Every finding on record at Paradigm at Westbury

Based on interviews and record reviews, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 1 resident reviewed for discharge. The facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility. The facility failed to ensure Resident #1's was not discharged to a hotel on 04/04/2026; she was informed of the discharge on [DATE]. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services.Findings included: Record review of Resident #1's face sheet dated 03/16/2026 revealed she was a [AGE] year-old female admitted with the following diagnosis: UTI, sclerosis (hardening of tissue from overgrowth), lymphedema (swollen caused by accumulation of protein), atrophy (cell breakdown exceeds cell production), fracture of left lower leg and neurogenic bladder (difficulty to control urination). Record review of Resident #1's MDS dated [DATE] revealed a BIMS was scored of 15-indicating intact thinking. Section GG-Functional abilities revealed she required assistance with bathing, lower body dressing, toileting, rolling left and right, sitting to stand, lying to sitting on side of bed, sit to stand, picking up objects and transfers. Section H, bladder and bowel revealed; always incontinent of urine and frequently incontinent of stool. Section Q-Discharge Plan-revealed active discharge planning already occurring for the resident to return to the community and referral was made to the Local Contact Agency. Record review of resident #1's care plan dated 03/16/2026 revealed: Urinary incontinence. Goal: will have no alterations in skin integrity related to incontinence. Interventions: apply a house moisture barrier cream after each episode of incontinence, monitor resident for signs and symptoms of UTI-pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fever, chills, altered mental status, change in behavior and [NAME] in eating patterns, assist the resident to use the toilet regularly. Report any changes in skin integrity to the nurse. Resident is at risk of falls and injuries. Goal: Will be free from falls and injuries. Intervention: Provide prompt assistance, ensure call light is within reach and answer promptly and encourage resident to ask for assistance. Resident has self-care deficits and at risk for further decline. Goal: Resident will be well dressed, groomed, clean, dignity will be maintained and will have no further decline. Interventions: Anticipate needs and assist with activities of daily living, extensive 2 person assist for transfer and 1 person assistance for personal hygiene/ grooming, toileting, dressing, bed mobility and cueing as needed to perform activities of daily living. Resident is at risk for malnutrition. Goal: Will experience no adverse effects of malnutrition. Interventions: Monitor meal intakes, intervene with any weight loss and weight as indicated. Resident is at risk for pressure ulcer formation. Goal: Will be free from alteration in skin integrity/formation of pressure wounds. Interventions: Assist resident with toileting, incontinent care, turning/re-positioning, weekly skin checks, serve diet as ordered, monitor intake and offer substitutes if less than 75 % of meal eaten. In an interview with Resident #1 on 08/15/22026 at 10:54 a.m., she said a day before her discharge, the SW and another staff came to her room demanded she pay a co-pay of $200 a day. Resident #1 said she was told if she could not make the payment, she would have to leave but did not give her 30-days' notice. She said when she was told by the SW and another staff that she had to leave, she asked them where she was supposed to go. She said she told the staff she did not have anywhere to go. She said she signed the discharge on [DATE] and called Metro lift that dropped her at a hotel. Resident #1 said when they told her to leave, that made her feel very bad and that the facility did not care about her. She said the discharge affected her health because the hotel did not have a hospital bed and she had a UTI because she urinated on herself several times. She said she left on 4/4/2026, the facility reached out to her on 04/07/2026 via telephone asking her to return. She said she did not want to return because she was sad and they gave her a discharge paper which she signed took along with her but could not find when she made her complaint. In an interview with RN A on 08/15/2026 at 1:00 p.m., she said unsafe discharge was any discharge against medical advice. She said if a resident was discharged and they did not have a place to go, that it would be considered unsafe to discharge. She said a discharge had to be done following the proper discharge process and following all the steps. If Resident #1 had a place where she could be discharged to pending appliances, but the facility went ahead a discharge her, that was unsafe discharge. RN A said the consequences of such a discharge was the fact that the resident's health could decline. She said Resident #1's quality of life could be compromised because that resident did not have the resources to care for herself. RN A said she expected the facility to have held on to the discharge process until the discharge location was settled. In an interview with RN B on 08/15/2026 at 2:12 p.m., she said if Resident #1's discharge was pending home modifications, and the facility discharged her to an unknown location because the resident could not make a daily co-pay of $200, that was unsafe discharge. RN B said unsafe discharge was not good because the resident could die, have skin breakdown, be stressed, be affected mentally or call 911 to be taken to the hospital from their discharged location because they were not ready for discharge. In an interview with SW A on 08/15/2026 at 2:25 p.m., she said unsafe discharge process was when a resident did not have the proper placement, amenities or required health equipment. She said if Resident #1's discharge was planned; she expected the facility to notify the RP/ POA. She said if Resident #1's stay was covered by insurance, her last covered day would be reflected two days before. She said if she had been the SW, and the resident felt the notice time was short, she would have given her an appeal form. She expected the business office to give the resident 30 days' notice, give a copy to the SW and a copy to Ombudsman. SW A checked her database and said she did not find the NOMNC, 30 days' notice and the letter to the Ombudsman office. She said if there were no 30-day notice and notification to Ombudsman, that would be an unsafe discharge. In a telephone call on 08/15/2026 with Ombudsman A at 2:54 p.m., he searched his database and did not find 30 days' notice. He said the Ombudsman office expected a 30-day discharge notification even for planned discharges. He said the only time 30 days' notice was not necessary was when a resident voluntarily wanted to leave. A telephone call on 08/15/2026 at 3:03 p.m., was unsuccessful to the facility's former SW who discharged Resident #1. A telephone call on 08/15/2026 at 3:07 p.m., was unsuccessful to the facility's BOM. A telephone call on 08/17/2026 at 8:47 a.m., was un successful to reach LVN A who discharged Resident #1. A telephone call on 08/17/2026 at 11:31 a.m., was unsuccessful to reach the medical provider. In an interview with the DON on 08/15/2026 at 3:11 p.m., she said unsafe discharge was when the resident did not have what they needed to meet their care or not being educated upon discharge. She said she would let a resident who insisted on leaving go if they were alert, and oriented but she would get APS involved even in a situation where the resident was forced to leave. The discharge process was the responsibility of the BOM, but she expected the facility to issue a 30 days' notice and talk to the Ombudsman before Resident #1 was discharged . In an interview with the ADM 08/15/2026 at 3:32 p.m., she said when you discharge a resident you want them to have a place to go. She said the residents had the right to decide where they wanted to go. She said what the resident considered adequate could be different from what the facility considered adequate. The ADM said, the only time a facility would notify the Ombudsman was if the facility forced them out. She said Resident #1 agreed to leave and refused home health which was offered to her during a telephone call 3 days after she left. The ADM [NAME] if Resident #1 had refused to leave, then the facility would have notified the Ombudsman office. Record review of Resident #1's orders did not have a physician discharge order. Record review of facility's document dated 06/2025 and titled: Policies and Procedures Discharge/Transfer. Policy: The facility is committed to ensuring safe discharge disposition and will make every effort to facilitate a smooth transition of care. In cases of difficulty or immediate discharge, the facility will follow CMS and state guidelines to maintain regulatory compliance and protect resident's rights and well-being.

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 2 of 3 residents (Resident #57 and Resident #91) reviewed for nutrition status. The facility failed to identify and verify significant weight loss for Resident #91 who lost 32.4 pounds in 27 days. The facility failed to provide dietary interventions for Resident #91's initially identified weight loss on 5/13/2026 (118.8lbs from 148.6 lbs.), until 5/27/2026. The facility failed to ensure Resident #57 had daily weights obtained per physician order. These failures could place residents at risk for compromised nutrition, decline in function and unplanned weight changes. Findings included: Resident #91 Record review of Resident #91's admission record, dated 05/29/2026, revealed a [AGE] year-old male, admitted [DATE], with the following diagnoses including chronic diastolic congestive heart failure (a condition where the heart muscle becomes stiff and cannot relax properly between heart beats causing a backup of blood into the body and lungs), chronic viral hepatitis C (long lasting persistent infection caused by the hepatitis C virus that targets the liver), and chronic obstructive pulmonary disease (a group of progressive long-term lung disease that cause obstructed airflow and make it difficult to breath). Record review of Resident #91's admission MDS assessment, dated 12/21/2025, revealed a BIMS score of 9 out of 15 indicating moderate cognitive impairment. Resident #57 Record review of Resident #57's admission record, dated 05/29/2026, revealed a [AGE] year-old female, admitted [DATE], with the following diagnoses including acute kidney failure (a sudden and rapid decline in kidney function that develops within hours or a few days), end stage renal disease 9the final most severe stage of chronic kidney disease and indicate the kidneys have lost 85% to 90% of their normal function and can no longer filter enough waste to keep a person alive), acute on chronic systolic congestive heart failure (describes a person with a longstanding history of heart failure[a condition where the heart muscle becomes stiff and cannot relax properly between heart beats causing a backup of blood into the body and lungs] who experience a sudden, severe worsening of their symptoms), moderate protein calorie malnutrition (a condition where a deficiency in macronutrients[protein and calories] causes measurable physical decline), and required hemodialysis (a life-sustaining medical procedure for people with kidney failure). Record review of Resident #57's admission MDS assessment, dated 05/07/2026, revealed a BIMS score of 10 out of 15 indicating moderate cognitive impairment and required set-up assistance with meals and could feed himself. During an interview and observation with Resident #91, on 5/26/26 at 11:15 a.m., he said he was supposed to have large portions with his meals, and he was not getting them. The resident stated he was hungry after meals and felt like he was not getting enough food. Resident #91 could not recall who he told when he was hungry. In an observation of Resident #91, he appeared thin, gaunt, and emaciated and his limbs appeared to be spindly. Resident #91 said he had no wounds, open sores or skin breakdown, and no wounds or skin issues were observed at that time. Resident #91 said he was given breakfast, lunch and dinner daily and also received snacks and beverages throughout each day. During an observation on 05/26/2026 at 12:54 pm of Resident #91's lunch meal tray revealed a regular portion of food and his meal ticket delivered with the meal revealed no note for large portions. The resident consumed 100% of the meal. Resident #91 did not complain of hunger at that time and did not request additional food. Record review on 05/26/2026 at 1:54 pm of Resident #91's physician orders revealed no order for large portions. Record review on 05/26/2026 at 2:10 pm of Resident #91's May 2026 weight log revealed Resident #91's weight was documented as 118.8lbs on 05/13/2026. Record review on 05/26/2026 at 3:57 pm of Resident #91's care plan revealed Resident #91 was at risk for malnutrition initiated on 01/05/2026 with a goal of Resident #91 will not experience an adverse effect of malnutrition through the review date and included the intervention to consult RD as indicated and intervene with any weight loss. Record review on 05/26/2026 at 2:15pm of Resident #57's May 2026 MAR-TAR revealed an order with a start date of 05/01/2026 to Monitor weight daily every, day shift, for fluid overload and there were no weights documented on 05/01/2026, 05/02/2026, 05/03/2026, 05/07/2026, 05/12/2026, 05/16/2026, 05/27/2026, 05/21/2026, 05/25/2026, 05/26/2026 or 05/28/2026. Continued record review revealed Resident #57's first weight recorded on 05/06/2026 as 126.2lbs and on 05/27/2026 as 115.7lbs. Record review on 05/26/2026 at 4:02 pm of Resident #57's care plan revealed Resident #57 was at risk for malnutrition/malnourished initiated on 05/21/2026 with a goal Resident #57 would not experience any adverse effects of malnutrition and interventions that included, weigh as indicated and document/intervene with any weight loss. Record review on 05/26/2026 at 4:22 pm of Resident #91's EMR revealed no RD notes since 01/28/2026 and revealed his BMI of 21.8 was low for his height and revealed a weight at that time of 143.6lbs. His meal intake revealed 75%-100% eaten at each meal. During an interview with RNA A on 5/27/26 at 2:20 pm, she said she weighed Resident #91 on 5/13/26 and reported the weight (118.9lbs.) to Unit Manager A. During an interview with Unit Manager A on 5/27/26 at 2:25pm, she stated that she had requested RNA A to reweigh Resident #91 via text message on 5/18/26 after reviewing the 5/13/26 weights RNA A had submitted. Unit Manager A said she requested a reweight for any resident who had significant weight changes to verify they were correct. She said she did not reweigh the residents herself because the RNAs were responsible for weighing residents. Unit Manager A said she did not follow up on Resident #91's weight after the text message on 5/18/26 and could not explain why. During an observation and interview of Resident #91 on 5/27/26 at 2:38pm he was reweighed by RNA A and RNA B via Hoyer scale. He was wearing a facility gown and incontinent brief, and his bony prominences were visible on his bilateral legs. Surveyor observed the digital weight screen which read 116.2 lbs. and RNA A stated oh, you've lost some more weight. Record review on 05/27/2026 at 2:55 pm of Resident #91's MD order summary revealed an order dated 5/27/26 for Dietician consult re-weight loss. Record review of Resident #91's physician orders revealed an order, dated 5/27/26 at 4:31 p.m. after the surveyor requested the resident be weighed. Mirtazapine Oral tablet 7.5 mg give 1 tablet by mouth at bedtime for appetite stimulation for 60 days. Record review on 05/27/26 at 4:37 pm of a facility provided undated list of residents being followed for weight loss revealed Resident #91 and Resident #57 were not on the list to see the Registered Dietician. Record review on 5/27/26 at 5:45 pm of Resident #91's nursing progress note, dated 5/27/26 at 5:33 pm, revealed gave new orders for the resident to be seen and additionally followed by Registered Dietician, weekly weights for eight weeks, Mirtazapine 7.5mg daily at bedtime, labs, and House 2.0 with all meals. During an interview with DON on 5/27/26 at 6:20 pm and again on 5/28/29 at 10:10 am, she said Unit Manager A was over the weight, and nutrition resident systems. The DON said she did not know why Resident #91's weight loss had not been reported on 05/13/2026 or 05/18/2026, and she was not sure if Resident #91 had been seen, evaluated, or followed by the facility RD. She explained that Monitor daily weights, order actually meant the resident required daily weights. The DON said she was unsure if Resident #57 or if any resident had a daily weight order. The DON said the order usually was required for residents who had weight loss, dialysis and or congestive heart failure, to ensure there was no fluid overload. The DON said the RNAs were responsible for obtaining any daily weights and Unit Manager A was responsible for all weights and entering orders and then communicating the orders to the RNAs. The DON said the facility held daily clinical meetings in the morning and could not recall if Resident #91 or Resident #57 had been discussed. The DON said that monthly orders were reviewed by each Unit Manager for their respective units, and she did not know if Resident #57 or Resident #91's orders had been reviewed for the month of May 2026. The DON said she was just made aware of the weight concerns for Resident #57 and Resident #91 on 05/26/2026 and 05/27/2026 after the survey team entered the facility. Record review on 5/28/26 at 10:02 a.m. of undated facility list titled: Residents being followed by Dietician Company A revealed neither Resident #91 nor Resident #57 were on the list. During an interview with Unit Manager A on 5/28/26 at 11:55 am she said she was responsible for monitoring resident weights and maintaining weight lists for residents under 100 lbs., with significant weight loss, residents with congestive heart failure, and residents that required dialysis pre and post weights. Unit Manager A said residents should be weighed upon admission or readmission within 24-48 hours, and dialysis residents should have a post dialysis weight that should be recorded on the dialysis communication sheets before and after each dialysis visit. Unit Manager A said Resident #57 should have dialysis weights at least 3 times per week post dialysis and did not know why there were no dialysis weights on at least 2 dates for Resident #57 and why she had no daily weights as ordered. Attempts made to contact NP and MD for residents #57 and #91 on 5/28/26 at 11:14 am and at 1:55pm and did not receive return calls prior to facility exit. Interview with RNA B on 5/28/26 at 1:10 pm she said there were no weekly weights obtained or logged for any resident including Resident #57 because she had been working the floor as a CNA the entire month of May and had not had time to complete any daily weights. RNA B said Unit Manager A and the DON were aware the RNAs could not complete daily weights. Repeatedly requested facility policy and procedure on weight management on 05/27/2026 at 6:30 pm from Administrator and DON, 05/28/2026 at 09:27 am from the DON and again on 5/30/2026 at 4:00pm and was informed via email, by the DON that the facility had no Policy specifically titled Weight Management. Record review of undated facility policy and procedure titled, Weights-Obtaining revealed in part: It is the policy of this facility that resident weights will be recorded and monitored at least monthly. Procedures:1) Weigh Residenta. Upon admission / Readmissioni. Then weekly x 3 weeksii. Monthly and/ or per physician orders. 3) Record all weights on the Vitals tab in (EMR).4) If there is an actual 5% or more gain or loss in one month, notify the resident/family, physician, and Clinical Dietitian. Document this notification per facility protocol. 6) Review significant, unplanned changes and insidious gradual weight loss or gain trends in weightsduring weekly at risk and QA meetings.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 4 (Resident #81, Resident #12, Resident #92 and Resident #101) of 9 residents reviewed for infection control. The facility failed to ensure Resident #81's and Resident #101's urinary catheter bags were not touching or lying on the ground. The facility failed to ensure RN B used a gown when providing enteral feeding to Resident #12 and LVN D used a gown and followed appropriate wound care protocol when providing wound care to Resident # 92. These failures could place residents at risk of infection, decline in health, or cross contamination.Findings included: 1. Record review of Resident #81's face sheet, dated 5/27/26, revealed a [AGE] year-old female admitted on [DATE] with diagnoses including epilepsy (chronic brain disorder characterized by seizures) and obstructive (condition where urine is prevented from flowing normally) and reflux uropathy (condition where urine flows backward into the kidneys). Record review of Resident #81's quarterly MDS, dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 3 that indicated severe cognitive impairment. Section H of the MDS for Bowel and Bladder revealed an indwelling catheter. Record review of Resident #81's physician orders, dated 5/29/26, revealed an order for indwelling urinary catheter using a closed drainage system to change monthly and as needed with revision date of 12/31/25. Record review of Resident #81's care plan, dated 5/27/26, revealed Resident #81 had an indwelling urinary catheter and was at risk for increased urinary tract infections with intervention to keep the tubing/bag below the bladder level and to secure the tubing via clip as indicated. 2. Record review of Resident #101's face sheet, dated 5/12/26, revealed a [AGE] year-old female admitted on [DATE] with diagnoses including unspecified focal traumatic brain injury (a brain injury localized to a specific area of the brain) and peritonitis (a serious potentially life-threatening inflammation of the peritoneum [a silky smooth transparent membrane that lines the abdominal and pelvic cavities and encases most of your internal organs]. Record review of Resident #101's admission MDS assessment, dated 5/19/26, section C (Cognitive Patterns) revealed a BIMS could not be conducted as the resident was rarely or never understood. Section H of the MDS for Bowel and Bladder revealed an indwelling catheter. Record review of Resident #101's physician orders, dated 5/29/26, revealed an order for indwelling urinary catheter using a closed drainage system to change monthly and as needed with revision date of 5/12/26. Record review of Resident #101's care plan, dated 5/28/26, revealed Resident #101 had an indwelling urinary catheter and was at risk for increased urinary tract infections. 3. Record review of Resident # 12's face sheet, dated 05/30/2026, revealed a [AGE] year-old male admitted [DATE] with diagnoses including gastrostomy status (a tube is surgically inserted into the stomach) and dysphagia (difficulty swallowing) Record review of Resident #12's quarterly MDS assessment, dated 03/05/2026, revealed the resident did not have a BIMS score to identify level of cognition. Further review revealed the resident was dependent on staff for all ADL care and had a G-tube. Record review of Resident #12's physician order, dated May 2026, revealed an order dated 02/09/2026 for continuous enteral feeding via pump for 22 hours and an order dated 3/13/2026 for Enhanced Barrier Precautions PPE- gloves/gown during high contact resident care activities for C. Auris. Record review of Resident #12's care plan, dated 03/05/2026, revealed Resident #12 had an enteral feeding for nutrition and required Enhanced Barrier Precaution. 4. Record review of Resident #92's face sheet, dated 5/30/2026, revealed a [AGE] year-old male admitted [DATE] and readmitted on [DATE] with diagnosis including pressure ulcers (localized damage to the skin and underlying tissue)for sacral region(large triangular shaped bone situated at the base of the spine, directly below the lumbar region and just above the tailbone) (stage IV) {the most severe form of pressure injury}and right and left buttock (stage IV). Record review of Resident # 92's quarterly MDS assessment, dated 05/08/2026, revealed a BIMS score of 15 indicating cognitively intact. Further review revealed the resident had pressure ulcers and wound infection. Record review of Resident #92's physician order, dated r May 2026, revealed an order dated 2/21/2026 for daily wound care to sacral, right ischial (lower and back part of the hip bone) and left ischial and an order dated 04/04/2024 for Enhanced Barrier Precautions PPE, gloves/gown, during high contact resident care activities. Record review of Resident # 92's care plan, dated 03/26/2026, revealed Resident #92 had pressure ulcers to sacral, right and left ischial and was at risk for further skin breakdown and infection. During an observation on 5/26/26 at 9:34 a.m., Resident #81was lying in bed and her urinary catheter bag was hanging on Resident #81's bed rail and the bag was tilted lying on the floor and the bottom on the bedside table that was next to Resident #81's bed. During an observation on 5/27/26 at 1:46 p.m., Resident #81was lying in bed and her urinary catheter bag was hanging on the bed rail below the level of Resident #81 and the bag was halfway lying on the floor mat that was next to the bed and on the ground. During an observation and interview on 5/27/26 at 1:34 p.m., RN Z said urinary catheter bags should hang on the foot of the bed below the level of the resident and should not be on the floor. Observation indicated RN Z raised Resident #81's bed and added a strap that also secured the urinary catheter bag to the bed rail. RN Z said the urinary catheter bag touching the floor was an infection concern. After adjusting Resident #81's bed and adding the strap to the urinary catheter bag, RN Z said this was how it should be. RN Z said sometimes the CNAs changed the resident and left the bed down which caused the urinary catheter bag to touch the floor. During an interview on 5/27/26 at 1:52 p.m., CNA Z said urinary catheter bags should be positioned on the bed below the resident's bladder. CNA Z said urinary catheter bags should not be dragging on the floor and should be hanging on the side rail of the bed. CNA Z said when she changed Resident #81 and did her peri care (the cleansing of the genital and anal areas)he urinary catheter bag was hanging on the end of the bed and not on the floor. CNA Z said usually during her last round she emptied the urinary catheters, and she probably would have caught that the urinary bag was on the floor when she emptied Resident #81's urinary catheter. CNA Z said the effect it could have on the resident if the urinary catheter bag was touching the floor was that the urinary catheter bag could get contaminated, urine could not drain properly, leak out or obstruct the flow of urine. During an observation on 05/26/2026 10:38 A.M., Resident #101 who was seated in her bed and her entire urinary catheter bag and drainage port, was lying on the floor.During an observation and interview on 5/26/26 at 10:40 a.m., RN Y said Resident #101's urinary catheter bag was not supposed to be on the floor, and Resident #101 could get an infection because her catheter bag was lying on the floor. RN Y said and then demonstrated there was no hook for the bag to attach to the bed, so the bag ended up on the floor. The charge nurse picked the bag up off of the floor with her gloved hand and was holding it low so that it remained below the resident's bladder. RN Y said she was sure the night shift put it there and then called RNA A to the room because she was the aide working with the resident for the day. RN Y said she would change Resident #101's entire indwelling foley catheter bag system and notify the MD.During an observation and interview on 5/26/26 at 10:42 a.m. with RNA A who said she did 6 am shift rounds on Resident #101 and at least one additional round and Resident #101's the indwelling catheter bag was not on the floor. RNA A said they did not know how it got on the floor again and grabbed a large pink emesis basis for RN Y to set the urinary bag into without it touching the floor. RNA A said the catheter bag should never be on the floor because the resident could get an infection or a worsened infection from it being on the floor. During an observation on 5/28/2026 at 11:12 a.m., Resident #101 was clean and dressed lying in bed with her urinary catheter bag hanging on the bed rail below Resident #101 with the urinary catheter bag lying face down on the floor on the right side of the bed. During interview and observation on 5/28/26 at 11:28 a.m., LVN Z accompanied the surveyor to Resident #101's room. LVN Z said it fell when she saw Resident #101's urinary catheter bag on the floor. LVN Z said the urinary catheter bag was supposed to be hanging and she did not know what happened. LVN Z repositioned Resident #101's urinary catheter bag on the lower bed rail hanging below the level of Resident #101. LVN Z said that once she saw a urinary catheter bag on the ground, she picked it up. LVN Z said that it would not be good for the urinary catheter bag to be on the floor as it could get contaminated but said the urinary catheter was not open and it was closed because it was not leaking urine. During an interview on 5/28/26 at 12:57 p.m., CNA Y said she was taking care of Resident #101. CNA Y said urinary catheter bags were supposed to hang on the side of the bed and should be 2-3 inches above the floor. CNA Y said after she took care of the resident, she made sure to hang the urinary catheter bag where it should be on the bed. CNA Y said if the urinary catheter bag was on the floor, it could cause an infection. CNA Y said sometimes the way that Resident #101 moved caused the urinary catheter bag to fall and then they picked it back up. CNA Y said her last in-service regarding urinary catheters was within the last month and was about taking care of the urinary catheters and hanging the urinary catheters on the bed after taking care of the residents and what it could cause if not taking care of the resident correctly. During an observation on 5/29/26 at 11:12 a.m., Resident #81 was lying in bed, and her urinary catheter bag was lying on the floor mat positioned next to Resident #81's bed and the bedside table's wheel that was positioned across Resident #81's bed was on top of the urinary catheter bag. During an interview on 5/29/26 at 11:13 a.m., RN Y observed Resident #81's urinary catheter bag and said it should not be on the floor underneath the bedside table, and moved the bedside table off the urinary catheter bag. RN Y said that she was not Resident #81's nurse and the C hall nurse was Resident 81's nurse. During an interview on 5/29/26 at 11:15 a.m., the Unit Manager said she was filling in on C hall that included Resident #81. Surveyor informed the Unit Manager that the bedside table was also on top of the urinary catheter and RN Y moved the table off Resident #81's urinary catheter bag. The Unit Manager said the urinary catheter bag should not have been on the floor and should have been hanging towards the end of the bed and she would talk to the CNAs. The Unit Manger said the urinary catheter bag should be kept off the floor and that she would get a basin to put the urinary catheter bag in to keep it off the floor. The Unit Manager said the effect it could have on the resident if the urinary catheter bag was on the floor was that it could cause an infection and would definitely be an issue due to contamination due to the urinary catheter being connected to an opening in the body. The Unit Manager said she usually was on the A and B hallways, and her duties included monitoring and making sure assessments were done. The Unit Manger said she went by the resident rooms and checked the placement of the urinary catheter bags, and they were not on the floor. The Unit Manager said CNAs received training that included urinary catheter bags should be placed at the foot of the bed and should not be on the floor. The Unit Manager said CNAs had received training regarding urinary catheters during orientation and in-services. The Unit Manger said that she also gave verbal instructions when she saw issues. During an interview on 5/29/2026 at 11:24 a.m., the ADON said the effect it could have on the resident if their urinary catheter bag was on the floor was that there could be drainage issues or the urinary catheter could pull and cause trauma. ADON said all nursing staff were responsible for checking that the urinary catheter bag was properly positioned. The ADON said that whoever went in the residents' rooms needed to make sure someone was aware if the urinary catheter bag was not positioned correctly. The ADON said that nursing staff were trained regarding urinary catheters upon hire and then quarterly. ADON said they also had different education and competencies including skills check offs. ADON denied any problems regarding urinary catheter placement in the past. During an interview on 5/29/2026 at 11:26 a.m., the DON said that the effect it could have on the resident if the urinary catheter bag was on the floor was that it could pull and cause trauma, not properly draining, could allow bacteria to grow or become dislodged. The DON said it was the responsibility of the nursing staff and the CNA who provided care to check the placement of the urinary catheter bag and should be placed on the non-moving rail. The DON said the nurse should have monitored the placement of the urinary catheter bag. The DON said management observed urinary catheter placement when they made rounds in the mornings and evenings. The DON said nursing staff were trained regarding urinary catheters by in-services upon hire and quarterly. The DON said there was also education and training in their online system. During an interview on 5/29/2026 at 1:02 p.m., CNA Z said regarding Resident #81 they always had the bed in the lowest position, so the urinary catheter bag dragged the floor. CNA Z said after she did Resident #81's peri care this morning she had positioned her urinary catheter correctly, so she did not know what happened regarding Resident #81's urinary catheter bag positioning. CNA Z said that when she did her rounds, she put Resident #81's urinary catheter bag in a basin so it was not on the floor. CNA Z said they tried to keep Resident #81s bed in the lowest position since Resident #81 was a fall risk. During an interview on 5/29/2026 at 2:31 p.m., the DON said, regarding urinary catheter bags not being on the floor, it was nursing knowledge and nothing should be on the floor as the floor was dirty. During an observation on 5/26/2026 at 11:25 a.m., LVN B provided wound care to Resident #92 without wearing a gown as per EBP protocol. LVN B removed all three dirty dressings at the same time and discarded the dirty gloves. LVN B donned (put on) clean gloves and cleaned wound #1 with wound cleanser and applied a clean dressing to wound #1 using the same gloved hands. LVN B discarded the dirty gloves, donned clean gloves to clean wound #2 and using the same gloved hands applied a clean dressing for wound #2. LVN B repeated the same for wound #3. During an interview on 5/26/2026 at 11:47 a.m., LVN B stated he should have changed gloves after cleaning the wound. He said he should have sanitized his hands and donned clean gloves when applying a clean dressing to each wound. LVN B stated the negative outcome was cross contamination and infection if the infection prevention protocols were not followed. LVN B did not respond as to why he did not use a gown while providing wound care for Resident #92. During an observation on 05/27/2026 at 8:56 a.m., RN B provided medication administration through the g-tube to Resident #12 without wearing a gown as per EBP protocol. During an interview on 5/27/2026 at 12:41 pm, RN B said she was not familiar with the EBP protocol. After reading the poster posted by a resident's bed, RN B stated EBP was used as a precaution to prevent transmission of infections to others and herself. RN B stated she did not wear a gown while administering medication via g-tube to Resident # 12 this morning. Record review of the facility's policy titled, Catheter Care, dated 2/2024, revealed catheter management positioning that included to ensure the catheter bag was positioned below the level of the bladder to allow for proper drainage and avoid reflux of urine. Record review did not reveal any information regarding urinary catheter bags and their relation to the ground. Record review of the facility's policy titled, Enhanced Barrier Precaution, revised 03/2024, read in part, . Policy: Enhanced Barrier Precaution is an infection control intervention designed to reduce the transmission of multidrug-resistance organism and employs targeted gown and glove use during high-contact resident care activities.Guidance/Procedure: EBP are indicated for residents with the following: wounds and /or indwelling medical devices. examples of indwelling medical devices: central lines, urinary catheters, feeding tubes.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 12.0% based on 3 errors out of 25 opportunities (Resident #108 and Resident #80) reviewed for medication administration. The facility failed to ensure RN A administered insulin injection at the appropriate site as per physician's order for Resident #108.The facility failed to ensure MA A accurately dispensed and administered oral medication and eye drops as per physician's orders for Resident #80. These failures could place residents at risk for incomplete therapeutic outcomes and decline in health. Findings included: 1. Record review of Resident # 108's face sheet, dated 05/30/2026, revealed a [AGE] year old female admitted [DATE], with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia (inability of the body's cell to respond properly to the hormone insulin), Cerebral Infarction (death of brain tissue cause by prolonged lack of blood flow and oxygen) and Heart Failure (heart is not pumping blood efficiently to meet body's need for oxygen and nutrients). Record review of Resident #108's quarterly MDS assessment, dated 04/06/2026, revealed a BIMS score of 7, indicating severe cognitive impairment with thinking and memory. Record review of Resident #108's Medication Administration Record dated May 2026, revealed an order for Novolog Flex Pen 100 unit/ml solution pen-injector. Inject as per sliding scale: if 70-149 = 0 units; 150-199 = 2 units; 200-249 4 units; 250-299 = 6 units; 300+ = 8 units; Notify NP/MD, subcutaneously (under the skin) before meals for DM II with start date of 4/11/2026. During medication observation on 5/27/2026 at 8:42 a.m., RN A entered Resident #108's room and Resident #108 was finishing her breakfast. RN A performed finger stick using aseptic technic (free from harmful germs that can cause infections). Observation indicated Resident #108's blood glucose level was 255. RN A, went to her medication cart and prepared 6 units of insulin Novolog and 25 units of insulin Toujeo SoloStar . RN A checked her computer and stated based on site rotation, the two insulins would be administered on Right Lower Quadrant of abdomen. Upon entering Resident #108's room, RN A instructed the resident to expose her abdominal area. Instead, Resident #108 exposed her right arm. RN A cleaned Resident # 108's deltoid area (large triangular muscle that covers shoulder joints) with an alcohol wipe and administered 6 units of insulin Novolog. Then RN A cleaned the back area under the right arm with an alcohol wipe and administered 25 units of insulin Toujeo under the skin. During an interview with RN A on 5/27/2026 at 8:52 a.m., RN A stated she should not have administered the Novolog insulin on Resident #108's deltoid (intramuscular) area because that was not an appropriate site for insulin injections. RN A stated insulin injections were supposed to be injected into areas of fatty tissue such as the subcutaneous area (under the skin) for better insulin absorption. RN A stated she automatically administered the Novolog insulin on the deltoid (intramuscular) area because Resident # 108 had exposed the right arm and stated she wanted it on her arm. RN A had no response to why she administered the Toujeo insulin correctly but not the Novolog insulin. 2. Record review of Resident # 80's face sheet, dated 5/30/2026, revealed a [AGE] year old female, admitted [DATE], with diagnoses including Constipation (when having a bowel movement becomes difficult, painful or happens less often than normal), Essential Hypertension (when the force of blood pumping through the blood vessels are consistently high) and Cerebral Infarction (death of brain tissue cause by prolonged lack of blood flow and oxygen). Record review of resident # 80 quarterly MDS record dated 05/12/2026 revealed a BIMS score of 2, which indicates the resident has severe cognitive impairment with thinking and memory. Record review of Resident # 80's Medication Administration Record for MAY 2026 revealed an order for Sennosides Tablet 8.6 mg - Give 2 tablet by mouth two times a day for constipation with a start date of 02/18/2026 and an order for Artificial Tears Solution 0.5-06% (Polyvinyl Alcohol-Povidone) - Instill 2 drops in both eyes two times a day for dry eyes with a start date of 08/13/2024. During an observation of medication administration for Resident # 80 on 5/27/2026 at 10:20 am, MA A took resident's blood pressure and dispensed the following medications: Aspirin 81mg - 1 tablet, Lisinopril 5 mg - 1 tablet, Omega 3 fish oil 1000mg - 1 tablet, Senna Plus 8.6mg - 1 tablet, Vitamin D3 1000 iu (25mcg) - 1 tablet. After administering all the medication, MA A returned to medication cart and started checking off the EMAR in her computer. MA A stated Resident # 80 was supposed to receive artificial tears eye drops but she did not have one in her cart. She said she would get the mediation from the central supplies room. Med Aide A walked to an unidentified door nearby and knocked several times. When no one answered, MA A returned to her medication cart and stated, I suppose no one is in there. They must all be in a meeting. MA A then signed off her computer. After medication reconciliation for Resident # 80 on 5/27/2026 at 11.00 a.m., it was identified that Resident # 80 was supposed to receive 2 pills of Sennosides Tablet. During an interview on 5/27/2026 at 4:45 pm, DON stated her expectations were for the nurses and Med Aides to audit their carts and replenish the cart accordingly. DON stated the Med Aide should notify the nurse or let the unit manager know if they need OTC medications so that they can get it for the Med Aides. Record review of facility's policy on Medication Administration and Management read in part .Administering the Medication Pass, # 5: The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member reads the label on the medication 3 times; a) before removing the medication from the drawer; b)before pouring the medication; c) after pouring the medication.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1 (D Hall) of 4 medication aide carts, 2 (B Hall and D Hall) of 4 nurse medication carts and 2 (A Hall and D Hall) of 4 medication storage rooms reviewed for medications storage. -Facility failed to ensure medication aide cart and nurse cart did not have medications that were discontinued. -Facility failed to ensure medication storage room did not have any items stored under the sink. These failures could place residents at risk for drug diversion and contamination of supplies placed under the sink. Findings included: During an observation on 5/27/2026 at 2:15pm, D hall medication aide cart revealed the following medications: Quetiapine 25mg - pharmacy issue date 3/28/2026 with remaining 9 pills for Resident # 74, Potassium Chloride Liquid 10% - pharmacy issue date 12/8/2025, give 15ml in the evening for 5 days for Resident # 64 and Amlodipine 2.5mg give 1 tab daily - pharmacy issue date 7/15/2025 for Resident # 44. During a record review and interview on 5/27/2026 at 2:25pm, Med Aide J stated Resident # 74 was no longer taking Quetiapine 25 mg and Resident # 44 was no longer taking Amlodipine because those medications were discontinued. Med Aide J stated discontinued medication should be removed from the cart and returned to pharmacy. Med Aide J stated she audited her cart weekly to make sure expired and discontinued medications were removed. During an observation of D hall medication storage room on 5/27/2026 at 2:35 pm with LVN C, a box of mixed supplies was discovered under the sink. The box contained IV start kits, feeding tubes, piston syringes and suction catheters. During an interview on 5/27/2026 at 2:40 pm, LVN C stated there should not be anything stored under the sink because the items could get destroyed if the ink leaked. LVN C stated these items should be kept on the rack provided for storing supplies. During an observation on 5/27/2026 at 2:45 pm, D hall nurse cart revealed 2 unopened bottles of Ketoconazole 2% shampoo - pharmacy issue date 9/01/2025 and 9/10/2025 with instructions to use on shower days for Resident # 75 and one bottle of Ketoconazole 2% cream - pharmacy issue date 1/14/2026 with instructions to be applied on shower days for Resident # 103. During a record review and interview on 5/27/2026 at 3:04 pm, LVN C stated she was unsure if Resident # 75 was given this shampoo on his shower days. LVN C stated newer dispensed bottles may have been used first instead of using bottles dispensed on 09/01/2025 and 09/10/2025. LVN C stated she would ensure Resident # 75 got this shampoo on his upcoming shower days. LVN C stated Resident # 103's Ketoconazole 2% cream was discontinued. LVN C stated expired medications should not be in the cart due to possibility of medication administration error. During an observation on 5/27/2026 at 3:10 pm, B hall nurse cart revealed a bottle of Potassium Chloride - pharmacy issue date 3/4/2026 with instructions give 20ml daily for 5 days for Resident # 3. During interview on 5/27/2026 at 3:20pm, RN A stated expired and discontinued medications should be removed from cart to eliminate medication error. RN A stated she audited her cart weekly, but she was unsure how this was missed. During an observation of A hall medication storage room on 5/27/2026 at 3:50 pm with Unit Manager A, 11 urine measuring hats for over toilet use, 1 pair of Booties in a plastic wrap and 3 suction machines under the sink. One of the lower cabinets had an opened colostomy bag with a hair strand stuck on the colostomy bag, a bottle of medication Sevelamer Carbonate (a medication used to remove excess phosphorus from the body) with no name on the bottle, an opened container of piston syringe containing the piston syringe and an opened container of urethral catheterization tray containing a catheter, sterile gloves, and a packet of lubrication. During an interview on 5/27/2026 at 4:05 pm, Unit Manager A stated no items should be stored under sink due to risk of damage if there was a sink leak or burst pipes. Unit Manager A stated she audited the medication room daily and audited the medication cart weekly. During an interview on 5/27/2026 at 4:45pm, the DON stated expired and discontinued medications should be removed from medication cart. The DON stated her expectation is for nurses and unit managers to audit carts and medication storage room weekly. The DON stated medications carts are also audited by Pharmacy Consultants weekly. During an interview on 5/27/2026 at 4:50 pm, the facility policy on medication storage was requested from the DON and the Administrator. The policy was not provided upon exit. During an interview on 5/28/2026 at 1:30 p.m., the facility policy on medication storage was requested from the DON and it was not provided upon exit.

Based on interview and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 2 of 9 residents reviewed for immunizations. (Resident #2 and Resident #115)The facility failed to document, in Resident #2's and Resident #115's medical records, having had received education, whether by self or with responsible party, of the benefits and potential side effects of the influenza immunization and receipt of the of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal.This failure could place residents at risk of contracting a viral illness, influenza and pneumococcal, or being informed of the benefits/risk which could cause respiratory complications and potential adverse health outcomes. Findings included : Resident #2Record review of Resident #2's face sheet dated 5/29/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute kidney failure with tubular necrosis (disorder where the kidney's ability is impaired to filter blood and regulate fluids and electrolytes). Record review of Resident #2's admission MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS could not be conducted as the resident was rarely or never understood. Section O revealed Resident #2 did not receive the influenza vaccine in this facility and was not in the facility during this year's influenza vaccination season. Section O revealed Resident #2's pneumococcal vaccination was not up to date and was offered and declined. Record Review of Resident #2's care plan did not reveal any information related to immunizations. Record Review of Resident #2's electronic medical record revealed No data available under the immunization's tab. Resident #115Record review of Resident #115's face sheet dated 5/29/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including end stage renal disease (final stage of chronic kidney disease characterized by a permanent loss of kidney function). Record review of Resident #115's entry MDS dated [DATE] did not reveal any information related to Resident #115's cognition or immunization status. Record review revealed Resident #115's Medicare 5 Day and Death in facility MDS both dated 5/26/26 were In Progress. Record Review of Resident #115's care plan did not reveal any information related to immunizations. Record Review of Resident #115's electronic medical record revealed No data available under the immunization's tab. During interview on 5/29/2026 at 9:36 a.m., the ADON said she was the facility's Infection Preventionist. The ADON said residents were asked during the admission process if they have had flu, pneumonia and/or COVID vaccines and if they have not had then the facility offered the vaccines and administered the vaccines. The ADON said if the resident refused vaccines, then their refusal was documented. The ADON said immunization information should have been documented in the immunization tab in electronic medical record or in the admission packet. The ADON said it was the infection nurse's responsibility to enter vaccine information in the electronic medical record which would be her, the ADON. The ADON said with new admissions she looked at the residents' paperwork to see if they have had the vaccines. The ADON said vaccines were offered during care plan meetings and updated in the electronic medical record, especially if the resident was new. The ADON said for new residents said she tried to get immunization information entered within a 72 hour time frame from admission and that was her goal. The ADON was unable to find Resident #115's admission packet with information regarding vaccines.During interview on 5/29/2026 at 1:08 p.m., the ADON said Resident #115 he had came late to the facility the past Friday 5/22/26 and had passed away on 5/26/26. The ADON said she was not sure if the social worker had a chance to get Resident #115's admission paperwork done as she did not see it in the system. The ADON said the admission paperwork should have been completed in the 72 hour time span from admission. The ADON said she was still looking for Resident #2's admission paperwork. During interview on 5/29/2026 at 2:31 p.m., the DON said obtaining immunization information from residents fell on the infection control nurse but nursing management which includes the DON and unit managers could also assist with entering immunization information and the admitting nurse could also input information. The DON said the effect it could have on the resident if immunization information was not obtained was not major as immunization history could be looked up to see if they have had immunizations and if not then immunizations were offered to see if they want the immunization. The DON said not all people believe in immunizations so she could not say it was a high risk. During interview on 5/29/2026 at 2:31 p.m., the ADON said regarding Resident #2 she was not able to find the admission paperwork. The ADON said she had called Resident #2's family member to get her immunization information and was entering that information now. The ADON said that not having immunization information could put residents at risk of infectious diseases and spreading of things. The ADON said she was not sure who was responsible for completing the admission paperwork that included the immunization paperwork, but she would find out. The ADON said the Administrator would check in the morning meetings that things had been completed when asked if anyone checked that the admission paperwork was completed. During interview on 5/29/2026 at 2:59 p.m., the DCE (Director of Customer Engagement) said in the admission packet residents were given information regarding flu, pneumonia and COVID vaccinations. The DCE said there were also consents for flu, pneumonia and COVID vaccinations that the resident could either accept or decline the vaccination. The DCE said she was the person responsible for completing the admission packets. The DCE said had been in contact with Resident #2's family member this morning and would email the admission paperwork to the family member to sign as Resident #2 was unable to sign the admission paperwork herself. The DCE said she had just started 5/26/26 at the facility and a DCE from another location had been helping and training her. The DCE said the facility did not have a DCE prior to her starting at the facility but did not know for how long. The DCE said her training regarding her position was the training she received from the other DCE. Regarding Resident #115, the DCE said she did not see him on her unresolved list of things that should be completed. The DCE said she received the list of items that needs to be completed on the application reside. During interview on 5/29/2026 at 3:15 p.m., the Administrator said the DCE (Director of Customer Engagement) or Admissions was responsible for completing the admission paperwork. The Administrator said the current DCE started this week. The Administrator said the last day for the previous DCE was 4/30/26. The Administrator said that they had a DCE from a sister facility who came out and assisted but was not at the facility full time during the time the facility was without a DCE. The Administrator said there was a corporate employee that pulled information and did audits weekly to check that admission packets were completed.Record review of the facility's Infection Control Policies and Procedures with the subject of Immunizations: Resident/Employees with revision date of 2/2022 revealed federal and state regulations are followed regarding immunizations for residents and The facility offers pneumococcal immunizations to residents at risk for pneumococcal disease.

Based on interview and record review , the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 2 of 9 residents who were reviewed for immunizations. (Resident #2 and Resident #115) The facility failed to document, in Resident #2's and Resident #115's medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal.This failure could place residents at risk of not being informed of complications and potential adverse health outcomes.Findings included: 1. Record review of Resident #2's face sheet, dated 5/29/26, revealed a [AGE] year-old female admitted [DATE] with diagnosis including acute kidney failure with tubular necrosis (disorder where the kidney's ability is impaired to filter blood and regulate fluids and electrolytes). Record review of Resident #2's admission MDS assessment, dated 5/11/26, section C (Cognitive Patterns) revealed a BIMS could not be conducted as the resident was rarely or never understood. Section O (Special Treatments, Procedures, and Programs) revealed Resident #2 did not receive the influenza vaccine in this facility and was not in the facility during this year's influenza vaccination season. Section O revealed Resident #2's pneumococcal vaccination was not up to date and was offered and declined. Record review of Resident #2's care plan, dated5/29/26 did not reveal any information related to immunizations. Record review of Resident #2's electronic medical record, accessed 5/28/26 at 3:02 p.m. revealed No data available under the immunization's tab. 2. Record review of Resident #115's face sheet, dated 5/29/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including end stage renal disease (final stage of chronic kidney disease characterized by a permanent loss of kidney function). Resident #115 was discharged [DATE].Record review of Resident #115's entry MDS assessment, dated 5/22/26, revealed no information related to Resident #115's cognition or immunization status. Record review revealed Resident #115's Medicare 5 Day and Death in facility MDS both dated 5/26/26 were In Progress. Record review of Resident #115's care plan, dated 5/29/26, did not reveal any information related to immunizations. Record review of Resident #115's electronic medical record accessed 5/28/26 at 3:02 p.m., revealed No data available under the immunization's tab. During an interview on 5/29/2026 at 9:36 a.m., the ADON said she was the facility's Infection Preventionist. The ADON said residents were asked during the admission process if they had received the influenza , pneumonia and/or COVID vaccines and if they had not, then the facility offered the vaccines and administered the vaccines. The ADON said if the resident refused vaccines, then their refusal was documented. The ADON said immunization information should have been documented in the immunization tab in electronic medical record or in the admission packet. The ADON said it was her responsibility as the infection nurse to enter vaccine information in the electronic medical record. The ADON said with new admissions she looked at the residents' paperwork to see if they had the vaccines. The ADON said vaccines were offered during care plan meetings and updated in the electronic medical record, especially if the resident was new. The ADON said for new residents said she tried to get immunization information entered within a 72 hour time frame from admission and that was her goal. The ADON said she was unable to find Resident #115's admission packet with information regarding vaccines.During an interview on 5/29/2026 at 1:08 p.m., the ADON said Resident #115 arrived late Friday 5/22/26 and passed away on 5/26/26 . The ADON said she was not sure if the social worker had a chance to get Resident #115's admission paperwork done as she did not see it in the system. The ADON said the admission paperwork should have been completed in the 72 hour time span from admission. The ADON said she was looking for Resident #2's admission paperwork. During an interview on 5/29/2026 at 2:31 p.m., the DON said obtaining immunization information from residents fell on the infection control nurse but nursing management which included the DON and unit managers also assisted with entering immunization information and the admitting nurse could also input information. The DON said the effect it could have on the resident if immunization information was not obtained was not major, as immunization history could be looked up to see if they had immunizations and, if not, then immunizations were offered. The DON said not all people believed in immunizations so she could not say it was a high risk. During an interview on 5/29/2026 at 2:31 p.m., the ADON said she was not able to find Resident #2's admission paperwork. The ADON said she had called Resident #2's family member that morning to get her immunization information and was entering that information now . The ADON said that not having immunization information could put residents at risk of infectious diseases. The ADON said she was not sure who was responsible for completing the admission paperwork that included the immunization paperwork, but she would find out. The ADON said the Administrator checked during the morning meetings that the admission paperwork was completed. During an interview on 5/29/2026 at 2:59 p.m., the DCE (Director of Customer Engagement) said in the admission packet residents were given information regarding flu, pneumonia and COVID vaccinations. The DCE said there were also consents for flu, pneumonia and COVID vaccinations that the resident could either accept or decline the vaccination. The DCE said she was the person responsible for completing the admission packets. The DCE said had been in contact with Resident #2's family member this morning and would email the admission paperwork to the family member to sign as Resident #2 was unable to sign the admission paperwork herself. The DCE said she had just started 5/26/26 at the facility and a DCE from another location had been helping and training her. The DCE said the facility did not have a DCE prior to her starting at the facility but did not know for how long. The DCE said her training regarding her position was the training she received from the other DCE. Regarding Resident #115, the DCE said she did not see him on her unresolved list of things that should be completed. The DCE said she received the list of items that needs to be completed on the app reside. During an interview on 5/29/2026 at 3:15 p.m., the Administrator said the DCE (Director of Customer Engagement) or Admissions was responsible for completing the admission paperwork. The Administrator said the current DCE started this week. The Administrator said the last day for the previous DCE was 4/30/26. The Administrator said that they had a DCE from a sister facility who came out and assisted but was not at the facility full time during the time the facility was without a DCE. The Administrator said there was a corporate employee that pulled information and did audits weekly to check that admission packets were completedRecord review of the facility's policy titled, Infection Control Policies and Procedures: Immunizations: Resident/Employees, revised 2/2022, revealed federal and state regulations were followed regarding immunizations for residents.

Based on interview, observation and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1 (Resident #41) of 6 residents reviewed for care plan.The facility failed to ensure that Resident #41 was care planned regarding refusal to have a privacy cover on his urinary catheter bag. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of Resident #41's face sheet, dated 5/7/26, revealed a [AGE] year-old male, admitted [DATE], with diagnoses including paraplegia (loss of the ability to move in part or most of the legs and lower body) and obstructive (condition where urine is prevented from flowing normally) and reflux uropathy (condition where urine flows backward into the kidneys).Record review of Resident #41's admission MDS assessment, dated 5/9/26, section C (Cognitive Patterns) revealed a BIMS score of 15 that indicated was intact. Section H (Bladder and Bowel) revealed an indwelling catheter. Record review of Resident #41's progress noted, dated 5/26/26 at 12:56 p.m. by Unit Manager B, revealed, Nursing staff offered to change the resident's urinary bag to the bag that has the privacy cover on it. The resident refused to have the correct foley (urinary) bag with privacy cover placed. Record review of Resident #41's progress note, dated 5/28/26 at 8:17 p.m. by LVN Z, revealed, Resident refused facility privacy bag. Record review of Resident #41's Order Listing Report, dated 5/29/26, revealed a physician order for an indwelling urinary catheter using a closed drainage system to be changed monthly and as needed with revision date of 5/7/26. Record review of Resident #41's care plan, dated 5/29/26, revealed Resident #41 had a urinary catheter with intervention to provide a privacy bag. Resident #41's care plan also revealed a care plan focus of refusal to let staff change the urinary catheter bag, but no information was found regarding refusing privacy bag for urinary catheter. During an observation on 5/26/26 at 10:25 a.m., Resident #41 was lying in bed with his blanket over his head with his urinary catheter hanging on the bed with no privacy cover. During an interview on 5/27/2026 at 3:04 p.m., LVN Z said the urinary catheter bags should have a privacy bag all of the time. LVN Z said when residents entered from the hospital, they arrived with clear urinary bags and the facility put their own privacy bag on the urinary catheter bag. LVN Z said if there was not a privacy cover on the urinary catheter bag it could be a body image issue.During an interview on 5/28/2026 at 10:20 a.m., LVN Z said Resident #41 always refused and had said I will do what I want to do, and you can't control me. LVN Z said that the MDS nurse updated the care plans. LVN Z said if a resident refused the urinary privacy bag it should have been put on the care plan. LVN Z said she documented refusals and then let the MDS nurse know about the refusal. During an interview on 5/28/2026 at 10:36 a.m., Resident #41 said he did not care much about the privacy bag for the urinary catheter bag. Resident #41 said he refused to let the facility change the urinary catheter bag because he did not like the bags that the facility had that already had the cover on it. Resident #41 said that someone from the facility had tried to talk to him a couple times and he just rode off. Resident #41 said that not having a privacy cover on the urinary catheter bag did not really bother him and he was barely inside and was not around people. Resident #41 said it is on me; they tried to add it referring to the privacy cover for the urinary catheter bag. During an interview on 5/28/26 at 4:35 p.m., the MDS Nurse said if a resident refused a privacy cover on the urinary catheter bag should be care planned. The MDS Nurse said she was responsible for care planning refusals if the floor nurse let her know and then she would care plan the issue. The MDS nurse said she care planned Resident #41 regarding refusal to have his urinary catheter changed but denied being informed regarding Resident #41's refusal to have a privacy cover on his urinary catheter bag. The MDS Nurse said the floor nurses or the unit Manager told her information regarding updating the care plan. The MDS Nurse said the effect it could have on the resident if refusals were not care planned was that the staff would not know how to take care of the resident. During an interview on 5/29/26 at 9:36 a.m., the ADON said if a resident refused care, it should have been on the care plan. The ADON said Resident #41's refusal to have a privacy cover on his urinary catheter bag should have been on the care plan. The ADON said she was involved in the daily standup/clinical meetings, but she did not add information to the care plans. The ADON said they did not have separate privacy covers for the urinary catheter bags and the privacy cover comes attached to the facility's urinary catheter bag. The ADON said Resident #41 did not have the facility's urinary catheter bag. During interview on 5/29/2026 at 10:11 a.m., the DON said if a resident refused care, it should have been on the care plan. The DON answered yes that Resident #41's refusal to have a privacy cover on his urinary catheter bag should have been on the care plan. The DON said that MDS Nurse updated the care plans. The DON said they have daily standup/clinical meetings where the MDS Nurse received communication to update the care plan. The DON said Resident #41 went to the hospital and had his urinary catheter changed out while he was at the hospital and returned to the facility without a privacy cover. During an interview on 5/29/2026 at 11:10 a.m., RN Y said Resident #41 refused to have a privacy cover on his urinary catheter bag. RN Y said Resident #41 said it was ok referring to the urinary catheter bag without the privacy cover and said leave this one like this referring to the urinary catheter bag without a privacy cover. During an interview on 5/29/2026 at 11:45 a.m., RN Y said regarding Resident #41 refusal of the privacy cover to the urinary catheter bag that she told them in the office this information. When asked who she told in the office, RN Y said Unit Manager B. RN Y said I don't know regarding this information being on the resident's care plan. Record review of the facility's policy titled, Care Plan Revisions, with revision date 5/2022, revealed, Care plans will be modified as needed by the MDS Coordinator or other designated staff member.

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 #1) of 3 residents reviewed for resident rights. This failure could affect the resident who required assistance with her Activities of Daily Living (ADL) from facility staff by placing them at risk for social isolation, loss of dignity, and self-worth. - The facility failed to ensure Resident #1 was provided with personal grooming (changed brief and clean clothing) before her discharge to the hospital on [DATE]. This failure placed residents at risk for embarrassment, at risk of loss of dignity and a decrease in quality of life.The findings include: Record review of Resident #1's Face Sheet dated 10/17/2025 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 10/17/2025. Resident #1 had diagnoses included: End stage renal disease (inadequate kidneys function), acute kidney failure (condition where the kidneys suddenly lose their ability to filter waste products from the blood), protein-calorie malnutrition (inadequate food intake), hypertensive heart and chronic kidney disease without heart failure (damages the heart and kidneys, but the heart does not experience heart failure), cognitive communication deficit (difficulty with memory, problem solving, and speech), and aphasia (inability to speak). Record review of Resident #1's 10/09/2025 psychosocial evaluation reflected the residents had a Brief Interview for Mental Status (BIMS) score of 11 indicating the resident had moderate cognitive impairment. Record review of Resident #1's undated Care Plan reflected: FOCUS: ADL self-care performance deficit related to immobility. GOAL: Maintain current level of function through the review date. INTERVENTION/TASKS: Bathing/Showering: the resident had total dependency on 2 staff to provide bath/shower as necessary. Dressing: The resident required Partial/moderate assistance by 1 staff to dress. Record review of Resident #1's Progress Note dated 10/16/2025 at 01:10 a.m. reflected Resident #1 had a Change of Condition (critical labs) and was sent to the hospital, created by Registered Nurse (RN) A. During an interview on 10/17/2025 at 06:45 pm. Hospital RN A stated that Resident #1 had been admitted to the hospital with dirty clothes, dirty brief, unclean skin, and an odor. Hospital RN A stated it appeared that Resident #1's less than well appearance had contributed to the inadequate ADLs the resident received at the facility she had admitted from. She stated that the hospital staff had to changed Resident #1's out of her dirty clothes and soiled brief when the resident arrived at the hospital. During an observation on 10/20/2025 at 08:05 am. Resident #1 was observed in bed. The resident appeared clean and groomed with no odors. The resident had not aroused to voice or sound. During an observation on 10/20/2025 at 08:12 a.m. Hospital RN B stated that Resident #1 had been compliant with ADLs, but staff were performing 100% of care ADL care. Resident #1 had not been communitive or able to answer or respond to questions or commands and had been disoriented times 4 (refers to a state where an individual is not aware of four key aspects: person, place, time, and event). During an interview on 10/20/2025 at 11:41 a.m. Family A stated Resident #1's hair had to be cut off because the facility had not groomed the resident's hair and it had continuously become tangled and unmanageable. Family A stated that no formal complaint had been made with the facility. She stated that the issues were addressed with the on shift staff at the times of the occurrences (no specific days or times were provided). Family A stated that staff had to be asked for clean gowns to change Resident #1 out of dirty gowns at least 3x a week after observing the resident in soiled briefs, unbrushed and tangled hair, unbrushed teeth, and dirty gowns. During an interview on 10/21/2025 at 02:07 p.m. RN A stated that on 10/16/2025 at about 01:00 a.m. Resident #1 had been prepared to discharge to the hospital. She stated that a certified nurse aid (CNA) had been responsible for changing the resident's brief and clothing to ensure that the resident discharged in an appropriate manner to the hospital. RN A stated that she had not recalled who the CNA had been who changed the resident for discharge because she had been preparing the resident's face sheet and ensuring that the resident's heart vest had a charged battery. During an interview on 10/21/2025 at 03:08 p.m. CNA A stated she had worked on 10/15/2025 from 10 p.m. through 10/16/2025 at 6 a.m. She stated she had not assisted in preparing Resident #1 for discharge on the early morning hours of 10/16/2025. During an interview on 10/21/2025 at 03:16 p.m. CNA B stated she had worked on 10/15/2025 from 10 p.m. through 10/16/2025 at 6 a.m. and had not been aware of Resident #1's discharge to the hospital nor prepared the resident for discharge. During an interview on 10/21/2025 at 05:27 p.m. CNA C stated she had worked on 10/15/2025 from 10 p.m. through 10/16/2025 at 6 a.m. and had not worked with Resident #1 on 10/15/2025 or 10/16/2025 and had not assisted with the resident's discharge to the hospital during her shift. During an interview on 10/22/2025 at 10:31 a.m. CNA D stated she had worked on 10/15/2025 from 10 p.m. through 10/16/2025 at 6 a.m. but had not assisted or worked with Resident #1 to prepare the resident for discharge to the hospital. During an interview on 10/22/2025 at 11:20 a.m. Director of Nursing (DON) stated that the staffing schedule dated 10/15/2025 shift 10 p.m. into 10/16/2025 to 6 a.m. reflecting that CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F had worked and confirmed that all CNA's on the schedule had been the actual CNAs who had worked on those dates. During an interview on 10/22/2025 at 01:04 p.m. CNA E stated she had worked on 10/15/2025 from 10 p.m. through 10/16/2025 at 6 a.m. She stated she had been familiar with Resident #1 but had not assisted in the preparation of resident's discharge to the hospital on the morning of 10/16/2025. During an interview on 10/22/2025 at 02:50 p.m. CNA F stated she worked 10/15/2025 at 10 p.m. to 6 a.m. on 10/16/2025, had been familiar with Resident #1, but had not assisted in sending the resident out to the hospital on [DATE]. During an interview on 10/23/2025 at 02:01 p.m. the Administrator (ADM) stated that she had not been made aware of any issues with Resident #1's discharge to the hospital on [DATE]. ADM stated that it had been her expectations that residents discharged out of the facility were to be clean and comfortable, requiring staff to ensure that the residents' briefs and clothing were clean and appropriate for outside of the facility. She stated that nurses and the CNA assigned to Resident #1 were responsible for ensuring the resident discharged appropriately on 10/16/2025. She stated that all residents deserve the right to quality of care. During an interview on 10/23/2025 at 02:14 p.m. DON stated that the nurse who had sent Resident #1 out uncleaned, should have admitted they had not had the time or had an issue that hindered them in ensuring Resident #1 had a proper appearance before discharging out of the facility. She stated she had not been made aware that Resident #1 had been sent out to the hospital in a less than appropriate condition. She stated it had been her expectation that staff would have changed Resident 1's brief and ensured the resident had on clean clothing before sending the resident out of the facility. She stated at 01:00 a.m. the staff would have been completing rounds and stated maybe the staff were assisting other residents during that time frame and were unavailable to ensure Resident #1 had been properly prepared to discharge to the hospital. Record review of the facility's staffing schedule dated 10/15/2025 10 p.m. into 10/16/2025 at 6 a.m. reflected that CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F worked and were on shift. Record review of undated facility policy titled EXHIBIT 4 State Resident Rights. Texas Human Resources Code Title 6, Section102.003 Rights of the Elderly. (a) An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights. (b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: (1) has the right to make the individual's own choices regarding the individual's personal affairs, care, benefits, and services;(2) has the right to be free from abuse, neglect, and exploitation; and (3) if protective measure are required, has the right to designate a guardian or representative to ensure the right to quality stewardship of the individual's affairs. (f) An elderly individual may complain about the individual's care or treatment.

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 1 of 3 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 was provided with personal grooming before her discharged to the hospital on [DATE]. This failure could place residents at risk for discomfort and dignity issues.Findings included: Record review of Resident #1's Face Sheet dated 10/17/2025 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 10/17/2025. Resident #1 had diagnoses included: Acute kidney failure (condition where the kidneys suddenly lose their ability to filter waste products from the blood), contusion (bruising) of right lower leg, End stage renal disease (inadequate kidneys function), hypertensive heart and chronic kidney disease without heart failure (damages the heart and kidneys, but the heart does not experience heart failure), protein-calorie malnutrition (inadequate food intake), dysphagia (difficulty swallowing), cognitive communication deficit (difficulty with memory, problem solving, and speech), and aphasia (inability to speak). Record review of Resident #1's psychosocial evaluation dated 10/09/2025 reflected the residents had a Brief Interview for Mental Status (BIMS) score of 11 indicating the resident had moderate cognitive impairment. Record review of Resident #1's undated Care Plan reflected: FOCUS: The resident had an ADL self-care performance deficit related to immobility. GOAL: Resident will maintain current level of function in through the review date. INTERVENTION/TASKS: Bathing/Showering: the resident is totally dependent on 2 staff to provide bath/shower as necessary. Dressing: The resident requires Partial/moderate assistance by 1 staff to dress. FOCUS: The resident had oral/dental health problems. GOAL: Resident will remain free of infection, pain or bleeding in oral cavity by review date. INTERVENTION/TASKS: Administer medications as ordered. Monitor/document for side effects and effectiveness. Coordinate arrangements for dental care, transportation as needed/as ordered. Monitor/document/report as needed (PRN) any signs and symptoms (s/sx) of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken eroded, decayed, tongue (black, coated, inflamed white, smooth), ulcers in mouth, lesions. Record review of Resident #1's Progress Note dated 10/16/2025 at 01:10 a.m. and created by RN A reflected Resident #1 had a Change of Condition (critical labs) and was sent to the hospital. During an observation on 10/20/2025 at 08:05 am. Resident #1 was observed in bed. The resident had not aroused to voice or sound. The resident appeared clean and groomed with no odors. During an interview on 10/17/2025 at 06:45 pm. Hospital Registered Nurse (RN) A stated that Resident #1 had been admitted to the hospital with a less than well appearance: dirty clothes, soiled brief, with unclean skin, and an odor. She stated the hospital staff had to change the resident's soiled brief and clothing immediately upon arriving at the hospital. She stated that it appeared that Resident #1 had not been receiving inadequate ADLs at the facility she had arrived from. During an observation on 10/20/2025 at 08:12 a.m. Hospital RN B stated that Resident #1 had not been communitive or able to answer or respond to questions or commands and had been disoriented times 4 refers to a state where an individual is not aware of four key aspects: person, place, time, and event). Hospital RN B stated Resident #1 had been compliant with ADLs, but staff were performing 100% of care. During an interview on 10/20/2025 at 11:41 a.m. Family A stated since Resident #1 had been admitted , observations had been made at least 3 times a week (no specific days or times were provided) where resident had been uncleaned in soiled briefs, unbrushed and tangle hair, unbrushed teeth, and stained/dirty gowns. Family A stated that staff had to be asked for clean gowns to change Resident #1 and change soiled briefs. Family A stated Resident #1's hair had to be cut off because the facility had not groomed the resident's hair. Family A stated that she had not made a formal complaint, only addressed the issue with the staff on shift at the times. During an interview on 10/21/2025 at 2:07 p.m. RN A stated that on 10/16/2025 at or about 01:00 a.m. she prepared Resident #1 to discharge to the hospital. She stated a certified nurse aid (CNA) changed the resident's brief and put on appropriate clothes for the hospital. RN A stated that she had not recalled who the CNA had been who changed the resident's brief and clothing because she had been preparing printing the resident's face sheet and ensuring that the resident's heart vest had a charged battery. During an interview on 10/21/2025 at 3:08 p.m. CNA A stated she had worked on 10/15/2025 from 10 p.m. through 10/16/2025 at 6 a.m. She stated she had been aware that Resident #1 had a change of condition and had been sent out to the hospital, but CNA stated she had not assisted changing the resident's brief or dressing for the discharge on the early morning hours of 10/16/2025. During an interview on 10/21/2025 at 3:16 p.m. CNA B stated she had worked on 10/15/2025 from 10 p.m. through 10/16/2025 at 6 a.m. but had not worked with Resident #1 nor prepared her for discharge to the hospital. During an interview on 10/21/2025 at 5:27 p.m. CNA C stated she had worked on 10/15/2025 from 10 p.m. through 10/16/2025 at 6 a.m. but had not worked with Resident #1 nor prepared the resident for discharge to the hospital on the early morning hours of 10/16/2025. During an interview on 10/22/2025 at 10:31 a.m. CNA D stated she had worked on 10/15/2025 from 10 p.m. through 10/16/2025 at 6 a.m. but had not worked with Resident #1 nor prepared her for discharge to the hospital. During an interview on 10/22/2025 at 11:20 a.m. Director of Nursing (DON) stated that the staffing schedule dated 10/15/2025 shift 10 p.m. into 10/16/2025 at 6 a.m. reflecting that CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F were working and on shift and no other's CNAs worked that shift's date/times. During an interview on 10/22/2025 at 01:04 p.m. CNA E stated she had worked on 10/15/2025 from 10 p.m. through 10/16/2025 at 6 a.m. but had been familiar with Resident #1 nor prepared the resident for discharge to the hospital on the early morning hours of 10/16/2025. During an interview on 10/22/2025 at 2:50 p.m. CNA F stated she worked 10/15/2025 at 10 p.m. to 6 a.m. on 10/16/2025. She stated that she had been familiar with Resident #1 and had not assisted in sending Resident #1 out to the hospital on the early morning of 10/16/2025. During an interview on 10/23/2025 at 02:01 p.m. the Administrator (ADM) stated that she had not been made aware of any issues with Resident #1's discharge to the hospital and it had been her knowledge that the resident had discharged in stable condition. She stated it had been her expectations that residents discharged out of the facility for any reason, change of condition or not were to be clean and comfortable which meant changing a resident's brief and placing them in clean clothing, appropriate for outside. She stated that all residents deserve the right to quality of care. She stated that nurses and the CNA assigned to Resident #1 were responsible for ensuring the resident discharged appropriately. During an interview on 10/23/2025 at 02:14 p.m. DON stated she had not been made known that Resident #1 had been sent out to the hospital in less than appropriate conditions. She stated that the nurse or other staff who had sent Resident #1 out uncleaned should had admitted they had not had the time or there was an issue properly preparing the resident to discharge. She stated it had been her expectation that someone would have changed Resident 1's brief and ensured she had on clean clothes and had been in a clean and upkept situation before sending the resident out of the facility. She stated at 01:00 a.m. the staff should have been doing their rounds, and maybe the staff were busy and unable to assist in ensuring Resident #1 had been properly cleaned and dressed to discharge to the hospital. Record review of staffing schedule for 10/15/2025 10 p.m. to 6 a.m. on 10/16/2025 reflected that CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F worked and were on shift. Record review of facility policy revised dated 3/2019 and titled Nursing Policies and Procedures reflected Subject: Activities of daily living - Highest Level of Functioning Policy: It is the policy of this facility to provide care and services to ensure that a resident is able to maintain their ability to self-perform their activities of daily living, at their level of functioning prior to facility admission, unless circumstances of the individual's clinical condition demonstrate that diminishment in ability was unavoidable. The facility is responsible to provide necessary care to all resident who are unable to carry out activities of daily living on their own to ensure they maintain proper . grooming and hygiene. Definitions: Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating and communication. Record review of facility policy revised dated 10/2023 and titled Policies and Procedures Standards of Care. Policy the purpose of this policy is to establish and maintain acceptable standards of care for all residents, ensuring their safety, well-being, and dignity are maintained. Procedure: 1. Health and Safety Standards a. All care provided will comply with current guidelines, best practices, and Federal/State regulations. Responsibility: All staff members are responsible for adhering to this policy and for providing care that meets these standards. The administrator will oversee the implementation and compliance with this policy.

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care consistent with professional standards of practices for 5 of 5 residents (CR # 1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for respiratory care related to tracheostomy care. The facility failed to train nurses on tracheostomy care, including LVN A. On 8/21/2025, LVN A noticed CR #1's trach appeared to be at an angle and when CR # 1 was repositioned, his entire tracheostomy was out and, on his chest below his chin. Attempts to reinsert the tracheostomy canula were unsuccessful as the stoma was closed. CR # 1 was admitted to the hospital with evidence of prolonged decannulation SNF stay. The facility failed to ensure licensed nursing staff were trained to provide tracheostomy care for CR # 1, Resident # 2, Resident # 3, Resident # 4 and Resident # 5 An Immediate Jeopardy (IJ) situation was identified on 8/27/2025. The IJ template was provided to the facility on 8/27/2025 at 1:15 p.m.,. While the IJ was removed on 8/28/2025 at 4:13 pm the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained and due to the facility's need to evaluate the effectiveness of thee corrective systems. This failure could place residents at risk for respiratory distress, serious injury harm, impairment or death. Record review of CR # 1's face sheet, dated 8/22/2025, revealed he was a [AGE] year-old male that had been admitted on [DATE] with diagnoses of Cerebral Infarction due to unspecified Occlusion and Stenosis of unspecified Cerebral Artery (a medical condition where a blood vessel in the brain becomes blocked or narrowed, leading to a loss of blood flow to the brain.), Type 2 Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels), Hemiplegia-unspecified affecting right dominant side(a condition where there is paralysis or weakness on one side of the body (hemiplegia), and the affected side is the dominant (usually the right) side of the brain, Convulsions (uncontrolled and involuntary rapid tensing and relaxing of muscles, causing the body to shake) and Hypertension (a chronic condition characterized by persistently elevated blood pressure levels). Record review of CR # 1' s MDS, dated [DATE], indicated CR # 1 had a BIMS score of 6 (cognitive impairment). CR # 1 was total dependent and required assistance of two people for all ADLs. CR # 1 was always incontinent (unable to control) of bowel and bladder. CR #1 sometimes make was able to make self-understood ad understood other.Record review of CR #'1 care plan, dated 8/14/2025, revealed it did not address he had a tracheostomy (direct airway into the trachea (windpipe) through a surgical incision in the neck) or the care of the tracheostomy. Record review of CR # 1's physician order report start date 7/17/2025 and no end date revealed, CR # 1 trach care: HOB- elevate head of bed every shift, suctioning-every shift suction, trach tie-every day shift every 7 days, change tubing and mask-every shift every Sunday, 5L O2 via trach collar (to help patients breathe independently after a tracheostomy, to deliver humidified air or medications, and to facilitate weaning from mechanical ventilation)continuously. Titrate to keep O2>90% every shift, disposable inner cannula (is a single-use plastic tube that fits inside the main, or outer, tracheostomy tube) every day shift change, oral care-every shift provide oral care, site dressing-every shift trach site clean.Record review of CR # 1's progress notes documented by LVN A, dated 8/21/2025 at 9:25 pm read in part change of condition identified dislodged tracheostomy tube. [ What do you think is going on with the resident. Nurse in patient's room for medication administration nurse noticed patient's trach is tilted to the side upon assessment when the 4x 4 gauze is removed the trach is observed laying on the patient's chest. An attempt made to replace the trach unsuccessful. The step-down trach unable to enter as well. [ CR # 1] oxygen saturation fluctuating 88%-91% patient bagged. Oxygen saturation increased to 97 %. 911 called, patient transferred to a {local hospital emergency room} for trach replacement.Record review of CR #1's hospital records, dated 8/22/2025, revealed, No distal tracheostomy tract appreciated with tracheoscopy, trach has likely been out for extended period. Stoma (a surgically created opening on the abdomen to an internal organ) significantly stenosed to size barely larger than flexible laryngoscope. Evidence of prolonged decannulation during SNF stay.Record review of CR # 1's hospital progress notes, dated 8/27/2025, read in part [CR # 1] was recently admitted to a local hospital on 6/19/2024 altered mental status , acute metabolic encephalopathy complicated by aspiration pneumonia which required prolonged intubation and eventually trach placement on 7/3/2025. [CR#1] was administered for respiratory monitoring due to trach dislodgement after an unknown period.Record review of Resident # 2's face sheet dated 8/28/2025 revealed Resident # 2 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in low blood oxygen levels), diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels), narcolepsy without cataplexy (a type of narcolepsy characterized by excessive daytime sleepiness (EDS) but without the sudden loss of muscle tone (cataplexy) that is typically associated with narcolepsy), and tracheostomy status ( refers to a patient having an existing tracheostomy, indicated by a stoma or opening in the neck to the windpipe (trachea), often using a tracheostomy tube).Record review of Resident # 2's MDS, dated [DATE], indicated Resident # 2 was unable to perform the BIMS. Resident # 2 was active diagnosis included Acute Respiratory Failure with Hypoxia (life-threatening condition where the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in low blood oxygen levels) Resident # 2 was total dependent and required assistance of two people for all ADLs. Resident # 2 was always incontinent (unable to control) of bowel and bladder. Resident # 2 was unable to communicate. Resident # 2 rarely self-understood and rarely understood other. Record review of Resident # 2's care plan dated, 8/26/2025, revealed: Focus-Resident # 2 had a tracheostomy and is at risk for changes in secretions, infection, and respiratory distress. Goal: Resident # 2 would not experience no adverse effects through the review date (target date 9/8/2025). Interventions: conduct routine equipment maintenance and changes as indicated, emergency equipment: ambu bag (a portable, handheld device used to provide positive pressure ventilation to patients who are not breathing or are not breathing adequately), and spare trach (a crucial piece of emergency equipment for individuals with a tracheostomy, in case the original tube becomes dislodged, blocked, or damaged), encourage resident to keep head of bed elevated, follow physicians orders: O2 administration, medication administration, labs and x-rays, notify the physician of any adverse findings/changes, and observe for needed suctioning of increased secretions/congestion suctioning-assess for relief, observe for signs and symptoms of infection (redness, swelling, warmth, pain, increased secretions, malodorous secretions, bleeding), and provide tracheostomy site care as ordered. Record review of Resident # 3's face sheet, dated 8/28/2025, revealed Resident # 3 was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (occur when there isn't enough oxygen in the blood), encephalopathy ( a general term for a condition that affects brain function), respiratory disorders in diseases classified elsewhere (lung or airway conditions caused by an underlying, systemic disease), and tracheostomy status (refers to a patient having an existing tracheostomy, indicated by a stoma or opening in the neck to the windpipe (trachea), often using a tracheostomy tube).Record review of Resident # 3's MDS, dated [DATE], re-entry from an acute hospital. Resident # 3 was unable to perform the BIMS. Resident # 3 was total dependent and required the assistance of two people for ADLs. Resident # 3 was always incontinent (unable to control) of bowel and bladder. Resident # 3 had a tracheostomy. Record review of Resident # 3's care plan, dated 8/26/2025, revealed it did not address he had a tracheostomy or the care of the tracheostomy.Record review of Resident # 4's face sheet, dated 8/28/2025, revealed Resident # 4 was a [AGE] year-old that admitted to the facility on [DATE] with diagnoses of cerebral infarction due to the thrombosis of right middle cerebral artery (an ischemic stroke where a clot blocks the right MCA (middle cerebral artery), starving a portion of the right brain of blood and oxygen) tracheostomy status, atrioventricular block (a condition where the electrical signals that control the heartbeat do not properly travel from the atria (upper chambers of the heart) to the ventricles (lower chambers)), and dependence on supplemental oxygen (the need for continuous or intermittent supplemental oxygen therapy to maintain adequate oxygen levels in the body).Record review of Resident # 4's MDS, dated [DATE], indicated Resident # 4 was unable to conduct BIMS. Resident # 4 was total dependent and required the assistance of two people for ADLs. Resident # 4 was always incontinent of bladder and bowel. Resident # 4 had a tracheostomy. Resident # 4 was unable to communicate with others. Record review of Resident # 4's care plan, dated 7/21/2025, revealed Focus: Resident# 4 had a tracheostomy related to chronic respiratory failure, and is at risk for increased secretion, congestion and infarctions; Goal: Resident # 4's secretions/congestion would be relived with suctioning or medications and will have no occurrence of infection over the next 90 days; Interventions: encourage Resident # 4 to keep head of bed elevated, ensure all equipment is in proper working order each shift, give medication per order-monitor labs/x-rays- report result to physician, keep extra same tracheostomy size equipment and /or next smaller size-down in room; observe for needed suctioning of increased secretions/congestion-provide suctioning -assess for relief, and observe for sign and symptoms of infection-report to physician. Record review of Resident # 5's face sheet dated, 8/28/2025, revealed Resident # 5 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of acute respiratory failure, unspecified whether with hypoxia or hypercapnia (a medical condition in which the lungs fail to adequately exchange oxygen and carbon dioxide gases in the blood), anoxic brain damage (a condition where the brain does not receive enough oxygen, leading to brain cell damage or death), and tracheostomy status. Record review of Resident # 5's MDS, dated [DATE] indicated Resident # 5 was unable to perform BIMS. Resident # 5 was total dependent and required the assistance of two people for all ADLs. Resident # 5 was always incontinent of bowel and had a foley catheter (tube into the bladder to drain urine). Resident # 5 had a tracheostomy. Resident # 5 was unable to communicate. Record review of Resident # 5's care plan, not dated, revealed: Focus: Resident # 5 had a tracheostomy and was at risk for changes in secretions, infection, and respiratory distress; Goal: Resident # 5's tracheostomy would experience no adverse effect through the review date (target date 8/31/2025); Interventions: conduct routine equipment maintenance and changes as indicated, emergency equipment: Ambu Bag and Spare Trach to bedside, encourage resident to keep head of bed elevated, follow Physicians orders: O2 administration, medication administration, labs and x-ray, notify the physician of any adverse findings and changes, observe for signs and symptoms of infection, and provide tracheostomy site care as ordered. Observation of Resident # 2 on 8/26/2025 at 11:06 am revealed he had an ambu bag and emergency tracheostomy supplies at the bedside as well as ample supplies of saline, suction tips and tubing including yankauer ( is a suctioning tool used in medical procedures) and was a 7 Shiley (type of breathing tube, specifically a tracheostomy tube) with adequate supplies of extra Shiley's at bedside. He had Jevity 1.5 hanging and infusing via pump at 85/hr. with water bolus infusing via pump as well at 40ml/hr. Both were dated and labeled 8/26/25. His tracheostomy tubing was connected via bedside concentrator at 4/L/min (refers to supplemental oxygen administered at a flow rate of 4 liters per minute) with humidified air water bottle dated 8/23/25 and trach tubing dated 8/26/25. O2 in use and EBP signs posted with EBP supplies readily available at bedside.Observation of Resident # 4 on 8/26/2025 at 11:37 a.m., revealed Resident # 4's O2 in use and EBP signs posted. Resident was resting in bed appropriately dressed and groomed. His call light was within reach and his facial beard was clean and trimmed as well as his fingernails. He had Jevity 1.5 infusing via pump at 65 ml/hr. with water bag flush connected and infusing via pump at 50 ml/hr. Both bags were dated 8/25/25. Resident was able to nod his head yes and no in response to questions, He nodded yes when asked if he was ok. His bedside concentrator was set at 5/L/min and infusing via trach tubing. Trach tubing was dated 8/25/25.Interview with the RT on 8/26/2025 at 11:28 a.m., she said that she provided facility nursing staff training at the facility yearly and prn. She said that training included return demonstrations and in-services on cleaning, maintenance and changing or trach as well as emergency care. Observation of CR # 1 on 8/27/2025 at 3:10 pm at a local hospital, revealed CR #1 was lying in bed asleep. CR # 1 did not have a tracheostomy at the time of this visit. Hospital Nurse A stated that CR# 1 was stable. Hospital Nurse A declined to provide any additional information regarding CR #1. Interview with the ADON on 8/26/2025 at 6:01 pm she stated that a Respiratory Therapist trained the nursing staff on Tracheostomy care. She stated she had not been trained on Tracheostomy care while working at this facility. Interview with the Administrator on 8/26/2025 at 6:15 pm, investigator inquired about tracheostomy training for nursing staff who were scheduled for 8/26/205 on the pm shift. (LVN A, LVN B, and LVN C). He stated that these nurses had not been trained by this facility on tracheostomy care. He stated he would conduct an Audit on Tracheostomy care training.Interview with LVN A on 8/26/2025 at 6:48 p.m., who said she was CR #1's charge nurse on the evening of 8/21/25. She said she did initial rounds at the beginning of her shift 6pm-6am which included checking CR #1 at the bedside, but only saying hello and CR #1 appeared to be breathing normally and in no apparent distress. LVN A said she did not notice any abnormalities with CR #1's tracheostomy at that time and continued her initial resident rounds. LVN A said she did not recall the time, but more than an hour later she returned to CR #1's bedside to provide medications and obtain vital signs and noticed CR #1's trach appeared to be at an angle, so she asked CNA A to assist her with repositioning the resident and when CR #1 was repositioned she noticed his entire tracheostomy was out and sitting on his chest below his chin. LVN A said she attempted to reinsert the tracheostomy canula but the surface of the stoma was closed. She grabbed the emergency kit at the bedside and attempted to utilize the step down (a downsized tube size) shiley (a type of tracheostomy tube) but that did not work either, so she initiated a code which included activation of 911. LVN A said they did not know how long CR #1's tracheostomy tube had been out. LVN A said she had not been trained at or by the facility to perform tracheostomy care. LVN A said she did not remember any competency or return demonstration trainings or assessments at this facility. Interview with LVN B on 8/26/2025 at 7:20pm revealed she worked at facility for 3 months and had not been trained or in-serviced on Trach care. She said she had worked with 1 current facility tracheostomy resident, CR # 1 and also worked the night CR #1 had his change in condition. LVN B said she did not attempt to reinsert CR #1's Tracheostomy tube on 8/21/25 because it did not look like it could be reinserted without causing additional trauma. LVN B explained that CR #'1 tracheostomy site appeared to have closed already. LVN B said she felt comfortable providing trach care to CR #1 even though she had not been trained by this facility on trach care. Interview with LVN C on 8/26/2025 at 7:37pm who said she had worked at facility for about 1 year and was trained tracheostomy care with a return demonstration about 3 weeks to a month ago. LVN C said the ADON did training with her early in the morning. LVN C said they had never done any training with an RT at this facility and never received trach training certificate at this facility. The surveyor notified the Administrator on 8/27/2025 at 1:15 pm., that they had a current Immediate Jeopardy related to respiratory/tracheostomy care. The IJ template was emailed to the to the Administrator on 8/27/2025 at 1:37 pm and a Plan of Removal was requested. The plan of removal was accepted on 8/27/2025 at 7:20 p.m. and included: Plan of Removal: Date: August 27, 2025 Immediate Action: According to the IJ Template, F695 Respiratory/Tracheostomy care and suctioning. The facility failed to ensure that CR # 1 who needed respiratory care, including tracheotomy care, circuit was attached appropriately causing it to become dislodged. The facility failed to ensure licensed nursing staff were trained to provide tracheostomy care. Resident #1 was transferred on 8/21/2025 to the ER and remains in the hospital.The four tracheostomy residents in house were assessed by the Respiratory Therapist and Director of Nursing on 8/27/25, residents were stable, and no signs of respiratory distress or complications were identified. The Respiratory Therapist validated that each resident had the correct tracheostomy supplies at bedside and the required emergency equipment readily available. On 8/27/25, the Respiratory Therapist provided tracheostomy care education and completed skill validation for the Director of Nursing. On 8/26/25, the Regional Nurse Consultant provided one-on-one training to the nurse on duty, covering tracheostomy care and suctioning procedures. A skills validation was completed during the session to ensure the nurse demonstrated competency with facility protocols. No issues were identified.Action: All licensed nursing staff will receive education and skills validation on tracheostomy care and suctioning, to be provided by a Respiratory Therapist and/or DON/ADON. The training will include: Routine tracheostomy care Suctioning of artificial airways Emergency response procedures, including accidental decannulation Signs and Symptoms of respiratory distress Oxygen TherapyA skills check-off will be completed to verify competency. Licensed nursing staff will not be allowed to work their next scheduled shift until both the education and competency validation have been completed. All newly hired licensed staff will receive this training as part of their orientation process. They will not be allowed to accept independent assignments until their skill check-off has been completed and approved by respiratory therapy or clinical leadership.Responsible: Director of Nursing Completion: August 28, 2025 Action: Ad Hoc QAPI conducted on 8/27/25 with Medical Director, Administrator, DON, & ADON regarding IJ F695.Responsible: Administrator/Director of NursingCompletion: August 27, 2025 Action: Administrator reviewed the facility policy for tracheostomy care and suctioning. No changes were made. Completion: August 27,2025 Monitoring: Observation of Resident #2 on 8/28/2025, revealed Resident # 2 was lying in bed and Resident # 2 did not display signs or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. Observation of Resident # 3 on 8/28/2025 revealed Resident # 3 was lying in bed, and Resident # 3 did not display signs or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. Observation of Resident # 4 on 8/28/2025 revealed Resident # 4 was lying in bed, and Resident # 4 did not display signs or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. Observation of Resident # 5 on 8/28/2025 revealed Resident # 5 was lying in bed, and Resident # 5 did not display sign or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. In a telephone interview with LVN B on 8/28/2025 at 11:10 am she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent performing tracheostomy care. LVN B stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. In a telephone interview with LVN C on 8/28/2025 at 11:25 am she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent performing tracheostomy care. LVN C stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. In a telephone interview with LVN A on 8/28/2025 at 2:15 pm she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent in performing tracheostomy care. LVN A stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. On 8/28/2025 telephone interviews were conducted with LVN D, LVN, E, LVN F, LVN G, LVN H, LVN I, LVN J, AND RN A. All staff stated they were in-serviced on tracheostomy care and management. All staff reported the completed a returned demonstration and felt competent in performing tracheostomy care. These staff worked various shifts to include morning shift, night shift and weekend shifts. Record review of the facility policies and procedures for Tracheostomy Management, dated 5/2022, revealed Licensed Nurses providing care for residents with tracheostomies will be trained on tracheostomy care. Precautions/Side Effect: accidental decannulation Record review of the facility policies and procedures for Tracheostomy Care, dated 11/22, read in part Tracheostomy care is performed aseptically for cleaning of the tracheostomy tube and soma site, to prevent plugging of the tracheostomy tube, to prevent airway obstruction, to prevent infection of trach site, and to maintain a patent airway for suctioning. Precaution /side effect(s): accidental decannulation. On 8/28/2025 at 4:13 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of potential more than minimal harm that is not immediate jeopardy because all staff had not been trained on 8/26/2025.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, for daily living for residents living on 1 of 4 halls (Hall D) reviewed for resident rights in that: 1. Four rooms on Hall D (westside of building) had room temperatures of more than 81 degrees Fahrenheit (rooms 404, 405, 406, and 407). This failure could have caused hyperthermia, hospitalization, and a diminished quality of life. Findings Included: Hall D Observation of Rooms #404, 405, 406, and 407 on 5/1/2025 at 10:34 a.m. had the following room temperatures: room [ROOM NUMBER] -temperature was 84.0 degrees Fahrenheit. room [ROOM NUMBER]- temperature was 82.4 degrees Fahrenheit. room [ROOM NUMBER]- temperature was 82.2 degrees Fahrenheit. room [ROOM NUMBER]- temperature was 81.5 degrees Fahrenheit. Observation on 5/1/2025 at 10:34am of the wall thermostat located between room [ROOM NUMBER] and #404 had a temperature of 86 degrees. Observation on 5/1/2025 at 10:42am revealed a cart across from nursing station on Hall D (400) revealed 2 large coolers, a blue cooler was filled with ice and a yellow and red cooler had water. Observation on 5/1/2025 at 1:14pm, the wall thermostat located between rooms [ROOM NUMBERS] had a temperature of 88 degrees Fahrenheit. Record review of the facility's floor plan revealed: Hall D(400) was a L shaped hall. Rooms 401-407 was at the end of the hall (Westside) and rooms 408-423 were after passed the nursing station to the right (Southwest). Record review of Maintenance room/air temperature logs revealed: -Room temperatures had been taken between 4/25/2025-5/1/2025 4/25/2025 -Temperatures taken at 1pm and 3pm 1:00pm- Rooms 403, 404, 405 and 406 had temperatures of 82 degrees Fahrenheit. 3:00pm- Only room # 403 and 406 had temperatures of 81.9 and rooms [ROOM NUMBERS] had temperatures of 81.9 degrees Fahrenheit. 4/26/2025 and 4/27/2025- None of the rooms were documented with temperatures over 81 degrees Fahrenheit. 4/29/2025- Room temperatures were taken at 8:30am, 11:30am, 1:30pm, 3:30pm, and 5:30pm- room [ROOM NUMBER] room temperature rose to 82 degrees Fahrenheit at 3:30pm. 5/1/2025- Room temperatures were taken at 8:30 and 10am- At 10:00am room# 404 and 406 rose to 82 degrees Fahrenheit. Record review of invoice from a local HVAC company revealed the scope of their work on 4/25/2025 was the following: -Pull permit for removal of old chiller -Remove attic unit and haul away debris -Provide and install (2) 5-ton condensers, (2) air handlers, (2) heat kits, (2) drain pans, (4) float switches, (1) furnace switches, and flush copper lines -Electricians to install dedicated electrical wiring and breakers for (2) air handler units. Record review of TULIP on 5/1/2025 revealed no incidents had been called into CII. Further, the facility was on initially certified on 1/26/1998. An interview with the Maintenance Director on 5/1/2025 at 10:20 am, revealed the HVAC system started having cooling issues on 4/25/2025. He stated that the chillers had to be replaced for two units. He said that 2 units had been ordered but they were waiting on an electrician to come and complete the work. He said the electricians were on their way to the facility and after they completed the electrical work, the system should be up and running. Observation rounds ensued with him. He said portables were installed immediately, but Hall D only had one return for hot air to circulate. He said the portables were immediately placed down Hall D with room numbers 401-407 were located; and two portables were placed on the other part of Hall D where 408-415 because this part of the hall had two return vents. He stated the facility had about 5 fans and they had been disbursed to residents requesting one. He said upper management were aware of not all the residents having a fan in their rooms. He stated that the wall thermometer between rooms #403 and #404 controlled the temperatures in rooms 401-407. An observation and interview with Resident #1 at 10:38am, he stated that the air had been down, and his room was hot for about 6-8 days. Observation of his room revealed he had no fans, and it was warm in this room. He said he did not ask for a fan. He said management knew the air conditioning was down. He said he was doing fine despite the heat. He said he did not want to change rooms. Observation and Interview with Resident #2 on 5/1/2025 at 11:13am, he had been a resident for about one year he stated the air conditioner had been out before but for only two days. He stated the problem with the air conditioner not cooling this time started on last Wednesday (4/24/2025) or Thursday (4/25/2025). He stated staff did bring him a fan after he requested one. Observation of a floor oscillating fan at his bedside another fan was observed on the dresser near the TV and one standing fan facing his roommate. Resident #2 did not have a shirt on. He was covered by a sheet. He stated he was hot and preferred not to have clothing on. An interview with RN A on 5/1/2025 at 11:35am, she stated she worked at the facility part-time and had been an employee for three to four years. She stated most times she worked Hall D and stated that she had been out for about a month and returned to work on April 30th she stated that she did have a few complaints from residents in room [ROOM NUMBER] and 404 but no residents have been sent out to the hospital due to the heat. She said the nurses worked 12-hour shifts and her shift was 6:00 AM until 6:00 PM. She stated that she is constantly rounding and checking for comfort and stated that rooms 404, 403,406 were all located on the [NAME] side of the building where the sun hit. She stated that she offered the residents to come out of the rooms during the day and sit in the dining area and other places that were a little bit cooler. Some residents preferred this, while others wanted to remain in their rooms. She said she none of the residents asked her for a fan. She said the heat could have caused a heat stroke, or hyperthermia. She stated they did not have any residents that were hospitalized due to air conditioning issue. An interview with CNA A on 5/1/2025 at 11:48am, she had worked on hall D for almost a month. She said she normally worked the 6a-2pm shift and Hall A. She stated while working they have been sweating and multiple residents complained about the heat. She said throughout the day, she had been standing in front of the portable to cool off. She said the nurses were doing rounds as well as the CNAs. She said everybody in the building was aware that the air was not working properly. She said it is important for the residents and staff to stay hydrated. She said she had asked the residents if they wanted their doors opened, but opening the doors could have caused privacy issues. She said without air circulating throughout the rooms it was very hot. An interview with RN B on 5/1/2025 at 1:19pm, she said she had been employed for 2 months PRN. She said on Sunday (April 27th) she worked and found it to be hot down Hall D and in the rooms. She said she called Maintenance because he was not usually there on weekends. She said she was told the electrician would be there on the following day to complete the electrical parts for the air conditioning to work. She said her job as a nurse was to ensure that the residents had water and ice to keep cool. She said she offered to open the residents' doors and even to come out during the daytime in cooler areas. She said heat strokes and dehydration could have happened due to the broken air conditioning system. She said the key was keeping the residents hydrated until it was fixed. She stated no residents had been sent out due to the heat. A subsequent observation and interview with the Maintenance Director on 5/1/2025 at 3:03pm, it had been pointed out to him that there was a discrepancy in the temperature logs that were submitted by the Administrator. Observations ensued again and he took temperatures for each of the following rooms: Thermometer located on Hall D now read 87 degrees Fahrenheit near room [ROOM NUMBER]. room [ROOM NUMBER]- 84 degrees room [ROOM NUMBER]- 82.7 degrees room [ROOM NUMBER]- 81.3 degrees room [ROOM NUMBER] - 81.3 degrees He said the vents should be pushing at least 65 degrees from the vents now that the electrical work had been completed. He said it might take longer for the area to cool down. An interview with the DON on 5/2/2025 at 1:08pm, DON, she said she had communicated with the residents, and she was told they were okay and none of them wanted their doors opened for the air to circulate. She said she had no complaints from residents and no requests for fans. She said the air conditioning not working when it was warm outside could have caused residents to have heat exhaustion, and dehydration could have been a concern. She was asked if she would have done anything differently, she said she should have asked the residents about room changes or a fan would be offered in the future even if they say they are ok or do not want to leave the room to go to cooler areas. An interview with the Administrator on 5/2/2025 at 2:04pm, he stated they noticed that the building was getting warm on last week in particular Hall D. He said they had a company come out to charge the system, but it did not hold a charge. He said they immediately ordered the portables. He said the units came in on Monday (4/28/2025) the air conditioning units had to be pulled from the roof and then the new units installed. They had to then schedule the electrician to come out to do all the electrical work. He said the management team did Ambassador rounds and checked to ensure the residents were ok. He said they offered to move them, but no one wanted to be moved. He said he had some rooms they could have gone to, but they preferred to remain in their current rooms. He said the residents that resided in rooms with temperatures over 81 degrees could have suffered from dehydration and other negative results. The facility nurses and staff provided ice and water to the residents. He said he also purchased 20 fans on yesterday (5/1/2025). Record review of the facility's resident rights policy revised on 6/2019 stated it is the policy of this facility that the facility staff will provide the residents with the right to an environment that preserves dignity and contributes to a positive self-image. 7. Create a home-like environment for the residents that included: (e) Proper temperature and ventilation. (h) Comfortable and safe temperature levels. Record review of TULIP on 5/2/2025 revealed there were no incidents called in to HHSC CII to for this issue. Further, the facility was initially licensed on 1/26/1998.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. -MA J would have administered the incorrect dosage if not for Surveyor intervention. -Five medications for Resident #66 were not available. -The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered 17 times in March to Resident #96 as ordered on 12/01/2024 by the physician. -The facility failed to ensure Resident #72 was not administered insulin outside of the parameters. These failures could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health. Findings included: Resident #66 Record review of the Admission Record for Resident #66 revealed he was [AGE] years old and was admitted to the facility on [DATE]. His diagnoses included, but were not limited to, major depressive disorder, muscle weakness, and hypertension (high blood pressure). Record review of the March 2025 Physician's Orders for Resident #66 revealed: Isosorbide Mononitrate ER [extended release] 24-hour 30 mg. Give one by mouth one time a day for hypertension. Duloxetine HCL [hydrochloride] Oral Capsule Delayed Release Particles 60 mg. Give one capsule by mouth in the morning for anxiety. Amlodipine Besylate 10 mg give one tablet by mouth one time a day related to essential hypertension. Calcium + Vitamin D3 oral tablet 600 - 10 mg-mcg (Calcium Carbonate - Cholecalciferol) Give 1 tablet by mouth one time a day for calcium deficiency. Fenofibrate Oral tab 160 mg Give 1 tablet by mouth in the morning for cholesterol. Vitamin D (Ergocalciferol) oral capsule 50 mcg. Give 1 capsule by mouth in the morning for Vitamin D deficiency. Observation on 03/26/25 at 9:10 a.m. revealed MA J prepared to administer medications to Resident #66. LVN I was standing at her medication cart outside of Resident #66' room. Continued observation revealed MA J entered the room and retrieved Resident #66' blood pressure. It was 166 mmHg, and the pulse was 94. She informed LVN I, who said to give the medications. Continued observation revealed MA J returned to her cart and began dispensing medications for Resident #66. The following medications were not available: Eliquis 5 mg (1), Amlodipine 10 mg (1), Isosorbide mononitrate 30 mg (1), Duloxetine HCl 60 mg (1), Calcium 600 + Vitamin D (1), Fenofibrate 160 mg (1), and Vitamin D 50 mg (1). Observation on 03/27/25 at 9:44 a.m. revealed UM K brought 2 tablets of Eliquis 2.5 mg and 2 tablets of Amlodipine 5 mg. MA J placed 2 tablets of Eliquis 2.5 mg and 1 tablet of Amlodipine 5 mg in a med cup. The Surveyor asked MA J what dosage strength the Amlodipine tablet she dispensed was. MA J said It's a 10 mg. MA J closed the drawer of the med cart. The Surveyor asked MA J to look at the emptied Amlodipine blister package. MA J looked at the emptied blister package and said it was 5 mg. MA J then retrieved the other Amlodipine 5 mg tablet and added it to the med cup to complete the 10 mg dosage. MA J entered Resident #66' room and administered the medications. In an interview on 03/27/25 at 1:10 p.m., UM C said Resident #66' Isosorbide Mononitrate 30 mg tablets and Duloxetine HCl 60 mg tablets would not be delivered to the facility until the next day. Record review of Resident #66' March 2025 MAR revealed the resident did not receive the Isosorbide mononitrate 30 mg (1), Duloxetine HCl 60 mg (1), Calcium 600 + Vitamin D (1), Fenofibrate 160 mg (1), or the Vitamin D 50 mg (1) on 03/27/25. In an interview on 03/27/25 at 1:15 p.m. Resident #66 said no one has rechecked his BP since he received his morning medications. At that time LVN I checked Resident #66' BP: 150/94 mmHg and pulse: 103 bpm. In an interview on 03/27/25 at 2:50 p.m. the DON said the medication cards had a blue area on them to indicate when the medication was to be reordered. She said the MA could reorder the medications on the computer program. She said she was not made aware of Resident #66' situation. In an interview on 03/27/25 at 2:55 p.m. UM C said she just called the Nurse Practitioner but has not heard back. She said she rechecked Resident #66' BP, and it was 137/91 mmHg. In an interview on 03/27/25 at 3:00 p.m. the DON said the staff should have rechecked Resident #66' BP 30 minutes after the morning medication administration. Resident #96 Record review of Resident #96's admission face sheet, undated, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included: traumatic subdural hemorrhage (a type of bleeding near the brain), hypertension (high blood pressure), cognitive communication deficit (disruption in communication due to underlying cognitive difficulties causes may include brain injury or stroke). Record review of Resident #96's Annual Minimum Data Set (MDS) dated [DATE] reflected the resident's Brief Interview for Mental Status (BIMS- a score used to assess cognitive function) was not scored which indicated the resident was unable to complete the interview. The resident's skills for daily decision making was score at three which indicated the resident's decision making was severely impaired. The MDS identified Resident #96's active diagnosis was medically complex conditions. Record review of Resident #96's care plan initiated 03/22/2024, revision updated 01/15/2025, reflected: Focus: The resident had a history of hypertension. The resident was at risk for fluctuation in blood pressure values, hypertension, hypotension (low blood pressure) and other complications. Goal: The resident's blood pressure would stay within normal limits. The resident would not have signs or symptoms of hypertension or hypotension. Interventions: Give medications as ordered Record review of Resident #96's order summary report, active orders dated as of 03/26/2025, revealed, Midodrine 10 mg give one tablet by G-tube (A tube through the skin into the stomach to deliver nutrition and medications) three times a day for hypotension. Hold if SBP (systolic blood pressure; the top blood pressure reading from the pressure in the arteries when the heart beats) > (greater than) 110. Order dated 12/01/2024. Record review of Resident #96's March 2025 Medication Administration Record (MAR) dated 03/01/2025 -03/31/2025 reflected, the resident was administered Midodrine 10 mg outside of the physician set parameter of SBP over 110 on: 03/03/2025 at 1:00 PM with BP 118/77 by RN A 03/03/2025 at 9:00 PM with BP 112/66 by LVN B 03/07/2025 at 9:00 AM with BP 119/71 and at 1:00 PM with BP 122/68 by RN A 03/09/2025 at 9:00 PM with BP 112/59 by LVN B 03/12/2025 at 1:00 PM with BP 111/65 by RN A 03/13/2025 at 1:00 PM with BP 122/67 by RN A 03/17/2025 at 1:00 PM with BP 115/62 by RN A 03/18/25 at 1:00 PM with BP 112/67 by RN A 03/21/2025 at 9:00 AM with BP 113/62 and at 1:00 PM with BP 119/61 by RN A 03/21/2025 at 9:00 PM with BP 118/77 by LVN B 03/22/2025 at 9:00 AM with BP 122/67 and at 1:00 PM with BP 111/61 by RN A 03/23/2025 at 9:00 AM with BP 113/67 by RN A 03/25/2025 at 1:00 PM with BP 115/78 by RN A In an interview on 03/26/2025 at 08:40 AM with Resident #96's NP she stated the reason for putting the parameter on the resident's SBP was to keep the Midodrine from being administered over a certain BP reading. The purpose of the medication was to elevate the BP when it was too low. The parameter was to prevent the resident's BP from going to go too high. The NP stated the resident was stable at 110. The resident had chronic low BP and was not at risk for adverse effects. The NP stated the resident was not at risk for hypertension. To prevent the medication from being administered outside parameters again she would change the SBP parameter to 130. In an observation on 03/26/2025 at 9:30 AM revealed Resident #96 was in bed with the head of her bed elevated. In a phone interview on 03/26/2025 at 9:50 AM RN A stated when she gave BP medications, she checked the BP to make sure it was alright to give. RN A stated Resident #96 was consistently low, so she gave the Midodrine to help make the BP go higher. RN A stated she would not have given the medications if the BP was over the ordered parameter. RN A stated she was not sure why she would have given it if the BP was high. In an interview with the DON and record review of the MAR on 03/26/2025 at 10:18 AM the DON stated the initials on the MAR did belong to RN A and the medication was administered. The DON stated according to the physician's order the SBP was over 110 and the medication should have been held not given. The DON stated it was given according to the MAR documentation. The DON stated she did not know why that happened. The DON stated the risk of giving the medication was it could cause hypertension. The DON stated she would begin in-servicing immediately on administering BP meds to prevent this again. In a phone interview on 03/26/2025 at 10:27 AM LVN B stated the Midodrine was not to be given if the resident's BP was over 110 systolic and he would not have given it. LVN B stated she did not know why it was given because the risk was high blood pressure. In a phone interview on 03/26/2025 at 11:27 AM the facility Pharmacist stated Midodrine was to be given for low BP to cause the BP to elevate. The Pharmacist stated the physician ordered the parameter so the resident's BP would remain in a specific set range. He stated the risk of administering the medication when the BP was above the parameter was a result of the BP being too high. In an interview with the Administrator and record review of the MAR at 03/26/2025 at 2:25 PM the Administrator stated clearly the parameter was not followed. He stated the risk was hypertension. To prevent medication from being given outside parameters again they were training the staff on medication administration. He stated they were looking at ways to highlight the parameter on the MAR for it to show better. In an interview on 03/27/2025 at 11:59 AM Unit Manager LVN C stated new nurses were trained on the unit they were hired to work on along with a trainer. The training reviewed looking at the entire order, knowing the greater than and lesser than sign. LVN C stated when a BP was outside the ordered parameter the medication was to be held. The nurse was to document it was held and why it was held such as outside ordered parameters. The risk of giving this medication was resulting in the BP going too high. LVN C stated the expectations were medications were given as ordered and document accordingly. During a follow up interview on 03/28/2025 at 9:11 AM the DON stated the unit managers were responsible for monitoring the medications were administered according to the physician's order and all medications were available daily. The DON stated the administrative team had met with the Medical Director on how to better monitor and following the MAR. Resident #72 Record review of Resident #72's undated, face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: Type 2 Diabetes Mellitus (long term condition in which the body has trouble controlling blood), metabolic encephalopathy (Condition where the brain does not receive enough nutrients or oxygen to function properly), and chronic kidney disease, stage 3 (moderate kidney damage and loss of kidney function). Record review of Resident #72's Admission MDS assessment dated [DATE] revealed a BIMS summary score of 13, indicating the resident was cognitively intact. Record review of Resident #72's Care Plan dated 01/26/25 indicated he had a diagnosis of Diabetes Mellitus. Interventions were to give diabetes medications per order, and monitor/document for side effects and effectiveness. Record review of Resident #72's MD order on 03/26/25 revealed orders for: Insulin Glargine Solution100 UNIT/ML Inject 22 unit subcutaneously one time a day for Diabetes, hold if BS less than 120, order date 01/13/2025. Record review of Resident #72's MAR for February 2025 revealed LVN H administered 22 units of Insulin Glargine 100 UNIT/ML on 02/12/25 with a blood sugar reading of 98. Record review of Resident #72's MAR for March 2025 revealed LVN L administered 22 units of Insulin Glargine 100 UNIT/ML on 03/11/25 with a blood sugar reading of 65. In an interview on 03/26/25 at 1:39 PM Resident #72 said last month his BS went too low and he had to eat candy to bring it back up. He said that had happened once since at the facility and denied it being a regular occurrence. He said he knew when his BS was too low or too high. He denied S/S from BS being too high or the need for emergency medication or hospitalization since being admitted to the facility. In a telephone interview on 03/27/25 at 11:48 AM LVN L said she gave the resident food before administering his insulin on 03/11/25. She said she checked Resident #72's blood sugar after he ate but did not record it in the EMR. She said the risk of administering insulin out of parameters set by the MD could place Resident #72 at risk for hypoglycemia (blood sugar levels below the standard range), which could lead to coma or death. In an interview on 03/27/25 at 12: 38 PM LVN C, (unit manager) for 100 and 200 halls revealed medication administration training was conducted with a preceptor to include a check-off. He said the nurses were trained to hold insulin if the BS was not within the parameters per the MD orders. LVN C said the risk of not administering Insulin as ordered or administering too much insulin could cause hypoglycemia or hyperglycemia (blood sugar levels above the standard range), which could result in an adverse reaction or death. In an interview on 03/27/25 at 1:06 PM the ADON said if a resident's blood sugar was outside parameters, the staff should notify the MD, RP and document all interventions. She said the nurse should not give insulin outside of the MD orders because it could place the resident at risk of hypoglycemia or hyperglycemia, which could lead to possible hospitalization . In an Interview on 03/27/25 at 1:19 PM the DON said her expectations were for the nursing staff to read the resident's BS parameters and follow the MD orders. The risk of giving insulin outside the parameters could lead to hospitalization coma and/or death. The DON said if a resident had an elevated or low BS, the staff should immediately notify the MD and follow the MD orders. The DON said hypoglycemia or hyperglycemia could lead to hospitalization or death. An attempt to interview LVN H on 03/27/25 at 1:46 PM was unsuccessful. A voicemail message was provided. In an Interview on 03/27/25 at 6:00 PM the Administrator said the staff needed follow the physician's orders. He said the staff should document and notify the physician if the BS was outside the parameters. He said the risk of administering insulin outside of the physician's orders could lead to a potentially negative outcome. In a telephone interview on 03/27/25 at 6:15PM LVN H said she had on-boarding training on medication administration. She said Resident #72's blood sugar ran high and denied giving him medication when his blood sugar was recorded at 98. She denied that Resident #72 received intervention for S/S of hypoglycemia after the administration of insulin on 02/12/25. LVN H said the risk of administering medication outside of the parameters could lead to hospitalization or death. Record review of the facility's Medication Administration and Management policy revised 6/2019 reflected in part, .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: A. The Right Patient/resident, B The Right Drug, C. The Right Dose, D. The Right Time, E. The Right Route, F. The Right Charting, G. The Right Results, H. The Right Reason. 11. The authorized staff member administers SQ, IM, Intradermal medications as follows: A. Review physicians orders. B. Follow 8 Rights of Medication administration . The facility policy Medication Administration and Management (revised June 2019) revealed in part, .9. Medications are administered no more than one (1) hour before or one (1) hour after the designated medication pass time.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The facility had a medication error rate of 16% based on 6 errors for 37 opportunities. Surveyor intervention was required to prevent one MA from administering the incorrect dose of a blood pressure medication. The errors effected 1 resident (Resident #66) of 6 residents reviewed for medication administration. -MA J would have administered the incorrect dosage if not for Surveyor intervention. -Five medications for Resident #66 were not available: Isosorbide Mononitrate (for blood pressure), Duloxetine HCl for (for depression), Calcium 600 + Vitamin D, Fenofibrate (for cholesterol), and Vitamin D. The medications were not administered on 03/27/25. The failures placed resident at risk for inadequate therapeutic outcomes and a decline in health. Findings included: Record review of the Admission Record for Resident #66 revealed he was [AGE] years old and was admitted to the facility on [DATE]. His diagnoses included, but were not limited to, major depressive disorder, muscle weakness, and hypertension (high blood pressure). Record review of the March 2025 Physician's Orders for Resident #66 revealed: Isosorbide Mononitrate ER [extended release] 24-hour 30 mg. Give one by mouth one time a day for hypertension. Duloxetine HCL [hydrochloride] Oral Capsule Delayed Release Particles 60 mg. Give one capsule by mouth in the morning for anxiety. Amlodipine Besylate 10 mg give one tablet by mouth one time a day related to essential hypertension. Calcium + Vitamin D3 oral tablet 600 - 10 mg-mcg (Calcium Carbonate - Cholecalciferol) Give 1 tablet by mouth one time a day for calcium deficiency. Fenofibrate Oral tab 160 mg Give 1 tablet by mouth in the morning for cholesterol. Vitamin D (Ergocalciferol) oral capsule 50 mcg. Give 1 capsule by mouth in the morning for Vitamin D deficiency. Observation on 03/26/25 at 9:10 a.m. revealed MA J prepared to administer medications to Resident #66. LVN I was standing at her medication cart outside of Resident #66' room. Continued observation revealed MA J entered the room and retrieved Resident #66' blood pressure. It was 166 mmHg, and the pulse was 94. She informed LVN I, who said to give the medications. Continued observation revealed MA J returned to her cart and began dispensing medications for Resident #66. The following medications were not available: Eliquis 5 mg (1), Amlodipine 10 mg (1), Isosorbide mononitrate 30 mg (1), Duloxetine HCl 60 mg (1), Calcium 600 + Vitamin D (1), Fenofibrate 160 mg (1), and Vitamin D 50 mg (1). Observation on 03/27/25 at 9:44 a.m. revealed UM K brought 2 tablets of Eliquis 2.5 mg and 2 tablets of Amlodipine 5 mg. MA J placed 2 tablets of Eliquis 2.5 mg and 1 tablet of Amlodipine 5 mg in a med cup. The Surveyor asked MA J what dosage strength the Amlodipine tablet she dispensed was. MA J said It's a 10 mg. MA J closed the drawer of the med cart. The Surveyor asked MA J to look at the emptied Amlodipine blister package. MA J looked at the emptied blister package and said it was 5 mg. MA J then retrieved the other Amlodipine 5 mg tablet and added it to the med cup to complete the 10 mg dosage. MA J entered Resident #66' room and administered the medications. In an interview on 03/27/25 at 1:10 p.m., UM C said Resident #66' Isosorbide Mononitrate 30 mg tablets and Duloxetine HCl 60 mg tablets would not be delivered to the facility until the next day. Record review of Resident #66' March 2025 MAR revealed the resident did not receive the Isosorbide mononitrate 30 mg (1), Duloxetine HCl 60 mg (1), Calcium 600 + Vitamin D (1), Fenofibrate 160 mg (1), or the Vitamin D 50 mg (1) on 03/27/25. In an interview on 03/27/25 at 1:15 p.m. Resident #66 said no one has rechecked his BP since he received his morning medications. At that time LVN I checked Resident #66' BP: 150/94 mmHg and pulse: 103 bpm. In an interview on 03/27/25 at 2:50 p.m. the DON said the medication cards had a blue area on them to indicate when the medication was to be reordered. She said the MA could reorder the medications on the computer program. She said she was not made aware of Resident #66' situation. In an interview on 03/27/25 at 2:55 p.m. UM C said she just called the Nurse Practitioner but has not heard back. She said she rechecked Resident #66' BP, and it was 137/91 mmHg. In an interview on 03/27/25 at 3:00 p.m. the DON said the staff should have rechecked Resident #66' BP 30 minutes after the morning medication administration. The facility policy Medication Administration and Management (revised June 2019) revealed in part, .9. Medications are administered no more than one (1) hour before or one (1) hour after the designated medication pass time.

Based on observations, interviews and record review, the facility failed to ensure residents were free from significant medication errors for 2 of 41 residents (Residents #'s 96 and Resident #72) reviewed for significant medication errors. 1. The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered 17 times in March to Resident #96 as ordered on 12/01/2024 by the physician. 2. The facility failed to ensure Resident #72 was not administered insulin outside of the parameters. These failures could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health. Findings included: 1.Record review of Resident #96's admission face sheet, undated, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included: traumatic subdural hemorrhage (a type of bleeding near the brain), hypertension (high blood pressure), cognitive communication deficit (disruption in communication due to underlying cognitive difficulties causes may include brain injury or stroke). Record review of Resident #96's Annual Minimum Data Set (MDS) dated [DATE] reflected the resident's Brief Interview for Mental Status (BIMS- a score used to assess cognitive function) was not scored which indicated the resident was unable to complete the interview. The resident's skills for daily decision making was score at three which indicated the resident's decision making was severely impaired. The MDS identified Resident #96's active diagnosis was medically complex conditions. Record review of Resident #96's care plan initiated 03/22/2024, revision updated 01/15/2025, reflected: Focus: The resident had a history of hypertension. The resident was at risk for fluctuation in blood pressure values, hypertension, hypotension (low blood pressure) and other complications. Goal: The resident's blood pressure would stay within normal limits. The resident would not have signs or symptoms of hypertension or hypotension. Interventions: Give medications as ordered Record review of Resident #96's order summary report, active orders dated as of 03/26/2025, revealed, Midodrine 10 mg give one tablet by G-tube (A tube through the skin into the stomach to deliver nutrition and medications) three times a day for hypotension. Hold if SBP (systolic blood pressure; the top blood pressure reading from the pressure in the arteries when the heart beats) > (greater than) 110. Order dated 12/01/2024. Record review of Resident #96's March 2025 Medication Administration Record (MAR) dated 03/01/2025 -03/31/2025 reflected, the resident was administered Midodrine 10 mg outside of the physician set parameter of SBP over 110 on: 03/03/2025 at 1:00 PM with BP 118/77 by RN A 03/03/2025 at 9:00 PM with BP 112/66 by LVN B 03/07/2025 at 9:00 AM with BP 119/71 and at 1:00 PM with BP 122/68 by RN A 03/09/2025 at 9:00 PM with BP 112/59 by LVN B 03/12/2025 at 1:00 PM with BP 111/65 by RN A 03/13/2025 at 1:00 PM with BP 122/67 by RN A 03/17/2025 at 1:00 PM with BP 115/62 by RN A 03/18/25 at 1:00 PM with BP 112/67 by RN A 03/21/2025 at 9:00 AM with BP 113/62 and at 1:00 PM with BP 119/61 by RN A 03/21/2025 at 9:00 PM with BP 118/77 by LVN B 03/22/2025 at 9:00 AM with BP 122/67 and at 1:00 PM with BP 111/61 by RN A 03/23/2025 at 9:00 AM with BP 113/67 by RN A 03/25/2025 at 1:00 PM with BP 115/78 by RN A In an interview on 03/26/2025 at 08:40 AM with Resident #96's NP she stated the reason for putting the parameter on the resident's SBP was to keep the Midodrine from being administered over a certain BP reading. The purpose of the medication was to elevate the BP when it was too low. The parameter was to prevent the resident's BP from going to go too high. The NP stated the resident was stable at 110. The resident had chronic low BP and was not at risk for adverse effects. The NP stated the resident was not at risk for hypertension. To prevent the medication from being administered outside parameters again she would change the SBP parameter to 130. In an observation on 03/26/2025 at 9:30 AM revealed Resident #96 was in bed with the head of her bed elevated. In a phone interview on 03/26/2025 at 9:50 AM RN A stated when she gave BP medications, she checked the BP to make sure it was alright to give. RN A stated Resident #96 was consistently low, so she gave the Midodrine to help make the BP go higher. RN A stated she would not have given the medications if the BP was over the ordered parameter. RN A stated she was not sure why she would have given it if the BP was high. In an interview with the DON and record review of the MAR on 03/26/2025 at 10:18 AM the DON stated the initials on the MAR did belong to RN A and the medication was administered. The DON stated according to the physician's order the SBP was over 110 and the medication should have been held not given. The DON stated it was given according to the MAR documentation. The DON stated she did not know why that happened. The DON stated the risk of giving the medication was it could cause hypertension. The DON stated she would begin in-servicing immediately on administering BP meds to prevent this again. In a phone interview on 03/26/2025 at 10:27 AM LVN B stated the Midodrine was not to be given if the resident's BP was over 110 systolic and he would not have given it. LVN B stated she did not know why it was given because the risk was high blood pressure. In a phone interview on 03/26/2025 at 11:27 AM the facility Pharmacist stated Midodrine was to be given for low BP to cause the BP to elevate. The Pharmacist stated the physician ordered the parameter so the resident's BP would remain in a specific set range. He stated the risk of administering the medication when the BP was above the parameter was a result of the BP being too high. In an interview with the Administrator and record review of the MAR at 03/26/2025 at 2:25 PM the Administrator stated clearly the parameter was not followed. He stated the risk was hypertension. To prevent medication from being given outside parameters again they were training the staff on medication administration. He stated they were looking at ways to highlight the parameter on the MAR for it to show better. In an interview on 03/27/2025 at 11:59 AM Unit Manager LVN C stated new nurses were trained on the unit they were hired to work on along with a trainer. The training reviewed looking at the entire order, knowing the greater than and lesser than sign. LVN C stated when a BP was outside the ordered parameter the medication was to be held. The nurse was to document it was held and why it was held such as outside ordered parameters. The risk of giving this medication was resulting in the BP going too high. LVN C stated the expectations were medications were given as ordered and document accordingly. During a follow up interview on 03/28/2025 at 9:11 AM the DON stated the unit managers were responsible for monitoring the medications were administered according to the physician's order and all medications were available daily. The DON stated the administrative team had met with the Medical Director on how to better monitor and following the MAR. 2. Record review of Resident #72's undated, face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: Type 2 Diabetes Mellitus (long term condition in which the body has trouble controlling blood), metabolic encephalopathy (Condition where the brain does not receive enough nutrients or oxygen to function properly), and chronic kidney disease, stage 3 (moderate kidney damage and loss of kidney function). Record review of Resident #72's Admission MDS assessment dated [DATE] revealed a BIMS summary score of 13, indicating the resident was cognitively intact. Record review of Resident #72's Care Plan dated 01/26/25 indicated he had a diagnosis of Diabetes Mellitus. Interventions were to give diabetes medications per order, and monitor/document for side effects and effectiveness. Record review of Resident #72's MD order on 03/26/25 revealed orders for: Insulin Glargine Solution100 UNIT/ML Inject 22 unit subcutaneously one time a day for Diabetes, hold if BS less than 120, order date 01/13/2025. Record review of Resident #72's MAR for February 2025 revealed LVN H administered 22 units of Insulin Glargine 100 UNIT/ML on 02/12/25 with a blood sugar reading of 98. Record review of Resident #72's MAR for March 2025 revealed LVN L administered 22 units of Insulin Glargine 100 UNIT/ML on 03/11/25 with a blood sugar reading of 65. In an interview on 03/26/25 at 1:39 PM Resident #72 said last month his BS went too low and he had to eat candy to bring it back up. He said that had happened once since at the facility and denied it being a regular occurrence. He said he knew when his BS was too low or too high. He denied S/S from BS being too high or the need for emergency medication or hospitalization since being admitted to the facility. In a telephone interview on 03/27/25 at 11:48 AM LVN L said she gave the resident food before administering his insulin on 03/11/25. She said she checked Resident #72's blood sugar after he ate but did not record it in the EMR. She said the risk of administering insulin out of parameters set by the MD could place Resident #72 at risk for hypoglycemia (blood sugar levels below the standard range), which could lead to coma or death. In an interview on 03/27/25 at 12: 38 PM LVN C, (unit manager) for 100 and 200 halls revealed medication administration training was conducted with a preceptor to include a check-off. He said the nurses were trained to hold insulin if the BS was not within the parameters per the MD orders. LVN C said the risk of not administering Insulin as ordered or administering too much insulin could cause hypoglycemia or hyperglycemia (blood sugar levels above the standard range), which could result in an adverse reaction or death. In an interview on 03/27/25 at 1:06 PM the ADON said if a resident's blood sugar was outside parameters, the staff should notify the MD, RP and document all interventions. She said the nurse should not give insulin outside of the MD orders because it could place the resident at risk of hypoglycemia or hyperglycemia, which could lead to possible hospitalization . In an Interview on 03/27/25 at 1:19 PM the DON said her expectations were for the nursing staff to read the resident's BS parameters and follow the MD orders. The risk of giving insulin outside the parameters could lead to hospitalization coma and/or death. The DON said if a resident had an elevated or low BS, the staff should immediately notify the MD and follow the MD orders. The DON said hypoglycemia or hyperglycemia could lead to hospitalization or death. An attempt to interview LVN H on 03/27/25 at 1:46 PM was unsuccessful. A voicemail message was provided. In an Interview on 03/27/25 at 6:00 PM the Administrator said the staff needed follow the physician's orders. He said the staff should document and notify the physician if the BS was outside the parameters. He said the risk of administering insulin outside of the physician's orders could lead to a potentially negative outcome. In a telephone interview on 03/27/25 at 6:15PM LVN H said she had on-boarding training on medication administration. She said Resident #72's blood sugar ran high and denied giving him medication when his blood sugar was recorded at 98. She denied that Resident #72 received intervention for S/S of hypoglycemia after the administration of insulin on 02/12/25. LVN H said the risk of administering medication outside of the parameters could lead to hospitalization or death. Record review of the facility's Medication Administration and Management policy revised 6/2019 reflected in part, .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: A. The Right Patient/resident, B The Right Drug, C. The Right Dose, D. The Right Time, E. The Right Route, F. The Right Charting, G. The Right Results, H. The Right Reason. 11. The authorized staff member administers SQ, IM, Intradermal medications as follows: A. Review physicians orders. B. Follow 8 Rights of Medication administration .

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were labeled and dated. 2. The facility failed to ensure that all kitchen staff were wearing a beard guard. 3. The facility failed to ensure food was safely stored in designated areas at all times. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation on 03/25/25 at 8:15 AM during the kitchen tour with the Dietary Manager revealed the following: 1. There was 1 bag of shredded cheddar cheese in the refrigerator that was open but not dated . 2. There was a 50-pound bag of flour in the kitchen's dry storage room that was not properly sealed . In an interview on 03/25/25 at 10:52 AM the Dietary Manager said food should be dated and sealed. She said the flour that she had been using was sealed in a container and the flour observed was just the extra flour that was leftover and not properly sealed. She said the risk of not properly sealing the flour could lead to insects in the flour which could lead to foodborne illnesses. Observation on 03/26/25 at 11:53 AM revealed [NAME] A not wearing a beard guard while in the kitchen. He was prepping to make mashed potatoes. In an interview on 03/26/25 at 11:59 AM the Dietary Manager said everyone with facial hair should wear a beard guard. She said the risk was hair could fall in the food, which could cause food borne illness. In an interview on 03/27/25 at 3:31 PM [NAME] A said he was supposed to wear a beard guard prior to entering the kitchen. He said the risk of not wearing a beard guard could lead to food contamination. In an interview on 03/27/25 at 3:35 PM [NAME] B said all staff with facial hair should have a beard guard. He said the last in-service on beard guards was approximately 2 weeks ago. He said the risk of not wearing a beard guard was hair could drop in the food and cause a food illness. In an interview on 03/28/25 at 10:27 AM the Administrator said his expectations was for all kitchen personnel to wear beard guards when in the kitchen. He said he had address beard guards previously, and the staff had been in-services on both beard guards and appropriated storage and labeling. The surveyor requested policy on 03/28/25 on beard guards, but the policy was not received prior to exit. Record review of the Food and Drug Administration Food Code Policy, dated 2022, read in part, .Section 2-402 Hair Restraints 2-402.11 Effectiveness.(B) FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES .

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 garbage dumpsters reviewed for disposal of garbage. The facility failed to ensure 1 of 1 dumpster lid was secured. This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents. Finding included: Observation on 03/25/25 at 8:19 AM of the facility's dumpster location revealed the dumpster lid was open with debris on the outside of the dumpster. Interview on 03/27/25 at 10:52 AM with the Dietary Manager , she said she had worked at the facility for 8 months. She said the entire facility used the dumpster, but she knew the kitchen staff were responsible for making sure the dumpster lids were closed. She said some of the staff had a hard time closing the lid on the dumpster. The Dietary Manager said they had to use a stick to open and close the dumpster lid. The Dietary Manager said if the lids were left open it could attract more rodents. Interview on 03/27/25 at 3:31PM with [NAME] A, who worked at the facility for 6 months, he said the dumpster should be always closed. He said the expectation was for the area around the dumpster to be cleaned and the dumpster lid to be closed at all times. He said rodents can get into the dumpster. Interview on 03/28/25 at 10:27 AM with the Administrator who said the dumpster should be closed. He said he was trying to get a new dumpster because it was hard to close. He said making sure the dumpster was closed had been discussed with staff on 03/17/25. He said the risk of having the dumpster open was rodents and vermin. Record review of the facility's Nutrition Services Policies and Procedures policy, revised 06/2019 revealed in part . Policy: Waste will be disposed of in a manner to prevent transmission of disease, nuisance or breeding place for insects and feeding places for rodents and other mammals. Procedure: 5 Cover waste containers and close dumpsters at all times .

Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (CR#1) of 1 resident reviewed for accidents hazards/supervision. The facility failed to prevent CR#1 from falling from his bed and sustaining a minor head injury on 08/05/24 while CNA A performed a bed bath alone even though the resident required 2-person assist. This failure could place residents at risk of harm, potential accidents, and a diminished quality of life. Findings included: Record review of CR#1's face sheet dated 1/26/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included acute and chronic respiratory failure with hypoxia, cerebral infarction (blood supply to part of the brain that is blocked or reduced), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), history of falling and functional quadriplegia (the lack of ability to use one's limbs or to ambulate due to extreme debility or frailty). Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS of 0 indicating severe cognitive impairment. Further review of the MDS indicated CR#1 had impairment on both sides of his upper and lower extremities, was dependent on staff for rolling left and right, moving from a sitting position to a lying position, toilet transfers and tub/shower transfers. Record review of CR#1's care plan dated 2/14/24 indicated he was at risk for falls and injuries related to impaired cognition and late effects of Cerebrovascular Accident (blood flow to the brain interrupted, leading to brain tissue damage), and a history of falls. Interventions included staff anticipating the resident's needs, asking for assistance from staff, universal fall precautions, and staff education on 2-person assist, which was added on 8/6/24. Further review of CR#1's care plan also indicated he was prescribed an anticoagulant for embolic stroke and was at risk for increased bleeding and bruising. Record review of the Provider Investigation Report (PIR) was submitted on 8/5/25 with allegations of Resident/Patient/Client Abuse that were inconclusive and signed by the Administrator on 8/12/24. The Provider Response section read in part .MD and family notified of the incident. Staff educated on abuse and neglect. Resident assessed for injuries . The Investigation Summary section read in part . on 8/7/24 administrator was notified by DON that CR #1 had a witness fall .family member was notified of the incident and told the facility that he was upset .family stated felt like the facility neglected CR#1 . CR #1 had a scratch above left eyebrow, neuros initiated, wound care provided, resident was sent to ER .CT results were negative . Several attempts were made to obtain the CT scan results from the hospital before exiting the facility but were unsuccessful. Record review of the CR #1's MAR for the month of August indicated Eliquis oral table 5 mg was administered via PEG-Tube every 12 hours from 8/1/24 to 8/5/24 for atrial fibrillation. Record review of CR #1's electronic health record did not reveal neuro checks documented for the resident on 8/5/24. Several attempts were made to obtain CR #1's neuro checks for 8/5/24 but were unsuccessful. Record review of progress notes on 8/5/25 entered at 9:44 am, by RN A read in part . at approximately 09:30 CNA A notified me that CR#1 had a fall and was on the floor. I began assessing the patient B/P 149/99, p 100, temp 97.3, 02 98% via trach. Patient had a 2 in laceration above left eyebrow. Neuro checks initiated, NP was notified of patient's condition and ordered a STAT CT scan post fall. Patient was transported to hospital. Patient left the facility at approximately 11:48am . Record review of the facility's investigation documents revealed a handwritten and signed statement from CNA A, dated 08/05/24. CNA A wrote, To whom it may concern .I was in the room with CR#1 this morning giving him a bed bath. He was on his left side. I was trying to pull him on his back, and he went over and fell out of the bed. I try to catch him but in the process I fell down. Record review of CNA A's timesheets for 08/01/2024-09/01/2024 revealed CNA A worked 9.25 hours on 08/05/2024, 8 hours on 08/06/2024 , 0 hours 08/07/2024-08/10/2024 and 8.5 hours on 08/11/2024. Telephone interview on 1/24/25 at 3:14 pm with CNA A, she said she worked with CR#1 often. CNA A said CR#1 was a two-person assist, total care, and non-verbal. She said at the time of the alleged incident the other aide was busy, and she thought she could handle giving the resident a bed bath by herself. She said she took the draw sheet on the left side of the resident's bed and when she tried to push him over on his side, the resident rolled off his bed onto the floor. She said CR#1 rolled out of his bed and fell because he was on the edge of his bed. She said she tried to get on the other side of the bed to catch him but in the process, she fell on the floor as she was trying to catch him. She said she immediately began calling for help from the door of the resident's room. She said the wound care nurse and the restorative aide came in the room to assist with the situation. She said did not know everything that was done for the resident after he fell , but knew he ended up being sent to the hospital. She said she knew she was supposed to have assistance from a second person with CR#1 but believed she could handle the bed bath on her own. Interview on 1/24/25 at 6:34 pm with the Administrator, she said the alleged incident was reported to HHSC by the former Administrator. She said she was not aware of the circumstances of the alleged incident. She said she was familiar with the resident and based on his size alone, for the safety of both the aide and the resident, the aide should have known better. She said all CNAs were trained on providing 2-person assists. She said if the incident had occurred while she was the administrator, she would have suspended CNA A and potentially terminated her . She said the risk could have caused a decline in the CR #1's health, or worse, death. Interview on 1/25/25 at 3:47 pm with RN A, she said she was working the day CR#1 had his fall. She said CNA A knew CR#1 was a 2-person assist. RN A said the risk to the resident with not performing a 2-person assist with CR #1 was he could have suffered from internal injuries. RN A said she assessed CR#1 when he was on the floor. She said CR #1 had one facial expression as his baseline, he was not able to communicate, and his pupils were always dilated because he had a head injury. She said CR#1 was lying on his right side and it looked like he hit his head at the base of the feeding pump pole because his eyebrow was touching the leg of the pole. RN A said CR#1 had a cut on his eyebrow which was bleeding. She said the resident's injury was small enough to have a butterfly bandage placed over the cut. RN A said she took vitals, and all vitals were within CR#1's baseline. RN A said she notified the resident's NP, DON, and unit manager. She said she texted the NP regarding the resident's fall, and the NP texted back almost immediately. She said the NP ordered a CT scan for the resident. RN A said she conducted neuro checks on CR#1 every 15 minutes the first hour after his fall and did 1 30-minute check the second hour because the resident was transported to the ER. RN A said there was a book that contained nursing documentation and should have the neuro checks. She said once the book was filled it got moved. Interview on 1/24/25 at 6:34 pm with the ADON, she said she was working the day of the alleged incident with CR#1. She was a unit manager at the time. She said she was working a different hall, so she did not know anything about what took place before or after the resident fell . She said she became aware of the incident that day because CR#1's assigned nurse, RN A, came and told her the resident fell . She said she could not remember the details RN A gave her. She said she could not remember what time of day the incident occurred or the time of day when she spoke with RN A. She said she did not know how the resident fell or what care was provided to the resident afterwards. She said all CNA's had been trained on doing 2-person assists. She said if CNA A knew CR#1 required 2-person assist for a bed bath, she should have waited until a second person was available to give the bath. She said not providing residents with adequate assistance put them at high risk but could not say exactly what the potential outcomes would be. Interview with the Nurse Practitioner on 1/27/25 at 3:57 pm she said according to her notes on 8/5/24, she was notified that CR #1 had a witnessed fall. The Nurse Practitioner said she arrived at the facility shortly after the fall. She said on her documentation, CR #1 had a scratch on the left eyebrow. The Nurse Practitioner said because CR #1 did not have hematoma or bruising, the facility did not have to call 911. She said she would have to look through her records to verify whether the resident was on an anticoagulant on 8/5/24, said she recalled getting notified and ordering a CT scan for the resident. The Nurse Practitioner could not recall if she specified the order for the CT scan as a STAT order . Said even if it was a STAT order, depending on the resident, the need for emergency medical treatment or calling 911 was subjective. The incident took place five months ago, she saw a lot of patients and could not recall the details for this specific resident. She said she could not make a determination on whether the facility should have called 911 for CR#1 on 8/5/24. Several attempts were made to obtain the CT scan results from the hospital before exiting the facility but were unsuccessful. Telephone interview with CNA A on 01/27/25 at 1:48 PM, she said she was suspended from work for 3 days due to the incident with CR#1. She said she was also in-serviced on the electronic system to access resident care plans, abuse and neglect, 2-person assists and total care residents. Record review of the facility's policy on Transfers/Lifts dated 1/2024 read in part . to ensure the safety, dignity, and well-being of residents during transfers and lifts . Hoyer lift- x2 staff members .

Based on observation, interview, and record review, the facility failed to provide to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for three of three resident hallways (B, C, D) and facility common areas reviewed for environment. 1. The facility failed to maintain two working HVAC units to distribute heat to halls B and C. 2. The facility failed to maintain temperatures in Halls B, C and D (rooms 201, 209, 211, 215, 313, 314, 315, 317, and 401) were above 71 degrees Fahrenheit (61-70 degrees Fahrenheit). An Immediate Jeopardy (IJ) was identified on 1/10/2025. The I.J. template was provided to the facility on [DATE] at 5:14 p.m. While the IJ was removed on 1/15/2025, the facility remained out of compliance at a scope of widespread with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . These deficient practices could place residents at risk of living in an unsafe, uncomfortable environment and decreased quality of life due. Findings included: Observations on 1/10/2025 at 12:08 p.m. - 1:24 p.m., revealed rooms on B and C halls had cold air blowing from the vents. Hallways B, C, D and the common area temperatures reflected the following (temperatures taken by the Acting Maintenance Dir .): o Hall B thermostat - 64 degrees Fahrenheit o Hall B common area - 57 degrees Fahrenheit o room [ROOM NUMBER] - 65 degrees Fahrenheit o room [ROOM NUMBER] - 67 degrees Fahrenheit o room [ROOM NUMBER] - 68 degrees Fahrenheit o room [ROOM NUMBER] - 65 degrees Fahrenheit o Hall C thermostat - 69 degrees Fahrenheit o room [ROOM NUMBER] - 66 degrees Fahrenheit o room [ROOM NUMBER] - 71 degrees Fahrenheit o room [ROOM NUMBER] - 65 degrees Fahrenheit o room [ROOM NUMBER] - 66 degrees Fahrenheit o Hall D thermostat - 70 degrees Fahrenheit o Hall D common area - 61 degrees Fahrenheit o room [ROOM NUMBER] - 62 degrees Fahrenheit Record review of Outside temperature reflected the following - 1/9/25 low 37 degrees - high 41 degrees 1/10/25 low 37 degrees - high 43 degrees 1/11/25 low 33 degrees - high 41 degrees 1/12/25 low 41 degrees - high 51 degrees 1/13/25 low 39 degrees - high 53 degrees 1/14/25 low 39 degrees - high 52 degrees Interview on 1/10/2025 at 12:10 p.m., the Acting Maintenance Dir. said the heating system was not working properly and had been in and out within the past week. She said the HVAC vendor came out to the facility on [DATE]. She said the ADMIN and DON were aware the vendor came out and repairs were needed to the heating unit. She said it was not clear to her the unit was not blowing heat, and she assumed the repairs that were needed was not related to the HVAC system not blowing heat. She said there was a part that needed to be ordered. She said rooms were cold and the air was blowing cold without heat. She said Maintenance A had been checking the temperatures on the halls, but not in the resident rooms. She said she had not been instructed to place portable heaters throughout the facility . Interview and observation on 1/10/2025 at 12:15 p.m. revealed Resident #1 told the ADMIN he was cold. Resident #1 was in bed with a blanket over him . Resident #1 said he was cold, and the blankets were not enough to keep him wrong. Interview and observation on 1/101/2025 at 12:36 p.m., Resident #2 said he was cold. He was observed shivering. Resident #2 had one blanket that covered his waist down. The vent in the room was closed but blowing cold air which could be felt (68 degree Fahrenheit) (temperatures taken by the Acting Maintenance Dir.). The vent was directed toward Residents #2 and #5 head. Interview on 1/10/2025 at 1:17 p.m., Resident #3 said cold air was coming from the vent in his room (62 -64 degrees Fahrenheit - room [ROOM NUMBER] ) (temperatures taken by the facility staff). Resident #3 had on a sweater and jeans. He had a thin blanket on his bed . Interview on 1/10/2025 at 12:45 p.m., the ADMIN said the HVAC vendor was out to the facility on the 1/7/2025 to attempt to make repairs. She said 1/6/2024 was her first full day in the facility since she started on 12/20/2025. She said she was not told cold air was being blown through the vents. She said she instructed Maintenance A to update her when the temperatures fell below 72 degrees in the facility on 1/7/2025. The ADMIN said she was told by Maintenance A and the Acting Maintenance Dir. the temperatures had not fallen below 72 degrees. She said she was told in the morning meeting (approximately 9:00 a.m. on 1/10/2025) by a staff who performed angel rounds (routine rounds to check on residents), the rooms were cold. She said she had not checked the temperatures on the halls or checked how the temperatures felt in the residents' rooms of halls B and C because she was told the temperatures had not fallen below 72 degrees She said there were parts needed to repair the HVAC system. She said she was informed the HVAC system was in and out by Maintenance A and the Acting Maintenance Dir. She said because she had not been in the building full time and was not aware the HVAC heating system was not functioning properly. Interview on 1/10/2025 at 1:17 p.m., Maintenance A said the HVAC system on B and C hall was in and out for a few weeks. He said he was told to take the temperatures and let the ADMIN know if it fell below 72 degrees. He said he did not check the resident rooms or the vents. He said the HVAC vendor came out on 1/7/2025 and he needed to order parts. He said the parts would be in on 1/12/2025. He said the facility was not allowed to put in portable heaters. He said he had not turned off the HVAC unit from blowing cold air. He said the heat was not working. Interview on 1/10/2025 at 1:47 p.m., the ADMIN said she needed to contact the HVAC vendor and get an update on what repairs were needed. She said she would have to contact her corporate management and request portable industrial heaters, since the current units were not blowing heat. Interview on 1/10/2025 at 2:42 p.m., the DON said cold temperatures and residents shivering would indicate the environment was not comfortable. She said she had not instructed the nursing staff to monitor room temperatures or signs and symptoms related to the cold temperatures. She said the resident rooms were cold but she was not aware prior to surveyor intervention. Interview on 1/10/2025 at 3:19 p.m., the ADMIN said the HVAC vendor closed the vents on 1/7/2025 when the temperatures dropped outside in order to stop the cold air that was blowing from the HVAC system. She said they thought by closing the vents it would prevent the room temperatures from dropping even further. She said the facility had approximately 8-10 small heaters that could be used in resident rooms. Interview on 1/10/2025 at 5:01 p.m., the ADMIN said the HVAC vendor needed to secure an electrician because two relays (mechanisms that turn a unit on and off when it reaches a certain temperature) needed to be installed on Hall B. She said this would take about 10-15 minutes to install. Observation on 1/10/2025 at 5:30 p.m. revealed the room temperatures for Hall B (B5, B7 - thermostats) was 67 degrees Fahrenheit and 64 degrees Fahrenheit (temperatures taken by the facility staff). Record review of the facility's policy Emergency Preparedness - Loss of Heating Element (revised date 11/20/2024) revealed the following: Policy - Emergency Preparedness - Loss of Heating Element Policies and Procedures Policy The Facility will ensure the safety and comfort of residents, staff, and visitors in the event of heating system failure, this policy provides guidelines to maintain safe indoor temperatures and minimize risks during cold conditions. Procedure I. Initial Response: Notify the Maintenance Director and Administrator immediately. Contact a licensed HVAC professional to assess and repair the heating system. Ensure the repair company can respond promptly and is familiar with the facility's equipment. 2. Temperature Monitoring: Begin routinely monitoring and recording indoor temperatures in all resident rooms and common areas. 3. Resident Safety and Comfort: Provide residents with extra clothing, blankets, and thermal wear as needed. Relocate residents to warmer areas of the facility if temperatures become unsafe in their rooms. Distribute portable heating elements to maintain comfort in common areas and resident rooms, following fire safety guidelines. 4. Resident Assessment and Monitoring: Nursing staff will assess residents for signs of hypothermia or cold stress as indicated. Increase fluid intake and provide warm beverages or meals, ensuring dietary needs are met. Notify the resident's physician if a resident shows signs of cold-related health concerns. 5. Staff Coordination: Assign additional staff to assist with monitoring residents and maintaining communication with families. Provide staff with clear instructions on their roles and expectations during the event. 6. Communication: Notify residents, families, and responsible parties about the heating issue and actions being taken. 7. Regulatory Compliance: Self-Report Heating Element Loss. Maintain all documentation, including repair logs, temperature records, resident assessments, and communication efforts, for survey readiness . An IJ was identified on 1/10/2025. The IJ template was provided to the Administrator and the DON on 1/10/2025 at 5:14 p.m. The following Plan of Removal submitted by the facility was accepted on 1/11/2025 at 7:48 p.m.: PLAN OF REMOVAL Name of facility: [Facility] Date: 01/10/2025 According to the IJ Template the facility failed to ensure to maintain safe and comfortable temperatures throughout the building when heating units were not functioning for 3 days. Immediate Action Taken 1. On 01/10/2025 DON assessed Residents #1, #2, #3, #4 affected by the uncomfortable temperature and were provided extra blankets and nursing added layers of clothing on affected residents. Residents were offered to be taken to the dining room where the HVAC is operating. Nursing staff immediately began monitoring resident's vitals, temperature, and any other cold-related health concerns. MD was notified and no new orders were given. 2. DON assessed 100% of the residents and identified that no other residents were to be at risk. 01/10/2025. 3. On 01/10/2025 facility purchased anti-tip portal heaters HVAC vendor was contacted to request industrial portable heaters. On 01/10/2025 HVAC vendor arrived and installed 4 industrial portable heaters to compensate for the HVAC failure and will remain in place until HVAC is repaired. 4. On 1/10/25 the administrator and maintenance supervisor routinely rechecked temperatures on Hall B 72, Hall C 70, Hall D 75, room [ROOM NUMBER] room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Common Area B, room [ROOM NUMBER], room [ROOM NUMBER] and readjusted the temporary HVAC unit until the temperatures reached 71 degrees. On 01/11/2025 temp was 71 degrees. The maintenance director/trained designee will conduct the temperature checks every 2 hours and make adjustment to the temporary heating unit as needed until HVAC is fixed. The administrator will oversee the temperature log for accuracy. 5. On 01/10/2025 a regional contractor assessed the HVAC unit and determined the heater exchange was not functioning, and on 01/11/2025 a certified HVAC specialist conducted a follow-up assessment. Contractor revealed transmitter conductor was not connected. When contractor connected the conductor the HVAC unit started working and hot air started blowing out in the front section of Hall B. The shorter section of Hall B and Hall C require a higher voltage electric wire, requiring electrician to install and then heater exchanger needs to be installed. On 01/13/25 electrician will come to the facility to connect the higher voltage that is required on hallway B and C. 01/13/2025 is the anticipated repair date for when the heater exchange needs to be installed and when the contractor connected the conductor. Facilities [sic] Plan to ensure compliance quickly 1. On 01/10/2025 Administrator and DON reviewed Policies and Procedures for Emergency Preparedness on Loss of Heating Element which will include Educating Staff on Initial Response, How to Monitor Temperature, Ensuring Resident Safety and Comfort, Completing Resident Assessment and Monitoring, Staffing Coordination, Notifying families, and Regulatory Compliance. No change was needed. 2. On 01/10/2025 the Regional Nurse Consultant educated DON and Administrator on emergency preparedness- loss of heating element- topics to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance. 3. On 1/10/25 The Administrator and DON educated all staff on emergency preparedness heating elements to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance, and reporting failure of HVAC system and temperatures outside of normal range to administrator immediately. Staff will receive education before start of their next shift and new hires will receive education at orientation. Completion date 1/11/25. 4. On 1/10/25 The Administrator educated the Acting Maintenance Director on routine temperature check for HVAC failure and reporting temperature outside of normal range. Educated to also include emergency preparedness heating elements. Completion date 1/10/25. On 01/10/2025 Administrator and DON completed an Ahoc QAPI with Medical Director regarding the Immediate Jeopardy the facility received related to the F921: Safe/Functional/Sanitary/Comfortable/Environment and reviewed plan to sustain compliance. Monitoring of the plan of removal included the following: Observation on 1/11/2025 at 7:58 p.m. revealed temporary industrial heating units were being utilized on Units B (2 industrial heaters), Main common area (1 industrial heater), and Unit C (1 industrial heater). Parts of Unit B and Unit C had temperatures below 72 degrees Fahrenheit (Thermostat B7 on Unit B was 68 degrees Fahrenheit, room [ROOM NUMBER] was 71 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] was 69 degrees Fahrenheit, Unit C - room [ROOM NUMBER] was 66 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] was 66 degrees Fahrenheit, room [ROOM NUMBER] was 67 degrees Fahrenheit, and room [ROOM NUMBER] was 66 degrees Fahrenheit). Residents were observed to have blankets, appropriate clothing, and small heaters (specific rooms and common areas). Observations on 1/11/2025 at 8:00 p.m. revealed signs posted at all nursing stations revealed Monitor Resident For: Shivering, Numbness, Change of Skin Color, Decreased Temperature, and Dry Mucus Membranes. Observations on 1/12/2025 - 1/15/2025 revealed temporary industrial heating units were being utilized on Units B (2 industrial heaters), Main common area (1 industrial heater), and Unit C (1 industrial heater) remained in use until the 2 HVAC units were repaired and the heater for Units B and C were able to maintain a temperature above 71 degrees Fahrenheit. Observation and interview on 1/11/2025 at 8:15 p.m. revealed Resident #1 in bed with two blankets over him. He said he was warm. Resident #1 had a small portable heater in the room and the temperature was 76 degrees Fahrenheit. Observation and interview on 1/11/2025 at 8:19 p.m. revealed Resident #2 had a small portable heater in his room. He said the small heater made a difference, and he was no longer shivering. The temperature was 71 degrees Fahrenheit. Observation on 1/12/2025 at 5:40 p.m. of Resident #3 and Resident #4's room revealed the temperature was 74 degrees Fahrenheit. Observation on 1/13/2025 at 10:06 a.m. revealed temperatures in the common areas, resident room ranged from 67 -78 degrees Fahrenheit. Observation on 1/14/2025 at 3:53 p.m. revealed temperatures in the facility ranged from 73-85 degrees Fahrenheit on Halls A, B, C, and D. Observation on 1/15/2025 at 10:35 p.m. revealed temperatures in the facility ranged from 73-75 degrees Fahrenheit on Halls A, B, C, and D. Interviews were conducted on 1/11/2025 - 1/14/2025 with staff on all shifts RN A, RN B, RN C (day), RN D, LVN B (night) - (Nurses 6:00 a.m. - 6:00 p.m., 6:00 p.m. - 6:00 a.m.), CNA A, CNA B, CMA A (day), CNA C, CNA D (night), CNA E , CNA F (morning)- (6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. - 6:00 a.m.), the DON, ADON, ADMIN, Maintenance A, Maintenance Dir., Former Acting Maintenance Dir., HK Supervisor, and Activity Director to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding related to emergency preparedness heating elements to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance, and reporting failure of HVAC system and temperatures outside of normal range to administrator immediately . Nursing staff reported they monitored residents hourly, checked for signs and symptoms of hypothermia (condition of having a lower body temperature than normal) like shivering, skin color, numbness, offered. Interview on 1/12/2025 at 5:25 p.m., Resident #6 said she did not have any complaints and the nursing staff came into her room to ensure she was comfortable, warm and they checked her vitals. Interview on 1/14/2025 at 3:28 p.m., Maintenance A said the 2 new HVAC units were installed, wired and the appropriate breaker to support the wattage was installed. He said he would begin to open the vents in rooms to ensure the warm air was flowing. He said the temperature was set high but would adjust the temperature to an appropriate level. Record review of the facility's document Ad Hoc QAPI dated 1/10/2025 revealed the following in part: On 01/10/2025 [Facility] to ensure to maintain safe and comfortable temperatures throughout the building when heating units were not functioning for 3 days. Root Cause Analysis: Inclement weather with outside temperatures as low as 38 degrees and high 50 degrees. On 01/10/2025 residents observed to cold due to vent blowing cold air Record review of nurses' notes and vitals dated 1/10/2025 - 1/15/2025, for all affected residents revealed nurses documented monitoring of resident vitals which included resident temperatures were within normal range. Record review of the facility's Temperature logs, dated 1/10/2025 - 1/15/2025, revealed all halls (including Hall B 72, Hall C 70, Hall D 75 (thermostat), room [ROOM NUMBER] room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Common Area B, room [ROOM NUMBER], room [ROOM NUMBER]) temperatures were monitored hourly until the two HVAC heating units were repaired. Record review of the facility's Education In-Service Attendance Record - Monitoring Temperatures, dated 1/10/2025, by the ADMIN to the HK Supervisor, Maintenance A, and HK A. Summary of training session - Monitor temperature on specified hallways and keep updated logs of monitoring. Notify [ADMIN] [phone number] of any temperature less than 72 degrees Fahrenheit. Record review of the facility's Education In-Service Attendance Record - Emergency Preparedness - Loss of Heating Element, dated 1/10/2025 by RNC to the DON and ADMIN. Record review of the facility's receipt, dated 1/11/2025, for 21 additional blankets. Observation on 1/11/2025 at 7:58 p.m. revealed temporary industrial heating units were being utilized on Units B (2 industrial heaters), Main common area (1 industrial heater), and Unit C (1 industrial heater). Parts of Unit B and Unit C had temperatures below 72 degrees Fahrenheit (Thermostat B7 on Unit B was 68 degrees Fahrenheit, room [ROOM NUMBER] was 71 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] was 69 degrees Fahrenheit, Unit C - room [ROOM NUMBER] was 66 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] was 66 degrees Fahrenheit, room [ROOM NUMBER] was 67 degrees Fahrenheit, and room [ROOM NUMBER] was 66 degrees Fahrenheit). Residents were observed to have blankets, appropriate clothing, and small heaters (specific rooms and common areas). Record review of the facility's email written by the ADMIN, dated 1/13/2025 at 1:53 p.m., in response to the question if there was an update on repairs revealed the following: Yes, just now. Corporate has approved full installation on HVAC units for B, C Hall. This is in addition to the work getting done today. Full installation should be completed today. The goal is to have a fully functional system with zero space heaters and auxiliary heaters in the facility. Record review of HVAC vendor email, dated 1/10/2025 at 5:52 p.m. revealed the following: Upon thorough assessment of the system, it was determined that specific parts were required to address the identified issues. These parts were promptly ordered on January 7, 2025. The scheduled installation of the ordered parts is planned for January 12, 2025, to ensure the HVAC system is restored to proper working condition Record review of HVAC vendor email (dated 1/11/2025 at 4:18 p.m.) revealed the following: I am writing to provide an update on the measures we have taken to address the heating issues at [Facility, located at [Facility Address] On 01/11/2025, I dispatched an HVAC technician to assess and service the two malfunctioning heating units. While the technician was able to keep the units operational, they are not currently functioning at full capacity. To mitigate the impact on the affected areas, we delivered Four 1.25-ton portable .heat pump units yesterday and placed them in the hallways needing supplemental heat. Additionally, this morning, we delivered five more portable heaters, strategically placing them in the affected areas to ensure warmth throughout the facility. This afternoon, the HVAC technician returned to inspect the units again to confirm they are still providing some heat. I will continue to send the technician daily to monitor and maintain the heating units as best as possible while repairs are underway. Furthermore, the portable heaters will remain in place until the issue with the heating units is fully resolved The Administrator was informed the Immediate Jeopardy was removed on 1/15/2025 at 4:13 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 jeopardy and a scope of widespread due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 5 residents (CR #1) whose assessments were reviewed, in that: CR#1's admission weight was not accurate on the initial MDS dated [DATE]. CR#1's significant weight loss was not reflected on her quarterly MDS dated [DATE]. This failure could place residents at-risk for weight loss for not receiving the care and services to increase weight loss due to inaccurate assessments. Findings Included: Record review of CR#1's face sheet, dated 10/15/2024, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included hypotension (low blood pressure), unspecified intestinal obstruction(blockage of part of the small or large intestine), hypertension (high blood pressure), multiple myeloma not having achieved remission (type of white blood cell that becomes cancerous and multiplies), vascular dementia (memory loss), mild protein calorie malnutrition (diet lacking in protein and starch), dysphagia oral phase (difficulty speaking), cognitive communication (difficulty communication because of brain injury) and anxiety (worry and fear). Record review of CR#1's weight record at the facility revealed the following weights were taken: Admission weight was 4/12/2024: 99.0 lbs Weekly weights were 4/19/2024: 96.4, 4/26/2024: 100.00 lbs., 5/01/2024: 99.3 lbs., 5/03/2024: 101.3 lbs., 5/10/2024: 101.0 lbs. , 6/02/2024: 98.0 lbs., 7/03/2024: 97.7 lbs., 8/01/2024: 89.6 lbs., 8/30/2024: 100.0 lbs., 9/05/2024: 90.4 lbs., 9/27/2024: 80.1 lbs, 10/01/2024: 80.4 lbs, 10/02/2024: 81.1 and 10/09/2024; 78.04 lbs. Further record review revealed a weight loss of 7.9 % between 7/03/2024 97.7 lbs. and 8/01/2024 89.6 lbs. Record review of the hospital discharge report dated 4/12/2024 for CR#1 revealed that on 4/07/2024 the resident weighed 54.3 kg which was equal to 119.46 lbs. Record review of CR #1's admission MDS, dated [DATE], revealed her BIMS score was 07 of 15 reflecting she had moderate cognitive impairment. Further record review of CR #1's Admission MDS Section K0200 revealed a weight of 119 pounds, K0300 coded as no or unknown weight loss. Review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score was 07 of 15 reflecting the resident had moderate cognitive impairment. Further review revealed K0200 a weight of 119 lbs, and K0300 revealed no or unknown weight loss. Review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score was 07 of 15 reflecting the resident had moderate cognitive impairment. Further review reveald K0200 a weight of 119 lbs, and K0300 no or unknown weight loss. Interview on 10/15/2024 at 3.00pm with LVN-A regarding the MDS for CR #1, she said they did not have a MDS nurse. She said the MDS nurse who did CR#1's MDS was no longer working at the facility. She said she was the Unit Manage and stated CR #1 had some weight loss. She said the dietitian had evaluated the resident. She was eating and was receiving supplements while she was at the facility. She then looked at the facility's weight records and compare it with the hospital recorded weight and said the MDS nurse must have gotten the 119 pounds recorded on the initial MDS from the hospital report because the initial weight at the facility was 99.0 lbs. She further stated that the resident weight loss at the facility's was gradual weight loss. At that point she agreed that the weight on the initial and quarterly MDSs were not accurate. She said the MDS persons should have checked the facility's weight records on admission and document on the initial MDS. She said if she was not sure of the resident's weigh she should reweigh the resident. Interview on 10/15/2024 at 4.03 p.m. with the DON, she said they did not currently have a MDS nurse. She said she was new to the facility and was working on MDS and care plan issues. She acknowledged that CR#1's MDS's weights were not accurate. She said they recognized that they had issues with MDSs and would be addressing the issues as soon as the new MDS nurse got on board. She said they would have to make corrections to the MDS to reflect the resident's admission weight. Further interview with the DON revealed that the expectation of the MDS nurse was to physically assessed residents, observe residents, weigh residents, interview staff and residents and conduct a complete assessment before documenting on the MDS. Record review of the facility's Nursing Policies and Procedures dated 06/2019 revealed in part, . Subject Minimum Data Set Policy: It is the policy of this facility that a registered nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS which is a comprehensive, accurate, standardized reproducible assessment will be completed on each resident using the RAI process. Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals. Life history, and preferences and other guidance for further assessment once problems have been identified. Procedures: 1. Review resident records. 2. If a CAA is triggered, the facility will further assess the resident to determine if the resident is at risk. 3. Interview, observe and physically assess the resident to obtain validation of items identified on the medical record and to collect information for items where no documentation exists. 9. Each assessment must represent an accurate picture of the resident status during the observation period of the MDS.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking. 1. The facility failed to secure smoking paraphernalia and supervise smoking for Resident #1, who was paralyzed on one side and had a known history of dropping cigarettes which resulted in multiple burn holes in his clothing and the armrest of his wheelchair. 2. The facility failed to secure smoking paraphernalia and supervise smoking for Resident #2 and Resident #3, who were known to have unsafe smoking habits and were either prescribed oxygen or had a roommate who was prescribed oxygen. An Immediate Jeopardy (IJ) was identified on 02/03/2024 at 8:33 a.m. The IJ template was provided to the facility on [DATE] at 8:33 a.m. While the IJ was removed on 02/04/2024, the facility remained out of compliance at a scope of pattern 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 placed smoking residents and their roommates at risk of serious harm/injury from possible accidental cigarette burns and fires from lighter/oxygen ignition. Findings included: Resident #1 Record review of Resident #1's face sheet dated 02/02/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with diabetes (a chronic health condition that affects how the body turns food into energy; too much sugar in the blood), acute kidney failure (when the kidneys suddenly cannot filter waste from the blood), acute respiratory failure (when the blood does not have enough oxygen or has too much carbon dioxide), vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), generalized muscle weakness (muscle weakness due to a chronic condition or infection), aphasia (a disorder that affects how you communicate/speak), seizures (a sudden, uncontrolled burst of electrical activity in the brain), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted flow to the brain; ischemic stroke) affecting left non-dominant side, and traumatic subdural hemorrhage (a pool of blood between the brain and the outermost covering) with loss of consciousness. Record review of Resident #1's quarterly MDS dated [DATE] revealed he had unclear speech/slurred or mumbled words; he had impaired vision - saw large print, but not regular print in newspaper/books; he had a BIMS score of 4 (severe cognitive impairment); he had functional limitation in range of motion on one side (upper and lower extremity); he was wheelchair bound; he required setup or clean-up assistance with eating; he required supervision or touching assistance with oral hygiene; he required partial/moderate assistance with upper body dressing; he required substantial/maximal assistance with toileting hygiene, bathing, lower body dressing, and personal hygiene; and he was always incontinent of bowel and bladder. Record review of Resident #1's care plan revised 12/12/2023 revealed the following care areas: * Smoking: Resident #1 had a potential for injury related to smoking. He was evaluated to be a safe smoker. His family preferred the facility to keep his cigarettes for him. Resident #1 had impaired cognition related to dementia and encephalopathy (a broad term for any brain disease that alters brain function or structure). Revised 12/01/2023. Goal included: Resident #1's risk for injury and danger to himself and the environment related to smoking in his room, will be minimized with interventions. Interventions included: Evaluation for assistive devices as indicated. Inform resident of facility's smoking policy and potential consequences of noncompliance. Orient to designated smoking area(s). Provide information and education in smoking cessation options as indicated. Reinforce to Resident #1 that smoking is not permitted in rooms, only in designated areas. Smoking apron if indicated. Smoking assessment upon admission, quarterly, annually, and significant change. Smoking material to be maintained by staff if indicated. Supervised Smoker (Date initiated 06/23/2023). * Resident #1 had difficulty with communication related to chronic aphasia, late effects of CVA (stroke). Goal included: Resident #1 will communicate basic needs over the next 90 days. Interventions included: Allow resident time to communicate needs. Approach in a calm manner. Praise resident for all efforts to communicate. Provide writing tablet for resident to communicate with staff. Speech Therapy referral as needed. * ADL self-care deficits: Resident #1 had ADL self-care deficits related to muscle weakness, deconditioning, and dementia. He was at risk for further decline in ADL functioning and injury. Goal included: will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide assistance for ambulation per therapy orders. Provide encouragement and cueing as needed to performed ADL cares. Provide extensive assist x1 for eating. Provide extensive assist x1 for personal hygiene/grooming. Provide extensive assist x1 for upper/lower body dressing. Provide extensive assist x2 for bed mobility. Provide extensive assist x2 for toileting/incontinent care. Provide privacy and maintain dignity. Provide total assist x1 for bathing. Provide total assist x1 for locomotion on/off unit. Provide total assist x2 for transfers. * Dementia: Resident #1 has a diagnosis of vascular dementia and metabolic encephalopathy, and is at risk for increased confusion and decline in ADLs as the diseases progress. Goal included: Resident #1's needs will be anticipated and met by staff. Interventions included: Administer medication(s) as ordered by MD. Assist resident with ADLs as needed. Re-assure resident when confusion has increased. Re-orient resident daily as needed. Verbal reminders and cues to assist resident with daily orientation. Record review of Resident #1's, Resident Smoking Behavior Contract dated and signed by Resident #1 on 08/01/2022 revealed, . I understand that I must follow each and every rule governing smoking and should I violate even one rule, even one time, I am aware that the facility may temporarily suspend, revoke, and/or initiate discharge proceedings and I will not be allowed to live in this building . I agree to only soke in the designated area. I agree that, if my assessment shows I need assistance, I will only smoke at the designated times, unless with my family. I agree that, if my assessment shows I need assistance, I am not allowed to have in my possession and must permit the facility to store smoking materials (cigarettes, tobacco, rolling papers, lighters, matches) . I will smoke carefully to minimize risk for burning my clothes or fingers (or any other person). I know that careless smoking will cause my privileges to be suspended. I agree to allow staff to check/search my room for contraband (such as hidden cigarettes, lighters, and matches) at staff discretion Record review of Resident #1's, Smoking Safety Screen dated 07/05/2023 (the name of the staff who completed the assessment was not listed on the document) revealed, 1. Does resident have cognitive loss? (Yes) 2. Does resident have any visual deficits? (Yes) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (No) 7. Resident Need for Adaptive Equipment - Supervision . 8. Resident Requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) . 8c. Resident is safe to smoke independently and to store own smoking materials? (No) . Resident #1 wants to smoke more than the designated smoking times. He can become very angry if not given the opportunity to smoke his cigarette. He has good ability to understand others however due to his dementia, his speech is not clear. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: Resident #1 is safe to smoke with supervision. Resident #1 does not like to be supervised and will go out on pass or go out in order to find cigarettes. This is another reason he is an unsafe smoker. Record review of Resident #1's, Smoking Safety Screen dated 12/01/2023, competed by the Activity Director revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (Yes) 7. Resident Need for Adaptive Equipment - (Nothing was checked) . 8. Resident Requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) . 8c. Resident is safe to smoke independently and to store own smoking materials? (No) . Resident can smoke safely without supervision but per the family request, they would like for the facility to store his cigarettes. 2. Team Decision: Safe to smoke without supervision. 3. Rationale/conditions: Resident #1 can smoke safely without supervision but per the family request, they would like for the facility to store his cigarettes. Observation of Resident #1 on 02/02/2024 at 10:00 a.m. revealed he was alert and self-ambulated via wheelchair. Resident #1's left arm and leg were immobile (due to cerebral infarction). Resident #1 was outside in the courtyard smoking a cigarette with Resident #2, Resident #3, and several other residents. No staff were observed outside with the residents for approximately eight minutes until the Activity Assistant went outside. Observation and interview with Resident #1 on 02/02/2024 at 11:30 a.m. revealed he was outside in the courtyard smoking a cigarette unsupervised. Resident #1's speech was slurred, and he also communicated by shaking his head and making other gestures. Resident #1's left arm/hand rested in his lap. The left armrest of his wheelchair was wide and was covered with a black, soft cushion. The cushion had 7-8 holes (the orange-colored foam of the cushion could be seen through the holes) of varied sizes with the largest approximately dime-sized. Resident #1 stated he was allowed to keep his own cigarettes and lighters in a small bag which was hanging from his neck. He stated the facility's staff allowed him to go outside to the smoking area alone as he pleased. He indicated, by holding up his lit cigarette when asked what caused the holes on his armrest, the holes in the cushion of his armrest were caused by cigarettes. Resident #1 demonstrated how he placed lit cigarettes on the cushioned armrest while he reached for his bottle of water which was located on the section of the cushioned armrest behind the lit cigarette, opened it, and drank from it all with his right hand. Resident #1 stretched out the left sleeve of his jacket with his right hand and pointed out 4-6 holes. He indicated the holes on his jacket were caused when the lit cigarettes fell from the cushioned armrest, onto his jacket. He indicated when the lit cigarettes fell from the armrest onto his jacket, he brushed the cigarettes down to the ground with his right hand. He stated that happened multiple times with at least one recent incident (he could not say when the incident occurred). He stated he sometimes burned himself when the cigarettes fell on to his clothes, but he did not have any visible skin injuries. Observation of Resident #1's arm at that time revealed no skin injuries. He stated his clothes never caught on fire and he got scared when the cigarettes fell on to his clothes, but he never reported the incidents to staff. Further review of Resident #1's care plan, revised 12/12/2023, revealed no plan or interventions regarding the burn holes in his clothes or the armrest of his wheelchair. Resident #2 Record review of Resident #2's face sheet dated 02/02/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with hypertensive heart disease (changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), acute and chronic respiratory failure with hypoxia (sudden respiratory failure and over time; when you do not have enough oxygen in your blood), and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease affecting right dominant side. Record review of Resident #2's admission MDS dated [DATE] revealed she had a BIMS score of 7 (severe cognitive impairment); she had upper extremity impairment on one side and bilateral (both sides) lower extremity impairments; she ambulated via wheelchair; she required partial/moderate assistance with toileting hygiene, bathing, upper body dressing, and lower body dressing; and she was frequently incontinent of bowel and bladder. Record review of Resident #2's care plan revised on 02/01/2024 revealed the following care areas: * Resident #2 has episodes of inappropriate behaviors and is at risk for further increased episodes and injury as evidenced by: 1) Refusal of Care. 2) Requesting to smoke outside of designated smoking times. 3) Agitation (yelling/hitting walls). Goal included: episodes of inappropriate behaviors will be reduced no more than 2 episodes weekly and will be free from injury. Interventions included: Encourage to attend social activities of preference. Observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli. Provide psych consult as ordered. * SMOKING: Resident #2 has a potential for injury related to smoking. Goal included: Resident #2's risk for injury related to smoking will be minimized with interventions. Interventions included: Evaluation for assistive devices as indicated. Inform resident of facility's smoking policy and potential consequences of noncompliance. Orient to designated smoking area(s). Provide information and education in smoking cessation options as indicated. * COGNITIVE IMPAIRMENT: Resident #2 has impaired cognition and is at risk for further decline and injury. Goal included: Resident #2's needs will be met, and dignity maintained. Interventions included: Allow time for tasks and responses. Explain all procedures using terms gestures the resident can understand. Involve in care to maintain or increase level of independence. Praise for tasks the resident completes. Repeat information as needed. * SHORTNESS OF BREATH: Resident #2 is at risk for respiratory distress/failure and increased episodes of SOB related to COPD (disease that causes airflow blockage and breathing-related problems) and history of acute/chronic respiratory failure. Goal included: Resident #2 will be free from any respiratory distress/failure and will have minimal/no further episodes of shortness of breath. Interventions included: Allow breaks when performing tasks - do not rush. Apply O2 per order - encourage to take slow, deep breaths. Check pulse oximetry as ordered. Minimize stress/anxiety - allow to verbalize feelings when appropriate. Observe for s/sx of respiratory infection - report any noted to MD. Provide respiratory treatments as ordered - observe for signs of relief from SOB. * ADL SELF CARE DEFCITS: Resident #2 has ADL self-care deficits related to muscle weakness, history of CVA with right hemiplegia, and is at risk for further decline in ADL functioning and injury. Goal included: Resident #2 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Anticipate needs - provide prompt assistance. Encourage independent function as able. Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide encouragement and cueing as needed to performed ADL cares. Provide privacy and maintain dignity. Record review on 02/03/2024 at 10:35 a.m. of Resident #2's Clinical Physician Orders for February 2024 revealed the following order: * Oxygen @ 2-3 LPM via nasal cannula continuously while in room. Monitor O2 saturation. Every shift. Start Date: 02/02/2024. Revision Date: 02/02/2024 at 6:00 p.m. (while in room was added to the order) Record review on 02/02/2024 at 3:07 p.m. of Resident #2's MAR for February 2024 revealed: * Oxygen @ 2-3 LPM via nasal cannula continuously. Monitor O2 saturation every shift. Order Date: 01/24/2024. The order was followed on 02/01/2024 and 02/02/2024. Observation of Resident #2 on 02/02/2024 at 10:00 a.m. revealed she was outside in the courtyard smoking unsupervised with Resident #1, Resident #3, and several other residents without an apron on. Record review of Resident #2's Smoking Safety Screen dated 02/02/2024 at 10:30 a.m. revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (No) . Safety: 6. Can resident light own cigarette? (Yes) 6a. Does the resident or the resident's roommate use oxygen? (Yes) . 8. Resident requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) 8b. Resident is safe to smoke independently but resident/roommate uses oxygen and needs facility to store lighter and cigarettes? (No) . Resident #2 is safe to smoke without supervision however, she uses O2 and needs the facility to store smoking material. Team Decision: safe to smoke without supervision. Rationale/conditions: Resident #2 is safe to smoke without supervision however, she uses O2 and needs the facility to store smoking material. Observation and interview with Resident #2 on 02/02/2024 at 1:15 p.m. revealed she was outside smoking unsupervised with several other resident. Resident #2 was alert and self-ambulated via wheelchair. Resident #2 stated she kept her own cigarettes and lighters and held up a white plastic shopping bag where her smoking supplies were stored. Resident #2's left hand was in a black splint. She stated she was admitted to the facility two months ago and the facility's staff allowed her to go outside and smoke unsupervised whenever she wanted to. She said she was on oxygen, and she knew how to operate her own tank/concentrator when she returned to her room. Resident #2 stated she never smoked around oxygen, dropped cigarettes, or sustained burn holes in her clothes. Resident #3 Record review of Resident #3's face sheet dated 02/04/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with cerebral aneurysm (a weakness in a blood vessel in the brain that balloons and fills with blood), epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures), benign neoplasm of the brain (non-cancerous mass of cells that grow relatively slow in the brain), and vascular dementia (brain damage caused by multiple strokes). Record review of Resident #3's quarterly MDS dated [DATE] revealed she had a BIMS score of 8 (moderate cognitive impairment); she ambulated via wheelchair; she required partial/moderate assistance with toileting hygiene, bathing, upper body dressing, and personal hygiene; and she required substantial/maximal assistance with lower body dressing. Record review of Resident #3's care plan revised 11/27/2023 revealed the following care areas: * Communication impairment: Resident #3 has Dysarthria (slurred speech), late effects of CVA, and is at risk for further decline and injury. Goal included: Staff will anticipate and meet needs Resident #3 is not able to effectively communicate. Interventions included: Allow time for resident to digest information - do not rush. Approach in a calm manner using eye contact - call resident by name. Reduce or remove interfering environmental stimuli. Use communication tools, terms, gestures the resident can understand. * Cognitive impairment: Resident #3 has impaired cognition related to intracranial aneurysm and is at risk for further decline and injury. Goal included: Resident #3's needs will be met, and dignity maintained. Interventions included: Allow time for tasks and responses. Explain all procedures using terms gestures the resident can understand. Involve in care to maintain or increase level of independence. Praise for tasks the resident completes. Repeat information as needed. * ADL SELF CARE DEFCITS: Resident #3 has ADL self-care deficits related to history of stroke and is at risk for further decline in ADL functioning and injury. Goal included: Resident #3 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Anticipate needs - provide prompt assistance. Encourage independent function as able. Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide encouragement and cueing as needed to performed ADL cares. Provide privacy and maintain dignity. Further review of Resident #3's care plan, revised 11/27/2023, revealed smoking was not listed as a care area. Record review of Resident #3's Smoking Safety Screen dated 12/01/2023 revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (Yes) 6a. Does the resident or the resident's roommate use oxygen? (Yes) 7. Resident Need for Adaptive Equipment. 7a. Smoking apron . 8. Resident requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) 8b. Resident is safe to smoke independently but resident/roommate uses oxygen and needs facility to store lighter and cigarettes? (No) 8c. Resident is safe to smoke independently and to store own smoking materials? (Do not mark yes if resident or roommate is on oxygen) (No) . Resident #3 does need facility to store her cigarettes, but she refuses to allow us to store them. She also needs a smoking apron but refuses to use one. Team Decision: Safe to smoke with supervision. Rationale/conditions: Resident #3 needs supervision and a smoking apron but she refuses to use one and allow the facility to store them. Observation of Resident #3 on 02/02/2024 at 10:00 a.m. revealed she was outside in the courtyard smoking unsupervised with Resident #1, Resident #2, and several other residents without an apron on. Observation and interview with Resident #3 on 02/02/2024 at 1:20 p.m. revealed she was alert and self-ambulated via wheelchair. Resident #3 stated she was allowed to keep her own smoking supplies. She stated the facility's staff allowed her to go outside and smoke unsupervised whenever she wanted to. Resident #3 stored her cigarettes and lighter in her pocket. She stated she never smoked around anybody with oxygen or got holes in her clothes from cigarettes. Observation of Resident #3's room on 02/04/2024 at 10:30 a.m. revealed her roommate had an oxygen concentrator at bedside in the space between her bed and Resident #3's bed. In an interview with the Activity Assistant in the outside courtyard on 02/02/2024 at 10:10 a.m., she stated she usually supervised resident smoking during her shift. She stated the residents were scheduled to smoke four times per day and were allowed to smoke two cigarettes each time. She stated some of the residents kept their own cigarettes and lighters even though they were not supposed to. She said previously, staff kept all residents' supplies, but after management changed several times, the residents just started keeping their own supplies. She stated there were two residents outside at that time, Resident #2 and Resident #3, who were burners. She said that meant the residents sometimes got burn holes in their clothes (Resident #1 had already went inside the building at that time). She said Resident #1 kept his own cigarettes and lighters. She said the facility was supposed to keep Resident #1's supplies at his family's request, but even though the family member brought the supplies to staff, Resident #1 always came up with cigarettes and lighters. She stated Resident #1 kept his cigarettes and lighters in a stash, but she did not know where the stash was. She stated the staff needed to step up their game regarding storage of smoking supplies and supervision. She said she thought smoking times were 9:00 a.m., 11:00 a.m., 3:00 p.m., and 5:00 p.m., or something like that. She stated the staff shared smoking supervision duties, but she mostly went outside. She said Resident #1's chair had a couple of burn holes that probably happened when he smoked unsupervised. She stated Resident #1 was known to sneak outside to smoke. She stated she worked at the reception desk on weekends, and she often saw Resident #1 go outside and light a cigarette from the window (the outside courtyard was located in the center of the facility with windows all around it). She said she never reported Resident #1's behaviors because all the staff knew about it, and they saw what she saw when he went out and smoked unsupervised. In an interview with the Activity Director on 02/02/2024 at 11:15 a.m., she stated she was hired almost one year ago. She stated managing smoking had been a struggle since she was hired because residents did not follow smoking times and they refused to allow staff to keep their lighters and cigarettes. She stated they care planned the residents' refusal to adhere to the smoking policy. She said there were a lot of smoking residents and the staff tried to stay outside with them while they smoked. She said when the staff saw residents outside, they tried to go out and supervise. She said the staff tried to their best to encourage smoking at scheduled times. She said they tried to explain the importance of supervised smoking to some family members, but they continued to bring the supplies to residents. She said prior to her hire, the facility had residents sign smoking contracts, so some residents had them and some did not. She said Resident #1 kept his own supplies because he refused to give them up and he had been observed outside smoking alone. She said Resident #1's family member wanted her to keep his smoking supplies, but somehow, Resident #1 still got them. She stated Resident #1 refused to wear an apron. In a follow-up interview with the Activity Director on 02/02/2024 at 2:50 p.m., she stated she was responsible for completing each resident's safe smoking assessment. She said she determined if each resident was a safe smoker by observing if they could safely light their own cigarette. She stated she observed while the residents were unaware if they could hold the cigarette, if they dropped the cigarette, and if any ashes fell . She stated she also reviewed the residents' cognition and acuity. She stated Resident #1 had those burn holes in his cushion and his jacket when she was hired and she had been there almost a year. She said to her Resident #1 was a safe smoker. In an interview with the Interim DON on 02/02/2024 at 3:58 p.m., she stated she was the facility's Regional Nurse Consultant, and she was onsite that day because the facility did not have a DON. She said Resident #2 was on oxygen when she went to her room, PRN. She stated Resident #2 did not take her oxygen when she went outside to smoke. The Interim DON said she would go get Resident #2's lighters from her because she was not supposed to have them in her room with the oxygen. She said Resident #1 received weekly skin assessments, so they always monitored him for any burns. In a follow-up interview with the Interim DON on 02/02/2024 at 4:09 p.m., she stated Resident #2 refused to give up her lighter and stated she would bring the lighter to the nurse's station when she completed her breathing treatment. In an interview with LVN C on 02/04/2024 at 11:00 a.m., she stated some of the residents would sneak outside to smoke unsupervised because they kept their own supplies. She stated the staff could take their lighters 10 times, but they still came up with more lighters. In a telephone interview with CNA F on 02/04/2024 at 11:15 a.m., she stated she worked on the 10:00 p.m. - 6:00 a.m. shift and she previously seen residents try to go outside and smoke during her shift. She stated the residents kept their own smoking supplies. She said when she saw residents go outside to smoke, she reported them to her nurse. In a telephone interview with CNA I on 02/04/2024 at 11:30 a.m., he stated he worked on the 2:00 p.m. - 10:00 p.m. shift and as far as he knew, the residents were previously able to smoke at will because they kept their own smoking supplies and he often saw residents smoking unsupervised. Record review of the facility's Smoking Policy revised 06/2019 revealed, To provide a healthy living environment with respect for the health and well-being of each resident, staff member, and visitor. It is also the objective of this policy to communicate to each resident/POA that they are responsible for following each rule and on-going compliance with the Resident Smoking Policy. Policy: It is the policy of this facility to provide smoking policies and procedures supporting residents' preference to smoke. Our policies have been developed to reduce risk related to smoking behaviors and to support the well-being of residents residing in the facility. Smoking will occur in a designated smoking area, at designated times. Residents who desire to smoke will be evaluated to determine level of smoking dependence. A Smoking Behavior Contract must be completed, signed, and followed by each resident/representative who smokes. Failure to honor the Smoking Behavior Contract and the Smoking Policy will be addressed to minimize potential risk to residents residing in the facility, up to and including involuntary discharge of the individual. Notice of Smoking Policy: 1. At the time of admission, each resident and legal representative shall be informed of and receive a written copy of the facility's Smoking Policy. 2. Each resident who desires to smoke shall receive and have explained the Smoking Behavior Contract. The resident/POA is required to complete, sign, and follow the Smoking Behavior Contract. Smoking Safety - Resident Assessment. 1. Residents who desire to smoke will be assessed using the Smoking - safety Screen, documented in the computer system, for their ability to smoke safely. Assessments will be conducted at the time of admission, quarterly and at the time any condition or behavioral change impacts their ability to smoke safely. 2 . A plan of care shall be developed consistent with the resident's smoking risk assessment . 4. Residents who are determined by the interdisciplinary team as needing supervision will be within eyesight of facility staff, family, or other resident representative during the time of the smoking session. 5. Residents who are determined by the interdisciplinary team as needing assistance with smoking will receive assistance from facility staff, family, or another representative. Smoking - General Guidelines: . 3. Oxygen use is prohibited in smoking areas to avoid risk of negative outcome during smoking times. No resident may smoke near/around oxygen. 4. Residents who are deter [TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to follow their own established smoking policy for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking and compliance. 1. The facility failed to effectively intervene or implement their own smoking policy when Residents #1 was known to be non-compliant and continued to store his own smoking paraphernalia. 2. The facility failed to assess Resident #2 for safe smoking upon admission on 01/22/2024 until 02/02/2024. Resident #2 and Resident #3 did not sign smoking contracts until 02/03/2024. 3. The facility failed to implement their smoking policy and allowed Resident #2, who was prescribed oxygen and Resident #3, whose roommate was prescribed oxygen, to store their own smoking paraphernalia. An Immediate Jeopardy (IJ) was identified on 02/03/2024 at 8:33 a.m. The IJ template was provided to the facility on [DATE] at 8:33 a.m. While the IJ was removed on 02/04/2024, the facility remained out of compliance at a scope of pattern 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 placed smoking residents and their roommates at risk of serious harm/injury from possible accidental cigarette burns and fires from lighter/oxygen ignition. Findings included: Resident #1 Record review of Resident #1's face sheet dated 02/02/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with diabetes (a chronic health condition that affects how the body turns food into energy; too much sugar in the blood), acute kidney failure (when the kidneys suddenly cannot filter waste from the blood), acute respiratory failure (when the blood does not have enough oxygen or has too much carbon dioxide), vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), generalized muscle weakness (muscle weakness due to a chronic condition or infection), aphasia (a disorder that affects how you communicate/speak), seizures (a sudden, uncontrolled burst of electrical activity in the brain), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted flow to the brain; ischemic stroke) affecting left non-dominant side, and traumatic subdural hemorrhage (a pool of blood between the brain and the outermost covering) with loss of consciousness. Record review of Resident #1's quarterly MDS dated [DATE] revealed he had unclear speech/slurred or mumbled words; he had impaired vision - saw large print, but not regular print in newspaper/books; he had a BIMS score of 4 (severe cognitive impairment); he had functional limitation in range of motion on one side (upper and lower extremity); he was wheelchair bound; he required setup or clean-up assistance with eating; he required supervision or touching assistance with oral hygiene; he required partial/moderate assistance with upper body dressing; he required substantial/maximal assistance with toileting hygiene, bathing, lower body dressing, and personal hygiene; and he was always incontinent of bowel and bladder. Record review of Resident #1's care plan revised 12/12/2023 revealed the following care areas: * Smoking: Resident #1 had a potential for injury related to smoking. He was evaluated to be a safe smoker. His family preferred the facility to keep his cigarettes for him. Resident #1 had impaired cognition related to dementia and encephalopathy (a broad term for any brain disease that alters brain function or structure). Revised 12/01/2023. Goal included: Resident #1's risk for injury and danger to himself and the environment related to smoking in his room, will be minimized with interventions. Interventions included: Evaluation for assistive devices as indicated. Inform resident of facility's smoking policy and potential consequences of noncompliance. Orient to designated smoking area(s). Provide information and education in smoking cessation options as indicated. Reinforce to Resident #1 that smoking is not permitted in rooms, only in designated areas. Smoking apron if indicated. Smoking assessment upon admission, quarterly, annually, and significant change. Smoking material to be maintained by staff if indicated. Supervised Smoker (Date initiated 06/23/2023). * Resident #1 had difficulty with communication related to chronic aphasia, late effects of CVA (stroke). Goal included: Resident #1 will communicate basic needs over the next 90 days. Interventions included: Allow resident time to communicate needs. Approach in a calm manner. Praise resident for all efforts to communicate. Provide writing tablet for resident to communicate with staff. Speech Therapy referral as needed. * ADL self-care deficits: Resident #1 had ADL self-care deficits related to muscle weakness, deconditioning, and dementia. He was at risk for further decline in ADL functioning and injury. Goal included: will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide assistance for ambulation per therapy orders. Provide encouragement and cueing as needed to performed ADL cares. Provide extensive assist x1 for eating. Provide extensive assist x1 for personal hygiene/grooming. Provide extensive assist x1 for upper/lower body dressing. Provide extensive assist x2 for bed mobility. Provide extensive assist x2 for toileting/incontinent care. Provide privacy and maintain dignity. Provide total assist x1 for bathing. Provide total assist x1 for locomotion on/off unit. Provide total assist x2 for transfers. * Dementia: Resident #1 has a diagnosis of vascular dementia and metabolic encephalopathy, and is at risk for increased confusion and decline in ADLs as the diseases progress. Goal included: Resident #1's needs will be anticipated and met by staff. Interventions included: Administer medication(s) as ordered by MD. Assist resident with ADLs as needed. Re-assure resident when confusion has increased. Re-orient resident daily as needed. Verbal reminders and cues to assist resident with daily orientation. Record review of Resident #1's, Resident Smoking Behavior Contract dated and signed by Resident #1 on 08/01/2022 revealed, . I understand that I must follow each and every rule governing smoking and should I violate even one rule, even one time, I am aware that the facility may temporarily suspend, revoke, and/or initiate discharge proceedings and I will not be allowed to live in this building . I agree to only soke in the designated area. I agree that, if my assessment shows I need assistance, I will only smoke at the designated times, unless with my family. I agree that, if my assessment shows I need assistance, I am not allowed to have in my possession and must permit the facility to store smoking materials (cigarettes, tobacco, rolling papers, lighters, matches) . I will smoke carefully to minimize risk for burning my clothes or fingers (or any other person). I know that careless smoking will cause my privileges to be suspended. I agree to allow staff to check/search my room for contraband (such as hidden cigarettes, lighters, and matches) at staff discretion Record review of Resident #1's, Smoking Safety Screen dated 07/05/2023 (the name of the staff who completed the assessment was not listed on the document) revealed, 1. Does resident have cognitive loss? (Yes) 2. Does resident have any visual deficits? (Yes) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (No) 7. Resident Need for Adaptive Equipment - Supervision . 8. Resident Requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) . 8c. Resident is safe to smoke independently and to store own smoking materials? (No) . Resident #1 wants to smoke more than the designated smoking times. He can become very angry if not given the opportunity to smoke his cigarette. He has good ability to understand others however due to his dementia, his speech is not clear. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: Resident #1 is safe to smoke with supervision. Resident #1 does not like to be supervised and will go out on pass or go out in order to find cigarettes. This is another reason he is an unsafe smoker. Record review of Resident #1's, Smoking Safety Screen dated 12/01/2023, competed by the Activity Director revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (Yes) 7. Resident Need for Adaptive Equipment - (Nothing was checked) . 8. Resident Requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) . 8c. Resident is safe to smoke independently and to store own smoking materials? (No) . Resident can smoke safely without supervision but per the family request, they would like for the facility to store his cigarettes. 2. Team Decision: Safe to smoke without supervision. 3. Rationale/conditions: Resident #1 can smoke safely without supervision but per the family request, they would like for the facility to store his cigarettes. Observation of Resident #1 on 02/02/2024 at 10:00 a.m. revealed he was alert and self-ambulated via wheelchair. Resident #1's left arm and leg were immobile (due to cerebral infarction). Resident #1 was outside in the courtyard smoking a cigarette with Resident #2, Resident #3, and several other residents. No staff were observed outside with the residents for approximately eight minutes until the Activity Assistant went outside. Observation and interview with Resident #1 on 02/02/2024 at 11:30 a.m. revealed he was outside in the courtyard smoking a cigarette unsupervised. Resident #1's speech was slurred, and he also communicated by shaking his head and making other gestures. Resident #1's left arm/hand rested in his lap. The left armrest of his wheelchair was wide and was covered with a black, soft cushion. The cushion had 7-8 holes (the orange-colored foam of the cushion could be seen through the holes) of varied sizes with the largest approximately dime-sized. Resident #1 stated he was allowed to keep his own cigarettes and lighters in a small bag which was hanging from his neck. He stated the facility's staff allowed him to go outside to the smoking area alone as he pleased. He indicated, by holding up his lit cigarette when asked what caused the holes on his armrest, the holes in the cushion of his armrest were caused by cigarettes. Resident #1 demonstrated how he placed lit cigarettes on the cushioned armrest while he reached for his bottle of water which was located on the section of the cushioned armrest behind the lit cigarette, opened it, and drank from it all with his right hand. Resident #1 stretched out the left sleeve of his jacket with his right hand and pointed out 4-6 holes. He indicated the holes on his jacket were caused when the lit cigarettes fell from the cushioned armrest, onto his jacket. He indicated when the lit cigarettes fell from the armrest onto his jacket, he brushed the cigarettes down to the ground with his right hand. He stated that happened multiple times with at least one recent incident (he could not say when the incident occurred). He stated he sometimes burned himself when the cigarettes fell on to his clothes, but he did not have any visible skin injuries. Observation of Resident #1's arm at that time revealed no skin injuries. He stated his clothes never caught on fire and he got scared when the cigarettes fell on to his clothes, but he never reported the incidents to staff. Further review of Resident #1's care plan, revised 12/12/2023, revealed no plan or interventions regarding the burn holes in his clothes or the armrest of his wheelchair. Resident #2 Record review of Resident #2's face sheet dated 02/02/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with hypertensive heart disease (changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), acute and chronic respiratory failure with hypoxia (sudden respiratory failure and over time; when you do not have enough oxygen in your blood), and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease affecting right dominant side. Record review of Resident #2's admission MDS dated [DATE] revealed she had a BIMS score of 7 (severe cognitive impairment); she had upper extremity impairment on one side and bilateral (both sides) lower extremity impairments; she ambulated via wheelchair; she required partial/moderate assistance with toileting hygiene, bathing, upper body dressing, and lower body dressing; and she was frequently incontinent of bowel and bladder. Record review of Resident #2's care plan revised on 02/01/2024 revealed the following care areas: * Resident #2 has episodes of inappropriate behaviors and is at risk for further increased episodes and injury as evidenced by: 1) Refusal of Care. 2) Requesting to smoke outside of designated smoking times. 3) Agitation (yelling/hitting walls). Goal included: episodes of inappropriate behaviors will be reduced no more than 2 episodes weekly and will be free from injury. Interventions included: Encourage to attend social activities of preference. Observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli. Provide psych consult as ordered. * SMOKING: Resident #2 has a potential for injury related to smoking. Goal included: Resident #2's risk for injury related to smoking will be minimized with interventions. Interventions included: Evaluation for assistive devices as indicated. Inform resident of facility's smoking policy and potential consequences of noncompliance. Orient to designated smoking area(s). Provide information and education in smoking cessation options as indicated. * COGNITIVE IMPAIRMENT: Resident #2 has impaired cognition and is at risk for further decline and injury. Goal included: Resident #2's needs will be met, and dignity maintained. Interventions included: Allow time for tasks and responses. Explain all procedures using terms gestures the resident can understand. Involve in care to maintain or increase level of independence. Praise for tasks the resident completes. Repeat information as needed. * SHORTNESS OF BREATH: Resident #2 is at risk for respiratory distress/failure and increased episodes of SOB related to COPD (disease that causes airflow blockage and breathing-related problems) and history of acute/chronic respiratory failure. Goal included: Resident #2 will be free from any respiratory distress/failure and will have minimal/no further episodes of shortness of breath. Interventions included: Allow breaks when performing tasks - do not rush. Apply O2 per order - encourage to take slow, deep breaths. Check pulse oximetry as ordered. Minimize stress/anxiety - allow to verbalize feelings when appropriate. Observe for s/sx of respiratory infection - report any noted to MD. Provide respiratory treatments as ordered - observe for signs of relief from SOB. * ADL SELF CARE DEFCITS: Resident #2 has ADL self-care deficits related to muscle weakness, history of CVA with right hemiplegia, and is at risk for further decline in ADL functioning and injury. Goal included: Resident #2 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Anticipate needs - provide prompt assistance. Encourage independent function as able. Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide encouragement and cueing as needed to performed ADL cares. Provide privacy and maintain dignity. Record review on 02/03/2024 at 10:35 a.m. of Resident #2's Clinical Physician Orders for February 2024 revealed the following order: * Oxygen @ 2-3 LPM via nasal cannula continuously while in room. Monitor O2 saturation. Every shift. Start Date: 02/02/2024. Revision Date: 02/02/2024 at 6:00 p.m. (while in room was added to the order) Record review on 02/02/2024 at 3:07 p.m. of Resident #2's MAR for February 2024 revealed: * Oxygen @ 2-3 LPM via nasal cannula continuously. Monitor O2 saturation every shift. Order Date: 01/24/2024. The order was followed on 02/01/2024 and 02/02/2024. Observation of Resident #2 on 02/02/2024 at 10:00 a.m. revealed she was outside in the courtyard smoking unsupervised with Resident #1, Resident #3, and several other residents without an apron on. Record review of Resident #2's Smoking Safety Screen dated 02/02/2024 at 10:30 a.m. revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (No) . Safety: 6. Can resident light own cigarette? (Yes) 6a. Does the resident or the resident's roommate use oxygen? (Yes) . 8. Resident requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) 8b. Resident is safe to smoke independently but resident/roommate uses oxygen and needs facility to store lighter and cigarettes? (No) . Resident #2 is safe to smoke without supervision however, she uses O2 and needs the facility to store smoking material. Team Decision: safe to smoke without supervision. Rationale/conditions: Resident #2 is safe to smoke without supervision however, she uses O2 and needs the facility to store smoking material. Record review of Resident #2's Resident Smoking Behavior Contract revealed it was signed and dated 02/03/2024. Observation and interview with Resident #2 on 02/02/2024 at 1:15 p.m. revealed she was outside smoking unsupervised with several other resident. Resident #2 was alert and self-ambulated via wheelchair. Resident #2 stated she kept her own cigarettes and lighters and held up a white plastic shopping bag where her smoking supplies were stored. Resident #2's left hand was in a black splint. She stated she was admitted to the facility two months ago and the facility's staff allowed her to go outside and smoke unsupervised whenever she wanted to. She said she was on oxygen, and she knew how to operate her own tank/concentrator when she returned to her room. Resident #2 stated she never smoked around oxygen, dropped cigarettes, or sustained burn holes in her clothes. Resident #3 Record review of Resident #3's face sheet dated 02/04/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with cerebral aneurysm (a weakness in a blood vessel in the brain that balloons and fills with blood), epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures), benign neoplasm of the brain (non-cancerous mass of cells that grow relatively slow in the brain), and vascular dementia (brain damage caused by multiple strokes). Record review of Resident #3's quarterly MDS dated [DATE] revealed she had a BIMS score of 8 (moderate cognitive impairment); she ambulated via wheelchair; she required partial/moderate assistance with toileting hygiene, bathing, upper body dressing, and personal hygiene; and she required substantial/maximal assistance with lower body dressing. Record review of Resident #3's care plan revised 11/27/2023 revealed the following care areas: * Communication impairment: Resident #3 has Dysarthria (slurred speech), late effects of CVA, and is at risk for further decline and injury. Goal included: Staff will anticipate and meet needs Resident #3 is not able to effectively communicate. Interventions included: Allow time for resident to digest information - do not rush. Approach in a calm manner using eye contact - call resident by name. Reduce or remove interfering environmental stimuli. Use communication tools, terms, gestures the resident can understand. * Cognitive impairment: Resident #3 has impaired cognition related to intracranial aneurysm and is at risk for further decline and injury. Goal included: Resident #3's needs will be met, and dignity maintained. Interventions included: Allow time for tasks and responses. Explain all procedures using terms gestures the resident can understand. Involve in care to maintain or increase level of independence. Praise for tasks the resident completes. Repeat information as needed. * ADL SELF CARE DEFCITS: Resident #3 has ADL self-care deficits related to history of stroke and is at risk for further decline in ADL functioning and injury. Goal included: Resident #3 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Anticipate needs - provide prompt assistance. Encourage independent function as able. Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide encouragement and cueing as needed to performed ADL cares. Provide privacy and maintain dignity. Record review of Resident #3's Smoking Safety Screen dated 12/01/2023 revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (Yes) 6a. Does the resident or the resident's roommate use oxygen? (Yes) 7. Resident Need for Adaptive Equipment. 7a. Smoking apron . 8. Resident requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) 8b. Resident is safe to smoke independently but resident/roommate uses oxygen and needs facility to store lighter and cigarettes? (No) 8c. Resident is safe to smoke independently and to store own smoking materials? (Do not mark yes if resident or roommate is on oxygen) (No) . Resident #3 does need facility to store her cigarettes, but she refuses to allow us to store them. She also needs a smoking apron but refuses to use one. Team Decision: Safe to smoke with supervision. Rationale/conditions: Resident #3 needs supervision and a smoking apron but she refuses to use one and allow the facility to store them. Record review of Resident #3's Resident Smoking Behavior Contract revealed it was signed and dated 02/03/2024. Observation of Resident #3 on 02/02/2024 at 10:00 a.m. revealed she was outside in the courtyard smoking unsupervised with Resident #1, Resident #2, and several other residents without an apron on. Observation and interview with Resident #3 on 02/02/2024 at 1:20 p.m. revealed she was alert and self-ambulated via wheelchair. Resident #3 stated she was allowed to keep her own smoking supplies. She stated the facility's staff allowed her to go outside and smoke unsupervised whenever she wanted to. Resident #3 stored her cigarettes and lighter in her pocket. She stated she never smoked around anybody with oxygen or got holes in her clothes from cigarettes. Observation of Resident #3's room on 02/04/2024 at 10:30 a.m. revealed her roommate had an oxygen concentrator at bedside in the space between her bed and Resident #3's bed. In an interview with the Activity Assistant in the outside courtyard on 02/02/2024 at 10:10 a.m., she stated she usually supervised resident smoking during her shift. She stated the residents were scheduled to smoke four times per day and were allowed to smoke two cigarettes each time. She stated some of the residents kept their own cigarettes and lighters even though they were not supposed to. She said previously, staff kept all residents' supplies, but after management changed several times, the residents just started keeping their own supplies. She stated there were two residents outside at that time, Resident #2 and Resident #3, who were burners. She said that meant the residents sometimes got burn holes in their clothes (Resident #1 had already went inside the building at that time). She said Resident #1 kept his own cigarettes and lighters. She said the facility was supposed to keep Resident #1's supplies at his family's request, but even though the family member brought the supplies to staff, Resident #1 always came up with cigarettes and lighters. She stated Resident #1 kept his cigarettes and lighters in a stash, but she did not know where the stash was. She stated the staff needed to step up their game regarding storage of smoking supplies and supervision. She said she thought smoking times were 9:00 a.m., 11:00 a.m., 3:00 p.m., and 5:00 p.m., or something like that. She stated the staff shared smoking supervision duties, but she mostly went outside. She said Resident #1's chair had a couple of burn holes that probably happened when he smoked unsupervised. She stated Resident #1 was known to sneak outside to smoke. She stated she worked at the reception desk on weekends, and she often saw Resident #1 go outside and light a cigarette from the window (the outside courtyard was located in the center of the facility with windows all around it). She said she never reported Resident #1's behaviors because all the staff knew about it, and they saw what she saw when he went out and smoked unsupervised. In an interview with the Activity Director on 02/02/2024 at 11:15 a.m., she stated she was hired almost one year ago. She stated managing smoking had been a struggle since she was hired because residents did not follow smoking times and they refused to allow staff to keep their lighters and cigarettes. She stated they care planned the residents' refusal to adhere to the smoking policy. She said there were a lot of smoking residents and the staff tried to stay outside with them while they smoked. She said when the staff saw residents outside, they tried to go out and supervise. She said the staff tried to their best to encourage smoking at scheduled times. She said they tried to explain the importance of supervised smoking to some family members, but they continued to bring the supplies to residents. She said prior to her hire, the facility had residents sign smoking contracts, so some residents had them and some did not. She said Resident #1 kept his own supplies because he refused to give them up and he had been observed outside smoking alone. She said Resident #1's family member wanted her to keep his smoking supplies, but somehow, Resident #1 still got them. She stated Resident #1 refused to wear an apron. In a follow-up interview with the Activity Director on 02/02/2024 at 2:50 p.m., she stated she was responsible for completing each resident's safe smoking assessment. She said she determined if each resident was a safe smoker by observing if they could safely light their own cigarette. She stated she observed while the residents were unaware if they could hold the cigarette, if they dropped the cigarette, and if any ashes fell . She stated she also reviewed the residents' cognition and acuity. She stated Resident #1 had those burn holes in his cushion and his jacket when she was hired and she had been there almost a year. She said to her Resident #1 was a safe smoker. In an interview with the Interim DON on 02/02/2024 at 3:58 p.m., she stated she was the facility's Regional Nurse Consultant, and she was onsite that day because the facility did not have a DON. She said Resident #2 was on oxygen when she went to her room, PRN. She stated Resident #2 did not take her oxygen when she went outside to smoke. The Interim DON said she would go get Resident #2's lighters from her because she was not supposed to have them in her room with the oxygen. She said Resident #1 received weekly skin assessments, so they always monitored him for any burns. In a follow-up interview with the Interim DON on 02/02/2024 at 4:09 p.m., she stated Resident #2 refused to give up her lighter and stated she would bring the lighter to the nurse's station when she completed her breathing treatment. In an interview with LVN C on 02/04/2024 at 11:00 a.m., she stated some of the residents would sneak outside to smoke unsupervised because they kept their own supplies. She stated the staff could take their lighters 10 times, but they still came up with more lighters. In a telephone interview with CNA F on 02/04/2024 at 11:15 a.m., she stated she worked on the 10:00 p.m. - 6:00 a.m. shift and she previously seen residents try to go outside and smoke during her shift. She stated the residents kept their own smoking supplies. She said when she saw residents go outside to smoke, she reported them to her nurse. In a telephone interview with CNA I on 02/04/2024 at 11:30 a.m., he stated he worked on the 2:00 p.m. - 10:00 p.m. shift and as far as he knew, the residents were previously able to smoke at will because they kept their own smoking supplies and he often saw residents smoking unsupervised. Record review of the facility's Smoking Policy revised 06/2019 revealed, To provide a healthy living environment with respect for the health and well-being of each resident, staff member, and visitor. It is also the objective of this policy to communicate to each resident/POA that they are responsible for following each rule and on-going compliance with the Resident Smoking Policy. Policy: It is the policy of this facility to provide smoking policies and procedures supporting residents' preference to smoke. Our policies have been developed to reduce risk related to smoking behaviors and to support the well-being of residents residing in the facility. Smoking will occur in a designated smoking area, at designated times. Residents who desire to smoke will be evaluated to determine level of smoking dependence. A Smoking Behavior Contract must be completed, signed, and followed by each resident/representative who smokes. Failure to honor the Smoking Behavior Contract and the Smoking Policy will be addressed to minimize potential risk to residents residing in the facility, up to and including involuntary discharge of the individual. Notice of Smoking Policy: 1. At the time of admission, each resident and legal representative shall be informed of and receive a written copy of the facility's Smoking Policy. 2. Each resident who desires to smoke shall receive and have explained the Smoking Behavior Contract. The resident/POA is required to complete, sign, and follow the Smoking Behavior Contract. Smoking Safety - Resident Assessment. 1. Residents who desire to smoke will be assessed using the Smoking - safety Screen, documented in the computer system, for their ability to smoke safely. Assessments will be conducted at the time of admission, quarterly and at the time any condition or behavioral change impacts their ability to smoke safely. 2 . A plan of care shall be developed consistent with the resident's smoking risk assessment . 4. Residents who are determined by the interdisciplinary team as needing supervision will be within eyesight of facility staff, family, or other resident representative during the time of the smoking session. 5. Residents who are determined by the interdisciplinary team as needing assistance with smoking will receive assistance from facility staff, family, or another repre [TRUNCATED]

Based on interview and record review the facility failed to ensure treatment and care in accordance with professional standards of practice was provided to 1 of 8 residents (Resident #83) reviewed for quality of care. The facility failed to check Resident #83's vital signs, including his blood sugar, when he experienced a change in condition on 11/28/23. When emergency personnel arrived, they discovered his blood sugar was 48. Resident #83 was admitted to the hospital for symptomatic hypoglycemia. This failure could place residents at risk of decline in health or hospitalization . Findings included: Record review of Resident #83's face sheet dated 12/14/23 revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included type 2 diabetes, cirrhosis of the liver (severe scarring of the liver that can be caused by many forms of liver diseases and conditions), chronic kidney disease, heart failure, and myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blocks in the arteries). Record review of Resident #83's Discharge Return Anticipated MDS assessment dated [DATE] revealed a staff assessment for mental status was conducted. The assessment indicated his cognitive skills for daily decision making were moderately impaired. He required staff assistance with ADL care. He had an unplanned discharge to a short-term general hospital. Record review of Resident #83's care plan dated 10/30/23 revealed he was a diabetic and was at risk for fluctuations in blood glucose levels hypo/hyperglycemia (hypoglycemia is a condition resulting when the blood glucose levels drop below the specified limits (72mg/dL. Hyperglycemia is a condition of high blood sugar that affects people with or without diabetes) and other complications. Interventions were to check fasting blood sugar as ordered, monitor for changes in mental status - report any noted to MD/RP and document in the clinical record, monitor for excessive thirst, appetite, or voiding, change in level of consciousness or mood, diaphoresis (sweating that does not occur due to heat but follows a sudden chill feeling in the body) - report to MD. Record review of Resident #83's Order Summary Report for December 2023 revealed orders for: send to (hospital) for further evaluation per family request Dx: facial drooping, disoriented, distended abdominal, weak hand grips, order date 11/28/23. Continue to monitor blood sugar before meals and at bedtime, order date 10/24/23. Finger stick blood sugar notify MD for less than 70 or greater than 350 before meals and at bedtime, order date 10/16/23. Record review of Resident #83's SBAR note effective 11/28/23 and signed by Unit Manager S on 12/4/23 revealed Resident #83 experienced a change in condition which consisted of facial drooping, disorientation, a distended abdomen and weak hand grips. The vitals documented were blood glucose 211 mg/dL (11/28/23 at 7:34 a.m.), blood pressure 140/65 (11/27/23), Pulse 78 (11/27/23), Oxygen 97% (11/28/23 at 7:39 a.m.), Respirations 18 (11/28/23 at 7:07 a.m.), and pain 0 (11/28/23 at 7:37 a.m.). The functional capacity review indicated changes in speech, gastrointestinal system review indicated diarrhea and the recommendation was to transfer resident to the hospital. The resident/RP was notified on 11/28/23 at 8:45 a.m. Record review of Resident #83's Progress Notes dated 11/28/23 at 10:05 a.m. written by RN K revealed the resident was transferred this morning at approximately 8:45 a.m. to the hospital for further evaluation and treatment. Record review of Resident #83's MAR for November 2023 revealed Insulin Glargine 60 units was documented as administered by LVN A on 11/28/23 at the 5:30 a.m. administration time; Resident #83's blood sugar was 211 mg/dL. RN documented that Resident #83's blood sugar was 71 mg/dL on 11/28/23 at the 6:30 a.m. scheduled time. Insulin Glargine was ordered on 11/7/23 and discontinued on 12/5/23. Record review of Resident #83's blood sugar summary dated 12/14/23 revealed his blood sugar was documented as 71 mg/dL by RN K on 11/28/23 at 7:30 a.m. His blood sugar was recorded as 211 mg/dL by LVN A on 11/28/23 at 7:31 a.m. and 11/28/23 at 7:34 a.m. Record review of Resident #83's undated hospital records revealed on 11/28/23 at 10:10 a.m. Resident #38 was seen, and the chief complaint was a [AGE] year-old gentleman was sent to the emergency department from the skilled nursing facility for severe hypoglycemia of 48. The HPI indicated the resident said he did not like the food at the nursing facility and he did get his Humalog and Lantus earlier that morning. Fingerstick glucose was 48 at the outside facility and 59 here, patient did receive IV dextrose (dextrose is a form of sugar. Dextrose 5% in water is used to treat low blood sugar, insulin shock, or dehydration) with improvement in glucose levels to 119 followed by 121. He was admitted under hospitalist service for symptomatic hypoglycemia. In an interview on 12/12/23 at 12:48 p.m. Resident #83 said he recently went to the hospital. He said he was screaming for help at the facility because he was lightheaded, dizzy, and sweating. He said when the ambulance arrived at the facility, they checked his blood sugar, and it was 49. He said the ambulance staff gave him glucose. He said no facility staff came to check on him prior to the ambulance coming. In a telephone interview on 12/13/23 at 1:36 p.m. RN K said on the day of the incident she checked Resident #83's blood sugar around 6:30 or 7:00 a.m. and it was 70 something. She said she offered him orange juice because his blood sugar was low, but he refused. She said he was at his baseline and was not showing any signs or symptoms of hypoglycemia. She said after she checked his blood sugar, she went to care for another resident. She said Unit Manager K called 911 because the dietary aide visited Resident #83. She said emergency personnel arrived at the facility quickly and the captain checked his blood sugar, and it was 48. She said she was waiting on the head of department to assist Resident #83 because he was insisting to go back to the hospital. In an interview on 12/13/23 at 2:35 p.m. Unit Manager K said on the day of the incident a kitchen staff member notified her that she believed Resident #83 had a stroke. She said the CNA's informed her that he was different and was not at his baseline. She said she checked the resident's code status and assessed his hands, eyes, speech, and orientation. She said he was alert and verbal, there was no grip in his left hand, his speech was slurred, mouth was drooping to the left, and he was able to follow the penlight. She said she informed someone to call 911. When the paramedics arrived, they checked his vitals, and his blood sugar was in the 40s. She said his nurse (RN K) was across the hall providing care to another resident. She said RN K informed her that she just took his vitals, and his blood sugar was within normal limits, and he did not need to go to the hospital. She said she did not take his blood sugar because RN K alerted her that she had just taken them and felt like he didn't need to go to the hospital. She said she recalled the nurse saying his blood sugar was 122 but may have mixed it with the blood sugar reading of 211. She said when there is a change in condition, they were to conduct a SBAR, check the vital signs which included blood pressure, O2, blood sugar, listen to their lungs and heart, conduct a pain assessment, fall risk assessment, physical assessment, and check the code status. She said the resident was not showing any signs of hypoglycemia which included altered mental status, slurred speech, sweating, and thirst. She said without taking his blood sugar it was hard to say if he was hypoglycemic. She said if a resident was hypoglycemic, she would get orders from the MD, follow the orders, and notify the RP. If the blood sugar is low, they can give the resident something to drink such as orange juice or something sweet. In an interview on 12/13/23 at 3:02 p.m. the Dietary Manager said the incident with Resident #83 happened early in the morning before breakfast. She said the Cook reported to her that Resident #83 did not look right. She said she swiftly went to the front of the facility and told the first nurse she saw (Unit Manager K). She said the floor nurse was in another resident's room with the door closed. She said Resident #83 did not look like his normal self and was not responsive. In a telephone interview on 12/13/23 at 4:42 p.m. RN K said Resident #83's baseline was always calm, like he was not ok. She said when she last saw him, he did not have a droopy face, slurred speech, or loss of hand grips. She said she was unsure of the timeframe between when she last checked his blood sugar and when the paramedics arrived. She said when the Unit Manager K responded to Resident #83, she was assisting another resident. She said Unit Manager K told her she would call 911. She said she did not remember telling the Unit Manager K that she just checked Resident #83's vital signs. She said his last blood sugar was 71 mg/dL and she did not check it again. She said if a resident experienced a change in condition, they were to initiate a SBAR, call the MD/NP, RP, fill in the diagnosis, vitals, and follow the instructions on the SBAR form. She said she did not do a change in condition on Resident #83. In a telephone interview on 12/14/23 at 8:25 am RN K said she nor Unit Manager K checked Resident #83's blood sugar again prior to 911 arriving. She said LVN A was not in the facility during the incident. In an interview on 12/14/23 at 10:05 am the Cook said she checked on Resident #83 around 2 p.m. the day prior to the incident. He informed her that he felt bad, his stomach was hurting, he could not eat, and he wanted to go to hospital. She said she notified RN K, and the nurse told her ok. She said when she arrived at the facility the next day (11/28/23) he was not himself. She said he was not at his normal alertness, his mouth was twisted, he was talking out of his head, and he was in a state she never seen him in. She said she went to the kitchen and reported it to the Dietary Manager. She said Unit Manager K came and conducted a stroke test, talked to the resident, saw that he was not himself and immediately called 911. She said she did not see the nurse take his vitals. She said she (the Cook) gave him 2 cups of orange juice prior to EMS arriving. She said when EMS arrived his blood sugar was 48. In an interview on 12/14/23 at 11:17 a.m. the DON said if a resident experienced a change in condition, staff were to check vital signs, do a head-to-toe assessment, and contact the doctor. She said the vitals included the blood pressure, temperature, oxygen, pulse, pain, and blood sugar. She said if the resident was diabetic or showing signs of hypoglycemia staff should check the blood sugar. She said signs of hypoglycemia included lethargy and sweating. She said if the change in condition was an emergency, staff should still check and monitor the vital signs before EMS arrives. She said if a nurse said they just checked the vitals, the nurse responding to the change in condition should recheck the vitals because the resident was not at baseline. She said vital signs should be documented in the nursing notes and on the SBAR form. In an interview on 12/14/23 at 11:45 a.m. the Administrator said he arrived at the facility the morning of the incident (11/28/23), the ambulance was already at the facility. He said the Fire Marshall asked who the last person was to check Resident #83's blood sugar. He said the CNA and nurse said the resident's blood sugar had dropped and it looked like he was seizing. He said he referred the incident over to the previous interim DON and did not receive a report that he could recall. In an interview on 12/14/23 at 11:53 a.m. the Corporate Nurse said when there was a change in condition staff should complete an SBAR, vitals, and notify the family and doctor. She said with Resident #83's change in condition the staff saw he had an immediate change in condition, which was facial drooping/stroke, and they called 911. She said if the resident was having stroke like symptoms, she would expect them to get him oxygen and call 911. She said she would check the blood sugar if the resident was lethargic, sweaty, and not responding. In an interview on 12/14/23 at 12:09 p.m. the Administrator said he expected staff to notify the DON and Administrator on changes in condition. He said on the day of the incident he arrived at the facility around 9:15 a.m. and emergency personnel were present. He said Resident #83 may have been seizing because his blood sugar was low. In an interview on 12/14/23 at 12:14 p.m. the Medical Director said if a resident experienced a change in condition, he would recheck the blood sugar because the resident could be hypoglycemic. He said blood sugar should be part of the vital sign check whether the resident was diabetic or not. He said sometimes nurses would use the last blood sugar based on their level of comfort and experience. He said low blood sugar could exacerbate old stroke symptoms. He said calling 911 was appropriate for the situation but it would have helped to check the resident's blood sugar. He said staff could check the vitals while 911 was on the way. In a telephone interview on 1/5/24 at 2:54 p.m. with the NP, she said Resident #83 had chronic diarrhea and had an active diagnosis of Clostridium difficile (an infection of the large intestine caused by the bacteria clostridium difficile), so having episodes of diarrhea was expected. She said he was non-compliant and refused medications. The nurse documented every time the resident was non-compliant, and the nurses notified her. She said the resident had the right to refuse. She said he was alert and oriented x 3 (knows who he is, where he is and the approximate time). She said she educated the resident on being compliant, but the resident refused to take his medications and wanted to go to the hospital. She said the resident thought he would receive better care at the hospital. She said as a provider she could not do anything as a resident has right to refuse. Record review of the facility's Change in Condition Communication policy dated June 2019 reflected in part, Policy: to improve communication between physicians and nursing staff to promote optimal patient/resident care . Procedures: 1. Complete assessment of the resident which may include but is not limited to: . e. vital signs, TPR, BP, I/O, lung sounds, N/V abdominal assessment, pain, last BM, blood glucose . 2. Complete SBAR . 8. In the event of a life-threatening event - contact 911 immediately Record review of the facility's Hypoglycemia policy dated 12/2021 read in part, .Policy: the facility will respond to hypoglycemic episodes timely to ensure resident safety. Definition: low blood sugar is when your blood sugar levels have fallen low enough that you need to take action to bring them back to your target range. This is usually when your blood sugar is less than 70 mg/dL. Procedures: licensed nurse will monitor residents blood glucose according to physician orders. Licensed nurse with monitor residents blood glucose with signs or symptoms of hypoglycemia. Signs and symptoms of hypoglycemia . inability to concentrate, confusion, slurred speech, slowed reaction time, extreme fatigue, disoriented behavior

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one (Resident #1) of five reviewed for accidents and supervision. The facility failed to adequately supervise and properly position Resident #1 in her wheelchair to prevent her from falling. Resident #1, who was a quadriplegic (paralysis of all four limbs), fell face forward from her wheelchair to the floor and sustained a facial injury, pain, and two broken teeth. This failure could place residents at risk of falls and injury. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnosis included: quadriplegia (a pattern of paralysis - which is when you can't deliberately control or move your muscles - that can affect a person from the neck down), cognitive communication deficit, contracture of muscle, and altered mental status. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 which indicated moderate cognitive impairment. Her assistance needs ranged from extensive to total dependence on two staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. She was impaired on both sides of her upper and lower extremities. She used a wheelchair as a mobility device. Record review of Resident #1's care plan dated 12/20/22 revealed Resident #1 was at high risk for falls. Resident #1 required a customized wheelchair and preferred her wheelchair reclined when up in wheelchair. Resident #1 had a fall without injury on 4/20/22 and a fall with injury on 10/19/22, date initiated: 6/4/21 and revised on 10/20/22. Interventions/tasks included: 10/19/22 Resident #1 experienced a witnessed fall where she slid out of her wheelchair and sustained a facial injury that affected her oral cavity and required suturing. Resident was sent to ER to eval and treat. Neuros upon return. Continue PT (PT to evaluate chair appropriateness). Antibiotic therapy for oral suturing. Pain medication PRN, bolsters, date initiated: 10/19/22, revised on 10/25/22 . ensure resident body is properly aligned in chair when seated. Do not let resident sit in chair too long, date initiated: 6/10/21, revised on 10/20/22 . recline resident's wheelchair after meals, date initiated: 10/20/22 . Record review of Resident #1's incident report dated 10/19/22 written by LVN A read in part, .Resident was observed sliding out of her wheelchair on the floor. Staff were unable to intervene prior to resident sliding out of the chair . Resident experienced an injury to her face. First aide / ROM performed. 911 notified for transfer and resident was transferred to the ER to eval and treat . Record review of MA's witness statement dated 10/19/22 read in part, .witness (Resident #1) sliding from wheelchair, but it was too late to grab her. Immediately called all nurses stat to unit . Record review of Resident #1's progress note dated 10/19/22 at 3:22 p.m. written by LVN A read in part, . (Resident #1) fell from the wheelchair to the floor and sustained two bruises on her lips and was bleeding from the mouth. Two small pieces of teeth were recovered onsite. The fall was witnessed by CMA 911 was called at 2:35 p.m. and transported her to the (hospital) . At the time of departure resident could verbalize her pain which she rated at 8/10 . The (family member) was called at 3:00 p.m. to notify him of the incident but an unknown caller had called him to report about the fall . Record review of Resident #1's progress note dated 10/19/22 at 8:39 p.m. written by LVN A read in part, .Resident came back via EMS transportation from medical appointment at (hospital) with her (family member) present. (Family member) gave report to the writer that the resident had 6 stitches, two of resident front teeth are mouth (sic) . Record review of the staffing schedule dated 10/19/22 revealed LVN A, MA, CNA A, CNA B, and CNA C were assigned to Unit C/D from 6 a.m. - 2 p.m. Record review of Resident #1's progress note encounter dated 10/21/22 written by the NP read in part, .chief complaint / nature of presenting problem: evaluation of traumatic oral injury with loss of teeth and laceration to right upper side of the lip . History of present illness: . on 10/19, I was notified that she fell from chair to for (sic) which she sustained laceration on the right side of her lip, and 2 teeth were recovered from the floor . In an observation on 1/10/23 at 2:29 p.m. Resident #1 was sitting in the common area on Unit C with her wheelchair tilted back at approximately 120 degrees. In an interview on 1/10/23 at 2:33 p.m. with MA, she said on the day Resident #1 fell the staff were in a meeting after lunch around 1 p.m. on another unit, Unit D. She said she left the meeting a little early and returned to Unit C to finish charting. She said Resident #1 was sitting straight up in her chair and the chair was leaning a little back. She said she saw Resident #1 slide out of her wheelchair and went face first. She said she ran over to the resident, but the resident fell to the floor and hit her head. She said she immediately called everyone in the building for assistance. She said LVN A assessed the resident and she had blood coming from her mouth and one of her teeth were missing. She said Resident #1 was normally positioned with her wheelchair tilted back at 30 degrees (if tilted back past 90 degrees, 30 degrees would equal 150 degrees). She said she believed whoever fed the resident for lunch that day forgot to tilt her wheelchair back. She said for the resident to slide out she had to have been upright. She said prior to the resident's fall she did not notice the position of the chair until after everything happened. In an interview on 1/11/23 at 9:51 a.m. with RA A, she said on the day Resident #1 fell in October of 2022 she was in a meeting. She said her wheelchair reclined because it was safer. In an interview on 1/11/23 at 9:58 a.m. with RA B, she said she was in a meeting when Resident #1 fell . She said Resident #1's wheelchair was supposed to recline back to at least 45 degrees (135 degrees). She said the therapy department in serviced staff on reclining the resident before and after the fall. She said she was not supposed to sit straight up because she could fall forward. In an interview on 1/11/23 at 10:23 a.m. with LVN A, he said on the day Resident #1 fell all staff were in a meeting on D unit. He said a CNA was still on C unit providing care for a resident. He said he was going back and forth between the meeting on D unit to monitor residents on C unit because there were residents in the common area, including one resident with behavior problems. He said he did not remember how Resident #1's chair was positioned prior to her fall. He said if the resident was reclined back with her feet up, she could not fall face forward. He said he believed a staff member did not push her back and her sling was too small. He said he assessed the resident, and she was bleeding from her mouth and one of her teeth were cracked. In an observation and interview on 1/11/23 at 10:41 a.m. of Resident #1, she was lying in her bed cradled in a fetal position. She said she did not remember falling out of her chair. In an interview on 1/11/23 at 11:30 a.m. with CNA C, she said on the day Resident #1 fell , she had left for the day and found out the next day. She said she did not know who did not tilt the resident back. She said Resident #1 should be reclined in her wheelchair unless she is eating. She said the resident could go forward and fall if sitting straight up. She said they were trained after the incident on how to position the resident in bed and in her wheelchair when feeding and not feeding. She said when the resident was not eating, she should be reclined back in her wheelchair at a 45-degree angle (135 degrees) with pillows on each side. She said they were reclining the resident prior to her fall because she is in a fetus position, and they could not sit a person like that straight up. She said that was why Resident #1 had the tilt chair for the last 2-3 years. In an interview on 1/11/23 at 11:40 a.m. with the Director of Rehab, she said Resident #1 had a customized wheelchair for three years that fit her body for positioning and cushion. She said training was conducted with staff on positioning of lower extremities, body alignment in the chair and tilting of the chair when the resident started to use the chair. She said the training/protocol was the same prior to and after her fall. She said she instructed the staff to recline the resident back at an angle where the resident could still see the tv and function. She said she should be reclined back at approximately 110 or 120 degrees to decrease risk of falls and to promote comfort and relief. She said she did not know how she fell or how she was positioned that day. She said after the fall she in serviced the staff on proper positioning in the bed and chair. In an interview on 1/11/23 at 12:53 p.m. with the Administrator, she said on the day Resident #1 fell they had just finished a staff meeting. She said residents were sitting in the area on unit C and MA stayed with them while the in-service meeting was held. She said MA ran and said a resident fell on the C/D unit. She said she saw Resident #1 on the floor bleeding. She said she cleared the other residents out of the sitting area and Resident #1 was taken by 911. She said the resident had 2 broken teeth and was sent back to the facility with a dental order. She said the resident had a lot of swelling and her pain was controlled. She said once her stitches and swelling went down, the facility sent her to a community dentist. The community dentist examined her broken teeth and recommended an oral surgeon to pull them. She said the Rehab department assessed her for eating and she did not have any complications. She said the resident slides and was in a specialized wheelchair but was not sure how the resident was regularly positioned. She said her wheelchair did require some tilting and staff were aware of that. She said MA did not say how the resident was positioned in the wheelchair prior to her fall. She said restorative aides assist the residents with feeding. She said no staff acknowledged that they did not tilt the resident's wheelchair back and said she could not confirm or deny if it was tilted. She said the risk of the resident not being appropriately tilted is her falling. She said they concluded that Resident #1's wheelchair was not tilted to the degree it was supposed to be tilted and reeducated the staff on wheelchair positioning. In an interview on 1/11/23 at 1:45 p.m. with MA, she said on the day Resident #1 fell she was positioned much further up than she normally was. She said she was positioned upright at approximately 80 - 85 degrees (100- 95 degrees), with 90 degrees being straight up. She said the resident was normally tilted back in her wheelchair at 45 degrees (135 degrees). She said they were in a meeting that day for quite some time, approximately 45 minutes. She said she was not sure who was on Unit C when she returned. In an interview on 1/11/23 at 1:52 p.m. with CNA A, she said she was in a meeting when Resident #1 fell (on 10/19/22). She said they always reclined the resident back. In an interview on 1/11/23 at 1:57 p.m. with CNA B, she said she was in a meeting when Resident #1 fell . She said the resident's wheelchair was normally always tilted back. In a telephone interview on 1/11/23 at 2:22 p.m. with Resident #2, he said he witnessed Resident #1's fall in October 2022. He said all the staff were in a meeting and Resident #1 was in the common area on Unit C watching tv. He said the resident's chair was not straight up but was not reclined like normal. In a telephone interview on 1/11/23 at 2:53 p.m. with the DON, she said Resident #1's fall occurred before she started working at the facility. She said Resident #1's tooth was broken, and she needed to see a dentist. She said she was unsure of any problems with Resident #1's wheelchair. In an interview on 1/11/23 at 3:39 p.m. with the Administrator, she said the charge nurse, direct care staff, CNA, and anyone that provided care for Resident #1 was responsible for ensuring she was positioned properly. She said she assumed the fall was related to the wheelchair. She said the wheelchair was supposed to be tilted but when the resident ate, she sat up for choking precautions. She said she expected staff to put her wheelchair back in a tilted position after eating because that was her plan of care for safety. She said the Rehab Director's recommendation was for her to tilt back in the specialized chair. Record review of the facility's Accidents and Incidents - Investigating and Reporting policy dated 9/19/21 read in part, . All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator . 3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device . Record review of the facility's Fall Management policy dated 1/2019 read in part, . It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care .

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 13 residents (CR#1) reviewed for abuse. The facility failure to prevent abuse of CR#1 when licensed nurse RN A left assigned unit without a licensed nurse coverage. The facility failure to prevent abuse of CR#1 when facility staff failed to immediately initiate emergency life-saving procedures to CR#1 found unresponsive in the unit without a licensed nurse coverage. CR#1 was pronounced dead at the facility by Emergency medical services. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 10:40 AM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed facility residents at risk of abuse and neglect. Findings included: Record review of CR#1's face sheet dated [DATE], revealed she was [AGE] years old, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 was a full code (perform CPR). Record review of CR# 1's admission MDS dated [DATE] revealed a BIMS of 11, which indicated CR #1 had mild cognitive impairment. Further review of CR#1's MDS indicated she required limited assistance from staff for ADLS. Record review of CR #1's care plan dated[DATE] indicated CR#1 had ADL self-care deficits and required limited assistance from staff for ADLS. Further review of CR#1's care plan revealed she was a full code, with interventions to initiate CPR and call 911, if residents heart stops. Record review of CR #1's order summary dated [DATE] revealed CR#1 to be a full code. Record review of the staffing scheduled for 10 PM - 6 AM shift indicated RN A, worked on Unit D (covid hall) Record review of CR#1's police report with reported date of [DATE] and reported time of 8:43 AM read in part, [CR#1] was last known to be alive at 0630 hrs and was pronounced deceased at 0842 hrs . The reporter [MA B] stated that she is the medical aid for the complainant at the [MEDICATION(S)] Nursing Facility. [MA B] stated that at 0700 hrs she started her rounds to check the status of her patients. [MA B] stated that she entered into the complainant room at 0715 hrs to give her medication and to complete her morning change. [MA B] stated that she called the complainant's name and shrugged her, but she was unresponsive. [MA B] stated that she called the other aides to assist her with the complainant. [MA B] stated that the other aides at the facility assisted her with performing CPR on the complainant. [MA B] stated that they were unsuccessful in resuscitating the complainant and then called 911. Record Review of CR#1's nursing notes written on [DATE] at 8:01 AM by RN B read, Arrived facility at 0800 and received report from [MA B] in the Covid-19 unit that [CR#1] may have coded (not responsive to calls and physical stimulus). I asked [MA B] to return to patient and commence CPR while I check patient status. Resident record indicates Full Code status. Joined [MA B] and commenced CPR on [CR#1]at about 0805. Emergency crew (911) contacted for additional help. Emergency crew arrived shortly after and took over Patient rescue efforts. Record Review of CR#1's nursing notes written on [DATE] at 8:03 AM by RN B read, Patient assessed. Zero pulse noted. Skin is warm to touch but clammy. [MEDICATION(S)] 1G given via right lateral thigh for suspected [CONDITION(S)]. Record Review of CR#1's nursing notes written on [DATE] at 9:14 AM by RN B read, Received a call that patient has indeed coded (passed). Patient NP notified as well as Patient Guardian. Record review of RN A's time sheet revealed she arrived at the facility on [DATE] at 5:50 PM and clocked out on [DATE] at 7 AM. In an interview on [DATE] at 11:21 AM with RN B, he stated He worked yesterday morning ([DATE]), stated he came in late, which he informed the scheduler that he would be running late. He stated when he arrived around 7:55 AM, RN C met him at the door and they began walking towards the station and RN C was giving him report. RN B stated as they were walking towards his unit, MA B came over to get him stating CR #1 was in distress and needed help. He stated he told MA B to go perform CPR while he goes to check the residents chart for her code status. RN B stated when he entered the room, he began to assist MA B with CPR on CR#1. RN B stated EMS was called and took over CPR once they arrive to the facility, but he was notified shortly afterwards that the patient passed away. RN B stated he last seen the patient a couple days ago before she was moved to the covid unit. In an interview on [DATE] at 11:42 AM with MA B, she stated on [DATE] she arrived at work at 6 AM. She stated RN A was there, but she believes she left around 6:30 AM after giving report and letting her know all the residents were stable. MA B stated she recalls before RN A left; she was coming out of CR#1's room from checking on her but did not say anything was wrong with her. MA B stated while doing her rounds, she got to CR #1's room around 7:15 AM-7:20AM and found her unresponsive. She stated she attempted to wake up CR #1, but she was not responding, so she left the unit (covid unit) to go find a nurse to assist her. MA B stated she went to another unit (unit a) and asked another CNA for the nurse but couldn't find one and was told the nurse was outside. She stated when she kept looking around, she found RN B coming into the building, with RN C, and informed him that CR #1 was unresponsive, who instructed her to begin CPR. MA B stated it is not normal practice for the nurse to leave the facility without another nurse to give report to and oversee the care of the residents. In an interview on [DATE] at 12:10 PM with the Regional Director of Clinical Services, he stated he is over the building until administrative staff is hired. He stated the previous Administrator, DON and ADON all quit last week, and he just recently started working in the building. He stated he was not aware that RN A left was not in the building but stated there was another nurse in the facility. He stated he expects nurses to give report to another nurse before leaving their shift and not leaving before a nurse arrives due to the safety of the residents and the medical care they require. Observation made on [DATE] at 12:40 PM of the crash cart on unit c had suction machine, oxygen and bandages on the cart. No additional supplies. Check off for the cart had not been completed since [DATE]. In an interview on [DATE] at 12:43 PM with MA C, she stated she went to go grab the crash cart to assist with the code on yesterday ([DATE]) for CR#1. She stated she grabbed the crash cart and ran to CR#1's room, but when the staff opened the cart, there was nothing on the crash cart that would assist with saving CR# 1's life. MA C stated she had to run to another nursing station and get their crash cart and return to CR #1's room. In an interview on [DATE] at 12:49 PM with RN B, he stated he was not assigned to work on the COVID unit on yesterday ([DATE]). He stated he went on the unit when he was approached by MA B that CR#1 was unresponsive. In an interview on [DATE] at 1:44 PM with the Activity Director (AD), she stated she arrived to work around 7:50AM and a housekeeper was yelling to her that a resident coded. She stated she went over to assist and entered the room to see CR#1 was on the floor. She stated MA B went to get the AED machine and the crash cart was brought into the room but was missing materials. The AD stated RN B came into the room and took over doing CPR and MA B was only doing compressions for the resident while she was on the floor. She stated when 911 came in and they were working on CR#1 for about 30 minutes, but she was not revived. In an interview on [DATE] at 1:50 PM with RN A, she stated she worked with CR#1 last night ([DATE]) and she was stable. She stated when she last seen CR#1 a little after 6 AM, her oxygen level was 96 percent and she was not in any distress. She stated CR#1 was talking to the staff when they were assisting her with ADL care. RN A stated MA B came onto the unit, she gave her a report about the patients and then she left the building. She stated there was no nurse for her to give report to and she had a personal matter to handle. RN A stated all the residents were stable when she left the building. RN A stated is not normal practice to leave the unit without giving report, but she stated she talked to RN and he stated he was on the way to the facility. RN A stated she did not tell any other nurses that she was leaving the building, due to letting MA B know she was leaving and giving her a report of the residents. In an interview on [DATE] at 2:10 PM with the Staffing Coordinator, she stated RN B had informed her that he would be running late and would be in around 8AM for his shift on [DATE]. She stated nurses are not to leave any unit without another nurse being on shift. She stated RN A was to stay on shift until RN B arrived. In an interview on [DATE] at 3:17 PM with RN C, he stated he worked on unit c, which is across the covid unit. He stated he was not aware that RN A left the building. He stated he only went to the covid unit once during the night to deliver medication. In an interview on [DATE] at 3:36 PM RN B, he stated he did not check CR#1's vital because she was already nonresponsive when he went to her room. He stated her fingertips were already cold and other parts of her body were still warm. In an interview on [DATE] at 3:38 PM with MA D, she stated she worked with CR#1 on night shift on [DATE]. She stated RN A kept checking CR#1's oxygen level overnight due to CR#1 taking out her oxygen off. MA D stated RN A informed her that CR#1 was a priority resident to check to make sure her oxygen was in place, but CR#1 was stable overnight. MA D stated she left around 5:55 AM and RN A was still in the building. Review of the facility Abuse/Neglect Policy with a revision date of ,d+[DATE] read in part, Neglect is the failure to care for a person in a manner, which would avoid harm ad pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 10:40 AM. The Regional Director of Clinical Services was notified. The Regional Director of Clinical Services was provided the Immediate Jeopardy template on [DATE] at 10:4 AM. The following Plan of Removal was submitted and accepted on [DATE] at 3:19 PM: Immediate Actions: [DATE] 5PM ADHOC QAPI meeting was initiated by Regional Director of Clinical Services to address sufficient and competent staffing and shift change protocol. Staffing policy, to include the covid hall, was reviewed. Regional Director of Clinical Services reviewed staffing patterns and assignments to ensure adequate coverage of all units. Inservice topics were discussed to ensure that staff will not leave their shift early before the next appropriate staff assumes responsibility, which included training that in the event a nurse needs to leave emergently- they must still pass responsibility and report with another nurse. In the event that a nurse must leave emergently, nursing leadership must be notified immediately (DON, ADON or Unit Manger). ADHOC QAPI was updated [DATE] to reflect Immediate Jeopardy situation and repeat of audits. AD ADHOC QAPI was updated [DATE] to reflect that Nurses are expected to monitor their residents for changes in condition throughout their shift, especially on the COVID19 unit. In the event of an emergency, staff will call a code blue and nursing staff will immediately respond. ADHOC QAPI was updated [DATE] to reflect that Nurses are expected to hand off responsibilities, narcotic keys and a shift report prior to leaving the facility or leaving their assigned unit. ADHOC QAPI was updated [DATE] to review Advanced Directive Policies. ADHOC QAPI was finalized [DATE] and reviewed by Regional Director of Clinical Services, Medical Director, Interim DON, HR/AIT, Staffing Coordinator and Social Worker. [DATE] after facility notification of incident, Regional Director of Clinical Services initiated an in-service with nursing staff on shift-shift reporting, resident responsibility/assignment hand off (to include break times or leaving the facility), crash cart audits, emergency life-saving procedures (resuscitation/CPR/vital sign assessment). Education will continue until all nurses receive the education (including PRN nurses). Nurses will be educated prior to their next working shift if they have not received the education. Education will be provided in new hire orientation (facility staff or agency staff). Director of Nursing / Designee will ensure completion. [DATE] after facility notification of incident, Regional Director of Clinical Services performed grand rounds on the COVID19 unit to ensure all residents were stable and that the facility had sufficient nursing coverage. Regional Director of Clinical Services repeated grand rounds on the COVID19 unit on [DATE]. [DATE] after facility notification of incident, Regional Director of Clinical Services updated Crash Cart Checklist and added the checklist to the crash carts for night shift to audit crash carts. [DATE] after facility notification of incident, Regional Director of Clinical Services audited all crash carts to ensure appropriate life-saving equipment, such as: Ambu Bag, Suction machine, 0xygen tank, CPR board and gloves were available. Audits were repeated [DATE]. Night shift nurses assigned to their perspective unit will be responsible for checking and ensuring crash carts are stocked and ready for use daily. [DATE], after facility notification of incident, Regional Director of Clinical Services verified that the facility has three working AEDs and are all ready for application. The AEDs are centrally located on A, B and C unit. The AEDs are adhered to the walls in AED cases for easily identification. Audits were repeated [DATE] with no adverse findings. [DATE] Regional Director of Clinical Services updated crash cart checklist to reflect AED inspection. [DATE] AED training was initiated in concurrence with CPR/Resuscitation Training by the Regional Director of Clinical Services to nursing staff. Education will continue until all nurses receive the education (including PRN nurses). Nurses will be educated prior to their next working shift if they have not received the education. Education will be provided in new hire orientation (facility staff or agency staff). Director of Nursing / Designee will ensure completion. [DATE] Inservice initiated by Regional Director of Clinical Services to nursing staff with the topic of CPR/Resuscitation. Education will include assessing vital signs/blood sugar on non-responsive residents with documentation, utilizing Electronic Health Care Record/Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This will be accomplished by enforcement from nursing leadership, specifically oversight from the Director of Nursing. Education will continue until all nurses receive the education (including PRN nurses). Nurses will be educated prior to their next working shift if they have not received the education. Education will be provided in new hire orientation (facility staff or agency staff). Director of Nursing / Designee will ensure completion. [DATE] Regional Director of Clinical Services performed an Advanced Directive Audit to ensure all residents had an updated code status in their medical record. All DNRs were validated with an OOH-DNR. OOH-DNR binders are all updated at each station to reflect residents with active OOH-DNRs. Ongoing: [DATE] Facility initiated an investigation on the incident. Investigation included witness interviews, 24-hour report review and time clock review. RNA confirmed that she left her shift without giving a hand off report. Investigation was completed [DATE]. Root Cause Analysis directed the facility to enforce/in-service on shift to shift reporting and hand off of responsibilities, Crash Cart Checklist/Audits and emergency/CPR/Resuscitation training. RNA was removed from the schedule [DATE] pending interview, education and counseling by Regional Director of Clinical Services. RNB was counseled and educated on ensuring a hand off of responsibilities when leaving his assigned unit. Director of Nursing / Designee will perform random mock codes starting [DATE] to evaluate staff knowledge and response. These codes will assess the staff's ability to respond to an emergency. Details of the mock code will be recorded, and training opportunities will be identified and addressed. Director of Nursing / Designee will audit the crash carts and crash cart logs to ensure crash cart checks are effective and that life-saving equipment is available. These audits were initiated [DATE] and will occur three times a week for six weeks. Administrator hired with start date of [DATE]. Permanent DON hired with start date of [DATE]. RN ADON hired with start date of [DATE]. Unit Manager LVN hired with start date of [DATE]. Interim DON hired with start date of [DATE], who currently is responsible for supervising the nursing department. Surveyor Monitored the plan of removal as follows: Observation were started on [DATE] at 1:58 PM and continued through [DATE] at 7:42 PM. Observation of crash carts and AED machines on Unit A, Unit B, Unit C and Unit D revealed no concerns. All four crash carts had check list for items required on crash cart. Observation of staffing levels on multiple shifts on Unit A, Unit B, Unit C, and Unit D revealed no concerns with supervision. Interviews were started on [DATE] at 11:24 AM and continued through [DATE] at 7:19 PM with 27 staff across all three shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: MA A, CNA A, LVN B, MA B, LVN A, MA C, LVN D, RN B, CNA B, , CNA C, CNA D, Resident Services Coordinator, ADON, Unit Manager, MA D, RN E, Housekeeper, CNA E, CNA F, CNA G, CNA H, LVN C, LVN E, PT, RN D, LVN F, and Regional Director of Clinical Services. All staff interviewed verbalized adequate understanding of plan of removal training received. Record review of facility in-service training revealed: [DATE] - CPR/AED training [DATE] - Nurse to Nurse Report, Resident Responsibility/Assignment, Crash Cart Checklist, ER Life Saving Procedures. Record review of the facility POR binder revealed AD HOC QAPI meetings held on [DATE], [DATE], [DATE], and [DATE] which also included a review of: Sufficient / Competent Staffing and Shift Change/Break protocol, Emergency Life Saving Procedures, Crash Cart audits, Advanced Directives / Code Status review, Mock Code review, AED audits, staffing audits, crash cart check list, 24-hour report review and clock review. [DATE] - Facility Provider Investigation Report [DATE] - Mock Code Review [DATE] - Crash Cart Audits [DATE] - Crash Cart Audits [DATE] - Crash Cart Audits [DATE] - Crash Cart Audits [DATE] - AED Audits [DATE] - AED Audits [DATE] - AED Audits [DATE] - AED Audits [DATE] - Staffing Audits [DATE] - Staffing Audits [DATE] - Staffing Audits [DATE] - Staffing Audits [DATE] - New Administrator's hire date [DATE] - New Unit Manager's hire date [DATE] - New DON's hire date [DATE] - New ADON's hire date [DATE] - Interim DON's hire date [DATE] - Record of Conversation with RN A and RN B revealed one on one training and intervention provided. Record review of 5 of 5 residents revealed Advanced Directives were in place for Resident #2, Resident #3, Resident #4, Resident #5, and Resident#6. The Regional Director of Clinical Services was informed the Immediate Jeopardy was removed on [DATE] at 7:42 PM. The facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to have staff trained to immediately initiate emergency life-saving procedures to CR#1. The facility failed to ensure the crash cart was properly stocked with items needed to provide immediate life saving measures to CR#1. Resulting in a delay in the provision of care/treatment due to staff having to go to another unit to obtain a crash cart. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 10:40 AM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings included: Record review of CR#1's face sheet, [DATE], revealed she was [AGE] years old, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 was a full code (perform CPR). Record review of CR# 1's admission MDS, dated [DATE], revealed a BIMS of 11, which indicated CR #1 had mild cognitive impairment. Further review of CR#1's MDS indicated she required limited assistance from staff for ADLs. Record review of CR #1's care plan, dated [DATE], indicated CR#1 had ADL self-care deficits and required limited assistance from staff for ADLS. Further review of CR#1's care plan revealed she was a full code, with interventions to initiate CPR and call 911, if the resident's heart stopped. Record review of CR #1's order summary dated [DATE] revealed CR#1 to be a full code. Record review of RN A's time sheet revealed she arrived at the facility on [DATE] at 5:50 PM and clocked out on [DATE] at 7 AM. Record review of CR#1's police report with reported date of [DATE] and reported time of 8:43 AM read in part, [CR#1] was last known to be alive at 0630 hrs and was pronounced deceased at 0842 hrs . The reportee [MA B] stated that she is the medical aid for the complainant at the [MEDICATION(S)] Nursing Facility. [MA B] stated that at 0700 hrs she started her rounds to check the status of her patients. [MA B] stated that she entered into the complainant room at 0715 hrs to give her medication and to complete her morning change. [MA B] stated that she called the complainant's name and shrugged her but she was unresponsive. [MA B] stated that she called the other aides to assist her with the complainant. [MA B] stated that the other aides at the facility assisted her with performing CPR on the complainant. [MA B] stated that they were unsuccessful in resuscitating the complainant and then called 911. Record Review of CR#1's nursing notes, written on [DATE] at 8:01 AM by RN B reflected, Arrived facility at 0800 and received report from [MA B] in the Covid-19 unit that [CR#1] may have coded (not responsive to calls and physical stimulus). I asked [MA B] to return to patient and commence CPR while I check patient status. Resident record indicates Full Code status. Joined [MA B] and commenced CPR on [CR#1]at about 0805. Emergency crew (911) contacted for additional help. Emergency crew arrived shortly after and took over Patient rescue efforts. Further review of CR#1's nursing notes written by RN B at 1:03 PM ready, Mortician arrived and picked up [CR#1's] body . Record Review of CR#1's nursing notes written on [DATE] at 8:01 AM by RN B read, Arrived facility at 0800 and received report from [MA B] in the Covid-19 unit that [CR#1] may have coded (not responsive to calls and physical stimulus). I asked [MA B] to return to patient and commence CPR while I check patient status. Resident record indicates Full Code status. Joined [MA B] and commenced CPR on [CR#1]at about 0805. Emergency crew (911) contacted for additional help. Emergency crew arrived shortly after and took over Patient rescue efforts. Record Review of CR#1's nursing notes written on [DATE] at 8:03 AM by RN B read, Patient assessed. Zero pulse noted. Skin is warm to touch but clammy. [MEDICATION(S)] 1G given via right lateral thigh for suspected [CONDITION(S)]. Record Review of CR#1's nursing notes, written on [DATE] at 8:25 AM by RN B reflected, Received a call that patient has indeed code (passed) . Record Review of CR#1's nursing notes written on [DATE] at 9:14 AM by RN B read, Received a call that patient has indeed coded (passed). Patient NP notified as well as Patient Guardian. In an interview on [DATE] at 11:21 AM with RN B, he stated he worked yesterday morning ([DATE]), stated he came in late, which he informed the scheduler that he would be running late. He stated when he arrived around 7:55 AM, RN C met him at the door, and they began walking towards the station and RN C was giving him report. RN B stated as they were walking towards his unit (unit c), MA B came over to get him stating CR #1 was in distress and needed help. He stated MA B informed him that CR#1 was nonresponsive. He stated he told MA B to go perform CPR while he checked the resident's chart for her code status. RN B stated when he entered the room, he began to assist MA B with CPR on CR#1. RN B stated EMS was called by a staff member and took over CPR once they arrived at the facility, but he was notified about ,d+[DATE] minutes later by EMS that the patient passed away. RN B stated he last saw the patient a couple of days ago before she was moved to the covid-19 unit. Record review of CR#1's nursing note dated [DATE] indicated CR#1 was transferred to the COVID unit. In an interview on [DATE] at 11:42 AM with MA B, she stated on [DATE] she arrived at work at 6 AM. She stated RN A was there, but she believes she left around 6:30 AM after giving report and letting her know all the residents were stable. MA B stated she recalls before RN A left; she was coming out of CR#1's room from checking on her but did not say anything was wrong with her. MA B stated while doing her rounds, she got to CR #1's room around 7:15 AM-7:20AM and found her unresponsive. She stated she attempted to wake up CR #1, but she was not responding, so she left the unit (covid unit) to go find a nurse to assist her. MA B stated she went to another unit (unit a) and asked another CNA for the nurse but couldn't find one and was told the nurse was outside. She stated when she kept looking around, she found RN B coming into the building, with RN C, and informed him that CR #1 was unresponsive, who instructed her to begin CPR. MA B stated it is not normal practice for the nurse to leave the facility without another nurse to give report to and oversee the care of the residents. In an interview on [DATE] at 12:10 PM with the Regional Director of Clinical Services, he stated he is over the building until administrative staff is hired. He stated the previous Administrator, DON and ADON all quit last week, and he just recently started working in the building. He stated he was not aware that RN A left was not in the building but stated there was another nurse in the facility. He stated he expects nurses to give report to another nurse before leaving their shift and not leaving before a nurse arrives due to the safety of the residents and the medical care they require. Observation made on [DATE] at 12:40 PM of the crash cart on unit c had suction machine, oxygen and bandages on the cart. No additional supplies. Check off for the cart had not been completed since [DATE]. In an interview on [DATE] at 12:43 PM with MA C, she stated she went to go grab the crash cart to assist with the code on yesterday ([DATE]) for CR#1. She stated she grabbed the crash cart and ran to CR#1's room, but when the staff opened the cart, there was nothing on the crash cart, such as oxygen, ambu bag, pulse oximeter, that would assist with saving CR# 1's life. MA C stated she had to run to another nursing station and get their crash cart and return to CR #1's room. MA C stated the second crash cart, from unit a, had all the supplies needed to assist with a code. In an interview on [DATE] at 1:44 PM with the AD, she stated she arrived to work on [DATE], around 7:50 AM and a housekeeper was yelling to her that a resident coded. She stated she went over to assist and entered the room to see CR#1 was on the floor. She stated MA B went to get the AED machine and the crash cart was brought into the room but was missing items, such as oxygen, ambu bag, pulse oximeter and back board. The AD stated RN B came into the room and took over doing CPR and MA B was only doing compressions for the resident while she was on the floor. She stated when 911 came in, they were working on CR#1 for about 30 minutes, but she was not revived. In an interview on [DATE] at 3:17 PM with RN C, he stated he worked on unit c, which is across the covid unit. He stated he was not aware that RN A left the building. He stated he only went to the covid unit once during the night to deliver medication. In an interview on [DATE] at 3:36 PM RN B, stated he did not check CR#1's vitals because she was already nonresponsive when he went to her room. He stated her fingertips were already cold and other parts of her body were still warm. RN B did not check CR#1's pulse, heart rate or blood pressure. Record review of RN B's employee file indicated his CPR card was current and expires [DATE]. Record review facility Nursing Policies and Procedures: Emergency Cart (Crash Cart) with a revision date on [DATE] reflected in part, Check, restock and seal the emergency cart after each use and/or opening, while verifying that the emergency cart is ready to use. The licensed nurse staff member or designee signs roster (log) indicating that emergency cart has been checked . Emergency cart checklist: CPR board, box of gloves, portable suction machine, ambu bag (manual resuscitator), oxygen tubing, nasal cannula, yankaur (oral suctioning tool), mask-goggles, KY jelly, tape and alcohol pads. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 10:40 AM. The Regional Director of Clinical Services was notified. The Regional Director of Clinical Services was provided the Immediate Jeopardy template on [DATE] at 10:4 AM. The following Plan of Removal was submitted and accepted on [DATE] at 3:19 PM: [MEDICATION(S)] at Westbury Plan of Removal for IJ on Neglect [DATE] Immediate Actions: [DATE] 5PM ADHOC QAPI meeting was initiated by Regional Director of Clinical Services to address sufficient and competent staffing and shift change protocol. Staffing policy, to include the covid hall, was reviewed. Regional Director of Clinical Services reviewed staffing patterns and assignments to ensure adequate coverage of all units. Inservice topics were discussed to ensure that staff will not leave their shift early before the next appropriate staff assumes responsibility, which included training that in the event a nurse needs to leave emergently- they must still pass responsibility and report with another nurse. In the event that a nurse must leave emergently, nursing leadership must be notified immediately (DON, ADON or Unit Manger). ADHOC QAPI was updated [DATE] to reflect Immediate Jeopardy situation and repeat of audits. AD ADHOC QAPI was updated [DATE] to reflect that Nurses are expected to monitor their residents for changes in condition throughout their shift, especially on the COVID19 unit. In the event of an emergency, staff will call a code blue and nursing staff will immediately respond. ADHOC QAPI was updated [DATE] to reflect that Nurses are expected to hand off responsibilities, narcotic keys and a shift report prior to leaving the facility or leaving their assigned unit. ADHOC QAPI was updated [DATE] to review Advanced Directive Policies. ADHOC QAPI was finalized [DATE] and reviewed by Regional Director of Clinical Services, Medical Director, Interim DON, HR/AIT, Staffing Coordinator and Social Worker. [DATE] after facility notification of incident, Regional Director of Clinical Services initiated an in-service with nursing staff on shift-shift reporting, resident responsibility/assignment hand off (to include break times or leaving the facility), crash cart audits, emergency life-saving procedures (resuscitation/CPR/vital sign assessment). Education will continue until all nurses receive the education (including PRN nurses). Nurses will be educated prior to their next working shift if they have not received the education. Education will be provided in new hire orientation (facility staff or agency staff). Director of Nursing / Designee will ensure completion. [DATE] after facility notification of incident, Regional Director of Clinical Services performed grand rounds on the COVID19 unit to ensure all residents were stable and that the facility had sufficient nursing coverage. Regional Director of Clinical Services repeated grand rounds on the COVID19 unit on [DATE]. [DATE] after facility notification of incident, Regional Director of Clinical Services updated Crash Cart Checklist and added the checklist to the crash carts for night shift to audit crash carts. [DATE] after facility notification of incident, Regional Director of Clinical Services audited all crash carts to ensure appropriate life-saving equipment, such as: Ambu Bag, Suction machine, 0xygen tank, CPR board and gloves were available. Audits were repeated [DATE]. Night shift nurses assigned to their perspective unit will be responsible for checking and ensuring crash carts are stocked and ready for use daily. [DATE], after facility notification of incident, Regional Director of Clinical Services verified that the facility has three working AEDs and are all ready for application. The AEDs are centrally located on A, B and C unit. The AEDs are adhered to the walls in AED cases for easily identification. Audits were repeated [DATE] with no adverse findings. [DATE] Regional Director of Clinical Services updated crash cart checklist to reflect AED inspection. [DATE] AED training was initiated in concurrence with CPR/Resuscitation Training by the Regional Director of Clinical Services to nursing staff. Education will continue until all nurses receive the education (including PRN nurses). Nurses will be educated prior to their next working shift if they have not received the education. Education will be provided in new hire orientation (facility staff or agency staff). Director of Nursing / Designee will ensure completion. [DATE] Inservice initiated by Regional Director of Clinical Services to nursing staff with the topic of CPR/Resuscitation. Education will include assessing vital signs/blood sugar on non-responsive residents with documentation, utilizing Electronic Health Care Record/Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This will be accomplished by enforcement from nursing leadership, specifically oversight from the Director of Nursing. Education will continue until all nurses receive the education (including PRN nurses). Nurses will be educated prior to their next working shift if they have not received the education. Education will be provided in new hire orientation (facility staff or agency staff). Director of Nursing / Designee will ensure completion. [DATE] Regional Director of Clinical Services performed an Advanced Directive Audit to ensure all residents had an updated code status in their medical record. All DNRs were validated with an OOH-DNR. OOH-DNR binders are all updated at each station to reflect residents with active OOH-DNRs. Ongoing: [DATE] Facility initiated an investigation on the incident. Investigation included witness interviews, 24-hour report review and time clock review. RNA confirmed that she left her shift without giving a hand off report. Investigation was completed [DATE]. Root Cause Analysis directed the facility to enforce/in-service on shift to shift reporting and hand off of responsibilities, Crash Cart Checklist/Audits and emergency/CPR/Resuscitation training. RNA was removed from the schedule [DATE] pending interview, education and counseling by Regional Director of Clinical Services. RNB was counseled and educated on ensuring a hand off of responsibilities when leaving his assigned unit. Director of Nursing / Designee will perform random mock codes starting [DATE] to evaluate staff knowledge and response. These codes will assess the staff's ability to respond to an emergency. Details of the mock code will be recorded, and training opportunities will be identified and addressed. Director of Nursing / Designee will audit the crash carts and crash cart logs to ensure crash cart checks are effective and that life-saving equipment is available. These audits were initiated [DATE] and will occur three times a week for six weeks. Administrator hired with start date of [DATE]. Permanent DON hired with start date of [DATE]. RN Adon hired with start date of [DATE]. Unit Manager LVN hired with start date of [DATE]. Interim DON hired with start date of [DATE], who currently is responsible for supervising the nursing department. Surveyor Monitored the plan of removal as follows: Observation were started on [DATE] at 1:58 PM and continued through [DATE] at 7:42 PM. Observation of crash carts and AED machines on Unit A, Unit B, Unit C and Unit D revealed no concerns. All four crash carts had check list for items required on crash cart. Observation of staffing levels on multiple shifts on Unit A, Unit B, Unit C, and Unit D revealed no concerns with supervision. Interviews were started on [DATE] at 11:24 AM and continued through [DATE] at 7:19 PM with 27 staff across all three shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: MA A, CNA A, LVN B, MA B, LVN A, MA C, LVN D, RN B, CNA B, , CNA C, CNA D, Resident Services Coordinator, ADON, Unit Manager, MA D, RN E, Housekeeper, CNA E, CNA F, CNA G, CNA H, LVN C, LVN E, PT, RN D, LVN F, and Regional Director of Clinical Services. All staff interviewed verbalized adequate understanding of plan of removal training received. Record review of facility in-service training revealed: [DATE] - CPR/AED training [DATE] - Nurse to Nurse Report, Resident Responsibility/Assignment, Crash Cart Checklist, ER Life Saving Procedures. Record review of the facility POR binder revealed AD HOC QAPI meetings held on [DATE], [DATE], [DATE], and [DATE] which also included a review of: Sufficient / Competent Staffing and Shift Change/Break protocol, Emergency Life Saving Procedures, Crash Cart audits, Advanced Directives / Code Status review, Mock Code review, AED audits, staffing audits, crash cart check list, 24-hour report review and clock review. [DATE] - Facility Provider Investigation Report [DATE] - Mock Code Review [DATE] - Crash Cart Audits [DATE] - Crash Cart Audits [DATE] - Crash Cart Audits [DATE] - Crash Cart Audits [DATE] - AED Audits [DATE] - AED Audits [DATE] - AED Audits [DATE] - AED Audits [DATE] - Staffing Audits [DATE] - Staffing Audits [DATE] - Staffing Audits [DATE] - Staffing Audits [DATE] - New Administrator's hire date [DATE] - New Unit Manager's hire date [DATE] - New DON's hire date [DATE] - New ADON's hire date [DATE] - Interim DON's hire date [DATE] - Record of Conversation with RN A and RN B revealed one on one training and intervention provided. Record review of 5 of 5 residents revealed Advanced Directives were in place for Resident #2, Resident #3, Resident #4, Resident #5, and Resident#6. The Regional Director of Clinical Services was informed the Immediate Jeopardy was removed on [DATE] at 7:42 PM. The facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to develop and implement their written policies and procedures for abuse for 1 (Resident #3) of 5 residents reviewed for abuse. -The facility failed to protect Resident #3 from being physically and psychologically harmed by CR #2 who had untreated and unsupervised behaviors. CR #2 hit Resident #3 in the jaw and verbally threatened him of further harm. -The facility failed to ensure interventions were in place to address CR #2's history of aggressive behaviors and assaults. -The facility failed to supervise and treat CR #2 when his aggressive behaviors escalated. These failures affected one resident causing him pain and fear and placed him at risk for further physical and psychological harm. Intake # 5 Findings Include: CR #2 Record review of CR #2's face sheet, he was a [AGE] year-old male who admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #2's 30-day MDS assessment dated [DATE] indicated a BIMS score of 10 - moderate cognitive impairment. His mood assessment indicated feelings of being down, depressed, or hopeless. His behavior assessment indicated no behaviors including physical, verbal, or rejection of care. These assessments were competed by the Social Worker. Record review of CR #2's Physician orders [REDACTED]. . [MEDICATION NAME] 15 mg give 1 tablet by mouth at bedtime for depression . order date, 4/2/2019 . Observation: Antidepressant medication - observe for behavior withdrawn/noncompliant behavior/aggressive or agitated behavior . order date, 4/2/2019 . Record review of CR #2's care plan received on 5/24/2019 had no interventions for behaviors/aggressive behaviors prior to 5/22/2019. Record review of CR #2's behavior note dated 4/13/19 at 6:23 a.m. written by RN A read, At about 0600 resident observed smoking at the main entrance to the facility. This nurse instruct on smoking policy and designated area for smoking and resident states Leave me alone. No interventions were documented on the care plan following the behavior. Record review of CR #2's behavior note dated 4/17/2019 at 4:56 a.m. written by RN B read, Resident refused wound care this morning; Resident was verbally abusive, very aggressive; Resident ordered me to leave his room; Resident in stable condition; No interventions were documented on the care plan following the behavior. Record review of CR #2's behavior note dated 4/17/2019 at 3:50 p.m. written by RN A read, At about 0845 this nurse heard noises down the hall and noted the noise was coming from room (number). Upon entry room, this nurse observed resident on bed B on wheelchair by bed A (CR#2) bedside table and took lunch bag from bed A (CR#2) table. Then Bed B resident requested for Resident on bed A (CR#2) to leave his lunch bag. Then Resident on bed A (CR #2) stood up making attempt to fight with resident on bed B. Resident on bed A (CR#2) states He is always going through my stuffs. Am tired of it. This nurse call for assist and attempt to calm resident. Resident continues to talk back and forth with resident on bed B. Resident moved to room (number). Resident is his own RP and aware of room change. Resident was able to calm down. ADON, DON and Administrator aware. No interventions were documented on the care plan following the behavior. Record review of CR #2's behavior note dated 4/19/2019 at 6:27 a.m. written by RN C read, Pt refused vitals taken this morning before vitals . watching tv at dining area. No interventions were documented on the care plan following the behavior. Record review of CR #2's behavior note dated 5/9/2019 at 1:14 a.m. and written by RN D read Note Text: patient refused to have AP and lateral x-ray [MEDICATION NAME] spine done. Patient cursed at x-ray technician and demanded that x-ray technician to leave room . No interventions were documented on the care plan following the behavior. Record review of CR #2's behavior note dated 5/17/2019 at 9:04 a.m. written by LVN A read, Resident was asked to get vitals taken and drsg done before leaving to [MEDICAL TREATMENT] Resident stated No, your not touching me [***] you [***] . Ask resident So you are refusing wound care and vitals being taken? Resident stated [***] you supervisor aware. Resident left to [MEDICAL TREATMENT] with (name) EMS at 9:00 a.m. No interventions were documented on the care plan following the behavior. Record review of CR #2's nursing note dated 5/22/19 at 4:45 p.m. and written by the Unit Manager read, Note Text: around 430 p.m. yelling was heard coming from room (number) - went in to eval the noise and (CR #2) stated that he and roommate (Resident #3) got into an argument because (Resident #3) left his w/c in the middle of the room which blocked (CR #2) from being able to get to his bed. At this time (Resident #3) was no longer in the room- he left the room to report to mgmt that (CR #2) hit him in the jaw while he was laying down- (CR #2) denied hitting (Resident #3) but made threats that he would hit him after mgmt left the bldg. - the two were separated immediately - individually assessed for injuries related to the incident - no new skin issues noted on either resident - no c/o pain or discomfort from (Resident #3) - (Resident #3) stated that he wanted to press charges against (CR #2) - HPD was contacted immediately - SW present at the time - q15 min safety checks initiated on both residents - HPD arrived and proceeded with pressing charges against (CR#2) and he was taken into police custody incident # . - investigation in progress. Record review of the facility's incident report involving CR #2 and Resident #3 dated 5/22/19, revised on 5/24/19 and prepared by the DON read in part, . Resident: (CR #2) . Incident Description: . Resident was reported by another resident, his roommate that he was physically aggressed by him. Resident hit roommate on the jaw while lying in his bed . Record review of CR #2's behavior note dated 5/23/19 8:37 a.m. written by Social Worker reads The police arrested him for Assault (number) officer (name/unit). She states that due to the nature of the assault it would not be a good idea to put the two together or even on the same unit. States he will not be coming back and would not recommend that our facility take him back. SW gave her an updated face sheet to include his family members in Beaumont. The [MEDICAL TREATMENT] center was called last evening as well to inform them that he did go to jail. The [MEDICAL TREATMENT] nurse informed SW that he does have a history of issues at the various [MEDICAL TREATMENT] centers in Beaumont and their doctor was the only one who accepted him. Record review of CR #2's care plan last revised on 5/22/19 read in part, . has potential to be verbally aggressive with others. According to his family he has a history of verbal aggression and non-compliance related to dementia, ineffective coping skills, poor impulse control . (CR #2) states he does have problem with getting along with others. He states he has been to jail before several times for getting into fights. He thought that moving from his hometown (name) would help him to have improved behavior. He has a history of homelessness as well . Interview/Entrance Conference on 5/24/19 at 9:25 a.m. with Administrator, Don, and Unit Manager. DON said the police were called and CR #2 was arrested and no longer in the facility and Resident #3 did not have any injuries. Interview on 5/24/19 at 10:11 a.m. with the Activities Assistant, she said on an unknown date, CR #2 was upset that $60 was missing and got into a big argument with Resident #4. Interview on 5/24/19 at 12:09 p.m. with the Administrator, he said he heard CR #2 came back to the facility this morning (5/24/19), got something and left. Interview on 5/24/19 at 12:19 p.m. with the DON, she said CR #2 came to the front desk and received his belongings and left out of the building. Interview on 5/24/19 at 1:30 p.m. with the Unit Manager about the incident between CR #2 and Resident #3 on 5/22/19, she said she personally heard commotion around 4:30 p.m. She said CR #2 denied hitting Resident #3, but she heard him threaten Resident #3. She said they had not had any issues with CR #2 and Resident #3 before that day. She said the verbal altercation between the two residents was new. She said the police were at the facility by 5:15 p.m. Interview on 5/24/19 at 5:47 p.m. with the DON, she said CR#2's previous behaviors, before the incident on 5/22/19, should have been updated on the care plan. She said her expectation was for the Social Worker, MDS nurse, or Unit Manager to update it. She said after the incident occurred between CR #2 and Resident #3 on 5/22/19, she immediately informed the Social Worker to update their care plans. Interview on 5/24/19 at 6:00 p.m. with the Social Worker, the Surveyor showed the Social Worker CR #2's behavior events in the nursing notes from 4/13/19 to 5/17/19. The Social Worker read the notes and said she was not aware that CR #2 was having behavioral issues. She said that CR #2 had issues with another roommate and he was moved to a different room. She said she did not know he was aggressive and was not able to address his behaviors. She said if she would have known about his behaviors, she would have referred him to psychiatric services. Interview on 5/24/19 at 6:20 p.m. with the Administrator, he said there was no record of a psychiatric referral for CR #2. Resident #3 Record review of Resident #3's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Handwritten on the face sheet was a BIMS score of 10 (moderate cognitive impairment). Record review of Resident #3's care plan last reviewed on 5/22/19 revealed he had an ADL self-care performance deficit and needed extensive/total assistance of 1-2 staff for bathing, bed mobility, personal hygiene, toilet use, and transfers. He was cognitively impaired, had acute/chronic pain, and had a history of [REDACTED]. Record review of the facility's incident report involving CR #2 and Resident #3 dated 5/22/2019 4:30 p.m. and revised on 5/24/2019 10:53 a.m. by the Unit Manager read in part, . Resident: (Resident #3) . Nursing Description: (Resident #3) reported that while laying down in his bed his roommate (CR #2) punched him in the jaw- the incident was not witnessed by the staff - however I was on the hall a few doors down and heard verbal commotion and yelling - at the time it was unclear if the yelling was playful or aggressive being that the two always talk loudly at one another. We went in to assess and eval the situation and found that the two were in an altercation and (Resident #3) reported that (CR #2) punched him in the jaw and he wished to press charges . Immediate action taken Description: Resident #3 was immediately removed and kept away from CR #2, CR #2 assessed from head to toe for any injuries, assessed for pain, HPD notified per resident request. SW (name), NP (name), and FM (name) notified - monitored closely - investigation initiated . Record review of Resident #3's late entry behavior note dated 5/22/19 9:55 a.m. written by Social Worker read Resident #3 presents very depressed and upset. States his roommate just hit him in the jaw and wants to call the police. He was very upset about the entire thing. States he wants to press charges against his roommate. States he (Resident #3) already sees the psych nurse. States he does not want the roommate in the room with him anymore. Nursing called the police and they interviewed him after then arrived. Record review of Resident #3's Pain assessment dated [DATE] 2:15 p.m. read in part . Comments: Stated no pain only when this writer touch left jawl area. No swelling nor bruising noted. Stated doesn't need any pain med . written by LVN Q. Interview on 5/24/19 at 11:44 a.m. with Resident #3, he said on the day of the incident he was lying down in his bed with the bedside tray and wheelchair close to his bed. He said CR #2 was in the room, he took cigarettes and lighter out of a drawer and could not get to his bed. CR #2 pushed the bedside tray into Resident #3's bed, hitting Resident #3's hip. Resident #3 asked CR #2 what he was doing. CR #2 replied why the [***] are you worried? Resident #3 replied, [***] you. CR #2 then stood up from his wheelchair and punched Resident #3 in the left jaw. Resident #3 left the room to report the incident to the nurse. He said he wanted to press charges against CR #2. He said the police came to the facility and heard CR #2 threatening him and took him to jail. Resident #3 said he saw CR #2 at the facility this morning (5/24/19) by himself. Resident #3 said he did not feel safe around CR #2 because he threatened him. He said CR #2 told him you better not sleep in the room, I will jump on you. Resident #3 said that he could not walk but CR #2 could walk. He said he wanted to move to another facility because he did not feel safe. Record review of facility Abuse/Neglect Policy: read in part .It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, is appropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegations. These guidelines include compliance with the seven (7) federal component of prevention and investigation . Abuse Coordinator . The administrator is the abuse coordinator in the facility and is responsible for development and implementing the abuse prevention training curriculum and conducting the investigation in situations of alleged abuse/neglect . physical abuse includes but not limited to inflection of injury that occur other than by accidental means . any person my potentially cause harm to a resident. Potential aggressors include but are not limited to facility staff, other residents, state employees, family members, guardian and other visitors . verbal abuse includes but not limited to the use of oral, written or gestured language . Mental abuse includes but is not limited to humiliation, harassment, thret of bodily harm, punishment, isolation (involuntary, imposed seclusion) or deprivation to provoke fear of shame .

Based on observation, interview and record review, the facility failed to maintain an Infection Control Program designed to prevent the development and transmission of disease and infection, for 5 of 24 residents reviewed for infection control, (Residents #21, 3, 23, 1 and 4), in that: - Resident #21 was not placed on contact isolation after testing positive for conjunctivitis, MRSA and [DIAGNOSES REDACTED] (bacterial infection of the eye) in his eyes. - Resident #3 was removed from contact isolation for MRSA of the wound without a doctor order. Staff did not follow infection control procedures when disposing of linen that was soiled by the wound. - The facility failed to use sterile technique, sterile equipment, and to follow manufacturer's recommendation during Tracheotomy suctioning for Resident #23. - The facility failed to use sterile technique, sterile equipment and to follow manufacturer's recommendation during Tracheotomy suctioning for Resident #1. Staff did not follow infection procedures when performing indwelling catheter care. - Staff failed to follow infection control procedures while performing incontinent care for Resident #4. - Wash basins, urinal and other personal care items not labeled. An IJ was identified on [DATE]. While the IJ was lowered on [DATE] the facility remained out of compliance at a scope of widespread and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to facility requiring more time to monitor the plan of removal for effectiveness. These deficient practices affected 5 residents and placed 117 residents at risk for contracting infections, hospitalization s, decrease in quality of care and their quality of life. Resident #21 Record review of Resident #21's face sheet revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #21's MDS dated [DATE] revealed a BIMS score of 9 indicating moderately cognitively skills. Resident #21 required limited assistant with one person for bed mobility, transfers, dressing and toilet use. Resident #21 required extensive assistance with two person physical assistant for personal hygiene. Resident #21 requires a walker as a mobility device. Record review of care plan for Resident #21 dated [DATE] revealed a care plan for an actual left eye infection. Interventions were to provide antibiotic therapy as ordered. Record review of MD progress note on Resident #21 dated [DATE] revealed that Resident #21 was being treated with [MEDICATION NAME] eye drops for the conjunctivitis but the there was no progress noted. Note said: Patient continues to rub his eye and unable to control his behavior. It is easily distractible but he can return to original status. Appears to be contagious to self and others. Conjunctivae and lids appears [DIAGNOSES REDACTED]tous with discharge. Record review of MD progress note on Resident #21 dated [DATE] revealed in part: Resident #21 continues to have crusted discharge for both eyes with [DIAGNOSES REDACTED]. He has a very poor hygiene and does not seem to be washing his hands as directed. Record review on of MD progress note on Resident #21 dated [DATE] revealed that a culture was sent out which reported MRSA of the eye. Currently he is receiving [MEDICATION NAME] for conjunctivitis. There was no mentioned of isolation precautions. Record review revealed that LVN C received a verbal physician order on [DATE] to culture left eye discharge. Record review of MD progress note dated [DATE] revealed in part: conjunctivitis onset 3 weeks ago was becoming chronic associated with history of MRSA which was treated with multiple antibiotics. Conjunctiva and lids appear [DIAGNOSES REDACTED]tous on the left with yellow discharge. [MEDICATION NAME] 100 mg twice daily for seven days . Lactobacillus 1 tab daily for 14 days . Stay in room when possible until culture cleared. Record review of the laboratory results dated [DATE] at 12:19 PM revealed expired swab. Record review of laboratory results dated [DATE] at 1:10 PM revealed Isolate: 2+ gram negative Rod Isolated. Record review of MD progress note dated [DATE] revealed Resident #21 was started on [MEDICATION NAME] and culture was sent out of the left eye today . culture and sensitivity reports growth of [DIAGNOSES REDACTED] (bacterial infection of the eye) and MRSA in his eyes. Record review of MD progress note on Resident #21 dated [DATE], revealed MRSA of the left eye was being treated with [MEDICATION NAME] and Bactrim Patient is noncompliant with the isolation and staying in her room. He continues to wander around the building. Spoke with the management about making patient compliant with isolation . Observation and interview with Resident #21 on [DATE] at 11:30 AM he stated he was on isolation in his room because of an infection in his left eye. Resident #21 stated a nurse instructed him to stay in his room however he was unable to give the name of the nurse. Upon observation of the room no PPE was observed in the room and there was no sign on the door to indicate he was on isolation. Observation outside of the room revealed the room was occupied by two residents. Resident #21 was observed ambulating in his room independently. Resident #21 also stated he was continent of his bowel and bladder and was able to ambulate to his bathroom independently. In an interview with LVN-E on [DATE] at 11:40 AM he said he was not aware of Resident #21 being on isolation. He said he would have to check because there were no isolation supplies observed in Resident #21 room. Observation of Resident #21 on [DATE] at 12:40 PM revealed resident walking in his room independently. PPE noted hanging on the room door indicating he was on isolation. Observation of Resident #21 on [DATE] at 2:30 PM revealed Resident #21 in his room walking independently. PPE supplies were no longer observed on the door of his room. Observation and interview on [DATE] at 09:30 AM revealed Resident #21 in the room sitting on his bed, he said he will be glad when he is able to get out of his room. Resident states he has never been stuck in his room or on isolation before. Red and yellow bags with boxes observed in resident's bathroom. PPE noted hanging on resident's door. Resident states his roommate was out of the room at current time. Record review of the Physician's order dated on [DATE] at 09:30 AM revealed Resident #21 was placed on isolation for conjunctivitis. Interview with the Interim DON on [DATE] at 12:00 p.m. she said that the order was incorrect and the resident was placed on isolation for MRSA of the eye. Interview on [DATE] at 12:35 PM with CNA-E she said that she knows when residents were on isolation by looking to see if any PPE was hanging on the door. Observation on [DATE] at 12:37 PM revealed Resident #21 eating lunch from regular food tray inside his room. CNA noted putting gown and gloves on prior to entering the room. Phone interview with NP on [DATE] at 4:00 PM. she stated she placed Resident #21 on contact isolation the same day he was started on antibiotic. She states she gave a verbal order to the nurse to start antibiotics and to place him on contact isolation. She also stated Resident #21 was non-complaint with the isolation precaution protocol. She stated she encouraged staff to remind Resident #21 to wash his hands frequently. She stated the isolation precautions were never discontinued by her. Resident #3: Record review of Resident #3's face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; severe protein-calorie malnutrition, gastrostomy status, unspecified dementia without behavioral disturbance, anorexia, hypotension unspecified, dysphagia, oropharyneal phase, abnormal weight gain, dietary Folate deficiency, anemia, contractures unspecified knee, diaper dermatitis, urinary tract infection and osteo[DIAGNOSES REDACTED] unspecified and MRSA. Record review of the MDS assessment dated [DATE] revealed that Resident #3's cognition was severely impaired and required total assistance with activities of daily living, was incontinent of bladder and bowel, and had MRSA on a wound. Record review of Resident #3's Physician's Telephone orders dated [DATE] revealed wound culture of the right distal medial foot. Record review of Resident #3's Physician's Telephone orders dated [DATE] revealed contact isolation for MRSA and to place resident on antibiotic ([MEDICATION NAME] 100 mg twice daily for 10 days) via Gastrostomy Tube (GT). Observation during initial tour on [DATE] at 8:40 a.m. revealed Resident #3 lying in bed and she was on contact isolation. The resident had isolation precaution posted at the door and in the room there were two hazardous hampers colored yellow and red. In an interview with RN C during initial rounds on [DATE] at 8:40 a.m., she said Resident #3 was on contact isolation for MRSA in the wound to the foot. In an interview with CNA GG on [DATE] at 2:00 p.m. she said Resident #3 was in on contact isolation. Observation on [DATE] at 8:00 a.m. Resident #3 was lying in her bed. No isolation sign was posted on the door. Observation on [DATE] at 9:30 a.m. revealed no isolation sign on the door. Resident #3 was noted to be contracted to bilateral lower extremities. A wound dressing to right medial great toe was noted. Incontinent care was performed by CNA GG and CNA L. At that time, Resident #3's wound dressing that was supposed to cover the right great toe came off; Resident #3 had large bowel movement and soiled the linen. CNA GG placed the soiled linen in a clear plastic bag and took it to the soiled linen room. In an interview with CNA GG on [DATE] at 10:00 a.m. she was told Resident #3's contact isolation was discontinued. In an interview with RN C on [DATE] at 12:25 p.m. she said Resident #3 was not supposed to be on isolation and there were no order for isolation and that was why it was discontinued on [DATE] in the evening. Record Review of the Physician Order's dated [DATE] for Resident #3 revealed an order clarification for contact isolation for MRSA of right foot. During an interview with the Administrator on [DATE] at 4:45 p.m. she said no residents were on isolation. During an interview with the Interim DON on [DATE] at 4:50 p.m. regarding justifying taking Resident #3 off isolation, she said she had an order. When asked to provide a copy of the discontinued order, she looked on the computer did not find any order. No copy was provided by the facility. Observation of Resident #3 lying on [DATE] at 8:40 am revealed a contact isolation sign was posted at the door and PPE was in the room. During an interview with RN C on [DATE] at 9:40 a.m. she said Resident #3 was placed on isolation again because they received an order from the Nurse Practitioner. Interview on [DATE] at 9:25 a.m. with LVN-T said if he receive a lab result on a resident testing positive for MRSA, he place the resident on isolation and notify the staff so they would know to wear their PPE(Personal Protective Equipment) and initiate an SBAR as well as notify the physician. LVN-T said the reason he would take these precautionary measures was because MRSA was very hard to get rid of and was contagious. Interview on [DATE] at 9:40 a.m. RN-F said if a resident tested positive for MRSA said she would notify the physician and go ahead and place the resident (s) on contact isolation precautions because MRSA was contagious and they need to protect the other residents and staff members. In an interview with the NP on [DATE] at 2:51 p.m. the NP said she was aware that Resident #3 was placed on contact isolation on [DATE] by the on call NP. She said she did not discontinued the isolation and nobody had called her to discontinued Resident #3's contact isolation. The NP said she came to the facility on [DATE] evening and placed Resident #3 back on isolation because it should not have been discontinued. In an interview on [DATE] at 11:50 am the Housekeeping Director said that they have a specific protocol to clean the rooms for those residents in isolation. She said that the housekeeping staff will know who was in isolation because there will be a sign on the door. She said the staff will use PPE before entering the room, clean, and then disposed of the trash in the biohazards bags. Resident #23: Record review of Resident #23's face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; tracheotomy status, shortness of breath and chronic obstructive pulmonary disease with acute exacerbation. Record review of the Monthly tracking Infection Control Report dated [DATE] noted one infection. Record review of the MDS assessment dated [DATE] revealed that Resident #23's cognition was moderately impaired and required total assistance with activities of daily living. Further review revealed that the resident had a tracheostomy tube. During an observation on [DATE] at 12:55 p.m., LVN E provided tracheotomy care for Resident # 23. LVN E did not use a sterile tracheotomy tray. LVN E washed hands and used the clean gloves. He opened Resident #23's nightstand drawer and removed an opened Sleeved suction catheter that was dated [DATE]. He connected the tubing to the suction machine and took off the neck collar. LVN E then opened the normal saline and poured it in an open suctioned cup that was located at the bedside table and then suction inside Resident #23's trach. Record review of the Manufacturer recommendation written on Sleeved suction catheter kit package revealed: sterile in unopened undamaged package. Do not re-sterilize. Single use only. Do not reuse. Avoid excessive heat. Protect from freezing. During an interview on [DATE] at 1:10 p.m., LVN E regarding Tracheotomy care he said that tracheotomy suctioning was just a clean technique and he only use a sterile technique while changing the inner cannula. LVN E said he was taught that an opened sleeved suction catheter can be reused. He said he was trained by the staff development manager recently. During an interview on [DATE] at 9:50 a.m., with the staff development manager regarding Tracheotomy care, she said tracheotomy suctioning was just a clean technique and a sterile technique was only used while changing the inner cannula. She said this is what she teaches the facility staff. At this time the nurse surveyor presented the Manufacturer's recommendation on Sleeved suction catheter kit, indicating they were for single used and must be sterile. The staff development manager said to be honest with you, I was not aware of the manufacturer's recommendation on Sleeved suction catheter kit. I am going to show that to the Administrator. Resident #1: Record review of Resident #1's face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; tracheotomy status, persistent vegetative state, chronic respiratory failure unspecified, anoxic brain damage not elsewhere classified, gastrostomy status, shortness of breath, cerebral infarction, contractures-unspecified knee, muscle wasting and atrophy, do not resuscitate, essential (primary) hypertension and abnormal weight loss. Record review of the MDS assessment dated [DATE] revealed that Resident #1's cognition was severely impaired and required total assistance with activities of daily living. Further review revealed that the resident had an indwelling catheter, colostomy bag and tracheostomy tube. Record review of the most recent Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident scored was 'blank' on the Brief Interview for Mental Status (BIMS), which reflected severely impaired skills for daily decision making. Record review of Resident #1's Tracheotomy status care plan dated [DATE] addressed suctioning. Record review of Resident #1 care plan revised on [DATE] revealed that resident was being care planned for the use of an indwelling catheter. Interventions included to anchor catheter to prevent excess tension, position catheter bag and tubing below the level of the bladder, observe and document intake and output and check tubing for kinks each shift. Observation on [DATE] at 8:30 a.m. revealed Resident #1 in bed during incontinent/indwelling catheter care. The indwelling urinary catheter was hanging from the bottom of the bed rail. The resident's catheter tubing was not secured in place. The catheter tubing was between her legs and the left leg had an indentation mark on the inner thigh about 5 cm in length. The indwelling catheter tubing had whitish sediment in the tubing. During an observation on [DATE] at 11:15 a.m., RN C provided tracheotomy care for Resident # 1. An opened sleeved suction catheter kit was noticed on the bedside table. RN C proceeded to open the sterile tracheotomy tray with clean gloves and re-gloved sterile gloves and touched the underside of the opened tray with her sterile gloves. Using the same gloves she picked up the opened normal saline half bottle, took the sleeved suction catheter kit left on the bedside table and took off the neck collar. RN C suctioned Resident #1 in a circular motion while inserting the Sleeved suction catheter tubing 5 times without rinsing the suction catheter with normal saline. Copious phlegm was noted. During an interview on [DATE] at 11:45 a.m., RN C regarding Tracheotomy care she said she used the sleeved suction catheter and the normal saline that morning too. She said she was trained by the staff development manager, that the Sleeved suction catheter can be reused because they did touch the catheter inside the sleeve. RN C said she was new and still learning and was very appreciative for error pointed out. Record review of the Manufacturer's recommendation written on Sleeved suction catheter kit package revealed: sterile in unopened undamaged package. Do not re-sterilize. Single use only. Do not reuse. Avoid excessive heat. Protect from freezing. Observation on [DATE] at 5:00 p.m. revealed CNA K and CNA N providing catheter care for Resident #1. CNA K changed gloves 5 times while cleaning indwelling catheter and frontal peri area without washing her hands and using hand sanitizer. Record review of infection log on [DATE] revealed Resident #1 was treated with [MEDICATION NAME] for urinary tract infection. Precaution as appropriate Resident #4: Review of Resident # 4's face sheet, revealed Resident #4 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation during incontinent care on [DATE] at 1:24 p.m. revealed CNA Q and CNA LL providing incontinent care for Resident # 4. CNA Q put on gloves and during care the gloves became soiled with feces. The gloves were not changed. No hand hygiene was provided at that time. CNA Q continued to provide incontinent care using the soiled gloves until Resident # 4's brief was applied. During an interview on [DATE] at 8:47 a.m. CNA Q she confirmed she should have changed gloves during incontinent care for Resident #4, after coming in contact with fecal material. In an interview with the Interim DON on [DATE] at 2:40 p.m. confirmed staff was supposed to change gloves during care when contact with infectious or potentially infectious material is made. Environment: Observation on [DATE] at 8:20 a.m. inside room [ROOM NUMBER] revealed 3 wash basins in the bathroom, not inside of plastic bags and two were unlabeled. The room was occupied by two residents. Observation on [DATE] at 8:42 a.m. inside the bathroom in room [ROOM NUMBER] revealed on top of the sink was a toothbrush laying out with no name and not in plastic bag. A pair of gloves were sitting inside of roll of toilet paper. A commode plunger un-contained was sitting on left side of commode on floor. The room was occupied by two residents. Observation on [DATE] at 8:55 a.m. room [ROOM NUMBER] in bathroom toothpaste with 2 shaving razors along with a toothbrush inside of a cup with no name. The room was occupied by two residents. Interview on [DATE] at 1:55 p.m. CNA-CC said resident personal belongings were supposed to be labeled with their names on it and stored in a separate plastic bag. CNA-CC said the reason the staff label and bag the resident personal belongings was for infection control purposes. CNA-CC said most of the resident items were not labeled. Interview on [DATE] at 2:50 p.m. the Interim DON said the residents personal belongings were supposed to be labeled with the residents name on it especially toothpaste and toothbrushes and then placed in a plastic bag. The Interim DON said the reason why the facility separate personal items, label, and bag them to prevent infections. Record review of the facility Infection Prevention Manual for Long Term Care dated (c) 2012 ICP Associates, Inc. Contact Precautions: Purpose: It is the intent of this facility to use contact precautions in addition to standard precautions for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the resident's environment Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are transmitted by direct or indirect contact with the patient or the patient ' s environment. A single-patient room is preferred for patients who require Contact Precautions. When a single-patient room is not available, consultation with infection control is necessary to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). HCP caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient ' s environment. Lippincott Procedure: Tracheostomy Care/Tracheostomy Suctioning Suggested Procedure: 1. Gather equipment: Sterile tracheostomy care tray, normal saline, hydrogen peroxide, eye protection, suction apparatus, and anesthesia bag. 2. Wash hands. Put on clean gloves and remove dressing (keep obturator at bedside in clean, clear package). 3. Remove clean gloves and rewash hands. Loosen caps on hydrogen peroxide and normal saline. 4. Open sterile tracheostomy care tray. 5. Don sterile gloves. 6. Remove drape with plastic liner from tray and set up sterile field. 7. Arrange contents of tray onto sterile field. 8. Pour saline and cleaning solution into two separate containers. 9. Remove trach collar. 10. Remove inner cannula (may use sterile 4X4 to stabilize trach plate with sterile dominant hand) and immerse in cleaning solution. Clean inner cannula with brush and pipe cleaners. (Shiley has inner cannula; [MEDICATION NAME] foam cuff does not have inner cannula). 11. Immerse and rinse inner cannula in sterile saline/sterile. Review of the facility policy labeled perineal care of the male resident, date [DATE], revealed staff should put on gloves to comply with standard precautions . Furthermore, gloves are removed after use, before touching non-contaminated items and surfaces, and before going to another patient. The facility Administrator, Executive Director, Regional Clinical Services and Interim DON were notified on [DATE] at 12:43 p.m. that an IJ had been identified due to the above failures. The facility submitted several plans of removal (PoR) that required corrections and a revision was accepted on [DATE]. The following plan of action to remove the IJ was submitted by the Administrator on [DATE] at 11:45 p.m. the Plan of removal included in part: .PLAN TO REMOVE IMMEDIATE JEOPARDY Tracheostomy Care/Isolation Practices/Infection Control The RT completed an assessment of residents with tracheostomy care. No signs or symptoms of infection were noted. This was completed [DATE]. The DON and Dr. completed an assessment of all residents for signs and symptoms of infection for proper isolation and infection control practices. Dr. identified two residents with infection, both placed on isolation. This was completed [DATE]. Licensed nursing staff (RN/LVN) will be re-educated on Tracheostomy care by Nursing or Respiratory Therapy. Education to include the following: -How and when to suction a patient with a tracheostomy -Proper suctioning technique -Proper use of sleeved suctioning catheter -Proper tracheostomy site care and dressing changes -Securing the tracheostomy tube -Proper infection control practices during tracheostomy care -Isolation policy, procedures and practices Section 4 page ,[DATE]. Type and Duration of Precautions Needed for Selected Infection and Conditions. CDC Guidelines for Isolation Precautions. Since 2012 it has been facility policy to use CDC guidelines. -Identifying infection using McGeer criteria Section 2 page Surveillance page ,[DATE]. -Completing nursing care plan -Notifying physicians of change of patient condition Licensed nursing staff (RN/LVN) will be educated starting [DATE] until [DATE] by 4 p.m. CNA/direct care staff will be re-educated on infection control practices by DON on Education including discussion about the following: -Using Stop and Watch to notifying licensed nurse of change of patient condition -Hand hygiene -Proper glove use -Donning and removing PPE -Standard precautions -Contact precautions -Proper disposal and nurse notification of loose/detached dressings when caring for patients CNA/direct care staff will be educated on infection control starting [DATE]-[DATE] ending at 4:00 p.m. Staff failing to attend the scheduled educations will not be able to work until education is completed .' Interview on [DATE] at 8:40 a.m. the Medical Director said that if a resident has MRSA in a wound that can be contained and secured with a dressing, he would not isolate the resident. The Medical Director said if the dressing did come off, the CNA should let the nurse know. He said that MRSA was everywhere, all on the rails and counter tops, but that if the MRSA was in a wound that is MDRO (Multiple Drug Resistant Organism) .We would Isolate. The facility was monitored from [DATE] to [DATE] to verify that the plan was implemented. Monitoring of POR included in part: Interviews on with multiple nurses from different shifts on [DATE] , [DATE] and [DATE] revealed they had been in-serviced on documentation, tracheostomy care and proper isolation practices , and notifying the physician of any change in resident condition, signs and indwelling catheter care. Interviews on [DATE], [DATE] and [DATE] with multiple RN's and CNAs from different shifts revealed they received in-service on change in resident condition, reporting to the nurse and indwelling catheter care. Observation of trach care were conducted on ,[DATE] and ,[DATE]. No infection control and technique issues were observed. Record review revealed the facility had completed an audit for all the residents with contact isolation, catheters and Tracheostomy care to ensure MD was notified of any changes. In an interview on [DATE] at 11:00 a.m., the Administrator said the reason why she felt the facility had an IJ was because of confusion related to isolation precautions and infection control concerns with tracheostomy care. In an interview on [DATE] at 9:45 a.m. the DON said all nursing staff are trained on infection control and tracheostomy care. She said she felt the IJ situation came about because nursing staff were unaware of sterile procedure for tracheostomy care and infection control concerns related to isolation. The Administrator and Interim DON were informed on [DATE] at 11:45 a.m. that the IJ was lowered; however the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm that is not an IJ due to need for continued monitoring of staff. and effectiveness of plan of removal. According to the CMS form 672 the facility census was 122.

Based on observation, interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of for 5 of 27 residents reviewed for Administration, in that: - The Administrator failed to supervise the Interim DON in her responsibilities in the areas of staff training, staff monitoring, and implementing preventive measures for infection control and proper [MEDICAL CONDITION] care. - The Interim DON failed to monitor her staff and provide staff training in the areas of infection control and proper [MEDICAL CONDITION] care. An IJ was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of widespread and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure affected 5 resident and placed 117 residents at risk of contracting infections, decline in quality or care and quality of life. Findings include: Resident #21 Record review of Resident #21's face sheet revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #21's MDS dated [DATE] revealed a BIMS score of 9 indicating moderately cognitively skills. Resident #21 required limited assistant with one person for bed mobility, transfers, dressing and toilet use. Resident #21 required extensive assistance with two person physical assistant for personal hygiene. Resident #21 requires a walker as a mobility device. Record review of care plan for Resident #21 dated [DATE] revealed a care plan for an actual left eye infection. Interventions were to provide antibiotic therapy as ordered. Record review of MD progress note on Resident #21 dated [DATE] revealed that Resident #21 was being treated with [MEDICATION NAME] eye drops for the [MEDICAL CONDITION] but the there was no progress noted. Note said: Patient continues to rub his eye and unable to control his behavior. It is easily distractible but he can return to original status. Appears to be contagious to self and others. Conjunctivae and lids appears [DIAGNOSES REDACTED]tous with discharge. Record review of MD progress note on Resident #21 dated [DATE] revealed in part: Resident #21 continues to have crusted discharge for both eyes with [DIAGNOSES REDACTED]. He has a very poor hygiene and does not seem to be washing his hands as directed. Record review on of MD progress note on Resident #21 dated [DATE] revealed that a culture was sent out which [MEDICAL CONDITION] of the eye. Currently he is receiving [MEDICATION NAME] for [MEDICAL CONDITION]. There was no mentioned of isolation precautions. Record review revealed that LVN C received a verbal physician order on [DATE] to culture left eye discharge. Record review of MD progress note dated [DATE] revealed in part: [MEDICAL CONDITION] onset 3 weeks ago was becoming chronic associated with history [MEDICAL CONDITION] which was treated with multiple antibiotics. Conjunctiva and lids appear [DIAGNOSES REDACTED]tous on the left with yellow discharge. [MEDICATION NAME] 100 mg twice daily for seven days . Lactobacillus 1 tab daily for 14 days . Stay in room when possible until culture cleared. Record review of the laboratory results dated [DATE] at 12:19 PM revealed expired swab. Record review of laboratory results dated [DATE] at 1:10 PM revealed Isolate: 2+ gram negative Rod Isolated. Record review of MD progress note dated [DATE] revealed Resident #21 was started on [MEDICATION NAME] and culture was sent out of the left eye today . culture and sensitivity reports growth of [DIAGNOSES REDACTED] (bacterial infection of the eye) [MEDICAL CONDITION] in his eyes. Record review of MD progress note on Resident #21 dated [DATE], [MEDICAL CONDITION] of the left eye was being treated with [MEDICATION NAME] and Bactrim Patient is noncompliant with the isolation and staying in her room. He continues to wander around the building. Spoke with the management about making patient compliant with isolation . Observation and interview with Resident #21 on [DATE] at 11:30 AM he stated he was on isolation in his room because of an infection in his left eye. Resident #21 stated a nurse instructed him to stay in his room however he was unable to give the name of the nurse. Upon observation of the room no PPE was observed in the room and there was no sign on the door to indicate he was on isolation. Observation outside of the room revealed the room was occupied by two residents. Resident #21 was observed ambulating in his room independently. Resident #21 also stated he was continent of his bowel and bladder and was able to ambulate to his bathroom independently. In an interview with LVN-E on [DATE] at 11:40 AM he said he was not aware of Resident #21 being on isolation. He said he would have to check because there were no isolation supplies observed in Resident #21 room. Observation of Resident #21 on [DATE] at 12:40 PM revealed resident walking in his room independently. PPE noted hanging on the room door indicating he was on isolation. Observation of Resident #21 on [DATE] at 2:30 PM revealed Resident #21 in his room walking independently. PPE supplies were no longer observed on the door of his room. Observation and interview on [DATE] at 09:30 AM revealed Resident #21 in the room sitting on his bed, he said he will be glad when he is able to get out of his room. Resident states he has never been stuck in his room or on isolation before. Red and yellow bags with boxes observed in resident's bathroom. PPE noted hanging on resident's door. Resident states his roommate was out of the room at current time. Record review of the Physician's order dated on [DATE] at 9:30 AM revealed Resident #21 was placed on isolation for [MEDICAL CONDITION]. Interview with the Interim DON on [DATE] at 12:00 p.m. she said that the order was incorrect and the resident was placed on isolation [MEDICAL CONDITION] of the eye. Interview on [DATE] at 12:35 PM with CNA-E she said that she knows when residents were on isolation by looking to see if any PPE was hanging on the door. Observation on [DATE] at 12:37 PM revealed Resident #21 eating lunch from regular food tray inside his room. CNA noted putting gown and gloves on prior to entering the room. Phone interview with NP on [DATE] at 4:00 PM. she stated she placed Resident #21 on contact isolation the same day he was started on antibiotic. She states she gave a verbal order to the nurse to start antibiotics and to place him on contact isolation. She also stated Resident #21 was non-complaint with the isolation precaution protocol. She stated she encouraged staff to remind Resident #21 to wash his hands frequently. She stated the isolation precautions were never discontinued by her. Resident #3: Record review of Resident #3's face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; severe protein-calorie malnutrition, gastrostomy status, unspecified dementia without behavioral disturbance, anorexia, [MEDICAL CONDITION] unspecified, dysphagia, oropharyneal phase, abnormal weight gain, dietary Folate deficiency, [MEDICAL CONDITION], contractures unspecified knee, diaper [MEDICAL CONDITION], urinary tract infection and osteo[DIAGNOSES REDACTED] unspecified [MEDICAL CONDITION]. Record review of the MDS assessment dated [DATE] revealed that Resident #3's cognition was severely impaired and required total assistance with activities of daily living, was incontinent of bladder and bowel, and [MEDICAL CONDITION] on a wound. Record review of Resident #3's Physician's Telephone orders dated [DATE] revealed wound culture of the right distal medial foot. Record review of Resident #3's Physician's Telephone orders dated [DATE] revealed contact isolation [MEDICAL CONDITION] and to place resident on antibiotic ([MEDICATION NAME] 100 mg twice daily for 10 days) via Gastrostomy Tube (GT). Observation during initial tour on [DATE] at 8:40 a.m. revealed Resident #3 lying in bed and she was on contact isolation. The resident had isolation precaution posted at the door and in the room there were two hazardous hampers colored yellow and red. In an interview with RN C during initial rounds on [DATE] at 8:40 a.m., she said Resident #3 was on contact isolation [MEDICAL CONDITION] in the wound to the foot. In an interview with CNA GG on [DATE] at 2:00 p.m. she said Resident #3 was in on contact isolation. Observation on [DATE] at 8:00 a.m. Resident #3 was lying in her bed. No isolation sign was posted on the door. Observation on [DATE] at 9:30 a.m. revealed no isolation sign on the door. Resident #3 was noted to be contracted to bilateral lower extremities. A wound dressing to right medial great toe was noted. Incontinent care was performed by CNA GG and CNA L at the time, Resident #3 had large bowel movement and soiled the linen. The wound dressing to right medial great toe came off. CNA GG placed the soiled linen in a clear plastic bag and took it to the soiled linen room. In an interview with CNA GG on [DATE] at 10:00 a.m. she was told Resident #3's contact isolation was discontinued. In an interview with RN C on [DATE] at 12:25 p.m. she said Resident #3 was not supposed to be on isolation and there were no order for isolation and that was why it was discontinued on [DATE] in the evening. Record Review of the Physician Order's for Resident #3 revealed an order clarification for contact isolation [MEDICAL CONDITION] of right foot. During an interview with the Administrator on [DATE] at 4:45 p.m. she said no residents were on isolation. During an interview with the Interim DON on [DATE] at 4:50 p.m. regarding justifying taking Resident #3 off isolation, she said she had an order. When asked to provide a copy of the discontinued order, she looked on the computer did not find any order. No copy was provided by the facility. Observation of Resident #3 lying on [DATE] at 8:40 a.m. revealed a contact isolation sign was posted at the door and PPE was in the room. During an interview with RN C on [DATE] at 9:40 a.m. she said Resident #3 was placed on isolation again because they received an order from the Nurse Practitioner. Interview on [DATE] at 9:25 a.m. with LVN-T said if he receive a lab result on a resident testing positive [MEDICAL CONDITION], he place the resident on isolation and notify the staff so they would know to wear their PPE(Personal Protective Equipment) and initiate an SBAR as well as notify the physician. LVN-T said the reason he would take these precautionary measures was [MEDICAL CONDITION] was very hard to get rid of and was contagious. Interview on [DATE] at 9:40 a.m. RN-F said if a resident tested positive [MEDICAL CONDITION] said she would notify the physician and go ahead and place the resident (s) on contact isolation precautions [MEDICAL CONDITION] was contagious and they need to protect the other residents and staff members. In an interview with the NP on [DATE] at 2:51 p.m. the NP said she was aware that Resident #3 was placed on contact isolation on [DATE] by the on call NP. She said she did not discontinued the isolation and nobody had called her to discontinued Resident #3's contact isolation. The NP said she came to the facility on [DATE] evening and placed Resident #3 back on isolation because it should not have been discontinued. In an interview on [DATE] at 11:50 a.m. the Housekeeping Director said that they have a specific protocol to clean the rooms for those residents in isolation. She said that the housekeeping staff will know who was in isolation because there will be a sign on the door. She said the staff will use PPE before entering the room, clean, and then disposed of the trash in the biohazards bags. Resident #23: Record review of Resident #23's face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; tracheotomy status, shortness of breath and [MEDICAL CONDITION] with acute exacerbation. Record review of the Monthly tracking Infection Control Report dated [DATE] noted one infection. Record review of the MDS assessment dated [DATE] revealed that Resident #23's cognition was moderately impaired and required total assistance with activities of daily living. Further review revealed that the resident had a [MEDICAL CONDITION]. During an observation on [DATE] at 12:55 p.m., LVN E provided tracheotomy care for Resident #23. LVN E did not use a sterile tracheotomy tray. LVN E washed hands and used the clean gloves. He opened Resident #23's nightstand drawer and removed an opened Sleeved suction catheter that was dated [DATE]. He connected the tubing to the suction machine and took off the neck collar. LVN E then opened the normal saline and poured it in an open suctioned cup that was located at the bedside table and then suction inside Resident #23's trach. **** Record review of the Manufacturer's recommendation written on Sleeved suction catheter kit package revealed: sterile in unopened undamaged package. Do not re-sterilize. Single use only. Do not reuse. Avoid excessive heat. Protect from freezing. During an interview on [DATE] at 1:10 p.m., LVN E regarding Tracheotomy care he said that tracheotomy suctioning was just a clean technique and he only use a sterile technique while changing the inner cannula. LVN E said he was taught that an opened sleeved suction catheter can be reused. He said he was trained by the staff development manager recently. During an interview on [DATE] at 9:50 a.m., with the staff development manager regarding Tracheotomy care, she said tracheotomy suctioning was just a clean technique and a sterile technique was only used while changing the inner cannula. She said this is what she teaches the facility staff. At this time the nurse surveyor presented the Manufacturer's recommendation on Sleeved suction catheter kit, indicating they were for single used and must be sterile. The staff development manager said, to be honest with you, I was not aware of the manufacturer's recommendation on Sleeved suction catheter kit. I am going to show that to the Administrator. Resident #1: Record review of Resident #1's face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; tracheotomy status, persistent vegetative state, chronic [MEDICAL CONDITION] unspecified, [MEDICAL CONDITION] not elsewhere classified, gastrostomy status, shortness of breath, cerebral infarction, contractures-unspecified knee, muscle wasting and atrophy, do not resuscitate, essential (primary) hypertension and abnormal weight loss. Record review of the MDS assessment dated [DATE] revealed that Resident #1's cognition was severely impaired and required total assistance with activities of daily living. Further review revealed that the resident had an indwelling catheter, [MEDICAL CONDITION] bag and [MEDICAL CONDITION]. Record review of the most recent Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident scored was 'blank' on the Brief Interview for Mental Status (BIMS), which reflected severely impaired skills for daily decision making. Record review of Resident #1's Tracheotomy status care plan dated [DATE] addressed suctioning . Record review of Resident #1 care plan revised on [DATE] revealed that resident was being care planned for the use of an indwelling catheter. Interventions included to anchor catheter to prevent excess tension, position catheter bag and tubing below the level of the bladder, observe and document intake and output and check tubing for kinks each shift. Observation on [DATE] at 8:30 a.m. revealed Resident #1 in bed during incontinent/indwelling catheter care. The indwelling urinary catheter was hanging from the bottom of the bed rail. The resident's catheter tubing was not secured in place. The catheter tubing was between her legs and the left leg had an indentation mark on the inner thigh about 5 cm in length. The indwelling catheter tubing had whitish sediment in the tubing. During an observation on [DATE] at 11:15 a.m., RN C provided tracheotomy care for Resident # 1. An opened sleeved suction catheter kit was noticed on the bedside table. RN C proceeded to open the sterile tracheotomy tray with clean gloves and re-gloved sterile gloves. She touched the underside of the opened tray with her sterile gloves. Using the same gloves she picked up the opened normal saline half bottle, took the sleeved suction catheter kit left on the bedside table and took off the neck collar. RN C suctioned Resident #1 in a circular motion while inserting the Sleeved suction catheter tubing 5 times without rinsing the suction catheter with normal saline. Copious phlegm was noted. During an interview on [DATE] at 11:45 a.m., RN C regarding Tracheotomy care she said she used the sleeved suction catheter and the normal saline that morning too. She said she was trained by the staff development manager, that the Sleeved suction catheter can be reused because they did touch the catheter inside the sleeve. RN C said she was new and still learning. Record review of the Manufacturer's recommendation written on Sleeved suction catheter kit package revealed: sterile in unopened undamaged package. Do not re-sterilize. Single use only. Do not reuse. Avoid excessive heat. Protect from freezing. Observation on [DATE] at 5:00 p.m. revealed CNA K and CNA N providing catheter care for Resident #1. CNA K changed gloves 5 times while cleaning indwelling catheter and frontal peri area without washing her hands and using hand sanitizer. Record review of infection log on [DATE] revealed Resident #1 was treated with [MEDICATION NAME] for urinary tract infection. Precaution as appropriate Resident #4: Review of Resident # 4's face sheet, revealed Resident #4 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation during incontinent care on [DATE] at 1:24 p.m. revealed CNA Q and CNA LL providing incontinent care for Resident #4. CNA Q put on gloves and during care the gloves became soiled with feces. The gloves were not changed. No hand hygiene was provided at that time. CNA Q continued to provide incontinent care using the soiled gloves until Resident # 4's brief was applied. During an interview on [DATE] at 8:47 a.m. CNA Q she confirmed she should have changed gloves during incontinent care for Resident #4, after coming in contact with fecal material. In an interview with the Interim DON on [DATE] at 2:40 p.m. confirmed staff was supposed to change gloves during care when contact with infectious or potentially infectious material is made. Environment: Observation on [DATE] at 8:20 a.m. inside room [ROOM NUMBER] revealed 3 wash basins in the bathroom, not inside of plastic bags and two were unlabeled. The room was occupied by two residents. Observation on [DATE] at 8:42 a.m. inside the bathroom in room [ROOM NUMBER] revealed on top of the sink was a toothbrush laying out with no name and not in plastic bag. A pair of gloves were sitting inside of roll of toilet paper. A commode plunger un-contained was sitting on left side of commode on floor. The room was occupied by two residents. Observation on [DATE] at 8:55 a.m. room [ROOM NUMBER] in bathroom toothpaste with 2 shaving razors along with a toothbrush inside of a cup with no name. The room was occupied by two residents. Interview on [DATE] at 1:55 p.m. CNA-CC said resident personal belongings were supposed to be labeled with their names on it and stored in a plastic bag. CNA-CC said the reason the staff label and bag the resident personal belongings was for infection control purposes. CNA-CC said most of the resident items were not labeled. Interview on [DATE] at 2:50 p.m. the Interim DON said the residents personal belongings were supposed to be labeled with the residents name on it especially toothpaste and toothbrushes and then placed in a plastic bag. The Interim DON said the reason why the facility separate personal items, label, and bag them to prevent infections. Record review of the facility Infection Prevention Manual for Long Term Care dated (c) 2012 ICP Associates, Inc. Contact Precautions: Purpose: It is the intent of this facility to use contact precautions in addition to standard precautions for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the resident's environment Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are transmitted by direct or indirect contact with the patient or the patient ' s environment. A single-patient room is preferred for patients who require Contact Precautions. When a single-patient room is not available, consultation with infection control is necessary to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). HCP caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient ' s environment. Lippincott Procedure: [MEDICAL CONDITION] Care/[MEDICAL CONDITION] Suctioning Suggested Procedure: 1. Gather equipment: Sterile [MEDICAL CONDITION] care tray, normal saline, hydrogen peroxide, eye protection, suction apparatus, and anesthesia bag. 2. Wash hands. Put on clean gloves and remove dressing (keep obturator at bedside in clean, clear package). 3. Remove clean gloves and rewash hands. Loosen caps on hydrogen peroxide and normal saline. 4. Open sterile [MEDICAL CONDITION] care tray. 5. Don sterile gloves. 6. Remove drape with plastic liner from tray and set up sterile field. 7. Arrange contents of tray onto sterile field. 8. Pour saline and cleaning solution into two separate containers. 9. [MEDICAL CONDITION]. 10. Remove inner cannula (may use sterile 4X4 to [MEDICAL CONDITION] with sterile dominant hand) and immerse in cleaning solution. Clean inner cannula with brush and pipe cleaners. (Shiley has inner cannula; [MEDICATION NAME] foam cuff does not have inner cannula). 11. Immerse and rinse inner cannula in sterile saline/sterile. Review of the facility policy labeled perineal care of the male resident, date [DATE], revealed staff should put on gloves to comply with standard precautions . Furthermore, gloves are removed after use, before touching non-contaminated items and surfaces, and before going to another patient. The facility Administrator, Executive Director, Regional Clinical Services and Interim DON were notified on [DATE] at 12:43 p.m. that an IJ had been identified due to the above failures. The facility submitted several plans of removal (PoR) that required corrections and a revision was accepted on [DATE]. The following plan of action to remove the IJ was submitted by the Administrator on [DATE] at 11:45 p.m. the Plan of removal included in part: .PLAN TO REMOVE IMMEDIATE JEOPARDY [MEDICAL CONDITION] Care/Isolation Practices/Infection Control The RT completed an assessment of residents with [MEDICAL CONDITION] care. No signs or symptoms of infection were noted. This was completed [DATE]. The DON and Dr. completed an assessment of all residents for signs and symptoms of infection for proper isolation and infection control practices. Dr. identified two residents with infection, both placed on isolation. This was completed [DATE]. Licensed nursing staff (RN/LVN) will be re-educated on [MEDICAL CONDITION] care by Nursing or Respiratory Therapy. Education to include the following: -How and when to suction a patient with a [MEDICAL CONDITION] -Proper suctioning technique -Proper use of sleeved suctioning catheter -Proper [MEDICAL CONDITION] site care and dressing changes -Securing the [MEDICAL CONDITION] -Proper infection control practices during [MEDICAL CONDITION] care -Isolation policy, procedures and practices Section 4 page ,[DATE]. Type and Duration of Precautions Needed for Selected Infection and Conditions. CDC Guidelines for Isolation Precautions. Since 2012 it has been facility policy to use CDC guidelines. -Identifying infection using McGeer criteria Section 2 page Surveillance page ,[DATE]. -Completing nursing care plan -Notifying physicians of change of patient condition Licensed nursing staff (RN/LVN) will be educated starting [DATE] until [DATE] by 4 p.m. CNA/direct care staff will be re-educated on infection control practices by DON on Education including discussion about the following: -Using Stop and Watch to notifying licensed nurse of change of patient condition -Hand hygiene -Proper glove use -Donning and removing PPE -Standard precautions -Contact precautions -Proper disposal and nurse notification of loose/detached dressings when caring for patients CNA/direct care staff will be educated on infection control starting [DATE]-[DATE] ending at 4:00 p.m. Staff failing to attend the scheduled educations will not be able to work until education is completed .' Interview on [DATE] at 8:40 a.m. the Medical Director said that if a resident [MEDICAL CONDITION] in a wound that can be contained and secured with a dressing, he would not isolate the resident. The Medical Director said if the dressing did come off, the CNA should let the nurse know. He said [MEDICAL CONDITION] was everywhere, all on the rails and counter tops, but that if [MEDICAL CONDITION] was in a wound that is MDRO (Multiple Drug Resistant Organism) .We would Isolate. The facility was monitored from [DATE] to [DATE] to verify that the plan was implemented. Monitoring of POR included in part: Interviews on with multiple nurses from different shifts on [DATE] , [DATE] and [DATE] revealed they had been in-serviced on documentation, [MEDICAL CONDITION] care and proper isolation practices , and notifying the physician of any change in resident condition, signs and indwelling catheter care. Interviews on [DATE], [DATE] and [DATE] with multiple RN's and CNAs from different shifts revealed they received in-service on change in resident condition, reporting to the nurse and indwelling catheter care. Observation [MEDICAL CONDITION] were conducted on ,[DATE] and ,[DATE]. No infection control and technique issues were observed. Record review revealed the facility had completed an audit for all the residents with contact isolation, catheters and [MEDICAL CONDITION] care to ensure MD was notified of any changes. In an interview on [DATE] at 11:00 a.m., the Administrator said the reason why she felt the facility had an IJ was because of confusion related to isolation precautions and infection control concerns with [MEDICAL CONDITION] care. In an interview on [DATE] at 9:45 a.m. the DON said all nursing staff are trained on infection control and [MEDICAL CONDITION] care. She said she felt the IJ situation came about because nursing staff were unaware of sterile procedure for [MEDICAL CONDITION] care and infection control concerns related to isolation. The Administrator and Interim DON were informed on [DATE] at 11:45 a.m. that the IJ was lowered; however the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to need for continued monitoring of staff and effectiveness of plan of removal. According to the CMS form 672 the facility census was 122.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, for two of two residents with tracheotomies. (Resident #1 and #23) - The facility failed to use sterile technique, sterile equipment, and to follow the manufacturer's recommendation during Tracheotomy suctioning for Resident #1. - The facility failed to use sterile technique, sterile equipment, and follow the manufacturer's recommendation during Tracheotomy suctioning for Resident #23. An IJ was identified on 07/14/17. While the IJ was lowered on 07/18/17 the facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to facility requiring more time to monitor the plan of removal for effectiveness. This failure placed the 2 residents with Tracheotomies at risk of Infection in the trachea and around the tracheotomy tube, hospitalization and a decline in their quality of life. Findings Included: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; tracheotomy status, persistent vegetative state, chronic [MEDICAL CONDITION] unspecified, [MEDICAL CONDITION] not elsewhere classified, gastrostomy status, shortness of breath, cerebral infarction, contractures-unspecified knee, muscle wasting and atrophy, do not resuscitate, essential (primary) hypertension and abnormal weight loss. Record review of the MDS assessment dated [DATE] revealed that Resident #1's cognition was severely impaired and required total assistance with activities of daily living. Further review revealed that the resident had an indwelling catheter, [MEDICAL CONDITION] bag and tracheotomy tube. Record review of the most recent Minimum Data Set (MDS) assessment, dated 05/16/17, revealed the resident scored was 'blank' on the Brief Interview for Mental Status (BIMS), which reflected severely impaired skills for daily decision making. Record review of Resident #1's Tracheotomy status care plan dated 2/15/17 addressed suctioning. During an observation on 7/12/17 at 11:15 a.m., RN C provided tracheotomy care for Resident # 1. An opened sleeved suction catheter kit was noticed on the bedside table. RN C proceeded to open the sterile tracheotomy tray with clean gloves and re-gloved sterile gloves and touched the underside of the opened tray with her sterile gloves. Using the same gloves she picked up the half bottle of normal saline that was already opened, took the sleeved suction catheter kit left on the bedside table and took off the neck collar. RN C suctioned Resident #1 in a circular motion while inserting the Sleeved suction catheter tubing 5 times without rinsing the suction catheter with normal saline. Copious phlegm was noted. During an interview on 7/12/17 at 11:45 a.m., RN C regarding Tracheotomy care she said she used the sleeved suction catheter and the normal saline that morning too. She said she was trained by the staff development manager, that the Sleeved suction catheter can be reused because they did not touch the catheter inside the sleeve. RN C said she was new and still learning. Record review of the Manufacturer's recommendation written on Sleeved suction catheter kit package revealed: sterile in unopened undamaged package. Do not re-sterilize. Single use only. Do not reuse. Avoid excessive heat. Protect from freezing. Resident #23: Record review of Resident #23's face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; tracheotomy status, shortness of breath and [MEDICAL CONDITION] with acute exacerbation. Record review of the Monthly tracking Infection Control Report dated 6/1/17 revealed Resident #23 was on [MEDICATION NAME] ( antibiotic) [MEDICATION NAME] for Tracheotomy infection. Record review of the MDS assessment dated [DATE] revealed that Resident #23's BIMS score was 10 indicating he was moderately impaired. He required total assistance with activities of daily living. Further review revealed that the resident had a tracheotomy tube. During an observation on 7/13/17 at 12:55 p.m., LVN E provided tracheotomy care for Resident #23. LVN E did not set up a sterile tracheotomy tray. LVN E washed hands and used the clean gloves. He opened Resident #23's nightstand drawer and removed an opened Sleeved suction catheter that was dated 7/13/17. He connected the tubing to the suction machine and took off the neck collar. LVN E then opened the normal saline and poured it in an open suctioned cup that was located at the bedside table and then suction inside Resident #23's trach. During an interview on 7/13/17 at 1:10 p.m., LVN E regarding Tracheotomy care he said that tracheotomy suctioning was just a clean technique and he only used a sterile technique while changing the inner cannula. LVN E said he was taught that an opened sleeved suction catheter can be reused. He said he was trained by the staff development manager recently. During an interview on 7/14/17 at 9:50 a.m., with the staff development manager regarding Tracheotomy care, she said tracheotomy suctioning was just a clean technique and a sterile technique was only used while changing the inner cannula. She said this is what she teaches the facility staff. At this time the nurse surveyor presented the Manufacturer's recommendation on Sleeved suction catheter kit, indicating they were for single use and must be sterile. The staff development manager said, to be honest with you, I was not aware of the manufacturer's recommendation on Sleeved suction catheter kit. I am going to show that to the Administrator. Lippincott Procedure: [MEDICAL CONDITION] Care/[MEDICAL CONDITION] Suctioning Suggested Procedure: 1. Gather equipment: Sterile [MEDICAL CONDITION] care tray, normal saline, hydrogen peroxide, eye protection, suction apparatus, and anesthesia bag. 2. Wash hands. Put on clean gloves and remove dressing (keep obturator at bedside in clean, clear package). 3. Remove clean gloves and rewash hands. Loosen caps on hydrogen peroxide and normal saline. 4. Open sterile [MEDICAL CONDITION] care tray. 5. Don sterile gloves. 6. Remove drape with plastic liner from tray and set up sterile field. 7. Arrange contents of tray onto sterile field. 8. Pour saline and cleaning solution into two separate containers. 9. [MEDICAL CONDITION]. 10. Remove inner cannula (may use sterile 4X4 to [MEDICAL CONDITION] with sterile dominant hand) and immerse in cleaning solution. Clean inner cannula with brush and pipe cleaners. (Shiley has inner cannula; [MEDICATION NAME] foam cuff does not have inner cannula). 11. Immerse and rinse inner cannula in sterile saline/sterile water. The facility Administrator, Executive Director, Regional Clinical Services and Interim DON were notified on 7/14/17 at 12:43 p.m. that an IJ had been identified due to the above failures. The facility submitted several plans of removal that required corrections and a revision was accepted on 7/18/17. The POR included in part: PLAN TO REMOVE IMMEDIATE JEOPARDY [MEDICAL CONDITION] Care/Isolation Practices/Infection Control The RT completed an assessment of residents with [MEDICAL CONDITION] care. No signs or symptoms of infection were noted. This was completed 7/15/17 . Licensed nursing staff (RN/LVN) will be re-educated on [MEDICAL CONDITION] care by Nursing or Respiratory Therapy. Education to include the following: - How and when to suction a patient with a [MEDICAL CONDITION] - Proper suctioning technique - Proper use of sleeved suctioning catheter - Proper [MEDICAL CONDITION] site care and dressing changes - Securing the [MEDICAL CONDITION] - Proper infection control practices during [MEDICAL CONDITION] care . After 4:00 p.m. July 15, 2017, DON/designee will monitor the completion of daily [MEDICAL CONDITION] care and proper isolation practices by reviewing documentation in the electronic medical record system. A review will occur during the morning clinical meeting. After 4:00 p.m. July 15, 2017, DON/Designee will monitor [MEDICAL CONDITION] care and proper isolation practices during daily rounds . The facility was monitored from 07/15/17 to 07/18/17 to verify that the plan was implemented. Monitoring of POR included in part: Interviews with multiple nurses from different shifts on 07/15/17 , 07/16/17 and 7/17/17 revealed they had been in-serviced on documentation, [MEDICAL CONDITION] care and proper isolation practices , and notifying the physician of any change in resident condition, signs and indwelling catheter care. Interviews on 07/15/17, 07/16/17 and 7/17/17 with multiple RN's and CNAs from different shifts revealed they received in-service on change in resident condition and reporting to the nurse. Observation [MEDICAL CONDITION] were conducted on 07/17 and 07/18. No infection control and technique issues were observed. Record review revealed the facility had completed an audit for all the residents with contact isolation, catheters and [MEDICAL CONDITION] care to ensure MD was notified of any changes. In an interview on 07/18/17 at 11:00 a.m., the Administrator said the reason why she felt the facility had an IJ was because of confusion related to isolation precautions and infection control concerns with [MEDICAL CONDITION] care. In an interview on 07/18/17 at 9:45 a.m. the DON said all nursing staff are trained on infection control and [MEDICAL CONDITION] care. She said she felt the IJ situation came about because nursing staff were unaware of sterile procedure for [MEDICAL CONDITION] care and infection control concerns related to isolation. The Administrator and Interim DON were informed on 07/18/17 at 11:45 a.m. that the IJ was lowered; however the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more that minimal harm that is not an IJ due to need for continued monitoring of staff and effectiveness of plan of removal. Record review of the facility's 672 revealed 2 residents on Tracheostomies.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program that used standard and transmission-based precautions to prevent spread of infections to for one (Residents #13) of 6 residents reviewed for infection control. - Resident # 13 did not receive proper Foley catheter care to prevent infections. This failure affected 1 resident and placed 9 residents with indwelling Foley catheters at risk for infections to include UTI Findings include: Record review of Resident #13 face sheet revealed an [AGE] year old admitted to the facility on [DATE] with the following diagnoses; Atrial Fibrillation, Pressure Ulcer of sacral region stage 4, Hypertension, Type 2 Diabetes Mellitus, Gastrostomy, Dysphagia, Cerebral Infarction, Pain, and [DIAGNOSES REDACTED]. Record review of Resident #13's care plan dated 05/18/17 revealed that she had a Foley catheter due to having a Stage 4 pressure ulcer on the sacrum. interventions included to anchor the catheter, check tube for kinks, provide perineal care as indicated, notify nurse of redness or irritation at insertion cite. Observation on 05/19/17 at 11:30 a.m. revealed Resident #13 received Foley catheter care by CNA-W. CNA-W proceeded to clean Foley tubing starting at the base moving away from resident perineal area. CNA-W then changed gloves and got a new cloth wetting with soap and water and began to clean groin starting on the right side moving to the left side. CNA W did not clean the resident's vaginal or meatus area. Interview on 05/19/17 at 12:00 noon CNA-W was asked by this surveyor how did she think she did. CNA-W said she tried to give the best quality care to make Resident # 13 comfortable. This surveyor asked CNA why did she not clean resident vaginal/meatus area and CNA said she thought she did. Record review of Resident # 13 Care Administration record did not show documentation of Foley catheter care until 05/18/17 and resident was admitted to facility on 05/13/17. Record review of facility policy on Indwelling Catheter Care (daily cleansing) revised 12/2009 reading in part: Care and maintenance of indwelling catheters is essential to prevent infection and/or complications cleaning of the outside of the catheter and the tissue surrounding the meatus with warm soap and water. According to a list provided by the DON, 10 residents had indwelling urinary catheters.

Based on observation, interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of for 2 out of 17 residents ( CR # 12 and Resident #3) who were reviewed for administration. - The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of abuse and neglect for CR #12 and Resident #3. - The Administrator failed to supervise the DON to emsure she carried out her responsibilities in the areas of nursing staff training/monitoring, to provide accurate and complete assessments, documentation, and appropriate treatment and implement preventive measures to avoid the worsening of UTI's. - The DON failed to provide staff training/monitoring, to implement measures to provide the appropriate treatment, complete and accurate assessment and implement preventive measures to prevent the worsening of UTI's. - The DON failed to train the staff to follow physician orders. - The DON failed to monitor and assess CR #12. An IJ was identified on 05/22/17. While the IJ was lowered on 05/25/2017, the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy and a scope of pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures affected 2 residents and placed 119 residents at risk of abuse, neglect and a decline in their quality of care. Findings include: In an interview on 5/23/2017 at 3:05 p.m. the Administrator said the reason why the facility had an IJ was because of a lack of training with the staff on the nursing units, following up with management, and lack of communication. The Administrator said she realize there were problems that need to be corrected. In an interview on 5/23/2017 at 2:00 p.m. the DON said RN-B was a new nurse on Hall-100 that was overwhelmed and she was looking at getting an extra nurse. The DON said the facility was very hard to manage and had a very high turnover rate. The DON said she did not give any specific training on the care of residents with high acuity levels (level of severity of illness) with the nursing staff. The DON said the reason why the facility had an IJ was because they did not follow-up with the Doctor and document. In an interview on 05/24/17 at 1:20 p.m. the DON said that it was the ADON that took care of CR #12 on 05/11/17 on the 2p-10p shift. The ADON said she does not remember if she took care of CR #12 on 05/11/17 on the 2-10 shift but can verify by looking on the sign in sheet on Hall-100. The ADON confirmed that it was the DON that took care of CR #12 on the 2p-10p shift on 05/11/17. Further confirmation of the MAR indicated [REDACTED]. Interview on 05/24/17 at 1:40 pm the DON confirmed she worked as a nurse on the floor on 05/11/17 and was the nurse that took care of CR #12. She said she did not document at all on CR #12 during her shift because she had 3 admissions that she was trying to attend to as well. The DON said she was sorry. CR #12 Record review of CR #12 face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION], Pressure Ulcer of Sacral Region Stage 4, [MEDICAL CONDITION], Acute Embolism [MEDICAL CONDITION], Hypertension, Convulsions, Shortness of Breath, Gastrostomy, Dysphagia, [MEDICAL CONDITION], Contracture left Elbow, [MEDICAL CONDITIONS], Hematuria, Fever, and [MEDICAL CONDITION]-Resistant Staphylococcus Aureus. Record review of the MDS assessment dated [DATE] revealed that CR #12 cognition was severely impaired and required total assistance with activities of daily living Further review revealed that the resident had an indwelling catheter as well as a [MEDICAL CONDITION] bag and problematic fever. CR #12 had a stage 4 pressure ulcer to sacral area. Record review of CR #12 physician progress notes [REDACTED].initial urinalysis reported positive for UTI, Bactrim was started empirically. Currently sensitivity reports resistance to Bactrim will discontinue the Bactrim now. Since resident is asymptomatic at this time and fever subsided, will hold off on starting additional medication, monitor . Record review of Progress notes on 05/04/17 revealed in part: .resident family member reports that Resident Foley got pulled out accidentally a few times over the past few days, which may have contributed to hematuria but will continue to monitor . Record review of CR #12 Order Recap Report dated 05/07/17 revealed to monitor and record urine output every shift for urine output and Foley catheter care every shift to prevent infection. Record review of CR #12 Administration Report for the month of May 2017 revealed that resident urinary output was not monitored from 05/04/17-05/06/17 on all three shifts and only 2 shifts on 05/07/17 (6a-2p 400ml & 2p-10p 600ml). From 05/08/17 to 05/11/17 urine output monitored 2 times a day only. On 05/11/17 resident output was 100ml on the 6a-2p, 200ml on 2p-10p shift, and 250 ml on the 10p-6a shift. Further record review of CR #12 Administration Report for the month of May 2017 revealed that last temperature taken on CR #12 was on 05/04/2017 reading 97.8. Record review of CR #12 nurses notes for the month of May 2017 revealed in part: -05/02/17 heart rate 113 orders received from NP to increase hydration from 23ml/hr to 35ml/hr and observe tolerance. Resident heart rate dropped to 99. - nurses' notes from 05/03/17-05/09/17 revealed no documentation of vital signs, catheter care or assessments. -05/10/17 at 9:06 Tylenol 325mg via [DEVICE] for temperature of 100.8 rechecked and temperature 99.0. There was no documentation that the physician was informed or documentation of any other assessments or vitals. -05/11/17- no assessments or vital signs were documented. -05/12/17 During rounds in resident's room at 4am noted resident moaning with increased labored breathing temperature 101.2 axilla, pulse oximeter 82%, respirations 22, B/P 156/88, pulse 166. Tylenol 325mg one tab given via [DEVICE], 911 called, family members called. Record review of CR #12 SBAR Notes dated 05/12/17 documented at 4:40 a.m. by LVN-F reading in part: .Resident moaning and B/P 156/88, pulse irregular 166, Respirations 22 labored, Temperature101.2 axilla, and Oxygen saturation 82%. Tylenol 325mg one tab via [DEVICE]. Resident continuing to moan 911 called and family members were called . Record review of CR #12 hospital records dated 05/12/17 in the emergency room revealed Foley catheter was inserted with the return of 1500ml of urine yellow, hazy with sediments. Resident lab values showed resident had developed Acute [MEDICAL CONDITION]: -BUN 58 (norm 6-20) -[MEDICATION NAME] 1.2( norm 0.5-.9) -Blood Culture [DIAGNOSES REDACTED] (bacteria)- positive [MEDICATION NAME] 1000mg intravenous times one dose given. Resident was placed on contact isolation in the ICU unit and was started on Fluconazole 200mg intravenous every 24 hours and was discontinued on 05/17/17. Resident was now receiving Zerbaxa 1500mg every 8 hours intravenous initiated on 05/17/17. In a phone interview with CR #12's family member on 05/18/17 at 12:30 pm, she said that she visit the facility on 05/10/17 and the resident's Foley catheter was leaking. She said that a CNA told her that a male nurse did not change the Foley but instead pushed it further. She said that when she returned to the facility on [DATE] at around 9:30 am she noticed that the Foley was no longer leaking but there was no urine in the Foley bag. She said she asked staff about the urine and they told her the bag had just been emptied. She continued to say that she stayed with the resident until about 4 pm that day and did not see any staff come in to check or change the urine bag. She also noted there was barely any urine in the bag. The family member then said she received a call from the facility at approximately 2 am to tell her the resident was in a lot of pain and distress and was taken to the hospital. Observation on 05/18/17 at 3:00 pm revealed that CR #12 was in the intensive care unit in a local hospital. The resident was on contact isolation. She had a Foley catheter and a feeding tube for nutrition. Interview on 05/19/17 at 10:30 a.m. LVN- A said he took care of CR #12 about 2 weeks ago. LVN-A said resident was running a low grade fever of 99.5 axillary and Foley catheter was leaking. LVN-A said the doctor was called and received orders to change Foley catheter but he did not document this on the clinical record. Interview on 05/19/17 at 1:25 p.m. the Medical Doctor said he never gave an order to discontinue monitoring the resident for UTI which it was the reason to monitor intake and output. The Medical Doctor said if a resident does not have a Foley then there is no need to monitor output. The MD said what would cause CR #12 to retain a high urine residual after a Foley catheter was changed. He said it could have been some kind of blockage like the tubing was kinked or mucus clot. The MD said if that happened, the resident would have experience some abdominal distention along with pain and there would be very little to no urine output in the bag. He also said that would have to go on for some days and the resident would be in a lot of pain. Interview on 05/19/17 at 5:55 p.m. LVN-F said when she came to work on the 10p-6a shift on 05/11/17 CR #12 was resting quietly in bed. LVN-F said she never received report of issues with the resident or that the Resident's Foley had been leaking. LVN-F said when rounds were being made around 4 a.m. found resident moaning. He took vital signs and resident had a fever and was in distress. LVN-F said could not remember who gave her report on the 2p-10p shift. Interview on 05/19/17 at 2:30 pm the NP said CR #12 was a very sick resident. NP said the nursing staff should have been monitoring very closely and reporting to her or the Physician signs of UTI such as foul smelling cloudy urine, fever, and discomfort such as facial grimacing, but the staff did not. The NP said CR #12's medical history warrant close monitoring and report of any change in condition. The NP said she never gave orders to discontinue monitoring the resident's temperature. The NP said the reason why she did not treat CR #12 with further antibiotic therapy when she find out resident was resistant to medication Bactrim, was because the resident had just been given a round of intravenous antibiotic therapy [MEDICATION NAME]. The NP said that was why she wanted the staff to monitor resident for further signs of UTI. Interview on 05/22/17 at 3:50 p.m. RN-B said he did change CR #12 Foley catheter on the week resident went to hospital with the assistance of a CNA because the catheter was leaking. RN-B said the resident's family member was visiting on that shift but was not present in the room when the Foley was changed. RN-B said he was successful on the first try with the return of clear yellow urine but does not remember the date it was done or the urine output. RN-B said he did not document any of this in the clinical chart. Resident #3: Record review of the facility face sheet revealed Resident #3 was a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the facility's Incident report dated 04/27/17 for Resident #3 revealed in part: .Incident/Accident Description Findings: writer notified that resident sustained [REDACTED]. RP notified, NP notified. Res was sent to local hospital for evaluation and treatment . Record review of a concern form dated 04/27/17 completed by the ADON read in part, report came from CNA A about unintentionally hurting a patient (Resident #3) .RCS A was immediately reassigned to another assignment and instructed on the need to remain on new assignment until further notice. CNA was reinforced on the need to transfer patient on hoyer lift with the help of another trained staff. CNA A verbalized understanding. Abuse coordinator- Administrator notified. Patient treated according to doctor's orders . During an interview on 5/9/17 at 12:19 pm with the DON, she said she was not in the building on 4/27/17. She further revealed when she was notified about the incident, she completed an incident report, interviewed CNA A, and instructed other staff members on transferring using the Hoyer lift. DON revealed that the incident was not called into DADS because it was an accident, even though the family raised concerns about possible abuse. In an interview on 5/9/17 at 12:43 pm CNA A said that while performing incontinent care for Resident #3, her weight shifted to her (CNAs) wrist and she pushed in the opposite direction to prevent her wrist from getting hurt. She stated she didn't realize how forceful she pushed the resident. She revealed that she attempted to perform incontinent care by herself despite the resident being care planned for two person assist. She said that there were 2 other Aides that day working but they were all busy and that was why she proceeded to do it herself. After incontinent care she revealed that she requested the assistance from the housekeeper to watch while she transfers resident to the wheelchair via hoyer lift. After the resident was transferred to the wheelchair and assisted to the day area she noticed something wrong with Resident #3's eye and the skin tear on her left elbow and notified the ADON. She said she told the ADON on 4/27/17. Then on Monday 5/8/17 the Administrator asked her what happened and she was taken off the unit on 5/1/17. In an interview on 5/9/17 at 1:40pm with ADON, she said that she was notified by CNA A on 4/27/17 about Resident #3's injury to her eye. Afterwards she assessed the resident, called the Administrator, and instructed CNA A to stay away from the resident. She said that the NP was in the building and also assessed the resident. They were monitoring the resident and later decided to send the patient out because the eye got more swollen and she couldn't open her eyes anymore. The resident was transferred to local Hospital for and returned that evening. Further interview revealed the resident's family questioned the resident's care and felt that the CNA was taking out frustration out on the resident. The family implied suspicions of abuse. The ADON said she changed CNA A's assignment but did not suspend her. The ADON said she called the Administrator and notified her of all that happened and the Administrator replied, You've done what you are supposed to do. The ADON said that she did not notify the state of this because she notified the Administrator and felt that Administrator would do it. She said that if she couldn't get a hold of the Administrator then she would have called the state herself. In an interview on 5/9/17 at 2:02pm with the Administrator, she said no additional documentation was available regarding the Incident involving Resident #3. The Administrator stated she had known about the incident only since 5/8/17 when the family of Resident #3 called her in regards to CNA A's interaction with Resident #3.The family told her that CNA A had lied, in that the injury sustained by Resident #3 was a swollen eye. The Administrator revealed during further interview she was not present at the facility on 4/27/17 and the ADON was in charge. However she did not leave any written instructions for her but verbally educated her on things that needed to be done. She continued to say that she was having a personal family crisis on 04/27/17 so she cannot refute whether or not the ADON called her on 04/27/17 or not because she cannot remember. She stated the ADON should have reported the incident to DADS and further investigated. She also stated that CNA A admitted she was a little rough and was providing care by herself instead of with two persons. Surveyor asked if she had taken any steps since this was reported to her yesterday (5/8/17). The Administrator said that she had not called this to the State yet but will and that she had not suspended CNA A but she planned on it. The Administrator and DON were notified on 05/22/17 at 4:50 pm of the IJ situation and a POR was requested. The POR was received and after 2 revisions it was accepted on 05/23/17 at 6:43pm. POR included in part: . Audit will be completed by DON/designee on all residents with Urinary Tract infections currently to ensure notification to physician and family and documentation is completed. Start 5/22/2017 at 6p. Finish 5/23/2017 at 11p . Staff will be re-educated by DON/ADON/Unit Manager/ Staff development Coordinator/District Director of Clinical Services. All nursing staff will be included in the re-education, including Resident Care Specialist (CNA). -The policy and procedure for monitoring Urinary Tract Infections -Notifying physicians of any change of condition -DON/designee will review all physician orders [REDACTED]. -Proper and timely documentation to include vital signs, assessments, Foley changes and intake/output if ordered -Foley catheter care including changing Foleys and documentation on Foley care -Charge nurse will be responsible for monitoring input/output when ordered by Physician -DON/designee will follow up weekly to verify compliance . In an interview on 05/24/17 at 1:20p.m. the DON said that it was the ADON that took care of CR #12 on 05/11/17 on the 2p-10p shift. The ADON said she does not remember if she took care of CR #12 on 05/11/17 on the 2-10 shift but can verify by looking on the sign in sheet on Hall-100. The ADON confirmed that it was the DON that took care of CR #12 on the 2p-10p shift on 05/11/17. Further confirmation of the MAR indicated [REDACTED]. Interview on 05/24/17 at 1:40 pm the DON confirmed she worked as a nurse on the floor on 05/11/17 and was the nurse that took care of CR #12. She said she did not document at all on CR #12 during her shift because she had 3 admissions that she was trying to attend to as well. The DON said she was sorry. The facility was monitored from 05/24/17 to 05/25/17 to verify that the plan was implemented. Monitoring of POR included in part: Interview on with multiple nurses from different shifts on 05/24/17 and 05/25/17 revealed they had been in-serviced on documentation, SBAR, physical assessment, Catheter care, and notifying the physician of any change in resident condition, signs and symptoms of infection especially UTI's. Interview on 05/24/17 and 05/25/17 with multiple CNAs from different shifts revealed they received in-service on change in resident condition and reporting to the nurse. Record review revealed the facility had completed residents' assessments on 05/23/17 and 05/24/17 to ensure they did not missed any changes in condition. Record review revealed the facility had completed an audit for all the residents with catheters and urinary tract infections to ensure MD was notified of any changes. The Administrator and DON were informed on 05/25/17 at 1:55 pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to the facility CMS form 672 the census was 120.

Based on observation, interview, and record review, the facility failed to consult with the resident physician when the resident experience a significant change in condition for one of 17 residents (CR #12) reviewed for notification of changes. -The facility failed to consult with CR #12's Physician when resident urinary catheter was leaking on two different occasions and coming out. -The facility failed to assess CR #12's vital signs and urinary output and notify the Physician of findings. -The facility failed to monitor CR #12 even though resident had a history UTI's and report change in resident condition. -CR #12 was transferred to the hospital and admitted to ICU on 05/12/17 and was admitted with Acute [MEDICAL CONDITIONS] secondary to UTI, [MEDICAL CONDITION], Kleibsella and MDRO infection, and Fever. An IJ was identified on 05/22/17. While the IJ was lowered on 05/25/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. This failure affected one resident and placed 9 residents that had urinary catheters at risk of not being provided with appropriate and timely medical intervention resulting in infections, a decline in their quality of care, and quality of life. Findings Included: Record review of CR #12 face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION], Pressure Ulcer of Sacral Region Stage 4, [MEDICAL CONDITION], Acute Embolism [MEDICAL CONDITION], Hypertension, Convulsions, Shortness of Breath, Gastrostomy, Dysphagia, [MEDICAL CONDITION], Contracture left Elbow, [MEDICAL CONDITIONS], Hematuria, Fever, and [MEDICAL CONDITION]-Resistant Staphylococcus Aureus. Record review of CR #12 care plan revised on 09/23/16 revealed that resident was being care planned for the use of an indwelling catheter. Interventions included to anchor catheter to prevent excess tension, observe and document intake and output, signs and symptoms of pain/discomfort due to catheter, record/report to MD for fever, and check tubing for kinks each shift. Record review of the MDS assessment dated [DATE] revealed that CR #12 cognition was severely impaired and required total assistance with activities of daily living Further review revealed that the resident had an indwelling catheter as well as a [MEDICAL CONDITION] bag and problematic fever. CR #12 had a stage 4 pressure ulcer to sacral area. Record review of CR #12 physician progress notes [REDACTED].initial urinalysis reported positive for UTI, Bactrim was started empirically. Currently sensitivity reports resistance to Bactrim will discontinue the Bactrim now. Since resident is asymptomatic at this time and fever subsided, will hold off on starting additional medication, monitor . Record review of Progress notes on 05/04/17 revealed in part: .resident family member reports that Resident Foley got pulled out accidently a few times over the past few days, which may have contributed to hematuria but will continue to monitor . Record review of CR #12 Order Recap Report dated 05/07/17 revealed to monitor and record urine output every shift for urine output and Foley catheter care every shift to prevent infection. Record review of the MAR indicated [REDACTED]. Further review revealed Tylenol administered on 05/10/17 at 9:06 pm. Record review of CR #12 Treatment Administration Report for the month of May 2017 revealed that resident urinary output was not monitored from 05/04/17-05/06/17 on all three shifts and only 2 shifts on 05/07/17 (6a-2p 400ml & 2p-10p 600ml). From 05/08/17 to 05/11/17 urine output monitored 2 times a day only. On 05/11/17 resident output was 100ml on the 6a-2p, 200ml on 2p-10p shift, and 250 ml on the 10p-6a shift. Further record review of CR #12 Administration Report for the month of May 2017 revealed that last temperature taken on CR #12 was on 05/04/2017 reading 97.8. Record review of CR #12 nurses' notes for the month of May 2017 revealed in part: -05/02/17 heart rate 113 orders received from NP to increase hydration from 23ml/hr to 35ml/hr and observe tolerance. Resident heart rate dropped to 99. - nurses' notes from 05/03/17-05/09/17 revealed no documentation of vital signs, catheter care or assessments. -05/10/17 at 9:06 Tylenol 325mg via [DEVICE] for temperature of 100.8 rechecked and temperature 99.0. There was no documentation that the physician was informed or documentation of any other assessments or vitals. -05/11/17- no assessments or vital signs were documented. -05/12/17 During rounds in resident's room at 4am noted resident moaning with increased labored breathing temperature 101.2 axilla, pulse oximeter 82%, respirations 22, B/P 156/88, pulse 166. Tylenol 325mg one tab given via [DEVICE], 911 called, family member called. Record review of CR #12 SBAR Notes dated 05/12/17 documented at 4:40 a.m. by LVN-F reading in part: .Resident moaning and B/P 156/88, pulse irregular 166, Respirations 22 labored, Temperature101.2 axilla, and Oxygen saturation 82%. Tylenol 325mg one tab via [DEVICE]. Resident continuing to moan 911 called and family member were called . Record review of CR #12 hospital records dated 05/12/17 in the emergency room revealed Foley catheter was inserted with the return of 1500ml of urine yellow, hazy with sediments. Resident lab values showed resident had developed Acute [MEDICAL CONDITION]: -BUN 58 (norm 6-20) -[MEDICATION NAME] 1.2( norm 0.5-.9) -Blood Culture [DIAGNOSES REDACTED] (bacteria)- positive [MEDICATION NAME] 1000mg intravenous times one dose given. Resident was placed on contact isolation in the ICU unit and was started on Fluconazole 200mg intravenous every 24 hours and was discontinued on 05/17/17. Resident was now receiving Zerbaxa 1500mg every 8 hours intravenous initiated on 05/17/17. Interview on 05/18/17 at 11:55 a.m. RN-D said the nurses monitor residents output with a urinary catheters every shift. The CNA's empty the Foley bag and report the amount to the nurse so the output can be recorded. RN-D said signs and symptoms of UTI are fever, foul odor and cloudy urine along with discomfort. RN-D said she would report these findings to the Doctor or NP. In a phone interview with CR #12's family member on 05/18/17 at 12:30 pm, she said that she visit the facility on 05/10/17 and the resident's Foley catheter was leaking. She said that a CNA told her that a male nurse did not change the Foley but instead pushed it further. She said that when she returned to the facility on [DATE] at around 9:30 am she noticed that the Foley was no longer leaking but there was no urine in the Foley bag. She said she asked staff about the urine and they told her the bag had just been emptied. She continued to say that she stayed with the resident until about 4 pm that day and did not see any staff come in to check or change the urine bag. She also noted there was barely any urine in the bag. The family member then said she received a call from the facility at approximately 2 am to tell her the resident was in a lot of pain and distress and was taken to the hospital. Observation on 05/18/17 at 3:00 pm revealed that CR #12 was in the intensive care unit in a local hospital. The resident was on contact isolation. She had a Foley catheter and a feeding tube for nutrition. Interview on 05/19/17 at 10:30 a.m. LVN- A said he took care of CR #12 about 2 weeks ago. LVN-A said resident was running a low grade fever of 99.5 axillary and Foley catheter was leaking. LVN-A said the doctor was called and received orders to change Foley catheter but he did not document this on the clinical record because he got busy with multiple admissions that day and forgot. Interview on 05/19/17 at 12:45 p.m. the DON said CR #12 was transferred to the hospital because of a fever and infection of the bladder. This surveyor requested the names of the nurses and CNA's that administer care to CR #12 on 05/11/17 for all three shifts and the DON said she would have to look and see and report back to surveyor the staff that was taking care of CR #12. Interview on 05/19/17 at 1:25 p.m. the Medical Director said he never gave an order to discontinue monitoring the resident for UTI which it was the reason to monitor intake and output. The Medical Doctor said if a resident does not have a Foley then there is no need to monitor output. The MD said what would cause CR #12 to retain a high urine residual after a Foley catheter was changed. He said it could have been some kind of blockage like the tubing was kinked or mucus clot. The MD said if that happened, the resident would have experience some abdominal distention along with pain and there would be very little to no urine output in the bag. He also said that would have to go on for some days and the resident would be in a lot of pain. Interview on 05/19/17 at 2:30 pm the NP said CR #12 was a very sick resident. NP said the nursing staff should have been monitoring very closely and reporting to her or the Physician signs of UTI such as foul smelling cloudy urine, fever, and discomfort such as facial grimacing, but the staff did not. The NP said CR #12's medical history warrant close monitoring and report of any change in condition. The NP said she never gave orders to discontinue monitoring the resident's temperature. The NP said the reason why she did not treat CR #12 with further antibiotic therapy when she find out resident was resistant to medication Bactrim, was because the resident had just been given a round of intravenous antibiotic therapy [MEDICATION NAME]. The NP said that was why she wanted the staff to monitor resident for further signs of UTI. Interview on 05/19/17 at 5:55 p.m. LVN-F said when she came to work on the 10p-6a shift on 05/11/17 CR #12 was resting quietly in bed. LVN-F said she never received report of issues with the resident or that the Resident's Foley had been leaking. LVN-F said when rounds were being made around 4 a.m. found resident moaning. He took vital signs and resident had a fever and was in distress. LVN-F said could not remember who gave her report on the 2p-10p shift. Interview on 05/22/17 at 3:20 pm the DON said it was RN-B that took care of CR #12 on 6a-2pm shift on 05/11/17and that she was still looking to see who was the nurse who worked with the resident on the 2-10pm shift. The DON said she was aware of CR #12's Foley catheter leaking. The DON said the staff was to keep resident clean, dry and monitor resident for UTI symptoms such as change in color of urine, cloudiness, checking vital signs, palpate the bladder. The DON said the staff should have been taking the Resident's vital signs at least daily. The DON said she and her ADON that monitor the staff to ensure they were monitoring the residents and reporting changes in condition to the Physician. The DON said the reason why they stopped administering the last dose of antibiotics was because CR #12 had completed all her doses. The DON said it was RN-B that changed the resident Foley catheter because RN-B told her. Interview on 05/22/17 at 3:50 p.m. RN-B said he did change CR #12 Foley catheter on the week resident went to hospital with the assistance of a CNA because the catheter was leaking. RN-B said the resident's family member was visiting on that shift but was not present in the room when the Foley was changed. RN-B said he was successful on the first try with the return of clear yellow urine but does not remember the date it was done or the urine output. RN-B said he did not document any of this in the clinical chart. Record review of facility Policy on Changes in Resident Condition revised 02/2017: .The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Communication with the Interdiscipinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. Changes in condition are communicated from shift to shift through the 24 hour report . The Administrator and DON were notified on 05/22/17 at 4:50 pm of the IJ situation and a POR was requested. The POR was received and after 2 revisions it was accepted on 05/23/17 at 6:43pm. POR included in part: . Audit will be completed by DON/designee on all residents with Urinary Tract infections currently to ensure notification to physician and family and documentation is completed. Start 5/22/2017 at 6p. Finish 5/23/2017 at 11p . Staff will be re-educated by DON/ADON/Unit Manager/ Staff development Coordinator/District Director of Clinical Services. All nursing staff will be included in the re-education, including Resident Care Specialist (CNA). -The policy and procedure for monitoring Urinary Tract Infections -Notifying physicians of any change of condition -DON/designee will review all physician orders [REDACTED]. -Proper and timely documentation to include vital signs, assessments, Foley changes and intake/output if ordered -Foley catheter care including changing Foleys and documentation on Foley care -Charge nurse will be responsible for monitoring input/output when ordered by Physician -DON/designee will follow up weekly to verify compliance . In an interview on 5/23/2017 at 2:00 p.m. the DON said RN-B was a new nurse on Hall-100 that was overwhelmed and she was looking at getting an extra nurse. The DON said the facility was very hard to manage and had a very high turnover rate. The DON said she did not give any specific training on the care of residents with high acuity levels (level of severity of illness) with the nursing staff. The DON said the reason why the facility had an IJ was because they did not follow-up with the Doctor and document. In an interview on 5/23/2017 at 3:05 p.m. the Administrator said the reason why the facility had an IJ was because of a lack of training with the staff on the nursing units, following up with management, and lack of communication. The Administrator said she realize there were problems that need to be corrected. In an interview on 05/24/17 at 1:20p.m. the DON said that it was the ADON that took care of CR #12 on 05/11/17 on the 2p-10p shift. The ADON said she does not remember if she took care of CR #12 on 05/11/17 on the 2-10 shift but can verify by looking on the sign in sheet on Hall-100. The ADON confirmed that it was the DON that took care of CR #12 on the 2p-10p shift on 05/11/17. Further confirmation of the MAR indicated [REDACTED]. Interview on 05/24/17 at 1:40 pm the DON confirmed she worked as a nurse on the floor on 05/11/17 and was the nurse that took care of CR #12. She said she did not document at all on CR #12 during her shift because she had 3 admissions that she was trying to attend to as well. The DON said she was sorry. The facility was monitored from 05/24/17 to 05/25/17 to verify that the plan was implemented. Monitoring of POR included in part: Interview on with multiple nurses from different shifts on 05/24/17 and 05/25/17 revealed they had been in-serviced on documentation, SBAR, physical assessment, Catheter care, and notifying the physician of any change in resident condition, signs and symptoms of infection especially UTI's. Interview on 05/24/17 and 05/25/17 with multiple CNAs from different shifts revealed they received in-service on change in resident condition and reporting to the nurse. Record review revealed the facility had completed residents' assessments on 05/23/17 and 05/24/17 to ensure they did not missed any changes in condition. Record review revealed the facility had completed an audit for all the residents with catheters and urinary tract infections to ensure MD was notified of any changes. The Administrator and DON were informed on 05/25/17 at 1:55 pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provided by the DON, 10 residents had indwelling urinary catheters.

Based on observation, interview, and record review, the facility failed to ensure resident were free from neglect for one of 17 residents reviewed for neglect (CR # 12) -The facility failed to assess CR #12's vital signs and urinary output and notify the Physician of findings. -The facility failed to monitor CR #12 even though resident had a history UTI's and report change in resident condition. -The facility failed to consult with CR #12's Physician when resident urinary catheter was leaking on two different occasions and coming out. -CR #12 was transferred to the hospital and admitted to ICU on 05/12/17 and was admitted with Acute [MEDICAL CONDITIONS] secondary to UTI, [MEDICAL CONDITION], Kleibsella and MDRO infection, and Fever. An IJ was identified on 05/22/17. While the IJ was lowered on 05/25/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. This failure affected one resident and placed 9 residents that had urinary catheters at risk of not being provided with appropriate and timely medical intervention resulting in infections, a decline in their quality of care, and quality of life. Findings Included: Record review of CR #12 face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION], Pressure Ulcer of Sacral Region Stage 4, [MEDICAL CONDITION], Acute Embolism [MEDICAL CONDITION], Hypertension, Convulsions, Shortness of Breath, Gastrostomy, Dysphagia, [MEDICAL CONDITION], Contracture left Elbow, [MEDICAL CONDITIONS], Hematuria, Fever, and [MEDICAL CONDITION]-Resistant Staphylococcus Aureus. Record review of CR #12 care plan revised on 09/23/16 revealed that resident was being care planned for the use of an indwelling catheter. Interventions included to anchor catheter to prevent excess tension, observe and document intake and output, signs and symptoms of pain/discomfort due to catheter, record/report to MD for fever, and check tubing for kinks each shift. Record review of the MDS assessment dated [DATE] revealed that CR #12 cognition was severely impaired and required total assistance with activities of daily living Further review revealed that the resident had an indwelling catheter as well as a [MEDICAL CONDITION] bag and problematic fever. CR #12 had a stage 4 pressure ulcer to sacral area. Record review of CR #12 physician progress notes [REDACTED].initial urinalysis reported positive for UTI, Bactrim was started empirically. Currently sensitivity reports resistance to Bactrim will discontinue the Bactrim now. Since resident is asymptomatic at this time and fever subsided, will hold off on starting additional medication, monitor . Record review of Progress notes on 05/04/17 revealed in part: .resident family member reports that Resident Foley got pulled out accidently a few times over the past few days, which may have contributed to hematuria but will continue to monitor . Record review of CR #12 Order Recap Report dated 05/07/17 revealed to monitor and record urine output every shift for urine output and Foley catheter care every shift to prevent infection. Record review of the MAR indicated [REDACTED]. Further review revealed Tylenol administered on 05/10/17 at 9:06 pm. Record review of CR #12 Treatment Administration Report for the month of May 2017 revealed that resident urinary output was not monitored from 05/04/17-05/06/17 on all three shifts and only 2 shifts on 05/07/17 (6a-2p 400ml & 2p-10p 600ml). From 05/08/17 to 05/11/17 urine output monitored 2 times a day only. On 05/11/17 resident output was 100ml on the 6a-2p, 200ml on 2p-10p shift, and 250 ml on the 10p-6a shift. Further record review of CR #12 Administration Report for the month of May 2017 revealed that last temperature taken on CR #12 was on 05/04/2017 reading 97.8. Record review of CR #12 nurses' notes for the month of May 2017 revealed in part: -05/02/17 heart rate 113 orders received from NP to increase hydration from 23ml/hr to 35ml/hr and observe tolerance. Resident heart rate dropped to 99. - nurses' notes from 05/03/17-05/09/17 revealed no documentation of vital signs, catheter care or assessments. -05/10/17 at 9:06 Tylenol 325mg via [DEVICE] for temperature of 100.8 rechecked and temperature 99.0. There was no documentation that the physician was informed or documentation of any other assessments or vitals. -05/11/17- no assessments or vital signs were documented. -05/12/17 During rounds in resident's room at 4am noted resident moaning with increased labored breathing temperature 101.2 axilla, pulse oximeter 82%, respirations 22, B/P 156/88, pulse 166. Tylenol 325mg one tab given via [DEVICE], 911 called, family member called. Record review of CR #12 SBAR Notes dated 05/12/17 documented at 4:40 a.m. by LVN-F reading in part: .Resident moaning and B/P 156/88, pulse irregular 166, Respirations 22 labored, Temperature101.2 axilla, and Oxygen saturation 82%. Tylenol 325mg one tab via [DEVICE]. Resident continuing to moan 911 called and family member were called . Record review of CR #12 hospital records dated 05/12/17 in the emergency room revealed Foley catheter was inserted with the return of 1500ml of urine yellow, hazy with sediments. Resident lab values showed resident had developed Acute [MEDICAL CONDITION]: -BUN 58 (norm 6-20) -[MEDICATION NAME] 1.2( norm 0.5-.9) -Blood Culture [DIAGNOSES REDACTED] (bacteria)- positive [MEDICATION NAME] 1000mg intravenous times one dose given. Resident was placed on contact isolation in the ICU unit and was started on Fluconazole 200mg intravenous every 24 hours and was discontinued on 05/17/17. Resident was now receiving Zerbaxa 1500mg every 8 hours intravenous initiated on 05/17/17. Interview on 05/18/17 at 11:55 a.m. RN-D said the nurses monitor residents output with a urinary catheters every shift. The CNA's empty the Foley bag and report the amount to the nurse so the output can be recorded. RN-D said signs and symptoms of UTI are fever, foul odor and cloudy urine along with discomfort. RN-D said she would report these findings to the Doctor or NP. In a phone interview with CR #12's family member on 05/18/17 at 12:30 pm, she said that she visit the facility on 05/10/17 and the resident's Foley catheter was leaking. She said that a CNA told her that a male nurse did not change the Foley but instead pushed it further. She said that when she returned to the facility on [DATE] at around 9:30 am she noticed that the Foley was no longer leaking but there was no urine in the Foley bag. She said she asked staff about the urine and they told her the bag had just been emptied. She continued to say that she stayed with the resident until about 4 pm that day and did not see any staff come in to check or change the urine bag. She also noted there was barely any urine in the bag. The family member then said she received a call from the facility at approximately 2 am to tell her the resident was in a lot of pain and distress and was taken to the hospital. Observation on 05/18/17 at 3:00 pm revealed that CR #12 was in the intensive care unit in a local hospital. The resident was on contact isolation. She had a Foley catheter and a feeding tube for nutrition. Interview on 05/19/17 at 10:30 a.m. LVN- A said he took care of CR #12 about 2 weeks ago. LVN-A said resident was running a low grade fever of 99.5 axillary and Foley catheter was leaking. LVN-A said the doctor was called and received orders to change Foley catheter but he did not document this on the clinical record because he got busy with multiple admissions that day and forgot. Interview on 05/19/17 at 12:45 p.m. the DON said CR #12 was transferred to the hospital because of a fever and infection of the bladder. This surveyor requested the names of the nurses and CNA's that administer care to CR #12 on 05/11/17 for all three shifts and the DON said she would have to look and see and report back to surveyor the staff that was taking care of CR #12. Interview on 05/19/17 at 1:25 p.m. the Medical Director said he never gave an order to discontinue monitoring the resident for UTI which it was the reason to monitor intake and output. The Medical Doctor said if a resident does not have a Foley then there is no need to monitor output. The MD said what would cause CR #12 to retain a high urine residual after a Foley catheter was changed. He said it could have been some kind of blockage like the tubing was kinked or mucus clot. The MD said if that happened, the resident would have experience some abdominal distention along with pain and there would be very little to no urine output in the bag. He also said that would have to go on for some days and the resident would be in a lot of pain. Interview on 05/19/17 at 2:30 pm the NP said CR #12 was a very sick resident. NP said the nursing staff should have been monitoring very closely and reporting to her or the Physician signs of UTI such as foul smelling cloudy urine, fever, and discomfort such as facial grimacing, but the staff did not. The NP said CR #12's medical history warrant close monitoring and report of any change in condition. The NP said she never gave orders to discontinue monitoring the resident's temperature. The NP said the reason why she did not treat CR #12 with further antibiotic therapy when she find out resident was resistant to medication Bactrim, was because the resident had just been given a round of intravenous antibiotic therapy [MEDICATION NAME]. The NP said that was why she wanted the staff to monitor resident for further signs of UTI. Interview on 05/19/17 at 5:55 p.m. LVN-F said when she came to work on the 10p-6a shift on 05/11/17 CR #12 was resting quietly in bed. LVN-F said she never received report of issues with the resident or that the Resident's Foley had been leaking. LVN-F said when rounds were being made around 4 a.m. found resident moaning. He took vital signs and resident had a fever and was in distress. LVN-F said could not remember who gave her report on the 2p-10p shift. Interview on 05/22/17 at 3:20 pm the DON said it was RN-B that took care of CR #12 on 6a-2pm shift on 05/11/17and that she was still looking to see who was the nurse who worked with the resident on the 2-10pm shift. The DON said she was aware of CR #12's Foley catheter leaking. The DON said the staff was to keep resident clean, dry and monitor resident for UTI symptoms such as change in color of urine, cloudiness, checking vital signs, palpate the bladder. The DON said the staff should have been taking the Resident's vital signs at least daily. The DON said she and her ADON that monitor the staff to ensure they were monitoring the residents and reporting changes in condition to the Physician. The DON said the reason why they stopped administering the last dose of antibiotics was because CR #12 had completed all her doses. The DON said it was RN-B that changed the resident Foley catheter because RN-B told her. Interview on 05/22/17 at 3:50 p.m. RN-B said he did change CR #12 Foley catheter on the week resident went to hospital with the assistance of a CNA because the catheter was leaking. RN-B said the resident's family member was visiting on that shift but was not present in the room when the Foley was changed. RN-B said he was successful on the first try with the return of clear yellow urine but does not remember the date it was done or the urine output. RN-B said he did not document any of this in the clinical chart. Record review of the facility Policy and Procedure with title Abuse & Neglect Prohibition revised on January 2017, revealed in part the facility prohibits neglect, mental or physical abuse . will conduct a prompt investigation . notify the proper authorities . complete pre-employment background screening . all new and present employees receive continuous education, training on abuse prohibition to include: reporting and identification of persons who could fall victim to abuse and persons who may inflict abuse on another individual . The Administrator and DON were notified on 05/22/17 at 4:50 pm of the IJ situation due to the above failures and a POR was requested. The POR was received and after 2 revisions it was accepted on 05/23/17 at 6:43pm. POR included in part: . Audit will be completed by DON/designee on all residents with Urinary Tract infections currently to ensure notification to physician and family and documentation is completed. Start 5/22/2017 at 6p. Finish 5/23/2017 at 11p . Staff will be re-educated by DON/ADON/Unit Manager/ Staff development Coordinator/District Director of Clinical Services. All nursing staff will be included in the re-education, including Resident Care Specialist (CNA). -The policy and procedure for monitoring Urinary Tract Infections -Notifying physicians of any change of condition -DON/designee will review all physician orders during the clinical morning meeting to ensure they were implemented -Proper and timely documentation to include vital signs, assessments, Foley changes and intake/output if ordered -Foley catheter care including changing Foleys and documentation on Foley care -Charge nurse will be responsible for monitoring input/output when ordered by Physician -DON/designee will follow up weekly to verify compliance . In an interview on 5/23/2017 at 2:00 p.m. the DON said RN-B was a new nurse on Hall-100 that was overwhelmed and she was looking at getting an extra nurse. The DON said the facility was very hard to manage and had a very high turnover rate. The DON said she did not give any specific training on the care of residents with high acuity levels (level of severity of illness) with the nursing staff. The DON said the reason why the facility had an IJ was because they did not follow-up with the Doctor and document. In an interview on 5/23/2017 at 3:05 p.m. the Administrator said the reason why the facility had an IJ was because of a lack of training with the staff on the nursing units, following up with management, and lack of communication. The Administrator said she realize there were problems that need to be corrected. In an interview on 05/24/17 at 1:20p.m. the DON said that it was the ADON that took care of CR #12 on 05/11/17 on the 2p-10p shift. The ADON said she does not remember if she took care of CR #12 on 05/11/17 on the 2-10 shift but can verify by looking on the sign in sheet on Hall-100. The ADON confirmed that it was the DON that took care of CR #12 on the 2p-10p shift on 05/11/17. Further confirmation of the MAR indicated [REDACTED]. Interview on 05/24/17 at 1:40 pm the DON confirmed she worked as a nurse on the floor on 05/11/17 and was the nurse that took care of CR #12. She said she did not document at all on CR #12 during her shift because she had 3 admissions that she was trying to attend to as well. The DON said she was sorry. The facility was monitored from 05/24/17 to 05/25/17 to verify that the plan was implemented. Monitoring of POR included in part: Interview on with multiple nurses from different shifts on 05/24/17 and 05/25/17 revealed they had been in-serviced on documentation, SBAR, physical assessment, Catheter care, and notifying the physician of any change in resident condition, signs and symptoms of infection especially UTI's. Interview on 05/24/17 and 05/25/17 with multiple CNAs from different shifts revealed they received in-service on change in resident condition and reporting to the nurse. Record review revealed the facility had completed residents' assessments on 05/23/17 and 05/24/17 to ensure they did not missed any changes in condition. Record review revealed the facility had completed an audit for all the residents with catheters and urinary tract infections to ensure MD was notified of any changes. The Administrator and DON were informed on 05/25/17 at 1:55 pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provided by the DON, 10 residents had indwelling urinary catheters.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 17 residents reviewed for quality of care. (CR # 12) -The facility failed to consult with CR #12's Physician when resident urinary catheter was leaking on two different occasions and coming out. -The facility failed to assess CR #12's vital signs and urinary output and notify the Physician of findings. -The facility failed to monitor CR #12 even though resident had a history UTI's and report change in resident condition. -CR #12 was transferred to the hospital and admitted to ICU on 05/12/17 with Acute [MEDICAL CONDITIONS] secondary to UTI, [MEDICAL CONDITION], Kleibsella and MDRO infection, and Fever. An IJ was identified on 05/22/17. While the IJ was lowered on 05/25/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. This failure affected one resident and placed 9 residents that had urinary catheters at risk of not being provided with appropriate and timely medical intervention resulting in infections, a decline in their quality of care, and quality of life. Findings Included: Record review of CR #12 face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION], Pressure Ulcer of Sacral Region Stage 4, [MEDICAL CONDITION], Acute Embolism [MEDICAL CONDITION], Hypertension, Convulsions, Shortness of Breath, Gastrostomy, Dysphagia, [MEDICAL CONDITION], Contracture left Elbow, [MEDICAL CONDITIONS], Hematuria, Fever, and [MEDICAL CONDITION]-Resistant Staphylococcus Aureus. Record review of CR #12 care plan revised on 09/23/16 revealed that resident was being care planned for the use of an indwelling catheter. Interventions included to anchor catheter to prevent excess tension, observe and document intake and output, signs and symptoms of pain/discomfort due to catheter, record/report to MD for fever, and check tubing for kinks each shift. Record review of the MDS assessment dated [DATE] revealed that CR #12 cognition was severely impaired and required total assistance with activities of daily living Further review revealed that the resident had an indwelling catheter as well as a [MEDICAL CONDITION] bag and problematic fever. CR #12 had a stage 4 pressure ulcer to sacral area. Record review of CR #12 physician progress notes [REDACTED].initial urinalysis reported positive for UTI, Bactrim was started empirically. Currently sensitivity reports resistance to Bactrim will discontinue the Bactrim now. Since resident is asymptomatic at this time and fever subsided, will hold off on starting additional medication, monitor . Record review of Progress notes on 05/04/17 revealed in part: .resident family member reports that Resident Foley got pulled out accidently a few times over the past few days, which may have contributed to hematuria but will continue to monitor . Record review of CR #12 Order Recap Report dated 05/07/17 revealed to monitor and record urine output every shift for urine output and Foley catheter care every shift to prevent infection. Record review of the MAR indicated [REDACTED]. Further review revealed Tylenol administered on 05/10/17 at 9:06 pm. Record review of CR #12 Treatment Administration Report for the month of May 2017 revealed that resident urinary output was not monitored from 05/04/17-05/06/17 on all three shifts and only 2 shifts on 05/07/17 (6a-2p 400ml & 2p-10p 600ml). From 05/08/17 to 05/11/17 urine output monitored 2 times a day only. On 05/11/17 resident output was 100ml on the 6a-2p, 200ml on 2p-10p shift, and 250 ml on the 10p-6a shift. Further record review of CR #12 Administration Report for the month of May 2017 revealed that last temperature taken on CR #12 was on 05/04/2017 reading 97.8. Record review of CR #12 nurses' notes for the month of May 2017 revealed in part: -05/02/17 heart rate 113 orders received from NP to increase hydration from 23ml/hr to 35ml/hr and observe tolerance. Resident heart rate dropped to 99. - nurses' notes from 05/03/17-05/09/17 revealed no documentation of vital signs, catheter care or assessments. -05/10/17 at 9:06 Tylenol 325mg via [DEVICE] for temperature of 100.8 rechecked and temperature 99.0. There was no documentation that the physician was informed or documentation of any other assessments or vitals. -05/11/17- no assessments or vital signs were documented. -05/12/17 During rounds in resident's room at 4am noted resident moaning with increased labored breathing temperature 101.2 axilla, pulse oximeter 82%, respirations 22, B/P 156/88, pulse 166. Tylenol 325mg one tab given via [DEVICE], 911 called, family member called. Record review of CR #12 SBAR Notes dated 05/12/17 documented at 4:40 a.m. by LVN-F reading in part: .Resident moaning and B/P 156/88, pulse irregular 166, Respirations 22 labored, Temperature101.2 axilla, and Oxygen saturation 82%. Tylenol 325mg one tab via [DEVICE]. Resident continuing to moan 911 called and family member were called . Record review of CR #12 hospital records dated 05/12/17 in the emergency room revealed Foley catheter was inserted with the return of 1500ml of urine yellow, hazy with sediments. Resident lab values showed resident had developed Acute [MEDICAL CONDITION]: -BUN 58 (norm 6-20) -[MEDICATION NAME] 1.2( norm 0.5-.9) -Blood Culture [DIAGNOSES REDACTED] (bacteria)- positive [MEDICATION NAME] 1000mg intravenous times one dose given. Resident was placed on contact isolation in the ICU unit and was started on Fluconazole 200mg intravenous every 24 hours and was discontinued on 05/17/17. Resident was now receiving Zerbaxa 1500mg every 8 hours intravenous initiated on 05/17/17. Interview on 05/18/17 at 11:55 a.m. RN-D said the nurses monitor residents output with a urinary catheters every shift. The CNA's empty the Foley bag and report the amount to the nurse so the output can be recorded. RN-D said signs and symptoms of UTI are fever, foul odor and cloudy urine along with discomfort. RN-D said she would report these findings to the Doctor or NP. In a phone interview with CR #12's family member on 05/18/17 at 12:30 pm, she said that she visit the facility on 05/10/17 and the resident's Foley catheter was leaking. She said that a CNA told her that a male nurse did not change the Foley but instead pushed it further. She said that when she returned to the facility on [DATE] at around 9:30 am she noticed that the Foley was no longer leaking but there was no urine in the Foley bag. She said she asked staff about the urine and they told her the bag had just been emptied. She continued to say that she stayed with the resident until about 4 pm that day and did not see any staff come in to check or change the urine bag. She also noted there was barely any urine in the bag. The family member then said she received a call from the facility at approximately 2 am to tell her the resident was in a lot of pain and distress and was taken to the hospital. Observation on 05/18/17 at 3:00 pm revealed that CR #12 was in the intensive care unit in a local hospital. The resident was on contact isolation. She had a Foley catheter and a feeding tube for nutrition. Interview on 05/19/17 at 10:30 a.m. LVN- A said he took care of CR #12 about 2 weeks ago. LVN-A said resident was running a low grade fever of 99.5 axillary and Foley catheter was leaking. LVN-A said the doctor was called and received orders to change Foley catheter but he did not document this on the clinical record because he got busy with multiple admissions that day and forgot. Interview on 05/19/17 at 12:45 p.m. the DON said CR #12 was transferred to the hospital because of a fever and infection of the bladder. This surveyor requested the names of the nurses and CNA's that administer care to CR #12 on 05/11/17 for all three shifts and the DON said she would have to look and see and report back to surveyor the staff that was taking care of CR #12. Interview on 05/19/17 at 1:25 p.m. the Medical Director said he never gave an order to discontinue monitoring the resident for UTI which it was the reason to monitor intake and output. The Medical Doctor said if a resident does not have a Foley then there is no need to monitor output. The MD said what would cause CR #12 to retain a high urine residual after a Foley catheter was changed. He said it could have been some kind of blockage like the tubing was kinked or mucus clot. The MD said if that happened, the resident would have experience some abdominal distention along with pain and there would be very little to no urine output in the bag. He also said that would have to go on for some days and the resident would be in a lot of pain. Interview on 05/19/17 at 2:30 pm the NP said CR #12 was a very sick resident. NP said the nursing staff should have been monitoring very closely and reporting to her or the Physician signs of UTI such as foul smelling cloudy urine, fever, and discomfort such as facial grimacing, but the staff did not. The NP said CR #12's medical history warrant close monitoring and report of any change in condition. The NP said she never gave orders to discontinue monitoring the resident's temperature. The NP said the reason why she did not treat CR #12 with further antibiotic therapy when she find out resident was resistant to medication Bactrim, was because the resident had just been given a round of intravenous antibiotic therapy [MEDICATION NAME]. The NP said that was why she wanted the staff to monitor resident for further signs of UTI. Interview on 05/19/17 at 5:55 p.m. LVN-F said when she came to work on the 10p-6a shift on 05/11/17 CR #12 was resting quietly in bed. LVN-F said she never received report of issues with the resident or that the Resident's Foley had been leaking. LVN-F said when rounds were being made around 4 a.m. found resident moaning. He took vital signs and resident had a fever and was in distress. LVN-F said could not remember who gave her report on the 2p-10p shift. Interview on 05/22/17 at 3:20 pm the DON said it was RN-B that took care of CR #12 on 6a-2pm shift on 05/11/17and that she was still looking to see who was the nurse who worked with the resident on the 2-10pm shift. The DON said she was aware of CR #12's Foley catheter leaking. The DON said the staff was to keep resident clean, dry and monitor resident for UTI symptoms such as change in color of urine, cloudiness, checking vital signs, palpate the bladder. The DON said the staff should have been taking the Resident's vital signs at least daily. The DON said she and her ADON that monitor the staff to ensure they were monitoring the residents and reporting changes in condition to the Physician. The DON said the reason why they stopped administering the last dose of antibiotics was because CR #12 had completed all her doses. The DON said it was RN-B that changed the resident Foley catheter because RN-B told her. Interview on 05/22/17 at 3:50 p.m. RN-B said he did change CR #12 Foley catheter on the week resident went to hospital with the assistance of a CNA because the catheter was leaking. RN-B said the resident's family member was visiting on that shift but was not present in the room when the Foley was changed. RN-B said he was successful on the first try with the return of clear yellow urine but does not remember the date it was done or the urine output. RN-B said he did not document any of this in the clinical chart. Record review of facility Policy on Changes in Resident Condition revised 02/2017: .The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Changes in condition are communicated from shift to shift through the 24 hour report . The Administrator and DON were notified on 05/22/17 at 4:50 pm of the IJ situation due to the above failures and a POR was requested. The POR was received and after 2 revisions it was accepted on 05/23/17 at 6:43pm. POR included in part: . Audit will be completed by DON/designee on all residents with Urinary Tract infections currently to ensure notification to physician and family and documentation is completed. Start 5/22/2017 at 6p. Finish 5/23/2017 at 11p . Staff will be re-educated by DON/ADON/Unit Manager/ Staff development Coordinator/District Director of Clinical Services. All nursing staff will be included in the re-education, including Resident Care Specialist (CNA). -The policy and procedure for monitoring Urinary Tract Infections -Notifying physicians of any change of condition -DON/designee will review all physician orders [REDACTED]. -Proper and timely documentation to include vital signs, assessments, Foley changes and intake/output if ordered -Foley catheter care including changing Foleys and documentation on Foley care -Charge nurse will be responsible for monitoring input/output when ordered by Physician -DON/designee will follow up weekly to verify compliance . In an interview on 5/23/2017 at 2:00 p.m. the DON said RN-B was a new nurse on Hall-100 that was overwhelmed and she was looking at getting an extra nurse. The DON said the facility was very hard to manage and had a very high turnover rate. The DON said she did not give any specific training on the care of residents with high acuity levels (level of severity of illness) with the nursing staff. The DON said the reason why the facility had an IJ was because they did not follow-up with the Doctor and document. In an interview on 5/23/2017 at 3:05 p.m. the Administrator said the reason why the facility had an IJ was because of a lack of training with the staff on the nursing units, following up with management, and lack of communication. The Administrator said she realize there were problems that need to be corrected. In an interview on 05/24/17 at 1:20p.m. the DON said that it was the ADON that took care of CR #12 on 05/11/17 on the 2p-10p shift. The ADON said she does not remember if she took care of CR #12 on 05/11/17 on the 2-10 shift but can verify by looking on the sign in sheet on Hall-100. The ADON confirmed that it was the DON that took care of CR #12 on the 2p-10p shift on 05/11/17. Further confirmation of the MAR indicated [REDACTED]. Interview on 05/24/17 at 1:40 pm the DON confirmed she worked as a nurse on the floor on 05/11/17 and was the nurse that took care of CR #12. She said she did not document at all on CR #12 during her shift because she had 3 admissions that she was trying to attend to as well. The DON said she was sorry. The facility was monitored from 05/24/17 to 05/25/17 to verify that the plan was implemented. Monitoring of POR included in part: Interview on with multiple nurses from different shifts on 05/24/17 and 05/25/17 revealed they had been in-serviced on documentation, SBAR, physical assessment, Catheter care, and notifying the physician of any change in resident condition, signs and symptoms of infection especially UTI's. Interview on 05/24/17 and 05/25/17 with multiple CNAs from different shifts revealed they received in-service on change in resident condition and reporting to the nurse. Record review revealed the facility had completed residents' assessments on 05/23/17 and 05/24/17 to ensure they did not missed any changes in condition. Record review revealed the facility had completed an audit for all the residents with catheters and urinary tract infections to ensure MD was notified of any changes. The Administrator and DON were informed on 05/25/17 at 1:55 pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provided by the DON, 10 residents had indwelling urinary catheters.

Based on observation, interview and record review the facility failed to ensure who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for to 2 out of 8 residents (Residents #2 and #1) that were reviewed for urinary incontinence. -Resident #2 brief and bed linen were soaked in urine. His scrotum and buttocks areas were red and macerated. - Resident # 1 and Resident # 2 did not receive timely incontinent care. - Resident # 1 developed red rash throughout the inner thigh, perineal, groin, and buttock area. A Foley catheter was inserted to help with the rash and [MEDICATION NAME] was ordered for [DIAGNOSES REDACTED]. This failure affected 2 residents and placed 19 incontinent residents in unit D at risk of urinary tract infections, rashes, skin breakdown and a decline in their quality of life. Findings include: Resident #2 Record review of Resident # 2 face sheet revealed an [AGE] year old male admitted to the facility on [DATE] with the following diagnoses; Malignant Neoplasm of kidney, Cerebral Infarction, Hypertension, Depression, Chronic Pain, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux Disease, GOUT, [MEDICAL CONDITION] and [MEDICAL CONDITION], Low Back Pain, Dysphagia, [MEDICAL CONDITION], Anxiety, and Opioid Abuse. Record review of Resident # 2 Minimum (MDS) data set [DATE] revealed a BIMS score of 7 indicating moderately impaired cognitive skills and requires total assistance with personal hygiene and toilet use along with bed mobility, transfers, and dressing. Record review of Resident # 2 Care Plan dated 04/01/16 and revised 06/30/16 for incontinence and to check resident every 2 hours and assist with toileting as needed, observe for patterns on incontinence and initiate toileting schedule if indicated, and provide pericare after each incontinent episode. Observation on 10/07/16 at 10:07 a.m. of incontinent care provided to Resident # 2 revealed that CNA-D repositioned Resident # 2 to his left side. Resident # 2's brief and bedding were soaked with urine. LVN-N assisted CNA-D with incontinent care of Resident # 2. After the soiled brief was removed from the resident, it was observed that Resident # 2's buttock and scrotum area had redness and were macerated along with skin breakdown to 3 areas on the left buttock. Interview on 10/07/16 at 10:07 a.m. with LVN-N she said she would notify the wound care nurse about new skin breakdown to the resident's buttock area. Interview on 10/07/16 at 12:20 p.m. the DON said residents who were incontinent of bowel and bladder were to be checked and changed every 2 hours or as needed. The DON said Resident # 2 brief and bedding soaked in urine should not have happen. The DON said she know about Resident # 1 having wounds to her heels. Resident #1: Record review of Resident #1 face sheet revealed an [AGE] year old admitted to the facility on [DATE] with the following diagnoses; Dementia, Gastrostomy, Anorexia, [MEDICAL CONDITION], Anxiety, Gastro-[MEDICAL CONDITION] Reflux Disease without Esophagitis, Dysphagia, Constipation, Contracture of Knee, and [DIAGNOSES REDACTED]. Record review of Resident #1 Minimum (MDS) data set [DATE] revealed a BIMS score of 3 indicating she had severely impaired cognitive skills and required total assistance with activities of daily living (toileting, personal hygiene, dressing, transfer, eating, transfers, and mobility). Record review of Resident # 1 Care plan dated 02/20/16 and revised 09/08/16 revealed resident has potential for pressure ulcer related to impaired physical mobility and bowel and bladder incontinence. Provide incontinence care after each incontinence episode. Observation on 10/7/16 at 10:50 a.m. of Resident # 1 revealed she was resting in bed receiving nutrition via Gastrostomy Tube. Resident # 1's foley catheter bag was at her bedside. CNA-D and CNA-B were providing care to Resident # 1. The resident had extensive redness to her inner thigh, groin, perineal, and buttock area along with noted varied excoriations to the buttocks. Interview on 10/7/16 at 10:50 a.m. with CNA-D and CNA-B regardng the resident's redness, CNA-D said the rash was due to Resident # 1 not being turned and cleaned like she should be. Interview on 10/7/16 at 10:55 a.m. with LVN-O regarding extensive redness to Resident # 1 perineal area, she said the reason the Physician gave orders to insert a foley catheter was because she has wounds on her heels and she was contracted and tended to touch her buttocks with the dressing on her feet. LVN-O said Resident # 1 was incontinent so the Physician only ordered the foley catheter for 3 weeks so that we can get her rash healed and it is beginning to look better. Record review of Resident # 1 Wound Care Specialist Evaluation notes dated 10/6/16 revealed Resident # 1 has wound on buttock stage 2 wound of at least 14 days duration, Diagnosis: [REDACTED]. Record review of Physicain orders dated 10/6/16 revealed in part ok to insert foley for sacral ulcers times 3 weeks. Interview on 10/07/16 at 12:50 p.m. the Nurse Practitioner said the extensive red rash to Resident # 1's perineal area was the result of moisture and Resident # 1 had been started on the antibiotic [MEDICATION NAME] for rash to perineal area. Record review of facility policy on incontinent care revised 10/2/15 reading perineal care of the female and male resident which includes external genitalia and anal area should be performed during the daily bath and if the resident is incontinent after urination and bowel movements. The procedure promotes cleanliness and prevents infection. Further record review of facility policy regarding skin management revised 08/2012 read in part : .Residents who are at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and or integrity. On- going monitoring and evaluation are provided to ensure optimal resident outcomes . According to the DON there were 21 residents residing in Unit D that were incontinent of the bladder.

Based on observation, interview and record review the facility failed to ensure that 3 of 14 sampled residents with pressure ulcers received the necessary treatment and services to promote healing, prevent infection (Resident #15) and prevent new sores from developing. (Residents #s 15, 11 and 9 ). Resident #15 had a pressure ulcer on the left heel. On 03/15/11 he developed an unstageable pressure ulcer to his sacral area and a stage II pressure ulcer to his gluteal fold which staff were unaware of. Staff had not established Resident #15's fluid needs and his mouth and lips were dry and cracked and he asked for water. He was transferred to a hospital on [DATE]. Resident #11 had a pressure ulcer on her hip. She developed new pressure ulcers on her left heel and staff had not done skin checks and had no orders for wound care. Resident #9 had a pressure on her coccyx and buttocks and staff had not provided wound care. These failures affected three residents and placed 18 residents at risk for the development of new pressure ulcers, delay in treatment resulting in worsening of the resident's skin and a decline in health. Findings include: Resident #15 Record review of Resident #15 ' s face sheet and medical record revealed that he was admitted to the facility on [DATE]. Resident's [DIAGNOSES REDACTED]. Record review of Resident #15 ' s Braden Scale for predicting Pressure Sore Risk dated 3/4/11 revealed a score of 15 that predicted a mild risk for developing pressure sores. Observation of Resident #15 on 03/14/11 at 8:50 am revealed he was lying in bed. Resident had on a hospital gown, his mouth, lips, were dried and cracked. Observation on 3/15/11 at 8:45 a.m. of Resident #15 revealed he was lying flat in bed in a hospital gown, his mouth, lips, fingernails, skin were dry and cracked. Continued observation revealed that resident had a heel protector boot on his right foot. In an interview at this time Resident asked for some water. In an interview on 3/15/11 at 8:52 a.m. Licensed Vocational Nurse (LVN) J stated that Resident #15 could only have thickened liquids. In further interview he stated that Resident had a pressure ulcer on the left heel. In an interview on 3/15/11 at 9:03 a.m. Certified Nurse Aide D stated that she was doing showers today and she would give Resident #15 a shower, cut his hair, check to see if she could cut his nails, brush his teeth and put his catheter bag in a privacy bag. Observation on 3/15/11 at 2:01 p.m. revealed that the Certified Nurse Aides B, D and the Air Mattress Worker were putting air in Resident #15's new air mattress on the bed. In an interview at this time CNA D stated that a stage two pressure sore was found on Resident's area during ADL care today. Further observation of Resident #15 at this time revealed that he was dressed, showered, his teeth were cleaned, and his skin was moist. In an interview on 3/15/11 at 2:29 P.M. the Assistant Director of Nurses (ADON) stated that the staff found a stage II pressure ulcer on Resident #15 's sacral area during ADL care and she also stated that she did not know how the staff did not find the stage two pressure sores before today. In an interview on 3/16/11 at 8:29 a.m. the Treatment Nurse she stated that she had talked to the doctor yesterday about Resident #15 ' s "stage II pressure sore and the doctor said that the pressure sore was not there a couple of days ago." Record review of Resident #15's Daily Skilled Nursing Summary from March 4, 2011 to March 15, 2011 revealed there was documentation that Resident had been turned and repositioned every two hours only two days on March 11, 2011 on the 11 p.m. to 7 am shift and on March 14, 2011 on the 11 p.m. to 7 a.m. shift. In an interview on 3/16/11 at 8:39 a.m. the ADON stated that she did not have documentation that the staff turned and repositioned Resident #15 every two hours but she would do an in- service on pressure sore prevention, and ADL care. In an interview on 3/16/11 at 8:47 a.m. Registered Nurse Z stated that they were sending Resident #15 out to the hospital and the DON and ADON would know why Resident #15 was being sent to the hospital. In an interview on 3/16/11 at 8:48 a.m. the Treatment Nurse stated that Rresident #15 was going to the hospital due to a change in condition. Record review of the Physician Telephone Orders dated 3/15/11 revealed: " 1. right sacral cleanse with wound cleanser apply [MEDICATION NAME] gel et dry dressing (drsg) Cleanse dry. 2. Gluteal fold cleanse with wound cleanse apply [MEDICATION NAME] gel et dry drg change daily 3. Left (Lt) Ischial cleanse with wound cleanser apply [MEDICATION NAME] gel et dry drsg, change daily 4. Right heel cleanse with wound cleanser pat dry apply [MEDICATION NAME] spray daily. " Further review revealed discontinue elevate legs et float heels at all times. Apply Provolune boots to both (Right and left) feet at all times (to float heels may remove for bathing. Low air Loss Mattress to bed. " Review of the Physician ' s Telephone Orders date 3/16/11 revealed: " Nothing by mouth NPO until ambulance arrive In an interview on 3/17/11 at 12:19 p.m. the Occupational Therapist Registered (OTR) stated that Resident #15 was weak and he was dependent on staff for feeding and all of his ADL care. Record review of Resident #15 ' s Weekly Pressure Ulcer Record dated 3/4/11 revealed Resident had 5 cm in length by 4cm in width with no depth eschar that was unstagable on his left heel. Record review of Resident #15 ' s Weekly Pressure Ulcer Record dated 3/15/11 revealed: new site A II right sacral wound 8.5 by 2.5 cm and o.1 depth and no undermining. Further review revealed New site stage two to gluteal fold 6.4 by 1.0 cm, 0.1 depth and no undermining, serosanguineous exudate, wound was red. Record review of the Physician's Assistant notes dated 3/8/11 revealed: "Skin No rash, itching, skin discoloration to right side of face." Further review of the Physician Assistant ' s notes dated 3/15/11 revealed: "Skin color, turgor, moisture normal. No evidence of abnormal pigmentation, or depigmentation, abrasions [MEDICAL CONDITION], or masses. Sacral area noted with stage II/ skin abrasion measures about 5.5 X 2.5, Gluteal fold with 6.4 X1.0 X 0.1 and left ischeal area with 0.5 X 0.5. New order silverdene to wounds and zinc oxide to sacral area two times a day and every two hour turning. Record review of Resident #15 's hospital physical and history dated 3/16/11 revealed Extremities: Bilateral Lower Extremity contractures. The patient has heel boots as well as stage two to stage three sacral as well heel decubitus. " Record review of the ADL in service dated 3/16/11 revealed handouts on: Performing oral care, perineal care of the female patient, perineal care of the male patient. Record review on the in- service dated 3/16/11 on Pressure prevent revealed: " Objective to prevent the development of a pressure ulcer according to standard of care ... Turn and reposition the patient every 1 to 2 hours, unless contraindicated, lift do not slide, the patient to change position, Use pillows for positioning and comfort, Under pressure redistribution devices as appropriate ...Keep the patient ' s skin clean and dry. Document the procedure." Further review of the in service revealed a pocket handout revealed: " Turning Schedule 7:00 AM back, 9AM right side, 11:00 AM, 1:00 PM left side, 3:00 PM right side, 5:00 PM Back, 7:00 PM left side, 9:00 PM right side, 1:00 PM left side, 3:00 AM right side, 5:00 AM left side. " Resident #11 Review of the admission sheet revealed Resident #11 was an [AGE] year old female admitted 12/29/09. She had [DIAGNOSES REDACTED]. She was totally dependent on tube feeding for her nutrition. She had a catheter for a [DIAGNOSES REDACTED]. Resident #11 - Skin check weekly on Wednesday 7-3 shift documented on 3/2/11 and 3/9/11 Nails cleaned and trimmed. Observations of Resident #11 on 3/15/11 at 9:00 am reveal her left foot had 3+ [MEDICAL CONDITION]. Left great toe free edge of nail was 1.6 cm long. Length of free edge of #2 toe nail was 0.8 cm long and curved under to touch skin. Length of other 3 nails similarly long and curved under. When boot removed, noxious foot odor became apparent while standing 4 feet away. Skin of both feet was dry and cracked. Observations of Resident #11, with CNA H and CNA E assistance, on 3/15/11 at 9:00 am revealed: Left heel was discolored, dry and closed; appeared to be deep tissue injury. Right heel open wound, bright pink/red wound bed, approximately 3 x 3 cm. Right lateral aspect of foot at the first joint was black, approximately 1 x 2 cm. Posterior thigh open, red wound roughly 4" long and crescent shaped. In an interview at 9:00 am on 3/15/11, CNA E observed the crescent shaped wound and commented it was probably from the catheter tube. Review of physician orders [REDACTED]. Record review revealed, wound care orders written on 3/15/11 included Clean right and left stage I heel ulcers with normal saline and dress everyday. After performing wound care and observing Resident 11's skin, in an interview on 3/15/11 at 3:30 pm, Wound Care Nurse said she was unaware of the wounds and had not received orders for wound care on the heels. Resident #9 Record review of admission sheet revealed Resident #9 was an [AGE] year old female, admitted on 2/10/11. She had a history of [REDACTED]. She was a total care resident unable to turn or reposition herself. She had moderate dementia; but was able to communicate verbally, describe her history, and express needs, preferences and dislikes. Observations of Resident ' s skin, on 3/14/11 at 12:45 pm revealed, bilateral heel and ankle dressings were not dated. Coccyx dressing was discolored, nearly detached from skin and not dated. Right hip had open 1 x 1 cm undressed wound. There was a 7.5 cm long open wound posterior to the peri-rectal area and the depression of a catheter tube. On 3/15/11 at 2:40 pm wound care provided by staff was observed on the Resident #9. In an interview on 3/15/11 at 2:40 pm the Wound Care Nurse stated she was not able to do the wound care on Resident #9 on 3/14/11. The coccyx and buttocks wounds were open and should be dressed, but were not. There was no ointment on the peri-area and there should be. Review of treatment record for 03/2011 revealed wound care was not signed off on 3/14/11 for Resident #9. Wound care orders dated 3/1/11, were reviewed for Resident #9; - Feet and ankles clean, apply granules, hydrogel, cover with dressing everyday - Left lower buttocks - clean, apply [MEDICATION NAME] and dress everyday. - Coccyx - clean, apply [MEDICATION NAME] and dressing everyday - Perineum - clean and apply A&D ointment everyday and as needed. The CMS 672 listed 21 residents with pressure ulcers.

Based on observation, interview and record review the facility failed to provide one of 24 sampled residents with sufficient fluid intake to maintain proper hydration and health. (Resident #15) The facility failed to: 1. Ensure that the Registered Dietitian completed Resident #15's Nutritional Assessment and ensure that Resident's fluid needs were being met. 2. Ensure they had orders to monitor Resident #15's intake and output of fluids. 3. Monitor for signs and symptoms of dehydration. Resident #15 was transferred to a hospital and diagnosed with [REDACTED]. This failure affected one resident and placed 16 residents at risk of dehydration. Findings include: Resident #15 Record review of Resident #15's face sheet and medical record revealed that he was admitted to the facility on [DATE]. Resident's [DIAGNOSES REDACTED]. Observation of Resident #15 on 03/14/11 at 8:50 am, revealed he was lying in bed and appeared fatigued. Resident had on a hospital gown, his mouth, lips, fingernails and skin were dried and cracked. Resident's hair was dried kinky/matted and uncombed and his facial hair was not groomed or shaven. On the right side of Resident was his Foley catheter bag and it was placed between the iron bar separating the mattress and the bedrails. Observation of the catheter and the Foley bag revealed: The Foley catheter's tubing was filled with cloudy urine draining into the Foley catheter bag. There was 250 cc of cloudy urine in the bag. There was a long tubing draining into the Foley bag. Observation on 3/15/11 at 8:45 a.m. of Resident #15 revealed he was lying flat in bed and appeared in a hospital gown, his mouth, lips, fingernails, skin were dry and cracked. Resident's hair was dried kinky/ matted and uncombed and his facial hair was not groomed and unshaven. Resident's teeth were filled with white matter and not brushed. Continued observation revealed that resident had a heel protector boot on his right foot. In an interview at this time Resident asked for some water. In an interview on 3/15/11 at 8:52 a.m. Licensed Vocational Nurse (LVN) J stated that Resident #15 could only have thickened liquids. Observation at this time revealed LVN J gave Resident #15 a few sips of thickened water. In further interview he stated that Resident had a pressure on the left heel. He also stated that Resident 's Foley catheter bag was supposed to be hung on the bed and he did not why Resident had the Foley catheter but he was admitted to the facility with it. In continued interview he stated that would have staff take care of all of Resident ADL needs and have staff to pick up the catheter bag off of the floor. He also stated that Resident could only have thickened water. Review of Web MD dated March 8, 2010 revealed signs of dehydration included thirst, less frequent urination than normal dry skin and fatigue... Review of Resident #15's Physician's Telephone Orders dated 3/15/11 revealed: "Insert midline for IV fluids Diagnose(DX) dehydration." Observation on 03/15/2011 at 8:52 am and 4:50 pm revealed Resident #15 did not have IV fluids infusing. Review of Resident #15's Medical Nutritional Therapy Review dated 3/811 revealed that the Registered Dietitian did not assess Resident's nutritional needs. Further review of resident's Nutritional section of the medical record revealed that the Registered Dietitian had not seen Resident after he was admitted to the facility 03/04/11. There was no documented calculation of daily fluid needs for Resident #15. Review of the Nurses' notes and dietary notes revealed no documentation from March 4, 2011 to March 15, 2011 about Resident #15 refusing fluids or foods. Review of the Nursing Daily Skilled Summary from March 5, 2011 to March 15, 2011 revealed that the skin assessment part of the form was blank and there were no problems documented about the skin turgor. Review of Resident #15's transfer form date 3/1/11 to the nursing home revealed that his weight was 56.7 kgs. (125 pounds). Review of the Pocket Resource for Nutrition assessment dated 2005 revealed "Adult Fluid Requirements: Wt (kg) x 30 ml = daily Fluid Requirement" Resident #15's daily fluid requirement was 1701 ml/day. There was no documented plan to ensure Resident #15 received the daily fluid requirement. Review of Resident #15's entire medical record revealed no documentation of resident's fluid intake from 3/4/11 to 3/15/11 and no intake and output records for Resident #15. Review of Resident #15's nurses notes dated 3/15/11 3:30 p.m. revealed that resident voided a small amount, but no documentation of the actual amount voided. Review of Resident #15's hospital physical and history dated 3/16/11 revealed "This is a [AGE] year old male, who was brought in due to dehydration ... He is currently in ICU, though pending transfer to medical floor. ..." Further review of resident's hospital labs dated 3/16/11 revealed Resident #15's creatinine was 11.2 (H), reference range (0.8 to 1.3 mg/dl). Resident #15's sodium was 143 (H), reference range (135-141). Blood Urea Nitrogen (BUN) was 195 ( H) reference range ( 5 to 25 mg/dl). Review of WebMD updated August 12, 2008 revealed a high BUN is caused by severe dehydration or shock.... that dehydration can cause high creatinine blood levels. Review of Web MD updated 9/18/08 revealed high sodium levels can be caused by not drinking enough water and being dehydrated. Review of the facility's Hydration Management policy dated June 2007 revealed Residents are provided with sufficient fluid intake to maintain proper hydration and health. Residents identified at risk for fluid volume deficit will be assessed timely and provided appropriate interventions to promote/ ensure adequate hydration. ... 2. Residents identified with the potential for or actual hydration issues will be referred to the Registered Dietitian. ... 3. Residents identified with potential / actual hydration issues will be reviewed/ assessed by the interdisciplinary team for attributing risk factors/conditions. These risk factors and preventive interventions will be documented in the care plan and progress notes of the medical record..." Review of Resident #15's Initial Plan of Care dated 3/4/11 revealed: "Resident will have adequate nutrition and hydration with enteral feeding ordered as evident by moist mucosa, adequate skin turgor and stable weight thru next review." The CMS 672 listed 17 bedfast residents.