Every finding on record at Park Manor of Humble

Based on interview, and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily and systematically organized in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #1) reviewed for clinical records.The facility failed to document the monitoring of Resident #1's unwitnessed fall on 5/1/26 and 5/2/26 in a timely manner. This failure could place residents at risk for a delay in care, injury, and hospitalization.Findings included:Record review of Resident #1's admission Record, dated 5/21/26, revealed an [AGE] year-old female admitted on [DATE]. Her diagnoses included traumatic subdural hemorrhage without loss of consciousness (is bleeding that occurs between the dura mater and the arachnoid mater of the brain), Alzheimer's disease with late onset, bilateral osteoarthritis of hip (the protective cartilage that cushions the ends of the bones wears down over time), contracture of right and left hip (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility), cognitive communication deficit, personal history of traumatic brain injury, fracture of lower end of right femur, and osteoporosis (bones to become weak and brittle).Record review of Resident #1's quarterly MDS assessment, dated 3/22/26, revealed a BIMS score of 1 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care.Record review of Resident #1's care plan, dated 3/19/26, revealed she was at high risk for falls related to a balance problem. She had an actual fall with no injury related to poor balance on 5/1/26 (revised on 5/9/26). Interventions included physical therapy to evaluate.Record review of Resident #1's nursing notes, dated 5/1/26 at 12:20 p.m. by RN R (created 11 days later on 5/12/26 at 3:27 p.m.), read in part, .LATE ENTRYNote Text: Writer was notified that resident was on the floor in her room. Writer went in room observed resident lying on her left side close to her bed. Resident is A&Ox3. She was able to answer question. Resident reported that she was trying to go back to bed and fell. Resident denied hitting her head on the floor but she said that she has a little pain in her left thigh, writer looked at her thigh, no bruise and no visible injury observed. Resident has shock (sic) on. Writer saw resident in room with volunteers 10 minutes ago. Resident reported that they was praying for her and left her in her room with the door closed. Resident has her floor matt (sic) on. resident wnl. bp 122/66 HR 67 SO2 97%RA. TEMP 97.6 ACTIVE ROM. Resident was picked up from the floor and put back in her chair. Resident reported pain and pain med administered. RP made aware. DON and (family member) notified. Resident is at the nursing station.Record review of Resident #1's nursing note dated 5/1/26 at 2:14 p.m. by RN R (created 2 days later on 5/3/26 at 3:49 p.m.), read in part, .resident is at the nursing station. writer went and asked if she is still in pain. Resident denied pain or discomfort. Resident has no visible injury, will be monitoring . Record review of Resident #1's nursing note, dated 5/3/26 at 3:02 p.m. by LVN G, read in part, . Resident has a bruise on Right side of jaw. Resident stated that she fell. I ask (sic) her what happened, did she fall. she said yes, she fell. and then I asked her who picked her up and she said she doesn't know. (Family member) is in her room, and other (family member) on video on the tablet. (Family member) stated that he seen (sic) her (Resident #1) in the room.Record review of Resident #1's Pain Assessment regarding her fall on 5/1/26 revealed it was dated 5/1/26 but created 2 days later on 5/3/26 by RN R. Record review of Resident #1's Neurological Assessment regarding her fall on 5/1/26 revealed it was dated 5/1/26 but created 2 days later on 5/3/26 by RN R. Record review of Resident #1's Fall Risk Assessment regarding her fall on 5/1/26 revealed it was dated 5/1/26 but created 2 days later on 5/3/26 by RN R. During an interview on 5/21/26 at 11:21 a.m., LVN G said she was coming onto her shift on Sunday 5/3/26 and Resident #1's family member asked what happened to the resident's face and no staff (on duty) knew. She said the resident had a bruise on the jawline that appeared red, purple and blue and Resident #1 said that her jaw hurt. LVN G said Resident #1 said she fell but did not know who picked her up. LVN G said no one gave her report on a fall. She said the nurse who she relieved was unaware of the fall but informed her the ADON knew what occurred and would speak to the family. LVN G said she put a progress note in the system but did not call the MD or NP at that time. She said she did not conduct an assessment because the ADON already knew about it and she was unsure if the incident was noted in the computer system prior because she did not look. She said as soon as she left Resident #1's room she left the building because the CNAs were acting unusual, and did not leave report for the next person. She said if a resident reported a fall the nursing staff were supposed to check on them, call the MD, do an incident report, and assess for any bruising. During an interview on 5/21/26 at 11:57 a.m., RN R said nursing staff always kept Resident #1 at the nursing station because she was a fall risk. On 5/1/26 two volunteers brought Resident #1 to her room, prayed with her and left her in the room with the door shut. She said a CNA discovered the resident fell and reported it to the nurse (RN R). When she arrived at the room, she assessed the resident and there was no bruising. She said the resident expressed pain in the middle of her chin and she administered Tylenol. The resident told her she did not hit her head but she started neuro checks. She reported the fall to the DON. She said she forgot to notify the resident's family member and thought she notified the provider but was unsure. The DON informed her to monitor the resident for bruising and pain in case she needed to be sent to the ER. She said when she left for the day (at 2:00 p.m.) the resident was fine. She said she did not write anything down on paper regarding the fall and was unsure what she documented in the resident's electronic medical record that day. She said the next nurse arrived late for her shift and she (RN R) was already gone. She said the manager should have reported the fall to the next nurse. She said she may have forgotten to document the fall that day and might have documented it later. She said the Unit Manager called her later to ask what happened and said she did not document it. She said if the resident had no injuries the fall protocol was to notify the family, MD and monitor to see if there were any symptoms of pain.During an interview on 5/21/26 at 1:26 p.m., LVN L said she was Resident #1's nurse on 5/2/26 and 5/3/26 from 6:00 a.m. - 2:00 p.m. She said she was made aware of the fall on Saturday (5/2/26) but could not recall from whom. She said the resident was fine on Saturday and had no bruise or pain. She said she checked Resident #1's vital signs, conducted neuros and asked if she was in pain. She said she forgot to document anything about the resident's fall in the medical record and did not know why. She said after a fall, nurses should document, conduct neuros, vital signs, and assess for injuries and pain. She said the facility did provide an in-service on falls and documentation that following Monday, 5/4/26, after the incident.During an interview on 5/21/26 at 1:43 p.m., the DON said on 5/1/26 she went to Resident #1's room with RN R and saw the resident on the floor. She said the resident was assessed and did not have pain at the time and there were no bruises at the time. She said she left the room and RN R took over the incident. She said on Sunday, 5/3/26, she received a phone call from the facility that Resident #1's family member was upset because of the bruising on her face and that no one notified them. She said some documentation regarding Resident #1's fall was missing in the chart and on 5/3/26 the Unit Manager contacted RN R to ensure it was completed. She said there was a conversation with the nurses on ensuring documentation was done but nothing was documented on paper. During an interview on 5/21/26 at 2:30 p.m., LVN B said she worked with Resident #1 on 5/2/26 and was not aware she fell because she was not notified. She said she did not monitor her for falls during her shift and did not conduct neuro checks. She said she was normally notified of falls through the 24-hour report or through shift change report. She said after a resident falls, nursing staff conduct a fall follow up for 3 days and document in the electronic medical record. She said Resident #1 was a fall risk and was at her baseline on Saturday (5/2/26) with no changes noticed.During an interview on 5/21/26 at 2:38 p.m., the Unit Manager said she was unaware about Resident #1's fall on 5/1/26 and 5/2/26. She said on Sunday, 5/3/26, she saw on the 24 hour report that neuro checks were initiated but not locked in the system. She said concerns were noted with the documentation on this fall. She said she called RN R so she could do the documentation. During an interview on 5/21/26 at 3:17 p.m., the DON said for a fall, nursing staff should assess the resident for injuries, pain, provide medication, ask them what happened/what were you trying to do and notify the family and MD. She said neuro checks should be started if it was an unwitnessed fall. The DON said the follow up documentation included status post 1-3 days per shift. She said the follow up included monitoring for any bruising that occurred, complaints of pain, and ensuring the resident was not trying to do the activity they were doing prior to falling. She said communication from shift to shift should be on the 24-hour sheet and verbal person to person she be conducted when doing rounds. She said she was unsure if the nurse on the 2:00 p.m. - 10:00 p.m. shift on 5/1/26 was notified of Resident #1's fall and said she did not inform her because that was not something she did. She said if the information on the fall was not given during report the next shift nurse could check the documentation. She said if there was no documentation the next shift would not know. She said a conversation was had with the nurses on proper documentation, status post monitoring, and communicating with one another about the falls but there was no record of that. She said the Unit Manager, ADON, and DON provided oversight to ensure the documentation was done. During an interview on 5/21/26 at 4:46 p.m., the Administrator said he expected nursing staff to start the documentation right away, start neuro checks, notify the MD and RP, and pass the information on to the next shift and monitor the resident for the next three days. He said the fall process was in place to ensure there were no major injuries following a fall, including bruises. The Administrator said the risk of not following the process would include missing a change in condition.Record review of the facility's policy titled, Assessing Falls and Their Causes, dated October 2010 read in part, .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Steps in the Procedure.After a Fall: 5. Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. 6. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. 7. An incident report must be completed for resident falls. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services no later than 24 hours after the fall occurs. Defining Details of Falls: 1. After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred.

Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #1) reviewed for quality of care.The facility failed to ensure nurses monitored Resident #1 after an unwitnessed fall on 5/1/26 according to the facility policy.The facility failed to document the monitoring of Resident #1's unwitnessed fall on 5/1/26 and 5/2/26. This failure could place residents at risk for a delay in care, injury, and hospitalization.Findings included:Record review of Resident #1's admission Record, dated 5/21/26, revealed an [AGE] year-old female admitted on [DATE]. Her diagnoses included traumatic subdural hemorrhage without loss of consciousness (is bleeding that occurs between the dura mater and the arachnoid mater of the brain), Alzheimer's disease with late onset, bilateral osteoarthritis of hip (the protective cartilage that cushions the ends of the bones wears down over time), contracture of right and left hip (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility), cognitive communication deficit, personal history of traumatic brain injury, fracture of lower end of right femur, and osteoporosis (bones to become weak and brittle).Record review of Resident #1's quarterly MDS assessment, dated 3/22/26, revealed a BIMS score of 1 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care.Record review of Resident #1's care plan, dated 3/19/26, revealed she was at high risk for falls related to a balance problem. She had an actual fall with no injury related to poor balance on 5/1/26 (revised on 5/9/26). Interventions included physical therapy to evaluate.Record review of Resident #1's nursing notes, dated 5/1/26 at 12:20 p.m. by RN R (created 5/12/26 at 3:27 p.m.), read in part, .LATE ENTRYNote Text: Writer was notified that resident was on the floor in her room. Writer went in room observed resident lying on her left side close to her bed. Resident is A&Ox3. She was able to answer question. Resident reported that she was trying to go back to bed and fell. Resident denied hitting her head on the floor but she said that she has a little pain in her left thigh, writer looked at her thigh, no bruise and no visible injuryobserved. Resident has shock (sic) on. Writer saw resident in room with volunteers 10 minutes ago. Resident reported that they was praying for her and left her in her room with the door closed. Resident has her floor matt (sic) on. resident wnl. bp 122/66 HR 67 SO2 97%RA. TEMP 97.6 ACTIVE ROM. Resident was picked up from the floor and put back in her chair. Resident reported pain and pain med administered. RP made aware. DON and (family member) notified. Resident is at the nursing station.Record review of Resident #1's nursing note, dated 5/3/26 at 3:02 p.m. by LVN G, read in part, . Resident has a bruise on Right side of jaw. Resident stated that she fell. I ask (sic) her what happened, did she fall. she said yes, she fell. and then I asked her who picked her up and she said she doesn't know. (Family member) is in her room, and other (family member) on video on the tablet. (Family member) stated that he seen (sic) her (Resident #1) in the room.During an interview on 5/21/26 at 11:21 a.m., LVN G said she was coming onto her shift on Sunday 5/3/26 and Resident #1's family member asked what happened to the resident's face and no staff (on duty) knew. She said the resident had a bruise on the jawline that appeared red, purple and blue and Resident #1 said that her jaw hurt. LVN G said Resident #1 said she fell but did not know who picked her up. LVN G said no one gave her report on a fall. She said the nurse who she relieved was unaware of the fall but informed her the ADON knew what occurred and would speak to the family. LVN G said she put a progress note in the system but did not call the MD or NP at that time. She said she did not conduct an assessment because the ADON already knew about it and she was unsure if the incident was noted in the computer system prior because she did not look. She said as soon as she left Resident #1's room she left the building because the CNAs were acting unusual, and did not leave report for the next person. She said if a resident reported a fall the nursing staff were supposed to check on them, call the MD, do an incident report, and assess for any bruising. During an interview on 5/21/26 at 11:57 a.m., RN R said nursing staff always kept Resident #1 at the nursing station because she was a fall risk. On 5/1/26 two volunteers brought Resident #1 to her room, prayed with her and left her in the room with the door shut. She said a CNA discovered the resident fell and reported it to the nurse (RN R). When she arrived at the room, she assessed the resident and there was no bruising. She said the resident expressed pain in the middle of her chin and she administered Tylenol. The resident told her she did not hit her head but she started neuro checks. She reported the fall to the DON. She said she forgot to notify the resident's family member and thought she notified the provider but was unsure. The DON informed her to monitor the resident for bruising and pain in case she needed to be sent to the ER. She said when she left for the day (at 2:00 p.m.) the resident was fine. She said she did not write anything down on paper regarding the fall and was unsure what she documented in the resident's electronic medical record that day. She said the next nurse arrived late for her shift and she (RN R) was already gone. She said the manager should have reported the fall to the next nurse. She said she may have forgotten to document the fall that day and might have documented it later. She said the Unit Manager called her later to ask what happened and said she did not document it. She said if the resident had no injuries the fall protocol was to notify the family, MD and monitor to see if there were any symptoms of pain.During an interview on 5/21/26 at 1:26 p.m., LVN L said she was Resident #1's nurse on 5/2/26 and 5/3/26 from 6:00 a.m. - 2:00 p.m. She said she was made aware of the fall on Saturday (5/2/26) but could not recall from whom. She said the resident was fine on Saturday and had no bruise or pain. She said she checked Resident #1's vital signs, conducted neuros and asked if she was in pain. She said she forgot to document anything about the resident's fall in the medical record and did not know why. She said after a fall, nurses should document, conduct neuros, vital signs, and assess for injuries and pain. She said the facility did provide an in-service on falls and documentation that following Monday, 5/4/26, after the incident.During an interview on 5/21/26 at 1:43 p.m., the DON said on 5/1/26 she went to Resident #1's room with RN R and saw the resident on the floor. She said the resident was assessed and did not have pain at the time and there were no bruises at the time. She said she left the room and RN R took over the incident. She said on Sunday, 5/3/26, she received a phone call from the facility that Resident #1's family member was upset because of the bruising on her face and that no one notified them. She said some documentation regarding Resident #1's fall was missing in the chart and on 5/3/26 the Unit Manager contacted RN R to ensure it was completed. She said there was a conversation with the nurses on ensuring documentation was done but nothing was documented on paper. During an interview on 5/21/26 at 2:30 p.m., LVN B said she worked with Resident #1 on 5/2/26 and was not aware she fell because she was not notified. She said she did not monitor her for falls during her shift and did not conduct neuro checks. She said she was normally notified of falls through the 24-hour report or through shift change report. She said after a resident falls, nursing staff conduct a fall follow up for 3 days and document in the electronic medical record. She said Resident #1 was a fall risk and was at her baseline on Saturday (5/2/26) with no changes noticed.During an interview on 5/21/26 at 2:38 p.m., the Unit Manager said she was unaware about Resident #1's fall on 5/1/26 and 5/2/26. She said on Sunday, 5/3/26, she saw on the 24 hour report that neuro checks were initiated but not locked in the system. She said concerns were noted with the documentation on this fall. She said she called RN R so she could do the documentation. During an interview on 5/21/26 at 3:17 p.m., the DON said for a fall, nursing staff should assess the resident for injuries, pain, provide medication, ask them what happened/what were you trying to do and notify the family and MD. She said neuro checks should be started if it was an unwitnessed fall. The DON said the follow up documentation included status post 1-3 days per shift. She said the follow up included monitoring for any bruising that occurred, complaints of pain, and ensuring the resident was not trying to do the activity they were doing prior to falling. She said communication from shift to shift should be on the 24 hour sheet and verbal person to person she be conducted when doing rounds. She said she was unsure if the nurse on the 2:00 p.m. - 10:00 p.m. shift on 5/1/26 was notified of Resident #1's fall and said she did not inform her because that was not something she did. She said if the information on the fall was not given during report the next shift nurse could check the documentation. She said if there was no documentation the next shift would not know. She said a conversation was had with the nurses on proper documentation, status post monitoring, and communicating with one another about the falls but there was no record of that. She said the Unit Manager, ADON, and DON provided oversight to ensure the documentation was done. During an interview on 5/21/26 at 4:46 p.m., the Administrator said he expected nursing staff to start the documentation right away, start neuro checks, notify the MD and RP, and pass the information on to the next shift and monitor the resident for the next three days. He said the fall process was in place to ensure there were no major injuries following a fall, including bruises. The Administrator said the risk of not following the process would include missing a change in condition.Record review of the facility's policy titled, Assessing Falls and Their Causes, dated October 2010 read in part, .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Steps in the Procedure.After a Fall: 5. Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. 6. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. 7. An incident report must be completed for resident falls. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services no later than 24 hours after the fall occurs. Defining Details of Falls: 1. After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature control, and only permit only authorized personnel to have access to the keys for 2 of 5 residents (Resident #115 and Resident #48) reviewed for storage of medications.The facility failed to keep Resident #115's medication secured. Four plastic eye dropper bottles of Eyes Alive (Carboxymethylcellulose sodium 0.5%) were found on Resident #115's bedside tray table. Resident #115 did not have orders to self-administer.The facility failed to ensure Resident #48's Xiidra eye drops (used to treat the signs and symptoms of dry eye disease) were stored at the proper temperature according to the medication label.The deficient practice could place residents at risk of not receiving the therapeutic benefit of medications, drug diversion, or ingestion of unprescribed medications to residents, staff, and visitors.Findings included:1.Record review of Resident #115's undated face sheet revealed an [AGE] year-old male who admitted into the facility on [DATE]. He had diagnoses of cholangitis (infection and inflammation of the bile ducts which could lead to jaundice), hypertension (high blood pressure) , muscle weakness, kidney failure, and sepsis (infection leading to organ dysfunction).Record review of Resident #115's admission MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognition.Record review of Resident #115's active physician orders as of 04/07/2026 revealed the following scheduled medication, Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5%, instill 1 drop in both eyes four times a day for dry eyes. There was no physician order authorizing Resident #115 to self-administer Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5%,Record review of Resident #115's e-MAR dated 04/07/2026 revealed MA C administered Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5%, during the morning and afternoon medication pass.During an observation and interview with Resident #115 on 04/07/2026 at 10am, four plastic eye dropper bottles of Eyes Alive (Carboxymethylcellulose sodium 0.5%) were found at the bedside tray table. Resident #115 stated his family member, and the staff will leave the medication near, so he is able to administer if he needed to. This surveyor asked Resident #115 if he had other mediations stored in the room and he stated in his nightstand. This surveyor asked for permission to review the nightstand, and it was a box of Eyes Alive (Carboxymethylcellulose sodium 0.5%) found in the bottom drawer with twelve additional eye dropper bottles.During an interview with LVN B on 04/07/2026 at 10:08am she stated that the expectation for medication storage is that all medications are kept in the nurse medication cart, medication room, or aide cart. LVN B stated that eye drops are administered by the medication aide when they are non antibiotic, and by a nurse if the medication is an antibiotic. LVN B stated that rounds are conducted every two hours or as needed. She also stated that Resident #115 was not authorized to self administer medications and that she has not left medications in the resident's room nor observed medications stored in the resident's nightstand. LVN B stated the identified risk of prescribed medications being left accessible includes the potential for another resident to take the medication or for overdose.During an interview with MA C on 04/07/2026 at 10:19am she stated she administered medications in the 300 and 400 halls. She stated she recalled Resident #115 and administered his eye drops, although she was unable to recall specific details at the time of the interview. MA C stated the eye drops are kept on the medication cart and that she has never left the medication in the resident's room. She was unsure whether the resident can self administer the medication but stated she administers it to him. She denied ever leaving the medication accessible to the resident or stored in the nightstand. MA C further stated that the expectation for medication storage is that medications are kept refrigerated in the medication room or secured in a locked cart and that medications should not be left out due to the risk of another resident taking them.During an interview with the DON on 04/09/2026 at 10:50am she stated that the expectation for medication storage is that all medications are to be kept in the medication cart or medication room. The DON stated that storing medications in a resident's room poses the risk of the resident self administering medications without authorization.2. Record review of Resident #48's admission record dated 4/9/26 revealed a [AGE] year-old male who readmitted to the facility on [DATE]. His diagnoses included other age-related incipient cataract, bilateral (early-stage lens clouding that may cause subtle vision changes.)Record review of Resident #48's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care.Record review of Resident #48's Order Summary Report revealed an order for Lifitegrast ophthalmic solution 5% (Xiidra) instill 1 drop in both eyes two times a day for dry eyes, order dated 2/5/26.In an observation on 4/9/26 at 10:33 a.m. of the medication room refrigerator with the DON revealed Resident #48's Xiidra eye drops were in the door of the refrigerator. The temperature of the refrigerator was 40 F. Observation of the Xiidra prescription box indicated to store the eye drops at room temperature, between 68 F - 77 F.In an observation and interview on 4/9/26 at 10:35 a.m. the DON reviewed the Xiidra eye drops instruction insert and said the eye drops were to be stored between 68 F - 77 F. She said she was unsure who placed Resident #48's eye drops in the refrigerator. She said the eye drops should not be stored in the refrigerator so the drops will not be cold going into the resident's eye.In an interview on 4/9/26 at 1:50 p.m. the DON said she expected medications to be stored properly, and nursing staff could refer to the pharmacy insert, pharmacy, or verify with a nurse on how to properly store the medication.Record review of facility policy revised December 2012 for Storage of Medications read.Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.10. Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.

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 9%, based on 3 errors out of 31 opportunities, which involved 2 of 5 residents (Resident #29 and #114) and 2 of 4 staff (MA C and MA L) reviewed for medication administration.MA C did not offer or apply Lidocaine patches to all areas indicated in the MD order and administered the wrong Iron supplement to Resident #114 on 4/8/26. MA L did not administer the correct dose of Clearlax (used for the relief of occasional constipation) to Resident #29 on 4/8/26.These failures could place residents at risk of ineffective therapeutic outcomes. Findings include:Record review of Resident #114's admission record dated 4/9/26 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included displaced fracture of fifth cervical vertebra, central cord syndrome (incomplete spinal cord injury, primarily affecting the upper limbs and resulting from trauma or degenerative changes in the cervical spine), and person injured in motor vehicle accident.Record review of Resident #114's Order Summary Report revealed orders for:Lidocaine patch 5% apply to bilateral hips/knees topically one time a day for pain and remove per schedule, order date 4/1/26.Ferrous Gluconate 324 (37.5 Fe) mg give 1 tablet by mouth one time a day for anemia, order date 4/2/26.An observation on 4/8/26 at 8:37 a.m., during medication pass, revealed MA C prepared Resident #114's medication for administration. She prepared Lidocaine patch 5%, Ferrous sulfate 325 (65 FE) mg, Sevelamer, Carvedilol, Eliquis, Famotidine, Januvia, Lokelma, Nifedipine, Telmisartan, and Vit D3. MA C entered Resident #114's room and administered all medications to Resident #114. She asked Resident #114 where he wanted the Lidocaine patch and he indicated the left knee, MA C applied the Lidocaine patch to the left knee and exited the room. In an interview and observation on 4/8/26 at 8:50 a.m., MA C said Resident #114's iron supplement order was for Ferrous gluconate. She said she was unsure if Ferrous gluconate and Ferrous sulfate were the same medication. During medication pass she compared the eMAR to the medication and noticed it was one strength off and had a different name but did not think anything of it. Observation of the medication cart revealed ferrous gluconate was not on it. She said Ferrous Gluconate iron was used for dialysis patients. MA C said the instructions for the Lidocaine patch were to apply to bilateral hips/knees and said she was unsure what bilateral meant. She said she applied the patch to his left knee and that was where the patient wanted it. She questioned the instructions to the order previously, but the patient wanted the left knee. To ensure medication administration accuracy MA C said she checked the medication and dosage. In an interview on 4/8/26 at 11:54 a.m. Resident #114 said facility staff always placed the Lidocaine patch on his left knee. He said the pain was not as bad on the other side as it was on the left side.In an interview on 4/8/26 at 1:27 p.m. the DON said she expected nursing staff to read the MD order and apply the Lidocaine patch to the hips and knees. She said bilateral indicated two sides. She said Resident #114's order needed to be clarified, and she would expect staff to get clarification from the nurse, who would reach out to the doctor to see where the patches should be placed. She said placing the patch to the left knee only was not following the order. The patient's pain could be at risk of not being properly managed. She said Lidocaine was a localized patch (used to provide temporary relief from pain by delivering the local anesthetic directly to the skin. They work by numbing the nerves in a specific area). She said Ferrous sulfate and gluconate were assumed to be different because the names were different. Ferrous sulfate and gluconate are used to treat and prevent iron deficiency anemia and were the same concept, but what the staff administered to Resident #114 was not the correct medication. She said staff should ensure everything matches including the right medication, time, dosage, resident, and route, and to ensure the medication is available on the cart. Iron is a supplement to manage anemia.2. Record review of Resident #29's admission record dated 4/9/26 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included hemiplegia and hemiparesis (hemiplegia is paralysis of one side of the body, while hemiparesis is weakness on one side) following cerebral infarction (stroke) affecting left non-dominant side, depression, and mental disorder.Record review of Resident #29's quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care.Record review of Resident #29's Order Summary Report revealed an order for Miralax oral powder 17 gm/scoop (Polyethylene Glycol 3350) give 1 scoop by mouth two times a day for constipation, mix with at least 4 oz of water or juice, order date 8/22/25.In an observation on 4/8/26 at 9:30 a.m. during medication pass revealed MA L prepared Resident #29's morning medication for administration. She prepared Amlodipine, Senna-Plus, Magnesium oxide, and Clearlax (Miralax) PEG 3350. Observation of the Clearlax measuring top had 17 gm inscribed in it along with up arrows that pointed to the top of the white section. MA L filled approximately half of the white section with powder and did not prepare the entire 17 grams. She mixed the powder with water and administered all medications to Resident #29.In an interview on 4/8/26 at 9:34 a.m. MA L said she poured Resident #29's Clearlax powder to the line that was at the halfway point of the white section. She said she knew how much to prepare based on the instructions on the label which indicated 1 scoop. This Surveyor pointed out the 17 gm and up arrows to MA L and she said she had not seen that before. She said she used a different bottle in the past that was labeled differently. She said it was important to administer the full dose so the resident could have a bowel movement. She said she would report to the nurse that Resident #29 only received half of the medication, and also did not consume all the liquid in the cup. In an interview on 4/8/26 at 1:27 p.m. the DON said the Clearlax bottle top should be 17 grams, and the powder should be poured in the top. She said medication aides should follow the instructions on the bottle which informed you where to stop. She said the resident could be at risk of her bowels not being regulated properly if the full dose was not received. In an interview on 4/8/26 at 3:31 p.m. the Administrator said he expected staff to follow the rights of medication administration, try to get it right every time, and for the medication error rate to stay under 5%.Record review of the facility's Administering Medications policy dated December 2012 read in part, .Medications shall be administered in a safe and timely manner, and as prescribed.3. Medications must be administered in accordance with the orders, including any required time frame. 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of 5 residents (Resident #67) reviewed for infection control.CNA A failed to cleanse the tip of the penis while performing incontinent care for Resident #67.CNA A failed to maintain a sanitary environment by placing packages of used supplies back onto a clean linen cart.Findings included:Record review of Resident #67's face sheet dated 04/08/26 revealed a [AGE] year-old admitted to the facility on [DATE]. His diagnoses included progressive multifocal leukoencephalopathy (a serious viral infection of the brain); other combined immunodeficiencies (a group of inherited disorders of the immune system, leading to increased susceptibility to infections), urinary tract infection; Hemiplegia (one sided paralysis or severe loss of strength on one side); Dysarthria and anarthria (a motor speech disorder characterized by slurred or slow speech); chronic kidney disease; hypertension and muscle weakness.Record review of Resident #67's admission MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition. He was dependent on assistance for toileting hygiene. He required maximal assistance with lower body dressing and showers. He required moderate assistance with upper body dressing and supervision for personal hygiene and oral hygiene. He used a wheelchair for mobility. He was always incontinent of bowel and bladder.Record review of Resident #67's undated care plan last reviewed on 03/13/26 revealed: Focus - Resident #67 had a urinary tract infection, date initiated was 03/10/26. Goal - Resident #67's urinary tract infection will resolve without complications. Interventions included- Resident/caregiver teaching should include good hygiene practices: wipe and cleanse from front to back. Clean peri area well after BM to help prevent bacteria in urinary tract. Focus - Resident #67 had an ADL self-care performance deficit r/t hemiplegia and impaired balance. Interventions included - Toilet use: the resident requires (x1) staff participation to use toilet.Observation and interview on 04/08/26 at 4:45 AM, CNA A and CNA D performed incontinent care for Resident #67. CNA A gathered a clean brief, two packages of disposable wipes, and one box of gloves from the clean cart in the hallway then brought the items and a personal hand sanitizer bottle into Resident #67's room. CNA A and CNA D performed hand hygiene and put on clean gowns and gloves. CNA A placed the supplies including a personal hand sanitizer onto the overbed table. CNA A unfastened Resident #67's brief. With a clean wipe CNA A cleansed the lower abdomen, the left and right groin. With a new cleansing wipe CNA A cleansed from the base of the penis towards the opening of the urethra with one motion. CNA A did not cleanse the opening of the urethra. Resident #67 was able to roll to his right side as CNA D stood by. Resident #67 had a small bowel movement and CNA A cleansed the buttocks and anus using several clean wipes until the skin was clean. CNA A removed the soiled brief and disposed of it in the plastic trash liner. CNA A removed soiled gloves, used hand sanitizer to cleans hands, and put on clean gloves from the box of gloves. CNA A placed the clean brief beneath Resident #67 and then fastened the brief. CNA A and CNA D pulled bed covers over Resident #67. Both CNA's removed the used gowns and gloves then washed their hands at the sink. CNA D removed the trash bag from the room. CNA A took from the room: the 2 packages of disposable wipes, the box of gloves and bottle of hand sanitizer then placed them onto the shelf of the linen cart between clean folded linen. CNA A stated she did not realize that she did not clean the tip of the penis because she was nervous. CNA A stated it was important to clean this area to prevent build up of germs which could cause infection. CNA A stated she did not think it was a problem to bring the package of disposable wipes and box of gloves out of the room and back onto the cart. CNA A later stated she understood the items should not have been placed back onto the clean cart after using them for incontinent care because this would be cross contamination.In an interview on 04/08/26 at 5:30 AM, CNA D stated all resident rooms had packages of cleansing wipes in drawers and gloves were stored in the bathroom. CNA D stated the clean cart should remain clean and would never remove items from the cart, bring them into a resident room, use them on a resident then put them back onto the cart due to infection control issues. CNA D stated doing so would be cross-contaminating dirty items onto a clean linen cart where items were kept and used for all residents. CNA D stated when performing incontinent care for a male resident she would always start by cleaning the tip of the penis for infection control. CNA D stated if the tip of the penis was not cleaned first the risk would be pain, UTI and confusion from the UTI.In an interview on 04/08/26 at 5:35 AM, the DON stated cleansing wipes and gloves should not be returned to the clean cart, they should remain in the resident room due to infection and cross-contamination. The DON stated anything on the packages may infect the next resident for example, a package may be contaminated with stool then used for another resident and this could cause infection for that resident. In an interview on 04/08/26 at 5:45 AM, LVN E stated when cleaning peri area during incontinent care for a male resident, she would start at the tip of penis to prevent spread of bacteria, for infection control practices. LVN E stated the carts in the hallways are for clean supplies only and packages of cleansing wipes, boxes of gloves stay in the room to prevent contamination.In an interview on 04/08/26 at 11:00 AM, the DON stated when performing incontinent care for a male resident she expected that the aides start cleansing the front of the peri area, clean the tip of the penis first and that this was facility policy to do so. The DON stated if the tip of the penis was not cleaned the resident would be at risk of infection, UTI and would probably not feel well because of an infection.Record review of the facility policy for Perineal Care revised on December 2011 read in part: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.10. For a male resident:.b. Wash perineal area starting with urethra and working outward.(1) Retract foreskin of the uncircumcised male. (2) Wash and rinse urethral area using a circular motion. (3) Continue to wash the perineal area including the penis, scrotum and inner thighs.Record review of the facility Policies and Practices - Infection Control, revised August 2010, read in part: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors.2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility; b. Maintain a safe, sanitary, and comfortable environment.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency) in accordance with State law through established procedures for 2 of 6 residents (Residents #39 and #52) reviewed for reporting allegations of abuse, neglect, and exploitation. -The facility failed to report an allegation of abuse of Resident #39 and Resident #52 to the State Agency within the two-hour timeframe. This failure could place residents at risk of abuse and neglect. Findings include: Resident #39 Record review of Resident #39's clinical record dated 2/5/25 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included bipolar disorder (a mental health condition that causes extreme mood swings), major depressive disorder, atherosclerotic heart disease (plaque buildup, or fatty deposits, in your arteries), and NSTEMI myocardial infarction (a type of heart attack that usually happens when your heart's need for oxygen can't be met). Record review of Resident #39's quarterly MDS assessment, dated 11/11/24 revealed a BIMS score of 15 out of 15 which indicated intact cognition. She required assistance from staff with ADL care. Record review of Resident #39's care plan reviewed 12/6/24 revealed she had potential for psychosocial well-being problem. She had a diagnosis of schizoaffective disorder bipolar type. Interventions were to encourage resident to verbalize feelings of perceptions, and fears. She was also a recipient of alleged verbal aggressive behavior from a resident at risk for psychosocial well-being problem dated 2/3/25. Interventions were to allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. Record review of Resident #39's nursing notes dated 2/3/25 at 5:17 p.m. by the Social Worker read in part, This writer and Administrator went to speak with resident in regards to statement made to Surveyor that her roommate is verbally abusing her. This writer asked her what was stated that made her feel verbally abused. She states her RM is Cussing and yelling in the room and she, the RM, states I am the reason her family does not come to see her and that I am the reason [Administrator] will not let her DC from facility. She also asked me why do you look like that why are you in that chair, are you touching my things, are you stealing my stuff. [Resident #39] reports then she had a traumatic childhood and does not need her bringing all that back to her. I did not want state thinking that you were not assisting me. I just wanted to get out of there, she is nonstop on a 10 all the time . Record review of Resident #39 and Resident #26's chart revealed they shared the same room from 1/16/25 - 2/3/25. In an interview on 2/3/25 at 1:03 p.m. Resident #39 said her roommate (Resident #26) was rude and verbally abusive to her. She said Resident #26 yelled at her and started arguments. She said they were not getting along before they moved in together. She said she spoke to the Administrator previously about changing rooms but there were no rooms available. She said she was informed today there was a room available for her to move to. She said she had been roommates with Resident #26 for approximately 1-3 weeks and was physically and mentally exhausted. In an interview on 2/3/25 at 1:14 p.m. the Social Worker said some residents complained about Resident #26 but she did not know Resident #39 felt abused by the her. In an interview on 2/3/25 at 1:17 p.m. the State Surveyor reported to the Administrator that Resident #39 said she felt verbally abused by her roommate, Resident #26. Administrator said this was the first time he heard she felt abused. In an interview on 2/3/25 at 2:22 p.m. the Administrator said they moved Resident #39 to another room and would interview her. In an interview on 2/4/25 at 12:22 p.m. the Administrator said during his interview with Resident #39 (on 2/3/25) she informed him that Resident #26 would cuss and she did not like those words, it reminded her of childhood trauma. He said Resident #39 informed him she might not have used the right words (regarding abuse) and just wanted to be moved as quickly as possible. In an interview on 2/5/25 at 8:15 a.m. Resident #39 said Resident #26 would yell, cuss, and accuse her of theft. She said she was weary and felt abused and threatened by her and thought the Administrator and Social Worker understood that. She said when the Administrator and Social Worker interviewed her (on 2/3/25), they did not ask her if she felt abused. In an interview on 2/5/25 at 9:19 a.m. Resident #26 said she and Resident #39 were roommates for a couple of weeks. She said they did not get along, but she never yelled, cussed, or treated her bad. In an interview on 2/5/25 at 9:28 a.m. the Social Worker said she and the Administrator spoke with Resident #39 (after being informed of the incident on 2/3/25) to obtain her statement and the resident restated verbal abuse. She said Resident #39 informed her that Resident #26 would cuss in the room and asked her if she was touching or stealing her stuff. The Social Worker said Resident #39 mentioned emotional childhood trauma that she did not want brought back. She said when Resident #39 first moved in with Resident #26, Resident #39 requested a room change because they were too much alike. She said the facility tried to move her last week but was unable to (for various reasons). She said Resident #26 had issues with some of the residents at the facility, but no one previously said she was verbally abusive. In an interview on 2/5/25 at 9:43 a.m. the Administrator said when he and the Social Worker talked to Resident #39, she did not state she felt abused and there was no emotional change. He said when the facility followed up with her, she kept saying she was happy to be out of there and thought it was best to report the incident. He said he was first alerted by the State Survey on Monday 2/3/25 about the allegation of abuse. He said generally with any allegation of abuse, if stated they feel they've been abused, they would report it within 2 hours to the State Agency. He said it was a case by case with the resident, and Resident #39 may have used the wrong words. He said they determined it would best to report the incident to the State Agency and reported it this morning 2/5/25, outside of the reporting window. In an interview on 2/5/25 at 10:09 a.m. the DON said she was informed yesterday 2/4/25 by the Social Worker that Resident #39 felt verbally abused by Resident #26. She said verbal abuse was the threat to do harm, cussing at them, and being called out of their name (someone referring to you in a way that is demeaning or disrespectful). She said she conducted in-services with staff on abuse, neglect, resident rights, and customer service. In an interview on 2/5/25 at 2:07 p.m. the Administrator said he was the Abuse Coordinator and was responsible for reporting allegations of abuse which included physical, sexual, and verbal. He said verbal abuse could include degrading, putting someone down, or making fun of them. Record review of facility incident report regarding Resident #39 revealed a received date of 2/5/25 via web application. Resident #52 Record review of Resident #52's quarterly MDS assessment, dated 1/24/25 revealed a [AGE] year-old male who readmitted to the facility on [DATE]. His diagnosis included stroke, end stage renal disease, and Alzheimer's disease. He had a BIMS score of 6 out of 15 which indicated severe cognitive impairment. He required assistance from staff with ADL care. In an interview on 2/3/25 at 9:25 a.m. Resident #52 said last month the shower lady (name unknown) pushed him into the wall. He said his back was hurting. This Surveyor reported it to the Administrator, and he said they would check his arm out. In an interview on 2/5/25 at 9:28 a.m. the Social Worker said she was informed of the situation with Resident #52 yesterday 2/4/25 by the Administrator. She said Resident #52 told her a girl picked him up like a football and slammed him against the wall approximately one year ago. In an interview on 2/5/25 at 9:57 a.m. the Administrator said he was originally made aware of the allegation of abuse of Resident #52 on Monday, 2/3/25. He said he was unable to get details from Resident #52. He said the Social Worker spoke with the resident this morning and stated the incident occurred one year ago. He said Resident #52 was requesting an x-ray of his back. He said he generally reported to the State Agency allegations of abuse within 2 hours and start the investigation. Record review of facility incident report regarding Resident #52 revealed a received date of 2/5/25 via web application. Record review of the facility's Reporting Abuse to Facility Management policy dated 2009 read in part, .It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management . 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 2. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability . Record review of the facility's Resident-to-Resident Altercations policy dated 2016 read in part, .All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator . 11. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy .

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 6 residents (Resident #42) reviewed for quality of care. The facility failed to obtain physician orders for an abrasion that Resident #42 sustained on his left leg after an incident on 2/1/25. This failure could place residents at risk of infections. Findings included: Record review of Resident #42's admission record dated 2/5/25 revealed a [AGE] year-old male who readmitted on [DATE]. Diagnoses included severe protein calorie malnutrition, chronic kidney disease, elevated white blood cell count, hemiplegia (a symptom that involves one-sided paralysis), acute pancreatitis (inflammation of the pancreas), and weakness. Record review of Resident #42's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated intact cognition. He required assistance from staff with ADL care. Record review of Resident #42's care plan dated 1/9/25 revealed he had potential impairment to skin integrity related to muscle weakness. Interventions were to observe skin injury for abnormalities, failure to heal, s/sx of infection, maceration etc. and report to MD. Resident #42 had a skin tear to left lower leg date initiated 2/1/25. Interventions were to treat area as indicated, if skin tear occurs, notify MD, family (date initiated 2/1/25). Record review of Resident #42's nursing note dated 2/1/25 by RN K read in part, .The medication aid informed the nurse that the patient had a scratch to his left lateral calf that was bleeding. The nurse clean [sic] with NS and apply a dry dressing. Record review of Resident #42's incident report dated 2/1/25 by RN K read in part, The CMA informed the nurse that the patient has some blood on his LL leg . The patient stated that he did not know how he did it . The nurse assess the area clean with NS pat dry and applied a dry dressing . No notifications to agencies/people were found on the incident report. Record review of Resident #42's nursing note dated 2/5/25 at 1:32 p.m. by the Wound Care Nurse read in part, .resident noted to have an open area to the lle . NP at facility and made aware. Upon assessment of area new order given to treat using TAO and cover with border gauze QOD and prn. Resident and RP made aware of new open area and tx in place . Record review of Resident #42's MD orders for February 2025 revealed no active, completed, or discontinued orders to address the skin tear to his left leg prior to 2/5/25. In an observation and interview on 2/3/25 at 9:52 a.m. of Resident #42 revealed there was a white dressing on his left leg dated 2/1/25 signed by P(unknown letter). Resident #42 said he scratched his leg on the door last night. In an interview and observation on 2/3/25 at 12:10 p.m. revealed Resident #42 was in the hallway. There was an open oval shaped scab area on his left leg near the knee. He said he removed the bandage from his left leg after his shower. In an observation on 2/3/25 at approximately 12:45 p.m. revealed there was a dressing on Resident #42's left leg dated 2/3/25 signed by DW that covered the previously observed open area. In an observation and interview on 2/5/25 at 12:56 p.m. of Resident #42's left leg revealed an uncovered scab/wound to his left leg near the knee. The area appeared pink. In an interview on 2/5/25 at 12:57 p.m. LVN W said Resident #42 had a skin tear and the Wound Care Nurse was going to look at it. She said she covered the area on Monday 2/3/25 until the Wound Care Nurse could look at it. In an interview on 2/5/25 at 1:03 p.m. the Wound Care Nurse said she was going to get an order to cover the area on Resident #42's leg. In an interview on 2/5/25 at 1:05 p.m. LVN W said she cleaned the area on Resident #42's left lower leg on Monday 2/3/25 but did not tell the Wound Care Nurse about it because it slipped her mind. She said she normally reported concerns to the Wound Care Nurse. She said she was not aware of the area until the resident asked her for a band-aid to cover it since the Surveyor kept asking about the open area. In an interview on 2/5/25 at 1:12 p.m. Resident #42's NP said he learned of the area on the Resident's leg today 2/5/25. He said the area looked fresh and appeared to be an abrasion. He said he provided orders to clean it with saline and triple antibiotic ointment every other day and to keep an eye on it. He said there was no drainage, but it was important to address because it could become infected. He said the facility normally notified him of areas like this one. In an observation and interview on 2/5/25 at 1:15 p.m. the Wound Care Nurse said she looked at the area on Resident #42's lower left extremity on Monday and it did not look the way it did today. The Wound Care Nurse showed the Surveyor what she saw on Monday which was a tiny circle area near the back of the lower left leg. In an interview on 2/5/25 at 1:25 p.m. LVN W said she saw the round shaped pink area on Resident #42's left lower leg near the knee on Monday 2/3/25 when she cleaned it. In an interview on 2/5/25 at 1:33 p.m. the Unit Manager said she spoke with RN K about Resident #42's incident over the weekend and the information provided was vague. She said she talked with RN K about notifications and said she should have put in an order. She said RN K should have notified the RP, DON, and the MD for an order. She said there was no order in the system. She said she saw the dressing on the resident Monday but did not see the skin underneath. She said she told the wound care nurse to follow up on it. In an interview on 2/5/25 at 1:46 p.m. the Shower Tech said she assisted Resident #42 with showers on Monday 2/3/25 and Wednesday 2/5/25. She said he had a pink circular area on his left leg today around 11 a.m. She said on Monday she noticed scratches to his leg. She said she documented the new area on the Kardex. In an interview on 2/5/25 at 1:57 p.m. RN K said Resident #42 sustained a scrape to his left lower calf leg (over the weekend). She said it looked like 3 superficial scratches, about the size of a millimeter and similar to a previously healed scab. She said she patted it dry and put a border dressing on it. She said she dropped the ball and forgot to notify the NP because she got caught up late in the evening and the area was superficial. She said she would normally notify the NP that she cleaned it and put something on it. She said she notified the next shift that he had a scratch. In an interview on 2/5/25 at 2:14 p.m. the DON said on Monday 2/3/25 Resident #42 had a skin tear/abrasion and LVN W dressed it. She said she just learned of it and did not know what it looked like. She said a skin tear was considered an incident and nursing staff should notify the RP, MD/NP of the issue and write an incident report. She said RN K should have received an order for treatment, put it in the system, and carry it out because the area needed to be treated. She said if the incident process was not done the next shift would not know what to do for the skin tear/abrasion. In an interview on 2/5/25 at 2:10 p.m. the Administrator said he expected nursing staff to obtain orders right away for treatment provided and document it in the system. Record review of the facility's Skin Tears - Abrasions and Minor Breaks, care of policy October 2009 read in part, . The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin . 1. Obtain a physician's order as needed . 1. An abrasion is an area on the skin that has been damaged by shearing, scraping, rubbing or trauma. A skin tear is the disruption of epidermis resulting in a lifting or shearing of the skin. 2. If the wound is bleeding, gently apply a compress with pressure over the wound. Reinforce the compress as needed to control any bleeding. 3. If the bleeding persists after efforts to stop it, or an object is embedded into the abrasion, or other medical attention is needed, notify the physician . 1.Notify the responsible family member. Physician notification may be routine (that is, non-immediate) if the abrasion is uncomplicated or not associated with significant trauma . Record review of the facility's Change in a Residents Condition or Status policy dated 2016 read in part, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident;

Based on observations, interviews, and record reviews the facility failed to maintain an effective pest control program to remain free of pests and rodents for four of four residents and one of four halls. The facility failed to ensure the building is free of cockroaches. This failure could place residents at risk of, infection, skin irritation, allergies, which could result in unsanitary living conditions and decline in health and well-being. Finding included: In an interview with Resident #37 on 01/23/2025 at 10:42am, Resident #37 stated the facility did have roaches and it's because a few residents eat in their rooms. Resident #37 stated there were times when they would try to stomp on the roaches with their shoe and would miss. When addressing the issue to the facility staff, Resident #37 was told it was a delusion of seeing the roaches, but an exterminator was brought in shortly after speaking with facility staff. The exterminator did place pellets along the side of the walls to kill any sighting of roaches. In an interview with Resident #21 on 01/24/2025 at 10:25am Resident #21 stated there was a concern with the roaches in the facility. Resident #21 also stated the last sighting of roaches was a couple of days ago in their room. Resident #21 also stated the roaches use to be worse, but things have gotten better over time. In an interview with MAINT on, 01/24/2025 at 9:08 am, MAINT stated the facility used an electronic request, which all staff members have access to log for seen pest, regardless of if they are alive or dead. There was also a logbook for any sightings of roaches that was reported by staff, which was checked daily, several times a day. The facility has had a roach issue within the last three months and used a pest control service. When there was a sighting of roaches in a specific hallway, the pest control company focused more on the hall that has the most sighting of roaches. The pest control does come out twice a month and is on call as needed. In an interview with CMA2 on 01/24/2025 at 10:34 am CMA2 said she had been at the facility for less than a month and normally worked a rotating shift CMA2 stated if a roach was in front of them, they would kill it, pick it, and contact maintenance or housekeeping to address the issues. In an observation on 1/24/25 at 11:25am, a small roach was seen in the conference room, crawling on the back of a chair by the Survey team. During an interview with ADMN on 01/24/2025 at 11:34am the ADMN was informed that the Survey team saw a roach crawling on the chair in the conference room. ADMN stated the first thing that could be done was to clear the room and contact someone from the maintenance facility to come in and spray. ADMN also stated that if that wasn't necessary at the time, pest control would be called, due to a sighting of the live roach in the conference room. The ADMN said there had been recent foundation work completedin the facility and it was unknown where the roaches were coming from. ADMN was questioned about the can of RAID (commercial bug spray) that was sitting on the desk in the office and ADMN stated they were unsure why it was there, but possibly brought in by someone on the maintenance team. ADMN confirmed pest control does come to the facility on ce a week and the maintenance team at the facility does spray as needed or if an issue was brought to their attention. ADMN stated there were no other concerns at this time with pests, just roaches. In an interview with ADON on 01/24/2025 at 12:33pm she said she had been with the facility for seven years and had experienced the pest control issue with roaches for some time. ADON stated the facility does have a treatment plan with the pest control company, as they do come out and spray. ADON has seen reports of residents who have complained about the issue and does follow up with the resident in a substantial amount of time to see if the issue has been resolved but cannot recall when the last time was it was reported individually to them. Record review of the Pest Control Logbook, Perfect Pest Control, where facility staff was to provide sighting of dead or alive roaches starting 09/2024 to the most recent physical sighting of roaches, 01/22/2025. The halls of the roaches were within the halls of 100-400. There were also sightings of roaches within this time frame in the admissions office, conference room, laundry, and in the hallways. Record review of Pest Control Service Inspection Report for the last 90 days dated, 11/18/2024,revealed in this weekly visit the technician treated the following rooms: 111, 112, 114, 115, and 117 as it was reported of live roaches and they were observed during the visit for treatment. It was noted that in room [ROOM NUMBER], there was poor sanitation in the room, which many roaches were seen by the technician. Record review of the Pest Control Service Inspection Report for the last 90 days dated, 12/09/2024 with several sightings of live roaches in the following rooms: 110, 112, 114, 115, 116, and 117. It was noted some of the rooms had food in the drawers and rooms need storage improvement. The facility was using weekly service treatment at this time. Record review of Perfect Pest Control Service Inspection Report for the last 90 days dated, 01/06/2025 from the pest technician for a weekly visit. It was documented by the technician of the pest control company the focus of the week was the 300 hallway and treated. A room on the 400 hall was logged for roach issues and treated. There were multiple cockroaches observed in the laundry room. The facility was using weekly service treatment at this time. Record review of the facility policy and procedure for Pest Control, revised August 2008 read in part: Policy Statement - Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation - 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by pest control company. 3. Windows are always screened 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 3 of 6 residents (Resident #1, #2, and #3) reviewed for pest control. -Resident #1 had one medium sized roach crawling on the wall behind her bed. -Resident #2 had several medium and small size roaches crawling on the floor and wall next to her bed. -Resident #3 had a small roach crawling on the wall in her room. This failure could place residents at risk of residing in an environment with pests. Findings included: Resident #1 Record review of Resident #1's face sheet dated 10/15/24 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included anxiety, bipolar disorder (mental illness characterized by extreme mood swings), insomnia (difficulty either falling or staying asleep), cognitive communication deficit, and muscle weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. She required substantial assistance from staff for ADL care. Resident #1's active diagnoses included bipolar, insomnia, and muscle weakness. Record review of Resident #1's care plan dated 9/23/24 revealed the following: Focus - [Resident #1] is demonstrating ineffective coping: Sleepiness/Insomnia related to restlessness. Goal - Meet individual requirements for sleep to function safely without fatigue. Resident #2 Record review of Resident #2's face sheet dated 10/15/24 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included hypertension (high blood pressure), saddle embolus of pulmonary artery (large blood clot gets stuck in the main pulmonary artery), dementia (memory loss), and pressure ulcer of unspecified site, unstageable. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated she was cognitively intact. She required moderate assistance from staff for ADL care. Resident #2's active diagnoses included stroke, hypertension, and dementia. Resident #3 Record review of Resident #3's face sheet dated 10/15/24 revealed an [AGE] year-old female who admitted on [DATE]. Her diagnoses included type 2 diabetes (high glucose), glaucoma (condition that damages the eye's optic nerve), morbid obesity, major depressive disorder, anxiety, and cognitive communication deficit. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 which indicated she was cognitively intact. She required assistance from staff for ADL care. Resident #2's active diagnoses included she had medically complex conditions, hypertension, depression, and cognitive communication deficit. Observation and Interview on 10/15/2024 at 9:15 a.m. of Resident #1 revealed she was awake lying in bed. Resident #1 responded to this State Surveyor's greeting and said, I am tired. Resident #1 took a long sigh said she was tired from waking up throughout the night from swatting at and killing roaches that had been crawling in her bed. There was a roach crawling on the wall behind the resident's bed. There were two dead roaches that were flattened at her bedside. CNA A walked into Resident #1's room and killed the roach. CNA A left to notify the ADMIN. Resident #1 said she has had roaches in her bed and had to continuous swat them off her bed and they have crawled on her as well. She said she has told numerous staff every day. She said the facility said they had sprayed but she did not think it worked. In an interview on 10/15/2024 at 9:16 a.m. CNA A said she saw roaches in resident #1 and 2's room. She said she saw the roaches on Resident #1's bedside table and her bed. She said she documented the sightings in the pest control binder at the nurse's station. She said Resident #1 appeared tired when she rounded at the beginning of her shift (6:00 a.m.). She said the resident was at risk for skin irritation and fear of the roaches crawling on her. Observation and Interview on10/15/2024 at 9:22 a.m. of Resident #2 revealed she was sitting on the edge of her bed. She said she saw roaches in her room on the floor and her walls. Resident #2 had several roaches crawling on the floor and wall next to her bed. Resident #2's head was looking down and said she did not like the roaches in her room. She said it made her skin crawl. Observation and interview on 10/15/24 at 9:30 a.m. of Resident #3 revealed she was lying in bed. She said saw roaches crawl on her walls. She had a fly swatter and said she used it to kill roaches that crawled on her bed. She said the facility sprayed her room a few weeks ago but she said she still saw roaches. She said the pest control placed a roach motel in the room to catch the roaches. There was a green paper tube that was full of dead roaches. Interview on 10/15/2024 at 9:40 a.m. this State Surveyor notified the ADMIN about the roach activity observed. Interview on 10/15/24 at 1:42 p.m. with the ADMIS said she was assigned to Resident #2 for daily Angel Rounds. She said angel rounds were performed daily to ask the residents if they had any concerns and check the room for any problems. She said she saw live and dead roaches in Resident #3's room last week. She said after she saw the roaches, she notified staff in the morning meetings. She said when she saw the live roaches, she did not bring it to Resident #3's attention and was not able to say how the resident reacted. Interview on 10/15/24 at 1:50 p.m. with the Dir. of T&L said she had seen roaches in Resident #2's room from time to time. She said Resident #2 had complained about the roaches in her room and the Dir. of T&L said she advised staff in the morning meeting (consisted of department heads). She said she last saw roaches yesterday (10/14/24) but did not attend the morning meeting today because she had an appointment . In an interview on 10/15/24 at 1:57 p.m. the DON said she made daily rounds to identify any concerns in resident rooms. She said crumbs and food kept in the room by residents contributed to increased roach activity. She said pest control came monthly and when there were active sightings. She said the risk for residents was skin irritation. She said all staff were responsible for identifying pests in resident rooms. Interview on 10/15/24 at 2:12 p.m. the ADMIN said the facility staff performed ambassador rounds daily to identify resident concerns and/or room concerns. He said staff were instructed, if they saw any type of insect, to document it in the pest control binder. He said the facility had tried making sure open food was not in the rooms and deep cleaned the rooms when pests were found. He said the facility had monthly pest control and additional visits from pest control when activity was seen. He said roaches or any type of pest was not acceptable in resident rooms . Record review of facility pest control vendor service form dated 10/8/24 and 10/14/24 revealed the following: 10/8/24 - Reported Activity: Log book - German cockroaches in various rooms. Observed issues - German cockroach evidence. 10/14/24 - No facility log entries. Dead roaches found . Record review of the facility's Pest Control policy dated May 2001 (Revised May 2008) revealed the following read in part, Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects . Record review of the facility's pest control binder dated 9/9/24 - 10/15/24 revealed the facility had roach sightings in Resident #1's room on 10/15/24 and Resident #2's room on 9/30/24, 10/3/24, and 10/15/24. Pest control vendor has an entry that indicated the book was reviewed on 10/14/24.

Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect for 3 (Resident #1, #5, and #7) of 10 residents reviewed for residents' rights in that: -Resident #1 was found to have soiled (feces) wipes left in her brief until her scheduled shower time. -Residents #5 and #7 did not have their briefs changed in a timely manner according to the facility's policy and procedures. These deficient practices could place residents at risk for impaired dignity, loss of self-worth, and a decline in psychosocial well-being. Findings included: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Lymphedema (define), Rheumatoid Arthritis (define), Primary Hypertension (high blood pressure), and Generalized Muscle Weakness. Observation and Interview on 5/11/2024 at 1:57 PM revealed Resident #1 alert and oriented to person, place, time, and event. Her daughter was at her bedside. Staff transferred Resident #1 from the bed to her wheelchair. She was waiting to be discharged from the facility. The resident said the facility was short staffed, so the level of care was inadequate and unacceptable . She said she was incontinent to bowel and bladder. She said the CNA left soiled (feces) wipes in her brief before bringing her to take her scheduled shower. She said knowing a soiled wipe had been left in her brief made her feel uncomfortable and upset. She said she told her daughter, spoke with the administrator, and filed a grievance. She said the treatment and conditions were unacceptable, and she could not wait to leave the facility. She said she felt dehumanized when they left the soiled wipe in her brief. She said she was embarrassed and worried about potential infection from the fecal contact with her private parts. Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of schizoaffective disorder (combination of symptoms of schizophrenia and mood disorder, such as depression or Bipolar Disease), Bipolar Disorder (mental illness that causes unusual shifts in mood from extreme highs to lows), Dysphagia (difficulty swallowing), Generalized Muscle Weakness, and Morbid Obesity. Record review of Resident #5's MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating she was cognitively intact. Interview on 05/11/24 at 3:53 PM, Resident #5, said she had been at the facility for five years. She said she has to call the CNA several times before they change her brief. She said it would take so long she had to use her cell phone to contact the front desk staff because the call light was not answered. She said the problem was not enough staff. She said there had been a slow decline in care, and she would get very upset when it took so long to change her brief because she had sensitive skin, and she worried her urine would cause skin breakdown and turn into some worse. She said she felt like less of a person while she waited hours to change her soiled briefs. She said it made her feel like no one cared. Resident #7 Record review of Resident #7's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Dementia (memory loss), Primary Hypertension (high blood pressure), Peripheral Vascular Disease (poor circulation), and Muscle Wasting. Record review of resident #7's MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Interview on 5/12/24 at 10:25 AM with Resident #7, he said his shower days were Tuesdays, Thursdays, and Saturdays. He said sometimes he had gone without his brief being changed during an entire shift. He said the facility was shorthanded and needed help. He said, I feel small and not like a human being when they do not change me when I need to be changed. In a telephone interview on 05/12/24 at 11:24 AM with CNA A, she said she had worked at the facility for 7 years. She said she worked as the shower tech from 6:00 AM to 2:00 PM Monday through Friday. She said she remembered a resident who had a wipe with stool left in her brief. She said it was removed when she took her brief off for her scheduled (Mondays, Wednesdays, and Fridays) shower . She said she thought it was an accident and wasn't purposely left in the brief by CNA B. CNA A said this was the first time she witnessed a wipe left in a resident's brief. Interview on 05/12/24 at 1:05 PM with the Administrator, he said the reason why CNA B was no longer on the schedule was due to the incontinent care concern with Resident #1. Record review of facility policy titled Resident Rights and Guidelines for all Nursing Procedures, undated, read in part, . Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including Resident dignity and respect . Record review of facility policy titled Perineal Care, revised December 2011, read in part, .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .

Based on, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (CR #1) out of 10 residents reviewed for quality of care in that: 1-The facility failed to obtain physician orders on [DATE] prior to treating CR#1 with loperamide to treat diarrhea. 2-The facility failed to arrange emergency transportation to local hospital when requested by RR for CR#1 when he expressed having trouble breathing on [DATE] and complained of abdominal pain with diarrhea. CR#1 was wheeled to a local hospital on [DATE] and expired while at the hospital on [DATE]. 3-The facility failed to establish if CR#1 wanted to the leave the facility to the hospital when requested by the Resident Representative (RR) when he was alert and oriented times four. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:20 pm. While the IJ was removed on [DATE], the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could expose residents to low quality of care, worsening of condition, hospitalization , and death. Findings included: Record review of CR#1's face sheet dated, [DATE], reflected he was a [AGE] year-old male, admitted to the facility on [DATE] as his own responsible party with diagnoses of metabolic encephalopathy (chemical imbalance in the blood affecting the brain), sepsis(infection), pneumonia (lung infection), end stage renal disease (kidney failure), pleural effusion (excess fluid affecting the lungs), dyspnea(Shortness of breath), atherosclerotic heart disease(plaque buildup in the arteries of the heart), and atrial fibrillation(irregular heartbeat). CR#1 was discharged on [DATE]. Record review of CR#1 baseline care plan dated [DATE] with no information to indicate CR#1 admitted with diarrhea. Record review of CR#1's entry MDS (Minimum Data Set) assessment dated [DATE] reflected an admitted [DATE]. The MDS assessment indicated CR#1 had a pay source of Medicare and Medicaid was pending. Record review of CR#1's undated physician order summary did not reveal orders for loperamide , used to control and relieve the symptoms of diarrhea. Record review of electronic medical records (EMR) for CR #1 did not reveal progress notes completed, or Situation, Background, Assessment, and Recommendation (SBAR) completed by LVN A regarding CR#1 change in condition after he expressed having trouble breathing or diarrhea on [DATE] to LVN A. Record review of electronic medical records (EMR for CR #1) did not reveal a Situation, Background, Assessment, and Recommendation (SBAR) completed by LVN B regarding CR#1 change in condition after he expressed abdominal pain on [DATE] to LVN B. Record review of CR#1's nursing progress note entered by LVN B dated [DATE] read in part Upon arrival, resident noted saying I'm in pain, I don't know what to do repeatedly. When asked for a specific location of pain, resident touched his abdomen, RR present in room. Writer palpated residents abdomen, upper quadrants hard but non distended (enlarged), lower quadrants soft, non distended. Resident states he has frequent regular bowel movements and ,d+[DATE] nurse(LVN A) stated resident had a large bowel movement(bm ) on her shift. Vitals assessed and are all wnl (within normal limits), NP (Nurse Practitioner) notified and gave orders to get STAT Chest XRAYS and KUB. Writer informed residents RR of this information however she refused stating he needs to be seen in the ER immediately. Residents RR dressed resident, transferred him into his wheelchair and rolled him out of the facility. RR informed that by making this call, resident is leaving Against Medical Advice(AMA ). RR begin calling staff members idiots and continued to leave the facility. DON and NP notified. Record review of CR#1 medical records from local hospital with admitted [DATE] and discharge date of [DATE] revealed in the discharge summary no diagnosis for diarrhea and no orders for loperamide was provided at discharge. Record review of CR#1 medical records from local hospital with admitted [DATE] with chief complaint of diarrhea and shortness of breath (SOB). Computed Tomography Scan(CT SCAN a diagnostic imaging procedure) completed of abdomen and pelvis with left free intraperitoneal gas suspicious for perforated hollow viscus (air under the diaphragm suggesting a hole or series of holes in the intestine or bowel) with recommendation for surgical consult. CT SCAN revealed complete collapse of left lower lobe and partial collapse of the right lower lobe. Death summary revealed family declined surgical intervention, made CR#1 do-not-resuscitate (DNR), and resident transition care to comfort measures only. Resident expired on [DATE] while at the hospital. In a phone interview on [DATE] at 9:10 am with RR, she said that CR#1 called her on [DATE] at 5:00am saying he could not breath and his stomach hurt bad, so she went to the facility. She said a nurse came into the room when she arrived at the facility, and said she contacted a doctor, he ordered a x-ray that would take 4 hours. She said she told the nurse (name unknown) she could not wait 4 hours because CR#1 could not breathe, and the nurse said that's what the doctor said to do. She said she told the nurse she was taking him to emergency room (ER). She said that she asked nurses at the facility to help put CR#1 in the car, and she was told they were not allowed to help. She called 911 to take CR#1 to the hospital, Emergency Medical Services (EMS) told her that permission was needed to come on private property, she asked a nurse to give EMS permission to come on the property, and she was told they could not give permission. She said that she had to push CR#1 in his wheelchair to the ER (located 0.6 miles from the facility). She said that while at the hospital CR#1 had a CT scan that confirmed a perforated intestine (diagnostic imaging procedure to confirm presences of a hole or series of holes in the intestine or bowel). In an interview on [DATE] at 10:50am with ADMIN, he said he received a called from RR on [DATE], who was upset about policy and procedure regarding leaving against medical advice (AMA) and where responsibility lies. He said CR#1 was at the facility less than 10 hours, and while admitted complained of abdominal pain. He said that stat KUB (X-ray of abdominal area for causes of abdominal pain) and other tests were ordered but RR did not want to wait. He said that RR took CR#1 from the facility AMA, could not get CR#1 in the vehicle, staff explained that once she took resident from the facility help could not be provided. He said that according to the RR she called 911, was told that permission was required to come to the facility, but he had not heard of a dispatcher needing permission to come to the facility before. In an interview on [DATE] at 12:48pm with LVN C, she said that she worked from 6:00am-2:00pm on [DATE] as the treatment nurse. She said that she was going to respond to the call light of CR#1, RR came into the hall as she approached the door, she asked if RR if she needed anything, and RR said she was taking CR#1 to the hospital. She said that she told RR to allow her to get LVN B, the nurse assigned to the hall. She said that she told LVN B that RR wanted to take CR#1 to the hospital, and she went back to her duties. She said that she overheard nursing staff (names unknown) saying that CR#1 was leaving AMA, she did not hear the details why, or if staff offered assistance with transportation. In a phone interview on [DATE] at 12:59pm with LVN B, she said that she worked on [DATE] from 6:00am-2:00pm. She said that at 7:00am RR was at the facility an alerted that CR#1 was having abdominal pain and there was no mention of CR#1 having trouble breathing. She said that she assessed CR#1, his stomach was not distended, his vitals were in normal range, CR#1 said that he had pain in abdomen, RR said she wanted CR#1 to go to the hospital, and she explained to RR that she had to call the doctor first. She said that she called NP, who ordered stat labs and x-ray. She said that she returned to the room of CR#1 who had been dressed and placed in wheelchair by RR, and RR said that she was not willing to wait on labs and she was taking CR#1 to the hospital immediately. She said that she told RR to wait on labs and then they could send CR#1 out to the hospital. She said that she called DON, while RR called 911 as she was taking CR#1 to the front entrance, and she tried to explain that CR#1 would be leaving AMA. She said that RR was still on the phone with 911 as she passed LVN C, RR spoke to LVN C, RR called them idiots, and left the facility with CR#1. She said that RR never asked her for assistance or for her to speak with anyone while on the phone with 911. She said that she did not follow RR and CR#1 outside and she was unsure if other staff followed them. She said that process if resident or family is requesting to go out to the hospital is to notify the physician for order, if physician does not give the order, the family or resident can call 911 themselves. In a phone interview on [DATE] at 1:28pm with NP, he said that he was notified CR #1 was having abdominal pain, orders given for stat x-ray and KUB, but residents family was refusing and wanted to go to the hospital. He said that if a resident or family was wanting to refuse treatment and go the hospital, he would always say send them to the hospital. He said that a resident and family have the right to refuse treatment and go to the hospital. He said that he could not see a situation where he would not give order to send resident to the hospital when requested, by resident or family as long as family has POA (Power of Attorney) and can make decision. In an interview on [DATE] at 2:03pm with CNA E, he said that he worked a double on [DATE] from 6:00am-2:00pm and 2:00pm 10:00pm. He said that he rounded during shift change on second shift with another CNA (name unknown), and CR#1 was observed on the floor of his room. He said that CR#1 had diarrhea. He said that a nurse (name unknown) was alerted who came to assess CR#1. He said that CR#1 said appeared to have normal breathing. He did not know what was done to treat diarrhea. He said that worked 6:00am-2:00pm on [DATE]. He said that he was running late to work, and it was approximately 7:00am when he saw CR#1 being pushed in a wheelchair by RR towards the hospital. He said that he reported what he saw to the DON when got to the facility. In a phone interview on [DATE] at 2:03pm with CNA F, she said that she worked from 3:20pm on [DATE] to 5:00am on [DATE]. She said that CR#1 complained his stomach was hurting and had diarrhea. She said that CR#1 went to the bathroom approximately four times with diarrhea. She said that the nurse (name unknown) gave CR#1 medication for his stomach, but she was unsure what the name of the medication was. She said that CR#1 did not say he was having trouble breathing. In a phone interview on [DATE] at 3:40am with LVN A, she said that she worked on [DATE] from 10:00pm until 6:00am on [DATE]. She said that at the start of the shift CR#1 was observed with diarrhea, and she gave him over the counter medication, loperamide. She said that CR#1 had two more episodes of diarrhea after the medication was given, and the diarrhea had subsided by the morning of [DATE]. She said that right before shift change, CR#1 said he was having trouble breathing. She said that she observed CR#1 laying down, with breathing unlabored. She said that she checked CR#1 vitals and oxygen saturation was between ,d+[DATE]. She said that she elevated the head of CR#1. She said that during shift change RR complained that the abdomen of CR#1 looked distended while she was giving report at the end of her shift. She said that three were two other nurses (names unknown) present to assess CR#1. She said that his stomach did not appear to be distended but RR wanted CR#1 to go to the hospital. She said that they tried explaining that it was not the facility protocol to send resident to the hospital without order from doctor and the doctor may request labs first. She said that another nurse in the room told RR that she could call 911. She said that RR wheeled CR#1 out of the facility. In an interview on [DATE] at 4:16pm with DON , she said that she started at the facility in January of 2024. She said that she was told that the RR of CR#1 signed him out AMA and took him to the hospital. She said that staff told her they saw RR pushing CR#1 to the hospital. She said that there were calls to the facility with concerns that two residents had eloped because they were seen walking to the hospital. She said that RR spoke to ADMIN and said that she called 911, but EMS was not dispatched because they needed permission to come on the property. She said that she did an in-service (training) after the incident because it was bad for optics and concerns for customer service after the facility received calls with concerns that two residents had eloped and were seen walking down the street. She said that a resident or family can refuse treatment and request to be sent to the hospital. She said that staff should consider if resident was able to speak for themselves when the request was made by family. She said that staff should contact the doctor because a resident cannot be discharged or transferred without an order from the doctor, or it was considered AMA. She said that if staff tell a doctor that family or resident wanted to go the hospital and the physician says to let them go that was not AMA. She said that resident and family have the right to call 911, remain inside of the facility and wait on EMS to arrive. She said that staff should speak with 911 dispatcher if requested. She said that staff are not able to assist with transferring a resident into a personal vehicle after leaving AMA because the resident and family have taken responsibility at that time. In a follow up interview on [DATE] at 11:47am with LVN C, she said that she was nowhere near RR and CR#1 while RR was on the 911 call. She said that she was never asked to speak with 911 dispatcher, and he was not asked to help transfer CR#1 into the vehicle of RR so that he could be taken to the hospital. She said that she never entered the room of CR#1 and she only saw him briefly from the hallway. She said that CR#1 appeared to have normal breathing, she was not aware of CR#1 to have diarrhea or abdominal pain. She said that if a resident or family member were refusing treatment and requested resident transferred to the hospital she would explain to the family the steps she needed to take first, which included assessment of resident, followed by contacting the physician to provide information of the assessment and get order to send the resident to the hospital in the way requested by resident or family to avoid discharging AMA. She said that she has never had a physician refuse to provide the order to transfer to the hospital to avoid discharging AMA. She said if a resident or family were speaking with 911 dispatcher and to help with transfer she would speak with dispatcher if requested. She said that she had been trained that if a resident has discharged AMA, staff cannot help with transfers to get them in the car, but no other training was provided about what to do after. She said that she would help transfer to the car even though she was trained not to ensure the resident made it safely inside the car. In a phone interview on [DATE] at 12:20pm with Physician, she said that a resident or responsible party have the right to refuse treatment and request transfer to hospital, and she has never not provided an order to transfer a resident when requested. She said that if a resident discharged AMA she would expect the facility to follow their policy. She said if a resident discharged AMA and there was a concern with their safety during the discharged , she would give an order to send the resident to the hospital by 911. She said that a resident being pushed to the hospital by a relative would be considered unsafe. In a phone interview on [DATE] at 1:05pm with LVN B, she said that she worked on [DATE] from 6:00am-2:00pm. She said that LVN A, CR#1, or RR had not disclosed to her that CR#1 had diarrhea or trouble with his breathing. She said that both incidents are considered a change in condition. She said that notification should have been made to the physician. She said that if she had been made aware of the change in condition, she would have provided the information to NP when CR#1 expressed he had abdominal pain. She said that RR left the facility with CR#1 before she could give her the discharge AMA documents, she left before she had a chance to do anything. She said that she did not follow RR and CR#1 to the front of the building or outside of the facility. She said RR did not ask her to speak with 911 or for assistance with getting CR#1 into her vehicle. She said that she had been trained that staff could not help with transferring to a vehicle. She said that there had been no training on what step should be taken after a resident was outside of the facility during a discharge AMA. In a phone interview on [DATE] at 1:16pm with LVN A, she said that CR#1 never told her that he had trouble breathing and she denied that she had provided the information in a previous interview. She said that a resident expressing they had trouble breathing with oxygen saturation in normal range is not a change of condition and she had no need to complete to a SBAR but the information should have been documented. She said that when CR#1 had diarrhea it was a change in condition, and she did notify the physician to treat the diarrhea. She said that there should have been a progress note and SBAR completed, and if tasks were not completed it, should have been done. She said that both LVN B and LVN C were present in the room when CR#1 was assessed for abdominal pain, but she did not remember if it was LVN B or LVN C that told RR to call 911. She said RR did not ask her to speak with 911 or for assistance with getting CR#1 into her vehicle. She said that she had been trained that staff could not help with transferring to a vehicle. She said that there had been no training on what step should be taken after a resident is outside of the facility during a discharge AMA. In an interview on [DATE] at 2:03pm with RN I, she said that did not work on [DATE] but she knew that State Survey Agency (SSA) was investigating CR#1 being pushed in a wheelchair to the hospital by RR. She said that if she had been on duty the situation would not have gotten that far because she would have assessed resident, called the physician, and asked for order to send CR#1 to the hospital by 911 or scheduled transport depending on RR request. She said there has never been situation that a physician declined the order. She said that she would have done what every was necessary to prevent the family from walking to the hospital because that was not safe. She said there had been no training about what step should be taken in a situation like what happened to CR#1, only that you provide care while in facility and cannot help with transferring the resident into a vehicle once the leave the facility. She said although she had not been trained to do so, she would have followed CR#1 and RR to parking lot to ensure she was going to be able to transfer the resident safely to the vehicle. She said that if she observed the transfer to be unsafe, RR was unable to get CR#1 in the car or started walking with CR#1 she would have called 911, followed by DON, Administrator, and physician. In an interview on [DATE] at 2:28pm CSD said that he was a RN with corporate office. He was not made aware of situation with CR#1 being discharged AMA. He said that if a resident or responsible party requested to have a resident sent to the hospital the nurse should first ask to assess the resident so that notification could be made to the physician. He said that the physician may give orders for treatment prior to the order to go the hospital. He said that if the resident or responsible party are not in agreement with treatment then the nurse should call the physician and give information to physician for order of emergency or non emergency transportation to the hospital based on what resident or responsible party wanted. He said that if a physician declines to provide the order the family could be educated on calling 911 but staff should be available to assist. He said if the decision is to discharge AMA, care is still provided while inside of the facility. He said that staff are not able to help transfer a resident to vehicle because the facility can be liable if something happened during the transfer once outside of the facility. He said that staff should be contacting the DON or ADMIN when there is a discharge AMA for instructions. In an interview on [DATE] at 3:04pm with RVP, she said that she was not made aware of situation with CR#1 being discharged AMA. She said that if a resident or responsible party was requesting to be sent to the hospital, staff should notify the physician for an order to send the resident based on the request by emergency or non-emergency transport. She said that a resident or responsible party have the right to decline treatment and seek treatment at the hospital. In an interview on [DATE] at 4:13pm with local emergency service staff, he said that he reviewed the 911 call placed on [DATE] between 6:43am-7:00am by RR, and RR was clearly inside of the facility. He said that he may not have all the details correct but he could provide his account of what he remembered hearing. He said that RR said that CR#1 needed to go the hospital due to stomach pain. He said that the dispatcher asked to speak to someone inside of the facility, and RR could be heard asking for someone at the facility to speak with the dispatcher, and staff could beard in the background refusing to get on the phone. He said that the dispatcher told RR that since she was still inside of the facility EMS could not be dispatched and told her she could once she was outside of the facility. He said that there were no calls from the facility or RR from outside of the facility. In an interview on [DATE] at 4:40pm with ADMIN, he said that he spoke with the local emergency service staff about the 911 call. He said that he was not concerned about the call because RR said that CR#1 was having stomach pain and not SOB, as accounted by the staff. He said that he was told that staff was in the background saying that they were handling the situation. In an interview on [DATE] at 9:40am with DON and ADMIN present. She said that any medication that was given to a resident must have a physician order prior to administering the medication. She said that the facility does have over the counter medication in stock. She said that she did not know if the facility had standing orders for over-the-counter medications, but she would find out. In an interview on [DATE] at 10:15am with Medical Director, he said that a physician order must be obtained prior to administering the medication to include over the counter medication. He said that if staff provided a medication without an order the staff would be practicing outside of their scope as a nurse. He said that the risk to a resident could be adverse reaction to the medication, may require further treatment, or being sent to the hospital. He said that a resident or responsible party have the right to decline treatment and seek treatment at the hospital. He said that staff should call the physician to provide information on why the resident or responsible party is insisting to go to the hospital and request an order in line to what the resident or responsible party is requesting. He said that when the family is at the bed side, they may see something that staff may not see. He said that he had never heard of a situation when a physician blocked a resident or responsible party from going to the hospital when they are insisting. He said that there should never be a situation where a resident is pushed to the hospital by wheelchair because staff did not obtain an order to send the resident to the hospital by emergency or non-emergency transport when requested. He said that staff should use their best judgement and call 911 to avoid the situation. Interview on [DATE] at 11:08am with DON, she said that the facility does not have standing orders for medications and all medications require an order. She said that she was unsure if they had loperamide in stock for over-the-counter medication but she would find out. In an interview on [DATE] at 11:20am with DON, she said that the facility did have the over-the-counter medication loperamide that is used to treat diarrhea, and she provided an unopened box to view. She said that she was unsure of how to view medication orders on a discharged resident, but she would find out. In an interview on [DATE] at 11:26am with DON while MDS Nurse was present said that there was not a progress note or SBAR completed to show that CR#1 had diarrhea. If resident had diarrhea. She said that diarrhea would be considered a change in condition if the resident had not admitted with the diagnosis. She reviewed CR#1 admission medical records and admission progress note with no information regarding diarrhea. She reviewed CR#1 physician orders with no orders provided for loperamide. She said that if CR#1 had diarrhea the physician should have been notified for orders on treatment, and medication should not have been given without an order. She said that without the order the nurse would be practicing outside of the scope of a nurse. She said that nursing staff never provided information that CR#1 was treated for diarrhea and the information was new to her. Record review on [DATE] at 12:22pm of written statement provided by local emergency service staff read in part, .On 18th of February, 2024, at 07:43:03 hrs, our dispatchers in the police department received a 911 call . On the call she states that she wanted to request an ambulance .for CR#1 because he was having some breathing issues and his stomach was hurting. The dispatcher stated that, because her husband was a patient at that medical facility, the staff would have to request us to come and take him to another medical facility. The dispatcher then asked if one of the staff members could maybe speak with her, versus having to call separately requested that t . staff speak with the dispatcher and give permission for the ambulance to come and take her husband (the patient). The staff was heard on the 911 call stating that they would not speak with the 911 dispatcher she was going to take him to the hospital herself and then disconnected the call . In a phone interview on [DATE] at 12:30pm with LVN A, she said she did not notify a physician when CR#1 had diarrhea. She said that she gave CR#1 over the counter anti diarrhea medication without a physician order, she did not enter a progress or SBAR, or tell any other staff during shift change that CR#1 had been treated for diarrhea. She said that she got overwhelmed with duties and she forgot to complete the steps. She said that she meant to call the doctor after she gave the medication, she forgot, and it was stupid mistake. She said that she knew that an order was needed prior to giving any medication. She said that she had been suspended. She said that she practiced outside of her scope as a nurse, could have put CR#1 at risk, and if the physician was contacted, they may have provided different orders. Record Review of facility policy titled Administering Medications Dated Revised [DATE] revealed, in part, Policy Statement. Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 3.Medications must be administered in accordance with the orders, including any required time frame . Record Review of facility policy titled Discharging a Resident without a Physician's Approval Dated Revised [DATE] revealed, in part, .A physician's order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advise . Record Review of facility policy titled Transfer or Discharge, Emergency Dated Revised [DATE] revealed, in part, .Policy Statement. Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). Policy Interpretation and Implementation. 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institutions, our facility will implement the following procedures: a. notify the residents attending physician; c. prepare the resident for transfer; f. assist in obtaining transportation; and g. others as appropriate or as necessary Record Review of facility policy titled Transportation, Social Services Dated Revised [DATE] revealed, in part, .Policy Statement. Our facility shall help arrange transportation for residents as needed. 1. Except in emergencies, the resident or his or her representative (sponsor) shall be expected to arrange for transportation This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified on [DATE]. The Administrator was provided with the IJ template on [DATE] 4:17pm. The following Plan of Removal submitted by the facility was accepted on [DATE] 1:19pm. The plan of removal reflected the following: Facility Name: Plan of Removal -The facility failed to obtain physician orders on [DATE] prior to treating CR#1 with loperamide to treat diarrhea. -The facility failed to arrange emergency transportation to local hospital for CR#1 when requested by family on [DATE]. What corrective actions have been implemented for the identified residents? A. On [DATE] resident CR#1 involved in alleged deficient practice was discharged to the hospital against medical advice per R R's request and did not return to the facility. The attending physician was notified on [DATE] at 7:31 am and this was documented in the resident clinical record. B. On [DATE] at 5:00 pm Administrator notified the Medical Director, and the attending physician of alleged deficient practice. C. On [DATE] LVN A was in-serviced on Notifying the Physician Immediately of Change of Condition Occurs and Obtaining Orders from the Physician before Treating the Resident. D. On [DATE] LVN A was suspended on [DATE] pending investigation due to investigation findings. E. On [DATE] LVN B was in-serviced on Assisting Residents/RR with Arranging Emergency Transportation Upon Request. F. Clinical Services Director reviewed facility policy on [DATE] regarding notification of physician and no revisions were deemed necessary. G. Clinical Services Director reviewed facility policy on [DATE] regarding administering medications and no revisions were deemed necessary. H. Clinical Services Director reviewed facility policy on [DATE] regarding discharging a resident without a physician's approval and revisions were made. Summary of revision: The Administrator and Director of Nursing will be promptly notified. The Charge Nurse will assist with arranging emergency transport or regular transport as applicable upon resident or representative (sponsor) request. The Attending physician will be up [TRUNCATED]

Based on interview and record review, that facility failed to extend to the resident representative ' s the right to make decisions on behalf of the resident for 1 of 10 residents (CR#1) reviewed for resident rights in that. 1. The facility failed to establish if CR#1 wanted to the leave the facility to the hospital when requested by the Resident Representative (RR) when he was alert and oriented times four. 2. The facility failed to arrange emergency transportation to local hospital when requested by RR for CR#1 when he expressed having trouble breathing on [DATE] and complained of abdominal pain with diarrhea. CR#1 was wheeled to a local hospital on [DATE] and expired while at the hospital on [DATE]. - An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:43pm. While the IJ was removed on [DATE], the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of not receiving treatment when requested by the resident or RR. Findings included : Record review of CR#1's face sheet dated, [DATE], reflected he was a [AGE] year-old male, admitted to the facility on [DATE] as his own responsible party with diagnoses of metabolic encephalopathy(chemical imbalance in the blood affecting the brain), sepsis(infection), pneumonia (lung infection), end stage renal disease (kidney failure), pleural effusion (excess fluid affecting the lungs), dyspnea(Shortness of breath), atherosclerotic heart disease(plaque buildup in the arteries of the heart), and atrial fibrillation(irregular heartbeat). CR#1 was discharged on [DATE] against medical advice in the care of RR who pushed him by wheelchair to the hospital Record review of CR#1 baseline care plan dated [DATE] with no information to indicate resident cognitive level. Record review of CR#1's admission nursing progress note entered by RN D with effective date [DATE] read in part, .Resident awake alert oriented x4. Resident denies pain or discomfort. No acute distress noted. Lungs clear bilaterally. Respiration even and [unlaboured]. Abdomen soft. Bowel present x 4 [quadrents] . Record review of CR#1's nursing progress note entered by LVN B dated [DATE] read in part Upon arrival, resident noted saying I'm in pain, I don't know what to do repeatedly. When asked for a specific location of pain, resident touched his abdomen, RR present in room. Writer palpated residents abdomen, upper quadrants hard but non distended (enlarged), lower quadrants soft, non distended. Resident states he has frequent regular bowel movements and ,d+[DATE] nurse(LVN A) stated resident had a large bowel movement(bm) on her shift. Vitals assessed and are all wnl (within normal limits), NP (Nurse Practitioner) notified and gave orders to get STAT Chest XRAYS and KUB. Writer informed residents RR of this information however she refused stating he needs to be seen in the ER immediately. Residents RR dressed resident, transferred him into his wheelchair and rolled him out of the facility. RR informed that by making this call, resident is leaving Against Medical Advice(AMA). RR begin calling staff members idiots and continued to leave the facility. DON and NP notified. Record review of CR#1 medical records from local hospital with admitted [DATE] with chief complaint of diarrhea and shortness of breath (SOB). Computed Tomography Scan(CT SCAN a diagnostic imaging procedure) completed of abdomen and pelvis with left free intraperitoneal gas suspicious for perforated hollow viscus (air under the diaphragm suggesting a hole or series of holes in the intestine or bowel) with recommendation for surgical consult. CT SCAN revealed complete collapse of left lower lobe and partial collapse of the right lower lobe. Death summary revealed family declined surgical intervention, made CR#1 do-not-resuscitate (DNR), and resident transition care to comfort measures only. Resident expired on [DATE] while at the hospital. In a phone interview on [DATE] at 9:10 am with RR, she said that CR#1 called her on [DATE] at 5:00am saying he could not breath and his stomach hurt bad, so she went to the facility. She said a nurse came into the room when she arrived at the facility, and said she contacted a doctor, he ordered a x-ray that would take 4 hours. She said she told the nurse (name unknown) she could not wait 4 hours because CR#1 could not breathe, and the nurse said that's what the doctor said to do. She said she told the nurse she was taking him to emergency room (ER). She said that she asked nurses at the facility to help put CR#1 in the car, and she was told they were not allowed to help. She called 911 to take CR#1 to the hospital, Emergency Medical Services (EMS) told her that permission was needed to come on private property, she asked a nurse to give EMS permission to come on the property, and she was told they could not give permission. She said that she had to push CR#1 in his wheelchair to the ER(located 0.6 miles from the facility). She said that while at the hospital CR#1 had a CT scan that confirmed a perforated intestine (diagnostic imaging procedure to confirm presences of a hole or series of holes in the intestine or bowel). In an interview on [DATE] at 10:50am with ADMIN, he said he received a called from RR on [DATE], who was upset about policy and procedure regarding leaving against medical advice (AMA) and where responsibility lies. He said CR#1 was at the facility less than 10 hours, and while admitted complained of abdominal pain. He said that stat KUB (X-ray of abdominal area for causes of abdominal pain) and other tests were ordered but RR did not want to wait. He said that RR took CR#1 from the facility AMA, could not get CR#1 in the vehicle, staff explained that once she took resident from the facility help could not be provided. He said that according to the RR she called 911, was told that permission was required to come to the facility, but he had not heard of a dispatcher needing permission to come to the facility before. In an interview on [DATE] at 12:48pm with LVN C, she said that she worked from 6:00am-2:00pm on [DATE] as the treatment nurse. She said that she was going to respond to the call light of CR#1, RR came into the hall as she approached the door, she asked if RR if she needed anything, and RR said she was taking CR#1 to the hospital. She said that she told RR to allow her to get LVN B, the nurse assigned to the hall. She said that she told LVN B that RR wanted to take CR#1 to the hospital, and she went back to her duties. She said that she overheard nursing staff (names unknown) saying that CR#1 was leaving AMA, she did not hear the details why, or if staff offered assistance with transportation. In a phone interview on [DATE] at 12:59pm with LVN B, she said that she worked on [DATE] from 6:00am-2:00pm. She said that at 7:00am RR was at the facility an alerted that CR#1 was having abdominal pain and there was no mention of CR#1 having trouble breathing. She said that she assessed CR#1, his stomach was not distended, his vitals were in normal range, CR#1 said that he had pain in abdomen, RR said she wanted CR#1 to go to the hospital, and she explained to RR that she had to call the doctor first. She said that she called NP, who ordered stat labs and x-ray. She said that she returned to the room of CR#1 who had been dressed and placed in wheelchair by RR, and RR said that she was not willing to wait on labs and she was taking CR#1 to the hospital immediately. She said that she told RR to wait on labs and then they could send CR#1 out to the hospital. She said that she called DON, while RR called 911 as she was taking CR#1 to the front entrance, and she tried to explain that CR#1 would be leaving AMA. She said that RR was still on the phone with 911 as she passed LVN C, RR spoke to LVN C, RR called them idiots, and left the facility with CR#1. She said that RR never asked her for assistance or for her to speak with anyone while on the phone with 911. She said that she did not follow RR and CR#1 outside and she was unsure if other staff followed them. She said that process if resident or family was requesting to go out to the hospital was to notify the physician for an order, if physician does not give the order, the family or resident can call 911 themselves. In a phone interview on [DATE] at 1:28pm with NP, he said that he was notified CR#1 was having abdominal pain, orders given for stat x-ray and KUB, but residents family was refusing and wanted to go to the hospital. He said that if a resident or family was wanting to refuse treatment and go the hospital, he would always say send them to the hospital. He said that a resident and family have the right to refuse treatment and go to the hospital. He said that he could not see a situation where he would not give order to send resident to the hospital when requested, by resident or family as long as family has POA (Power of Attorney) and can make decision. In an interview on [DATE] at 2:03pm with CNA E, he said that he worked 6:00am-2:00pm on [DATE]. He said that he was running late to work, and it was approximately 7:00am when he saw CR#1 being pushed in a wheelchair by RR towards the hospital. He said that he reported what he saw to the DON when got to the facility. In a phone interview on [DATE] at 3:40am with LVN A, she said that during shift change RR complained that the abdomen of CR#1 looked distended while she was giving report at the end of her shift. She said that three were two other nurses (names unknown) present to assess CR#1. She said that his stomach did not appear to be distended but RR wanted CR#1 to go to the hospital. She said that they tried explaining that it was not the facility protocol to send resident to the hospital without order from doctor and the doctor may request labs first. She said that another nurse in the room told RR that she could call 911. She said that RR wheeled CR#1 out of the facility. In an interview on [DATE] at 4:16pm with DON, she said that she started at the facility in January of 2024. She said that she was told that the RR of CR#1 signed him out AMA and took him to the hospital. She said that staff told her they saw RR pushing CR#1 to the hospital. She said that there were calls to the facility with concerns that two residents had eloped because they were seen walking to the hospital. She said that RR spoke to ADMIN and said that she called 911, but EMS was not dispatched because they needed permission to come on the property. She said that she did an in-service (training) after the incident because it was bad for optics and concerns for customer service after the facility received calls with concerns that two residents had eloped and were seen walking down the street. She said that staff should consider if resident is able to speak for themselves when the request is made by family. She said that staff should contact the doctor because a resident cannot be discharged or transferred without an order from the doctor, or it is considered AMA. She said that if staff tell doctor that family or resident is wanting to go the hospital and the physician says to let them go that is not AMA. She said that resident and family have the right to call 911, remain inside of the facility and wait on EMS to arrive. She said that staff should speak with 911 dispatcher if requested. In a follow up interview on [DATE] at 11:47am with LVN C, she said that she was nowhere near RR and CR#1 while RR was on the 911 call. She said that she was never asked to speak with 911 dispatcher, and he was not asked to help transfer CR#1 into the vehicle of RR so that he could be taken to the hospital. She said that she never entered the room of CR#1 and she only saw him briefly from the hallway. In a phone interview on [DATE] at 12:20pm with Physician, she said that a resident or responsible party have the right to refuse treatment and request transfer to hospital, and she has never not provided an order to transfer a resident when requested. She said that if a resident discharged AMA, she would expect the facility to follow their policy. She said if a resident discharged AMA and there was a concern with their safety during the discharged , she would give an order to send the resident to the hospital by 911. She said that a resident being pushed to the hospital by a relative would be considered unsafe. In a phone interview on [DATE] at 1:05pm with LVN B, she said that she worked on [DATE] from 6:00am-2:00pm. She said that RR left the facility with CR#1 before she could give her the discharge AMA documents, she left before she had a chance to do anything. She said that she did not follow RR and CR#1 to the front of the building or outside of the facility. She said RR did not ask her to speak with 911 or for assistance with getting CR#1 into her vehicle. She said that she had been trained that staff could not help with transferring to a vehicle. She said that there had been no training on what step should be taken after a resident is outside of the facility during a discharge AMA. In a phone interview on [DATE] at 1:16pm with LVN A, she said that both LVN B and LVN C were present in the room when CR#1 was assessed for abdominal pain, but she did not remember if it was LVN B or LVN C that told RR to call 911. She said RR did not ask her to speak with 911 or for assistance with getting CR#1 into her vehicle. She said that she had been trained that staff could not help with transferring to a vehicle. She said that there had been no training on what step should be taken after a resident was outside of the facility during a discharge AMA. In an interview on [DATE] at 2:03pm with RN I, she said that did not work on [DATE] but she knew that State Survey Agency (SSA) was investigating CR#1 being pushed in a wheelchair to the hospital by RR. She said that if she had been on duty the situation would not have gotten that far because she would have assessed resident, called the physician, and asked for order to send CR#1 to the hospital by 911 or scheduled transport depending on RR request. She said there has never been situation that a physician declined the order. She said that she would have done what ever was necessary to prevent the family from walking to the hospital because that was not safe. She said there had been no training about what step should be taken in a situation like what happened to CR#1, only that you provide care while in facility and cannot help with transferring the resident into a vehicle once the leave the facility. She said although she had not been trained to do so, she would have followed CR#1 and RR to parking lot to ensure she was going to be able to transfer the resident safely to the vehicle. She said that if she observed the transfer to be unsafe, RR was unable to get CR#1 in the car or started walking with CR#1 she would have called 911, followed by DON, Administrator, and physician. In an interview on [DATE] at 2:28pm with CSD, he said that he was a RN with corporate office. He was not made aware of situation with CR#1 being discharged AMA. He said that if a resident or responsible party requested to have a resident sent to the hospital the nurse should first ask to assess the resident so that notification could be made to the physician. He said that the physician may give orders for treatment prior to the order to go the hospital. He said that if the resident or responsible party are not in agreement with treatment then the nurse should call the physician and give information to physician for order of emergency or non-emergency transportation to the hospital based on what resident or responsible party wanted. He said that if a physician declines to provide the order the family could be educated on calling 911 but staff should be available to assist. He said if the decision is to discharge AMA, care would still be provided to a resident while inside of the facility. He said that staff are not able to help transfer a resident to vehicle because the facility can be liable if something happened during the transfer once outside of the facility. He said that staff should be contacting the DON or ADMIN when there is a discharge AMA for instructions. In an interview on [DATE] at 3:04pm with RVP, she said that she was not made aware of situation with CR#1 being discharged AMA. She said that if a resident or responsible party was requesting to be sent to the hospital, staff should notify the physician for an order to send the resident based on the request by emergency or non-emergency transport. She said that resident and responsible have the right to decline treatment and seek treatment at the hospital. In an interview on [DATE] at 4:13pm with local emergency service staff, he said that he reviewed the 911 call placed on [DATE] between 6:43am-7:00am by RR, and RR was clearly inside of the facility. He said that he may not have all the details correct but he could provide his account of what he remembered hearing. He said that RR said that CR#1 needed to go the hospital due to stomach pain. He said that the dispatcher asked to speak to someone inside of the facility, and RR could be heard asking for someone at the facility to speak with the dispatcher, and staff could beard in the background refusing to get on the phone. He said that the dispatcher told RR that since she was still inside of the facility EMS could not be dispatched and told her she could once she was outside of the facility. He said that there were no calls from the facility or RR from outside of the facility. In an interview on [DATE] at 4:40pm with ADMIN, he said that he spoke with the local emergency service staff about the 911 call. He said that he was not concerned about the call because RR said that CR#1 was having stomach pain and not SOB, as accounted by the staff. He said that he was told that staff was in the background saying that they were handling the situation. In an interview on [DATE] at 10:15am with Medical Director, he said that a resident or responsible party have the right to decline treatment and seek treatment at the hospital. He said that staff should call the physician to provide information on why the resident or responsible party was insisting to go to the hospital and request an order in line to what the resident or responsible party is requesting. He said that when the family is at the bed side, they may see something that staff may not see. He said that he had never heard of a situation when a physician blocked a resident or responsible party from going to the hospital when they are insisting. He said that there should never be a situation where a resident is pushed to the hospital by wheelchair because staff did not obtain an order to send the resident to the hospital by emergency or non-emergency transport when requested. He said that staff should use their best judgement and call 911 to avoid the situation. Record review on [DATE] at 12:22pm of written statement provided by local emergency service staff read in part, .On 18th of February, 2024, at 07:43:03 hrs, our dispatchers in the police department received a 911 call . On the call she states that she wanted to request an ambulance .for CR#1 because he was having some breathing issues and his stomach was hurting. The dispatcher stated that, because her husband was a patient at that medical facility, the staff would have to request us to come and take him to another medical facility. The dispatcher then asked if one of the staff members could maybe speak with her, versus having to call separately requested that t . staff speak with the dispatcher and give permission for the ambulance to come and take her husband (the patient). The staff was heard on the 911 call stating that they would not speak with the 911 dispatcher she was going to take him to the hospital herself and then disconnected the call . In a phone interview on [DATE] at 12:30pm with LVN A, she said CR#1 was alert but had some confusion, and she did not remember anyone asking CR#1 if he wanted to go to the hospital or asking RR if she had legal authority to make decisions. In a phone interview on [DATE] at 12:54pm with CNA F, she said she worked on [DATE] on double shift starting at 2:00pm, and she left at 5:00am on [DATE]. She said that during her shift CR#1 was alert but had some confusion. In an interview on [DATE] at 3:09pm with CNA E, he said that during his shift on [DATE] from 6:00am-10:00pm CR#1 was alert but had some confusion. In an interview on [DATE] at 8:30 am with LVN C, she said when RR and CR#1 were at the front lobby area near entrance there were staff at the nursing station, but she could not recall who. She said that RR was on the phone calling 911, but she did not stick around to hear what was being said. She said CR#1 appeared to be alert, and she did not remember any asking CR#1 what he wanted. In a phone interview on [DATE] at 10:57am with RR, she said that she had dual Power of Attorney (POA) executed to make medical and final decision for CR#1 since 2016. She said that no one at the facility asked if she had a POA. She said that CR#1 did have some confusion, but he was alert and able to talk. She said that no one at the facility asked CR#1 if he wanted to go to the hospital. She said that she was given an admission packet at admission, and it had information on rights and facilities policy procedures. Record review on [DATE] at 1:20pm of dual Power of Attorney (POA) executed to make medical and final decision between CR#1 and RR date [DATE]. Record review on [DATE] at 9:43am of the audio recording of the911 call provided by local city officials. In the call RR could be heard on the call with a dispatcher requesting emergency assistance for CR#1, due to CR#1 being unable to breath and abdominal pain. The dispatcher requested to speak with staff at the facility. RR responded that staff would not help, and staff would not help place CR#1 in her vehicle so that RR could transport to the hospital. The dispatcher explained to RR that emergency services could not be dispatched unless the call came from the facility. RR could be heard asking staff to speak with the dispatcher, staff could be heard saying that they could not speak with dispatcher, and RR could be heard saying that CR#1 would die because staff could not assist and emergency would not be dispatched. The dispatcher was heard explaining to RR that emergency service could not be dispatched without speaking to staff, and RR replied with staff would not speak with dispatcher, RR would push CR#1 to the hospital, they would freeze, and CR#1 would die from pneumonia. In an interview on [DATE] at 12:03pm with LVN W, she said that worked on the morning of [DATE] from 6:00am-2:00pm. She said that heard yelling at the front of the building at lobby. She said that when she approached the nurses' station, she could see CR#1 seated in wheelchair with RR, they were still inside the facility near the nurses station, and the only staff present was LVN C. She said that RR was on the phone with 911 but she did not hear the call from the beginning. She said that RR was asking for EMS, but she guessed the dispatcher was not going to send EMS because she said that, thank you for nothing, she was going to push him to the hospital, if CR#1 got pneumonia and died it would be on everyone, hung up the call, and pushed CR#1 out of the building. She said that LVN C told her that CR#1 was discharging AMA. She said she did not know if RR had legal authority to take CR#1 from the facility. She said that CR#1 appeared to be alert, and LVN C or she asked CR#1 if he wanted to leave the facility to go to the hospital. In a phone interview on [DATE] at 1:02pm with LVN B, she said that CR#1 was alert, but she did not remember asking if he wanted to go to the hospital. She did not remember asking RR if she had the legal authority to make decisions for CR#1. In an interview on [DATE] at 1:22pm with Director of Admission, she said that prior to admission she tries to obtain information on responsible party and if there was a POA. She said that if she receives the POA she files it in her office. She said that she does not have a way to document her efforts prior to admission because there was no chart. She said that if information was not received prior to admission the resident was named their own responsible party until follow up can be made by admission or social worker to confirm. She said that upon admission there was another attempt to get the information. Record review of facility policy titled, Statement of Resident Rights, undated revealed, in part, You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law .You have a right to: 1. All care necessary for you to have the highest possible level of health and welfare; 21. Discharge yourself from the facility unless you have been adjudicated mentally incompetent; Record Review of facility policy titled Discharging a Resident without a Physician's Approval Dated Revised [DATE] revealed, in part, .A physician's order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advise .7. The charge nurse will assist with arranging emergency transport or regular transport as applicable upon resident or representative (sponsor) request Record Review of facility policy titled Transfer or Discharge, Emergency Dated Revised [DATE] revealed, in part, .Policy Statement. Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). Policy Interpretation and Implementation. 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institutions, our facility will implement the following procedures: a. notify the residents attending physician; c. prepare the resident for transfer; f. assist in obtaining transportation; and g. others as appropriate or as necessary Record Review of facility policy titled Transportation, Social Services Dated Revised [DATE] revealed, in part, .Policy Statement. Our facility shall help arrange transportation for residents as needed. 1. Except in emergencies, the resident or his or her representative (sponsor) shall be expected to arrange for transportation This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified on [DATE]. The Administrator was provided with the IJ template on [DATE] 5:42pm. The following Plan of Removal submitted by the facility was accepted on [DATE] 9:46 AM. The plan of removal reflected the following: Facility Name: Plan of Removal -The facility failed to arrange emergency transportation to local hospital for CR#1 when requested by the responsible party on [DATE]. What corrective actions have been implemented for the identified residents? F. On [DATE] CR#1 involved in alleged deficient practice was discharged to the hospital against medical advice per(for each) RR's request and did not return to the facility. He was discharged via(by means of) non-emergency services and completed by RR. The attending physician was notified on [DATE] at 7:31 am and this was documented in the resident clinical record. G. On [DATE] at 6:30 pm Administrator notified the Medical Director, and the attending physician of alleged deficient practice. H. Facility auditing the resident's medical record from [DATE] to [DATE] to determine if a POA was listed and the POA was included. Social Workers and Medical Records will be completing the audit, and the completion date is [DATE]. I. Regional [NAME] President reviewed facility policy on [DATE] regarding resident rights and no revisions were deemed necessary. J. On [DATE] LVN A received a 1:1 training on Resident Rights Establishing from the resident if they want to go to the hospital when the POA requests and Assisting residents POA with arranging transportation when they request for the resident to be sent to the hospital. Training was provided by Director of Nursing and Assistant Director of Nursing. K. On [DATE] LVN B received a 1:1 training on Resident Rights Establishing from the resident if they want to go to the hospital when the POA requests and Assisting residents POA with arranging transportation when they request for the resident to be sent to the hospital. Training was provided by Director of Nursing and Assistant Director of Nursing. L. On [DATE] LVN C received a 1:1 training on Resident Rights Establishing from the resident if they want to go to the hospital when the POA requests and Assisting residents POA with arranging transportation when they request for the resident to be sent to the hospital. Training was provided by Director of Nursing and Assistant Director of Nursing. M. On [DATE] LVN D[LVN W] received a 1:1 training on Resident Rights Establishing from the resident if they want to go to the hospital when the POA requests and Assisting residents POA with arranging transportation when they request for the resident to be sent to the hospital. Training was provided by Director of Nursing and Assistant Director of Nursing. How were other residents at risk to be affected by this deficient practice identified? B. All residents have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? D. An in-service was initiated on [DATE] by the Director of Nursing and Nurse Managers with the licensed nursing staff on the Resident Rights Policy. In-service includes, Establishing from the resident if they want to go to the hospital when the POA requests and Assisting residents POA with arranging transportation when they request for the resident to be sent to the hospital. Licensed nurses will not be allowed to return to work until they receive this in-service. Nurses who are unable to physically attend the in-service training in person will be in-serviced via (by means of) phone. The completion date was [DATE]. E. Licensed nursing staff will complete a Resident's Rights Pre/Post Test Competency. Nurses in-serviced over the phone will not be allowed to work until they complete the Resident's Rights Pre/Post Test Competency. The completion date was [DATE]. F. During the in-service training, there will be a discussion. QA to ensure understanding and competency. Learning will be measured by a pre/post-test, nurses who fail will be further educated and/or progressively disciplined as indicated. The completion date was [DATE]. G. An in-service was completed on [DATE] by the Administrator with the Admissions Director, Director of Business Director, and Social Worker on Obtaining the Power of Attorney. The completion date was [DATE]. In-service includes, Requesting a copy of the POA Before Admission. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. The State Surveyor(SS) confirmed the Plan of Removal for the IJ by monitoring from [DATE] through [DATE] as follows: In an on [DATE] at 11:26am with Unit Manager A, she said that she was an LVN. She said that she had been trained on Residents rights. She said that if a resident with a responsible party makes a care decision, the nurse must consider the rig [TRUNCATED]

Based on observation, interview, and record review , the facility failed to consult with the resident's physician; and notify the resident representative for 1 of 10 residents (CR#1) reviewed for change of condition, in that, 1. LVN A failed to immediately notify the physician on [DATE] when CR#1 was observed with diarrhea, and LVN A failed to immediately notify the physician when CR#1 said he was having trouble breathing on [DATE]. CR#1 was admitted to a local hospital on [DATE] and died while in the hospital on [DATE]. 2. The facility failed to establish if CR#1 wanted to the leave the facility to the hospital when requested by the Resident Representative (RR) when he was alert and oriented times four. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] 11:27am. While the IJ was removed on [DATE], the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could expose residents to low quality of care, worsening of condition, hospitalization , and death. Findings included: Record review of CR#1's face sheet dated, [DATE], reflected he was a [AGE] year-old male, admitted to the facility on [DATE] as his own responsible party with diagnoses of metabolic encephalopathy(chemical imbalance in the blood affecting the brain), sepsis(infection), pneumonia (lung infection), end stage renal disease (kidney failure), pleural effusion (excess fluid affecting the lungs), dyspnea (Shortness of breath), atherosclerotic heart disease (plaque buildup in the arteries of the heart), and atrial fibrillation (irregular heartbeat). CR#1 was discharged on [DATE]. Record review of electronic medical records (EMR) for CR #1 did not reveal progress notes completed by LVN A on [DATE], or Situation, Background, Assessment, and Recommendation (SBAR) completed by LVN A regarding CR#1 change in condition after he expressed having trouble breathing or observed with diarrhea on [DATE]. Record review of physician order summary for CR#1 revealed no orders for anti-diarrhea medication. Record review of CR#1 baseline care plan dated [DATE] with no information to indicate CR#1 admitted with diarrhea. Record review of CR#1 medical records from local hospital with admitted [DATE] and discharge date of [DATE] revealed in the discharge summary no diagnosis for diarrhea an no orders for anti-diarrhea medication was provided at discharge. Record review of CR#1 medical records from local hospital with admitted [DATE] with chief complaint of diarrhea and shortness of breath (SOB ). Computed Tomography Scan(CT SCAN a diagnostic imaging procedure) completed of abdomen and pelvis with left free intraperitoneal gas suspicious for perforated hollow viscus (air under the diaphragm suggesting a hole or series in the intestine or bowel) with recommendation for surgical consult. CT SCAN revealed complete collapse of left lower lobe and partial collapse of the right lower lobe. Death summary revealed family declined surgical intervention, made CR#1 do-not-resuscitate (DNR ), and resident transition care to comfort measures only. Resident expired on [DATE] while at the hospital. In an interview on [DATE] at 9:10 am with RR, she said that CR#1 complained of being unable to breath and stomach pain. She said that she did not want to wait four hours while the facility had imaging done. She said that she wheeled CR#1 to a local hospital after facility staff refused to help transfer CR#1 to her vehicle, facility staff refused to help arrange transportation, and she was not able to get assistance with transportation from Emergency Medical Services (EMS) when she contacted 911. In an interview on [DATE] at 2:03pm with CNA E, he said that he worked a double on [DATE] from 6:00am-2:00pm and 2:00pm 10:00pm. He said that he rounded during shift change on second shift with another CNA (name unknown), and CR#1 was observed on the floor of his room. He said that CR#1 had diarrhea. He said that a nurse (name unknown) was alerted who came to assess CR#1. He said that CR#1 said appeared to have normal breathing. He did not know what was done to treat diarrhea. In a phone interview on [DATE] at 2:03pm with CNA F, she said that she worked from 3:20pm on [DATE] to 5:00am on [DATE]. She said that CR#1 complained his stomach was hurting and had diarrhea. She said that CR#1 went to the bathroom approximately four times with diarrhea. She said that the nurse (name unknown) gave CR#1 medication for his stomach, but she was unsure what the name of the medication was. She said that CR#1 did not say he was having trouble breathing. In a phone interview on [DATE] at 3:40am with LVN A, she said that she worked on [DATE] from 10:00pm until 6:00am on [DATE]. She said that at the start of the shift CR#1 was observed with diarrhea, and she gave him over the counter medication, loperamide. She said that CR#1 had two more episodes of diarrhea after the medication was given, and the diarrhea had subsided by the morning of [DATE]. She said that right before shift change, CR#1 said he was having trouble breathing. She said that she observed CR#1 laying down, with breathing unlabored. She said that she checked CR#1 vitals and oxygen saturation was between ,d+[DATE]. She said that she elevated the head of CR#1. In a phone interview on [DATE] at 12:20pm with Physician, she said that she confirmed that nursing staff did not contact the on-call service or NP when CR#1 had trouble breathing or diarrhea, both would be considered a change in condition and required notification. She said that notification would still be required even if the oxygen saturation was in normal range. She said that notification was completed when CR#1 expressed he was having abdominal pain and after he had a fall. She said that orders would have been provided to address both diarrhea and complaint of having trouble breathing at the same time with the abdominal pain. She said that it was important to have the information since CR#1 had pneumonia and sepsis. She said that based on the information provided orders would have been given for testing and treatment of diarrhea prior to deciding to send CR#1 to the hospital. In a phone interview on [DATE] at 12:45pm with NP, he said that when he was contacted after CR#1 complained of abdominal pain he was not informed there was a concern for diarrhea or with residents breathing. He said that notification would be required if a resident had trouble breathing with an oxygen saturation in range. He said that staff should have provided the information to an on-call physician or when they spoke with him because both incidents are a change in condition. He said that it was important to have the information due to CR#1 diagnosis of pneumonia and sepsis He said that he would have given additional orders for testing and treatment of diarrhea before deciding to send CR#1 to the hospital. In a phone interview on [DATE] at 1:05pm with LVN B, she said that she worked on [DATE] from 6:00am-2:00pm. She said that LVN A, CR#1, or RR had not disclosed to her that CR#1 had diarrhea or trouble with his breathing. She said that both incidents are considered a change in condition. She said that if CR#1 said he had trouble breathing and his oxygen saturation was in normal range it would still be a change in condition. She said that notification should have been made to the physician. She said that if she had been made aware of the change in condition, she would have provided the information to NP when CR#1 expressed he had abdominal pain. In a phone interview on [DATE] at 1:16pm with LVN A, she said that CR#1 never told her that he had trouble breathing and she denied that she had provided the information in a previous interview. She said that a resident expressing they had trouble breathing with oxygen saturation in normal range is not a change of condition and she had no need to complete to a SBAR but the information should have been documented. She said that when CR#1 had diarrhea it was a change in condition, and she did notify the physician to treat the diarrhea. She said that there should have been a progress note and SBAR completed, and if tasks were not completed it, should have been done. In an interview on [DATE] at 2:20pm with DON, she said that if a resident had trouble breathing that would be a change in condition even with a normal range oxygen saturation. She said that the resident's physician should have been notified so that orders to treat the issues could have been provided. She said that without treatment the condition could progress, and the resident may need to be sent to the hospital. She said that when there is a change in condition staff should notify the physician, complete a SBAR, and progress note. In an interview on [DATE] at 2:28pm with CSD, he said that he is a RN with corporate office. He said that if a resident expressed, they had trouble breathing even when the oxygen saturation is in normal range it would be considered a change in condition. He said that the physician should be notified so it could be determined why the resident had trouble breathing, and if the physician was not notified when there was a respiratory issue the resident could end up being sent to the hospital. He said that when there is a change in condition staff should notify the physician, complete a SBAR, and progress note. Record Review of facility policy titled Change in a Resident's Condition or Status Dated Revised [DATE] revealed, in part, Policy Statement. Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation. 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; . i. specific instruction to notify the Physician of changes in the resident's condition . This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified on [DATE] 11:23am. The Administrator was provided with the IJ template on [DATE] 11:27 am. The following Plan of Removal submitted by the facility was accepted on [DATE] at 6:44pm. The plan of removal reflected the following: Plan of Removal Name of Facility: What corrective actions have been implemented for the identified residents? A. On [DATE] resident CR#1 involved in alleged deficient practice was discharged to the hospital against medical advice per RR's request and did not return to the facility. The attending physician was notified on [DATE] at 7:31 am and this was documented in the resident clinical record. B. On ,d+[DATE]/ 2024 at 12:16 pm Administrator notified the Medical Director, and the attending physician of alleged deficient practice. C. Nurse Managers completed a 100% respiratory assessment of all residents residing in the facility for respiratory concerns on [DATE], and none were identified. D. Facility auditing the change in conditions from [DATE] to the [DATE] for respiratory concerns and notification to the physician. Nurse Managers will be auditing, and the completion date is [DATE]. E. Clinical Services Director reviewed facility policy on [DATE] regarding notification of physician and no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. All residents have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. An in-service was initiated on [DATE] by the Corporate Clinical Service Director and Director of Nursing with the licensed nursing staff to notify the attending physician immediately when a change of condition occurs. In-service includes Report any changes from resident's baseline to the physician. Licensed nurses will not be allowed to return to work until they receive this in-service. The completion date is [DATE]. B. An in-service was initiated on [DATE] by DON and the Administrator with the facility frontline staff, CNAs, housekeeping, dietary, and rehab staff on reporting any changes immediately in resident conditions to the charge nurse. The completion date is [DATE]. C. Newly hired nurses will be in-serviced by the Director of Nursing or designee on immediately notifying the attending physician of patient change of conditions. How will the system be monitored to ensure compliance? A. The 24-hour report will be reviewed daily by the Director of Nursing or designee to audit nurse documentation in progress notes notifying the attending physician of patient change of conditions. Discrepancies noted during reviews will be immediately corrected by contacting the attending physician of the change of condition and completing documentation in the patient's progress note. Further training will be provided as identified by the nurse manager who identified the discrepancy when and if necessary. Review will be documented on an audit report form. B. The DON/designee will review 24-hour report to ensure nurses document timely notification to the attending physician of resident changes of condition 2x week X 6 weeks. Review will be documented on an audit report form. C. Administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction for six weeks. Review will be documented on an audit report form. Quality Assurance An impromptu Quality Assurance and Performance Improvement (QAPI) review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. The State Surveyor (SS) confirmed the Plan of Removal for the IJ by monitoring from [DATE] through [DATE] as follows: In a phone interview on [DATE] at 10:15am with Medical Director, he said that he participated by phone in a QAPI to discuss change of condition. He said that staff should report any change of condition to the primary physician, nurse practitioner, on call physician, and he can be contacted if other contacts fail. He said that change in condition would include respiratory issues even with normal oxygen saturation and Diarrhea. He said that a failure to report a change to a physician could cause delay in care, exacerbate the condition, require a higher level of care, and cause a resident to need hospitalization . In an interview on [DATE] at 11:26am with DON while MDS Nurse was present. She said that there was not a progress note or SBAR completed to show that CR#1 had diarrhea. If resident had diarrhea. She said that diarrhea would be considered a change in condition if the resident had not admitted with the diagnosis. She reviewed CR#1 admission medical records and admission progress note with no information regarding diarrhea. She reviewed CR#1 physician orders with no orders provided for loperamide. She said that if CR#1 had diarrhea the physician should have been notified for orders on treatment, and medication should not have been given without an order. She said that without the order the nurse would be practicing outside of the scope of a nurse. In an interview on [DATE] at 11:26am with DON while MDS Nurse was present. She said that there was not a progress note or SBAR completed to show that CR#1 had diarrhea. If resident had diarrhea. She said that diarrhea would be considered a change in condition if the resident had not admitted with the diagnosis. She reviewed CR#1 admission medical records and admission progress note with no information regarding diarrhea. She reviewed CR#1 physician orders with no orders provided for loperamide. She said that if CR#1 had diarrhea the physician should have been notified for orders on treatment, and medication should not have been given without an order. She said that without the order the nurse would be practicing outside of the scope of a nurse. In a phone interview on [DATE] at 12:30pm with LVN A , she said she did not notify a physician when CR#1 had diarrhea. She said that she had been trained on change in condition. She said that she gave CR#1 over the counter anti diarrhea medication without a physician order, she did not enter a progress or SBAR, or tell any other staff during shift change that CR#1 had been treated for diarrhea. She said that she got overwhelmed with duties, she forgot to complete the steps, and she had been trained to do so. She said that she meant to call the doctor after she gave the medication, she forgot, and it was stupid mistake. She said that she knew that an order was needed prior to giving any medication. She said that she had been suspended. She said that she practiced outside of her scope as a nurse, could have put CR#1 at risk, and if the physician was contacted, they may have provided different orders. In an interview on [DATE] at 2:48pm with LVN G, she said that she was trained prior to shift on topic, Change in Condition. She defined a change in condition as anything from a resident's baseline. She said that a notification to physician, family, and facility management should be made when there is a change in condition, and progress note, physician orders, and SBAR should be completed in EMR. She said that anyone that was not a RN or LVN were trained to report a change in condition to a nurse immediately and they can document the change on stop and watch a form similar to a SBAR. In an interview on [DATE] at 2:54 pm with RN H, she said that she was trained prior to shift on topic, Change in Condition. She defined a change in condition as anything from a resident's normal behavior or condition. She said that a notification to physician, family, and facility management should be made when there is a change in condition, and progress note, physician orders, and SBAR should be completed in EMR. She said that anyone that was not a RN or LVN were trained to report a change in condition to a nurse immediately and they can document the change on stop and watch a form similar to SBAR. In an interview on [DATE] at 2:58 pm with RN I, she said that she was trained prior to shift on topic, Change in Condition. She defined a change in condition as anything from a resident's baseline. She said that a notification to physician, family, and facility management should be made when there is a change in condition, and progress note, physician orders, and SBAR should be completed in EMR. She said that anyone that was not a RN or LVN were trained to report a change in condition to a nurse immediately and they can document the change on stop and watch a form similar to SBAR. In an interview on [DATE] at 3:00pm with LVN J, she said that she was trained prior to shift on topic, Change in Condition. She defined a change in condition as anything from a resident's baseline. She said that a notification to physician, family, and facility management should be made when there was a change in condition, and progress note, physician orders, and SBAR should be completed in EMR. She said that anyone that was not a RN or LVN were trained to report a change in condition to a nurse immediately and they can document the change on stop and watch a form similar to SBAR. In an interview on [DATE] at 3:03pm with CNA K, she said that she was trained prior to shift on topic, Change in Condition. She defined a change in condition as anything from a resident's normal health or behavior. She said that she was trained that she has to report a change in condition to a nurse immediately. She said that she can document the change on a stop in watch form or complete the documentation in the EMR for the resident. In an interview on [DATE] at 3:06pm with RA L, she said that she was trained prior to shift on topic, Change in Condition. She said that she was trained that she had to report a change in condition to a nurse immediately. She said that she can document the change on a stop in watch form that are located at the nurse station. She defined a change in condition as anything medical, issue or behavior she had not seen the resident to have prior. In an interview and observation on [DATE] at 3:09pm with CNA E, he said that he was trained prior to shift on topic, Change in Condition. He said that he was trained to report a change in condition to a nurse immediately. He said that he can document the change in the EMR, but he was not sure of the name of the form the change is documented on. He demonstrated in the EMR how to complete a new alert for a resident using the stop and watch. He defined a change in condition as a new symptom or behavior he had not been aware of a resident to have prior. In an interview on [DATE] at 3:13pm with COTA, PTA, and SLP, who said that they were trained prior to shift on change in condition, they defined change in condition as change from residents baseline that must be reported immediately to a nurse, and documented on the stop and watch form if staff do not have access to EMR for residents. In an interview on [DATE] at 3:20pm with CNA M, she said that she had not received a training prior to shift 2:00pm-10:00pm. She was not able to define a change in condition, who to report a change to, or how the change would be documented. In an interview and observation on [DATE] at 3:24pm with CNA N, he said that he was trained prior to shift on topic, Change in Condition. He said that he was trained to report a change in condition to a nurse immediately. He said that he can document the change in the EMR on stop and watch. He demonstrated in the EMR how to complete a new alert for a resident using the stop and watch. He defined a change in condition as anything new from a resident's baseline. In an interview on [DATE] at 3:29pm with DON and CSD, both were informed that CNA M denied being trained, and they both said that CNA M had been trained and they would pull CNA M from the floor to provide additional training. In an interview on [DATE] at 3:32pm with LVN O, she said that she was trained prior to shift on topic, Change in Condition. She defined a change in condition as anything from a resident's baseline. She said that a notification to physician, family, and facility management should be made when there was a change in condition, and progress note, physician orders, and SBAR should be completed in EMR. She said that anyone that was not a RN or LVN were trained to report a change in condition to a nurse immediately and they can document the change on stop and watch a form similar to SBAR. In an interview on [DATE] at 4:33pm with CNA P, she said that she was trained prior to shift on topic, Change in Condition. She defined a change in condition as anything from a resident's normal baseline. She said that she was trained that she had to report a change in condition to a nurse immediately. She said that she can document the change on a stop in watch form or complete the documentation in the EMR for the resident under stop and watch. In an interview on [DATE] at 4:35pm with Dietary Manager, she said that she was trained prior to shift on topic, Change in Condition. She said that all staff in dietary had been trained prior to shift. She defined a change in condition as anything from a resident's baseline. She said that she was trained that she had to report a change in condition to a nurse immediately. She said that she can document the change on a stop in watch form and give it to a nurse. In an interview on [DATE] at 4:39pm with RN D, she was not knowledgeable on the topic of change in condition. In an interview on [DATE] at 4:55pm with Cook, she said that she had been trained on abuse and neglect at the start of her shift and there was another topic put she could not recall the name or details of the training. In an interview on [DATE] at 5:00pm with DON, RVP, and CSD, they were made aware that Cook and RN D was not knowledgeable of training on change in condition, and they both said that she would be pulled and retained. In an interview on [DATE] at 5:37am with RN Q, he said that he had been trained [DATE] on change in condition. He defined a change in condition as anything out of the baseline. He said that a notification to physician, family, and facility management should be made when there is a change in condition, and progress note, physician orders, and SBAR should be completed in EMR. He said that all other staff were trained to report a change immediately to RN or LVN, and document on stop and watch. In an interview on [DATE] at 5:43am with RN R, she said that she had been trained [DATE] on change in condition. She defined a change in condition as anything out of the baseline. She said that a notification to physician, family, and facility management should be made when there was a change in condition, and progress note, physician orders, and SBAR should be completed in EMR. She said that all other staff were trained to report a change immediately to RN or LVN, and document on stop and watch. In an interview on [DATE] at 5:46am with CNA S, she could not provide information on training on topic of change in condition. In an interview on [DATE] at 6:01am with CNA T, she said that she was trained prior to shift on topic, Change in Condition on [DATE]. She defined a change in condition as anything from a resident's normal condition that was new. She said that she was trained that she had to report a change in condition to a nurse immediately. She said that she can document the change on a stop in watch form or complete the documentation in the EMR for the resident under stop and watch. In an interview on [DATE] at 6:08am with CNA U, she said that she was trained prior to shift on [DATE]. She could not remember name of the training, but she was trained to report changes in the residents health or behavior to a nurse immediately. She said that she can document the change in the EMR or by form that are located at the nurse's station. In an interview on [DATE] at 6:13am with CNA M, she said that she was trained on [DATE] on topic, Change in Condition. She defined a change in condition was any new symptom that a resident did not have before, that could be with health or behavior. She said that she was trained that she had to report a change in condition to a nurse immediately. She said that she can document the change on a stop in watch form or complete the documentation in the EMR for the resident under stop and watch. In an interview on [DATE] at 6:18am with CNA V she said that she was trained on [DATE] on topic, Change in Condition. She defined a change in condition was any unusual or not the normal for a resident's health or behavior. She said that she was trained that she had to report a change in condition to a nurse immediately. She said that she can document the change on a stop in watch form or complete the documentation in the EMR for the resident under stop and watch. In an interview on [DATE] at 7:55am with DON, she was informed of CNA S inability to provide information on the training topic of change in condition. In an interview on [DATE] at 8:47am with Floor Tech, he said that he was trained on [DATE] on change in condition. He defined a change in condition as something he had not observed before with a resident's health or behavior. He said that he had to report the change to a nurse immediately and document it on the stop and watch form. In an interview on [DATE] at 8:54am with Housekeeper, she said that she was trained on [DATE] on change in condition. She defined a change in condition as anything new with a resident's health or behavior. She said that she had to report the change to a nurse immediately and document it on the stop and watch form. In a phone interview on [DATE] at 9:38am with CNA S, she said that she received one on one training on topic change in condition and stop and watch. She defined as change in condition as something new from a resident's baseline. She said that she had to report to a nurse immediately, she could fill out the stop and watch form at the nurse station, but as a CNA she should document in EMR for the resident. In a phone interview on [DATE] at 9:41am with RN D, said that she received a one-on-one training on [DATE] on change in condition. She defined a change in condition as anything out of the resident's normal behavior or medical condition. She said that a notification to physician, family, and facility management should be made when there was a change in condition, and progress note, physician orders, and SBAR should be completed in EMR. She said that all other staff were trained to report a change immediately to RN or LVN. In a phone interview on [DATE] at 9:46am with Cook, she said that she received one on one training on topic change in condition and stop and watch. She defined a change in condition as a resident being sick, looks sick, or change from their behavior that she had not seen before. She said that she had to report to a nurse immediately, she could fill out the stop and watch form at the nurse station. In a phone interview on [DATE] at 9:50am with MDS Nurse, she said that she completed an audit for change in conditions from [DATE] to the [DATE] for respiratory concerns and notification to the physician with concerns identified. She said that she had been trained [DATE] on change in condition. She defined a change in condition as anything out of the baseline. She said that a notification to physician, family, and facility management should be made when there is a change in condition, and progress note, physician orders, and SBAR should be completed in EMR. She said that all other staff were trained to report a change immediately to RN or LVN, and document on stop and watch. In an interview on [DATE] at 8:45am with LVN C, she said that she had been trained [DATE] on change in condition. She defined a change in condition as anything out of the baseline. She said that a notification to physician, family, and facility management should be made when there is a change in condition, and progress note, physician orders, and SBAR should be completed in EMR. She said that all other staff were trained to report a change immediately to RN or LVN, and document on stop and watch. In an interview on [DATE] at 10:57am with RR, she said that she was made aware of CR#1 had diarrhea by CR#1 and nurse at the facility the night of [DATE]. She said that she was told that CR#1 received medication to treat the diarrhea. She said that when she arrived at the facility the morning of [DATE] he no longer complained of diarrhea. Record review of the plan of removal was completed from [DATE] through[DATE]: -In-service training documentations were reviewed with all staff scheduled trained prior to the start of their shift, with no newly hired employees. -Respiratory assessment of all current residents for respiratory concerns completed on [DATE] by unit managers with no issues identified. -Audit on change in conditions from [DATE] to the [DATE] for respiratory concerns and notification to the physician completed by MDS on XXX[DATE] with no concerns identified. -Notification made to the Medical Director who participated in Impromptu QAPI to address change in condition completed on [DATE]. An [NAME] [TRUNCATED]

Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 (Resident #1) of 5 residents reviewed for resident call system. -The facility failed to ensure Resident #1's call light was in working order. This failure could have placed residents at risk of not receiving assistance when needed. The findings included: Record review of Resident #1's Admission Record, dated 11/14/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnoses included metabolic encephalopathy (a condition in which brain function is disturbed due to different diseases or toxins in the body), acute respiratory failure with hypoxia (condition where the lungs cannot provide enough oxygen to the blood), type 2 diabetes mellitus with hyperglycemia (high blood sugar), end stage renal disease (kidney failure), and acquired absence (loss or amputation) of right leg below knee Record review of Resident #1's quarterly MDS assessment, dated 10/17/2023, revealed a BIMS score of 11, indicating cognition was moderately impaired. Record review of Resident #1's care plan, undated, revealed she exhibited an ADL self-care performance deficit. Resident required as needed assistance with toileting, bathing, and eating. Further review revealed resident was a moderate risk for falls related to a balance problem. Interventions included encouraging resident to use call light for assistance as needed. Observation and interview on 11/14/2023 at 12:55 p.m., Resident #1 was in her room lying in bed. She said her call light sometimes worked, at other times did not work, and said it was a daily problem. The resident pushed her call light, and the light did not turn on. The resident pushed her call light again and the light did not turn on. Observation on 11/14/2023 at 1:53 p.m., Resident #1 pushed her call light, and it did not turn on. Observation on 11/14/2023 at 1:57 p.m., Nurse C pushed Resident #1's call light and the light turned on. She turned off the call light, pushed it again, and the light did not turn on. She said she did not know the call light was not working correctly and that the resident had not mentioned to her that the call light was not working properly. In an interview on 11/14/2023 at 2:05 p.m., the Maintenance Director said he had been working at the facility for approximately 2 years. He said his job responsibilities included checking and ensuring call lights worked. He said call lights were checked monthly. He said he was not aware Resident #1's call light was not working properly. He said staff never reported the issue to him verbally and/or submitted a work order. He said a non-working call light could pose a great risk to residents who require assistance with their care. He said he wanted all call lights to work at all times. Record review of the facility's Work Orders, Maintenance, revised 04/2010, read in part .1 .work orders must be filled out and forwarded to the Maintenance Director. 2. It shall be the responsibility of the department directors, charge nurse and/or certified staff to fill out and forward such work orders to the Maintenance Director through the TELS system. 3. Department managers, charge nurses, and certified staff have access to submit work orders .

Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 (Resident #2) of 5 residents reviewed for respiratory care. -The facility failed to ensure Resident #2's physician orders for oxygen administration were being followed. This failure placed residents who received oxygen therapy at risk of for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment. The findings included: Record review of Resident #2's Admission Record, dated 11/08/2023, revealed a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident's diagnoses included rhabdomyolysis (breakdown of damaged skeletal muscle), malignant neoplasm (cancer) of connective and soft tissue of right lower limb including hip, acute on chronic diastolic (congestive) heart failure, and obstructive sleep apnea (sleep disorder in which breathing repeatedly stops and starts). Record review of Resident #2's care plan, undated, revealed he had oxygen therapy that was to be administered as ordered. Record review of Resident #2's MDS assessment, dated 10/14/2023, revealed a BIMS score of 13, indicating cognition was intact. Further review indicated the resident was on oxygen therapy. Record review of Resident #2's physician orders, undated, reflected in part .O2: O2 at 2L/minute via nasal cannula continuously, every shift, start date 10/08/2023 . Observation on 11/08/2023 at 10:20 a.m. revealed Resident #2 was asleep in bed. Resident had oxygen via nasal cannula in place and was set at 3L per minute. Observation and interview on 11/08/2023 at 3:15 p.m., Nurse A checked Resident #2's O2 setting and said it was set to 3L/minute. She said she believed the order was for 2L/minute. She said she was responsible for checking the O2 setting on her shift. Nurse A checked the physician order in the computer system and said the O2 order was for 2L per minute. She said the resident was on hospice and was seen at approximately 2:10 p.m. today by the Hospice Nurse. In a follow-up interview on 11/08/2023 at 3:32 p.m., Nurse A said she had been working at the facility for approximately one month. She said she was working the 2 p.m. to 10 p.m. shift. She said her job responsibilities included checking and setting the O2 liters on the machines. She said Nurse B worked the morning shift and told her the Hospice Nurse changed Resident #2's O2 order today and increased it to 3L/minute. In an interview on 11/08/2023 at 3:40 p.m., Nurse B said she had been working at the facility for approximately 2 years and a few months. She said her job responsibilities included checking O2 settings and entering physician orders into the computer system. She said the Hospice Nurse came to the facility shortly after 12 p.m. today and assessed Resident #2. She said the Hospice Nurse changed Resident #2's O2 setting to 3L/minute. She said the hospice nurse gave a verbal order to increase Resident #2's O2 L/minute. In a telephone interview on 11/08/2023 at 4:13 p.m., the Hospice Nurse said she saw Resident #2 today between 1:00 p.m. and 1:30 p.m. She said she turned up the O2 liters on his machine to 3L/minute and reported it to LVN B. She said she told LVN B to report the change to Resident #2's doctor. Record review of the facility's Administering Medications policy, revised 12/2012, read in part .3. Medications must be administered in accordance with the orders, including any required time frame .

Based on observations, interviews, and record reviews the facility failed to maintain an effective pest control program so that it remains free of pests for 1 (Resident #53) of 24 residents and one area (The Conference Room) reviewed for pests. -The facility failed to ensure the building was free of cockroaches and fruit flies. These failures could put residents at risk of, infection, allergies, skin irritation, unsanitary living conditions and decline in health and well-being. Findings include: Resident #53 Record review of Resident #53's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnosis included diabetes, paralysis to left side of body following a stroke, malnutrition, memory deficit, narrowing of the arteries, bipolar disorder (a mental disorder), dementia, delusional disorders, age related cognitive decline, elevated blood pressure and progressive lung disease. Record review of Resident #53's annual MDS dated [DATE] revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. Section E revealed he had behaviors of rejecting care. Section G revealed he required extensive assistance with personal hygiene and supervision for eating and toilet use. Record review of Resident #53's undated care plan included: Focus - Resident #53 had ADL Self Care Performance Deficit r/t communication problems, inappropriate behavior, resistive behavior, dementia, incontinent episodes, unsteady gait, poor balance, and weakness. Goal - Will be cleaned, well-groomed, appropriately dressed through next review date. Interventions included - Eating: The resident requires supervision/set up help by staff participation to eat. During an observation and interview on 10/31/2023 at 3:20PM, Resident #53 room was at the end of 100 Hall. He was side lying in bed. There was a meal tray on the overbed table next to the bed. There were at least five large fruit flies on the uncovered bowl of sliced fruit. There were more fruit flies scattered on the empty dinner plate. Resident #53 did not say anything when he was told there were fruit flies. Resident #53 raised himself up and looked at the tray then lowered himself back on the bed. During an observation on 11/01/2023 at 12:30 PM, there was one live small cockroach found in the Conference Room on the carpeted floor. During an interview on 11/01/2023 at 2:00 PM, the DON stated the Maintenance Director was responsible to check for pests. The DON stated the facility has had cockroaches in the building and if problems persist with pests in a particular room, the resident would be removed and the whole room would be cleaned. The DON stated the meal trays from resident rooms are picked up by nursing staff once the residents have completed the meal. The DON stated some residents eat slowly and expected that when CNAs do their rounds, within an hour of finishing the meal they trays would be picked up. When asked about the fruit flies on Resident #53's tray the DON stated, she was not aware of it and the tray should have been picked up when he was done eating. During an interview on 11/03/2023 at 3:10 PM, the Maintenance Director stated pests have been an issue since he started working at the facility 2 years ago. He stated cockroaches have been in the building off and on and that it was a seasonal thing. He stated that pest control services come once a month or as needed and that it was important for infection control reasons. He stated that cockroaches were a nuisance and carry diseases. He stated for pests such as cockroaches and fruit flies, the pest control service technician would make recommendations such as: do not leave food out in the open and to keep food covered. During an interview on 11/05/2023 at 11:45 AM, LVN L stated she was in charge of 100 Hall. LVN L stated she would not wait for a CNA to clean up messes in resident rooms. She stated it was important to do so to keep bugs away and reduce germs when the resident eats in his room. She stated Resident #53 was very messy and so it was important to clean up as soon as possible. LVN L stated she did not know if Resident #53 had ever requested to leave a tray in the room. She stated she had not seen any bugs in his room and had not been in his room yet. When asked about the fruit flies that were found on Resident #53's tray, LVN L stated trays should be picked up after the resident was done with the meal. LVN L stated keeping food out of the room will keep bugs away as germs may get onto the food and the resident could get sick. LVN L said it would not be sanitary as the nursing staff deal with a lot of feces in resident rooms and bugs can get on to unclean surfaces then get onto food. LVN L stated keeping foods out of the rooms as much as possible to prevent the spread of germs and prevent illness. LVN L stated Resident #53 ate breakfast in the dining room and that she would make sure he eats lunch in the dining room as well. During a telephone interview on 11/06/2023 at 10:30 AM, the Administrator stated yes, the facility had cockroaches or other bugs in the building prior to the survey and at any time a report on pest sightings, the facility Maintenance Director will spray, or pest control services will come if there are multiple sightings. The Administrator stated that Resident #53's room was treated for fruit flies on Sunday 11/05/2023 and again during the morning of 11/06/2023. The Administrator stated Resident #53 likes to keep the window open from time to time and he said there was a screen on the window. The Administrator stated it was more of just an inconvenience, that no one wants to have fruit flies in the room. The Administrator stated the resident would be offered to move out of the room to perform a deep clean. He also stated that the facility would conduct a root cause analysis. The Administrator stated that the goal would be to manage the pests as best as possible. The Administrator stated that although it would not be possible to eliminate the pests, but it would be desirable. He said he was the person responsible to keep the building free of pests. The Administrator stated some residents like to keep food containers out and not every resident was going to be clean. He said his expectation from the staff would be to help keep the rooms clean by picking up the trays after the residents were done eating. Record review of the Pest Control Service Information dated 11/01/2023, re-service read in part: .Observed issue, one cockroach in 207 .Technician Comments .One nymph German cockroach was observed but nothing of major concern. room [ROOM NUMBER] next door was also inspected and treated out of precaution . Record review of the Pest Control Service Information dated 11/01/2023, monthly service, read in part: .Observed issues German cockroaches 115, 205, 208 .Site Recommendations .Conducive Conditions, limit or place food from nightstands in containers to limit .for pest .live activity was only found in rooms 115, 205, 208 .kitchen also noted seeing gnats in the pantry . Record review of the Pest Control Service Information dated 09/08/2023, monthly service read in part: .Technician Comments: .the main areas of concern were the far end of 300 hall and various areas of 100 and 400 halls. The kitchen had no noted issues since our previous visit, but I did notice some small flies .Active German cockroaches were seen in the Administration office . Record review of the Pest Control Service Information dated 08/14/2023 for follow up visit read in part: .Technician Comments .room [ROOM NUMBER] .high volume of food debris around Bed A .room [ROOM NUMBER] .5 German Cockroaches were found .room [ROOM NUMBER] yielded nymph German cockroaches behind nightstand .302 .dead cockroach activity was found . Record review of the Pest Control Service Information dated 08/02/2023, monthly service read in part: .Technician Comments .Live German cockroaches observed in 305 and 304 .several German cockroach sightings were noticed in the actual hallway Record review of the facility policy and procedure for Pest Control, revised August 2008 read in part: Policy Statement - Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation - 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by pest control company. 3. Windows are screened at all times 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 9 residents (Resident #107) reviewed for significant medication errors. -The facility failed to administer the correct dose of Xtandi (a cancer medication) to Resident #107 as ordered by the Physician. This failure could place residents at risk of not receiving the therapeutic effect of the medication. Findings include: Record review of Resident #107's face sheet dated 11/2/23 revealed a [AGE] year-old male who admitted to the facility on [DATE]. His diagnosis included acute respiratory failure, pleural effusion, anemia, hypertension, heart failure, acute kidney failure, and weakness. Record review of Resident #107's admission Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 13 out of 15 which indicated intact cognition. He required extensive assistance with ADL care. Record review of Resident #107's physician orders revealed an order for Xtandi give 160 mg by mouth one time a day for cancer drugs, order date 10/30/23. In an Observation and Interview on 11/2/23 at 8:28 a.m. MA A prepared Resident #107's medication for administration. MA A retrieved Resident #107's Xtandi bottle from the medication cart. The strength on the bottle read 80 mg. MA A prepared Xtandi 80 mg 1 tablet, Lasix 80 mg 1 tablet, Carvedilol 6.25 mg 1 tablet, and Fluticasone nasal spray. MA A said she had 3 pills in the medication cup. MA A administered the medication to Resident #107 and documented the administration on the electronic MAR. MA A did not administer Xtandi 160 mg as ordered by the physician. MA A said she was trained to verify the right resident, dose, and quantity on the MAR. She said the directions for Xtandi on the MAR were to give 160 mg by mouth and the medication bottle said to take two tablets. She said she was a little nervous and made a mistake. She said the full dose for Resident #107 was 160 mg, but she gave him one tablet which equaled 80 mg. She said she was not sure what could happen if the resident only received half of the prescribed dose. She said she would go back and give Resident #107 an additional tablet. Interview on 11/2/23 at 1:24 p.m. the DON said nursing staff were trained to check the MAR, physician's order, resident, route, how much. She said the directions on the MAR should contain the medication name, and most of the time indicate the number of tablets to administer. She said nursing staff should follow doctor's orders so the resident could get better, and not get worse or sick. She said the DON, ADON, and Pharmacy Consultant conducted in-services and walk throughs to ensure staff followed proper protocol and a competency check was conducted every year. She said every medication was a significant medication and was unsure of what could happen if Resident #107 did not receive his full dose of Xtandi. She said the person who administered the medication was responsible to ensure the correct medication was given. Record review of the facility's Administering Medications policy dated December 2012 read in part, .Policy Statement - Medications shall be administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation - 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and or have related functions. 3. Medications must be administered in accordance with the orders, include any required time frame . 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication

Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 8 residents (Resident #76) reviewed for quality of care. The facility failed to ensure Resident #76 was assessed by a licensed nurse in a timely manner when she began to show signs and symptoms of hypoglycemia (low blood sugar). CNA K reported the hypoglycemic episode to RN A, who did not respond to the incident. CNA K provided Resident #76 with juice and sugar packets and the resident was not assessed until the following shift, approximately 1 hour later. This failure could place residents at risk of hospitalization . Findings include: Record review of Resident #76's face sheet dated 11/2/2023 revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included type 2 diabetes mellitus without complications, hypoglycemia, weakness, injury of the head, morbid obesity, heart failure, and acute kidney failure. Record review of Resident #76's 5-day MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating no cognitive impairment. She required extensive assistance with ADL care. Record review of Resident #76's care plan initiated on 9/15/23 revealed her diabetes diagnosis and insulin medication were not care planned. Record review of Resident #76's physician orders included the following: -Insulin glargine-yfgn 100 unit/mL inject 32 units two times a day, hold for blood sugar less than 100, order date 10/20/23. -Admelog Solostar 100 unit/mL inject 20 units before meals, hold for blood sugars less than 130 and call MD, order date 9/29/23. Record review of Resident #76's Medication Administration Record for October 2023 revealed Admelog Solostar was documented as administered on 10/29/23 at 4:30 p.m. by (RN A). The blood sugar was documented as 168. Insulin Glargine-yfgn was documented as administered on 10/29/23 at HS by (RN A). The blood sugar was recorded as 195. Record review of Resident #76's blood sugar summary, documented by RN A, revealed her blood sugar was 168 mg/dL on 10/29/23 at 4:09 p.m. and 195 mg/dL on 10/29/23 at 7:09 p.m. In an interview on 10/31/23 at 10:35 a.m., Resident #76 said on Sunday night (10/29/23) a new nurse (RN A) on the 2 p.m. - 10 p.m. shift gave her short acting insulin. She said she crashed, had shakes, and was sweating. She said she pushed the call light and told CNA K that her sugar was dropping. She said CNA K left the room and told RN A. CNA K returned to the room and said the nurse did not say anything. Resident #76 asked CNA K to bring her 2 packs of sugar and cranberry juice. She said she drank the juice and sugar and felt better. She said later the 10 p.m. - 6 a.m. nurse, LVN B, checked her blood sugar and it was normal. She said RN A did not do anything and did not come down to see her. She said she had been diabetic for over [AGE] years and the short acting insulin caused her to crash quickly. In an interview on 11/2/23 at 11:43 a.m. Resident #76's MD said the facility did not report any hypoglycemic episodes to her regarding Resident #76. She said Resident #76 told her on Tuesday (10/31/23) that she took the short acting insulin, did not really eat, and had to drink juice. She said the resident could pass out if she did not receive juice or sugar. In an interview on 11/2/23 at 2:20 p.m., CNA K said around Monday (10/30/23) at approximately 8 p.m. Resident #76 told her that her blood sugar was dropping. She said Resident #76 was out breath, tired, slumped over, had slurred speech and was not like herself. She said she felt it was an immediate situation. CNA K said she left the room and told RN A and the nurse replied ok and did not do anything. CNA K said she went to the kitchen and got 2 cups of juice and 2 packs of sugar and took them to Resident #76. She said she told RN A that she was bringing the items down to Resident #76 and that she needed to go and check on her. She said RN A never checked the blood sugar before or after the incident. She said RN A was asleep and another nurse had to wake her up. CNA K said she brought the juices and sugar to Resident #76, and she drank one juice and the sugar and started to feel better. She said she reported the incident to the nurse on the next shift, LVN S. She said she also reported it to LVN E and the medication aide who worked 2-10 p.m. She said abuse and neglect should be reported to the nurse, DON, and to the Administrator. She said she did not report the incident to any other nurse because she was in panic mode and was not thinking. In a telephone interview on 11/2/23 at 3:28 p.m., LVN S said on Sunday (10/29/23) CNA K reported to her that an unknown resident's blood sugar was low, and that CNA K reported it to RN A but was unsure what the nurse (RN A) did or did not do. LVN S said she reported it to LVN B. In a telephone interview on 11/2/23 at 3:37 p.m., LVN B said when she arrived to work on Sunday night (10/29/23, 10 p.m. - 6 a.m. shift) LVN S told her to go check on Resident #76. She said she assessed Resident #76, and her blood sugar was 190 or 195. She said Resident #76 told her that her blood sugar dropped earlier, and the previous nurse did not check on her. LVN B said she gave the resident crackers and juice to have overnight. LVN B said RN A did not say anything about Resident #76's blood sugar during change of shift report. In a telephone interview on 11/2/23 at 3:41 p.m., RN A said she worked with Resident #76 on 10/29/23 and did not have any concerns with the resident during her shift. She said she gave Resident #76 insulin twice during her shift, one was long acting and the other was short acting. She said Resident #76 did not have any hypoglycemic episodes that she knew of. She said no aides reported anything to her regarding Resident #76. She said she was unaware if an aide gave juice or sugar to a resident and if so, the aides did not tell the nurse. She said Resident #76 would sometimes refuse her short acting insulin because it would make her feel bad. She said she did not doze off at the nursing station. In an interview on 11/2/23 at 5:16 p.m., the DON said she was just notified of the incident with Resident #76. She said CNA K did not report it to her at the time and did not tell anyone else. She said she expected the nurse to get up and go see about the resident because she could go into a coma. She said the nurse should have completed a hypoglycemic assessment and notified the MD. She said LVN E reported to her on Monday 10/30/23 that RN A dozed off at the nursing station. She said she provided a one-to-one in-service with her. In an interview on 11/2/23 at 5:42 p.m., the Administrator said he just learned of the incident with Resident #76. He said CNA K did not report it to anyone. He said the facility started in-services staff on calling the DON or Administrator if the nurse does not react. He said RN A had been written up previously and was about to be termed due to previous concerns including lack of knowledge. In a telephone interview on 11/3/23 at 10:52 a.m., the NP said Resident #76's blood sugar ranged from 80-200. He said the resident would often refuse her insulin because she felt her blood sugar would drop. He said he had not seen or heard of a hypoglycemic episode with Resident #76. In an interview on 11/3/23 at 11:54 a.m., the Administrator said CNA K should have called the DON and reported the concern about Resident #76 to other nurses. He said she should not have waited to the end of the shift because it could lead to something serious. He said there was a gap when the facility was not responsive to Resident #76. In an telephone interview on 11/3/23 at 4:46 p.m., RN A said the facility fired her. Record review of RN A's 1 on 1 In-service Record dated 10/30/23 revealed the in-service topic: no sleeping while on clock. The nurse voiced understanding. The in-service was signed by the DON, RN A, and the Unit Manager. Record review of the facility's Insulin Administration policy dated April 2007 read in part, . Reporting: 2. Notify the physician if the resident has signs and symptoms of hypoglycemia that are not resolved by following the facility protocol for hypoglycemia management . Record review of the facility's Nursing Care of the Resident with Diabetes Mellitus policy dated April 2009 read in part, .3. Hypoglycemia (blood sugar below reference ranges). Signs and symptoms of hypoglycemia usually have a sudden onset and may include the following: a. weakness, dizziness, or faintness; b. restlessness and/or muscle twitching; e. excessive perspiration; . i. numbness of the tongue and lips/thick speech; j. stupor, unconsciousness and/or convulsions; and coma. If these, or other abnormal conditions exist, notify the physician (for hypoglycemia, follow steps in Management of Hypoglycemia below) . Management of Hypoglycemia . 3. For symptomatic (lethargic, drowsy) but responsive (conscious) residents with hypoglycemia (<70 mg/dl or less than the physician-ordered parameter): a 1. Immediately give the resident an oral form of rapidly absorbed glucose (4 oz juice or 5-6 ounces of soda); 2. Recheck blood glucose in 15 minutes; 3. Repeat juice if indicated, recheck blood glucose in 15 minutes. Record review of the facility's Change in a Resident's Condition policy dated April 2007 read in part, .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a. an accident or incident involving the resident .

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident which included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 1 of 3 residents (CR # 42) record reviewed for baseline care plan. The facility failed to initiate a base line-care plan with goals, interventions, treatments, and psychosocial needs to address Resident# 42's medical needs, coordinate care with interdisciplinary teams to assure the resident received care at professional standards. This deficient practice could place residents at risk of not having their immediate individual, medical, functional, and psychosocial needs identified and met and could cause a physical or psychosocial decline in health. Findings include: Record review of Resident #42's EMR face sheet accessed on 9/25/2020 at 2:00 PM, revealed he was admitted on [DATE] and readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] = is a cause of staph infection that is difficult to treat because of resistance to some antibiotics) of right foot, contact isolation and anxiety disorder. Record review of Resident #42's quarterly MDS dated [DATE], revealed Section C: Cognitive Patterns revealed resident had a BIMS of 9 of 15, he was moderately impaired cognitively and ADL activity assistance occurred with two-person physical assist. Record review of CR #42's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #42's medical record revealed there was no documentation of a baseline care plan. There were no plans to address contact isolation, medications, ADL's, (activity of daily living) psychosocial well-being, wound treatment and bowel incontinence for re-admission on 9/17/22. Observation during initial rounds on 9/25/22 at 9:30 AM, revealed Resident # 42 was on contact isolation with sign posted on the door, resident had bandage to his right foot. Resident #42 had left (AKA)above knee amputation. During an interview on 09/26/22 3:40 PM, MDS/PPS Coordinator A, said she just started working for the facility about 3 weeks ago, and she had been auditing residents charts and had problems with care plans. She said base line care plan should be done in 48 hours on resident admission and any change in conditions. During an interview on 9/27/22 at 11:02 AM, the DON said Resident #42 was readmitted on contact isolation, the admission nurse was responsible for completing the base line care plan. The DON said the admitting was not available for interview. The DON said if the nurse missed it, it would be her responsibility to catch it. In an interview on 9/28/22 at 12:51 PM, the DON said baseline care plans were to ensure the proper care of residents and know interventions needed. She stated every resident must have a baseline care plan on admission to provide the best quality of care and she would be auditing baseline care plans, and this would be ongoing. Record review of the facility's Care Plan on - Baseline, Policy Statement (revised December 2009) indicated A baseline care plan to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on observation, interview, and record review, the facility failed to ensure residents with mental disorder received an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, to determine whether the individual required specialized services for one of four (Residents #42) resident reviewed for PASARR. -The facility failed to conduct an accurate PASRR screenings for Resident #42 upon their admission. This failure could affect residents who require PASRR services and place them at risk of not having their special needs assessed and met by the facility. Findings include: Record review of Resident #42's EMR (electronic monitoring record) face sheet accessed 9/25/2020 at 2:00 PM, revealed he was admitted on [DATE] and readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 42's quarterly MDS dated [DATE], revealed his BIMs score was 09 out of 15, which indicated he was moderately cognitively intact. Section A of the MDS regarding PASRR, was coded 0, which indicated no mental illness . Record review of Resident #42's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/26/22 3:40 PM, MDS/PPS Coordinator A, said she started working with the facility about 3 weeks ago, and she had been auditing residents charts and found out some resident did not have PASRR level 1 assessment . Resident #42's mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #42's admitted d 02/25/22 the question in section C read in part .Is there evidence or an indicator this is an individual that has a Mental illness . revealed the answer to this question was changed to Yes after the interview with MDS/PPS Coordinator A at 4:00 PM. During a follow-up interview on 9/27/2022 at 3:51 PM with MDS/PPS Coordinator A and the DON, both said they would have to look for that PASRR Level I assessments for Resident # 42 if it was done. Resident #42 has been in and out on admission to hospital. DON said her expectation was for all resident to be screen for PASSR level 1 on admission. The DON did not have any PASRR level 1 assessment for Resident #42 prior to exit. During an interview with the Administrator and DON on 09/28/22 at 12:00 PM they said the Quality Assurance committee had identified issues with the MDS assessments and care plans. He said the facility was working on those issues. Record review of the facility's PASRR CLINICAL POLICY dated 12/2014 read in part, .Purpose .The PASSR level 1 (PL1) Screening Form is designed to identify persons who are suspected of having Mental Illness (MI). Intellectual Disability (ID) of a Developmental Disability (DD) also referred to as Related Conditions . The PASRR Evaluation (PE) is designed to confirm to confirm the suspicion of MI, ID or DD/RC and ensure the individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain the individual 's level of functioning . If documentation entered on the PL 1 Indicates MI/ID/DD, a PE Must be completed .

Based on observation, interview, and record review the facility failed to provide care and services, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 3 of 19 residents (Residents #39, #52, and #50) reviewed for pressure ulcers. -Facility staff failed to reposition Resident #39 who had a necrotic pressure ulcer. -The facility failed to reposition Resident #52. -The Wound Care Nurse failed to provide incontinent care after she removed saturated incontinent brief and before providing wound care for Resident #50. These failures affected 3 residents and placed 10 residents with pressure ulcers at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: Resident # 39 Record review of resident #39's face sheet revealed she was a [AGE] year-old woman admitted to the faculty on 10/26/16. Her [DIAGNOSES REDACTED]. Record review of Resident #39's admission physician order dated 10/26/16 did not reveal and treatment for [REDACTED]. Record review of Resident #39's quarterly MDS assessment dated [DATE] revealed resident BIMS was 4, indicating severely impaired cognition. Further review of Resident #39's MDS revealed also revealed resident required extensive assistance from two people for ADL care. It also revealed that she was at risk for developing pressure ulcers. Record review of Resident #39's Braden scale assessment dated [DATE] revealed score of 14 (moderate risk). Record review of Resident #39's care plan dated 07/30/18 revealed had an ADL Self Care Deficit related to Dementia, Fatigue, right [MEDICAL CONDITION], limited range of motion. The interventions included: extensive assistance from staff with activities of daily living. There was a general care plan for the prevention of pressure ulcers, but there was care plan for wound care. Record review of Resident #39's Nutrition Progress Note dated 8/10/2018 revealed that she had lost 11% of her body weight over the last month. She also received multiple diet restrictions which may not be useful at this time. Recommendations included: to discontinue no added salt, discontinue health shakes with meals. Start med pass 2.0 or health shakes 90 ML three times after each meal. Record review of Resident #39's wound care progress note dated 08/15/18 revealed that the unstageable wound was debrided, it measured 8.8 centimeters (cm) x 7.3 cm x 2.1 cm. The order was to clean the wound with Dakins, pat dry apply Santyl, calcium alginate and cover with boardered dressing every day. Record review of Resident #39's undated unavoidable pressure ulcer risk assessment form, that was not signed by the doctor, revealed in the risk factors for developing pressure sores were: continuous urinary incontinence, or chronic voiding dysfunction, Diabetes and chronic bowel incontinence. The form also indicated that the head of her bed was elevated the majority of the day due to medical necessity. Observation on 08/14/18 at 10: 00 a.m., revealed Resident #39 was laying on her back. She was on a pressure relieving mattress that was the standard mattress in the facility. Observation on 08/14/18 at 12:00 p.m., revealed Resident #39 was laying on her back. She was on a pressure relieving mattress that was the standard mattress in the facility. Observation on 08/14/18 at 2:00 p.m., revealed Resident #39 was laying on her back. She was on a pressure relieving mattress that was the standard mattress in the facility. Observation on 08/15/18 at 8:00 a.m., revealed Resident #39 was laying on her back. She was on a pressure relieving mattress that was the standard mattress in the facility. Observation on 08/15/18 at 11:00 a.m., revealed Resident #39 was laying on her back. She was on a pressure relieving mattress that was the standard mattress in the facility. Observation on 08/15/18 at 1:45 a.m., revealed Resident #39 was lying on her back. She was on a pressure relieving mattress that was the standard mattress in the facility. Interview on 08/15/18 at 2.00 p.m., LVN 11 stated that residents with wounds or at risk of breaking down were turned every two hours to prevent the wounds from getting worse. If the residents were at risk for skin break down they should be turned and repositioned every two hours and provided frequent incontinent care to prevent skin break down. She stated that she had not turned or repositioned the Resident #39 today. Observation on 08/15/18 at 4:00 p.m., revealed Resident #39 was lying on her back. She was on a pressure relieving mattress that was the standard mattress in the facility. Observation on 08/16/18 at 9:00 a.m., revealed Resident #39 was sitting on a wheel chair. Interview on 08/16/18 at 9:30 a.m., Wound Care Nurse stated that the Resident #39 had a wound on the sacrum when she started working on Monday, but is was flat black in color. When the wound care doctor debrided the wound on Wednesday, it opened. Observation on 08/16/18 at 11:00 a.m., revealed Resident #39 was sitting on a wheel chair. Observation on 08/16/18 at 1:45 p.m., revealed Resident #39 was sitting on a wheel chair. Interview on 08/16/18 at 2:15 p.m., CNA #41 stated she transferred resident to her wheel chair before breakfast and she was still sitting in her wheel chair. Record review of Resident #39's lab result dated 08/16/18 revealed that [MEDICATION NAME] was 14.6 while the reference range was 17.6-36.0. Interview on 08/17/18 at 10:15 a.m., the Wound Care Nurse stated that residents with wounds should be turned and repositioned every two hours for comfort and relieve pressure on the site so that the wound will not get worse. Observation on 08/17/18 at 10:10 a.m., revealed that Resident #39's wound was necrotic (black as a charcoal) and had a foul decaying odor. The mattress on her bed was an air mattress. Interview on 08/17/18 at 3:27 p.m., Resident #39's responsible party stated that the facility told him that Resident #39 had a wound on the bottom but did not tell him how bad it was. He stated that Resident #39 did not have a wound when admitted to the facility. He also stated that she is always laying on her back in her urine and bowel movement whenever he visited. Interview on 08/17/18 at 5:00 p.m., the DON stated the facility's protocol was to turn and reposition resident every two hours, provide an air mattress, refer for dietitian consult, notify resident's doctor, and wound doctor consult, and follow the wound care doctor's order. She stated that when they observed the area they initiated treatment and she was seen by a wound care doctor. The DON stated that it was a black area on the sacrum until the wound doctor debrided it. Interview on 08/18/18 at 1:55 p.m. Wound Care Nurse stated that she notified Resident #39's family that the wound care doctor debrided her wound but did not tell him that he had any odor or described how it looked and it measured. Resident #52 Record review of Resident #52's Face Sheet revealed she was an [AGE] year-old female admitted to the facility 3/2/09 with a recent readmission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #52's Significant Change MDS dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. She required extensive to total assistance from 1 to 2 staff members for ADLs. One stage 4 pressure ulcer was recorded measuring 7.7 centimeters (cm) x 8.0 cm x 3.1 cm. Resident #52 was not coded for having a catheter. Record review Resident #52's Care Plan revealed a pressure injury on right hip initiated on 6/21/18 and revised on 8/13/18. Record review of Resident #52's Wound Care Note dated 3/30/18 revealed Weekly assessment to area, no change. Wound Care doctor made rounds. Resident sacrum stage 3, resolved, closed, no drainage. Continues with difficulty turning and repositioning because of refusal, not easily altered. Continues with low air loss mattress in place to prevent wound reopening. No complaints of pain or any discomfort voiced. Physician and RP aware. Record review of Resident #52's Wound Care Note dated 4/19/18 revealed Late Entry: Resident was fully assessed and observed 4/19/18 an unstageable in identical area of previous resolved stage 3 wound. Treatment started as ordered. No complaints of pain or any discomfort voiced. Physician and RP notified. Record review of Resident #52's Wound Care Note dated 4/27/18 revealed Weekly assessment to area, no change. Wound Care Physician made rounds. Resident continues with sacrum unstageable, 8 centimeters (cm) x 4 cm x 0 cm, moderate serosanguineous drainage. Treatment continues as ordered. No complaints of pain or any discomfort voiced. Physician and responsible party (RP) aware. Record review of Resident #52's Physician's Order dated 6/8/18 revealed she was readmitted to the facility after a sacral debridement. Record review of Physician's Order dated 6/21/18 revealed an order to cleanse right hip with normal saline, pat dry, and apply [MEDICATION NAME] with calcium alginate and cover with dry dressing daily. Record review of Resident #52's Braden Scale dated 6/30/18 revealed a score of 10 indicating a high risk for pressure ulcers. Record review of Resident #52's Nursing Note dated 7/7/18 revealed New orders received to insert Foley catheter for wound promotion relates to stage 4 sacral wound. RP informed of new orders and no concerns voiced at this time. Record review of Resident #52's Wound Care Progress Note dated 7/10/18 revealed Wound Care Physician debrided the sacral and hip pressure ulcers. The post debridement measurements for the sacrum was 6.6 cm x 6.4 cm x 1.4 cm and for the hip was 3.7 cm x 2.4 cm x .4 cm. Further review revealed Wound healing is influenced by multiple factors. Important to this factor is appropriate and timely offloading, use of appropriate transfer techniques, routine cleansing of the wound bed after soiling, adequate nutrition and maintenance of chronic health issues, and use of and compliance with recommended treatment. Record review of Resident #52's Weekly Skin assessment dated [DATE] revealed a stage 3 pressure ulcer to the right hip measuring .4 cm x .6 cm x .2 cm. and a stage 4 pressure ulcer to the sacrum measuring 6.5 cm x 5.9 cm x 1.1 cm. Record review of Physician's Orders dated 8/2/18 revealed the following orders: -Wound vac: clean wound with Dankins, cleanse with each dressing change and pat dry every Monday, Wednesday, and Friday -Wound vac: wound vac continuously at 125 mgm hg to sacral wound. Record review of Resident #52's Weekly Skin assessment dated [DATE] revealed a stage 3 pressure ulcer to the right hip measuring .5 cm x 1.4 cm x .4 cm. and a stage 4 pressure ulcer to the sacrum measuring 6.5 cm x 5.8 cm x 1.1 cm. Record review of Resident #52's Care Plan dated 8/13/18 revealed she had a reoccurring pressure injury to the sacrum and a stage 3 pressure ulcer on the right hip. The goal was the pressure ulcer would show signs of healing and remain free from infection. Interventions included administering treatments as ordered and providing a pressure relieving device while in bed. Care plan also stated to document wound appearance, color, wound healing, s/sx of infection, wound size, and stage and report to the physician and responsible party (RP), as needed, any changes in skin status. Care plan did not indicate Resident #52 was non-compliant with repositioning. In an observation and interview on 08/15/18 at 01:03 p.m. revealed Resident #52 was lying in bed with her knees facing the window. An unidentifiable odor was observed. Surveyor asked how she was doing and she smiled and responded fine. Record review of Resident #52's Wound Care Progress Note dated 8/15/18 revealed measurements for right hip were 1.5 cm x .8 cm x 1.0 cm and 6.7 cm x 5.8 cm x 1.2 cm for the pressure ulcer to the sacrum. Record review of Resident #52's Physician's Order dated 8/15/18 revealed an order to cleanse pressure ulcer to right hip with normal saline, pat dry, apply silver alginate, and cover with dry dressing daily. Observation on 08/16/18 at 06:17 p.m. revealed Resident #52 lying in bed with her knees facing the right. Observation on 08/17/18 at 07:19 a.m. revealed Resident #52 lying in bed with her knees facing the right. Observation on 08/17/18 at 08:30 a.m. revealed Resident #52 lying in bed with her knees facing the right. Observation on 08/17/18 at 09:53 a.m. Resident #52 lying in bed on her back with knees facing the window. Observation on 08/17/18 at 10:31 a.m. revealed Resident #52 lying in bed with her knees facing the right. Observation on 08/17/18 at 2:30 p.m. revealed Resident #52 lying in bed with her knees facing the right. A wedge was underneath her left side. In an interview on 08/18/18 at 09:31 a.m., Unit Manager #1 stated he had been in the facility for 4 weeks and Resident #52 had been non-compliant with repositioning and turning the entire time. He stated her non-compliance was care planned. In an interview on 08/18/18 at 09:45 a.m., CNA #22 stated there are 8/9 residents who require extensive assistance and need repositioning on 400 hall including Resident #52. She stated Resident #52 refused repositioning at times. CNA #22 stated she would then place a pillow under her to relieve some pressure. Resident #50 Record review of Resident #50's file revealed she was [AGE] years old and was admitted to the 5/5/15 and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #50's quarterly MDS assessment dated [DATE], staff assessed her as having long and short term memory problems and severely impaired cognitive skills. She was incontinent of bowel and bladder. And she required extensive assistance from two people for incontinent care. She did not have pressure wounds. Record review of Resident #50's care plan revised on 6/28/18 revealed she had bowel and bladder incontinence and was at increased risk for skin breakdown. The interventions were to check the resident during rounds and as required for incontinence. Wash, rinse and dry perineum. Record review of Resident #50's care plan dated 8/13/18 addressing MASD (moisture associated skin damage). Observation and interview on 08/17/18 at 9:14 a.m., revealed Resident #50's incontinent brief was soaked from front to back. The blue lines on the brief was macerated and barely visible. The urine soaked through the brief, onto the draw sheet and had formed a ring on it. It also soaked on to the mattress. When the Wound Care Nurse removed the brief, the Surveyor asked the Wound Care Nurse to squeeze the brief who then stated that the brief was saturated. Observation on 08/17/18 at 9:25 a.m., wound care observed on revealed that Resident 50's brief was saturated with urine. The draw sheet and mattress were soaked. When the wound care nurse removed the brief, the surveyor asked the wound care nurse to squeeze the brief and she stated that it was saturated. The Wound Care Nurse did wound care without providing incontinent care. She cleaned the wound bed and did not did not clean the peri area of the wound. Then she applied calcium alginate on the three wound sites and used skin prep to wipe around the alginate and applied boarded foam dressing. then she positioned the resident on her back on the wet draw sheet that was wet with urine. Interview on 08/17/18 at 9:35 a.m., Wound Care Nurse stated, oh I see why incontinent care would have been done before doing the wound care. she stated that she did not clean the peri wound, but the order was to clean the wound. She stated that she laid the resident back on the wet draw sheet while the CNA brings a clean sheet. Interview on 08/17/18 at 10:00 a.m., CNA #13 stated that he changed Resident #50 about 6:00 a.m. when he came to work this morning. He stated that he made rounds every two hours. He also stated resident's brief was saturated. Record review of the facility policy on wound care dated 2001 MED-PASS, Inc Revised (MONTH) 2011 stated wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or normal saline solution. Record review of the facility policy on prevention of pressure ulcers dated 2001 MED-PASS, Inc Revised Mach 2005 stated on the general guideline #1: pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation(blood flow) to that area and subsequent destruction of tissue. The facility's Centers for Medicare and Medicaid Services (CMS) Form 672 dated 08/14/18 identified 13 residents with pressure ulcers.

The facility failed to monitor weight loss for CR #1; he had a significant weight loss of 18.2 % in 90 days and 21.3 % in 180 days; --CR #1 was admitted to a local hospital on [DATE] due to abnormal laboratory values. CR #1 was readmitted on 3/11/2015 with [DIAGNOSES REDACTED]. --CR #1 lost 10 lbs. on the first week after re-admission to the facility from the hospital on March 11, 2015 -facility failed to follow the dietary recommendations after CR #1 experienced a decrease in food intake -CR #1 was readmitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. An immediate jeopardy (IJ) was identified on 4/27/2015. While the IJ was removed on 4/27/2015, the facility remained out of compliance at scope of a pattern and a severity level of actual harm because all staff had not been trained on the monitoring and management of resident's weight. . These failures affected 1 CR and could place 1 current resident identified with unplanned significant weight loss/gain at risk for continued weight loss and decline in health related to poor nutrition. Findings include: Intake # 4 Record review of CR #1's face sheet revealed a [AGE] years old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. CR #1 was discharged to a local hospital on [DATE] due to unable to follow commands, lethargic, not verbally responsive, low blood pressure, weak pulse and eye arousal upon loud stimuli. Record review of CR #1's quarterly MDS with an assessment reference date 03/18/2015 revealed he required limited assistance of one person with eating. His assessment noted he did not have weight loss and was not on a physician prescribed weight loss regimen. CR#1 weighed 148 pounds and measured 72 inches in height. His BIMS score was 3 out of a possible 15. Observation on 4/7/2015 at 11:55 am revealed CR #1 was in a local hospital in the Critical Care Unit. Further observation revealed he had oxygen at 2.5 liters per minute via nasal cannula and an IV line to his left forearm with 0.45% of Sodium Chloride. In an interview on 4/7/2015 at 12:20 p.m. with critical care registered nurse at a local hospital revealed that CR #1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED].). She further stated CR #1's Sodium levels were 146 (high) (Reference 134-145); BUN (blood, urea and nitrogen (blood test that reveals how well your kidneys are working. Dehydration can make levels higher.) Levels 48 (high) (9 - 20); and creatinine levels (Creatinine blood test that measures kidney function) were 3.1 (high) (0.7-13). Record review of CR #1's nutrition assessment dated [DATE] revealed in part, "annual on [AGE] year old male. Current weight: 152.7. Desirable body weight range: 152 - 189 lbs. By mouth intakes have been varied 0 - 100% per nursing records. Weight 1/7/2015 was 152.7 lbs. Monthly weight history: 12/14/2014 was 180.7 lbs. Weight is down 15.4% in 30 days. At risk for further weight loss and dehydration due to medical condition, decreased appetite and advanced age. Goals are for no further significant weight... (Change)". Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's progress notes dated 3/5/2015 at 2:34 pm revealed in part, "CR #1 observed shaking, having tremors in hands and being confused. MD notified and new order received for CBC and Chem 7 (is a basic metabolic panel blood test that provides key information regarding fluid and electrolyte status, kidney function and blood sugar levels). Record review of CR #1's laboratory results dated [DATE] revealed in part: "Sodium 149 high Reference (134-145); BUN 58 high (9 - 20); -Creatinine - Serum 2.5 high (0.7 - 1.3)..." Record review of physician orders [REDACTED]. Record review of CR #1's progress notes dated 3/6/2015 at 5:30 pm revealed in part, " Doctor notified of laboratory results. Orders received to send resident to hospital for evaluation". In continued record review revealed progress notes dated 3/11/2015 revealed in part, " CR #1 arrives to facility via ambulance on stretcher with [DIAGNOSES REDACTED]. Further record review revealed laboratory results dated [DATE] revealed in part: -Sodium 142 -BUN 14 -Creatinine - serum 1.4 Record review of the comprehensive plan of care initiated 4/9/2013 with target date 5/31/2015, revealed in part: CR #1 has a potential nutritional problem related to Alzheimer's and his memory being impaired. Further review revealed CR #1 was at risk for dehydration or potential fluid deficit related to diuretic use. Goal: will be free of symptoms of dehydration. Record review of CR #1's nutrition progress note dated 3/25/2015 read in part: " [AGE] year old male readmitted with [DIAGNOSES REDACTED]. Diet in orders is mechanical soft. Medications include [MEDICATION NAME], and [MEDICATION NAME] and atorvastatin calcium. By mouth intakes varied with less than 50% at many meals. Laboratory values on 3/6/2015 sodium 149 high, BUN (blood urea nitrogen) 58 high and creatinine 2.5 high. Weight on March 13, 2015 was 147.8 lbs. Down 18.2 in 90 days and 21.3% in 180 days. Resident continues at risk for weight decreased due to advanced age and overall medical condition. Recommendations: 1. - Modify med plus to 120 ml by mouth four times a day without stop date. 2. - Add house shake to be offered after each meal without stop date. 3. - Add multivitamins with minerals by mouth every day. 4. - weekly weights for 8 weeks 5. - All options (tube feeding, hospice) should be addressed with responsible party. -Will also recommend considering stopping [MEDICATION NAME] (diuretic) due to history of dehydration, urinary tract infection and poor intakes. Record review of CR #1's comprehensive plan of car created 12/16/14 and updated 2/4/2015 and 3/11/2015, revealed in part: Problem: weight loss related to [MEDICAL CONDITION], cardiac heart failure, depression and dysphagia. Goal: resident weight will remain stable over the next 90 days. Further record review of progress notes revealed no follow up on dietary recommendations or notification to MD or family. Record review of CR #1's SBAR - Physician/NP/PA Communication and progress note dated 4/6/2015 at 15:18 revealed in part: - Situation: Describe the problem/symptoms: Lethargic, responding to loud verbal stimuli only, vitals abnormal. - Background: 2. - Pertinent medical history: decreased intake and decreased fluids. 4. - Vitals e. - most recent blood pressure: 112/48. 8. - Functional Status - Indicate if there is a change in functional status c. - deteriorated. - Describe appearance: Resident unable to follow commands appears lethargic, not verbally responsive, blood pressure low compared to baseline, weak pulse, eye arousal upon loud stimuli. Order received to 911 out to a local hospital. Record review of weight record for CR #1 revealed: - 11/10/2014 = 180.2 lbs. - 12/14/2014 = 180.7 lbs. - 1/7/2015 = 152.7 lbs. - 2/10/2015 = 144.4 lbs. - March 2015 = 148.2 lbs. (weight before going to hospital per Director of Nursing) - 3/13/2015 = 147.8 (weight upon returning from hospital) - 3/20/2015 = 137.8 Further record review revealed no further weekly weights for CR #1. In an interview on 4/7/2015 at 3:10 p.m. the DON revealed significant changes in weight was a change in condition and the facility protocol for weight loss was to notify the MD, registered dietician and family. When asked if the MD and registered dietician were notified on 2/10/2015 that CR #1 had weight loss of 8.3 lbs. in one month, the DON stated as she looked at the computer " I don't see the notifications". She further stated said " the ADON was in charge of following with the weights and she is no longer here". In continued interview at that time, the DON was asked if the MD was made aware of the weight loss of 10 lbs. in a week on 3/20/2015 and she stated " I don't see it, but I don't know how that can be possible". The DON was further asked if dietary recommendations for CR #1 dated 3/25/2015 were followed and she responded " that's why the ADON is no longer here, the recommendations were not followed". The DON stated "recommendations were supposed to be addressed by the ADON and weights were supposed to be followed up by the ADON as well, will have the unit managers responsible for that now, last day for the ADON was 3/26/2015. Dietary recommendations were supposed to be addressed on 4/6/2015 but CR #1 went to the hospital". DON further stated residents who eat less than 75% of meals were supposed to be offered a substitute. In an interview on 4/7/2015 at 4:00 p.m. the Dietary Manager stated CR #1 had a decreased appetite in last 4 months and he was not eating well. She further stated that CR #1 was supposed to be on restorative feeding but he refused to get out of bed most of the time and he would eat his meals in bed "the staff on the floor would assisted him with his meals". Record review of the facility's Weight Assessment and Intervention, revised December 2008, revealed in part: - Highlights: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. - Significant changes definition: 6. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. - 1 month - 5% weight loss is significant; greater than 5% is severe. - 3 months - 7.5 % weight loss is significant; greater than 7.5% is severe. - 6 months - 10% weight loss is significant; greater than 10% is severe. Record review of the facility's Nutrition assessment revised December 2008 revealed in part: - Purpose of Nutritional Assessment. 1. - The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. 2. - The nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. An immediate jeopardy (IJ) was identified on 4/27/2015. While the IJ was removed on 4/27/2015, the facility remained out of compliance at scope of a pattern and a severity level of actual harm because all staff had not been trained on the monitoring and management of resident's weight. The plan of removal included: 1. The DON and the Administrator identified a system problem in implementing recommendations to address unplanned weight loss and presented the problem to the QA committee and formed a Weight Loss Committee on 4/8/15. Policies and procedures were developed concerning notification to the Medical Doctor and families of significant weight loss, as well as ensuring dietary recommendations are followed. 2. The DON and Administrator developed a Dietary Binder and Weight Variance Log that is kept at the nurse's station for nursing staff to document concerns to be communicated to the Registered Dietician. The Registered Dietician will address concerns and assess [DEVICE] residents weekly. 3. Facility Restorative Aides have been re-trained on 4/9/15 on properly recording height and weight of residents. 4. Facility nursing staff, (RN's, LVN's, and CNA's) were in serviced on 4/8/15 on notifying the Medical Doctor/Provider with (resident) medical changes. 5. The Registered Dietitian will assess all Gastrostomy Tubes residents and any residents identified by the weight loss committee. Identification: In an interview on 4/27/15 at 12:22 PM, the DON explained that since the initial exit date on 4/7/15, the facility had implemented several changes. She stated a Weight Loss Committee had been formed and met on 4/8/15 where residents with weight loss concerns were addressed. She stated the facility had implemented a dietary Binder and Weight Variance Log for communication with the Registered Dietician. She stated the Registered Dietician would make weekly visits to the facility and also see residents with G (gastronomy)-tube weekly. In continued interview, the DON stated, the Restorative Nurse Aides had been re-trained on properly taking residents heights and weights. She stated all nursing staff had been trained on 4/8/15 on reporting a change of condition to the appropriate person, such as the Provider/Medical Doctor. She stated there was a QA (Quality Assurance) meeting held on 4/8/15 regarding concerns and implementing an immediate plan of correction related to following dietary recommendations and monitoring weight loss for residents. Monitoring by surveyor revealed: 1. Record review of the Immediate Plan of Correction related to nutrition, hydration, and Physician notification of changes. 2. Record Review of the Weight Loss Committee sign in sheets revealed sheets dated 4/8/15, 4/16/15, and 4/22/15. 3. Record review of the Intake, Measuring and Recording Policy dated September 2005. 4. Record review of the Encouraging and Restricting Fluids Policy, dated September 2005. 5. Record review of in-services conducted with staff revealed topics included: Flushes and [DEVICE]s on 4/7/15, Measuring Input on 4/7/15, Change in Condition Reporting on 4/8/15, Intake, Measuring, and Recording on 4/9/15, Encouraging and Restricting Fluids on 4/9/15. 6. Staff interviews were conducted with nursing staff on 4/27/15 between 12:00 PM and 2:30 PM regarding reporting changes in condition as well as communicating dietary concerns or general weight concerns. All staff interviewed was aware of newly implemented programs to include documenting in the Dietary Binder and reporting weight variances. All staff was aware of how to report a change in condition to the appropriate person and how weight changes were to be communicated to the Registered Dietician who visited weekly. 7. Record review of an additional two residents added to the sample for documentation and implementation of dietary recommendations revealed there were not any new concerns and recommendations were being followed as prescribed by the Registered Dietician and approved by the Medical Doctor. 8. Interview on 4/27/15 at 2:32 PM with the DON revealed all dietary recommendations were faxed to the Medical Doctor weekly and the physician had the ability to agree with the recommendations or implement new orders. She stated implementing new dietary recommendations was monitored by communication in the Dietary Binder as well as the weekly Weight Committee meetings. She stated she would be meeting with the Restorative Aides and the Assistant Director of Nursing regarding weekly weights to ensure compliance. She stated the DON and Administrator will report any significant weight changes at the monthly QA meeting. Other monitoring included the Unit Manager will complete the Registered Dietician's recommendations and turn in evidence to the DON noting RP and MD notification within 48 hours. The DON will complete an audit of the Registered Dieticians recommendations for the last 30 days to ensure recommendations have been implemented. According to CMS 672, the facility had 1 resident with unplanned significant weight loss/gain.

Based on observation, interview and record review, the facility failed to prevent unplanned weight loss, monitor weight loss for one of six residents (CR #1) reviewed for nutrition and necessary care and services to prevent continued weight loss when he was identified with a nutritional problem, as evidenced by: --The facility failed to monitor weight loss for CR #1; he had a significant weight loss of 18.2 % in 90 days and 21.3 % in 180 days; --CR #1 was admitted to a local hospital on [DATE] due to abnormal laboratory values. CR #1 was readmitted on 3/11/2015 with [DIAGNOSES REDACTED]. --CR #1 lost 10 lbs. on the first week after re-admission to the facility from the hospital on March 11, 2015 -facility failed to follow the dietary recommendations after CR #6 experienced a decrease in food intake -CR #1 was readmitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. An immediate jeopardy (IJ) was identified on 4/27/2015. While the IJ was removed on 4/27/2015, the facility remained out of compliance at scope of a pattern and a severity level of actual harm because all staff had not been trained on the monitoring and importance of consulting the physician related to resident changes. These failures affected 1 CR and could place 1 current resident identified with unplanned significant weight loss/gain at risk for continued weight loss and decline in health related to poor nutrition. Findings include: Intake # 4 Record review of CR #1's face sheet revealed a [AGE] years old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. CR #1 was discharged to a local hospital on [DATE] due to unable to follow commands, lethargic, not verbally responsive, low blood pressure, weak pulse and eye arousal upon loud stimuli. Record review of CR #1's quarterly MDS with an assessment reference date 03/18/2015 revealed he required limited assistance of one person with eating. His assessment noted he did not have weight loss and was not on a physician prescribed weight loss regimen. CR#1 weighed 148 pounds and measured 72 inches in height. His BIMS score was 3 out of a possible 15. Observation on 4/7/2015 at 11:55 am revealed CR #1 was in a local hospital in the Critical Care Unit. Further observation revealed he had oxygen at 2.5 liters per minute via nasal cannula and an IV line to his left forearm with 0.45% of Sodium Chloride. In an interview on 4/7/2015 at 12:20 p.m. with critical care registered nurse at a local hospital revealed that CR #1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED].). She further stated CR #1's Sodium levels were 146 (high) (Reference 134-145); BUN (blood, urea and nitrogen (blood test that reveals how well your kidneys are working. Dehydration can make levels higher.) Levels 48 (high) (9 - 20); and creatinine levels (Creatinine blood test that measures kidney function) were 3.1 (high) (0.7-13). Record review of CR #1's nutrition assessment dated [DATE] revealed in part, "annual on [AGE] year old male. Current weight: 152.7. Desirable body weight range: 152 - 189 lbs. By mouth intakes have been varied 0 - 100% per nursing records. Weight 1/7/2015 was 152.7 lbs. Monthly weight history: 12/14/2014 was 180.7 lbs. Weight is down 15.4% in 30 days. At risk for further weight loss and dehydration due to medical condition, decreased appetite and advanced age. Goals are for no further significant weight... (Change)". Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's progress notes dated 3/5/2015 at 2:34 pm revealed in part, "CR #1 observed shaking, having tremors in hands and being confused. MD notified and new order received for CBC and Chem 7 (is a basic metabolic panel blood test that provides key information regarding fluid and electrolyte status, kidney function and blood sugar levels). Record review of CR #1's laboratory results dated [DATE] revealed in part: "Sodium 149 high Reference (134-145); BUN 58 high (9 - 20); -Creatinine - Serum 2.5 high (0.7 - 1.3)..." Record review of physician orders [REDACTED]. Record review of CR #1's progress notes dated 3/6/2015 at 5:30 pm revealed in part, " Doctor notified of laboratory results. Orders received to send resident to hospital for evaluation". In continued record review revealed progress notes dated 3/11/2015 revealed in part, " CR #1 arrives to facility via ambulance on stretcher with [DIAGNOSES REDACTED]. Further record review revealed laboratory results dated [DATE] revealed in part: -Sodium 142 -BUN 14 -Creatinine - serum 1.4 Record review of the comprehensive plan of care initiated 4/9/2013 with target date 5/31/2015, revealed in part: CR #1 has a potential nutritional problem related to Alzheimer's and his memory being impaired. Further review revealed CR #1 was at risk for dehydration or potential fluid deficit related to diuretic use. Goal: will be free of symptoms of dehydration. Record review of CR #1's nutrition progress note dated 3/25/2015 read in part: " [AGE] year old male readmitted with [DIAGNOSES REDACTED]. Diet in orders is mechanical soft. Medications include [MEDICATION NAME], and [MEDICATION NAME] and atorvastatin calcium. By mouth intakes varied with less than 50% at many meals. Laboratory values on 3/6/2015 sodium 149 high, BUN (blood urea nitrogen) 58 high and creatinine 2.5 high. Weight on March 13, 2015 was 147.8 lbs. Down 18.2 in 90 days and 21.3% in 180 days. Resident continues at risk for weight decreased due to advanced age and overall medical condition. Recommendations: 1. - Modify med plus to 120 ml by mouth four times a day without stop date. 2. - Add house shake to be offered after each meal without stop date. 3. - Add multivitamins with minerals by mouth every day. 4. - weekly weights for 8 weeks 5. - All options (tube feeding, hospice) should be addressed with responsible party. -Will also recommend considering stopping [MEDICATION NAME] (diuretic) due to history of dehydration, urinary tract infection and poor intakes. Record review of CR #1's comprehensive plan of car created 12/16/14 and updated 2/4/2015 and 3/11/2015, revealed in part: Problem: weight loss related to [MEDICAL CONDITION], cardiac heart failure, depression and dysphagia. Goal: resident weight will remain stable over the next 90 days. Further record review of progress notes revealed no follow up on dietary recommendations or notification to MD or family. Record review of CR #1's SBAR - Physician/NP/PA Communication and progress note dated 4/6/2015 at 15:18 revealed in part: - Situation: Describe the problem/symptoms: Lethargic, responding to loud verbal stimuli only, vitals abnormal. - Background: 2. - Pertinent medical history: decreased intake and decreased fluids. 4. - Vitals e. - most recent blood pressure: 112/48. 8. - Functional Status - Indicate if there is a change in functional status c. - deteriorated. - Describe appearance: Resident unable to follow commands appears lethargic, not verbally responsive, blood pressure low compared to baseline, weak pulse, eye arousal upon loud stimuli. Order received to 911 out to a local hospital. Record review of weight record for CR #1 revealed: - 11/10/2014 = 180.2 lbs. - 12/14/2014 = 180.7 lbs. - 1/7/2015 = 152.7 lbs. - 2/10/2015 = 144.4 lbs. - March 2015 = 148.2 lbs. (weight before going to hospital per Director of Nursing) - 3/13/2015 = 147.8 (weight upon returning from hospital) - 3/20/2015 = 137.8 Further record review revealed no further weekly weights for CR #1. In an interview on 4/7/2015 at 3:10 p.m. the DON revealed significant changes in weight was a change in condition and the facility protocol for weight loss was to notify the MD, registered dietician and family. When asked if the MD and registered dietician were notified on 2/10/2015 that CR #1 had weight loss of 8.3 lbs. in one month, the DON stated as she looked at the computer " I don't see the notifications". She further stated said " the ADON was in charge of following with the weights and she is no longer here". In continued interview at that time, the DON was asked if the MD was made aware of the weight loss of 10 lbs. in a week on 3/20/2015 and she stated " I don't see it, but I don't know how that can be possible". The DON was further asked if dietary recommendations for CR #1 dated 3/25/2015 were followed and she responded " that's why the ADON is no longer here, the recommendations were not followed". The DON stated "recommendations were supposed to be addressed by the ADON and weights were supposed to be followed up by the ADON as well, will have the unit managers responsible for that now, last day for the ADON was 3/26/2015. Dietary recommendations were supposed to be addressed on 4/6/2015 but CR #1 went to the hospital". DON further stated residents who eat less than 75% of meals were supposed to be offered a substitute. In an interview on 4/7/2015 at 4:00 p.m. the Dietary Manager stated CR #1 had a decreased appetite in last 4 months and he was not eating well. She further stated that CR #1 was supposed to be on restorative feeding but he refused to get out of bed most of the time and he would eat his meals in bed "the staff on the floor would assisted him with his meals". Record review of the facility's Weight Assessment and Intervention, revised December 2008, revealed in part: - Highlights: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. - Significant changes definition: 6. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. - 1 month - 5% weight loss is significant; greater than 5% is severe. - 3 months - 7.5 % weight loss is significant; greater than 7.5% is severe. - 6 months - 10% weight loss is significant; greater than 10% is severe. Record review of the facility's Nutrition assessment revised December 2008 revealed in part: - Purpose of Nutritional Assessment. 1. - The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. 2. - The nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. An immediate jeopardy (IJ) was identified on 4/27/2015. The facility provided the following plan to remove the immediacy jeopardy on 4/27/2015. The plan of removal included: 1. The DON and the Administrator identified a system problem in implementing recommendations to address unplanned weight loss and presented the problem to the QA committee and formed a Weight Loss Committee on 4/8/15. Policies and procedures were developed concerning notification to the Medical Doctor and families of significant weight loss, as well as ensuring dietary recommendations are followed. 2. The DON and Administrator developed a Dietary Binder and Weight Variance Log that is kept at the nurse's station for nursing staff to document concerns to be communicated to the Registered Dietician. The Registered Dietician will address concerns and assess [DEVICE] residents weekly. 3. Facility Restorative Aides have been re-trained on 4/9/15 on properly recording height and weight of residents. 4. Facility nursing staff, (RN's, LVN's, and CNA's) were in serviced on 4/8/15 on notifying the Medical Doctor/Provider with (resident) medical changes. 5. The Registered Dietitian will assess all Gastrostomy Tubes residents and any residents identified by the weight loss committee. Identification: In an interview on 4/27/15 at 12:22 PM, the DON explained that since the initial exit date on 4/7/15, the facility had implemented several changes. She stated a Weight Loss Committee had been formed and met on 4/8/15 where residents with weight loss concerns were addressed. She stated the facility had implemented a dietary Binder and Weight Variance Log for communication with the Registered Dietician. She stated the Registered Dietician would make weekly visits to the facility and also see residents with G (gastronomy)-tube weekly. In continued interview, the DON stated, the Restorative Nurse Aides had been re-trained on properly taking residents heights and weights. She stated all nursing staff had been trained on 4/8/15 on reporting a change of condition to the appropriate person, such as the Provider/Medical Doctor. She stated there was a QA (Quality Assurance) meeting held on 4/8/15 regarding concerns and implementing an immediate plan of correction related to following dietary recommendations and monitoring weight loss for residents. Monitoring by surveyor revealed: 1. Record review of the Immediate Plan of Correction related to nutrition, hydration, and Physician notification of changes. 2. Record Review of the Weight Loss Committee sign in sheets revealed sheets dated 4/8/15, 4/16/15, and 4/22/15. 3. Record review of the Intake, Measuring and Recording Policy dated September 2005. 4. Record review of the Encouraging and Restricting Fluids Policy, dated September 2005. 5. Record review of in-services conducted with staff revealed topics included: Flushes and [DEVICE]s on 4/7/15, Measuring Input on 4/7/15, Change in Condition Reporting on 4/8/15, Intake, Measuring, and Recording on 4/9/15, Encouraging and Restricting Fluids on 4/9/15. 6. Staff interviews were conducted with nursing staff on 4/27/15 between 12:00 PM and 2:30 PM regarding reporting changes in condition as well as communicating dietary concerns or general weight concerns. All staff interviewed was aware of newly implemented programs to include documenting in the Dietary Binder and reporting weight variances. All staff was aware of how to report a change in condition to the appropriate person and how weight changes were to be communicated to the Registered Dietician who visited weekly. 7. Record review of an additional two residents added to the sample for documentation and implementation of dietary recommendations revealed there were not any new concerns and recommendations were being followed as prescribed by the Registered Dietician and approved by the Medical Doctor. 8. Interview on 4/27/15 at 2:32 PM with the DON revealed all dietary recommendations were faxed to the Medical Doctor weekly and the physician had the ability to agree with the recommendations or implement new orders. She stated implementing new dietary recommendations was monitored by communication in the Dietary Binder as well as the weekly Weight Committee meetings. She stated she would be meeting with the Restorative Aides and the Assistant Director of Nursing regarding weekly weights to ensure compliance. She stated the DON and Administrator will report any significant weight changes at the monthly QA meeting. Other monitoring included the Unit Manager will complete the Registered Dietician's recommendations and turn in evidence to the DON noting RP and MD notification within 48 hours. The DON will complete an audit of the Registered Dieticians recommendations for the last 30 days to ensure recommendations have been implemented. According to CMS 672, the facility had 1 resident with unplanned significant weight loss/gain.

Based on observation, interview and record review, the facility failed to adequately supervise one of 18 residents ( Resident #14) reviewed for accidents, when two CNAs (CNA A and CNA B) assisted the resident with a transfer which caused injuries to the resident. Resident #14 was transferred from her wheelchair to a shower chair by two staff members without the use of a gait belt as requested by the resident, and received a skin tear to her left forearm and bruising to both arms as a result. Resident #14 suffered pain and emotional distress following the incident. This failure affected one resident by causing her pain, emotional distress and injuries and placed the remaining 97 residents requiring staff assistance with transfers at risk for falls, injuries, pain and trauma while being assisted with transfers by staff. Findings include: Record review of Resident #14's face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. This resident was [AGE] years of age. Record review of Resident #14's Significant Change MDS dated [DATE] revealed under Cognitive Patterns, she scored a 15 of 15 on her Brief Interview for Mental Status indicating Resident #14 had no cognitive impairment. This document also revealed under Functional Status, she required limited physical assistance from one staff member for transfers. Record review of Resident #14's Care Plan read in part; "Transferring - Transfer: The resident requires limited assistance with transfers." This document was not dated. An observation on 10/1/2014 at 9:10 AM of Resident #14 revealed the resident sitting in bed in her room. Resident #1 was observed to be blind and had a lower limb amputation of her right leg, below the knee. Resident #1 was observed to have the following bruises to her bilateral arms: - Right forearm: Dark purple bruise wrapping around almost the entire arm approximately 8 cm wide. - Left forearm: Bandage covering skin tear near the wrist. Dark purple bruising approximately 10 cm across surrounding the bandage. Unable to determine length of bruise due to it being covered by the bandage. - Left upper arm: Dialysis port observed above the residents elbow. Dark purple bruising approximately 10 cm across and 4 cm long was observed directly above the resident's dialysis port. In an interview on 10/1/2014 at 9:10 AM with Resident #14, when asked about abuse, neglect and/or mistreatment by facility staff, she said on 9/30/2014 at approximately 3:00 PM two staff members had transferred her from her wheelchair to the shower chair without a gait belt by grabbing her arms in the facility's shower room. She said she had asked the staff members (CNA's A and B) to use a gait belt when transferring her, but the staff members ignored her request and transferred her without a gait belt resulting the large bruises to both arms and the skin tear. The resident stated she was in pain and the injuries were sore. She said she reported to RN A after the incident as to what had happened. She said she told RN A that CNA ' s A and B had hurt her. She also said she was crying while they were transferring her. She then said she was afraid to even get out of bed because she was fearful that the staff were going to hurt her again. Resident #14 was very emotional and was crying during the interview. In an interview on 10/1/2014 at 9:26 AM with RN B when asked if CNA's A and B used a gait belt when transferring Resident #14 on 9/30/2014, she said no. When asked if the CNA's should have used a gait belt to transfer Resident #14, she said yes. When asked why the CNA's did not use a gait belt to transfer the resident, she said CNA B told her they did not have a gait belt. In an interview on 10/1/2014 at 10:04 AM with CNA B, when asked about the incident with Resident #14, she said she knew Resident #14 was a one person transfer with assistance but the resident had asked for two aides to assist in transferring her, so CNA A came in to assist. She said they conducted a two person transfer for Resident #14, but during the transfer, the resident was kicking, hollering and moving her arms around. She said the resident started to slide out of the shower chair so they tried to grab her and in doing so, the resident put all of her weight on the aides. She said they could not get her back in the shower chair so they put her back in the wheelchair and the resident was still screaming. She said she did not know how the resident received the skin tear to her left arm. When asked to describe how they transferred the resident, she said they used a two person "under arm transfer". When asked if the resident had asked the CNA's to use a gait belt in her transfer, she said "No, not one time". She said the resident did not mention the gait belt until the nurse came in. When asked how residents were supposed to be transferred, she said "with a gait belt". When asked why they didn't use a gait belt, she said she did not have a gait belt and when she asked the nurse (RN A) how to transfer the resident she was told it was okay to use do a two person transfer without a gait belt. In an interview on 10/1/2014 at 10:22 AM with CNA A, when asked how long she had been working at the facility, she said her first day of work was last Wednesday (9/24/2014). When asked about the incident with Resident #14, she said Resident she put her arm under the left arm of the resident while CNA B had put her arm under the resident's right arm. She said the resident put all of her weight on them during the transfer to the shower chair. When asked if the resident had asked them to use a gait belt for the transfer, she said no. When asked if the resident supported her own weight at any point during the transfer, she said she had her foot on the ground but she still put all of her weight on the aides. When asked if she had received any training by the facility on resident transfers, she said not yet. When asked what the facility policy was for resident transfers, she said to use a gait belt at all times. When asked why she did not use a gait belt, she said "I didn't know". She said the CNA she orienting with did not say anything about using a gait belt. In an interview on 10/1/2014 at 9:52 AM with the DON, she said that Resident #14 was blind and normally a one person assist with transfers but the resident was not familiar with CNA's A and B and had requested a two person transfer. When asked if CNA's A and B had received gait belt transfer training, she said CNA B had been trained on gait belt transfers but CNA A had not been trained by the facility on gait belt transfers because she was new and had just started work last week and was going to receive gait belt transfer training today. When asked if CNA A had been transferring residents in the facility prior to being trained by the facility on transfers, she said yes. In an interview on 10/1/2014 at 11:02 AM with RN B, when asked what Resident #14 had told her about the incident, she said the resident told her that she had asked the aides to use a gait belt and they ignored her. She said the aides "picked her up so rough" that she was not able to get her bearings and her leg gave out and she went limp. She said the resident also told her that her arms were in pain and that she had told the CNA's she had an old graft in her left arm from when she went to dialysis but they ignored her. In an interview on 10/1/2014 at 1:28 PM with RN A, when asked about the incident with Resident #14, she said she was made aware of the incident by RN B. She said she went in the resident's room and saw she had a skin tear where 2-3 inches of her epidermis was pulled off. She said Resident #14 was very upset and crying about the incident. She said the resident was very particular about people touching her left arm. She said the CNA's held her under her left arm and the resident had told them not to hold her under that arm. When asked if the bruises and skin tear on the resident prior to the incident on 9/30/2014, she said no. When asked what she saw following the incident, she said the resident had three new bruises on both forearms and the upper left arm. She said CNA's A and B did not use a gait belt when transferring the resident. When asked if the resident reported to her that she told the CNA's to use a gait belt, she said yes. When asked if she reported what the resident told her to anyone, she said her supervisor (RN B) was already aware. When asked if she told RN B what Resident #14 had told her, she said no because RN B was already aware of the incident. An observation on 10/01/2014 at 3:10 PM of Resident #14 in her room sitting in a wheelchair revealed she was visibly upset and said she was crying in pain. Her right lower forearm was observed to have a very dark purplish/red bruise, approximately 5-8 cm across, going all around her arm. Her entire left arm was covered in dark purple bruising. There was dark purple bruising and some swelling noted around her left upper arm around the dialysis shunt. Observation on 10/01/2014 at 3:10 PM of RN A stated that the bruising on Resident # 14's arms "Were not that dark yesterday." RN A began to cut the Kerlix dressing from the resident's arm, and Resident # 14 was grimacing and crying out, saying nothing had happened like this to her before. While observing RN A change the resident's dressing, Resident #14 was stated "I feel traumatized. I'm scared and I shouldn't be." The resident was also heard during the bandage change saying "When something like this happens, I miss my husband and I want to go with him. I told them my skin was sensitive and to use a belt but they didn't listen to me! I'm sorry but I haven't stopped crying. Why didn't they listen to me? I don't have a bad memory." Resident #14 was observed to be crying while making the above statements. Continued observation on 10/01/2014 at3:20 PM of the removal of Resident #14's dressing by RN A revealed a large area of skin, the top dermis, came off with the dressing. The area measured about 3 inches long by 1.5 inches wide. The wound bed was bleeding. RN A proceeded to cleanse the wound with normal saline, applied TAO to a non-adhesive dressing and re-wrapped Resident # 14's arm in Kerlix. When Resident #14 asked what the site looked like (Resident # 14 is blind) RN A told her "It is a very large skin tear, the top flap came off with bruising all around. Your skin is pulled off with bruising all around it. The aides picked her up under her arms." In an interview on 10/1/2014 at 3:48 PM with RN A, when asked if she told CNA's A and B it was okay to transfer Resident #14 without a gait belt, she said no. She said she told CNA B if she was not comfortable transferring Resident #14 on her own to get another staff member to assist. She said she assumed the CNA's were using a gait belt to transfer the resident. She said the gait belt was never part of their conversation about transferring Resident #14. In an interview on 10/2/2014 at 9:06 AM with the Administrator, when asked if she had gone to see the resident yet, she said yes, she went to see her yesterday. She said the resident did not want CNA's A and B working with her anymore so we removed them from providing care to her. She said Resident #14 reported to her that the CNA's did not use a gait belt and they did not transfer her appropriately. When asked if the resident reported to her that she asked the CNA's to use the gait belt and they didn't, she said yes. She also said the resident told her she was afraid to get out of bed and that the resident was tearful. Record review of the facility's "Two Person Transfer" policy and procedure read in part; "Policy Statement - In order to protect the safety and well-being of staff and residents, and to promote quality of care, the facility uses appropriate techniques and devices to lift perform two person stand-pivot transfers. ...1. Gait belt transfer devices shall be used when performing a two person assistance transfer. If transferring to/from a wheelchair, the wheelchair should be a 45 degree angle to the other surface. ...8. Staff responsible for direct resident care will be trained in the use of gait belts for resident transfers. 9. Staff will be observed for competency in using gait belts with resident transfer and observed periodically for adherence to policies and procedures regarding use of gait belts and safe resident transfer techniques. 10. The facility strives to provide gait belts to each CNA providing direct resident care." This document was dated October 2011. According to the CMS Form 672, there were 98 residents in the facility who required assistance from staff with transfers.

Based on observation, interview and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident ' s dignity and respect in full recognition of his or her individuality for one of 18 residents (Resident #14) reviewed for dignity and respect. Resident #14 was transferred by CNA A and CNA B without the use of a gait belt, even though the resident requested they use a gait belt. Resident #14 received skin tears, bruising, pain and emotional distress from the transfer. This failure affected one resident and had the potential to affect the remaining 97 residents in the facility requiring staff assistance with transfers at risk for injury, pain, emotional distress, loss of the resident's self-esteem and diminished quality of life. Findings include: Record review of Resident #14's face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. This resident was [AGE] years of age. Record review of Resident #14's Significant Change MDS dated [DATE] revealed under Cognitive Patterns, she scored a 15 of 15 on her Brief Interview for Mental Status indicating Resident #14 had no cognitive impairment. This document also revealed under Functional Status, she required limited physical assistance from one staff member for transfers. Record review of Resident #14's Care Plan read in part; "Transferring - Transfer: The resident requires limited assistance with transfers." This document was not dated. In an interview on 10/1/2014 at 9:10 AM with Resident #14, when asked about abuse, neglect and/or mistreatment by facility staff, she said on 9/30/2014 at approximately 3:00 PM two staff members had transferred her from her wheelchair to the shower chair without a gait belt by grabbing her arms in the facility's shower room. She said she had asked the staff members (CNA's A and B) to use a gait belt when transferring her, but the staff members ignored her request and transferred her without a gait belt resulting the large bruises to both arms and the skin tear. The resident stated she was in pain and the injuries were sore. She said she reported to RN A after the incident as to what had happened. She said she told RN A that CNA ' s A and B had hurt her. She also said she was crying while they were transferring her. She then said she was afraid to even get out of bed because she was fearful that the staff were going to hurt her again. Resident #14 was very emotional and was crying during the interview. In an interview on 10/1/2014 at 9:26 AM with RN B when asked if CNA's A and B used a gait belt when transferring Resident #14 on 9/30/2014, she said no. When asked if the CNA's should have used a gait belt to transfer Resident #14, she said yes. When asked why the CNA's did not use a gait belt to transfer the resident, she said CNA B told her they did not have a gait belt. In an interview on 10/1/2014 at 10:04 AM with CNA B, when asked about the incident with Resident #14, she said she knew Resident #14 was a one person transfer with assistance but the resident had asked for two aides to assist in transferring her, so CNA A came in to assist. She said they conducted a two person transfer for Resident #14, but during the transfer, the resident was kicking, hollering and moving her arms around. She said the resident started to slide out of the shower chair so they tried to grab her and in doing so, the resident put all of her weight on the aides. She said they could not get her back in the shower chair so they put her back in the wheelchair and the resident was still screaming. She said she did not know how the resident received the skin tear to her left arm. When asked to describe how they transferred the resident, she said they used a two person "under arm transfer". When asked if the resident had asked the CNA's to use a gait belt in her transfer, she said "No, not one time". She said the resident didn't mention the gait belt until the nurse came in. When asked how residents are supposed to be transferred, she said "with a gait belt". When asked why they didn't use a gait belt, she said she did not have a gait belt and when she asked the nurse (RN A) how to transfer the resident she was told it was okay to use a two person transfer without a gait belt. In an interview on 10/1/2014 at 10:22 AM with CNA A, when asked how long she had been working at the facility, she said her first day of work was last Wednesday (9/24/2014). When asked about the incident with Resident #14, she said she put her arm under the left arm of the resident while CNA B had put her arm under the resident's right arm. She said the resident put all of her weight on them during the transfer to the shower chair. When asked if the resident had asked them to use a gait belt for the transfer, she said no. When asked if the resident supported her own weight at any point during the transfer, she said she had her foot on the ground but she still put all of her weight on the aides. When asked if she had received any training by the facility on resident transfers, she said not yet. When asked what the facility policy was for resident transfers, she said to use a gait belt at all times. When asked why she did not use a gait belt, she said "I didn't know". She said the CNA she was orientating with did not say anything about using a gait belt. In an interview on 10/1/2014 at 9:52 AM with the DON, she said that Resident #14 was blind and normally a one person assist with transfers but the resident was not familiar with CNA's A and B and had requested a two person transfer. When asked if CNA's A and B had received gait belt transfer training, she said CNA B had been trained on gait belt transfers but CNA A had not been trained by the facility on gait belt transfers because she was new and had just started work last week and was going to receive gait belt transfer training today. When asked if CNA A had been transferring residents in the facility prior to being trained by the facility on transfers, she said yes. In an interview on 10/1/2014 at 11:02 AM with RN B, when asked what Resident #14 had told her about the incident, she said the resident told her that she had asked the aides to use a gait belt and they ignored her. She said the aides "picked her up so rough" that she was not able to get her bearings and her leg gave out and she went limp. She said the resident also told her that her arms were in pain and that she had told the CNA's she had an old graft in her left arm from when she went to [MEDICAL TREATMENT] but they ignored her. In an interview on 10/1/2014 at 1:28 PM with RN A, when asked about the incident with Resident #14, she said she was made aware of the incident by RN B. She said she went in the resident's room and saw she had a skin tear where 2-3 inches of her epidermis was pulled off. She said Resident #14 was very upset and crying about the incident. She said the resident was very particular about people touching her left arm. She said the CNA's held her under her left arm and the resident had told them not to hold her under that arm. When asked if the bruises and skin tear on the resident prior to the incident on 9/30/2014, she said no. When asked what she saw following the incident, she said the resident had three new bruises on both forearms and the upper left arm. She said CNA's A and B did not use a gait belt when transferring the resident. When asked if the resident reported to her that she told the CNA's to use a gait belt, she said yes. When asked if she reported what the resident told her to anyone, she said her supervisor (RN B) was already aware. When asked if she told RN B what Resident #14 had told her, she said no because RN B was already aware of the incident. An observation on 10/01/2014 at 3:10 PM of Resident #14 in her room sitting in a wheelchair revealed she was visibly upset and said she was crying in pain. Her right lower forearm was observed to have a very dark purplish/red bruise, approximately 5-8 cm across, going all around her arm. Her entire left arm was covered in dark purple bruising. She had a Kerlix wrap around her forearm. There was dark purple bruising and some swelling noted around her left upper arm around the [MEDICAL TREATMENT] shunt. Observation on 10/01/2014 at 3:10 PM RN A stated that the bruising on Resident # 14's arms "Were not that dark yesterday." RN A began to cut the Kerlix dressing from the resident's arm, and Resident # 14 was grimacing and crying out, saying nothing had happened like this to her before. While observing RN A change the resident's dressing, Resident #14 stated "I feel traumatized. I'm scared and I shouldn't be." The resident was also heard during the bandage change saying "When something like this happens, I miss my husband and I want to go with him. I told them my skin was sensitive and to use a belt but they didn't listen to me! I'm sorry but I haven't stopped crying. Why didn't they listen to me? I don't have a bad memory." Resident #14 was observed to be crying while making the above statements. In the continued interview on 10/01/2014 at 3:10 PM when Resident #14 asked what the site looked like (Resident # 14 is blind) RN A told her "It is a very large skin tear, the top flap came off with bruising all around. Your skin is pulled off with bruising all around it. The aides picked her up under her arms." In an interview on 10/1/2014 at 3:48 PM with RN A, when asked if she told CNA's A and B it was okay to transfer Resident #14 without a gait belt, she said no. She said she told CNA B if she was not comfortable transferring Resident #14 on her own to get another staff member to assist. She said she assumed the CNA's were using a gait belt to transfer the resident. She said the gait belt was never part of their conversation about transferring Resident #14. In an interview on 10/2/2014 at 9:06 AM with the Administrator, she said Resident #14 reported to her that the CNA's did not use a gait belt and they did not transfer her appropriately. When asked if the resident reported to her that she asked the CNA's to use the gait belt and they didn't, she said yes. She also said the resident told her she was afraid to get out of bed and that the resident was tearful. When asked, if she investigated the incident further, she said with the resident's anxiety, she tried not to have too many people bothering her and she felt it was not proper for her to pry any further. When asked what the resident's allegations sound like, she said "sounds like abuse, that is why we called in a psychiatrist". When asked if RN B reported to her on 10/1/2014 that CNA's A and B were "rough" with Resident #14, she said yes. Record review of the facility's "Two Person Transfer" policy and procedure read in part; "Policy Statement - In order to protect the safety and well-being of staff and residents, and to promote quality of care, the facility uses appropriate techniques and devices to lift perform two person stand-pivot transfers. ...1. Gait belt transfer devices shall be used when performing a two person assistance transfer. If transferring to/from a wheelchair, the wheelchair should be a 45 degree angle to the other surface. ...8. Staff responsible for direct resident care will be trained in the use of gait belts for resident transfers. 9. Staff will be observed for competency in using gait belts with resident transfer and observed periodically for adherence to policies and procedures regarding use of gait belts and safe resident transfer techniques. 10. The facility strives to provide gait belts to each CNA providing direct resident care." This document was dated October 2011. Record review of the Resident Rights, not dated, revealed According to the CMS Form 672, there were 98 residents in the facility who required assistance from staff with transfers.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the resident ' s overall well-being. The facility failed to ensure that advanced directives were followed and implemented for one of eight sampled residents. (Resident #1). On [DATE], Licensed Vocational Nurse (LVN) A failed to provide cardiopulmonary resuscitation (CPR) and to call 911 when Resident #1 was found unresponsive. The resident was a Full Code (sustain life by whatever means necessary). Resident #1 was transferred to the hospital, where he was later pronounced brain dead and expired. Failure to appropriately respond according to Resident #1 ' s advance directives resulted in the resident not receiving life sustaining interventions. This failure affected one resident and placed 52 other residents on the 200 and 300 hallways at risk for not receiving life sustaining interventions. Incident # 2 Findings Include: Record review of Resident #1's Admission ' s Orders revealed he was an [AGE] year old male, admitted on [DATE] at approximately 8:00 p.m. and discharged on [DATE] with [DIAGNOSES REDACTED]. Record review of the Emergency Medical Services (EMS) Report dated [DATE] revealed Resident #1 was transferred to the Hospital by local 911 EMS on [DATE] at 4:07 am, where the resident expired. Record review of facility form titled Advanced Directive Discussion dated [DATE] revealed the Responsible Party for Resident #1 selected Cardiopulmonary Resuscitation (CPR) to be provided to the resident in the event the resident stopped breathing. Record review of the facility's Investigative Summary report dated [DATE] revealed that LVN A was notified Resident #1 was having difficulty breathing and later stopped breathing. According to the Summary, LVN A stated she did chest compressions for about five minutes and then went to the desk to check the resident's chart to see if he was a DNR (Do Not Resuscitate) or a full code. LVN A also stated no one continued CPR on the resident once she went to the nurses' station. Further review of statements made by CNA B and CNA C revealed they did not witness LVN A performing any chest compressions or breathing per the ambu bag. Further review of the Investigative Summary revealed that EMS entered Resident #1's room and asked if CPR had been initiated and CNA B and CNA C told them "no." Report revealed that LVN A stated she was determining whether the resident was a full code or DNR. When asked, CNA B and CNA C told EMS Resident #1 was in that condition for 10 to 15 minutes. In an interview on [DATE] at 11:50 am the Director of Nursing (DON) revealed once CPR had been initiated, it cannot be stopped until EMS arrived and took over. She said there was no instance where a nurse can call a code. She said the CNAs were to follow the nurse ' s discretion, which included going to get the crash cart and calling 911. She stated their facility used the dot system, where a resident ' s code status could be determined by looking for the green or red dot outside the door by the resident's name and the green and red paper inside the resident ' s chart. The DON stated without a DNR order a resident was to be treated as a full code. In an interview on [DATE] at 5:45 am CNA B stated that she asked CNA C to come to Resident #1's room to help perform incontinent care and to reposition the resident. She said at that time she noticed the resident had mucous coming from his nose and mouth and he was taking short and fast breaths. CNA B said she told CNA C to go and get the nurse. CNA B said that LVN A told them that his breathing was normal. While they waited for LVN A to come to the room, they performed incontinent care and repositioned the resident. CNA B said she went to get a towel to wipe the mucous from Resident #1's face and CNA C stuck her head out of the room and told her to go here because he was not breathing. CNA B said when the nurse entered the room, she started "freaking out" as if she didn ' t know what to do. She stated LVN A told them to stay in the room while she went to the nurse's station to verify if Resident #1 was a DNR or not. She said LVN A then told her to call 911. CNA B stated LVN A told her to go back to the room because someone had to be in there when EMS arrived. CNA B stated once EMS arrived and noticed CPR was not being performed, they asked her how long had the resident been like that and she told them for five to six minutes. CNA A stated she did not see LVN A perform chest compressions on Resident #1. In an interview with LVN A on [DATE] at 12:45 pm, she stated she checked on Resident #1 twice, suctioned his trach, and he was breathing normally. She stated around 2:00 am she went back to the nurse ' s station to complete paperwork when CNA C came to her to tell her that Resident #1 was not breathing. She said she took the medication cart with her to the resident ' s room. She stated she sent the CNAs looking for the other nurse. LVN A said before starting compressions, she went back to the desk to check the resident ' s code status. She stated she called the daughter and did not get an answer. So, she called the nephew, who stated he would try and get in contact with his aunt. LVN A said she told the other nurse to stay at the desk and call 911. LVN A stated she then went back to the room and started compressions. LVN A said she did not use the ambu bag. Further interview at the time, LVN A said she then sent the CNAs to the desk to bring her Resident #1's chart. She said when the chart was brought down to the room, she stepped out and looked at the chart again to determine whether he was DNR or not. LVN A stated that was when EMS arrived. LVN A said when she first found the resident she massaged his sternum and then did chest compressions. She stated she did not use the ambu bag because she was not instructed or trained on how to do CPR on a resident with a trach. When asked again, LVN A said when she first entered the room, she repositioned the resident, and turned on the suction machine. She stated she started sternum massages for five to ten minutes. LVN A said Resident #1 wasn't breathing during this time and she couldn't get any vital signs. Record review of the facility's investigation report revealed a signed statement made by LVN A, which stated, "I did massage my resident chest (compressions)." It further revealed she asked one of the aides to call 911. It stated she remember continuing chest massages and asking the aides to get the other nurse. She said when EMS arrived, they took over CPR. Record review of the EMS report dated [DATE] revealed the resident was found lying supine in the bed with a suction tube inside [MEDICAL CONDITION] with the suction unit off. The report stated CPR had not been initiated. "The patient was unresponsive, apneic (temporary suspension of breathing), and pulseless." Record review of the History and Physical from the Hospital dated [DATE] revealed Resident #1 was in respiratory distress when EMS arrived and CPR had not been initiated. It further revealed the resident was found to be asystole (no electrical activity in the heart) and it was unclear as to how long he was in that state. Record review of the Patient Transfer Form dated [DATE] revealed the resident was unresponsive and without vital signs when transferred to the Hospital. Record review revealed an American Cross Card showed LVN A completed the requirements for Adult & Child CPR with the completion date of [DATE]. The date of [DATE] was written under the completion date. The reverse side of the card includes the instructor ' s signature along with LVN A ' s signature. Record review of the facility ' s CPR and BLS (Basic Life Support) policy revised [DATE] revealed under General Guidelines, " ...7. If an individual (resident, visitor, or staff) is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillations exists for that individual; or b. There are obvious signs of irreversible death (e.g. rigor mortis). " Record review of the facility ' s CPR and BLS policy revised [DATE] revealed under Preparation, " ...2 ...Nurse performing chest compressions is the designated team leader who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. " According to the room roster, the facility census was 52 residents on the 200 and 300 hallways.