Every finding on record at Paradigm Northwest

Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for reporting. LVN A failed to follow the facility policy for reporting an injury of unknown origin for Resident #1 to Administrator D and DON E that was discovered on 07/27/2026. This failure could place residents at risk for not having incidents reported as required. Findings included: Record review of Resident #1's Care Plan revealed that resident was a [AGE] year-old male. Resident #1 was admitted to the facility on [DATE] and discharged on 07/27/2026. Resident #1 was diagnosed with Intracranial Hemorrhage (stroke), Acute and Chronic Respiratory Failure (not enough oxygen in the body), Sepsis (bodies extreme response to an infection that can lead to organ failure), Dysphagia (Difficulty swallowing), Protein-calorie malnutrition, Bronchopneumonia (infection of the bronchi in the lungs), Encephalopathy (brain disfunction that causes memory loss and cognition decline), Staphylococcus Aureus (bacterial skin infection), Pseudomonas (bacterial infection), Tracheostomy (surgically created hole in the throat), Gastrostomy (surgically created hole in the stomach). Record review of Resident #1's Brief Interview Mental Status Assessment revealed Resident #1 had a score of 0 indicating Resident #1 had severe cognitive impairment. Record review of Resident #1's Minimum Data Set revealed Resident #1 required assistance with all activities of daily living. Resident #1 required assistance with urinary and bowel incontinence. Resident #1 was paraplegia. Record review of Resident #1's hospital records revealed Resident #1 did not have an order for blood thinners while at the hospital. Record review of Resident #1's electronic medical records reflected Resident #1 had the initial skin assessment on 7/24/2026. The note stated that there were no skin injuries observed. Record review of Resident #1's electronic medical records reflected Resident #1 had a skin assessment on 7/27/2026. LVN A documented that there was bruise observed on the top of Resident #1's left hand. A description of the bruise was not documented. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 7/25/2026. RT H documented that at approximately 11:45; Resident #1 self-decannulated. The tracheostomy tube was immediately reinserted without complications. Interview on 08/04/2026 at 10:00 AM with RT H revealed that she worked with Resident #1 on 07/25/2026. She stated that Resident #1 had removed his tracheostomy during her shift. She stated that she placed it back in and made the appropriate notifications. She stated that Resident #1 was assessed and his vitals were stable. Interview on 08/04/2026 at 10:29 AM with RN G revealed that she worked with Resident #1 on 07/25/2026 and 07/26/2026. She stated that she did not observe bruising on either of his hands on 07/25/2026 or 07/26/2026. She stated that on 07/25/2026 Resident #1 pulled his tracheostomy out and RT H had to put it back in. She stated that notifications were made each time and each time Resident #1 had vitals assessed and was stable. She stated that Resident #1 also removed his clothes constantly. She stated that she dressed him three separate times. She stated that Family Member F was present on 07/25/2026. She stated that Resident #1 is not verbal and unable to communicate. She stated that he did not have incidents on 07/26/2026. Interview on 08/04/2026 at 3:00 PM with LVN A revealed that she worked with Resident #1 as a wound care nurse. She stated that she performed a skin assessment on Resident #1 on 07/27/2026 . She stated it was her own initial assessment since she had never seen him before for wound care. She stated that she is trained to find things that a regular nurse might not see on their initial assessment. She stated that there was small bruising to Resident #1's left hand. She stated that it was not a big bruise. She stated it appeared as if he had received a blood draw. She stated that it looked old and that it didn't seem like it was anything to be concerned about. She stated that she documented it on the skin assessment because she wanted to notate it. She stated that she knew nothing about his right hand being bruised. She stated that she was not told about his right hand being bruised. She stated that she had not established a base line of care with Resident #1 yet since this was her first day working with him. She stated that Resident #1 was admitted from the hospital on [DATE]. She stated that Resident #1 received blood thinners while he was at the hospital. She stated that Resident #1 removed his tracheostomy and kept taking off his clothing. She stated that she did not review his initial skin assessment from 07/24/2026 to see if the bruise to his left hand was new or a change in condition. She stated that if she had known this patient already and seen a new bruise then she would have reported this as a change in condition or injury of unknown origin but since it was her first time seeing him, she didn't report it. She stated that facility training requires her to tell the administrator and director of nursing about any new bruise that is found. Interview on 08/04/2026 at 3:32 PM with Family Member #1 revealed that Resident #1 did not admit to the facility with bruises to his hands on 07/24/2026. She stated that she saw Resident #1 on 07/24/2026, 07/25/2026, 07/26/2026, and 07/27/2026. She stated that the bruises first appeared on 07/27/2026. She stated that she informed the facility about the bruising to Resident #1's right hand on 07/27/2026 around 10:00 AM. She stated that she told DOR B it was not there on 07/25/2026 or 07/26/2026. She stated that she was very mad and directly told DOR B to tell the nurses look at Resident #1's hand. She stated that she was very frustrated because she was telling DOR B about the bruising on the right hand and felt like the facility did not take her concerns seriously. She stated the bruise was about palm sized, about 3 inches. She stated it was on the top side of his right hand. She stated that she thought it was a new bruise because it was brown and dark red. She stated that another bruise also appeared on his left hand later that same day. She stated that Resident #1's bruises had already healed by 08/04/2026 and were no longer visible. Interview on 08/04/2026 at 4:00 PM with Physician I, revealed that he was notified about Resident #1 removing his tracheostomy. He stated he personally went to visit Resident #1 on 07/27/2026 and assessed his tracheostomy. He stated that Resident #1 was stable and his vitals were normal. He stated that there were no concerns. He stated that he was not notified of any bruising to Resident #1's hands. He stated he did not look at Resident #1's hands. Interview on 08/04/2026 at 4:07 PM with Physician J, revealed that bruising is very common in the elderly. She stated that there could be many causes that lead to bruising. Interview on 08/05/2026 at 10:06 AM with DOR B, revealed that she saw Resident #1 on 7/27/2026. She stated that she was told by Resident #1's family that there was a small red dot on Resident #1's right hand. She stated that she did not know if it was a bruise or not. She stated that she told LVN C that the family was concerned about a bruise on Resident #1's hand. She stated that she did not tell Administrator D or DON E about the bruise. She stated this conversation occurred around 10:00 AM on 07/27/2026. Interview on 08/05/2026 at 10:29 AM LVN C stated she was told by DOR B that the family was concerned about Resident #1's hand on 07/27/2026. She stated that she did not see Resident #1 on 07/24/2026, 07/25/2026, or 07/26/2026. She stated that she read the progress notes for Resident #1 at the start of her shift and discovered that Resident #1 was fighting with the staff over the weekend. She stated Resident #1 constantly removed his clothes and removed his tracheostomy. She stated that she observed Family Member F saying what is this regarding Resident #1's skin. She stated it was either redness or an old bruise about the size of a quarter. She stated that the bruise looked like it might have been an old bruise from a blood draw. She stated that she informed DON E about the families concerns and was told by DON E to go tell LVN A. She stated that she told LVN A to go look at Resident #1's bruise for Family Member F. She stated that every change in condition is to be reported to DON E. Interview on 08/05/2026 at 11:30 AM DON E stated staff were trained to notify the administrator and director of nursing if they find any injury of unknown origin. She stated if someone was just admitted from the hospital then they could have come with a bruise from the hospital. She stated the initial skin assessment performed on 07/24/2026 did not document that there was a bruise already present on Resident #1's hand the day he arrived from the hospital. She stated had she known about the allegation of abuse or injury of unknown origin to Resident #1's hand then she would have assessed Resident #1 herself and told Administrator D. She stated that neither LVN A, DOR B, nor LVN C told her about the bruising to Resident #1's hand. Interview on 08/05/2026 at 11:45 AM with Administrator D, revealed that she was not notified of any bruising to Resident #1's hand. She stated that had she of known that there was an allegation of abuse or injury of unknown origin to Resident #1's hand then she would have reported the incident to the Texas Health & Human Services Commission. Record Review of the Facility Abuse & Neglect Reporting Policy dated October 2024, states that: Injury of Unknown SourcePhysical injury observed on a resident where the cause or origin of the injury cannot be readily determined or explained.TrainingThe Facility will train each employee on this policy during orientation, and annually thereafter, and may provide additional training if deemed necessary by the Facility.The Facility will provide training to staff regarding related policies and procedures pursuant to applicable state and federal regulations. PreventionThe Facility will address all concerns through the grievance process. Residents, families, and staff will be able to report incidents and concerns without fear of retaliation.The Facility will instruct staff to report any signs of stress from employees, family, and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate, as required by state and federal regulations.The Facility will instruct staff to report any signs of stress from employees, family, and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate, as required by state and federal regulations. InvestigationThe Facility will conduct a timely investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property. The investigation should include: gathering evidence, interviewing witnesses, conducting surveys as indicated, reviewing medical records, and examining any relevant documentation. Reporting and ResponseDo report injuries of an unknown source immediately, but not later than two hours after the incident occurs or is suspected.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development of pressure ulcers for 3 of 8 (Resident #2. Resident #1, and Resident #3) reviewed for pressure ulcers. The facility failed to turn/re-position Resident #2 every 2hrs and PRN on 4/9/26 and 4/10/26, to help heal his severe sacrum and L thigh pressure ulcers.The facility failed to turn/reposition Resident #1 every 2hrs and PRN on 4/9/26 and 4/10/26, causing the resident to develop redness to her tailbone.The facility failed to turn/reposition Resident #3 every 2hrs and PRN on 4/9/26 and 4/10/26, to help prevent pressure ulcers. This failure could place residents at risk for developing a pressure ulcer or worsening of a pressure ulcer, which could cause pain and infection. Findings include: Record review of Resident #2's undated face sheet revealed he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses of severe sepsis (infection throughout body) with septic shock (organs stop working), osteomyelitis (infection of bone), urinary tract infection, stage 4 pressure ulcer of sacrum (muscle and bone visible to tailbone), COPD (lung disease), type 2 diabetes mellitus (high blood sugar), acute and chronic respiratory failure (not enough oxygen), afib (irregular heart beat), chronic kidney disease (kidneys do not filter effectively), heart failure (heart does not pump effectively), stage 3 pressure ulcer of left ankle (fat visible), unstageable pressure ulcer of right heel (scab or dead tissue covering), unstageable pressure ulcer of left heel, non-pressure (from issues with blood flow) ulcer of right foot with bone involvement, non-pressure ulcer of left lower leg, colostomy (opening to the outside with pouch to collect stool), and gastrostomy (tube into stomach for nutrition). Record review of Resident #2's MDS admission assessment dated [DATE] revealed a BIMS score of 13 out of 15 which indicated normal cognition. The resident had an impairment on one side of both the upper and lower extremities and used a wheelchair for mobility. Resident #2 was substantial/max assistance (helper does more than half the effort) for ADLs. Resident #2 had one Stage 3 (full thickness tissue loss with fat visible) pressure ulcer, two Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers, four unstageable pressure ulcers, three venous/arterial (caused by decreased blood flow) ulcers, and an infection to his foot. Resident #3 was receiving pressure ulcer/injury care, surgical wound care, application of nonsurgical dressings, application of dressings to feet, and had a pressure reducing device for his bed. Record review of Resident #2's Care Plan dated 2/19/26 revealed a focus of Pressure Injury: Resident #2 had multiple pressure injuries and was at risk for further skin break down, infection, worsening of existing pressure injury, new pressure injury formation. Unstageable to R heel. Unstageable to L heel. Stage 3 to L foot. Unstageable to L ankle. Stage 4 to L buttock. Stage 4 to sacral. Unstageable to R buttock. The goal was to have the pressure injuries show signs and symptoms of improvement through the review date. The interventions included consulting wound care, using pillows and/or positioning devices for resident positioning and comfort, providing ordered diet/feedings/supplements and encouraging intake to promote wound healing, and assisting with turning/re-positioning during rounds and PRN. Record review of Resident #2's previous hospital's wound care notes from 1/24/26 at 7:45pm revealed wound care was consulted for extensive stage 4 pressure ulcers to both ischium (buttocks), sacrum, and unstageable pressure ulcers to feet/ankles. The consult indicated Resident #2 had labs done that revealed he was malnourished and recommended supplements. Record review of Resident #2's Braden Scale from 3/11/26 at 1:40pm revealed he was high risk for developing pressure ulcers. Record review of Resident #2's Mini Nutritional Assessment from 4/6/26 at 2:26pm revealed the resident was malnourished. Record review of Resident #2's April 2026 Physician Orders revealed the following orders from MD J: Referral to Dr. [name] wound care team for an assessment, evaluation, and treatment of care. Ordered on 2/20/26.Low air loss mattress, every shift. Ordered on 2/20/26.Heel protectors to bilateral feet, every shift. Ordered on 2/20/26.Proteinex Oral Liquid, 30ml via PEG BID for wound healing. Ordered on 3/13/26. Record review of Resident #2's Wound Care Note dated 4/6/26 at 2:19pm from NP S revealed he had a L buttock pressure ulcer that was 25cm x 14cm x 2.5cm with an area of 350cm. He also had a sacral pressure ulcer that was 9.5cm x 15cm x 1cm with an area of 142.5cm. Resident #2 also had a R buttock pressure ulcer that was 8.5cm x 10cm x 1cm with an area of 85cm. The wounds had been unchanged from the previous week. In an observation and interview on 4/9/26 at 10:40am, Resident #2 was observed to by lying on his back in bed. He had a sacrum pressure ulcer that was the size of a small dinner plate that connected to a L thigh pressure ulcer that was the size of two softballs next to each other. Resident #2 said he tried to stay on his side as much as possible but he always ended up on his back. There were no extra pillows or wedges observed in his room. In an interview and observation on 4/9/26 at 11:00am, RN O said Resident #2 was supposed to have a wedge for positioning. There was a wedge pillow observed on Resident #2's roommate's bed. Once wound care was finished, the resident was left on his back. In an observation on 4/9/26 at 3:50pm, Resident #2 was lying on his back in bed with no pillows or wedges. In an observation on 4/10/26 at 8:40am, Resident #2 was asleep on his back in bed with no pillows or wedges. In an observation on 4/10/26 at 9:19am, Resident #2 was asleep on his back in bed with no pillows or wedges. In an interview on 4/10/26 at 11:00am, NP S said Resident #2's wounds were not changing. She said they were not getting worse, but they were not getting better either. She said turning/repositioning would help some, but his wounds were so bad and he had so many other co-morbidities she did not know how much it would help. She said the turning/repositioning was not keeping his wounds from healing. NP S said the wounds were worse when he was first admitted and now they have plateaued. In an observation on 4/10/26 at 12:09pm, Resident #2 was asleep on his back in bed with no pillows or wedges. Record review of Resident #2's Turning and Repositioning Task as of 4/10/26 revealed the following: 4/9/26: No documentation of the resident being turned all day.4/10/26: Resident was turned at 1:14am and 9:56am. In an interview on 4/10/26 at 2:09pm, the ADM said the wedge that was on Resident #2's roommate's bed, was Resident #2's. She said it must have accidentally got put on the roommate's bed. 2. Record review of Resident #1's undated face sheet revealed she was an [AGE] year old female who admitted to the facility on [DATE] with diagnosis of need for assistance with personal care. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderately impaired cognition. The resident was dependent for all ADLs and was frequently incontinent of bowel and bladder. Resident #1 had a PEG tube for nutrition and was at risk for pressure ulcers. At the time of the assessment the resident had no unhealed pressure ulcers, venous/arterial ulcers, or other wounds/skin problems. The resident had a tracheostomy (hole in neck to secure an airway) and was taking diuretics (medications to increase urination). Record review of Resident #1's Care Plan dated 10/1/25 revealed a focus of Risk for Pressure Wounds: Resident #1 was at risk for alteration in skin integrity and pressure ulcer formation AEB decline in physical/cognition function. The goal was for the resident to be free from any alterations in skin integrity over the next 90 days. Interventions included assisting with turning/repositioning during rounds and PRN and providing pressure reducing device for bed and wheel chair. Record review of Resident #1's Mini Nutritional Assessment from 3/9/26 at 12:39pm revealed the resident was malnourished. Record review of Resident #1's Braden Scale (measures risk of developing pressure ulcers) from 3/21/26 at 8:25am revealed the resident had a mild risk of developing pressure ulcers. Record review of Resident #1's Skin Observation from 3/30/26 at 9:35pm revealed she had developed redness to her sacrum. Record review of Resident #1's Skin Observation from 4/6/26 at 10:50am revealed she had developed redness to her sacrum. In an observation on 4/9/26 at 11:50am, Resident #1 was sitting up in bed eating lunch. In an observation on 4/9/26 at 3:50pm, Resident #1 was asleep on her back in bed. In an observation on 4/10/26 at 8:39am, Resident #1 was asleep in bed on her back. In an observation on 4/10/26 at 9:19am, Resident #1 was asleep in bed on her back. In an observation and interview on 4/10/26 at 12:08pm, Resident #1 was sitting up in bed. She said she never got turned from side to side. There were no extra pillows or wedges observed in her room. Record review of Resident #1's Turning and Repositioning Task from 4/10/26 revealed the following: 4/9/26: She was turned at 8:27pm4/10/26: She was turned at 1:08am and 9:48am 3. Record review of Resident #3's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of spinal stenosis of lumbar region (narrowing of the spinal canal in the lower back), extrapyramidal and movement disorder (uncontrolled movements), and need for assistance with personal care, severe obesity. Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. The resident was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting and required a Hoyer lift to get out of bed to wheelchair. Resident #3 was always incontinent of bowel and bladder. The assessment indicated she was at risk of developing pressure ulcers. Record review of Resident #3's Care Plan dated 9/26/25 revealed a focus of Risk for Pressure Wounds: Resident #3 was at risk for alteration in skin integrity and pressure ulcer formation. The goal was to be free from alteration in skin integrity/formation of pressure wounds over 90 days. Interventions included assisting with turning/repositioning during rounds and PRN and using padding between areas of pressure and positioning devices for proper body alignment. Record review of Resident #3's Braden Scale from 3/8/26 at 2:26pm revealed she was mild risk for developing pressure ulcers. Record review of Resident #3's Skin/Wound Note from 3/25/26 at 10:36pm revealed she had open skin on the back of her left and right thighs that had re-opened from old wounds. In an interview and observation on 4/9/26 at 9:58am, Resident #3 was on her back in bed. Resident #3 said the staff never come in to turn/reposition her. In an interview and observation on 4/9/26 at 12:00pm, Resident #3 was on her back in bed. She said no one had turned her and she was normally out of bed by then and in her wheelchair. In an observation on 4/10/26 at 8:41am, Resident #3 was asleep in bed on her back. In an interview and observation on 4/10/26 at 9:15am, Resident #3 was lying on her back in bed. She said she had not been turned/repositioned. In an observation and interview on 4/10/26 at 10:32am, Resident #3 was lying on her back in bed. She said she had not been turned/repositioned. In an observation and interview on 4/10/26 at 12:10pm, Resident #3 was sitting up in bed eating lunch. She said no one had turned her/repositioned her. Record review of Resident #3's Turning and Repositioning Task from 4/10/26 revealed the following: 4/9/26: She was turned at 1:42am and 5:51pm4/10/26: It was documented that she could turn herself at 1:06am In an interview on 4/9/26 at 9:53am, LVN J said they turn/reposition residents every 2hr. She said she and the CNA or the respiratory therapist would turn the resident. LVN J said she oversaw the turning/repositioning to ensure it was done. She said they turned residents from their back, to facing the window, to facing the door. In an interview on 4/9/26 at 10:20am, RN O said the staff were not 100% at turning/repositioning the residents. She said she was not sure if the lack of turning/repositioning was affecting the residents because she was only PRN. In an interview on 4/10/26 at 2:09pm, the ADM said she knew her staff were turning/repositioning residents but thought they were not documenting it. She said if residents were not turned/repositioned it could cause skin break down. Record review of the facility's policy and procedure on Turning and Repositioning (revised 6/2019) read in part: It is the policy of this facility that all residents identified at risk for skin breakdown will be placed on a turning/repositioning program. The turning/repositioning programs should be individualized to the resident. It should be organized, planned, documented, monitored, and evaluated based on an assessment of the resident's needs. The expected repositioning times and positions should be defined by the facility team to ensure that the care providers have a clear understanding of the resident's individualized turning/repositioning program. Completion of turning/repositioning should be documented. by the CNA or licensed nurse. Documentation should be performed in [EMR].

Based on observations, interviews, and record reviews, 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 1 out of 8 residents (Resident #2) reviewed for infection control. The following occurred on 4/9/26 during wound care to Resident #2: RN O failed to wash/sanitize her hands after changing gloves.RN O failed to change gloves after wound care was finished between each wound.RN O failed to clean the wounds with one gauze at a time and used the gauze more than once.RN O failed to change her gloves after cleaning the wound and prior to putting clean treatment on the wound.RN O failed to use a new piece of honey fiber (wound care medication) when a piece fell off the resident's wound on to his brief, and she picked it back up and re-used it.RN O failed to remove her dirty gloves after wound care and proceeded to touch his clean sheets.RN O failed to keep the Santyl (wound care medication) tube from becoming contaminated by putting the tip of the medication tube directly on the same tongue depressor repeatedly after each application. These failures could place residents at risk of exposure and/or possible transmission of communicable diseases and infections, and cross contamination of wounds. The findings included: Record review of Resident #2's undated face sheet revealed he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses of severe sepsis (infection throughout body) with septic shock (organs stop working), osteomyelitis (infection of bone), urinary tract infection, stage 4 pressure ulcer of sacrum (muscle and bone visible to tailbone), COPD (lung disease), type 2 diabetes mellitus (high blood sugar), stage 3 pressure ulcer of left ankle (fat visible), unstageable pressure ulcer of right heel (scab or dead tissue covering), unstageable pressure ulcer of left heel, non-pressure (from issues with blood flow) ulcer of right foot with bone involvement, non-pressure ulcer of left lower leg, colostomy (opening to the outside with pouch to collect stool), and gastrostomy (tube into stomach for nutrition). Record review of Resident #2's MDS admission assessment dated [DATE] revealed a BIMS score of 13 out of 15 which indicated normal cognition. The resident had an impairment on one side of both the upper and lower extremities and used a wheelchair for mobility. Resident #2 was substantial/max assistance (helper does more than half the effort) for ADLs. The assessment indicated the resident had an indwelling catheter (tube into bladder to drain urine) and a colostomy. The resident was receiving nutrition through a PEG tube (tube into stomach for nutrition). According to the assessment, Resident #2 had one Stage 3 (tissue loss with fat visible) pressure ulcer, two Stage 4 (tissue loss with exposed bone, tendon, or muscle) pressure ulcers, four unstageable pressure ulcers, three venous/arterial (caused by decreased blood flow) ulcers, and an infection to his foot. Resident #3 was receiving pressure ulcer/injury care, surgical wound care, application of nonsurgical dressings, application of dressings to feet, and had a pressure reducing device for his bed. Record review of Resident #2's Care Plan dated 2/19/26 revealed a focus of Pressure Injury: Resident #2 had multiple pressure injuries and was at risk for further skin break down, infection, worsening of existing pressure injury, new pressure injury formation. Unstageable to R heel. Unstageable to L heel. Stage 3 to L foot. Unstageable to L ankle. Stage 4 to L buttock. Stage 4 to sacral. Unstageable to R buttock. The goal was to have the pressure injuries show signs and symptoms of improvement through the review date. The interventions included consulting wound care and performing treatments per order. Record review of Resident #2's April 2026 Physician Orders revealed the following orders from MD J: Left heel - Cleanse with normal saline and pat dry. Apply betadine and cover with a border dressing daily and PRN. Every day shift from 6am to 2pm, and as needed. Ordered 2/20/26 at 8:22am.Right lateral foot - Cleanse with normal saline and pat dry. Apply betadine and leave open to air daily and PRN. Every day shift from 6am to 2pm, and as needed. Ordered on 2/20/26 at2:18pm.Right heel - Cleanse with normal saline and pat dry. Apply calcium alginate (wound care medication) to open area. Apply betadine to necrotic area and cover with a border gauze daily and PRN. Every day shift from 6am to 2pm. Ordered on 2/20/26 at 2:19pm.Right toes - Cleanse with normal saline and pat dry. Apply betadine and leave open to air daily and PRN. Every day shift from 6am to 2pm, and as needed. Ordered on 2/27/2 at 7:49am.Left toes - Cleanse with normal saline and pat dry. Apply betadine and cover with a border dressing daily and PRN. Every day shift from 6am to 2pm, and as needed. Ordered 2/27/26 at 7:51am.Left foot - Cleanse with normal saline and pat dry. Apply Honey Fiber as primary dressing. Cover with a border gauze as secondary dressing daily and PRN. Every day shift from 6am to 2pm, and as needed. Ordered on 2/27/26 at 8:00am.Right ankle - Cleanse with normal saline and pat dry. Apply betadine and leave open to air daily and PRN. Every day shift from 6am to 2pm, and as needed. Ordered on 2/27/26 at 1:53pm.Right buttock - Cleanse with normal saline and pat dry. Apply Honey Fiber as primary dressing. Cover with a border gauze as secondary dressing daily and PRN. Every day shift from 6am to 2pm, and as needed. Ordered on 2/27/26 at 1:56pm.Sacral wound - Cleanse with normal saline and pat dry. Apply Honey Fiber as primary dressing. Cover with a border gauze as secondary dressing daily and PRN. Every day shift from 6am to 2pm, and as needed. Ordered on 2/27/26 at 1:58pm.Left buttock - Cleanse with normal saline and pat dry. Apply Honey Fiber as primary dressing. Cover with a border gauze as secondary dressing daily and PRN. Every day shift from 6am to 2pm, and as needed. Ordered on 2/27/26 at 2:06pm.Left lower leg - Cleanse with normal saline and pat dry. Apply betadine and cover with a border dressing daily and PRN. Every day shift from 6am to 2pm, and as needed. Ordered on 2/27/26 at 2:08pm.Santyl External Ointment 250 unit/gm, apply to left ankle topically every day shift from 6am to 2pm for wound healing. Ordered on 3/6/26 at 2:38pm.Santyl External Ointment 250 unit/gm, apply to left buttock topically every day shift from 6am to 2pm for wound healing. Ordered on 3/6/26 at 2:42pm.Santyl External Ointment 250 unit/gm, apply to sacral wound topically every day shift from 6am to 2pm for wound healing. Ordered on 3/6/26 at 2:44pm.Ertapenem (antibiotic) Sodium Solution Reconstituted, 1gm IV QD for wound infection for 14 days. Ordered on 3/19/26.Left ankle - Cleanse with normal saline and pat dry. Apply Santyl and calcium alginate as primary dressing. Cover with border gauze daily as secondary dressing and PRN. Every day shift from 6am to 2pm, and as needed. Ordered 3/29/26 at 6:26pm. In an interview and observation on 4/9/26 at 10:20am, RN O cleaned table a bedside table, put a chuck on it, and applied wound care supplies. She said the Wound Care MD came every Monday and measured the wounds. She said she was PRN and only came when the normal wound care nurse was out sick or something. RN O put gauze in a cup and soaked it in iodine. She put saline tubes in a cup. She put bordered gauze patches, Santyl, honey fiber, calcium alginate, dry gauze, a chuck, a tongue depressor, a bio bag and some gloves on the table. Resident #2 was observed on his back in bed. He had an air mattress, a foley, prevalon boots (air boots to help prevent pressure ulcers), a PEG, a colostomy, and O2 via NC. In an interview and observation on 4/9/26 at 10:40am, RN O donned a gown and 2 pairs of gloves without washing her hands or sanitizing them first. The nurse adjusted Resident #2's oxygen tubing then adjusted his bed. RN O took off Resident #2's blanket and left the sheet on him because he did not have a gown on. RN O turned Resident #2 to his right side and put a chuck down and a bio bag. RN O removed Resident #2's brief then removed her top dirty gloves and donned new ones on top without cleaning her hands. The nurse put gauze in a cup and soaked it with saline, removed Resident #2's dirty wound bandage, removed her outer dirty gloves and then put clean gloves over the first set of gloves and never cleaned her hands. Resident #2's wound on his sacrum extended to his left thigh and was severe. The wound to his sacrum was the size of a small dinner plate that connected to a L thigh pressure ulcer that was the size of two softballs next to each other. The wound had muscle and bone exposed. RN O cleaned the wound with gauze soaked in saline and then flipped the same piece of gauze and cleaned the wound again, instead of getting a fresh piece of gauze each time. After cleaning the wound, she did not remove her dirty gloves or clean her hands and proceeded to dry the wound with gauze. She dried the wound; she removed both sets of gloves and put on a pair of clean gloves without cleaning her hands. RN O then applied Santyl to Resident #2's sacrum wound. The nurse used the same tongue depressor multiple times on the wound and put the tip of the Santyl medication tube directly on the tongue depressor. RN O applied honey fiber to the sacrum wound and left thigh wound. A piece of honey fiber from Resident #2's sacrum fell off on to his brief and RN O picked it up and put it back on the sacrum. RN O then removed her dirty gloves and donned new ones without cleaning her hands. She applied a bordered dressing with the date/initials. The nurse removed the bandages from Resident #2's L knee, L LE without taking her gloves off and washing her hands first. Then the nurse removed her dirty gloves, and put on clean gloves, but she did not wash her hands first. RN O put dry gauze in a cup, sprayed it with saline and then cleaned the wounds with gauze soaked in saline. She took the pieces of gauze and folded them over and wiped them with the same piece of gauze twice instead of getting a fresh piece each time. She got done cleaning with saline; she did not change her gloves or clean her hands and then she applied honey fiber to the wounds. She removed her gloves and put on clean gloves without cleaning her hands and then applied a bordered gauze with initials/date. She finished and did not change her gloves or clean her hands and went on to Resident #2's next wound. RN O cleaned Resident #2's L heel with gauze soaked in saline. The nurse did not remove her gloves and clean her hands and then cleaned Resident #2's heel with gauze soaked in iodine. RN O removed her gloves and put new ones on, without cleaning her hands. She proceeded to put a bordered dressing on his L heel. She removed the dirty dressing from Resident #2's L foot. The nurse without changing her gloves or washing her hands, RN O picked up dry gauze and saline and squirted the saline on his foot as she wiped it with the dry gauze. Without changing her gloves she picked up gauze soaked in iodine and wiped Resident #2's toes repeatedly with the same piece of gauze. She removed her gloves and applied new ones without hand hygiene and then put a bordered dressing on with initials/date. The nurse tucked the chuck under the resident and turned the resident to his L side. The nurse had the same gloves on and removed the prevalon boot from Resident #2's R foot, R LE, and R foot. RN O then removed her gloves and applied new gloves without washing her hands. She put gauze in a cup and sprayed it with saline and cleaned Resident #2's R heel with a gauze, with the same piece of gauze more than once. without removing her gloves or washing her hands, she applied calcium alginate. RN O cleaned part of the heel with gauze soaked in iodine and applied a bordered dressing with initials/date. The nurse removed the dirty bandage from Resident #2's R fore foot, removed her gloves and put clean ones on without cleaning her hands. She sprayed his toes with saline while she wiped multiples times with the same gauze; without changing gloves or washing her hands, she picked up the gauze soaked in iodine and cleaned the toes multiple times with the same gauze. RN O removed her gloves and put clean ones on, without cleaning her hands. She applied a bordered dressing gauze with initials/date and then put Resident #2's R foot back in the prevalon boot. RN O removed the dressing from Resident #2's R upper leg. She changed her gloves but did not wash her hands. The nurse washed the wound with gauze soaked in saline with the same piece of gauze, more than once. Without changing her gloves or washing her hands, she dried the wound, applied calcium alginate, and then applied a bordered dressing with initials/date. RN O still had dirty gloves on and then touched Resident #2's clean draw sheet and blanket. In an interview on 4/9/26 at 11:47am, RN O said it would take too long if she had to wash her hands after each wound and between cleaning the wound and putting the treatment on the wound. She said Resident #2 had so many wounds that she would be in there for too long if she had to wash her hands that many times. She said she had other residents with just as many wounds and she would never finish if she did that. RN O said she thought she had changed her gloves enough and at the appropriate times. She said there was a risk of infection and cross contamination. In an interview on 4/9/26 at 12:06pm, the DON said the nurse's hands should be washed and gloves should be changed in between each wound and when going from dirty to clean. She said after the dirty diaper and dirty bandage was removed, the nurse would remove their dirty gloves and then sanitize their hands and put on new gloves. The DON said after the wound was cleaned, the nurse would remove their dirty gloves, clean their hands, and then put clean gloves on. She said the process was done for infection control so dirty hands were not infecting the wounds. She said when the nurse was cleaning the wound it would be cleaned with one gauze at a time and then thrown away, due to infection control. The DON said Resident #2 did have a lot of wounds, but no other residents had that many wounds and RN O needed to follow infection control practices for every resident. Record review of the facility's policy and procedure on Wound Evaluation (revised: 6/2019) read in part: It is the policy of this facility to evaluate wounds during dressing changes. Evaluation should be performed on admission, weekly and on discovery. Evaluation is the process in which wound characteristics, underlying conditions and contributory medical history are identified and documented. Evaluation should result in treatment approaches including intervention for causative factors and a prognosis for healing. Evaluation is the ongoing process of gathering data that becomes the basis of measurement of wound progress. With each dressing change the clinician should observe and document the following: General appearance. Drainage. Surrounding skin. Wound odor. Record review of the facility's policy and procedure on Infection Control Program (revised: 6/2024) read in part: The Facility will establish a comprehensive infection control program encompassing essential elements to safeguard the health and safety of residents, staff, and visitors. The Facility is dedicated to maintaining a safe and healthy environment by implementing an effective infection control program that adheres to state and federal regulations and follows evidence-based practices recommended by the CDC. The program's objectives encompass key infection control ideologies: prevention, identification, reporting, investigation, and control of infections and communicable diseases among residents, employees, and visitors. The Facility promotes awareness and adherence to infection control practices through the Infection Control Committee.The Infection Control Committee is tasked with ensuring compliance with policies and procedures, reviewing data and trends related to infections, conducting training and education sessions, performing audits to assess adherence to standards, and continuously monitoring and evaluating the effectiveness of infection control measures.The committee plays a pivotal role in promoting a safe and healthy environment for residents, staff, and visitors by overseeing all aspects of infection prevention and control within the facility.The Infection Preventionist will provide initial and ongoing infection control training for all staff, including competency assessments where indicated. The Infection Preventionist will use evidence-based practices to educate all staff members within their respective departments.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 2 out of 8 residents (Resident #3 and Resident #4) reviewed for ADLs. The facility failed to check and/or change Resident #3 for more than six hours on 4/9/26 and for more than seven hours on 4/10/26.The facility failed to check and/or change Resident #4 for more than five hours on 4/9/26. This failure could place residents at risk of skin breakdown, infection, and reduced feelings of self-worth. Findings included: 1.Record review of Resident #3's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of spinal stenosis of lumbar region (narrowing of the spinal canal in the lower back), type 2 diabetes (high blood sugar), heart failure (heart is not pumping effectively), extrapyramidal and movement disorder (uncontrolled movements), need for assistance with personal care, severe obesity, and TIA and CVA (mini stroke and stroke). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. The resident was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting and required a Hoyer lift to get out of bed to wheelchair. Resident #3 was always incontinent of bowel and bladder. Further review revealed to the assessment she was at risk of developing pressure ulcers. Record review of Resident #3's Care Plan dated 9/26/25 revealed the following focus areas: *Urinary Incontinence: Resident #3 had bladder incontinence. The goal was to have no alterations in skin integrity related to incontinence or brief use through the review date. The interventions included performing routine rounding to include incontinence care and brief changes.*Bowel Incontinence: Resident #3 had bowel incontinence. The goal was to no alterations in skin integrity related to incontinence or brief use through the review date. The interventions included performing routine rounding to include incontinence care and brief changes.*Pressure Wounds: Resident #3 was at risk for alteration in skin integrity and pressure ulcer formation. The goal was to be free from alteration in skin integrity/formation of pressure wounds over 90 days. Interventions included assisting the resident with incontinent care and assisting her for toileting as indicated. Record review of Resident #3's Physician Orders revealed an order for Furosemide (increases urination) Oral Tablet 20mg 1 PO QD from MD J ordered on 3/24/26. In an interview on 4/9/26 at 9:53am, LVN J said they changed residents Q2hr and PRN. She said even if the resident was sleeping they would check to see if the resident needed to be changed. In an interview and observation on 4/9/26 at 9:58am, Resident #3 was observed on her back in bed. She said the staff did not change her as often as they should. She said she had not been changed since 4:30am that morning. She said she was about to push the call light to ask to be changed because she was currently soiled with urine, and then she pushed the call light. In an interview and observation on 4/9/26 at 12:00pm, Resident #3 was observed on her back in bed. She said she still had not been changed yet and was soiled with urine. She said staff came in and turned off the call light and said they would get an aide to come change her. In an interview on 4/9/26 at 12:34pm, Med Aide L said they rounded Q2hr and PRN. She said if the resident was sleeping, they still would check to see if the resident needed to be changed. She said she did not change residents because she passed meds, but if she really needed to help she would. In an interview and observation on 4/9/26 at 4:09pm, Resident #3 was in her wheelchair. She said she had finally been changed, but she did not remember when it was. In an observation and interview on 4/10/26 at 9:15am, Resident #3 was on her back in bed. She said she was last checked/changed at 4:30am. She said no one had asked her or checked to see if she needed to be changed since then. She pushed her call light at 9:17am to be changed because she was soiled with urine. In an observation and interview on 4/10/26 at 9:23am, Resident #3's call light was off. Resident #3 said someone came in and turned her call light off and said they would tell the CNA to come change her. In an observation and interview on 4/10/26 at 10:32am, Resident #3 was lying on her back in bed. Resident #3 said she still had not been changed yet, was soiled with urine, and no one had come in. In an interview on 4/10/26 at 10:34am, CNA G said she was taking care of Resident #3 and she had the front of Resident #3's hall and the front of the 100 hall. She said the 100 hall was where the trach and vent residents were, so the hall was very heavy. She said she was on her way to Resident #3's room to help her. In an interview and observation on 4/10/26 at 12:10pm, Resident #3 was sitting up in bed eating lunch. Resident #3 said she had just been changed a few minutes ago due to being soiled with urine, from when she had been waiting from the morning. Record review on 4/10/26 of Resident #3 Bladder Elimination Task revealed the following: 4/9/26: She was changed at 1:41am and 5:51pm by unknown staff4/10/26: She was changed at 1:06am by unknown staff 2. Record review of Resident #4's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis and weakness) after a stroke, elevation of liver enzymes, type 2 diabetes (high blood sugar), high blood pressure, and lack of coordination. Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15, which indicated severely impaired cognition. Resident #4 had an impairment on one side of both her upper and lower extremities and used a wheelchair for mobility. She was substantial/max assistance (helper does more than half the effort) with toileting. According to the assessment the resident was frequently incontinent of bowel and bladder and was at risk for pressure ulcers. Record review of Resident #4's Care Plan dated 11/27/25 revealed the following focus areas: of*Risk for Pressure Wounds: Resident #4 was at risk for alteration in skin integrity and pressure ulcer formation. The goal was to be free from alteration in skin integrity/formation of pressure wounds over the next 90 days. The interventions included assisting the resident with toileting and assisting the resident with incontinent care as indicated.*Urinary Incontinence: Resident #4 had bladder incontinence related to functional impairment. The goal was to have no alterations in skin integrity related to incontinence or brief use through the review date. The interventions included performing routine rounding to include incontinence care and brief changes and remind and assist the resident to use the toilet regularly as indicated/able. *Bowel Incontinence: Resident #4 had bowel incontinence related to functional impairment. Resident #4 was to have no alterations in skin integrity related to incontinence or brief use through the review date. The interventions included performing routine rounding to include incontinence care and brief changes and remind and assist the resident to use the toilet regularly as indicated/able. **ADL Self Care Deficits: Resident #3 had ADL self-care deficits and was at risk for further decline in ADL functioning. The goal was for the resident to be clean and have dignity maintained. The interventions included providing extensive assistance of 1 support persons for toileting/incontinence care. Record review of Resident #4's Physician Orders revealed an order for Hydrochlorothiazide (increases urination) Oral Tablet 12.5mg 1 PO QD from MD J ordered on 11/29/25. In an interview on 4/9/26 at 12:55pm, Resident #4 said she would not see an aide for four or more hours at a time, routinely. She said she routinely had to wait two and a half hours to be changed, when she was already soiled with urine and feces. Resident #4 said staff came in and turned off the call light but never told the aide she needed to be cleaned. She said today she has not been checked/changed or even been asked since 8:30am. In an interview on 4/9/26 at 1:15pm, CNA S said she checked Resident #4 and changed her roommate before lunch, which was around noon. In an interview on 4/9/26 at 1:20pm, Resident #4 said CNA S changed her roommate but did not check her or ask her anything Resident #4 said she was currently soiled with urine. Record review on 4/10/26 of Resident #4's Bladder Elimination Task revealed the following: 4/9/26: She was changed at 8:25am, 4:25pm, and 11:59pm by unknown staff4/10/26: She was changed at 6:53am by unknown staff Record Review of the March 2026 Patient Complaint/Grievance Tracking Log revealed Resident #4 made a complaint about ADLs on 3/4/26. In an interview on 4/10/26 at 9:27am, the ADM said she was the Interim ADM and had been there since 2/27/26. She said she rounded on every resident, every morning and afternoon/evening. She said they also had Ambassador Rounds where leadership rounded on residents. The ADM said since she rounded on every resident it forced leadership to be accountable for Ambassador Rounds because she would find out if they did not perform their rounds. She said when she rounded she did not get any complaints from resident about not being changed. In an interview on 4/10/26 at 2:09pm, the ADM said ultimately the DON oversaw staff to ensure they were changing residents, and the DON performed care huddles with staff to keep reminding them of any issues/concerns. The ADM said if there was a concern found during leadership rounds, they would in-service the staff then. She said she has also called night shift staff if there was an issue/concern with them. Record review of the facility's policy and procedure on Activities of Daily Living (ADLs) - Highest Level of Functioning (revised 1/2026) read in part: It is the policy of this facility to support each resident in maintaining or improving their highest practicable level of functioning related to Activities of Daily Living (ADLs), based on the resident's assessed needs, preferences, goals, and clinical condition. The facility promotes resident independence to the greatest extent possible while providing necessary assistance, supervision, and interventions when residents are unable to safely perform ADLs independently. Activities of Daily Living (ADLs) include personal care tasks such as bathing, dressing, grooming, oral hygiene, eating, transferring, bed mobility, toileting, and communication.Care will be delivered in a manner that supports resident dignity, choice, and autonomy and avoids creating unnecessary dependence.Additional nursing or functional support interventions may be considered based on the resident's condition, response to care, and goals, but are not required for all residents.Direct care staff, including Certified Nursing Assistants (CNAs), provide routine care.

Based on interview and record review, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care for 1 (Resident #1) of 12 resident reviewed for person centered care plans. The facility failed to revise Resident #1's care plan to address ongoing refusals of medication, ADLs, meals, and wound care. This failure could place residents at risk for not receiving individualized responsive care and a decline in wellbeing. Findings included:Record review of Resident #1's face sheet, reviewed 1/9/26, revealed a [AGE] year-old male, admitted on [DATE]. His admitting diagnoses included metabolic encephalopathy (brain dysfunction caused by an underlying condition), cerebral infarction (stroke), Type 2 Diabetes (body is insulin resistant), viral pneumonia, end stage renal disease (final stage of chronic kidney disease), cognitive communication deficit, need for assistance with personal care, dependance on renal care, and acquired absence of left leg below knee. He was discharged on 1/8/26. Record review of Resident #1's MDS dated [DATE], documented a BIMS of 6 indicating severe cognitive impairment. Section GG- Functional Abilities documented that he was dependent on staff to complete shower/bathing himself, upper body dressing, lower body dressing, sitting to stand, toilet transfer, chair to bed transfer, and toileting hygiene. Resident #1 required the maximal assistance for oral hygiene, personal hygiene, and was moderate assistance for eating. Section H- Bowel and Bladder documented that he was always incontinent. Record review of Resident #1's care plan, reviewed 1/9/26, dated 1/1/26, documented the following pressure injuries: wound to right hip, stage 3 to right heel, stage 3 to sacral wound, unstageable to left BKA. No additional information besides wound care was included in Resident #1's care plan. Record review of Resident #1's weight and vitals reviewed 1/9/26, revealed he weighed 185.5 lbs on 12/23/25. No additional weights were documented. Record review of Resident #1's progress notes, dated 12/22/25- 1/9/26, revealed the following medication refusals and were documented in the progress notes as followed:1/8/26: refused Insulin.1/8/26 at 6:21 a.m.: refused B/S check despite the education provided.1/7/26 at 3:11 p.m.: Insulin refused.1/7/26 at 2:23 p.m.: refused1/7/26 at 5:48 a.m.: refused1/6/26 at 8:00 p.m.: refused1/6/26 at 5:41 a.m.: refused1/5/26 at 4:19 p.m.: Pain Relief External Patch 4 %: refused nurse informed.1/5/26 at 8:48 a.m.: refused1/4/26 at 8:53 p.m.: refused all meds nurse informed1/4/26 at 4:44 p.m.: Patient refused B/S check x3 despite all the education given, patient still refused.1/4/26 at 9:36 a.m.: refused1/3/26 at 9:31 p.m.: refused all medications, nurse informed.1/3/26 at 4:09 p.m.: Patient refused.1/3/26 at 2:11 p.m.: Resident refused Medications, accuchecks (glucose monitoring product), and both meals this shift. Resident refused x several attempts. MD notified. Will continue to monitor.1/3/26 at 9:43 a.m.: refused1/2/26 at 11:15 p.m.: levofloxacin Oral Tablet 750 MG; Give one tablet by mouth one time only related to acute upper respiratory infection. Resident refused the one-time dose, was educated on the reason why the antibiotic was prescribed but still he remained adamant.1/2/26 at 2:39 p.m.: refused1/2/26 at 10:46 a.m.: refused1/1/26 at 3:07 p.m.: refused1/1/26 at 10:00 a.m.: refused12/31/26 at 5:42 p.m.: refused. Nurse informed.12/30/25 at 8:59 a.m.: refused12/30/25 at 11:00 a.m.: refused12/29/25 at 10:49 a.m.: refused12/28/25 at 9:51 p.m. refused, nurse informed.12/27/25 at 3:47 p.m.: refused12/26/25 at 12:13 p.m.: refused12/26/25 at 8:51 a.m.: refused12/25/25 at 1:01 p.m.: refused B/S check x 312/24/25 at 9:14 p.m.: refused, nurse informed12/24/25 at 12:57 a.m.: refused12/23/25 at 8:23 p.m.: refused12/23/25 at 4:22 p.m.: refused Record review of Resident #1's progress notes, dated 1/5/26 at 2:36 p.m., the WCN, documented: During wound rounds with the WCD, resident allowed for wound care team to assess wounds and obtain measurements. Resident then requested that staff return to apply dressings because he was tired. Upon re-entering his room, resident stated his wound care had already been done. After attempting to re-orient resident and explaining that treatments have not been completed, resident continued to refuse treatments today. Attempted to notify resident's FM, but no answer on either telephone number listed. Record review of Resident #1's POC, dated 12/22/25- 1/9/26, revealed Task for Eating - (The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) documented:12/24/25- refused12/22/25, 12/23/25, 12/25/25, 12/26/25, 12/27/25, 1/5/26, 1/8/26, 1/9/26- Not applicable- not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. Record review of Resident #1's POC, dated 12/22/25- 1/9/26, Task Nutrition - (what percentage of the meal was eaten) documented:12/28/25, 12/31/25, 1/1/26, 1/2/26, 1/4/26: consumed 0-25% of a meal.12/27/25, 12/31/25, 1/1/26, 1/4/26, 1/6/26, 1/7/26, 1/8/26: consumed 26-50% of a meal.12/23/25, 12/24/25, 12/26/25, 12/28/25, 12/29/25, 1/2/26, 1/3/26, 1/4/26 1/5/26, 1/6/26: response not required (did not occur). During an interview on 1/9/26 at 12:50 p.m., CMA C stated that she had worked at the facility for 11 years. She recalled that Resident #1 seemed to be very depressed and would always say not right now whenever she attempted to give his medications. She stated when he refused, she would usually try 2-3 times and then inform the nurse. She stated in efforts for Resident #1 to take his medicine, she purchased pudding and soda from the store. She stated she also tried ice-cream and soup from the kitchen to serves with his medications, but he refused. She stated she did the best she could. During an interview on 1/9/26 at 1:09 p.m., the WCN stated she worked at the facility for two years and was familiar with Resident #1. She stated he had a stomp (lower extremity was amputated) with wounds under his stomp, on the right heel, right hip, sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis), redness, and an opening in the groin area that went back to the gluteal folds (the horizontal skin crease located directly below the buttocks, marking the boundary where they meet the upper thigh). The WCN stated he refused a lot of care and she reached out to the FM so they could encourage him. The WCN stated the FM would be on the phone during wound care so that she could provide treatment. The WCN stated she saw a decline with his wounds and that was more so redness and irritation on the left gluteal folds. She stated when she went in to do wound care, he told staff it was already done. She stated most days she was able to provide wound care, but when he had a very adamant no, she would have to reach out to his FM. In an interview on 1/9/26 at 3:07 p.m., the DON stated Resident #1 was admitted for therapy but he refused medications, showers, or anything patient care related. The DON stated for assistance, staff called his FM and they assisted by talking with him over the phone and encouraging his cooperation. She stated Resident #1 stated he was tired of wound care and refused care. The DON stated Resident #1 also refused meals and his FM brought him home cooked meals. The DON stated the NP was very aware that Resident #1 refused care and the NP rounded at the facility daily between the hours of 9:00 a.m. - 11:00 a.m. During an interview on 1/9/26 at 4:20 p.m., the ADM stated she was informed that Resident #1's care plan was not updated and the only area of care mentioned in the care plan was for wound care. The ADM was asked for the contact information for the NP, who was currently on leave. During a follow up interview on 1/20/26 at 11:30 a.m., the ADM stated she had spoken with the FM of Resident #1 in the past and let her know that Resident #1 was a failure to thrive. Resident #1 did not care to do dialysis, eat when fed, nor participated in therapy. The ADM said she went into Resident #1's room a couple of times and told him that he needed to be changed and explained to him that because he had a sacral wound, he was at risk of deterioration or infection. ADM informed the surveyor that the NP was no longer with the medical group that oversaw the residents at the facility, but there was a new NP working in her place. She was asked to provide an additional contact number and stated she would ask the DON if she had one. No additional number was found. During a follow up interview on 1/20/26 at 11:49 a.m., the DON stated she started working at the facility in October 2025. She could not say why none of Resident #1's refusals were documented inside of the care plan. The DON stated the MDS nurse resigned during Resident 1's admission and the MDS nurse had to take time off. She explained that the MDS nurse was responsible for updating the care plans and she would gather information by going to speak with different residents and sitting in at clinical meetings. Wound care was responsible for updating their part in the care plan but for the nursing and activities department, the MDS nurse was responsible for making any updates. DON stated that when the MDS nurse was not in the building, she would update acute changes in the care plan, but for the most part, the responsibility fell on the MDS nurse. When the MDS Nurse informed administration she would be absent, a representative from the facilities corporate office would assist. The DON stated that care plans that were not updated could affect how the aids provided care, but they received daily communication from the nurses. The POC inside the Kardex filtered directly from the care plan and would reflect any information documented. During an interview on 1/20/26 at 12:17 p.m., the DSS stated she began working in the facility on 11/3/25. The DSS stated her job responsibilities were handling all discharges, services such as dental, vision, podiatry, hearing, various assessments, grievances/concerns, and completing her portion of the MDS. She stated she had 72 hours to complete her portion of the MDS upon admission and the nurses would do their own care plan, but staff were to complete update care plans whenever they were needed. The DSS stated she did not remember completing Resident #1's care plan, but his initial social services assessment was completed 12/23/25. She stated that she was educated by the ADM (after 1/9/25) because she was not aware that she had to complete the care plan or how to do them. She explained that she initially held care plan meetings with the family and did not inform department heads to attend because she didn't want to bother them. The ADM stated all department heads should be present during care plan meetings and they should be scheduled right after their morning meeting. During an interview on 1/20/26 at 12:56 p.m., LVN A stated she was a charge nurse and had worked at the facility for 17 months. She stated Resident #1 was non-compliant and she felt he had a failure to thrive. Resident #1 did not want to eat and he shook his head no when staff brought him food. The FM was concerned that he refused meals and wanted staff to call during every meal, but LVN A let her know that it was not feasible while assisting other residents with meals. When meals came, LVM A stated she encouraged Resident #1 by waking him up, arousing him, and setting up his tray. She stated that staff had also tried to feed him, but he refused to be fed. LVN A stated she tried to encourage Resident #1 to eat, but she did not do anything with care plans. In an interview on 1/20/26 at 2:16 p.m. with the DM, she stated that she had worked at the facility for four years and was not made aware that Resident #1 refused meals. During an interview on 1/20/26 at 2:28 p.m. CNA B stated she began working at the facility in October 2025. She stated at the beginning of each shift, she received a report from the nurse and CNA on the previous shift and they would walk from room to room to give her updates. She stated she was told Resident #1 was total care. She could not remember his appetite or how much food he ate during meals. She stated she also never witnessed him refusing to eat and he never spoke to her. During an attempted telephone interview on 1/20/26 at 2:43 p.m., the previous MDS Nurse did not answer and the voicemail was not set up; however, a text message requesting a call back was sent. During an attempted telephone interview on 1/20/26 at 2:52 p.m., with the NP, the call went to voicemail and a message was left requesting a return call back. During an attempted telephone interview on 1/20/26 at 2:56 p.m., the Dietician did not answer and a voicemail was left requesting a call back. During an attempted telephone interview on 1/21/26 at 10:11 a.m., 10:12 a.m., and 1:16 p.m., the previous MDS Nurse did not answer and the voicemail was not set up; however, a text message requesting a call back was sent. In an interview on 1/21/26 at 12:43 p.m. with the RA, she stated that as soon as a resident was admitted , she would weigh them and weigh them weekly for 4 weeks and then collect their weights monthly. She stated Resident #1 allowed her to capture his weight upon admission but refused the following weeks. During an interview on 1/21/26 at 1:29 p.m. the ADM stated completing the care plans was a shared responsibility between nurse management and the MDS nurse. She explained that if there was a consistent behavior, the MDS nurse would capture it and update the care plan. All members of the IDT have their own section, and once completed, they signed and locked it in the system. ADM stated in the absence of the MDS nurse, the facility had a corporate representative that could assist with completing the care plans. Record review of the facility's policy, revised June 2024, titled, Care plan meeting documented that care plan meetings were to be held upon admission, quarterly/annually, after a significant change, and as needed. Record review of the facility's policy, revised May 2022, titled, Care Plan Revisions documented: 1. The comprehensive care plan will be reviewed and revised every quarter, when a resident experiences a status change and as deemed necessary. 2. Procedure for reviewing and revising the care plan is as follows: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable.b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.c. The care plan will be updated with the new or modified interventions.d. Staff involved in the care of the resident will report resident response to new or modified interventions.e. Care plans will be modified as needed by the MDS Coordinator or other designated staff member.f. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 16%, based on 4 errors out of 25 opportunities, which involved 1 (Resident #71) of 8 residents reviewed for medication errors. -LVN W administered Escitalopram 5 mg to Resident #71 instead of Escitalopram 10 mg and administered Multivitamin with minerals instead of Multivitamins without minerals according to Physician orders on 12/10/25. (Escitalopram is used to treat depression and generalized anxiety disorder). -LVN W crushed and administered Lansoprazole delayed release ODT and Potassium micro extended release via g-tube to Resident #71 on 12/10/25 when it should not have been crushed according to the pharmacy label.These failures could place residents at risk of inadequate therapeutic outcomes. Findings included:Record review of Resident #71's face sheet dated 12/11/25 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included mood disorder with manic features (manic features refer to symptoms associated with mania, characterized by elevated mood, increased energy, and impulsive behavior, often seen in conditions like bipolar disorder), adjustment disorder with mixed anxiety and depressed mood (adjustment disorder is a mental health condition characterized by an excessive emotional or behavioral response to a significant stressor, leading to distress and functional impairment), gastro-esophageal reflux disease (a condition in which stomach acid repeatedly flows back up into to the tube connecting the mouth and stomach), vitamin deficiency, and hypokalemia (low potassium levels in the blood).Record review of Resident #71's admission MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired. She was dependent on staff for ADL care, and she had a feeding tube.Record review of Resident #71's care plan dated 11/13/25 revealed she had a history of depression. Interventions were to give medications per order.Record review of Resident #71's Order Summary Report for December 2025 revealed active orders for:Escitalopram 10 mg give 1 tablet via g-tube one time a day related to adjustment disorder with mixed anxiety and depressed mood, order date 12/2/25,Lansoprazole DR ODT 30 mg 1 tablet via g-tube one time a day related to GERD, order date 10/22/25,Multiple vitamin (Multivitamin) give 1 tablet via g-tube one time a day related to vitamin deficiency, order date 10/22/25,Potassium chloride Crys ER 20 mEQ give 1 tablet via g-tube one time a day related to hypokalemia, order date 12/2/25.In an observation on 12/10/25 at 8:53 a.m. LVN W prepared Resident #71's medication for g-tube administration. She prepared Escitalopram 5 mg, Multivitamin with minerals, Lansoprazole DR ODT 30 mg, Potassium micro 20 mEQ ER, Diltiazem, Thiamine, Chlorhexidine, and Clonidine. The pharmacy label for Lansoprazole DR ODT read to dissolve in apple juice if given via g-tube. The pharmacy label for Potassium ER read do not crush, dissolve in water for g-tube. LVN W crushed each pill, placed them into separate medication cups, and dissolved them in water. She then administered the pills to Resident #71 via g-tube.In an interview on 12/10/25 at 10:11 a.m. LVN W said she administered one Escitalopram 5 mg tablet to Resident #71 but should have administered two. She said she administered multivitamins with minerals instead of multiple vitamins (multivitamin) which she said was not correct because of the minerals. She said she did not realize at the time of preparation that she administered the incorrect medication and said she needed to verify the correct medication name, resident, dose, route, and time. She said she crushed the potassium and the pharmacy label read do not crush, dissolve in water. She said Potassium should not be crushed because it was a lethal, dangerous drug. She said she crushed the Lansoprazole and the pharmacy label read do not crush, dissolve in apple juice. She said she was rushing, and the residents were new to her. She said she should review the pharmacy labels when administering medications so she would know what to do.In an interview on 12/10/25 at 4:59 p.m. the Administrator said the facility tried not to have any medication errors. She said she expected staff to follow the MD orders, crush/do not crush instructions and pharmacy labels.In an interview on 12/11/25 at 2:12 p.m. the DON said she expected nursing staff to check the rights of medication administration which included the right patient, medication, dose, and documentation. She said staff should check the pharmacy labels because it would inform if the medication was crushable or not. She said crushing a delayed or extended-release medication would release all the medication at one time and it would not be distributed like it should. She said there were no negative effects to the resident. She said the risk of Resident #71 receiving Escitalopram 5 mg instead of 10 mg was not getting the full treatment. She said the resident received an extra vitamin when she was administered Multivitamin with minerals instead of multiple vitamins (Multivitamin). Record review of the facility's policy Medication Administration and Management dated 6/2019 read in part, .It is the policy of this facility that the facility will implement a Medication Management Program that incorporates systems with established goals to meet each resident's needs as well as regulatory requirements.M. Authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff must understand: A. Indications/Reasons for therapy. B. Effectiveness of the therapeutic goal. C. Drug actions. D. The 8 Rights for administering medication: 1) The Right Patient/Resident 2) The Right Drug 3) The Right Dose 4) The Right Time 5) The Right Route 6) The Right Charting 7) The Right Results 8) The Right Reason.D. Always follows pharmacy and/or manufacturer's specifications. E. Crushes medication according to physician order using proper device: Medications which cannot be crushed: 1) Enteric-coated tablets 2) Sustained or extended-release tablets 3) Effervescent tablets 4) Sublingual or buccal tablets 5) Capsules.

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 21 residents (Resident #10) reviewed for advance directives. The facility failed to ensure Resident #10's Out of Hospital Do Not Resuscitate (OOH-DNR) form was signed and dated by two witnesses and failed to ensure all persons who signed the form acknowledged that the document was properly completed. This failure could place residents at risk for not having their end of life wishes honored and having incomplete records. Findings included: Record review of Resident #10's admission Record generated on [DATE] revealed she was admitted to the facility on [DATE] and had diagnoses of bipolar disorder (a mental health condition causing extreme mood swings, from emotional highs to lows, affecting energy, judgment, and behavior), major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities), type 2 diabetes (a common condition where the body either doesn't produce enough insulin or can't use insulin effectively, leading to high blood sugar levels because sugar can't get into cells for energy) and morbid obesity (a severe form of obesity defined by a Body Mass Index (BMI) of 40 or higher). She was [AGE] years of age. The section for Advance Directive revealed she requested do-not-resuscitate, or DNR (a medical instruction telling healthcare providers not to perform cardiopulmonary resuscitation if a patient's breathing or heart stops). Record review of Resident #10's care plan dated [DATE] revealed she requested a code status of DNR. Interventions included, inform MD and staff of DNR status. Maintain copy of code status on chart. Make sure code status is signed and placed in clinical record. Monitor for any decline or change in condition and withhold (cardiopulmonary resuscitation) per residents' wishes. Record review of Resident #10's OOH-DNR dated [DATE] revealed it was signed by Resident #10 on [DATE] and MD S on [DATE]. MD S's signature was at the bottom of the form under a statement that stated, all persons who have signed above must sign below, acknowledging that this document has been properly completed. The document was not signed by two witnesses. In an interview on [DATE] at 12:25pm, the Social Worker said she recently started working at the facility. She said she had completed 3 to 4 advance directives since she started. She said she made sure all parties sign the OOH-DNR document, including the resident, physician and notary or two witnesses. She said if an OOH-DNR document was filled out incorrectly, it could be invalid and a resident would be considered full code (when a patient has requested all possible life-saving measures like CPR if their heart stops or they stop breathing). She said she was not working here when Resident #10 signed an OOH-DNR. In an interview on [DATE] at 12:33pm, ADON A said the facility's social worker was responsible for ensuring the OOH-DNR was completed. She said when the form was complete, the ADONs update the resident's code status in the electronic medical record. She said advanced directives were important because it depicted whether they were full code She acknowledged Resident #10's OOH-DNR form was incomplete. Record review of the Instructions for Issuing an OOH-DNR Order dated [DATE] provided by the Texas Department of State Health Services revealed the OOH-DNR must be signed and dated by two competent adult witnesses who have witnessed the competent adult person making his/her signature. Record review of the facility's policy regarding Advanced Directives dated 6/2019 revealed, It is the policy of this facility to:.ensure the resident's choice about advance directives is respected. ensure compliance with state law respecting advance directives. Pursuant to state laws, any person may make a formal declaration specifically authorizing the withholding or withdrawal of resuscitative measures if they stop breathing and their hearts stop beating.Once a DNR is signed by resident or legal representative, it needs to be witnessed by an individual who is not a staff member.

Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #3) of 5 residents reviewed for PASRR.- The facility failed to perform a new PASRR level 1 assessment on Resident #3 due to diagnoses of Schizoaffective Disorder and Bipolar Disorder.This failure could place residents at risk of not receiving needed services and support for mental illness and a decrease in quality of life. Findings Included:Record review of Resident #3's undated face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE], with the most recent admission date of 10/29/25. He had diagnoses of tracheostomy status (tube in throat for breathing), quadriplegia (paralysis of upper and lower extremities), anxiety disorder, bipolar disorder (brain disorder causing extreme shifts in mood, energy, activity levels, and concentration), and Schizoaffective disorder (symptoms of schizophrenia (hallucinations, delusions, disorganized thinking) with those of a mood disorder).Record review of Resident #3's admission MDS assessment dated [DATE] revealed the resident was not considered by the state level II PASRR process to have had a serious mental illness and/or intellectual disability. The assessment revealed a BIMS was unable to be completed due to his medical condition. Resident #3 had moderately impaired (decisions poor; cues/supervision required) cognitive skills for daily decision making. The MDS assessment had anxiety disorder and Bipolar disorder checked off as diagnoses under active diagnoses. The assessment also revealed Resident #3 was taking antianxiety medicationRecord review of Resident #3's Care Plan with the last care plan review completed on 11/18/25, revealed a Focus: Resident has impaired cognition and is at risk for further decline AEB resident is diagnosed with bipolar disorder, and anxiety disorder (Initiated: 6/6/24). The goal was to have the resident's needs met over the next 90 days (Initiated 6/6/24, Revised: 4/24/25). The interventions included repeating information as needed and using terms the resident understands. Focus: The resident has a history of alteration in mood r/t anxiety (Initiated: 8/5/24, Revised: 6/9/25). The goal was to preserve the resident's dignity and quality of life through the review date. Interventions included administering medications as ordered and referring to counseling. Focus: Resident has been identified as having PASRR positive status (having a serious mental illness or an intellectual disability) related to severe mental illness AEB bipolar disorder (Initiated: 8/8/24, Revised: 1/4/25). The goal was for the resident to maintain his highest level of practicable wellbeing over the next 90 days. Interventions included coordinating services with LMHA or MHMR.Record review of Resident #3's previous hospital records dated 4/19/24 revealed a medical history of Bipolar/Manic/schizophrenia/Depression/Anxiety/PTSD and he was taking Depakote and Buspar (medications for mental illness).Record review of Resident #3's PASRR Level 1 Screening dated 5/13/24 reflected he did not have any evidence of mental illness.Record review of Resident #3's May 2024 MAR-TAR revealed he received Methylphenidate HCl (medication for ADHD) Tablet 5mg, Give 0.5 tablet PO QD for ADHD related to Bipolar Disorder. Ordered 5/14/24 and discontinued 5/29/24. He also received Buspirone HCl (Buspar) tablet 15mg, Give 1 tablet via G-tube (tube into stomach for nutrition) BID related to anxiety disorder. Ordered 5/14/24 and discontinued 5/29/24.Record review of Resident #3's Physician Progress Notes dated 5/16/24 from NP A revealed the resident had Bipolar 1 disorder and was taking Methylphenidate HCl Tablet 5mg.Record review of Resident #3's hospital records dated 5/28/24 revealed medical history of bipolar disorder.Record review of Resident #3's hospital records dated 6/19/24 revealed medical history of paranoid schizophrenia (severe mental illness characterized by intense paranoia, hallucinations [especially voices], and delusions [false beliefs, often of persecution]).Record review of Resident #3's Psychiatric Initial assessment dated [DATE] from NP L, revealed hospital records noted paranoid schizophrenia. NP L prescribed Buspar 1 tablet 15mg BID for anxiety.Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS could not be performed due to his medical condition. Resident #3 had severely impaired (never/rarely made decisions) cognitive skills for daily decision making. The assessment had anxiety disorder and bipolar marked as active diagnoses and revealed the resident was taking an antianxiety medication.Record review of Resident #3's Psychiatric assessment dated [DATE] from NP L, revealed he was being treated for Bipolar disorder and anxiety disorder.Record review of Resident #3's hospital records dated 11/21/24 revealed medical history of anxiety and bipolar disorder.Record review of Resident #3's hospital records dated 6/29/25 revealed medical history of bipolar disorder and schizophrenia.Record review of Resident #3's Psychiatric assessment dated [DATE] from NP L revealed Spoke with [family member] regarding pt's psychiatric history. [Family member] reports pt was dx with Paranoid Schizophrenia in his teenage years as well as hx of Bipolar disorder. Pt has hx of mood lability (goes up and down), delusions, auditory and visual hallucinations (hearing/seeing things not there), hx of SI (wanting to kill oneself) and HI (wanting to kill others). Pt was admitted to [hospital] for Delusions approximately 3.5 years ago. She reports a hx of tx with Geodon and Depakote (medications for psychiatric illness), as well as other psychiatric medications. She reports medications were stopped after MVA. [Family member] also reports pt has been observed with multiple personalities and states I have met 4 of them.Record review of Resident #3's Psychiatric assessment dated [DATE] from NP L, revealed the resident met criteria for Schizoaffective Disorder.Record review of Resident #3's Physician Progress Note dated 10/8/25 from NP A revealed medical history of anxiety, paranoid schizophrenia, and schizoaffective disorder, bipolar type.Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS could not be performed due to his medical condition. Resident #3 had severely impaired (never/rarely made decisions) cognitive skills for daily decision making. The assessment had anxiety disorder, bipolar disorder, and schizophrenia marked as active diagnoses and revealed the resident was taking an antianxiety and an antidepressant.Record review of Resident #3's Physician Orders revealed the following orders from MD J:- Observation: Behaviors, Target Behaviors (anxiety), every shift. Ordered on 10/30/25.- Observation: Antianxiety Medication (side effects). Document Y if free from side effects and N if side effects are present, every shift. Ordered on 10/30/25.- Sertraline HCl (medication for anxiety) Oral Tablet 25mg, Give 1 tablet via G-tube QD for other specified anxiety disorders. Ordered on 11/11/25.- Buspirone HCl Oral Tablet 10mg, Give 1 tablet via G-tube BID for other specified anxiety disorders. Ordered on 11/11/25.Record review of Resident #3's Mental Illness/Dementia (severe cognitive decline (memory, thinking, reasoning) that impairs daily life) Resident Review dated 12/10/25 from the MDS Coordinator revealed the resident's PASRR Level 1 assessment was completed on 5/13/24. The resident did not have dementia and was diagnosed with schizoaffective disorder on 7/23/25. A new positive PASRR Level 1 was submitted on 12/10/25.In an interview on 12/11/25 at 11:29am, the MDS Coordinator said she was unsure of why Resident #3's care plan said he was PASRR positive and was receiving services because when she went to the PASRR website, it did not show a Level 2 (process to determine if resident would qualify for services) was ever completed for him. She said when the Investigator asked for the Level 2 yesterday (12/10/25) for the resident, she and the Corporate Nurse performed an audit and realized a new PASRR 1 was never filed for Resident #3, so they filed one. She said the initial PASRR should have said yes for mental illness since he had a history of it. The MDS Coordinator did not feel the resident missed out on anything because he was still getting medication, psychiatric services, activities, and there were no services he was missing.In an interview on 12/11/25 at 11:44am, the DON said PASRR was for residents to receive extra services if they were positive (had diagnosed mental illness or intellectual disabilities). She said if a resident was marked negative (no diagnosed mental illness or intellectual disabilities) when they should have been positive, or if a new PASRR Level 1 was not completed after a new diagnosis, the resident would be without potential resources they could have had.Record review of the facility's policies and procedures on PASRR (revised 1/2025) read in part: This policy ensures compliance with federal and Texas Health and Human Services Commission (HHSC) regulations regarding the Preadmission Screening and Resident Review (PASRR) process. The goal is to identify individuals with Mental Illness (MI), Intellectual Disability (ID), or Developmental Disability/Related Conditions (DD/RC) and ensure appropriate placement and specialized services.The PASRR Level I (PL1) Screening Form is designed to identify individuals who are suspected of having mental illness (MI), intellectual disability (ID), or a developmental disability (DD). The referring entity (RE).or nursing facility (NF) will screen the individual and fill out all fields of the PL1 Screening Form and enter the PL1 Screening Form into the LTC Online Portal. If documentation entered on the PL1 Screening Form indicates a suspicion of MI/ID/DD, a PASRR Evaluation (PE) must be completed. PASRR Evaluation (PE) Conducted by: The LA (LIDDA, LMHA, or LBHA). Negative PE: No PASRR specialized services required. Positive PE: Determines specialized service needs and appropriate placement options. Specialized Services: Nursing Facility Specialized Services (NFSS) - Services provided by the nursing facility (e.g., durable medical equipment, habilitative therapies). LA Specialized Services - Services provided by the LA (e.g., independent living skills, day habilitation). Authorization: NFSS requests are submitted via the LTC Online Portal. Monitoring: Regular review of specialized service effectiveness during care plan meetings.

Based on observation, interview and record review the facility failed to ensure residents 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 demonstrates that this was not possible or resident preferences indicate otherwise for 2 of 21 residents (Residents #3, #9) reviewed for nutritional status.The facility failed to ensure Resident #9's enteral feeding (a form of nutrition that was delivered into the digestive system as a liquid form via the feeding tube) was administered as ordered by the physician on 12/9/25 and 12/10/25.The facility failed to ensure Resident #3's enteral feeding was administered as ordered by the physician on 12/10/25.This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life.Findings included:Resident #9Record review of Resident #9's care plan dated 8/16/25 revealed she was readmitted to the facility on [DATE] with diagnoses of hypothyroidism (happens when your thyroid gland does not make enough thyroid hormones to meet your body's needs), dementia, muscle wasting and atrophy and severe protein-calorie malnutrition. She was [AGE] years old. Further review of the care plan revealed she required the use of a feeding tube for nutrition and was at risk for unplanned weight loss, dehydration and nutritional complications. Interventions included, Follow Physician's orders for feedings and water flushes.monitor weight every month/(as needed), notify the physician of any adverse findings/changes.Record review of Resident #9's Nutrition Assessment from the acute care hospital dated 8/14/25 revealed the acute care dietician stated Resident #9 received a g-tube and would start enteral nutrition on 8/14/25. The acute care dietician revealed an order for enteral nutrition which included Jevity 1.2 cal at 80 mL/hour.Record review of Resident #9's physician order dated 8/15/25 revealed an enteral feeding order written by NP A for Jevity 1.5 cal at a rate of 45 mL/hour via g-tube continuously for 22 hours. The order was discontinued on 10/27/25.Record review of Resident #9's physician order dated 10/28/25 revealed an enteral feeding order written by MD J for Jevity 1.5 cal at a rate of 50 mL/hour via g-tube continuously for 22 hours.In an observation on 12/9/25 at 10:00am, Resident #9 received Jevity 1.5 cal formula at a rate of 44 mL/hour by enteral feeding.In an observation on 12/10/25 at 9:15am, Resident #9 had a 1-liter bottle of Jevity 1.5 cal formula hanging near her bed on a pole. The bottle contained approximately 775 mL of liquid. There was a handwritten note on the bottle stating it was placed on 12/9/25 at 8:00pm with a rate of 45 mL/hour. The pump was beeping and the display stated, pump inactive. Pump has been idle for 10 minutes, press continue.In an interview on 12/10/25 at 9:22am, LVN R said Resident #9's enteral feeding pump was most likely paused by the CNA so they could change her brief. She said a CNA can pause the pump and the nurse would start it again. She said the CNAs were usually good about notifying her when the pump needed to be turned back on. She said she had not been notified this morning of the pump being idle.In an interview on 12/10/25 at 10:52am, CNA U said he was assigned to care for Resident #9. He said when he needed to pause the enteral feeding pump, he notified the nurse. He said he did not push any of the buttons or pause the feeding. He said about an hour ago, LVN R turned off Resident #9's pump so that he could provide incontinent care. He said he only changed her once since arriving at 6am. He said when he arrived, he believed Resident #9's enteral feed pump was on, and LVN R did not indicate anything was wrong with it.In an observation and interview on 12/10/25 at 11:55am, LVN R said they should follow physician's orders for enteral feedings. She said Resident #9's formula bottles usually lasted about 24 hours. She said the bottle was placed at 8:00pm on 12/9/25. She said the feeding was interrupted for water flushes and they could take a while. She said Resident #9's physician order stated the formula rate should be set at 50 mL/hour. LVN R walked to Resident #9's room. She increased the feeding rate from 45 mL/hour to 50 mL/hour. She said when she monitored residents with enteral feedings, she checked for residuals (involves aspirating stomach contents through a g-tube to assess gastric emptying and feeding tolerance), abdominal distress, body positioning, site of g-tube insertion and rate. She said at times, the pump will pause because the tube was blocked and she had to fix it. She said residents who do not receive nutrition as ordered by the physician were at risk of weight loss, malnutrition and skin integrity problems.In an interview on 12/10/25 at 1:20pm, when asked about Resident #9's enteral feeding order, NP E said she had not visited the facility since before 10/1/25 and no longer worked at the facility. She said she could not remember and did not have access to Resident #9's medical records.In an interview on 12/10/25 at 2:01pm, MD J said he started working at the facility about 2 months ago. He said the dietician made recommendations for formula rate and he reviewed and either agreed or disagreed. He said Resident #9 had some unavoidable weight loss due to thyroid levels. When informed of the amount of formula in the formula bottle this morning at 9:15am, he said she received a little less than usual. He said it would be hard to generalize and state that the issue could cause weight loss.In an interview on 12/10/25 at 4:50pm, LVN T said when Resident #9 was readmitted from the hospital with a new g-tube, NP A wrote the order for the enteral feeding. She said NP E wanted her to start at 45 mL/hour and wanted it to be gradually increased to 60 mL/hour. She said she worked the 2pm-10pm shift and she changed Resident #9's formula during her shift, usually around 8pm-8:30pm. She said she made a mistake and was setting Resident #9's enteral feed rate at 45 mL/hour instead of 50 ml/hour as ordered. She said 45mL/hour was her previous order. She said sometimes, the CNAs paused the enteral feed pump and forgot to tell the nurse so they could turn it back on.In an interview on 12/11/25 at 3:07pm, CNA I said she never touched a resident's enteral feeding pump. When asked about Resident #9's enteral feeding pump on the night of 12/9/25, she said she did not notice anything out of the ordinary. She said if there was something wrong with it or if it was beeping, she would have notified the nurse. Resident #3Record review of Resident #3's undated face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE], with the most recent admission date of 10/29/25. He had diagnoses of tracheostomy status (tube in throat for breathing), quadriplegia (paralysis of upper and lower extremities), stage 4 pressure ulcer of sacral region (pressure ulcer to the tailbone exposing muscle or bone), stage 3 pressure ulcer to right ankle (pressure ulcer exposing fat), gastrostomy status (tube into stomach for nutrition), dysphagia (trouble swallowing), and muscle wasting and atrophy (muscles are decreasing).Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS could not be performed due to the resident's medical condition. The assessment revealed the resident was severely impaired (never/rarely made decisions) with decisions regarding tasks of daily life. Resident #3 was dependent (helper does all of the effort) for all ADLs. The assessment revealed the resident was on a feeding tube and was receiving 51% or more total calories and 501 cc/day or more of his fluid intake through it. There was no indication of weight loss noted. According to the assessment, the resident had 2 stage 3 pressure ulcers, 1 stage 4 pressure ulcer, 2 unstageable pressure ulcers (unable to see how deep it is due to dead tissue), and 1 deep tissue injury (deep bruise that can develop into a pressure ulcer).Record review of Resident #3's Care Plan with the last care plan review completed on 11/18/25, revealed a Focus: Resident is at risk for aspiration, unplanned weight loss, dehydration, and nutritional complications AEB receiving total nutrition/hydration via feeding tube. The goal was for the feeding tube to remain patent (unclogged) and for the resident to be adequately nourished over the next 90 days. Interventions included following physician orders for feedings and water flushes and monitoring weight every month/PRN and reporting any loss or gain of 5% to MD/RP.Record review of Resident #3 Physician Orders revealed an order from MD J for: Enteral Feeding- Jevity 1.5 @ 70/hr with 60/hr free water flush via G-Tube continuously x 22 hours. 22 hours accounts for ADL care. Ordered on 11/21/25 at 2:02pm.Record review of Resident #3's December 2025 MAR-TAR revealed daily nurse initials at 7am and 7pm from 12/1/25 through 12/11/25, indicating the nurse signed off that the resident was receiving the Jevity 1.5 @ 70/hr with 60/hr free water flush.In an observation on 12/10/25 at 11:40am, Resident #3's feeding pump was beeping when the Investigator went in the room, and the feeding was not running. It is unknown how long the machine was beeping or not running. There was a 1500ml bottle of Jevity 1.5 hanging on the pole next to his bed, that indicated it had been hung at 4:00am. The Jevity bottle had 1300ml left in it at 11:40am. The pump was set at 70ml/hr and should have been running for about 7.5hr at that time. Therefore, Resident #3 should have received 525ml of feeding by 11:40am, but only 200ml was missing from the bottle.In an interview on 12/10/25 at 2:30pm, Dietician B said that she was covering for the primary dietician, Dietician A, while she was on leave. She said Dietician A assessed Resident #9 on 12/8/25 and consulted MD J regarding malabsorption. She said malabsorption affected a resident's ability to absorb nutrition they take in. She said Resident #9's formula requirements were calculated based on her ideal body weight rather than her current weight. She said if a resident did not receive nutrients based on the physician's orders, the risk to the resident would depend on a lot of factors, stating that is why they overestimated Resident #9's needs. She said if she received a little less, then it would not have too much effect. She said if the resident had malabsorption, she could not absorb any more nutrients to support or gain weight. In an interview on 12/11/25, the DON said CNAs could pause an enteral feeding pump to provide care then the nurses could start it again. She said if it was paused for too long, it would start to alarm. When informed surveyors observations of Resident #9's enteral feeding that was not consistent with physician's orders, she said those were calories she was not receiving. She said she was unsure if Resident #9 had a clinical condition that caused weight loss.Record review of the facility policy regarding Enteral Feedings dated 9/2023 revealed, The facility will provide adequate care for residents with enteral feeding tubes to prevent complications. Facility will obtain physician orders for enteral feeding (formula and flush orders). Facility will follow physician orders and document feedings on (electronic medication administration record).

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 21 Residents (Resident #10) reviewed for care plans. The facility failed to ensure Resident #10 had a plan of care to address a diagnosis and symptoms of major depressive disorder, including tearfulness and sadness. These failures could place residents at risk of not having their needs met or a decline in psychological health. Findings include: Record review of Resident #10's admission Record generated on 12/11/25 revealed she was admitted to the facility on [DATE] and had diagnoses of bipolar disorder, major depressive disorder, type 2 diabetes and morbid obesity. She was [AGE] years of age. Record review of Resident #10's Default Progress Note dated 7/7/25 revealed Resident #10 had a diagnosis of depressive disorder, single episode, severe without psychotic features. Presently, she admits to severe depression. This episode of depression has been present for the last several years.The symptoms are constant and overwhelming. Record review of Resident #10's care plan dated 9/15/25 revealed she was receiving psychotropic medication (drugs that alter brain activity to treat mental health conditions like depression, anxiety, ADHD, and schizophrenia by adjusting brain chemical messengers such as serotonin, dopamine, and norepinephrine) and was at risk of adverse reactions and episodes of driven behavior. Interventions included, give medication as ordered. monitor for adverse reactions. monitor for episodes of depressive driven behaviors such as spontaneous crying, sad mood effect, self imposed isolation, mood not easily altered, etc. Record review of Resident #10's admission MDS assessment dated [DATE] revealed her BIMS was 15, indicating she had no cognitive impairment. She did not report feeling down, depressed, or hopeless. Record review of Resident #10's Psychological Services Progress Note dated 12/7/25 revealed she had a diagnosis of major depressive disorder. The summary and plan revealed Resident #10 was stuck in past pain and holds on to regret, which continues to impact her mood and emotional functioning.She described ongoing guilt and unresolved memories that weigh heavily on her. In an observation and interview on 12/9/25 at 11:10am, Resident #10 was tearful and crying. She shared information about her past, stating that it made her feel sad and full of regret and she thought about it constantly. She said she had been feeling sad for a long time. In an interview on 12/11/25 at 2:07pm, the DON said if a resident had symptoms of depression, then they should be addressed in the resident's care plan. In an interview on 12/11/25 at 2:47pm, the MDS Coordinator said she was responsible for completing a resident's care plan. She said she would write a care plan if a resident was admitted to the facility with a diagnosis of depression. She said she reviewed resident's treatment record and progress notes in the morning meetings to look for any changes that could indicate a resident's care plan needed to be updated. When asked if tearfulness or sadness should be care planned, she said yes. She said she could not remember if Resident #10 had problems with her mood. She said Resident #10 shared information with her about her former family member that made her upset and she hurt about what happened in her past. In an interview on 12/11/25 at 3:30pm, the MDS Coordinator said Resident #10's care plan for psychotropic medication use dated 9/15/25 should be sufficient for the resident when care planning for depressive symptoms. Record review of the facility policy regarding Care plan Revisions dated 5/2022 revealed the comprehensive care plan would be reviewed and revised every quarter, when a resident experiences a status change and as deemed necessary. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician and the resident representative. the MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.

Based on observations, interviews, and record reviews, 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 1 out of 5 resident rooms (Resident #5) reviewed for infection control. - CNA D failed to wear appropriate PPE during incontinence care with Resident #5, when she was on Enhanced Barrier Precautions.- CNA D threw Resident #5's dirty brief on the floor instead of in the trash can.These failures could place residents and staff at risk of cross contamination and risk for infection.The findings included:Record review of Resident #5's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE], with the most recent admission being 8/7/25. She had diagnoses of sepsis (infection throughout body), acute and chronic respiratory failure (not enough oxygen), type 2 diabetes (body does not produce insulin or body resists it), stage 3 pressure ulcer of right buttocks (fat exposed with no bone or muscle showing), and heart failure (heart does not pump effectively).Record review of Resident #5's Care Plan dated 4/13/24 revealed a Focus: Resident #5 has a tracheostomy (tube in throat to assist with breathing) and is at risk for increased secretions, congestion, and infection (Initiated: 4/13/24, Revised: 7/24/24). The goal was to have the secretions/congestion relieved with suctioning/medication and have no infection over the next 90 days (Initiated: 4/13/24, Revised: 4/22/24). Interventions included providing oxygen, tracheostomy care, and tubing change per orders. Focus: Resident #5 requires enhanced barrier precautions AEB indwelling medical device (Initiated: 4/12/24, Revised: 8/10/25). The goal was to have no adverse effects related to the requirements of enhanced barrier precautions through the review date (Initiated: 4/12/24, Revised: 4/22/24). Interventions included PPE: gown and gloves during high-contact resident care activities (dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, wound care). Focus: Resident #5 has a pressure injury to right rear thigh (Initiated: 8/22/25, Revised: 9/23/25). The goal was to show signs and symptoms of improvement through the review date. Interventions included monitoring site for s/s of infection, presence of dressing if indicated, or onset of pain, consult Wound MD, and assist with turning/re-positioning.Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. The resident was dependent (helper does all of the effort and resident does none of the effort) for toileting, shower/baths, lower body dressing, and putting on/taking off footwear. The resident was frequently incontinent of bladder and always incontinent of bowel. The MDS revealed the resident was on oxygen, non-invasive mechanical ventilator (delivers air/oxygen to lungs using mask or other device without endotracheal tube), IV medications, and received tracheostomy care and suctioning.Record review of Resident #5's Physician Progress Note dated 10/10/25 from NP H revealed she had a tracheostomy and a stage 3 pressure ulcer to her right buttocks. SKIN- skin breakdown on buttocks.RESPIRATORY- tracheostomy 6XLT secured and intact, on ATC (artificial tracheostomy collar) [strap that holds trach in place] with 6L oxygen, PMV (speaking valve for tracheostomy patients) used intermittently during the day. Assessment and Plan: Chronic respiratory failure with hypercapnia [too much carbon dioxide in blood] *: Patient has a tracheostomy and is currently on ATC 6L oxygen with PMV. Patient consistently refusing BiPAP therapy [breathing therapy using machine and mask to deliver two pressure levels]. No acute respiratory distress noted today. Continuing DuoNeb [nebulizer] via trach four times daily and scopolamine patch every 72 hours for respiratory management.Pressure ulcer of right buttock, stage 3 *: Patient has stage 3 pressure ulcer to right buttock which has been improving per previous evaluation. Daily wound care is provided. Continue Vitamin C 500mg daily to support wound healing. Staff will continue to monitor and provide wound care. Patient is currently unable to get out of bed due to non-functioning wheelchair, which may impact wound healing.Record review of Resident #5's Wound Care Note dated 10/13/25 from NP S revealed a wound to her right thigh with orders for daily and PRN wound care.Record review of Resident #5's Pulmonary Progress Note dated 11/12/25 from NP B revealed she was being seen for tracheostomy management. Physical Examination Neck: Tracheostomy XLT #6 with PMW (Permanent Mechanical Windpipe).Continue monitoring tracheostomy site for appropriate healing. Continue nocturnal [nighttime] ventilator [machine] support as needed.Monitor trach site for bleeding.Record review of Resident #5's Physician Progress Note dated 11/18/25 from MD J revealed Chronic Respiratory Failure, Unspecified.Maintain airway support, suction trach as needed, and monitor respiratory effort and oxygen saturation. Continue Albuterol nebulizer four times daily to support airway clearance and improve airflow.Record review of Resident #5's Skin Observation dated 12/2/25 revealed she had maceration (skin breakdown due to moisture) to the right rear thigh that was being treated with barrier cream with each incontinence episode.Record review of Resident #5's Respiratory Progress Note dated 12/9/25 from RT N revealed Resident was received on room air with PMV attached, wearing Shiley #6XL T, BL 02 via ATC Trach intact and secured. No respiratory distress noted. E-kit at bedside. Will continue to monitor.Record review of Resident #5's Physician Orders from 12/9/25 revealed the following orders:- Trach Care: Disposable Inner Cannula, every day. Change Shiley 6XLT Inner Cannula Daily and PRN. Ordered by MD G on 8/7/25.- Change Vent Circuit (tubing for the vent) Q30 days and PRN, every 30 days. Ordered by MD G on 8/8/25.- Enhanced Barrier Precautions - PPE: Gloves/Gown during high-contact resident care activities, every shift. Ordered by NP A on 8/11/25.- Trach Care: Trach Site - Cleanse with NS, pat dry, apply fenestrated dressing, every shift and PRN. Ordered by NP A on 8/11/25.- Trach Care: O2 via trach collar continuously. Titrate to keep O2 >90%, every shift. Ordered by MD V on 8/11/25.- Ascorbic Acid Tablet 500mg, 1 PO QD for Wound Healing. Ordered by MD J on 10/1/25.- License nurse to monitor: R Thigh (Rear) for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site, and for presence of dressing Q shift. Ordered by MD J on 10/15/25.Record review of Resident #5's December 2025 MAR-TAR revealed the order for Enhanced Barrier Precautions was checked off by staff for each shift, from 12/1/25-12/9/25.In an observation on 12/9/25 at 9:57am Resident #5 had an EBP sign on the door to her room and a cart that had PPE in it, outside her room. She was lying on her back in bed, on an air mattress, and had a tracheostomy. Resident #5 was receiving incontinence care by CNA D who was wearing gloves, but no gown. Resident #5's dirty brief was observed on the floor next to her bed and not in the trash can.In an interview on 12/9/25 at 10:03am, CNA D said EBP was when you have to wear a gown and gloves with residents who had G-tubes, open wounds, or residents in isolation. She said the PPE had to be worn anytime she performed patient care, and it was to protect herself from contamination. CNA D said she was unaware EBP was for residents with trachs and without wearing a gown she could get germs on herself and give it to others. She also said she normally threw the brief in the trash can, but she forgot to bring the trash can next to the bed. She said the dirty brief on the floor could cause contamination.In an interview on 12/11/25 at 11:44am, the DON said EBP was for residents who had open wounds, lines, and trachs. She said gown and gloves were required for any patient care like wound care, incontinent care, or medication administration. The DON said EBP was to protect the patient from getting any infection. She said not following EBP could cause cross contamination. She said a dirty brief on the floor caused contamination and then it could be spread around.Record review of the facility's policies and procedures on Enhanced Barrier Precautions (revised March 2024) read in part: Enhanced Barrier Precautions is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms and employs targeted gown and glove use during high-contact resident care activities for targeted residents. Enhanced Barrier Precautions (EBP).expands the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following:.Wounds and/or indwelling medical devices.Examples of chronic wounds: pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Examples of indwelling medical devices: central lines [IV line goes in deeper vein and stays longer], urinary catheters [tube into bladder to drain urine], feeding tubes, and tracheostomies.EBP should be employed for the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, and wound care.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety.The facility failed to obtain the food temperatures of the lunch meal prior to serving residents on 10/4/25.The facility failed to ensure a storage bag of peaches, and a container of rice were properly labeled and dated.These failures could place residents at risk of food-borne illness. Findings Include:Record review of the facility's Production Sheet dated 10/4/25 revealed there were no food temperatures documented for the lunch meal which consisted of golden-brown oven fried chicken, black eyed peas, seasoned broccoli, buttered cabbage, chilled peaches, and a biscuit.In an interview on 10/7/25 at 10:00 a.m. the [NAME] said he prepared the lunch meal on Saturday 10/4/25 and did not take the food temperatures. He said the lunch meal was the biggest meal he had to prepare, and he got distracted. He said he tried a piece of the chicken to ensure it was done. He said he was previously trained by the DM on taking the food temperatures. He said the purpose of obtaining the food temperatures was to ensure the food was done and did not contain any bacteria. In an observation on 10/7/25 at 10:08 a.m. of the walk-in refrigerator with the DM revealed there was 1 plastic storage bag of peaches with no label or use by date and 1 silver container of cooked rice with no label or use by date.In an interview on 10/7/25 at 10:11 a.m. the DM said food should be labeled immediately. She said she normally completed rounds to verify that labels were present. She said the purpose of labeling and dating food was to know when it was made and when to toss it. She said she expected food temperatures to be obtained the moment the food is cooked to confirm the proper temperature and to avoid food borne illness. She said there was a high risk of foodborne illness spreading if the temperatures were not taken. In an interview on 10/7/25 at 1:15 p.m. the Administrator said anytime staff opened something it should be properly stored, dated and labeled before storing the item. She said the food temperature should be taken before each meal to ensure the food is not too hot or too cold and documented in the logbook. She said obtaining the temperatures was important to ensure the food is cooked to the right temperature for consumption purposes. She said if the temperatures were not taken, the food may be undercooked which could result in foodborne illness and make the residents sick, or the food could burn the residents. Record review of the facility's undated Nutrition Services Policies and Procedures policy revealed in part, .Subject: Safe Food Temperatures. Policy: It is the policy of this facility that food temperatures will be maintained at acceptable levels during food storage, preparation, holding, serving, delivery, cooling and reheating. Procedures. 7. Check and record trayline food temperatures on the food temperature record before each meal. If the food temperatures are not within acceptable parameters, reheat the food to at least 165F for 15 seconds (for hot foods) or discard it.Record of the facility's Nutrition Services Policies and Procedures policy dated 8/12/2019 revealed in part, .Food Safety in Receiving and Storage. General Food Storage Guidelines. 3. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight fitting lid. Label both the container and its lid with the common name of the contents and the date it was transferred to the new container. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging. Refrigerated Storage Guidelines. 12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by date and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Discard after three days unless otherwise indicated. Refer to Cold Storage Chart.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for oxygen.- The facility failed to ensure Residents #1 had an order for oxygen, when she was on 2L O2 via NC.This failure could place residents at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment.Findings included:Record review of Resident #1's undated face sheet revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of acute and chronic respiratory failure (not enough oxygen in the blood), cerebral infarction (stroke), aphasia (unable to speak), type 2 diabetes mellitus (body does not produce insulin or resists it), pneumonitis (inflammation) due to inhalation of food and vomit, and a stage 3 pressure ulcer to her sacrum (pressure ulcer revealing fat but not to the bone, of her tailbone). The picture of the resident on the face sheet revealed she had oxygen on.Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15, which indicated severely impaired cognition. The resident was dependent (the helpers did all the effort and resident does none of the effort) for all self-care and mobility. According to the MDS, the resident was on oxygen.Record review of Resident #1's Baseline Care Plan dated 9/5/25, revealed the resident was receiving oxygen and had a Focus: oxygen use: required supplemental oxygen, with a goal to maintain adequate oxygen saturation levels and respiratory comfort through the review date. The interventions included assessing for signs of hypoxia (not having enough oxygen), changing the tubing when soiled or contaminated, following physician orders for oxygen therapy delivery, monitoring for side effects of oxygen therapy (dry mucous membranes, oxygen toxicity) and report to MD as needed, monitor/clean the oxygen concentrator filter as needed, provide humidification as indicated, and routinely monitor the resident's oxygen saturation levels.Record review of Resident #1's Comprehensive Care Plan dated 9/5/25, revealed a Focus: Oxygen Use: required supplemental oxygen (Initiated: 9/8/25). The goal was to maintain adequate oxygen saturation levels and respiratory comfort through the review date (Initiated: 9/8/25, Target: 9/22/25). The interventions included following physician orders for oxygen therapy delivery, monitoring for side effects of oxygen therapy (dry mucous membranes, oxygen toxicity) and report to MD as needed and routinely monitor the resident's oxygen saturation levels.Record review of Resident #1's previous hospital records dated 9/3/25 at 12:53am by CRRT M, revealed she was on O2 at 2L via NC.Record review of Resident #1's Admission/readmission assessment dated [DATE] at 4:38pm by unknown nurse, revealed the resident was using O2 at 2 LPM.Record review of Resident #1's oxygen saturations from 9/5/25-9/23/25, revealed she was on oxygen via nasal cannula.Record review of Resident #1's Progress Notes dated 9/6/25 at 10:52am by LVN R, revealed the resident's O2 was 98% and the method was oxygen via nasal cannula. The note also said the resident was provided education on oxygen management.Record review of Resident #1's H&P dated 9/8/25 at 10:00am by NP C, revealed .Continues to require oxygen via nasal cannula and nebulizer treatments.Will monitor respiratory status and oxygen saturation.Record review of Resident #1's H&P dated 9/22/25 at 8:00am by NP C, revealed .She was maintained on O2 via nasal cannula during this time.Continues to require oxygen via nasal cannula and nebulizer treatments.Will monitor respiratory status and oxygen saturation.Record review of Resident #1's Progress Notes dated 9/22/25 at 7:54pm by LVN S, revealed the resident's O2 was 99% and the method was oxygen via nasal cannula.In an observation on 9/23/25 at 9:23am, Resident #1 was lying on her right side in bed, with O2 at 2L via NC on.In an observation on 9/23/25 at 11:19am, Resident #1 was lying in bed with O2 via NC on.Record review of Resident #1's Physician Orders on 9/23/25, dated 9/5/25-9/23/25 by MD G, revealed no orders for oxygen.In an interview on 9/23/25 at 1:09pm, LVN H said Residents who were on oxygen had their pulse ox documented once per shift. She said if a Resident was on oxygen there would be an order for it, and they documented the pulse ox also. LVN H said there was not an order for oxygen in the chart for Resident #1. She did not feel that anything would happen to the resident being on oxygen without an order because the resident needed it.In an interview on 9/23/25 at 1:29pm, the Interim DON said the policy was there would be an order for oxygen, and then the nurse confirmed the resident was on the correct amount by documenting on the MAR-TAR the amount of oxygen the resident was on. She said if the resident was on oxygen, the nurse should have noticed there was not an order and called the MD to get one. The Interim DON said the nurse knew how much oxygen to put the resident on without an order, because the MD always ordered between 2-4 liters. She said she did not think anything would happen to the resident because she needed the oxygen.Record review of the facility's policy and procedure on Physician Orders (Revised 12/2024) read in part: All physician orders must be accurate, timely, and documented in the resident's medical record. Only authorized individuals (e.g., physicians, nurse practitioners, or physician assistants) may write or verbally provide orders. Verbal orders must be promptly documented, signed, and authenticated by the prescribing practitioner within the timeframe. The facility staff must ensure that all orders are obtained, clarified, and carried out promptly, with documentation. Orders for treatments, medications, or procedures may be requested or clarified during: Routine visits. As-needed communication for resident care changes.If an order is received verbally or via telephone: A licensed nurse or authorized staff member must document the order in the medical record immediately. The order must include: Resident's name. Date and time of the order. Specific details of the order. The name and title of the prescribing practitioner. The facility staff must transcribe and verify the order accurately into the medical record.Facility staff are responsible for: Reviewing the order promptly. Ensuring that all orders are correctly implemented within the timeframe specified. Communicating any barriers to implementation to the prescribing practitioner. Documentation of implementation must include: Date and time the order was carried out. Name and credentials of the staff member completing the task. Any resident responses or outcomes, as applicable. If clarification is required, the staff member must: Contact the prescribing practitioner for clarification. Document the clarification conversation and any modifications in the medical record. Record review of the facility's policy and procedure on Oxygen Therapy: General Administration & Care (Revised 8/2019) read in part: It is the policy of this facility that the facility will provide oxygen therapy by means of various administration devices.Start O2 flow rate at the prescribed liter flow.Document initiation of therapy in the medical record, per documentation standards.(Note: For oxygen saturation below 89% emergency use of oxygen from 2-4L is appropriate to prevent worsening of hypoxemia and negative outcomes. The physician should be notified, and an order obtained for continued use of oxygen as soon as medically practicable.)

Based on observation, interview, and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 5 residents reviewed for notification of changes. The facility failed to establish contact with the NP after Resident#1 had an unwitnessed fall where he was found lying face down on the floor on 8/13/25 at 11am. LVN A sent the NP a text at 11:40 am but she was not aware until she received a second text notification at 12:44 pm. Resident #1 was transported to the hospital at 1:30 pm, after an induration formed above his left brow. An IJ was identified on 8/15/25 at 6:05 pm. The IJ template was provided to the facility on 8/15/25 at 7:10 pm. While the IJ was removed on 8/16/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or additional injury, paralysis or death. Finding included:Record review of Resident#1's face sheet revealed a fifty-six-year-old man who was admitted to the skilled nursing facility on [DATE]. His admitting diagnoses were hemiplegia and hemiparesis following cerebral infraction affecting the right dominant side (paralysis and weakness on one side of the body), paraplegia, cerebral aneurysm (blood vessel in the brain), a cerebral infraction (stroke), and the use of a tracheostomy. Record review of Resident #1's care plan disclosed that he utilized a feeding tube for meals and required supplemental oxygen. Record review of Resident #1's progress note dated 8/13/25 at 1:30 pm by LVN A documented unwitnessed fall, resident on floor next to bed in prone position with head turned to the left side. Bilateral arms straight and bilateral legs straight. Small swelling to left upper temporal noted upon assessment. Resident assisted back to bed x4. Vital signs obtained BP: 123/87 pulse: 89 respiratory: 20 temperature: 96.8. Neurological checks initiated per protocol. Physician and family notified. Resident mother stated resident tends to move a lot and he will try to get out of bed and this is not a new action for him. Precautions have been put in place. Two bedside mats or placed next to resident bed. Bed will continue to be lowered to ground call light within reach. In an interview with LVN A on 08/14/25 at 3:38 pm, she stated that Resident #1's mother alerted her that he was on the floor around 11am. She stated that she found him laying with his arms to his side and he did not have any signs of pain. The NP was notified, and she began neuro checks. After a few checks, she noticed a raised area forming above his brow and she alerted the NP who was also in the building at that time. The NP ordered Resident #1 to be sent out for further evaluation. LVN A explained that no fall protocols were put into place because he had not moved much since his admission, and they were not aware that he was able to move on his own. In an interview with Resident #1's family member on 08/15/25 at 10:50 am, she stated that when she entered his room at 11am, he was laying on the floor facedown with his trach still connected to his throat. LVN A was immediately alerted, and staff came inside the room and began assessments. She stated that she informed that staff amongst admission that Resident #1 could move and prior to him coming to the facility, he had done physical therapy at other facilities. EMS was called and he was transported to the hospital at 1:30 pm due to swelling above his left eyebrow. In an interview with CNA A on 8/15/25 at 11:53 am, she explained that she had worked with Resident #1 on 8/13/25 around 9:30 am to shower him. She stated that day, he was moving a lot. He would constantly move his legs up and down and he moved his head a lot. Resident #1 slept on an air mattress and before she left his room after his shower, she lowered his bed to the lowest position. She recalled that there was not a fall mat next to his bed because he was a new admit and she guessed nursing staff did not see a need for it at the time. In an interview with the Unit Manager on 8/15/25 at 12:16 pm, she stated that Resident #1 was nonverbal, but he could follow people with his eyes. She explained that he was able to move his arms and legs and described them as jerk like reactions. She stated that since Resident #1 was admitted , he had begun to move a lot more and his mother had also noticed his increase in movement. On that day of the fall, she was called to his room (time unknown) by LVN A and noticed that he was face down on the ground. There was no blood, and he was able to move his head. Initially there was no swelling, but after a few hours swelling began to appear on his left side. The Unit Manager recalled that the NP was in the building, but she could not recall if she assessed him immediately after the fall. The Unit Manager stated that the protocol after an unwitnessed depended on if it was a fall with an injury; then they would be sent out immediately. If there was an unwitnessed fall without injury, the facility's fall protocol was to notify the physician of NP and get an order to send them out. The surveyor asked that since Resident #1 had a history of head injuries, previously suffered from a stroke, and was found face down from an unwitnessed fall, would he be qualified to be sent out? Unit Manager took a long pause and said she was thinking and stated that he had no visible injuries, but he was a special situation and if the NP was in the building, she would have grabbed her to come see. In an interview with the DON on 8/15/25 at 12:35 pm, she stated that she did not know when the NP assessed Resident #1, but she was informed by LVN A when he fell, and she was informed when the swelling appeared. She stated that when LVN A noticed the swelling around 1-1:30 pm during neuro-checks and he was sent out afterwards. When the DON and Surveyor reviewed his orders, the DON confirmed that Resident #1 was on Aspirin, which was a blood thinner and the harm in not seeking emergency medical services post fall could be hemorrhaging or bleeding. She stated that no fall preventions were in place because Resident #1 was not able to move, and she believed he may have fell on the floor due to increased alertness. In an interview with the NP on 8/15/25 at 1:30 pm, she stated that LVN A sent her a text message on 8/13/25 at 11:40 am but she did not see the message. She could not give a definite time, but she stated that she entered the facility sometime between 12 pm and 2 pm to complete rounds. While she was there, LVN A sent her a second text message at 12:44 pm and informed her that Resident #1 had some swelling on his head post fall, and she went in to assess him. The NP found a little induration on the left side of his temple and stated that because he was on blood thinners, she ordered him to be sent out because she was concerned about internal bleeding. She stated that if someone had a fall where they hit their head, whether witnessed or unwitnessed, it would be best practice to send them out for a CT scan. This was especially significant for Resident #1 because he had a suspected head injury and was on blood thinners at the time. NP also noted that when she assessed Resident #1 that day, he was notably more alert, was able to shake his head, and seemed to understand her in conversation. Observation on 8/15/25 at 2:57 pm in the hospital, Resident #1 was sitting in bed at a 90-degree angle and his eyes were bright and alert. He seemed to have a smile on his face and followed the surveyor around the room as she spoke to him. He was nonverbal but attempted to make grunts and groans in response to conversation. In an interview with the HSW (Hospital Social Worker) on 8/15/25 at 2:59 pm, she explained that Resident #1 was admitted for a fall on 8/13/25. She stated that his admitting diagnoses were interval acute bleeding to the left side of the head, and he had new chronic appearing left frontal sub [NAME] hematoma Internal bleeding to the side. HSW stated that in addition to that, he was currently being treated for sepsis and pneumonia, which was present upon admittance. Record review of the facility's policy titled Fall Management revised July 2024 displayed that:1. The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medication review, and receive orders as indicated.2. If the resident's condition warrants, the charge nurse will arrange for appropriate emergency services or hospital transfer in collaboration with the Physician/Physician Extender. The ADM and DON were notified on 8/15/25 at 7:10 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 8/16/25 at 12:30 pm: Plan of Removal: F580 - Notification of ChangesAugust 16, 2025Immediate action:The facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or conditions or clinical conditions. Resident #1 was transferred on 8/13/2025 to the ER and remains in the hospital. Action: LVN A was immediately re-educated by the DON on 8/15/25 on the facility's fall protocol and notification procedures, including the requirement to make direct verbal communication with the provider NP/physician for all significant changes, and event escalation if the NP/Physician does not respond.Responsible: Director of Nursing Completion: August 16, 2025 The Administrator and Director of Nursing notified the Medical Director of the IJ F-0580.Responsible: Administrator/Director of NursingCompletion: August 16, 2025 Action: Ad Hoc QAPI conducted on 8/15/25 with Medical Director, Administrator, DON, & Unit Managers regarding IJ F0580 and F684.Responsible: Administrator/Director of NursingCompletion: August 16, 2025 Action: All license staff will be re-educated by the DON/Designee on the following: facility fall protocol to include immediate provider notification following all unwitnessed falls, regardless of visible injury. All license staff will be educated prior to the start of their next shift. Staff will not provide direct resident care until training/education has been completed. Staff should follow facility protocol and provide verbal communication to the provider.Escalation Protocol for Provider Notification:In the event of an unwitnessed fall and any other changes of condition from resident's baseline:1. Notify the Nurse Practitioner (NP) immediately.2. If the NP does not respond, contact the attending physician.3. If the attending physician does not respond, contact the Medical Director.4. If the Medical Director does not respond, contact the Administrator.Responsible: Director of Nursing/DesigneeCompletion: August 16,2025 Action: Administrator reviewed on 8/15/25 the facility falls policy and changes of conditions notification policy and no changes were needed. Responsible: AdministratorCompletion: August 16, 2025 The Surveyor monitored the POR on 8/16/25 as followed: Review of an in-service titled QAPI 8/15/25: Notification of Change and Quality of Care documented that all nursing staff had been educated on physician escalation notification, all unwitnessed or witnessed falls with a strike to head should be sent out immediately, and the physician or extending physician should be notified immediately. Attendees including the ADM, DON, and Unit Managers. Review of the in-services dated 8/15/25 titled Education Change of Condition, Physician Escalation Protocol for Provider Notification, and Fall management displayed that all nursing staff were educated. During interviews on 8/16/25 from 2:00 pm - 4:45 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-services. All staff stated that if a resident was experiencing a change in condition, the protocol would be to first assess the resident and if there was a deviation from their baseline, their NP or MD should be notified immediately. If the resident has interventions in place, nurses were to follow them or follow the orders given by the NP/MD. If the NP/MD is not available, 911 should be called so that the resident can receive a higher level of care. It was verbalized that the chain in notification would be that the NP would be notified first and if there was no answer, an attempt would be made to the MD, and the immediate scalation would be to call 911 and the ADM. All nurses should continue providing care until EMS arrives. Review of the Facility's QAPI Agenda, dated 8/15/25, reflected that the MD had reviewed and agreed with the plan. MD was interviewed and stated that a QAPI was held and the team developed a plan to address the issues of the IJs. LVN A was interviewed on 8/16/25 at 2:40 pm. She stated that she was in-serviced on fall management and escalation provider protocol. She said that if a resident has a fall, she was to contact the NP and MD, and if they didn't answer, she must call the administrator or EMS right away. The ADM and DON were notified on 8/16/25 6:05 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to contact 911 after Resident#1 was found laying face down on the floor after an unwitnessed fall on 8/13/25 at 11am. Resident was transported to hospital at 1:30pm, after an induration began to form above his left brow. An IJ was identified on 8/15/25 at 6:05 pm. The IJ template was provided to the facility on 8/15/25 at 7:10 pm. While the IJ was removed on 8/16/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or additional injury, paralysis or death.Findings included:Record review of Resident#1's face sheet revealed a fifty-six-year-old man who was admitted to the skilled nursing facility on [DATE]. His admitting diagnoses were hemiplegia and hemiparesis following cerebral infraction affecting the right dominant side (paralysis and weakness on one side of the body), paraplegia, cerebral aneurysm (blood vessel in the brain), a cerebral infraction (stroke), and the use of a tracheostomy. Record review of Resident #1's care plan disclosed that he utilized a feeding tube for meals and required supplemental oxygen. Record review of progress note dated 8/13/25 at 1:30 pm by LVN A documented unwitnessed fall, resident on floor next to bed in prone position with head turned to the left side. Bilateral arms straight and bilateral legs straight. Small swelling to left upper temporal noted upon assessment. Resident assisted back to bed x4. Vital signs obtained BP:123/87 pulse:89 res:20 temp:96.8. Neurological checks initiated per protocol. Physician and family notified. Resident mother stated resident tends to move a lot and he will try to get out of bed and this is not a new action for him. Precautions have been put in place. Two bedside mats or placed next to resident bed. Bed will continue to be lowered to ground call light within reach. In an interview with LVN A on 08/14/25 at 3:38 pm, she stated that Resident #1's mother alerted her that he was on the floor around 11am. She stated that she found him laying with his arms to his side and he did not have any signs of pain. The NP was notified and she began neuro checks. After a few checks, she noticed a raised area forming above his brow and she alerted the NP who was also in the building at that time. The NP ordered Resident #1 to be sent out for further evaluation. LVN A explained that no fall protocols were put into place because he had not moved much since his admission, and they were not aware that he was able to move on his own. In an interview with Resident #1's family member on 08/15/25 at 10:50 am, she stated that when she entered his room at 11am, he was laying on the floor facedown with his trach still connected to his throat. LVN A was immediately alerted and staff came inside the room and began assessments. She stated that she informed that staff amongst admission that Resident #1 could move and prior to him coming to the facility, he had done physical therapy at other facilities. EMS was called and he was transported to the hospital at 1:30 pm due to swelling above his left eyebrow. In an interview with CNA A on 8/15/25 at 11:53 am, she explained that she had worked with Resident #1 on 8/13/25 around 9:30 am to shower him. She stated that day, he was moving a lot. He would constantly move his legs up and down and he moved his head a lot. Resident #1 slept on an air mattress and before she left his room after his shower, she lowered his bed to the lowest position. She recalled that there was not a fall mat next to his bed because he was a new admit and she guessed nursing staff did not see a need for it at the time. In an interview with the Unit Manager on 8/15/25 at 12:16 pm, she stated that Resident #1 was nonverbal but he could follow people with his eyes. She explained that he was able to move his arms and legs and described them as jerk like reactions. She stated that since Resident #1 was admitted , he had begun to move a lot more and his mother had also noticed his increase in movement. On that day of the fall, she was called to his room (time unknown) by LVN A and noticed that he was face down on the ground. There was no blood and he was able to move his head. Initially there was no swelling, but after a few hours swelling began to appear on his left side. The Unit Manager recalled that the NP was in the building, but she could not recall if she assessed him immediately after the fall. The Unit Manager stated that the protocol after an unwitnessed depended on if it was a fall with an injury; then they would be sent out immediately. If there was an unwitnessed fall without injury, the facility's fall protocol was to notify the physician of NP and get an order to send them out. The surveyor asked that since Resident #1 had a history of head injuries, previously suffered from a stroke, and was found face down from an unwitnessed fall, would he be qualified to be sent out? Unit Manager took a long pause and said she was thinking and stated that he had no visible injuries but he was a special situation and if the NP was in the building, she would have grabbed her to come see. In an interview with the DON on 8/15/25 at 12:35 pm, she stated that she did not know when the NP assessed Resident #1, but she was informed by LVN A when he fell and she was informed when the swelling appeared. She stated that when LVN A noticed the swelling around 1-1:30 pm during neuro-checks and he was sent out afterwards. When the DON and Surveyor reviewed his orders, the DON confirmed that Resident #1 was on Aspirin, which was a blood thinner and the harm in not seeking emergency medical services post fall could be hemorrhaging or bleeding. She stated that no fall preventions were in place because Resident #1 was not able to move and she believed he may have fell on the floor due to increased alertness. In an interview with the NP on 8/15/25 at 1:30 pm, she stated that LVN A sent her a text message on 8/13/25 at 11:40 am but she did not see the message. She could not give a definite time but she stated that she entered the facility sometime between 12 pm and 2 pm to complete rounds. While she was there, LVN A sent her a second text message at 12:44 pm and informed her that Resident #1 had some swelling on his head post fall and she went in to assess him. The NP found a little induration on the left side of his temple and stated that because he was on blood thinners, she ordered him to be sent out because she was concerned about internal bleeding. She stated that if someone had a fall where they hit their head, whether witnessed or unwitnessed, it would be best practice to send them out for a CT scan. This was especially significant for Resident #1 because he had a suspected head injury and was on blood thinners at the time. NP also noted that when she assessed Resident #1 that day, he was notably more alert, was able to shake his head, and seemed to understand her in conversation. Observation on 8/15/25 at 2:57 pm in the hospital, Resident #1 was sitting in bed at a 90-degree angle and his eyes were bright and alert. He seemed to have a smile on his face and followed the surveyor around the room as she spoke to him. He was nonverbal but attempted to make grunts and groans in response to conversation. In an interview with the HSW (Hospital Social Worker) on 8/15/25 at 2:59 pm, she explained that Resident #1 was admitted for a fall on 8/13/25. She stated that his admitting diagnoses were interval acute bleeding to the left side of the head, and he had new chronic appearing left frontal sub [NAME] hematoma Internal bleeding to the side. HSW stated that in addition to that, he was currently being treated for sepsis and pneumonia, which was present upon admittance. Record review of the facility's policy titled Fall Management revised July 2024 displayed that:1. The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medication review, and receive orders as indicated.2. If the resident's condition warrants, the charge nurse will arrange for appropriate emergency services or hospital transfer in collaboration with the Physician/Physician Extender. The ADM and DON were notified on 8/15/25 at 7:10 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 8/16/25 at 12:30 pm:Plan of Removal: F684 Quality of CareDate: August 16, 2025 Immediate Action:According to the IJ Template, F684 Quality of Care, The facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-center care plan, and the residents' choices, in that: The facility failed to contact 911 after Resident#1 was found face down on the floor after an unwitnessed fall on 8/13/2025. Resident #1 was transferred on 8/13/2025 to the ER and remains in the hospital. Action: LVN A Was immediately re-educated by the DON on 8/15/25 on the facility's fall protocol and notification procedures, including the requirement to make direct verbal communication with the provider NP/physician for all significant changes.Responsible: Director of Nursing Completion: August 16, 2025 Action: August 15, 2025 Regional MDS Nurse and Director of Nursing audited all falls within the past 30 days to determine all care plans have appropriate interventions were in place. All care plans were confirmed to be up to date.Responsible: Regional MDS Nurse and Director of Nursing Completion Date: August 16, 2025 August 15, 2025 - All licensed nursing staffAction: Director of Nursing will educate all nursing staff on Fall Management, and Changes of Condition Policies and Procedures before the start of their next shift. The DON will educate all licensed nursing staff to ensure all residents receive appropriate and immediate care after an unwitnessed fall. The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medication review, and receive orders as indicated. The Director of Nursing to train on the proper protocols to take once a resident has a fall and if there is a delay in physician response. In the event of a witnessed or unwitnessed fall of a resident anticoagulants staff will immediately send out to ER 911. No staff will be able to work until they are educated and trained. Responsible: Director of Nursing Completion Date: August 16, 2025 Action: Ad Hoc QAPI conducted on 8/15/25 with Medical Director, Administrator, DON, & Unit Managers regarding IJ F0580 and F684.Responsible: Administrator/Director of NursingCompletion: August 16, 2025 August 15, 2025 - Facility Medical Director NotifiedAction Taken: The Medical Director was notified and provided the following protocol for unwitnessed falls:If the resident is not coherent and cannot reliably state whether they hit their head: Send to ER via 911 immediately.If the resident is coherent and reliably states, they did not hit their head:Proceed with: Appropriate assessments Neurological checks Vital signs monitoringIf any change in condition occurs later: Send to ER via 911.Head Injury Protocol for Residents on AnticoagulantsIn the event of a witness or unwitnessed fall, if the resident: Strikes their head, and Is currently on anticoagulant therapyStaff must: Call 911 immediately and send the resident to the emergency room (ER) for evaluation.The staff have received education on witnessed/unwitnessed falls of residents on anticoagulants that strike their head. The medical director protocol was not added to the policy instead we will keep the information included in our current fall management policy that states The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medication review including anticoagulants, and receive orders as indicated.Responsible: Administrator/Director of NursingCompletion Date: August 16, 2025 August 15, 2025 - Daily Fall Review and Care Plan UpdatingAction: The IDT Team will review all falls daily during the clinical morning meeting. The MDS Coordinator/Designee will update the care plan as needed. Designee/DON will monitor falls during weekends and after hours electronically in Point Click Care system and communicate with present licensed nursing staff.Responsible: DON/DesigneeCompletion Date: August 16, 2025 The Surveyor monitored the POR on 8/16/25 as followed: Review of an in-service titled QAPI 8/15/25: Notification of Change and Quality of Care documented that all nursing staff had been educated on physician escalation notification, all unwitnessed or witnessed falls with a strike to head should be sent out immediately, and the physician or extending physician should be notified immediately. Attendees including the ADM, DON, and Unit Managers. Review of the in-services dated 8/15/25 titled Education Change of Condition, Physician Escalation Protocol for Provider Notification, and Fall Management displayed that all nursing staff were educated. During interviews on 8/16/25 from 2:00 pm - 4:45 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-services. All staff stated that if a resident was experiencing a change in condition, the protocol would be to first assess the resident and if there was a deviation from their baseline, their NP or MD should be notified immediately. If the resident has interventions in place, nurses were to follow them or follow the orders given by the NP/MD. If the NP/MD is not available, 911 should be called so that the resident can receive a higher level of care. It was verbalized that the chain in notification would be that the NP would be notified first and if there was no answer, an attempt would be made to the MD, and the immediate scalation would be to call 911 and the ADM. All nurses should continue providing care until EMS arrives. Review of the Facility's QAPI Agenda, dated 8/15/25, reflected that the MD had reviewed and agreed with the plan. MD was interviewed and stated that a QAPI was held and the team developed a plan to address the issues of the IJs. LVN A was interviewed on 8/16/25 at 2:40 pm. She stated that she was in-serviced on fall management and escalation provider protocol. She said that if a resident has a fall, she was to contact the NP and MD, and if they didn't answer, she must call the administrator or EMS right away. The ADM and DON were notified on 8/16/25 6:05 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 (CR#1) residents reviewed for accidents and supervision. 1. The facility failed to ensure CR#1 received adequate supervision and assistance devices to prevent accidents resulting in CR#1 sliding out of bed to the floor sustaining a cut to the right eye and left thalamic bleed (a type of intracerebral hemorrhage) without intraventricular (inside the brain's ventricles) involvement. 2. CNA A failed to ensure two-person assistance was used to provide care to CR #1, who required total assistance with all ADLs, and resulted in CR#1 sliding out of bed to the floor. The noncompliance was identified as PNC. The IJ began on 08/11/2025 and ended on 08/12/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of experiencing serious injury, pain, hospitalization and death. Findings include: Record review of CR#1's face sheet, dated 08/08/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), dysphagia (difficulty swallowing), respiratory failure (when the lungs cant properly exchange gases causing abnormal level of carbon dioxide or oxygen in the blood), cerebral infarction (brain tissue dies due to lack of blood supply), unspecified hypoxia (low oxygen in the blood), and hypertension (high blood pressure), Constipation (difficultly passing stool) vitamin deficiency (too little of one or more of the essential vitamins in the body), gastroesophageal reflux disease (a digestive disease in which the stomach acid or bile irritates the food pipe lining), feeding tube (a device that delivers liquid nutrition directly to the stomach or small intestine through a tube), anticoagulant therapy (treatment that prevents or reduces blood clotting), tracheostomy (a surgical procedure that creates an opening in the wind pipe to help with breathing) and need assistance with personal care. Record review of CR#1's baseline care plan, dated 8/5/2024, revealed he was assessed as dependent on staff for all areas of ADL's. Record review of CR#1's revised care plan, dated 8/5/2025, revealed the following areas of concern: Focus: ADL Self Care Deficits: CR#1's has ADL selfcare deficits and is at risk for further decline in ADL functioning and injury AEB decline physical function.Goal: CR#1 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury the next 90 daysIntervention: Anticipate needs - provide prompt assistance. Encourage independent function as able Encourage resident to ask for assistance for ADL care as neededEnsure call light is within reach and answer in a timely mannerKeep daily preferred routine unchangedProvide (Total) assistance of (2 of support persons) for transfersProvide (Total) assistance of (1 of support persons) for bathingProvide (Total) assistance of (1 of support persons) for bed mobilityProvide (Total) assistance of (1 of support persons) for eating via peg tubeProvide (Total) assistance of (1 of support persons) for personal hygiene/groomingProvide (Total) assistance of (1 of support persons) for toileting/incontinent careProvide (Total) assistance of (1 of support persons) for upper/lower body dressingFocus: Bowel Incontinence: CR#1 has bowel incontinence related to:Goal: CR#1 will have no alterations in skin integrity related to incontinence or brief use through the review dateIntervention: Monitor for signs of discomfort or agitation that may indicate the need for toiletingPerform routine rounding to include incontinence care and brief changes. Record review of CR#1's nurses notes, dated 8/6/2025, revealed CR#1 had a change in condition: - Fall 8/06/2025 at 5:00 AMLocation of the Fall: Resident's room classification of the Fall: witnessed with Head Injury:What was the resident doing prior to the Fall:Resident AAOx1, nonverbal. Vital Signs Post Fall Event: Blood Pressure-122/68, Pulse-72.Resident was sent to the hospital. Record review of CR#1's, undated, hospital records revealed he was admitted to a local hospital on [DATE] with a cut to the right eye, swollen shoulder and was later diagnosed with left thalamic bleed without intraventricular involvement. Observation on 8/08/2025 at 12:00 PM of CR#1 at the hospital revealed CR#1 was in bed. He appeared to be asleep, he did not respond when his name was called. He was clean and without odor, he was observed with a raise to the right-side front of his head, he had swelling to the right shoulder. There were no other visible injuries. In an interview on 8/8/2025 at 12:05 PM, the hospital RN said the resident was admitted to the facility on [DATE] from the nursing home due to a fall. She said he had swelling to the right shoulder, a cut to the right eye and a raise to the right front of the head but she did not know if the raise to the front of the head was because of the fall or an old injury. She said the family mentioned an injury to the left hand, but she did not see any injury to the left hand on her assessment. In an interview on 8/8/2025 at 12:45 PM, the DON said LVN B called and told her CR#1 slid off the bed to the ground when CNA A provided care to him, 911 was called and they sent him to the hospital. She said during the investigation CNA A told her she provided care to CR#1 and did not ask for help and the resident slid out of bed to the floor and sustained a cut to the right eye. Further interview revealed the resident was new and the staff were not sure of his mobility status. The DON revealed if a resident had a tracheostomy, sacral pressure sore or total care, they needed 2 persons for transfers and incontinent care. She said CNA A's decision to provide care to CR#1 by herself instead of asking for help resulted in CR#1 having a fall with injuries and was hospitalized . She said CNA A was in-serviced on getting assistance when providing care for residents who were total care. She said in-service began the same day with Nursing staff, ensuring them, there should be two persons assist when providing care to residents who were new and mobility not known, tracheostomy, sacral pressure sore and total care with ADLs. In an interview on 08/08/2025 at 1:17 PM with CNA A, she stated she was providing her last incontinent care to CR#1 at around 5:00 AM and everyone was busy, and she decided to do it by herself. She said she turned CR#1 to his side, and he slid off the bed to the floor. She said she did not ask for help. She said when the resident fell to the floor, she called the nurse for help and he came immediately and assessed the resident, called 911 and the doctor, the DON and the family, and the resident was sent to the hospital. She said she worked with CR#1 earlier in her shift and she knew the resident was two-person assist because she was assisted by the nurse. She said she knew CR#1 was total care with ADLs, but she thought she could do it by herself since everyone was busy. She said she did not know he would slide off the mattress. She said she was immediately trained on transfer and two-person assistance with bed mobility and incontinent care. She said she would never attempt to transfer or provide incontinent care to any resident who was total care. In an interview with CNA T on 8/8/2025 at 2:05 PM, she said she worked the 6-2 AM shift. She said she was in-serviced on abuse neglect, transferring and having two staff assisting when providing incontinent care to residents who were total care with ADL and could not assist the staff, infection control and dignity. In an interview with CNA F on 8/8/2025 at 3:39 PM, she said she worked at the facility for 4 years. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care with residents who were total care with ADL and could not assist the staff. In an interview with LVN A on 8/8/2025 at 3:58 PM, she said she worked at the facility for 4 years. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care to residents who were total care with ADL and could not assist the staff for repositioning. In an interview with LVN C on 8/8/2025 at 4:37 PM, she said she worked the 2-10 shift. She said she was in-serviced on turning and reposition of residents, abuse neglect, transferring and have two staff to provide care to residents who were total care with ADL and could not assist the staff In an interview with MA/CNA J on 8/8/2025 at 4:47 PM, she said she worked at the facility for the last 2 months and she worked the 6 -2 PM shifts. She said she was in-serviced on abuse neglect, privacy, transferring with 2 persons when using the Hoyer lift and have two staff to provide incontinent care with residents who were total care with ADL and could not assist the staff. In a telephone interview on 08/08/2025 at 4:57 PM with LVN B, he said he worked the 10:00 PM - 6:00 AM shift on 8/6/2025 when the incident with CR#1 took place. He said he worked with CNA A that night and assisted her in changing CR#1 during the night. He said the CNA did not call him to assist her during her 5:00 AM rounds. He said when the CNA called for him the resident was on the floor. He said he immediately called 911, the doctor, the DON and the family and the resident was sent to the hospital. He said the resident had a cut to the right eye and he did not see any other visible injury. In an interview with MA B on 8/8/2025 at 5:00 PM, she said she worked at the facility for 2 years. She said she was in-serviced on abuse neglect, fall precaution, two staff with transferring and have two staff to provide care with residents who were total care with ADL and could not assist the staff with repositioning, and infection control. In an interview with LVN E on 8/8/2025 at 5:08 PM, she said she worked the 2:00 PM-10:00 PM shift. She said she was in-serviced on abuse neglect, two persons assist with transferring and providing care to residents who were total care with ADLs. She said she also was in-serviced on infection control and dignity. In a follow-up interview with the DON on 08/11/2025 at 11:41 AM, she stated CR #1's care plan should have been updated to reflect two staff were required for bed mobility/incontinent care. She stated CR #1 was very new to the facility and they were still assessing him, so the revision was missed. She said the MDS was going to do an audit and all persons who were total care they should be two person assist for bed mobility and they were going to update the MDS and care plans. In an interview with CNA N on 8/11/2025 at 4:17 PM, she said she worked the 2-10 PM shift. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff, resident rights, infection control and falls. She said if she was not sure if the resident was a two person assist, she would ask the nurse, look at the computer or call for help. In an interview with CNA O on 8/11/2025 at 4:20 PM, she said she worked the 2-10 PM shift. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff, infection control, and resident rights. In an interview with CNA P on 8/11/2025 at 4:25 PM, she said she worked the 2-10 PM shift. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff. In an interview with LVN G on 8/11/2025 at 4:45 PM, she said she worked the 2-10 PM shift. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff. In an interview with MA K on 8/11/2025 at 4:49 PM, she said she worked the 2-10 PM shift. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff. In an interview on 8/11/2025 at 4:55 PM with the Administrator regarding the PNC IJ she said it came about because the CNA did not ask for help to provide care to CR#1 and he fell and sustained injuries to his face and head. She said the aide was in-service and all staff were in-service on transfers and using two people when providing incontinent care and transferring residents. In a follow-up interview with the DON on 08/12/2025 at 11:30 AM, she said CR #1's care plan should have been updated to reflect two staff were required for bed mobility/incontinent care. She stated CR #1 was very new to the facility and they were still assessing him, so the revision was missed. In an interview with LVN K on 8/12/2025 at 2:43 PM, he said he worked the 10:00 PM-6:00 AM shift. He said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff and infection control. In an interview with LVN D on 8/12/2025 at 3:14 PM, she said she worked the 2:00 PM-10:00 PM shift. She said she was in-serviced on abuse neglect, two persons assist with transferring and providing care to residents who were total care with ADLs. She said she also was in-serviced on infection control and dignity. In an interview with LVN H on 8/12/2025 at 3:45 PM, she said she worked the 2 PM-10 PM shift. She said she was in-serviced on abuse neglect, transferring and always to have two staff to provide care for residents who were total care with ADLs and could not assist the staff. Record review of staff training record revealed they were trained on incontinent, transfer and ensure two staff assisted when incontinent care was being done. Record review of the facility's, undated, policy and procedure on Incident and Accident read in part .Introduction:Ensuring resident safety management, incident response, in a nursing facility requires a structured approach to risk management, incident response and regulatory compliance. Incident vs Accident* Incident: Unexpected or unusual event within the facility that potentially affects resident safety, well-being, or quality of care.* Accident: An unplanned and unforeseen event resulting in harm, injury, or damage to a resident, staff member, visitor or property.Types of incidents and Accidents:Falls: Any unintentional descent to the floor, including assisted falls.Fractures or bodily injury: Any incident resulting in injury requiring medical attention. Record review of the facility's in-services revealed CNA A (received written disciplinary warning and 1:1 education) and nursing staff were educated on 08/06/2025, 08/07/2025 and 8/8/2025 regarding two-person assistance for residents who were total care or if staff were unsure of their mobility status related to incontinent care. Record review of In-Service, dated 08/06/2025, revealed CNA A (CNA A received 1:1 education) and all other nursing staff were educated by the DON regarding demonstrating accessing and utilizing the Kardex on PCC (the facility's computer system). Record review of in-Service, dated 08/06/2025, 08/07/2025 and 08/08/2025 revealed all staff were educated by the DON and Administrator regarding Abuse and Neglect, transferring of resident and 2 person to provide incontinent care for resident. Record review of the facility's Ad hoc Qapi dated 8/7/2025 revealed:Findings: Certified Nursing Assistant performed incontinent care on a resident that required a two-person bed mobility.1.The resident does not currently reside at the facility. He is currently at the local hospital.2. Certified Nursing Assistance was provided one and one education of the Kardex and before providing care to review the Kardex and use appropriate supervision and assistance.3. 100 percent audit was completed by nurse management to ensure all resident Kardex had the mobility and transfer status present.4. Administrator provided educational in-service on incident accident/accident policies and procedures and abuse/neglect and exploitation.5. DON/designee provided education on the Kardex. Kardex Competency skills training check off completed for Certified Nursing Assistant, and nurses. 6. All training and education will be provided before the next shift including PRN staff. All information was reviewed with the Administrator, DON, Unit Manager, Medical Director, during the Ad hoc QAPI meeting on 8/7/2025 to review all findings.7. During the morning clinical meeting, accidents and incident will be review daily and at-risk meetings for trends with IDT team members brought to monthly QAPI. The noncompliance was identified as PNC. The IJ began on 08/11/2025 and ended on 08/12/2025. The facility had corrected the noncompliance before the survey began.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 residents (Resident #1 and Resident #2) reviewed for comprehensive care plans. The facility failed to ensure Resident #1 and Resident #2's comprehensive care plans included all care areas triggered on their assessments. This failure could place residents at risk of not receiving care and services specific to their needs. Findings include: 1. Record review of Resident #1's admission face sheet, dated 08/12/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included respiratory failure (occurs when the lungs can't properly exchanges), cerebral infarction (in a pathological process that results in an area of necrotic tissue in the brain), sepsis (immune response triggered by an infection), metabolic encephalopathy (a change in brain function), acute respiratory failure with hypoxia (a medical condition where the lungs cannot adequately oxygenate the blood), Diabetes Mellitus (high blood sugar), hypertension (high blood pressure) narcolepsy (chronic sleep disorder), chronic congestive heart failure (a condition where the heart doesn't pump blood as well as it should), right AKA amputation (above the knee amputation). Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 was coded as severely impaired for cognition skills for decision making, dependent on staff for ADL care, has a Foley catheter and frequently incontinent of bowel. Resident #1 was triggered for cognition, incontinence, pressure sore, activities, dehydration, feeding tube, psychosocial well-being, communication, nutrition and return to the community. Record review of the care plan, initiated 6/06/2025, revealed the care plan did not addressed cognition, activities, communication and returning to the community. 2. Record review of Resident #2's admission face sheet, dated 08/12/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included anemia (not having sufficient health red cells), neurogenic bladder (lack of bladder control), aphasia (a language disorder that affect communication), Parkinson (disorder of the central nervous system that control movements), dehydration (loss of body fluid cause by illness), hypokalemia (a blood level that is below normal in potassium), malnutrition (when the body lacks nutrients), dysphagia (difficulty swallowing foods or liquids), fracture (a break in bone), urinary tract infection (infection of the bladder), cognitive deficit (a brain function deficit that impact a person's ability to think learn and remember), lack of coordination (impaired balance), muscle weakness (decreased strength in the muscles), schizophrenia (disorder that affects a person's ability to think, feel and behave clearly) and falls. Record review of Resident #2's admission MDS, dated [DATE], revealed Resident #2 had a BIMS score of 03, which indicated she was severely impaired for cognition skills for decision making, dependent on staff for ADL care, has a Foley catheter and always incontinent bowel. Resident #2 was triggered for cognition, incontinence, pressure sore, activities, dehydration, falls, psychosocial well-being, communication and nutrition. Record review of Resident #2's care plan, initiated 6/06/2025, revealed the care plan did not address cognition, activities and nutrition. In an interview on 8/12/2025 at 2:18 PM, the DON said they did not have a MDS Coordinator. She said the corporate nurse was helping them and was doing a 100% audit to ensure all triggered areas on the MDS were captured on the care plan. She said they were going to try and ensure all triggered areas on the MDS were captured on the care plans to ensure residents care needs were addressed. Record review of the policy and procedures, dated March 2022, Care Plans, Comprehensive Person-Centered read in part .Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 6 hallways, (Hall 200) and Resident #30's room. The facility had live gnats in areas of the facility including Halls 200, and Resident #30's room. This failure could place residents at risk for decreased resident health, safety and quality of life. Findings included:Record review of Resident #30's Electronic Health Record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Bipolar, Acute Respiratory failure, Type 2 Diabetes, and Cognitive Communication Deficit. Record review of the Resident #30's Quarterly MDS revealed a BIMS score of 15, which indicates cognitively intact. Section GG of the MDS revealed the resident did not use any mobility devices and she required set or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral hygiene, Toileting hygiene, shower/bathe self, Upper body dressing, Lower body dressing, putting on/taking off footwear, and Personal hygiene. In an observation on 08/05/25 at 08:27am, approximately 12 gnats were observed on Hall 200. In an observation on 08/05/25 at 08:50am approximately 10 gnats were flying around Resident #30's room. In an interview/observation on 08/05/25 at 8:50am, Resident #30 said the facility had an issue with gnats. While interviewing Resident #30 approximately 10 gnats were observed flying in the resident's room. Resident #30 said there had been a concern with gnats for a while. Resident #30 reported pest control was observed at the facility in the past but reported pest control had never treated her room. She stated she eats lunch in the dining room. There was no food observed in the resident's room. In an interview on 08/05/25 at 9:06am, the Maintenance Director stated pest control treated the facility bi-weekly or weekly depending on the situation. He stated pest control was out on last week. The Maintenance Director reported he does get complaints occasionally from residents (specific names were not provided) about gnats and stated the last complaint was about 2 weeks ago and stated pest control had come out to treat the facility. The Maintenance Director stated Pest Control had treated the facility this week. In an observation on 08/05/25 approximately 4 live gnats were observed flying around in the facilities conference room. In an interview on 08/05/25 at 10:56am, the Administrator stated the facility had been having an on-going issue with gnats and reported it typically happens when it rains. She stated the staff had been educating families with bringing in live plants and informing them on how it increases the risk of gnats. She stated pest control comes to the facility monthly or as often as they need them to treat the facility. She stated if they have issues with pest, pest control usually comes out immediately. Record review of the facility's service inspection report revealed the facility was treated 08.04.25 . The facility was treated for American Roach, German Roaches, Gnats/Fruit/Crane, Spiders. The areas treated were the kitchen, laundry, break room and therapy room. Prior to 08/05/25, the facility was treated on 07/07/25. The facility was treated for House / Fruit / Blow / Flesh / Stable Flies, American Roach, Asian Roaches, German Roaches, Fire Ants, Little Black Ants, Nuisance Ants. The facility was not treated for gnats during this visit. Record review of the facility's pest control policy (Revised 06/2019), reflected Policy Statement: 1. It is the policy of this facility that the facility will maintain an effective pest control program to prevent or eliminate infestation of pests and rodents.

Based on observation, interviews, and record reviews, the facility failed to revise the comprehensive care plan for 2 (Resident #1 and CR #2) of 5 residents reviewed for care plan timing and revision. -The facility failed to revise Resident #1's care plan for a suprapubic catheter (tube inserted into bladder through incision in abdomen) after 3/26/25. -The facility failed to revise CR #2's care plan for severe contractures (shortening/hardening of muscles, tendons, and other tissue) after 5/19/25. This failure could place residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. The findings included: Record review of Resident #1's undated face sheet revealed an [AGE] year-old female who was originally admitted to the facility on [DATE], with the most recent admission of 3/14/25. Her diagnoses included respiratory failure (not enough oxygen in the blood), COPD (long-term lung disease), hypertension (high blood pressure), neuromuscular dysfunction of the bladder (nerves controlling bladder function are damaged), functional quadriplegia (unable to move arms and legs due to disability and not a spinal cord injury), TIA (mini stroke), dysphagia (trouble swallowing), tracheostomy (opening in neck for access to the windpipe), gastrostomy (opening into stomach from abdomen), dependence on ventilator (dependence on a machine to breathe), and heart failure (heart does not pump efficiently). Record review of Resident #1's admission MDS Assessment, dated 03/18/25, revealed a BIMS score of 14 which indicated normal cognition. The MDS revealed she had an indwelling catheter. Record review of Resident #1's Care Plan dated 2/25/25, revealed the resident was care planned for having urinary incontinence but not having a suprapubic catheter. Record review of Resident #1's physician orders revealed an order for a urethral indwelling catheter dated 3/26/25 by MD S. Record review of Resident #1's progress notes, dated 05/13/25 at 6:14 p.m., revealed the resident had a suprapubic catheter and the foley catheter was draining clear yellow urine. During an observation and interview on 6/12/25 at 2:30 p.m., Resident #1 was lying on her back in bed. She said she had a suprapubic catheter. The foley bag was observed hanging on the side of her bed. Record review of CR #2's undated face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE], with the most recent admission being 6/3/25. His diagnoses included osteomyelitis (bone infection), anoxic brain injury (brain infection due to loss of oxygen), dysphagia (trouble swallowing), sepsis (infection throughout body), pneumonia (lung infection), type 2 diabetes (body does not produce insulin or resists it), endocarditis (infection of the heart), epilepsy (seizures), dependence on ventilator (requires a machine to breathe), persistent vegetative state (awake but shows no signs of awareness or consciousness), respiratory failure (not enough oxygen in the blood), tracheostomy status (opening in neck for access to the windpipe), and gastrostomy status (opening into stomach from abdomen). Record review of CR #2's admission MDS Assessment, dated 5/12/25, revealed a BIMS score was not performed due to his medical condition. His cognitive skills for daily decision making were severely impaired. CR #2 was dependent on staff for all of his ADLs. He had an impairment in both extremities, on the top and bottom. Record review of Resident #2's Care Plan dated 9/27/24, revealed the resident was not care planned for his contractures. Record review of CR #2's progress notes, dated 5/19/25 from MD S, revealed the resident had contractures. Record review of CR #2's previous hospital records dated 5/25/25 from MD A, revealed he had contracted extremities. During a telephone interview on 6/12/25 at 12:16 p.m., CNA E said CR #2's right leg was contracted up to his chest and his left leg was contracted behind his back. During a telephone interview on 6/12/25 at 12:30 p.m., CNA B said CR #2's legs were contracted so that his right leg was crossed over his left leg, like he was sitting crisscrossed. During a telephone interview on 6/12/25 at 12:45 p.m., LVN D said CR #2's legs were really contracted, crisscrossed and turned to the right, while his chest turned towards the left. During an interview on 6/12/25 at 4:19 p.m., the MDS nurse said she was the one who created and updated the care plans for residents. She said she went through the admissions and updated as situations arose. She said she was the one who updated catheters and contractures on the resident's care plans. She said Resident #1's care plan was taken care of by a third party who handled all the Managed Care residents, and she did not know why the catheter was not on the care plan. She said she was going to do a 100% audit of all the residents with catheters to ensure they were on their care plans. The MDS nurse said she saw CR #2's contractures were not on his care plan that morning (6/12/25) and added it. She said the contractures should have been on the care plan before and she was going to do a 100% audit on all of the residents with contractures to make sure they were on their care plans. She said she did not think those two focuses (catheters and contractures) not being on the care plan would affect the residents or care because there was an order in the system, and it was on the MAR for the catheter and catheter care. Record review of the facility's policy and procedure on Careplan Revisions (Revised 5/2022) read in part: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents within the facility. The comprehensive care plan will be reviewed and revised every quarter, when a resident experiences a status change and as deemed necessary. Procedure for reviewing and revising the care plan is as follows: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The care plan will be updated with the new or modified interventions e. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. f. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs .

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #1) reviewed for infection control. 1. RT A failed to wash her hands or use hand sanitizer between gloves changes while providing Tracheostomy (Trach) care for Resident #1. 2. RT A failed to ensure she did not double glove in placed of hand hygiene while providing Tracheostomy Care. These failures could place residents at risk for spread of infection. Findings include: Record review Resident #1's face sheet, dated 03/05/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute respiratory failure with hypoxia (a condition where the lungs are unable to exchange oxygen and carbon dioxide properly, resulting in low oxygen levels in the blood), dependence of respirator (ventilator) status, hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high), diabetes (a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively, leading to high blood sugar levels), Chronic Obstructive Pulmonary Disease (a condition caused by damage to the airways or other parts of the lung), and Tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). Record review of Resident #1's care plan, dated 12/31/24, reflected a focus area that Resident #1 had a tracheostomy and was at risk for changes in secretions, infection, and respiratory distress. Record review of Resident 1's quarterly MDS assessment, dated 01/04/25, reflected a BIMS score of 15, which indicated cognition was cognitively intact. Section O- Respiratory Treatment- E1. Tracheostomy Care. During an observation on 03/05/25 at 10:59 AM revealed Trach Care was provided by RT A. RT A entered Resident #1's room and placed Trach supplies on the bedside table. RT A donned mask, gown, and gloves. RT A was observed donning another pair of gloves on top of the initial pair of gloves she already had on (RT A had 2 pair of gloves on). After suctioning Resident #1, RT A was observed removing the 2nd layer of gloves, and disposed of them. RT A was then observed opening a Trach care kit and putting sterile gloves on top of the initial pair of gloves she already had on. RT A was observed cleaning Resident #1's Trach site and doffing off after Trach care was completed and using hand sanitizer. Hand washing/ Hand sanitizer was not observed in between glove changes Trach Care. Resident #1's O2 Stat was monitored throughout Trach care and RT A engaged with Resident #1 throughout Trach care ensuring the resident was not in distress. During an interview on 03/05/25 at 11:30 AM with RT A, she stated she was not seen sanitizing her hands while in Resident #1's room because she had just sanitized them before leaving the nurses station prior to entering the room. She stated they were supposed to sanitize their hands before and after suctioning the resident. She stated she did not sanitize her hand because she worked with a clean pair of gloves at all times and that was her purpose of having 2 pair of gloves on at all times. During an interview on 3/05/25 at 12:57 PM, the DON stated hands should be washed or use of hand sanitizer used in between glove changes. She stated when trach care was being provided the staff were to sanitize or wash before care and to also let the patient know what was being done. She stated the staff were to use the Trach care kit with the sterile gloves. She stated staff were expected to sanitize or wash hands prior to beginning care, dispose of gloves, perform hand hygiene before putting on sterile gloves, dispose of gloves again and perform hand hygiene again. She stated she was unsure of why RT A used multiple pairs of gloves while providing care and stated it would have been appropriate for RT A to wash her hands or use hand sanitizer in between glove changes. She stated the risk of not performing hand hygiene was infection. Record review of the facility's policy on Tracheostomy Care, revised date of 11/2022, reflected, It is the policy of this facility that Tracheostomy care is performed aseptically for cleaning of the tracheostomy tube and stoma 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 . Procedures: 1. Review Orders for tracheostomy care (should contain the frequency & type of care) 2. Gather necessary equipment 3. Identify the resident, introduce self, and explain procedure to the resident. 4. Wash hands prior to setting up equipment. 5. Suction resident. 6. Remove drain sponge and disposable inner cannula. 7. Perform hand hygiene with soap and water. 8. Prepare new inner cannula by opening slightly 9. Open normal saline bottle and set aside 10. Open trach care kit 11. Aseptically DON sterile gloves 12. Aseptically place drape on surface and dump contents of kit 13. Place tray on the drape 14. Pour normal saline into tray (may use wound cleanser as indicated) 15. Place sponges / gauze into saline in the tray 16. With a non-dominant hand, pick up new inner cannula and with the dominant hand, replace inner cannula. (Or follow instructions below for non-disposable inner cannula) 17. Cleanse stoma with gauze / applicators 18. Cleanse trach phalange with sponges 19. Replace drain sponge 20. Change tie if soiled 21. NOTE: Monitor 02 saturation throughout procedure 22. Monitor the patient's response to the procedure. If any adverse reaction is noted, discontinue the procedure, and notify physician.

Based on observations, interviews, and record review, the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 77 residents (CR #1) reviewed for CPR. 1. RN A failed to call a code blue and obtain assistance from available staff when CR #1 was found unresponsive. This led to a delay of approximately ,d+[DATE] minutes before CPR was started on CR #1. 2. RN A initiated CPR with improper chest compressions and depth during CPR on CR #1 on [DATE]. 3. LVN A failed to place the mask over the resident's nose and mouth, ensuring a good seal. 4. Staff failed to ensure the crash cart had AED pads and was ready for use during CPR on CR #1. This led to a delay of approximately ,d+[DATE] minutes before CPR was started on CR #1. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 9:45 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level of actual harm that was not immediate jeopardy because all staff had not been trained on [DATE]. These failures placed residents at risk of experiencing worsening of condition, extended pain, and death from possible delays in the initiation of an emergency response and improper implementation of CPR. Findings included: Record review of CR #1's face sheet dated [DATE] revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. CR #1's diagnoses included respiratory failure, Crohn's disease (swelling and irritation of the tissues in the digestive tract), Asperger's syndrome (neurodevelopment disability that affects the ability to effectively interact and communicate with people), cirrhosis of the liver (liver damage from conditions such as hepatitis B or C, or chronic alcohol use), gastroesophageal reflux (condition in which stomach acid moves up into the esophagus, causing heartburn), pneumonia, and malnutrition. She was discharged to a medical examiner after she died on [DATE]. Record review of CR #1's 5-day MDS dated [DATE] revealed she had a BIMS score of 00 (severe cognitive impairment); CR #1 ambulated via wheelchair; and CR #1 was dependent for ADL's (eating, toileting, shower, oral hygiene, and dressing). Record review of CR #1's care plan meeting, dated [DATE] revealed the following in part: .[ CR#1] will remain full code. [CR #1] does not have a POA . Record review of progress notes dated [DATE] at 10:50 a.m. by MA A revealed the following: cant [can't] swallow notified nurse [RN A] Record review of progress notes dated [DATE] at 12:34 p.m. by RN A revealed the following in part: .Change of Condition Identified: leukocytosis (above the normal range of white blood cells) . [PCP] present and visited resident [CR #1] . What do you think is going on with the resident: Resident lab results show WBC 22.1. [PCP] present and visited resident. New orders received as follows: 1) CXR 1-V & UA w/ C&S 2) Ceftriazone (antibiotic that is used to treat many kinds of bacterial infections, including severe or life-threatening )1gm IV QD x7 days 3) May place midline for ABX therapy 4) Levothyroxine (used to treat hypothyroidism - underactive thyroid) 50mg PO QD (RP ) notified of new orders and gave verbal consent for midline placement. Physician Notified: [PCP], [DATE] 12:00 PM Record review of CR #1's progress notes dated [DATE] by RN A revealed the follow in part: [CR #1] was observed unresponsive sitting in wheelchair. [CR #1] was confirmed full code, transferred to bed, and CPR was called. 911 was called @1321 [1:21 p.m.] which EMS arrived to room shortly after. EMS continued life saving measures. [Family member] was notified of resident's condition [CR #1] was pronounced deceased @1351 [1:51 p.m.] per EMS personnel. Resident was last seen alive between ,d+[DATE]:30 [12:00 p.m. - 12:30 p.m.] during lunchtime sitting in wheelchair . Record review of CR #1's EMS Report dated [DATE] revealed: . Primary Impression: Cardiac - Cardiac Arrest . Call Received - 1:22 p.m. Dispatched - 1:23 p.m. On Scene - 1:24 p.m. At Patient - 1:42 p.m. Narrative: History - Nursing home staff stated they walked into the patient's room and found her unresponsive. The last time they saw . Assessment - On arrival, The pt was in bed in her room and nursing staff was doing very poor, slow CPR, and ventilating the pt on high flow oxygen via BVM . She was not conscious, not breathing, and without a pulse. There were no signs of rigor mortis. Her alive was one hour prior. The nursing home nurse states she has not been sick and does not know what could have caused it . Her airway appeared clear. Eyes appeared fixed, dilated, and non-reactive. Breath sounds: absent bi laterally. ABD: soft/nondistended. Skin: cool/dry. Rx/Treatment - Nursing home staff started CPR prior to arrival. 303 [EMS] arrived prior to 409 [FD ] and started ALS resuscitation. Upon contact, the nursing staff was doing low quality compressions and was corrected on proper rate and depth . After 20 minutes of high quality ALS resuscitation the family and POA called back and stated they wanted resuscitation terminated. Transport - The patient was not transported as resuscitation was terminated at 13:51 pm. Call complete. In service. Record review of RN A's cell phone call history dated [DATE] revealed 911 was called at 1:21 p.m. Record review of crash cart check list dated [DATE]st -18th 2024 revealed AED - function and ready. Observation and interview of the facility's crash carts, with the DON and LVN E, on [DATE] at 4:11 p.m. revealed it was located at the front 300 hall, approximately ,d+[DATE] yards away from the nurse's station. The AED was in a case on the outside of the crash cart, after unlocking case mild pitch siren and blue light. The code status binder was on the cart. There were no pads located in the AED machine, but pads were in a zipped side pocket of the bag the AED was in. No extra pads were observed in the drawers of the crash cart. A second crash cart on 100 hall was observed and had a pad in the AED machine and extra pad in the bottom drawer of the crash cart. The DON said LVN E was responsible for checking the crash carts daily. The DON said if a resident was found unresponsive, the staff should call out code blue, direct another staff to call 911, and verify code status to start CPR as soon as possible. She said she was not at the facility on [DATE]. She said she would have preferred for the AED to be used because it would instruct the staff what to do if there was no pulse or heartbeat. She said RN A was not able to locate the AED pads. The DON said RN A should have stayed with CR #1. She said he could have directed CNAs and Nurses to call 911, get the crash cart, which she thought he had done. She said this was a part of the delegation process during a code blue. LVN E said she checked the carts daily and remembered seeing AED pads. Interview on [DATE] at 9:11 a.m., with RN A said he worked the 6:00 a.m. - 2:00 p.m. on [DATE] when CR #1 expired. He said he was notified by CNA B who came and told him, CR #1 was unresponsive. He said he went to CR #1's room (on 500 hall) and checked her pulse and she did not have one. He said he left the room, went to get the crash cart (on 300 hall adjacent to the 500 hall). He said CNA B was left in the room with CR #1. RN A said on his way back with the crash cart, he looked at CR #1's code status in the binder on the crash cart and called 911. RN A said he left CNA B in the room with CR #1. RN A said when he returned to the room, CNA B assisted and placed CR #1 in the bed from her wheelchair. He said he did not yell out for help or code blue after CR#1's pulse was taken or instruct CNA B to get the crash cart. RN A said he told, CR #1's assigned CNA B, to get help. RN A said he placed the backboard under the resident. He said he attempted to use the AED and could not locate the pads. RN A said he started chest compressions. RN A said RT A and LVN A came in and assisted with the bag valve mask. He said he was not sure of the time when they both came in, but it was within a minute. RN A said he continued chest compressions until EMS arrived. He said he did not recall if EMS or the FD gave him direction on his CPR technique. He said he was CPR certified and was trained by the facility on the Code Blue protocol. He said code blue was called when a resident was unresponsive, without a pulse, and needed CPR . Interview on [DATE] at 9:55 a.m. with CNA B said she worked 6:00 a.m. - 2:00 p.m. on [DATE]. She said she had not worked with CR #1 before. She said she saw therapy worked with CR #1 in the morning when they took her for a swallow test at approximately 7:00 a.m. CNA B said she was working on the hall next to CR #1's room, when HK A came to tell her CR #1 was not okay. CNA B went to CR #1's room, saw her sitting in her wheelchair. CNA B said she touched CR #1's leg, and CR #1 did not move. CNA B said CR #1's eyes were open, and her head faced toward the hallway. She said she left immediately and notified RN A. CNA B said RN A went to CR #1's room, checked for CR #1's pulse, and left to get the crash cart. CNA B said she waited with CR #1 until RN A came back with the crash cart. CNA B said she could not remember how much time past, but she said it was approximately a few minutes when RN A returned to the room. She said RN A opened the AED and a siren started. She said, less than a minute RT A and LVN A came in to assist and she left out of the room. She said she did not see if RN A used the AED and did not see CPR performed on CR #1. She said EMS arrived quickly but could not remember how long it took. He said he was CPR certified . He said his CPR trained him to complete 30 chest compression and two breaths. In an interview on [DATE] at 12:58 p.m. CNA A said she had not worked with CR #1 prior to [DATE]. She said she recalled CR #1 had a swallow test around 7:00 a.m. on [DATE]. She said therapy assisted CR #1 with her meal. She said she saw CR #1 around 11:45 a.m. and assisted her with her lunch. She said CR #1 did not eat much. CNA A said she brought CR #1's roommate back to the room at approximately 12:30 p.m. CNA A said CR #1 was in her wheelchair looking out into the hallway. She said she saw staff running to CR #1's room and she stood at CR #1's door but left shortly after RN A and CNA A started to assist CR #1. She said EMS arrived approximately 5 minutes after the staff went in to assist CR #1. In a telephone interview on [DATE] at 1:47 p.m. PCP A said she saw CR #1 on [DATE] at approximately 10:00 a.m. She said CR #1's vitals were within normal limits. PCP A described CR #1 as chronically ill, lungs were clear, sounds reduced, heart was regular, very pale, and malnourished. She said there were no acute care issues. She said the b/p was on the low side but no interventions were needed. In a further interview, PCP A said when a code blue was called the staff should response as a team. She said the staff who found the unresponsive resident should yell out for help from the other staff by asking them the resident code status, get the crash cart, call 911, and immediately start CPR. She said if one staff completed all of the task, a delay in CPR could happen. In a telephone interview on [DATE] at 3:41 p.m. RT A said she was on another hall when she and LVN A were asked by (unknown CNA) to assist with CR #1. She said she could hear the AED siren as she ran down the hall. She said she did not hear anyone yell out code blue. She said she grabbed the O2 tank as she entered CR #1's room, LVN A grabbed the Ambu bag (manual resuscitator). She said LVN A placed the bag over CR #1's mouth without securing a tight seal. She said without a tight seal around the mouth and nose the resident would not get the full benefit of the manual breaths. RT A said she took over bagging CR #1 while RN A continued chest compressions until EMS took over. She said she did not remember if RN A said there were no pads for the AED or if she saw him search for them at some point and could not locate them. She said she saw a pulse oximeter on CR #1's finger but did not remember what the reading was. She said she did not remember if the paramedics educated RN A on the depth of his compressions. She said the facility had provided mock code blue trainings where the staff had to act out the code. She said she was CPR certified . She said a delay in CPR and use of the AED could negatively affect the resident. In a telephone interview on [DATE] at 3:48 p.m. LVN A said he rushed down with RT A to assist with CR #1. He was asked how he assisted, and he continued to repeat I did what needed to be done as a team. He later said he initially placed the Ambu bag on CR #1 and then RT A took over. He said RT A connected the bag to the oxygen, he said he did not know why, and he left before EMS arrived, to get the paperwork ready for EMS. He said he was CPR certified . In a second telephone interview at [DATE] at 8:59 a.m. PCP A said it should be a team effort when a code blue was called. She said the staff that found an unresponsive resident should have called out for help from several staff to bring the crash cart (which had the code status binder on it), get oxygen, call 911, and begin CPR. He should not have left the resident . In a telephone interview on [DATE] at 1:42 p.m. the EMS Supervisor said the verbiage low quality chest compression and depth indicated in the EMS Run sheet indicated the CPR provided for CR #1 did not get the full effect or benefit of the chest compression to aid in life sustaining efforts He said the chest compressions should be ,d+[DATE] inches as referenced by the American Heart Association. He said he would have to get permission for this state surveyor to interview the paramedics that responded to CR #1. Record review of American Heart Association dated [DATE] (https://cpr.heart.org/en/resources/what-is-cpr) revealed the following in part: Automated External Defibrillators (AED) AEDs can greatly increase a cardiac arrest victim's chances of survival . For healthcare providers and those trained: conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to-breaths. In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min and to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches . Hands-Only CPR consists of two easy steps: Call [DATE] (or send someone to do that) Push hard and fast in the center of the chest . About High-Quality CPR High-quality CPR should be performed by anyone - including bystanders. There are five critical components: Minimize interruptions in chest compressions, Provide compressions of adequate rate and depth . Record review of the facility's Policies and Procedures for CPR - Cardiopulmonary Resuscitation policy, revised [DATE] revealed, Policy The Facility will administer CPR per American Heart Association Guidelines and regulatory expectations for residents with a Full Code status, Procedure, In the event of a medical emergency 2. Check the resident for responsiveness. 3. Validate the resident's code status. a. If the resident is a Full Code, proceed with step #4. 4. Activate the Emergency Response System Code Blue and staff call 911. 5. Assess respirations/pulse simultaneously (within 10 seconds). a. If NO respirations (or only gasping) and NO pulse i. Start CPR. ii. Apply AED as soon as available and follow the prompts. iii. Perform cycles of 30 compressions and 2 breaths via ambu-bag. iv. Continue until EMS providers take over, the resident regains pulse, or receives a Physician Order to cease rescue efforts. 6. Document .Progress Notes . AED Considerations The Facility has an AED available for emergency use, is kept in a location easily accessible by staff, and is rescue-ready. Crash Cart Considerations Ensure the crash cart is ready for immediate use during a code situation . Conduct daily checks to ensure all items are present and in working order and document these checks on a log attached to the cart and regularly check . Ambu Bag Considerations Place the mask over the resident's nose and mouth, ensuring a good seal. Hold the mask with your thumb and index finger forming a C around the mask, while the other three fingers lift the jaw. An IJ was identified on [DATE]. The IJ template was provided to the Administrator and the DON on [DATE] at 10:10 a.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 6:57 p.m.: Allegation: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice. F678 CPR IJ Plan of Removal for F678 [DATE] According to the IJ Template: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice. The Administrator and DON notified the Medical Director of the IJ on [DATE] and held an ADHOC QAPI meeting to review the IJ template and POR . On [DATE], the Director of Nursing conducted a 1:1 education with RN A. Topic: CPR Policies and Procedures highlighting: assessing the resident, calling for assistance code blue which activates the staff to assist and expedites the 911 response, validating the code status by a quick glance of the Code Status Binder, and initiating CPR with effective chest compressions (compression rate of ,d+[DATE] and a depth of 2 inches, Ambu-bag use (providing a seal), and applying the AED for residents with a Full Code status. The DON initiated education on [DATE] with Nurses, and Respiratory Therapist on the CPR Policies and Procedures highlighting: assessing the resident, calling for assistance code blue which activates the staff to assist and expedites the 911 response, validating the code status by a quick glance of the Code Status Binder, and initiating CPR with effective chest compressions (compression rate of ,d+[DATE] and a depth of 2 inches, Ambu-bag use (providing a seal), and applying the AED for residents with a Full Code status. All Nurses and Respiratory Therapists will not be allowed to work their assigned shift until training is completed. Staff will verbalize understanding at of end of training session and further training will be provided as needed. Education will be provided in orientation for new hires. Completion date of [DATE]. The DON initiated education on [DATE] with CNA role and code blue situation. CNA will immediately report unresponsive residents to the charge nurse, can assist in announcing code blue and can respond with crash cart and AED to the CODE Blue site. CNA will not be allowed to worked their assigned shift until training is completed. Education will be provided in orientation for new hires. Completion date of [DATE]. The Regional RT and Clinical Team conducted a Mock Code on [DATE] with return demonstration with all staff on site during the 2nd shift. The RT and Clinical Team will conduct a Mock Code with return demonstration for the next 3 shifts with return demonstration to ensure understanding. The Regional RT and Clinical Team will conduct routine Mock Codes to ensure education compliance. Findings will be brought to QAPI and the facilities plan to maintain compliance will be updated as indicated. The facility will maintain compliance with professional standards by treating residents who are Full Code and unresponsive (no pulse) by: assessing the resident, calling for assistance code blue which activates the staff to assist and expedites the 911 response, validating the code status by a quick glance of the Code Status Binder, and initiating CPR with effective chest compressions (compression rate of ,d+[DATE] and a depth of 2 inches, Ambu-bag use (providing a seal), and applying the AED. The Facility will update the code status binder with OOH DNRs as DNRs are implemented. Residents without OOH DNR forms will be considered Full Code. The facility inspects and replenish crash cart daily and after code events by DON/designee to ensure crash cart is rescue ready. The Administrator reviewed the facility policy on [DATE] and no changes were required. The plan of completion is [DATE]. Monitoring of the plan of removal included the following: Record review of Education In-Service Attendance Record dated [DATE] - [DATE] revealed all nurses, CNAs (including RN A, LVN A) were provided education by LVN B - unit manager regarding nurses are responsible to ensure crash carts are restocked after code and CPR protocol. Record review of Education In-Service Attendance Record - Mock Code dated [DATE] -[DATE] (2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m., and 6:00 a.m. - 2:00 p.m.) revealed all staff (nurses, CNAs, therapy staff, hk, were provided demonstration and return demonstration education by the Resp. Therapy Manager regarding Resident found unresponsive - What are our duties? (attachment: Policies and Procedures for CPR - Cardiopulmonary Resuscitation policy, revised [DATE]) Mock Code o Initiator: discovered resident, check vitals, called for help, started chest compressions. o Announcer: was code announced overhead o Leader: was control taken and directives given o Recorder: was documentation initiated o PPW (paperwork): was direction given to start paperwork for transfer? (copy of face sheet, etc.) o AED: was the AED initiated when bought [brought] to the scene? o Compressions: was compressions started at discovery and continued until arrival of AED? o Ventilations: was oxygen delivery via Ambu setup and started when emergency cart arrived Observation on [DATE] at 1:30 p.m. of Mock Code Blue - regarding the CPR procedure, checking code status before initiating CPR, assessing resident's pulse before initiating CPR, initiating CPR on residents who are full code and are without pulse, not initiating CPR on residents with a faint pulse, and administering oxygen via Ambu bag . No concerns with the mock code. Record review of Mock Code Blue inservice dated [DATE] at 9:30 a.m. revealed all facility staff were educated by a Regional Respiratory Manager regarding checking the crash cart, stocking the crash cart, AED use/location, steps of CPR, crash cart key location, clean up after and restocking, roles of staff during an emergency situation (all staff), and a mock code blue. Record review of the facility's document Ad Hoc QAPI dated [DATE] revealed the interdisciplinary team met to discuss CPR, the crash cart, code statuses, staff roles, and the AED. Observation of the two facility crash carts on [DATE] at 1:54 p.m. revealed both were fully stocked and code blue ready, including new AED chest pads visible in the AED and extras in the drawers. Interviews were conducted on [DATE] - [DATE] with staff on all shifts (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. CNAs and Nurses) including the Administrator, the DON, RN A (morning shift), LVN A (morning shift), (morning shift), CNA A (morning shift), CNA B (morning shift), LVN C (evening shift), OT A (evening), Shower Tech A (morning shift), CNA C (night shift), CNA E (night shift) LVN F (night shift), LVN D (secure unit morning shift), RT A (morning shift) 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 of requirements, training material, and expectations related to code blue, restock crash cart and CPR protocol. The Administrator, the DON, were able to explain the importance of calling codes and using proper terminology when requesting assistance in the event of an emergency, prompt response to an emergency, retrieving the crash cart/AED, and appropriate implementation of the entire CPR process. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 3:01 p.m. 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 that were put into place.

Based on observation, interview, and record review, the facility failed to provide routine and emergency drugs and biologicals and 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 for 1 (Resident #1) of 5 residents reviewed for pharmacy services. -The facility failed to send Resident #1's insulin medications with him when he went out on pass/leave for two days. Resident returned back to the facility with a blood sugar level of 457.0 mg/dL. -The facility failed to complete the Medication/Release Receipt form for Resident #1 when he went out on pass/leave for two days. On 02/13/24 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/14/24, the facility remained out of compliance at no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This deficient practice could place residents at risk of not receiving the desired therapeutic effect of their medications, result in worsening or exacerbation of chronic medical conditions due to missed doses, and/or death. The findings included: Record review of Resident #1's Admission Record, dated 02/13/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar). Record review of Resident #1's Quarterly MDS assessment, dated 01/26/24, revealed a BIMS score of 15, indicating resident was cognitively intact. Further review of Section I - Active Diagnoses, Metabolic, I2900., revealed diabetes mellitus was marked as an active diagnosis. Section N - Medications, N0300., Injections, N0350., Insulin, revealed resident received insulin injections . Record review of Resident #1's undated physician orders, reflected in part .Lantus SoloStar subcutaneous solution pen-injector 100 unit/mL .inject 45 unit subcutaneously every 12 hours .start date: 01/30/24 .and Insulin Lispro (1 Unit Dial) subcutaneous solution pen-injector 100 unit/mL .inject 20 unit subcutaneously before meals .start date: 01/30/24 . Record review of Resident #1's Medication Administration Record, dated 02/13/24, revealed he missed 4 doses of his Lantus SoloStar and 6 doses of his Insulin Lispro when he was out on pass. Further review revealed he received 1 of 2 doses of his Lantus SoloStar and 2 of 3 doses of his Insulin Lispro before he went out on leave on 02/10/24. Record review of Resident #1's Blood Sugar Value, dated 2/12/24 at 16:57 (4:57 p.m.), revealed it was 457.0 mg/dL. In an interview on 2/13/24 at 12:45 p.m., Nurse A said she had been working at the facility for approximately one year. She said Resident #1 was a diabetic and had an order for insulin. She said she did not pull and send the resident's insulin with him before he went out on pass on 02/10/24. She said she did not think about it and said the resident was in a hurry to leave. She said she worked Friday, 02/09/24, Saturday, 02/10/24, and Sunday, 02/11/24 and did not receive a telephone call or any messages about his insulin not being sent with him. She said a medication list was not sent with the resident. She said if a resident was not sent home with their insulin medications, they could become hyperglycemic (high blood sugar in the bloodstream) or hypoglycemic (condition in which your blood sugar is lower than the standard range). In a telephone interview on 02/13/24 at 1:37 p.m., the DON said the Medication Release/Receipt form should have been completed by facility staff based on their policy . Observation and interview on 02/13/24 at 4:15 p.m., revealed Resident #1 was awake and lying in bed. He said he went out on pass/leave Saturday morning, 02/10/24, at approximately 8:30 a.m. and returned back to the facility on Monday, 02/12/24, at approximately 1:30 p.m. He said a staff member (name unknown) packaged up his medications and put them inside his bag. He said he did not see what medications they put inside his bag. He said the facility's van driver dropped him off at his family member's home which was an hour and a half away from the facility. He said when his family member and he noticed his insulin medications were not sent, his family member called the facility and was told (name unknown) that his nurse was on lunch, and someone would call back. He said no one ever called them back. In a follow-up interview on 02/14/24 at 2:13 p.m., Resident #1 said not having and taking his insulin medications while he was out on pass made him feel light-headed and said it made his stomach hurt. He said he thought about going to the hospital because of the way he was feeling but decided not to because he thought it was just him overreacting. He said when he returned to the facility on Monday, 02/12/24, he was feeling light-headed . On 02/14/24 at 2:26 p.m., an attempted telephone interview was made with Resident #1's family member but there was no answer, and the voicemail box was full. On 02/14/24 at 3:03 p.m., an attempted telephone interview was made with the facility's NP but there was no answer. A voicemail was left requesting a return phone call. Record review of the facility's Day Outings/Therapeutic Leave of Absence policy, revised 6/2019, read in part .4) Facility staff will complete the Medication Release/Receipt if appropriate for resident/legal representative signature . This was determined to be an Immediate Jeopardy (IJ). The Unit Managers were notified on 02/13/24 at 5:55 p.m. that an IJ was identified due to the above failures and the IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on 02/14/24 at 9:42 a.m. and included: [Facility Name] - IJ Plan of Removal for F755 2/13/2024 Allegation F755: Pharmacy Services The facility staff failed to follow their nursing policy and procedure Day Outings/Therapeutic Leave of Absence when Resident #1 went out on pass/leave for two days. The facility failed to provide Resident #1 his insulin medications when he went out on pass/leave for two days. Resident #1 returned from a leave of absence with family on 2/12/24 at 2:00pm. Resident's blood sugar was assessed by charge nurse on 2/12/24 @ 16:47 and was noted to be 457 and resident #1 received 20 units of Insulin Lispro for coverage. Resident #1's Nurse Practitioner was notified on 2/12/24 by the Unit Manager of 457 blood sugar and missed insulin doses while out on pass and no new orders were received. Resident #1's concern that he was not provided with his insulin while out on pass was brought through the grievance process and investigated by nursing leadership on 2/12/24. Counseling was provided to the charge nurse who was over Resident #1's care at the time he was given his medication and left the faciity on [DATE]. The investigation was completed on 2/13/24. Resident #1 was assessed by the Nurse Practitioner on 2/13/24 with no adverse effects noted and no new orders received. The Administrator notified the Medical Director of the IJ on 2/13/24. The Unit Manager initiated education with Charge Nurses on 2/13/24. Topics included: Leave of Absence Policies and Procedure and Leave of Absence Medication Release form. The Charge Nurse will ensure that residents going out on pass are provided scheduled medications for the time frame they're predicted to be out on pass (including insulin) and that the quantities of medications provided, and medications received back are documented on the release form. The Charge Nurse should provide education on medication instructions, side effects, and signs or symptoms of missed doses. Charge nurses will be educated before starting their next shift. New Hires (Charge Nurses) will receive education in orientation. Completion date 2/14/24. The IDT clinical leadership team will review residents who or on leave in the morning meeting for compliance with the leave of absence policies and procedures. Started on 2/13/14 and will be an ongoing practice. On 2/13/24 The Unit Manager reviewed all residents who went on a leave of absence for the past 7 days with no adverse findings noted. Review was completed on 2/13/24. The Administrator reviewed the Leave of Absence Policy and Procedure on 2/13/24 with no changes required. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 02/14/24 through 02/14/24. Monitoring of the POR included: During interviews on 02/14/24 between 10:53 a.m. and 3:10 p.m. with staff from all shifts, the following Nurses were able to verbalize an understanding of the Day Outings/Therapeutic Leave of Absence policy and procedures and steps to follow when a resident goes out on pass and requires their medications to be released: Unit Managers A and B and Nurses A, B, C, D, E, and F. During an interview on 02/14/24 at 10:53 a.m., the DON said in-service trainings were started on 02/13/24 and completed in-person and over the telephone. She said the staff who completed the in-service trainings over the telephone would sign the in-service sheet when they returned for assignment. During an interview on 02/14/24 at 1:26 p.m., Unit Manager B said during their morning meetings they would review which resident(s) who were on leave, their leave status, and if there were any changes. During interviews on 02/14/24 at 1:48 p.m., Unit Manager A said she completed a review on all residents who went out on pass in the past 7 days. She said there was 1 resident who went on a leave of absence and took her medications with them. Record review of Resident #2 who went out on leave of absence in the past 7 days was completed. The resident was not a diabetic and no concerns were found during review. Record review of Resident #1's progress notes, dated 02/13/24, revealed he was assessed, the NP was notified, and no new orders were given. His blood sugar was noted to be 457 upon return. NP went to the facility on [DATE] and rounded on the resident. Record review of Resident #1's grievance Concern Report, dated 02/12/24, revealed resident reported that his insulin medication was not sent home with him when he went out on pass. The investigation details revealed Nurse A said she did not provide the insulin medications to him. The findings on the facility's investigation included the following: Nurse A was educated, in-serviced, received 1:1 counseling, and the facility would provide his insulin when he goes out on pass. Record review of Resident #1's NP's progress note, dated 02/13/24, revealed resident was seen and assessed by the NP. The NP assessed Resident #1 for a follow-up on elevated blood sugars reported upon return to facility from therapeutic pass. NP obtained permission from the resident to send in an order for a new medication since he had a change in insurance and resident agreed. Record review of Education In-Service Attendance Records, topic OOP [out on pass] Medications, dated 02/12/24, revealed 6 nurse staff signatures. Record review of Education In-Service Attendance Records titled Medications Released, dated 02/13/24, revealed 11 nurse staff signatures. Record review of Education In-Service Attendance Record, topic Policy & Procedures, dated 02/13/24, revealed 15 nurse staff signatures. Record review of Education In-Service Attendance Record, topic Request for Pass Medication/Leave of absence, dated 02/13/24, revealed 11 nurse staff signatures. The Administrator was notified the Immediate Jeopardy (IJ) was removed on 02/14/24 at 3:23 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and based on the comprehensive assessment for 1 (Resident #87) of 8 residents reviewed for assessments. -The facility (RN A) failed to complete an assessment, incident report, neuro-checks, and facility monitoring requirements after Resident #87 was said to have had an unwitnessed fall. These failures placed the resident(s) at risk of harm for not receiving care and services. Findings included: Resident #87 Record review of Resident #87's face sheet dated 5/24/2022 revealed a [AGE] years old male, admitted on [DATE] and readmitted on [DATE] and the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #87's MDS dated [DATE] revealed a BIMS of 15 which indicated the resident was cognitively intact. Section J1800 did not indicate the resident had a fall history. Record review of Resident #87's care plan dated 5/19/2022 (last care plan review completed) revealed the following in part: Focus - I have had an actual fall with unsteadiness 11/14/2019 unwitnessed fall with no injuries, 2/9/2022 slide off the side of bed, 5/15/2022 suspected fall with bruising. Goal - I will resume usual activities without further incident through the review date. (target date 7/23/2022) Interventions - .Encourage resident to ask for assistance. Observe/document/report PRN x 72h MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. (date initiated 3/22/2022) Focus - I am at risk for falls r/t poor balance; unsteady gait (date revised 3/22/2022) Goal - My risk and injury potential will be minimized through the next review date. (revision date 4/25/2022). Interventions - Anticipate and meet my needs. (revised 1/15/2019) Be sure my call light is within reach and encourage me to use it for assistance as needed. I need a prompt response to all request for assistance Record review of facility nurses' note for Resident #87 written by RN A dated 5/15/2022 at unknown time (late entry for 5/14/2022) revealed the following: 5/14/2022 21:29 (11:29 p.m.) Nursing Note Late Entry: Note Text: This writer was informed of the recent incident of suspected fall to the resident. Nurse only heard the Rcs (RC X) and another Resident (Resident #10) talked about the fall. Nurse went into resident's (Resident #87) room to ask, resident denied fall. Nurse assessed patient from head to toe, no distress, discomfort or injury noted at the time of this assessment. V/signs checked; B/p--114/64, p-86, R-20. Resident asked to be changed, same done and given snack as requested. Resident in stable condition. In-coming Nurse (LVN P) notified to monitor resident. Record review of nurses' note (written by LVN P on - 5/15/2022 at 7:42 a.m.) revealed the following in part: .SBAR Summary: Vitals Signs: BP 121/79 - 5/15/2022 8:07 a.m. Position: Lying left /arm, P 64 - 5/15/2022 08:07 a.m. Pulse Type: Regular R 16 - 5/15/2022 8:07 a.m. Temperature 96.9 - 5/14/2022 8:09 a.m. Route: Axilla (armpit) Weight 172.6 lb. - (last taken 4/20/2022) O2 98.0 % - 5/14/2022 - Method: Room Air RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: suspected of fall with possible head injury due to new bruising to left torso and back of right thigh. Decline in cognitive baseline, temp 95.3 Additional Nursing Notes as applicable: Received orders from Dr. to send to hospital for CT scan . Record review of nurse's note (written by LVN P on 5/15/2022 at 9:27 a.m.) revealed the following in part: Resident #87 transported to hospital ER for suspected fall with possible head injury . Interview via telephone on 5/24/2022 at 11:37 a.m. with Resident #87's Guardian said he was told on 5/15/2022 by LVN P that Resident #87 was found on the floor and had vomited on 5/15/2022. The Guardian said Resident #87 was sent to the ER unresponsive. The Guardian said he was informed by the hospital staff that when Resident #87 arrived at the hospital he had bruising to his torso area. He said he last saw Resident #87 in April 2022 but could not remember the date. He said Resident #87 did not have bruising in April 2022. During this visit in April 2022, he said Resident #87 did have a rash in his groin area and complained about wait time for care needed. The Guardian said Resident #87 was impatient and wanted care immediately but this was talked about in his care plan. Interview on 5/25/2022 at 10:17 a.m. the ER RN said when Resident #87 arrived at the hospital emergency room he had a bruised bilateral abdomen (midline of the stomach area). The ER RN said the emergency room doctor said Resident #87 had a traumatic inquiry not consistent with a fall .injury to his pancreas which was not consistent with a fall. The ER RN said Resident #87 was currently intubated (insertion of a tube either through the mouth or nose and into the airway to aid with breathing). She said she Resident #87 had bruising on the sides of his torso and one spot on his back the size of a fist. She said the bruises that Resident #87 had occurred within the last 24-48 hours. Interview on 5/25/2022 at 11:07 a.m. with Resident #87's roommate (Resident #95) was attempted, and he was not able to answer questions or communicate what happened to Resident #87. Record review of Resident #95's Quarterly MDS dated [DATE] revealed his BIMS was a 3 which indicated he had severe cognitive impairment. Interview on 5/25/2022 2:56 p.m. with RN A said she had worked for the facility for approximately 2 months. RN A said she worked on 5/14/2022 from 2:00 p.m. - 10:00 p.m. She said as she was coming from assisting a resident with a fall, she overheard RC X say to Resident #10 that Resident #87 did not fall. RN A said she did not ask RC X and Resident #10 any questions and proceeded to Resident #87's room. RN A said she asked Resident #87 if he fell and he told her he did not. RN A said she completed an incontinent change and while doing so, she looked for injuries. RN A said she asked Resident #87 if he fell and she said he denied pain. RN A said she took Resident #87's vitals (signs checked; B/p--114/64, p-86, R-20) while he was in bed (she had this written in a person note book that she referred to during the interview). RN A said because Resident #87's vital were in normal range, he had no bruising and he said he did not fall. She said she disregarded protocol for unwitnessed falls based on Resident #87's response. She said when a resident had an unwitnessed fall, she had been trained to assess the resident, take vitals, check for pain, start neuro checks, complete incident report and follow the facility's fall management policy. She said the fall management policy was used to monitor if a resident had any change in condition which could be an indication of a decline in a resident's health. She said Resident #87 was sleep for the rest of her shift. RN A said she told LVN P to keep an eye on him (Resident #87). RN A did not provide an answer to why she said keep an eye on Resident #87 or what she meant. RN A said injuries or change in condition could present after the fall and may not show up immediately and that was why the fall management policy was used to monitor changes in the resident. She said she did not make any other notifications related to an unwitnessed fall for Resident #87. She said she later talked to Resident #10 on 5/16/2022 who said he picked up Resident #87 from the floor. She said RC X was the aide assigned to Resident #87 during her shift. Interview on 5/25/2022 at 12:00 p.m. with the DON, she said she was not told Resident #87's had unwitnessed fall on 5/14/2022 until 5/16/2022 after she reviewed the 24 hour-report and was told by RN C (worked 6:00 a.m. - 2:00 p.m. on 5/15/2022). The DON said she was aware Resident #87 was sent out to the hospital but was not aware of Resident #87's possible unwitnessed fall prior to being sent out. The DON said RN C told her when he went to Resident #87 room at the beginning of his shift he saw vomit on the floor, the resident was in bed, vitals were taken, and his temperature had dropped and was low (95.3). Resident #87 was sent out to the hospital. The DON interviewed LVN P (worked 10:00 p.m. 5/14/2022 - 6:00 a.m. 5/15/2022). LVN P said Resident #87 had no changes throughout the night. The DON interviewed Resident #10 (BIMS 8) and he told her that he helped Resident #87 from the floor. The DON said Resident #10 said he snatched Resident #87 from the floor from behind to help him up to the bed. The DON interviewed NA J (worked on 5/14/2022 2:00 p.m. - 10:00 p.m.) and he told her Resident #10 said he picked up Resident #87 from the floor and put him back in the bed. The DON said NA J told her he did not report it to the nurse. The DON interviewed RC X. The DON said she was told by RC X that Resident #10 said he picked up Resident #87. The DON said the facility's policy on fall management was not followed. The DON said Resident #87 should have had neuro checks that would have been followed by a physical assessment to monitor for any change in condition that could detect injuries or change in mental status. The DON said a full and documented assessment should have been completed since there was a possible fall. The DON said there could be a delay in care without the assessments being completed. Interview on 5/25/2022 at 4:17 p.m. with NA J (temporary nurse aide) said he worked on 5/14/2022 on the 2:00 p.m. -10:00 p.m. shift. NA J said he was not assigned to Resident #87. NA J said Resident #10 approached him in the hallway and said he had helped Resident #87 from the floor back into his bed. NA J said he went to Resident #87's room, pulled back the covers to see if the resident had any bruises. NA J said he did not see any visible bruises and went back to tell Resident #10 that he should not help a resident off the floor. NA J said he did not report the possible fall of Resident #87 to a nurse because he was busy doing something, did not see the nurse on the hall and forgot. NA J said the nurse on duty was RN A. NA J said he had been trained that if a had resident has a fall, then he should have reported it to the nurse so they could start their assessment. NA J said the nurse should check the resident for injuries, take the resident's vitals, and monitor the resident every 15-30 minutes and let the next nurse know. NA J said if a resident was not monitored after a fall it could lead to injuries that were not detected. Interview on 5/26/2022 at 9:35 a.m. LVN P said he worked the 10:00 p.m. - 6:00 a.m. shift on 5/14/2022 - 5/15/2022. He said he completed shift change with RN A. LVN P said RN A did not inform him of a fall for Resident #87 or to monitor him. LVN P said RN A informed him of another resident who had a fall. LVN P said he completed the facility fall management protocol which was continue the neuro checks that had been started by RN A, but he had not been told to complete neuro checks for Resident #87. LVN P said the fall management protocol is was is started to assess the resident for injuries, check for pain, initiate neuro check to monitor a change in condition, document the incident and inform the next shift. LVN P said the protocol was to ensure if there is was a decline in the resident's health then it is was detected, and they receive the care that was needed. LVN P said during his shift he rounded and did not see bruising on Resident #87. LVN P said Resident #87 kept his overhead light on throughout the night. LVN P said he brought water to Resident #87. LVN P said there was no other interaction with Resident #87 and last saw him at the end of his shift around 5:30 a.m. LVN P said he did not see vomit in his room. LVN P said the fall management protocol should have been started if a resident said they picked up another resident from the floor and be treated as an unwitnessed fall. Interview on 5/26/2022 at 9:50 a.m. with RC X said she worked a double shift from (5/14/2022 at 2:00 p.m. until 5/15/2022 at 6:00 a.m.) RC X said she clocked in at 2:35 p.m. and clocked out at 5:45 a.m. RC X said she worked with Resident #87 on the day shift and was assigned to him. RC X said Resident #87 had no problems during her day or night shift and provided normal care for him like incontinent changes and meal services. RC X said between 7:30 p.m. and 8:00 p.m. on 5/14/2022 she said Resident #10 said Resident #87 had fallen and he picked him up from the floor. RC X said Resident #10 was a strong able body man and would be able to pick up Resident #87. RC X said she told RN A that Resident #87 fell . RC X said RN A went to check on Resident #87 but RC X did not stay to see what RN A did. RC X said later in the evening she was asked to work a double shift around 9:30 p.m. and RN A asked her if the incident should be written up. RC X said she did not answer RN A. RC X said RN A should know the fall protocol. RC X said RN A should have assessed the resident physically, started neuro checks, monitored the resident for change in condition, documented on the neuro checks form and in PCC and advised the next nurse of the neuro checks that needed to continue. RC X said Resident #87 slept throughout the night and she last remembered checking in on him around 2:45 a.m. where he was asleep in bed. RC X said she did not inform the nurse on the next shift (RN C) of Resident #87's unwitnessed fall because that was RN A's job. RC X said she was to inform a nurse if a resident had a fall. Resident #10 Record review of Resident #10's face sheet dated revealed at [AGE] year-old male admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #10's Quarterly MDS dated [DATE] revealed he had a BIMS of 8 which indicated he was moderately cognitively impaired. Further review of Section C1310 revealed Resident #10 had no evidence of acute change in mental status, no evidence of difficulty focusing, no evidence of disorganized thoughts. Interview on 5/26/2022 at 10:34 a.m. with Resident #10 who said he heard Resident #87 hollering and yelling (not able to give a specific day and time). Resident #10 said it was a little over a week ago when he helped Resident #87 from the floor back into his bed. Resident #10 said when he heard Resident #87 yelling for help, he went towards Resident #87's room. Resident #10 said he was sitting in the common area of the hall 400 which is halfway down the hall. Resident #10 said his room was a few doors from Resident #87. Resident #10 said when he arrived at the room, Resident #87 was somewhat on his knees with his head under the bed and his wheelchair on the back of his legs. Resident #10 said he moved the wheelchair and attempted to pick up Resident #87 from the front with his arms under Resident 87's armpits. Resident #10 said he became weak and let Resident #87 back down and then picked him up from behind (described like the position a person would be in if giving the [MEDICATION(S)] maneuver). Resident #10 said he then laid him face down on the bed. Resident #10 said Resident #87's left arm was stuck under him and he helped him to free it. Resident #10 said he told NA J that he helped Resident #87 from the floor and later NA J came to his room and told him not to help a resident up from a fall and tell a staff. Interview on 5/26/2022 at 11:49 a.m. RN A said she should have called the physician and made notification immediately to the RP, DON and the oncoming nurse but since she saw Resident #87 in the bed, and he denied he fell she did not go further with the fall management protocol. Interview on 5/27/2022 at 10:45 a.m. the District Director of Clinical Services said she started on 5/10/2022 with the facility. She said she had not been able to facilitate trainings or in-services yet. She said her expectation after an unwitnessed fall was for a nurse to start the fall management protocol. She said the fall management protocol included the physical assessment for injuries, timely neuro check follow-ups, incident report, SBAR, skin assessment, and pain assessment by the nurse. She said if the neuro checks are not completed then a change in condition for the resident could be missed and result in a resident's decline and place the resident at risk for further decline or injury. She said even if the resident appears alert and oriented during the initial assessment, but it was said there could have been a fall then she expected it to be treated like a fall. She said the DON reviews the 24-hour report daily and falls are discussed in daily morning meetings. She said the DON is responsible for the training of staff on the fall management protocol. She said they use skill checks to ensure staff are following protocol. She said RN A had worked for approximately 2 months and her orientation and skills had been checked off for fall management. Record review of Resident #87's hospital records dated 5/15/2022 revealed the following: brought in from nursing home today. Patient found to be hypothermic (lower body temperature than normal body temperature) at 88 degrees Fahrenheit .vomiting in the ER .Patient had total body CT scan for trauma evaluation which revealed findings concerning for bowel contusion (bruising), left lateral chest wall and pulmonary contusion (bruising), and soft tissue contusions (bruising) left lateral hip and buttock. Neurological - Awake, tired appearing very weak Notes: .found down on floor at a skilled nursing facility, suspected traumatic fall, presenting with multiple contusions visible on the left chest wall with severe abdominal guardian/discomfort on palpation (by touch). Record review of witness statement from NA J dated 5/16/2022 revealed the following in part: NA J said Resident #10 told him that he picked up Resident #87. NA J said he went to check on Resident #87. NA J said [Resident #10] was in the bed and didn't notice any changes. NA J said he did not report the fall to a nurse. Record review of witness statement from LVN P dated 5/16/2022 revealed the following in part: LVN P said on the off going nurse (RN A) told him about a fall for a resident but it was not Resident #87. Record review of witness statement from RC R dated 5/16/2022 revealed the following in part: RC R said she went into Resident #87's room on 5/15/2022 to provide incontinent care at the beginning of her 6:00 a.m. - 2:00 p.m. She said she noticed a bruise on his back and then she notified RN C. Record review of witness statement from the DON dated 5/16/2022 revealed the following in part: The DON said Resident #10 stopped her in the hallway. The DON said Resident #10 described Resident #87 physical and ethnic characteristics and said he put him back in the bed. The DON said Resident #10 said I heard a yell and got up to go check. Resident #10 said Resident #87 was on the floor with his right knee between the wheelchair and the bed . Resident #10 said he tried to untangle Resident #87's leg .Resident #87 said he snatched him up from the front Resident #10 said he got weak and then snatched him (Resident #87) up from the back and got him (Resident 87) back in the bed. Resident #10 said he told the boy with the gold hair and earring (later identified as NA J) that he picked up Resident #87. Resident #10 described RN A to the DON as a nurse having her skin color. Interview on 6/25/21 at 4:40 p.m. with the Administrator, he said RN A should have assessed Resident #1 immediately after she though there was an unwitnessed fall, notified the physician, DON and the resident's responsible party. The Administrator said RN A should have documented the incident on an incident report and in the nurse's notes. The Administrator said RN A should have updated the next shift at shift change to ensure the resident was monitored. The Administrator said it was important to notify the physician after a fall for further care instruction the physician could have had. The Administrator said after an unwitnessed fall neuro checks were required to ensure there was not a change in condition. The Administrator said the protocol and policy was to call the DR, NP RP and to start the neuro checks, document in notes and incident reports. The Administrator said RN A did not tell us, and I was not aware of Resident #1's fall until 6/22/21. The Administrator said the DON is responsible for Record review of Resident #87's Skin- Head to Toe Checks dated 5/16/2022 at 8:00 a.m. by RN C revealed the following in part: Skin Integrity: New Bruises Site: Chest, right gluteal fold Record review of Resident #87's SBAR dated 5/15/2022 at 7:42 a.m. by RN C revealed the following in part: Mental Status Changes - Increased confusion, decreased consciousness GI/abdomen - Vomiting Assessment: Suspected of fall with possible head injury due new bruising to left torso and back of right thigh. Decline in cognitive baseline, temp 95.3 Record review of facility policy Fall Management (revised on 7/2017) revealed the following in part: Policy The facility will assist each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision . Falls defined: .regarding falls state that a fall is defined as unintentionally coming to rest on the ground, floor or other lower level . Clarification: The presence or absence of a resultant injury is not a factor in the definition of a fall. A fall without injury is still a fall. When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there . Record review of facility flow chart Fall Management System (copyright 2017) revealed the following in part: Resident Fall: Complete Documentation: Event reporting/Risk Console Start IDT post fall review SBAR communication form 24-hour report Neuro checks .

Based on observation, interview and record review the facility failed to ensure that residents received the necessary treatment and services, to promote healing, prevent infection for 1 of 3 residents (Resident #61) reviewed for pressure ulcers, in that: -Resident #61 was not provided an air flow mattress as prescribed per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could affect residents with wounds or who are at risk of developing wounds by placing them at risk of infection, a decline in health, pain, and/or hospitalization . Findings included: Resident #61 Record review of the face sheet for Resident #61 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #61's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #61's admission MDS assessment dated [DATE] revealed a BIMS of 11 out of 15 indicating she was moderately impaired cognitively. Further review of Section M revealed Resident #61 was identified for being at risk for developing pressure ulcers/injuries. Record Review of Resident #61's care plan initiated 3/10/21 read in part . Focus: Resident has Potential/Actual Skin Issues . Goals: Resident's skin will remain intact without signs of breakdown by next review date . Interventions: Provide wound care/preventative skin care per order . Record review of Resident #61's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Sacrum - apply [MEDICATION(S)] and leave open to air dry with an start date of 3/23/21. Record review of Resident #61's paper chart on 4/21/21 at 10:55 a.m. revealed no handwritten DC orders for the air mattress. Record review of Nurses Notes dated 4/16/21 at 1:26 p.m. read in part . Skin/Wound Note . Late Entry: Note Text: This nurse enters residents room to apply barrier cream as ordered Resident states my bottom hurts a lil more today upon assessment noted more redness to excoriated . Record review of Resident #61's electronic record revealed she was moved from the COVID-19 unit on 3/31/21 to her current room. The air mattress was not moved from the COVID-19 unit and Resident #61 was not provided an air mattress in her room. Resident #61 did not have an air mattress per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #61's weekly wound assessment notes by Wound Care A revealed the following: 3/10/21: Stage II sacrum (.5 cm x .5 cm, .5 cm x .5 cm, .5 cm x .5 cm, .2 cm x.2 cm). Resident #61 had an air mattress . 3/16/21 - Excoriation - air mattress. 3/24/21 - Excoriation - air mattress. 4/12/21 - Excoriation - No air mattress. 4/16/21 - 7 cm x 4 cm x.1 cm - No air mattress. Resident (#61) complained of pain to buttock. Right gluteal Fold - Pressure (redness noted wound bed red/black eshcar [dark, crusty tissue at either the bottom or the top of a wound] intact surrounding skin has drainage noted) Record review of Resident #61's wound care doctors notes dated 3/15/21 revealed the following: 3/15/21 Wound status: Not healed Plan of care: Apply [MEDICATION(S)] oxide No measurements 4/19/21 Wound status: Not healed Stage : 3 Plan of care: multivitamin with minerals, vitamin C, [MEDICATION(S)] and protein supplements Measurements: 7 cm length, 3.5 cm width, .1 cm depth Wound orders Wound #1 Left Buttock: Cleanse wound with normal saline. Wound Dressing: Apply Alginate, Cover wound with dry absorptive dressing. Change dressing daily. Pressure relief/offloading: Air mattress, reposition per facility protocol, off-load wound Wound #2 Right Buttock: Cleanse wound with normal saline. Wound Dressing: Apply Santyl (collagenase), Apply Alginate Cover wound with dry absorptive dressing. Change dressing daily. Pressure relief/offloading: Air mattress, reposition per facility protocol, off-load wound Observation and Interview on 4/20/21 at 8:55 a.m., Resident #61 was resting in bed. Resident #61's was lying in bed and did not have an air mattress. She said she had a wound on her bottom. Observation on 4/21/21 at 9:50 a.m., revealed Resident #61 did not have an air mattress. Interview on 4/21/21 at 9:57 a.m., Unit Manager B said she was not sure what type of bed Resident #61 was supposed to have. Unit Manager B reviewed the resident physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Unit Manager B said to ask the wound care nurse. Unit Manager B said the wound care nurse is responsible to ensure residents have the equipment prescribed in their physician orders. Interview on 4/21/21 at 10:09 a.m., Wound Care Nurse A said Resident #61 had a current stage 3 wound in the middle of her buttock. She said Resident #61 was admitted to the facility on the COVID-19 positive unit in March with a stage 2 that healed while she was on the COVID-19 unit. Wound Care Nurse A said the resident was on the air flow mattress while on the COVID-19 unit and moved to her current room. Wound Care Nurse A said the air mattress was sent back to the vendor because the facility had a practice that equipment did not move from the COVID-19 unit to the non- COVID-19 halls. Wound Care Nurse A said she did not think Resident #61 needed the air mattress after she moved from the COVID-19 unit because the wound healed and for a stage two or less an air mattress was not used. The Wound Care Nurse reviewed the census and Resident #61 was without an air mattress for 20 days. She said the resident did not have the air mattress after being moved from the COVID-19 unit to her current room. Wound Care Nurse A said Resident #61 did not have a discontinue order for the air mattress. Wound Care Nurse A said she is trained to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound Care Nurse A said she asked the central supply staff to order an air mattress last Thursday or Friday, after Resident #61 complained of a little more pain to her buttock. She said she told this to central supply because she said the Wound Care Doctor would want the air mattress in place. She said the Wound Care Doctor staged the pressure wound at a stage 3 on 4/19/21. Wound Care Nurse A said if the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 4/21/21 at 10:23 a.m., the DON said Resident #61 was admitted with a stage 2 pressure wound and was on an air mattress on the COVID-19 unit. She said Resident #61 moved from the COVID-19 unit and the air mattress would have been sent back to the vendor because they do not take any equipment from the COVID-19 unit to the non-COVID-19 halls. She said all orders that are active for Resident #61 should be in place and followed. The DON said it should have been communicated to the central supply staff to order another air mattress for Resident #61 to have in her current room. The DON said it is the responsibility of the nursing team to ensure Resident #61 had the air mattress per her physician orders. Interview on 4/21/21 at 10:40 a.m., the Central Supply Clerk said she is responsible for sending back equipment that was used on the COVID-19 positive unit. She said equipment used on the COVID-19 positive unit is not used on the non-COVID-19 halls. She said she did not remember who told her but she was told to send back Resident #61's bed to the vendor. She said she did not have access to any resident physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 4/21/21 at 11:21 a.m., The Wound Care Doctor said Resident #61 had a current stage 3 pressure wound to the middle of her buttock. He said he did not discontinue Resident #61's air mattress. He said even if the wound was resolved he would not discontinue the mattress because the risk of future pressure ulcers would remain. Wound Care Doctor said Resident #61's wound was not resolved. Wound Care Doctor said Wound Care Nurse A should have clarified with him before she discontinued the air mattress for Resident #61. Interview on 4/21/21 at 12:40 p.m., the DON said she reviewed Resident #61's record and there was not an order to discontinue her air mattress. The DON provided a policy titled Sava Standard Support Surface. The DON said it had a flow chart that for a stage two or lower an air mattress was not used. The DON was asked if this policy would cancel a physicians order and she said No. Record Review of SavaSeniorCare Standard Support Surface Algorithm dated 2015, revealed a flow chart, read in part . High Risk of presence of Pressure Ulcers Braden Score: 13-18 . Stage I, Stage II . Moisture management required? . After 30 days, re-evaluate patient for continued need; stepdown surface or buyout of current surface . NO . facility owned foam mattress . if wound not healing . P.R.O. Matt Plus with Control Unit .YES . DermaFloat Low Air Loss* .*use product indicated or apropriate substitute of equal of better features content and specifications . Interview on 4/21/21 at 12:44 p.m., CNA K said she is a shower tech. She said she would notify the nurse if a resident has a change in their skin. She said she could not remember if Resident #61 had a pressure wound. She said Resident #61 did not have an air mattress but was not aware that her orders required her to have one. She said she did not see Resident #61's skin yesterday since the resident did not want to take a shower. Observation and Interview on 4/21/21 at 1:25 p.m. with Wound Care Nurse A, Resident #61 was lying on an air mattress that had not been fully inflated. Wound Care Nurse A said the resident was just transferred onto the air mattress. She uncovered the wound to Resident #61's buttocks and noted open areas on the left and the right mid buttocks. The total diameter of the area was approximately 3 cm x 3cm. The were several open areas which appeared to be maceration from moisture that had worsened. Interview on 4/22/21 at 10:03 a.m., Unit Manager B said it is a team effort with her and the wound care nurse to ensure residents have what is ordered based on their physician orders. She said she or the wound care nurse would usually tell the central supply clerk to order equipment like an air mattress. She said she did not ask the central supply clerk to order an air mattress for Resident #61. Interview on 4/22/21 at 11:49 a.m., the Administrator said the nursing staff are responsible to ensure all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 4/22/21 at 2:06 p.m., Wound Care Nurse A said if she would have needed the mattress, and because Resident #61 had excoriation after she was moved that she did not feel that the resident needed the air mattress. She said she did not clarify with the wound care doctor on whether Resident #61 should have kept the air mattress. She said and air mattress is used for stage 2 or higher. Wound Care Nurse A said a pressure wound never goes away. Wound Care Nurse A said there are times when a resident could have an air mattress and there was not an open pressure wound. She said a resident could be prone to pressure wounds and then prevention measures are put in. She said she worked this past weekend and she did treat Resident #61 with barrier cream. She said Resident #61 said she had pain and she said she told the resident that the wound could be tunneling. Wound Care Nurse A further described the wound, it was still excoriated on the left and right buttock and had more opening. Wound Care Nurse A was shown a policy provided by the DON titled Sava Standard Support Surface and she said she had never seen or been trained on the document. She said the policy explained that if a resident had a pressure wound of two or below , then the resident did not require more than a regular bed. She further said she is trained to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 4/23/21 at 2:03 p.m., the Medical Dirirector said she did rounds weekly and checked the standards of care. She said her expectation was for nursing staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said if Resident #61 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of facility policy Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2017) read in part . Orders given by a physician . must be accepted by a licensed nurse . the facility will not allow the delegation of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of facility policy Skin Management (rev. July 2017) read in part . Appropriate prevent surfaces (e.g., beds . etc.) will be implemented for residents identified at risk . The nurse will initiate treatments, interventions, . in a timely manner .'

Based on observation, interview, and record review, the facility failed to ensure a safe and accident free environment for 1 (Resident #1) of 2 residents reviewed for accidents and supervision, in that: -Resident #1 feel from bed while bring provided incontinent care but CNA A. -Resident #1 was transferred to a local hospital with a cheek and lip laceration. This failure affected one resident and placed 46 additional residents who were dependent of two persons assist for transfer and bed mobility for the risk of fall. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year old female with a facility admission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04 which indicated the resident had severe cognitive impairment. The MDS further revealed Resident #1 required extensive assistance with two persons physical assist for bed mobility, transfer, dressing and toilet use. In an observation with Resident #1 on 02/28/2017 at 09:30 a.m. revealed Resident #1 lying on her bed with no acute distress noted. She had an abrasion to the left of her cheek, laceration to lip and blood stains on her lower chin area. Resident #1 was non-verbal. Record review of Resident #1's Care revealed the following care plans dated 02/24/2017 with a revision date of 02/28/2017: -Risk for falls as evidenced by cognitive impairment and physical impairment. Interventions: Dignity will be maintained, resident will not experience falls or injuries from fall. Continued review of the same record revealed the care plan did not specify how many persons should assist Resident #1 for bed mobility, incontinent care, and transfer assistance according to the MDS. In an interview with the Administrator on 02/28/2017 at 11:00 a.m., she said she knew the resident fell from the bed when CNA (Certified Nurse Aide) A was performing incontinent care. She said she didn't really know much about the incident, she said the incident was brought to her attention in the morning meeting. She said the resident was taken to the emergency room (ER) immediately. She said she did not report the incident to the state agency because she felt the incident was witnessed by CNA A and it was not abuse. In an interview with the DON (Director of Nurses) on 02/28/2017 at 11:10 a.m., he said he was not present at the time of the incident. On 02/24/17, CNA A reported that while she was performing incontinent care, Resident #1 fell off the bed. He said CNA A immediately screamed for help. RN (Registered Nurse) A assessed Resident #1 for injuries. He said RN A called the 911 ambulance service to transport Resident #1 to the ER for further evaluation. He said Resident #1 was totally dependent and she required transferring by mechanical lift. He said the facility policy was that two persons must assist with a mechanical transfer but one person can assist with her incontinent care. He stated that was why the CNA A was by herself when performing Resident #1's incontinent care. In an interview with CNA A on 02/28/2017 at 11:25 a.m. CNA A said she was trying to put Resident #1's brief on, she rolled Resident #1 to her side and Resident #1 accidentally fell on the floor. She said she immediately called out to RN A. RN A assessed Resident #1 before sending the resident to the ER for further evaluation. She said she was counseled by the DON on how to reposition and transfer residents. She said there was an in-service on 02/27/2017 for all staff regarding mechanical lift transfers and repositioning. In an interview with RN A on 03/01/2017 at 9:20 a.m., he said CNA A reported to him about the fall of Resident #1. He stated that CNA A was by herself giving incontinent care to the resident when Resident #1 fell off the bed. He said he quickly went to the resident's room and found her on the floor with a little laceration on her lip. He stated he assessed the resident and treated the laceration. He stated he called the emergency medical service (EMS) ambulance to transfer Resident #1 to the ER. When the EMS team assessed the resident, they wanted the resident to stay in the facility because there was no injury that warranted for the resident to go to ER. He stated he insisted for the EMS team to take the resident to ER, he stated it would be good if further evaluation was done on the resident in order to rule out any fracture. He stated the EMS team took the resident to ER and brought her back that same day. He stated from the hospital discharge summary given to the resident the CT scan revealed there was no injury sustained. He stated there was an abrasion to the left cheek and the lip laceration was treated. Record review of Resident #1's hospital discharge summary revealed Resident #1 was admitted to theER on [DATE] at 08:43 a.m. The summary revealed Resident #1 fell from bed with a baseline abrasion to left cheek and laceration to lip. CT scan to Brain, Maxillofacial and Spine done on Resident #1, revealed no further injury was sustained. Resident #1 was discharged to facility on the same day to be monitored by the primary provider. Review of CMS Form 672, Resident Census and Conditions of Residents, dated 02/28/17, indicated 47 residents required assistance with transfers and incontinent care.

Based on observation, interview and record review the facility failed to ensure that 1 of 24 residents reviewed for skin issues ( Residents #1) who entered the facility without a pressure sore did not develop a pressure sore. The facility failed to: -Provide pressure sore prevention and Resident # 1 developed 4 stage IV pressure sores, one on the left hip, one on the sacral area (above the buttocks), and one on each ear. Resident # 1 required hospitalized from [DATE] -3/21/2012 to have her pressure sores debrided (surgical removal of dead tissue). These failures affected 1 resident and placed an additional 107 residents at risk for the development of pressure ulcers, delay in treatment resulting in worsening of the resident's skin and a decline in health. An Immediate Jeopardy was identified on 3/29/2012 at 1:15 PM. While the IJ was removed on 4/2/2012 at 2:25 PM, the facility remained out of compliance at a scope of pattern and a severity of no actual harm that is not immediate jeopardy because all staff had not been trained and the effectiveness of training had not been assessed or monitored. Finding Include: Resident # 1 Record review of Resident # 1's face sheet revealed she was admitted on [DATE] from another skilled nursing facility. It further revealed that she had the following Diagnoses: [REDACTED]. Record review of Resident # 1's 12/22/2011 at 3:30 PM nursing admission assessment revealed that she did not have a pressure sore on admission. Her Braden scale score was 11 (for predicting pressure score risk a score of 10-12 is a high risk). Additional risk factors identified included impaired or decreased mobility and decreased functional ability, cognitive impairment, urinary and/or fecal incontinence. Review of Resident #1's admission MDS dated [DATE] revealed that she has short and long term memory problems with severely impared daily decision making. In section B (hearing, speach and vision) it is coded that she has no speach and is rarely/never understood and rarely/never understands. In section G it is coded that she required extensive assistance with bed mobility and did not transfer in and out of bed. She was total care with toileting, hygiene and bathing. She was always incontinent of bowel and had an indwelling catheter. She received 51% or more of her nutrition through [DEVICE]. On the pain assesment section they coded no non-verbal sounds, vocal complaints of pain, facial expressions, or protective body movements or postures. Section M was coded with a stage II pressure ulcer "date of the oldest stage II" was 12/22/12. (Pressure ulcer A) Record review of Resident #1's nursing weekly/monthly summary dated 1/6/2012 revealed under skin turgor was checked "good" and no preventative skin care, pressure relieving or reduction mattress or chair pad were checked. Pressure ulcer A (left buttock) Record review of Resident # 1's weekly pressure ulcer record dated 12/30/2011 revealed: Pressure ulcer to left buttock measuring length 5 cm, width 3cm, depth 0.5cm, date of onset 12/30/2011, stage 2 with scant amount of serosanguineous (both blood and the liquid part of blood referred to as serum). The wound bed was red and surrounding skin was normal. Weekly progress note stated " Resident note to have skin breakdown on (L) buttocks. Xeroform gauze ordered to L (left) buttocks 3x a week and monitor daily for s/s of infection. " Specialty Interventions included: Bed - type pressure relief and Positioning Devices type pillows. Record review of Resident #1's 1/7/2012 weekly pressure ulcer record progress notes revealed the wound to the left buttock was healed. Record review of Resident # 1's medical record revealed no further head to toe skin checks for December 2011. Record review of Resident # 1's January 2012 head to toe skin checks revealed the following: -1/3/2012 skin not intact, rash, perineal blisters groin and back. -1/10/12 no assessment documented as completed. -1/17/2012 skin intact. -1/31/2012 skin not intact. " Nickel sized opening at sacrum (with) scant drainage (pressure ulcer B). Skin tear upper right leg without drainage." Previously identified area not checked and preventative measures in place not checked. Pressure Ulcer B (sacral wound) In an interview on 03/30/12 at 1:15 PM, LVN A stated that it was her signature on the head-to-toe skin check for Resident #1 dated 01/31/11. She stated she did not do anything about the new area. She stated she did not remember if she assumed a dressing was being done and that she knew better. She stated she should have told the treatment nurse. Record review of Resident # 1's nurse's notes and physician's orders revealed no physician notification of the wounds on 1/31/2012 and no treatment ordered or provided. Record review of the facility's form weekly pressure ulcer record dated 11/2009, the description of stages reads in part: " ... Stage 2: a partial thickness loss of skin layers that presents clinical as an abrasion, blister or shallow crater. Stage 3: a full thickness of skin is lost, exposing the subcutaneous tissues presents as a deep crater with or without undermining adjacent tissue ....Stage 4: a full thickness of skin and subcutaneous tissue is lost, exposing muscle and bone... Unstageable: necrotic tissue grayish yellow slough or soft/hard Eschar present ... Deep tissue injury: purple/maroon colored intact skin. Record review of weekly pressure ulcer record dated 2/20/2012 with date of onset: 02/20/12. Site: Sacral. Date of 02/20/12, stage II, size 5 cm x 3 cm, depth is 0.2 cm. Exudate type is serosanguineous, small amount. Wound bed is red. Surrounding skin color is normal for skin. Surrounding skin is normal for skin. Pain related to wound: Yes. See pain management flow sheet. Initial evaluation: Resident found with stage II wound to sacral wound. Wound cleaned and [MEDICATION NAME] dressing placed over wound. We will continue to monitor daily for signs and symptoms of infection. Specialty interventions: Bed, pressure relief. Positioning devices: Pillows. Other: Side wedge. Record review of weekly pressure ulcer record for Sacral wound dated 02/27/12, revealed stage IV sacral pressure sore, size 5 x 3 cm, depth 0.5 cm, with undermining at 12 o'clock of 0.5 cm. Purulent moderate amount of drainage with odor. Yellow wound bed. Surrounding skin color is bright red. Weekly note: Wound deteriorated significantly, less than 50% slough. Discontinue [MEDICATION NAME]. HF blue with Santyl ordered to be changed daily and monitored for signs and symptoms of infection. Specialty interventions: Air mattress. Wound has deteriorated. Record review of weekly pressure ulcer record of sacral wound dated of 03/04/12, revealed stage IV to sacral. Serosanguineous drainage with odor. Wound bed is red and surrounding skin color is dark red, purple. Wound improved. Slough less than 20%. No redness noted on surrounding skin. HF blue with Santyl continued daily and monitor for signs and symptoms of infection. Record review of Resident #1's Change of Condition form dated 2/10/2012 revealed " problem skin area on L hip " noted on 2/10/2012, " L hip purplish-reddish area " . Nurse's note on the Change of Condition form read " This nurse called to resident's room to observe area on (left) hip. Large reddish-purplish area noted on the (left) hip. Appears to be skin tear. Notified wound care nurse (LVN G). Area evaled (sic) and treated per wound care nurse. (Dr. #1) notified " . The return call/new order stated " ordered to have wound care nurse eval and tx." Record review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Apply [MEDICATION NAME] dressing every other day. This was discontinued on 2/17/2012. Record review of Resident #1's MD orders revealed no physician's orders on 2/10/2012 LVN G was observed providing pressure ulcer treatment to Resident # 1 on 3/28/2012 at 9:15 AM. The sacral pressure sore had 30 to 40 % yellow slough covering the wound bed. Record review of an e-mail that was provided on 03/29/12 by LVN G regarding Resident #1, Doctor #2 (wound care doctor) wrote for Resident #1 on 02/22/12: sacral 2 x 3, 100% slough. Treatment: Santyl and [MEDICATION NAME] Blue. Pressure Ulcer C (left hip) Record review of Resident #1's Change of Condition form dated 2/10/2012 revealed "problem skin area on L hip " noted on 2/10/2012, " L hip purplish-reddish area " . Nurse's note on the Change of Condition form read " This nurse called to resident's room to observe area on (left) hip. Large reddish-purplish area noted on the (left) hip. Appears to be skin tear. Notified wound care nurse (LVN G). Area evaled (sic) and treated per wound care nurse. (Dr. #1) notified " . The return call/new order stated " ordered to have wound care nurse eval and tx." Record review of Resident #1 MD orders revealed no physician's orders on 2/10/2012. Record review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Apply Xeroform and cover with dry dressing every other day. This was discontinued on 2/17/2012 Record review of weekly pressure ulcer report dated 2/20/2012 with a date of onset: 02/20/12. Site: Left hip. On 02/20/12, unstagable, size 6 x 3.5 cm, depth 0.1 cm, no undermining, no exudate (drainage). Wound bed is yellow. Surrounding skin is bright red. Pain related to wound: Yes. See pain management flow sheet. Initial evaluation progress note states resident noted to have unstagable wound to left hip from possible DTI (deep tissue injury). Wound cleansed and dried. Santyl applied to wound bed and covered with dry dressing. We will continue to monitor daily for signs and symptoms of infection. Weekly pressure ulcer record dated 02/27/12, left hip pressure sore now unstagable, size 6 length x 3.5 cm width, depth is 0.5 cm, no undermining. Exudate is purulent with odor. Large amount of exudate. Wound bed is red and yellow. Surrounding skin is bright red. Surrounding skin is not documented. Weekly pressure ulcer record dated 03/04/12, left hip, size 6 x 4.5 cm; depth is 2 cm, no undermining. Serosanguineous odor, large amount of drainage. Wound bed red and yellow. Record review of an e-mail that was provided on 03/29/12 by LVN G regarding Resident #1, Doctor #2 (wound care doctor) wrote for Resident #1 on 02/22/12: left ischial 6 x 3.5, 100% slough. Treatment: Santyl and [MEDICATION NAME] Blue. Review of Resident # 1' s medical record revealed no other documentation from wound care doctor (Dr. # 2). LVN G was observed providing pressure ulcer treatment to Resident # 1 on 3/28/2012 at 9:15 AM. The hip wound measured 6.4 cm length and 5.2 cm width by 2.0 cm depth with undermining (the wound if larger under the skin then it appears on the outside) from 9:00 AM to 3:00 PM. There was approximately 10 % slough (dead tissue) covering the wound. In an interview with LVN G on 03/28/12 at 9:15 AM he stated that Resident #1's wounds developed while she was in the facility and were "the worst in the building". In an interview on 03/29/12 at 12:15 PM, LVN G stated that the head to toe skin checks from January 2012 and March 2012 for Resident #1 may be the only ones done since he took over wound care in February. He stated Resident #1 was not admitted with skin issues. He stated he took over wound care on 02/20/12 for the left hip, un-stageable, possibly from deep tissue injury. He stated he was not notified on 01/31/12 of a wound, and his documentation starts on 02/20/2012. He stated " we are missing a month of head to toe assessments " for Resident #1. He stated he was working during this time frame. He stated the staff is supposed to come to him with any skin issues within 24 hours and he should have been notified. He further stated the wound areas for Resident #1 in February were different than the area that was identified in December 2011. LVN G stated that he felt the resident had not been turned properly and was not on an air mattress because the wounds were not a stage III or higher. He stated Resident #1 was put on an air mattress on 02/27/12. He further stated he could not remember if they told him about it and as soon as he gets wound notification he starts intervention. He stated staff are supposed bring him a "Stop and Watch" form when they find a skin problem. Pressure Ulcers D and E (right ear and left ear) In an interview on 03/28/12 at 12:30 PM, LVN G stated Resident #1's ear wounds were noticed on 02/22/12. He stated a neck pillow was ordered which did not help. He stated that the resident has poor neck control and sweats. He stated the wounds on the ears were because of sweat, lack of hygiene and lack of turning. LVN G stated that Resident #1 came in with no skin issues. Record review of weekly pressure ulcer record dated 2/22/2012, right ear. Date of onset: 02/22/12. Date 02/22/12, stage IV, size 0.5 x 0.5 cm, depth is 0.2 cm. Serous scant amount of drainage. Wound bed is red. Surrounding skin is normal. Pain related to wound: Yes. See pain management flow sheet. Initial evaluation: New stage IV to right ear. Wound cleansed and dried. Iodosorb gel to ear daily and continue to monitor for signs and symptoms of infection. Record review of weekly pressure ulcer record dated 03/04/12. Right ear: Size 1 x 0.5 cm, depth is 0.2 cm. Wound bed is red and black. Surrounding skin color bright red, dark red, and purple. Surrounding skin maceration, induration. Weekly note: Wound deteriorating. Continue Iodosorb gel and offloading and monitor daily for signs and symptoms of infection. Physician notified. Awaiting neck pillow. Record review of Resident #1's weekly pressure ulcer record dated 2/12/2012 with date of onset 2/12/2012 revealed Left ear stage II pressure sore with a length of 0.5 cm, width of 0.5 cm and depth of 0.5 cm, with scant serous (bodily fluids that are typically pale yellow and transparent) drainage with swelling to surrounding tissue and pink in color. Pain related to the wound was checked yes - see pain management flow sheet. Initial evaluation progress note read " Pt was found to have sm area to the left ear stage II. Area was cleaned, applied TAO and dry drsg. Monitor for any (changes) or s/s of infection " . Further review of this weekly pressure ulcer record on 2/20/2012 for the left ear revealed it was now a stage IV with small amount serosanguineous drainage with dark red/purple skin color. It no longer had swelling to the surrounding skin. The progress note revealed that the treatment was changed to idosorb gel. A side wedge was added to the specialty interventions. Weekly pressure ulcer record dated 02/27/12. Left ear: Surrounding skin color dark red, purple. Record review of Resident # 1's medical record revealed no head to toe skin checks for February 2012. Record review of Resident #1 nurse's notes between 12/25/2011 and 1/21/2012 revealed no documentation of any skin breakdown or wounds. Record review of the facility's turn and reposition detailed report for Resident #1 reveals the following: -There were 9 days documented the resident was turned and positioned 4 times (01/09/12, 01/14/12, 01/21/12, 01/30/12, 02/01/12, 02/03/12, 02/11/12, 02/15/12, and 02/18/12). -There were 50 days documented the resident was turned and positioned 3 times (12/23/11, 12/26/11 through 01/08/12, 01/11/12 through 1/13/2012, 01/15/12, 01/18/12, 01/20/12, 01/23/12, 01/24/12, 01/26/12 through 01/28/12, 02/05/12, 02/07/12 through 02/09/12, 02/13/12, 02/14/12, 02/19/12 through 02/21/12, 02/23/12, 02/25/12, 02/27/12, 02/29/12, 03/01/12, 03/03/12, 03/05/12, 03/06/12, 03/08/12 though 03/11/12, 03/14/12, 03/23/12, and 03/27/12). -There were 26 days documented the resident was turned and positioned 2 times (12/24/11, 12/25/11, 01/10/12, 01/16/12, 01/17/12, 01/22/12, 01/25/12, 01/29/12, 01/31/12, 02/02/12, 02/04/12, 02/06/12, 02/10/12, 02/12/12, 02/17/12, 02/22/12, 02/26/12, 03/02/12, 03/04/12, 03/07/12, 03/12/12, 03/13/12, 03/15/12, 03/25/12, 03/26/12, and 03/28/12). -There were 4 days documented the resident was turned and positioned 1 times (02/16/12, 02/24/12, 02/28/12, and 03/24/12). -There was no documentation that the resident was turned and positioned on 1 day (01/19/12). Record review of Resident #1's laboratory service revealed on 12/27/11 [MEDICATION NAME] level (lab that measures amount protein in the blood to evaluate nutritional status) of 3.6 (expected range 3.5-5.7). Record review of Total Enteral/[MEDICATION NAME] Nutrition Review dated 3/2/12 written by Dietician A revealed: ...Resident with recent skin breakdown, last [MEDICATION NAME] within normal limits, tube feeding provides calories, protein and fluid that meet estimated needs to at least maintain weight and support healing...Suggest 1. try tube feed change to Pevative @ 65 mL/hr x 22 hrs peg tube via pump...Pevative contains... protein and extra nutrients that may help support/promote wound healing... no labs since last review Record review of March 2012 MAR indicated [REDACTED]@ 65 mL/hr x 22 hrs until she went to the hospital on [DATE]. She was not receiving any vitamins, minerals or protein supplements. Record review of Resident #1's laboratory service collected on 03/06/12, [MEDICATION NAME] level 2.5 (expected range 3.5-5.7). Change of condition form dated 03/15/12. Situation: Multiple wounds for debridement on 03/17/12. Wound needing debridement of left hip. Pertinent history includes pain, new onset of wounds. Pain level location: Resident nonverbal, but facial grimacing noted during left hip, right and left ear, and sacral dressing changes. Change in skin is yes. Wound status: Left hip, stage IV, sacral stage IV, right ear and left ear stage IV, right and left heel stage I redness. New orders: Transfer to (local hospital) for left hip wound debridement. Record review of Resident #1 physician's order dated 3/15/2012 revealed to discharge resident to hospital for wound debridement of left stage IV hip wound and to treat and evaluate stage IV to sacral and stage IV' s to both ears. At that time, LVN G said the physician had not dictated her notes and was out of the country at present. In an interview on 04/02/12 at 9:50 AM, Doctor #1 stated Resident #1 was in pain when she left the hospital and she should have been on pain medication at this facility. He stated "nobody notified me". He further stated that the wounds are a mystery to him. The side wound on her hip seemed to be pressure, but it was initially reported to him as a skin tear. He stated that given her medical condition, she was not a candidate for a flap but went to the hospital for debridement. The surgeon and the family decided on conservative wound treatment at that point. He stated that he did not often see the DON or speak with her, but other staff members were accessible to him. He spoke to the administrator and requested proper training at the facility to care for residents at risk for skin issues and the risk for skin tears. In an interview with the DON on 3/30/2012 at 4:15 PM she said the nurses were responsible for the weekly skin assessments. When she was asked who was responsible for making sure the nurses were doing the skin assessments she said the unit managers usually were responsible. She said that both of the unit managers were out on leave. The DON said since they were both out, she and the ADON would be responsible for making sure the nursing staff was doing the skin assessments. When she was asked about Resident # 1's January 2012 skin assessment she said that would have been the unit manager. She further stated " I don't have anything to do with it ." The DON said the nurses know to do the skin assessments and they know the days they were supposed to do the skin assessments. Record review of the facility's revised 1/7/2012 Pressure ulcer prevention policy read in part: " Introduction: As the name implies, pressure ulcer results when pressure-applied with great force for a short period or with less force for long period-impairs circulation, depriving tissues of oxygen and other life-sustaining nutrients. This process damages skin and underlying structures. Untreated, resulting ischemic [MEDICAL CONDITION] can lead to serious infection... Successful pressure ulcer treatment involves relieving pressure, restoring circulation, promoting adequate nutrition and, if possible, resolving or managing related disorders. Typically, the effectiveness and duration of treatment depends on the pressure ulcers characteristics. . . Implementation... Turn and reposition the patient every 1 to 2 hours, unless contraindicated. For patients with limited mobility, use pressure-redistribution device, such as air, gel, or 4 (inch) . . . foam mattress overlay . . . " Record review of the facility's skin management policy, revision date of February 2010, read in part, "Unavoidable pressure ulcers per CMS guidelines: Unavoidable: means that the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with the resident's needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. All of these must be clearly documented in the resident's clinical record ...Newly admitted residents ...#9. A physician's order will be written to monitor each ulcer and documentation on the TAR will reflect the status of the dressing, surrounding skin color and skin and pain associated with the wound ...#16. Skin assessments: A. "Weekly skin check" will be transcribed onto the treatment record including the day and shift on which the check will be conducted. B. Completion of the weekly skin assessment will be noted on the treatment administration record (TAR) with the licensed nurse's initial. C. Skin assessment findings will be documented weekly on the head-to-toe skin check form ...D. A change of condition form . . . is to be completed and a new physician's order obtained for new alterations noted as needed ... Record review of the facility ' s June 2007 Documentation policy and procedures, read in part: " Purpose: Healthcare personnel will complete documentation requirements as outlined by the company and recorded in the medical record using accepted principles of documentation . . . Aspects of residents care, such as observation and assessments, administration of medications, and services or treatments performed, must be documented in the residents medical record according to company policy... Entries There should be no blank lines or gaps left between entries, with the exception of the resident's care plan... Procedure: . . . 1. Chart events as they occur... " A plan to remove the IJ was submitted and required revision. The following plan of removal, submitted by the facility after corrections, was accepted on 3/30/2012 at 5:00 PM. Immediate Action Plan to Abate Immediate Jeopardy Pressure Sore Prevention, Identification and Treatment March 29, 2012 Issue: Immediate identification of residents with skin integrity issues. Action: Resident #1 is currently receiving treatment, care and services for current pressure ulcers. A new Weekly Head To Toe Skin Check revealed no new pressure areas. In order to establish a baseline of altered skin integrity, a Head to Toe Skin Check was completed on all residents in the facility on 3/29/12 and the results were documented on the Weekly Head to Toe Skin Check form. A risk review/Braden Scale was completed for residents with the potential for skin integrity issues in accordance with facility practice guidelines. Findings of actual pressure ulcers on Residents #2, #3, #4, #5, #6, and #7 (which were Resident #27, 38, 39, 25, 11, 47), other skin issues or those at risk were communicated to the attending physician via the Change of Condition form and orders received for treatment interventions or prevention were implemented. Any concerns, actual or potential for skin integrity concerns were addressed in the residents ' care plan. Issue: Failure of licensed staff to complete weekly head to toe skin checks Action: Weekly Head to Toe Skin Checks of residents are now scheduled in order to identify actual or potential areas at risk for skin breakdown. Licensed staff will be educated regarding completion of Weekly Head to Toe Skin Checks (Facility ' s Skin Management Practice Guidelines) and the schedule for completion of the weekly skin checks, and physician notification by the Staff Development Coordinator/designee. Licensed staff were provided with a copy of the Practice Guidelines and schedule. Education was completed with 14 licensed staff on March 29th and 12 licensed staff on March 30. The remainder of the licensed staff (8) will not be allowed to work until they have been educated. The Staff Development Coordinator/Designee will educate the remaining licensed staff prior to the staff member taking their assignment on their next scheduled shift. Action: Certified nursing assistants have been educated by the Staff Development Coordinator/designee and instructed to notify their charge nurse via the STOP & WATCH form of any new skin integrity issues identified while providing care. Education was completed with 25 Certified Nursing Assistants on March 29th and with12 Certified Nursing Assistants on March 30. The remainder of the Certified Nursing Assistants (7) will not be allowed to work until they have been educated. The Staff Development Coordinator/Designee will educate the remaining certified nursing assistants prior to the staff member taking their assignment on their next scheduled shift. Action: The DON/designee will now validate daily in accordance with the schedule that the Weekly Head to Toe Skin Checks are completed and documented. Daily monitoring will continue for 30 days and then randomly thereafter. Any discrepancies will be immediately addressed with the licensed staff. The monitoring started on March 29 with the completion of the Weekly Head To Toe Skin Checks. Action: Any licensed staff that fails to complete a Weekly Head to Toe Skin Check will be counseled and re-educated as necessary Action: New employees will continue to be educated to the Skin Management System upon hire. This education will include the documentation of Weekly Head to Toe Skin Checks, physician and responsible party notification, Stop and Watch use, and documentation of Change of Condition. Issue: Timely response to Change of Condition related to skin integrity Action: Licensed staff have been educated that if a skin integrity issue is identified via the Weekly Head to Toe Skin Check or via a STOP & WATCH form, a Change of Condition form is to be completed immediately, the physician is to be notified and any orders to treat the skin integrity issue are to be implemented. Additionally, licensed staff will document Changes of Condition on the 24 Hour report. Education was completed with 14 licensed staff on March 29th and 12 licensed staff on March 30. The remainder of the licensed staff (8) will not be allowed to work until they have been educated. The Staff Development Coordinator/Designee will educate the remaining licensed staff prior to the staff member taking their assignment on their next scheduled shift. Action: As of 3/30/12, the DON and/or designee will now review the 24 Hour report, Weekly Head to Toe Skin Checks and the STOP & WATCH forms daily and will follow up on any noted Changes of Condition to assure that proper intervention has occurred and has been documented. Action: The Treatment Nurses have been re-educated regarding timely documentation of physician ' s orders on March 29th and March 30. Issue: Staff knowledge of pressure sore prevention and treatment Action: The direct care staff was educated regarding Pressure Ulcer Prevention and Management. This education included: Turning and repositioning, utilizing the stop and watch tool, reporting of changes, preventative care, relieving pressure, restoring circulation, promoting adequate nutrition, hydration and resolving and/or managing related disorders. This education was completed with 39 staff on March 29th and 24 direct care staff on March 30. The remainder of the licensed staff (15) will not be allowed to work until they have been educated. The Staff Development Coordinator/Designee will educate the remaining licensed staff prior to the staff member taking their assignment on their next scheduled shift. The DON and/or Unit Manager will monitor residents during routine rounds in the facility for pressure prevention beginning March 30. Monitoring of Plan Action: A Quality Assurance and Assessment committee meeting will be held on 3/30/12 to review the plan. The Facility Medical Director has been notified and approves this plan. The Quality Assurance and Assessment Committee subcommittee will meet weekly for 30 days to review the facility ' s compliance with the plan of immediate action. The DON or designee will report the status of each Action and also report any noted trends/patterns. The QA & A subcommittee will take further action as deemed necessary. Action: The Regional Clinical Director will now consult weekly with the DON/designee to review the status of the Skin Management System and make recommendations to this plan as indicated. Record review of Lippincott ' s Nursing Procedures fifth edition, copyright 2009 by Lippincott Williams and Wilkins, pages 784 to 792 read in part: " Pressure ulcer care: A pressure ulcer is a lesion caused by unrelieved pressure that results in damage to underlying tissues. Most pressure ulcers develop over bony prominences, where friction and shearing force combine with pressure to breakdown skin and underlying tissues ... ...Ideally, prevention is the key to avoiding extensive therapy. Preventive strategies include recognizing the risk, decreasing the effects of pressure, assessing nutritional status, avoiding excessive bed rest, and preserving skin integrity. ... Treatment includes methods to decrease pressure, such as frequent repositioning to shorten pressure duration, and the use of special equipment to reduce pressure intensity. Treatment may involve special pressure-reducing devices, such as beds, mattresses, mattress overlays, and chair cushions .... Preventing Pressure Ulcers: Turn and reposition the patient every 1 to 2 hours unless contraindicated. For a patient who can't turn himself or who is turned on a schedule, use a pressure-reducing device, such as air, get, or a 4 " (10.2 -cm) foam mattress overlay. Low - or - high -air-loss bed therapy may be indicated to reduce excessive pressure and promote evaporation of excess moisture .... Emphasize the importance of regular position changes ... According the CMS Form 672 there were 108 residents in the chair all or most of the time.

Based on observation,interviews and record review, the administrator and DON failed to effectively and efficiently manage facility resources. The administration's failures contributed to an immediate jeopardy at F-314 and substandard quality of care at F-309. The DON failed to: Immediate Jeapardy 1) ensure staff were trained and supervise staff to identify residents with skin integrity issues, conduct head to toe skin checks, notify the physician of wounds, and prevent new and avoidable pressure sores from developing. Resident # 1 developed a new pressure sore on 1/31/12 and had no head to toe skin checks for February 2012 and developed Stage IV pressure sores by the end of February 2012. Non-Immediate Jeopardy 1) ensure staff obtain and administer Resident # 1's pain medication from 3/13/2012 through 3/30/2012, and obtain and administer Resident # 48's pain medication from admission on 3/12/2012 through 3/30/2012. 2) ensure staff provide for the accuracy of specimen collection and develop systems to ensure the timeliness of laboratory services for 3 of 24 sampled residents (Resident #'s 4,11,17). Resident #4's sputum culture was not sent to the laboratory in a sterile container on 3/22/12 and the reculture was not sent to the laboratory until 3/27/12. The new results dated 3/31/12 were not printed by the facility until 4/2/12 indicating that Resident # 1's sputum had many Pseudomonas aeruginosa with respiratory flora present. 3) ensure the facility had an effective infection control program, laboratory services program and wound care program; the facility failed to maintain an infection control program to provide a safe and sanitary environment to prevent the development and transmission of disease and infection. 4) ensure the facility staff administer medication without an error rate of greater than 5 %. The medication error rate was 19% involving 5 staff, 2 shifts and 7 residents (Resident #'s 20, 21, 28, 29, 34, 35, and 36). These residents received either incorrect medications, an incorrect amount, at the incorrect time, or incorrectly administered. The Administrator failed to: 1) ensure the DON trained and supervised staff to identify residents with skin integrity issues, conduct head to toe skin checks, notify the physician of wounds, and prevent new and avoidable pressure sores from developing. Five of 37 sampled residents (# 1,7,11,25,27) and 2 random residents (# 39 and 47) entered the facility without a pressure sore and developed new pressure sores. Non-Immediate Jeopardy 1) ensure that all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin were reported immediately to the administrator and to other officials in accordance with State law, and were thoroughly investigated. Resident #28 had scratches of unknown origin on her back and the event was not thoroughly investigated and reported to the state. Resident # 40 was alleged to have been verbally/mentally abused by staff and the incident was not thoroughly investigated and not reported to the state. 2) ensure that the DON supervised staff to obtain and administer Resident # 1's pain medication from 3/13/2012 through 3/30/2012, and obtain and administer Resident # 48's pain medication from admission on 3/12/2012 through 3/30/2012. 3) ensure the facility had an effective infection control program, laboratory services program and wound care program; the facility failed to maintain an infection control program to provide a safe and sanitary environment to prevent the development and transmission of disease and infection. An Immediate Jeopardy was identified on 3/29/2012 at 1:15 PM. While the IJ was removed on 4/2/2012 at 2:25 PM, the facility remained out of compliance at a scope of pattern and a severity of no actual harm that is not immediate jeopardy because all staff had not been trained and the effectiveness of training had not been assessed or monitored. These failures placed 129 residents at risk for not receiving needed care and services and not being protected from abuse and neglect. Findings include: Pressure Sores The facility failed to: -Provide pressure sore prevention and Resident # 1 developed 4 stage IV pressure sores, one on the left hip, one on the sacral area (above the buttocks), and one on each ear. Resident # 1 required hospitalized from [DATE] -3/21/2012 to have her pressure sores debrided (surgical removal of dead tissue). These failures affected 1 resident and placed an additional 107 residents at risk for the development of pressure ulcers, delay in treatment resulting in worsening of the resident's skin and a decline in health. In an interview with the DON on 3/30/12 at 4:15 PM she said the nurses were responsible for the weekly skin assessments. When she was asked who was responsible for making sure the nurses were doing the skin assessments, she said the unit managers usually were responsible. She said that both of the unit managers were out on leave. The DON said since there were both out, she and the ADON would be responsible for making sure the nursing staff was doing the skin assessments. When she was asked about Resident # 1's January 2012 skin assessment, she said that would have been the unit manager doing it. She further stated, "I don't have anything to do with it." The DON said the nurses know to do the skin assessments and they know the days they were supposed to do the skin assessments. In an interview with the Administrator on 4/9/12 at 2 PM she stated that she supervises the DON on her job responsibilities including but not limited to pressure sore management. Pain Medication The facility failed to: -Consult Resident # 1's physician when skin breakdown was identified on 1/31/2012. Resident #1 entered the facility with no skin breakdown and developed four stage IV pressure ulcers. -Consult Resident # 1's physician when she did not receive her ordered pain medication for 8 days (from 3/22/2012 through 3/30/2012) resulting in painful wound care as evidenced by grimacing during treatment and staff reporting that it was a painful treatment. -Consult Resident # 48's physician when she did not receive her ordered pain medication for 18 days (from 3/13/2012 through 3/30/2012) resulting in resident's complaints of pain. -Consult Resident # 15's physician when she developed redness to her lower extremities resulting in an ER visit for [MEDICAL CONDITION] on 3/25/2012. Failure to consult with the physician when pain medication was not available affected 2 residents and placed the additional 43 residents on the pain management program at risk for physical, mental and psychosocial problems. Failure to notify regarding skin changes affected one resident and placed an additional 50 residents receiving skin care and wound treatment at risk for delay in treatment resulting in worsening of the resident's skin and a decline in health. In an interview with the DON on 4/02/12 at 11:56 AM she stated the [MEDICATION NAME] for Resident #1 was a scheduled medication on readmission (3/21/12) and that the medication was not received by the facility. She stated the nurse should have initialed, circled their initials and then documented on the back why the medication was not administered. She further stated the nurse should then notify the M.D and document the notification in the nurse's notes. The nurse should have followed up to be sure the resident received the prescribed medications. The DON further stated it was the nurse's responsibility to follow-up with both the doctor and the pharmacist. She stated that the nurse should document on all calls to the pharmacy and the doctor in the nurse's notes. In an interview on 4/2/2012 at 2:29 PM the DON stated Resident #48 [MEDICATION NAME] was never ordered from the pharmacy. She stated she was not sure why it was signed off on the MAR and the blanks were incorrect documentation. She further stated that there was no "count sheet " for this medication since it was never in the building. In an interview with the DON on 4/2/2012 at 7:35 AM she was given Resident # 15's 3/26/2012 progress note to read. She said that she was not previously aware that the doctor had not been notified/consulted. The DON said that the nurse was supposed to assess the resident. She further stated they were supposed to notify the family and the physician to obtain treatments and carry them out. Medication Administration -LVN B was prepared to administer a PRN dose [MEDICATION NAME] (medication used to treat high blood pressure) 0.1 mg to Resident # 20 on 3/27/2012 when her blood pressure was lower than the parameters ordered to administer the medication. -MA A was prepared to administer [MEDICATION NAME] 100 mg (medication used to treat high blood pressure) 3/28/2012 and she did administer [MEDICATION NAME] (medication used to treat high blood pressure) to Resident # 21 when both medications were to be held for a HR less than 60 and the resident had a pulse (HR) of 54. -MA C administered [MEDICATION NAME] 5 mg (medication used to treat bladder and urinary disorders) to Resident # 28 on 3/27/2012 when there was not a physician's order [REDACTED]. -MA B administered [MEDICATION NAME] 125 mcg (medication used to treat heart failure and abnormal heart rhythms) to Resident #29 on 03/28/12 did not take a apical pulse (pulse using a stethoscope to listen to chest to obtain the heart rate) as ordered by physician. -MA A administered cough suppressant ([MEDICATION NAME]) 10 cc to Resident #34 on 03/27/12 when 15 cc was ordered. -MA B administered [MEDICATION NAME] 600 mg (medication used to lower cholesterol and triglycerides in the blood) to Resident #35 on 03/28/12 at 1:40 PM when it was ordered before meals. - MA B administered [MEDICATION NAME] 25 mg tablets, three tablets to Resident #36 on 03/28/12 at 1:45 PM when the medication was scheduled to be administered at 12:00 PM. In an interview with the DON on 03/29/12 at 1:40 PM, she said when administering medications, the staff should make sure it is the right med, the right dose, the right time. She said there is an hour window before or an hour after the scheduled time to administer a medication. When she was asked if she watched the staff do med pass, she said that she did and the pharmacy consultant did as well. At that time, a request was made to her for documentation regarding these observations. The DON said when administering [MEDICATION NAME], staff should take a pulse; take it for a full minute to make sure it is within the parameters to administer the [MEDICATION NAME]. She said blood pressure and heart rate out of range parameters, if medication was administered, the resident could bottom out (low blood pressure), have [MEDICAL CONDITION]. Infection Control Staff failed to follow infection control procedures for 14 of 37 sampled residents (Resident #s 2, 3, 4, 5, 7, 13, 15, 16, 20, 21, 27, 29, 31, 32) and 4 of 4 random residents (Resident #s 38, 39, 45, and 46 ) receiving wound care, incontinent care and medications. - CNA E did not wash her hands before leaving the room after providing incontinent care to Resident # 2. - CNA D did not change her gloves appropriately before putting on barrier cream on Resident # 3. -LVN D did not sanitize the blood pressure cuff before and after use when caring for Resident # 4. She placed the cups of medication on a table that was not clean and did not have a barrier. She did not wash her hands between glove changes and left the room without washing her hands. - The Rehab Tech did not wash her hands before leaving the room of Resident # 3 when assisting with incontinent care. - CNA B did not change her gloves appropriately after touching contaminated areas and re-used the same area of the incontinent wipes when providing incontinent care to Resident # 5. - CNA G and CNA F did not clean the bedside table before placing the supplies used for the care and the clean linen on it when providing care for Resident # 7. Both CNAs did not wash their hands prior to beginning care and when they changed gloves. -LVN E left Resident # 9's room while wearing gloves and without washing her hands. She placed supplies that had been used in the resident ' s room back onto and in the treatment cart. - CNA A re-used the same area of the incontinent wipes when providing incontinent care to Resident # 13. - CNA C did not change her gloves appropriately after touching contaminated areas and re-used the same area of the incontinent wipes when providing incontinent care to Resident # 15. -Resident #16 who was supposed to wear a face mask due to infection when out of the room was served lunch in the dining room. He removed the mask to eat. -LVN B did not clean or sanitize the blood pressure cuff before or after use on Resident # 20. She did not wash her hands before care and left the room without washing her hands. -MA A put the tissue on top her MAR and she gave to Resident # 21 to wipe her eyes after administering eye drops. MA A did not clean or disinfect her blood pressure cuff before and after use on Resident # 21. -LVN E did not wash her hands between gloves changes when providing wound care for Resident # 27. She placed a wet brief over the wound that she did not put a dressing on. She left the room without washing her hands. -MA B and LVN I did not clean and sanitize their blood pressure cuffs before they used them to take Resident # 29's blood pressure. LVN I did wash hands before caring for Resident # 29. -LVN E left Resident # 31's room wearing gloves and without washing her hands. She placed clean gloves on a dirty table. -LVN E did not change her gloves after cleansing Resident # 32's wound. She did not wash her hands between glove changes and she left the room while wearing gloves without washing her hands. She placed Resident # 32 ' s foot on a chair in the room with putting down a drape. -LVN E left Resident # 38's room without washing her hands and wearing gloves. -LVN A did wash her hands before she left Resident # 45's room after providing care. -LVN D did not wash her hands before she left Resident # 46's room after providing care. In an interview with the DON on 03/28/12 at 1:40 PM, she said that hands were supposed to be washed between glove changes. She said regarding putting hands in pockets without washing them, pockets were not clean. She said the blood pressure cuff should be cleaned between every resident with germicidal wipes. She said failure to clean the blood pressure cuff is an infection control issue and if placed on the bed, organisms on the bed could then be transferred everywhere. Laboratory Services Resident # 4's 3/22/11 sputum culture was collected in a wound swab instead of in a sterile container as stated in a 3/23/12 final result report. The reculture was not obtained until 3/27/12 and the final 3/31/12 results indicated Pseudomonas aeruginosa of the sputum. Resident # 11 had a physician order [REDACTED]. The 1/14/12 incomplete lab report revealed that the specimen was not collected and instructed the facility to collect the specimen And submit to the laboratory. The lab specimen was not collected. Resident # 17 had a physician's orders [REDACTED]. The 1/11/12 final results print out from the laboratory service indicated that the specimen was not collected. The DON stated the specimen was never collected. Interview with the DON on 3/28/12 at 11 AM revealed that the facility had no record that the 1/8/12 laboratory order was collected for Resident # 11. Interview with the DON on 3/28/12 at 4:15 PM was done. She stated that the ua lab for Resident # 17 was never collected. When asked who was responsible to check that the laboratory orders were obtained and the results were received, she stated that "we are". When asked who was"we are", she stated that it was the DON or ADON or licensed staff. A plan to remove was submitted and required revision. The following plan of removal, submitted by the facility after corrections, was accepted on 3/30/2012 at 5:00 PM. While the IJ was removed on 4/2/2012 at 2:25 PM, the facility remained out of compliance at a scope of pattern and a severity of no actual harm that is not immediate jeopardy because all staff had not been trained and the effectiveness of training had not been assessed or monitored. Abuse and Neglect Resident #28 Record review of the facility's grievance log revealed a Concern Form signed by the PTA on 3/20/12. The "Description of Concern" read, "Pt's spouse reported several scratches on back of Pt's Right shoulder. When I was transferring her into the standing frame, I discovered at LEAST 4 (four), 6-10 inch scratches along Right scapular spine. The skin did not appear broken or bleeding, but the scratches were red & irritated. The scratches were about ? inch wide, some fainter than others. Pt. cannot recall when they happened, and the Pt's spouse stated that she didn't get OOB all weekend. I didn't see them on Friday, 3/16/12, when I had Pt. in standing frame. Pt./spouse also reported that some of the RCS's are "pretty rough with me when they move me!" Scratches were also brought to the wound RN's attention today (LVN G)". Record review of the second page of the grievance form titled "Concern Form - Action" revealed it was signed on 3/29/12 by LVN J. The date listed that the concern came to her attention was 3/28/12. Documentation under the section "Please describe action that has been taken" read, "scratches have disappeared at time of investigation. Husband stated he is satisfied with care. Assured him that aides will be instructed to hold res. over with palm of hand. Nursg. Mgt. will monitor RCS's nails". "Date concerned individual initially contacted:" read 3/29/12. "Date of Follow Up:" read 3/29/12. A question on the form which read "Is the individual who raised concern satisfied with the resolution" was checked "Yes". An interview was conducted with Resident # 28 on 3/30/12 at 3:30 PM. She was able to speak clearly and she stated that she cannot hear and would like to communicate in writing. The surveyor's questions were written down for her to read and answer. Resident # 28 stated the scratches were observed on her back and she does not know or remember how they happened. Resident # 28 appeared to become very nervous at this time and began to stutter and stopped talking for a few moments. She stated the scratches did not hurt. When she was asked how staff treat her she stated "sometimes they are rough". She then stated that she felt that staff did not like her. When asked which staff persons she felt did not like her she stated, "the nurses that worked with me". She stated, "None of them are nice. I feel like I'm not likeable to them". Resident # 28 was asked who was rough with her. She stated she could not say as she did not know everyone's name. She was asked if anyone came by to ask her about the scratches or the rough handling and she responded, "No". An interview was conducted with Resident # 28's spouse on 4/2/12 at 9:50 AM. He stated that Resident # 28's scratches didn't break the skin and cleared up and went away. He was asked about rough treatment by staff. He responded, "Yea, they are rough with her". He stated that sometimes they just send in CNAs to work with her that are too small to move her. He stated that there were two CNAs "who really don't like her at all". He gave the first name of one of them and stated he did not know the other one's name, but that they worked together. He stated those CNAs were still taking care of her. Resident # 28's husband stated she "gets very upset" about the rough handling and mistreatment. An interview was conducted with the PTA on 4/2/12 at 10:00 AM. The PTA stated the scratches he observed on Resident # 28 were very red and inflamed, but they were not "oozing " . He stated some of the scratches were darker than others which indicated to him that they didn't all happen at the same time. He stated, "It didn't look like a one time pass" . He stated he was told that staff had not gotten Resident # 28 out of bed at all that previous weekend and the scratches were not there when he had worked with her on the previous Friday. The PTA was asked for clarification about his handwritten documentation which appeared to read "1/4 inch wide" . He verified that he had written that the scratches were ? inch wide. He further stated, "they were as wide as my pinky fingernail". The PTA stated he was very concerned about it and thought it should be further investigated. An interview was conducted with LVN J on 4/2/12 at 10:21 AM. She stated she was given this incident to follow up on by the DON. She stated she received it eight days later. She stated, " I went to the resident's room to investigate and the scratches were gone". She stated her husband told her he thought it happened while staff were transferring her. She stated, "I asked him if he had any problems with the treatment by staff. He said no". She stated she reported back to the DON. LVN J was asked if she had any other documentation of her investigation. She responded "No". LVN J was asked if she talked to any of the CNAs about it. She responded, "No. I didn't know who was on". In an interview with the DON on 4/2/12 at 12:46 PM she was shown the Concern Form for this incident. She stated, "This one I wasn't aware of". She was asked if injuries of unknown origin and an allegation of rough handling by staff should be investigated. She stated, "Surely. You always investigate further when there is any bruising of anything". In an interview with the ADM on 4/2/12 at 4:10 PM she stated this incident with Resident # 28 came up in the morning meeting. She stated, "We sent it back with instructions to conduct an investigation". The ADM stated they do an investigation first before reporting an injury of unknown origin. When the ADM was asked about the allegation of rough handling by staff she stated that Resident # 28 "moans a great deal when touched or turned at all". She stated Resident # 28 "turns on the call light a great deal when her husband is not here" and she's "always saying she's wet". The ADM stated she understood that the investigation was not thorough. Resident #40 Record review of the facility's grievance log revealed a Concern Form dated 2/28/12 which read, "At 8:50 am I visited (Resident # 40) & she stated she didn't have a good night because one of the nurses who she thought was new (younger girl) called her a liar several times. Apparently they argued about a pill found on her bed & had fallen to the floor. (Resident # 40) states the girl called her a liar several times". The Concern Form was signed by the Business Office Mgr on 2/28/12. Record review of the second page of the form titled "Concern Form - Action" revealed it listed the ADON's name at the top and listed the date the concern came to his attention as 3/3/12. Documentation under the section " Please describe action that has been taken " read, "Spoke with (Resident #40) and reassured her of N.W.'s staff's commitment to her health and well-being as well as a sensitivity to her changing needs. Staff inserviced on the changing needs of the residents by staff developer". This page was signed by the ADON on 3/13/12. An interview was conducted with Resident # 40 on 4/1/12 at 4:00 PM. She stated she remembered the incident. She stated she had been given her medicine in a cup and she had set it down next to her on the bed and the pills spilled out of the cup. She stated the nurse got mad and apparently thought she spilled them on purpose. She stated the nurse called her a liar several times and raised her voice at her. Resident # 40 stated she had never seen the staff member before and never saw her again after that. She stated she did not know if she was a nurse or a medication aide and did not know her name. She stated the Business Office Mgr came in her room first thing the next morning. She stated, "They said they would investigate it, but they never did". Resident # 40 was asked if the ADON came by to talk to her about it and she stated, "No I don't recall him coming by to talk to me". Resident # 40 stated she did not know who the ADON was. Resident # 40 was asked if the incident upset her and she responded, "Yes it upset me. Naturally something like that is going to upset you. It hurt my feelings". In an interview with the Business Office Mgr on 4/2/12 at 10:11 AM she stated she went into Resident # 40's room the morning after this incident occurred. She stated the resident explained to her that the nurse thought she had dropped a pill on purpose and got mad at her. She stated Resident # 40 said the nurse told her she had done that before and accused her of lying. The Business Office Mgr said Resident # 40 felt like she had been disrespected and she did not know why the nurse had treated her that way. The Business Office Mgr stated she believed Resident # 40 that the incident had occurred as she had stated. She said that she told staff about it in the morning meeting. She said she kept checking back with Resident # 40 for 3 or 4 more days to find out if the incident had been investigated. The last time she checked it had not been investigated yet. She stated she kept bringing it up in the morning meeting and they kept saying they would address it. She said she got busy and did not know if they ever investigated it or not. In an interview with the ADON on 4/2/12 at 10:55 AM he stated this concern was brought up by the Business Office Mgr in the morning meeting. He stated the facility had an Ambassador Program and the Business Office Mgr was Resident # 40's Ambassador. He stated the resident was upset "about the demeanor and affect of the staff members". He stated when he went by to interview Resident # 40 she wasn't able to remember the exact date the incident occurred. He stated, "We weren't able to figure out who she was talking about". He stated when he talked to Resident # 40 she didn't tell him that the staff member called her a liar. He stated, "She just kept saying over and over that the staff was questioning her about the pill as though she didn't believe her". The ADON stated he referred it to the Staff Dvlpmt Coord to do an in-service on communicating with the residents. The ADON was asked if he interviewed any of the staff or any other residents. He stated "No". The ADON was asked if he had any other documentation of his investigation. He stated "No". In an interview with the DON on 4/2/12 at 12:46 PM she was shown the Concern Form and asked if she thought it was an allegation of verbal/mental abuse. The DON stated, "Name calling is verbal abuse". She was asked if this incident was further investigated. The DON stated that Resident # 40 did not say to the ADON that the staff person called her a liar. She stated that she thought the ADON did talk to the staff about the incident. She stated she would talk to the ADON further about it. In an interview with the ADM on 4/2/12 at 4:10 PM she looked at the Concern Form for Resident # 40 and stated she did not remember the incident. She stated typically she would have the SW interview this resident and investigate. A plan to remove the IJ was submitted and required revision. The following plan of removal, submitted by the facility after corrections, was accepted on 3/30/2012 at 5:00 PM. Immediate Action Plan to Abate Immediate Jeopardy Pressure Sore Prevention, Identification and Treatment March 29, 2012 Issue: Immediate identification of residents with skin integrity issues. Action: Resident #1 is currently receiving treatment, care and services for current pressure ulcers. A new Weekly Head To Toe Skin Check revealed no new pressure areas. In order to establish a baseline of altered skin integrity, a Head to Toe Skin Check was completed on all residents in the facility on 3/29/12 and the results were documented on the Weekly Head to Toe Skin Check form. A risk review/Braden Scale was completed for residents with the potential for skin integrity issues in accordance with facility practice guidelines. Action: The DON/designee will now validate daily in accordance with the schedule that the Weekly Head to Toe Skin Checks are completed and documented. Daily monitoring will continue for 30 days and then randomly thereafter. Any discrepancies will be immediately addressed with the licensed staff. The monitoring started on March 29 with the completion of the Weekly Head To Toe Skin Checks. The DON and/or Unit Manager will monitor residents during routine rounds in the facility for pressure prevention beginning March 30. The census according to CMS Form 672 was 129.

Based on observation, interview and record review, the facility failed to consult with the physician for 3 of 25 residents reviewed for change of condition (Resident # 1, #15 and #48). The facility failed to: -Consult Resident # 1's physician when skin breakdown was identified on 1/31/2012. Resident #1 entered the facility with no skin breakdown and developed four stage IV pressure ulcers. -Consult Resident # 1's physician when she did not receive her ordered pain medication for 8 days (from 3/22/2012 through 3/30/2012) resulting in painful wound care as evidened by grimacing during treatment and staff reporting that it was a painful treatment. -Consult Resident # 48's physician when she did not receive her ordered pain medication for 18 days (from 3/13/2012 through 3/30/2012) resulting in resident's complaints of pain. -Consult Resident # 15's physician when she developed redness to her lower extremities resulting in an ER visit for [MEDICAL CONDITION] on 3/25/2012. Failure to consult with the physician when pain medication was not available affected 2 residents and placed the additional 43 residents on the pain managment program at risk for physical, mental and psychosocial problems. Failure to notify regarding skin changes affected one resident and placed an additional 50 residents receiving skin care and wound treatment at risk for delay in treatment resulting in worsening of the resident's skin and a decline in health. Finding Include: Resident # 1 Record review of Resident # 1's face sheet revealed that she was admitted on [DATE] from another skilled nursing facility. It further revealed that she had the following Diagnoses: [REDACTED]. Review of Resident #1's admission MDS dated [DATE] revealed that she has short and long term memory problems with severely impared daily decision making. In section B (hearing, speach and vision) it is coded that she has no speach and is rarely/never understood and rarely/never understands. In section G it is coded that she required extensive assistance with bed mobility and did not transfer in and out of bed. She was total care with toileting, hygiene and bathing. She was always incontinent of bowel and had an indwelling catheter. She received 51% or more of her nutrition through [DEVICE]. On the pain assesment section they coded no non-verbal sounds, vocal complaints of pain, facial expressions, or protective body movements or postures. Section M was coded with a stage II pressure ulcer "date of the oldest stage II" was 12/22/12. Record review of Resident # 1's 12/22/2011 nursing admission assessment revealed that she did not have a pressure sore on admission. Her Braden scale score was 11 (for predicting pressure score risk a score of 10-12 is a high risk). Additional risk factors identified included impaired or decreased mobility and decreased functional ability, cognitive impairment, urinary and/or fecal incontinence. Review of Resident #1's Significant Change MDS dated [DATE] revealed In section B (hearing, speach and vision) it is coded that she has no speach and is rarely/never understood and rarely/never understands. In section G it is coded that she required total care with bed mobility and transfer. She was total care with toileting, hygiene and bathing. She was always incontinent of bowel and had an indwelling catheter. She received 51% or more of her nutrition through [DEVICE]. On the pain assesment section they coded facial expressions (grimacing, winces, wrinkled forehead, furrowed brow, cleanched teeth or jaw). Section M revealed that she had one Stage I, and three Stage IV pressure sores. The worst pressure ulcer measurements were 6.0 cm x 4.6 cm x 4.8 cm with slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). Record review of Resident #1 3/21/12 - 3/31/12 physician's orders [REDACTED]. In an interview with LVN G on 03/28/12 at 9:35 AM he stated Resident #1 had been pre-medicated for pain for the dressing change of the sacral wound, the left hip wound and the left ear wound with regular strength Tylenol. He further stated that Resident #1 had [MEDICATION NAME] (generic name for [MEDICATION NAME]) ordered but it had not come in yet. LVN G said it was a painful dressing change and he had noticed facial grimacing from the resident during the dressing change but she was not able to verbalize. Observation of Resident #1 during wound care on 3/28/12 at 9:45 AM revealed she had facial grimacing and opened her eyes wide during performance of the procedure. Observation on 03/30/12 at 10:26 AM revealed that Resident #1 had facial grimacing when repositioned in bed. Record review of Resident # 1's January 2012 head to toe skin checks revealed the following: -1/3/2012 skin not intact, rash, perineal blisters groin and back. -1/10/12 no assessment documented as completed. -1/17/2012 skin intact. -1/31/2012 skin not intact. " Nickel sized opening at sacrum (with) scant drainage. Skin tear upper right leg without drainage." Previously identified area not checked and preventative measures in place not checked. Record review of Resident # 1's nurse's notes and physician's orders [REDACTED]. In an interview on 03/30/12 at 1:15 PM, LVN A stated that it was her signature on the head-to-toe skin check for Resident #1 dated 01/31/12. She stated she did not do anything about the new area. She stated she did not remember if she assumed a dressing was being done and that she knew better. She stated she should have told the treatment nurse about the wound. She further stated the medication for Resident #1, [MEDICATION NAME], was not in the building. She stated she was going to call the pharmacy "today" (3/30/12). She stated she did not call the other days she worked and she had no excuse for not calling. She stated she would usually ask the evening nurse to call if she could not. She stated she was not managing Resident #1's pain. Record review of Resident #1's MAR dated 03/21/12 - 03/31/12 revealed the following: Medication [MEDICATION NAME]/APAP 10/325 mg 1 four times per day per [DEVICE] (tube inserted into the abdomen for the purpose of administering medications and liquid nutrition). [DIAGNOSES REDACTED]. According to the MAR dated 03/21/12 through 03/30/12 the first dose of [MEDICATION NAME]/APAP was given at 7 PM on 3/30/2012. Documented on the back of the MAR on 03/25/12 at 7:00 AM and 7:00 PM revealed "[MEDICATION NAME] ([MEDICATION NAME]) 10/325 mg, not here". Review of Resident # 1's medical record revealed no documentation that the physician had been notified/consulted when her pain medication was not available and not being administered. In an interview on 3/29/12 at 1:45 PM the DON stated there are no emergency kits for narcotics. She stated if the medication was called in it would come in on the next run. The pharmacy makes several runs a day. She further stated if the medication is still not there the nurse was supposed to call the pharmacy to get the medication. In an interview with LVN A, who worked on the hall and cared for Resident #1, on 03/30/12 at 3:50 PM she stated she had not called the pharmacy regarding Resident #1's [MEDICATION NAME]. In an interview with the DON on 3/30/2012 at 4:15 PM regarding Resident # 1's MAR she said there was no explanation for the why the medication was not given on most of the days. She said the staff not administering the medication should always write their initials and circle them in the correct space on the MAR. The DON stated clearly from the 23rd to the 30th it does not look like she got the [MEDICATION NAME]. She further stated the staff should have followed through and should not have waited a whole week before consulting with the doctor/pharmacy. When asked what should have been done she said the staff should have called the pharmacy, especially when the resident missed a dose. The DON further stated the doctor would need to be notified that the medication was not in the facility and the resident had missed a dose. She further stated the staff would need to document that the doctor was notified and the medication had not arrived. In an interview with LVN A on 03/30/12 at 4:20 PM she stated she had called the pharmacy on that day and they told her there was no prescription from the doctor for the medication. She further stated she contacted Doctor #1 who stated he had called that prescription in to the pharmacy already. In an interview on 04/02/12 at 9:50 AM, Doctor #1 stated Resident #1 was in pain when she left the hospital and she should have been on pain medication at this facility. He stated "nobody notified me" that she was not getting her pain medication. He stated, "I talked with the pharmacy and sent two prescriptions, one to (a local pharmacy) and one to their pharmacy" and that they were original prescriptions from the hospital. He stated, "I don't know why she did not get the medication". He stated that the pharmacy contacted him to get the prescription. He further stated that the wounds were a mystery to him. He stated that he spoke to the administrator and requested proper training at the facility to care for residents at risk for skin issues. In an interview on 4/02/12 at 10:50 AM, the pharmacist stated Resident #1 did not have a prescription or a doctor's order for the [MEDICATION NAME] until 3/30/12. She stated that they faxed a notification to the facility on [DATE] that stated they needed a prescription for the [MEDICATION NAME], but there had been no follow-up response. She stated that the [MEDICATION NAME] was filled on 03/30/12 after receiving the script from the doctor. In an interview with the DON on 4/02/12 at 11:56 AM she stated the [MEDICATION NAME] for Resident #1 was a scheduled medication on readmission (3/21/12) and that the medication was not received by the facility. She stated the nurse should have initialed, circled their initials and then documented on the back why the medication was not administered. She further stated the nurse should then notify the M.D and document the notification in the nurse's notes. The nurse should have followed up to be sure the resident received the prescribed medications. The DON further stated it was the nurse's responsibility to follow-up with both the doctor and the pharmacist. She stated that the nurse should document on all calls to the pharmacy and the doctor in the nurse's notes. Resident # 48 Record review of Resident #48's face sheet revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #48's readmission/return assessment dated [DATE] revealed that she has clear speech and she is understood and she understands verbal content. Her pain assessment interview revealed her to state that yes, she has had pain or hurting in the past 5 days. Frequency was coded as frequently and the pain effect on the resident was that it made it hard for her to sleep at night and limited her daily activities. Pain intensity was "moderate". Observation of Resident # 48 on 3/31/2012 at 11:35 AM she was lying in bed and had dressings to both feet. She was awake and alert and able to answer questions. In an interview with Resident # 48 on 3/31/2012 at 11:35 AM she said that she had pain all over, a 5 on a scale of 1 to 10 with 10 being the worst. She said that pain medication " helps cool it down somewhat " . Resident # 48 said that her pain was mostly in the heels and ankles on the inside and outside. Record review of Resident #48's 3/13/2012 physician's orders [REDACTED]. Further review of these physician orders [REDACTED]. Record review of Resident #48's 03/13/2012 to 03/31/2012 MAR revealed the following; [MEDICATION NAME] 7.5 mg/[MEDICATION NAME] 325 mg 1 tablet twice a day for a [DIAGNOSES REDACTED].M. and 9 PM. There was no documentation that the medication was administered on following dates and times: 3/13/2012 to 3/30/2012 for the 9:00 AM dose. For the 3/13/2012 through 3/17/2012, 3/21/2012 through 3/23/2012, and 3/27/2012 through 3/29/2012 for 9:00 PM.. There were initials that were circled (indicating that the medication was not administered) on 3/18/2012, 3/20/2012, and 3/26/2012 for 9:00 PM. There were initials that the medication was administered on 3/19/2012, 3/24/2012, and 3/25/2012 for 9:00 PM. On the back of MAR there was documentation 03/20/12, [MEDICATION NAME] 7.5/325 PO 9:00 PM, unavailable. Instructions on the MAR read: A. Put initial in appropriate box when medication or treatment is given. B. Circle initials when medication or treatment is refused. C. State reason for refusal on Nurse's Notes. Record review of the Resident # 48's medical record revealed no documentation that the physician had been notified the resident was not receiving her scheduled pain medication. In an interview with the DON on 3/29/2012 at 1:45 PM she stated if a medication was not available the nurse was to call the pharmacy for a STAT run. She stated it was the nurse's responsibility to ensure the residents received the right medications, dose, and at the right time. In an interview on 03/30/12 at 1:15 PM, LVN A, who was a charge nurse for the hall the resident lived on, said Resident #48 did not have her pain medication and needed a prescription from the doctor. She stated that she had called the doctor "today" and that she had the pain medication now. She admitted that Resident #48 had been there for two weeks without pain medication. She stated that the unit managers were not in the building and had been out on leave for a while. In an interview with LVN H on 4/2/3012 at 1:20 PM she stated that no one had notified her that Resident #48 was out of medication. In an interview the ADON on 4/2/2012 at 1:35 PM he stated the reason there was no count sheet for Resident #48's [MEDICATION NAME] was most likely because the medication was not in the building. He stated the issue was with calling the MD for a prescription for the pharmacy to fill. In an interview with LVN H, who was a charge nurse for the hall where Resident #48 resided, on 4/2/2012 at 2:10 PM she acknowledged her initials on Resident #48 MAR on 3/24/2012. She stated she must have given the medication since her initials were on the MAR. She had no explanation as to how she could have given the medication since it was never in the building. In an interview with MA D on 4/2/2012 at 2:20 PM she stated she knew the [MEDICATION NAME] for Resident #48 was not delivered and she had let the charge nurses know since the resident had complained of pain. She stated she had to administer regular Tylenol instead since the [MEDICATION NAME] was not available. In an interview on 4/2/2012 at 2:29 PM the DON stated Resident #48 [MEDICATION NAME] was never ordered from the pharmacy. She stated she was not sure why it was signed off on the MAR and the blanks were incorrect documentation. She further stated that there was no "count sheet " for this medication since it was never in the building. In an interview LVN G on 4/2/2012 at 2:45 PM he acknowledged his signature on Resident #48 MAR dated 3/25/2012 and stated the medication "must have been there for me to give it". He further stated he was not sure. He had no explanation for how he could have given the medication since it was never in the building. Resident # 15 Record review of Resident #15's face sheet revealed that she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #15's annual MDS dated [DATE] revealed she had clear speech, was understood and understands, and had short and long term memory problems. She was independent with bed mobility transfer and walking and hygiene. She needed limited assistance with dressing and supervision with toileting. There were no skin issues identified on the MDS. An observation of Resident # 15 on 4/2/2012 at 10:30 AM revealed the risident sitting on the couch in the front lobby. She had redness to both of her lower legs and dry flaky skin. Record review of Resident #15's 03/26/12 nurse practitioner progress note revealed that the resident was seen today (3/26/12) for follow up of left leg [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. The skin revealed the left leg [DIAGNOSES REDACTED], warmth, [MEDICAL CONDITION]. Under diagnostic tests, it revealed a venous Doppler (test to check for blood clots) negative to left lower extremity. "1. [MEDICAL CONDITION] (left) leg - (per family member); the (symptom) has been there for 4 weeks. My last visit with her on 03/13 did not detect any [MEDICAL CONDITION]. Nurse was notified by family a week ago but the message did not get to me. Will start on Bactrim DS (antibiotic) 1 tablet by mouth every day times 14 days. 2. Bilateral lower extremity [MEDICAL CONDITION], new onset . . .". Record review of Resident #15's medical record revealed no documentation that the doctor had been notified regarding redness to her lower extremities until 03/25/12. Record review of Resident #15's change of condition for 03/25/2012 nurse's note read "6:45 PM; Family returned back with resident to facility and complaint (sic) of resident (left) leg swollen and stated they called MD and MD stated they should take resident to ER. Family took resident to ER and back without (unreadable) MD having to see resident . . .NP notofied . . . new orders". Record review of Resident #15's nurse's note 03/25/12 at 1:50 PM read "Resident's family here to take resident out of the facility. Family ....stated she complaint (sic) and notified nurse to assess and treat resident's leg (left) possibly cellulites (sic) and rash to bottom. Wound care nurse assessed resident's leg and states that the NP will take a look at it tomorrow (03/26/12) and he will start treatment to the leg and bottom. Resident denies any pain and no s/s of distress noted. Will continue to monitor resident". On 03/25/12 at 3:40 PM, the nurse's note read: Resident's family member ....call (sic) to notify nurse that she is taking resident to ER and that resident was spitting blood and left leg feeling warm. As such, she called M.D. and M.D. gave her orders to go to the ER with the resident. Nurse asked the family member to notify the facility of the resident's condition when they get to the ER. Awaiting a call from the ER or the resident's family. Record review of Resident #15's head to toe skin checks for January 2012 revealed the skin was intact on 01/04/12, 01/11/12, and 01/25/12. During an interview with Resident # 15's family member on 3/28/2012 at 12:20 PM he stated that the nurses (LVN H, LVN L and the ADON)working on the floor had been informed by him around the 18th of March regarding the redness to the resident's legs. He said a small infection starting on her legs had gained fever and gotten much worse. He said "her legs have split and need wound care". The family member stated that he later had a conversation with facility staff who informed him that they could find no record of being informed about the redness. In an interview with the NP on 3/30/2012 at 11:25 AM she said she was in the facility 4 times a week and the doctor was in twice a week. She stated Resident # 15's family member called and reported the redness to her leg on 3/25/12. The NP said she was not notified by the facility nurses although the family said they had reported the symptoms. She further stated she had asked the nurses and no one was aware of the resident's skin issues. In an interview with the DON on 4/2/2012 at 7:35 AM she was given Resident # 15's 3/26/2012 progress note to read. She said that she was not previously aware that the doctor had not been notified/consulted. The DON said that the nurse was supposed to assess the resident. She further stated they were supposed to notify the family and the physician to obtain treatments and carry them out. Record review of the facility's policy and procedure revised June 2008 titled Changes in Resident Condition read in part "The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. ... #2) ...b. provide assessment information to the physician... #3) Changes in condition are communicated from shift to shift through the 24 hour report management system."... According to CMS Form 672 the facility census was providing skin or wound care to 51 residents and had 45 residents on the pain management program.

Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain the highest practical physical well-being of residents, in accordance with their assessments and plans of care. The facility failed to: -Obtain and administer Resident # 1's [MEDICATION NAME] 10/325 mg (pain medication) for 8 days from 3/22/2012 through 3/30/2012 at 1:00 PM resulting in the resident experiencing pain as evidenced by facial grimacing during wound care -Obtain and administer Resident # 48's [MEDICATION NAME] 7.5 /325 mg for 18 days from admission on 3/13/2012 through 3/30/2012 resulting in the resident experiencing pain. Failure to administer pain medication affected 2 residents and placed an additional 43 at risk for worsening physical, mental well-being. Findings include: Resident # 1 Record review of Resident # 1's face sheet revealed that she was admitted on [DATE] from another skilled nursing facility. It further revealed that she had the following Diagnoses: [REDACTED]. During an observation on 03/30/12 at 10:26 AM, Resident #1 was noted to have facial grimacing when being repositioned in bed. In an interview with LVN G on 03/28/12 at 9:35 AM he stated Resident #1 had been pre-medicated for pain for the dressing change with regular strength Tylenol. He further stated that Resident #1 had [MEDICATION NAME] ordered but it had not come in yet. LVN G said it was a painful dressing change and he had noticed facial grimacing from the resident during the dressing change but she was not able to verbalize. Record review of Resident #1's MAR dated 03/21/12 - 03/31/12 revealed the following: Medication [MEDICATION NAME]/APAP 10/325 mg 1 four times per day per [DEVICE] (tube inserted into the abdomen for the purpose of administering medications and liquid nutrition). [DIAGNOSES REDACTED]. Medication was not given 03/22/12 through 03/30/12 at 1:00 PM. The first dose was given at 7 PM on 3/30/2012. Documented on the back of the MAR on 03/25/12 at 7:00 AM and 7:00 PM "[MEDICATION NAME] ([MEDICATION NAME]) 10/325 mg, not here". Record review of Resident # 1's PRN Pain Medication Administration Record dated 03/2012 lists medication: Tylenol 650 mg every four PRN. There was no documentation noted for entire month of 03/2012. Review of a Change of condition form dated 03/15/12 revealed Situation: Multiple wounds for debridement on 02/17/12. Wound needing debridement of left hip. Pertinent history includes pain, new onset of wounds. Pain level location: Resident nonverbal, but facial grimacing noted during left hip, right and left ear, and sacral dressing changes. Change in skin is yes. Wound status: Left hip, stage IV, sacral stage IV, right ear and left ear stage IV, right and left heel stage I redness. New orders: Transfer to (local hospital) for left hip wound debridement. Record review of Resident # 1's 3/22/2012 at 1:00 AM Nursing Admission Assessment revealed medications verified with doctor and faxed to pharmacy. It further revealed that some medications were received. Record review of Resident # 1's Nursing Daily Skilled Summary revealed on 3/23/2012, 3/25/2012, and 3/27/2012 nothing checked for pain management. The 3/28/2012 Nursing Daily Skilled Summary pain management, pain treatment checked no. Review of Resident # 1's medical record revealed no further Nursing Daily Skilled Summaries. Record review for Resident #1's 12/22/11 Pain Evaluation revealed the following: -Prior history of pain or hurting, yes is checked, chronic back pain. -Manner of expression and associated symptoms, grimacing is checked. -Resident unable to describe due to cognitive impairment is checked. Record review for Resident #1's 3/21/2012 Pain Evaluation revealed the following: -[DIAGNOSES REDACTED]. -Pain management, been on a scheduled pain management regimen, yes is checked. -PRN pain medications, yes is checked. -Receiving non-medication intervention for pain, yes is checked. -Interview: Resident unable to answer. -Potential underlying cause, ulcer wound is checked and written in [MEDICAL CONDITION]. -Resident unable to describe due to cognitive impairment quality of pain or hurting. -Manner of expressing pain and associated symptoms: grimacing, groaning, frowning, tearful, elevated pulse, inflammation, warmth, tenderness are all checked. -What relieves the pain or hurting, medication administration is checked. In an interview with the DON on 3/29/12 at 1:45 PM she stated there are no emergency kits for narcotics. She stated if the medication was called in it would come in on the next run. The pharmacy makes several runs a day. She further stated if the medication is still not there the nurse was supposed to call the pharmacy to get the medication. In an interview on 03/30/12 at 1:15 PM, LVN A stated the medication for Resident #1, [MEDICATION NAME], was not in the building. She stated she was going to call the pharmacy "today". She stated she did not call the other day when she was taking care of Resident # 1 and she had no excuse for not calling. She stated she would usually let the evening nurse call if she could not. She stated she was not managing Resident #1's pain which was negelectful. In an interview with LVN A on 03/30/12 at 3:50 PM she stated she had not called the pharmacy regarding Resident #1's [MEDICATION NAME]. In an interview with the DON on 3/30/2012 at 4:15 PM regarding Resident # 1's MAR she said there was no explanation of why the medication was not given on most of the days. She said the staff not administering the medication should always put their initials and circle them. The DON stated "clearly from the 23rd to 30th it does not look like she got the [MEDICATION NAME]". She further stated the staff should have followed through, should not have allowed a whole week to pass without action. When she was asked how long was an acceptable period to wait for a medication she said that depended on when the resident was admitted to the facility. She said if admitted in the evening they should have it the next day and if not received the pharmacy should have been contacted. When asked what should have been done, she said the staff should have called the pharmacy, especially when the resident missed a dose. The DON further stated the doctor would need to be notified that the medication was not in the facility and the resident had missed a dose. She further stated the staff would need to document that the doctor was notified and the medication had not arrived. The DON said it was a medication error if the medication was not given. She said that Tylenol was not as strong as [MEDICATION NAME]. When she was asked if Resident # 1's pain was controlled she said that was a " hard question to answer " . She further stated an assessment would need to be done for indications of pain or grimacing. She said that she could not say the resident was not in pain. In an interview with LVN A on 03/30/12 at 4:20 PM she stated she had called the pharmacy who told her there was no prescription from the doctor for the medication. She further stated she contacted Doctor #1 who stated he had called that medication in to the pharmacy already. An interview was conducted with LVN C on 3/31/2012 at 8:40 AM. She said if a medication that was ordered was not available on the medication cart the nurse would need to look in the medication room for the medication and if not there call the pharmacy. She further stated they would need to document the call to pharmacy in the nursing notes, call the doctor and let the DON know. LVN C stated if they needed a hard copy prescription from the doctor they would need to keep following up until they got it. She said if they did not give the medication for 10 days it would be neglect. In an interview with LVN F on 3/31/2012 at 9:00 AM she said if a prescribed medication was not in the building the nurse would need to call the pharmacy if it was not one the medication in the emergency medication kit. She said the facility did not have a starter medication kit (emergency kit) for narcotics (pain medication). She further stated if the medication was not available the nurse would need to call the doctor and the pharmacy. She said not getting the medication for 10 days would be a medication error. LVN F said not providing care would be neglect. In an interview on 04/02/12 at 9:50 AM, Doctor #1 stated Resident #1 was in pain when she left the hospital and she should have been on pain medication at this facility. He stated "nobody notified me". He stated, "I talked with the pharmacy and sent two prescriptions, one to (a community pharmacy) and one to their pharmacy" and that they were original prescriptions. He stated, "I don't know why she did not get the medication". He stated that the pharmacy contacted him to get the prescription. He stated that he did not often see the DON or speak with her, but other staff members were accessible to him. In an interview on 4/02/12 at 10:50 AM, the pharmacist stated Resident #1 did not have a prescription or a doctor's order for the [MEDICATION NAME]. She stated that they faxed a notification to the facility on [DATE] that stated they needed a prescription for the [MEDICATION NAME], but there had been no follow-up response. She stated that the [MEDICATION NAME] was filled on 03/30/12 after receiving the prescription from the doctor. In an interview on 4/2/2012 at 1:20 PM, LVN H stated she had called the doctor's office regarding Resident #1 needing a prescription to fill the [MEDICATION NAME] but then she was off the next few days and did not notice when she returned to work the medication was still not available. Record review of Resident #1's care plan dated 12/22/2011 and reviewed on 12/29/11 and 3/23/12 revealed the following: Pain/Discomfort actual is checked, related to (the following are checked): recent surgery, skin ulcer/wound, fracture pelvic, chronic pain back,[MEDICAL CONDITION], and s/p wound debridement. Approaches included: " ...administer [MEDICATION NAME] as ordered, implement pain management flow sheet, observe resident for signs and symptoms of pain including verbal expressions and nonverbal expression (facial grimacing, bracing, restlessness, rubbing, other), notify physician if interventions are not consistently effective, medicate resident for pain prior to treatments and therapy, if indicated.. " ; Goal was for reduced pain as measured by verbal expression and/or decrease in behaviors associated with pain. Initial plan of care dated 3/21/12 revealed pain as an actual problem with a goal of " ...will have pain alleviated with both pharmacological and non-pharmacological interventions with evidence of pain relief through.. non- verbal indicators such as grimacing, groaning, crying. Interventions initiated included: ... Provide medications as ordered and document effective results of medication administration ... " Resident # 48 Record review of Resident #48's face sheet revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Observation of Resident # 48 on 3/31/2012 at 11:35 AM revealed she was lying in bed and had dressings to both feet. During an interview with the DON on 3/29/2012 at 1:45 PM she stated if a medication was not available, the nurse was to call the pharmacy for a STAT run. She stated it was the nurse's responsibility to ensure the residents received the right medications, dose, and at the right time. In an interview on 03/30/12 at 1:15 PM, LVN A stated that Resident #48 did not have her pain medication and needed a prescription from the doctor. She stated that she had called the doctor "today" and that she had the pain medication now. She admitted that Resident #48 had been there for two weeks without pain medication. She stated that the unit managers were not in the building and had been out on leave for a while. In an interview with Resident # 48 on 3/31/2012 at 11:35 AM she said that she had pain all over. She rated it a 5 on a scale of 1 to 10 with 10 being the worst. She said that pain medication " helps cool it down somewhat " . Resident # 48 said that her pain was mostly in her heels and ankles on the inside and outside. During an interview with the ADON on 4/2/2012 at 1:35 PM he stated the reason there was no count sheet for Resident #48's [MEDICATION NAME] was mostly likely because the medication was not in the building. He stated the issue was with calling the MD for a prescription for the pharmacy to fill. During an interview with LVN H on 4/2/2012 at 2:10 PM she acknowledged her initials on Resident #48's MAR on 3/24/2012. She stated she must have given the medication since her initials were on the MAR. During an interview with MA D on 4/2/2012 at 2:20 PM she stated she knew the [MEDICATION NAME] for Resident #48 was not delivered and she had let the nurses know since the resident had complained of pain. She stated she had to administer regular Tylenol instead since the [MEDICATION NAME] was not available. During an interview on 4/2/2012 at 2:29 PM, the DON stated Resident #48's [MEDICATION NAME] was never ordered from the pharmacy. She stated she was not sure why it was signed off on the MAR and the blanks were incorrect documentation. She further stated that there was no " count sheet " for this medication since it was never in the building. During an interview with LVN G on 4/2/2012 at 2:45 PM he acknowledged his signature on Resident #48's MAR dated 3/25/2012 and stated "the medication must have been there for me to give it." He further stated he was not sure. Record review of Resident #48's Pain Evaluation dated 3/13/2012 revealed that during the interview the resident stated she had pain. There was no intensity of the pain documented. Record review of Resident #48's 3/13/2012 physician's orders [REDACTED]. Further review revealed the following order: [MEDICATION NAME] 7.5mg/[MEDICATION NAME] 325mg one tablet twice a day. Record review of Resident #48's 03/13/2012 to 03/31/2012 MAR revealed the following; [MEDICATION NAME] 7.5 mg/[MEDICATION NAME] 325 mg 1 tablet twice a day for a [DIAGNOSES REDACTED].M. and 9 PM. There was no documentation that the medication was administered on following dates and times: 3/13/2012 to 3/30/2012 for the 9:00 AM dose. For the 3/13/2012 through 3/17/2012, 3/21/2012 through 3/23/2012, and 3/27/2012 through 3/29/2012 for 9:00 PM.. There were initials that were circled on 3/18/2012, 3/20/2012, and 3/26/2012 for 9:00 PM. There were initials that the medication was administered on 3/19/2012, 3/24/2012, and 3/25/2012 for 9:00 PM. On the back of MAR there was documentation 03/20/12, [MEDICATION NAME] 7.5/325 PO 9:00 PM, unavailable. Record review of Resident #48's PRN Pain Medication Administration Record, no date, revealed [MEDICATION NAME] 5/325 2 tablets by mouth every four hours PRN initialed at 7:00 PM on 3/26/2012. There was no description of pre-administration for pain or post-administration for pain documented. Record review of Resident #48 's interview for Section J Pain for MDS 3.0 dated 3/20/2012 revealed the following: Pain intensity is rated as a 5 on a scale of 0-10, intensity is described as " moderate " , and frequency is described as " frequently " . Record review of Resident #48's interview for Section J Pain for MDS 3.0 dated 3/26/2012 revealed the following: Pain intensity is described as " moderate " and frequency is described as " frequently " . Record review of Resident #48's Quarterly MDS dated [DATE] revealed under section J, pain presence is coded as " yes " , frequency is " frequently " , the pain makes it difficult to sleep at night and has limited her day-to-day activities. The pain is described as " moderate " . Record review of Resident #48's Initial Plan of Care dated 3/13/2012 revealed Pain as and actual problem. Interventions initiated included " .. provide medications as ordered and document effective results of medication administration.. " and " notify MD of unrelieved pain " . Record review of Resident #48's Care Plan Pain dated 1/11/2012 and updated 3/13/2012 list in part: Approach(es) - Administer [MEDICATION NAME] as ordered. See physician order. Implement pain management flow sheet. Observe resident for signs and symptoms of pain. Medicate resident for pain prior to treatments and therapy, if indicated. Record review of Resident #48's nurses note dated 3/16/2012 revealed " Weekly IDT (interdisciplinary team) meeting for pain. Res DX: Decubiti, DM, Chronic A-fib. Pain meds: [MEDICATION NAME] ([MEDICATION NAME]) 7.5/325 PO BID. Care plan updated. Pain assessment complete. Will continue to monitor. " Record review of the facility's pain management program dated July 2010 revealed " ... 4 .... Implement new orders received ....10. The staff will implement the Care Plan, monitor the resident, and administer therapeutic interventions for pain, if ordered .... 11. The Licensed Nurse when administering scheduled or routine pain medications, will record the drug administration on the routine MAR ... 12. The License Nurse when administering PRN pain medications, will record the drug administration on the PRN Pain Medication Administration ... 14. Monitoring ...". Continued review of the pain management program form revealed the following ... Staff implements Plan of Care - LN administers pain medication - LN records medication administration ... " Record review of facility's June 2007 Documentation policy and procedure read in part: " Purpose: Healthcare personnel will complete documentation requirements as outlined by the company and recorded in the medical record using accepted principles of documentation. Fundamental Information: Integrity: Aspects of residents care, such as observation and assessments, administration of medications, and services or treatments performed, must be documented in the resident ' s medical record according to company policy... Credibility: Be specific. Entries should reflect factual statements. Do not speculate or provide opinion. Avoid generalizations (examples to avoid; " appears, " " seems, " " apparently, " " I think. " ). Be objective. Document only what can be seen, heard, touched, felt, or smelled. Document the resident's response to care where appropriate. Use quotation marks when quoting a resident. Be complete. All facts and pertinent information related to an event, course of treatment, resident condition, response to care, and deviation from standard treatment (including the reason for the deviation) must be documented. If an original entry is incomplete, follow guidelines for making a late entry, addendum, or clarification... Be legible... There should be no blank lines or gaps left between entries, with the exception of the residents care plan... Procedure: General: 1. Chart events as they occur and maintain chronological order... 6. Medication and treatment records: When a medication or treatment is administered, the nurse initials the appropriate box on the medication administration record or treatment administration record. If the medication or treatment is not administered as ordered, the nurse circles the appropriate box and enters the reason for the omission per facility policy. If the medication or treatment is an " as often as necessary " (PRN) order, the nurse initials the appropriate box and documents the reason for administration in the appropriate section per facility policy, as well as the residents response to the medication or treatment... Charting errors and/or admissions... 5. Omissions on flow sheets. A. It is considered willful falsification and illegal to go back and complete and/or fill-in " holes " on any type of flow sheet. B. If an omission occurs with total recall by the person providing the service/medication/treatment, narrative documentation explaining the omission can be completed in the progress notes or on the narrative response section of the back of the flow sheet/record... According to the CMS 672 form there were 45 residents on pain management.

Based on observation, interview, and record review the facility failed to consult with the NP or MD for one of eight sampled residents (CR # 1) when there was a significant change in the resident's condition and need to alter treatment that resulted in CR # 1 being hospitalized and placed on a ventilator. The facility failed to: Consult with the NP or MD when abnormal results were obtained for stat lab tests completed on 12/03/2010 by 8:17PM. CR # 1 had an elevated potassium level, significant decrease in renal function, and that a large amount of protein and blood was present in her urine. CR # 1 was transferred to the hospital on [DATE] at 5:30PM where she was admitted with altered mental status, [MEDICAL CONDITION] (potassium level too high), and acute [MEDICAL CONDITION]. The failure to consult with the MD after obtaining abnormal lab values affected one resident and could affect all 123 residents by placing them at risk for undetected health issues, delayed treatment, and a decline in their health status. Findings included: Complaint # 0 A review of CR # 1's Admission MDS completed on 9/30/2010 revealed that she was a [AGE] year old female admitted to the facility on [DATE]. A review of CR # 1's Physician Summary Orders dated 12/2010 revealed her [DIAGNOSES REDACTED]. A review of CR # 1's Physician Telephone Orders revealed an order dated 12/03/2010 that read in part " CBC, BMP and UA CS stat. Call Physician (with) Result. . . " . A review of CR # 1's BMP collected 12/03/2010 at 18:11 (6:11PM) revealed that CR # 1's potassium level was 5.6 (normal range 3.5 - 5.3), her BUN (test to determine kidney function) was 68 (normal range 7 - 25), and her creatinine level was 4.6 (normal range 0.6 - 1.2). These test results had a release date and time of 12/03/2010 at 20:00 (8:00PM). This document was not found in CR #1's medical record. It was provided by the DON on 12/14/2010. This document did not indicate that the results had been faxed or called into the MD. A review of CR # 1's UA collected 12/03/2010 at 18:11 (6:11PM) revealed that CR # 1's urine contained a large amount of blood (normal result is negative) and 30mg/dl of protein (normal result is negative). These test results had a release date and time of 12/03/2010 at 20:17 (8:17PM). This document was not found in CR # 1's medical record. It was provided by the DON on 12/14/2010. This document did not indicate that the results had been faxed or called into the MD. A review of CR # 1's physician progress notes [REDACTED]. . .". A review of CR # 1's BMP dated 11/26/2010 revealed her potassium level at 4.7 (normal), her BUN at 30 (elevated), and her creatinine level at 0.9 (normal). These results had written documentation on it that indicated that these results were reported to the MD by phone. A review of CR # 1's UA dated 11/26/2010 revealed that her urine was negative for blood or protein. These results had written documentation on it that indicated that these results were reported to the MD by phone. A review of CR # 1's "Change in Condition" form dated 12/04/2010 revealed that her altered level of consciousness and lethargy was documented to have stated at 14:30 (2:30PM) on 12/04/2010 by LVN A. The document read in part "1430 (2:30PM): (patient) in bed. Lethargic. (patient) family requests labs be drawn . . . 15:00 (3:00PM) (vital signs) taken per family request. BP 83/61. . . family requests (patient) be sent to (Hospital). 1530 (3:30PM) VS rechecked 94/70 . . . 77% (oxygen saturation, normal range 92% - 100%). . . (patient) started on 1.5L (oxygen delivered through the nose) . . .1600 (4:00PM) (NP) notified of (change) in (patient) condition. Order received to send (patient) to (Hospital) . . .1730 (5:30PM) (patient) was transfered (sic) via ambulance to (Hospital). . .". A review of CR # 1's Physician Telephone Orders revealed an order dated 12/04/2010 at 2:45PM that read "Please draw CBC, CMP, (and) [MEDICATION NAME] (hormone released when the body is under stress) level". This order had "void" and line written through it. An interview was conducted with LVN A by phone on 12/20/2010 at 1:50PM. LVN A stated that she worked with CR # 1 on 12/04/2010. She stated that day was the first day that she had ever worked with CR # 1. LVN A stated that she received verbal report from the off-going nurse that CR # 1 had been "real lethargic" lately. She stated that she did not know what was CR # 1's normal behavior. LVN A stated that she took CR # 1's blood pressure at the family's request. She stated that the BP result was low and that she informed her supervisor, RN B. She stated that she and RN B continued to monitor CR # 1 until she was sent to the hospital. When asked if she was aware that CR # 1 had stat labs completed on 12/03/2010, she stated "no". When asked how long it took to get stat-lab results, she stated that it took a couple of hours. She stated that abnormal results needed to be reported to the MD. An interview was conducted with the DON on 12/20/2010 at 2:47PM. She stated that the nurses were responsible for following up on labs. The DON stated that the nurse should write on the 24 hour report or verbally report to the oncoming nurse that labs were completed or pending. She stated that stat labs had a turn around time, time to complete and report results, of three to four hours. She stated that the results were faxed by the lab to the facility. She stated that when critical values were obtained that the lab would also call the results to the facility. The DON stated that the lab results then needed to be communicated to the MD by fax or phone. She stated that the manner of communication to the MD depended on the MD to be notified, because each MD had a preferred manner of notification. An interview was conducted with Family Member on 12/09/2010 at 11:04AM. Family Member stated that he was at the facility the day CR # 1 was transferred to the hospital. He stated that her oxygen level and blood pressure were very low that day. He stated that because she was not breathing right at the hospital that she was placed on a ventilator. An interview was conducted on 12/20/2010 at 2:38PM by phone with Lab Tech A. Lab Tech A stated that CR # 1's stat lab blood work was faxed to the facility on [DATE] at 20:10 (8:10PM). A review of CR # 1's Hospital ER notes revealed that she arrived on 12/04/2010 at 18:19 (6:19PM). These notes read in part ". . . Presenting complaint: (EMS) states (patient) from (Facility) with (complaints of) AMS (for) 24 hours; (patient) alert, groaning; . . . (patient's) son stated that his mother 'has been sleepy since yesterday, comes in and out'. . .". A review of CR # 1's Hospital Physicians Orders revealed her admission [DIAGNOSES REDACTED]. An interview was conducted with Hospital RN A on 12/09/2010 at 3:15PM. RN A stated that he worked in the ICU and that CR # 1 was his patient. He stated that CR # 1 was admitted to the ICU for alerted mental status, acute [MEDICAL CONDITION], and [MEDICAL CONDITION]. He stated that CR # 1 was still on a breathing machine and was not able to communicate. Requests for additional documentation related to CR # 1 from 12/02/2010 to 12/04/2010 and 12/03/2010 lab result notification were requested from the DON on 12/14/2010 at 2:45PM and 12/20/2010 at 12:00PM. No additional documentation was provided by the time of exit. A review of a policy and procedure entitled "Changes in Resident Condition" read in part "The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. . . The resident, attending physician and legal representative or designated family member are notified when there is . . . a significant change in the resident ' s physical, mental or psychosocial status. . . a need to alter treatment significantly. . .". There were 123 residents per the facility census.