Every finding on record at Park Manor of Westchase

Purpose: P1 Complaint Investigation Date: 6/2/2026 Intake: 1093120 [3030810] Census: 99 Abbreviations:Admin-AdministratorADL-Activities Daily LivingBIMS-Brief Interview for Mental StatusBOM-Business Office ManagerCNA-Certified Nurse AssistantC/O-Complaints OfCR-Closed RecordCVA-Cerebral Vascular AccidentDME-Durable Medical EquipmentDON- Director of NursingDX-DiagnosisFM-Family MemberHHC-Home Health CareHO-History OfHTN-HypertensionHX-HistoryIDT-Interdisciplinary TeamLTC-Long Term CareLVN - Licensed Vocational NurseMD-Medical DoctorMDS- Minimum Data SetNOMNC-Notice of Medicare Non-CoverageNP-Nurse PractitionerOT-occupational TherapyPCC-Point Click CarePCP-Primary Care PhysicianPRN- Pro Re NataPT-Physical TherapyROM- Range of MotionR/T-Related ToS/S-Signs and SymptomsSW-Social WorkerTrans-TransportationWC-WheelchairBased on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility for 1 of 5 residents (CR #1) reviewed for a safe transfer and discharge.1.The facility failed to arrange a safe and orderly discharge through care planning involving CR #1 and FM #2.2.The facility failed to secure a proper placement for CR #1's discharge from the facility on 5.26.26 , that resulted in CR #1 admitting to a boarding home without skilled services, home health, DME, transportation to dialysis, and communication services.These failures could place residents at risk of emotional distress and not receiving care and services to meet their needs upon discharge.Findings included:Record review of CR #1's undated face sheet revealed he was admitted to the facility on [DATE] and discharged on 05/26/26. CR#1 had diagnoses of Cerebral Infarction (stroke-lack of blood and oxygen to brain), Fracture Of Neck of Right Femur (broken hip), COMPRESSION FRACTURE OF FIRST THORACIC VERTEBRA (break in spine cord), END STAGE RENAL DISEASE (kidney disease), DEPENDENCE ON RENAL DIALYSIS (excess waste is filtered from the blood),TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (body doesn't produce insulin), CONGESTIVE HEART FAILURE (heart muscle too weak to pump blood efficiently), NONRHEUMATIC AORTIC VALVE STENOSIS (narrowing of aortic valve that obstructs blood flow from the heart to the body, REPEATED FALLS, PAROXYSMAL ATRIAL FIBRILLATION (the upper chambers of the heart beat chaotically and rapidly), and HYPERTENSION (high blood pressure).Record review of CR #1's Discharge MDS assessment dated [DATE], revealed a BIMS score of 15, which meant CR#1 has normal thinking and memory (no or very little impairment).Record review of CR #1's Baseline Care Plan, dated 01/30/26, revealed the following:Focus: CR#1 is at risk for falls R/T weakness and lack of coordination, h/o falls preadmit. Date Initiated: 01/31/2026Revision on: 04/16/2026Goal: CR#1 Will be free of minor injury through the review date. Date Initiated: 01/31/2026; Revision on: 02/04/2026Target Date: 04/30/2026Interventions: The residents need a safe environment: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. Date Initiated: 02/04/2026Focus: CR#1 is at risk for impairment to skin integrity r/t decreased mobility and incontinence. Date Initiated: 02/04/2026Revision on: 02/04/2026Goal: CR#1 will be free from injury through the review date. Date Initiated: 02/04/2026. Revision on: 02/04/2026Target Date: 04/30/2026Interventions: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date Initiated: 02/04/2026Focus: CR#1 has Hip Fracture r/t Fall, post Right Hip Hemiarthroplasty. Date Initiated: 02/04/2026. Revision on: 02/04/2026Goal: CR#1 will remain free of complications related to hip fracture, such as contracture formation, embolism andimmobility through review date. Date Initiated: 02/04/2026. Revision on: 02/04/2026. Target Date: 04/30/2026Interventions: Evaluate/provide with/observe use of adaptive devices PRN [as needed]: Fracture pan, Gait belt, Abduction pillow, Walker, Wheelchair, Elevated toilet seat. Date Initiated: 02/04/2026. Follow MD orders for weight bearing status. See MD orders and/or PT treatment plan. Date Initiated: 02/04/2026. Modify environment as needed to meet current needs: Non-slip surface for bath/shower, Bed in lowest position with wheels locked, Floors that are even and freefrom spills, clutter, Adequate, glare-free light.Focus: CR#1 has the potential for hypo/hyperglycemia related to Diabetes Mellitus Date Initiated: 02/04/2026. Revision on: 02/04/2026.Goals: CR#1 will have no complications related to diabetes through the review date. Date Initiated: 02/04/2026. Revision on: 02/04/2026. Target Date: 04/30/2026.Interventions: CR#1 will have no complications related to diabetes through the review date. Date Initiated: 02/04/2026. Revision on: 02/04/2026. Target Date: 04/30/2026.Record review of CR#1's order dated 1.30.26 revealed CR#1 is scheduled for dialysis 3 times weekly on Monday, Wednesday and Friday.Record review of Care Conference Summary dated 4/22/2026 revealed, Diagnosis, cognitive, visual, communication, ADL, continent, falls and safety, skin, pain, activities, therapy, and medication issues were all discussed with the resident's representative; however, the resident representative was unavailable. The notes for the dietary plan comments read, the care plan was unable to reach the resident family member. Continue with plan of care and monitor intake.Record review of CR#1's Care Conference Summary dated 5/1/2026 revealed Diagnosis, cognitive, visual, communication, ADL, continent, falls and safety, skin, pain, activities, therapy, and medication issues were all discussed with the resident's representative. Social Services topics discussed with resident were, mood/behavior (comments read, Patient was in good mood and participate.), Discharge potential (comment read, Patient states home with [FM #2]), discharge location, PCP, pharmacy, DME, home health agency upon discharge, dental, optometry, audiology, podiatry care, and psychology/psychiatry.Record review of CR#1's Social Services care summary revealed, care conference completed with patient. Unable to reach [FM #2] for scheduled meeting. Patients were reminded of discharge 5.8.26. Patient states no concerns regarding care at facility. During this conference, the activities, dietary, and therapy were discussed with resident representative.Record review of Initial Social Services History dated 2.23.26 revealed the following:2. FM#2 is the responsible party and contact information listed.III. Communication: 110 . Spanish is CR#1's preferred language. 110b. CR#1 stated he needed an interpreter to communicate with a doctor or health care staff.IV, Discharge planning: 3. Resident need assistance post discharge.Record Review of nursing note written by SW dated 5.26.26 at 1:50pm revealed, Social Worker did make an attempt to contact patient's FM#2 regarding discharging patient into group home. Unable to reach or leave voice note as voicemail is full. Social Worker did send a text message to FM#2 informing of patient's discharge into a group homeRecord review of discharge signed by the physician on 5/26/26 at 2:41pm that stated, ok for resident to discharge home with hhc of choice & to be evaluated for pt/ot/st & skilled nursing as needed. This was on a Physicians Telephone Orders sheet. Record review of CR #1's Discharge Plan of Care dated 5.26.26 at 2:51pm revealed, CR#1 is an Assist of 1 (meaning he needs only one person to assist him in his ADL's).Record Review of the signed Discharge document with an effective date of 5.26.26 signed by the CR#1 with an unreadable date of signature. The document was in English.Record review of Discharge Summary notes written by SW dated 5.26.26 at 3:27pm revealed, Social Worker did speak with patient and FM#2, face to face, regarding discharge and notified patient of discharge folder needing to be taken upon leaving the facility. Patient and family notified of HHC, DME, transportation time and follow up appointment with PCP; all information are in discharge packet. Patient and FM #2 acknowledged.Record review of Health Status note written by LVN A dated 5.26.26 at 4:48pm revealed, Resident discharged to Group Home and picked up at this time by EMS via stretcher. Resident transferred in stablecondition. All prescribed medications, belongins and discharge paperwork were provided to the resident/transport staff upon discharge. Resident's [FM #2] notified of dischage. [sic]Record review of emails dated 5.26.26 between the Admin, the Director, and SW revealed the following: -----Original Message-----From: Admin <Admin's email.>Sent: Tuesday, May 26, 2026 2:25 PMTo: Director <Director's email ; SW < -SW's email>Subject: CR#1Hi Director,Can you reach out to our facility social worker regarding the discharge plan and process?She's attached here.Thanks,Admin From: SW <SW email >Date: Tue, May 26, 2026 at 2:28 PMSubject: RE: CR#1To: Admin <Admin's email>, Director <Director's email >Hi Director,I had called regarding the following:admission summary completed with patient and on .PCP (the physician that comes to the home):P:A:Pharm (what's your preferred):A;P:Thank you ---------- Forwarded message ---------From: SW <SW email.com>Date: Tue, May 26, 2026 at 3:50 PMSubject: RE:CR#1To: < Admin <Admin's email.>, >, Director <Director's email >>Hi Director,I got the information from previous referral. Please see the following:A. CR#1- 05.26.26DC: Group Home A: Address of group homeP: Director and the contact numberPCP: P: PCP's contact number*Patient will be seen within 7 days of discharge*Pharm: PharmacyA: pharmacy addressP: Phone: Pharmacy numberHHC: Name of HHCP= Phone contact for HHCF= Fax contact for HHCE= HHC email addressDME: has walker at home ; wc via:Equip rental (Unable to receive due to insurance)- [FM] states patient already has one at home. He'll bring it to the group homeTrans:T: 4 pmC: contact numberThank youRecord Review of The Director email regarding invoices from the facility revealed the following:$200 for service period 5.27.26 _Prorated 5 days and due on 5.31.26$1200 for service period 6.1.26 June 2026-Full Month and due on 6.30.26$1200 for service period 7.1.26 July 2026-Full Month and due on 7.31.26On 6.2.26 at 7:57am a telephone interview with FM#1, who stated the CR#1 was illegally discharged and transferred to a group home not prepared to address his medical needs. FM#1 stated the group home was some random house and had no air condition. FM#1 stated group home staff attempted to take CR#1's cell phone. He stated the family picked up CR#1 after he called upset, crying and frightened, and took him home. FM#1 stated CR#1 was not given a 30-day notice for discharge. He stated CR#1 was wheelchair bound.On 6.2.26 at 9:08am an interviewed with the SW, who stated she was responsible for completing discharges for residents who are transitioning to another facility, group homes, or other areas. SW stated the original plan on 2.3.26 was to discharge CR#1 home with FM#2, but there were no official discharge date s at that time. SW stated on 4.23.26 and 4.27.26 she tried reaching out to make contact with FM#2, which was unsuccessful.SW stated CR#1 was in the facility for skilled nursing and she was not required to give a 30-day discharge, SW stated she was unsure if CR#1 was given a 30-day notice. SW stated the Admin found the group home and spoke with the group home manager. She stated the facility moved forward with CR#1's discharge after several unsuccessful attempts were made to contact with FM#2 to discuss discharge planning. The SW stated she had no documentation of non-payment to the facility. SW stated she attempted to contact FM#2 on 4/27/26 she attempted to telephone FM#2 but unsuccessful; however, she did not complete documentation. SW stated on 5/12/26, FM#2 arrived at the facility and made a request for CR#1 to go on hospice. SW stated CR#1 didn't meet the criteria for hospice. SW stated she spoke with DON about FM#2's request and sent a referral to a Hospice team on 5/12/26 anyway. SW stated the referral was an informal phone call inquiring about CR#1's eligibility for hospice. SW stated a Hospice case manager texted her and told her that they were not going to be able to accept CR#1 because there werewas no hospice diagnosis. SW stated CR#1's discharge was not a norm. She stated there was usually a smoother transition with Nomnc (notification of funds running out and given a resident an opportunity to appeal the facility decision to discharge) being provided and discharge planning. She stated CR#1 did not get a 30-day discharge notification and there was no documentation that allowed CR#1 to appeal the discharge. SW stated the adverse effect of not receiving a Nomnc or 30-day discharge notice was not knowing a discharge date , no safe discharge planning, and lack of documentation provided by the facility to CR#1 and family.On 6.2.26 at 10:03am telephone interview with CR#1 and FM#2, CR#1 requested all telephone interviews be conducted with FM#2 as CR#1 was Spanish speaking and unable to understand. FM#2 stated CR#1 arrived at the facility on 1/31/2026. FM#2 stated he came from the hospital to another rehabilitation facility that ultimately transferred CR#1 to this facility for physical therapy. FM#2 stated he worked 80-100 hours a week and was unable to answer his telephone. FM#2 stated he has informed the facility to leave a message or voicemail on his cell phone and on breaks he would check it and respond. FM#2 stated he was not contacted by facility regarding discharge on the day CR#1 was actually taken to some house nor did he receive a message for that day. FM#2 stated he did not know CR #1 was going to be discharge until the day he was discharge. He stated his dad was getting insurance while in the hospital and when he discharged for his therapy. FM#2 stated at one point in he was informed by the facility that the insurance was going to stop paying and he would need to pay out of pocket. He stated the facility told him he would get a 30-day notification. FM#2 stated with the notification it would give him enough time to plan and prepare for CR#1's discharge. FM#2 stated at no time did he or CR #1 get notification, in writing from the insurance company that they were not going to pay or his funds had or was getting ready to run out. He stated he was never given an exact date of discharge until notified, after he left the facility, the same day of CR#1's discharge. FM#2 stated he visited CR #1 on 5/12/26 and at no time did the SW or anyone say anything to him regarding the discharge. FM#2 stated on 5/26/26 he visited CR#1 at the facility between 2:00pm-3:00pm. He stated he did not receive prior notification CR#1 was being discharged that day. FM#2 stated he left the facility at around 3:00pm and while going to work he received a call from the administrator Administrator at 4:48pm telling him his father was being discharged . He stated the Admin told him he was seen in the facility, and he asked why no one told him CR #1 was going to be discharged . FM#2 described the discharge as deceitful and stated it created a lot of stress for CR#.1. FM#2 stated he never inquired about CR#1 being on hospice. He stated he did not know what Hospice was until someone contacted him on 5/12/26 and told him CR#1 did not qualify for hospice. FM#2 stated both, he and CR#1 found out CR#1 was being sent to a group on the day of discharge. He was told the group home would have nurses and his stay would be cheaper and was smaller in capacity. FM#2 was told the group home was like the facility but at a smaller capacity. FM#2 stated there was nothing he could do to stop the discharge because he had to get to work; however, he felt that if the group home was just a smaller version of the facility, then it would be okay until he found another placement. FM#2 stated within an hour of CR#1 being transferred to the group home, CR#1 called him, literally crying and stated that he was in a not so good place. CR#1 told him everyone was independent and no one spoke Spanish. FM#2 stated he went to the group home and removed resident the same day. FM#2 stated CR#1 told him when he arrived at the group home some lady was trying to get him to take a shower. CR#1 told her he had already taken a shower at the facility and did not want to take another one. CR#1 told FM#2 that the lady became angry, began using profane language at him and threw his food on the floor. CR#1 stated another group home resident threatened to take his phone. He stated the group home did not have air conditioner.On 6.2.26 at 10:30am an interview with MDS Coordinator, she stated she completed the admissions, discharges, care plan, LTC for Medicaid and Medicare residents. The MDS stated CR#1 was an admitted Medicare A recipient. The MDS Coordinator, stated CR#1 was discharged [DATE] to a group home. She stated CR#1 did not receive a Nomnc because he was Medicare A and he only received 100 days of skilled services up until 5/8/26 that ended his Medicare A, then on 5/9/26 CR#1 was transferred to private pay until 5/27/26. The MDS Coordinator stated after Medicare A days are used, a resident does not get a discharge letter if a resident or facility feels the resident needs on-going nursing care or therapy for their needs. If facility feels resident needs on-going care, then the resident stays in facility for therapy or skilled nursing. The MDS Coordinator stated CR#1 needed on-going therapy. The MDS Coordinator, stated CR#1 entered the facility without being able to ambulate due to a hip replacement. She stated on 5/26/26 CR#1 was deemed able to safely discharge to community due to being able to complete his own ADL's. The MDS Coordinator, stated CR#1 never received a 30-day discharge notice even after the facility was aware that placement may be an issue.On 6.2.26 at 11:35am an interview with BOM, she stated CR#1 arrived at facility for skilled nursing and covered under what she believed to be Medicare A. BOM stated CR#1 did not qualify for Medicaid because he did not meet medical necessity. BOM stated she believesd she spoke with the FM#2 once or twice. She stated FM#2 told her he would come in and pay, but he did not. She stated she had asked him to pay at least a couple of weeks, which would have been $3,052. BOM stated she typically does a 30-day discharge if the resident had not paid in 6 months, but because CR#1 had not reached 6 months she did not issue a 30-day notice for discharge. The BOM stated she was not involved in CR#1's group home placement. She stated she would have been involved if CR#1 had received a 30-day discharge and if medical records would have to be sent to the admitting facility; however, because that didn't happen, she was not involved in the discharge or the discharge planning for CR#1. The BOM stated she was in the facility on 5/26/26 and seen FM#2 but did not approach or remind him regarding the money owed for private pay.On 6.2.26 at 12:15pm a telephone interview with the Director, she stated she managed the group home. She stated CR#1 arrived 5/26/26. The Director stated she received a call a week ago from a staff member at the facility asking if she had room and she stated she did. She stated the staff member said the facility would provide payment for CR#1's stay for a few months. The Director stated she sent an invoice via email. She stated emails regarding this resident was back and forth with the Admin and she believed the SW. The Director stated that prior to resident being transferred to the group home, the agreement with the facility was that the facility would pay her $1200 a month for three months to house the CR#1 then CR#1 would begin to pay the rest himself. The Director stated she was shocked when CR#1 arrived to the home on a stretcher and then transferred to a wheelchair by ambulance workers. She stated CR#1 was unable to walk or communicate because he spoke Spanish, which she was not told to her prior. The Director stated there was another resident at the facility that spoke Spanish and was able to translate a little bit and CR#1 was able to inform her that he has dialysis 3 times weekly. The Director stated there are no nurses on staff but there was a caregiver that could assist CR#1 with his ADL's. She stated the qualifications of the caregiver in the group home was just a current CPR certification. The Director stated she was not licensed when questioned about having staff in the group home who assist others with their ADL's. The Director stated she would have to consult with the actual owner of the group home and disconnected from the telephone interview and then reconnected after 15 minutes stating she had made a mistake, that the facility was not a group home, it was a boarding house and every resident was independent. The Director stated after about an hour of being at the boarding house the CR#1's FM#2 picked him up. The Director stated she never spoke with FM#2; however, she received a phone call from the caregiver of the home to let her know that CR#1 was leaving with FM#2. The Director stated there were 10 residents residing in the boarding home.On 6.2.26 at 1:36pm an interview with CR#1 who stated he was never informed he was being discharged to group home prior to the day he was transferred. CR#1 stated the SW told him that the group home would be the same as the nursing home, same nursing staff, but smaller with less residents. CR#1 stated SW said insurance was not paying nursing home. CR#1 stated the communications was with [FM #2] only, but it was for a future transfer not that same day. CR#1 stated he was unable to walk or fend for himself. He stated he was wheelchair bound and a fall risk. CR#1 stated he has trouble going to the bathroom by himself. CR#1 stated when he arrived at the home he felt very fearful and anxious. He stated all the residents there were walking around themselves and totally independent. He stated one of the workers, a black woman, was very verbally vicious towards him. CR#1 stated she yelled at him because she wanted to force him to take a shower and he was unable to take a shower by himself. CR#1 stated he never saw the shower. He never was told that there was a shower chair or even asked him if he needed assistance. CR#1 stated she appeared aggressive with him and threw food toward him, which landed on the floor. Then she began cursing him. CR#1 stated he was diabetic and the home did not appear that he would have any special meals due to his diagnosis. He stated the woman did not speak Spanish. He stated there was a person at the home that spoke Spanish but refused to interpret for him. He stated he was nervous, scared and he was told that another resident wanted his telephone and that they were going to steal it during the night. He stated he was left in the living room and was never taken to a bedroom. CR#1 stated the facility only sent him with his medication the clothes he was wearing. He stated the SW did mention a group home but led him to believe it was the same as a smaller nursing home. CR#1 stated the facility only sent him with his medications and discharged summary from the hospital and not from facility. He stated he was not informed if transportation was set up for dialysis or not. CR#1 stated this was an emotional ordeal for him.On 6.2.26 at 2:32pm an interview with Admin who stated CR#1 and FM #2 were informed of Discharges during the admission process. The Admin stated when CR#1 was getting close to discharge CR#1 and FM#2 were notified and to determine their transportation needs and wants. The Admin stated CR#1 was admitted and noted to be skilled and the plan was to return home with FM#2. She stated there were 3 different care plan meetings that were initiated by SW. The Admin stated FM#2 wanted CR#1 to stay in facility, but CR#1 did not meet medical necessity. She stated the facility had made several attempts to contact FM#2 regarding CR#1's pay responsibility because his insurance had been exhausted in the 100 days. She stated at one point FM#2 had confirmed CR#1 would live with him, but then stated FM#2 informed her that he had a family and did not want the responsibility of CR#1 to fall on his family. The Admin stated at this time FM#2 wanted CR#1 to go to a group home. The Admin stated there was conversation about group home a week prior to CR#1's discharge. That conversation was on or around that Thursday (5/21/26) or Friday (5/22/26). The Admin stated sometime in the middle of May 2026, there were conversations with FM#2 about CR#1 being on hospice to continue to stay in the facility, but CR#1 did not qualify. The Admin stated resident was discharged into the community and therefore the facility was not required or obligated to give 30-day notice. The Admin stated the day CR#1 was discharged she sent a text message to FM#2 about CR#1's discharge and the name and address of the group home. The Admin also stated social services, over the last few months, have made several efforts to contact FM#2 regarding CR#1's stay or discharge plans. Most times the facility was unable to make contact with FM#2. She stated FM#2 would always say he was unable to answer calls. The Admin stated transportation to the group home was paid for by the facility and the discharge document that was signed on the day of discharge by CR#1. She stated CR#1 has a BIMS of 15 and he could sign the documents without FM#2 even though FM#2 was the responsible party. The Admin stated it was not uncommon for the facility to give funds for placement for resident discharge to assist.On 6.2.26 at 2:32pm in a follow-up telephone interview with FM#2, he stated he was not married and does not have a live in partner and he has never had a conversation about sticking CR#1 into some unknown home. FM#2 stated he would never do that. FM#2 stated he had a conversation with the DON regarding placing CR#1 in a facility paid for by the government due to his military status and CR#1 being his dependent. FM#2 stated he was visiting CR#1 at the facility and staff were there. FM#2 stated staff waited for him to leave to have CR#1 sign discharge papers. FM#2 stated CR#1 does not speak or read English; therefore, the facility should never have convinced him to sign anything. FM#2 stated the behavior of the facility was deceitful.On 6.2.26 at 4:14pm in an interview with DON, who stated she explained to CR#1 in Spanish that the group home was a smaller setting and a safe discharge. She stated CR#1 was not a social type of person. The DON stated FM#2 was at the facility the same day CR#1 discharge. DON stated FM #2 had said he needed to leave to go to work after discussing the discharge. DON stated she did not inform FM#2 the discharge was going to be 5/26/27. The DON stated after FM#2 left the facility she spoke with CR#1 in Spanish and told him what the discharge form stated, and CR#1 signed it. The DON stated CR#1's BIMS was 15 and it was not a requirement to have FM#2 to sign the discharge form. The DON stated she was told that the place was a group home not a boarding house. She stated she did not investigate the status of the placement where CR#1 was taken to ensure it was a safe placement. The DON stated the discharge form signed by CR#1 was not documented in nursing notes or anywhere else. The DON stated the adverse effect of an unsafe placement would place a resident somewhere where their needs would not be taken care of it could be potentially dangerous for them.On 6.12.26 at 1:55pm in an interview with Rehab Director, he stated he worked with CR#1 when he arrived in the facility. He stated CR#1 was evaluated on 2/1/26 with both, OT and PT departments. He stated CR#1 did not need speech therapy after being screened. He stated CR#1 had no deficits or any cognition or swallowing issues, which is also a part of the speech therapy screen process. The rehab director stated CR#1's during the initial evaluation levels of function for bed mobility, transfer and ambulation CR#1 was maximum assist (totally dependent on staff). The Rehab Director stated upon discharge, CR#1's discharge summary revealed he was supervision to get to bed and would need someone to be there just in case of any issues. He stated CR#1 needed 90% supervision in areas of PT prior to discharge and afterwards he was 100% independent. Rehab Director stated when CR#1's pain was under control; he became transfer supervision with assistance because CR#1 continued to have an unsteady gait. Rehab Director stated there was not much gait training with CR#1 because of the pain in his lower extremities. He stated CR#1's main barrier while in therapy was his knee pain. Rehab Director stated upon discharge All CR#1's transfers were with supervision. Rehab Director stated during OT, CR#1 was Maximum assist with OT on upper and lower body dressing (totally dependent on staff). Rehab Director stated at discharge, CR#1 was independent for personal hygiene, upper body dressing. Rehab Director stated the OT summary upon discharge stated, CR#1 was modified independent (Rehab Director did not know what modified independent meant). Rehab Director stated an example that he believes modified independent meant was if CR#1 was given a shirt from the drawer CR#1 could put it on himself; however, Rehab Director was unsure if CR#1 could get the shirt out of the drawer himself. The Rehab Director stated regarding CR#1's toileting, CR#1 needed supervision on discharge because it would be difficult for CR#1 to wipe himself clean. The Rehab Director stated CR#1's wheelchair mobility status was independent.On 6.13.26 at 4:54pm a follow up interview with SW who stated she received safe discharge training (6.12.26). She stated she completed an audit of all residents currently identified as potential discharges to ensure: The discharge location can safely meet the resident's medical, nursing, functional, psychosocial, communication, and supervision needs. At time all the discharges met the needs of the residents. She stated appropriate documentation supports the discharge decision has been documented in PCC [electronic medical record] along with doctors' order for discharge. Conversation was and will be conducted with residents, responsible parties, physicians and IDT [interdisciplinary team] team . Tto ensure required notices (NOMNC) and notify last day of coverage, via care plan meetings, in person, phone calls and document in PCC. The Social Worker contacted all residents (15) discharged within the previous 30 days and verified that the discharge location remains appropriate and that no concerns regarding safety or unmet needs existed. This will be completed by end of day 6/13/2026. Stated the discharge checklist in-service training has been implemented in each area started with SW, then she sends her completed section then she emails to the entire team and then the final copy goes to the Administrator. She stated effective communication with the team, advocating, and documentation in PCC. Ensuring IDT team is also documenting.On 6.13.26 follow up interview at 5:08pm with DON who stated she received training (6.12.26) on the requirements for safe and appropriate discharge planning, which includes the checklist completed starting with social worker. She stated that the Resident rights related to discharge and transfer, assessment of medical, functional, psychosocial, communication, and supervision needs are met before discharge. She stated the documentation requirements would be IDT documentation, and PCC. She stated the last documentation is the licensed nurse who will document the resident leaving the facility. The DON stated the social worker will complete notification requirements for residents and responsible parties and verification that the receiving location can meet the resident's identified needs.Any staff member absent from education will receive training prior to participating in discharge planning activities. The Systemic changes are the mandatory Discharge Readiness Checklist to be completed prior to every discharge. The checklist requires verification and sign-off by her, Administrator, Socia

Based on observation, interview and record reviews the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 12 residents (Resident #6 and #107) reviewed for call light placement.The facility failed to ensure Resident #6's call light was within reach on 04/07/2026, while he was asleep in bed.The facility failed to ensure Resident #107's call light was within reach on 04/07/2026 and 04/08/2026, while he was lying in bed.These failures could place residents at risk of not receiving immediate assistance when needed.Findings include: 1. Record review of Resident #6's face sheet, dated 04/08/2026, reflected, a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included acute osteomyelitis (serous infection of the bone marrow), right ankle and foot, dementia (decline in mental ability severe enough to interfere with daily life, resulting from brain cell damage), without [NAME] disturbance (cognitive decline-such as memory loss, confusion, and impaired reasoning-without accompanying neuropsychiatric symptoms like aggression, hallucinations, agitation, or severe personality changes), psychotic disturbance (mental health state characterized by a loss of contact with reality), mood disturbance (serious mental health condition characterized by severe, persistent, and abnormal emotional states), and anxiety (overwhelming, feeling of fear, dread, or unease in response to stress or perceived threats), type 2 diabetes mellitus with hyperglycemia (a chronic metabolic condition where the body resists or inadequately uses insulin, leading to sustained high blood glucose levels), acquired absence of left leg below knee, severe protein-calorie malnutrition (a life-threatening, extreme nutritional deficiency), pain in right lower leg, and cognitive communication deficit (an impairment in communication). Record review of Resident #6's Quarterly MDS, dated [DATE], reflected, the resident had a BIMS score of 07, which indicated the resident had severe cognitive impairment. He used a wheelchair for mobility. He required substantial assistance from staff with personal hygiene and lower body dressing. He was always incontinent with bladder and bowel. Record review of Resident #6's care plan reflected the resident had impaired cognitive function/impaired thought processes r/t impaired decision making, dated 06/12/202. The resident had an ADL self-care performance deficit r/t left-below the knee amputation, dated 06/12/2025. The resident had an actual fall r/t cognitive impairment on 06/10/2025 and 11/28/2025. Record review of Resident #6' progress note, dated 03/04/2026 at 02:06 p.m., reflected the resident was discontinued from the falling star program (visual alert safety system designed to identify residents at high risk of falling and prevent injuries) due to resident's last fall on 11/25/2025, but safety precautions were to remain in place. Record review of Resident #6' progress note, dated 03/7/2026 at 10:49 p.m., reflected the resident was to be turned and repositioned every 2 hours and for safety precautions, bed to be in lowest position and call light within reach. Created by RN A. During an observation on 04/07/2026 at 8:30 a.m., revealed Resident #6 was observed sleeping in his bed with the call out of reach laying over a nightstand table, under a pillow, with the call light button draped down the side of the nightstand farthest from the resident. During an interview on 04/07/2026 at 08:33 a.m., LVN A stated she was unaware of how Resident #6's call light had been placed out of reach, on the nightstand, and under a pillow. She stated the staff who changed the resident's bedding must have forgotten to reattach the cord to the resident. She stated the call light needed to be within reach at all times in the event the resident needed to call for help. During an interview on 04/07/2026 at 08:35 a.m., Resident #6 stated he was doing okay and was not aware as to when or who placed his call light over the nightstand. During an interview on 04/07/2026 at 10:40 a.m., CNA A stated on this day around 9:00 a.m., it had been her responsibility to provide Resident #1 with patient care. She stated she provided the resident with incontinent care, changed his gown, bed linen, and transferred the resident from the bed to a chair and back to the bed. She stated when she completed patient care, the resident's call light was placed within reach and at no time after providing the resident care had she seen the resident's call light out of position. She stated sometimes the resident moved and the call light would be caught up under the bed. She stated the resident's call light not being within reach was not good for the resident if something went wrong and he needed to call for assistance such as falling on the floor. She stated the resident falling on the floor and unable to call for help would leave the resident in a bad way. She stated she received in-service training on call lights every day and received the last training on 04/06/2026. During an interview on 04/08/2026 at 03:17p.m., with the ADM and the DON, the DON stated resident call lights were to be within reach at all times for a resident to call for assistance. She stated a resident could fall at any moment reaching for an item they may need. She stated failure to place a call light within reach could result in a resident experiencing a fall with a fracture. She stated CNAs and nurses were required to round/check on residents every 2-hours and ensure call lights were in place and within reach. The ADM stated the importance of having a resident's call light within reach was to prevent a resident overreaching and having an incident or accident. She stated an adverse effect of not ensuring call lights were within reach were falls with injury and the inability for staff to provide timely care. She stated the facility provided call light positioning, answering, and personal items within reach at bedside in-service training daily, and in the facility's daily morning huddle/meeting. 2. Record review of Resident #107's face sheet reflected, a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included diabetes mellitus (high blood sugar levels resulting from the body's inability to produce or properly use insulin), repeated falls, mild cognitive impairment (decline in mental abilities).Record review of Resident #107's admission MDS (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status, used in nursing homes), dated 04/02/2026, reflected a, BIMS (a standardized, mandatory 0-15 point cognitive assessment tool used in long-term care settings to measure mental acuity in residents, scores between 0 and 7 indicate severe cognitive impact, scores between 8 and 12, moderate impairment while scores above 13 show little to no impairment) of 14. He used a walker for mobility. He required substantial assistance from staff with personal hygiene and lower body dressing. He was always incontinent with bowel.Record review of Resident #107's Care Plan, dated 02/05/2025, reflected Problem: The Resident was at high risk for falls related to new environment, unsteady gait and history of falls prior to admission. Goal: The resident will be free of falls. Interventions included: Be sure call light was within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance.During an observation and interview on 04/07/26 at 11:31 a.m., reflected, Resident #107 lying in bed, his call light was on the floor, and out of Resident #107's reach. Resident #107 stated he could not reach his call light. During an observation and interview on 04/08/26 at 9:18 a.m., revealed, Resident #107 lying in bed, his call light was on the floor, and out of Resident #107's reach. Resident #107 stated he could not reach his call light.During an interview on 04/08/26 at 9:23 a.m., CNA B stated call lights should be within residents' reach. She stated Resident #107 needed the call light to request assistance when needed. CNA B stated she checked the call lights which included Resident #107's call light at the beginning of her shift and every 2 hours. CNA B stated if call lights were not within the residents' reach, they could fall.During an interview on 04/08/26 at 9:27 a.m., LVN B stated call lights should be within reach of residents. He stated nurses and CNAs should have noticed Resident #107's call light was out of his reach when they went to Resident #107's room and clipped it to his bed. He stated if call lights were not within residents' reach, they could fall.Record review of in-service training, dated 04/08/2026, titled Call Lights reflected . Answer call lights in a timely manner! All staff can answer. Make sure call lights within reach and properly functioning. Signed by multiple facility staff, conducted by LVN D. The in-service included the staff identified to care for Resident #6 and #107.Record review of the facility's, undated, policy titled: Policy: Call System, Residents Policy Statement, reflected, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.Policy Interpretation and Implementation1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.2. Call system communication may be audible or visual. The system may be wired or wireless. Record review of the facility's, undated, policy titled: Policy Answering the Call Light Level I, reflected, Purpose The purpose of this procedure is to respond to the resident's requests and needs. General GuidelinesBe sure that the call light is plugged in at all times.When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.Some residents may not be able to use their call light. Be sure you check these residents frequently.

Based on interview and record review, the facility failed to ensure withing 14-days the facility completed a resident assessment, and electronically transmitted encoded, accurate, and complete MDS data to the CMS System for 2 of 5 closed records (CR #10 and CR #25) reviewed for MDS transmission. The facility failed to ensure CR #10's admission MDS assessment was completed and transmitted within 14 days of CR's entry. The facility failed to ensure CR #25's admission MDS assessment was completed and transmitted within 14 days of CR's admission. Thess failures could place residents at risk of not having assessments completed and submitted in a timely manner as required.The findings were: Record review of CR #10's face sheet dated 04/09/2026, reflected, a [AGE] year-old male who was admitted to the facility on [DATE], readmitted to the facility on [DATE] and 11/02/2025, and discharged on 11/12/2025. CR #10's diagnoses included acute on chronic combined systolic/ diastolic (heart failure) (congestive), end stage renal disease (chronic kidney failure), and dependence on renal dialysis (life-sustaining treatment for kidney failure that removes waste and extra fluid from the blood). Record review on 04/09/2026 at 01:04 p.m. revealed CR #10's entry MDS assessment, dated 10/02/2025, required the completion of the resident's compressive MDS assessment, by 10/16/2026 (14-days from resident's entry/admission). The compressive MDS Assessment was completed on 11/12/2026 was 27-days overdue. During an interview on 04/09/2026 at 1:22 p.m., LVN A stated she was responsible for completing CR #10's comprehensive MDS assessments. She stated the importance of completing a resident's comprehensive assessment was ensure the resident's care plan reflected a clear picture of the resident's care needs to the facility's nursing staff. She stated the importance of completing a resident's discharge MDS assessment was to close the resident's care plan making the plan inactive for staff's awareness the resident was no longer in the facility and for billing to discontinue. She stated she completed CR #10's compressive MDS late because the resident had multiple readmission and discharges during his stay and she could never determine if the resident was going to readmit and stay or discharge and remain out of the facility. She stated she had 14-days from the resident's admission/entry and 14-days from a resident's discharge to complete his comprehensive assessment and/or discharge assessment. She stated when the resident discharged on 11/12/2025, she went to complete his MDS discharge summary, realized she had not completed his comprehensive assessment and completed both the comprehensive and discharge assessments on the same date of 11/12/2025. Record review of CR #25's face sheet, dated 04/08/2026, reflected, an [AGE] year-old female who was admitted to the facility on [DATE], readmitted to the facility on [DATE], and discharged on 11/26/2025. CR #25's diagnoses included hemiplegia and hemiparesis (one-sided body weaknesses caused by brain damage, usually from stroke, trauma, or tumors) following cerebral infarction affecting side (functional deficits on the opposite side of the body from the brain injury due to nerves crossing in the brainstem), spastic hemiplegia affecting right dominant side (a non-progressive neurological condition causing paralysis, muscle stiffness, and reduced function in the right arm and leg), and epilepsy (chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain). Record review on 04/09/2026 at 12:55 p.m., revealed CR #25 had a completed discharge MDS assessment dated [DATE] initiated by the resident's 11/26/2025 discharge with no return, and an incomplete admission MDS record dated 12/03/2025. During an interview on 04/09/2026 at 1:22 p.m., LVN A stated she was responsible for completing CR #25's entry and discharge MDS assessments. She stated on 12/03/2025 she entered an admission record for CR #25 not realizing leaving the 12/03/2025 admission record incomplete started the 14-day requirement for competition and failure to complete. During an interview on 04/09/2026 at 03:30 p.m., the ADM and the DON stated they were not aware of CR #10's untimely admissions and assessments or CR #25's last admission record which showed incomplete. The ADM and the DON stated it was their expectations that the MDS assessment was completed within the required 14-days after entry/admission and discharge for regulation requirements and billing purposes. The ADM stated adverse effects of not completing a MDS assessment timely could result in billing inaccuracies. Record review of the facility policy, dated 2001 and revised 09/2010, titled MDS Completion and Submission Timeframes. Policy Statement reflected, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 1. The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted. in accordance with current federal and state guidelines. Discharge Assessment - return not anticipated (Non-Comprehensive), MDS Completion date: discharge date + 14 calendar days. Discharge Assessment - return anticipated (Non-Comprehensive): MDS Completion date: discharge date + 14 calendar days.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 8 (Resident #21 and Resident #33) resident rooms reviewed for accident hazards. The facility failed to ensure mouthwash, hand sanitizer, lotion, hair products and bath wash were properly stored and not out in the open in Resident #21's room on 04/07/2026, 04/08/2026, and 04/09/2026. The facility failed to ensure mouth wash, lotion and hair products were properly stored and not out in the open in Resident #33's room on 04/07/2026, 04/08/2026, and 04/09/2026. These failures could place residents at risk of injury due to unnecessary access to potentially harmful substances. Findings include: Record review of Resident #21's face sheet dated 04/09/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmission on [DATE]. Resident #1 had diagnoses which included angina pectoris (chest pain or discomfort caused by reduced blood flow and oxygen to the heart muscle), hypertension (high blood pressure, is a chronic condition where blood force against artery walls is consistently too high), hyperlipidemia ( high levels of lipids (fats), such as cholesterol and triglycerides, in the blood), insomnia (sleep disorder characterized by difficulty falling sleeping, staying asleep, or waking too early, leading to day time fatigue, irritability, and poor concentration), depression (a serious, common mood disorder causing persistent sadness, loss of interest, and physical symptoms that impair daily life), atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup narrows the heart's natural arteries, restricting blood flow without causing chest pain), dementia (aging syndrome causing cognitive decline-memory loss, poor judgment, and communication issues-due to brain damage.), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, generalized anxiety disorder (persistent, excessive, and uncontrollable worry about every day, routine events), and cognitive communication deficit (communication impairment stemming from underlying cognitive issues). Record review of Resident #21's Quarterly MDS (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status, used in nursing homes), dated 01/20/2026, reflected the resident had a BIMS score of 09 which indicated the resident had severe impaired cognition. Record review of Resident #21's care plan reflected the resident had exhibited an ADL Self Care Performance Deficit, which required assistance with cognitive deficit and dementia disease progression dated 10/16/2025. The resident had a deficit in memory, judgement, decision making and thought process r/t dementia dated 01/21/2025. The resident used antidepressant medication, was at risk for side effects r/t depression dated 01/21/2025. The resident was an elopement risk r/t impairment, and safety awareness dated 02/23/2026, and 04/08/2026 at 02:26 p.m. During an observation and interview on 04/07/2026 at 11:31 a.m., revealed Resident #21 sitting at the bedside with various personal items were observed with Resident #21's name written on them on 3 of 3 dressers: 1-bottle of mouth, 1-container of hand sanitizer, 1-bottle of lotion, 1-bottle of hair product, and 1-bottle of bath wash. During an observation on 04/08/2026 at 12:28 a.m., in Resident #21's room revealed there were various personal items on 3 of 3 dressers: 1-bottle of mouth wash, 7-bottles/containers of lotion, 2-bottles of hair products in and around. During an observation on 04/09/2026 at 01:33 p.m., in Resident #21's room there were various personal items on 3 of 3 dressers: 1-bottle of mouth, 7-bottels/containers of lotion, 2-bottle of hair products. Record review of Resident #21's progress notes dated 01/15/2026 at 02:21 p.m., reflected order for resident to continue on: Mirtazapine Oral Tablet 30 mg (Mirtazapine), administer 1 tablet by mouth at bedtime for depression, created by DON. Record review of Resident #33's face sheet dated 04/09/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmission on [DATE]. Resident #1 had diagnoses which included artificial hip joint (replaces a damaged hip joint (usually due to arthritis or injury) with titanium, ceramic, and high-density plastic components to eliminate pain and restore mobility), type 2 diabetes mellitus without complications (characterized by high blood glucose, without associated chronic organ damage), hypertension (high blood pressure, is a chronic condition where blood force against artery walls is consistently too high), mild cognitive impairment of uncertain or unknown etiology (aging and dementia, characterized by memory or thinking problems that are noticeable to others but do not prevent daily independence), and presence of cardiac pacemaker (a small, surgically implanted medical device that uses electrical impulses to regulate a slow heart rate). Record review of Resident #33's Quarterly MDS, (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status, used in nursing homes), dated 03/07/2026, reflected the resident had a BIMS score of 15, which indicated the resident had intact cognition. Record review of Resident #33's care plan reflected the resident had behavior problems r/t outstanding bill and offers staff money and was witnessed giving money to other residents dated 01/31/2025. The resident had impaired cognitive function/impaired thought processes r/t cognitive communication deficit dated 01/31/2025. During an observation and interview on 04/07/2026 at 11:31 a.m., Resident #33 was observed sitting at the bedside and stated she had no complaints or concerns to address and she was Resident #21's roommate who had a diagnosis of dementia. Various personal items were observed on 2 of 2 dressers: 1-bottle of mouth, 7-bottels/containers of lotion, 2-bottle of hair products. During an observation on 04/08/2026 at 12:28 p.m., in Resident #33's room there were various personal items on 2 of 2 dressers: 1-bottle of mouth, 7-bottels/containers of lotion, 2-bottle of hair products in and around in a wicker basket. During an observation on 04/09/2026 at 01:33 p.m., in Resident #33's room there were various personal items on 2 of 2 dressers: 1-bottle of mouth, 7-bottels/containers of lotion, 2-bottle of hair products in a wicker basket. During an interview on 04/08/2026 at 03:17 p.m., with the ADM and the DON, the DON stated the resident's personal items could be kept at bedside when labeled to identify the item belonging to the resident. She stated residents had the right to have their personal care items near them for use. She stated she had not considered but understood the risk of items being left at bedside for residents with altered mental cognitive impairment who may wander into other resident rooms and inadvertently consume those personal care products. She stated the danger of a resident consuming personal care products could place their health at risk. She stated she would address the location personal items should now be kept away to assure wandering residents with impaired cognition would not consume. The ADM deferred to the DON's statement and agreed the risk for having items assessable to wandering residents had not outweighed the residents' right to have personal items visible at the bedside. The ADM stated the facility would put a new procedure in place to ensure resident's personal items were stowed away, yet accessible at their leisure. Record review of in-service training dated 04/08/2026 titled Prevention of incidents and accidents, reflected, During daily room rounds, managers should ensure patients of rooms are free of any hazards at the bedside of our residents. This presents incident/injury. Signed by multiple facility staff, conducted by the ADM.

Based on observation, and interviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety and nutrition services for facility residents.1. The facility failed to ensure food items were properly labeled and dated in the Resident Guest Refreshment Room, located on 400 hall.2. The facility failed to ensure foods were properly sealed in the Resident Guest Refreshment Room, located on 400 hall.3. The facility failed to ensure the Resident Guest Room, on 400 hall did not present with a foul odor. These failures could place residents at risk of foodborne illness and disease.Findings include:On 04/09/26, during observation rounds in the Resident Guest Refreshment Room (a room designated for outside vendors and family members to store food items in a refrigerator or freezer) located on the 400-hall, in the refrigerator, it was noted to have an unsecured, unlabeled and undated white bag inside. The bag was partially opened and inside the bag was a white styrofoam container with what appeared to be food items exposed, which violated the Safety of Foods Brought by Visitors facility policy. Additionally, an unpleasant odor was present in the room at the time of observation.Interview on 04/09/26 at 12:07 PM with CNA A revealed an unpleasant smell in the Refreshment room; however, CNA A was unable to give the smell a description. CNA A stated Maintenance had been working in the area since last year, but the smell continues to be in the room. CNA A stated the room was where the resident's family brought in the food. CNA A stated when the water ran in the sink it appeared to get rid of the smell. CNA A stated while the water was running it disappeared. CNA A stated she would not put her food in the refrigerator because the smell made it a health hazard. Interview on 04/09/26 at 11:45 AM with Maintenance, he stated over a year ago the Refreshment room was checked out by a plumbing company that placed a Sure Seal Drain Trap device (floor drain device used to stop odors & bugs), where the odors were suppressed in the pipes. Maintenance stated he would call the plumbing company to come out again today. Maintenance stated he was also looking at replacing the refrigerator in the room and he himself would not place food in the refrigerator due to the smell in the room.Interview on 04/09/26 at 12:21 PM with the Dietary Mgr, who stated families brought food into the facility for all residents and it was stored in the 400-hall Resident Guest Refreshment Center. The food was accepted by nursing staff and not the Dietary Mgr. She stated all nursing staff are to ensure the food is labeled with resident name and the date the food was brought to the facility prior to accepting it. The Dietary Mgr stated she very seldom went into that room. The Dietary Mgr stated the CNAs were supposed to tell housekeeping, the DON or the Administrator regarding the odor of the room. The Dietary Mgr stated she would not recommend food be placed in that area due to the smell. She stated all food should be labeled, dated and have resident name on it when it came to the facility. If food was not labeled and dated it should be thrown out. The Dietary Mgr stated she did not know whose responsibility it was to clean the refrigerator. She stated during the 24-hour meeting there were issues regarding the facility; however, she did not remember a discussion regarding the refreshment center.Interview on 04/09/26 at 12:34 PM, with the ESM, she stated she was responsible for housekeeping, laundry, and the refreshment center room. The ESM stated staff were expected to clean and disinfect the refreshment center room like any other area of the facility. The ESM stated she believed the smell came from the P-trap (area under refrigerator that can maintain sitting water) under the refrigerator. The ESM stated she had not been informed of any smell in the refreshment room by staff. She stated each Friday the refrigerator was supposed to be cleaned out and disinfected. The ESM stated when housekeeping cleaned the refreshment room, they were not allowed to discard food items; however, if there were items in refrigerator, then housekeeping may bring this information to the nursing staff attention. The ESM stated during the 24-hour morning meetings, there wasn't any conversation on the smell of that room.Interview on 04/09/26 at 12:47 PM, the DON stated when the family brought food into the facility the food was placed in the refrigerator located in the Refreshment Room, which was designated for outside food brought in to residents. She stated the food should always be labeled and dated and the facility had also had a conversation with the family members. The DON stated it was nursing responsibility to ensure the food was labeled and dated with the resident name on it. The DON stated on Friday's housekeeping cleaned out the refrigerator and nursing staff usually discarded food. She stated if the refrigerator was opened and food was in there with no label or date; this should be brought to the nursing attention and those food items should be discarded. The DON stated the adverse effect of food not being labeled or dated could cause residents to have a stomach virus. The DON stated an unpleasant smell in the refreshment room was reported to maintenance and housekeeping. She stated this could also be discussed in the 24-hour meeting. The DON stated she was informed about the smell in the past, but not this week. She stated staff may report the smell while passing in the hall; however, maintenance stated it was due to pipes getting dry, which was addressed by the plumbing company. The DON stated she did not know if a plumber was called out on this issue nor did she know how long the smell had been an issue. The DON stated she could not recall if housekeeping had informed the nursing staff about food not labeled or dated in the refrigerator. The DON stated she had not checked the refrigerator in the refresher room in a while. The DON stated the staff should monitor and put a sign up which indicated the refrigerator would be cleaned on Friday and food left over would be discarded.Interview on 04/09/26 at 1:08 PM with the ADM she stated family was allowed to bring residents' food into the facility. She stated family were informed that when food was brought into the facility it must be labeled with the name of the resident and dated. She stated the nursing staff are aware of the name, date and food labeling protocol too. The ADM stated the food should not be opened or exposed. The ADM stated the adverse effect of the food not being labeled was that it could be given to the wrong residents and could cause illness if not properly maintained. The ADM stated the Refreshment Room refrigerator was cleaned out weekly and food should be discarded by nursing staff, which was the only department authorized to discard food. She stated afterwards housekeeping cleaning the refrigerator and other parts of the room. The ADM stated the smell in the Refreshment room was unpleasant and this had been discussed in the daily morning meeting (usually department managers). She stated she was informed the smell/odor came from the P-Trap (Dryness under sink). The admin stated a plumber came to the facility and evaluated this situation in the past. The admin stated to her knowledge it's not something that was hazardous. Record review of the facility's Safety of Foods Brought By Visitors policy reflected: .4. When the food item is for later consumption, the staff member will ensure the food is in a sealed container, label with resident's name and date received, and stored in refrigeration if needed. All refrigerated home-cooked items will be disposed of if not eaten in three (3) days from the date received.

Based on interview, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (CR #1) reviewed for supervision.The facility failed to provide sufficient supervision to CR#l on 01/31/2026 at 8:00pm, he was located at approximately 7:00 AM on 02/01/2026, approximately 7 miles from the facility, in the parking lot of a local Emergency Care Center. Upon discovery, CR #1 had sustained a laceration to his right eye, suspected to be from a fall. CR #1 required hospitalization from 02/01/2026 through 02/02/2026.These failures could result in residents not receiving appropriate supervision leading to elopement, injuries, hospitalization, or death.The noncompliance was identified as PNC. The noncompliance began on 01/31/2026 and ended on 02/02/2026. The facility had corrected the noncompliance before the survey began. Record review of CR #1 Facesheet revealed a [AGE] year-old male, was admitted on [DATE] with diagnoses including vascular dementia (block blood flow to your brain) and discharged from the facility on 02/01/2026 to local acute hospital. Record Review of CR #1's MDS dated [DATE] indicated that Resident #1 had a Brief Interview for Mental Status (BIMS), score of 9 out of 15, indicating moderate cognitive impairment. He had no behaviors, including wandering, and required partial/moderate assistance with transfers with ADLs. Record review of CR #1 physician order with order start dated of 01/16/2026 revealed CR #1 may go out on pass with medications. Record review of CR #1's comprehensive care plan initiated on 01/26/2026 did not include a care plan identifying CR #1 as an elopement risk prior to the occurrence of the elopement on discharge on [DATE]. Record reviewed of skilled nursing note dated, 01/28/2026 at 11:24pm noted no exit seeking behavior. Record review of CR #1 MAR revealed that medications were administered 01/31/2026 at 7:19pm. Further review revealed medication administered at 8:18pm by CMA A. Further review revealed no significant missed meds on 01/31/2026, after CR #1 was reported missing Record review of the facility entrance and exit log revealed no record that CR #1 had signed out nor notified staff of departure on 01/31/2026. Record review of CR #1 hospital record revealed in physician notes CR #1 was admitted to the hospital on [DATE] at 8:34am and discharged on 02/02/2026. Further review of record revealed RN from local ED searched patient's name and found a missing person's report from 1/31/2026. History was obtained from nursing facility and Cr #1's family member. Patient was initially placed in nursing home due to his difficulties with ambulation. However, he was able to ambulate with a walker of admission. On presentation to the ED, he was brought in by a local unhoused person who stated that she found him in the parking lot. At time he was cold, was bleeding from his right scalp and had minor lacerations to his bilateral hands. CT head negative for intracranial abnormalities, just showed right periorbital soft tissue swelling related to CR #1 fall/trauma Present on admission. infectious causes. Found to be dehydrated and hypotonic saline was administered. Patient medically optimized for discharge on [DATE].Record review of facility investigation evidence revealed CR #1 was located at approximately 7:00 AM on 02/01/2026, approximately 7 miles from the facility, in the parking lot of a local Emergency Care Center. Upon discovery, CR #1 had sustained a laceration to his right eye, suspected to be from a fall. CR #1 required hospitalization from 02/01/2026 through 02/02/2026.Further review of the investigation evidence revealed the facility's immediate actions: The facility staff performed an immediate search of hall 200, the patient's room, and the patient's bathroom, followed by all adjacent halls, exits, and communal areas. Once it was noted that the patient was no longer in the facility, the exterior and perimeter of the facility, including the neighboring streets where checked, as well as the closet hospital to the facility The facility nurse supervisor notified the Administrator and DON that CR #1 had 8:30p.Within 30 mins of identifying that the patient was not in the immediate vicinity, a 911 call was made at 8:59p, and a missing person's report was filed, and an investigator was assigned to the case.The facility provided all necessary information, personal and clinical history, to the initial responding officers, as well as the assigned investigator, and a missing person's bulletin was provided.Facility staff performed a facility wide census and confirmed that all other facility residents were accounted for and safe.CR #1 's responsible party, was notified, along with the attending physician. Staff in-services related to the management of a patient elopement were initiated.Verified functioning of all facility doors was evaluated to ensure full operational. The time schedule for the door was verified and noted to be 7p as programmed.Staff searched for CR #1 until after midnight on 02/01/2026.The Administrator remained in contact with local police Investigator and received updates throughout the night on 01/31/2026.Elopement risk assessments for complete for all resident, and care plans were verified by the DON to reflect elopement risk. Interviews on 02/08/2026 at 12:13pm, the receptionist stated that there was front door coverage until 8:00 p.m. and all residents should be in account for by 8:00pm. The receptionist stated that she was required to seek coverage at the front desk if she had to take breaks. She stated that the front desk was not to be left unattended. She stated she was made aware of the CR #1 incident occurrence on 01/31/2026. She stated she had worked the day of the incident and recalled seeing CR #1 on earlier during the day, prior to her shift ending at 5:00pm. She stated she was informed that CR #1 had gone missing around 8:00pm after she had left for the day. She stated that since the incident on 01/31/2026. The facility changed the receptionist's hours (8:00am -8:00pm). She stated that she has been trained in elopement risk and management. She stated if a resident is identified as missing, she would first notify the house supervisor. Interview on 02/08/2026 at 12:36pm CR#1 pervious roommate stated he recalled seeing CR # 1 on 01/31/2026 evening, but he could not recall the time CR #1 left the room.Interview on 02/08/2026 at 12:50pm, Nurse A stated she was present at the facility on 01/31/2026. She stated she was not the primary nurse assigned to CR #1. She stated she was familiar with CR #1 and he did not have history of exit seeking behavior. She recalled seeing the resident sometime after dinner between 5:00pm and 6:00pm, but she did not recall seeing him exit the building. She stated an elopement code was implemented around 8:00 after being notified by other staff (she could not recall names) that CR #1 was missing. She staff all staff begin searching the facility and surrounding area for CR #1, who was not found prior to her shift end. She stated, a resident count was completed and verified no other residents had gone missing. She stated she believed CR #1 may have gone missing when 911 was called by another resident in the same hall (200 Hall). She stated she believe the receptionist shift ended at 5:00 on 01/31/2026 and the 9ll call by the resident happened after 7:00pm. She stated the facility had provided training on Elopement Response and she would notify the supervisor when first observed that a resident goes missing.Interview on 02/08/2026 at 1:00pm, the DON stated she was informed of the incident at approximately 8:30pm on 01/31/2026. She stated she was informed that staff had last seen CR #1 at 7:00 p.m. during medication rounds. The DON stated that she was aware that CR #1 was not compliant with signing in and out. The DON stated the receptionist was responsible for checking to ensure all residents and visitor sign in and out. The DON stated there was a receptionist at the front desk after from 8:00am - 8:00pm daily. She stated prior 01/31/2026 there was a receptionist for 8:00am - 5:00pm, but hour had since been extended and implemented on 02/01/2026 in the facility's response to CR #1's incident. She stated there should not be residents leaving the facility after 8:00pm and staff trainings had been provided on the recently implemented receptionist coverage. The DON stated there was no policy specifying how frequently staff should round on residents. She stated residents and their responsible party were educated on admission to them that residents were to sign out when leaving the facility on a leave pass. The DON stated that residents have the right to leave the facility when they like during identified pass hours. She stated it was the facility's responsibility for ensuring the safety and the account of resident leaving or returning. The DON stated that the facility ensured the account of a daily accurate census in the effort to monitor and account for residents. The DON said an elopement code was initiated during the incident as staff were unaware CR #1 had gone missing. The DON based on the facility's root analysis, it was likely that the resident exited the building on 01/31/2026, during a 911 emergency response to another resident. She stated first responders were present at the facility and the door was held open as they prepared another resident for transport. The DON stated staff were trained on elopement code and process on 02/01/2026, following the incident. She stated the facility had implemented a Resident Roster list that remained at the front desk with the receptionist, which identified residents needing assistance when exiting. She stated that direct care staff were made of aware of the list and how the list prevented future incidents form occurring. She stated staff were also educated on increased precaution during a 911 emergency response. She stated one staff member is to remain at the door entrance during after hour 911 emergency response.Interview attempt on 02/08/2026 at 1:13pm to CR #1's responsible party, left voicemail message requesting a follow up.Interview attempt on 02/08/2026 at 1:13pm to CR #1's responsible party, left voicemail message requesting a follow up.Interview attempt on 02/08/2026 via telephone at 1:30pm to CMA A (assigned to CR#1 on the date/time of incident), left voicemail message requesting a follow up.Interview attempt on 02/08/2026 via telephone at 1:38pm to CNA E (assigned to CR#1 on the date/time of incident), left voicemail message requesting a follow up. Interview on 02/08/2026 at 4:00pm, the administrator stated she was notified by the nursing supervisor on 01/31/2026 at approximately 8:30pm that CR #1 had gone missing and an Elopement Code was called. She stated she was informed that the facility staff performed an immediate search of hall 200, the patient's room, and the patient's bathroom, followed by all adjacent halls, exits, and communal areas. Once it was noted that the patient was no longer in the facility, the exterior and perimeter of the facility, including the neighboring streets where checked, as well as local hospital closet hospital to the facility. She stated a 911 call was made on 01/31/2026 at 8:59p, but facility continued the search for CR #1 until after midnight on 02/01/2026. She stated a missing person's report was filed, and an investigator was assigned to the case. She stated she remained in contact with local police investigator assigned. She stated CR #1's family was notified. She stated a facility audit of residents was continued on 01/31/2026 at approximately 9:00pm. She stated following the incident, in-services related to the Management of a patient elopement were initiated on 02/01/2026. The deficient practice occurred on 01/31/2026 and was corrected prior to the surveyor's onsite visit on 02/08/2026. The facility provided evidence that: Record review of facility's documented interview on 01/31/2026, time not recorded, CMA A stated she administered CR #1 evening medications at approximately 7:00 PM (time verified as 7:18p). Following medication administration, she responded to other residents requesting assistance and continued medication pass. The Certified Nursing Assistant (CNA) assigned to CR #1 later notified her that the resident was not present in his room. An immediate search was initiated. According to her, the patient was not more confused than his baseline.Record review of facility's documented interview on 01/31/2026, time not recorded, CNA E she assisted the patient to the dining room for breakfast and lunch on the date of the incident. At approximately 6:30 PM-7:00 PM, she observed Cr #1 seated in a chair in his room while she was providing care to his roommate. She then exited the room to provide care to other residents. She is unable to recall the exact time, but shortly thereafter observed increased activity in the hallway related to another resident's room and briefly stopped to assist. When she later returned to CR #1's room, she noted that he was not present. She immediately notified other staff, and a search for the resident was initiated. When the CAN E was asked if the CR #1 was more confused than usual, she stated no.Record review of email from local police investigator confirmed that a 911 call was made by the facility on 01/31/2026 at 7:43 involving an emergency with another facility resident. Further review of record confirmed call was made by the facility on 01/31/2026 at 8:59pm to report that CR #1 was missing. Record review of facility incident record dated 01/31/2026 at 7:43pm confirmed another incident did occurrence, involving a 911 call, around the time the facility discovered CR #1 had gone missing.Record review of local police event history, confirmed police were called to report CR #1 as missing on 01/13/2026 at 8:59pm and police were dispatched at 9:02pm. An immediate facility-wide elopement risk reassessment was conducted on 02/01/2026.Staff received re-education on monitoring residents with cognitive impairment 02/01/2026.Door alarm systems were evaluated and tested.Monitoring rounds were reinforced during evening hours.No further incidents of elopement occurred after implementation of corrective actions.Record review of in - service trainings: Receptionist In-service- Front Desk Expectations/Elopement Drill, dated 02/02/2026 General Staff In-service - Elopement Drill/ Managing patient elopement, dated 02/01/2026 and 02/02/2026Interviews on 02/08/2026 starting at 11:00am with staff, 3 CNAs (CNA Q, CAN L, and CNA, T,) and 3 Nurses (LVN L, LVN M, and LVN, J) revealed staff had been recently in-serviced on resident sign-in/sign-out procedures. The staff stated they conducted resident rounds every two hours and were required to call an Elopement Code for identified missing residents who could not be accounted for. All interviewed staff were familiar with the Resident Roster list, which identified residents needing assistance when exiting, and explained who was responsible for monitoring the front door. All interviewed staff stated they had previously provided care for CR #1 during is stay of 01/16/2026 - 01/31/2026. All stated that CR #1 did not demonstrate exit-seeking behaviors prior to the 01/31/2026.

Based on interview and record review the facility failed to develop and implement a baseline for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for 1 of 5 residents ( Resident # 1) reviewed for care plans. The facility failed to develop a comprehensive care plan which addressed and included measurable objectives and timeframes related to Resident # 1's pressure wound of the left lateral thigh (a position or direction that is away from the midline or middle of the body) thigh which she had since her admission 4/24/2025. This deficient practice could affect any resident and contribute to residents not having their needs met according to their assessment. The findings were: Review of Resident # 1's face sheet, dated 6/5/2025, revealed she was admitted to the facility on [DATE] with diagnoses including: Conversion Disorders with Seizures or Convulsions (functional neurological symptom disorder), Schizophrenia (a chronic brain disorder that affects a person's ability to think, feel, and behave clearly), Bipolar Disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, impacting a person's ability to carry out daily tasks), Muscle Wasting and Atrophy (the decrease in size and strength of muscle tissue). Review of Resident # 1's Care Plan initiated on 4/28/2025 revealed there was no indication that Resident # 1 had a pressure wound of the left lateral thigh. This care plan revealed the following: focus-Resident # 1 had a Urinary Tract Infection and was at risk for adverse reactions. The goal was Resident # 1's Urinary Tract Infection would be resolved without complications by the review date. The interventions were to check resident during rounds for incontinence, encourage adequate fluid intake, give antibiotic therapy as ordered, observe/document/report to MD for s/sx of UTI: frequency (how often something occurs or repeats over a specific period of time) , urinary urgency (a sudden, compelling urge to urinate that is difficult), malaise (pain), foul smelling urine, dysuria (painful or burning urination), fever (a temporary increase in body temperature, usually above 100.4°F (38°C), and is often a sign that your body is fighting off an infection), nausea and vomiting (common symptoms that can be caused by a variety of factors, including infections), flank pain (pain in the side of the body, specifically between the lower ribs and the hip), Supra-pubic pain (pain in the lower abdomen above the pubic bone), hematuria (blood in urine), cloudy urine, Altered mental status (a change in a person's level of awareness, thinking, or behavior). Females to wipe and cleanse from front to back. Clean peri area well after bowel movement. Review of Resident #1's MDS assessment, dated 4/28/2025, revealed her BIMS score was 13 of 15 reflecting Resident # 1 was cognitively intact; she required partial assistance with self-care, indoor mobility and functional cognition; substantial/maximal assistance with lower body dress, shower/bathing; partial/moderate assistance with upper body dress, oral hygiene and eating, roll left to right, sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer and walk 10 feet; always incontinent with urinary and bowel. Resident # 1 was at risk of developing pressure ulcers/injuries. Resident # 1 had one or more unhealed pressure ulcers/injuries; 1 stage 4 pressure ulcer present upon admission, and MASD; pressure ulcer/injury care, and applications of ointments/medications. Record review of Resident # 1's , Wound Care Physicians progress notes, dated 4/30/2025, 5/2/2025 and 5/9/2025, revealed Resident # 1 had a wound on her left lateral thigh. Record review of local hospital Physical Exam, dated 4/23/2025 revealed Resident # 1 had a pressure ulcer left buttock (stage III/unstageable-the ulcer is so covered with slough or eschar that the full depth of tissue damage cannot be assessed). Record review of local hospital Physician's Attestation, dated 4/20/2025, revealed Resident # 1 had a large pressure ulcer on left buttock: at least stage III/unstageable. No sign of active infection. Continue local wound care. Will get wound care consult. Turn patient every 2 hours. Record review of Internal Medicine Physician's progress notes, dated 4/26/2025, revealed in part [Resident # 1] had a stage 3 ulcer on left buttock and follow up recent Sepsis (a life-threatening condition that arises when the body's response to an infection spirals out of control, damaging its own tissues and organs)/UTI/Syncope (a temporary loss of consciousness caused by a sudden decrease in blood flow to the brain) and possible seizure (a sudden, temporary change in brain activity that can cause a variety of effects, including muscle spasms, loss of consciousness, and changes in behavior or awareness). Record review of ambulance communication form for Non-Emergency Transports, dated 4/24/2025, revealed that Resident # 1 was transported from a local hospital to the nursing facility. Resident # 1 was bed confined and could not support herself while seated in a wheelchair due to seizures, weakness and unable to ambulate. Resident # 1 had a pressure ulcer. In an interview with LVN A on 6/6/2025 at 11:54 am she stated that she provided care to Resident # 1 two or three days before Resident # 1 was discharged to the local hospital. She stated that Resident # 1 did not have a UTI. She stated that Resident # 1 had a pressure sore on the sacrum area (the region of the lower back, specifically the part of the spine located at the base of the lumbar vertebrae) She stated that she did not know when Resident # 1 developed her pressure ulcer. She stated that she reviewed the care plans for every resident that she provided care to. In an interview with LVN C on 6/6/2025 at 3:56 pm she stated that she provided care to Resident # 1. She stated that Resident # 1 did not have a UTI. She stated that Resident # 1 was admitted with a pressure sore on the left hip. She stated that a wedge was used as a pressure ulcer prevention. She stated that Resident # 1 was also repositioned every two hours. She stated that she did not observe Resident #1's pressure ulcer as the wound care nurse provided care to this ulcer. She stated that she reviewed her resident's care plan. She stated that Resident # 1 was care planned for the pressure ulcer. In an interview with the Wound Care Nurse on 6/6/2025 at 4:19 pm he stated that he provided wound care to Resident # 1. He stated that Resident # 1 was admitted to the nursing facility on 4/24/2025 with a pressure ulcer to the left hip He said that the wound care Physician ordered Santyl on 4/25/2025 and they proceeded with treatment which was once daily. He stated that he put the interventions in place and educated Resident # 1. He stated that Resident # 1's pressure ulcer was located on the left lateral thigh. He stated that the pressure ulcer interventions included positioning pillow and wedges to offload. He stated that Resident # 1's interventions were documented on Resident #1's care plan. He stated that the MDS nurse completed the care plan. In an interview with RN A on 6/6/2025 at 4:48 pm she stated that she was the MDS and Care Plan coordinator. She stated that she completed the MDS for all residents. She stated that she completed the Care Plan for Long Term Care residents. She stated that the Care Plan for SNF residents was completed by another nurse and this nurse was no longer with this nursing facility. RN A stated that she completed the MDS for Resident #1 and the MDS reflected that Resident # 1 had a pressure ulcer. She stated that she did not complete the Care Plan for Resident # 1 and she did not know why Resident # 1 was not care planned for a pressure ulcer. She stated that the wound care nurse also completed the care plan for residents who were receiving wound care. RN A stated that all residents should have an individualized care plan as this would ensure effective and personalized care was provided to the resident. In an interview with the DON on 6/6/2025 at 5:00 pm she stated that Resident # 1 was admitted to the nursing facility for skilled nursing. She stated that Resident # 1 was admitted with a pressure ulcer. She stated that she could not remember where the pressure ulcer was located. She stated that Resident # 1 was seen by the Wound Care Physician the following day after she was admitted . She stated that Resident # 1 had wound care treatment every day. She stated that the Wound Care Physician visited Resident # 1 once a week. She stated that Wound Care or MDS nurse should have completed the care plan for Resident # 1. The DON stated that she did not know why Resident # 1 was not care planned for the pressure ulcer. She stated that Resident # 1 had an UTI prior to her admission to the nursing facility. She stated that Resident #1's UTI was resolved prior to admission. She stated that she did not know why Resident was care planned for a UTI. In an interview with Wound Care Nurse on 6/11/2025 at 9:30 a.m., he stated he completed care plans within 21 days of admission and in the care plan he documented the wounds; this was for all residents with wounds. He stated that Resident # 1 did not have a care plan as they had 21 days to complete the care plan, and Resident # 1 was discharged from the facility on the 21st day. He stated that Resident # 1 went to the hospital for abnormal laboratory values. He stated that the day Resident # 1 was hospitalized , Resident # 1 was scheduled to be seen by the wound care Physician, but Resident # 1 went to the hospital before the Wound Care Physician could see her. He stated that Resident # 1 did not acquire any additional wounds while in house. He stated that Resident # 1 did not have a wound vac (a medical device that uses suction to help heal wounds that are slow to close) while at this facility. In an interview with RN B on 6/11/2025 at 12:55 p.m., she stated the wound care nurse did the care plan for wounds. She stated that the care plan should be completed within 20-21 days upon admission. RN B stated that if a Resident was admitted with a wound this would be included in the baseline care plan. She stated that Resident # 1 had one wound on admission, and she did not know how many wounds Resident # 1 had when she was discharged from the facility. RN B denied providing wound care to Resident # 1. In an interview with the Administrator on 6/11/2025 at 2:53 pm, she stated that care plans were completed by the MDS coordinator. She stated that she did not know why Resident # 1 was not care planned for a pressure ulcer. \ Record review of the facility's Care Plans, Comprehensive Person-Centered, policy revised December 2016, revealed in part A comprehensive, person-centered care plan that includes measurable objectives ad timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident 8) The comprehensive, person-centered care plan will a) include measurable objectives and timeframes; b) describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being; c) include the resident's stated goals upon admission and desired outcomes; g) incorporate identified problem areas; incorporate risk factors associated with identified problems; 10) identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident and the endpoint of the interdisciplinary process; 12) the comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment ( MDS).

Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 23 residents (CR #1) reviewed for adequate supervision. -CR #1 left the faciity on [DATE] on pass and did not return. The facility did not know where he was and did not make attempts to locate CR#1. This deficiency exposed residents living in the facility to potential harm, injury or death due to not being adequately monitored. An Immediate Jeopardy (IJ) was identified on 02/21/2025. The IJ template was provided to the facility on [DATE] at 11:13am. While the IJ was removed on 02/21/2025 at 1:40pm with the Administrator, DON, and Regional VP of Operations. While the IJ was lowered, the facility remained out of compliance at a scope of isolation and a severity of harm with potential for more than the minimal harm that is not an immediate jeopardy because all staff had not been trained on adequate supervision when residents leave the facility and elopement protocols. Findings: Record review of CR #1's face sheet dated 02/20/25 revealed a [AGE] year-old male was admitted to the facility on ,d+[DATE]//24. CR #1 had diagnoses included: cerebral infraction (stroke), traumatic subdural hemorrhage (bleeding that happens between the brain and the skull), hemiplegia and hemiparesis affecting right dominant side (paralysis on one side of the body, and weakness on one side of the body), Raynaud's Syndrome without gangrene (decreased blood flow to the fingers), acute metabolic acidosis (collection of conditions that often occur together and increased risk of diabetes, stroke and heart disease), and pigmentary glaucoma (right eye, severe stage) (pigments flakes from the iris and blocks the eyes drainage system). Record review of CR #1's admission MDS assessment dated [DATE] revealed CR #1 BIMS was 15 which indicated intact cognition. CR #1 required touching to limited assistance with ADL with one staff assistant. Further review revealed the resident was incontinent of bowel and bladder. Record review of CR #1's care plan revision on 02/06/25 revealed CR #1 had ADL self-care performance deficit, requires assistance. Interventions: ensure frequently used items are within reach. Further review revealed CR#1 had the potential for S/S of complications of cardiac problem related to coronary artery disease. Intervention: document and report to MD for S/S of fatigue, muscle weakness, nausea, and vomiting. CR#1 has cerebral vascular accident. Intervention: observe/document/report MD for neurological deficits: level of consciousness, dizziness, and weakness. CR #1 was on anticoagulant therapy (when residents take blood thinners for treatment of heart diseases) related to cerebral infraction. Intervention: observe/document/report to MD S/S of anticoagulant complications: sudden severe headaches, bruising, SOB, sudden changes in mental status. Record review of CR #1's AMA documentation was dated 01/16/25 at 6:00 a.m. and signed by the Physician. Record review of CR #1's on-pass sign-out sheet revealed CR #1 signed out on 01/16/25 and did not sign back in. Record review of CR #1 progress note dated 01/16/25 by LVN QQ read CR #1 out on pass this a.m., in stable condition. Record review of the hospital record dated 01/16/25 revealed CR # 1 was admitted to the hospital at 8:28 p.m., with admitting diagnosis code: Stroke. The records stated that he was at home watching TV and woke up with some vomiting which was unusual for him and unable to move his right hand and had some numbness. He then took himself to the hospital. Interview on 2/19/2025 at 5:20pm with the Administrator and the DON, the Administrator said CR #1 was his own RP. When he left no one at the facility was able to contact him. CR#1 went out on pass often. The Administrator said she did not know if the Ombudsman was informed that CR#1 left the facility. The DON said CR#1 was medically stable when he left the faciity on [DATE]. Record review of the facility's incident/accident log from September 2024 to February 2025 revealed CR#1 was not listed as having any incidents or accidents. Interview on 2/20/2025 at 2:33pm with MA B stated she worked all shifts. She stated observed CR#1 leaving theh facility with his backpack on 1/16/2025 around 9:30 am to 10:00 am and did not know if CR#1 had told someone he was leaving. MA B said CR#1 did not complain about any health conditions at the time. She did not know if CR#1 was coming back or not, but CR#1 left frequently, and she figured he would come back. MA B said resident would tell their nurse who has the logbook and residents would sign out and sign in when they arrive back to the facility. CR#1 would stay out for not long, and he would run a couple of errands and come back. MA B did not know if CR#1 came back that particular day or not, and when the resident did not return, the DON asked staff if anyone saw him leave so MA B told her she saw CR#1 exit the facility with his backpack. MA B did write a statement on what she saw. She worked until 5pm the next day, and remembered the facility was looking for CR#1 before that time. The DON called the code, asked staff to look down the hall for CR#1 and also searched his room, activities room, and staff conducted a perimeter search outside the facility. MA B said she did not get an update on what happened to CR#1 after he left. CR#1 was quiet, reserved and kept to himself and he did not have a roommate while he was at the facility. MA B said CR#1 was oriented times three (he was oriented to himself, place and time). MA B said residents who leave would get assessed by a nurse before they left and after they come back. Interview on 2/20/2025 at 3:09pm, LVN QQ stated he worked 6a-2pm and he said he was on duty on 01/16/2025 when CR#1 left. He was not sure when CR#1 signed out. LVN QQ saw CR#1 come up to the front desk that day but LVN QQ was not paying close attention to him. CR#1 would say he was grown and that he didn't like when staff asked him where he went. To LVN QQ's knowledge, CR#1 never left the facility without signing out. LVN QQ did not look for CR#1 because he would always come back the next shift. The facility had a sign out book sitting on the counter and each resident had their own sheet. CR#1 knew how to access his own sheet because the book is in alphabetical order. The last time LVN QQ saw CR#1, he left in a stable condition. LVN QQ would visually look at residents before they left, and to him CR#1 was walking and LVN QQ didn't see anything going on that was concerning. LVN QQ could not remember much as he was working down the hall. LVN QQ found out CR#1 did not return to the facility the next day. Interview on 2/20/2025 at 4:10pm, LVN B stated she worked on 2p-10p shift. She said the facility tells residents nurses need to know where they're going so nurses can account for residents. Nurses talked to residents to make sure they're fine before leaving. Nurses are to conduct assessments before and after residents come back to make sure they're fine, if they have any pain, and how their outing was. She said CR#1 was alert and oriented times four. CR#1 knew the binder/book and several occasions LVN B told him to let people know when he was leaving. LVN B got a report that day that he left. He would leave as early as 6am and come back between 7:00 pm to 8:00 pm. When it was 9:00pm that day, LVN B sent a message to the DON to let her know CR#1 did not come back yet. LVN B called the phone number on CR#1's facesheet but it was not active, and she documented the call attempt. She heard the DON came to the facility that night but she left at 11:00 pm before the DON came. LVN B did not do any other documentation for CR#1, and on her rounds she did not see him either and that was unusual to her. When LVN B returned to work the next day, she knew the DON reached out to CR#1's physician but did not know what else the DON did as part of management duties. LVN B knew CR#1 still did not come back the next day. Interview on 2/20/2025 at 4:25pm with the DON, she said when the facility had a brand new resident, they educate them on on-pass protocols and initiate a new sing out sheet. Residents were taught to sign in, sign out and always let staff know they are going out. The binder was accessible to residents. For alert residents they could sign themselves out and let a nurse know verbally that they were leaving. The DON said for residents on skilled, they needed to be back by midnight and if not insurance would not pay. Before residents left on-pass, the facility would make sure they received therapy. For CR#1's case, the nurse called the DON and she made attempts to contact him that night and the next morning. The DON had progress notes documenting the attempts. The DON said she did not call the police because CR#1 was awake, alert and he left the facility every day and it was nothing new. She did not recall consulting with corporate if this incident was reportable or not. The DON did not worry because CR#1 left in a stable condition while at the facility. She said a visual assessment consisted of visually making sure the resident was stable, capable, alert and did not have shortness of breath. She said she found out CR#1's status of being in the hospital on 02/20/2025. Interview with MD A on 2/20/2025 at 4:57pm, he was CR#1's primary physician. He said the facility notified him that CR#1 left on 1/16/2025 and he was told on 1/17/2025 that CR#1 did not return. MD A said he and the facility waited a full day to see if they could find the resident and conducted a search. He said the facility did everything they could. The facility informed him on 1/16/2025 at night that CR#1 left and when MD A came on 1/17/2025 for rounds he signed the AMA paperwork. MD A said he signed the AMA paperwork because CR#1 left and did not come back, and that's what MD A said the protocol was and that's what had done. CR#1 would go to appointments, but this time was different. The facility told MD A that they tried to look for the resident. The MD said he was trying to get CR#1 a long-term care bed. CR#1 had a lot of co-morbidities, and he was a very sick resident so that's why he needed to be at a facility like this one. CR#1 had agreed to be a LTC resident. MD A said CR#1 could make some decisions on his own and that cognitive impairment was not too bad. The facility still had not found CR#1 the next day. The Administrator was at the facility on 1/17/2025 and MD A and they both did the AMA paperwork. The facility did mention to him that CR#1 was found, and he did not receive any other updates. The nurses told MD A that CR#1 went out that day without telling anyone which was normal for CR#1. MD A said he was worried about CR#1 and told the facility to keep looking out for CR#1 and get in touch with emergency services and any of CR#1's contacts since that was the usual protocol. If CR#1 was found through emergency services, they would have notified the facility. If MD A knew the resident went to the hospital, he would have gone there to check on him, or the hospital would communicate with the facility about the resident, and MD A would find out about the resident's condition through the facility. Interview with the Administrator on 02/20/2025 at 5:20pm, she said that the facility would see if residents were able to come and go on-pass based on cognition and also if residents were their own RP. The facility would also involve a resident's emergency contact, especially if residents left and came back with someone listed in their records. CR#1's physician was aware he would leave and come back. it was not uncommon for CR#1 to sign out and leave the facility. The facility required residents going out on-pass to sign in and out of the facility and nurses are to make sure residents were alert and make note of resident status. Nurses would assess the resident to make sure they were stable, but the Administrator did not know if nurses checked resident vitals. In her point of view, residents can leave on-pass if they are able to self-direct their own care and that residents' physicians would know if they were able to take care of themselves. it was not uncommon for CR#1 to sign out and leave the facility. was high-functioning with a BIMS score of 15 (he was cognitively intact) and would leave with his FM and took public transportation from what she understood. The Administrator said nurses assessed residents throughout the day so not assessing when residents left on-pass would not be harmful to residents. MA A saw CR#1 leave with his backpack and LVN QQ said CR#1 left when he came to the facility on his shift at 6a-2p. She said nurses are expected to come to the facility 15 minutes before the start of their shift. The Administrator said the facility called his phone number in his clinicals, but it did not work. The phone number for his family member also did not work. The Administrator called the rehab facility CR#1 was at from 1/23/2025 to 2/12/2025 and they had the same phone number she had. If a resident signed out and did not come back, the facility would make an attempt to reach the person to get a timeline, but his number was not work at the time and the facility documented attempts to reach him. The police were not notified. The facility did not note the resident to be missing, since he was daily directing his own care. The facility did not suspect the resident was in danger or missing based off of his habits. The Administrator said CR#1 told someone he was not feeling well, packed his bags and left the facility, telling someone he was going to the hospital. According to hospital records the Administrator received on 2/20/2025, the resident stated he was at home watching TV when he went to the hospital. On a number of occasions, CR#1 said he would go back to his prior arrangement. The resident met with someone who was helping him go to a group home and the Administrator said she would look for the documentation. She reported CR#1 leaving to the corporate side and to CR#1's physician. No one in corporate said CR#1 leaving was reportable to her knowledge. After CR#1's physician was notified, CR#1 was given AMA and the physician did not give any orders to continue to look for the resident given CR#1's health status, cognitive status and his habits. Record review of the facility's policy on Signing Residents Out last revised August 2006, the policy read in part, 1. Each resident leaving the premises (excluding transfers/discharges) must sign out . 3. Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once .6. Inquiries concerning the signing out of residents should be referred to the Director of Nursing Services or to the Administrator. Record review of the facility's policy on Discharging the Resident without a Physician's Approval revised October 2012, the policy read in part, This was determined to be an IJ on 02/21/2025 at 11:13am. The DON was notified. The Administrator and DON were provided with the IJ template on 02/21/2025 at 1:19pm and a Plan of Removal was requested. The following plan of removal was accepted on 02/21/2025 at 4:12pm. Plan of Removal [Facility Name] Plan of Removal F689 2/21/2025 [Facility Name] submits the following Plan of Removal for the alleged failure to ensure residents remain free from accidents and hazards. What corrective actions have been implemented for the identified residents? CR#1 is no longer a resident at the time of this plan of removal. No corrective action possible to be taken for CR#1. How were other residents at risk to be affected by this deficient practice identified? An audit of all residents who go out on pass within the last 30 days was conducted by the DON on 2/21/25 to ensure that adequate supervision and follow-up was completed for these residents. At the time of the audit, it was noted that there are fifteen residents who routinely go out on pass and no additional supervision or follow-up was required. These residents were verified to be in-house by the DON on 2/21/25. All residents who leave out on pass have the potential to be affected by this alleged deficient practice. All residents who reside in the facility have the right to go out on pass and physician orders are not required to do so. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? CR#1 is no longer a resident of the facility as of 2/21/25. All nursing staff, including CNAs, CMAs and nurses to be in-serviced by DON/Designee on ensuring adequate supervision for residents who leave out on pass and do not return. Additionally, they will be in-serviced on reviewing care plan interventions specific to residents going out on pass. This will be completed by 2/21/25. This includes notifying the administrator, DON and appropriate law enforcement agencies when a resident does not return from being out on pass. What corrective actions were taken? 1. The following actions were initiated immediately on 2/21/25. a. On 2/21/25 an audit was completed by DON (Director of Nursing) to ascertain all residents who go out on pass to ensure that their care plans reflected as such. The facility PPS nurse received this list from the DON and will update and revise all resident care plans for those who go out on pass. This will be completed by end of business 2/21/2025. b. DON and Administrator were educated on 2/21/25 by RVP (Regional [NAME] President of Operations) and CSD (Regional Clinical Services Director) on ensuring adequate supervision and follow up for residents who leave out on pass and do not return. c. Newly hired nurses and CNAs to be in-serviced during orientation by DON/Designee on proper procedure for residents who leave out on pass and do not return. d. In-services conducted by DON with nursing staff (CNAs, LVNs, RNs, CMAs) on 2/21/2025 regarding residents signing out on pass, reviewing and completion of the resident sign out book, and what to do if they do not return from being out on pass. This would include notifying the Administrator, MD and DON, attempting to contact the resident or RP, searching the premises, and (if resident is unable to be contacted or located) notifying local law enforcement and APS. In-services for all nursing staff to be completed by end of day 2/21/2025. e. Nursing staff will not be allowed to provide direct care until completion of in-services regarding residents signing out on pass, what to do if residents do not return from being out on pass and following care plan interventions. f. The facility chief nursing officer reviewed and revised the facility sign-out policy on 2/21/25 to reflect actions needed when a resident does not return from being out on pass. g. All residents who reside in the facility have the right to go out on pass and physician orders are not required to do so. h. Facility social worker/designee to audit and correct all active resident charts to verify contact information is up to date for the resident and/or RP. This will be completed by end of day 2/22/25. How will the system be monitored to ensure compliance? Nursing staff will review residents sign out book during shift change to identify any residents who are out on pass. If a resident is out on pass greater than eight hours the nursing staff will attempt to contact the resident or RP to ascertain their whereabouts and wellbeing. If unable to reach the resident or RP the nursing staff will notify the DON, MD, and appropriate law enforcement agencies. DON/Designee will review resident sign out book as part of the morning meeting process to ensure residents and staff are following the facility out on pass policy. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 2/21/22 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring/Observations/Interviews/Record Reviews Record review of the IJ plan binder: -The facility's policy for signing residents out last revised 02/21/2025, read in part, If a resident who has signed out has not returned the same day, then the staff will notify the DON and/or the Administrator. Facility staff will attempt to contact the resident/responsible party to determine whether the resident will be returning to the facility on another date. If the resident or responsible party cannot be reached, then the DON and/or the Administrator will initiate an immediate search of the premises. If the resident is not found during this search, then the DON/Administrator will notify local law enforcement/APS. -QAPI Signature page dated 2/21/25 related to CR#1's discharge 1/16/25, Administrator and Medical Director signed along with facility department heads. In-service sheet dated 2/21/2025 regarding team update on resident safety. -List of 25 residents highlighted with history of OPT (going out on past) in past 30 days, care plans were updated to include focus area of going out on pass with interventions which included ensuring resident has facility information, ensuring resident signs the out on pass book and notify when resident returns, and staff will verify resident has returned at the end of their shift monitoring if there is any change in condition, initiated 02/21/2025. -1 to 1 in-service record dated 02/21/2025, topic included residents leaving AMA versus residents out on pass, policy education and review. It read in part, out on pass isn't considered AMA if they don't return. A search must be performed as they are a missing resident. If they want to leave, they must fill out AMA paperwork or if refused to sign must make intentions known otherwise if any resident who leaves will be treated as a missing resident regardless of his or her BIMS. The in-service was completed by the Regional Nurse and Regional VP of Operations -In-service for nursing staff dated 02/21/2025 from 9:30am to 9:50 am completed by the Administrator which covered the Signing Resident Out policy last revised August 2006. This included sign-in, sign-out procedure, out on pass procedure including residents exiting the building must sign out and if staff recognized a resident had not returned that it be reported to Administrator. -In-service for nursing staff dated 02/21/2025 at 10:00 am completed by the DON, which covered residents who have gone out in the past and have not returned to the facility is considered missing residents. -In-service for staff dated 02/21/2025 at 3:40pm and ongoing, which covered checking resident care plans and interventions for those who go out on pass, residents signing out for a pass, nursing documentation being completed, ensuring residents return in stable condition, and reporting a resident not returning within eight hours to management. -Blank sign out sheet with the following columns: date, resident out on pass (yes or no), shift 6-2, shift 2-10, shift 10-6, and DON/Admin initial. -Complete census of residents dated 02/21/2025 at 6:49pm with a note, As of 7:30pm 2/21/25, all phone numbers verified and/or corrected and signed by the Administrator. Residents were marked as being their own RP or marked as updated. -Signing Residents Out policy last revised 02/21/2025 read in part, If a resident who has signed out has not returned the same day, then the staff will notify the DON and/or the Administrator. Facility staff will attempt to contact the resident/responsible party to determine whether the resident will be returning to the facility on another date. If the resident or RP cannot be reached, then the DON and/or the Administrator will initiate an immediate search of the premises. If the resident is not found during this search, then the DON/Administrator will notify local law enforcement/APS . Interview with the DON on 2/22/2025 at 9:20am, she said she did an audit for 23 residents and will update their care plan. Interview with RN W on 2/22/2025 at 9:27am, she said she received education on when a resident wanted to go out, she would check their condition and if they're able to make a healthy decision, check their physical condition, check who their RP was, check on transportation, if they needed skilled care during their time on-pass, if they required medication before leaving, check that the resident's contact information is current and let them know to call if they needed the facility's help. She was also educated on checking vital signs, documenting how long they will stay outside, educate the family about conditions to look out for, and see if the nursing supervisor approved resident's on-pass. If residents did not return according to the provided timeline, she would call their phone number to see if they were okay and tell her supervisor about the situation. Residents have the right to go and the facility should make sure they were safe. She said no residents had left the building on-pass on 2/21/2025 that she was aware of. Interview with CNA C on 2/22/2025 at 11:36am, she worked 6:00 am to 2:00pm. She was in-serviced on making sure residents told a nurse and signed out before leaving. If staff see residents leaving out the door to call them and verify they followed the protocols. CNA C said staff have to know who residents are leaving with, and if staff have not seen residents return for eight hours, to let a nurse know and they will call the resident to find out how they are. Interview with CNA B on 2/22/2025 at 11:42am, she worked 6:00 am to 2:00 pm and 2:00pm to 10:00pm. She received inservices on confirming with residents who were leaving on why they are going out, if they signed out yet and making sure they check with nurses at the facility. Interview with LVN C on 2/22/2024 at 11:54am, he said he worked 10:00 pm to 6:00 am shift. He was inserviced on making sure residents leaving are competent and finding out who is responsible for them. Nurses are to make sure residents come back, and if they do not staff will initiate a search by calling the resident's RP. If staff are unable to get hold of the person, to notify the DON and Administrator. Leaving is not considered AMA. Nurses document procedures such as going out on pass and documenting the resident's current status, who they are leaving with, how they are before leaving, where they are going and when they are coming back to the facility. Nurses document in the resident's medical records and a physical sheet for residents on each hall. Interview with the DON on 2/22/2025 at 12:02pm, she in-serviced staff on what to do when residents go out on pass, including checking the resident's care plan, filling out the sign out form and documenting on-pass residents in each nurse's log and to check that before each shift to know which residents are coming back on that shift. Nurses are to help residents sign out, ask where they're going and document in residents' progress notes, make sure phone numbers are working, add vital signs and making sure residents want any medication for pain before leaving. If residents do not appear well, nursing staff are to report to the DON so that the resident and/or family members can be educated to make sure residents stay staff. If residents haven't returned, staff are to call the resident. If they have not returned and if they don't answer, report to management (Unit manager, Administrator, Social Worker, DON). If a resident is unable to be found, the facility will search the area. If the resident is unable to be found, the facility will call hospitals and police after 24 hours. The DON said that going forward, the facility will visit the resident's address on file if they do not return to the facility after being out on-pass. The DON said that CR#1 was going out every day and never had any problems with health. He did have medical conditions but no severe changes in conditions while at the facility. The DON said management estimated that CR#1 was able to take care of himself. The DON was notified 01/16/2025 around 9:00 pm through text and she called CR#1 at home and he did not answer. She also called early in the morning the next day. The DON said if residents are not located, they could be on the street in hot or cold weather. The DON will monitor the effectiveness of implemented procedures by reviewing resident sign-out logs for each hall at the end of the day for 30 days. The DON will continue to educate and in-service staff on what to do when residents are leaving a facility and what staff do if they have not returned. Interview with the AD on 02/22/2025 at 12:15pm, she was in-serviced on resident rights, asking residents where they are going if they leave the building. Staff should also check to make sure residents told their nurse and that the nurses are aware of residents leaving on-pass. If she noticed residents have not returned she would report it right away to the DON and Administrator. She would also assist with locating residents. Interview with CNA F on 2/22/2025 at 12:25pm, she said she worked 10:00 pm to 6: 00 am and sometimes helped with 6:00 am to 2:00 pm shift. CNA F said she was in- serviced on asking residents leaving the building where they are going, if they signed out, if they spoke to their nurse, and when they're coming back. She would notify her nurse if the resident has not returned. She would communicate concerns with the nurse on residents out on-pass. She had in-services on resident rights in the past. Interview with the Receptionist on 2/22/2025 at 12:29pm, she said she was in-serviced on stopping residents leaving and making sure they were signed out or direct them to the nurse's station. Interview with the Administrator on 2/22/2025 at 12:38pm, she said she was in-serviced by the Regional VP of Operations on 2/21/2025. She conducted in-services for department managers, coordinators and direct care staff about the new sign-in and sign-out policy and what needed to be done if residents leave, including redirecting them to nurse's station to sign in the log book, educating nurses on confirming a resident's RP, having contact information of the resident or family member, making sure residents return and reporting immediately to her or the DON if residents do not return. The Administrator said staff are to conduct follow-ups by calling the resident's RP and confirming an expected time to come back. If staff cannot get a response, they are to search the facility and premises and get law enforcement involved and calling the location resident said they were going. The Administrator said CR#1 signed out and the follow-up did not take place at the time. She was informed on 01/16/2025 late in the evening. She said CR#1 was not considered missing due to him frequently leaving the facility on-pass, but if a resident was noted to be missing and had not come back when they said they would, the facility would conduct a search and notify law enforcement. The Administrator said based off the conditions of CR#1 at the time and his habits, the facility felt he left the facility of his own choosing and was not in immediate danger. She discussed CR#1 with the DON, notified the doctor who gave us the discharge directives which was the AMA paperwork. The Administrator will monitor the implemented procedures with continuing to follow the sign-in and sign-out log and shift reports which they were already doing. She will also monitor the new separate logs for each hall in which nurses will review before starting the shift. Staff are expected to send a message to the DON and the Administrator for the time being when residents go out so they can make sure residents return. The monitoring period will be 90 days, and binders are to be reviewed at morning meetings, with the weekend RN supervisor monitoring to ensure protocols are being done. Interview with the BOM on 2/22/2025 at 12:50pm, she said she was in-serviced on letting the DON and Administrator know when she sees a resident leaving the facility. She said she will call the resident o [TRUNCATED]

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Resident #31, Residents #41 and Resident #76) reviewed for infection control practices. - The facility failed to ensure CNA C followed proper infection control and hand hygiene for Resident #31 during Foley and incontinent care. - CNA AA did not utilize appropriate hand hygiene during Foley catheter care for Resident #41 - CNA AA did not utilize appropriate hand hygiene during incontinent for Resident #41 - The facility failed to ensure CNA F Donned proper PPE while providing incontinent care for Resident # 76 who was in enhanced barrier precaution isolation. These failures could place residents at risk of infection or a decline in health. The findings include: Resident #31 Record review of Resident #31's sheet dated 02/19/25 revealed a [AGE] year-old female was initially admitted to the facility on ,d+[DATE]//21 and readmitted on [DATE]. Resident #31 had diagnoses included: chronic kidney disease (a condition where kidneys are damaged and cannot filter blood properly), diabetes mellitus (body do not produce enough insulin or use it properly) and heart failure (heart cannot pump enough blood to meet the body's needs). Record review of Resident #31's Quarterly MDS assessment dated [DATE] revealed Resident BIMS was 09 which indicated moderately impaired cognition. Resident #31 required extensive assistance with ADL(activity of daily living) with one staff assistant. Further review revealed the resident was incontinent of bowel and she had an indwelling catheter. Record review of Resident # 31's care plan initiated on 12/20/23 revealed Resident #31 had Indwelling Catheter dx: neurogenic bladder(lack of bladder control) Interventions: Position catheter bag and tubing below the level of the bladder. Check for incontinence during rounds, wash, rinse, dry perineum(patch od sensitive skin between virginal opening and anus) and change clothing PRN after incontinence episodes. Record review of Resident #31's order summary report for February 2025 read in part . FC: Foley catheter 16 FR 10 cc bulb to bedside drainage, diagnosis: neurogenic bladder ordered date 02/27/24 . During an observation on 01/18/25 at 9:54 a.m., when CNA C was providing Foley and incontinent care for Resident #31, CNA C placed a clear plastic bag on the clean field, and it was touching the clean incontinent brief and wipe packet. CNA C placed the used wipes, which had bowel movements, and used incontinent briefs, which also had bowel movements, in the clear plastic bag. CNA C changed dirty gloves with bowel movements three times without sanitizing or washing her hands. When CNA C was about to DON(putting on gloves)the fourth gloves, the IP told her to go and wash her hands. During an interview on 02/18/25 at 12:54 p.m., CNA C said she should not have placed the thrash bag on the clean field and had the soil linen and wipes in the bag because of cross-contamination. CNA C said she forgot to wash her hands after she changed gloves three times, which had a bowel movement. CNA C said the IP told her to wash her hands when she was about to [NAME] the fourth glove without washing or sanitizing her hands. CNA C said it was an infection control issue because she did not wash her hands. CNA C said she had been in service on infection control and was educated to wash or sanitize her hands when she changed gloves to prevent cross-contamination. She stated the nurses monitored the aides when the nurses made rounds. During an interview on 02/19/25 at 8:20 a.m., the IP said CNA C should not have placed a trash bag on a clean field on a bedside table with clean supplies for incontinent care to prevent cross-contamination. The IP said CNA C changed dirty gloves three times without washing or sanitizing her hands, and on the fourth change, she told CNA C to go and wash her hands because of cross-contamination. During an interview on 02/19/25 at 10:49 a.m., the DON said CNA C should sanitize her hands after removing dirty gloves. The DON said CNA C should have sanitized her hands when she changed the used gloves to prevent cross-contamination. The DON said CNA C should not place her trash on the clean field to avoid cross-contamination. The DON said the IP had in-service on hand washing with the nursing staff, the nurses monitored the aides during rounding, and the nurse managers monitored the nurses. During an Interview on 02/19/25 at 3:04 p.m., the Administrator said that CNA C placed the dirty line bag on the clean field and did not wash her hands when she changed the dirty gloves during foley and incontinent care was an infection control issue, which was cross-contamination. Resident #41 Record review of Resident #41's face sheet, dated 02/19/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #41 had diagnoses which included: metabolic encephalopathy ( a brain condition that occurs due to an imbalance of chemicals in the blood) acute cystitis with hematuria (a bladder infection that causes blood in the urine), essential (primary) hypertension, (high blood pressure) hyperlipidemia( high levels of fat in the blood), Parkinson's disease with dyskinesia movements(a condition where a person with Parkinson's disease experiences involuntary muscle movement) and Foley catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine). Record review of Resident's #41 admission MDS assessment, dated 01/18/2025, reflected the BIMS score was 10, which indicated the resident's cognition was moderately impaired. Resident #41 had an indwelling catheter. Record review of Resident #41's care plan, date 01/30/25, reflected the resident was at risk of urinary tract infections. Interventions included for caregiver teaching to include good hygiene practices, wipe, and cleanse from front to back and clean peri area well after bowel movement in order to help prevent bacteria in urinary tract. Record review of physician's order dated 1/14/25 Order Summary: FC: Foley Catheter 16FR 10cc bulb to bedside drainage, Foley catheter care Q shift and PRN : Diagnosis: urinary obstruction. Observation on 02/19/25 8:49 AM Resident#41 was lying in bed, HOB at 35-degree, resident was lying on the right side with F/C hanging on the left of the bed frame not secured. Incontinent care performed by CNA AA and CNA BB assisting. CNA AA entered Resident #41's room with enhanced precaution and washed hands (don gown and gloves). CNA AA cranked resident #41's bed to the position of comfort, without changing the gloves, she used the same gloved hands removed resident's cover sheet, then positioned resident on his back, open up Resident #41's brief, the indwelling catheter tubing was under resident draw sheet with Resident #41, lying on it in the bed. Resident #41 had 200 yellow urine in the drainage bag and large BM. Using the wet wipes CNA AA cleaned the groin several times and cleaned F/C straight down twice not in a circular motion, then repositioned to his right side, using the same gloves got the wipes and cleaned the buttock with large, bowel movement several times. C.NA AA then changed gloves without washing hands or using hand sanitizers, before donning a clean gloves, she then touched resident #41's call light to call for the treatment nurse for the soiled dressing to the sacral area. At 2/19/25 at 9:06 AM treatment LVN QQ came in to change the treatment. Interview with CNA BB on 2/19/25 at 9:25AM, about the F/C and incontinent care, she said CNA AA did not washed her hands after changing gloves, and she did not cleaned the F/C in a circular motion and F/C was not secured and it should be positioned on the same side Resident #41 was lying to avoid pulling. C.NA BB said she had in-services for incontinent and F/C training last month. Interview with CNA AA on 2/19/25 at 9:27 AM, about the incontinent and Foley catheter care, she thinks she did not do a good job, she said she was very nervous, and she forgot to changed her gloves and not changing gloves can cause cross contamination and infection. CNA AA had been working in the facility for 10 months and she had training for 6 weeks for incontinent and indwelling catheter care. Interview with the LVN QQ on 2/20/25 at 9:52 AM, LVN QQ been here a year in December 2024, 6-2p M-F, on 200 Hall which he worked has 2 residents with Foley catheter. CNAs and I monitor the Foley catheter. LVN QQ said he check the catheter when entered the facility, he said he checked on Resident #41l yesterday, I don't recall checking on the catheter today during multiple visits. LVN QQ said he was checking to make sure its flowing, making sure any sediment, blood in urine or if it's kinked up. It should have a stat lock to hold it. I don't know what it's called, could be safe lock. We lock it to hold it in place, stable, to prevent yanking, stretching, and causing trauma to the resident. If the urine isn't flowing and can be blocked. LVN QQ said he check it a couple of times a day, in the morning and see what the amount residents have in their bag and empty it. I will check it later in the afternoon. When I go in and out I do check on the bag. LVN QQ said he had in-services on catheter care, he doesn't remember when. Resident #41 does not have a history of UTI. Lack of Foley care can cause obstruction. In the continued interview, he was asked who was responsible for checking indwelling catheter was secured and monitoring it. LVN QQ said he was responsible and he checks it every so often and did not say when last the indwelling catheter was checked. During an interview on 2/20/25 at 5:25 PM, the DON revealed staff should be utilizing appropriate hand hygiene practices to prevent an infection. The DON revealed it was necessary to sanitize or wash the hands between glove changes. The DON stated she would conduct in-services now on peri care and infection control. Resident #76 Record review of Resident #76's sheet dated 02/19/25 revealed a [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #76 had diagnoses included: PEG tube (a feeding tube placed into the stomach), diabetes mellitus (body do not produce enough insulin or use it properly) and hypertension (blood vessels have persistently raised pressure). Record review of Resident #76's Quarterly MDS assessment dated ,d+[DATE] revealed Resident BIMS was 06 which indicated severely impaired cognition. Resident #76 required extensive assistance with ADL with one staff assistant. Further review revealed the resident had a PEG tube. Record review of Resident # 76's care plan initiated on 06/24/24revealed Resident #76 had requires tube feeding related to dysphagia. Intervention: keep HOB elevated 45 degrees during and thirty minutes after tube feed. Observe side effects of feed intolerance/ aspiration: diarrhea, N/V, increased cough, Record review of Resident #76's physician for February 2025 read in part . GT: head of bed elevated at 30 to 45 degrees except to allow for ADL care ordered date 06/07/24 . GT: flush GT with H2O at 38 ML/HR for 22 hours VIA pump QD . GT: give Jevity 1.5 at 60CC/HR for 22 hours ordered date 01/08/25 . During an observation on 02/19/25 at 9:54 a.m. revealed CNA F was providing incontinent care for Resident #76, who was in the EBP room, and he did not wear a protective gown. During an interview on 02/19/25 at 9:57 a.m., LVN S said CNA F should have worn the protective gown while he provided incontinent care for Resident #76 because she was on EBP. LVN S said he observed CNA F providing incontinent care without a gown, and that was when he gave CNA F a gown and told him to stop and don the gown. LVN S said the rationale for wearing a gown was to prevent cross-contamination because Resident #76 had a G tube and wound. LVN S said the nurse monitors the aides while the nurse managers monitor the nurses. LVN S said he had in service on infection control, including PPE. During an interview on 02/19/25 at 10:58 a.m., the DON said CNA F should have worn the gown while providing care for Resident # 76 in isolation to prevent cross-contamination. During an interview on 02/19/25 at 11:59 a.m., CNA F said he should have worn the gown while providing incontinent care for Resident #76 because she was in on enhanced barrier precaution and to prevent cross-contamination. CNA F said he had infection control training, including PPE. CNA F said the charge nurse monitored the aides during rounding. During an interview on 02/19/25 at 3:04 p.m., the Administrator said CNA F should have worn the disposable gown while he provided care for Resident #76 on enhanced barrier precautions to prevent cross-contamination. Record review of the facility undated in service on the importance of following up on ABP policy read in part . enhanced barrier precaution are essential to prevent the spread of infectious disease among staff and patients any patient placed on enhanced barrier precautions should be cared for in a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and multi drug resistance organism infection. when providing a daily living activities care for the patients, staff members must wear gowns . Goals . provide proper personal protective equipment as needed . Record review of facility hand washing/hand hygiene dated 2001 MED - PASS, Inc. Revised August 2015 read in part . the facility considers hand washing the primary means to prevent the spread of infections . policy implementation #7b . before and after direct contact with resident . #7m . after removing gloves .#9 . the use of gloves does not replace hand washing . 36918

Based on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 2 out of 3 residents, (CR #96 and CR #97) reviewed for MDS transmission. -The facility failed to transmit a completed Discharge MDS assessment for CR #96 within 14 days of completion. -The facility failed to transmit a completed Discharge MDS assessment for CR #97 within 14 days of completion. These failures could place residents at-risk of not having their assessment completed and submitted timely, which could result in denial of services and or payment for services. Findings included: Record review of CR #96's Admission Record revealed a [AGE] year-old male. CR #96 had an admitted [DATE] and discharge date of [DATE]. CR #96 diagnoses included acute on chronic systolic (congestive) heart failure (refers to a sudden worsening of symptoms in a patient who already has a chronic condition of systolic heart failure, meaning their heart muscle is weakened and cannot pump blood effectively, causing congestion in the body due to fluid buildup) and other abnormalities of gait (any unusual or irregular patterns of walking or movement that aren't categorized as a specific, well-defined gait abnormality). Record review of CR # 96's Discharge MDS assessment dated [DATE] revealed the assessment was not transmitted to CMS. Record review of CR #96's Discharge plan of care dated [DATE] revealed that CR #96 was discharged home with home health, PT, OT, and transition to home. CR #97 Record review of CR #97's Admission Record revealed a [AGE] year old male. CR #97 had an admitted 10/ ,d+[DATE] and discharge date of [DATE]. CR #97 diagnoses included Traumatic subdural hemorrhage with loss of consciousness status unknown (means a bleeding collection of blood within the brain's outer layer (subdural space) caused by a head injury, where the medical team cannot determine whether the patient lost consciousness following the injury due to a lack of information or the patient's condition at the time of assessment; essentially, it indicates a head injury with a potential brain bleed where the level of consciousness is not definitively known) and Epilepsy (A group of disorders marked by problems in the normal functioning of the brain. These problems can produce seizures, unusual body movements, a loss of consciousness or changes in consciousness, as well as mental problems or problems with the senses). Record review of CR # 97's Discharge MDS assessment dated [DATE] revealed the assessment was not transmitted to CMS. Record review of CR #97's Discharge Summary dated [DATE] read Note Text: Resident discharged home with his personal belongings. Discharge instructions and he verbalized understanding. Picked up by family member and resident ambulated on his own out of facility to personal car. An interview on [DATE] at 9:37 am with the MDS Coordinator she said that the Discharge MDS assessments for CR #96 and CR #97 should have been transmitted to CMS within 14 days and they were not. She said the facility uses the RAI Manual. She said there would be no harm to the resident, but the negative outcome would be that the facility would not be in compliance. She said the facility also has another staff member to help with MDS assessments when needed, the facility transmits assessments weekly, the MDS assessments that were not transmitted were missed. During an interview on [DATE] at 1:46 pm, with the Administrator she said that the expectation would be that the MDS assessments were transmitted based on policy. She said the negative outcome would be that the facility would not be in compliance with the regulations. An interview on [DATE] at 9:27 am with RN W, she said she has completed and transmitted CMS assessments at other facilities and has been placed to assist with assessments currently but has never had to assist because they prior MDS Coordinator and the current MDS Coordinator have never needed her assistance. She said that the RAI Manual was used as the facility policy for assessments. Record review of the CMS's RAI Version 3.0 Manual, Chapter 5: Submission and Correction of The MDS Assessment revised ,d+[DATE] revealed:5.1 Transmitting MDS data- All Medicare and/or Medicaid-certified nursing facilities or agents of those facilities must transmit required MDS data records to CMS. 5.2 Timeliness Criteria- completion timing. For all other comprehensive MDS assessments, Annual assessment updates. the completion may be no later than 14 days from the ARD. Upon a resident's entry, discharge to community, discharge to another facility or discharge deceased , a subset of items but be completed within 7 days of the Event Date.

Based on observation and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 3 (shared medication cart between Hall 100 and 400, 200 and 300 ) of 6 medication carts reviewed for medication storage. - The facility failed to ensure the 200,300, shared 100 and 400 hall medication carts did not contain eyedrops, ointment, and nasal spray that were opened but not labeled with the resident's name and not dated. This failure could place residents at risk of adverse medication reactions and infections. Findings Include: During observation on 02/19/25 at 2:50 PM, the following medications were found in the medication carts for 200 hall with LVN AA: Serevent Diskus (Salmeterol Xinafoate inhalation powder) open and not dated Trelegy Ellipta 200 mcg inhalation power open and not dated Nystatin & Triamcinolone Acetonide 60gms open and not dated Diclofenac Sodium topical gel 1% (NSAID) arthritis pain reliever open and not dated Interview with LVN AA on 2/19/25 at 2:50 PM, LVN AA asked the surveyor if she could date the medication because she was not sure when it was open. She said the reason for dating the medications was for the medication not to be used after 30 days for it to be effective. During observation on 02/19/25 at 3:05 PM, the following medications were found in the medication carts for 300 hall with LVN BB: Refresh Optive Mega -3 with 4 vials open and not dated Refresh Optive Mega -3 with 2 vials open and not dated Refresh Optive Mega -3 with 2 vials open and not dated Interview with LVN BB on 2/19/25 at 3:05 PM, LVN BB said she checks the medication cart for 300 halls daily for expired medications. LVN BB said eyedrops when medication open should be dated, to help the nurses know when to discard it after 30 days. During observation on 02/19/25 at 3:30 PM, the following medications were found in the medication carts shared between 100 and 400 hall with MA A. 1. Fluticasone USP 50 mcg nasal spray open and not dated 2. Fluticasone USP 50 mcg nasal spray open and not dated 3. Fluticasone USP 50 mcg nasal spray open and not dated 4. Fluticasone USP 50 mcg nasal spray open and not dated 5. Fluticasone USP 50 mcg nasal spray open and not dated 6. Fluticasone USP 50 mcg nasal spray open and not dated 7 Fluticasone USP 50 mcg nasal spray open and not dated 8. Fluticasone USP 50 mcg nasal spray open and not dated 9. Fluticasone USP 50 mcg nasal spray open and not dated 10. Allergy Nasal Spray open and not dated 11. Refresh Plus lubricant eye-30 single vial Interview with MA A on 02/19/25 at 3:30PM regarding medication not dated she said the resident gets it in the morning and not dating could cause harm to the resident because it will not be effective and she would showing the medication to the DON. In an interview with DON 2/19/25 at 4:00 PM, she said was not sure if they were supposed to labeled above medications when opened and the pharmacist was in the facility on 2/18/25 and said everything was fine. DON said they were going to look into their policy. Record review of the facility policy of storage of medications revised April 2007 :Policy Statement : The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and implementation did not address the labelling and dating of medications when opened. According to the United [NAME] health trust, recommendations were that drops and ointments are used within one month (https://www.ghc.nhs.uk/wp-content/uploads/CHST-Expiry-Dates-of-Medication.pdf).

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #31) reviewed for incontinent care. The facility failed to ensure CNA C did not place foley bag on Resident #31's bed during foley care. The facility failed to ensure CNA C properly cleaned Resident #31during incontinent care. This failure could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Record review of Resident #31's sheet dated 02/19/25 revealed a [AGE] year-old female was initially admitted to the facility on ,d+[DATE]//21 and readmitted on [DATE]. Resident #31 had diagnoses included: chronic kidney disease (a condition where kidneys are damaged and cannot filter blood properly), diabetes mellitus (body do not produce enough insulin or use it properly) and heart failure (heart cannot pump enough blood to meet the body's needs). Record review of Resident #31's Quarterly MDS assessment dated [DATE] revealed Resident BIMS was 09 which indicated moderately impaired cognition. Resident #31 required extensive assistance with ADL with one staff assistant. Further review revealed the resident was incontinent of bowel and she had an indwelling catheter. Record review of Resident # 31's care plan initiated on 12/20/23 revealed Resident #31 had Indwelling Catheter dx: neurogenic bladder Interventions: Position catheter bag and tubing below the level of the bladder. Check for incontinence during rounds, wash, rinse, dry perineum and change clothing PRN after incontinence episodes. Record review of Resident #31's order summary report for February 2025 read in part . FC: Foley catheter 16 FR 10 cc bulb to bedside drainage, diagnosis: neurogenic bladder ordered date 02/27/24 . During an observation on 01/18/25 at 9:54 a.m., CNA C placed Resident #31's Foley bag on the bed while she provided incontinence and Foley care for Resident #31. The IP was in Resident #31's room, and she observed the care with the surveyor. Resident #31's foley bag was on the bed from 9:54 a.m. to 10:10 a.m. until the IP told CNA C to put the foley bag down below Resident # 31's bladder. CNA C wiped Resident #31's peri area during the incontinent and foley care. Still, she did not separate the labia (fleshy folds of skin that make up the external female genitalia), and she also did not separate the buttocks when she cleaned the bowel movement. When CNA C wiped the foley catheter French towards the body, instead of wiping away from the body, she did not anchor the foley French close to the insertion site to prevent the foley French from pulling when she cleaned the catheter French. The IP asked CNA C if she had finished cleaning Resident #31 and she said yes. Then the IP asked CNA C to separate Resident #31 buttocks and clean it again. When CNA C separated Resident #31's buttocks, she cleaned in between the buttocks and the anal three times, and there was bowel movement on the wipes. Then CNA C separated Resident #31's labia, revealing the area was red. When CNA C wiped the inside of the labia area, Resident #31 shouted, OUCH, and there was bowel movement and a tinge of red streaks when she wiped Resident #31 three more times. During an interview on 02/18/25 at 1:03 p.m., CNA C said she left the Foley bag on top of the bed when she provided Foley and incontinent care for Resident #31 until the IP told her to place the bag below Resident #31 bladder, and she hung the foley bag on the rail of the bed. CNA C said she had in-service on Foley care and was told to have the Foley bag below the bladder so the urine would flow down. CAN C said she placed the bag on the bed, which was on the same level as the bladder and the urine would flow back and could cause infection (UTI) for Resident #31. During an interview on 02/18/25 at 1:03 p.m., CNA C said she should have separated Resident #31 labia and buttocks to clean Resident #31 properly. CNA C said when the IP told her to clean Resident #31, she did it three more times, and there was a bowel movement on the wipes. She said if she did not clean Resident #31 well, she could have all kinds of infections. CNA C did not state what types of infection. CNA C said she had an in-service on Foley care and incontinent care, and the trainer said to use soap and water and clean the area until it is clean. During an interview on 02/19/25 at 8:13 a.m., the IP Said CNA C should not have placed the foley bag on the bed because the urine would backflow into Resident #31, and it could cause infection such as UTI. The IP said the nursing staff was responsible for ensuring the Foley bag was placed below the bladder. The IP said CNA C should have separated the labia and cleaned the area and the buttocks properly. The IP said when she asked CNA C to clean the buttocks and peri area after she said she was done cleaning Resident #31. The IP said CNA C cleaned out bowel movement residue both from the peri area and the rectum three more times, and the wipes had bowel movements. During an interview on 02/19/25 at 10::08 a.m., LVN S said CNA C should place Resident #31 foley bag at the foot of the bed or on the rail below the resident's bladder for the urine to flow through gravity. LVN S said the urine would flow back into Resident #31 bladder because CNA C placed the Foley on the bed at the same level as the bladder, and it could cause infection (UTI). During an interview on 02/19/25 at 10:36 a.m., the DON said she expected CNA C to follow facility protocol on Foley care, and the IP would train CNA C before she started working on the floor, and she was trained. The DON said the Foley bag should not be above or at the same bladder level. The DON said the IP educated the aides not to put the Foley bag on the bed because the urine would flow back to the resident, and it would cause UTI. The DON said the staffing coordinator, the IP, and herself monitored the nurse during rounding, and the nurse monitored the aides. The DON said if CNA C did not separate the labia area and if she did not appropriately clean, Resident #31 could get an infection. The DON said CNA C should anchor the tubing clean in a circular motion and wipe away from the resident, not towards the resident, to prevent UTI. During an interview on 02/19/25 at 3:03 p.m., the Administrator said CNA C should not have placed the foley bag on the same level of the bladder because the urine would flow back into Resident #31 bladder and Resident #31 could have an infection. The Administrator said CNA C should clean Resident #31's peri and rectum areas properly to prevent infection and skin breakdown. Record review of the facility's policy on Peri Care dated 2001 MED - PASS, Inc. Revised October 2010 read in part . the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition .steps in the procedure #9b(1) separate labia and wash area downward from front to back . note: if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area .

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 5 residents (Resident #31) reviewed for ADLs. The facility failed to ensure Resident #31was provided personal grooming (facial hair on the chin and under the chin) by facility staff. This failure could place residents at risk for not receiving the assistance needed for daily care and services Findings included: Record review of Resident #31's sheet dated 02/19/25 revealed a [AGE] year-old female was initially admitted to the facility on ,d+[DATE]//21 and readmitted on [DATE]. Resident #31 had diagnoses included: chronic kidney disease (a condition where kidneys are damaged and cannot filter blood properly), diabetes mellitus (body do not produce enough insulin or use it properly) and heart failure (heart cannot pump enough blood to meet the body's needs). Record review of Resident #31's Quarterly MDS assessment dated [DATE] revealed Resident BIMS was 09 which indicated moderately impaired cognition. Resident #31 required extensive assistance with ADL with one staff assistant. Further review revealed the resident was incontinent of bowel and she had an indwelling catheter. Record review of Resident # 31's care plan revision on 11/20/24 revealed Resident #31 had ADL self-care performance deficit related to confusion, and impaired balance. Interventions: personal hygiene read the resident requires assistance of 1 staff participation with personal hygiene and oral care. During an observation on 02/18/25 at 9:50 a.m., Resident #31 had a facial hair on and under on her chin, and under her chain was black and white hair. During an interview on 02/18/25 at 9:50 a.m., Resident #31 said she wanted her facial hair shaved, and she had told the aides to shave her, but the aides did not, and she could not remember the aide's names. During an interview on 02/18/24 at 12:58 p.m., CNA C said she saw Resident #31 had facial hair on her chin and under her chin but did not shave Resident #31 because her shower days were during the evening shift. CNA C said the aides are responsible for shaving Resident #31, and she should be shaved on shower days and as needed. CNA C said Resident #31 shower days are on Tuesday, Thursday, and Saturday during the evening shift. CNA C said if Resident #31 wanted to be shaved and she was not shaved, Resident #31 may feel bad. CNA C said she had skills, such as check-off and in-service on ADL, which included shaving. CNA C said her training included asking the resident if the resident needed shaving whenever the resident had facial hair, and CNA C did not respond when she was asked why she did not ask Resident #31 if she needed to be shaved. CNA C said the nurses monitored the aide when the nurse made rounds. During an interview on 02/19/25 at 8:04 a.m., the IP said Resident #31 showers are scheduled three times a week and are on Tuesday, Thursday, and Saturday. The IP said Resident #31 should be shaved by the aide on shower days and as needed. The IP said Resident #31 should not have to ask to be shaved because it was part of the ADL care. The IP stated that unless the resident did not wish to be shaved, it was part of Resident #31's right to refuse care. The IP said Resident #31 would not feel very good because ladies want to look nice. The IP said the aides were responsible for shaving Resident #31, and the charge nurses monitored the aides. The IP said the nurse managers monitored the nurses during rounding. The IP said the aides had skills -check off, but she was unsure if it included shaving. The IP said the aides should check off on the POC if the aide shaved a resident. During an observation on 02/19/25 at 9:00 a.m., Resident #31 still had facial hair on her chin and under her chain. Resident #31 said she was not showered by the aide yesterday, and she thinks the aide showered two days ago, but the aide did not shave her. Resident #31 said CNA E did not ask if she needed to be shaved today. During an interview on 02/19/25 at 10::11 a.m., LVN S said when he made rounds yesterday (02/18/25) and today (2/19/25), he did not notice any facial on Resident #31chin. LVN S said the aides are supposed to shave Resident #31 on shower days and PRN. LVN S said none of the aides had told him that Resident #31 refused to shave. LVN S said Resident #31 would be depressed because female residents do not want facial hair. LVN S said CNA E did not tell him today (02/19/25) that Resident #31 refused to shave. During an interview on 02/19/25 at 10:53 a.m., the DON said the aide should ask the resident if the resident needed shaving, and Resident #31 wanted her daughter to shave her. The DON said the facility had no documentation of Resident #31 refusing to be shaved or wanting her daughter to shave her. The DON said Resident #31 would feel bad if she wanted her facial hair shaved, but the staff did not. The DON said she had never heard Resident #31 refuse to shave. During an interview on 01/20/25 at 12:04 p.m., FM #1 said she did not tell the facility that Resident #31 preferred for her to pluk or shave her. FM #1 said she lives out of state, and she even told the facility for staff to pluck or shave Resident #31, and she would pay for the services. FM #1 said Resident #31 had not told her she wanted her to be the person to shave her. Record review of the facility policy on shaving dated 2001MED - PASS, Inc. Revised December 2007 read in part . the purpose of this procedure is to promote cleanliness and to provide skin care .

Based on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 of 3 residents reviewed with gastrostomy tubes. (g-tubes) (Resident #76) CNA F did not inform the nurse to turn off Resident #76's gastrostomy tube feeding prior to providing care. CNA F lowered the head of Resident #76's bed to a flat position for incontinent care while the g-tube feeding continued to infuse. This failure could place residents with g- tubes at risk for complications, aspiration, and pneumonia. Findings included: Record review of Resident #76's sheet dated 02/19/25 revealed a [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #76 had diagnoses included: PEG tube (a feeding tube placed into the stomach), diabetes mellitus (body do not produce enough insulin or use it properly) and hypertension (blood vessels have persistently raised pressure). Record review of Resident #76's Quarterly MDS assessment dated ,d+[DATE] revealed Resident BIMS was 06 which indicated severely impaired cognition. Resident #76 required extensive assistance with ADL with one staff assistant. Further review revealed the resident PEG tube. Record review of Resident # 76's care plan initiated on 06/24/24revealed Resident #76 had requires tube feeding related to dysphagia. Intervention: keep HOB elevated 45 degrees during and thirty minutes after tube feed. Observe side effects of feed intolerance/ aspiration: diarrhea, N/V, increased cough, Record review of Resident #76's physician for February 2025 read in part . GT: head of bed elevated at 30 to 45 degrees except to allow for ADL care ordered date 06/07/24 . GT: flush GT with H2O at 38 ML/HR for 22 hours VIA pump QD . GT: give Jevity 1.5 at 60CC/HR for 22 hours ordered date 01/08/25 . During an observation on 02/19/25 at 9:30 a.m., it was revealed Resident #76 was lying on the bed with the head of the bed flat while G tube feeding was infusing. CNA F continued to provide incontinent care, and when he finished giving care, he still left Resident #76 head of flat. During an observation and interview on 02/19/25 at 9:49 a.m., LVN S said he observed Resident #76's head of the bed was flat, and the feeding was running. LVN S said Resident # 76 feeding should not be running while CNA F was providing incontinent care. LVN S said the head of the bed should not be flat because of aspiration, and if Resident #76 starts to aspirate and the resident was not found on time, that could be fatal for Resident#76. LVN S said CNA F should have told the nurse he was about to provide incontinent care so the nurse would turn off the G tube. After CNA F had provided the incontinent care for Resident #76, CNA F would tell the nurse, and the nurse would come and turn the feeding pulp on and make sure Resident #76's head of the bed was not flat. LVN S said the head of the bed should be between 35 and 40 degrees. LVN S said the charge nurse monitored the aides, but he did not know how the aides missed calling him. LVN S said the unit managers monitored the nurses during rounding. During an interview on 02/19/25 at 11:01 a.m., the DON said Resident #76's feeding should be placed on hold by the nurse while CNA F provided care for the resident. The DON said the feeding should be on hold to prevent Resident #76 from vomiting and abdominal pain. The DON said the facility has a standing order and protocol for residents on G tube, which is that the head of the bed should be elevated while the feeding is running and pulsed during care so the head of the bed can be lowered. The DON said CNA F was trained to tell the nurse to come to turn off the plump and to turn it back on aftercare. During an interview on 02/19/25 at 1:02 p.m., CNA F said the feeding was not stopped when he provided care for Resident #76 because he forgot about it. CNA F said the head of the bed was down, and he did not know what could happen to Resident #76 with the head of the bed down while the feeding was going on. CNA F said he had training on how to work with a resident with a G tube, and he did not remember what could happen to Resident #76, and the nurse monitored the aides during rounding. Record review of the facility undated training for staff on handling patients with PEG tubes during ADL care read in part .important steps before starting ADL care: 1. if a CAN is caring for a resident with a peg tube, they must call the nurse to pause the feeding before starting activities of daily living. This is particularly important if the care involves position changes, turning the patient, . that could increase the risk of aspiration. Reasons to pause feeding during ADL care .1. aspiration risk . repositioning the patient while they are being fed can lead to reflux and increase the risk of aspiration . resume feeding only once the patient is returned to a safe, upright position .

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 21 (Resident #44) residents for dignity. -RT A pushed Resident #44 into the dining room with his catheter bag strapped onto his leg which had urine in it and was exposed with no privacy cover. This failure could put residents at risk of psychosocial distress from failure to protect their dignity. Findings included: Record review of Resident #44's face sheet last captured 02/20/2025 revealed a [AGE] year-old male originally admitted on [DATE] and most recently admitted on [DATE]. His medical diagnoses included cognitive communication deficit, muscle wasting and atrophy (decrease in muscle function), Type 2 Diabetes Mellitus, and Alzheimer's Disease. Record review of Resident #44's Quarterly MDS dated [DATE] revealed a BIMS (assessment for resident's cognition) score of 00, indicating severe cognitive impairment. Resident #44 required partial assistance with eating, oral hygiene and upper body dressing and required total assistance with toileting, showering or bathing self, lower body dressing and putting on and taking off footwear. Record review of Resident #44's care plan last revised on 02/06/2025 revealed Resident #44 was care-planned for attempts pulling the FC (foley catheter) tubing out secondary to poor decision making and will place foley bag on top of the bed even after being educated on having the bag needed to lower than bladder, with interventions including: monitoring behaviors and documenting number of episodes and reminding and educating resident on importance of keeping the foley catheter tubing locked. Observation on 02/18/2025 at 12:25pm, Resident #44 was wheeled into the dining room by RT A with the resident's exposed foley bag strapped to his left leg with some urine noted in the bag. Resident #44 was wearing shorts at the time. Interview with ADON on 02/18/2025 at 12:25pm, she said that the foley bag being exposed was an issue with dignity and that she would not want people to know she had one. She said she would not have brought Resident #44 to the dining room without covering up the bag or have the resident wear long pants, which is why the Activities Director brought out a blanket to cover his waist down. Interview with RT A on 02/20/2025 at 9:30am, he said that the catheter bag needed to be covered and having it exposed affects a resident's dignity and privacy. RT A said he was coming down the hall and saw Resident #44 was coming from the gym, and when RT A saw his catheter bag exposed, he asked a staff member why his catheter bag was not covered. RT A then saw another resident about to fall in the hall so RT A left Resident #44 near the door of the resident's room to assist the other resident. When RT A came back to Resident #44's room, Resident #44 pointed to the dining room, so RT A wheeled him there and forgot to check on if the catheter bag was covered. He stated being trained on resident privacy and dignity . Record review of the facility's policy on urinary leg draining bags last revised October 2010 read in part, General Guidelines .4. Maintain privacy of drainage bag under resident clothing.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #81) reviewed for respiratory therapy in that: The facility failed to ensure Resident #81's oxygen was set according to physician orders. This failure could place residents at risk of respiratory distress. The findings were: Record review of Resident #81's face sheet dated 02/19/25 revealed a [AGE] years- old female was admitted to the facility on [DATE]. Resident #66 had diagnoses included: cerebral infraction (brain injury occurs when blood flow to the brain is blocked), hypertension (when blood against the walls of arteries is consistently too high), heart failure (heart cannot pump enough blood to meet the body's needs) and aphasia(language disorder that affects communication). Record review of Resident #81 admission MDS assessment dated [DATE] revealed Resident #81 had a BIMS of 00 out of 15 indicated severely impaired cognition. further review revealed Resident #81 was on oxygen therapy. Record review of Resident #81 care plan dated 02/03//25 revealed Resident#81 had potential for respiratory distress related to CVA, HX of TIA, CHF on oxygen therapy. Intervention: give nebulizer treatment and oxygen therapy as ordered. oxygen settings: 02 via nasal cannula @ 3L continuously. Record review of Resident#81's physician's order dated February 2025 read in part . O2: O2 at 3L/minute via nc continuously every shift stated 01/31//25 . During an observation on 02/18/25 at 10:31 a.m., revealed Resident #81 oxygen concentrator was set on 3.5L During an observation on 02/18/25 at 10:32 a.m., CNA C said the setting on the oxygen concentrator was between 3 and 4 L. During an observation and interview on 02/18/25 at 10:37 a.m., LVN S said the setting on the oxygen was 3.5 L. LVN S said he did not know how many liters of oxygen Resident #81 should be on. LVN S Resident #81 was moved to this hall yesterday (02/17/24). During an interview on 02/19/25 at 7:56 a.m., the IP said if the doctor's order said 2 to 3 L, Resident #81's should be set according to the order. The IP said it should not be above the order because Resident #81 could have COPD, and it would not be safe for the resident because it could do more harm than good. The IP said the charge nurses are responsible for making sure the setting on the concentrator was set according to the order. The IP said the nurse managers also check the sets on the oxygen concentrator when they make rounds. The IP said the nurse managers monitored the nurses, and the nurses had skills checks off, and it included oxygen administration. During an interview on 02/19/25 at 10::03 a.m., LVN S said Resident #81 setting on the oxygen concentrator should be set at what the physician ordered. LVN S said he did not get a report from the outgoing nurse and did not know why the concentrator was set at 3. 5 L. LVN S said the resident would have some adverse effects, but he could not verbalize what effect. During an interview on 02/19/25 at 10:27 a.m., the DON said LVN S or any other nurse did not tell her Resident #81 was having any respiratory issues, and they increased the O2 setting on the concentrator. The DON said the facility follows the physician's order. The DON said if Resident #81 was given more oxygen than ordered, the CO2 would increase, and Resident #81 would be more confused than usual. The DON said the charge nurse on the floor was responsible for monitoring the oxygen setting. The DON said the unit managers and the DON monitor the nurses during rounding. She said the nurses had a skills check-off, which included oxygen administration before working with residents with oxygen. Oxygen policy as requested from the administrator and DON on 02/19/25 at 4:29 p.m., through email and the policy was not provided upon exit.

Based on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bowel received appropriate treatment and services to prevent urinary tract infections for 1of 7 residents (Resident #3) reviewed for incontinent care in that: -Resident #3 did not receive incontinent care that followed infection control protocols. CNA A did not follow acceptable hand-sanitizing practices during incontinent care for Resident #3. These failures placed residents requiring incontinent care at risk of infections with the potential for complications and hospitalization . Findings include: Record review of Resident #3's face sheet dated 06/06/2024 revealed a [AGE] year-old admitted to the facility on [DATE] with the following diagnoses: metabolic encephalopathy (neurological disorder resulting in an alteration in mental status), dysphagia (difficulty swallowing food or liquid), cognitive communication deficit, acute kidney failure, morbid obesity due to excess calories, hemiplegia affecting the left side (paralysis), atherosclerotic heart disease (lesions on the arteries in the heart), hyperlipidemia (high levels of fat in the blood), glaucoma, and hypertension (high blood pressure). Record review of Resident #3's MDS (a resident assessment tool) dated 05/20/2024 revealed a BIMS score of 10, indicating moderately impaired cognition. Further record review revealed that Resident A required extensive assistance with activities and was always incontinent, meaning the helper does more than half the task for toileting. There was no UTI within the last 30 days of completing the MDS. Record review of Resident #3's care plan dated 05/20/2024 revealed that she has bowel incontinence and impaired mobility. Interventions include placing the call light within reach and providing peri-care after each incontinent episode by washing, rinsing, drying perineum, and changing clothing as needed after incontinence episodes. Interview on 06/06/24 at 11:41 a.m. with Resident #3, she said the staff do change her when she was dirty, and she was changed about two hours ago and she was wet, and she needed to be changed again. Observation and interview on 06/06/24 at 11:54 a.m., CNA A provided care for Resident #3, the CNA cleaned the resident's vagina area. CNA A wore gloves but did not wear a gown prior to providing care. Resident A had a series of bowel movements (BM); the CNA wiped Resident #3 three times, and on the fourth time the wipe did not have any BM on it. There was still a thin line of feces on the incontinent brief and a golf-sized BM attached to the resident rectum. CNA A said the resident could not push the BM out by herself most of the time. She then wiped the resident's rectum 8 more times and each time she wiped more BM came out of Resident #3's rectum. CNA A said wiping the resident helps her to have a BM. After every wipe, CNA A would change her gloves. CNA A did not sanitize her hand in between any glove changes. Interview on 06/06/24 at 1:51 p.m. with CNA A, with CNA B and the DON present, CNA A stated she has been at the facility for 1 year and 5 months. CNA A said the precautions by the door said she was supposed to put on PPE when she went into the room. She said she totally forgot and state surveyors conducting observations caught her off guard. CNA A said she did not sanitize her hands when she changed her gloves sometimes because she did not have any sanitizer in the room. She said using hand sanitizer was a precaution for bacteria. CNA A said she wiped BM from Resident #3's vagina, and there was BM still in her rectum. CNA A said she just finished showering Resident #3, that that while Resident #3 was in the shower she had a big BM, so CNA A cleaned her vagina while Resident #3 was sitting on the shower chair. CNA A said there was a little smear of BM on the incontinent brief because Resident #3 could not push out the BM in one sitting. She said if the resident had BM in her vagina the resident could have infection. CNA A said she had skills check off and in-services on incontinent care for residents. She said the nurse monitors the aides. She said she had in-services on infection control, and it included hand washing, donning (putting on PPE) and doffing (removing PPE) and PPE. Interview on 06/06/24 at 2:18 p.m., with the DON, said she expected the staff to don on gown and gloves before they go into a resident's room for incontinent care. She said it was for protection from different microorganisms. The DON said if the staff did not don PPE, they could spread germs. The DON said, You heard what the aide said, that she forgot. The DON said CNA A should have donned her PPE before going into her room and should have sanitized her hands between glove change to reduce the spread of germs. The DON said she thinks the BM in Resident #3's vagina was left over from the shower because you could not clean the vagina area well with the resident sitting on the shower chair. She said the resident could get infection, UTI, and bacteria can build up. The DON said when she became disabled, she expected the staff to clean her well and that she expected the same level of care for the resident. Record review of CNA A's in-service on incontinent care checks and pericarp dated 01/14/2024 revealed it was signed by CNA A. Record review of the facility's Infection Control Policies and Practices document revised August 2007 revealed that the objectives of their infection control policies are to prevent, detect, investigate and control infections in the facility and establish guidelines for implementing Standard precautions and that all personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Record review of the facility's Handwashing/Hand Hygiene policy statement revised August 2015 revealed that all personnel are to use an alcohol-based hand rub for such situations including before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, blood or bodily fluids, after handling contaminated equipment and after removing gloves. Record review of the facility's Perineal Care document revised October 2010 revealed that required equipment and supplies for performing this procedure included soap (or other authorized cleansing agent) and personal protective equipment. It also stated that after removing gloves and discarding them into a designated container, the personnel should wash and dry their hands thoroughly.

Based on observation, interview, and record review, the facility failed to establish, and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Residents #3, #5 and #9) reviewed for infection control procedures in that: -CNA A did not use an alcohol-based sanitizer between changing gloves while providing incontinent care to Resident #3. -LVN A did not clean Resident #5's peri-wound (the area around a wound) before applying dressing during wound care. -LVN A did not remove his gown and gloves after leaving Resident B's room and came back in again and continued providing care to Resident #5. -LVN A did not remove his gown and gloves after leaving Resident #9's room and came back in again and continued providing care to Resident #9. These failures placed residents at risk of developing infections, communicable diseases and or hospitalization . Findings included: Record review of Resident #3's facesheet dated 06/06/2024 revealed a [AGE] year-old admitted to the facility on [DATE] with the following diagnoses: metabolic encephalopathy (neurological disorder resulting in an alteration in mental status), dysphagia (difficulty swallowing food or liquid), cognitive communication deficit, acute kidney failure, morbid obesity due to excess calories, hemiplegia affecting the left side (paralysis), atherosclerotic heart disease (lesions on the arteries in the heart), hyperlipidemia (high levels of fat in the blood), glaucoma, and hypertension (high blood pressure). Record review of Resident #3's quarterly MDS (a resident assessment tool) dated 05/20/2024 revealed a BIMS score of 10, indicating moderately impaired cognition. Further record review revealed that Resident A required extensive assistance with activities and was always incontinent, meaning the helper does more than half the task for toileting. There was no UTI within the last 30 days of completing the MDS. Record review of Resident #3's care plan dated 05/20/2024 revealed that she has bowel incontinence and impaired mobility. Interventions include placing the call light within reach and providing peri-care after each incontinent episode by washing, rinsing, drying perineum, and changing clothing as needed after incontinence episodes. Record review of Resident #5's facesheet dated 06/06/2024 revealed a [AGE] year-old originally admitted to the facility on [DATE]. Their medical diagnoses included: dementia, hyperlipidemia (high fat content in the blood), heart failure, peripheral vascular disease (accumulation of fat and cholesterol in the arteries), Anxiety Disorder, and hypertension (high blood pressure). Record review of Resident #5's quarterly MDS dated [DATE] revealed the BIMS was not completed because the resident is rarely or never understood. The Staff Assessment for Mental status revealed the resident is severely impaired and never or rarely makes their own decisions. Further review revealed that for toileting hyigene, Resident #5 is dependent, meaning the helper does all of the effort of this activity. Record review of Resident #5's care plan dated 05/15/2024 revealed that Resident #5 is incontinent of bowel and bladder with potential for skin breakdown, with interventions including checking skin daily, checking resident on rounds and change promptly. Resident #5 also has an ADL self care performance deficit due to dementia and impaired mobility, and requires extensive assist with 1-2 staff participating in toilet use care. Record review of Resident #9's facesheet dated 06/06/2024 revealed a [AGE] year-old originally admitted on [DATE]. Their medical diagnoses included: dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, acute kidney failure, Anxiety Disorder, Bipolar Disorder, Major Depressive Disorder, Hypothyroidism (decreased production of hormones from the thyroid gland), and Hypertension (high blood pressure). Record review of Resident #9's quarterly MDS dated [DATE] revealed a BIMS score of 6, which indicates severe cognitive impairment. Further review revealed that for toileting hyigene, Resident #9 is dependent, meaning the helper does all of the effort of this activity. Record review of Resident #9's care plan revised on 02/15/2024 revealed that Resident #9 has bladder incontinence and is at risk for pressure ulcers. Interventions include: checking the resident during rounds and as required for incontinence, washing, rinsing and drying perineum and changing clothing as needed after incontinence episodes. Observation of Resident #5's wound measurement on 06/06/24 on 9:24 a.m. revealed the measurement by the WCD (Wound Care Doctor) of the resident's wound at 1.0x1.0cm. The WCD said the wound was 100% granulating tissues. He told the aide to reposition this resident every 2 to 3 hours. Observation and interview of Resident #5's wound care procedure 06/06/24 at 9:30 a.m., revealed the wound care nurse LVN A had cleaned the wound bed and padded it dry, but he did not clean the peri-wound and was about to apply dressing when the surveyor intervened. LVN A said he cleaned the wound itself but did not clean the peri-wound. LVN A wore the gown and the gloves he provided care for the resident and left the resident room and went to the treatment cart without doffing to get supplies and then came back and continued providing incontinent care. He said he should not have worn his gloves and gown outside and came back in because they were contaminated. Observation on 06/06/24 at 9:34 a.m., Resident #9's wound was measured by the WCD at 1.03 x 0.9 x 0.2 cm. The WCD said the wound treatment could be discontinued if the area keeps improving. He told LVN A to keep turning the resident every 2 to 3 hours. LVN A performed care for the resident, and he went outside the resident's room again with his gown and gloves that he used to provide wound care for the resident. LVN A then re-entered Resident #9's room and continued to provide incontinent care with the same gloves and gown. Based on observation, interview, and record review, the facility failed to establish, and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Residents #3, #5 and #9) reviewed for infection control procedures in that: -CNA A did not use an alcohol-based sanitizer between changing gloves while providing incontinent care to Resident #3. -LVN A did not clean Resident #5's peri-wound (the area around a wound) before applying dressing during wound care. -LVN A did not remove his gown and gloves after leaving Resident B's room and came back in again and continued providing care to Resident #5. -LVN A did not remove his gown and gloves after leaving Resident #9's room and came back in again and continued providing care to Resident #9. These failures placed residents at risk of developing infections, communicable diseases and or hospitalization . Findings included: Record review of Resident #3's facesheet dated 06/06/2024 revealed a [AGE] year-old admitted to the facility on [DATE] with the following diagnoses: metabolic encephalopathy (neurological disorder resulting in an alteration in mental status), dysphagia (difficulty swallowing food or liquid), cognitive communication deficit, acute kidney failure, morbid obesity due to excess calories, hemiplegia affecting the left side (paralysis), atherosclerotic heart disease (lesions on the arteries in the heart), hyperlipidemia (high levels of fat in the blood), glaucoma, and hypertension (high blood pressure). Record review of Resident #3's quarterly MDS (a resident assessment tool) dated 05/20/2024 revealed a BIMS score of 10, indicating moderately impaired cognition. Further record review revealed that Resident A required extensive assistance with activities and was always incontinent, meaning the helper does more than half the task for toileting. There was no UTI within the last 30 days of completing the MDS. Record review of Resident #3's care plan dated 05/20/2024 revealed that she has bowel incontinence and impaired mobility. Interventions include placing the call light within reach and providing peri-care after each incontinent episode by washing, rinsing, drying perineum, and changing clothing as needed after incontinence episodes. Record review of Resident #5's facesheet dated 06/06/2024 revealed a [AGE] year-old originally admitted to the facility on [DATE]. Their medical diagnoses included: dementia, hyperlipidemia (high fat content in the blood), heart failure, peripheral vascular disease (accumulation of fat and cholesterol in the arteries), Anxiety Disorder, and hypertension (high blood pressure). Record review of Resident #5's quarterly MDS dated [DATE] revealed the BIMS was not completed because the resident is rarely or never understood. The Staff Assessment for Mental status revealed the resident is severely impaired and never or rarely makes their own decisions. Further review revealed that for toileting hyigene, Resident #5 is dependent, meaning the helper does all of the effort of this activity. Record review of Resident #5's care plan dated 05/15/2024 revealed that Resident #5 is incontinent of bowel and bladder with potential for skin breakdown, with interventions including checking skin daily, checking resident on rounds and change promptly. Resident #5 also has an ADL self care performance deficit due to dementia and impaired mobility, and requires extensive assist with 1-2 staff participating in toilet use care. Record review of Resident #9's facesheet dated 06/06/2024 revealed a [AGE] year-old originally admitted on [DATE]. Their medical diagnoses included: dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, acute kidney failure, Anxiety Disorder, Bipolar Disorder, Major Depressive Disorder, Hypothyroidism (decreased production of hormones from the thyroid gland), and Hypertension (high blood pressure). Record review of Resident #9's quarterly MDS dated [DATE] revealed a BIMS score of 6, which indicates severe cognitive impairment. Further review revealed that for toileting hyigene, Resident #9 is dependent, meaning the helper does all of the effort of this activity. Record review of Resident #9's care plan revised on 02/15/2024 revealed that Resident #9 has bladder incontinence and is at risk for pressure ulcers. Interventions include: checking the resident during rounds and as required for incontinence, washing, rinsing and drying perineum and changing clothing as needed after incontinence episodes. Observation of Resident #5's wound measurement on 06/06/24 on 9:24 a.m. revealed the measurement by the WCD (Wound Care Doctor) of the resident's wound at 1.0x1.0cm. The WCD said the wound was 100% granulating tissues. He told the aide to reposition this resident every 2 to 3 hours. Observation and interview of Resident #5's wound care procedure 06/06/24 at 9:30 a.m., revealed the wound care nurse LVN A had cleaned the wound bed and padded it dry, but he did not clean the peri-wound and was about to apply dressing when the surveyor intervened. LVN A said he cleaned the wound itself but did not clean the peri-wound. LVN A wore the gown and the gloves he provided care for the resident and left the resident room and went to the treatment cart without doffing to get supplies and then came back and continued providing incontinent care. He said he should not have worn his gloves and gown outside and came back in because they were contaminated. Observation on 06/06/24 at 9:34 a.m., Resident #9's wound was measured by the WCD at 1.03 x 0.9 x 0.2 cm. The WCD said the wound treatment could be discontinued if the area keeps improving. He told LVN A to keep turning the resident every 2 to 3 hours. LVN A performed care for the resident, and he went outside the resident's room again with his gown and gloves that he used to provide wound care for the resident. LVN A then re-entered Resident #9's room and continued to provide incontinent care with the same gloves and gown. Interview on 06/06/24 at 11:41 a.m. with Resident #3, she said the staff do change her when she was dirty, and she was changed about two hours ago and she was wet, and she needed to be changed again. Observation on 06/06/24 at 11:54 a.m., CNA A provided care for Resident #3, the CNA cleaned the resident's vagina area. CNA A wore gloves but did not wear a gown prior to providing care. Resident #3 had a series of bowel movements (BM); the CNA wiped Resident A three times, and on the fourth time the wipe did not have any BM on it. There was still a thin line of feces on the incontinent brief and a golf-sized BM attached to the resident's rectum. CNA A said the resident could not push the BM out by herself most of the time. She then wiped the resident's rectum 8 more times and each time she wiped more BM came out of Resident #3 ' s rectum. CNA A said wiping the resident helps her to have a BM. After every wipe, CNA A would change her gloves. CNA A did not sanitize her hand in between any glove changes. Interview on 06/06/24 at 1:51 p.m. with CNA A, with CNA B and the DON present, CNA A stated she has been at the facility for 1 year and 5 months. CNA A said the precautions by the door said she was supposed to put on PPE when she went into Resident #3's room. She said she totally forgot and state surveyors conducting observations caught her off guard. CNA A said she did not sanitize her hands when she changed her gloves sometimes because she did not have any sanitizer in the room. She said using hand sanitizer was a precaution for bacteria. CNA A said she had skills check off and in-services on incontinent care for residents. She said the nurse monitors the aides. She said she had in-services on infection control, and it included hand washing, donning (putting on PPE) and doffing (removing PPE) and PPE. Interview on 06/06/24 at 2:18 p.m., with the DON, the DON said CNA A should have should have sanitized her hands between glove change to reduce the spread of germs. She said the resident could get infection, UTI, and bacteria can build up. The DON said when she became disabled, she expected the staff to clean her well and that she expected the same level of care for the resident. Interview on 06/06/24 at 2:39 p.m., LVN A said, he was also the Wound Care Nurse. LVN A said he did not clean the peri-wound on Resident #5 and was about to apply the dressing when the surveyor intervened. He said it was important to clean the peri wound to keep the bacteria from entering the wound. He said the wound could get infected if the bacteria from the peri-wound entered the wound. He said he wore the PPE (gloves and gown) out the room and he should not have worn them outside because they were contaminated. He said the Infection Control Preventionist (ICP) and the DON monitored him during care to make sure he was providing the care appropriately. He said he had skills check off on wound care, and infection control which included hand washing and PPE. Interview on 06/06/2024 at 3:26pm with the Administrator, he said the staff would be retrained for the infection control issues which include donning and doffing of PPE. The administrator said the staff could make mistakes when they perform for somebody, but it was not an excuse. Interview on 06/06/2024 at 3:27pm with the DON, she said LVN A should have donned and doffed the PPE the right way after he had provided wound care for the residents. The DON said peri-wound should be cleaned properly. She said if the peri-wound was not cleaned the bacteria from the peri wound could get into the wound, new microorganisms and necrosis and that sort of thing could happen and the wound could get worse. She said the DON and the ICP makes random rounds and monitor the wound care nurse. Interview on 06/06/24 at 3:54 pa.m. with the ICP, she said the staff coordinator used to do the in-services on incontinent care, but that person no longer work for the facility. She said her expectation for her nursing staff was that for residents on Enhanced Barrier Precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) they don their PPE inside the resident's room by the doorway before they touch the resident; for residents isolation PPE has to be donned outside the room. She said the staff must doff inside the room before leaving the room. She said the staff should doff PPE in the room because it has been contaminated after staff provided care. Record review of the facility's Wound Care policy revised December 2011 revealed that this procedure requires PPE, including gowns, gloves, masks as needed. Personnel are to wear gloves when physically touching the wound or holding a moist surface over the wound and wash tissue around the wound with antiseptic or normal saline solution. Record review of the facility's Infection Control Policies and Practices document revised August 2007 revealed that the objectives of their infection control policies are to prevent, detect, investigate and control infections in the facility and establish guidelines for implementing Standard precautions and that all personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Record review of the facility's Handwashing/Hand Hygiene policy statement revised August 2015 revealed that all personnel are to use an alcohol-based hand rub for such situations including before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, blood or bodily fluids, after handling contaminated equipment, after removing gloves, and before and after entering isolation precaution settings. Interview on 06/06/24 at 1:51 p.m. with CNA A, with CNA B and the DON present, CNA A stated she has been at the facility for 1 year and 5 months. CNA A said the precautions by the door said she was supposed to put on PPE when she went into Resident #3's room. She said she totally forgot and state surveyors conducting observations caught her off guard. CNA A said she did not sanitize her hands when she changed her gloves sometimes because she did not have any sanitizer in the room. She said using hand sanitizer was a precaution for bacteria. CNA A said she had skills check off and in-services on incontinent care for residents. She said the nurse monitors the aides. She said she had in-services on infection control, and it included hand washing, donning (putting on PPE) and doffing (removing PPE) and PPE. Interview on 06/06/24 at 2:18 p.m., with the DON, the DON said CNA A should have should have sanitized her hands between glove change to reduce the spread of germs. She said the resident could get infection, UTI, and bacteria can build up. The DON said when she became disabled, she expected the staff to clean her well and that she expected the same level of care for the resident. Interview on 06/06/24 at 2:39 p.m., LVN A said, he was also the Wound Care Nurse. LVN A said he did not clean the peri-wound on Resident #5 and was about to apply the dressing when the surveyor intervened. He said it was important to clean the peri wound to keep the bacteria from entering the wound. He said the wound could get infected if the bacteria from the peri-wound entered the wound. He said he wore the PPE (gloves and gown) out the room and he should not have worn them outside because they were contaminated. He said the Infection Control Preventionist (ICP) and the DON monitored him during care to make sure he was providing the care appropriately. He said he had skills check off on wound care, and infection control which included hand washing and PPE. Interview on 06/06/2024 at 3:26pm with the Administrator, he said the staff would be retrained for the infection control issues which include donning and doffing of PPE. The administrator said the staff could make mistakes when they perform for somebody, but it was not an excuse. Interview on 06/06/2024 at 3:27pm with the DON, she said LVN A should have donned and doffed the PPE the right way after he had provided wound care for the residents. The DON said peri-wound should be cleaned properly. She said if the peri-wound was not cleaned the bacteria from the peri wound could get into the wound, new microorganisms and necrosis and that sort of thing could happen and the wound could get worse. She said the DON and the ICP makes random rounds and monitor the wound care nurse. Interview on 06/06/24 at 3:54 pa.m. with the ICP, she said the staff coordinator used to do the in-services on incontinent care, but that person no longer work for the facility. She said her expectation for her nursing staff was that for residents on Enhanced Barrier Precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) they don their PPE inside the resident's room by the doorway before they touch the resident; for residents isolation PPE has to be donned outside the room. She said the staff must doff inside the room before leaving the room. She said the staff should doff PPE in the room because it has been contaminated after staff provided care. Record review of the facility's Wound Care policy revised December 2011 revealed that this procedure requires PPE, including gowns, gloves, masks as needed. Personnel are to wear gloves when physically touching the wound or holding a moist surface over the wound and wash tissue around the wound with antiseptic or normal saline solution. Record review of the facility's Infection Control Policies and Practices document revised August 2007 revealed that the objectives of their infection control policies are to prevent, detect, investigate and control infections in the facility and establish guidelines for implementing Standard precautions and that all personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Record review of the facility's Handwashing/Hand Hygiene policy statement revised August 2015 revealed that all personnel are to use an alcohol-based hand rub for such situations including before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, blood or bodily fluids, after handling contaminated equipment, after removing gloves, and before and after entering isolation precaution settings.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 6 (Resident #2 and Resident #4) residents reviewed for environmental concerns in that: The facility failed to provide a safe, clean and sanitary restroom for Resident #2 on 01/31/24. The facility failed to provide a safe, clean and sanitary resident room for Resident #4 on 01/31/24. These failures place residents at risk of infection and safety hazards due to an unsafe, unsanitary and uncomfortable environment. Findings included: 1. Record review of Resident #2's face sheet dated 01/31/24, revealed she was an [AGE] year-old woman admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (necrotic tissue in the brain due to disrupted blood supply and restricted oxygen supply); and Essential Hypertension (abnormally high blood pressure that is not the result of a medical condition); Hyperlipidemia (above normal lipid {fat} levels in the blood, which includes triglycerides and cholesterol); and, Anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure). Record review of Resident #2's quarterly MDS dated [DATE], revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment. Resident #2 used a wheelchair and required moderate assistance for toileting hygiene; maximum assistance for toilet transfer; supervision for eating and oral hygiene; maximum assistance for dressing and personal hygiene; and frequently experienced bowel and bladder incontinence. Record review of Resident #2's care plan revealed, she had an ADL self-care performance deficit which required assistance for toilet use, toilet hygiene and toilet transfer; a history of hoarding and rummaging which required the resident's room to be checked daily; and was considered a moderate fall risk related to deconditioning, gait/balance, vision and hearing problems. Resident #2's care plan did not reveal a history of or interventions for the resident exhibiting behaviors related to toilet use or spreading the resident's own feces in her restroom or resident room. Record review of Resident #2's progress notes did not reveal any incidents of the resident exhibiting behaviors related to toilet use and spreading the resident's own feces in her restroom or resident room. In an observation of Resident #2's room on 01/31/24 at 10:18 AM, the following was revealed: the restroom had two small brown spots, that appeared to be feces, near the grab bar on the wall. The water in the commode was cloudy and full of feces remnants, while the rest of the bowl was covered in dried feces particles. A trash bag of soiled briefs was sitting on top of the trash can on the floor, between the right side of the sink and the toilet. Abed pan sat inside of a clear plastic drawstring bag hanging in between the left side of the sink and the wall. In an interview with Resident #2 on 01/31/24 at 10:18 AM, she said she could not remember how long she lived at the facility. She said she used the toilet in her restroom to urinate and defecate every day. She said she had to have help from staff to get from her wheelchair to the toilet, and from the toilet back into her wheelchair. She said she could not remember the last time she used the restroom, but she thought it was today. She said she also wore briefs because sometimes she could not make it to the toilet to urinate. She said she did not know if the soiled briefs in the trash bag were worn by her. She said she did not know who put the trash bag in her restroom or where it came from. She said staff came by to clean her room every day. She said she did not think they cleaned her room today, but if they did not, somebody would come and do it. She said they (facility staff) knew her toilet was messed up . She said maintenance already came to fix the toilet. She said they (facility staff) told her when she put too much stuff in the toilet, that was what would happen . She said they (facility staff) told her to use the bed pan to take the water out of the toilet when it started to back up and get high. She said her toilet was backed up right now, but they (facility staff) fixed it. She said the toilet backed up and was fixed before but did not know when. In an interview with the Central Supply Coordinator on 01/31/24 at 10:22 AMShe said housekeeping had not cleaned resident rooms on the 300 hall yet. She said all staff were responsible for reporting maintenance issues. She said staff could use the computers to submit information, or notify maintenance verbally face to face. She said housekeeping cleaned all resident rooms each day. She said if any staff saw a toilet soiled with feces and a trash bag of soiled briefs in a resident's restroom, the staff was responsible for verbally notifying housekeeping, then housekeeping would address the situation immediately. She said she would notify housekeeping of the condition of Resident #2's restroom and ensure the situation was addressed. 2. Record review of Resident #4's face sheet dated 01/31/24, revealed he was an [AGE] year-old man admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy (metabolic issues {low or high glucose levels, low or high sodium levels, low thiamine level, low oxygen, low blood flow, high carbon dioxide levels, overabundance of fluid around the brain, kidney dysfunction or liver dysfunction} that cause brain dysfunction); Type 2 Diabetes with Hyperglycemia (blood glucose levels greater than 180 mg/dL one to two hours after eating in insulin resistant bodies); Chronic Pulmonary Disease (persistent or recurring inflammatory lung disease that causes obstructed airflow from the lungs); Dementia with other Mood Disturbances (loss of memory, language, problem-solving, and other thinking abilities severe enough to interfere with daily life and includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition or sleep disturbances); and, Restlessness and Agitation (a sense of inner tension, irritability, fidgeting, finger tapping or other repetitive movements). Record review of Resident #4's quarterly MDS dated [DATE], revealed the resident's BIMS score was 3, which indicated severe cognitive impairment. Resident #4 used a wheelchair and walker; continuously exhibited disorganized thinking; impairments on the left and right side of his upper and lower extremities; required maximum assistance for toileting hygiene, bathing, dressing and personal hygiene; supervision for oral hygiene; and moderate assistance with eating. Record review of Resident #4's care plan revealed, he was a moderate fall risk related to confusion, hypotension, and impaired balance; had a goal to minimize/prevent the risk Septicemia related to an inability to control urination; was to be offered a bed pan as needed; received diuretic therapy; and bowel incontinence care during rounds as needed. Resident #4's care plan did not reveal a history of or interventions for the resident exhibiting behavior related to toilet use or urinating in the resident's room. Resident #4's progress notes did not reveal any incidents of the resident exhibiting behavior related to toilet use or urinating in the resident's room. In an interview with Resident #4 on 01/31/24 at 10:25 AM, he said he was okay and did not provide any further responses. In an observation of Resident #4's room on 01/31/24 at 10:28 AM, the following was revealed: the resident was in his restroom with the door closed. An area of the floor, approximately three feet long and 2 feet wide, beneath the residents bed was covered in dried dark urine . The rest of the room was free of clutter and clean. In an interview with the Central Supply Coordinator at 10:29 AM, she agreed the substance on the floor underneath Resident #4's bed was urine. She said she did not know if housekeeping had already cleaned rooms on the 100 hall. She said she would notify housekeeping Resident #4's room needed attention immediately . In an interview with the Administrator on 01/31/24 at 10:33 AM, he said he was not aware of any concerns regarding the cleanliness of resident rooms. He said he would check with the necessary staff to get more information about Resident #4's and #2's room and correct any issues. In an interview with the Administrator on 01/31/24 at 11:50 AM, he said he had been the administrator since 1/10/24. He said it was his expectation for staff to notify housekeeping and maintenance of emergency situations immediately, so they could be addressed as quickly as possible. He said the facility used an electronic system on all the tablets and computers accessible to all staff where they could log in and put in a work order for maintenance issues. He said if it was an emergency, the staff could also send a text message to the Maintenance Director. He said the housekeeping services were contracted out, but the Housekeeping Supervisor attended facility morning meetings and was very involved with what was happening in the facility. He said she also went behind housekeeping staff to observe and addressed any concerns with cleanliness in resident rooms. He said everyone needed to be more diligent about notifying the necessary staff to address situations like Resident #2's and Resident #4's. He said after addressing the incidents this morning, he was made aware Resident #2 and Resident #4 had similar incidents in the past. He said the facility would address the incidents by ensuring additional room checks and cleaning were implemented throughout each day for Resident #2 and Resident #4. In an interview with the DON on 01/31/24 at 12:01 PM, she said she has worked at the facility since 12/4/24. She said whatever microorganisms were present in the feces left behind in Resident #2's restroom could cause the resident to get an infection, or possibly e. coli (a group of bacteria that causes infections in the gastrointestinal tract, urinary tract and other parts of the body). She said Resident #4, or the staff might have been prone to a fall, due to the urine on the floor in Resident #4's room. She said if Resident #4 encountered the urine he would have been at risk of an infection, based on whatever microorganisms that may have been present in the urine at the time of contact. In an interview with the DON on 01/31/24 at 2:44 PM, she said she wanted to share that both Resident #2 and Resident #4 were care planned for exhibiting behavior related to toileting. She said Resident #4 often spread her feces in places like her restroom and in her bed. She said Resident #4 urinating in his bed was a constant thing because he was bladder incontinent. She said Resident #4 was supposed to have a bed pan on his bedside table as an intervention. Record review of the policy, revised 09/05/2017, titled, Bathroom Cleaning revealed the following: DRY Steps: 1. Pull trash. Wipe can and if necessary replace liner . WET Steps: .5. Sanitize commode, tank, bowl & base . 6. Spot Clean - Walls . Additional information: Proper cleaning prevents the spread of infection . Record review of the policy, revised 09/05/2017, titled, Daily Patient Room Cleaning revealed the following: .5. Damp mop floor with germicide solution . Every room to be cleaned is that resident's home - Treat it as such .

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 of 4 residents (Resident #87, Resident #27, and Resident #80) reviewed for incontinent care. - The facility failed to ensure Resident #87's privacy bag, foley bag and tubing were not placed on the floor. - The facility failed to ensure Resident # 27's privacy bag, foley bag and tubing were not touching the floor, and LVN O followed appropriate procedure and infection control during foley care for Resident #27. - The facility failed to ensure CNA J cleaned Resident #80 completely during incontinent care. These failures could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Resident #87 Record review of Resident #87's face sheet dated 12/21/23 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. Resident #87 had diagnoses which atrial fibrillation (irregular and often very rapid heart rate), benign prostatic hyperplasia(condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and hypertension(a condition which the blood vessels have persistently raised pressure) Record review of Resident #87's 5-day MDS assessment, dated 10/28/23 revealed: Resident #87 revealed BIMS of 03 indicated severely impaired cognation Resident #87's functional status revealed he required limited assistance with bed mobility, transfer, dressing, bath, and personal hygiene. Resident #87 was frequently incontinent of bowel and had foley. Record review of Resident 87's care plan initiated 11/17/23 revealed the resident had indwelling catheter Intervention: Change catheter as indicated, check tubing for kinks each shift. Record review of Resident #87's December 2023 order summary report read foley catheter 16 - FR - 10 cc bulb to bedside drainage, diagnosis: acute kidney failure active date 11/17/23. During observation and interview on 12/20/23 at 9:21 a.m., revealed that Resident #87's privacy bag was lying on the floor and that half of the foley and tubing were on the floor, too. Resident # 87 was not able to state why or how long the bag and tubing had been on the floor. During observation and interview on 12/20/23 at 9:22 a.m., the Treatment nurse said the privacy bag, foley bag, and tubing were on the floor. The treatment nurse picked up the privacy bag, placed the Foley bag back into the privacy bag, hung the bag on the bed frame, and walked out of the room. During an interview on 12/20/23 at 12:18 p.m., The treatment nurse said she should have changed the Foley bag and the privacy bag before she hung it back on the bed frame. She said the germs on the floor could have gotten on the bags and tube, and if the germ came into contact with Resident #87, he could have an infection. During an interview on 12/20/23 at 4:30 p.m., the Unit manager said Resident #87 foley bag and tubing should not be on the floor to prevent Resident #87 from getting UTI. The Unit manager said she monitors the nurse while the nurse monitors the aides to prevent the bags and tubing from touching the floor. During an interview on 12/21/23 at 2:36 p.m., the ADON said Resident #87 Foley should be hung on the side of the bed by the nursing staff, and when in W/C, the aides should hang the Foley bag on the side of the W/C. The ADON said it was inappropriate for the Foley bag, tubing, and privacy bag to be on the floor. The ADON said the treatment nurse should have changed the Foley bag, tubing, and privacy bag to prevent the germs from traveling into Resident #87's bladder and causing a UTI. The ADON said the clinical staff should monitor residents with Foley. Resident #27 Record review of Resident #27's face sheet dated 12/21/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #27 had diagnoses which included neuromuscular dysfunction of bladder (lack of bladder control due to a brain, spinal cord or nerve problem), diabetes mellitus(disorder in which the body does not produce enough or respond to normally to insulin) and hypertension(a condition which the blood vessels have persistently raised pressure) Record review of Resident #27's quarterly MDS assessment, dated 12/09/23 revealed: Resident #27 revealed BIMS of 13 indicated intact cognation Resident #27's functional status revealed she required limited assistance with bed mobility, transfer, dressing, bath, and personal hygiene. Resident #1 was incontinent of bowel and had foley. Record review of Resident 27's care plan initiated 09/29/23 revealed the resident had indwelling catheter related to obstructive uropathy. Intervention: change catheter as ordered, position catheter bag and tubing below the level of the bladder. Record review of Resident 27's Licensed Nurse MAR dated for December 2023 read Foley catheter 16 FR 10 CC bulb to bedside drainage, diagnosis: urine retention start date 09/28/23. During an observation and interview on 12/20/23 at 12:02 p.m., revealed Resident #27's Foley bag, privacy bag, and tubing were touching the floor. Resident #27 said CNA J came and lowered her bed about an hour ago, and maybe that was when her Foley touched the floor. Resident #27 said she could not see the Foley touching the floor. During an observation and interview on 12/20/23 at 12:03 p.m., LVN O said she observed Resident #27's Foley privacy bag, Foley bag, and Foley tubing were touching the floor. LVN O elevated the bed, which prevented the Foley from touching the floor. LVN O said the bags and tubing had been contaminated, and the germs could go up to Resident #27's bladder, and she could have a UTI. LVN O said she should have disinfected the privacy bag and tubing or changed the Foley bag. During an interview on 12/20/23 at 12:11 a.m., CNA J said she did not know Resident #27's Foley bag, privacy bag, and tubing were touching the floor. CNA J said it was an infection control issue because the foley bags and tube had been contaminated, and Resident #27 could get an infection. CNA J said she had a skills check-off on Foley care. CNA J said the nurse monitored the aides when the nurse made random rounds. During an interview on 12/20/23 at 12:25 p.m., LVN O said she said she should have disinfected the privacy bag and tubing or changed the Foley bag for Resident #27 to prevent the spread of germs from the floor instead of elevation the bed with the contaminated Foley bags and tubing. LVN O said she had in-service and a skills check-off on working with a resident with Foley. During an observation on 12/20/23 at 2:05 p.m., LVN O and the Unit Manager provided Foley care for Resident #27. LVN O placed the Foley bag on the bed between Resident #27's legs for 10 minutes while LVN O provided Foley care for Resident #27. During an interview on 12/21/23 at 2:31 p.m., LVN O said she placed the Foley bag on the bed while she provided Foley care for Resident #27. LVN G said it was infection control issue because the urine would flow back into Resident #27's bladder, and the resident could get an infection. LVN O said she had a skills check-off for a resident who had a Foley. LVN O said the IP would monitor the nurses when she made random rounds. During an interview on 12/20/23 at 4:16 p.m., the Unit manager said LVN O placed the foley bag on Resident #27's bed during foley care, and she did not say anything to her because she thought she could not tell to put the foley below the bladder. The unit manager said the urine in the bag and tubing was going back to Resident #27 bladder, and it could cause UTI for Resident # 27. The Unit manager said she would be the person who monitored the nurses for Foley care, and she had not observed LVN O while she provided Foley care until today. Resident #80 Record review of Resident #80's face sheet dated 12/21/23 revealed a [AGE] year-old female admitted to the facility on [DATE].Resident #80 had diagnoses which included morbid obesity (weight is more than 80 to 100 pounds above ideal weight), anxiety disorder (an emotion characterized thoughts and physical changes), and hypertension (a condition which the blood vessels have persistently raised pressure) Record review of Resident #80's quarterly MDS assessment, dated 11/23/23 revealed: Resident #80 revealed BIMS of 13 indicated intact cognation Resident #80's functional status revealed she required extensive assistance with two staff assistance for bed mobility, transfer, dressing, bath, and personal hygiene. Resident #80 was incontinent of bladder and bowel. Record review of Resident 80's care plan initiated 09/06/23 revealed the resident was incontinent of bowel and bladder. Intervention: Check for incontinence during rounds; wash, rinse, dry perineum and change clothing PRN (as needed) after incontinence episodes. During an observation of incontinent care on 12/21/23 at 11:01 a.m. revealed CNA J did not separate Resident # 80's labia when she provided incontinent care. During an interview on 12/21/23 at 12:08 p.m., CNA J said she did not separate Resident #80's labia during incontinent care. CNA J said if the labia were not separated and cleaned correctly, the area could have some germs, which could cause Resident #80 to develop UTI. CNA J said she had a skills check-off, which included peri care, and the floor nurse monitored the aides when the nurse made random rounds. During an interview on 12/21/23 at 2:54 p.m., the ADON said CNA J should have separated Resident #80's labia and cleaned properly (first cleaned left, right, and in the middle) to prevent infection, which could cause UTI for Resident #80. The ADON said CNA J should have had skills - check off before she started working on the floor. During an interview on 12/21/23 at 3:23 p.m., the DON said CNA J should have separated Resident #80's labia and cleaned left, right, and then in the middle. The DON said Resident #80 labia was not cleaned properly. The DON said it could harbor bacteria and cause infection for Resident #80. Record review of the facility policy dated 2001 MED-PASS, Inc. (Revised October 2010) 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 . steps of the procedure #9b (1) . Separate labia and wash area downward from front to back . Record review of the facility policy dated 2001 MED-PASS, Inc. (Revised September 2014) read in part . The purpose of this procedure is to prevent catheter-associated urinary tract infections . maintaining unobstructed urine flow . 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview and record review, facility failed to ensure residents received treatment and care in accordance with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for three (CR #1, Resident #2, and Resident #3) of three residents reviewed for treatment of pressure ulcer. The facility failed to ensure CR #1, Resident #2, and Resident #3, received treatment and care in accordance with professional standards of practice, The facility failed to provide daily wound care for CR #1, Resident #2, and Resident #3, resulting in re-infection of wounds, hospitalization , and amputation of CR #1's right foot. Wounds were getting infected and some of the pressure ulcers increased in size and not improving. The facility failed to follow physician orders and treat pressure wounds daily for CR#1 Residents #2 and Resident #3, for multiple days. The facility failed to document wound care provided to CR #1, Resident #2, and Resident #3 on multiple days. The facility failed to provide wound care training for nurses who were responsible to provide wound care. An Immediate Jeopardy (IJ) was identified on 09/15/2023 While the IJ was removed on 09/18/2023 at 2:52pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficiencies could expose residents who received wound care at the facility to low quality of care, wound deterioration, worsening of condition, infection, sepsis, and hospitalization . Findings include CR #1 Review of face sheet revealed CR #1 was a [AGE] years old woman who was initially admitted to the facility on [DATE], current admission was on 05/23/2023. Her diagnoses include type 2 diabetes, metabolic encephalopathy, anemia, sepsis, acute pyelonephritis, cognitive communication impairment, and neuromuscular dysfunction. Review of MDS dated [DATE] sections M0100 and M0300 revealed CR #1 had stage 4 pressure ulcers. Review of care plan dated 7/20/2023 revealed resident (CR #1) had stage 4 pressure wounds with potential for further skin breakdown related to limited mobility. The goal, according to the care plan, was to ensure the pressure injury will show signs of healing and remain free from infection. The intervention was to Administer treatment as ordered and monitor for effectiveness. Assist resident with turning and repositioning during rounds. Review of Admission assessment on 05/23/2023 revealed resident had sacrum wound however, there was no detail assessment of the wound documented. Record review of wound care orders revealed the following: - 05/23/2023 Stage 4 pressure wound sacrum full thickness: everyday shift Treatment order: Cleanse wound to sacrum with ns, pat dry and apply medi honey/alginate calcium and cover with dry dressing. - 06/15/2023: Unstageable due to necrosis of right heel: everyday shift Treatment order: Cleanse w/ NS, pat dry, apply betadine to eschar on rt heel. Review of Treatment Administration Record (TAR) revealed there were no documentation of wound care provided for CR #1 on the following dates: 5/8/23, 5/13/23, 5/15/23, 5/16/23, 05/25/23, 06/02/23, 06/23/23, 06/26/23, 06/27/23, 06/28/23, 06/29/23, 7/8/23, 7/11/23, 7/15/23, 7/17/23, 7/22/23, 7/23/23, 7/30/23, 08/21/23, 08/25/23. Further review of Treatment Administration Record revealed that wound care were not provided daily according to the physician's orders. Review of Weekly Skin assessment dated [DATE] revealed: - Left heel pressure wound unstageable measuring 2.5cm x 2.5cm x 0.05cm. - Right heel pressure wound unstageable measuring 5cm x 8cm x 0.05cm. - Sacrum pressure wound unstageable measuring 7cm x 7cm x 0.3cm Review of Weekly Skin assessment dated [DATE] revealed: - Right heel pressure wound stage 4 measuring 5cm x 6.5cm x 0.05cm. - Sacrum pressure wound unstageable measuring 10cm x 12cm x 0.2cm Further review of the Weekly Skin Assessments revealed the assessment conducted by the facility did not include descriptions of the pressure ulcers such as drainage, odor or general look of the pressure ulcer. Review of Wound Care Doctor's note dated 08/29/2023 revealed: - Stage 4 pressure wound of the right heel full thickness. Wound Size (L x W x D): 5.0cm x 6.5cm x 0.5cm. Surface Area: 32.50 cm^2. Exudate: Moderate Serous. Thick adherent black necrotic tissue (eschar): 80 %. Slough: 20 %. Wound progress: Not Improved. Primary Dressing(s):Hypochlorous acid solution (vashe) apply once daily for 30 days: Moisten gauze with Vashe and place over wound, followed by ABD, kerlix and tape. - Stage 4 Pressure wound sacrum full thickness: Objective Control Infection, Healing Wound Size (L x W x D): 10 x 11 x 0.2 cm. Surface Area: 110.00 cm^2. Cluster Wound open ulceration area of 88.00 cm^2. Exudate: Moderate Serous. Thick adherent black necrotic tissue (eschar): 70 %. Other viable tissues: 10 % (Dermis, SubQ). Skin: 20 %. Wound progress: Improved evidenced by decreased surface area Primary Dressing(s):Leptospermum honey apply once daily for 23 days: Use either the medi-honey gauze, or honey with calcium alginate.; Alginate calcium apply once daily for 23 days Review of Wound Care Doctor's note dated 08/22/2023 revealed: - Stage 4 pressure wound of the right heel full thickness: Objective Control Infection Wound Size (L x W x D): 5.0 x 6.5 x 0.05 cm. Surface Area: 32.50 cm^2. Exudate: Moderate Serous. Thick adherent black necrotic tissue (eschar): 100 %. Wound progress: Not Improved. Primary Dressing(s): Leptospermum honey apply once daily for 30 days; Alginate calcium apply once daily for 30 days - Stage 4 pressure wound sacrum full thickness: Objective Control Infection, Healing Wound Size (L x W x D): 10 x 12 x 0.2 cm. Surface Area: 120.00 cm^2. Cluster Wound open ulceration area of 96.00 cm^2. Exudate: Moderate Serous. Thick adherent black necrotic tissue (eschar): 70 %. Other viable tissues: 10 % (Dermis, SubQ). Skin: 20 % Wound progress: Not Improved. Primary Dressing(s): Leptospermum honey apply once daily for 30 days: Use either the medi-honey gauze, or honey with calcium alginate.; Alginate calcium apply once daily for 30 days Review of Wound Care Doctor's note dated 08/15/2023 revealed: - Unstageable (due to necrosis) of the right heel full thickness: Objective Control Infection Wound Size (L x W x D): 5.0 x 6.5 x 0.05 cm. Surface Area: 32.50 cm^2. Exudate: None Thick adherent black necrotic tissue (eschar): 100 %. Wound progress: Not Improved Primary Dressing(s): Betadine apply once daily for 9 days: Apply Betadine to dry eschar, cover wound. Review of Wound Care Doctor's note dated 08/08/2023 revealed: - Unstageable (due to necrosis) of the right heel full thickness: Objective Control Infection Wound Size (L x W x D): 5 x 6 x 0.05 cm. Surface Area: 30.00 cm^2. Exudate: None Thick adherent black necrotic tissue (eschar): 100 %. Wound progress: Not Improved Primary Dressing(s): Betadine apply once daily for 16 days: Apply Betadine to dry eschar, cover wound. Review of Wound Care Doctor's note dated 07/25/2023 revealed: - Unstageable (due to necrosis) of the right heel full thickness: Objective Control Infection Wound Size (L x W x D): 5 x 6 x 0.05 cm. Surface Area: 30.00 cm^2. Exudate: None Thick adherent black necrotic tissue (eschar): 100 %. Wound progress: Not Improved Primary Dressing(s): Betadine apply once daily for 30 days: Apply Betadine to dry eschar, cover wound. Review of Wound Care Doctor's note dated 07/18/2023 revealed: - Unstageable (due to necrosis) of the right heel full thickness: Objective Control Infection Wound Size (L x W x D): 5 x 6 x 0.05 cm. Surface Area: 30.00 cm^2. Exudate: None Thick adherent black necrotic tissue (eschar): 100 %. Wound progress: Not Improved Primary Dressing(s): Betadine apply once daily for 9 days: Apply Betadine to dry eschar, cover wound. Record review of CR #1's blood sugar in the month of August 2023 was between 87 mg/dL to 476 mg/dL. Review of progress note dated 09/01/2023 documented by Nurse I revealed CR #1 was sent to the hospital on 09/01/2023 for change in condition. CR #1 was back to the facility same day. On 09/02/23 CR #1 was sent to the hospital again for change in condition. Progress note revealed resident (CR #1) to be clammy and pale in color vs obtained at 76/54-102-95.6-20-90% on room air. Resident with labored breathing, 911 was called to transport to hospital RP was notified of transport, on call NP notified of residents condition. Order obtained to send out to ER. Review of hospital record during CR #1's hospitalization starting on 9/02/2023 revealed: - Admission diagnoses: Septic Shock, UTI, osteomyelitis of right calcaneus, - On 09/06/2023 Pre-procedure diagnosis: Right foot infection with osteomyelitis. Unstageable sacral and left gluteal decubitus. - Procedure Performed: Right below knee amputation. Excisional sharp debridement of sacral and left gluteus. - Findings: decubitus 14cm x 30cm x 1.5cm On 09/07/2023 at 3:08pm in an interview with the ADON who stated CR #1 was sent to the hospital because CR #1's hemoglobin level was low. She stated CR #1 was on antibiotic for infection and they were doing follow-up lab on her. The ADON stated when they did the lab, they discovered CR #1's hemoglobin was low, and they sent her to the hospital. The ADON was shown the TARs with the missed days of wound care, the ADON stated oh! My . she said she would find out what happened. On 09/19/2023 at 9:53am in an interview with the Wound Care Doctor, she stated she always saw all the residents with wounds every week. She said everything was going on well with CR #1 until August 29, 2023. She stated she evaluated CR #1's wound during wound care rounding on August 29th, and she noticed the wound on resident's right foot was not looking good and she cultured it. The Wound Care Doctor stated the result came back with infection according to how she suspected it. She stated the result came back with: Isolate (Aerobic, result 1): Proteus mirabilis isolated moderate ESBL on 08/31/2023. Isolate (Aerobic, result 2): Light growth Klebsiella pneumoniae isolated on 09/01/23. The Wound Care Doctor also stated the CR #1's pressure ulcer at the sacrum was not as big as it was in the hospital. On 09/08/2023 at 9:55am Surveyor observed CR #1 at the hospital the Family member, she stated the last time she changed her, the sore at the bottom was little. She stated recently, about two to three weeks ago (did not remember date) when she helped to turn the resident while still at the facility, she found the sore at the bottom was so big and she asked what happened. She said the DON was in a meeting and the other lady (she did not know name) she spoke with stated she should not worry that they would take care of her. Resident #2 Review of face sheet revealed Resident #2 was a [AGE] years old male who was initially admitted to the facility on [DATE]. His current admission was on 03/08/2023 with diagnoses of quadriplegia, neuromuscular dysfunction of bladder, type 2 diabetes, osteomyelitis, pressure ulcer, essential primary hypertension, and anemia. Review of MDS dated [DATE] section M0100 and section M0300 revealed Resident #2 had stage 4 pressure ulcers. Review of care plan dated 06/14/2023 revealed Resident #2 had multiple pressure injuries with intervention to administer treatments as ordered and monitor for effectiveness. Record review of physician order for wound care revealed: - 03/16/2023 Stage 4 pressure wound Sacrum full thickness: everyday shift Treatment order: cleanse sacrum wound with normal saline, pat dry, apply anasept, apply calcium alginate to wound bed, cover with dry dressing. - 05/26/2023: Stage 4 pressure wound Left Ischium: cleanse wound with normal saline pat dry apply anasept/calcium alginate and cover with dressing daily - 03/16/2023: Stage 4 pressure wound Right ischium: everyday shift Treatment order: cleanse with normal saline/ wound cleanser, pat dry, apply anasept to alginate calcium, cover with dry dressing Resident #2's Wound Care Doctor's note revealed the Following: 08/29/2023 - Stage 4 pressure wound sacrum full thickness: Objective Control Infection, Manage Exudate Wound Size (L x W x D): 8.2 x 7.0 x 1.0 cm. Surface Area: 57.40 cm^2. Exudate: Moderate Serous. Slough: 80 %. Granulation tissue: 20 %. Wound progress: Not Improved Primary Dressing(s): Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days 08/22/2023 - Stage 4 pressure wound sacrum full thickness: Objective Control Infection, Manage Exudate. Wound Size (L x W x D): 7.0 x 7.5 x 0.5 cm. Surface Area: 52.50 cm^2 Exudate: Moderate Serous. Slough: 20 %. Granulation tissue: 80 %. Wound progress: Not Improved. Primary Dressing(s): Alginate calcium apply once daily for 9 days; Sodium hypochlorite gel (anasept) apply once daily for 16 days 08/15/2023 - Stage 4 pressure wound right heel full thickness: Objective Control Infection, Manage Exudate. Wound Size (L x W x D): 4.0 x 3.5 x 0.2 cm. Surface Area: 14.00 cm^2. Cluster Wound open ulceration area of 11.20 cm^2. Exudate: Moderate Serous. Slough: 20 % Granulation tissue: 30 %. Other viable tissues: 30 % (Muscle, Fascia, Tendon, SubQ). Skin: 20 %. Wound progress: Not Improved. Primary Dressing(s): Alginate calcium apply once daily for 16 days; Sodium hypochlorite gel (anasept) apply once daily for 23 days: Apply Anasept to subcutaneous tissue portion of the wound - Stage 4 pressure wound sacrum full thickness: Objective Control Infection, Manage Exudate. Wound Size (L x W x D): 7.0 x 7.2 x 0.5 cm. Surface Area: 50.40 cm^2. Exudate: Moderate Serous. Granulation tissue: 80 %. Other viable tissues: 20 % (Fascia, Muscle). Wound progress: Not Improved Primary Dressing(s): Alginate calcium apply once daily for 16 days; Sodium hypochlorite gel (anasept) apply once daily for 23 days - Stage 4 pressure wound of the right ischium full thickness: Objective Control Infection, Manage Exudate Wound Size (L x W x D): 7.5 x 3.0 x 1.1 cm. Surface Area: 22.50 cm^2. Exudate: Moderate Serous. Granulation tissue: 70 %. Other viable tissues: 30 % (Muscle). Wound progress: Not Improved Primary Dressing(s): Sodium hypochlorite gel (anasept) apply once daily for 23 days; Alginate calcium apply once daily for 23 days - Stage 4 pressure wound of the left ischium full thickness: Objective Control Infection, Manage Exudate. Wound Size (L x W x D): 4.5 x 2.5 x 0.2 cm. Surface Area: 11.25 cm^2 Periwound radius: Maceration. Exudate: Moderate Serous. Granulation tissue: 80 % Other viable tissues: 20 % (Muscle, Fascia, SubQ). Wound progress: Not Improved Primary Dressing(s): Alginate calcium apply once daily for 23 days; Sodium hypochlorite gel (anasept) apply once daily for 23 days: Apply Anasept to calcium alginate and place over wound Review of Treatment Administration Record revealed there was no documentation of wound care provided to Resident #2 on the following days: 04/08/23, 04/09/23, 04/11/23, 04/16/23, 04/23/23, 04/29/23, 04/30/23, 05/13/23, 05/15/23, 05/16/23, 05/18/23, 05/25/23, 06/09/23, 06/15/23, 06/21/23, 06/22/23, 06/28/23, 07/05/23, 07/07/23, 07/11/23, 07/17/23, 07/21/23, 07/22/23, 07/24/23, 08/21/23. Further review of Treatment Administration Record revealed that wound care were not provided daily according to the physician's orders. Review of progress notes revealed no documentation of wound care performed or attempts made to perform wound care for Resident #2 on the dates listed above. Review of Resident #2's census revealed Resident #2 was in-house from 03/08/2023 till the time of this investigation. Review of Physician note dated 05/11/2023 revealed Multiple open wounds .Wound culture pending. Preliminary report shows Mixed gram negative and gram-positive cocci isolated. Sensitivity report pending. Review of Physician note dated 05/17/2023 revealed Resident #2's wound culture to right buttock on 5/12/23 grew streptococcus and MRSA and Acinetobacter. Review of Physician note dated 08/31/2023 revealed the result of wound culture done on 08/30/23 showed heavy E.coli isolated ESBL. On 09/08/2023 at 5:12pm during observation and interview of Resident #2 in his room, he stated his wound got infected. He said he did not know how the wound was doing if it was getting better or not. He stated, well, I get wound care most of the time. On 09/17/2023 at 7:58am attempt to observe wound care to be performed on Resident #2, he declined to let Surveyor observe his wound, he said he was not comfortable with someone observing his wound. Resident #3 Review of face sheet revealed Resident #3 was initially admitted to the facility on [DATE] with diagnoses of type 2 diabetes, pressure ulcer, cerebral infarction,. atherosclerosis, hemiplegia and hemiparesis, hypertension. Resident #3's current admission was 05/22/2023 with new diagnoses of osteomyelitis of vertebral sacral region. Review of MDS dated [DATE] section M0100 through section M0300 revealed Resident #3 had pressure ulcers. Review of care plan dated 08/02/2023 revealed Resident #3 had pressure injuries to sacrum, left hip and right hip, with intervention to administer treatments as ordered and monitor for effectiveness. Review of Treatment Administration Record revealed there were no wound care provided for Resident #3 for the following days: 08/25/23, 7/2/23, 7/5/23, 7/6/23, 7/7/23, 7/9/23, 7/10/23, 7/11/23, 7/17/23, 7/21/23, 7/22/23, 7/24/23, 7/31/23, 06/08/23, 06/21/23, 06/22/23, 06/23/23, 06/26/23, 06/28/23. Further review of Treatment Administration Record revealed that wound care were not provided daily according to the physician's orders. Review of the Wound Care Doctor's note revealed the following: 08/29/2023 - Stage 4 pressure wound of the right hip full thickness: Objective Control Infection, Healing Wound Size (L x W x D): 2.0 x 2.5 x 0.7 cm. Surface Area: 5.00 cm^2. Exudate: Moderate Serous. Slough: 10 %. Granulation tissue: 80 %. Other viable tissues: 10 % (Muscle) Wound progress: Not Improved. Primary Dressing(s): Alginate calcium apply once daily for 30 days; Leptospermum honey apply once daily for 23 days 08/22/2023 - Stage 4 pressure Left hip full thickness: Objective Control Infection. Wound Size (L x W x D): 0.6 x 0.5 x 2.0 cm. Surface Area: 0.30 cm^2. Periwound radius: Mild erythema. Undermining: 4 cm. at 6 o'clock. Exudate: Moderate Serous. Other viable tissues: 100 % (Muscle, Fascia, SubQ). Wound progress: Not Improved Primary Dressing(s): Gauze packing strips (plain) 1/2 apply once daily for 30 days: Moisten with Vashe and pack into the wound.; Hypochlorous acid solution (vashe) apply once daily for 30 days. 08/15/2023 - Stage 4 pressure wound sacrum full thickness: Objective Control Infection. ound Size (L x W x D): 4.4 x 2.5 x 0.5 cm. Surface Area: 11.00 cm^2. Exudate: Moderate Serous. Slough: 10 %. Granulation tissue: 80 %. Other viable tissues: 10 % (Fascia, Muscle). Wound progress: Not Improved. Primary Dressing(s): Alginate calcium apply once daily for 9 days; Leptospermum honey apply once daily for 9 days Secondary Dressing(s): Foam w/border (silicone-sacrum) apply once daily for 9 days Peri Wound Treatment: Zinc ointment apply once daily for 9 days - Stage 4 pressure wound of the right hip full thickness: Objective Control Infection, Healing Wound Size (L x W x D): 2.0 x 2.0 x 0.3 cm. Surface Area: 4.00 cm^2. Exudate: Moderate Serous. Slough: 10 %. Granulation tissue: 80 %. Other viable tissues: 10 % (Muscle) Wound progress: Not Improved. Primary Dressing(s): Alginate calcium apply once daily for 16 days; Leptospermum honey apply once daily for 9 days Secondary Dressing(s): Gauze island w/ bdr apply once daily for 30 days Peri Wound Treatment: Skin prep apply once daily for 30 days 08/08/2023 - Stage 4 pressure Left hip full thickness: Objective Control Infection. Wound Size (L x W x D): 0.6 x 0.5 x 2.0 cm. Surface Area: 0.30 cm^2. Undermining: 4 cm. at 6 o'clock. Exudate: Moderate Serous. Other viable tissues: 100 % (Muscle, Fascia, SubQ). Wound progress: Not Improved. Primary Dressing(s): Gauze packing strips (iodoform) 1/2 apply once daily for 23 days: Pack wound daily with 1/2 iodoform gauze and cover with a dry dressing. Secondary Dressing(s): Gauze island w/ bdr apply once daily for 9 days Peri Wound Treatment: Skin prep apply once daily for 9 days Review of progress note revealed Resident #3 was sent out to hospital on 05/14/23 for peg tube placement. Review of hospital note dated 05/19/23 revealed Resident #3 was diagnosed with sacral osteomyelitis during the hospitalization . Review of Resident #3's census revealed resident was sent to the hospital on 5/13/2023 and came back on the 5/22/2023 On 09/08/2023 at 12:38pm in an interview with the Wound Care Nurse who stated she was working at the facility helping out with everything she said she was currently filling-in the position of the wound care nurse since the beginning of September 2023. She stated the Former Wound Care Nurse quit at the end of August 2023. She said if the wound care nurse was not here the floor nurses wound do the wound care. She said she documented all the wound care on TAR for all the care she had been doing since she became the wound care nurse. The Wound Care Nurse stated she was not sure if the Former Wound Care Nurse forgot to document on those days that wound care were missing on the TAR. She stated she was sure they were doing wound care and the Wound Care Doctor was always making rounding every week. On 09/08/2023 at 1:09pm attempt to call the Former Wound Care Nurse was made for interview. There was no response, the line stated, the person you are trying to reach is not accepting any call at this time . There was no prompt to leave voice message, but text message was sent. On 09/19/2023 at 11:57am, another attempt made to contact the Former Wound Care Nurse, but the line was 'saying' the same thing the person you are trying to reach . On 09/08/2023 at 1:26pm in an interview with Nurse A, she said she had been working at the facility for two years, she said the facility had a wound care nurse. She said sometime if the wound care nurse was not in the building, it was the floor nurse that would be responsible for wound care. On 09/08/2023 at 1:33pm in an interview with Nurse B who was the assigned nurse for Residnet #3 on 100 hall on 06/08/23, 06/21/23, 06/22/23, 06/23/23, 7/6/23, 7/7/23, 7/10/23, and 08/25/23 when there were no documentation of wound care. She stated she could not tell why wound care was missed on those multiple days. She stated the treatment nurse was always in charge of wound care. She stated she had been working at the facility for four years, she did wound care sometimes in the past when the wound dressing came off and she documented in the TAR. She said there was always a wound care nurse in the building Monday to Friday, she stated if the wound care nurse was not in the building the nurses were to do wound care. On 09/08/2023 at 1:49pm in an interview with Nurse C, she stated she had been working at the facility for three weeks. She said she did not usually do wound care, because the facility had wound care nurse. She stated if the wound care nurse was not in the building the nurses would do the wound care. She said she did wound care only two times since she started working at the facility. She stated she had wound care training from her former job, but she never had any training or hands-on checklist at the facility. She stated they asked her if she knew how to do wound and she told them she could do wound care. On 09/08/2023 at 2:06pm in an interview with CNA B who stated she had been working at the facility for one month. She said they turn resident every two hours. She said she did not see or notice any outdated dressing on any resident. On 09/08/2023 at 2:11pm in an interview with Nurse D who had been working at the facility for three years. She said she did not usually do wound care, she stated only if the dressing came off. She said the Wound Care nurse was always at the facility doing wound care and the wound care nurse was responsible to do wound care at all times when the wound care nurse was in the building. She stated she did not know about how the wound care was missed on those, so she never had to do wound care. She said they turn resident every two hours; CNAs document the ADLs. She said they did train for her - said she watched video and they did check offs for her by the former DON. On 09/18/23 at 10:42am in an interview with Nurse L who had been working at the facility for about 8 years. He stated he had taken care of both CR #1 and Resident #2 in the past. He stated they have wound care nurse, but if there was no wound care nurse in the building, he said the nurses would do the wound care. He stated he sometimes he would do wound care for resident when the wound care nurse did not come to work. He stated they document in the elctronic system and that was where he documented his wound care. Surveyor asked about the days that he worked and there were no wound care documented on those days. He stated he was not aware of that and cannot say anything for it. He said when the wound care nurse was not in the building and he did wound, he always documented his wound care. He stated it is normally said if you don't document it is not done. On 09/08/2023 at 4:52pm in an interview with Nurse E who was working at the facility since 2020. She said she usually worked on 200 hall where Resident #2's room was located. She stated it was possible that she was working on those days (05/15/23, 05/16/23, 05/18/23, 05/25/23, 06/09/23, 06/15/23, 06/21/23, 06/22/23, 06/23/23, 06/28/23, 07/05/23, 07/06/23, 07/07/23, 07/11/23, 07/21/23, 07/24/23, 08/21/23) but she stated it had been a long time ago and she would not remember. She said if the wound care nurse was in the building, the wound care nurse wound do the wound and should document. She stated when she did PRN wound dressing change, if the dressing comes off or becomes saturated, she documented in the TAR. On 09/13/2023 at 4:02pm in an interview with the ADON about the wound care missing on multiple days. She stated, if you can't find it then I have no idea. The ADON stated the wound care nurse was responsible for the wound care and should document everything she did The ADON also said the DON was the supervisor over the wound care nurse to oversee what the nurses were doing. She said both the DON, the Administrator and the wound care nurse already quit, he said, they all quit at the same time. On 09/15/2023 at 10:43am surveyor called the Wound care Doctor but there was no response, message left on the voicemail. On 09/15/2023 at 10 45am Surveyor called the Attending Physician, the call went to voice message and there was no prompt to leave message. On 09/15/2023 at 10 48 am in an interview with the Nurse Practitioner who was working with the Attending Physician, he stated he worked with the Attending Physician and saw the residents (CR #1, Resident #2, and Resident #3) regularly. He stated they (Nurse practitioner and the Attending Doctor) consulted the wound specialist (Wound Care Doctor) to follow up with the treatment of the residents wound. He said they gave recommendations such as offloading, turning the resident every two hours, good nutrition/ hydration, and wound care order was also given by the wound care specialist. He stated it was up to the facility to make sure all these recommendations were being done. He stated he believed that the nurses were doing what the wound care Doctor recommended, he said the expectation was that the staffs at the facility followed the order. He stated, I am pretty sure that was done, but I am not there every single day He stated he was sure indication was given about the needed recommendation to care for the wound. He stated, if the order is there, the order will be followed up by the nursing staff, he stated, we gave the order. He said he had no idea that the wound care was not being done as no one told him that. Surveyor asked if the resident could be affected, if the wound could get worse if those recommendations (repositioning, offloading) and order for daily dressing change were not being followed. He stated, of course yes. He stated the recommendations were given so the residents wound did not get worse and if the recommendations were not followed the residents would be affected. Review of policy titled 'Charting and Documentation' dated July 2017 revealed, in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives . 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting Review of policy titled pressure Ulcers/Skin Breakdown dated March 2014 revealed, in part, 1. The nursing staff and Attending Physician will assess and document an individual's significant risk fac-tors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin This was determined to be an Immediate Jeopardy (IJ) on 09/15/2023 at 12:49pm. The Administrator, DON and Clinical Services Director were notified. They were provided with the IJ template and the plan of removal on 09/15/2023 at 12:49pm. The Plan of Removal was accepted on 09/16/2023 at 1:32pm The plan of removal reflected the following: Plan of Removal was F686 - Skin Integrity/Pressure Ulcer Impact Statement: On 9/7/23 an abbreviated survey was initiated at the Facility. On 9/15/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to follow physicians orders and document wound care on residents #1, #2, and #3. How were other residents at risk to be affected by this deficient practice identified? All residents residing in the facility have the potential to be affected by this alleged deficient practice. Facility nurse managers (ADON, Unit managers and Treatment nurse) initiated a skin audit on residents with skin concerns residing in the facility on 9/15/23. Skins audit results will be reviewed b [TRUNCATED]

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 20 residents (CR #1 (Closed Record)) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure CR #1 had adequate supervision to prevent an accident on [DATE] which resulted in a fall with major injury (left sub-capital femoral neck fracture that resulted to him having surgery) on [DATE]. CR #1 declined and passed away on [DATE] after being released back to the facility from the hospital. The Facility failed to implement interventions after each incident of fall for CR #1 on, [DATE], [DATE] and [DATE], An Immediate Jeopardy (IJ) was identified on [DATE] at 5:23 PM. While the IJ was removed on [DATE] at 4:53 PM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy, CR #1 sustained servious injury and passed away due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents who require assistance with ADLs and place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings included: Record review of CR #1 of face sheet revealed [AGE] year-old male, date of admission was [DATE] readmission on [DATE] died on [DATE] diagnosis included cerebrovascular disease ( a disease of the heart or blood vessels), contusion ( any collection of blood out a blood vessel) of eyeball and orbital tissues, unspecified eye, lack of coordination, muscle weakness ( Generalized), cognitive communication deficit, dysphagia( difficulty swallowing ), oral phase, altered mental status, dementia ( the loss of cognitive functioning, thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities) unspecified severity, without behavioral disturbance, psychotic ( when people lose some contact with reality) disturbance, mood disturbance and anxiety. Record review of CR #1's Quarterly MDS dated [DATE] revealed CR #1 had a BIMSs score of 3 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of CR #1's Comprehensive Care Plan revealed that although his fall risk was care planned, all goals and interventions were either created or revised on [DATE] which was well after several falls and occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The date initiated was on [DATE] and was revised on [DATE]. The resident passed away on [DATE]. Record review of CR #1's Comprehensive Care Plan revealed that he is a high risk for falls, related to balance problem, history falls, unaware of safety needs, vision problem, AEB Fall Risk and assessment score 19 meaning high risk. There were no fall risk interventions in place after his fall on [DATE]. The interventions have not been updated since [DATE]. Record review of CR #1's fall incident and accident report revealed on the following dates: [DATE]: Incident Location: CR #1's room: Resident slipped out of his wheelchair trying to get in the bathroom. [DATE]: Incident Location: CR #1's room: Resident lower himself to the floor from his wheelchair. He had a bowel movement and urinated on the floor. [DATE]: Incident Location: CR #1's room: Resident slipped to the floor while transferring to bed without assistance. [DATE]: Incident Location: CR #1's room: Resident ambulate without assistance. [DATE]: Incident Location: Activity room on 300 hall: CR #1 found on the floor. Record review of CR #1's care plan conference summary dated [DATE] addressed recent combative behavior towards other resident, falls related to cognitive decline. Recommendation for memory care unit due to recent behaviors and room safety. There were no outcome of the conference. The conference consists of the facility Administrator, DON, SW, ADON and RP, Ombudsman very via telephone. Record review of Progress Notes documented by LVN A revealed CR #1 fell at the facility at 2:00p.m. on [DATE] and the x-ray was completed between 4:00p.m.-5:00p.m. On [DATE], his x-ray results came back at 9:55p.m. CR #1 was transported to the hospital on [DATE] at 1:13 PM. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 5:18 PM entered by LVN A, read in part, . CNA called the nurse from the nurse's station to activity room. Nurse arrived and saw resident lying on his left side on the floor. Resident complained of pain on the left leg when the nurse asked the resident. Assessment was done, no skin tear noted, no bruise noted, resident was able to move all his extremities, the CNA and the nurse assisted resident back to the wheelchair. CR #1 stated he was attempting to transfer himself without help from wheelchair to regular chair. Resident was assisted to bathroom after the fall without difficulty, no abnormality noted to both lower limbs or no sign and symptoms of pain noted. Tylenol prn 325mg 2 tablet was given as prescribed .NP gave orders for X-ray of left hip, femur, knee, Tibia-fibula, ulna radius, shoulder, left forearm. DON notified; RP notified. Vitals blood Pressure ,d+[DATE], Respiration 18, Pulse 80, temperature.97.6, O2 sat 97%room. Neurological in place. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 10:00 PM entered by LVN B, read in part, . radiological labs received and seen at 9:59 PM. Examination: left hip, left femur, left knee, left tibia/fibula (shin), left shoulder, left humerus, left elbow, left forearm. results received and reported to the oncoming nurse. NP notified of results. No NP's name and no impression from the left hip X-Ray noted. There was no new order. Record review of CR #1's of nurse's progress note documented by LVN B revealed that a provider from Health Agency called for an update on the resident's X-ray. Provider notified of radiological lab results and impression of the left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. Record review of CR #1's Progress Notes dated [DATE] at 13:05 PM entered by LVN A read, Resident was picked by EMS via stretcher to be transferred to ER. Resident ate his lunch. Resident was calm and quiet. Paperwork was sent along with X-RAY results. RP and NP were notified of the transfer to ER. Record review on [DATE] of CR #1's neurological assessment checks dated [DATE] revealed it was done by LVNA at 1:59 PM. Interview with the DON (Director of Nurses) on [DATE] at 11:14 AM, said resident CR#1 expired on [DATE]. sShe said the resident fell on [DATE] in the activity room, it was witnessed by another resident in the activity room because the activity assistant was busy transporting residents and there was nobody in the activity room. The DON said the facility was remodeling the dining area where they always have activities. She stated that CR#1 was trying to transfer from the wheelchair to a chair when he fell , an X-ray was done, and the resident was sent to the hospital. The DON said LVN B did not notify the on call NP of the impressions on the X-Ray and there were no new orders on [DATE]. Interview with the Activity Director on [DATE] at 3:40PM, she said she had been working in the facility for 5 years and they usually use the dining room for activity or activity room at end of 300 hall. Activities always invite the residents for activity by assisting residents to the activity room and residents should not be left unattended. Interview with the LVN A on [DATE] at 12:41 PM, LVN A said she was called to the activity room on 300 hall by a CAN CNA (Unknown). LVN A said she saw CR #1 lying on left side on the floor, an assessment was completed for CR #1. The DON, NP and RP were notified. This incident occurred during change at 2:00 PM. LVN A said while assessing CR #1 he was lying on his left side on the floor. CR #1 was saying ouch, ouch. She then assisted CR #1 to the wheelchair then transport him to his room. The NP gave her an ordered for X-Ray at about 2:30 PM. LVN A said she was not around when X-ray was completed. LVN A said an x-ray was ordered and it was done on the 2p.m.-10p.m. shift. LVN A said CR #1 was totally dependent on staffs for transfer from wheelchair to bed and from bed to wheelchair and monitored closely by keeping high risk for fall LVN A did SBAR assessment and documented in the progress note on [DATE]. Interview with Activity Assistant B on [DATE] at 1:05 PM, he said he was transporting residents while CR #1 was in the activity room on the 300 halls with other residents. He said CR #1 fell and they found him on the floor. LVN A was already checking CR #1 and took him to the room. Activity Assistant B confirmed that CR #1 was not able to ambulate, CR #1 was propelled by staff in the wheelchair. Activity Assistant B said he was not sure how long CR #1 was on the floor, he said probably was left unsupervised for about 10 to 20 minutes, he was transporting other residents for activity. Interview on [DATE] at 10:30 AM with CNA A said she worked 6:00 AM to 2:00 PM, she used to assist CR #1 with everything. She said she would transfer him to the wheelchair and bed, assist with incontinent care. She said his balance was unsteady. She said CR#1 was cognitively impaired and was not able to verbalize needs. Interview on [DATE] at 10:41 AM, with CNA B said she works the 2:00 PM to 10:00 PM shift. When she came to work the next morning, she was told CR #1 got up from the wheelchair and fell in the activity room. CNA B said she had been working at the facility for a year. She said there are two CNAs on each hall. Interview on [DATE] at 12:10 PM the Administrator said he was told by staff that CR #1 had fallen in the activity room while Activity Assistant B was busy transporting residents for activities. The Administrator said CR #1 was left unattended with other residents. He said CR #1 had history of falls. Interview with CR #1's NP on [DATE] at 4:00 PM, she said she was off duty on [DATE] at 6:00 PM and she saw CR #1's faxed X-Ray result on [DATE] at about 11:00AM and that was why she called the facility to send him to the hospital. NP said on call person should have sent CR #1 out to the hospital. Interview on [DATE] at 2:12 PM with LVN B he said he worked 2:00 PM to 10:00 PM for 3 months and he worked with CR #1. LVN B said he got the report from LVN A about CR #1 ' s fall and the X-Ray technician came to the facility between 4:00PM and 5:00 PM and the result of the X-Ray came in at 9:55 PM. LVN B said he called the on call NP team at 9:55 PM, he spoke to a NP, but he was not sure which NP he spoke with and there were no new orders. He read all examination to left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. LVN B said he did not read the x-ray impressions to the on-call person. Interview with the DON (Director of Nurses) on [DATE] at 11:14 AM, she said LVN B did not notify on call NP of the impressions on the X-Ray and there were no new orders on [DATE] from the on call NP. DON said LVN B was a new nurse and she had a 1 on 1 in-service with LVN B. Record review of CR#1 X-Ray exams result dated [DATE] from the facility revealed: Left hip 2 views: History: AP and cross table lateral do not manipulate. Findings: Right hip hemiarthroplasty ( partial hip replacement). An impacted sub capital left femoral neck fracture is noted. No other fracture or dislocation. IMPRESSION: Acute impacted sub capital left femoral neck fracture Record review of CR #1 Hospital interpretation & Diagnostics: Lab results interpretation Result: Recent Impressions: Cat Scan- CT Pelvis W/O Contrast [DATE] Impression: Sub capital Left femoral neck fracture CR #1 sustained a left sub-capital femoral neck fracture upon admission to the hospital, on [DATE]. Interview with the LVN A on [DATE] at 2:40 PM, LVN A said she worked the 10:00 PM to 6:00 PM shift on [DATE] and LVN B told her about CR#1's X-Ray result and stated no order was given from the on-call NP. LVN A said she faxed X- Ray result to CR #1's regular NP at 11:00 PM on [DATE]. Interview on [DATE] at 12:01 PM with MDS Coordinator A, said she has been the MDS nurse at the facility for 3 months and was still learning/training with the cooperate nurses. She said she had been a nurse for just one year and she is responsible for doing the MDS assessments, LTC's, annually, quarterly, and the newly admitted . She got her information from the hospital records, therapist notes, CNA notes and wound care nurse notes. She said the nurses are responsible for acute care plans and care plan meetings. She said whatever triggers are from the MDS, they are added to the care plan. She said on [DATE], she said did not do the intervention process on the care plan because she does not create the care plans. She said the nurses and the DON are responsible for completing the fall risk assessments. Interview on [DATE] at 12:10 PM the Administrator said he was told by staff that CR #1 had fallen on [DATE], an X-ray was done and LVN B was not able to explain the impression on the X-ray result to the on call NP and this lead to delay in transferring CR #1 to the hospital. Interview on [DATE] at 3:52 PM, with RP, she said CR #1 had many falls, CR #1 did not fall in his room because he had camera in the room. RP said on [DATE] the nurse called her about CR #1 fall at 2:00 PM. On [DATE] the visiting NP found X-Ray on [DATE] and call RP that CR #1 was going to the hospital. RP said NP said the facility did not receive a death certificate for CR #1, she said CR #1 had declined after the surgical procedure. NP said CR #1 had dementia. Interview on [DATE] at 12:23p.m., with the ADON, she said the fall risk assessments are completed upon admission, quarterly or when a resident had a fall. She said admission and quarterly assessment were assigned to her for review. She said if a resident falls, she was supposed to assess the resident. She said if the resident can move, the nurse would put them back in the bed and notify the DON and their responsible party. She said the nurse will also take the resident's vitals. She said she knows a resident is a fall risk because they will have a yellow star at the foot of the bed. She said it will also be listed in the Kardex. She said the Kardex is in a binder on each station and in the PCC. She said when the nurse does an assessment for fall precautions, they determine what is care planned by meeting with the resident and the resident's family and they put the plans in place from there. She said if there is a fall at the facility, they take the post worksheets to the morning meetings. She said the DON puts the interventions in place with the nurse and address it with IDT team. Interview on [DATE] at 2:01p.m., with LVN D said if a resident falls on her watch, she will call for assistance, complete a pain assessment, and if there is a head injury, she will have the resident sent out to the hospital. She said she will also notify the family, complete a progress note and a fall risk assessment. She said a fall risk assessment is completed when a resident is discharged or quarterly and if they have a fall. She said you will update the resident's care plan if they have a new fall or if the current plan isn't working. She said you know a resident is a fall risk because they will have a yellow star by the door and wheelchair. Interview on [DATE] at 6:00 PM, with the DON, said if a resident has a fall, she will assess them to make sure there are no injuries, call the doctor, and call the family. Residents should not be left unattended while in activities. She said normally the nurse does the fall risk assessment, but lately she has been doing it. She said if there is a fall with a resident, she will review what happen, and will conduct a morning meeting to see what needs should to be implemented for the care of the resident. She said the policy said, once there is a fall, they must do something about it which is to adjust the care plan and implement interventions. She said everyone on duty has been trained since they called the immediate jeopardy on the facility. She said the 2pm-10pm needs more training, but first shift and night shift has been trained. She said she has been coming in to work on different shifts to train each employee. Interview on [DATE] at 6:30 PM with the DON said the resident was left unsupervised with the activity assistant. The activity assistant was transporting residents while CR #1 was alone in the activity room with other residents. She said the CR #1 fell and they found him on the floor. She said he complained of pain to the left hip and an x-ray was ordered by the morning nurse (LVN A) and who completed an assessment. She said that CR #1 was transported to the hospital and the family was notified. The DON said CR #1 was able to ambulate and able to make needs known and she in-services with LVN B on documenting the name of the medical personnel and on how to read X-ray results noting the impressions. Followed-up interview on [DATE] at 6:30 PM, with the DON and the Administrator, said the root cause was leaving CR #1 and other residents unattended and not calling x-ray results timely into the physician. She said she discussed the IDT fall in the morning meetings. Interview on [DATE] at 6:34 PM, with the Administrator, said when a resident has a fall, the DON will notify him, no matter the time. He said he will ask what happened and if the resident was able to explain what happened to them. He said he will have a stand-up meeting and stand-down meeting. He said he will have a case management meeting, where the falls are discussed. He said the Quality Specialists have assignments and everyone has a sheet of the fall risk/intervention assessments. He said he does not participate in creating the care plans. He said he is a part of the huddle meetings and goes over resident devices. Record Review of the facility's policy titled Fall and Post-Fall Management, undated, read in part, . Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for the resident as well as staff safety. Identify residents at risk for falls during ADL execution by resident individually or with staff assistance. Initiate preventative approaches. Provide appropriate strategies and interventions directed to resident, environmental factors, and staff. Provide learning opportunities. Monitor and evaluate resident outcome . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:23 PM. The Administrator, DON, Executive Director and Regional RN were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 5:23 PM. The following Plan of Removal was submitted and accepted on [DATE] at 4:53 PM. Plan of Removal [DATE] Submission #3 Immediate action: Other residents affected: CR #1 died on [DATE] On [DATE] an audit of Fall Risk Assessment was completed. Any resident who was identify as being at high risk for falls was falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. Facilities Plan to Ensure Compliance: What does the facility need to change immediately to keep residents safe and ensure it does not happen again? What corrective actions have been implemented for the identified residents? The following action items were implemented immediately on [DATE]. CR #1 died on [DATE]. On [DATE] an audit of Fall Risk Assessments was completed. Any resident who was identified as being at high risk for falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. 2. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? An in-service was initiated with licensed nurses on [DATE], by the Director of Nursing/designee, on implementing timely interventions post fall to include transfers to the hospital as indicated by the resident assessment. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed An in-service was initiated with licensed nurses on [DATE], by the DON/designee on immediately notifying the DON and/or Administrator of any falls with major injury such as a fracture. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed An in-service was initiated with licensed nurses on [DATE], by the DON/designee on neglect, to include falls with fractures. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed An in-service was initiated with licensed nurses on [DATE], by the DON/designee on reporting radiology results timely to the resident's nurse practitioner and/or physician when the results are received. The education included notifying the DON if the nurse practitioner and/or physician do not respond timely to the notifications. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in servicing is completed An in-service was initiated with direct care staff on [DATE], by the DON/designee on ensuring interventions are in place to prevent falls, including keeping a high-risk resident in an area that can be easily visualized by staff for safety when out of their room. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed An in-service was initiated with the Unit Managers, ADON, and MOS staff, by the DON on updating the care plan with new interventions timely after each fall. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in servicing is completed The Director of Nurses/designee will complete in-servicing on implementing timely interventions post fall, physician notification of radiology results, neglect and implementing timely fall interventions post fall, and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. The DON/designee will in-service new hires during orientation on resident neglect, fall prevention and timely notification of radiology results to the physician and/or Nurse practitioner. CSD, DON and/or designee will complete one on one education with activity assistant and activity director that all residents who are at high risk for falls are not left alone when out of bed in an area that is not visible to staff. J. Educated/In-serviced nursing staff to notify the DON if X-Ray services do not respond in a timely manner. Monitoring: The Administrator, DON, ADON and Rehab Director will conduct random weekly checks, on all shifts, on the high risk fall residents or any new admits implementing timely interventions post fall, physician notification of radiology results, neglect and implementing timely fall interventions post fall, and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. For the next 30 days the DON and ADON will monitor the nursing staff per week given to determine retention of knowledge the universal fall precaution protocol. The results of these audits will be reviewed in the Quality Assurance and Performance Improvement meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. The QAPI Committee will continue to monitor monthly to identify any trends or patterns and make recommendations to revise the plan of correction as indicated. Surveyor Monitored the plan of removal as follows: Observations were started on [DATE] at different times, 8:30 AM, 9:30 AM, 11:00 AM, 2:30 PM, 3:30 PM, 4:30 PM, 5:50 PM, [DATE], 8:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM and continued through [DATE], 11:00 AM, 1:30 PM, 2:30 PM, 3:00 PM, 11:30 PM, 12:30 PM. Observations were started on [DATE] and continued through [DATE]. Observation of Resident ((#2, #3, #4, #5, #6, #7, #8, #9, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed bedrooms were free of clutter and adaptive devices were available for residents at risk for falls. Interviews were conducted on [DATE], [DATE], [DATE] with 23 with staff across all three shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: Administrator, DON, ADON, MDS Coordinator A, CNA A, CNA B, CNA C, LVN A, LVN B, LVN C, LVNC, LVN D, LVN E, LVN F, LVN G, MA A, MA B, MA C,CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN H and LVN I. All staff interviewed verbalized adequate understanding of plan of remove removal training received including Universal Fall Precautions policy/procedures, Kardex system, and Fall Prevention Procedures. Record review of the facility POR Binder revealed: Staff were in-serviced on [DATE], [DATE], regarding Fall Interventions and Intervention for high - Risk Fall. Universal Fall Precautions policy/procedure. Timely interventions Post Falls. Reporting, incidents, Kardex system and Fall Prevention Procedures. Reporting Radiology Results Timely. Immediately notify DON and /or Administrator. Reporting Abuse and neglect, Neglect and Resident's Rights. Record review of QAPI sign-in sheet revealed the facility held a QAPI on [DATE] to discuss and implement corrective action for CR#1's fall. Record review of the following residents (#2, #3, #4, #5, #6, #7, #8, #9, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and CR #1) revealed Kardex Reports for residents at risk for falls had interventions in place to address falls. Record review of Kardex Binder revealed the facility had a binder at Nurse Station for halls #halls #1, #2, #3 and #4 Record review of the following residents (CR #1) #2, #3, #4, #5, #6, #7, #8, #9, #9, #10 and #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed no care plans for residents at risk for falls. During an interview on [DATE] at 1:59p.m. with Regional RN said, she believes the facility currently has an IJ because of the resident's history of falls. She said the resident did not need a 1 on1 supervision, but because he had so many falls, it was a concern. She said when the residents are participating in activities, instead of staff taking residents back and forth, they should call for other staff members to come and get them. She said she wanted to make sure there is a system in place to move the residents back and forth to the activities area and that is a common area where other staff can see them. During an interview on [DATE] at 2:32p.m. the Administrator said, he believes the facility is currently has an IJ because there was a resident that fell and sustained a major injury. He said he has made sure that everybody understands how important it is to supervise residents. He said a big part of the morning meetings and meeting with quality assurance, is to make sure high-risk residents are always monitored. He said if there is a change in the environment, staff should know those changes and adapt to those changes. He said it is hard to do your job if you do not understand how to do certain things. He said he knows how staff is interacting with the residents by monitoring, walking around and observing what is happening on the floor and educating them with in-service trainings. During an interview on [DATE] at 1:33p.m. ADON said, she doesn't know why the facility has an IJ. She said she knew the incident that happened with the resident and that he had a fall. She said she was not working the day the resident had the fall. She said she could improve her work by being thorough with her documentation. She said all staff need to always monitor the residents at the facility. She said the fall risk residents she be around the nurse's station so that someone can keep a close eye on the residents. She said things would have gone differently if she was present at work during the incident with the resident. She said would have put interventions in place and care planned the falls based on how the falls happened. She said some of the trainings for staff are ongoing. She said she had a broad view on how to care for the residents. She said the purpose of having in-service training is so that staff understands how to take care of the residents. She said things change and staff must continue to receive training to adapt to those changes. She said she knows that staff can do their job because she follows ups with them every day and she have has them to show her how to perform their job duties. During an interview on [DATE] at 1:42p.m. with RN, she RN she said the facility has an IJ because there was a resident with frequent falls, and they did not move to prevent him for falling and it resulted in his death. She said she learned that when they have a problem everyone has a problem. She said direct staff had a better idea for interventions that she does. She said she shared with the team that a resident had a fall. She said they went back and reviewed what was going on with the resident. She said for now on she is going to pay closer attention to the residents that are high risk for falls. She said the care plans will be closely directed to the resident. She said she will work closer with the activities director and document to show that the residents are being monitored. She said staff need to be educated and reeducated when things are ongoing regarding in-service. She said she would go back and ask questions to staff and have them to demonstrate on the computer what they are supposed to be doing to make sure they understand how to do their job properly. She said staff needs more training on how to create care plans. She said the care plans was not being done correctly since she has been at the facility. She said the care plans needs to be individualized. Record review of facility falls and fall risk, managing revised [DATE]: Policy Statement: Based on previous evaluations and current data, the staff will identify interviews related to the resident's specific risks and causes [TRUNCATED]

Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for 1 of 20 residents (CR #1) reviewed for neglect. - The facility failed to ensure CR #1 had adequate supervision to prevent an accident on [DATE] which resulted in a fall with major injury (left femur fracture) requiring surgery on [DATE]. CR #1 passed away on [DATE] after being released back to the facility from the hospital. The facility failed to read and notify the NP accurately of X-Ray results of CR #1's impression of left femur fracture. - The facility failed to update CR #1's care plan and put interventions in place after continued falls. The facility failed to adequately educate staff on caring for residents with high risk for fall. - An Immediate Jeopardy (IJ) was identified on [DATE] at 5:23 PM. While the IJ was removed on [DATE] at 4:53 PM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy, CR #1 sustained serious injury and passed away. These failures could placed residents at risk of neglect Findings included: Record review of CR #1's face sheet revealed an [AGE] year-old male, admitted on [DATE], readmitted on [DATE], and expired on [DATE]. CR #1 diagnoses included cerebrovascular disease ( a disease of the heart or blood vessels), contusion ( any collection of blood out a blood vessel) of eyeball and orbital tissues, unspecified eye, lack of coordination, muscle weakness ( Generalized), cognitive communication deficit, dysphagia (difficulty swallowing ), oral phase, altered mental status, dementia ( the loss of cognitive functioning, thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities) unspecified severity, without behavioral disturbance, psychotic (when people lose some contact with reality) disturbance, mood disturbance and anxiety. Record review of CR #1's Quarterly MDS dated [DATE] revealed CR #1 had a BIMSs score of 3 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of Progress Note dated [DATE], written by LVN A revealed CR #1 fell at the facility at 2:00 p.m. on [DATE] and the x-ray was completed between 4:00p.m.-5:00p.m. On [DATE], his x-ray results came back at 9:55p.m. CR #1 was transported to the hospital on [DATE] at 1:13 PM. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 17:18 PM (5:18 PM) entered by LVN A, read in part, . CNA called the nurse from the nurse's station to activity room. Nurse arrived and saw resident lying on his left side on the floor. Resident complained of pain on the left leg when the nurse asked the resident. Assessment was done, no skin tear noted, no bruise noted, resident was able to move all his extremities, the CNA and the nurse assisted resident back to the wheelchair. CR #1 stated he was attempting to transfer himself without help from wheelchair to regular chair. Resident was assisted to bathroom after the fall without difficulty, no abnormality noted to both lower limbs or no sign and symptoms of pain noted. Tylenol prn 325mg 2 tablet was given as prescribed .NP gave orders for X-ray of left hip, femur ( thigh bone), knee ( joint flexes that is used to kneel), Tibia -fibula (two long bones in the lower leg), ulna radius (one of two bones that make up the forearm), shoulder, left forearm. DON notified; RP notified. Vitals blood Pressure ,d+[DATE], Respiration 18, Pulse 80, temperature.97.6, O2 sat 97% room. Neurological in place. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 22:00 PM (10:00 PM) entered by LVN B, read in part, . radiological labs received and seen at 2159 (9:59 PM). Examination: left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus ( upper arm bone) left elbow, left forearm. results received and reported to the oncoming nurse. NP notified of results. No NP's name and no impression from the left hip X-Ray noted. Record review of CR #1's comprehensive care plan dated [DATE] revealed that although high fall risk was care planned, all goals and interventions were either created or revised on [DATE] after several falls which occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The date initiated was on [DATE].CR #1 care plan was not revised until [DATE]. CR #1 passed away on [DATE]. Further review of CR #1's interventions revealed comprehensive care plan dated [DATE] had not been updated since [DATE] that he is a high risk for falls, related to balance problem, history of falls, unaware of safety needs, vision problem, as evidence by Fall Risk and assessment score 19. There were no fall risk interventions in place after his fall on [DATE]. Record review of CR #1's fall incident and accident report revealed on the following dates: [DATE]: Incident Location: CR #1's room: Resident slipped out of his wheelchair trying to get in the bathroom. [DATE]: Incident Location: CR #1's room: Resident lower himself to the floor from his wheelchair. He had a bowel movement and urinated on the floor. [DATE]: Incident Location: CR #1's room: Resident slipped to the floor while transferring to bed without assistance. [DATE]: Incident Location: CR #1's room: Resident ambulate without assistance. [DATE]: Incident Location: Activity room on 300 hall: CR #1 found on the floor. Record review of CR #1's nurse's progress note documented by LVN A dated [DATE] at 11:00 AM written by revealed that a provider from private agency called for an update on the resident. Provider notified of radiological lab results and impression of the left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. Record review of CR #1's Progress Notes dated [DATE] at 13:05 PM (1:05 PM) entered by LVN A, indicated resident was picked by EMS via stretcher to be transferred to ER. Resident ate his lunch. Resident was calm and quiet. Paperwork was sent along with X-RAY results. RP and NP were notified of the transfer to ER. Interview with the DON on [DATE] at 11:14 AM, said CR#1 expired on [DATE], she said CR #1 fell on [DATE] in the activity room., it was not witnessed by another resident in the activity room because the activity assistant was busy transporting the resident to activity and there was nobody in the activity room. The DON said the facility was remodeling the dining area where they always have activities. She stated the resident was trying to transfer from the wheelchair to a chair when he fell , X-ray was done, and resident was sent to the hospital. The DON said the process of reporting X-ray report, was to call the on call doctor and notify. DON said the LVN B did not notify the on call NP of the impressions on the X-Ray and there were no new orders on [DATE]. Interview with Activity Director on [DATE] at 3:40 PM, she said she had been working in the facility for 5 years and they usually use the dining room for activities or activity room at end of 300 hall and always invite the residents for activity by assisting resident to activity room. Interview with the LVN A on [DATE] at 12:41 PM, LVN A said she was called to the activity room on 300 hall by a CNA, LVN A said she saw CR #1 lying on left side on the floor, CR #1 assessment was done. The DON, NP and RP was notified. This occurred at the change of shift at 2:00 PM, LVN A did not remember which CNA called her to CR #1's room. LVN A said while assessing CR #1 lying on his left side on the floor, CR #1 was saying ouch, ouch. She then assisted CR #1 to the wheelchair then transported him to his room. The NP gave her an order for an X-Ray at about 2:30 PM. LVN A said she was not around when the X-ray was done to CR #1. LVN A said an x-ray was ordered and it was done on 2p.m.-10 p.m. shift. LVN A said CR #1 was totally dependent on staff for transfer from wheelchair to bed and from bed to wheelchair and he was cognitively impaired. Interview with Activity Assistant B on [DATE] at 1:05 PM, he said he was transporting residents while CR #1 was in the activity room on 300 hall with other residents. He saw CR #1 on the floor. LVN A was already checking CR #1 and was taken to the room. Activity Assistant B confirmed that CR #1 was not able to ambulate, CR #1 was propelled by staff in the wheelchair. Interview on [DATE] at 10:30 AM, CNA A said she works 6:00 AM to 2:00 PM, she used to assist CR #1 with everything. She said she would transfer him to the wheelchair and bed, assist with incontinent care. She said his balance was unsteady. She said CR#1 was cognitively impaired and was not able to verbalize needs, CR#1 should not be left unattended. Interview on [DATE] at 10:41 AM, with CNA B said she works 2:00 PM to 10:00 PM when came to work the [DATE] she was told CR #1 got up from the wheelchair and fell in the activity room. CNA B said she had been working at the facility for a year. She said there are two CNAs on each hall and CR#1 should not be left unattended. Interview on [DATE] at 12:10 PM, the Administrator said he was told by LVN A that CR #1 had fallen in the activity room while Activity Assistant B was busy transporting residents for activities. The Administrator said CR #1 was left unattended with other residents. Administrator was responsible for abuse/neglect training. Interview with CR #1's NP on [DATE] at 4:00 PM, she said she was off duty from 6:00 PM on [DATE] and she saw CR #1's X-Ray faxed result on [DATE] at about 11:00 AM and that was why she called the facility to send him to the hospital. NP said she always see her residents daily in the facility and the licensed staff would call the on-call NP after hour (after 6:00 PM) to notify NP about the laboratory and X-ray reports. Interview on [DATE] at 2:12 PM, with LVN B he said he worked 2:00 PM to 10:00 PM for 3 months and he worked with CR #1. LVN B said he got the report on [DATE] from LVN A about CR #1's fall and the X-Ray technician came to the facility between 4:00PM and 5:00 PM and the result of the X-Ray came in at 9:55 PM. LVN B said he called NP agency on-call he was not sure the NP he spoke to and there was no new order. He read all examination to left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. LVN B said he did not read the impressions to the on-call person. LVN B was supposed to read ( Impression: Sub capital Left femoral neck fracture and Acute impacted sub capital left femoral neck fracture) Record review of CR#1's X-Ray exams result dated [DATE] revealed: Left hip 2 views: History: AP and cross table lateral do not manipulate. Findings: Right hip hemiarthroplasty ( partial hip replacement). An impacted sub capital left femoral neck fracture is noted. No other fracture or dislocation. IMPRESSION: Acute impacted sub capital left femoral neck fracture Record review of CR #1's Hospital interpretation & Diagnostics: Lab results interpretation Result: Recent Impressions: Cat Scan- CT Pelvis W/O Contrast [DATE] Impression: Sub capital Left femoral neck fracture CR #1 sustained a left sub-capital femoral neck fracture upon admission to the hospital, on [DATE]. Interview with LVN A on [DATE] at 2:40 PM, LVN A said she worked 10:00 PM to 6:00 PM shift on [DATE] and LVN B told her about CR#1's X-Ray result and stated no order from the on-call NP. LVN A said she faxed X- Ray results to CR #1's regular NP at 11:00 PM on [DATE]. Interview on [DATE] at 12:01 PM, with MDS Coordinator A, said she had been the MDS nurse at the facility for 3 months and was behind was still learning/training with the cooperate nurses. She said she had been a nurse for just one year she is responsible for doing the MDS assessments, LTC's, annual and quarterly, newly admitted . She got her information from hospital records, therapist notes, CNA notes and wound care nurse notes. She said the nurses are responsible for acute care plans and care plan meetings. She said whatever triggers are from the MDS, they are added to the care plan. She said on [DATE], she said did not do the intervention process on the care plan because she does not create the care plans. She said the nurses and the DON are responsible for completing the fall risk assessments. Interview on [DATE] at 12:10 PM the Administrator said he was told LVN A hat CR #1 had fallen on [DATE], an X-ray was done and LVN B was not able to explain the impression on the X-ray result to the on call NP and this lead to a delay transferring CR #1 to the hospital. Interview on [DATE] at 3:52 PM, with RP, she said CR #1 had many falls, CR #1 did not fall in his room because he had camera in the room. RP said on [DATE] LVN A called her about CR #1 fall at 2:00 PM. On [DATE] the visiting NP found an X-Ray on [DATE] and called the RP and said that CR #1 was going to the hospital. she said CR #1 had declined after the surgical procedure done on [DATE] in the hospital NP said CR #1 had dementia Interview on [DATE] at 12:23p.m., with the ADON, she said the fall risk assessments are done on admission or when a resident has a fall and quarterly. ADON said does admission and quarterly assessments. She said if a resident falls, the nurses were supposed to assess the resident. She said if the resident can move, the nurse will put them back in the bed and notify the DON and their responsible party. She said the nurse will also take the resident's vitals. She said she knows a resident is a fall risk because they will have a yellow star at the foot of the bed. She said it will also be listed in the Kardex. She said the Kardex is in a binder on each station and in the PCC. She said when the nurse does an assessment for fall precautions, they determine what is care planned by meeting with the resident and the resident's family and they put the plans in place from there. She said if there is a fall at the facility, they take the post worksheets to the morning meetings. She said the DON puts the interventions in place with the nurse and address it with IDT team. ADON knew different form of abuse/neglect who to report it to including the state agency Interview on [DATE] at 2:01p.m., with LVN D said if a resident falls on her watch, she will call for assistance, complete a pain assessment, and if there is a head injury, she will have the resident sent out to the hospital. She said she will also notify the family, complete a progress not and a fall risk assessment. She said a fall risk assessment is completed when a resident is discharged or quarterly and if they have a fall. She said you will update the resident's care plan if they have a new fall or if the current plan isn't working. She said you know a resident is a fall risk because they will have a yellow star by the door and wheelchair. Interview on [DATE] at 6:00 PM, with the DON, said if a resident has a fall, she will assess them to make sure there are no injuries, call doctor and call the family. Residents will not be unattended while in activity. She said normally the nurse does the fall risk assessment, but lately she has been doing it. She said if there is a fall with a resident, she will review what happened, and will conduct a morning meeting to see what needs should to be implemented for the care of the resident. She said the policy said, once there is a fall, they must do something about it which is to adjust the care plan and make an intervention. She did in-services on ANE. She said everyone on duty has been trained since they called the immediate jeopardy on the facility. She had She said the 2pm-10pm needs more training, but first shift and night shift has been trained. She said she had been coming in to work on different shifts to train each employee. Interview on [DATE] at 6:30 PM, the DON said the resident was left unsupervised with the activity assistant. The activity assistant was transporting residents while CR #1 was alone in the activity room with other residents. She said CR #1 fell and they found him on the floor. She said he complained of pain to the left hip and an x-ray was ordered by the morning nurse (LVN A) and who also completed an assessment. She said that CR #1 was transported to the hospital and the family was notified. The DON said CR #1 was able to ambulate and able to make needs known and she in-services with LVN B on to document the name of the medical personal on and how to read X-ray results noting the impressions. In-services completed on [DATE]. Interview on [DATE] at 6:30 PM, the DON and the Administrator said the root cause was leaving CR #1 and other residents unattended and not calling the X-Ray in a timely. DON said she discussed the IDT fall in the morning meetings. Interview on [DATE] at 6:34 PM, the Administrator, said when a resident has a fall, the DON will call him, no matter the time. He said he will ask what happened and if the resident was able to explain what happened to them. He said he will have a stand-up meeting and standdown meeting. He said he will have a case management meeting, where the falls are discussed. He said the Quality Specialists have assignments and everyone has a sheet of the fall risk assessments. He said he does not participate in creating the care plans. He said he is a part of the huddle meetings and go over resident devices. Record review of facility policy Abuse, Neglect, Misappropriation of Property, date, on ,d+[DATE] revealed: According to Nursing Home Reform Act of 1987, all residents in nursing homes are entitled to receive quality care and live in an environment that improves or maintains the quality of their physical and mental health. This entitlement includes freedom from neglect, abuse, and misappropriation of funds. Neglect and abuse are criminal acts whether they occur inside or outside a nursing home. Residents do not surrender their rights to protection from criminal acts when they enter a facility. This information sheet presents resident rights with regard to neglect and abuse, and steps to take if these rights are jeopardized. Neglect: Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional. For example, a caring aide who is poorly trained may not know how to provide proper care. Abuse: Abuse means causing intentional pain or harm. This includes physical, mental verbal, psychological, and sexual abuse, corporal punishment, unreasonable seclusion, and intimidation. Record Review of the facility's policy titled Fall and Post-Fall Management, undated, read in part, . Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for the resident as well as staff safety. Identify residents at risk for falls during ADL execution by resident individually or with staff assistance. Initiate preventative approaches. Provide appropriate strategies and interventions directed to resident, environmental factors, and staff. Provide learning opportunities. Monitor and evaluate resident outcome . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:23 PM, due to the above failures. The Administrator, DON, Executive Director and Regional RN were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 5:23 PM. The following Plan of Removal was submitted and accepted on [DATE] at 4:53 PM. Plan of Removal Park Manor Of Westchase [DATE] Submission #3 Immediate action: Other residents affected: a. CR #1 died on [DATE] b. On [DATE] an audit of Fall Risk Assessment was completed. Any resident who was identify as being at high risk for falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. Facilities Plan to Ensure Compliance: What corrective actions have been implemented for the identified residents? 1. The following action items were implemented immediately on [DATE]. a. CR #1 died on [DATE]. b. On [DATE] an audit of Fall Risk Assessments was completed. Any resident who was identified as being at high risk for falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. 2. 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 with licensed nurses on [DATE], by the Director of Nursing/designee, on implementing timely interventions post fall to include transfers to the hospital as indicated by the resident assessment. b. An in-service was initiated with licensed nurses on [DATE], by the DON/designee on immediately notifying the DON and/or Administrator of any falls with major injury such as a fracture. c. An in-service was initiated with licensed nurses on [DATE], by the DON/designee on neglect, to include falls with fractures. d. An in-service was initiated with licensed nurses on [DATE], by the DON/designee on reporting radiology results timely to the resident's nurse practitioner and/or physician when the results are received. The education included notifying the DON if the nurse practitioner and/or physician do not respond timely to the notifications. e. An in-service was initiated with direct care staff on [DATE], by the DON/designee on ensuring interventions are in place to prevent falls, including keeping a high-risk resident in an area that can be easily visualized by staff for safety when out of their room. f. An in-service was initiated with the Unit Managers, ADON, and MDS staff, by the DON on updating the care plan with new interventions timely after each fall. g. The Director of Nurses/designee will complete in-servicing on implementing timely interventions post fall, physician notification of radiology results, neglect and implementing timely fall interventions post fall and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. h. The DON/designee will in-service new hires during orientation on resident neglect, fall prevention and timely notification of radiology results to the physician and/or Nurse practitioner. i. Educated/In-serviced nursing staff to notify the DON if X-Ray services do not respond in a timely manner Monitoring: The Administrator, DON, ADON and Rehab Director will conduct random weekly checks, on all shifts, on the high risk fall residents or any new admits implementing timely interventions post fall, physician notification of radiology results, neglect and implementing timely fall interventions post fall, and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. 3. How will the system be monitored to ensure compliance? a. The DON and Nurse Manger provided staff training and education on all high fall risk residents to assure assessments and care plans are updated. b. The DON and or Designee will review all radiology results to ensure they were communicated to the physician timely, and that interventions were implemented and added to the care plan to try to prevent falls. c. The DON and/or Nurse Managers will round on high fall risk residents daily to ensure safety measures are in place. Surveyor Monitored the plan of removal as follows: Observations were started on [DATE] and continued through [DATE]. Observation of Residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed bedrooms were free of clutter and adaptive devices were available for residents at risk for falls. Interviews were conducted on [DATE], [DATE], [DATE] with staff across all three shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: Administrator, DON, ADON, MDS Coordinator A, CNA A, CNA B, CNA C, LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, MA A, MA B, MA C,CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN H and LVN I. All staff interviewed verbalized adequate understanding of plan of remove training received including Abuse, Neglect and Expectation, Universal Fall Precautions policy/procedures, Kardex system, and Fall Prevention Procedures. Record review of the facility POR Binder revealed: Staff were in-serviced on [DATE], [DATE], regarding Fall Interventions and Intervention for high - Risk Fall. Universal Fall Precautions policy/procedure. Timely interventions Post Falls. Reporting, incidents, Kardex system and Fall Prevention Procedures. Reporting Radiology Results Timely. Immediately notify DON and /or Administrator. Reporting Abuse and neglect, Neglect and Resident's Rights Record review of QAPI sign-in sheet revealed the facility held a QAPI on [DATE] to discuss and implement corrective action for CR#1's fall. Record review of the following Residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and CR #1) revealed Kardex Reports for residents at risk for falls had interventions in place to address falls. Record review of Kardex Binder revealed the facility had a binder at Nurse Station for halls #1, #2, #3 and #4 Record review of the following Residents (CR #1 #2, #3, #4, #5, #6, #7, #8, #9 #10 and #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed no care plans for residents at risk for falls. Record review of facility falls and fall risk, managing revised [DATE]: Policy Statement: Based on previous evaluations and current data, the staff will identify interviews related to the resident's specific risks and causes to try to minimize complications from falling. Policy interpretation and Implementation. Prioritizing Approaches to Managing Falls and Fall risk . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped or until the reason for the continuation of the falling is identified as unavoidable. 6.In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention( e.g., dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exit that continue to present a risk for falling or injury due to falls. Record review of facility Safety and Supervision of Residents revised [DATE]: Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility -wide priorities. Policy Interpretation and Implementation . 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents 5. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify necessary. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff, b. Assigning responsibility for carrying out interventions. c. Providing training as necessary. d. Ensuring that interventions are implemented e. Documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed and d. Evaluating the effectiveness of new or revised interventions The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 2:45PM. The facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy, CR #1 sustained serious injury and passed due to the facility's need to evaluate the effectiveness of the corrective systems. Interview with DON on [DATE] at 10:20 AM, she said she was not sure how long CR #1 was on the floor in the activity room before been assisted by LVN A. The DON said CR #1 was not able to follow commands, he needed redirections and has to be assisted to standing and transfers from bed to wheelchair. The DON said they did discuss CR #1's repeated fall with the medical doctor and RP and documented interventions on CR #1 progress. The DON then checked all progress notes on the computer and did not see any falls intervention for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. DON said she was still learning, and this was first time as DON. The DON said she was going to check with the facility Administrator for CR #1's falls intervention documentation at 12:30 PM. DON did not find any falls intervention before surveyor exit. DON said she is documenting intervention on fall resident now has. During an interview with LVN C on [DATE] at 10:38 AM, he said he worked with CR #1, he had bad dementia, would get up from wheelchair and attempt to walk, then fall. LVN C said CR #1 was very confused and combative. CR #1 could not transfer from wheelchair safely and had to be redirected. CR #1 was on a low bed, with floor mat and the star program on door and his wheelchair. He knew different forms of abuse/neglect and who to report it to including reporting it to the state. Interview with LVN A on [DATE] at 10:50 AM, she said CR #1 was not able follow comman [TRUNCATED]

Based on interview and record review, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 20 residents CR #1(Closed Record) reviewed for abuse and neglect policies. The facility failed to ensure CR #1 had adequate supervision to prevent an accident which resulted in a fall with major injury (left femur fracture) requiring surgery on [DATE]. The facility failed to read and notify the NP accurately of X-Ray results of CR #1's impression of left femur fracture resulting in delayed treatment. The facility failed to update CR #1's care plan and put interventions in place after continued falls, An Immediate Jeopardy (IJ) was identified on [DATE] at 5:23 PM. While the IJ was removed on [DATE] at 4:53 PM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy, CR #1 sustained serious injury and passed away due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of lack of communication with families and providing physicians following allegations of Abuse, Neglect, and Exploitation. Findings included: Record review of CR #1's face sheet revealed an [AGE] year-old male, date of admission was [DATE], readmission on [DATE], and died on [DATE]. CR #1's diagnoses included cerebrovascular disease ( a disease of the heart or blood vessels), contusion ( any collection of blood out a blood vessel) of eyeball and orbital tissues, unspecified eye, lack of coordination, muscle weakness (Generalized), cognitive communication deficit, dysphagia (difficulty swallowing ), oral phase, altered mental status, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities) unspecified severity, without behavioral disturbance, psychotic (when people lose some contact with reality) disturbance, mood disturbance and anxiety. Record review of CR #1's Quarterly MDS dated [DATE] revealed CR #1 had a BIMSs score of 3 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of Progress Notes documented by LVN A revealed CR #1 fell at the facility at 2:00p.m. on [DATE] and the x-ray was completed between 4:00p.m.-5:00p.m. [DATE], his x-ray results came back at 9:55p.m. CR #1 was transported to the hospital on [DATE] at 1:13 PM. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 5:18 PM entered by LVN A, read in part, . CNA called the nurse from the nurse's station to activity room. Nurse arrived and saw resident lying on his left side on the floor. Resident complained of pain on the left leg when the nurse asked the resident. Assessment was done, no skin tear noted, no bruise noted, resident was able to move all his extremities, the CNA and the nurse assisted resident back to the wheelchair. CR #1 stated he was attempting to transfer himself without help from wheelchair to regular chair. Resident was assisted to bathroom after the fall without difficulty, no abnormality noted to both lower limbs or no sign and symptoms of pain noted. Tylenol prn 325mg 2 tablet was given as prescribed .NP gave orders for X-ray of left hip, femur, knee, Tibia-fibula, ( chin bone) ulna radius, shoulder, left forearm. DON notified; RP notified. Vitals blood Pressure ,d+[DATE], Respiration 18, Pulse 80, temperature.97.6, O2 sat 97% room.Neurological in place. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 22:00 PM entered by LVN B, read in part, . radiological labs received and seen at 2159. Examination: left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. results received and reported to the oncoming nurse. NP notified of results. No NP's name and no impression from the left hip X-Ray noted. Record review of CR #1's comprehensive care plan dated [DATE] revealed that although high fall risk was care planned, all goals and interventions were either created or revised on [DATE] which was well after several falls which occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The date initiated was on [DATE] and was revised on [DATE]. The resident passed away on [DATE]. Record review of CR #1's fall incident and accident report revealed on the following dates: [DATE]: Incident Location: CR #1's room: Resident slipped out of his wheelchair trying to get in the bathroom. [DATE]: Incident Location: CR #1's room: Resident lower himself to the floor from his wheelchair. He had a bowel movement and urinated on the floor. [DATE]: Incident Location: CR #1's room: Resident slipped to the floor while transferring to bed without assistance. [DATE]: Incident Location: CR #1's room: Resident ambulate without assistance. [DATE]: Incident Location: Activity room on 300 hall: CR #1 found on the floor. Further review of CR #1's interventions revealed comprehensive care plan have had not been updated since [DATE]. He is a high risk for falls, related to balance problem, history of falls, unaware of safety needs, vision problem, AEB Fall Risk and assessment score 19. There were no fall risk interventions in place after his fall on [DATE]. Record review of CR #1's of nurse's progress note documented by LVN B revealed that a provider from Health Agency called for an update on the resident. Provider notified of radiological lab results and impression of the left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. Record review of CR #1's Progress Notes dated [DATE] at 13:05 PM entered by LVN A revealed Resident was picked by EMS via stretcher to be transferred to ER. Resident ate his lunch. Resident was calm and quiet. Paperwork was sent along with X-RAY results. RP and NP were notified of the transfer to ER. Interview with the DON (Director of Nurses) on [DATE] at 11:14 AM, she said resident CR#1 expired on [DATE]., sShe said the resident fell on [DATE] in the activity room, it was witnessed by another resident in the activity room because the activity assistant was busy transporting the resident to activity and there was nobody in the activity room. The DON said the facility was remodeling the dining area where they always have activity. She stated that resident was trying to transfer from the wheelchair to a chair when he fell , X-ray was done, and resident was sent to the hospital. The DON said LVN B did not notify the on call NP of the impressions on the X-Ray and there werhoe no new orders on [DATE]. Interview with Activity Director on[DATE] at 3:40PM, she said she have been working in the facility for 5 years and they usually use dining room for activity or activity room at room at end of 300 hall always invite the residents for activity by assisting resident to activity room and not leaning resident not attended to. Interview with the LVN A on [DATE] at 12:41 PM, LVN A said she was called to the activity room on 300 hall by a C.NA. LVN A said she saw CR #1 lying on left side on the floor, CR #1 assessment was done. DON, NP and RP was notified. This occurred at the change of shift at 2:00 PM LVN A said while assessing CR #1 lying on left side on the floor, CR #1 was saying ouch, ouch. She then assisted CR #1 to the wheelchair then transported him to his room. NP gave her an ordered for X-Ray at about 2:30 PM. LVN A said she was not around when X-ray was done to CR #1. LVN A said an x-ray was ordered and it was done on 2p.m.-10p.m. shift. LVN A said CR #1 was totally dependent on staffs for transfer from wheelchair to bed and from bed to wheelchair, was cognitively. Interview with Activity Assistant B on [DATE] at 1:05 PM, he said was transporting residents while CR #1 was in the activity room on 300 halls with other residents. He said CR #1 fell found him on the floor and LVN A was already checking CR #1 and was taken to the room. Activity Assistant B confirmed that CR #1 was not able to ambulate, CR #1 was propelled by staff on the wheelchair. Interview on [DATE] at 10:30 AM with CNA A said she works 6:00 AM to 2:00 PM, she used to assist CR #1 with everything. She said she would transfer him to the wheelchair and bed, assist with incontinent care. She said his balance was unsteady. She said CR#1 was cognitively impaired was not able to verbalize needs. Interview on [DATE] at 10:41 AM, with CNA B said she works 2:00 PM to 10:00 PM when came to work on [DATE] she was told CR #1 got up from the wheelchair and fell in the activity room. C.NA B said she has been working at the facility for a year. She said there are two CNAs on each hall. Interview on [DATE] at 12:10 PM the Administrator said he was told by LVN A that CR #1 had fallen in the activity room while activity assistant B was busy transporting residents for activities. The Administrator said CR #1 was left unattended with other residents. He said CR #1. Interview with CR #1's NP on [DATE] at 4:00 PM, she said she was off duty from 6:00 PM on [DATE] and she saw CR #1's X-Ray faxed result on [DATE] at about 11:00AM and that was why she called the facility to send him to the hospital. Interview on [DATE] at 2:12 PM with LVN B he said he worked 2:00PM to 10:00 PM for 3 months and he worked with CR #1. LVN B said he got the report from LVN A about CR #1 fall and X-Ray technician came to the facility between 4:00PM and 5:00 PM and the result of the X-Ray came in at 9:55 PM. LVN B said he called on team, he was not sure the NP he spoke with and there was no new order. He read all examination to left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. LVN B said he did not read the impressions to the on-call person and he knew different forms of abuse/neglect who to report it to, including the state. Record review of CR#1 X-Ray exams result dated [DATE] from the facility revealed: Left hip 2 views : History: AP and cross table lateral do not manipulate. Findings: Right hip hemiarthroplasty ( partial hip replacement) . An impacted sub capital left femoral neck fracture is noted. No other fracture or dislocation. IMPRESSION: Acute impacted sub capital left femoral neck fracture Record review of CR #1 Hospital interpretation & Diagnostics: Lab results interpretation Result: Recent Impressions: Cat Scan- CT Pelvis W/O Contrast [DATE] Impression: Sub capital Left femoral neck fracture CR #1 sustained a left sub-capital femoral neck fracture upon admission to the hospital, on [DATE]. Interview with the LVN A on [DATE] at 2:40 PM, LVN A said she worked the 10:00 PM to 6:00 PM shift on [DATE] and LVN B told her about CR#1's X-Ray result and stated no new order from the on-call NP. LVN A said she faxed the X- Ray result to CR #1's regular NP at 11:00 PM on [DATE] because she saw the impression of fracture on the X-ray . Interview on [DATE] at 12:01 PM with MDS Coordinator A, said she has been the MDS nurse at the facility for 3 months and was behind was still learning/training with the cooperate nurses. She said she has been a nurse for just one year she is responsible for doing the MDS assessments, LTC's, annual and quarterly, newly admitted . She got her information's from hospital records, therapist notes, C.NA notes and wound care nurse notes. She said the nurses are responsible for acute care plans and care plan meetings. She said whatever triggers are from the MDS, they are added to the care plan She said on [DATE], she said did not do the intervention process on the care plan because she does not create the care plans. She said the nurses and the DON are responsible for completing the fall risk assessments. Interview on [DATE] at 12:10 PM the Administrator said he was told by LVN A that CR #1 had fallen on [DATE], X-ray was done and LVN B was not able to explain the impression on X-ray result to on call NP and this lead to delay transferring CR #1 to the hospital. Administrator and DON were responsible for ANE and they do random rounds and talk to residents. Interview on [DATE] at 3:52 PM, with RP, she said CR #1 had many falls, CR #1 did not fall in his room because he had camera in the room. RP said on [DATE] the nurse called her about CR #1 fall at 2:00 PM. On [DATE] the visiting NP found X-Ray on [DATE] and call RP that CR #1 was going to the hospital. RP said NP said the facility did not receive a death certificate for CR #1, she said CR #1 had declined after the surgical procedure. NP said CR #1 had diagnosis of dementia. Interview on [DATE] at 12:23p.m., with the ADON, she said the fall risk assessments are done on admission or when a resident has a fall and quarterly. She said admission assessments that are done quarterly, is assigned to her. She said if a resident falls, she is supposed to assess the resident. She said if the resident can move, the nurse will put them back in the bed and notify the DON and their responsible party. She said the nurse will also take the resident's vitals. She said she knows a resident is a fall risk because they will have a yellow star at the foot of the bed. She said it will also be listed in the Kardex. She said the Kardex is in a binder on each station and in the PCC. She said when the nurse does an assessment for fall precautions, they determine what is care planned by meeting with the resident and the resident's family and they put the plans in place from there. She said if there is a fall at the facility, they take the post worksheets to the morning meetings. She said the DON puts the interventions in place with the nurse and address it with IDT team. Interview on [DATE] at 2:01p.m., with LVN D said if a resident falls on her watch, she will call for assistance, complete a pain assessment, and if there is a head injury, she will have the resident sent out to the hospital. She said she will also notify the family, complete a progress not and a fall risk assessment. She said a fall risk assessment is completed when a resident is discharged or quarterly and if they have a fall. She said you will update the resident's care plan if they have a new fall or if the current plan isn't working. She said you know a resident is a fall risk because they will have a yellow star by the door and wheelchair. Interview on [DATE] at 6:00 PM, with the DON, said if a resident has a fall, she will access them to make sure there are no injuries, call doctor and call the family. Residents will not be left unattended while in activity. She said normally the nurse does the fall risk assessment, but lately she has been doing it. She said if there is a fall with a resident, she will review what happen, and will conduct a morning meeting to see what needs should to be implemented for the care of the resident. She said the policy said, once there is a fall, they must do something about it which is to adjust the care plan and make an intervention. She said everyone on duty has been trained on falls, ANE since they called the immediate jeopardy on the facility. She said the 2pm-10pm needs more training, but first shift and night shift has been trained. She said she has been coming in to work on different shifts to train each employee. Interview on [DATE] at 6:30 PM with the DON said the resident was left unsupervised with the activity assistant. The activity assistant was transporting residents while CR #1 was alone in the activity room with other residents. She said the CR #1 fell and they found him on the floor. She said he complained of pain to the left hip and an x-ray was ordered by the morning nurse (LVN A) and completed an assessment. She said that CR #1 was transported to the hospital and the family was notified. DON said CR #1 was able to ambulate and able to make needs known and she in-services LVN B on to document the name of the medical personal on and how to read X-ray results noting the impressions Followed-up interview on [DATE] at 6:30 PM, the DON and the Administrator, said the root cause was leaving CR #1 and other residents unattended and not calling X-Ray in a timely. DON said she discussed the IDT fall in the morning meetings. Interview on [DATE] at 6:34 PM, with the Administrator, said when a resident has a fall, the Don DON will call him, no matter the time. He said he will ask what happened and if the resident was able to explain what happened to them. He said he will have a stand-up meeting and standdown meeting. He said he will have a case management meeting, where the falls are discussed. He said the Quality Specialists have assignments for any fall intervention and everyone has a sheet of the fall risk assessments. He said he does not participate in creating the care plans. He said he is a part of the huddle meetings and go over resident devices. Record Review of the facility's policy titled Fall and Post-Fall Management, ,d+[DATE], read in part, . Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for the resident as well as staff safety. Identify residents at risk for falls during ADL execution by resident individually or with staff assistance. Initiate preventative approaches. Provide appropriate strategies and interventions directed to resident, environmental factors, and staff. Provide learning opportunities. Monitor and evaluate resident outcome . Record review of facility policy Abuse, Neglect, Misappropriation of Property, date, on ,d+[DATE] revealed: According to Nursing Home Reform Act of 1987, all residents in nursing homes are entitled to receive quality care and live in an environment that improves or maintains the quality of their physical and mental health. This entitlement includes freedom from neglect, abuse, and misappropriation of funds. Neglect and abuse are criminal acts whether they occur inside or outside a nursing home. Residents do not surrender their rights to protection from criminal acts when they enter a facility. This information sheet presents resident rights with regard to neglect and abuse, and steps to take if these rights are jeopardized. Neglect: Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional. For example a caring aide who is poorly trained may not know how to provide proper care. Abuse: Abuse means causing intentional pain or harm. This includes physical, mental verbal, psychological, and sexual abuse, corporal punishment, unreasonable seclusion and intimidation. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:23 PM, due to the above failures. The Administrator, DON, Executive Director and Regional RN were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 5:23 PM. The following Plan of Removal was submitted and accepted on [DATE] at 4:53 PM. Plan of Removal [DATE] Submission #3 Immediate action: Other residents affected: a. CR #1 died on [DATE] b. On [DATE] an audit of Fall Risk Assessment was completed. Any resident who was identify as being at high risk for falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. Facilities Plan to Ensure Compliance: Resident with alleged deficient practice died on [DATE]. How were other residents at risk to be affected by this deficient practice identified? a. Nursing staff completed audit on all residents with high fall risk on [DATE]. All residents that have high fall risk were identified at risk to be affected by the alleged deficient practice, none found to be affected. Nursing staff audited the 72 hours Summary Report for all residents residing in the facility on [DATE] for any changes in condition, none identified. There were 19 total residents identified, no other residents were affected. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. An in-services was initiated by DON and/or designee on [DATE] with all staff on how to identifying residents who trigger for high fall risk and ensuring that safety measures are in place. b. An in -services was initiated on [DATE] by DON and/or designee with licensed nurses on reporting radiology results in a timely manner to the resident's nurse practitioner, and/or physician when results are received. Nursing staff must notify the DON if the nurse practitioner and/or physician do not respond in a timely manner. c. An in-service was initiated on [DATE] with licensed nurses that residents that triggered for high fall risk must have appropriate care plan interventions in place including placing residents who are at high-risk for falls in an area that can be easily visualized by staff for safety when out of room. Staff educated that the DON and/or administrator must be notified immediately of any falls with major injuries such as fracture. d. An in-service was initiated on [DATE] with ADON, and MOS staff by DON on updating care plans with new interventions timely after each fall including transfers to hospital as indicated by the resident assessment. e. Newly hired licensed nursing staff will be trained during the orientation process on reporting injuries related to falls and identifying residents who are at high risk for falls upon admission. f. The Director of Nurses/designee will complete in-servicing on implementing timely interventions post fall, physician notification of radiology results, abuse/neglect and implementing timely fall interventions post fall and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. Monitoring: The Administrator, DON, ADON and Rehab Director will conduct random weekly checks, on all shifts, on the high risk fall residents or any new admits implementing timely interventions post fall, physician notification of radiology results, neglect and implementing timely fall interventions post fall, and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. a. The DON and Nurse Manger provided staff training and education on all high fall risk residents to assure assessments and care plans are updated. b. The DON and or Designee will review all radiology results to ensure they were communicated to the physician timely, and that interventions were implemented and added to the care plan to try to prevent falls. c. The DON and/or Nurse Managers will round on high fall risk residents daily to ensure safety measures are in place. Surveyor Monitored the plan of removal as follows: Observations were started on [DATE] at different times, 8:30 AM, 9:30 AM, 11:00 AM, 2:30 PM, 3:30 PM, 4:30 PM, 5:50 PM, [DATE], 8:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM and continued through [DATE], 11:00 AM, 1:30 PM, 2:30 PM, 3:00 PM, 11:30 PM, 12:30 PM. Observation of Resident ((#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed bedrooms were free of clutter and adaptive devices were available for residents at risk for falls. Interviews were conducted on [DATE], [DATE], [DATE] with staff across all three shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: Administrator, DON, ADON, MDS Coordinator A, CNA A, CNA B, CNA C, LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, MA A, MA B, MA C,CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN H and LVN I. All staff interviewed verbalized adequate understanding of plan of remove training received including Universal Fall Precautions policy/procedures, ANE, Kardex system, and Fall Prevention Procedures. Record review of the facility POR Binder revealed: Staff were in-serviced on [DATE], [DATE], regarding Fall Interventions and Intervention for high - Risk Fall. Universal Fall Precautions policy/procedure. Timely interventions Post Falls. Reporting, incidents, Kardex system and Fall Prevention Procedures. Reporting Radiology Results Timely. Immediately notify DON and /or Administrator. Reporting Abuse and neglect, Neglect and Resident's Rights. Record review of QAPI sign-in sheet revealed the facility held a QAPI on [DATE] to discuss and implement corrective action for CR#1's fall. Record review of the following residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and CR #1) revealed Kardex Reports for residents at risk for falls had interventions in place to address falls. Record review of Kardex Binder revealed the facility had a binder at Nurse Station for halls #1, #2, #3 and #4 Record review of the following residents ( CR #1 #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed no care plans and intervention for residents at risk for falls in place to address falls. During an interview on [DATE] at 1:59p.m. with Regional RN said, she believes the facility currently has an IJ because of the resident's history of falls. She said the resident did not need a 1 on1 supervision, but because he had so many falls, it was a concern. She said when the residents are participating in activities, instead of staff taking residents back and forth, they should call for other staff members to come and get them. She said she wanted to make sure there is a system in place to move the residents back and forth to the activities area and that is a common area where other staff can see them. During an interview on [DATE] at 2:32p.m. the Administrator said, he believes the facility is currently has an IJ because there was a resident that fell and sustained a major injury. He said he has made sure that everybody understands how important it is to supervise residents. He said a big part of the morning meetings and meeting with quality assurance, is to make sure high-risk residents are always monitored. He said if there is a change in the environment, staff should know those changes and adapt to those changes. He said it is hard to do your job if you do not understand how to do certain things. He said he knows how staff is interacting with the residents by monitoring, walking around and observing what is happening on the floor and educating them with in-service trainings. During an interview on [DATE] at 1:33p.m. the ADON house said, she doesn't know why the facility has an IJ. She said she knew the incident that happened with the resident and that he had a fall. She said she was not working the day the resident had the fall. She said she could improve her work by being thorough with her documentation. She said all staff need to always monitor the residents at the facility. She said the fall risk residents she be around the nurse's station so that someone can keep a close eye on the residents. She said things would have gone differently if she was present at work during the incident with the resident. She said would have put interventions in place and care planned the falls based on how the falls happened. She said some of the trainings for staff are ongoing. She said she had a broad view on how to care for the residents. She said the purpose of having in-service training is so that staff understands how to take care of the residents. She said things change and staff must continue to receive training to adapt to those changes. She said she knows that staff can do their job because she follows ups with them every day and she have them to show her how to perform their job duties. During an interview on [DATE] at 1:42p.m. with RN she said the facility has an IJ because there was a resident with frequent falls, and they did not move to prevent him for falling and it resulted in his death. She said she learned that when they have a problem everyone has a problem. She said direct staff had a better idea for interventions that she does. She said she shared with the team that a resident had a fall. She said they went back and reviewed what was going on with the resident. She said for now on she is going to pay closer attention to the residents that are high risk for falls. She said the care plans will be closely directed to the resident. She said she will work closer with the activities director and document to show that the residents are being monitored. She said staff need to be educated and reeducated when things are ongoing regarding in-service. She said she would go back and ask questions to staff and have them to demonstrate on the computer what they are supposed to be doing to make sure they understand how to do their job properly. She said staff needs more training on how to create care plans. She said the care plans was not being done correctly since she has been at the facility. She said the care plans needs to be individualized. Record review of facility falls and fall risk, managing revised [DATE]: Policy Statement: Based on previous evaluations and current data, the staff will identify interviews related to the resident's specific risks and causes to try to minimize complications from falling. Policy interpretation and Implementation. Prioritizing Approaches to Managing Falls and Fall risk . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped or until the reason for the continuation of the falling is identified as unavoidable. 6.In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 5. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 6. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention( e.g., dizziness or weakness) has resolved. 7. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. 8. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exit that continue to present a risk for falling or injury due to falls. Record review of facility Safety and Supervision of Residents revised [DATE]: Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility

Based on observation, interview, and record review the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician order for 1 (CR #1) of 20 residents reviewed for radiology services in that: -The facility failed to report CR#1's ( Closed Record) x-ray results of a fracture of the left hip, femur, in a prompt manner. CR #1 fell on [DATE] at 2:00 PM, X-Ray done and NP got result on [DATE] and CR #1 transferred to hospital at 1:13 PM on [DATE] - CR #1 had a hip fracture that had delayed treatment which caused harm to the resident. This failure has the potential to place residents who receive diagnostic testing for delayed treatment and hospitalization s. Findings: Record review of CR #1 of face sheet revealed [AGE] year-old male, date of admission was [DATE] readmission on [DATE] died on [DATE] diagnosis included cerebrovascular disease (a disease of the heart or blood vessels), contusion (any collection of blood out a blood vessel) of eyeball and orbital tissues, unspecified eye, lack of coordination, muscle weakness ( Generalized), cognitive communication deficit, dysphagia (difficulty swallowing), oral phase, altered mental status, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities) unspecified severity, without behavioral disturbance, psychotic (when people lose some contact with reality) disturbance, mood disturbance and anxiety. Record review of CR #1's Quarterly MDS dated [DATE] revealed CR #1 had a BIMs score of 3 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of Progress Notes revealed CR #1 fell at the facility at 2:00p.m. on [DATE] and the x-ray was completed between 4:00p.m.-5:00p.m. On [DATE], his x-ray results came back at 9:55p.m. CR #1 was transported to the hospital on [DATE] at 1:13 PM. Record review of CR #1's of nurse's progress note revealed that a provider from OPTUM Health called for an update on the resident. Provider notified of radiological lab results and impression of the left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. Record review of CR #1's Progress Notes dated [DATE] at 13:05 PM entered by LVN A Resident was picked by EMS via stretcher to be transferred to ER. Resident ate his lunch. Resident was calm and quiet. Paperwork was sent along with X-RAY results. RP and NP were notified of the transfer to ER. Interview with the DON (Director of Nurses) on [DATE] at 11:14 AM, said resident CR#1 expired on [DATE], she said resident fell on [DATE] in the activity room, it was witnessed by another resident in the activity room because the activity assistant was busy transporting the resident to activity and there was nobody in the activity room. DON said the facility was remodeling the dining area where they always have activity. She stated that resident was trying to transfer from the wheelchair to a chair when he fell , X-ray was done, and resident was sent to the hospital. DON said LVN B did not notify on call NP of the impressions on the X-Ray and there were no new orders on [DATE]. Interview with Activity Director on[DATE] at 3:40 PM, she said she have been working in the facility for 5 years and they usually use dining room for activity or activity room at room at end of 300 hall always invite the residents for activity by assisting resident to activity room. Interview with the LVN A on [DATE] at 12:41 PM, LVN A said she was called to the activity room on 300 hall by a CNA. LVN A said she saw CR #1 lying on left side on the floor, CR #1 assessment was done. DON, NP and RP was notified. This occurred at the change of shift at 2:00 PM, LVN A said while assessing CR #1 lying on left side on the floor, CR #1 was saying ouch, ouch. She then assisted CR #1 to the wheelchair then transport him to his room. NP gave her ordered for X-Ray at about 2:30 PM. LVN A said she was not around when X-ray was done to CR #1. LVN A said an x-ray was ordered and it was done on 2p.m.-10p.m. shift. LVN A said CR #1 was totally dependent on staffs for transfer from wheelchair to bed and from bed to wheelchair, was cognitively impaired. Interview with Activity Assistant B on [DATE] at 1:05 PM, he said was transporting residents while CR #1 was in the activity room on 300 halls with other residents. He said CR #1 fell and they found him on the floor. LVN A was already checking CR #1 and was taken to the room. Activity assistant B confirmed that CR #1 was not able to ambulate, CR #1 was propelled by staff on the wheelchair. Interview with DON on [DATE] at 4:00 PM, regarding CR # waiting for 17 hours before transferring CR #1 to the hospital for left hip fracture, she said X-Ray company has to be called and depending on where they were that determines their response. DON said she was going to do in-services on notifying NP/MD. Record review of in-services done on [DATE] revealed DON had: Educated/In-serviced nursing staff to notify the DON if X-Ray services do not respond in a timely manner Record review of the facility policy dated 2005 (Revised [DATE]) for Lab and Diagnostic Test Result-Clinical Protocol: 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager or a telephone message to another person acting as the physician's agent ( for example, office staff). a. Facility staff should document information about when, how and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis .

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 21 residents (CR #107) reviewed for quality of care, in that; The facility failed to timely check CR #107's blood pressure as ordered/scheduled for 8am. Blood pressure was checked at 1PM for 8AM administration which was 5 hours after the scheduled time. The facility failed to monitor and recheck CR #107's blood pressure and vital signs after 1:00pm following an identified change in condition of low blood pressure (,[DATE]). The facility failed to check CR #107's blood pressure at 4PM as ordered and scheduled on the MAR. As a result, CR#107 was found unresponsive after 7PM. 911 was called and they transferred resident to the hospital where he was diagnosed to have [MEDICAL CONDITION] and died on e hour after arrival. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures could affect all facility residents who may experience changes in their condition. Findings include: CR #107 Record review of CR #107's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Further review of the face sheet revealed resident was discharged on [DATE] at 8:00PM to an Acute Care Hospital. Record review of CR #107's Admission MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10 indicating his cognition was moderately impaired. Further review of the MDS revealed the resident had no skin issues. Record review of CR #107's care plan initiated on [DATE] revealed he had a potential for signs/symptoms and complication related to hypertension. His interventions included: avoid taking blood pressure reading after physical or emotional distress, document/report to Doctor PRN any signs/symptoms of malignant hypertension: headache, visual problems, confusion, lethargy, irritability, [MEDICAL CONDITION] activity, difficulty breathing. Give anti - hypertensive medications as ordered. Observe for side effects such as orthostatic [MEDICAL CONDITION], and increased heart rate. Further review of CR #107's care plan initiated on [DATE] revealed he had a potential for signs/symptoms of pacemaker malfunction. His interventions included to avoid activities and equipment which interfere with pacemaker activity: large magnets, MRI scanner, TENS machine. Document/report to MD PRN for signs/symptoms of cardiac output of pacemaker malfunction: dizziness, [MEDICAL CONDITION], difficulty breathing, lower than baseline blood pressure. Report resident complained of dizziness, pain or fatigue to the nurse. Further review of CR #107's care plan initiated on [DATE] revealed he had a code status of Full Code/CPR and the interventions were to: if the resident arrests CPR will be performed, 911/EMS called, MD /RP informed. Provide education to resident and of RP regarding code status. Further review of CR #107's care plan initiated on [DATE] revealed he had a potential/actual impairment to skin integrity to bilateral lower extremities related to [MEDICAL CONDITION] with risks for skin breakdown related to fragile skin/impaired circulation/ resident non-compliant with keeping legs elevated. His interventions included: administer treatment as ordered, avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of [REDACTED]. Use lotion on dry skin. No not apply on the site of injury. Observed for side effects of the antibiotics and over the counter pain medications: [REDACTED]. Observe skin injury for abnormalities, failure to heal, signs/symptoms of infection, maceration etc. and report to doctor. Record review of CR #107's Discharge MDS dated [DATE] revealed he was discharged to the community and his return was anticipated. The MDS was signed completed on [DATE]. Further review of CR#107's record revealed above discharge MDS was inaccurate as the resident was transferred to a hospital following a change in condition on [DATE]. Interview on [DATE] at 10:48AM, the MDS Coordinator said CR #107 was discharged to the hospital on [DATE] and did not return. She said the Discharge MDS should have reflected he was discharged to the hospital, not the community. The MDS Coordinator said the MDS was completed on [DATE] and locked on [DATE]. Record review of CR #107's physician order [REDACTED]. [MEDICATION NAME] HCl Tablet 10MG, 1 tablet by mouth every 8 hours for Hypertension ordered on [DATE]. [MEDICATION NAME] Solution Pen-Injector 100 UNIT/ML (Insulin [MEDICATION NAME]), Inject 5 unit subcutaneously for Diabetes Mellitus ordered on [DATE]. [MEDICATION NAME] Table 325MG, 1 tablet by mouth every 6 hours AS NEEDED for pain ordered on [DATE]. O2: 02 at 2 L/minute via N/C PRN as needed for shortness of breath ordered on [DATE]. Bactrim DS tablet ,[DATE] MG ([MEDICATION NAME] - [MEDICATION NAME]), 1 tablet by mouth one time a day for [MEDICAL CONDITION] ordered to start on [DATE]. [MEDICATION NAME] Tablet ([MEDICATION NAME]), 2MG orally two times a day for [MEDICAL CONDITION] related to Diastolic (congestive) heart failure started on [DATE]. [MEDICATION NAME] ER tablet Extended Release 24 hour 2.5MG, 1 tablet by mouth one time a day for diabetes mellitus started on [DATE]. Eliquis Tablet 2.5MG (Apixaban), 1 tablet by mouth two times a day for Anticoagulant therapy started on [DATE]. Record review of CR #107's Occupational Therapy notes dated [DATE] with no time revealed in part, .Patient required extensive rest breaks and complained of Bilateral Extremity pain. Nursing made aware and pain medication provided . Note was written by OTA #1 Phone interview on [DATE] at 1:30PM, OTA #1 said she could not recall who CR #107 was. Surveyor reviewed her note with her and she said she could not recall the situation but said if she documented pain medication was provided it did not necessarily mean she witnessed medication was given. She said if a nurse told her a resident was medicated for pain then she would document that medication was given without witnessing the administration based on the nurse's word. Record review of CR #107's (MONTH) 2019 MAR indicated [REDACTED]. Record review of CR #107's (MONTH) 2019 Medication Administration Record [REDACTED]. The times listed on MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR generates a progress note when medications are held to document why. Record review of CR #107's progress note generated from the electronic Medication Administration Record [REDACTED]. The note indicated MA #1 notified the nurse (LVN #1) of the blood pressure being ,[DATE]. Further review of the note revealed the blood pressure was taken at 1:16PM for the dose ordered at 8AM, indicating the medication administration attempt was 5 hours late. Phone Interview on [DATE] at 11:20AM, MA #1 could not recall any events from [DATE] or who CR #107 was. She said her protocol for passing medications was to document in the eMAR while she was passing medications so her eMAR note would have been entered at the time of the administration attempt (attempt was documented at 1:16PM). MA #1 said she could not recall if CR #107's [MEDICATION NAME] medication attempt for 8AM on [DATE] was late given her eMAR note was made at 1:16PM for the medication begin held. MA #1 said in a situation where the blood pressure was out of parameters for a medication to be given she would notify the nurse and they would then go in an assess the resident. Interview on [DATE] at 3:00PM, The DON said the Medication Administration Record [REDACTED]. She said as the staff cannot continue with passing medications until note is entered indicating the note was entered as the Medication was passing the medication. The DON was shown the time stamp of the note to be after 1:16PM for an administration time of 8AM, the DON said she was not sure if the medication was late or not. The DON said if a blood pressure if out of parameters the medication aide should notify the nurse for them to assess the resident and notify the physician if needed. Record review of CR #107's progress notes created on [DATE] at 1:20PM to reflect the date of [DATE] at 12:54PM revealed, Resident leg draining blood tinged fluids, on assessment, open blister noted to right leg, right leg firm, red and black in color, and [MEDICAL CONDITION] noted to left leg, vital signs stable at ,[DATE] - 88 - 20 - 97.4 - O2 Sat at 96 on 2L nc, denies pain at this time. Physician was called, informed of resident condition, and orders noted to Bactrim ds one tablet by mouth daily for seven days. Resident informed of new order. Note was entered by LVN #1 indicating he was notified by MA #1 of CR #107's blood pressure being out of parameters at 1:16PM. Note does not mention that blood pressure was rechecked and determined to be within parameters. Record review of CR #107's SBAR locked on [DATE] with an effective date of [DATE] at 1:13PM revealed the residents change in condition was bilateral lower extremities [MEDICAL CONDITION], redness, open draining blisters and the drainage was blood tinged. The resident's vitals were listed as BP ,[DATE], pulse 88, Respiration 20, Temperature 97.4, Pulse oximetry % 96 on O2 of 2L/min, and blood sugar 132. Resident was listed to have decreased mobility and wanted to be in bed at all times. The report revealed the physician was notified on [DATE] at 12:00PM and she ordered Bactrim DS one tab by mouth daily for 7 days. Further review of the SBAR revealed a nurse note created on [DATE] that linked to CR #107's progress notes. The nurses note revealed, Resident right leg draining blood tinged fluids, on assessment, open blister noted to right leg, right leg firm, red and black in color, and [MEDICAL CONDITION] noted to left leg, vital signs at BP ,[DATE] - Pulse 88 - Respiration 20 - 97.4. O2 sat at 96 on 2L/nc, denies pain at this time. Physician called, informed of resident condition, and orders noted to start Bactrim DS one tablet by mouth daily for seven days. Resident informed of new order. SBAR completed and locked by LVN #1 on [DATE]. Phone Interview on [DATE] at 11:00AM, LVN #1 said he did not recall who CR #107 was. Surveyor read LVN #1 assessment note from [DATE] to him and he said he could not recall completing the assessment, notifying the physician, or writing the note. Interview on [DATE] at 12:07PM, the Physician said she checked her notes and text messages and did not see where she was notified of CR #107 having a change in condition. She said she also spoke to her NP who also denied being notified of CR #107 having a change in condition on [DATE]. The Physician said she only recalled being informed of CR #107 being found unresponsive and being transferred to the hospital. The Physician was read the note entered by LVN #1 about CR #107 change in condition with swelling, drainage, discoloration, and noted vitals. The Physician said given the residents condition in the assessment she would not have ordered Bactrim for treatment and given the residents low blood pressure she most likely would have had the resident transferred to the hospital. The Physician said she does not recall speaking with anyone at the facility and giving that order. She also said she maybe did later sign the electronic order for the Bactrim but said she signs 100's of orders a day and most likely did not thoroughly read the order before signing it. The Physician said she knows she should not be doing that and that it's not a good practice to sign orders without reading them. Record review of CR #107's progress notes created on [DATE] at 8:28PM to reflect the date of [DATE] at 1:30PM revealed, initial dose of Bactrim ds antibiotic ordered for [MEDICAL CONDITION] administered and accepted without any difficulty, will continue to with plan of care. Note entered by LVN #1. Record review of CR #107's (MONTH) 2019 MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. Record review of CR #107's progress notes created on [DATE] at 8:34PM to reflect the date of [DATE] at 2:33PM revealed, Resident resting in bed with eyes opened, 02 at two liters via nasal canula infusing, O2 sat at 97, will continue with plan of care. Note was entered by LVN #1 and revealed there were no vitals rechecked at that time. Record review of CR #107's progress notes created on [DATE] at 8:36PM to reflect the date of [DATE] at 3:34PM revealed, Resident remained in bed with head of bed up at 45 degrees, no distress, will continue plan of care. Note was entered by LVN #1 and revealed there were no vitals rechecked at that time. Record review of CR #107's (MONTH) 2019 Medication Administration Record [REDACTED]. The times listed on MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Phone Interview on [DATE] at 11:20AM, MA #1 said she documents in the MAR indicated [REDACTED]. Review of CR #107's records revealed he was not out of the building until after 7PM and MA #1 said she could not recall what time she went in to give 4PM [MEDICATION NAME] dose. MA #1 said she could not recall finding CR #107 unresponsive or there being a code called for him. Interview on [DATE] at 3:00PM, The DON also said she did not know why the medication was not given or the blood pressure was not recorded for the 4PM dose of [MEDICATION NAME] since CR #107 did not leave the building until after 7PM. The DON said she would look at the records and speak to the staff to see what happened but did not report anything further to surveyors. Record review of CR #107's progress notes created on [DATE] at 8:40PM to reflect the date of [DATE] at 4:50PM revealed, Resident resting in bed with family at bedside, head of bed up at 45 degrees, no distress noted at this time, will continue with plan of care. Note was entered by LVN #1 and revealed there were no vitals rechecked at that time. Record review of CR #107's progress notes created on [DATE] at 8:45PM to reflect the date of [DATE] at 5:57PM revealed, resident repositioned for comfort, continued on O2 at two liters via nasal canula, O2 sat at 97%, will continue with plan of care. Note was entered by LVN #1 and revealed there were no vitals rechecked at that time. Record review of CR #107's progress note created on [DATE] at 9:21PM to the reflect the date of [DATE] at 8:30PM revealed, The CNA call the attention of the Nurse stating resident is unresponsive, nurse assess resident was unresponsive to verbal command or painful stimuli. Resident lowered to the floor, CPR initiated, 911 called, EMS arrived at the facility at 7:55PM resumed CPR, they were able to obtain pulse 114 and BP ,[DATE]. Resident was transfer to hospital via 911 after obtaining pulse and blood pressure at 8:25PM. Physician called at 8:26PM and informed of resident condition and transfer to hospital for further evaluation. Resident RP called at 8:30PM and informed her of resident condition and transfer to hospital. Interview on [DATE] at 1:30PM, CNA #1 said she worked with CR #107 on [DATE] and recalled he was just very tired and sleeping most of the day which was unusual for him because he usually could not sleep and would be up in his chair. CNA #1 said she did not think it was him having a change in condition because the resident had been up and not able to sleep over the past few days and thought it had finally caught up with him and was just tired. The CNA said the Medication Aide (MA #1) was the staff member who found CR #107 unresponsive. She said the medication aide found him when she went to pass CR #107's medication. CNA #1 said the time was around 7:00PM when the Medication Aide found CR #107. CNA #1 had last seen CR #107 about 30 minutes before he was found unresponsive because she was in the room changing his roommate and said the resident was alive and resting when she last saw him. Interview on [DATE] at 1:50PM, CNA #3 said she saw CR #107 on [DATE] and had worked with him in the past. She said she remember the resident's legs were swollen and they were leaking. She said they encouraged the resident to keep his legs elevated but he liked to be sitting up in a chair in his room. She said the Medication Aide (MA #1) was who found CR #107 unresponsive and thinks she was there to pass the residents medication. CNA #3 could not recall the time but said it was after dinner. Record review of CR #107's progress notes revealed a late entry note created on [DATE] at 10:15PM to reflect the date of [DATE] at 8:30PM, when EMS arrived at 7:55PM, they (EMS) took over CPR from nursing staff. Note was entered by LVN #1. Record review of CR #107's progress notes revealed a late entry note created on [DATE] at 11:37PM to reflect the date of [DATE] at 12:54PM, clarification on vitals: ,[DATE]. Note was entered by LVN #1. Record review of CR #107's clinical record revealed there was no further monitoring of vitals after change in condition and low blood pressure outside of parameters were identified on [DATE] at 1:00PM. Phone interview on [DATE] at 11:00AM, LVN #1 said he could not recall the situation with CR #107 on [DATE], so he could not speak on what the resident vitals were or if they were taken. LVN #1 said if he takes vitals during an assessment or code he would document them in the progress notes. LVN #1 said he would only initiate CPR if there was no pulse and would not take vitals until he was able to obtain a pulse in code situation. LVN #1 was read late entry note he entered on [DATE] after CR #107 passed about clarification of vitals being ,[DATE], he could not recall when or what those vitals were clarification for. Interview on [DATE] at 3:00PM, the DON said LVN #1 had made some errors in his documentation and agreed the documentation did not show CR #107's blood pressure/vitals were rechecked after he had a noted low blood pressure and change in condition. She said she had reviewed the records the next day after CR #107 passed away ([DATE]) and saw the low blood pressure of ,[DATE]. She said she asked LVN #1 if the ,[DATE] was the residents blood pressure and he said he had rechecked the blood pressure and it was ,[DATE]. She said she told LVN #1 to document the ,[DATE] vitals and that's where the late entry notes on [DATE] came from. The DON was shown that CR #107's medication was still held despite the claim the blood pressure was ,[DATE] which would have been within the parameters to give the medication. The DON was also shown the blood pressure was documented in the progress notes and SBAR by LVN #1 on [DATE] to be ,[DATE] and ,[DATE]. The DON said she had also tried speaking with LVN #1 to clarify what happened and his documentation but also reported to her he could not recall anything. The DON said LVN #1 should have been documenting that vitals in his notes if he was checking them during his monitoring of CR #107. The DON said in a situation where the blood pressure was part of a resident change in condition, it should be rechecked as part of monitoring the resident. The DON said she knows the nursing practice of, if isn't documented then it did not happen. Record review of CR #1's EMS report dated [DATE] revealed the call from the facility was received at 7:49PM and EMS arrived on scene at 7:54PM. The report revealed in part, .arrived on scene . patient was in care of E-83 (another response unit) with CPR in progress. E-83 stated that nursing home staff was doing CPR upon their arrival and had an AED applied with one no shock advised given. E-83 had their AED attached upon arrival and that had a no shock advised and then was switched to M-75 (the response unit who created report) life pack. Staff thought it was about 15 minutes since they last saw the patient. Staff said the patient leg had started swelling today and the doctor was going to start the patient on antibiotics . Doctor on scene instructed to give calcium and sodium [MEDICATION NAME]. Return of spontaneous circulation (ROSC). A blood pressure and 12 lead electrocardiogram (ECG) was obtained . Patient transferred to the hospital . Record review of CR #1's hospital records dated [DATE] at 8:31PM revealed a chief complaint of [MEDICAL CONDITION] and the resident was found down. Further review of the hospital record revealed in part, .Per EMS, nursing home staff noticed the patient was down and began CPR 45 minutes pre time of arrival. When EMS arrived on scene, patient was asystole. Sugar was 54. EMS continued CPR, intubated patient, and patient 2 epi, 2 calcium, D10 and 1 [MEDICATION NAME]. Patients pulses came back after calcium was administered, with a wide complex rhythm. Upon arrival to ED, patient had pulses . Further review of the record revealed the residents time of death was 9:11PM on [DATE] from [MEDICAL CONDITION]. Interview on [DATE] at 11:00AM, LVN #1 said he worked the weekend shift from 6AM - 10PM. LVN #1 said he could not recall who CR #107 was and did not recall any events from [DATE]. LVN #1 said he did not recall calling a code blue or giving CPR to CR #107 and said that he gave CPR all the time and could not recall the situation with CR #107. Record review of the facility's Change in a Resident's Condition or Status policy (Revised (MONTH) 2009) revealed in part, .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been . d. a significant change in the resident's physical/mental/emotional condition; e. a need to alter the resident's medical treatment significantly; g. A need to transfer the resident to a hospital/treatment center; i. instructions to notify the physician of changes in the resident's condition . 6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition . Record review of the facility's Charting and Documentation policy (Revised (MONTH) (YEAR)) revealed in part, . 2. The following information is to be documented in the resident's medical record: a. Objective observation; b. Medications Administered; c. Treatments or services performed; d. Changes in resident's condition; d. Events, incidents or accidents involving the resident; and f. Progress toward or changes in care plan goals and objectives . 7. Documentation of procedures and treatments will include care - specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual (s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment . The Administrator, DON, and Corporate Nurse was notified of Immediate Jeopardy (IJ) on [DATE] at 3:50PM due to the above failures. A copy of the IJ template was provided and a Plan of removal was requested. The final plan of removal was accepted on [DATE] at 4:20PM after several revisions were made. [DATE] Immediate Jeopardy Plan of Removal - Quality of Care/Resident Rights Each resident will receive, and the facility will provide the necessary treatment to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care. Communicating changes in resident condition protocol is as follows. It will start immediately: The DON/ Licensed Nurses in the facility shall promptly notify the resident, his or her Attending Physician, and resident responsible party of changes in the resident's medical/mental condition and/or status. The facility will then monitor the patient as necessary to ensure the interventions are appropriate and effective. The DON/Licensed Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: 1. A significant change in the resident's physical/emotional/mental condition; 2. A need to alter the resident's medical treatment significantly; 3. A need to transfer the resident to a hospital/treatment center; 4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or responsible party when: A significant change of condition is a decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); Impacts more than one area of the resident's health status; The final decision regarding what constitutes a significant change in status is based on the judgment of the clinical staff and the guidance of the Physician. The DON/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1. Resident #1 (CR #107) no longer resides in the facility. 2. On [DATE] the facility completed an audit of residents currently residing in the facility to ensure any residents with B/P's within the last 7 days that were less than ,[DATE] or greater than ,[DATE] have been identified, an assessment completed, and findings communicated to their physician. 3. On [DATE], An audit of residents who have had any change in condition within the last 7 days, to include any patient with a wound, pacemaker or [MEDICAL CONDITION] to ensure effective follow up and monitoring was conducted. 4. On [DATE], the Clinical Services Director initiated an in-service regarding monitoring and properly assessing residents with noted changes in condition and B/P's outside of ordered parameters and timely notifying the physician of the changes in condition with the DON and nurse management staff. The Licensed Nurse is to continue monitoring the resident Blood Pressure until normal values are obtained. 5. On [DATE], the DON initiated an in-service with the Licensed Nursing Staff regarding monitoring and properly assessing residents with noted changes in condition and B/P's outside of ordered parameters and notifying the physician of the changes in condition. The Licensed Nurse is to continue monitoring the residents Blood Pressure a minimum of every 2 hours until normal values are obtained and the B/P's are properly documented in the resident record. Licensed Nurses not receiving this in-service on [DATE] will not be allowed to work until the in-service is completed. 6. On [DATE], the DON initiated an in-service with the Medication Aides on how to properly take a blood pressure right before medication administration. The in-service included completing a Stop and Watch Tool to communicate any blood pressure outside of parameters that was taken prior to medication administration in which a medication was held. The Stop and Watch Tool will be given promptly to the Licensed Nurse at the time the medication is being held. Certified Medication Aides not receiving this in-service on [DATE] will not be allowed to work until the in-service is completed. 7. On [DATE], the DON initiated an in-service with the Licensed Nursing Staff on promptly completing an assessment on residents when a Stop and Watch tool is completed on any resident who has had a medication held due to a blood pressure being outside of parameters. Licensed Nurses not receiving this in-service on [DATE] will not be allowed to work until the in-service is completed. 8. On [DATE], the DON initiated an in-service with the Medication Aides and the Licensed Nursing Staff on the timely documentation of medication administration. This in-service includes but is not limited to timely administration, timely documentation, accurate documentation, proper documentation for reasons and follow to medications being held or missed. Licensed Nurses and Medication Aides not receiving this in-service on [DATE] will not be allowed to work until the in-service is completed. 9. On [DATE], the DON initiated an in-service with all staff on completing a Stop and Watch Tool to communicate any changes in condition to the Licensed Nursing Staff. If Licensed Nursing staff does not respond immediately staff is required to immediately notify the DON and if no response then the administrator. Staff not receiving this in-service on [DATE] will not be allowed to work until the in-service is completed. 10. On [DATE], the DON initiated an in-service with Licensed Nurses on pain management, to include, assessing the resident for pain, administering pain medication, assessing for effectiveness of the intervention and notifying the physician if the intervention was ineffective. An emphasis was relayed to the Licensed Nursing staff on ensuring that their documentation should reflect accurate documentation of the care and services given to the patient. Licensed Nurses not receiving the in-service on [DATE] will not be allowed to work until the in-service is completed. 11. Newly hired Certified Medication Aides will be in-serviced on timely administration and documentation of medications, how to take a blood pressure, and communicating B/P's outside of parameters and medications being held via a Stop and Watch tool to Licensed Nurses upon hire and then annually thereafter. 12. Newly hired Licensed Nurses will be in-serviced on assessing changes in condition, assessing residents with B/P's outside of ordered parameters, prompt notification to the physician of a change in condition, timely documentation of medication administration, and pain management upon hire and annually thereafter. 13. Seven days a week the nurse manager/designee will monitor appropriate assessment of residents who are having changes in condition and B/P's ou (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide treatment and care that are resident centered, in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 17 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 was properly assessed and appropriate intervention provided when he had a significant change in his condition. Resident #1 was sent to [MEDICAL TREATMENT] after he was observed with altered mental status and upon his arrival the [MEDICAL TREATMENT] center, he was immediately transferred to the hospital and had to be intubated upon his arrival to the emergency room and was diagnosed with [REDACTED]. This failure affected one resident and placed him at risk of health decline and diminished quality of life. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Admission MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident's mental status was moderately impaired. Further review of the MDS revealed he had adequate hearing, clear speech, and had no issues with making himself understood and understanding others. MDS Mood interview revealed resident would feel tired or have little energy most of the time. MDS also revealed resident received [MEDICAL TREATMENT]. Record review of Resident #1's 14 - day MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 indicating the resident's mental status was moderately impaired. Further review of the MDS revealed he had adequate hearing, clear speech, and had no issues with making himself understood and understanding others. MDS Mood interview revealed resident would feel tired or have little energy most of the time and had poor appetite several days. MDS also revealed resident received [MEDICAL TREATMENT]. Record review of Resident #1's care plan dated 6/10/19 revealed a risk for deficit in memory, judgement, decision making and thought process. His interventions included: Ask yes or no questions to determine resident's needs, Cue, reorient and supervise as needed, give medication as per physician's orders [REDACTED]. Further review of the care plan dated 6/10/19 revealed Resident #1 was on Anticoagulant therapy and was at risk for sporadic bruising and Bleeding. His interventions included: Observe/document/report to physician PRN signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Resident #1's care plan dated 6/10/19 revealed resident needed [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. His interventions included: HD: [MEDICAL TREATMENT] 3 times weekly on Monday, Wednesday and Friday Chair time: 2:00 PM, HD: (MONTH) change dressing to [MEDICAL TREATMENT] on the right [MEDICATION NAME] access site only if soiled with excessive drainage and notify doctor, HD: Monitor [MEDICAL TREATMENT] catheter and dressing for signs/symptoms of infection every shift, HD: Monitor Graft or Fistula for signs of bleeding every shift, HD: Monitor Graft or Fistula for Thrill and Bruit every shift, HD: [MEDICAL TREATMENT] access location: Right Arm No Needle stick or BP taken in affected extremity, HD: Obtain and Document Vital Signs prior to resident leaving for [MEDICAL TREATMENT], HD: Obtain and Document Vital Signs upon resident return to facility from [MEDICAL TREATMENT]. Further review of the care plan revealed it was not updated to reflect Resident #1's [DIAGNOSES REDACTED]. Observation and interview on 7/17/19 at 11:59AM, Resident #1 was observed in bed being assisted by two staff members with eating his food. Resident was greeted, and he responded he was doing okay. Record review of Resident #2's facesheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His Diagnoses: [REDACTED]. Interview on 7/18/19 at 1:40PM, Resident #2 (Resident #1's roommate) said he was concerned about the treatment of [REDACTED].#1). He said Resident #1 had just returned from the hospital on [DATE]. Resident #2 said Resident #1 was not acting himself over the weekend on 7/6/19 and 7/7/19. Resident #2 said on 7/8/19 the resident looked unresponsive and was not responding to people like he usually would. Resident #2 said he was upset because the nursing staff came in to assess Resident #1 on 7/8/19 at 1:45PM and laughed at his condition saying he was okay. Resident #2 said the DON refused to listen to him when he tried to tell them something was wrong with Resident #1. Resident #2 said the transportation service company came to pick up Resident #1 for [MEDICAL TREATMENT] and they did not think he looked well either and wanted to take him to the hospital, but the DON told them to take the resident to [MEDICAL TREATMENT] and said he was fine. Resident #2 said he doesn't know what ended up happening to the Resident #1 after that but said Resident #1 did not come back to the facility until 7/15/19 but seemed back to his regular self when he returned. Resident #2 said he had a recording of Resident #1 not responding to staff upon assessment and them laughing at him. Resident #2 said in the recording, EMS could also be heard suggesting the resident be sent to the hospital and the staff saying to send the resident to [MEDICAL TREATMENT]. Resident #2 played recording for surveyor. Record review of an audio recording provided by Resident #2 revealed on 7/8/19 at 1:46PM, three voices were heard that were identified by Resident #2 as the DON, transportation personnel, unidentified staff member, and Resident #2. In the recording, Resident #2 was heard speaking with transportation personnel about Resident #1's condition. The DON was heard speaking with another staff member and they were discussing his condition. One of the nurses stated, we should take him to [MEDICAL TREATMENT] and It's not like he's unresponsive. The DON was heard then yelling out Resident #1's name repeatedly (6 times) and there was no response heard. The DON then proceeded to laugh with the other nurse and said Resident #1 was acting like, I'm sleeping, don't talk to me. The last thing heard on the recording was the DON yelling out Resident #1's name again and said, you need to talk to us, what's going on?. There was no response heard. On 7/18/19, follow up interview with Resident #1 about Resident #2 concerns were not completed due to Resident #1 being out of the facility. Record review of Resident #1's progress note dated 7/8/2019 at 1:45PM was entered late and revealed, Resident out for [MEDICAL TREATMENT] responsive but sleepy. No signs or symptoms of pain/shortness of breath/distress noted. Thrill and Bruit palpable. Assisted with ADLs and tolerated well. Skin warm/dry to touch. Ate breakfast 90% and lunch 50%. Vital signs 138/53, p66, r18, t97.9, 98% room air. Note entered by LVN #4. Record of Resident #1's progress note dated 7/8/2019 at 11:23PM revealed, Resident did not return from [MEDICAL TREATMENT]. Called transportation company and [MEDICAL TREATMENT] center but was not successful in location resident. Called hospital and was informed that resident was brought there from the [MEDICAL TREATMENT] center. Called family and were already aware that the resident was transported to the hospital. DON aware. Record review of Resident #1' progress notes dated 7/8/2019 at 11:26PM revealed, MD notified of transfer. Record review of Resident #1's progress notes dated 7/9/2019 at 7:38AM revealed, late entry. 7/8/2019 2pm. Total care resident. [MEDICAL TREATMENT] staff here to transport. Resident noted to be slow to respond. Charge nurse notified of resident's status. Unstageable pressure injury to rt heel remains unchanged. stable eschar. moisture associated wound to sacral treatment with med honey slow healing. Complete status on skin status given to resident on Friday after skin rounds with wound care MD. Note was entered by the wound care nurse. Record review of Resident #1's emergency room discharge summary revealed the initial greet date and time was 7/8/19 at 3:29PM. Resident #1 presented to be unresponsive and his history was obtained from the paramedic. Residents condition was not a sudden onset and was noted the onset occurred days ago (3). The resident's history of present illness revealed, [AGE] year-old male is brought in by EMS for evaluation of altered mental status today. Per ER RN, patient was last seen at normal baseline by patient's roommate three days ago. The patient's roommate had expressed concern to the nursing home nurse that he was not acting like himself, but the nursing home nurse felt as though patient was fine. Patient was then sent to [MEDICAL TREATMENT] and RN at [MEDICAL TREATMENT] felt the patient could not get dialyzed, sending patient to the emergency room . At normal baseline, the patient is usually alert and responsive. Further review of the summary revealed on 7/8/19 at 3:55PM Resident #1 was intubated. Record review of Resident #1's hospital records revealed a Non-contrast CT of the brain completed on 7/8/19 at 7:30PM and compared to last CT done on 1/31/19 with an impression of, 1. New area of encephalomalacia (a localized softening of the substance of the brain, due to bleeding or inflammation) in the right posterior parietal position consistent with subacute infarct (stroke). 2. Otherwise unchanged. Record review of Resident #1's hospital records revealed a Magnetic Resonance Imaging (MRI) to the brain without contrast on 7/10/19 at 1:48PM with an impression of, 1. Early subacute bilateral cerebellar infarcts. 2. Petechial hemorrhage (subcutaneous hemorrhage occurring in minute spots) is noted in the right cerebellar infarct. Record review of Resident #1's hospital records revealed neurology follow up dated 7/10/19 at 10:24PM that noted in part, .MRI of the brain reported with early subacute bilateral cerebellar infarcts. Petechial hemorrhages noted in the right cerebellar infarct . Impression: 1. History of altered mental status, followed by unresponsiveness, which appeared to be secondary to acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. 2. MRI of the brain reported with multiple bilateral cerebellar infarction with petechial hemorrhage . Record review of Resident #1's hospital discharge summary dated 7/15/19 revealed in part, . 1. Altered mental status, most likely due to subacute infarct. Now more alert and awake. Get patient occupational therapy . 4. [MEDICAL CONDITION], off mechanical ventilator - extubated . Record review of Resident #1 progress notes dated 7/15/2019 at 11:11PM revealed, Readmit resident to room [ROOM NUMBER]W under the care and services of doctor. Diagnoses: [REDACTED]. Alert and oriented x3 but forgetful. On renal diet but eats fish only, no other meat. Two persons assist and total care, incontinent of bowel/bladder, reposition every 2 hours, Room air @ 100%, Low bed (air mattress), sacral wound (stage 3) and pressure to bilateral heel. Range of motion present to all extremities, abdomen soft non-distended, bowel sound present on all four quadrants, lung sounds present. On [MEDICAL TREATMENT] Monday/Wednesday/Friday. Call light within reach. Vital signs 139/74, r18, t98.2, p80, o2 sat 100% room air. Interview on 7/18/19 at 12:25PM, the DON said she was told by another nurse about Resident #1 appearing to be tired on 7/8/19. The DON said she went down and assessed the resident and felt he was fine, and he just needed to go to [MEDICAL TREATMENT]. She said the resident vitals were okay and her assessment revealed the resident was just sleepy and tired and continued to say [MEDICAL TREATMENT] patients are like that when they need [MEDICAL TREATMENT]. The DON continued to say the resident would have been fine if he had [MEDICAL TREATMENT] completed but said the [MEDICAL TREATMENT] centers are very cautious and if they think anything is wrong with you, they'll send to the hospital and not do [MEDICAL TREATMENT]. The DON said she had reviewed Resident #1's hospital records and said the resident had [MEDICAL CONDITION] with high potassium and it was because he did not get [MEDICAL TREATMENT]. The DON denied there being any information of Resident #1 having any type of mild stroke and said the only issue was that the resident needed [MEDICAL TREATMENT]. The DON said she did not notify the physician about Resident #1's condition before he went out to [MEDICAL TREATMENT] because she did not feel the resident had a change in condition. She described Resident #1's mental state before he went to [MEDICAL TREATMENT] as not unresponsive, just very tired and sleepy because he needed [MEDICAL TREATMENT]. Interview on 8/21/19 at 12:24PM, Resident #1's RP said the resident had a history of [REDACTED]. RP said she got a call from the [MEDICAL TREATMENT] center on 7/8/19 that Resident was not acting like himself and could not stay awake, so they transferred the resident to the hospital where he was diagnosed with [REDACTED]. The RP said she did not know of Resident #1 having any altered mental status on 7/8/19 until the [MEDICAL TREATMENT] center called her. Interview on 8/21/19 at 2:12PM, the wound care nurse said she saw Resident #1 on 7/8/19 before he left for [MEDICAL TREATMENT]. She said she went in to do wound care and observed resident to be sleepier than his normal. She said the resident would wake up but was more groggy than usual. She said she told the nurse about her observation of the resident and saw her and the DON down in the room assessing him after she told them. The wound care nurse said she wasn't sure what happened after that because she went on to her next resident. Interview on 8/21/19 at 4:43PM, the DON said the facility protocol was to send residents out to hospital if they presented with even a small change in condition. The DON reiterated that she did not think Resident #1 had a change in condition and stated, the day of [MEDICAL TREATMENT] they're going to be lethargic and then said the hospital said they just did [MEDICAL TREATMENT] and the resident was okay after. The DON said they did not notify the physician before Resident #1 went to [MEDICAL TREATMENT] and said they were going to wait and see what his condition was when he returned from [MEDICAL TREATMENT], but he never came back. She said they notified the physician Resident #1 was in the hospital when he did not return from [MEDICAL TREATMENT]. Interview on 8/21/19 at 5:57PM, Resident #1's physician said he was not informed by the facility on 7/8/19 about Resident #1's altered mental status before he was sent out to [MEDICAL TREATMENT]. The physician said if they would have called him, he would have told them to send the resident to the hospital because Resident #1 had a history of [REDACTED]. The Physician said he had a standing order to send resident to hospital for altered mental status. Record review of the facility change in a resident's condition or status policy (Revised (MONTH) 2009) revealed 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 (changes in level of care, billing/payments, residents' rights, etc.) . The nurse supervisor/charge nurse will notify the resident Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; g. A need to transfer the resident to a hospital/treatment center; i. Instruction to notify the physician of changes in the resident condition .

Based on observation, interview, and record review, the facility failed to immediately consult with the physician when there was a change in condition for 1 of 17 residents (Resident #1) reviewed for notification of changes, in that; Resident #1's physician was not consulted when he had a change in his mental status. Resident #1 was sent to [MEDICAL TREATMENT] center to receive [MEDICAL TREATMENT] after AMS was identified by the facility's DON Resident #1 arrived at the [MEDICAL TREATMENT] center with a change in his condition and was immediately transferred to the hospital where he was intubated and diagnosed with [REDACTED]. These failures affected one resident and placed him at risk of delay in treatment and decline in health. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Admission MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident's mental status was moderately impaired. Further review of the MDS revealed he had adequate hearing, clear speech, and had no issues with making himself understood and understanding others. MDS Mood interview revealed resident would feel tired or have little energy most of the time. MDS also revealed resident received [MEDICAL TREATMENT]. Record review of Resident #1's 14 - day MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 indicating the resident's mental status was moderately impaired. Further review of the MDS revealed he had adequate hearing, clear speech, and had no issues with making himself understood and understanding others. MDS Mood interview revealed resident would feel tired or have little energy most of the time and had poor appetite several days. MDS also revealed resident received [MEDICAL TREATMENT]. Record review of Resident #1's care plan dated 6/10/19 revealed a risk for deficit in memory, judgement, decision making and thought process. His interventions included: Ask yes or no questions to determine resident's needs, Cue, reorient and supervise as needed, give medication as per physician's orders [REDACTED]. Further review of the care plan dated 6/10/19 revealed Resident #1 was on Anticoagulant therapy and was at risk for sporadic bruising and Bleeding. His interventions included: Observe/document/report to physician PRN signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Resident #1's care plan dated 6/10/19 revealed resident needed [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. His interventions included: HD: [MEDICAL TREATMENT] 3 times weekly on Monday, Wednesday and Friday Chair time: 2:00 PM, HD: (MONTH) change dressing to [MEDICAL TREATMENT] on the right [MEDICATION NAME] access site only if soiled with excessive drainage and notify doctor, HD: Monitor [MEDICAL TREATMENT] catheter and dressing for signs/symptoms of infection every shift, HD: Monitor Graft or Fistula for signs of bleeding every shift, HD: Monitor Graft or Fistula for Thrill and Bruit every shift, HD: [MEDICAL TREATMENT] access location: Right Arm No Needle stick or BP taken in affected extremity, HD: Obtain and Document Vital Signs prior to resident leaving for [MEDICAL TREATMENT], HD: Obtain and Document Vital Signs upon resident return to facility from [MEDICAL TREATMENT]. Observation and interview on 7/17/19 at 11:59AM, Resident #1 was observed in bed being assisted by two staff members with eating his food. Resident was greeted, and he responded he was doing okay. Record review of Resident #2's facesheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His Diagnoses: [REDACTED]. Interview on 7/18/19 at 1:40PM, Resident #2 (Resident #1's roommate) said he was concerned about the treatment of [REDACTED].#1). He said Resident #1 had just returned from the hospital on [DATE]. Resident #2 said Resident #1 was not acting himself over the weekend on 7/6/19 and 7/7/19. Resident #2 said on 7/8/19 the resident looked unresponsive and was not responding to people like he usually would. Resident #2 said he was upset because the nursing staff came in to assess Resident #1 on 7/8/19 at 1:45PM and laughed at his condition saying he was okay. Resident #2 said the DON refused to listen to him when he tried to tell them something was wrong with Resident #1. Resident #2 said the transportation service company came to pick up Resident #1 for [MEDICAL TREATMENT] and they did not think he looked well either and wanted to take him to the hospital, but the DON told them to take the resident to [MEDICAL TREATMENT] and said he was fine. Resident #2 said he doesn't know what ended up happening to the Resident #1 after that but said Resident #1 did not come back to the facility until 7/15/19 but seemed back to his regular self when he returned. Resident #2 said he had a recording of Resident #1 not responding to staff upon assessment and them laughing at him. Resident #2 said in the recording, EMS could also be heard suggesting the resident be sent to the hospital and the staff saying to send the resident to [MEDICAL TREATMENT]. Resident #2 played recording for surveyor. Record review of an audio recording provided by Resident #2 revealed on 7/8/19 at 1:46PM, three voices were heard that were identified by Resident #2 as the DON, transportation personnel, unidentified staff member, and Resident #2. In the recording, Resident #2 was heard speaking with transportation personnel about Resident #1's condition. The DON was heard speaking with another staff member and they were discussing his condition. One of the nurses stated, we should take him to [MEDICAL TREATMENT] and It's not like he's unresponsive. The DON was heard then yelling out Resident #1's name repeatedly (6 times) and there was no response heard. The DON then proceeded to laugh with the other nurse and said Resident #1 was acting like, I'm sleeping, don't talk to me. The last thing heard on the recording was the DON yelling out Resident #1's name again and said, you need to talk to us, what's going on?. There was no response heard. On 7/18/19, follow up interview with Resident #1 about Resident #2 concerns were not completed due to Resident #1 being out of the facility. Record review of Resident #1's progress note dated 7/8/2019 at 1:45PM was entered late and revealed, Resident out for [MEDICAL TREATMENT] responsive but sleepy. No signs or symptoms of pain/shortness of breath/distress noted. Thrill and Bruit palpable. Assisted with ADLs and tolerated well. Skin warm/dry to touch. Ate breakfast 90% and lunch 50%. Vital signs 138/53, p66, r18, t97.9, 98% room air. Note entered by LVN #4. Record of Resident #1's progress note dated 7/8/2019 at 11:23PM revealed, Resident did not return from [MEDICAL TREATMENT]. Called transportation company and [MEDICAL TREATMENT] center but was not successful in location resident. Called hospital and was informed that resident was brought there from the [MEDICAL TREATMENT] center. Called family and were already aware that the resident was transported to the hospital. DON aware. Record review of Resident #1' progress notes dated 7/8/2019 at 11:26PM revealed, MD notified of transfer. Record review of Resident #1's progress notes dated 7/9/2019 at 7:38AM revealed, late entry. 7/8/2019 2pm. Total care resident. [MEDICAL TREATMENT] staff here to transport. Resident noted to be slow to respond. Charge nurse notified of resident's status. Unstageable pressure injury to rt heel remains unchanged. stable eschar. moisture associated wound to sacral treatment with med honey slow healing. Complete status on skin status given to resident on Friday after skin rounds with wound care MD. Note was entered by the wound care nurse. Record review of Resident #1's emergency room discharge summary revealed the initial greet date and time was 7/8/19 at 3:29PM. Resident #1 presented to be unresponsive and his history was obtained from the paramedic. Residents condition was not a sudden onset and was noted the onset occurred days ago (3). The resident's history of present illness revealed, [AGE] year-old male is brought in by EMS for evaluation of altered mental status today. Per ER RN, patient was last seen at normal baseline by patient's roommate three days ago. The patient's roommate had expressed concern to the nursing home nurse that he was not acting like himself, but the nursing home nurse felt as though patient was fine. Patient was then sent to [MEDICAL TREATMENT] and RN at [MEDICAL TREATMENT] felt the patient could not get dialyzed, sending patient to the emergency room . At normal baseline, the patient is usually alert and responsive. Further review of the summary revealed on 7/8/19 at 3:55PM Resident #1 was intubated. Record review of Resident #1's hospital records revealed a Non-contrast CT of the brain completed on 7/8/19 at 7:30PM and compared to last CT done on 1/31/19 with an impression of, 1. New area of encephalomalacia (a localized softening of the substance of the brain, due to bleeding or inflammation) in the right posterior parietal position consistent with subacute infarct (stroke). 2. Otherwise unchanged. Record review of Resident #1's hospital records revealed a Magnetic Resonance Imaging (MRI) to the brain without contrast on 7/10/19 at 1:48PM with an impression of, 1. Early subacute bilateral cerebellar infarcts. 2. Petechial hemorrhage (subcutaneous hemorrhage occurring in minute spots) is noted in the right cerebellar infarct. Record review of Resident #1's hospital records revealed neurology follow up dated 7/10/19 at 10:24PM that noted in part, .MRI of the brain reported with early subacute bilateral cerebellar infarcts. Petechial hemorrhages noted in the right cerebellar infarct . Impression: 1. History of altered mental status, followed by unresponsiveness, which appeared to be secondary to acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. 2. MRI of the brain reported with multiple bilateral cerebellar infarction with petechial hemorrhage . Record review of Resident #1's hospital discharge summary dated 7/15/19 revealed in part, . 1. Altered mental status, most likely due to subacute infarct. Now more alert and awake. Get patient occupational therapy . 4. [MEDICAL CONDITION], off mechanical ventilator - extubated . Record review of Resident #1 progress notes dated 7/15/2019 at 11:11PM revealed, Readmit resident to room [ROOM NUMBER]W under the care and services of doctor. Diagnoses: [REDACTED]. Alert and oriented x3 but forgetful. On renal diet but eats fish only, no other meat. Two persons assist and total care, incontinent of bowel/bladder, reposition every 2 hours, Room air @ 100%, Low bed (air mattress), sacral wound (stage 3) and pressure to bilateral heel. Range of motion present to all extremities, abdomen soft non-distended, bowel sound present on all four quadrants, lung sounds present. On [MEDICAL TREATMENT] Monday/Wednesday/Friday. Call light within reach. Vital signs 139/74, r18, t98.2, p80, o2 sat 100% room air. Interview on 7/18/19 at 12:25PM, the DON said she was told by another nurse about Resident #1 appearing to be tired on 7/8/19. The DON said she went down and assessed the resident and felt he was fine, and he just needed to go to [MEDICAL TREATMENT]. She said the resident vitals were okay and her assessment revealed the resident was just sleepy and tired and continued to say [MEDICAL TREATMENT] patients are like that when they need [MEDICAL TREATMENT]. The DON continued to say the resident would have been fine if he had [MEDICAL TREATMENT] completed but said the [MEDICAL TREATMENT] centers are very cautious and if they think anything is wrong with you, they'll send to the hospital and not do [MEDICAL TREATMENT]. The DON said she had reviewed Resident #1's hospital records and said the resident had [MEDICAL CONDITION] with high potassium and it was because he did not get [MEDICAL TREATMENT]. The DON denied there being any information of Resident #1 having any type of mild stroke and said the only issue was that the resident needed [MEDICAL TREATMENT]. The DON said she did not notify the physician about Resident #1's condition before he went out to [MEDICAL TREATMENT] because she did not feel the resident had a change in condition. She described Resident #1's mental state before he went to [MEDICAL TREATMENT] as not unresponsive, just very tired and sleepy because he needed [MEDICAL TREATMENT]. Interview on 8/21/19 at 12:24PM, Resident #1's RP said the resident had a history of [REDACTED]. RP said she got a call from the [MEDICAL TREATMENT] center on 7/8/19 that Resident was not acting like himself and could not stay awake, so they transferred the resident to the hospital where he was diagnosed with [REDACTED]. The RP said she did not know of Resident #1 having any altered mental status on 7/8/19 until the [MEDICAL TREATMENT] center called her. Interview on 8/21/19 at 2:12PM, the wound care nurse said she saw Resident #1 on 7/8/19 before he left for [MEDICAL TREATMENT]. She said she went in to do wound care and observed resident to be sleepier than his normal. She said the resident would wake up but was more groggy than usual. She said she told the nurse about her observation of the resident and saw her and the DON down in the room assessing him after she told them. The wound care nurse said she wasn't sure what happened after that because she went on to her next resident. Interview on 8/21/19 at 4:43PM, the DON said the facility protocol was to send residents out to hospital if they presented with even a small change in condition. The DON reiterated that she did not think Resident #1 had a change in condition and stated, the day of [MEDICAL TREATMENT] they're going to be lethargic and then said the hospital said they just did [MEDICAL TREATMENT] and the resident was okay after. The DON said they did not notify the physician before Resident #1 went to [MEDICAL TREATMENT] and said they were going to wait and see what his condition was when he returned from [MEDICAL TREATMENT], but he never came back. She said they notified the physician Resident #1 was in the hospital when he did not return from [MEDICAL TREATMENT]. Interview on 8/21/19 at 5:57PM, Resident #1's physician said he was not informed by the facility on 7/8/19 about Resident #1's altered mental status before he was sent out to [MEDICAL TREATMENT]. The physician said if they would have called him, he would have told them to send the resident to the hospital because Resident #1 had a history of [REDACTED]. The Physician said he had a standing order to send resident to hospital for altered mental status. Record review of the facility change in a resident's condition or status policy (Revised (MONTH) 2009) revealed 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 (changes in level of care, billing/payments, residents' rights, etc.) . The nurse supervisor/charge nurse will notify the resident Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; g. A need to transfer the resident to a hospital/treatment center; i. Instruction to notify the physician of changes in the resident condition .

Based on observation, interview, and record review , the facility failed to ensure each resident had the right to be free from neglect for one of seven residents (CR#1) reviewed for abuse and neglect. The facility failed to ensure that CR#1's call for help for shortness of breath was answered in a timely manner. The facility failed to ensure that CR#1's roommate's (Resident #2) call for staff to help CR#1 was not answered in a timely manner. CR#1who had shortness of breath and chest pain asked his Roommate (Resident #2) to call 911 (Emergency Medical Services) when staff did not respond to his call light for 30 minutes. EMS responded to call made by CR #1's roommate (Resident #2) and transferred CR #1 to the hospital where he expired a few hours after he was admitted to the ER. These failures affected one closed record who died . Findings include: TX 891/Intake # 9 CR#1 Record review of CR#1's face sheet revealed an [AGE] year-old male initially admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR#1's Quarterly MDS dated [DATE], revealed the resident had clear speech, he was usually understood by others and he usually understood others. His Brief Interview for Mental Status (BIMS), score was 7 indicating severe cognitive impairment for daily living decision making. He had no behavioral symptoms or mood problems. He needed extensive assistance of one staff for bed mobility, extensive assistance of two staff for transfer, he needed limited assistance of one staff for locomotion, dressing, eating, toilet use and personal hygiene. CR#1 needed supervision of one staff for walking with a walker, he was frequently incontinent of bowel and bladder. The resident received speech therapy, physical therapy and occupational therapy. Further review of CR#1's Quarterly MDS dated [DATE], revealed the resident had no prognosis, condition or chronic disease that may result in a life expectancy of less than 6 months. Record review of CR#1's care plan dated [DATE] revealed a problem of potential for alteration in comfort/pain related to (R/T) chest pain/[MEDICAL CONDITION] and [MEDICAL CONDITION]. The goal to the care plan indicated CR#1 would be free of pain as evidenced by (AEB) verbalization of comfort through the next review date (no review date was given). Interventions to the care plan indicated the following: When documenting chest pain, describe associated symptoms such as SOB (shortness of breath), change in respirations, increased heart rate. Administer oxygen as ordered. Check/document lung fields for crackles, wheezing, and report to physician any abnormal finding. Give [MEDICATION NAME] or any other medication/treatment as ordered, monitor/document effectiveness or side effects. Record review of CR#1's facility Nurses Notes dated [DATE] at 1:31 a.m., revealed the following: On ([DATE]) at 11:00 p.m., 911 EMS (emergency Medical Services) came and asked for room [ROOM NUMBER] (CR#1's room) that patient called that he needed 911. The nurse took 911/EMS to room [ROOM NUMBER], when they reached the room, CR#1 roommate, Resident #2 stated he called 911(EMS) for his roommate (CR#1). 911/EMS asked CR #1 what happened, and he stated he had SOB (shortness of breath). 911 checked his vital signs as follows: Blood pressure ,[DATE], Pulse 76, O2 (Oxygen ) level 97% on room air with clear lung sounds. 911/EMS asked if he (CR #1) wanted to go to the hospital and he said yes , 911 took CR#1 to the hospital for evaluation. The resident representative, physician and Director of Nursing (DON) were notified. Record review of EMS notes dated [DATE] at 10:52 p.m., revealed EMS arrived on location to find 85-year male patient (CR#1), sitting on bed in no apparent distress, complaining of SOB, patient stated SOB started around 1600 (4:00 p.m.) this afternoon. Patient's (CR#1's) roommate (Resident#2) stated he called 911 (EMS) for his SOB because the nurses at the facility were not helping the patient. Upon arrival the patient (CR #1) stated he wanted to go to the hospital because staff on the scene (facility staff) weren't helping him, Patient (CR #1 at the time was oriented X 4 (oriented to person, time, place and situation .). Patient was assisted to stretcher. Baseline vital signs (VS) were obtained and appeared WNL (within normal limits). Lung sounds were clear and equal in all 4 lobes. Cardiac monitor attached and remained throughout the assessment. 12 lead ECG (Electronic Cardiac Monitor) performed showing sinus tach ([MEDICAL CONDITION] at 125 BPM (heart beats per minute). The patient (CR #1) was placed on O2 (oxygen) via NC (nasal canular) at 3 LPM (liters per minute) for supplemental O2 (oxygen). Resident was transported via EMS to hospital ER, monitored in route for negative changes, none noted, unloaded without incident and taken into ER for triage. Report given to ER nurse. Record review of CR#1's hospital emergency response service record dated [DATE] at 23:09 -23:11 (11:,[DATE]:11 p.m.) revealed CR #1's vital signs (VS) as follows: HR (heart rate) 124 BP (blood pressure) ,[DATE] RR (respiratory rate) 16 O2 sat (oxygen saturation) 92%. on 3 LPM (liters per minute) Record review of CR#1's hospital ER Nurses Notes dated [DATE] at 2338 (11:38p.m.), revealed ER first documented (initial) Vital Signs (VS) as follows: Pulse Ox (oxygen levels) - 94% B/P (blood pressure) - ,[DATE] Temperature - 37.5 Pulse - 125 Respirations - 32 Record review of CR#1's hospital ER Nurses Notes dated [DATE], at 1:31 a.m., revealed the following: 85 y/o M (year-old male) present to the ED (emergency department/ER) with SOB that began around 1600 (4:00 p.m.) today. EMS stated they were called by the Pt's (Patient's) Roommate Resident #2's for (CR# 1) SOB. ER Nurses notes further documented Patient (CR #1) reports experiencing difficulty breathing intermittently since (MONTH) (YEAR). Pt (CR #1) denies any other complaints as of now. Review of all systems negative except Respiratory: Reports Shortness of breath. Denies cough. Record review of CR#1's ER medical record revealed the following: Differential [DIAGNOSES REDACTED]. Record review of CR#1's ER Physician notes dated [DATE] at 1:15 a.m., read in parts . Physician called to bedside for change in patient status. Patient had a coughing fit, expectorated large phlegm bolus and became hypotensive SBP (systolic blood pressure) 70's with HR (heart rate) in 50's. CR #1 responsive and answering questions. Repeat EKG concerning for compete heart block. Transcutaneous pacer pads placed, and [MEDICATION NAME] (Medication) ordered. Patient continued to deteriorate. Talked to (another physician) to update patient (CR#1) situation. Returned to bedside where patient (CR #1) ceased breathing and lost pulse. Patient (CR#1) DNR (Do Not Resuscitate). As patient is DNR, pulseless apneic in cardiac standstill in two views time of death called at 1:31 a.m., on [DATE] Record review of CR #1's physician's documentation dated [DATE] at 1:31 a.m., revealed the following: Condition: Guarded, Stable Primary Impression:[MEDICAL CONDITION] Secondary Impression: Bilateral pneumonia, cardiopulmonary arrest, complete heart block, elevated troponin, lactic acidosis. Disposition Decision: Time 01:30 a.m. Date: [DATE] deceased (Yes). Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's admission MDS dated [DATE], revealed the resident had clear speech. His Brief Interview for Mental Status (BIMS), score was 13 indicating his cognitive for daily living decision making was intact. He had no behavioral symptoms and his mood symptoms were trouble falling asleep or staying asleep, and poor appetite or overeating. The MDS indicated it was very important to use the telephone in private and choose his bedtime. The MDS indicated the resident had no functional limitations with range in motion with his bilateral upper and lower extremities. Record review of Resident #2's clinical records revealed no documentation that he called EMS when staff did not respond to call light on [DATE]. Interview on [DATE] at 10:08 a.m., Resident #2 stated on the night of [DATE], his roommate (CR #1) asked Resident #2 to call the nurse as CR #1 was having difficulty breathing. Resident #2 stated he pushed the button (call light) on, the assigned Certified Nursing Assistant (CNA #1) responded and Resident #2 told CNA #1 to tell the Licensed Nurse (LVN #1) CR #1 was having a hard time breathing. Resident #2 stated after waiting for more than 30 minutes , no nurse came, and CR #1 asked me to call 911. Resident #2 stated CR#1 was not able to breath , he asked me to call 911 because they (Nursing staff) did not come, he was not able to breath. Resident #2 stated he used his cell phone to call 911. Resident #2 stated LVN#1 came into the room with 911 when they responded and arrived into the room. Interview on [DATE] at 10:20 a.m., the DON stated, on [DATE], CR#1 complained of chest pain, he had a history of [REDACTED]. CR#1 was okay, he wanted to go to the hospital. The DON stated he reviewed nurse's notes, he talked to the nurse by telephone the day the resident went to the ER and there was no need for further follow up on the incident. The DON stated he did not document his conversation with LVN #1. The DON stated he did not interview or take a statement from the CNA#1 or anyone who worked that night, there was no need as there was no incident. He stated there was no incident, CR #1 just wanted to go to the hospital and his (roommate) (Resident #2) called 911. The DON stated there were no issues that needed to be reported to state agency. the DON stated , It was non-issue. Interview on [DATE] at 10:30 a.m., the Administrator stated she did not find out about Resident #2's call light not being answered until [DATE], when the surveyors brought it to her attention. The Administrator stated she then talked to LVN #1 and she denied the call light was on for 30 minutes. Interview on [DATE] at 11:00 a.m., LVN #1 stated, just after 10:00 p.m., Resident #2 pressed his call light, at that time I answered, Resident #2 stated he was waiting on a Pizza delivery he ordered. LVN #1 stated she saw CR#1 sitting at his bedside with no complaints or symptoms of distress. The Pizza man delivered Pizza at that time and no call light went on after that. LVN #1 stated 911 came and said they responded to a call from Resident #2, that his roommate (CR #1) had SOB. LVN # 1 stated she went with EMS to the residents' room. The LVN #1 said Resident #2 told EMS that he called 911 because his roommate (CR#1) had SOB, nurses did not respond to call light, they did nothing for him and CR#1 asked Resident #2 to call 911 to take him (CR #1) to the hospital. LVN #1 said CR #1 was sitting at his bedside and said he felt like he was short of breath. LVN #1 stated 911/EMS checked CR #1's vital signs and they were all within normal limits and EMS said there was nothing wrong with him. LVN #1 said CR #1 told EMS that he still wanted to go to the hospital as he was short of breath and EMS took him to the hospital. Interview on [DATE] at 1:39 p.m., the Administrator stated, no incident report or investigation was documented, the DON talked to Resident #2 and did not document anything, my expectation is to talk to the resident (Resident #2), ask what situation took place. The Administrator stated she expected an incident report and investigation to have been done. The Administrator stated, There was no documentation or incident done by the DON and there was no reporting (reporting to state agency)of the incident. Interview on [DATE] at 1:40 p.m., CNA #1 denied she responded to a call light in room [ROOM NUMBER]. She stated she only saw when 911 arrived and LVN#1 went into the room with 911. CNA #1 stated that 911 said there was nothing wrong with CR #1 but 911 told the resident they could take him to the hospital if he wanted. Interview on [DATE] at 5:00 p.m., the Administrator who was the facility's abuse and neglect prohibition coordinator stated, she was not aware CR #1 and Resident #2 stated to EMS in the presence of LVN #1, that staff did not respond to call light and that was why the residents decided to call 911. The Administrator stated she was not made aware and there was no documentation the residents voiced staff did not respond to call light for 30 minutes and that was why CR #1 asked Resident #2 to call 911 to take him to the hospital. The Administrator stated, If we would have known about the issue we would have written up a grievance and investigated and followed up. The Administrator further stated, if they said they (CR #1 and Resident #2) put the call light on and no one came, that situation would have been a grievance issue, we would have followed up and done in- servicing. The Administrator further stated education would have been done. The Administrator stated she did not talk to CNA #1 about the incident. The Administrator stated the DON should have written up the Resident's concerns and followed up on the concerns and staff should have been educated. Facility policy on quality of care was requested at this time, the administrator reported the facility did not have one. Interview on [DATE] at 10:00 a.m., the Administrator stated she took documented statements from LVN #1 and CNA #1 regarding CR#1's discharge from the facility on [DATE]. Record review of LVN #1 and CNA #1 statements dated [DATE], revealed LVN #1 and CNA #1 were present in the residents' room on [DATE], when CR #1 and Resident #2 told EMS services that staff did not respond to the call light for 30 minutes and that was why the residents called 911. Record review of LVN #1's statement dated [DATE], revealed LVN #1 was present when the residents told EMS about calling EMS because staff failed to respond to call light. LVN # 1 documented in her statement she escorted and stayed with EMS throughout EMS assessing, discussing events leading the residents calling 911, CR #1 requesting to be taken to the hospital, placing the resident onto a stretcher and taking CR#1 from his room to ambulance. LVN #1 documented in her statement dated [DATE] regarding the event of [DATE], the writer (LVN#1), took 911 (EMS) to room [ROOM NUMBER]. When we reached the room (Resident #2's name) stated he called 911 for (CR #1) that complained that he was having Sob (SOB). 911 checked VS and WNL and his lungs sound clear. 911 told CR #1 everything checked out okay and asked if he wanted to go (go to) hospital and he said yes. A written statement with a subject of Event pertaining to CR #1 dated [DATE], documented by the Administrator for CNA #1 documented, On [DATE] at approximately 01:00 a.m., CNA #1 saw EMS personal in the hallway with (LVN #1's name) outside of room [ROOM NUMBER], I went down there to see what was going on and I saw EMS personal talk with CR #1's name. I overheard the EMS telling CR #1's name that they didn't find anything wrong with him and that everything was looking normal. EMS stated to CR #1's name that his vital signs were okay, and his heart looked ok after they checked him out on their equipment. They then asked him if he wanted to go to the hospital anyway despite everything looking normal and CR #1's name stated that he would like to go and get checked out. EMS then loaded the resident onto the stretcher and took him to the emergency room to get checked out. Record review of facility's policy on abuse prevention dated (MONTH) 2006 revealed our facility will not condone any form of resident abuse and will continually monitor our facility's policies , procedures, training program, systems etc. to assist in preventing resident abuse. The facility's goal is to achieve an abuse free environment. Out abuse prevention /intervention program includes but is not necessarily limited to the following : encouraging all personnel, residents, family member , visitors etc., to report any signs or suspected incidents of abuse to facility management immediately. Inquiries concerning our abuse prevention /intervention program should be directed to the Administration or to the Director of nursing services. Record review of facility's Accommodation of Needs policy dated (MONTH) 2009, revealed the following: Policy Statement- Our facility's environment and staff behaviors are directed towards assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. To accommodate individual needs and preferences, staff attitudes and behavior must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accidence with the resident's wishes. Staff shall interact with the residents in a way that accommodates the physical and sensory limitations of the residents, promote communication and dignity.

Based on observation , interview and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one resident (CR #1) of seven residents reviewed for quality of care, in that; CR#1's call for help for shortness of breath was not answered in a timely manner. CR#1's roommate's (Resident #2) call for staff to help CR#1 was not answered in a timely manner. CR#1who had shortness of breath and chest pain asked his Roommate (Resident #2) to call 911 (Emergency Medical Services) when staff did not respond to his call light for 30 minutes. EMS responded to call made by CR #1's roommate (Resident #2) and transferred CR #1 to the hospital where he expired a few hours after he was admitted to the ER. These failures affected one closed record who died . Findings include: TX 891/Intake # 9 CR#1 Record review of CR#1's face sheet revealed an [AGE] year-old male initially admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR#1's Quarterly MDS dated [DATE], revealed the resident had clear speech, he was usually understood by others and he usually understood others. His Brief Interview for Mental Status (BIMS), score was 7 indicating severe cognitive impairment for daily living decision making. He had no behavioral symptoms or mood problems. He needed extensive assistance of one staff for bed mobility, extensive assistance of two staff for transfer, he needed limited assistance of one staff for locomotion, dressing, eating, toilet use and personal hygiene. CR#1 needed supervision of one staff for walking with a walker, he was frequently incontinent of bowel and bladder. The resident received speech therapy, physical therapy and occupational therapy. Further review of CR#1's Quarterly MDS dated [DATE], revealed the resident had no prognosis, condition or chronic disease that may result in a life expectancy of less than 6 months. Record review of CR#1's care plan dated [DATE] revealed a problem of potential for alteration in comfort/pain related to (R/T) chest pain/[MEDICAL CONDITION] and [MEDICAL CONDITION]. The goal to the care plan indicated CR#1 would be free of pain as evidenced by (AEB) verbalization of comfort through the next review date (no review date was given). Interventions to the care plan indicated the following: When documenting chest pain, describe associated symptoms such as SOB (shortness of breath), change in respirations, increased heart rate. Administer oxygen as ordered. Check/document lung fields for crackles, wheezing, and report to physician any abnormal finding. Give [MEDICATION NAME] or any other medication/treatment as ordered, monitor/document effectiveness or side effects. Record review of CR#1's facility Nurses Notes dated [DATE] at 1:31 a.m., revealed the following: On ([DATE]) at 11:00 p.m., 911 EMS (emergency Medical Services) came and asked for room [ROOM NUMBER] (CR#1's room) that patient called that he needed 911. The nurse took 911/EMS to room [ROOM NUMBER], when they reached the room, CR#1 roommate, Resident #2 stated he called 911(EMS) for his roommate (CR#1). 911/EMS asked CR #1 what happened, and he stated he had SOB (shortness of breath). 911 checked his vital signs as follows: Blood pressure ,[DATE], Pulse 76, O2 (Oxygen ) level 97% on room air with clear lung sounds. 911/EMS asked if he (CR #1) wanted to go to the hospital and he said yes , 911 took CR#1 to the hospital for evaluation. The resident representative, physician and Director of Nursing (DON) were notified. Record review of EMS notes dated [DATE] at 10:52 p.m., revealed EMS arrived on location to find 85-year male patient (CR#1), sitting on bed in no apparent distress, complaining of SOB, patient stated SOB started around 1600 (4:00 p.m.) this afternoon. Patient's (CR#1's) roommate (Resident#2) stated he called 911 (EMS) for his SOB because the nurses at the facility were not helping the patient. Upon arrival the patient (CR #1) stated he wanted to go to the hospital because staff on the scene (facility staff) weren't helping him, Patient (CR #1 at the time was oriented X 4 (oriented to person, time, place and situation .). Patient was assisted to stretcher. Baseline vital signs (VS) were obtained and appeared WNL (within normal limits). Lung sounds were clear and equal in all 4 lobes. Cardiac monitor attached and remained throughout the assessment. 12 lead ECG (Electronic Cardiac Monitor) performed showing sinus tach ([MEDICAL CONDITION] at 125 BPM (heart beats per minute). The patient (CR #1) was placed on O2 (oxygen) via NC (nasal canular) at 3 LPM (liters per minute) for supplemental O2 (oxygen). Resident was transported via EMS to hospital ER, monitored in route for negative changes, none noted, unloaded without incident and taken into ER for triage. Report given to ER nurse. Record review of CR#1's hospital emergency response service record dated [DATE] at 23:09 -23:11 (11:,[DATE]:11 p.m.) revealed CR #1's vital signs (VS) as follows: HR (heart rate) 124 BP (blood pressure) ,[DATE] RR (respiratory rate) 16 O2 sat (oxygen saturation) 92%. on 3 LPM (liters per minute) Record review of CR#1's hospital ER Nurses Notes dated [DATE] at 2338 (11:45 p.m.), revealed ER first documented (initial) Vital Signs (VS) as follows: Pulse Ox (oxygen levels) - 94% B/P (blood pressure) - ,[DATE] Temperature - 37.5 Pulse - 125 Respirations - 32 Record review of CR#1's hospital ER Nurses Notes dated [DATE], at 1:31 a.m., revealed the following: 85 y/o M (year-old male) present to the ED (emergency department/ER) with SOB that began around 1600 (4:00 p.m.) today. EMS stated they were called by the Pt's (Patient's) Roommate Resident #2's for (CR# 1) SOB. ER Nurses notes further documented Patient (CR #1) reports experiencing difficulty breathing intermittently since (MONTH) (YEAR). Pt (CR #1) denies any other complaints as of now. Review of all systems negative except Respiratory: Reports Shortness of breath. Denies cough. Record review of CR#1's ER medical record revealed the following: Differential [DIAGNOSES REDACTED]. Record review of CR#1's ER Physician notes dated [DATE] at 1:15 a.m., read in parts . Physician called to bedside for change in patient status. Patient had a coughing fit, expectorated large phlegm bolus and became hypotensive SBP (systolic blood pressure) 70's with HR (heart rate) in 50's. CR #1 responsive and answering questions. Repeat EKG concerning for compete heart block. Transcutaneous pacer pads placed, and [MEDICATION NAME] (Medication) ordered. Patient continued to deteriorate. Talked to (another physician) to update patient (CR#1) situation. Returned to bedside where patient (CR #1) ceased breathing and lost pulse. Patient (CR#1) DNR (Do Not Resuscitate). As patient is DNR, pulseless apneic in cardiac standstill in two views time of death called at 1:31 a.m., on [DATE] Record review of CR #1's physician's documentation dated [DATE] at 1:31 a.m., revealed the following: Condition: Guarded, Stable Primary Impression:[MEDICAL CONDITION] Secondary Impression: Bilateral pneumonia, cardiopulmonary arrest, complete heart block, elevated troponin, lactic acidosis. Disposition Decision: Time 01:30 a.m. Date: [DATE] deceased (Yes). Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's admission MDS dated [DATE], revealed the resident had clear speech. His Brief Interview for Mental Status (BIMS), score was 13 indicating his cognitive for daily living decision making was intact. He had no behavioral symptoms and his mood symptoms were trouble falling asleep or staying asleep, and poor appetite or overeating. The MDS indicated it was very important to use the telephone in private and choose his bedtime. The MDS indicated the resident had no functional limitations with range in motion with his bilateral upper and lower extremities. Record review of Resident #2's records [DATE] revealed no documentation that he called EMS when staff did not respond to call light. Interview on [DATE] at 10:08 a.m., Resident #2 stated on the night of [DATE], his roommate (CR #1) asked Resident #2 to call the nurse as CR #1 was having difficulty breathing. Resident #2 stated he pushed the button (call light) on, the assigned Certified Nursing Assistant (CNA #1) responded and Resident #2 told CNA #1 to tell the Licensed Nurse (LVN #1) CR #1 was having a hard time breathing. Resident #2 stated after waiting for more than 30 minutes , no nurse came, and CR #1 asked me to call 911. Resident #2 stated CR#1 was not able to breath , he asked me to call 911 because they (Nursing staff) did not come, he was not able to breath. Resident #2 stated he used his cell phone to call 911. Resident #2 stated LVN#1 came into the room with 911 when they responded and arrived into the room. Interview on [DATE] at 10:20 a.m., the DON stated, on [DATE], CR#1 complained of chest pain, he had a history of [REDACTED]. CR#1 was okay, he wanted to go to the hospital. The DON stated he reviewed nurse's notes, he talked to the nurse by telephone the day the resident went to the ER and there was no need for further follow up on the incident. The DON stated he did not document his conversation with LVN #1. The DON stated he did not interview or take a statement from the CNA#1 or anyone who worked that night, there was no need as there was no incident. He stated there was no incident, CR #1 just wanted to go to the hospital and his (roommate) (Resident #2) called 911. The DON stated there were no issues that needed to be reported to state agency. the DON stated , It was non-issue. Interview on [DATE] at 10:30 a.m., the Administrator stated she did not find out about Resident #2's call light not being answered until [DATE], when the surveyors brought it to her attention. The Administrator stated she then talked to LVN #1 and she denied the call light was on for 30 minutes. Interview on [DATE] at 11:00 a.m., LVN #1 stated, just after 10:00 p.m., Resident #2 pressed his call light, at that time I answered, Resident #2 stated he was waiting on a Pizza delivery he ordered. LVN #1 stated she saw CR#1 sitting at his bedside with no complaints or symptoms of distress. The Pizza man delivered Pizza at that time and no call light went on after that. LVN #1 stated 911 came and said they responded to a call from Resident #2, that his roommate (CR #1) had SOB. LVN # 1 stated she went with EMS to the residents' room. The LVN #1 said Resident #2 told EMS that he called 911 because his roommate (CR#1) had SOB, nurses did not respond to call light, they did nothing for him and CR#1 asked Resident #2 to call 911 to take him (CR #1) to the hospital. LVN #1 said CR #1 was sitting at his bedside and said he felt like he was short of breath. LVN #1 stated 911/EMS checked CR #1's vital signs and they were all within normal limits and EMS said there was nothing wrong with him. LVN #1 said CR #1 told EMS that he still wanted to go to the hospital as he was short of breath and EMS took him to the hospital. Interview on [DATE] at 1:39 p.m., the Administrator stated, no incident report or investigation was documented, the DON talked to Resident #2 and did not documented anything, my expectation is to talk to the resident (Resident #2), ask what situation took place. The Administrator stated she expected and incident report and investigation to have been done. The Administrator stated, There was no documentation or incident done by the DON and there was no reporting (reporting to state agency)of the incident. Interview on [DATE] at 1:40 p.m., CNA #1 denied she responded to a call light in room [ROOM NUMBER]. She stated she only saw when 911 arrived and LVN#1 went into the room with 911. CNA #1 stated that 911 said there was nothing wrong with CR #1 but 911 told the resident they could take him to the hospital if he wanted. Interview on [DATE] at 5:00 p.m., the Administrator who was the facility's abuse and neglect prohibition coordinator stated, she was not aware CR #1 and Resident #2 stated to EMS in the presence of LVN #1, that staff did not respond to call light and that was why the residents decided to call 911. The Administrator stated she was not made aware and there was no documentation the residents voiced staff did not respond to call light for 30 minutes and that was why CR #1 asked Resident #2 to call 911 to take him to the hospital. The Administrator stated, If we would have known about the issue we would have written up a grievance and investigated and followed up. The Administrator further stated, if they said they (CR #1 and Resident #2) put the call light on and no one came, that situation would have been a grievance issue, we would have followed up and done in- servicing. The Administrator further stated education would have been done. The Administrator stated she did not talk to CNA #1 about the incident. The Administrator stated the DON should have written up the Resident's concerns and followed up on the concerns and staff should have been educated. Facility policy on quality of care was requested at this time, the administrator reported the facility did not have one. Interview on [DATE] at 10:00 a.m., the Administrator stated she took documented statements from LVN #1 and CNA #1 regarding CR#1's discharge from the facility on [DATE]. Record review of LVN #1 and CNA #1 statements dated [DATE], revealed LVN #1 and CNA #1 were present in the residents' room on [DATE], when CR #1 and Resident #2 told EMS services that staff did not respond to the call light for 30 minutes and that was why the residents called 911. Record review of LVN #1's statement dated [DATE], revealed LVN #1 was present when the residents told EMS about calling EMS because staff failed to respond to call light. LVN # 1 documented in her statement she escorted and stayed with EMS throughout EMS assessing, discussing events leading the residents calling 911, CR #1 requesting to be taken to the hospital, placing the resident onto a stretcher and taking CR#1 from his room to ambulance. LVN #1 documented in her statement dated [DATE] regarding the event of [DATE], the writer (LVN#1), took 911 (EMS) to room [ROOM NUMBER]. when we reached the room (Resident #2's name) stated he called 911 for (CR #1) that complained that he was having Sob (SOB). 911 checked VS and WNL and his lungs sound clear. 911 told CR #1 everything checked out okay and asked if he wanted to go (go to) hospital and he said yes. A written statement with a subject of Event pertaining to CR #1 dated [DATE], documented by the Administrator for CNA #1 documented, On [DATE] at approximately 01:00 a.m., CNA #1 saw EMS personal in the hallway with (LVN #1's name) outside of room [ROOM NUMBER], I went down there to see what was going on and I saw EMS personal talk with CR #1's name. I overheard the EMS telling CR #1's name that they didn't find anything wrong with him and that everything was looking normal. EMS stated to CR #1's name that his vital signs were okay, and his heart looked ok after they checked him out on their equipment. They then asked him if he wanted to go to the hospital anyway despite everything looking normal and CR #1's name stated that he would like to go and get checked out. EMS then loaded the resident onto the stretcher and took him to the emergency room to get checked out. Record review of facility's Accommodation of Needs policy dated (MONTH) 2009, revealed the following: Policy Statement- Our facility's environment and staff behaviors are directed towards assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. To accommodate individual needs and preferences, staff attitudes and behavior must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accidence with the resident's wishes. Staff shall interact with the residents in a way that accommodates the physical and sensory limitations of the residents, promote communication and dignity.

Based on observation , interview and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of five residents (Resident #5 and #9) reviewed for quality of care, in that; Resident #5 with severe itching [MEDICAL CONDITION] was not provided alternative interventions to prevent her from scratching her skin and causing multiple open areas to her buttocks, legs and abdominal area. Resident #5 's was not taken to an ordered dermatologist follow up appointment. Resident #5 was not provided timely finger nail care resulting in the resident scratching open multiple skin areas. Resident #9 identified to have weight loss and who required assistance with feeding was not provided assistance with her feeding as care planned. Resident #9 identified to have weight loss and who required weekly weight as ordered by physician was not weighed weekly. These failures affected two residents who were placed at increased risk of health decline and diminished quality of life. Findings include: TX 821/ 4 Resident #5 Record review of Resident #5's Face sheet dated 11/10/18 revealed she was an [AGE] year-old female originally admitted to the facility 09/06/17 and readmitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] revealed a BIMS score of 8 indicating moderate cognitive impairment. She required extensive assistance of one staff for dressing, toilet use, and personal hygiene. She had no impairments in range of motion to upper and lower extremities . The MDS revealed the resident had [MEDICAL CONDITION] as an active [DIAGNOSES REDACTED]. Record review of Resident #5's care plan dated 01/31/18, revised on 09/12/18 read in part . Resident #5 exhibits actual impairment due to self-inflicting scratches continuously until she bleeds, she is at risk for further skin breakdown. Goal - Resident #5 will be free from injury/infection through 12/29/18. Intervention: Resident #5's nails will be cut to prevent scratching, Keep Resident #5's finger nails trimmed and filed to prevent the resident from sustaining injury should she scratch herself. Record review of Resident#5 dermatologist report revealed the dermatologist saw the resident on 06/18/18 for complaint of itching, she was diagnosed with [REDACTED]. Further review of report revealed dermatologist ordered new medications and follow up appointment as follows: [MEDICATION NAME] cream - To apply to all areas for 7days then every other day, alternate with (OTC) moisture lotion [MEDICATION NAME] cream 400mg - Apply to open excoriated [MEDICAL CONDITION] on body twice a day for 1-2 weeks till area are healed. [MEDICATION NAME]/[MEDICATION NAME] cream - Alternate every other day twice a day to buttock and vaginal area. Follow up with dermatologist 2-3weeks after this visit. Record review of Resident #5's clinical records revealed the facility did not make a follow up appointment within 2-3weeks as ordered. There was no documentation that indicated Resident #5 was sent for her follow up appointment as ordered by the dermatologist 2-3 weeks after the initial visit on 06/18/18. Record review of Resident #5's progress notes dated 11/9/18 at 2:26pm and 11/9/18 at 9:12pm, revealed Resident #5 continued to have itchy skin which she continuously scratched causing open skin areas on her buttocks, legs and abdominal area. Record review of Resident #5's record revealed Resident #5 was saw the dermatologist again on 08/31/18. Record review of Resident #5's dermatologist discharge summary dated 06/18/18 provided by the facility revealed summary did not have the page that stated Resident #5 should come back in 2 - 3 weeks for follow up with the dermatologist. Record review of Resident #5's Progress Notes dated 11/9/18 at 2:26pm., written by LVN #2 read in part Resident is alert, continues to scratch at her buttocks causing open wound. Record review of Resident #5's Progress Notes dated 11/9/18 at 9:12pm written by LVN #2 read in part Resident observed to be scratching self. Record review of Resident #5's Progress Notes dated 11/9/18 at 9:12pm, written by LVN #2 read in part offered nail trimming, resident stated my family member will do it for me, darling observed to be scratching self. Record review of Resident #5's Progress Notes dated 11/9/18 through 11/16/18 revealed no documentation indicating the resident's family member was notified of the resident's request to trim her finger nails. Record review of pictures sent in via email by the family member revealed resident has papule [MEDICAL CONDITION] that are disintegrated on her back, abdomen, vaginal area, segregated and pinky red on buttock areas. Scratch marks were also identified on these areas. Observation and interview of Resident #5 with LVN #1 on 11/16/18 at 11:55am, revealed Resident #5 was in bed awake. The resident was scratching her skin. Her finger nails were noted to be long and had brown substances underneath. Further observation of the resident's skin revealed she had blister like [MEDICAL CONDITION] that were circular, segregated and pinkish red on her buttocks, legs and abdominal areas. These [MEDICAL CONDITION] had scratch marks on and around it . In an attempted interview , Resident #5 was asked how she was doing but her response was itchy, itchy, itchy . as continued to scratch the left side of her buttock. Interview on 11/16/18 at 12:10p.m., LVN #1 said Resident #5's family member liked the resident to go to the salon to get her nails polished.LVN#1 could not tell why the resident's finger nails was not trimmed. Interview with the DON on 11/16/18 at 12:15pm, he said Resident #5's finger nails were long and needed to be trimmed down, he said he will get staff to trim them down. The DON further said sometimes he trimmed the resident's finger nails himself and will continue to make sure the fingernails nails were trimmed down always. Interview on 11/16/18 at 1:25p.m, LVN #4 said CNAs were responsible for the nail care of resident that are not diabetic during their shower or as needed, she said the nurses does the nail care of residents with diabetic. Interview on 11/16/18 at 2:00pm, CNA #B, said the CNAs were supposed to check on residents' finger nails every shower day. She said aides were supposed to trim finger nails down as needed. CNA #B said if a resident refused care, she would inform the nurse and document it. Interview on 11/21/18 at 10:25a.m., the DON was asked about other interventions that could prevent Resident #5 from scratching open her skin, the DON said the facility could not use mittens because it would be considered a restraint. The DON said he will discuss use of mittens with the resident's doctor. Interview on 11/16/18 at 11:00a.m., with NP #1, she said she first realized the skin issues on Resident #5's skin about 8 months ago when she saw the resident had flaky skin. NP#1 said she ordered [MEDICAL CONDITION] cream which did not work effectively as expected. NP#1 said she sent the resident to see the dermatologist about three times this year. Surveyor asked if she knew about a follow up appointment in the month of June, NP#1 said there was none, she wrote new referral orders whenever the resident was sent out to see the dermatologist. Interview on 11/16/18 at 11:07am, the Dermatologist office Staff#1 said Resident #5 was first seen in their office on 6/18/18 for skin related diseases. She stated the resident was prescribed some medications and she was asked to come back for follow up in 2 -3 weeks time. She stated whenever a resident comes for treatment, the office gives copies of the visit summary and all doctor's order to the resident to take back to the facility. She said the office also call for clarification on the documents sent with the resident, the family or the ambulance services to make sure they are aware of any doctor's order included in the documents. The Dermatologist office Staff #1 sent Resident#5's discharge summary to surveyor for verification. Record review of Resident#5's records sent by the dermatologist's office dated 6/18/18 read in part . Follow up with dermatologist 2-3weeks after this visit. Interview on 11/16/18 at 2:37p.m, the DON and Administrator said they were not aware Resident #5's dermatologist ordered a follow up visit that was missed. Interview with the DON on 11/21/18 at 10:25am., he said they (facility) had been working on Resident#5 to make sure she gets a good care. Surveyor asked him, if he had sent the resident to the hospital for evaluation when treatments were ineffective, the DON said the resident had not been sent to the hospital. The DON said he believed it was not an emergency situation that warrants the resident to be taken to the hospital. The DON said the skin issues had been going on for a while, he said he communicated with the doctors who told him what to do. He was not able to specifically state what the doctor instructed the facility to do but reported the resident saw the dermatologist. Interview with the Administrator on 11/21/18 at 10:40a.m., she said she thinks the doctor wrote somewhere that the resident's skin cannot be treated with medication, she said she was not sure. The Administrator said they were working with some doctors but did not say which doctors and what the doctor's plans were. Facility's policy on following physician order [REDACTED]. Interview with the Administrator on 11/21/18 at 10:40a.m., she said she thinks the doctor wrote somewhere that the resident's skin cannot be treated with medication, she said she was not sure. the Administrator said they are working with some doctors but did not say which doctors and what the doctor's plans were. Resident #9 Record review of Resident #9's face sheet dated 6/5/18 revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] and re- admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #9's care plan dated 09/07/13, revised on 04/30/18 revealed the following: Focus: partial documentation . Resident refuses to allow staff cuts her long nail at times and will only allow staff to clean, trim and polish them. Goal: Resident will allow staff to trim nails 1-2 time per month and cut her nail to prevent injury. Intervention: Keep nails as clean as possible on shower days. Focus: Resident require therapeutic regular- puree diet with regular consistency for nutritional support with potential for trending weight gain/loss related to impaired cognition, dementia and history of gain/loss. Goal: Resident #9 will have adequate nutrition by consuming 75 - 100% of meals through 12/29/18. Intervention: Resident #9 will be spoon fed at meal time. Record review of shower sheet for Resident #9 for the following days 10/23/18, 10/30/18,11/06/18 did not reveal any nurses' documentation on refusal of finger nails care Record review of Resident #9's MDS dated [DATE] revealed a BIMS score of 03, indicating severe cognition impairment. She required total dependence of one staff for the following ADL care: dressing, toilet use, and personal hygiene. She required extensive assistance of one staff for eating. Range of motion was coded as having impairment on both sides for upper and lower extremities. The MDS did not reveal the resident exhibited any behaviors including rejection of care from staff. Further record review of Resident #9's MDS dated [DATE] revealed the resident had weight loss of 5% or more in the last month or loss of 10% or more in the last 6months. The MDS revealed weight loss was coded as 2 indicating Resident #9 was not on a physician prescribed weight loss regimen. Record review of Resident #9's weight log revealed: - 6/28/18 - 173lbs - 7/10/18 - 158lbs - 8/10/18 - 164lbs - 9/10/18 - 160lbs - 10/10/18 - 162.2lbs - 11/10/18 - 159lbs Record review of Resident #9 physician order [REDACTED]. Record review of Resident #9 physician order [REDACTED]. Record review of Resident #9 chart and progress notes from 10/02/18 through 11/16/18 did not revealed weekly weight for resident #9. Record review of Resident #9 chart and progress notes from 6/28/18 through 11/16/18 did not reveal any other intervention put in place to ensure increased in quality of life for weight loss of 10.5% in 180 days apart from the med pass. Record review of resident #9 progress note on 11/16/18 at 4:34pm, after surveyor left the facility revealed new order by the physician for [MEDICATION NAME] 40mg 1tab po TID x 3days, multivitamin po daily, speech evaluation, weekly weight x4 and restorative dining. Record review of shower sheet for Resident #9 for the following days 10/23/18, 10/30/18,11/06/18 did not reveal any nurses' documentation on refusal of finger nails care. Observation of Resident #9 on 11/16/18 at 7:25a.m, revealed Resident #9 was sitting upright on her bed with breakfast tray on an over bed table feeding herself, she was observed feeding herself with about 60% of the food on her chest, food was observed not going directly to her mouth. Her finger nails were long with brown dirty particles underneath them . Interview on 11/16/18 at 7:40 a.m., CNA #A stated she was supposed to feed Resident #9, she said she just went out to get something, Surveyor asked how long she has been out of the room, she said just now, surveyor told CNA# A that she has been in the room for the past 15 minutes. CNA #A said there are two CNAs on the hall every day, she said one CNA would go to the dining room to assist with residents with feeding. She said one CNA would be on the hall to assist residents who needed to be fed. She said she would feed residents one by one until all residents are been fed. She said resident's food trays were supposed to be kept out of their sight until staff are ready to assist them. CNA #A, said she was not supposed to trim Resident #9's finger nails, she said the resident was diabetic. She said the nurses were responsible for trimming diabetic residents' nails. Interview on 11/16/18 at 8:10a.m, LVN #3 said the CNAs were not supposed to leave the meal trays in the room with residents who need feeding assistance . LVN#3 said the CNAs were to keep the tray out of the resident's sight until they were ready to assist them. She said the nurses at times helped the CNAs when there are a lot of residents to be assisted. She said the nurses were responsible for trimming diabetic resident's finger nails. She was not able to say why Resident #9's finger nails were not trimmed. Interview on 11/16/18 at 8:27am, LVN #1 said two CNAs works on the floor. During meal time, one would go to the dining room and the other one would be on the hall. She said if she was not busy, she could assist the CNA on the hall. She said the CNAs were not supposed to leave the meal trays in the residents rooms until they were ready to assist the residents with their meals. Interview on 11/16/18 at 1:25pm, LVN #4 said CNAs were expected not to leave the meal trays residents who need feeding assistance until they were ready to help them. She said at times, the Medication aides and Nurses assist the residents with their meals if they CNAs were busy. Interview on 11/16/18 at 2:00pm, CNA #B said they were taught not to leave trays in the sight of resident who needs feeding assistance She said the meal trays should be brought to the resident when they aides were ready to assist them. Interview on 11/16/18 at 2:37pm, the DON was asked why Resident #9 was not placed on other alternative intervention for the weight loss of 10.5% for 180 days, the DON said resident was given med pass. The DON said he will follow up with the dietician and the physician to see if something else will be given. Interview on 11/21/18 at 11:37a.m., the DON was asked why Resident #9 was not weighed according to the physician order, the DON said he weighed the resident monthly himself and document it. He did not state the reason the resident was not weighed weekly as ordered. Record review of Facility's Care of Fingernails/Toenails Policy, revised 04/2007, revealed Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Facility's policy on following physician order [REDACTED]. Facility's policy on weight assessment and intervention not dated revealed multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents.

Based on interview and record review, the facility failed to implement their policies and procedures that prohibit neglect, including injuries of unknown source for one of 12 residents (CR #1) reviewed for neglect. The facility failed to identify CR #1's fractures of unknown origin to her right leg and address her pain in a timely manner. This failure affected one closed record resident and placed 15 other residents on pain management at risk of injuries or neglect. Findings included: TX # 446/Intake # 6 TX # 429/Intake # 3 Record review of CR #1's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] and discharged on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's nurse notes from admission 9/27/16 to 10/11/16 revealed no documentation that CR #1 had pain or expressed presence of pain. Record review of CR #1's admission pain assessment dated [DATE] revealed resident was able to communicate appropriately, has had pain in the last 5 days, experienced occasional pain which has made it hard for her to sleep, and had limited day to day activities because of pain. Further review revealed CR #1's pain intensity was moderate. Staff assessment of pain revealed vocal complaints of pain and facial expressions indicating pain. Frequency of pain indicators were present for 1 to 2 days. Pain management interventions were non-medication and included turning and repositioning. Record review of CR #1's admission assessment MDS dated [DATE] revealed resident admitted from home, had a BIMS score of 8, indicating she was moderately cognitively impaired, and had no behaviors. Further review revealed CR #1 required extensive assistance with all ADLs and was dependent on staff for bathing. CR #1 had no limitations in her bilateral upper and lower extremities, was incontinent of both bowel and bladder, and had a [DIAGNOSES REDACTED]. Further review of this MDS revealed a staff assessment of pain should not be conducted, no entries for pain intensity were conducted, and no falls were documented. Record review of CR #1's admission orders [REDACTED]. Record review of CR #1's consolidated physician's orders [REDACTED]. Record review of CR #1's care plan dated 9/28/16 revealed the resident had a history of [REDACTED]. Further review of this care plan revealed CR #1 had chronic pain to her right leg related to disease process ([MEDICAL CONDITION] and osteopenia) and a previous history of right femur fracture. Goal, initiated on 10/21/16, was for the resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Approaches included: administer [MEDICATION NAME] as per orders, anticipate the resident's need or pain and respond immediately to any complaints of pain, notify physician if interventions are not successful or if current complaint is a significant change from resident's past experience of pain, observe record /report to nurse complaints of pain or request for pain treatment. Record review of CR #1's pain assessment flow sheet dated September 2016 revealed: 9/27/16 and 9/28/16 - (day shift) pain scale of zero originally written then a two was written over the zero. No intervention was provided. 9/27/16, 9/28/16 and 9/29/16 for evening shift had a pain score of zero, and no interventions. Record review of CR #1's Pain assessment flow sheet dated October 2016 revealed 10/1/16 to 10/11/16 no pain and no interventions were documented for day, evening or night shifts. Record review of CR #1's physical therapy daily treatment notes dated 9/28/16 revealed patient was evaluated, plan of care developed and skilled treatment recommended for therapeutic exercise/activities, neuromuscular rededication, wheelchair mobility and management (when ready) and patient /caregiver education and training. Patient completed assisted active range of motion to bilateral lower extremities in supine in order to improve the functional mobility and ADLs, patient required total assistance for all bed mobility tasks to include bed rolling, supine scooting, trained CNA on patient bed mobility skills which is total assist at this time requiring two people with supine sit and that patient will be transferred with Hoyer lift. Record review of CR #1's physical therapy, occupational and speech therapy daily notes from 09/29/16 through 10/10/16 revealed no mention of pain presence noted nor expressed by CR #1 during therapy sessions. Record review of CR #1's physical therapy progress and discharge summary dated 10/11/16 revealed therapy goals were not met, and patient hospitalized unexpectedly. Record review of CR #1's nurse notes dated 10/11/16 at 12:00 p.m. written by the DON revealed resident noted to occasionally complain of right leg pain since admission stating that my leg is broken. When questioned about why she thinks her leg is broken, the patient stated her husband gets drunk sometimes and that he beats her severely. NP notified yesterday of resident's continual complaint to right leg pain and that maybe we should get an X-ray to rule out any possibility she was admitted with an injury. NP ordered an X-ray of the right foot and right ankle on 10/11/16. NP notified of X-ray results which read: distal tibia and fibula fractures due to severe osteopenia. NP orders to send the resident to hospital ER, Responsible party notified. Record review CR #1's physician order [REDACTED]. Record review of CR #1's X-Ray result dated 10/11/16 revealed severe osteopenia with soft tissue swelling is present. There are acute comminuted slightly displaced and laterally and anteriorly angulated fractures of the distal tibia and fibula .Impression: distal tibia and fibular fractures. Record review of CR #1's physician order [REDACTED]. Record review of the facility's investigation report, which was not dated, revealed the facility became aware of CR #1's injury of unknown origin on 10/11/16, but did not report it to DADS until 10/20/16. The investigation summary revealed upon investigation resident had some leg pain upon admission which was controlled with pain medication. On 10/11/16 resident was complaining of pain and stated to DON that sometimes her husband gets drunk and beats her at home and asked us not to say anything to him because he would get angry. Resident was a poor historian. DON noted no signs of injury but requested an X-ray from the physician to rule out any serious injury. X-ray revealed severe osteopenia and [MEDICAL CONDITION] and fibula. Interview on 11/8/16 at 10:24a.m., the Administrator, who was the abuse and neglect coordinator, said CR #1 admitted from home and was there for therapy. She said the resident complained of pain to her leg, so an X-ray was done which revealed fractures. Interview on 11/8/16 at 11:37a.m., the ADON said CR #1 reported leg pain to another staff who notified her. She said the NP was called and ordered an X-ray, which revealed fractures. The ADON said CR #1 was then sent to the hospital for further evaluation. When asked if she assessed CR #1's leg at the time of the complaint, the ADON said she did and the resident's right leg had a little red spots, but was not swollen. Interview on 11/8/16 at 11:44a.m., LVN #2, who was CR #1's charge nurse during the morning shift on 10/10/16, said CR #1 complained of pain to her legs when her legs were moved, but also complained of pain when she was in a sitting position too. LVN #2 said CR #1 had frequently complained of pain to her right leg on and off since admission. LVN #2 said CR #1 always complained of pain to both legs and reported that either her leg was broken or her arm was broken. He further said CR #1 was admitted with a fracture to her left ankle. When asked if he assessed CR #1's leg on 10/10/16, LVN #2 said he did and CR #1's leg was not red or swollen. LVN #2 said he reported moderate pain when CR #1 was in her wheelchair and severe pain when CR #1 was in her wheelchair for a long period of time. LVN #2 said the resident had as needed [MEDICATION NAME] ordered for pain and was medicated before therapy. Interview on 11/8/16 at 1:33p.m., the Wound Care Nurse said CR #1 was admitted with incontinent [MEDICAL CONDITION], and provided skin care and barrier cream application as ordered with incontinent episodes. She further said CR #1 did not verbalize any pain and did not express pain during care. Interview on 11/8/16 at 1:47p.m., the Rehabilitation Director said CR #1 always complained of right leg pain, and did not want to get out of bed due to the pain. She said she may have treated CR #1 once. She further said if pain was verbalized by any resident, staff would ensure that pain medication was administered prior to therapy and staff would modify the treatment to accommodate the resident's tolerance level. If severe pain was expressed, staff would not treat the resident. The Rehabilitation Director said CR #1 was treated for [REDACTED]. Interview on 11/8/16 at 2:00p.m., the MDS Coordinator said she assessed CR #1 for admission MDS completion and the resident neither verbalized nor expressed pain to her bilateral lower extremities. Interview on 11/8/16 at 3:34p.m., the ADON said she was not aware CR #1 complained of pain from admission to the facility until 10/11/16. She said no one reported complaints of pain from CR #1 to her. The ADON said on 10/10/16 CR #1 complained of pain to someone before an X-ray was done. Interview on 11/8/16 at 3:41p.m., LVN #1 said he admitted CR #1 to the facility on [DATE]. He said the resident was not groomed upon admission and the spouse appeared to have been her caregiver. He said CR #1 had a little pain when moved but did not complain of pain while at rest. LVN #1 further said on 10/10/16, the AM nurse reported CR #1 kept complaining of pain so the NP was notified and an X-ray was ordered for the next day. When asked why the X-Ray was not done as soon as possible, LVN #1 said it was the NP's call. LVN #1 said he did not look at CR #1's leg. When asked how much pain CR #1 had on 10/10/16, LVN #1 said it was different from previous times. Interview on 11/8/16 at 3:54p.m., the DON said LVN #2, who was CR#1's charge nurse on 10/10/16, reported the resident had mild pain to her leg. The DON said in the past, CR #1 made reference to her leg being broken, or said her leg was sore sometimes. The DON said CR #1 was offered pain medication but refused, which was documented. (No record of this was found in CR #1's record). The DON further said he did not know why the staff were hung up on saying that the resident had right leg pain upon admission. Record review of CR #1's MAR indicated [REDACTED]. Interview on 11/8/16 at 4:33p.m. CNA #2 said CR #1 sometimes would say her back hurt while in her wheelchair, but also verbalized that her leg hurt all the time. CNA #2 also recalled that CR #1 complained of right leg pain. When asked if she reported this to anyone, CNA #2 stated she did not because CR #1 only complained to her when she was moved or turned during care and seemed to be fine after care. Interview on 11/8/16 at 4:54p.m., CNA #1 said CR #1 complained of little minor pains and leg pain during care. When asked why she did not report this pain, CNA #1 said in the past if CR #1's position was changed, she would be fine. CNA #1 said CR #1's legs were not swollen. Attempts were made to see CR #1 at her current facility, but CR #1 had been transferred to the hospital on [DATE] from the last known facility. Interview on 11/8/16 at 5:12p.m., when the Administrator was asked why CR #1's fractures identified on 10/11/16 were not immediately reported to the state until 10/20/16 she said because the staff reported the resident had been complaining of pain to her leg since admission. The Administrator further said CR #1 also told staff the spouse was abusive and kicked on her when drunk. Record review of the facility's policy on abuse and neglect dated August 2006 revealed the residents have the right to be free from abuse, neglect, misappropriation of residents' property, corporal punishment and involuntary seclusion. The DON reported 15 residents were on pain management.

Based on interview, and record review, the facility failed to provide the necessary care and services in accordance with the comprehensive assessment to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of twelve residents (CR #1) reviewed for quality of care. The facility failed to identify CR #1's fractures of unknown origin to her right leg and address her pain in a timely manner. This failure affected one closed record resident and placed 15 other residents on pain management at risk of complications which could lead to a decline in physical, mental and psychosocial health. Findings included: TX # 446/Intake # 6 TX # 429/Intake # 3 Record review of CR #1's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] and discharged on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's nurse notes from admission 9/27/16 to 10/11/16 revealed no documentation that CR #1 had pain or expressed presence of pain. Record review of CR #1's admission pain assessment dated [DATE] revealed resident was able to communicate appropriately, has had pain in the last 5 days, experienced occasional pain which has made it hard for her to sleep, and had limited day to day activities because of pain. Further review revealed CR #1's pain intensity was moderate. Staff assessment of pain revealed vocal complaints of pain and facial expressions indicating pain. Frequency of pain indicators were present for 1 to 2 days. Pain management interventions were non-medication and included turning and repositioning. Record review of CR #1's admission assessment MDS dated [DATE] revealed resident admitted from home, had a BIMS score of 8, indicating she was moderately cognitively impaired, and had no behaviors. Further review revealed CR #1 required extensive assistance with all ADLs and was dependent on staff for bathing. CR #1 had no limitations in her bilateral upper and lower extremities, was incontinent of both bowel and bladder, and had a [DIAGNOSES REDACTED]. Further review of this MDS revealed a staff assessment of pain should not be conducted, no entries for pain intensity were conducted, and no falls were documented. Record review of CR #1's admission orders [REDACTED]. Record review of CR #1's consolidated physician's orders [REDACTED]. Record review of CR #1's care plan dated 9/28/16 revealed the resident had a history of [REDACTED]. Further review of this care plan revealed CR #1 had chronic pain to her right leg related to disease process ([MEDICAL CONDITION] and osteopenia) and a previous history of right femur fracture. Goal, initiated on 10/21/16, was for the resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Approaches included: administer [MEDICATION NAME] as per orders, anticipate the resident's need or pain and respond immediately to any complaints of pain, notify physician if interventions are not successful or if current complaint is a significant change from resident's past experience of pain, observe record /report to nurse complaints of pain or request for pain treatment. Record review of CR #1's pain assessment flow sheet dated September 2016 revealed: 9/27/16 and 9/28/16 - (day shift) pain scale of zero originally written then a two was written over the zero. No intervention was provided. 9/27/16, 9/28/16 and 9/29/16 for evening shift had a pain score of zero, and no interventions. Record review of CR #1's Pain assessment flow sheet dated October 2016 revealed 10/1/16 to 10/11/16 no pain and no interventions were documented for day, evening or night shifts. Record review of CR #1's physical therapy daily treatment notes dated 9/28/16 revealed patient was evaluated, plan of care developed and skilled treatment recommended for therapeutic exercise/activities, neuromuscular rededication, wheelchair mobility and management (when ready) and patient /caregiver education and training. Patient completed assisted active range of motion to bilateral lower extremities in supine in order to improve the functional mobility and ADLs, patient required total assistance for all bed mobility tasks to include bed rolling, supine scooting, trained CNA on patient bed mobility skills which is total assist at this time requiring two people with supine sit and that patient will be transferred with Hoyer lift. Further review of CR #1's physical therapy, occupational and speech therapy daily notes revealed no mention of pain presence noted nor expressed by CR #1 during therapy sessions. Record review of CR #1's physical therapy, occupational and speech therapy daily notes from 09/29/16 through 10/10/16 revealed no mention of pain presence noted nor expressed by CR #1 during therapy sessions. Record review of CR #1's physical therapy progress and discharge summary dated 10/11/16 revealed therapy goals were not met, and patient hospitalized unexpectedly. Record review of CR #1's nurse notes dated 10/11/16 at 12:00 p.m. written by the DON revealed resident noted to occasionally complain of right leg pain since admission stating that my leg is broken. When questioned about why she thinks her leg is broken, the patient stated her husband gets drunk sometimes and that he beats her severely. NP notified yesterday of resident ' s continual complaint to right leg pain and that maybe we should get an X-ray to rule out any possibility she was admitted with an injury. NP ordered an X-ray of the right foot and right ankle on 10/11/16. NP notified of X-ray results which read: distal tibia and fibula fractures due to severe osteopenia. NP orders to send the resident to hospital ER, Responsible party notified. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's X-Ray result dated 10/11/16 revealed severe osteopenia with soft tissue swelling is present. There are acute comminuted slightly displaced and laterally and anteriorly angulated fractures of the distal tibia and fibula .Impression: distal tibia and fibular fractures. Record review of CR #1's physician order [REDACTED]. Record review of the facility's investigation report, which was not dated, revealed the facility became aware of CR #1's injury of unknown origin on 10/11/16, but did not report it to DADS until 10/20/16. The investigation summary revealed upon investigation resident had some leg pain upon admission which was controlled with pain medication. On 10/11/16 resident was complaining of pain and stated to DON that sometimes her husband gets drunk and beats her at home and asked us not to say anything to him because he would get angry. Resident was a poor historian. DON noted no signs of injury but requested an X-ray from the physician to rule out any serious injury. X-ray revealed severe osteopenia and [MEDICAL CONDITION] and fibula. Interview on 11/8/16 at 10:24a.m., the Administrator, who was the abuse and neglect coordinator, said CR #1 admitted from home and was there for therapy. She said the resident complained of pain to her leg, so an X-ray was done which revealed fractures. Interview on 11/8/16 at 11:37a.m., the ADON said CR #1 reported leg pain to another staff who notified her. She said the NP was called and ordered an X-ray, which revealed fractures. The ADON said CR #1 was then sent to the hospital for further evaluation. When asked if she assessed CR #1's leg at the time of the complaint, the ADON said she did and the resident's right leg had a little red spots, but was not swollen. Interview on 11/8/16 at 11:44a.m., LVN #2, who was CR #1's charge nurse during the morning shift on 10/10/16, said CR #1 complained of pain to her legs when her legs were moved, but also complained of pain when she was in a sitting position too. LVN #2 said CR #1 had frequently complained of pain to her right leg on and off since admission. LVN #2 said CR #1 always complained of pain to both legs and reported that either her leg was broken or her arm was broken. He further said CR #1 was admitted with a fracture to her left ankle. When asked if he assessed CR #1's leg on 10/10/16, LVN #2 said he did and CR #1's leg was not red or swollen. LVN #2 said he reported moderate pain when CR #1 was in her wheelchair and severe pain when CR #1 was in her wheelchair for a long period of time. LVN #2 said the resident had as needed [MEDICATION NAME] ordered for pain and was medicated before therapy. Interview on 11/8/16 at 1:33p.m., the Wound Care Nurse said CR #1 was admitted with incontinent [MEDICAL CONDITION], and provided skin care and barrier cream application as ordered with incontinent episodes. She further said CR #1 did not verbalize any pain and did not express pain during care. Interview on 11/8/16 at 1:47p.m., the Rehabilitation Director said CR #1 always complained of right leg pain, and did not want to get out of bed due to the pain. She said she may have treated CR #1 once. She further said if pain was verbalized by any resident, staff would ensure that pain medication was administered prior to therapy and staff would modify the treatment to accommodate the resident's tolerance level. If severe pain was expressed, staff would not treat the resident. The Rehabilitation Director said CR #1 was treated for [REDACTED]. Interview on 11/8/16 at 2:00p.m., the MDS Coordinator said she assessed CR #1 for admission MDS completion and the resident neither verbalized nor expressed pain to her bilateral lower extremities. Interview on 11/8/16 at 3:34p.m., the ADON said she was not aware CR #1 complained of pain from admission to the facility until 10/11/16. She said no one reported complaints of pain from CR #1 to her. The ADON said on 10/10/16 CR #1 complained of pain to someone before an X-ray was done. Interview on 11/8/16 at 3:41p.m., LVN #1 said he admitted CR #1 to the facility on [DATE]. He said the resident was not groomed upon admission and the spouse appeared to have been her caregiver. He said CR #1 had a little pain when moved but did not complain of pain while at rest. LVN #1 further said on 10/10/16, the AM nurse reported CR #1 kept complaining of pain so the NP was notified and an X-ray was ordered for the next day. When asked why the X-Ray was not done as soon as possible, LVN #1 said it was the NP's call. LVN #1 said he did not look at CR #1's leg. When asked how much pain CR #1 had on 10/10/16, LVN #1 said it was different from previous times. Interview on 11/8/16 at 3:54p.m., the DON said LVN #2, who was CR#1's charge nurse on 10/10/16, reported the resident had mild pain to her leg. The DON said in the past, CR #1 made reference to her leg being broken, or said her leg was sore sometimes. The DON said CR #1 was offered pain medication but refused, which was documented. (No record of this was found in CR #1's record). The DON further said he did not know why the staff were hung up on saying that the resident had right leg pain upon admission. Record review of CR #1's MAR indicated [REDACTED]. Interview on 11/8/16 at 4:33p.m. CNA #2 said CR #1 sometimes would say her back hurt while in her wheelchair, but also verbalized that her leg hurt all the time. CNA #2 also recalled that CR #1 complained of right leg pain. When asked if she reported this to anyone, CNA #2 stated she did not because CR #1 only complained to her when she was moved or turned during care and seemed to be fine after care. Interview on 11/8/16 at 4:54p.m., CNA #1 said CR #1 complained of little minor pains and leg pain during care. When asked why she did not report this pain, CNA #1 said in the past if CR #1's position was changed, she would be fine. CNA #1 said CR #1's legs were not swollen. Attempts were made to see CR #1 at her current facility, but CR #1 had been transferred to the hospital on [DATE] from the last known facility. Record review of the facility's policy on pain-clinical protocol revealed the physician and staff will identify individuals who have or who are at risk for having pain this includes a review of each person's known [DIAGNOSES REDACTED]. It also includes a review for any treatment that the resident currently is receiving for pain including complementary (non pharmacologic) treatments. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain. The staff and physician will identify the nature (characteristic such as location, intensity, frequency, pattern etc.) and severity of pain. The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep and the resident's quality of life including complications such as gait disturbances, social isolation and falls. The DON reported 15 residents were on pain management.

Based on interview, and record review, the facility failed to consult the physician when a change of condition occurred for 1 of 4 residents ( Resident CR#1 ) who were reviewed for changes in conditions. Resident CR#1 ' s physician was not consulted concerning the resident's complaint of right hip pain. This failure affected 1 resident and placed 94 residents at risk of not having their responsible party or interested family members or their physicians consulted when a change in their medical condition occurs which could delay treatment and cause a decline in their health and psychosocial well-being. Intake # 9 Findings include: Record review of Resident CR#1 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The record revealed the resident died at the facility on [DATE] while receiving services from Hospice. Record review of Resident CR#1 ' s annual MDS dated [DATE], revealed the resident was severely impaired for cognition with long and short term memory problems. The resident required extensive assistance from staff with all ADL ' s. Record review of Resident CR#1 ' s health status progress notes revealed the following: " [DATE] 21:04 (9:04 P.M.) Resident complained about right hip pain. I called (the physician) but office is closed. Called NP (nurse practitioner) and left message on her voicemail, awaiting call back. Will continue to monitor. " Further review of Resident CR #1's health status progress notes revealed no further documentation concerning doctor notification of the pain complaints of the resident on [DATE] or [DATE]. Record review of Resident CR#1 ' s (MAR) Medication Administration Record [REDACTED]. Continued review of the same MAR indicated [REDACTED]. The same MAR indicated [REDACTED]. Record review of Resident CR #1's physician's telephone orders revealed an order dated [DATE] for the resident to have an x-ray of the hip. Continued review of Resident CR#1 ' s health status progress notes revealed the following: " [DATE] 01:57 (1:57 A.M.) Resident had an x-ray of the right hip done for complaint of right hip pain. Impression indicated fracture or dislocation of the right femoral neck. Result was faxed to MD and called in to the NP. New order was given to transfer resident to the hospital at 6 am " Interview on [DATE] at 12:30 P.M. CNA #1 stated she had taken care of Resident CR#1 on [DATE] and had assisted the resident with transfers and the resident did not complain of pain during the transfer. Interview on [DATE] at 2:00 P.M. the DON stated Resident CR#1 complained of pain frequently. She stated hospice saw the resident almost daily and usually notified the physician of any changes or complaints. She further stated the nurse should have followed up with notifying the physician when the resident first complained of the hip pain. Record review of the facility provided policy titled: Change in a Resident ' s Condition or Status dated [DATE] did not address following up with the physician when there was no return call and leaving voice messages of resident's conditions. The facility reported a census of 94.

Based on observation, interview, and record review, the facility failed to provide laboratory services to meet the needs of 5 of 18 resident ' s (Resident #80, #36, #97, #4, and #42) who were reviewed for lab services. Resident #80 had panic lab values for potassium and abnormal levels of Urea Nitrogen (a test used to check kidney and liver functions) on 2/19/2014 that were not communicated to the physician until after 2/23/2014. The physician then ordered labs on 3/1/2014 to be collected on 3/2/214 and 3/3/2014. These labs were not collected with results called to the physician until 3/12/14. The results revealed a panic value level for Urea Nitrogen and the resident required admission to the intensive care unit at a local hospital for treatment on 3/12/2014. Resident # 36's abnormal lab value (BUN) on 2/7/2014 and panic lab values (BUNs) on 2/10/2014, 2/13/2014, and 2/15/2014 were not immediately communicated to the physician. The resident was admitted to the hospital on [DATE]. Resident ' s #97 and #4 did not have their labs performed as ordered by the physician. Resident # 42 did not have laboratory tests performed as ordered by the physician on 1/10/14. An immediate jeopardy (IJ) was identified on 3/13/14 at 3:00 P.M. The IJ was removed on 3/18/14 however the facility remained out of compliance at a scope of " wide spread " and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on policies and procedures concerning lab services. These failures affected 5 residents whose care was compromised due to staff not performing or reporting lab tests to physician's timely and placed 96 residents at risk of not receiving the lab services and care as ordered and a delay in physician notification which could result in delayed treatments and possible hospitalization . Intake # 8 Findings Include: Resident #80 Record review of Resident #80 ' s admission information revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #80 ' s re-admission MDS dated [DATE] revealed a BIMS score of 3 which indicated the resident was severely impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident required extensive assistance to total dependence of facility staff for all ADLs. Record review of Resident #80's Basic Metabolic Panel (BMP) lab results dated 2/19/2014 (no time) revealed a Potassium level of 5.3 ( normal range 3.5-5.1). This was flagged as a panic value. Record review of Resident #80 ' s nursing progress notes revealed the following documentation on 2/20/14 at 1345 (1:45 P.M.): "Received lab results, called MD (Medical Doctor) office and also called NP (Nurse Practitioner) to give report about this result, awaiting at this time for NP to call us back, report will be given to next shift to follow up." Record review of Resident #80's revealed the following was documented by facility staff on the lab result form and dated 2/23/14: "Paged several times with no answer. Unable to leave voice mail because voice mail is full. Held potassium today. Pt. on 10 meq of potassium daily. Please follow up." Need Urea Nitrogen Record review of Resident #80 ' s nursing progress notes dated 2/23/2014 at 11:43 A.M. revealed the following note: "pending call back potassium level high 5.3." Continued review of Resident #80 ' s medical record revealed there was no physician's order to hold the potassium. There was no documentation the physician was notified the potassium was held or of the panic level lab value. Record review of Resident #80's Physican's order dated 2/26/14 revealed an order for [REDACTED]. Record review of Resident #80's lab results of the BMP collected 2/26/14 revealed the resident's Potassium was 6.6 (normal 3.5-5.1). This was flagged as a panic value. Other lab values on the same form were Sodium 142 (normal 135-145) and Urea Nitrogen 59 (normal 8-23). Record review of Resident #80's computer generated Physican's order dated 2/27/14 revealed an order for [REDACTED]. Record review of Resident 80's BMP collected 2/27/14 Results dated 2/28/14 (no time) revealed the resident's Sodium was 136, Potassium 4.8 and Urea nitrogen 56. Record review of Resident #80's Physician's order dated 2/27/14 for [MEDICATION NAME] Powder to treat high potassium. Record review of Resident #80's BMP collected 2/28/14 with results dated 2/28/14 (no time) revealed the resident's Potassium 5.1 (This was flagged as a panic value), Sodium 135, and Urea Nitrogen 56. Record review of Resident #80 's two separate physician's orders revealed the following orders signed by LVN # 1: (On a hand written Physician's Telephone Order form dated 3/1/2014, (no time) Repeat BMP on Sunday 3/2/14. (On a computerized physician's order form) Verbal order 3/1/2014 at 0205 (2:05 A.M.) BMP to be drawn Monday 3/3/14 one time only. Record review of Resident #80 ' s nursing progress notes dated 3/11/14 at 2301 (11:01 P.M.) revealed the following documentation: Call to lab to request BMP results. BMP scheduled to be drawn on Sunday 3/2/14. Spoke to lab person and reports results are still pending in system but will fax to facility as soon as available. Continued review of Resident #80 ' s lab results between 3/2/2014 and 3/12/2014 revealed there were no BMP results for 3/2/14 or 3/3/14. Record review of Resident #80's BMP lab report dated 3/12/2014 revealed a Urea Nitrogen of 108 (reference range 8-23). This was identified on the lab result as a panic value. Record review of Resident #80's nursing progress notes dated 3/12/2014 at 2344 (11:44 P.M.) revealed the panic lab value was reported to the physician and orders received was to transfer the resident to the hospital. Record review of Resident #80 ' s lab results from the hospital emergency room dated 3/13/14 0052 (12:52 A.M.) revealed the following results: Sodium 155 (135-141) Potassium 5.0 (3.7-4.7) BUN 114 (5-25) Interview on 3/13/14 at 1:35 P.M. LVN #6 stated Resident #80 had been transferred to the hospital during the night due to panic levels on her labs. She stated each day the nurse should check the orders from the previous day to see if there are any labs or orders that need follow-up. She also stated each nurse should check the 24 hour report book for any needed follow-up with residents. She further stated she just started a few weeks ago and the facility had conducted an inservice on lab services earlier in the month which covered the procedure for ordering tests and notifying the physician. Interview on 3/13/14 at 3:45 P.M. RN #3 stated she could not find evidence the labs for Resident #80 had been drawn as ordered. She stated she did not know why the labs for 3/3/14 were not done and why there were orders for labs for 3/2/14 and 3/3/14 and the doctor should have been called to clarify what was needed. She also stated the nurse should check the 24 hour report book each day for any labs and follow-up on the results. She stated the lab did not come on the week-end unless the tests were ordered stat. Resident # 36 Record review of Resident #36 ' s face sheet revealed a 72 year old male admitted to the facility on [DATE] . His [DIAGNOSES REDACTED]. Record review of the resident ' s CBC and CMP lab result sheets revealed a collected and results dated 2/7/14. There was no documented time to indicate when the laboratory report was received by the facility. The resident ' s CBC revealed his White Blood Count (WBC) was 11.5 normal ranges were 4.0 -11.0. and his Complete Metabolic Panel (CMP)revealed the Blood Urea Nitrogen (BUN) was 61, which is an abnormal level with normal ranges being 7-25 . Continued review of the lab sheet revealed it was faxed to the physician on 2/10/14. Record review of Resident #36's Nurses Progress Notes dated 2/8/14 revealed the resident ' s physician was called at 11:13 A.M. and a voice message was left regarding the lab results of 2/7/12. Labs were faxed to his office. Continued review revealed another attempt to notify the physician was made on 2/8/14 at 5:31 P.M. Record review of Resident # 36 ' s CBC and CMP collected and results dated 2/10/14 revealed WBC 11.9. The CMP revealed " Report contains Panic Value " BUN was 82. Continued review of the CBC report revealed " Repeat in A.M. Review of the CMP report revealed " lab in A.M. called MD twice. Also called nurse practitioner and handed over to (RN#12 the next shift's nurse). Record review of Resident #36's Nurse ' s Progress Notes revealed 2/11/14 at 2:44 A.M. "received critical lab values for patient ' s chemistry profile and physician notified". 2/11/13 at 5:55 A.M. "Patient reassessed MD notified again regarding patient ' s condition and laboratory results". 2/11/14 at 6:10 A.M "Nurse Practitioner contacted. Her mailbox was full. (RN #12) told to follow up". Record review of the nurse ' s progress notes dated 2/11/14 at 3:15 P.M. revealed the resident was observed on the floor . Record review of the resident ' s record did not revealed any results for a CBC and CMP dated 2/11/13. Record review of the physician's orders dated 2/11/13 revealed an order to Repeat CBC in A.M. Record review of the resident's lab reports did not reveal any CBC results dated 2/12/14. Interview on 3/13/14 at 3:30 P.M. LVN #13 stated she was unable to locate any lab results dated 2/12/14. Record review of Resident # 36 ' s CBC and CMP results dated 2/13/14 revealed the WBC was 12.6 (normal range 4.4-10.5). Record review of the CMP lab form revealed a the collection of the specimen dated 2/12/14 at 8:15 A.M. and results dated 2/13/14 " Report contains Panic Value " BUN was 107. Review of the physician's orders revealed the physician was notified and an IV was started to treat the resident. Record review of the CMP lab form revealed a collection of the specimen dated 2/13/14 at 3:27 P.M. and results dated 2/13/14 " Report contains Panic Value " BUN 115 (normal range 8-23). Further review of the lab form revealed no documentation of the physician being notified of the panic value. Record review of the resident ' s lab results and nursing progress notes from 2/13/2014 and 2/14/2014 revealed no documentation the physician was notified of the lab results dated 2/13/14. Record review of the resident ' s CMP lab form collected on 2/14/14 and results dated 2/15/14 revealed Panic levels BUN Results 112. Continued review of the lab form revealed documentation the lab results were faxed to the physician on 2/15/14 and a copy of the form revealed documentation that on "2/16/14 left message faxed over" (to the physician). Record review of the Nurse ' s Progress Notes dated 2/15/14 revealed the "BUN Creatinine ration 80 was reported tonight. Left a voice message for MD. NP voice mail was full and could not receive messages. Lab results also faxed." Record review of the Nurse ' s Progress Notes dated 2/16/14 revealed Panic lab values notified Dr. who sent (Resident # 36) to Local Hospital due to possible infection. Record review of Resident # 36 ' s clinical record revealed a transfer form to a local hospital dated 2/16/14 due to lab values. Interview on 3/13/14. at 1:30 P.M. LVN # 7 stated staff were instructed to call the physician with any abnormal labs and if the staff cannot reach the physician they were to call the medical director. Interview on 3/13/14 at 3:30 P.M. LVN# 13 stated the physician was not notified of the labs in a timely manner and when the resident has a panic value the physician continues to be called until staff can talk with him. As of yesterday staff were instructed to call the medical director after the attending physician cannot be reached after 3 tries. Interview on 3/14/14 at 12:30 P.M. LVN #7 stated she remembered Resident #36 having Panic Labs on 2/13/14 and the DON was taking care of it for her. As the interview continued she stated the DON was no longer working at the facility. Resident #97 Record review of Resident #97 ' s admission information revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #97's medication review report revealed the following: [MEDICATION NAME] Sodium 2 mg daily as of 9/30/13 . Record review of Resident #97 ' s laboratory results dated [DATE] revealed the following results: PT 17.2 (12.1-14.9) INR 1.39 (1.5-3.0) Record review of Resident #97 ' s medical record revealed the following physician's orders: 12/17/13: CBC, BMP in A.M. 12/20/13: Draw PT/INR on 12/23/13 Monday. 1/10/14 Stat PT/INR 1/12/14 Increase [MEDICATION NAME] to 3 mg by mouth daily Repeat PT/INR in 2 weeks (1/26/14)(this was a Sunday) 1/23/14: Clarification: PT/INR on Monday (1/27/14) Record review of Resident #97 ' s lab results from 12/18/2014 thru 12/20/2014 revealed the CBC and BMP results for 12/18/13 were not on the chart nor were they available from the lab website for results. Record review of Resident #97 ' s lab results between 12/23/2014 through 12/25/2014 revealed the PT/INR results for 12/23/13 were not available on the chart nor were they available from the lab website. Record review of Resident #97 ' s lab results from 1/27/14 through 1/29/14 revealed the PT/INR results for 1/27/14 were not available on the chart nor were they available from the lab website. Observation on 3/13/14 at 8:30 A.M. revealed Resident #97 was sitting up in the geri-chair at the bedside. He was groomed and dressed in street clothes. He was able to answer simple questions but was not able to have a full conversation. The resident ' s speech was somewhat garbled and he was unable to clearly make his needs known. Interview on 3/13/14 at 3:45 P.M. RN #3 stated she could not find evidence the labs for Resident #97 had been drawn as ordered. Resident #4 Record review of Resident #4 ' s admission information revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #4 ' s physician's orders revealed the following: Dated 12/31/2013 - [MEDICATION NAME] (Levetiracetam) Solution 100 mg/ml give 5 ml via PE[DEVICE] every 12 hours at 5:00 A.M. and 5:00 P.M. related to [MEDICAL CONDITION]. Dated 2/28/2014 - CBC, BMP, levetiracetam level (this test is to monitor the theraputic dosage of the [MEDICATION NAME] medication given for [MEDICAL CONDITION]) and lipid panel on 3/7/2014. Record review of Resident #4 ' s chart revealed no lab results drawn on 3/7/2014 as ordered. Further review revealed lab results for lipid panel, drawn on 3/10/14 in chart. Record review of nurse ' s notes dated 3/11/14 revealed " CBC, BMP, levetiracetam level and lipid panel on 3/7/14 - received results of lipid profile - faxed to Dr. office. Please follow up " . Interview on 3/13/14 at 9:30 A.M. LVN #19 confirmed there were no lab results for a CBC, BMP and levetiracetam level in the resident ' s chart. She stated there was a Lipid panel result that was drawn on the 10th in the chart. She continued to verify there were no lab results in the computer system or in the lab book. She called the lab company and was informed there were no labs drawn on 3/7/2014 for Resident #4 and the only lab results since 3/7/14 was for a Lipid Panel drawn on 3/10/14. She stated the lab order for a CBC, BMP, levetiracetam level and Lipid Panel for 3/7/14 must have been missed. Record review of the Mayo Clinic Mayo Medical Laboratories website httt://www.mayomoedicallaboratories.com/test-catalog/print/ revealed Serum Levetiracetam laboratory tests were useful for monitoring serum concentration of levetiracetam ([MEDICATION NAME]), particularly in patients with [MEDICAL CONDITION], assessing compliance, and assessing potential toxicity. Resident # 42 Record review of Resident # 42 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her admission [DIAGNOSES REDACTED]. Record review of Resident # 42 ' s Physician ' s orders dated March 2014 revealed CBC with Differential, BMP, Calcium, Magnesium, Phosphorus, TSH, Lipid Profile and Vitamin D3 level in A.M. dated 1/10/14 at 12:33 A.M. Record review of the resident ' s lab reports dated from 1/10/2014 through 1/15/2014 revealed the above ordered lab results were not in the chart. Interview on 3/13/14 at 3:18 P.M. LVN #13 stated she was not able to find the lab results that were ordered on [DATE] in the chart or in the computer. After the IJ was called the facility requested the contract laboratory company to do a complete audit of the facility on the night of 3/13/2014. During that audit the lab results dated 1/10/14 for Resident #42 were located and provided to on 3/14/14 for review. Record review of the facility in-service training reports revealed the following in-services had recently been conducted for staff: 12/16/13 Labs on weekend, Critical labs. 1/10/14 Lab procedure/Protocol for lab monitoring. 1/22/14 [MEDICATION NAME] flowsheets. 3/7/14 PT/INR, [MEDICATION NAME] management. Lab procedure/monitoring. Interview on 3/13/14 at 2:00 P.M. the Interim DON stated the facility had given in-services for the nursing staff in 2014 due to stat lab results taking at least 12 hours for results and lab orders were found in the chart that had not been carried out timely. She also stated the nurses did not seem to recognize there was a problem with obtaining lab results. She said she personally called the lab to see why there was a delay with obtaining labs and results and was told the lab was undergoing construction and had to send the specimens out for testing. She said the lab did not notify the facility of the delays. Record review of the facility policy titled: Lab and Diagnostic Rest Results-Clinical Protocol dated 2005 (Revised April 2007) revealed in part the following: 1. A nurse will review all results a. If the staff that first receive or review lab and diagnostic test results cannot follow the remainder of the procedure for reporting and documenting the results and their implications, another nurse in the facility (Supervisor, Charge nurse, etc.) should follow or coordinate the procedure. Nursing staff will consider the following factor to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: 2. The result is something that should be conveyed to a physician regardless of other circumstances 4. High or toxic drug levels. If the a test was obtained to monitor the blood level of a medication and the level is reported as high or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation had been reviewed with the physician. Options for physician notification 1. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident ' s clinical status is unstable or current treatment needs review or clarification. Physician responses 1. a. A physician should respond with one hour regarding a lab test result requiring immediate notification. b. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. An immediate jeopardy (IJ) was identified on 3/13/14 at 3:00 P.M. and the Administrator was notified at that time. A plan to remove the immediate jeopardy (IJ) was submitted and accepted on 3/18/14. The plan included: The DON/Designee will ensure all nursing staff are inserviced on the Laboratory protocol to ensure all labs are drawn as ordered, results are communicated to the facility timely and the physician is notified promptly based on results. The protocol would be for the nurse to complete the requisition once the lab order is received and place it in the lab book for the lab to be drawn. Results will be faxed to the facility. Critical/panic results are called before faxing. Normal results are faxed to the physician. Abnormal results are called to the physician. The nurse will follow-up with the physician to verify the receipt of normal lab results and if no response with 24 hours the Medical Director is notified. If no response from the physician to receive abnormal/critical lab results within 2 hours the Medical Director is notified. Record review of the In-service form dated 3/14/14 and 3/15/14 revealed approximately 50% of the staff representing all three shifts had been in-serviced on the lab protocol. Interviews conducted on 3/15/14, 3/16/14 and 3/17/14 with 17 nursing staff representing all three shifts revealed staff were competent in the understanding of the laboratory protocol. Record review of the lab log from 3/14 14-3/18/14 revealed compliance with the facility Plan of Removal. The IJ was lifted on 3/18/14 at 9:48 A.M. and the Administrator was notified after verification of the plan implementation had occurred. However while the IJ was removed on 3/18/2014 the facility remained out of compliance at a scope of " wide spread" and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on the polices and procedures concerning laboratory services. The facility 672 listed a census of 101

Based on observation, interview, and record review, the Administration failed to manage the facility by not appointing an RN to supervise nursing and by not monitoring the laboratory services for 5 of 18 resident ' s (Residents #80, #36, #97, #4, and #42) who were reviewed for lab services. The Administrator did not appoint a facility Registered Nurse, to monitor nursing responsibilities in following physician's orders [REDACTED]. The Administrator did not appoint a facility Registered Nurse to monitor that abnormal and panic level lab values were reported to the physician timely. The Administrator did not train staff to notify the Medical Director or administration if a physician does not respond timely when being contacted concerning abnormal or panic value labs. The Administrator did not monitor the contracted laboratory company to ensure laboratory services were preformed and reported timely to ensure residents maintained their highest practical physical health. An immediate jeopardy (IJ) was identified on 3/13/14 at 3:00 P.M. and the Administrator was notified at that time. The IJ was removed on 3/18/14 however the facility remained out of compliance at a scope of " wide spread " and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on policies and procedures concerning laboratory services. These failures affected 5 residents whose care was compromised due to staff not performing or reporting lab tests to physicians timely and placed 96 residents at risk of not receiving the lab services/care as ordered and a delay in physician notification which could result in delayed treatments and possible hospitalization . Intake # 8 Findings included: Interview on 3/14/2014 at 12:15 P.M. the Administrator stated he was not aware there was an issue with labs in the facility. He stated he was not informed by the previous DON nor was he informed by the Interim DON. He stated since the Immediate Jeopardy had been called, the facility had implemented a new lab monitoring form that would allow the nursing staff to track all labs. He stated that he had called in the company's Vice President of Clinical Services to help assist with getting the facility back in order and he had other members from the corporate office who would assist until the situation was under control. He stated the Acting DON would be monitoring staff to ensure they were following up on labs and he would follow up with her to ensure the process was effective. He stated since the previous DON had been gone, he had not appointed an RN to follow up on any of the DON duties. Interview on 3/12/2014 during initial tour at 9:30 A.M. the MDS Coordinator revealed the facility had not had a Director of Nursing for over two weeks. She stated they had not hired one yet but the Regional Nurse had been coming to the facility frequently to offer direction. Interview on 3/12/2013 at 1:00 P.M. the Regional Nurse (Interim DON) revealed she had been in and out of the facility for the past 3-4 months offering direction for staff to ensure they were following policies and procedures. She stated she had only been the Interim DON for one week. Interview on 3/13/14 at 2:00 P.M. the Interim DON stated the facility had given in-services for the nursing staff in 2014 due to stat lab results taking at least 12 hours for results and lab orders were found in the chart that had not been carried out timely. She also stated the nurses did not seem to recognize there was a problem with obtaining lab results. She said she personally called the lab to see why there was a delay with obtaining labs and results and was told the lab was undergoing construction and had to send the specimens out for testing. She said the lab did not notify the facility of the delays. Record review of Previous DON's file revealed she was hired on 12/2/2013 and terminated on 3/3/2014. Record Review of Administrator " Duties and Responsibilities " revealed he was responsible for " assisting department directors in planning, conducting and scheduling of in-service training " , " Ensure that all employees follow the facility ' s established policies and procedures " and " make routine inspections of the facility to assure that established policies and procedures are being implemented and followed. Resident #80 Record review of Resident #80 ' s admission information revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #80's lab results dated 2/19/2014 revealed a Potassium level of 5.3 ( normal range 3.5-5.1). This was flagged as a panic value. The panic value lab results were not communicated to the physician until after 2/23/2014. The facility staff made several attempts to report the panic values but when unable to communicate the results to the physician they did not notify administration or the medical director. Record Review of Resident #80 ' s lab orders revealed an order for [REDACTED]. Resident # 36 Record review of Resident #36 ' s face sheet revealed a 72 year old male admitted to the facility on [DATE] . His [DIAGNOSES REDACTED]. Record review of Resident # 36's abnormal lab value (BUN) on 2/7/2014 and panic lab values on 2/10/2014 (BUN was 82) , 2/13/2014 (BUN 115), and 2/15/2014 (BUN 80) revealed they were not immediately communicated to the physician. Several attempts were made by facility staff to report the findings to the physician and to the nurse practitioner but they were unsuccessful. The staff did not report this inability to report the panic levels to the physician to administration or the medical director. Record review of Resident #36's physician orders [REDACTED]. Record review of the Nurse ' s Progress Notes dated 2/16/14 revealed Panic lab values notified Dr. who sent (Resident # 36) to Local Hospital due to possible infection. Resident #97 Record review of Resident #97 ' s admission information revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #97 ' s medical record revealed there were no CBC and BMP lab results for 12/18/13, 12/23/13, or 1/24/1. Interview on 3/13/14 at 3:45 P.M. RN #3 stated she could not find evidence the labs for Resident #97's labs had been drawn as ordered. Resident #4 Record review of Resident #4 ' s admission information revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #4 ' s physician's orders [REDACTED]. Interview on 3/13/14 at 9:30 A.M. LVN #19 called the lab company and was informed there were no labs drawn on 3/7/2014 for Resident #4. Resident # 42 Record review of Resident # 42 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her admission [DIAGNOSES REDACTED]. Record review of Resident # 42 ' s physician's order [REDACTED].M. Interview on 3/13/14 at 3:18 P.M. LVN #13 stated she was not able to find the lab results that were ordered on [DATE] in the chart or in the computer. Record review of the facility in-service training reports revealed the following in-services had recently been conducted for staff: 12/16/13 Labs on weekend, Critical labs. 1/10/14 Lab procedure/Protocol for lab monitoring. 1/22/14 [MEDICATION NAME] flowsheets. 3/7/14 PT/INR, [MEDICATION NAME] management. Lab procedure/monitoring. An immediate jeopardy (IJ) was identified on 3/13/14 at 3:00 P.M. and the Administrator was notified at that time. A plan to remove the immediate jeopardy (IJ) was submitted and accepted on 3/18/14. The plan included: The DON/Designee will ensure all nursing staff are inserviced on the Laboratory protocol to ensure all labs are drawn as ordered, results are communicated to the facility timely and the physician is notified promptly based on results. The protocol would be for the nurse to complete the requisition once the lab order is received and place it in the lab book for the lab to be drawn. Results will be faxed to the facility. Critical/panic results are called before faxing. Normal results are faxed to the physician. Abnormal results are called to the physician. The nurse will follow-up with the physician to verify the receipt of normal lab results and if no response with 24 hours the Medical Director is notified. If no response from the physician to receive abnormal/critical lab results within 2 hours the Medical Director is notified. Record review of the In-service form dated 3/14/14 and 3/15/14 revealed approximately 50% of the staff representing all three shifts had been in-serviced on the lab protocol. Interviews conducted on 3/15/14, 3/16/14 and 3/17/14 with 17 nursing staff representing all three shifts revealed staff were competent in the understanding of the laboratory protocol. Record review of the lab log from 3/14 14-3/18/14 revealed compliance with the facility Plan of Removal. The IJ was lifted on 3/18/14 at 9:48 A.M. and the Administrator was notified after verification of the plan implementation had occurred. However while the IJ was removed on 3/18/2014 the facility remained out of compliance at a scope of " wide spread" and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on the polices and procedures concerning laboratory services. The Facility's 672 reported a census of 101

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibit neglect of residents for 5 of 18 resident ' s (Resident #80, #36, #97, #4, and #42) who were reviewed for lab services. The facility staff did not report laboratory results timely to the physician or obtain laboratory tests for Resident #80 as ordered by the physician. Resident #80 had panic lab values for potassium and abnormal levels of Urea Nitrogen (a test used to check kidney and liver functions) on 2/19/2014 that were not communicated to the physician until after 2/23/2014. The physician then ordered labs on 3/1/2014 to be collected on 3/2/214 and 3/3/2014. These labs were not collected with results called to the physician until 3/12/14. The results revealed a panic value level for Urea Nitrogen and the resident required admission to the intensive care unit at a local hospital for treatment on 3/12/2014. The facility staff did not report Resident # 36's abnormal lab value (BUN) on 2/7/2014 and panic lab values (BUNs) on 2/10/2014, 2/13/2014, and 2/15/2014 immediately to the physician. The resident was admitted to the hospital on [DATE]. The facility staff did not perform Resident ' s #97 and #4's laboratory tests as ordered by the physician. The facility staff did not perform the laboratory tests for Resident # 42 as ordered by the physician on 1/10/14. An immediate jeopardy (IJ) was identified on 3/13/14 at 3:00 P.M. The IJ was removed on 3/18/14 however the facility remained out of compliance at a scope of " wide spread " and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on policies and procedures concerning lab services. These failures affected 5 residents whose care was compromised due to staff not performing or reporting lab tests to physician's timely and placed 96 residents at risk of not receiving the lab services and care as ordered and a delay in physician notification which could result in delayed treatments and possible hospitalization . Intake # 8 Findings include: Resident #80 had panic lab values for potassium and abnormal levels of Urea Nitrogen (a test used to check kidney and liver functions) on 2/19/2014 that were not communicated to the physician until after 2/23/2014. The physician then ordered labs on 3/1/2014 to be collected on 3/2/214 and 3/3/2014. These labs were not collected with results called to the physician until 3/12/14. The results revealed a panic value level for Urea Nitrogen and the resident required admission to the intensive care unit at a local hospital for treatment on 3/12/2014. Resident # 36's abnormal lab value (BUN) on 2/7/2014 and panic lab values (BUNs) on 2/10/2014, 2/13/2014, and 2/15/2014 were not immediately communicated to the physician. The resident was admitted to the hospital on [DATE]. Resident ' s #97 and #4 did not have their labs performed as ordered by the physician. Resident # 42 did not have laboratory tests performed as ordered by the physician on 1/10/14. An immediate jeopardy (IJ) was identified on 3/13/14 at 3:00 P.M. The IJ was removed on 3/18/14 however the facility remained out of compliance at a scope of " wide spread " and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on policies and procedures concerning lab services. These failures affected 5 residents whose care was compromised due to staff not performing or reporting lab tests to physician's timely and placed 96 residents at risk of not receiving the lab services and care as ordered and a delay in physician notification which could result in delayed treatments and possible hospitalization . Intake # 8 Findings Include: Resident #80 Record review of Resident #80 ' s admission information revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #80 ' s re-admission MDS dated [DATE] revealed a BIMS score of 3 which indicated the resident was severely impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident required extensive assistance to total dependence of facility staff for all ADLs. Record review of Resident #80's Basic Metabolic Panel (BMP) lab results dated 2/19/2014 (no time) revealed a Potassium level of 5.3 ( normal range 3.5-5.1). This was flagged as a panic value. Record review of Resident #80 ' s nursing progress notes revealed the following documentation on 2/20/14 at 1345 (1:45 P.M.): "Received lab results, called MD (Medical Doctor) office and also called NP (Nurse Practitioner) to give report about this result, awaiting at this time for NP to call us back, report will be given to next shift to follow up." Record review of Resident #80's revealed the following was documented by facility staff on the lab result form and dated 2/23/14: "Paged several times with no answer. Unable to leave voice mail because voice mail is full. Held potassium today. Pt. on 10 meq of potassium daily. Please follow up." Need Urea Nitrogen Record review of Resident #80 ' s nursing progress notes dated 2/23/2014 at 11:43 A.M. revealed the following note: "pending call back potassium level high 5.3." Continued review of Resident #80 ' s medical record revealed there was no physician's order to hold the potassium. There was no documentation the physician was notified the potassium was held or of the panic level lab value. Record review of Resident #80's Physican's order dated 2/26/14 revealed an order for [REDACTED]. Record review of Resident #80's lab results of the BMP collected 2/26/14 revealed the resident's Potassium was 6.6 (normal 3.5-5.1). This was flagged as a panic value. Other lab values on the same form were Sodium 142 (normal 135-145) and Urea Nitrogen 59 (normal 8-23). Record review of Resident #80's computer generated Physican's order dated 2/27/14 revealed an order for [REDACTED]. Record review of Resident 80's BMP collected 2/27/14 Results dated 2/28/14 (no time) revealed the resident's Sodium was 136, Potassium 4.8 and Urea nitrogen 56. Record review of Resident #80's Physician's order dated 2/27/14 for [MEDICATION NAME] Powder to treat high potassium. Record review of Resident #80's BMP collected 2/28/14 with results dated 2/28/14 (no time) revealed the resident's Potassium 5.1 (This was flagged as a panic value), Sodium 135, and Urea Nitrogen 56. Record review of Resident #80 's two separate physician's orders revealed the following orders signed by LVN # 1: (On a hand written Physician's Telephone Order form dated 3/1/2014, (no time) Repeat BMP on Sunday 3/2/14. (On a computerized physician's order form) Verbal order 3/1/2014 at 0205 (2:05 A.M.) BMP to be drawn Monday 3/3/14 one time only. Record review of Resident #80 ' s nursing progress notes dated 3/11/14 at 2301 (11:01 P.M.) revealed the following documentation: Call to lab to request BMP results. BMP scheduled to be drawn on Sunday 3/2/14. Spoke to lab person and reports results are still pending in system but will fax to facility as soon as available. Continued review of Resident #80 ' s lab results between 3/2/2014 and 3/12/2014 revealed there were no BMP results for 3/2/14 or 3/3/14. Record review of Resident #80's BMP lab report dated 3/12/2014 revealed a Urea Nitrogen of 108 (reference range 8-23). This was identified on the lab result as a panic value. Record review of Resident #80's nursing progress notes dated 3/12/2014 at 2344 (11:44 P.M.) revealed the panic lab value was reported to the physician and orders received was to transfer the resident to the hospital. Record review of Resident #80 ' s lab results from the hospital emergency room dated 3/13/14 0052 (12:52 A.M.) revealed the following results: Sodium 155 (135-141) Potassium 5.0 (3.7-4.7) BUN 114 (5-25) Interview on 3/13/14 at 1:35 P.M. LVN #6 stated Resident #80 had been transferred to the hospital during the night due to panic levels on her labs. She stated each day the nurse should check the orders from the previous day to see if there are any labs or orders that need follow-up. She also stated each nurse should check the 24 hour report book for any needed follow-up with residents. She further stated she just started a few weeks ago and the facility had conducted an inservice on lab services earlier in the month which covered the procedure for ordering tests and notifying the physician. Interview on 3/13/14 at 3:45 P.M. RN #3 stated she could not find evidence the labs for Resident #80 had been drawn as ordered. She stated she did not know why the labs for 3/3/14 were not done and why there were orders for labs for 3/2/14 and 3/3/14 and the doctor should have been called to clarify what was needed. She also stated the nurse should check the 24 hour report book each day for any labs and follow-up on the results. She stated the lab did not come on the week-end unless the tests were ordered stat. Resident # 36 Record review of Resident #36 ' s face sheet revealed a 72 year old male admitted to the facility on [DATE] . His [DIAGNOSES REDACTED]. Record review of the resident ' s CBC and CMP lab result sheets revealed a collected and results dated 2/7/14. There was no documented time to indicate when the laboratory report was received by the facility. The resident ' s CBC revealed his White Blood Count (WBC) was 11.5 normal ranges were 4.0 -11.0. and his Complete Metabolic Panel (CMP)revealed the Blood Urea Nitrogen (BUN) was 61, which is an abnormal level with normal ranges being 7-25 . Continued review of the lab sheet revealed it was faxed to the physician on 2/10/14. Record review of Resident #36's Nurses Progress Notes dated 2/8/14 revealed the resident ' s physician was called at 11:13 A.M. and a voice message was left regarding the lab results of 2/7/12. Labs were faxed to his office. Continued review revealed another attempt to notify the physician was made on 2/8/14 at 5:31 P.M. Record review of Resident # 36 ' s CBC and CMP collected and results dated 2/10/14 revealed WBC 11.9. The CMP revealed " Report contains Panic Value " BUN was 82. Continued review of the CBC report revealed " Repeat in A.M. Review of the CMP report revealed " lab in A.M. called MD twice. Also called nurse practitioner and handed over to (RN#12 the next shift's nurse). Record review of Resident #36's Nurse ' s Progress Notes revealed 2/11/14 at 2:44 A.M. "received critical lab values for patient ' s chemistry profile and physician notified". 2/11/13 at 5:55 A.M. "Patient reassessed MD notified again regarding patient ' s condition and laboratory results". 2/11/14 at 6:10 A.M "Nurse Practitioner contacted. Her mailbox was full. (RN #12) told to follow up". Record review of the nurse ' s progress notes dated 2/11/14 at 3:15 P.M. revealed the resident was observed on the floor . Record review of the resident ' s record did not revealed any results for a CBC and CMP dated 2/11/13. Record review of the physician's orders dated 2/11/13 revealed an order to Repeat CBC in A.M. Record review of the resident's lab reports did not reveal any CBC results dated 2/12/14. Interview on 3/13/14 at 3:30 P.M. LVN #13 stated she was unable to locate any lab results dated 2/12/14. Record review of Resident # 36 ' s CBC and CMP results dated 2/13/14 revealed the WBC was 12.6 (normal range 4.4-10.5). Record review of the CMP lab form revealed a the collection of the specimen dated 2/12/14 at 8:15 A.M. and results dated 2/13/14 " Report contains Panic Value " BUN was 107. Review of the physician's orders revealed the physician was notified and an IV was started to treat the resident. Record review of the CMP lab form revealed a collection of the specimen dated 2/13/14 at 3:27 P.M. and results dated 2/13/14 " Report contains Panic Value " BUN 115 (normal range 8-23). Further review of the lab form revealed no documentation of the physician being notified of the panic value. Record review of the resident ' s lab results and nursing progress notes from 2/13/2014 and 2/14/2014 revealed no documentation the physician was notified of the lab results dated 2/13/14. Record review of the resident ' s CMP lab form collected on 2/14/14 and results dated 2/15/14 revealed Panic levels BUN Results 112. Continued review of the lab form revealed documentation the lab results were faxed to the physician on 2/15/14 and a copy of the form revealed documentation that on "2/16/14 left message faxed over" (to the physician). Record review of the Nurse ' s Progress Notes dated 2/15/14 revealed the "BUN Creatinine ration 80 was reported tonight. Left a voice message for MD. NP voice mail was full and could not receive messages. Lab results also faxed." Record review of the Nurse ' s Progress Notes dated 2/16/14 revealed Panic lab values notified Dr. who sent (Resident # 36) to Local Hospital due to possible infection. Record review of Resident # 36 ' s clinical record revealed a transfer form to a local hospital dated 2/16/14 due to lab values. Interview on 3/13/14. at 1:30 P.M. LVN # 7 stated staff were instructed to call the physician with any abnormal labs and if the staff cannot reach the physician they were to call the medical director. Interview on 3/13/14 at 3:30 P.M. LVN# 13 stated the physician was not notified of the labs in a timely manner and when the resident has a panic value the physician continues to be called until staff can talk with him. As of yesterday staff were instructed to call the medical director after the attending physician cannot be reached after 3 tries. Interview on 3/14/14 at 12:30 P.M. LVN #7 stated she remembered Resident #36 having Panic Labs on 2/13/14 and the DON was taking care of it for her. As the interview continued she stated the DON was no longer working at the facility. Resident #97 Record review of Resident #97 ' s admission information revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #97's medication review report revealed the following: [MEDICATION NAME] Sodium 2 mg daily as of 9/30/13 . Record review of Resident #97 ' s laboratory results dated [DATE] revealed the following results: PT 17.2 (12.1-14.9) INR 1.39 (1.5-3.0) Record review of Resident #97 ' s medical record revealed the following physician's orders: 12/17/13: CBC, BMP in A.M. 12/20/13: Draw PT/INR on 12/23/13 Monday. 1/10/14 Stat PT/INR 1/12/14 Increase [MEDICATION NAME] to 3 mg by mouth daily Repeat PT/INR in 2 weeks (1/26/14)(this was a Sunday) 1/23/14: Clarification: PT/INR on Monday (1/27/14) Record review of Resident #97 ' s lab results from 12/18/2014 thru 12/20/2014 revealed the CBC and BMP results for 12/18/13 were not on the chart nor were they available from the lab website for results. Record review of Resident #97 ' s lab results between 12/23/2014 through 12/25/2014 revealed the PT/INR results for 12/23/13 were not available on the chart nor were they available from the lab website. Record review of Resident #97 ' s lab results from 1/27/14 through 1/29/14 revealed the PT/INR results for 1/27/14 were not available on the chart nor were they available from the lab website. Observation on 3/13/14 at 8:30 A.M. revealed Resident #97 was sitting up in the geri-chair at the bedside. He was groomed and dressed in street clothes. He was able to answer simple questions but was not able to have a full conversation. The resident ' s speech was somewhat garbled and he was unable to clearly make his needs known. Interview on 3/13/14 at 3:45 P.M. RN #3 stated she could not find evidence the labs for Resident #97 had been drawn as ordered. Resident #4 Record review of Resident #4 ' s admission information revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #4 ' s physician's orders revealed the following: Dated 12/31/2013 - [MEDICATION NAME] (Levetiracetam) Solution 100 mg/ml give 5 ml via PE[DEVICE] every 12 hours at 5:00 A.M. and 5:00 P.M. related to [MEDICAL CONDITION]. Dated 2/28/2014 - CBC, BMP, levetiracetam level (this test is to monitor the theraputic dosage of the [MEDICATION NAME] medication given for [MEDICAL CONDITION]) and lipid panel on 3/7/2014. Record review of Resident #4 ' s chart revealed no lab results drawn on 3/7/2014 as ordered. Further review revealed lab results for lipid panel, drawn on 3/10/14 in chart. Record review of nurse ' s notes dated 3/11/14 revealed " CBC, BMP, levetiracetam level and lipid panel on 3/7/14 - received results of lipid profile - faxed to Dr. office. Please follow up " . Interview on 3/13/14 at 9:30 A.M. LVN #19 confirmed there were no lab results for a CBC, BMP and levetiracetam level in the resident ' s chart. She stated there was a Lipid panel result that was drawn on the 10th in the chart. She continued to verify there were no lab results in the computer system or in the lab book. She called the lab company and was informed there were no labs drawn on 3/7/2014 for Resident #4 and the only lab results since 3/7/14 was for a Lipid Panel drawn on 3/10/14. She stated the lab order for a CBC, BMP, levetiracetam level and Lipid Panel for 3/7/14 must have been missed. Record review of the Mayo Clinic Mayo Medical Laboratories website httt://www.mayomoedicallaboratories.com/test-catalog/print/ revealed Serum Levetiracetam laboratory tests were useful for monitoring serum concentration of levetiracetam ([MEDICATION NAME]), particularly in patients with [MEDICAL CONDITION], assessing compliance, and assessing potential toxicity. Resident # 42 Record review of Resident # 42 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her admission [DIAGNOSES REDACTED]. Record review of Resident # 42 ' s Physician ' s orders dated March 2014 revealed CBC with Differential, BMP, Calcium, Magnesium, Phosphorus, TSH, Lipid Profile and Vitamin D3 level in A.M. dated 1/10/14 at 12:33 A.M. Record review of the resident ' s lab reports dated from 1/10/2014 through 1/15/2014 revealed the above ordered lab results were not in the chart. Interview on 3/13/14 at 3:18 P.M. LVN #13 stated she was not able to find the lab results that were ordered on [DATE] in the chart or in the computer. After the IJ was called the facility requested the contract laboratory company to do a complete audit of the facility on the night of 3/13/2014. During that audit the lab results dated 1/10/14 for Resident #42 were located and provided to on 3/14/14 for review. Record review of the facility in-service training reports revealed the following in-services had recently been conducted for staff: 12/16/13 Labs on weekend, Critical labs. 1/10/14 Lab procedure/Protocol for lab monitoring. 1/22/14 [MEDICATION NAME] flowsheets. 3/7/14 PT/INR, [MEDICATION NAME] management. Lab procedure/monitoring. Interview on 3/13/14 at 2:00 P.M. the Interim DON stated the facility had given in-services for the nursing staff in 2014 due to stat lab results taking at least 12 hours for results and lab orders were found in the chart that had not been carried out timely. She also stated the nurses did not seem to recognize there was a problem with obtaining lab results. She said she personally called the lab to see why there was a delay with obtaining labs and results and was told the lab was undergoing construction and had to send the specimens out for testing. She said the lab did not notify the facility of the delays. Interview on 3/14/2014 at 12:15 P.M. the Administrator stated he was not aware there was an issue with labs in the facility. He stated he was not informed by the previous DON nor was he informed by the Interim DON. He stated since the Immediate Jeopardy had been called, the facility had implemented a new lab monitoring form that would allow the nursing staff to track all labs. He stated that he had called in the company's Vice President of Clinical Services to help assist with getting the facility back in order and he had other members from the corporate office who would assist until the situation was under control. He stated the Acting DON would be monitoring staff to ensure they were following up on labs and he would follow up with her to ensure the process was effective. He stated since the previous DON had been gone, he had not appointed an RN to follow up on any of the DON duties. Record review of the facility policy titled: Lab and Diagnostic Rest Results-Clinical Protocol dated 2005 (Revised April 2007) revealed in part the following: 1. A nurse will review all results a. If the staff that first receive or review lab and diagnostic test results cannot follow the remainder of the procedure for reporting and documenting the results and their implications, another nurse in the facility (Supervisor, Charge nurse, etc.) should follow or coordinate the procedure. Nursing staff will consider the following factor to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: 2. The result is something that should be conveyed to a physician regardless of other circumstances 4. High or toxic drug levels. If the a test was obtained to monitor the blood level of a medication and the level is reported as high or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation had been reviewed with the physician. Options for physician notification 1. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident ' s clinical status is unstable or current treatment needs review or clarification. Physician responses 1. a. A physician should respond with one hour regarding a lab test result requiring immediate notification. b. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. An immediate jeopardy (IJ) was identified on 3/13/14 at 3:00 P.M. and the Administrator was notified at that time. A plan to remove the immediate jeopardy (IJ) was submitted and accepted on 3/18/14. The plan included: The DON/Designee will ensure all nursing staff are inserviced on the Laboratory protocol to ensure all labs are drawn as ordered, results are communicated to the facility timely and the physician is notified promptly based on results. The protocol would be for the nurse to complete the requisition once the lab order is received and place it in the lab book for the lab to be drawn. Results will be faxed to the facility. Critical/panic results are called before faxing. Normal results are faxed to the physician. Abnormal results are called to the physician. The nurse will follow-up with the physician to verify the receipt of normal lab results and if no response with 24 hours the Medical Director is notified. If no response from the physician to receive abnormal/critical lab results within 2 hours the Medical Director is notified. Record review of the In-service form dated 3/14/14 and 3/15/14 revealed approximately 50% of the staff representing all three shifts had been in-serviced on the lab protocol. Interviews conducted on 3/15/14, 3/16/14 and 3/17/14 with 17 nursing staff representing all three shifts revealed staff were competent in the understanding of the laboratory protocol. Record review of the lab log from 3/14 14-3/18/14 revealed compliance with the facility Plan of Removal. The IJ was lifted on 3/18/14 at 9:48 A.M. and the Administrator was notified after verification of the plan implementation had occurred. However while the IJ was removed on 3/18/2014 the facility remained out of compliance at a scope of " wide spread" and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on the polices and procedures concerning laboratory services. The facility 672 listed a census of 101

Based on observation, interview and record review the facility failed to implement their written policies and procedures that prohibit neglect of residents for for 5 of 18 resident ' s (Resident #80, #36, #97, #4, and #42) who were reviewed for lab services. The facility staff did not report laboratory results timely to the physician or obtain laboratory tests for Resident #80 as ordered by the physician. Resident #80 had panic lab values for potassium and abnormal levels of Urea Nitrogen (a test used to check kidney and liver functions) on 2/19/2014 that were not communicated to the physician until after 2/23/2014. The physician then ordered labs on 3/1/2014 to be collected on 3/2/214 and 3/3/2014. These labs were not collected with results called to the physician until 3/12/14. The results revealed a panic value level for Urea Nitrogen and the resident required admission to the intensive care unit at a local hospital for treatment on 3/12/2014. The facility staff did not report Resident # 36's abnormal lab value (BUN) on 2/7/2014 and panic lab values (BUNs) on 2/10/2014, 2/13/2014, and 2/15/2014 immediately to the physician. The resident was admitted to the hospital on [DATE]. The facility staff did not perform Resident ' s #97 and #4's laboratory tests as ordered by the physician. The facility staff did not perform the laboratory tests for Resident # 42 as ordered by the physician on 1/10/14. An immediate jeopardy (IJ) was identified on 3/13/14 at 3:00 P.M. The IJ was removed on 3/18/14 however the facility remained out of compliance at a scope of " wide spread " and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on policies and procedures concerning lab services. These failures affected 5 residents whose care was compromised due to staff not performing or reporting lab tests to physician's timely and placed 96 residents at risk of not receiving the lab services and care as ordered and a delay in physician notification which could result in delayed treatments and possible hospitalization . Intake # 8 Findings include: Record review of the facility's policy Recognizing Signs and Symptoms of Abuse/Neglect dated December 2006 revealed "Our facility will not condone any form of resident abuse or neglect... Neglect is defined as failure to provide goods and services as necessaroy to avoid physical harm, netal anguish, or mental illness..." Resident #80 had panic lab values for potassium and abnormal levels of Urea Nitrogen (a test used to check kidney and liver functions) on 2/19/2014 that were not communicated to the physician until after 2/23/2014. The physician then ordered labs on 3/1/2014 to be collected on 3/2/214 and 3/3/2014. These labs were not collected with results called to the physician until 3/12/14. The results revealed a panic value level for Urea Nitrogen and the resident required admission to the intensive care unit at a local hospital for treatment on 3/12/2014. Resident # 36's abnormal lab value (BUN) on 2/7/2014 and panic lab values (BUNs) on 2/10/2014, 2/13/2014, and 2/15/2014 were not immediately communicated to the physician. The resident was admitted to the hospital on [DATE]. Resident ' s #97 and #4 did not have their labs performed as ordered by the physician. Resident # 42 did not have laboratory tests performed as ordered by the physician on 1/10/14. An immediate jeopardy (IJ) was identified on 3/13/14 at 3:00 P.M. The IJ was removed on 3/18/14 however the facility remained out of compliance at a scope of " wide spread " and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on policies and procedures concerning lab services. These failures affected 5 residents whose care was compromised due to staff not performing or reporting lab tests to physician's timely and placed 96 residents at risk of not receiving the lab services and care as ordered and a delay in physician notification which could result in delayed treatments and possible hospitalization . Intake # 8 Findings Include: Resident #80 Record review of Resident #80 ' s admission information revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #80 ' s re-admission MDS dated [DATE] revealed a BIMS score of 3 which indicated the resident was severely impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident required extensive assistance to total dependence of facility staff for all ADLs. Record review of Resident #80's Basic Metabolic Panel (BMP) lab results dated 2/19/2014 (no time) revealed a Potassium level of 5.3 ( normal range 3.5-5.1). This was flagged as a panic value. Record review of Resident #80 ' s nursing progress notes revealed the following documentation on 2/20/14 at 1345 (1:45 P.M.): "Received lab results, called MD (Medical Doctor) office and also called NP (Nurse Practitioner) to give report about this result, awaiting at this time for NP to call us back, report will be given to next shift to follow up." Record review of Resident #80's revealed the following was documented by facility staff on the lab result form and dated 2/23/14: "Paged several times with no answer. Unable to leave voice mail because voice mail is full. Held potassium today. Pt. on 10 meq of potassium daily. Please follow up." Need Urea Nitrogen Record review of Resident #80 ' s nursing progress notes dated 2/23/2014 at 11:43 A.M. revealed the following note: "pending call back potassium level high 5.3." Continued review of Resident #80 ' s medical record revealed there was no physician's order to hold the potassium. There was no documentation the physician was notified the potassium was held or of the panic level lab value. Record review of Resident #80's Physican's order dated 2/26/14 revealed an order for [REDACTED]. Record review of Resident #80's lab results of the BMP collected 2/26/14 revealed the resident's Potassium was 6.6 (normal 3.5-5.1). This was flagged as a panic value. Other lab values on the same form were Sodium 142 (normal 135-145) and Urea Nitrogen 59 (normal 8-23). Record review of Resident #80's computer generated Physican's order dated 2/27/14 revealed an order for [REDACTED]. Record review of Resident 80's BMP collected 2/27/14 Results dated 2/28/14 (no time) revealed the resident's Sodium was 136, Potassium 4.8 and Urea nitrogen 56. Record review of Resident #80's Physician's order dated 2/27/14 for [MEDICATION NAME] Powder to treat high potassium. Record review of Resident #80's BMP collected 2/28/14 with results dated 2/28/14 (no time) revealed the resident's Potassium 5.1 (This was flagged as a panic value), Sodium 135, and Urea Nitrogen 56. Record review of Resident #80 's two separate physician's orders revealed the following orders signed by LVN # 1: (On a hand written Physician's Telephone Order form dated 3/1/2014, (no time) Repeat BMP on Sunday 3/2/14. (On a computerized physician's order form) Verbal order 3/1/2014 at 0205 (2:05 A.M.) BMP to be drawn Monday 3/3/14 one time only. Record review of Resident #80 ' s nursing progress notes dated 3/11/14 at 2301 (11:01 P.M.) revealed the following documentation: Call to lab to request BMP results. BMP scheduled to be drawn on Sunday 3/2/14. Spoke to lab person and reports results are still pending in system but will fax to facility as soon as available. Continued review of Resident #80 ' s lab results between 3/2/2014 and 3/12/2014 revealed there were no BMP results for 3/2/14 or 3/3/14. Record review of Resident #80's BMP lab report dated 3/12/2014 revealed a Urea Nitrogen of 108 (reference range 8-23). This was identified on the lab result as a panic value. Record review of Resident #80's nursing progress notes dated 3/12/2014 at 2344 (11:44 P.M.) revealed the panic lab value was reported to the physician and orders received was to transfer the resident to the hospital. Record review of Resident #80 ' s lab results from the hospital emergency room dated 3/13/14 0052 (12:52 A.M.) revealed the following results: Sodium 155 (135-141) Potassium 5.0 (3.7-4.7) BUN 114 (5-25) Interview on 3/13/14 at 1:35 P.M. LVN #6 stated Resident #80 had been transferred to the hospital during the night due to panic levels on her labs. She stated each day the nurse should check the orders from the previous day to see if there are any labs or orders that need follow-up. She also stated each nurse should check the 24 hour report book for any needed follow-up with residents. She further stated she just started a few weeks ago and the facility had conducted an inservice on lab services earlier in the month which covered the procedure for ordering tests and notifying the physician. Interview on 3/13/14 at 3:45 P.M. RN #3 stated she could not find evidence the labs for Resident #80 had been drawn as ordered. She stated she did not know why the labs for 3/3/14 were not done and why there were orders for labs for 3/2/14 and 3/3/14 and the doctor should have been called to clarify what was needed. She also stated the nurse should check the 24 hour report book each day for any labs and follow-up on the results. She stated the lab did not come on the week-end unless the tests were ordered stat. Resident # 36 Record review of Resident #36 ' s face sheet revealed a 72 year old male admitted to the facility on [DATE] . His [DIAGNOSES REDACTED]. Record review of the resident ' s CBC and CMP lab result sheets revealed a collected and results dated 2/7/14. There was no documented time to indicate when the laboratory report was received by the facility. The resident ' s CBC revealed his White Blood Count (WBC) was 11.5 normal ranges were 4.0 -11.0. and his Complete Metabolic Panel (CMP)revealed the Blood Urea Nitrogen (BUN) was 61, which is an abnormal level with normal ranges being 7-25 . Continued review of the lab sheet revealed it was faxed to the physician on 2/10/14. Record review of Resident #36's Nurses Progress Notes dated 2/8/14 revealed the resident ' s physician was called at 11:13 A.M. and a voice message was left regarding the lab results of 2/7/12. Labs were faxed to his office. Continued review revealed another attempt to notify the physician was made on 2/8/14 at 5:31 P.M. Record review of Resident # 36 ' s CBC and CMP collected and results dated 2/10/14 revealed WBC 11.9. The CMP revealed " Report contains Panic Value " BUN was 82. Continued review of the CBC report revealed " Repeat in A.M. Review of the CMP report revealed " lab in A.M. called MD twice. Also called nurse practitioner and handed over to (RN#12 the next shift's nurse). Record review of Resident #36's Nurse ' s Progress Notes revealed 2/11/14 at 2:44 A.M. "received critical lab values for patient ' s chemistry profile and physician notified". 2/11/13 at 5:55 A.M. "Patient reassessed MD notified again regarding patient ' s condition and laboratory results". 2/11/14 at 6:10 A.M "Nurse Practitioner contacted. Her mailbox was full. (RN #12) told to follow up". Record review of the nurse ' s progress notes dated 2/11/14 at 3:15 P.M. revealed the resident was observed on the floor . Record review of the resident ' s record did not revealed any results for a CBC and CMP dated 2/11/13. Record review of the physician's orders dated 2/11/13 revealed an order to Repeat CBC in A.M. Record review of the resident's lab reports did not reveal any CBC results dated 2/12/14. Interview on 3/13/14 at 3:30 P.M. LVN #13 stated she was unable to locate any lab results dated 2/12/14. Record review of Resident # 36 ' s CBC and CMP results dated 2/13/14 revealed the WBC was 12.6 (normal range 4.4-10.5). Record review of the CMP lab form revealed a the collection of the specimen dated 2/12/14 at 8:15 A.M. and results dated 2/13/14 " Report contains Panic Value " BUN was 107. Review of the physician's orders revealed the physician was notified and an IV was started to treat the resident. Record review of the CMP lab form revealed a collection of the specimen dated 2/13/14 at 3:27 P.M. and results dated 2/13/14 " Report contains Panic Value " BUN 115 (normal range 8-23). Further review of the lab form revealed no documentation of the physician being notified of the panic value. Record review of the resident ' s lab results and nursing progress notes from 2/13/2014 and 2/14/2014 revealed no documentation the physician was notified of the lab results dated 2/13/14. Record review of the resident ' s CMP lab form collected on 2/14/14 and results dated 2/15/14 revealed Panic levels BUN Results 112. Continued review of the lab form revealed documentation the lab results were faxed to the physician on 2/15/14 and a copy of the form revealed documentation that on "2/16/14 left message faxed over" (to the physician). Record review of the Nurse ' s Progress Notes dated 2/15/14 revealed the "BUN Creatinine ration 80 was reported tonight. Left a voice message for MD. NP voice mail was full and could not receive messages. Lab results also faxed." Record review of the Nurse ' s Progress Notes dated 2/16/14 revealed Panic lab values notified Dr. who sent (Resident # 36) to Local Hospital due to possible infection. Record review of Resident # 36 ' s clinical record revealed a transfer form to a local hospital dated 2/16/14 due to lab values. Interview on 3/13/14. at 1:30 P.M. LVN # 7 stated staff were instructed to call the physician with any abnormal labs and if the staff cannot reach the physician they were to call the medical director. Interview on 3/13/14 at 3:30 P.M. LVN# 13 stated the physician was not notified of the labs in a timely manner and when the resident has a panic value the physician continues to be called until staff can talk with him. As of yesterday staff were instructed to call the medical director after the attending physician cannot be reached after 3 tries. Interview on 3/14/14 at 12:30 P.M. LVN #7 stated she remembered Resident #36 having Panic Labs on 2/13/14 and the DON was taking care of it for her. As the interview continued she stated the DON was no longer working at the facility. Resident #97 Record review of Resident #97 ' s admission information revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #97's medication review report revealed the following: [MEDICATION NAME] Sodium 2 mg daily as of 9/30/13 . Record review of Resident #97 ' s laboratory results dated [DATE] revealed the following results: PT 17.2 (12.1-14.9) INR 1.39 (1.5-3.0) Record review of Resident #97 ' s medical record revealed the following physician's orders: 12/17/13: CBC, BMP in A.M. 12/20/13: Draw PT/INR on 12/23/13 Monday. 1/10/14 Stat PT/INR 1/12/14 Increase [MEDICATION NAME] to 3 mg by mouth daily Repeat PT/INR in 2 weeks (1/26/14)(this was a Sunday) 1/23/14: Clarification: PT/INR on Monday (1/27/14) Record review of Resident #97 ' s lab results from 12/18/2014 thru 12/20/2014 revealed the CBC and BMP results for 12/18/13 were not on the chart nor were they available from the lab website for results. Record review of Resident #97 ' s lab results between 12/23/2014 through 12/25/2014 revealed the PT/INR results for 12/23/13 were not available on the chart nor were they available from the lab website. Record review of Resident #97 ' s lab results from 1/27/14 through 1/29/14 revealed the PT/INR results for 1/27/14 were not available on the chart nor were they available from the lab website. Observation on 3/13/14 at 8:30 A.M. revealed Resident #97 was sitting up in the geri-chair at the bedside. He was groomed and dressed in street clothes. He was able to answer simple questions but was not able to have a full conversation. The resident ' s speech was somewhat garbled and he was unable to clearly make his needs known. Interview on 3/13/14 at 3:45 P.M. RN #3 stated she could not find evidence the labs for Resident #97 had been drawn as ordered. Resident #4 Record review of Resident #4 ' s admission information revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #4 ' s physician's orders revealed the following: Dated 12/31/2013 - [MEDICATION NAME] (Levetiracetam) Solution 100 mg/ml give 5 ml via PE[DEVICE] every 12 hours at 5:00 A.M. and 5:00 P.M. related to [MEDICAL CONDITION]. Dated 2/28/2014 - CBC, BMP, levetiracetam level (this test is to monitor the theraputic dosage of the [MEDICATION NAME] medication given for [MEDICAL CONDITION]) and lipid panel on 3/7/2014. Record review of Resident #4 ' s chart revealed no lab results drawn on 3/7/2014 as ordered. Further review revealed lab results for lipid panel, drawn on 3/10/14 in chart. Record review of nurse ' s notes dated 3/11/14 revealed " CBC, BMP, levetiracetam level and lipid panel on 3/7/14 - received results of lipid profile - faxed to Dr. office. Please follow up " . Interview on 3/13/14 at 9:30 A.M. LVN #19 confirmed there were no lab results for a CBC, BMP and levetiracetam level in the resident ' s chart. She stated there was a Lipid panel result that was drawn on the 10th in the chart. She continued to verify there were no lab results in the computer system or in the lab book. She called the lab company and was informed there were no labs drawn on 3/7/2014 for Resident #4 and the only lab results since 3/7/14 was for a Lipid Panel drawn on 3/10/14. She stated the lab order for a CBC, BMP, levetiracetam level and Lipid Panel for 3/7/14 must have been missed. Record review of the Mayo Clinic Mayo Medical Laboratories website httt://www.mayomoedicallaboratories.com/test-catalog/print/ revealed Serum Levetiracetam laboratory tests were useful for monitoring serum concentration of levetiracetam ([MEDICATION NAME]), particularly in patients with [MEDICAL CONDITION], assessing compliance, and assessing potential toxicity. Resident # 42 Record review of Resident # 42 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her admission [DIAGNOSES REDACTED]. Record review of Resident # 42 ' s Physician ' s orders dated March 2014 revealed CBC with Differential, BMP, Calcium, Magnesium, Phosphorus, TSH, Lipid Profile and Vitamin D3 level in A.M. dated 1/10/14 at 12:33 A.M. Record review of the resident ' s lab reports dated from 1/10/2014 through 1/15/2014 revealed the above ordered lab results were not in the chart. Interview on 3/13/14 at 3:18 P.M. LVN #13 stated she was not able to find the lab results that were ordered on [DATE] in the chart or in the computer. After the IJ was called the facility requested the contract laboratory company to do a complete audit of the facility on the night of 3/13/2014. During that audit the lab results dated 1/10/14 for Resident #42 were located and provided to on 3/14/14 for review. Record review of the facility in-service training reports revealed the following in-services had recently been conducted for staff: 12/16/13 Labs on weekend, Critical labs. 1/10/14 Lab procedure/Protocol for lab monitoring. 1/22/14 [MEDICATION NAME] flowsheets. 3/7/14 PT/INR, [MEDICATION NAME] management. Lab procedure/monitoring. Interview on 3/13/14 at 2:00 P.M. the Interim DON stated the facility had given in-services for the nursing staff in 2014 due to stat lab results taking at least 12 hours for results and lab orders were found in the chart that had not been carried out timely. She also stated the nurses did not seem to recognize there was a problem with obtaining lab results. She said she personally called the lab to see why there was a delay with obtaining labs and results and was told the lab was undergoing construction and had to send the specimens out for testing. She said the lab did not notify the facility of the delays. Interview on 3/14/2014 at 12:15 P.M. the Administrator stated he was not aware there was an issue with labs in the facility. He stated he was not informed by the previous DON nor was he informed by the Interim DON. He stated since the Immediate Jeopardy had been called, the facility had implemented a new lab monitoring form that would allow the nursing staff to track all labs. He stated that he had called in the company's Vice President of Clinical Services to help assist with getting the facility back in order and he had other members from the corporate office who would assist until the situation was under control. He stated the Acting DON would be monitoring staff to ensure they were following up on labs and he would follow up with her to ensure the process was effective. He stated since the previous DON had been gone, he had not appointed an RN to follow up on any of the DON duties. Record review of the facility policy titled: Lab and Diagnostic Rest Results-Clinical Protocol dated 2005 (Revised April 2007) revealed in part the following: 1. A nurse will review all results a. If the staff that first receive or review lab and diagnostic test results cannot follow the remainder of the procedure for reporting and documenting the results and their implications, another nurse in the facility (Supervisor, Charge nurse, etc.) should follow or coordinate the procedure. Nursing staff will consider the following factor to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: 2. The result is something that should be conveyed to a physician regardless of other circumstances 4. High or toxic drug levels. If the a test was obtained to monitor the blood level of a medication and the level is reported as high or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation had been reviewed with the physician. Options for physician notification 1. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident ' s clinical status is unstable or current treatment needs review or clarification. Physician responses 1. a. A physician should respond with one hour regarding a lab test result requiring immediate notification. b. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. An immediate jeopardy (IJ) was identified on 3/13/14 at 3:00 P.M. and the Administrator was notified at that time. A plan to remove the immediate jeopardy (IJ) was submitted and accepted on 3/18/14. The plan included: The DON/Designee will ensure all nursing staff are inserviced on the Laboratory protocol to ensure all labs are drawn as ordered, results are communicated to the facility timely and the physician is notified promptly based on results. The protocol would be for the nurse to complete the requisition once the lab order is received and place it in the lab book for the lab to be drawn. Results will be faxed to the facility. Critical/panic results are called before faxing. Normal results are faxed to the physician. Abnormal results are called to the physician. The nurse will follow-up with the physician to verify the receipt of normal lab results and if no response with 24 hours the Medical Director is notified. If no response from the physician to receive abnormal/critical lab results within 2 hours the Medical Director is notified. Record review of the In-service form dated 3/14/14 and 3/15/14 revealed approximately 50% of the staff representing all three shifts had been in-serviced on the lab protocol. Interviews conducted on 3/15/14, 3/16/14 and 3/17/14 with 17 nursing staff representing all three shifts revealed staff were competent in the understanding of the laboratory protocol. Record review of the lab log from 3/14 14-3/18/14 revealed compliance with the facility Plan of Removal. The IJ was lifted on 3/18/14 at 9:48 A.M. and the Administrator was notified after verification of the plan implementation had occurred. However while the IJ was removed on 3/18/2014 the facility remained out of compliance at a scope of " wide spread" and a severity level of " Actual Harm that is not Immediate Jeopardy " because all staff had not been trained on the polices and procedures concerning laboratory services. The facility 672 listed a census of 101

Based on observation, interview and record review the facility failed to ensure six of 28 sampled residents (#s 68, 64, 90, 94, 48 and 29) were assessed and provided the necessary care to treat their pain to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with their comprehensive assessments and plan of care. The facility failed to: - assess for Resident #68's pain during and after wound care on 3/30/11 and consult physician of the effectiveness of the pain management, - assess Resident #94's pain every shift in February and March, 2011 and assess pain prior to medicating to determine the medications' effectiveness on 3/11, 3/20, 3/21, 3/23, and 3/24/11, - assess Resident #64's pain on the evening shift in March, 2011 and consult with the physician on the effectiveness of the pain management, - assess Resident #90's pain, treat and consult with physician on effectiveness of pain management, - provide pain medication per care plan to Resident #48 prior to wound care on 3/30/11, assess level of pain during wound care on 3/30/11 and medicate according to the assessment, - and assess the effectiveness of Resident #29's routine pain medication as resident was having to self-medicate to alleviate pain. These failures to assess and treat in a timely manner caused six residents to endure unnecessary pain and placed 92 residents at risk of a deterioration in their health and adverse consequences. Findings include: Resident #68 Review of Resident #68's information sheet revealed she was admitted to the facility on [DATE] and readmitted [DATE]. Review of Resident #68's physician's orders [REDACTED]. Observation on 3/29/11 at 9:10 a.m. revealed that Resident #68's hands, left foot and neck were contracted. Resident had small amount of prespiration on her forehead and her face was grimacing in pain. During an interview at this time Resident # 68 said she had "terrible pain in her hands and feet." She told LVN # 3 the "pain is bad today." She also stated she had wounds on her bottom and on one of her heels. LVN # 3 stated that the resident had received a pain medication at approximately 8:00 a.m. LVN #3 did not offer any additional pain medication or state she would contact the physician. Observation of Resident #68 on 3/29/11 at 1:00 p.m. revealed she was in bed and resident stated she was still in pain. Observation of Resident #68 on 3/29/11 at 4:30 p.m. revealed resident in bed. She stated she still hurt in her hands and feet. She stated she had not received anything for her pain. Review on 3/30/2011of the PRN Administration Record dated March 2011 revealed on 3/29/11 Resident #68 did not receive any as needed pain medications on any of the shifts. Observation of Resident #68 on 3/30/11 at 9:00 a.m. she said no staff ever asked her about her pain. She said it hurt to be touched, to have anything, even a sheet, on top of her. She rated her pain as an 8 and said her hands, feet and upper bottom hurt. She said, "They're (staff) always in so much of a hurry" and was afraid staff would get mad if she complained of pain too often. The resident's facial grimaces reflected the pain the resident stated she was having. Observation on 03-30-11 at 9:50 A.M. revealed Resident #68 lying in bed, awake, alert and oriented to person, place, and time of day. LVN #3, wound care nurse, prepared to perform a wound treatment to Resident #68's sacral pressure ulcer. Immediately prior to entering the resident's room to perform wound care, LVN #3 asked LVN #1 if he had medicated Resident #68 for pain. LVN #1 stated he medicated Resident #68 that morning at 8 A.M. with [MEDICATION NAME] ([MEDICATION NAME]). LVN #3 asked him to reassess Resident #68 after wound care was done to check if she needed to be re-medicated for pain. Observation on 03-30-11 at 9:55 A.M. revealed LVN #3 performed wound care to Resident #68's Stage lV sacral pressure ulcer. Throughout the wound care treatment, Resident #68 complained of pain. Resident #68 moaned and cursed and repeatedly said "I'm hurting! I'm hurting!" At one point, Resident #68 said, "Too much pain girls, somebody help me!" Toward the end of the treatment, LVN #3 asked Resident #68 if she was okay. Resident #68 replied, "No I am not. I have terrible pain in my rear end." On 03-30-11 at approximately 10:40 A.M., surveyor asked LVN #1 what the post-wound care pain assessment showed for Resident #68. LVN #1 said he had not done the pain assessment on Resident #68. "I was waiting for you all to tell me you were through with the treatment." The wound care treatment on Resident #68 had been completed for approximately 25 minutes at that time. LVN #1 informed the surveyor 10 minutes later "You were right, she (Resident #68) was screaming in pain and I medicated her." Record Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of Resident #68's MDS dated [DATE] revealed she had experienced frequent pain in the last 5 days. Review of Care Plan dated 2/15/11 revealed Resident #68 was at risk for pain due to pressure ulcers,[MEDICAL CONDITION], and [MEDICAL CONDITION] pain. The documented goal was to have no unaddressed episodes of pain. The interventions were for nursing to assess for pain and document, observe for signs and symptoms of nonverbal pain, administer routine/prn medication as ordered, monitor medications for effectiveness, and notify the physician of any uncontrolled pain or change in type or severity of pain. Resident #94 Review of Resident #94's admission information revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 94 was [AGE] years old and his medical history included "Stiff Ma[DIAGNOSES REDACTED]," [MEDICAL CONDITION], Dementia, [MEDICAL CONDITION], Anxiety, and Hypertension. Observation on 03-29-11 at 10:25 A.M. during initial tour of the facility revealed Resident #94 sitting in his wheelchair, alert and oriented, with his chin bent to his chest. Resident #94's upper and lower extremities had varying degrees of contractures and he appeared very uncomfortable. Interview with Resident #94 at this same time: he stated "my pain is 10 out of 10." Resident #94 said he thought he had been given something for pain about 7 A.M. but was unsure of the name of the medication. Resident #94 was crying and visibly upset as he discussed his pain. Interview on 03-29-11 at 10:30 A.M the Unit Manager, LVN #10, stated Resident #94 had muscle spasms but was unsure what medication he took for these spasms. LVN #10 went on to say the resident refused narcotics and they had tried the medication [MEDICATION NAME]. LVN #10 was unsure if [MEDICATION NAME] was effective for the resident's pain. Observation on 03-30-11 at 5:30 P.M. revealed Resident #94 sitting in his wheelchair next to his bed. He stated at this time he was "hurting all over" and his pain rating was "7 to 10" (1 to 10 scale). When asked what he was being given for pain, Resident #94 said "[MEDICATION NAME], but it makes me dizzy." Resident #94 began to cry and said "Everybody here is mad at me because I can't take the pain." When asked what the staff said to him, Resident #94 responded "they tell me, 'you're doing OK.'" Observation on 03-31-11 at 11:20 A.M. revealed Resident #94 sitting in his wheelchair and he reported his pain was an "8" (1 to 10 scale) and began to cry. He stated the medicine he received for pain was [MEDICATION NAME]. Resident # 94 said he felt the staff did not want to bother having to reposition him so often. He went on to explain because of his condition, he needed frequent repositioning due to extreme muscle spasms and pain. He became visibly upset and said, "I just pray all the time for God to help me." During this same time, Resident #93 (Resident #94's roommate) stated he was very sleepy. "I was up all night last night because my roommate was yelling, 'Help me! Help me, I am in pain!' all night long and no one came to help him." Resident #93 went on to say "this happens to him all the time." Review of Resident #93's quarterly MDS, dated [DATE], revealed that according to the Brief Interview for Mental Status (BIMS) section C., Resident #93 scored a 15 which showed him to be "cognitively intact." Review on 4/1/11 of Resident #94's March 2011 MAR revealed he had not been medicated for pain at any time during the night of 03-31-11. Review of Resident # 94's quarterly MDS, dated [DATE] revealed he was able to understand others and make himself understood and his speech was clear. According to the Brief Interview for Mental Status (BIMS) section C., Resident #94 scored a 15 which showed him to be "cognitively intact." Resident #94 required extensive assistance from staff for all ADLs. According to the Pain Assessment Interview (section J), Resident #94 said he was in almost constant pain that kept him awake at night. Resident #94 rated his pain as "severe." Review of Resident #94's annual MDS, dated [DATE] revealed that "Pain" was identified as a Care Area Assessment (CAA) trigger. Review of Resident #94's Care Plan, dated 12-21-10 listed that the resident was experiencing frequent pain in his neck related to chronic neck flexion as a problem. Interventions included evaluate resident's pain daily using 1-10 scale. Resident's pain goal was to be a 3 or less. Staff were to monitor for worsening of resident's pain symptoms and report to physician. Further review of the Care Plan revealed no docoumentation concerning resident's refusal of narcotic medications or any other suggested alternatives for pain Review of the (every shift) "Pain Assessment Medication Sheet" for Resident #94 for February 2011 revealed several missed shifts of pain assessments. These included: 6 A.M. - 2 P.M. shift on 02-28-11 2 P.M.-10 P.M. shift on 02-23-11, 02-24-11, and 02-25-11 Review of the (every shift) "Pain Assessment Medication Sheet" for Resident #94 for 03-31-11 revealed the resident was not assessed for pain during the 6 AM to 2 P.M. shift and the 2 P.M. to 10 P.M shift. This was the same date Resident #93 (Resident # 94's roommate) stated he had been up all night because Resident #94 had been "yelling he was in pain all night" and no staff came to assist him. Review of the (every shift) "Pain Assessment Medication Sheet" for Resident #94 for February 2011 revealed (with the exception of the 4 missed assessments) that documented assessments were "O" (form indicated 'O' meant "no hurt") for all three shifts for every day of the month. The February 2011 pain assessments did not correlate to Resident #94's February 2011 MAR. Review of the February 2011 MAR for Resident #94 revealed he was medicated with PRN [MEDICATION NAME] 50 mg one (1) tab for pain on 02-05-11, 02-06-11, and 02-08-11 and medicated with PRN [MEDICATION NAME] 50 mg two (2) tablets on 02-07-11. Review of the "Pain Assessment Medication Sheet" for Resident #94 for March 2011 revealed (with the exception of the 2 missed assessments) documented assessments were "O " (form indicated 'O' meant "no hurt") for all three shifts for every day of the month with the exception of two (2) 10 PM to 6 AM shifts ( 03-16-11 and 03-21-11). The documentation for 03-29, and 03-30 revealed "0" for all three shifts and on 03-31 the day and evening shift were blank and a "0" was documented of for the night shift. These documented assessments were not consistent with Resident #94's description of his pain during surveyor observations and interviews on 03-29-11, 03-30-11, and 03-31-11. The March 2011 pain assessments did not correlate to Resident #94's March 2011 MAR. Review of the March 2011 MAR for Resident #94 revealed he was medicated with PRN [MEDICATION NAME] 50 mg one (1) tab for pain on 03-20-11 and 03-21-11 and medicated with PRN [MEDICATION NAME] 50 mg two (2) tablets on 03-23-11 and 03-24-11. Further review of Resident #94's March MAR revealed he was medicated with PRN Tylenol 325 mg one (1) tablet on 03-11-11. Review of the "every shift" pain assessments for all of the timeframes the PRN medications were administered showed pain was "O." Review of the nursing notes for Resident #94 for January through March 2011 revealed Resident # 94 refusing narcotic medications and also appointments with 2 neurologists. Nurse's Note dated 02-02-11 revealed the Resident #94 refused an alternative treatment for [REDACTED]. The Nurse Practitioner was notified of the resident's refusal. The Nurse's note dated 2-5-11 revealed that the resident "did not want narcotics due to the side effects." The nurses notes detailed three (3) nights in February and March 2011 that Resident # 94 was "up all night," "agitated", repeatedly requested that staff reposition him from the bed to the wheelchair all night long and that the resident called "911" himself on 01-30-11 and 03-25-11. Review of Resident #94's March 2011 Physician orders [REDACTED]. Further review of the March 2011 physician orders [REDACTED]. Scheduled: [MEDICATION NAME] 50 mg (1) tablet BID PRN: [MEDICATION NAME] APAP 5-325 mg q 8 hours [MEDICATION NAME] 400 mg BID, and [MEDICATION NAME] 325 mg q 4 hours, [MEDICATION NAME] 50 mg (1 or 2 tablets) q 6 hours The last time Resident #94's pain medication was changed or adjusted was on 02-14-11. Review in the Nurse's Notes revealed that the resident refused pain medication on 3-25-11 and requested to be sent to the emergency room where he recieved [MEDICATION NAME]. This was the only documentation where resident refused as needed pain medication in March. Review of the physician progress notes [REDACTED]. The note revealed that the resident refused medication for depression. The Progress notes dated 1-31-11 and 2-10-11 did not reveal any documentation concerning psychiatric services. Further review of the March 2011 physician orders [REDACTED]. Interview on 04-01-11 at 12:55 P.M. the DON stated that Resident #94 was very anxious, highly agitated, and frequently requested staff to reposition him due to his "stiff ma[DIAGNOSES REDACTED]" condition. She went on to say that he had refused narcotics and also appointments with neurologists. The DON said that Resident #94 was transferred to the hospital this morning (04-01-11) for severe pain and would be referred for psychiatric services. Review of a Patient Transfer Form revealed Resident #94 was transferred to a local hospital on 04-01-11 for "severe pain." Review of the Nurse's Notes dated 04-01-11 revealed Resident #94 had been up most all night complaining of pain and requesting repositioning. Resident #94 was medicated at 12:30 AM with Tylenol 325 mg. At 8 A.M., he stated his pain was a "20" (1 to 10 scale) and refused pain medication at this time, reported " pain medication was not working. " Resident # 94 requested to be sent to the hospital. Further review of the nursing notes, 04-01-11 (8:32 A.M.) revealed the NP was notified and gave orders for the resident to be sent to the ER and also " needed to be admitted to a psych unit. " Resident #64 Review of Resident #64's information sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #64's Physician order [REDACTED]. Observation at begining of tour on 3/29/11 at 8:50 A.M. a resident was heard yelling out for help from staff. This yelling persisted for at least 20 minutes intermitantly. Interview on 3/29/11 at 9:15 a.m. Resident #64 stated, "I'm hurting on my butt. I have a sore there. I'd rate the pain as a 10" (scale of 1 to 10 with 1 being "no pain" and 10 being "excruciating"). She also stated she had pain in her leg. Resident stated she had been yelling out in pain for help for a long time but no one ever came to assist. Observation at this time revealed the resident's face would grimace with every movement she made in bed. Review of the resident's Pain Assessment Medication Sheet dated March 2011 revealed documentation that the resident had no pain on the 6a-2p shift on 3/29/2011 and did not receive medication. Observation on 3/29/11 at 4:40 p.m. revealed Resident #64 in bed watching TV. She said she had not had any relief from the pain in her leg and the sore on her butt all afternoon. She said it did not do any good to tell staff any more because they did not do anything to relieve the pain. Interview on 3/30/11 at 12:00 noon Resident #64 stated her bottom "still hurt." She said she took some Tylenol that morning, but it had not relieved the pain. She said no staff had asked her if the Tylenol had been effective in relieving her pain. She stated that when she asked for pain medication it usually took a long time to get it. Observation on 3/30/11 at 5:00 p.m. revealed Resident #64 in bed getting ready to eat her dinner. She stated that today had not been a good day and that she hurt throughout the day. Interview on 3/31/11 at 5:00 p.m. Resident #64 stated she was happy as she had relatively little pain. Observation on 4/1/11 at 6:10 p.m. revealed Resident #64 in bed. She said she did have some pain but it was a little more tolerable this evening. She said she hoped the pain got better and that she would receive medication when she needed it. Review of the physician's orders [REDACTED]. Review of Pain Assessment Medication Sheet dated March 2011 using a pain scale of 1-3 mild, 4-6 moderate, 7-10 excruciating revealed Resident #64's pain was assessed and treated as follows: a. 3/16/11 pain level 2 on day shift and 8 on night shift - no additional pain medication on day shift - received [MEDICATION NAME] at 3:00 a.m. b. 3/17/11 pain level 3 on day shift- received [MEDICATION NAME] at 5:30 a.m. c. 3/18/11 pain level 2 on day shift and 7 on night shift - no additional pain medication on day shift - received [MEDICATION NAME] at 12:30 a.m. d. 3/19/11 pain level 3 on day shift - no addition medication given e. 3/20/11 pain level 3 on day shift - no additional pain medication given on day shift -[MEDICATION NAME] at 12:00 a.m. f. 3/21/11 pain level 7 on night shift - [MEDICATION NAME] at 2:30 a.m. and 8:30 p.m. g. 3/23/11 pain level 8 on night shift - [MEDICATION NAME] at 12:30 a.m. h. 3/26/11 pain level 8 on night shift - no additional pain medication given. i. 3/28/11 pain level 8 on night shift - [MEDICATION NAME] given at 12:00 a.m. j. 3/29/11 pain level 6 on night shift - [MEDICATION NAME] given at 12:30 a.m. Review of the resident's Pain Assessment Medication Sheet dated March 2011 revealed that there was no documentation on the evening shift of resident being in pain between 3/16/11 and 3/29/11. Review of the resident's MDS dated [DATE] revealed she received scheduled pain medication, and had frequent pain rated at 6 to 7. Further review of the same MDS revealed the resident was alert and oriented. Review of the resident's Nurse's Notes revealed that there had been no communication with the physician concerning pain management in March 2011. Interview on 4/1/11 at 4:30 P.M. LVN #2 stated she did not see any documentation concerning consulting with the physician concerning Resident #64's pain. Resident #90 Review of Resident #90's information sheet revealed she was admitted to the facility on [DATE]. Review of physician's orders [REDACTED]. Observation of the resident on 3/29/11 at 10:35 a.m. revealed she was in a wheelchair. Resident # 90 stated she was hurting. Interview at this time with LVN # 3 she stated Resident #90 had bilateral lower extremity contractures, a venous ulcer to the right foot, and she was alert and oriented X 2. Review of Resident # 90's MDS dated [DATE] revealed the resident's pain was frequent, bothered her sleep and limited her daily activities. Review of resident's Care Plan dated 2/11/11 revealed Resident #90 was at risk for pain due to [MEDICAL CONDITION], contractures, and a Stage III pressure ulcer. Care Planned interventions included to monitor and medicate for pain, with follow up monitoring for effectiveness of medication. Review of the resident's physician's orders [REDACTED]. Review of weekly Nursing Summary reports revealed: a. 3/24/11-no pain b. 3/17/11-no pain c. 2/17/11-no pain d. 12/24/10- no pain e. 7/24/10-no pain Review of Resident #90's Pain Assessment Medication Sheets dated December 2010 and January 2011 revealed no assessed pain. Requested on 4/1/11 at 4:30 P.M. from LVN #8 February and March 2011 assessment sheets but none were provided prior to exit. Review of Resident #90's Psychiatric Progress Notes revealed the resident was diagnosed with [REDACTED]. The provider documented the following: a. 1/28/11- " continues to struggle with pain " b. 1/12/11- " continues to have problems with pain " c. 12/27/10- " continues to have problems with pain " d. 11/27/10- " some pain/discomfort " e. 11/6/10- " some leg swelling/discomfort" Review of Resident #90's Nurses Notes between November 2010 and March 2011 revealed no correspondence with the doctor concerning pain. No documentation was present communicating the pain noted in the Psychiatric Progress notes. Resident #48 Observation on 3/29/11 at 10:49 a.m. with LVN #2 revealed Resident # 48 awake in bed (near the door). The resident was described as alert oriented to self, had behavior problems and would yell, spit and curse at staff during care. Resident #48 had bilateral above knee amputation, sacral stage IV pressure ulcer, was a fall risk, had a contracture to her right hand, and depended on staff for all activities of daily living. LVN #2 stated Resident #48 was not on any pain management. Review of Resident #48's admission records revealed Resident # 48 was admitted to facility on 9/25/09 with [DIAGNOSES REDACTED]. Review of Resident #48's quarterly MDS dated [DATE] revealed the resident's cognition for daily decision making was severely impaired. Review of the residents quarterly review MDS dated [DATE] revealed Resident #48 cognitive skills for daily decision making as (1) modified independence. Review of the resident's MDSs dated 1/15/11, 2/18/11 and 1/14/10 revealed Resident #48 had no impairment on her upper extremities. These MDSs also documented that the resident had impairment on both sides for the lower extremities. Review of the MDS dated [DATE] revealed Resident #48 was always incontinent of bowel, had an indwelling catheter and was totally dependent on staff for all activities of daily living. It also documented that Resident #48's indication of pain was vocal complaints of pain. The frequency of pain indicator was documented as (3) indicators of pain or possible pain observed daily. Review of Resident #48's physician's orders [REDACTED]. These medications included [MEDICATION NAME] 325 milligrams, 2 tablets every 6 hours for pain as needed and [MEDICATION NAME] APAP 5/325 milligrams, 1 to 2 tablets every 4 hours for pain as needed. Review of Resident #48's pain assessment medication sheet for March 2011 from 3/1/11 to 3/29/11 revealed that Resident #48 had no pain. Review of the PRN Medication Administration Record for March 2011 revealed Resident #48 was given [MEDICATION NAME] 325 milligrams 2 tablets to equal 650 milligrams by mouth for pain on 3/21/11. The same MAR revealed the resident had not received any [MEDICATION NAME] medication administered form 3/1/11 to 3/29/11. Review of the resident's Care plan dated 3/10/11 revealed Resident #48 had a stage IV pressure ulcer and was at risk for pain and infection. A wound vac machine was to be used for treatment to stage IV sore on the sacral area. Approach outlined included reposition resident every 2 hours. encourage resident to weight shift while sitting up in chair, administer resident ' s pain medication at least as needed prior to initiating treatment, resident needs elbow protectors on both elbows as needed. Resident needs pillows or other supportive/protective device to assist with positioning. Observation on 3/29/11 at 1:00 P.M. revealed Resident #48 lying on her back. She stated at this time she could not sleep. She had no splint or rolls on right hand. No postioning pillows in place. Interview at this time Resident #48 stated she could not sleep and asked surveyor to turn on the television. The resident had a right hand contracture extending from the right wrist to the tip of the right fingers. Resident stated she could not move or open her right hands and it was hurting. Observation made on 3/30/11 at 9:36 A.M, during incontinent and indwelling catheter care, Resident # 48 was observed crying and screaming at the top of her voice. She stated her buttocks were hurting a lot. Resident had tears streaming down her cheeks throughout the procedure. The resident cried out more intensely when turned or moved. After the care, LVN# 2 asked the resident why she was crying so much. The resident told her again that her buttocks were hurting a lot. She had breaks in her speech and cried out in between her words. LVN # 2 reassured her and said he would call her nurse to see what pain medications she should receive for her pain. The procedure was completed at 9: 54 A.M, LVN# 1 came to Resident # 48 ' s room and asked her where she was hurting. LVN # 1 did not rate the resident ' s pain level according to the facility's pain scale. Interview on 3/30/11 at 9:58 A.M, LVN # 1 was asked what pain medications Resident #48 received. LVN #1 said the resident had an order for [REDACTED]. Surveyor asked if the resident had any other medication ordered for pain. LVN #1 looked at Resident #48's MAR and told surveyor that resident had an order for [REDACTED]. LVN #1 administering one (I) tablet of [MEDICATION NAME] APAP 5/325 milligrams, by mouth to Resident #48 at 10:00 A.M. Review on 3/31/11 of the pain assessment medication sheet for Resident #48 on 3/30/11 revealed that Resident #48's pain scale was documented as (4) "hurts whole lot," level of consciousness was documented as (1) alert and oriented and intervention was documented as (0) no intervention. This documentation was completed following LVN #1's administrating the pain medication to Resident #48 after incontinent/ indwelling catheter care. LVN #1 administered one tablet of [MEDICATION NAME] 5/352 to the resident by mouth on 3/30/11 at 10:00 A.M, but documented no intervention on the resident ' s pain assessment sheet. Observation of wound care on 3/30/11 at 11:17 A.M. for Resident #48 revealed the resident complained of pain during the entire procedure. LVN #3 was asked by surveyor if the resident was offered any medication prior to the wound care as documented in the care plan. LVN #3 responded that she usually told the nurses to medicate the resident prior to wound care. She said she understood that wound care could be painful and relied on the nurses to medicate the resident. Interview on 3/30/11 at 12:00 p.m. CNA #7 said Resident #48 yelled at staff and would curse and spit at staff during care. When asked if she thought that the resident could be doing these behaviors due to pain during care, CNA #5 stated she knew that when moved, the resident would scream in pain during the care. Observation on 4/1/11 at 8:40 A.M. Resident #48 was observed sleeping. Staff reported to surveyor that resident had been medicated for pain. The resident slept for the rest of the morning. Resident #29 During initial tour on 3/29/11 at 9:13 A.M. LVN #2 stated that Resident #29 was not on pain management and had no pain issues. Review of the Admission records revealed Resident #29 was admitted to facility on 5/16/06 and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the facility's CMS 802 form revealed Resident #29 was interviewable and on pain management Review of the MDS dated [DATE] revealed Resident #29 was on a scheduled pain medication regimen. Pain presence was documented as "yes." Pain frequency was documented as occasionally. Pain intensity was a 4 using the zero to ten pain scale with zero being no pain and ten as the worst pain. Review of the resident's Care Plan dated 8/23/10 identified risk for pain related to disease and complaint of Joint /muscle pain. Goal was the resident would have no unaddressed episodes of pain. Approaches outlined included to observe for signs and symptoms of non verbal expression of pain. Encourage the resident to reposition in conduction with pain medication to assist in relieving episodes of pain. Administer routine and as needed pain medication as ordered. Monitoring effectiveness of medications. Notify the physician of any uncontrolled pain, change in type or severity of pain and notify responsible party as needed. Assess for pain and document. Review of the resident's Pain Assessment record for March 2011 documented that resident had no pain for the whole month. Review of the resident, MAR revealed the resident received [MEDICATION NAME] 100 milligrams by mouth two times daily for the entire month of March 2011. Review of the resident's MAR dated February 2011 revealed the resident received Tylenol 650 milligram on the first and second of February 2011. The [MEDICATION NAME] milligram two tablets was given on 2/28/11 for pain. Review of the resident's Nurse's Notes revealed no documentation in March 2011 that related to pain. Interview on 3/31/11 at 10:44 A.M. Resident #29 was in her room holding her right rib cage. She stated that she had shingles pain in her right rib cage. She said this pain was always present and that she was told that she would have to live with it. She stated that no staff asked her about her pain. She said she did not know if she received any medications for pain. She said she did not bother the nurse any more because there was nothing they could do for the pain. She stated she took her own pain medications every day. She stated she kept extra strength Tylenol at her bed side which she took every morning with breakfast and it helped her. She stated she ran out of the extra strength Tylenol and had asked her grand daughter to buy her some more. Interview on 3/31/11 at 2:00 p.m. LVN #1 stated he assessed residents for pain every time he went into a resident's room. He said staff used the numeric 0 to 10 scale. He said if a resident had multiple complaints of pain on one shift the highest number was entered on the MAR under pain assessmen