # 2 said the resident came back from the hospital with the [DIAGNOSES REDACTED]. During a phone interview on [DATE] at 4:30 P.M., RN # 1 said he recalled taking care of Resident # 3 the night of the fall. She was in bed and throughout the night was fine and intermittently at sleep. He said he saw the resident about 3:30 A.M., awake and in bed and about 4:15 A.M., she was sleeping. He said Resident # 3 had bilateral mittens on and the bed rails were up. He explained he could not tell how she fell but saw her mittens were loose when she was found on the floor decannulated and unconscious. He said he was called to her bedside by a CNA who was making rounds. He said he immediately called for help and started CPR with the Respiratory Therapist on duty. He said he recalled the resident had no pulse or respiration when found. He said he saw her 15 minutes previously. Resident was sent to the hospital when EMS arrived. Interview on [DATE] at 1:00 P.M., the ADON said Resident # 3 was always attempting to get out of bed. She said Resident # 3 refused to use a low bed but wanted a regular bed. ADON said Resident # 3 was cognitively intact and was able to make her needs known. She had mittens on both hands to prevent her from pulling out her [MEDICAL CONDITION] and had side rails. She said the facility did all they could. She said the facility had a care plan to address the falls. The ADON agreed that a fall care plan was ineffective if a resident continued to fall after the plan had been put in place. She agreed that every plan should be evaluated for effectiveness and updated if not effective. She said effectiveness of a plan would be measured from the resident's outcome. Interview on [DATE] at 11:20 A.M., the DON said she recalled the resident was a fall risk and the facility had put some things in place to prevent her from falling. She explained Resident # 3 was getting ready to be discharged home with family because that was her desire. The DON said Resident # 3 had a couple of falls before the fall in which her [MEDICAL CONDITION] was dislodged. The DON said she believed the plan was effective and that she received all the needed care. She stated " we did all we could do for her. " Record review of facility abuse and neglect policy titled " MR.TRIPPIS "(Training, Reporting, Investigation, Prevention, Protection, Identification and Screening) not dated revealed a facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident. " Facility ' s policy also defined neglect as in 40 TAC & 19.101(81). The facility CMS Form 672 listed 39 residents with tracheostomies.

Based on observation, interview and record review the facility failed to ensure 1 of 7 Residents (Resident # 14) reviewed for pain management was assessed and provided the necessary care to treat his pain, and assess the effectiveness of the pain medication , to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with their plan of care. This failure affected 1 resident who suffered uncontrolled generalized pain from contracted upper extremities and a Stage IV pressure ulcer to the Sacrum and placed 42 residents at risk of experiencing pain if not treated which may cause deterioration in their physical and mental health.. Findings include: Record review of Resident # 14's admission information revealed a [AGE] year old admitted to facility on 5/11/12 with the following Diagnoses: [REDACTED]. Record review of Resident #14's admission MDS dated [DATE] revealed Resident # 14 was severely impaired for decision making. It also revealed Resident # 14 received as needed pain medication or was offered and declined. It also revealed a pain assessment interview should be conducted. The MDS revealed staff assessment should be conducted as Resident # 14's indicator include; vocal complaints of pain and facial expression. The MDS concluded indicators of pain were or possible pain was observed present 3 to 4 days. Record review of Resident # 14's care plan dated 5/17/12 revealed Resident # 14 has "potential for pain" related to disease process: Cerebro Vascular Accident and Contractures .Goal and approaches were identified to include ;"...administer medication as ordered and monitor for unrelieved pain and report to physician for further instructions ..." Record review of Resident # 14's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This medication was administered four times in the June on the following days : 6/1/12, 6/3/12, 6/4/12 and 6/9/12. Record review of Resident # 14's treatment record dated June 1st to June 30 th 2012 revealed pain assessments were done on the three shifts and there was no record of pain presence in all assessments done. The assessment record did not match the medication record of as needed medication for pain administered four times in the month of June. Observation on 6/14/12 at 11:08 P.M., during wound care, Resident # 14 was noted moaning in pain. He verbalized he was in pain after wound care. Resident # 14 said he would like some medication for his wound . Interview on 6/14/12 at 11: 25 A.M., the Treatment nurse said Resident # 14 was not given any medication for pain prior to the wound care. She said the resident had a Stage IV sacral Pressure ulcer of about 14 inches in length. She said she would ask the nurse to give him something for pain. Observation and interview on 6/16/12 at 9:40 A.M. Resident # 14 during in -room visit was noted moaning and when asked if he was ok, he stated he was in pain. The DON was in the room when Resident # 14 voiced out his pain was rated a 5 in a scale of 5 with 5 being the maximum. The DON said she would get the nurse to assess the resident for pain. Resident # 14 received pain medication thereafter. Observation on 6/18/12 at 1:29 P.M., Resident # 14 was in bed moaning in pain when surveyor entered with Restorative Aide # 1. Resident # 14 stated he had generalized pain. The nurse was informed by the staff to assess the Resident. Interview on 6/18/12 at 2:00 P.M., LVN # 2 said Resident # 14 had actual pain. She said he complains of pain and received medication as needed. Interview on 6/18/12 at 2:15 P.M., the ADON said the resident's assessment record should reflect the medication administration record. She said the record showed that he was given medication a couple of times in the month of June while the assessments showed he had no pain. Record review of facility's policy on pain management revised August 2001 revealed the purpose of the procedure was to assess the Resident's pain level and provide optimal comfort through a pain control which was mutually established with the Resident, family and members of the health care team. Steps in the procedure: "...ask the resident if he/she is experiencing any pain, note the location of the pain and the level of pain using the numerical pain rating scale. Explain the pain rating scale to the Resident. Have the resident rate the pain on the 0-10 pain scale with 0 equaling "no pain" and 10 equaling "excruciating pain" ....Documentation: the person performing this procedure should record the following information in the Resident's medical record. (1) The date and time the procedure was performed, (2) the name and title of the individual(s) who performed the procedure, (3) daily assessment of pain, (4) all assessment data obtained during the procedure including the location of pain, level of pain using the pain scale and type of pain relief used. (5) 2-hour reassessment of pain and the Resident's response to the pain relief used. (7) The signature and the title of the person recording the data. Reporting: (3) notify the physician of unrelieved pain." The facility CMS Form 672 listed a census of 43 residents on pain management.

Based on observation, record review, and interview the facility failed to ensure 2 of 23 sampled residents (#' s 1 & 95) with limited Range Of Motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decline. The facility failed to: Ensure Resident # 95 was provided Range of Motion exercises, positioning and splints so as not to develop contratures. Ensure Resident # 1 received passive Range of Motion exercises, splints/hand rolls, or positioning devices for her contracture to her left hand to prevent further contractures. These failures caused 1 resident to develop contractures and placed 114 residents at risk for pain, loss of independence, and/or decline in range of motion and activities of daily living. Findings include: Resident # 95 Record review of Resident # 95 ' s admission sheet revealed he was admitted to the facility on [DATE]. Resident was a [AGE] year old male. His admitting [DIAGNOSES REDACTED]. Record review of the resident ' s Admission MDS assessment dated [DATE] in the Functional Limitation in Range Of Motion section documented there was no impairment on either the upper or lower extremities nor on the left or right side. Record review of the resident ' s Care Plan dated 12/8/10 revealed a problem area of " contractures/potential for contractures " with a goal documented that the resident would " be maintained at current rance (sic) level or Resident will be contracture free over the next 90 days " . The approaches outlined included: ortho checks, range of motion daily for at least 15 minutes, positioning every two hours and as needed, and " splinting as needed " . This care plan failed to identify whether there were actual contractures or if they were attempting to prevent contractures. There was no staff identified in the care plan to be responsible in implementing the approaches as documented above. Interview on 6/23/11 at 11:45 a.m. the DON stated Resident # 95 was admitted to the facility in December of 2010 and did not have contractures. She stated it appeared Occupational Therapy saw him 1/19/11 and referred him to the Restorative Nursing Program. She was unable to state whether or not he was supposed to wear splints. She stated if a resident had contractures, each contracture should be listed separately in the care plan, as well as each splint to be worn. Record Review of MDS dated [DATE] revealed impairment on both sides of the upper extremity and impairment on both sides to the lower extremity. Further review of this MDS revealed no PT/OT, nor Restorative Nursing Program at the time of the assessment reference period. There was no identified passive and/or active range of motion, nor was there an identified splint or brace. Record review of the resident ' s Care Plan dated 4/6/2011 revealed problem area of " potential for developing contractures due to impaired mobility. The goal was that he not develop any contractures over the next 90 days. The approaches outlined included: positioning devices as needed for proper body alignment, turn and reposition every 2 hours, contracture assessment every 3 months, and range of motion provided during ADL ' s. The care plan failed to identify the actual contractures and the limbs addressed as needing range of motion, It also failed to address what positioning devices were to be used for proper body alignment. Review of the resident's record revealed Restorative Nursing Program Plan of Care was implemented on 1/19/11. The record reflected documentation for February 2011, March 2011, and April 2011 of the restorative plan. It included Goals of: 1) Preserve bilateral upper extremity ROM, 2) Prevent decubitis, and 3) Preserve upper body function. Observation on 6/21/11 at 9:45 a.m. revealed Resident # 95 in bed, head of bed slightly elevated, with [DEVICE] [MEDICAL CONDITION] place, and both ? side rails were in the up position. The resident had contractures to his upper and lower extremities with a washcloths rolled up and placed in the palm of each hand. There were no splints in place. Observation on 6/21/2011 at 11:30 a.m. revealed the resident still in bed with washcloths in place in both hands and no splints to upper or lower body. Observation on 6/22/11 at 10:45 a.m. revealed the resident was up in a geri-chair, placed in the front lobby by the nursing station, with bilateral upper arm splints in place. Observation on 6/23/11 between 9:30 a.m. and 2:30 p.m. revealed resident was in his bed, with washcloths in place, no splints to upper extremity, and the head of the bed was slightly elevated. Interview on 06/22/11 at 12:30 P.M. the ADON said Resident # 95 ' s care plan should be followed. She stated the care plan should identify each contracture and/or limb with limited range of motion and specify exact treatment to be used. She stated if a splint was to be used, each splint to each part of the body should be listed, with the wearing schedule. She reviewed Resident # 95 ' s care plan and stated she would not be able to provide care for this resident based upon the resident's plan. Interview on 6/22/11 at 12:40 p.m. the MDS Nurse said she was unable to state whether Resident # 95 had contractures or if he had limited range of motion. She reviewed the Care Plan dated 4/6/11 and stated " it shouldn ' t be here " (in the chart) as it was not correct. After reviewing the Tabor ' s Medical Dictionary ' s definition of Contracture, the MDS Nurse stated Resident #95 was contracted with impairment to both upper and lower extremities. She said she did not write the care plan. She stated contractures should be listed separately in the care plan, and each splint to be used identified. Resident #1 Record review of Resident # 1 ' s admission sheet revealed she was admitted to the facility on [DATE]. The resident was an [AGE] year old female. Her admitting [DIAGNOSES REDACTED]. Record review of the resident ' s Admission MDS assessment dated [DATE] revealed in the Functional Limitation in Range Of Motion section the resident ' s upper extremity was impaired on one side and her lower extremities were impaired on both sides. Record review of the resident ' s Care Plan dated 5/04/2011 revealed the problem of contractures/potential for contractures with a goal documented that the resident would be maintained at the current level or would be contracture free over the next 90 days. The approaches outlined included: range of motion daily for least 15 minutes, positioning every two hours and as needed, splinting as needed, and Ortho checks. This care plan failed to identify the body part with contractures and failed to identify approaches to address the upper and lower contractures. There was no staff identified in the care plan to be responsible in implementing the approaches as documented above. Record review of the resident ' s Care Plan dated 4/22/2011 revealed use of restraint: mitten due to pulling at [MEDICAL CONDITION]. The goal was the resident would not dislodge her [MEDICAL CONDITION] in the next 90 days. The approaches included: apply mitten properly, visual check every 30 minutes, release every two hours for skin check. Record review of the resident's record revealed no documentation of restorative care treatments and no physical or occupational therapy documentation. Observation on initial rounds on 06/21/11 at 8:29 A.M. revealed Resident # 1 was lying in bed awake with half side rails in the up position. The resident was lying on her back and lower extremities were flexed to the right side. She had a mitten on her right hand and the fingers to the left hand were inwardly curved and could not be stretched /opened out upon request. She had no rolls or splint on the left hand. Resident #1 was able to move right hand but was unable to move her left hand. Observation on 06/21/11 at 10:40 A.M. revealed the resident had a mitten on her right hand and the fingers to the left hand were inwardly curved. She had no roll or splint on the left hand and was unable to move the left hand. Observation on 06/22/11 at 8:20 A.M. revealed she had mitten on her right hand. She had no roll or splint on the left hand and was unable to move the left hand. Observation on 06/22/11 at 10:20 A.M. revealed she had mitten on her right hand and the fingers to the left hand were inwardly curved. She had no roll or splint on the left hand and was unable to move the left hand. Observation on 06/22/11 at 12:20 P.M., she was lying in a Geri chair and had a mitten on her right hand. Family members were at her side. During an interview at this time the family member stated she removed the resident ' s mitten some times when she visited but did not recall ever seeing the mitten removed by staff. Fingers to the left hand were inwardly curved. She had no roll or splint on the left hand and was unable to move the left hand. Observation on 06/23/11 at 8:10 A.M. revealed the resident had no roll or splint on the left hand, a mitten was on the right hand. Observation on 06/23/11 at 1:50 P.M. revealed a towel rolled into a tube was in the resident's left hand and a mitten was on the right hand. Interview on 06/23/11 at 2:18 P.M. the ADON said Resident # 1 ' s care plan should be followed and the mitten should be removed as ordered. She said the nurses were responsible for removing and checking the skin area and documenting that they did so. She stated Resident # 1 had weakness to her left hand and was unable to move it. She said the resident received restorative care. She did not know how often the restorative care was done. She tried to open the resident's left hand and noted the left hand could be stretched out, she then said, she would have physical therapy evaluate the resident for a splint or hand roll to prevent the contracture from getting worse. Interview on 06/23/11 at 2:20 P.M. CNA # 3 said Resident # 1 was unable to move her left hand. He said Resident # 1 ' s right hand was very active. He said he did the restorative care for the resident. When asked about the roll in Resident # 1 ' s left hand today, he said the resident ' s left hand was fixed and unable to be opened. He said the resident needed a hand roll but had not been assessed by physical therapy so he had rolled up a towel and placed it in her hand to prevent her hand from getting worse. He stated he massages her hands when he works with her. When asked for the documentation of his restorative visits he stated he would get them. Prior to exit no documentation of restorative care was provided for review for Resident #1. Record review of the facility policy on contracture management,not dated, revealed: "(1) admission/readmissions: (a) resident admitted to facility received orders for physical /occupational/speech therapy if medically appropriate. Facility has up 14 days for acclimation of resident to facility medical/social stabilization. (b) If medically warranted, initial therapy screen performed and plan initiated. If not medically warranted, semi -comatose ventilator/trach/Gtube resident, nursing to maintain until restorative screen done and treatment initiated...(2) Nursing maintenance: (a) during patient care and bathing nursing is provided movement to extremities to promote circulation and prevention further contractures. (b) Placement of hand rolls and proper positioning with pillows to also prevent contracture is expected..." The facility's CMS form 672 listed 115 residents.

Based on observation, interview and record review, the facility failed to ensure that the environment remained free of accidents by removing from resident usage, a broken Hoyer lift that was used to transfer 1 of 6 sampled residents (#3) from her bed to her wheelchair. Resident #3 sustained an injury when CNA #1 used a defective Hoyer Lift to transfer her. This failure caused pain and a laceration to Resident #3 ' s head which required staples and placed 44 residents at risk of injuries during transfers. Findings include: Intake # 2 Record review of Resident #3 face sheet revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #3 ' s Care Plan dated March 2011 revealed that she was dependent on staff for all personal care. The same Care Plan revealed that the resident required two person assist with all transfers. Record review of the Unusual Occurrence Report dated 5/18/2011 revealed that on the same date, Resident #3 sustained a laceration to the left side of her head and a hematoma to the right side of her head when being transferred by CNA #1 by Hoyer lift (a hydraulic piece of equipment used to transfer residents from beds or chairs that require maximum assistance from staff to perform the task). The report revealed that the Hoyer lift malfunctioned and the bar hit the resident in the head causing a laceration. The resident was transferred to the hospital per physician orders. Record review of a written statement completed by CNA #1 on 5/18/2011 revealed she had taken Resident #3 to the shower using the Hoyer Lift. The statement revealed when the CNA was putting the resident back to bed, " the Hoyer lift went down over her head and she (Resident #3) hit her head on the head board. " Interview on 5/24/11 at 10:00 A.M. Resident #3 stated she remembered most of the incident. She stated she remembered falling backward on the bed when being placed back into the bed. She stated she hit the back of her head on the headboard and then the Hoyer lift fell and hit the side of her head. She stated she was transferred to the hospital for stitches. She said it was still very " sore " . Resident #3 stated CNA #1 was always so careful with her and she really trusted her and felt the CNA should not be held responsible. She said it was an accident. Observation, at this time, revealed Resident #3 had 5 staples to a laceration on the left lateral scalp. The resident had severe contractions of both hands and feet. Interview on 5/24/11 at 10:45 A.M. the Maintenance Supervisor stated he was told that one of the Hoyer Lift ' s front wheels had come off on 5/17/2011 in the late afternoon. He stated a CNA brought the wheel to him when he was in the Administrator ' s office. He stated he went that afternoon (5/17/2011) to buy the parts to fix it. When he returned to the facility he realized he forgot to buy a bolt he needed to complete the repair. He said he went back to the hardware store the next morning to buy that bolt. He said he did not move the Hoyer lift out of the hall and did not tag it to alert staff that it was broken but " should have. " Observation on 5/24/2011 at 12:00 P.M. of the Hoyer lift revealed all four wheels were in place. Interview on 5/24/11 at 1:00 P.M., LVN #1 stated she was the charge nurse for Hall 200 the day of the incident (5/18/2011). She stated prior to the incident she was unaware the Hoyer Lift was broken. She stated she assessed the resident after the incident, called the physician and the responsible party. She called for an ambulance and transferred the resident to the hospital. She stated the Resident returned to the facility the same afternoon with 5 staples in the left side of her head and a hematoma to the back of her head. LVN #1 stated CNA #1 told her the Hoyer Lift tilted over because one wheel was missing. Record review of the facility ' s employee handbook in the Health and Safety section revealed " ...It is also up to each employee to act responsibly with all equipment and supplies that are provided by the facility ...You are expected to maintain equipment and work areas in a safe and proper manner and follow all safety rules and safe working techniques ... " Review of a facility in-service training report dated 5/9/2011 revealed a recent in-service had been given including Hoyer lift transfer demonstration. It was documented that CNA #1 was present for the in-service. The facility CMS form 672 revealed 45 residents classified as being bedfast.