Every finding on record at Park Village Healthcare and Rehabilitation

Based on observations, interviews, and record reviews the facility failed to provide a notice of Medicaid rights and obligations and provide residents with a description of the requirements and procedures for establishing eligibility for Medicaid for one (Resident #1) of three residents reviewed. The facility failed to assist Resident #1 with the Medicaid application and Resident #1 did not receive his needed services from PASRR. This failure could place residents at risk for decreased awareness of their rights and could contribute to a decline in physical, mental, psychosocial well-being and quality of life.Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Attention-Deficit Hyperactivity Disorder (brain condition that causes ongoing trouble with focus, high energy, and acting without thinking), Bipolar Disorder (mental health condition that causes extreme shifts in a person's mood, energy, activity levels, and ability to concentrate), Cerebral Palsy (movement disorders that affect body movement, muscle coordination, and posture), Cerebral Infarction (serious medical emergency where a blocked blood vessel stops blood and oxygen from reaching an area of the brain), Depression (mood disorder that causes a persistent feeling of sadness and a loss of interest in activities you once enjoyed), Epilepsy (chronic brain disorder that causes recurring, unprovoked seizures), Hemiplegia (complete or severe paralysis on one side of the body) and Hemiparesis (muscle weakness on one side of the body), Intellectual Disability (significant limits in both intellectual functioning and adaptive behavior), Muscle Wasting and Atrophy (thinning, shrinking, or total loss of muscle mass), Muscle Weakness (reduced ability to exert force with your muscles). Review of Resident #1's quarterly MDS assessment, dated 07/25/26, reflected a BIMS score of 06, indicating he had severe cognitive impairment. Review of Resident #1's quarterly care plan, initiated 04/18/2026 reflected he had been identified as having PASRR positive status related to Epilepsy, Bipolar Disorder, Intellectual Disability, ADHD. Interventions included, IDT meeting to be completed as required. Notify physician and responsible party of any changes. PASRR evaluation to be completed by local authority. Review of Resident #1's IDT Care Conference, dated 05/22/26, reflected the following summary: Service Planning Team Information Tool Mobility changes: W/CAny wounds or Skin issues and their current status: Stage 4 and Stage 3: Air MattressAre they followed by: Psychiatrist/Psychologist: Yes - [Outside Vendor] Record review of Resident #1's PCSP, dated 05/22/2026 indicated Resident #1 had an Initial IDT meeting for specialized services on 05/22/2026. The PCSP form indicated that the SPT members recommended Resident #1 receive a CMWC and ongoing Habilitation Coordination. During an observation and interview on 08/24/26 at 12:20 PM, Resident #1 was clean and dressed appropriate for the weather. Resident #1 stated that he was doing fine. Resident #1 stated he believed he was supposed to have a remote control wheelchair. Resident #1 stated PT came to his room and evaluated him. Resident #1 stated the wheelchair he used was comfortable and staff added a cushion pad that was very soft. Resident #1 stated he was just ready to get his new wheelchair. Resident #1 stated an outside vendor visited him in his room. Resident #1 stated he received therapy and he worked with more than one person. During an interview on 08/25/26 at 12:45 PM, the ABOM stated that the facility had not applied for Medicaid for Resident #1. The ABOM stated she was in charge of Resident #1's Medicaid application process. The ABOM stated Resident #1 admitted from the hospital to the facility on [DATE] and after the 21st day he could qualify for Medicaid (around 05/18/26). The ABOM stated Resident #1 was not able to receive his needed services from PASRR and as of today (08/25/26), she still had not applied for Medicaid for Resident #1. The ABOM stated that she was in the process of completing Resident #1's Rep Payee Form for Social Security and she sent the form to the MD to sign it on 08/21/26. The ABOM stated she was handling the new BOM's and her own workload and being by herself, it was a lot. The ABOM stated the worse that could happen was Resident #1 would not be eligible to receive certain levels of care until Medicaid had been approved. The BOM stated it was up to her to get Resident #1's Medicaid portion completed in order for him to receive PASSR services. During an interview on 08/25/26 at 2:17 PM the DOR stated that Resident #1 was denied multiple times due to his Medicaid pending status. The DOR stated during the IDT meeting they discussed the customized manual wheelchair and a specialized mattress. The DOR stated therapy was recommended and Resident #1 was already receiving PT, OT and ST. The DOR stated Resident #1 was doing well and they were working on getting his customized manual wheelchair ordered once his Medicaid was approved. The DOR stated Resident #1's current wheelchair was safe and functional, however, the customized wheelchair would be catered to Resident #1's dimensions to prevent any skin breakdown. The DOR stated Resident #1's current wheelchair was not customized as approved. During an interview on 08/25/26 at 2:45 PM, the ADM he spoke with the ABOM and was informed Resident #1's Medicaid was in process. The ADM stated he spoke with the ABOM again this morning (08/25/26) and was informed she was awaiting the doctor's signature and once received, she would be able to submit his Medicaid application. Moving forward, the ADM stated he would ensure better communication to ensure everything was submitted timely and followed up. Record review of the facility's policy, titled, Resident Rights with a copyright date of 2023 reflected: As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States. Respect and Dignity. You have the right to be treated with respect and dignity, including the right to:.reside and receive services in the facility with reasonable accommodation of your needs and preferences except when to do so would endanger your or other residents' health or safety. Record review of a PASRR and NFSS Submission Process/Timelines in-service dated 08/25/26 reflected: Any Medicaid-certified nursing facility must complete a PASRR on every patient to:. Ensure that all patients receive the support they need to ensure their highest level of function (this is where we come in!). Get the evaluations completed as agreed in the care plan within 30 days! Common Issues. Because the patient must have a valid Level of Service on the MESAV, Medicaid pending patients cannot get approved for services!

Based on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for one (Resident #1) of three residents reviewed for resident rights regarding the timely submittal of Medicaid applications. The facility's ABOM failed to submit the Medicaid application for Resident #1 which caused his NFSS Referral for a CMWC and specialized mattress to be rejected after his PASRR IDT meeting held on 05/22/26. This failure could place residents at risk for not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life.Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Attention-Deficit Hyperactivity Disorder (brain condition that causes ongoing trouble with focus, high energy, and acting without thinking), Bipolar Disorder (mental health condition that causes extreme shifts in a person's mood, energy, activity levels, and ability to concentrate), Cerebral Palsy (movement disorders that affect body movement, muscle coordination, and posture), Cerebral Infarction (serious medical emergency where a blocked blood vessel stops blood and oxygen from reaching an area of the brain), Depression (mood disorder that causes a persistent feeling of sadness and a loss of interest in activities you once enjoyed), Epilepsy (chronic brain disorder that causes recurring, unprovoked seizures), Hemiplegia (complete or severe paralysis on one side of the body) and Hemiparesis (muscle weakness on one side of the body), Intellectual Disability (significant limits in both intellectual functioning and adaptive behavior), Muscle Wasting and Atrophy (thinning, shrinking, or total loss of muscle mass), Muscle Weakness (reduced ability to exert force with your muscles). Review of Resident #1's quarterly MDS assessment, dated 07/25/26, reflected a BIMS score of 06, indicating he had severe cognitive impairment. Review of Resident #1's quarterly care plan, initiated 04/18/2026 reflected he had been identified as having PASRR positive status related to Epilepsy, Bipolar Disorder, Intellectual Disability, ADHD. Interventions included, IDT meeting to be completed as required. Notify physician and responsible party of any changes. PASRR evaluation to be completed by local authority. Review of Resident #1's IDT Care Conference, dated 05/22/26, reflected the following summary: Service Planning Team Information Tool Mobility changes: W/CAny wounds or Skin issues and their current status: Stage 4 and Stage 3: Air MattressAre they followed by: Psychiatrist/Psychologist: Yes - [Outside Vendor] Record review of Resident #1's PCSP, dated 05/22/2026 indicated Resident #1 had an Initial IDT meeting for specialized services on 05/22/2026. The PCSP form indicated that the SPT members recommended Resident #1 receive a CMWC and ongoing Habilitation Coordination. During an observation and interview on 08/24/26 at 12:20 PM, Resident #1 was clean and dressed appropriate for the weather. Resident #1 stated that he was doing fine. Resident #1 stated he believed he was supposed to have a remote control wheelchair. Resident #1 stated PT came to his room and evaluated him. Resident #1 stated the wheelchair he used was comfortable and staff added a cushion pad that was very soft. Resident #1 stated he was just ready to get his new wheelchair. Resident #1 stated an outside vendor visited him in his room. Resident #1 stated he received therapy and he worked with more than one person. On 08/24/26 at 02:30 PM, a copy of the facility's PASRR policy was requested from the ADM. The ADM stated that the facility did not have a policy but followed the guidelines on HHSC's website. During an interview on 08/24/26 at 4:50 PM, the MDS Coordinator stated Resident #1 was PASRR positive. The MDS Coordinator stated on 05/22/2026, they had a PASRR IDT meeting and Resident #1 was approved for a customized manual wheelchair and a special mattress. The MDS Coordinator stated her role was to enter PASRRs for new residents and if the resident had a qualifying diagnosis, [outside vendor] came out to evaluate the resident. The MDS Coordinator stated after the PASRR meeting, she entered the notes from the PCSP Form into a cloud-based healthcare technology platform. The MDS Coordinator stated therapy took it from there. During an interview on 08/24/26 at 6:25 PM, the SW stated she was the PASRR Coordinator. The SW stated that Resident #1 was PASRR Positive. The SW stated she coordinated with PASRR to schedule Care Conferences, and any updates regarding transitioning out of the facility. The SW stated she scheduled initial, quarterly and annual PASRR IDT Meetings. The SW stated she believed she had submitted everything that was needed. The SW stated the ADM sent her an email on 08/03/26 and again today 08/24/26 asking her to follow-up with PASRR. During an interview on 08/24/26 at 06:50 PM, the DON stated Resident #1 was admitted to the facility on [DATE]. The DON stated on 08/03/26, the ADM sent an email to the SW to follow-up with PASRR. The DON stated the SW notified the state regarding the positive PASRR and scheduled an IDT meeting. The DON stated during the meeting, they identified any services the resident qualified for at that time. The DON stated Resident #1 was approved for a customized wheelchair and therapy would be the one to measure him. The DON stated if a wheelchair was approved, the facility would proceed with the resident being evaluated by therapy. The DON stated the facility must follow-through when someone requested additional information. The DON stated everyone included on the email should be following up. The DON stated moving forward, they would pay closer attention to the PASRR process to ensure everything was done correctly. On 08/25/26 at 10:26 AM, received an email from the ADM with a PDF that listed various links to PASRR guidelines contained on HHSC's website that the ADM stated the facility followed. During an interview on 08/25/26 at 12:45 PM, the ABOM stated that the facility had not applied for Medicaid for Resident #1. The ABOM stated she was in charge of Resident #1's Medicaid application process. The ABOM stated Resident #1 admitted from the hospital to the facility on [DATE] and after the 21st day he could qualify for Medicaid (around 05/18/26). The ABOM stated Resident #1 was not able to receive his needed services from PASRR and as of today (08/25/26), she still had not applied for Medicaid for Resident #1. The ABOM stated that she was in the process of completing Resident #1's Rep Payee Form for Social Security and she sent the form to the MD to sign it on 08/21/26. The ABOM stated she was handling the new BOM's and her own workload and being by herself, it was a lot. The ABOM stated the worse that could happen was Resident #1 would not be eligible to receive certain levels of care until Medicaid had been approved. The BOM stated it was up to her to get Resident #1's Medicaid portion completed in order for him to receive PASSR services. During a follow-up interview on 8/25/26 at 1:44 PM, the MDS Coordinator stated that she learned Resident #1 was Medicaid pending and that delayed the process. The MDS Coordinator stated her process was done correctly. The MDS Coordinator stated therapy put their request in but it kept being denied due to Resident #1 being Medicaid-pending. The MDS Coordinator stated she was in-serviced today (08/25/26) on the PASRR process by the Regional DOR. The MDS Coordinator stated she learned a resident would have to be Medicaid approved in order to receive PASRR services. During a follow-up interview on 08/25/26 at 1:56 PM, the SW stated the PCSP Form was not submitted timely by her and the MDS Coordinator as the form kept being rejected due to the resident being Medicaid-pending. The SW stated Resident #1 was Medicaid-pending and any services they would had entered would had been rejected. The SW stated she received a refresher today (08/25/26) on PASRR services. The SW stated that they went over timelines, what pre-admission looks like and to ensure information was entered into the system correctly and timely. During an interview on 08/25/26 at 2:17 PM the DOR stated that Resident #1 was denied multiple times due to his Medicaid pending status. The DOR stated during the IDT meeting they discussed the customized manual wheelchair and a specialized mattress. The DOR stated therapy was recommended and Resident #1 was already receiving PT, OT and ST. The DOR stated Resident #1 was doing well and they were working on getting his customized manual wheelchair ordered once his Medicaid was approved. The DOR stated Resident #1's current wheelchair was safe and functional, however, the customized wheelchair would be catered to Resident #1's dimensions to prevent any skin breakdown. The DOR stated Resident #1's current wheelchair was not customized as approved. The DOR stated that when a resident admitted to the facility and they were PASRR positive, they had a PASRR IDT meeting. The DOR stated the facility should had responded to the PASRR Specialist to let her know that Resident #1 was Medicaid-pending due to the form being rejected multiple times. The DOR stated they did not know the form was being rejected due to Resident #1 being Medicaid-pending. The DOR stated he submitted the form four times (6/29/26, 8/13/26, 8/19/26, and 8/24/26). The DOR stated moving forward, he would seek clarification for any rejections. The DOR stated the worse that could have happened was Resident #1 would not receive the approved services that he needed. During an interview on 08/25/26 at 2:45 PM, the ADM stated they made a referral and submitted it on 6/29/26, but it kept getting rejected. The ADM stated he spoke with the ABOM and was informed Resident #1's Medicaid was in process. The ADM stated he spoke with the ABOM again this morning (08/25/26) and was informed she was awaiting the doctor's signature and once received, she would be able to submit his Medicaid application. Moving forward, the ADM stated he would ensure better communication to ensure everything was submitted timely and followed up. The ADM stated the Regional DOR completed an in-service today on PASRR with the DOR, the MDS Coordinator and the SW. The ADM stated after the PASRR IDT meeting, it was the expectation that the facility communicated with PASRR and provided the services as was discussed in the IDT meeting. Record review of a PASRR and NFSS Submission Process/Timelines in-service dated 08/25/26 reflected: Any Medicaid-certified nursing facility must complete a PASRR on every patient to:. Ensure that all patients receive the support they need to ensure their highest level of function (this is where we come in!). Get the evaluations completed as agreed in the care plan within 30 days! Common Issues. Because the patient must have a valid Level of Service on the MESAV, Medicaid pending patients cannot get approved for services!

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 (CMS for FY Quarter 1 2026) of 4 quarters reviewed for compliance. The facility failed to submit accurate staffing information to CMS for FY Quarter 1 2026 (October 1-December 31). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.Findings included: Review of the CMS PBJ report for CMS for CMS for FY Quarter 1 2026 (October 1-December 31) indicated the facility failed to submit RN coverage for the quarter. During an interview with the Administrator on 05/13/26 at 11:17 AM, he stated Corporate resourced out the facility's PBJ requirements, and the data for FY Quarter 1 2026 (October 1-December 31) was initially rejected and then was not re-submitted within the required timeframe due to an oversight. The Administrator stated the risk of PBJ data not being submitted within the required timeframe included CMS not having accurate data for the facility. Review of CMS' Electronic Staffing Data Submission Payroll-Based Journal, dated June 2025 and reported by the Administrator on 05/13/26 at 11:38 AM to be used as the facility's policy for PBJ data, reflected, .Submission Timeliness and Accuracy. Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. and .Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely. Facilities may enter and submit data at any frequency throughout a quarter. The last accepted submission received before the deadline will be considered the facility's final submission.

Based on observation, interview and record review, the facility failed to facility properly labeled and stored all drugs and biological in accordance with currently accepted professional principles for medications on 3(300 hall, 100 South Hall, and 100 North Hall) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure Zofran 4 mg prescription medication used to prevent and treat nausea and vomiting was labeled with patients' labels on the 100-south hall -medication cart. The facility failed to ensure Linezolid 600mg prescription antibiotic primarily used to treat bacterial infections was labeled with patients' labels on the 100-south hall -medication cart. The facility failed to ensure Cospt prescription eye drop used to lower the fluid pressure inside your eye in patients with open-angle glaucoma or ocular hypertension (both involve high eye pressure due to improper fluid drainage) was labeled with patients' label on the 100-south hall -medication cart. The facility failed to ensure Acidophilus with pectin (a probiotic to promote the growth of healthy bacteria) which required refrigeration after opening was refrigerated on the 100-south hall -medication cart The facility failed to ensure Resident#98's - Basaglar Kwik Pen (a long-acting insulin prescribed to improve blood sugar control in adults with type 2 diabetes) Injection 100unit was dated after opening on the 100 north hall -medication cart. The facility failed to ensure Resident #120's Novolin 70/30 (a premixed human insulin used to control high blood sugar in people with diabetes) Flex pen was removed for the cart after the resident was discharged from the facility on the 100-north hall -medication cart. The facility failed to ensure Resident#30's - NovoLog insulin prescribed to improve blood sugar control in adults with type 2 diabetes) Injection 100unit was dated after opening on the 100-north hall -medication cart .The facility failed to ensure Resident#86's - Basaglar Kwik Pen (a long-acting insulin prescribed to improve blood sugar control in adults with type 1 or type 2 diabetes) Injection 100unit was dated after opening on the 300 hall -medication cart .The facility failed to ensure LVN C ensured that Resident# 107 swallowed his medication before leaving the resident room. These failures could place residents at risk of medication errors, reduced therapeutic effectiveness, unsafe administration, and potential adverse outcomes due to improper storage of medication. Findings included: Resident#98 Review of Resident #98's Quarterly MDS Assessment, dated [DATE], reflected an [AGE] year-old female admitted on [DATE], and had a BIMs score of 14 indicated she was cognitively intact. The resident had diagnoses which included Type 2 diabetes mellitus (a chronic metabolic condition characterized by insulin resistance and relative insulin deficiency). Review of Resident #98's Comprehensive Care Plan, initiated [DATE], reflected: Resident #98's Has Diabetes Mellitus. Interventions Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #98's active physician orders Dated:[DATE] reflected Basaglar Kwik Pen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA((high blood sugar) HOLD FOR FSBG LESS than 100 mg/dl start [DATE]. Resident#120Review of Resident #120's Discharge MDS Assessment, dated [DATE], reflected Resident #120 was admitted on [DATE], she was a [AGE] year-old female, discharged on [DATE]. Resident#30Review of Resident #30's Quarterly MDS Assessment, dated [DATE], reflected Resident #30 was admitted on [DATE], she was a [AGE] year-old female, and had a BIMs score of 12 indicated she had moderate cognitive impairment. The resident had diagnoses which included Type 2 diabetes mellitus (a chronic metabolic condition characterized by insulin resistance and relative insulin deficiency). Review of Resident #30's Comprehensive Care Plan, initiated [DATE], reflected: Resident #30's Has Diabetes Mellitus. Interventions Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #30's active physician orders Dated:[DATE] reflected Novolin Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) start [DATE]. Observation on [DATE] at 9:12 AM with LVN B on the 100 north-hallway's medication cart revealed Resident #98's opened Basaglar Kwik Pen ,Resident #120's (discharged Resident) NovoLog 70/30 insulin, and Resident #30's opened Novolin Insulin Aspart did not have an opening date.During an interview [DATE] at 9:16 AM with LVN B stated she was unaware Resident#98's Basaglar Kwik Pen Resident #120's (discharged Resident) opened NovoLog 70/30 insulin, and Resident #30's opened Novolin Insulin did not have opening dates. She stated the nurses were responsible for ensuring all insulin was dated after opening. She stated all insulins should be dated after opening because they expire 28 days after opening She stated that having insulin in the medication cart for residents that was no longer at the facility could result in administering insulin to the wrong resident, which may result in hospitalization She stated she had been in serviced on medication storage and labeling. Observation on [DATE] at 9:14 AM with LVN A on the 100 south-hallway's medication cart revealed opened Acidophilus with pectin was not refrigerated, Cospt with no patients' label, Zofran 4 mg prescription medication with no patients' label, Linezolid 600mg prescription with no patient label. During an interview on [DATE] at 9:18 AM, LVN A stated she thought Zofran was from over-the-counter house supply medication. She stated she was not aware that the acidophilus required refrigeration after opening. She stated the risk was medication losing its potency and not being effective if it was not refrigerated, and manufacturers recommended refrigerating. She stated that all prescription medications should be properly labeled with patients' labels because nurses would not know whose medication it was without a label. She stated she had been in serviced on medication storage. Resident#107 Review of Resident #107s Quarterly MDS Assessment, dated [DATE], reflected Resident #107 was admitted on [DATE] and had a re-entry on [DATE]. He was a [AGE] year-old male, and had a BIMs score of 15 which indicated he was cognitively intact. The resident had diagnoses which included hypertension (a condition in which the force of blood pushing against the walls of your arteries is consistently too high), aphasia (a neurological language disorder that impairs a person's ability to speak, write, and understand both spoken and written language), Review of Resident #107's Comprehensive Care Plan, initiated [DATE], reflected: no areas indicating he can have medication at bedside or self-medicate. Review of Resident #107's active physician orders Dated:[DATE] reflected no orders indicating he can have medication beside or self-medicate. Observation on [DATE] at 11:00AM during initial pool revealed a yellow oval pill in a medication cup on Resident#107 beside table. Resident#107 refused to respond to surveyor's question about the medication at bedside. During an interview [DATE] at 11:02 AM LVN revealed she administered Resident#107's morning medication. She stated she always ensured the residents swallowed their medication before leaving the room. She stated Resident 107 did not have physician orders to self-medicate or have medication at bedside. She stated the risk to the resident was over medicating or missing to take medication. She stated she had been in serviced on medication administration and medication storage and labelling. Resident#86 Review of Resident #86's Quarterly MDS Assessment, dated [DATE], reflected Resident #86 was admitted on [DATE]. She was an [AGE] year-old female, and had a BIMs score of 03 which indicated she had severe cognitive impairment. The resident had diagnoses which included Type 2 diabetes mellitus (a chronic metabolic condition characterized by insulin resistance and relative insulin deficiency). Review of Resident #86's Comprehensive Care Plan, initiated [DATE], reflected: Resident #86's Has Diabetes Mellitus. Interventions Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #86's active physician orders Dated:[DATE] reflected Basaglar Kwik Pen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA HOLD FOR FSBG LESS than 100 mg/dl start [DATE]. Observation on [DATE] at 10:15 AM, LVN E on the 300 hallway medication cart revealed opened insulin pens 1. Basaglar Kwik Pen (a long-acting insulin prescribed to improve blood sugar control in adults with type 1 or type 2 diabetes) Injection 100unit. During an interview on [DATE] at 10:15 AM, LVN E stated that the nurses were responsible for checking that all insulin pens had open dates. She stated that she opened Resident #86's Lantus the previous day and she should have dated it. She stated that it was important to date opened insulins because once they opened insulins expired after 28 days and it would not be effective in reducing blood sugar levels. She stated that she had been in-serviced on medication storage and dating all opened insulins. During an interview on [DATE] at 1:04 PM, the DON stated nurses were responsible for ensuring medication carts were clean, and all medications were properly labeled and not expired. She stated that the ADON audited the medication carts weekly, then the pharmacy consultant checks the medication room, and the medication carts every month. She stated that if a medication were supposed to be refrigerated, it should be refrigerated because the medication could lose its effectiveness. She stated the policy was to remove a discharged resident medication from the cart as soon as they were discharged . She stated all insulins should be dated when they were opened because insulin expired 28 days after opening. She stated that if the nurses are doing the medications rights, they should be able to ensure they give the right medication to the right patient. She stated that the nurses had been in serviced on medication storage. Review of the facility's policy Medication Access and Storage / Drug Destruction Revised 7/2023 reflected the following: Medications requiring storage at room temperature are kept at temperatures ranging from 15 C (59 F) to 30 C (86 F). Review of the facility's policy undated titled Injections, Insulin For storing: Remove insulin from the refrigerator. Wipe off top of bottle with alcohol. Date insulin once removed fridge, (if insulin is not dated, please refer to the date sent from the pharmacy)

Based on interview and record review, the facility failed to establish and implement smoking safety policies and procedures for 1 (Resident #59) of 6 residents reviewed for smoking safety. The facility failed to complete an initial smoking assessment for Resident #59 to determine the resident's ability to smoke safely, need for supervision, and appropriate smoking interventions in accordance with facility smoking policies. This failure placed residents at risk for smoking related accidents, burns, and other safety hazards.Findings included: Record review of Resident #59's MDS, dated [DATE], reflected he was an [AGE] year-old male who admitted to the facility on [DATE]. He had a BIMS score of 9, which indicated moderate cognitive impairment. His diagnoses included dependence on renal dialysis (routine dialysis treatments because the kidneys are no longer able to filter waste and fluid from the body on their own), Record review of Resident #59's Comprehensive Care Plan, dated 05/12/26, reflected he was at risk for smoking injury. The plan interventions reflected Resident #59 was to have a smoking assessment completed as needed. Record review of Resident #59's physician progress note dated 04/23/26, reflected the resident continued to smoke despite multiple medical comorbidities and was strongly counseled on smoking cessation. The physician noted the resident was at increased risk for cardiovascular and wound healing. Record review of Resident #59's EHR on 05/12/26, reflected the resident did not have an initial smoking assessment. During an interview with the DON on 05/13/2026 at 1:30 PM, she reported she completed audits of smoking assessments for residents. She stated if she saw that one was not completed then she would complete the assessment. She stated the initial smoking assessments were completed upon admission. She stated the risk for a resident not having a smoking assessment was staff would not know their smoking ability, capability, and put their safety at risk. Review of the facility's smoking policy, dated 03/19/26, reflected, Upon admission (7-10 days), residents who desire to smoke will be assessed as well as their ability to do so safely. All new admissions will be on supervised smoking until assessment is reviewed by the interdisciplinary team. The Interdisciplinary Team will accomplish this using the Smoking Assessment form and a review of the resident's clinical record. At the end of this period it will be determined if the resident will be allowed to smoke under supervision with or without protective devices.

Based on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 Residents (Resident# 103 and Resident# 8) of 6 Residents reviewed for pharmacy services. The facility failed to ensure proper storage and disposal of Resident #103's Tramadol HCL tab 50mg- (controlled medication) by taping a narcotic medication and storing it in the medication cart. The facility failed to ensure properly disposal of Resident #8's hydrocodone 5-325mg (controlled medication) which expired on [DATE]. These failures could place residents at risk of drug diversion, medication error, and risk of pills contamination due to broken seals.Findings included: Resident#8 Review of Resident #8's Quarterly MDS Assessment, dated [DATE], reflected a [AGE] year-old female admitted on [DATE], and had a BIMs score of 15 which indicated she was cognitively intact. The resident had diagnoses which included Diabetes Mellitus (chronic metabolic condition characterized by insulin resistance and relative insulin deficiency). Review of Resident #8's Comprehensive Care Plan, initiated [DATE], reflected: Resident #8's has acute/chronic pain. Interventions included Administer analgesia medication as per orders. Review of Resident #8's active physician orders Dated:[DATE] reflected Hydrocodone-Acetaminophen Oral Tablet 10-325MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. Observation on [DATE] at 9:13 AM with LVN A on the 100 south-hallway medication cart revealed Resident #8's Hydrocodone-Acetaminophen Oral Tablet 10-325MG with expiration date of [DATE]. During an interview on [DATE] at 9:16 AM with LVN A stated she was unaware that the hydrocodone had expired. She stated the nurses were responsible for ensuring expired medication was removed from the medications carts and given to the DON for proper destruction. She stated the risk to the residents was medication error and medication not being effective. She stated she had been in service on medication storage. Resident #103 Review of Resident #103's Quarterly MDS Assessment, dated [DATE], reflected an [AGE] year-old male admitted on [DATE], and had a BIMs score of 12 indicated he had moderate cognitively impairment. The resident had diagnoses which included Type 2 diabetes mellitus (a chronic metabolic condition characterized by insulin resistance and relative insulin deficiency), FOLLICULAR LYMPHOMA GRADE II, (a slow-growing non-Hodgkin's lymphoma (a group of blood cancers that develop in the lymphatic system when the body produces abnormal white blood cells). Review of Resident #103's Comprehensive Care Plan, initiated [DATE], reflected: Resident #103's Has acute/chronic pain r/t disease Process. Interventions included Administer analgesia medication as per orders. Give 1/2 hour before treatments or care. Review of Resident #103's active physician orders Dated:[DATE] reflected Ultram Oral Tablet 50 MG (Tramadol HCl) Give 1tablet by mouth every 4 hours as needed for Pain start date [DATE]. Observation on [DATE] at 9:10 AM, of the 100 north hall nurses' carts with LVN B indicated Resident # 103's Tramadol HCl Oral Tablet 50 MG had broken seals and the blister pack secured with tape. The damaged blister packs had the pills still inside at the time the surveyor inspected the medication cart. During an interview on [DATE] at 9:14 AM, LVN B stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics at change of shift. She stated that the risk of a damaged blister would be potential for drug diversion and contamination of the medication. She stated she had been in serviced on medication storage. During an interview on [DATE] at 1:04 PM, the DON stated nurses were responsible for ensuring medication carts were clean and all narcotic medication was properly secured and not expired. She stated that the ADON audited the medication carts weekly, then the pharmacy consultant checks the medication room, and the medication cart every month. She stated the risk was that the nurses would not know if the taped pill was the correct medication. She stated if the nurses did the medication rights, they should realize the medication was expired and not administer it. She stated the nurse had been in serviced on medication administration and narcotic count to include no taping medication but wasting the medication witnessed by another nurse. Review of the facility's policy titled Medication Access and Storage / Drug Destruction Revised 7/2023 reflected the following:Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. Narcotics are given to the Director of Nursing for destruction. They are inventoried and counted and kept under a double lock system until medication destruction can be completed with the Consultant Pharma

Based on interview and record review, the facility failed to develop and implement a baseline care plan 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 one (Resident #98) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #98 within 48 hours of her admission. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.Findings included: Review of Resident #98's Face Sheet, dated 05/14/26, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including Parkinsonism (a syndrome marked by tremor, muscular rigidity, and slow and difficult movement, occurring as a result of disease of the nervous system or exposure to certain drugs and toxins, and as a neurodegenerative disorder of unknown cause (Parkinson's disease), Type 2 Diabetes Mellitus (a chronic condition characterized by insulin resistance and high blood sugar levels, often manageable through lifestyle changes and medication), Dysphagia (the medical term for difficulty or discomfort in swallowing, which can range from mild problems with certain foods to an inability to swallow at all), and Need for Assistance with Personal Care (refers to a medical or functional status where a person requires help with everyday self-care activities because of physical, mental, or developmental limitations). Review of Resident #98's electronic medical record on 05/13/26 reflected her baseline care plan was completed on 01/28/26 (6 days following her admission). During an interview with the DON on 05/13/26 at 11:00 AM, she stated she had been employed by the facility since March of 2026, and it was her responsibility to oversee the timely completion of baseline care plans. She stated baseline care plans were required to be completed within 48 hours of a resident's admission to the facility. The DON confirmed Resident #98's baseline care plan was not completed within that required timeframe. She stated the risk of baseline care plans not being completed within the required timeframe included the potential for facility staff not knowing the resident's necessary plan of care. Review of the facility's Care Planning policy, dated 07/2025, reflected, .Initial care plan/Interim care plan - initial care plan is started within 48-hours of admission to provide an overview of the resident's care needs. Initial plan of care can be started in PCC/POC and/or through the use of resident care guidelines, shift to shift report.

Based on interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 5 residents (Resident #10) reviewed for PASRR Level I screenings. The facility did not correctly identify Resident #10 as having a mental illness and did not complete a new PASRR Level I Screening. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses.Findings included: Review of Resident #10's MDS, dated [DATE], reflected he was a [AGE] year-old male who admitted to the facility on [DATE], with a BIMS score of 3, which indicated severe cognitive impairment. Diagnoses included Schizoaffective Disorder (a mental health condition where someone experiences symptoms of schizophrenia, hallucinations or disorganized thinking, along with major mood episodes such as depression or mania). Record review of Resident #10's Comprehensive Care Plan, dated 01/06/26 reflected the resident was taking an anti-psychotic medication to treat schizoaffective disorder. Review of Resident #10's PASRR Level I Screening, dated 12/08/25, reflected there was no evidence that Resident #10 had indicators of a mental illness. During an interview with the MDS Nurse on 05/14/26 at 12:00 PM, she stated she reviewed Resident #10's medical records and stated he was admitted to the facility with the diagnosis of schizoaffective disorder. She stated she reviewed Resident #10's PASRR Level One Assessment and it indicated he did not have a mental illness. She stated the assessment should have indicated he did have a mental illness. During an interview with the MDS Resource Nurse on 05/14/26 at 2:15 PM, she stated Resident #10 was admitted to the facility with a diagnosis of schizoaffective. She stated he was ineligible for PASRR services per the RAI (Resident Assessment Instrument) guidelines. She stated the RAI guidelines state a resident must be diagnosed with a mental illness before the age of 18 to qualify for services. She stated she did not believe Resident #10 was diagnosed with schizoaffective before the age of 18. She stated it would have been in his medical records. The MDS Resource Nurse could not provide a specific date when the resident was diagnosed. She stated the facility did not have a PASRR policy, rather the facility followed RAI guidelines. She stated the MDS nurse would oversee PASRR for the facility but since she was in training, she and a traveling PASRR nurse was helping the facility with PASRR. She stated there was not a risk for residents with mental illness who had incorrect Level 1 PASRR assessments. She stated there would be a disservice for residents with cerebral palsy, autism, etc. as they would not receive services that PASRR could provide.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 residents (Resident #1) reviewed for assessments: The facility failed to ensure Resident #1's quarterly MDS assessment, dated 09/23/25, included the behavior of wandering in Section E of the assessment. These failures could place residents at risk for inadequate care.Findings include:Record review of Resident #1's face sheet, dated 10/07/25, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had diagnoses which included Heart Failure, Schizoaffective Disorder (mental disorder with persistent hallucinations, delusions, disorganized thinking and speech, and bizarre or inappropriate behavior), Insomnia (difficulty falling asleep or staying asleep), Dysphagia (difficulty swallowing which can lead to choking), Repeated Falls, Type 2 Diabetes (body does not use insulin effectively or does not produce enough insulin), Essential Hypertension (High Blood Pressure), Muscle Weakness, and Cognitive Communication Deficit (inability to communicate effectively).There was no diagnosis of Dementia (decline in cognitive functions) on Resident #1's face sheet.Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 00, which meant he had severe cognitive impairment. Section E of the MDS assessment noted the resident had no wandering behaviors. The MDS did not note Dementia as a diagnosis for Resident #1.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.In an interview on 10/08/25 at 12:45 PM, the DON stated Resident #1 did not have a diagnosis of Dementia. She stated staff might not been paying attention or accidentally selected Dementia as a diagnosis for Resident #1 on the Elopement Wandering Assessments. The DON reviewed all the assessments and stated she was not aware she also selected Dementia on one of Resident #1's assessments by accident. The DON stated whoever completed the assessment was responsible for ensuring the accuracy. The DON stated selecting Dementia as a diagnosis could affect the outcome of the assessment. She stated it could put the resident at a higher risk for elopement or wandering if selected incorrectly. She stated the wandering should be documented on all assessments on the resident's electronic record related to behavior. The DON stated the risk of noting Resident #1 had a diagnosis of Dementia or not noting the wandering behavior was the resident could be in places where he should not be and potentially be harmed.In an interview on 10/08/25 at 1:10 PM, the Administrator stated he had a lack of clinical background but would think the risk of inaccurate information on the electronic record could cause inaccurate results of assessments which could affect the resident. He stated the nursing staff were responsible for completing the assessments. Record review of the facility's policy titled, Resident Assessments, dated 11/2016 reflected the following: Policy It is the policy of this facility that residents will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences, using the RAI (Resident Assessment Instrument).

Based on interview and record review, the facility failed to ensure, in accordance with professional standards and practices, medical records were maintained on each resident that that were complete and accurately documented for 1 of 6 resident records (Resident #1) reviewed for treatment documentation. The facility failed to document Resident #1's routine wandering since his admission on [DATE] and his increased wandering about 2-4 weeks before 09/30/25.The facility failed to ensure 8 of Resident #1's Elopement Wandering Assessments, did not note an incorrect diagnosis of Dementia.This failure could place residents at risk of medical records not being an accurate representation of medical condition or medical needs.Findings include:Record review of Resident #1's face sheet, dated 10/07/25, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had diagnoses which included Heart Failure, Schizoaffective Disorder (mental disorder with persistent hallucinations, delusions, disorganized thinking and speech, and bizarre or inappropriate behavior), Insomnia (difficulty falling asleep or staying asleep), Dysphagia (difficulty swallowing which can lead to choking), Repeated Falls, Type 2 Diabetes (body does not use insulin effectively or does not produce enough insulin), Essential Hypertension (High Blood Pressure), Muscle Weakness, and Cognitive Communication Deficit (inability to communicate effectively). Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 00, which meant he had severe cognitive impairment. It also noted the resident had no wandering behaviors.Record review of the Progress Notes, with a start date of 03/02/23, on Resident #1's Electronic Record, reflected no notations of Resident #1's behavior of wandering, increased wandering, or any incidents with wandering.Record review of Resident #1's quarterly elopement risk assessment dated [DATE], reflected Resident #1 had a history of wandering but did not exhibit wandering behavior at the time of the assessment. The assessment noted a low risk for elopement. Record review of Resident #1's quarterly elopement risk assessment dated [DATE], reflected Resident #1 had a history of wandering but did not exhibit wandering behavior at the time of the assessment. The assessment noted a low risk for elopement.Record review of Resident #1's quarterly elopement risk assessment dated [DATE], reflected Resident #1 had a history of wandering but did not exhibit wandering behavior at the time of the assessment. The assessment noted a low risk for elopement.Record review of Resident #1's quarterly elopement risk assessment dated [DATE], reflected Resident #1 had an increased risk of elopement and noted him as a high risk for elopement. Record review of the Incident Report Log, dated 10/07/25, did not reflect any wandering incidents. Record review of Resident #1's Care Plan, dated 10/07/25, reflected wandering was not addressed on the care plan until 09/30/25, when the facility decided to place Resident #1 in memory care.Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 00, which meant he had severe cognitive impairment. Section E of the MDS assessment noted the resident had no wandering behaviors. The MDS did not note Dementia as a diagnosis for Resident #1.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia.Record review of Resident #1's quarterly Elopement Wandering assessment dated [DATE], reflected Resident #1 had a diagnosis of Dementia. In an interview on 10/08/25 at 12:45 PM, the DON stated Resident #1 had always wandered around but mostly wandered the hallways and near the dining area at the front. She stated it was about 2 weeks ago when the resident had a change in condition and wandered more around the building. The DON stated he started going into other residents' rooms and in other areas where he would not normally go. She stated she discussed it with the Administrator and the Medical Director. The DON stated she really had no reason as to why his wandering was not documented on his electronic record. The DON stated the risk of his wandering not ever documented on the progress notes was staff not able to identify what he had going on. the DON stated Resident #1 did not have a diagnosis of Dementia. She stated staff might not been paying attention or accidentally selected Dementia as a diagnosis for Resident #1 on the Elopement Wandering Assessments. The DON reviewed all the assessments and stated she was not aware she also selected Dementia on one of Resident #1's assessments by accident. The DON stated whoever completed the assessment was responsible for ensuring the accuracy. The DON stated selecting Dementia as a diagnosis could affect the outcome of the assessment. She stated it could put the resident at a higher risk for elopement or wandering if selected incorrectly. She stated the wandering should be documented on all assessments on the resident's electronic record related to behavior. The DON stated the risk of noting Resident #1 had a diagnosis of Dementia or not noting the wandering behavior was the resident could be in places where he should not be and potentially be harmed.In an interview on 10/08/25 at 1:10 PM, the Administrator stated notes on Resident #1's electronic record should have reflected his wandering. The Administrator stated the risk of the wandering not documented on the progress notes was a lack of communication and staff not understanding Resident #1's needs. The Administrator stated he had a lack of clinical background but would think the risk of inaccurate information on the electronic record could cause inaccurate results of assessments which could affect the resident. He stated the nursing staff were responsible for completing the assessments. Record review of the facility's policy titled, Documentation and Charting, dated 10/2021, reflected the following: POLICYIt is the policy of this facility to provide: A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. Record review of the facility's policy titled, Resident Assessments, dated 11/2016 reflected the following: Policy It is the policy of this facility that residents will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences, using the RAI (Resident Assessment Instrument).

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 6 residents, reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #1's wandering behavior and note interventions prior to 09/30/25. This failure could place resideFindings Include:Record review of Resident #1's face sheet, dated 10/07/25, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had diagnoses included Heart Failure, Schizoaffective Disorder (mental disorder with persistent hallucinations, delusions, disorganized thinking and speech, and bizarre or inappropriate behavior), Insomnia (difficulty falling asleep or staying asleep), Dysphagia (difficulty swallowing which can lead to choking), Repeated Falls, Type 2 Diabetes (body does not use insulin effectively or does not produce enough insulin), Essential Hypertension (High Blood Pressure), Muscle Weakness, and Cognitive Communication Deficit (inability to communicate effectively).Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 00, which meant he had severe cognitive impairment. It also noted the resident had no wandering behaviors.Record review of Resident #1's Care Plan, dated 10/07/25, reflected wandering was not addressed on the care plan until 09/30/25, when the facility decided to place Resident #1 in memory care.Record review of Resident #1's quarterly elopement risk assessment dated [DATE], reflected Resident #1 had a history of wandering but did not exhibit wandering behavior at the time of the assessment.Record review of Resident #1's quarterly elopement risk assessment dated [DATE], reflected Resident #1 had a history of wandering but did not exhibit wandering behavior at the time of the assessment.Record review of Resident #1's quarterly elopement risk assessment dated [DATE], reflected Resident #1 had a history of wandering but did not exhibit wandering behavior at the time of the assessment.In an interview with the DON and the Administrator on 10/07/25 at 12:00 PM, the DON stated Resident #1 had wandered the facility since she became the DON at the facility about two years ago. The DON stated Resident #1 was already a resident at the facility when she started working there. The DON stated the resident started to wander more recently. The DON stated in the past he wandered up and down the hallway and would sit at the front near the dining hall. The DON stated now he started to wander into other areas, and that was what prompted the staff to add wandering to the care plan on 09/30/25. The DON stated she, the Administrator, and Medical Director decided it was best to address the wandering and to admit Resident #1 to memory care. The Administrator stated he noticed Resident #1 started to wander more than in the past.In an interview on 10/07/25 at 12:19 PM, Nurse Aide A stated Resident #1 had always wandered the hallways and started to wander more recently. She stated the resident was starting to wander into other resident rooms. She stated in the past he would wander up and down the hallways, to the dining hall, would wait at the door for smoke breaks, and would go down to the therapy room.In an interview on 10/07/25 at 12:47 PM, The Medical Director stated Resident #1 was a regular wanderer around the facility, but lately he started to wander into other areas like the administration offices, into resident rooms, and tried to go to the kitchen.In a follow up interview on 10/08/25 at 12:45 PM, the DON stated as long as she had worked at the facility, Resident #1 was a wanderer, but he mainly wandered in the same areas. She stated within the last 30 days Resident #1's wandering increased, so they decided to add wandering to the care plan and place him in memory care on 09/30/25. The DON stated wandering was never added to the care plan, because it was routine wandering, he would go to the same places, and he never tried to exit the facility. The DON stated the risk of wandering not addressed in the care plan prior to 09/30/25 was staff would not be fully aware of all his behaviors and/or symptoms and how to address each best.In a follow up interview on 10/08/25 at 1:10 PM, the Administrator stated staff might not have known Resident #1's full needs with wandering not addressed in the care plan. He stated all of a resident's behaviors should be addressed in the care plan.Record review of the facility's policy titled, Resident Assessments, dated 11/2016, reflected the following: 5.Assessment information will be used to develop, review, and revise the resident's comprehensive care plan.

Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 2 of 18 residents (Resident #1, Resident #2) reviewed for abuse and neglect.The facility failed to thoroughly investigate inappropriate sexual behavior between Resident #1 and Resident #2. Resident #1 was observed in the dining room by CNA-A massaging the breast of Resident #2.An Immediate Jeopardy (IJ) was identified on 11/14/25. The IJ template was provided to the facility on [DATE] at 7:12 PM. While the IJ was removed on 11/15/25, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. Findings included: Record review of Resident #2's face sheet dated 11/15/25 reflected she was a [AGE] year-old female admitted into the facility 09/22/25 with a diagnosis of senile degeneration of brain (a general term for a decline in memory, thinking, and other cognitive abilities associated with aging). Record review of Resident #2's care plan dated 9/22/25 reflected ADL self-care performance deficit impaired mobility/cognition. Goal was to maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Interventions were to converse with resident while providing care, explain all procedures before starting, promote dignity by ensuring privacy, staff will provide appropriate level of physical assistance with ADL's, encourage them to participate to the fullest extent possible. Record review of Resident #2's initial assessment MDS dated [DATE] reflected a BIMS score of 01 (Severe Cognitively Impairment).Record review of Resident #1's face sheet dated 11/15/25 reflected he was a [AGE] year-old male admitted into the facility 07/14/25 with a diagnoses of brain compression (a serious condition caused by increased pressure within the skull that pushes the brain against its rigid covering), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident #1's care plan dated 9/3/25 reflected a focus of elopement risk and significantly intrudes on the privacy or activities, the goal was to maintain safety and would not leave the facility. Interventions/tasks were to distract resident from wandering by activities, food, conversation, television, document wandering behavior, identify pattern of wandering determine if aimless or escapist, is resident looking for something or did the wondering indicate he needed more exercise. Focus was a potential to demonstrate physical and verbal aggressive behaviors/manic episodes. Goal was to demonstrate effective coping skills and would not harm self or others. Interventions/tasks were to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort and body position, pain. Communication provides physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, encourage seeking out of staff members when agitated. When he becomes agitated, guide away from source of distress, engages calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #1's quarterly MDS dated [DATE] reflected he had a BIMS score of 09 (Moderately Cognitively Impaired).On 11/13/25 the State Surveyor observed the video dated 11/05/25, on the facility monitor, the video revealed the following:At 08:03 AM, Resident #1 left the dining room with a food tray and walked back into the dining room. At 08:29 AM Resident #1 came out of the dining room again and threw a bag away and went back into the dining room. At 08:30 AM CNA-A went into the dining room and came out of the room with Resident #2 and took her down the hall. Resident #1 followed CNA-A and Resident #2 out of the dining room and down the hallway, he was holding a green piece of material in his hand. A few minutes later at 08:51 AM Resident #2 was brought back to the hallway across from the nurses station. Resident #2 was sitting in the hall alone on a bench when Resident #1 went to the counter and stood there a few seconds and then walked over to Resident #2 turned around and kissed her on the top of her head.Record review of undated written statement of CNA-A reflected, This morning I witness [Resident #1] coming out of the dining room with a pull-up in his hand. I ask my co-worker where did he get it, he headed back to the dining room and shut the door that's when I went to check to see why he shut the door, as I enter the room both residents were standing by the table [Resident #1] in front of her massaging her chest with his hands holding (She had the top shirt on) her tank top. I told him to stop I patted the pt. realized her brief was off, grabbed her and started walking her out to notify my nurse and pt telling me he has her and I replied: I got her. [sic]Record review of the facility undated investigation reflected, We, [Administrator and DON, interviewed CNA-A 11/5/25 after reading her statement to get clarity on the incident between [Resident #2] and [Resident #1]. Upon speaking with her, her story was inconsistent with what was initially written as she stated she initially assumed that [Resident #1] was touching [Resident #2], by the way he was standing next to her, but was unsure if she could see that [Resident #1] was touching [Resident #2] or not as she did not observe it herself. She state that she saw [Resident #1] come out of the dining room with a brief in hand, she followed him back into the dining room and saw [Resident #1] standing next to [Resident #2], then walked out of the dining room and back to her room and notified the nurse of [Resident #1] carrying dirty brief to trash. [sic]In a face-to-face interview with the DON on 11/13/25 at 1:37 PM, she stated that she became aware of the alleged abuse when it was reported by LVN-B. She stated that LVN-B had conducted the assessment on Resident #2. She stated that she and the Administrator had interviewed CAN-A and CAN-A did not verbally provide the same information she had written in her statement. She stated CAN-A was asked about the discrepancy, but she did not remember the response. She stated based on the discrepancy she and the Administrator determined that nothing had happened between Resident #1 and Resident #2. She stated that Resident #1 had been sent to hospital for psych evaluation, but they sent him back with no new instructions. She stated that staff had documented it on 11/4/25 and during the early shift on 11/5/25 that Resident #1 had been going into other residents rooms. In a face-to-face interview with LVN-B on 11/14/25 at 6:42 AM she stated that on 11/05/25 she had been passing medications when CAN-A came and reported that Resident #1 was assisting Resident #2 and Resident #1 had Resident #2's undershirt and brief in his hands. She stated that she notified the Administrator immediately and completed a skin assessment on Resident #2 and did not see any injuries. She stated the resident did not exhibit any distress at the time of examination. In a face-to-face interview with the Administrator on 11/14/25 at 10:10 AM, he stated he stated that he was notified by LVN-B that CNA-A had walked into the dining room and found Resident #1 and Resident #2 in the dining room alone. He stated he conducted a soft investigation, he stated there was no difference between a soft investigation and a regular investigation. He stated that he would do the same thing for both investigations skin assessments, safe surveys, and in-services. He stated that the investigation depended on the situation. He stated in this soft investigation he did not identify anything that was reportable. The Administrator was asked, Was Resident #1 asked to help staff with ADL care? The Administrator denied that Resident #1 was asked to help with other residents ADL care. The Administrator was asked, If nothing happed between Resident #1 and Resident #2, how did Resident #2 end up without a brief, Resident #1 with a dirty brief to put in the trash, and they were the only two people in the room? He stated he could not assume that anything had happened between the residents because there were no witnesses. The Administrator stated the residents were at risk of the facility not creating an environment for resident safety. In a telephone interview on 11/21/25 at 10:35 AM with the NP, he stated he had not been told that there was a potential sexual abuse between Resident #1 and Resident #2. He stated he had first heard there was a significant event regarding Resident #1 when he was notified that the State was in the building. He stated the staff had informed him that Resident #1 had been going in and out of other residents rooms. He stated that Resident #1 had been very restless and was constantly going into rooms wiping down things. He stated the staff informed him that Resident #1 was not responding to direction, and he was trying to help a male resident back to bed. He denied he was ever informed of Resident #1 attempting to assist a female resident. He stated Resident #1 assisting residents placed the residents at risk of trips or falls. A. Record review of facility Abuse and Neglect Policy revised 10.2022 reflected, Investigation 1. All identified events are reported to the Administrator immediately.2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm (See, Protection, below).3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Upon receiving a report or allegation of a potential violation of this policy involving the taking, keeping, using, or distributing photos or video recordings, the Administrator or his or her designee will analyze the allegations and determine whether the conduct at issue implicates resident privacy or security as protected by the Health Insurance Portability and Accountability Act ( HIPAA). Any such actual or potential violation will be managed as per the Facility's HIPAA policies and procedures.5. The investigation will include the following: An interview with the person(s) reporting the incident; An interview with the resident(s); Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; A review of the resident's medical record; An interview with staff members (on all shifts) who may have information regarding the alleged incident; Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; An interview with staff members (on all shifts) having contact with the accused employee; and A review of all circumstances surrounding the incident. 6. To the extent there is evidence that could be used in a criminal investigation, staff will immediately notify the Administrator or his/her designee. Staff are not to tamper with or destroy any such evidence at any time. 7. At the conclusion of the investigation, the Facility will attempt to determine if abuse, neglect, misappropriation of resident property, or exploitation has occurred.8. The investigation, and the results of the investigation, will be documented. 9. All phases of the investigation will be kept confidential in accordance with the Facility's policies governing the confidentiality of medical records and privilege of quality assurance/ quality improvement programs. B. Protection 1. If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation: Respond immediately to protect the alleged victim and integrity of the investigation; Examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increase supervision of the alleged victim and residents; Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protect the involved persons from retaliation; and Provide emotional support and counseling to the resident during and after the investigation, as needed. 2. If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor and intervene as necessary to maximize resident health and safety.An IJ was identified on 11/14/25 and the IJ template was provided to the facility on [DATE] at 7:12 PM. The following Plan of Removal was submitted by the facility and was accepted on 11/15/2025 at 12:00 PM and indicated the following: The IJ Template was given on 11/14/23 at [7:05 PM]. The facility failed to protect Resident #2 from being sexually abused by Resident #1. The facility failed to provide supervision to prevent abuse.1. The facility place resident #1on 1:1 supervision. 2. The Medical Director was notified of IJs on 11/14/25 at [7:15 PM].3. Administrator suspended on 11/14/25 pending the outcome of the investigation. 4. The facility's policies on abuse and neglect prevention and reporting were reviewed by the Clinical Resource, Cluster Partners, and Cluster Administrator. There were no concerns and facility will continue with current policy. 5. Education/in-servicing was initiated on 11/14/25 with all staff on abuse and neglect to prevent abuse to residents in the facility. Education/in-servicing to be completed by the DON/ADON/Clinical Resource/Cluster DONs. Education/in-servicing on abuse and neglect included identification, prevention, reporting and what could happen should the staff member fail to follow facility policy including potential injury to a resident. Staff were instructed on examples of resident abuse/neglect and to report all allegations of abuse and neglect to the Abuse Coordinator. Knowledge check forms are completed with all staff on abuse and neglect training that was received. Education was given in person or via phone in written form and verbally to accommodate different learning styles of the staff for abuse/neglect. This education/in-servicing was given using developed policy and procedures based on best practice. With this education/in-servicing, staff will have definitions of the purposes and procedures and will decrease the likelihood of resident abuse or neglect occurrences. 6. All staff to receive education prior to working their next shift. PRN staff received the mandatory training notice and will receive education prior to their next shift.7. This education/in-servicing and the knowledge check forms will be completed with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. 8. An ad hoc QA meeting regarding items in the IJ template was completed on 11/14/25. Attendees will include the Medical Director, Clinical Resource, DON, ADON, Cluster Administrator, and will include the plan of removal items and interventions.9. The DON, ADON, Cluster DONs or Clinical Resource will complete knowledge checks with 10 staff weekly on abuse and neglect. These forms will be completed with staff randomly, sampling from each shift, weekend and weekday staff, and PRN staff. Any concerns with staff competency will be addressed immediately through re-education and/or staff counseling. 10. The Administrator and DON will investigate and report all allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 11. Summary of IJ, corrective actions and allegations of abuse/neglect to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. [Acting Administrator] LNFA Monitoring of the Plan of Removal from 11/15/25 included the following:The facility provided a binder with the following documentation to be reviewed, reviewed facility notification to MD at [7:15 PM], observed facility Administrator was no longer in the facility, an acting Administrator continued to meet with surveyor, record review of in-service training and education dated 11/14/25 and 11/15/25 completed by the Cluster nurses (nurses from sister facilities and regional staff. Record review of LVN, RN, ADON change in condition in-service dated 11/14/25 and 11/15/25 for all three shifts. Record review of ad hoc meeting notes dated 11/14/25 Attendees included the Medical Director by phone, Clinical Resource, DON, ADON, Administrator. Record revied of undated knowledge checks used to assess the knowledge of nursing staff. Record review of in-service dated 11/14/25 for Administrator and DON to investigate and report any allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 11/15/2025 at 12:32pm Resident #1 observation-He was in his room laying in his bed watching a women's soccer game on TV. He spoke to the surveyor and smiled. He stated that he was doing fine. Surveyor spoke to CNA-D who stated this hall is for men only. She stated that Resident #1 had been out of his room to smoke a cigarette, watch TV and had spoken to some of the men. She stated that Resident #1 had been in a good mood and there had not been any incidents since he had been on one-to-one supervision.Interviews with CNA-A, LVN-B, LVN-C, CNA-D, CNA-E, CNA-F, LVN-G, CNA-H, CNA-I, CNA-J, LVN-K, LVN-L, CNA-M, LVN-N, CNA-O, CNA-P, Staffing Coordinator, and ADON on 11/15/25 from 12:48 PM - 2:55 PM and interviews with LVN-Q, LVN-R, CNA-S, and LVN-T on 11/15/25 from 5:30 PM - 6:25 PM revealed, they had been in-serviced/educated on who the abuse coordinator was at the facility, how and who to report abuse to if they witnessed or suspected abuse. All staff stated they received re-education of inappropriate touching between residents and who it should be reported to and the time frame should be immediate. They stated residents who exhibit aggressive or inappropriate behaviors should be placed on 1:1 supervision immediately, notify the nurse management and administrator immediately. Interviews with LVN's revealed they knew they should call the police, send the resident to the ER for examination for inappropriate touching and abuse. LVN's interviewed also stated they had been re-educated on how to determine a change in condition and that the medical provider and family should be notified. They stated a change in condition would be weight, cognition, infection or new medications and that abuse/neglect would be considered a change in condition. The Administrator was informed that the Immediate Jeopardy was removed on 11/15/2025 at 3:35 PM. The facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse and neglect for 2 of 8 residents (Resident #1 and Resident #2) reviewed for abuse and neglect.The facility failed to ensure there was no inappropriate sexual behavior between Resident #1 and Resident #2. Resident #1 was observed in the dining room by CNA-A massaging the breast of Resident #2.An Immediate Jeopardy (IJ) was identified on 11/14/25. The IJ template was provided to the facility on [DATE] at 7:12 PM. While the IJ was removed on 11/15/25, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. This failure placed other female residents at risk and or potential risk of abuse/neglect Findings Included: Record review of Resident #2's face sheet dated 11/15/25 reflected she was a [AGE] year-old female admitted into the facility 09/22/25 with a diagnosis of senile degeneration of brain (a general term for a decline in memory, thinking, and other cognitive abilities associated with aging). Record review of Resident #2's care plan dated 9/22/25 reflected ADL self-care performance deficit impaired mobility/cognition. Goal was to maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Interventions were to converse with resident while providing care, explain all procedures before starting, promote dignity by ensuring privacy, staff will provide appropriate level of physical assistance with ADL's, encourage them to participate to the fullest extent possible. Record review of Resident #2's initial assessment MDS dated [DATE] reflected a BIMS score of 01 (Severe Cognitive Impairment).Record review of Resident #1's face sheet dated 11/15/25 reflected he was a [AGE] year-old male admitted into the facility 07/14/25 with a diagnoses of brain compression (a serious condition caused by increased pressure within the skull that pushes the brain against its rigid covering), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident #1's care plan dated 9/3/25 reflected a focus of elopement risk and significantly intrudes on the privacy or activities, the goal was to maintain safety and would not leave the facility. Interventions/tasks were to distract resident from wandering by activities, food, conversation, television, document wandering behavior, identify pattern of wandering determine if aimless or escapist, is resident looking for something or did the wondering indicate he needed more exercise. Focus was a potential to demonstrate physical and verbal aggressive behaviors/manic episodes. Goal was to demonstrate effective coping skills and would not harm self or others. Interventions/tasks were to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort and body position, pain. Communication provides physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, encourage seeking out of staff members when agitated. When he becomes agitated, guide away from source of distress, engages calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #1's quarterly MDS dated [DATE] reflected he had a BIMS score of 09 (Moderately Cognitive Impaired).Record review of progress notes of Resident #1 dated 11/4/25 at [1:59 PM] by LVN-B reflected, Kept going in other rooms while during shift, was found in multiple ladies' room and assisting residents to the restroom & was found after that in multiple male's room making beds. This nurse [LVN-B] discussed not going into rooms with the resident. Resident verbalized understanding. Notified NP of behaviors noted during this shift.Record review of progress note dated 11/05/25 at 3:32 AM for Resident #1 by LVN-C reflected, Res up and walking around hall and roaming in and out other patient's rooms. Res very aggressive and hard to redirect, tried to do virtual visit but iPad dead awaiting charging to call on call MD. [sic]Record review of progress note dated 11/05/25 at 4:23 AM for Resident #1 by LVN-C reflected, Res still agitated and aggressive. PRN orazepam was given but not effective. Res going in multiple women's rooms on unit. Hard to redirect. Res has been up all night walking and talking to self. [sic]Record review of progress note dated 11/05/25 at 4:50 AM for Resident #1 by LVN-C reflected, change in condition behavioral systems, nursing observations, evaluation, and recommendations are: Res has been up all night and going into female resident's rooms and when staff try to have him leave out room res becomes very aggressive in tone and hard to remove with verbal redirection. Res starts making demands like for food or water ect. Res was given PRN Ativan. Called spoke to on call NP. Gave order to give an additional Ativan of 0.5 mg and have NP and MD see patient once in facility. [sic]Record review of progress note dated 11/05/25 at 5:14 AM for Resident #1 by LVN-C reflected, PRN administration was: ineffective no change in behavior.Record review of Behavioral Changes and Sleep Disturbance dated 11/5/25 at 1:27 PM for Resident #1 reflected, [Resident #1] [was] a [AGE] year-old male resident at a care facility who [was] being evaluated today for behavioral changes and sleep disturbance. Staff report that the patient has been exhibiting increasingly erratic behavior over the past few days, including entering other residents' rooms without permission and refusing to leave another resident's room and became verbally aggressive with the night nurse. Staff members indicate that the patient has not slept for approximately two days, only taking brief naps during daytime hours but immediately awakening when someone enters his room. Alert but disoriented, exhibiting impulsive behaviors, poor insight and judgment. Non-compliant with facility rules and boundaries. Plans continue mental health management per psych provider, continue close supervision until stabilization of symptoms. Patient instructions, you are having trouble sleeping and have been walking into other people's rooms. Try to stay in your own room, especially at night. Use your own bathroom when needed. Completed by NPRecord review of progress note dated 11/06/25 at 5:12 AM for Resident #1 by LVN-C reflected, Early morning started going into other residents rooms. Res has not been seen by psych in last 48 hrs for follow up for behaviors at this time. Res harder to redirect and lorazepam not effective. Res not sleeping during night. [sic]Record review of NP visit with Resident #1 on 11/06/25 at 10:38 AM reflected, follow up for psychiatric issues and hypertension, patient demonstrates disorganized thinking and behavior. Constantly attempting to clean rooms and help other residents in ways that are sometimes inappropriate or dangerous.Record review on 11/13/25 of Resident #2 and Resident #1's progress notes did not reflect documentation of the sexual abuse incident, no documentation of notification to doctor, and no documentation of notification to designated representative. Record review of facility incident reports dated 10/15/25 through 11/11/25 reflected no incident report involving Resident #1 or Resident #2. On 11/13/25 the State Surveyor observed the video dated 11/5/25, on the facility monitor, the video revealed the following:At 08:03 AM, Resident #1 left the dining room with a food tray and walked back into the dining room. At 08:29 AM Resident #1 came out of the dining room again and threw a bag away and went back into the dining room. At 08:30 AM CNA-A went into the dining room and came out of the room with Resident #2 and took her down the hall. Resident #1 followed CNA-A and Resident #2 out of the dining room and down the hallway, he was holding a green piece of material in his hand. A few minutes later at 08:51 AM Resident #2 was brought back to the hallway across from the nurses' station. Resident #2 was sitting in the hall alone on a bench when Resident #1 went to the counter and stood there a few seconds and then walked over to Resident #2 turned around and kissed her on the top of her head.Record review of undated written statement of CNA-A reflected, This morning I witness [Resident #1] coming out of the dining room with a pull-up in his hand. I ask my co-worker where did he get it, he headed back to the dining room and shut the door that's when I went to check to see why he shut the door, as I enter the room both residents were standing by the table [Resident #1] in front of her massaging her chest with his hands holding (She had the top shirt on) her tank top. I told him to stop I patted the pt. realized her brief was off, grabbed her and started walking her out to notify my nurse and pt telling me he has her, and I replied: I got her.Record review of the facility undated investigation reflected, We, [Administrator and DON], interviewed CNA-A 11/5/25 after reading her statement to get clarity on the incident between [Resident #2] and [Resident #1]. Upon speaking with her, her story was inconsistent with what was initially written as she stated she initially assumed that [Resident #1] was touching [Resident #2], by the way he was standing next to her, but was unsure if she could see that [Resident #1] was touching [Resident #2] or not as she did not observe it herself. She state that she saw [Resident #1] come out of the dining room with a brief in hand, she followed him back into the dining room and saw [Resident #1] standing next to [Resident #2], then walked [Resident #2] out of the dining room and back to her room, and notified the nurse of [Resident #1] carrying dirty brief to trash.In a face-to-face interview with CNA-A on 11/14/25 at 6:29 AM, she stated on 11/05/25 she observed Resident #1 walking down the hallway with an adult brief and put it in the trash, she observed him return to the dining room and he closed the door. She stated that she followed Resident #1 into the dining room and observed him massaging the breast of Resident #2 on top of her blouse, she observed Resident #2's bra around her waist, she stated she patted below the waist of Resident #2 and noticed she did not have on a brief. She stated that Resident #1 and Resident #2 were the only people in the dining room. She stated that she asked Resident #1 why he had Resident #2's shirt and he stated he was taking care of her. CNA-A said that she told Resident #1 she was taking care of Resident #2. She stated after she ensured Resident #2 was dressed properly, she notified LVN-B. She stated she was asked by the Administrator to write a statement about what she saw when she entered the room. In a face-to-face interview with the DON on 11/13/25 at 1:37 PM, she stated that she became aware of the alleged abuse when it was reported by LVN-B. She stated that LVN-B had conducted the assessment on Resident #2. She stated that she and the Administrator had interviewed CNA-A and CNA-A did not verbally provide the same information she had written in her statement. She stated CNA-A was asked about the discrepancy, but she did not remember the response. She stated based on the discrepancy she and the Administrator determined that nothing had happened between Resident #1 and Resident #2. She stated that Resident #1 had been sent to hospital for psych evaluation, but they sent him back with no new instructions. She stated that staff had documented it on 11/4/25 and during the early shift on 11/5/25 that Resident #1 had been going into other residents' rooms. In a face-to-face interview with LVN-B on 11/14/25 at 6:42 AM she stated that on 11/05/25 she had been passing medications when CNA-A came and reported that Resident #1 was assisting Resident #2 and Resident #1 had Resident #2's undershirt and brief in his hands. She stated that she notified the Administrator immediately and completed a skin assessment on Resident #2 and did not see any injuries. She stated Resident #2 did not exhibit any distress at the time of examination. She stated that Resident #1 was not assessed by her, she assumed that he would be assessed by the DON because the DON was talking with him and his representative about sending him to hospital for evaluation. In a face-to-face interview with the Administrator on 11/14/25 at 10:10 AM, he stated he stated that he was notified on 11/5/25 by LVN-B that CNA-A had walked into the dining room and found Resident #1 and Resident #2 in the dining room alone after Resident #1 had been seen by CNA-A putting a dirty brief in the trash. He stated he did not take any action at that time because after interviewing the CNA-A, he and the DON did not think any abuse had occurred. He stated Resident #1 and Resident #2 were still located on the same locked unit. He stated the facility had sent Resident #1 out for assessment to two different hospitals and he was discharged back to the facility with no new orders. He denied the facility had put any extra monitoring in place to protect either of the residents. The Administrator stated the residents were at risk of the facility not creating an environment for resident safety. In a face-to-face interview with LVN-C on 11/14/25 at 5:20 PM she stated Resident #1 woke up in the middle of the night sometimes. She stated some nights he did not sleep; he would constantly want to wipe down the doorknobs and walls and sometimes he would go into other patient rooms. She stated he would only go into female patient rooms. She stated it was hard to redirect him. She denied she had seen him touch any of the women she would redirect him to leave the room sometimes he would comply and sometimes she would have to tell him several times. Last week Resident #1 came into a room while she was providing care, he walked up on her and she had to keep repeating for him to leave. She stated she stepped back from him and told him she was going to call the police, and he left the room. She stated Resident #1 had not exhibited any sexual behaviors during her shift. In a telephone interview on 11/21 /25 at 10:35 AM with the NP, he stated he had not been told that there was a potential sexual abuse between Resident #1 and Resident #2. He stated he had first heard there was a significant event regarding Resident #1 when he was notified that the State was in the building. He stated the staff had informed him that Resident #1 had been going in and out of other residents rooms. He stated that Resident #1 had been very restless and was constantly going into rooms wiping down things. He stated the staff informed him that Resident #1 was not responding to direction, and he was trying to help a male resident back to bed. He denied he was ever informed of Resident #1 attempting to assist a female resident. He stated Resident #1 assisting residents placed the residents at risk of trips or falls. Record review of facility Abuse: Prevention of and Prohibition Against revised date 10/2022 reflected, To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse is non-consensual sexual contact of any type with a resident. If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation: Respond immediately to protect the alleged victim and integrity of the investigation; An IJ was identified on 11/14/25 and the IJ template was provided to the facility on [DATE] at 7:12 PM. The following Plan of Removal was submitted by the facility and was accepted on 11/15/2025 at 12:00 PM and indicated the following: The IJ Template was given on 11/14/23 at [7:12 PM]. The facility failed to protect Resident #2 from being sexually abused by Resident #1.The facility failed to provide supervision to prevent abuse.1. The Medical Director was notified of IJs on 11/14/25 at [7:15 PM].2. The facility's policies on abuse and neglect prevention and reporting were reviewed by the Clinical Resource, Cluster Partners, and Administrator. There were no concerns and facility will continue with current policy. 3. The facility place resident #1 on 1:1 supervision. 4. Education/in-servicing was initiated on 11/14/25 with all staff on abuse and neglect to prevent abuse to residents in the facility. Education/in-servicing to be completed by the DON/ADON/Clinical Resource/Cluster DONs. Education/in-servicing on abuse and neglect included identification, prevention, reporting and what could happen should the staff member fail to follow facility policy including potential injury to a resident. Staff were instructed on examples of resident abuse/neglect and to report any and all allegations of abuse and neglect to the Abuse Coordinator. Knowledge check forms are completed with all staff on abuse and neglect training that was received. Education was given in person or via phone in written form and verbally to accommodate different learning styles of the staff for abuse/neglect. This education/in-servicing was given using developed policy and procedures based on best practice. With this education/in-servicing, staff will have definitions of the purposes and procedures and will decrease the likelihood of resident abuse or neglect occurrences. 5. All staff to receive education prior to working their next shift. All regular staff will receive the education by 11/14/2025 or prior to their next shift at the facility. PRN staff received the mandatory training notice and will receive education prior to their next shift.6. All nurses in-serviced/educated on resident's change in condition, examples of change in condition and proper documentation along with notification to Responsible Party and Medical Provider in resident's chart. This education was initiated on 11/14/25 and will be completed with all nurses prior to the start of their next shift.7. This education/in-servicing and the knowledge check forms will be completed with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. 8. An ad hoc QA meeting regarding items in the IJ template was completed on 11/14/25. Attendees will include the Medical Director, Clinical Resource, DON, ADON, Administrator, and will include the plan of removal items and interventions.9. The DON, ADON, Cluster DONs or Clinical Resource will complete knowledge checks with 10 staff weekly on abuse and neglect. These forms will be completed with staff randomly, sampling from each shift, weekend and weekday staff, and PRN staff. The facility does not use agency / registry staff. Any concerns with staff competency will be addressed immediately through re-education and/or staff counseling. 10. The Administrator and DON will investigate and report any and all allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 11. Summary of IJ, corrective actions and allegations of abuse/neglect to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. [Acting Administrator] LNFAMonitoring of the Plan of Removal from 11/15/25 included the following: 1. The facility provided a binder with the following documentation to be reviewed, reviewed facility notification to MD at [7:15 PM], record review of in-service training and education dated 11/14/25 and 11/15/25 completed by the Cluster nurses (nurses from sister facilities and regional staff. Record review of LVN, RN, ADON change in condition in-service dated 11/14/25 and 11/15/25 for all three shifts. Record review of ad hoc meeting notes dated 11/14/25 Attendees included the Medical Director by phone, Clinical Resource, DON, ADON, Administrator. Record revied of undated knowledge checks used to assess the knowledge of nursing staff. Record review of in-service dated 11/14/25 for Administrator and DON investigate and report any allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 11/15/2025 at 12:32pm Resident #1 observation-He was in his room laying in his bed watching a women's soccer game on TV. He spoke to the surveyor and smiled. He stated that he was doing fine. Surveyor spoke to CNA-D who stated this hall is for men only. She stated that Resident #1 had been out of his room to smoke a cigarette, watch TV and had spoken to some of the men. She stated that Resident #1 had been in a good mood and there had not been any incidents since he had been on one-to-one supervision.11/15/2025 at 12:39pm Resident #2 observation she was sitting in the dining room at a table. She did not respond to surveyor when surveyor spoke to her. Resident #2 was dressed appropriately and did not make any eye contact with surveyor. Surveyor spoke to CNA-E, and she stated Resident #2 had been doing well. CNA-E stated Resident #2 does not appear to be sad. CNA-E stated Resident #2 had been eating. CNA-E stated Resident #2 normally did not talk. Interviews with CNA-A, LVN-B, LVN-C, CNA-D, CNA-E, CNA-F, LVN-G, CNA-H, CNA-I, CNA-J, LVN-K, LVN-L, CNA-M, LVN-N, CNA-O, CNA-P, Staffing Coordinator, and ADON on 11/15/25 from 12:48 PM - 2:55 PM and interviews with LVN-Q, LVN-R, CNA-S, and LVN-T on 11/15/25 from 5:30 PM - 6:25 PM revealed, they had been in-serviced/educated on who the abuse coordinator was at the facility, how and who to report abuse to if they witnessed or suspected abuse. All staff stated they received re-education of inappropriate touching between residents and who it should be reported to and the time frame should be immediate. They stated residents who exhibit aggressive or inappropriate behaviors should be placed on 1:1 supervision immediately, notify the nurse management and administrator immediately. Interviews with LVN's revealed they knew they should call the police, send the resident to the ER for examination for inappropriate touching and abuse. LVN's interviewed also stated they had been re-educated on how to determine a change in condition and that the medical provider and family should be notified. They stated a change in condition would be weight, cognition, infection or new medications and that abuse/neglect would be considered a change in condition. The Administrator was informed that the Immediate Jeopardy was removed on 11/15/2025 at 3:35 PM. The facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 8 residents (Resident #2) reviewed had a change of condition.The facility staff failed to notify the designated representative and the NP of Resident #2 that she had been sexually abused by Resident #1.This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. Findings included:Record review of Resident #2's face sheet dated 11/15/25 reflected she was a [AGE] year-old female admitted into the facility 09/22/25 with a diagnosis of senile degeneration of brain (a general term for a decline in memory, thinking, and other cognitive abilities associated with aging). Record review of Resident #2's care plan dated 9/22/25 reflected ADL self-care performance deficit impaired mobility/cognition. Goal was to maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Interventions were to converse with resident while providing care, explain all procedures before starting, promote dignity by ensuring privacy, staff will provide appropriate level of physical assistance with ADL's, encourage them to participate to the fullest extent possible. Record review of Resident #2's initial assessment MDS dated [DATE] reflected a BIMS score of 01 (Severe Cognitive Impairment).Record review of Resident #1's face sheet dated 11/15/25 reflected he was a [AGE] year-old male admitted into the facility 07/14/25 with diagnoses of brain compression (a serious condition caused by increased pressure within the skull that pushes the brain against its rigid covering) and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident #1's care plan dated 9/3/25 reflected a focus of elopement risk and significantly intrudes on the privacy or activities, the goal was to maintain safety and would not leave the facility. Interventions/tasks were to distract resident from wandering by activities, food, conversation, television, document wandering behavior, identify pattern of wandering determine if aimless or escapist, is resident looking for something or did the wondering indicate he needed more exercise. Focus was a potential to demonstrate physical and verbal aggressive behaviors/manic episodes. Goal was to demonstrate effective coping skills and would not harm self or others. Interventions/tasks were to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort and body position, pain. Communication provides physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, encourage seeking out of staff members when agitated. When he becomes agitated, guide away from source of distress, engages calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #1's quarterly MDS dated [DATE] reflected he had a BIMS score of 09 (Moderately Cognitively Impaired).Record review of Resident #2 and Resident #1's progress notes revealed no documentation of the incident, no documentation of notification to doctor, and no documentation of notification to designated representative. On 11/13/25 the State Surveyor observed the video dated 11/5/25, on the facility monitor, the video revealed the following:At 08:03 AM, Resident #1 left the dining room with a food tray and walked back into the dining room. At 08:29 AM Resident #1 came out of the dining room again and threw a bag away and went back into the dining room. At 08:30 AM CNA-A went into the dining room and came out of the room with Resident #2 and took her down the hall. Resident #1 followed CNA-A and Resident #2 out of the dining room and down the hallway, he was holding a green piece of material in his hand. A few minutes later at 08:51 AM Resident #2 was brought back to the hallway across from the nurses' station. Resident #2 was sitting in the hall alone on a bench when Resident #1 went to the counter and stood there a few seconds and then walked over to Resident #2 turned around and kissed her on the top of her head.In a face-to-face interview with Resident #1 on 11/13/25 at 11:55 AM, he was asked about an incident between he and Resident #2, he responded I did not rape that woman. He stated he helped her change her dress and helped her put on another dress. Resident #1 did not respond to any other questions. In an attempted face to face interview with Resident #2 on 11/13/25 at 12:10 PM, she did not respond to any questions, she was dressed appropriately, and she smiled when investigator asked if she enjoyed her lunch. In a face-to-face interview with CNA-A on 11/14/25 at 6:29 AM, she stated on 11/05/25 she observed Resident #1 walking down the hallway with an adult brief and put it in the trash, she observed him return to the dining room and he closed the door. She stated that she followed Resident #1 into the dining room and observed him massaging the breast of Resident #2 on top of her blouse, she observed Resident #2's bra around her waist, she stated she patted below the waist of Resident #2 and noticed she did not have on a brief. She stated that Resident #1 and Resident #2 were the only people in the dining room. She stated that she asked Resident #1 why he had Resident #2's shirt and he stated he was taking care of her. CNA-A said that she told Resident #1 she was taking care of Resident #2. She stated after she ensured Resident #2 was dressed properly, she notified LVN-B. She stated she was asked by the Administrator to write a statement about what she saw when she entered the room. In a face-to-face interview with LVN-B on 11/14/25 at 6:42 AM she stated that on 11/05/25 she had been passing medications when CNA-A came and reported that Resident #1 was assisting Resident #2 and Resident #1 had Resident #2's undershirt and brief in his hands. She stated that she notified the Administrator immediately and completed a skin assessment on Resident #2 and did not see any injuries. She stated the resident did not exhibit any distress at the time of examination. She said she was told by the DON to wait for clarification of if Resident #1 and Resident #2 had engaged in a sexual act, before putting in a progress note and notifying the doctor and family. She stated she was supposed to wait until after the administrator finished his investigation. She stated no one ever returned to tell her the investigation was completed. In an interview on 11/14/25 at 9:55 AM with a Designated Representative, the Designated stated they had not been notified that Resident #2 that she had been sexually abused by Resident #1.In a telephone interview with the Administrator on 11/18/2025 at 2:38 PM, he stated notification was not made to the designated representative because of improper education of the nurse. He stated that the nurse was supposed to examine the residents and notify medical, the designated representative, the DON and the Administration . He stated that the residents were at risk of a lack of trust for the facility to make their loved ones safe.In a telephone interview with the DON on 11/18/25 at 2:44 PM, she stated that the LVN should have notified the designated representative once the Administrator had completed the investigation. She stated that she was not sure who made the decision not to notify the designated representative. She stated that the residents were at risk of ongoing abuse when the designated representative was not notified.In a telephone interview on 11/21/25 at 10:35 AM with the NP, he stated he had not been told that there was a potential sexual abuse between Resident #1 and Resident #2. He stated he had first heard there was a significant event regarding Resident #1 when he was notified that the State was in the building. He stated the staff had informed him that Resident #1 had been going in and out of other residents' rooms. He stated that Resident #1 had been very restless and was constantly going into rooms wiping down things. He stated the staff informed him that Resident #1 was not responding to direction, and he was trying to help a male resident back to bed. He denied he was ever informed of Resident #1 attempting to assist a female resident. He stated Resident #1 assisting residents placed the residents at risk of trips or falls. Record review of the facility Change of Condition policy revised 07/2015, reflected change in condition reporting 3. Licensed nurse will inform family/responsible party of change of condition and document notification. 4. All nursing actions, physician contacts and resident assessment information will be documented in the nursing progress notes.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation was made, if the events that caused the allegation involve abuse to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 2 of 8 residents (Resident #1 and Resident #2) reviewed for abuse and neglect.The facility did not make a report to local law enforcement or State Survey Agency (HHS) of an allegation on 11/05/25 when Resident #1 was found in the dining room massaging the breast of Resident #2 after he had taken off her adult brief. This failure could place residents at risk harm to include sexual abuse and could lead to diminished quality of life and psychosocial harm.Record review of Resident #2's face sheet dated 11/15/25 reflected she was a [AGE] year-old female admitted into the facility 09/22/25 with a diagnosis of senile degeneration of brain (a general term for a decline in memory, thinking, and other cognitive abilities associated with aging). Record review of Resident #2's care plan dated 9/22/25 reflected ADL self-care performance deficit impaired mobility/cognition. Goal was to maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Interventions were to converse with resident while providing care, explain all procedures before starting, promote dignity by ensuring privacy, staff will provide appropriate level of physical assistance with ADL's, encourage them to participate to the fullest extent possible. Record review of Resident #2's initial assessment MDS dated [DATE] reflected a BIMS score of 01 (Severe Cognitive Impairment).Record review of Resident #1's face sheet dated 11/15/25 reflected he was a [AGE] year-old male admitted into the facility 07/14/25 with a diagnoses of brain compression (a serious condition caused by increased pressure within the skull that pushes the brain against its rigid covering), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident #1's care plan dated 9/3/25 reflected a focus of elopement risk and significantly intrudes on the privacy or activities, the goal was to maintain safety and would not leave the facility. Interventions/tasks were to distract resident from wandering by activities, food, conversation, television, document wandering behavior, identify pattern of wandering determine if aimless or escapist, is resident looking for something or did the wondering indicate he needed more exercise. Focus was a potential to demonstrate physical and verbal aggressive behaviors/manic episodes. Goal was to demonstrate effective coping skills and would not harm self or others. Interventions/tasks were to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort and body position, pain. Communication provides physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, encourage seeking out of staff members when agitated. When he becomes agitated, guide away from source of distress, engages calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #1's quarterly MDS dated [DATE] reflected he had a BIMS score of 09 (Moderately Cognitively Impaired).Record review on 11/13/25 of Resident #2 and Resident #1's progress notes did not reflect documentation of the sexual incident, no documentation of notification to doctor, and no documentation of notification to designated representative. On 11/13/25 the State Surveyor observed the video dated 11/5/25 , on the facility monitor, the video revealed the following:At 08:03 AM, Resident #1 left the dining room with a food tray and walked back into the dining room. At 08:29 AM Resident #1 came out of the dining room again and threw a bag away and went back into the dining room. At 08:30 AM CNA-A went into the dining room and came out of the room with Resident #2 and took her down the hall. Resident #1 followed CNA-A and Resident #2 out of the dining room and down the hallway, he was holding a green piece of material in his hand. A few minutes later at 08:51 AM Resident #2 was brought back to the hallway across from the nurses station. Resident #2 was sitting in the hall alone on a bench when Resident #1 went to the counter and stood there a few seconds and then walked over to Resident #2 turned around and kissed her on the top of her head.Record review of undated written statement of CNA-A reflected, This morning I witness [Resident #1] coming out of the dining room with a pull-up in his hand. I ask my co-worker where did he get it, he headed back to the dining room and shut the door that's when I went to check to see why he shut the door, as I enter the room both residents were standing by the table [Resident #1] in front of her massaging her chest with his hands holding (She had the top shirt on) her tank top. I told him to stop I patted the pt. realized her brief was off, grabbed her and started walking her out to notify my nurse and pt telling me he has her and I replied: I got her. [sic]Record review of the facility undated investigation reflected, We, [Administrator and DON, interviewed CNA-A 11/5/25 after reading her statement to get clarity on the incident between [Resident #2] and [Resident #1]. Upon speaking with her, her story was inconsistent with what was initially written as she stated she initially assumed that [Resident #1] was touching [Resident #2], by the way he was standing next to her, but was unsure if she could see that [Resident #1] was touching [Resident #2] or not as she did not observe it herself. She state that she saw [Resident #1] come out of the dining room with a brief in hand, she followed him back into the dining room and saw [Resident #1] standing next to [Resident #2], then walked [Resident #2] out of the dining room and back to her room, and notified the nurse of [Resident #1] carrying dirty brief to trash. [sic]In a face-to-face interview with CNA-A on 11/14/25 at 6:29 AM, she stated on 11/05/25 she observed Resident #1 walking down the hallway with an adult brief and put it in the trash, she observed him return to the dining room and he closed the door. She stated that she followed Resident #1 into the dining room and observed him massaging the breast of Resident #2 on top of her blouse, she observed Resident #2's bra around her waist, she stated she patted below the waist of Resident #2 and noticed she did not have on a brief. She stated that Resident #1 and Resident #2 were the only people in the dining room. She stated that she asked Resident #1 why he had Resident #2's shirt and he stated he was taking care of her. CNA-A said that she told Resident #1 she was taking care of Resident #2. She stated after she ensured Resident #2 was dressed properly, she notified LVN-B. She stated she was asked by the Administrator to write a statement about what she saw when she entered the room. In a face-to-face interview with LVN-B on 11/14/25 at 6:42 AM she stated that on 11/05/25 she had been passing medications when CNA-A came and reported that Resident #1 was assisting Resident #2 and Resident #1 had Resident #2's undershirt and brief in his hands. She stated that she notified the Administrator immediately and completed a skin assessment on Resident #2 and did not see any injuries. She stated the resident did not exhibit any distress at the time of examination. In a face-to-face interview with the Administrator on 11/14/25 at 10:10 AM, he stated that he was notified by LVN-B that CNA-A had walked into the dining room and found Resident #1 and Resident #2 in the dining room alone. He stated he conducted a soft investigation, he stated there was no difference between a soft investigation and a regular investigation. He stated that he would do the same thing for both investigations, skin assessments, safe surveys, and in-services. He stated that the investigation depended on the situation. He stated in this soft investigation he did not identify anything that was reportable. The Administrator was asked, Was Resident #1 asked to help staff with ADL care? The Administrator denied that Resident #1 was asked to help with other residents' ADL care. The Administrator was asked, If nothing happed between Resident #1 and Resident #2, how did Resident #2 end up without a brief, Resident #1 with a dirty brief to put in the trash, and they were the only two people in the room? He stated he could not assume that anything had happened between the residents because there were no witnesses. The Administrator stated the residents were at risk of the facility not creating an environment for resident safety. Record review of facility Abuse and Neglect Policy revised 10.2022 reflected, Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. The Facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor and intervene as necessary to maximize resident health and safety. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.Record review of Long-Term Care Regulation Provider Letter dated 08/29/24 reflected, 2.1 Incidents that a NF Must Report to HHSC A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse1

Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #2) of 5 residents reviewed for abuse.The facility failed to ensure Resident #2 was free from abuse when Resident #1 punched him on 09/09/25, causing Resident #2 to have a scratch on his nose.This failure could place residents at risk for severe and long-lasting impacts on physical, psychological, and emotional wellbeing.Findings included:Resident #2Record review of Resident #2's MDS Assessment, dated 09/04/2025, reflected the Resident#2 was a [AGE] year-old male who originally admitted to the facility on [DATE]. He had BIMS score of 5 indicating severe cognitive impairment. His diagnoses included Non-Alzheimer's Dementia (cognitive decline that is not caused by Alzheimer's disease), Cerebrovascular Accident (a medical term for a condition where there's a sudden interruption of blood flow to the brain, causing damage to brain tissue), and hemiplegia (a medical condition that causes paralysis or severe weakness on one side of the body) . Record review of Resident #2's care plan, Date Initiated: 12/13/2022 reflected the following:[Resident#2] demonstrated physical behaviors toward another Resident who would not move out the way so he could pass by in his wheelchair. 9/15/25 resident to resident altercation in a resident's room. Interventions dated 9/15/25 indicated for 1:1 monitoring ; Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document and ; Document observed behavior and attempted interventions. Interventions dated 12/13/2022 indicated for Psychiatric/Psychogeriatric consult as indicated, when becomes agitated; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of Resident #2's Progress Notes reflected the following:*9/15/2025 2:32pm - Upon entering resident's room the charge nurse observed the two resident's grabbing at each other and pulling each other's shirt. Residents immediately separated and placed on 1:1 observation, NP G, Administrator, RP, NP F notified, skin assessment completed, and resident assisted out of the room and to the front lobby. This entry was written by LVN A. 9/15/2025 7:08 pm SW communicated with psychiatrist. Psych visited the residents due to res-to-res allegations. One on one discontinued per psych. This entry was written by SW. Record review of Resident#2's Psychiatric Subsequent assessment dated [DATE] Reflected that Patient is a [AGE] year-old African American Male admitted to the facility on [DATE] for Long Term Care. Seen for follow up visit. Seen sitting in lobby, agreed to go to room to complete visit. Has history of depression and dementia. Resident seen today due to having a altercation with another resident. When asked what happened he reports going in another residents room due to being previous resident in the room, he went in to get deodorant that he thought he left in the room. States He just jumper silly, I have clothes still in the room and when I went in he was sleep, he jumped up and tried to hit me and missed then he grabbed my wheelchair and turned it over. Declines being threatened by other resident. He was not the aggressor. I will discontinue 1:1 at this time, staff to call this writer for any concerning behavior with patient. Depression: Patient endorses current symptoms of loss of interest and decreased concentration and denies symptoms of sad moods, fatigue, guilt, feelings of worthlessness, psychomotor agitation, psychomotor slowing and suicidal ideation/intent/plan and appetite change. Patient endorses history of sad moods. This entry was entered by NP D Resident #1Record review of Resident #1's MDS Assessment, dated 09/29/2025, Reflected the Resident #1 was a [AGE] year-old male who originally admitted to the facility on [DATE] and re admitted [DATE]. He had a BIMS score of 03, indicating severe cognitive impairment. His diagnoses included Non-Alzheimer's Dementia (cognitive decline that is not caused by Alzheimer's disease), Cerebrovascular Accident (a medical term for a condition where there's a sudden interruption of blood flow to the brain, causing damage to brain tissue), hemiplegia (a medical condition that causes paralysis or severe weakness on one side of the body). Record review of Resident #1's care plan, Date Initiated: 03/14/2024 Revised on: 09/15/2025 Reflected Potential to demonstrate physical behaviors r/t Anger, Dementia, Poor impulse control**** Resident noted to have altercation with brother in dining room and aggressive/trying to hit staff members/swinging at staff. 9/15/25- resident to resident altercation in resident's room. Interventions 9/15/25 1:1 monitoring Date Initiated: 09/15/2025 Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 09/15/2025 Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 03/14/2024 Document observed behavior and attempted interventions. Date Initiated: 03/14/2024 Psychiatric/Psychogeriatric consult as indicated. Date Initiated: 03/14/2024 When becomes agitated: Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #1's Progress Notes reflected the following:*9/15/2025 2:34pm - Upon entering resident's room the charge nurse observed the two resident's grabbing at each other and pulling each other's shirt. Residents immediately separated and placed on 1:1 observation, [NP G], Administrator, [FM], [NP D] notified, skin assessment completed, and resident assisted out of the room and to the front lobby. This entry was written by LVN A.*9/15/2025 7:08pm SW communicated with psychiatrist. Psych visited the residents due to res-to-res allegations. One on one discontinued per psych. This entry was written by SW. Record review of Resident# 1's Psychiatric Subsequent assessment dated [DATE] reflected Seen for follow up visit. Resident seen resting in bed on 1:1. He has history of depression, anxiety, and dementia. He is being seen today due to having an altercation with another resident in which he was the aggressor. He has aphasia, so he is hard to understand. From what I understood he currently does not have a roommate and reports he was sleeping, and he was awakened due to the other resident coming into his room. He woke up startled and tried to get the other patient out of his room by swinging at him and turning over his wheelchair. He reports understanding that he cannot be aggressive with anyone in the facility. He declines being threatened by the other patient. Will discontinue 1:1 at this time. Will follow up with patient on Thursday and make changes to medications as needed Depression: Patient endorses current symptoms of decreased concentration and denies symptoms of sad moods, loss of interest, fatigue, guilt, feelings of worthlessness, psychomotor agitation, psychomotor slowing and suicidal ideation/intent/plan and appetite change. Patient endorses history of sad moods. This entry was entered by NP D Record review of the facility's incidents/accidents report from 07/01/25 to 10/01/25 reflected the incident on 09/15/2025 and there were no other incidents that involved Resident #1 or Resident #2. On 10/01/25 at 10:28 AM in an Observation and an interview with Resident #2 revealed he was sitting in a wheelchair in his room. Resident #2 said he was not in pain, the scratch to his nose had healed. He does not recall events leading to the altercation but he stated the crazy guy scratched his nose. He stated everyone was good to him, he got along with other residents and felt safe at the facility. On 10/01/2025 at 11:57AM in a telephone interview with LVN A revealed she was called to Resident#1's room by a lady who was at the facility to evaluate Resident#1 for transfer to an inpatient Physical therapy facility. LVN A stated when she got to the room Resident #2 was on the floor and Resident #1 was hitting Resident#2. She stated LVN A and the staffing coordinator separated Resident #1 from Resident #2, while CMA F assisted Resident #2 back to his chair. She stated she assessed Resident #2, he had a scratch on his nose and was bleeding. LVN A stated she treated the scratch on Resident #2 nose, then notified the MD, Administrator, DON, responsible parties, and psyche services. LVN A stated Resident #1 explained Resident#2 was in his closet taking his clothes and that was why they had an altercation. On 10/1/2025 at 2:01pm in an interview with the staffing coordinator revealed there was a vendor who was evaluating Resident #1 in his room alerted her and LVN A that Resident #1 and Resident #2 were fighting. She stated LVN A, CMA F and herself rushed to Resident #1s room. She stated she observed Resident#1 was on the chair punching Resident #2 who was on the floor next to Resident #2's wheelchair. She stated the staff separated the residents. She stated Resident#1 told the staff that Resident #2 was in his room going through Resident #1's personal belongings. She stated after the residents were separated and safe LVN A assessed the residents because Resident #2 was bleeding from his nose. She stated she was not aware of any incidents between Resident #1 and Resident #2 and was not aware if they had issues before. She stated she had been in-serviced on abuse neglect and resident to resident altercation. On 10/1/2025 at 11:15 am in an observation and interview with Resident #1 revealed he was in bed awake. Resident#1 shook his head from sided (indicating a no response) and said no when asked if anyone was in his room to take his personal belongings or if he had an altercation with another resident, he shook his head from side to side. On 10/1/2025 at 2:27PM Interview with the social worker revealed that when the altercation happened Resident#1 was in the process of transferring to an inpatient rehabilitation. She stated that Resident#1 and Resident #2 were roommates for a longtime and they got along very well. She stated that one day Resident #2 said that he no longer wanted to be roommates with Resident #1.She stated that there was no incident between the two of them. She stated that after the altercation she did one on one supervision with Resident #1 until he was cleared by psych. She stated that Resident #2 told her that he thought he had left some of his belongings in Resident#1s room, and that was the reason he had gone to Resident#1 room when the altercation happened. She stated that Resident#1 and Resident#2 have had no issues with other residents. She stated that she had been in-serviced on abuse prohibition and Resident to resident altercation. She stated that if two residents had an altercation, she would separate them notify the nurse to do an assessment, notify the DON and administrator. She stated that it the facility policy that after an altercation to have residents one on one supervision until they are evaluated by psyche services. On 10/1/2025 at 2:38pm in an interview with the DON revealed that the administrator and LVN A notified her of the altercation between Resident#1 and Resident#2. She stated that when the altercation happened Resident#2 was in Resident#1 closet taking his clothes out. The DON stated that LVN A, the staffing coordinator and CMA F separated the residents and the two residents were place on one-on-one supervision until they were evaluated by psych services. She stated that LVN A completed head to toe assessment, and Resident#2 had a scratch to his nose. The DON stated that the MD and responsible parties for both residents were notified. She stated that NP F evaluated Resident#1 and Resident#2 the discontinued the one-on-one supervision. She stated that the residents were separated by moving them to different sides of the hall to limit access to each other. She stated that the staff was in-serviced on Resident-to-Resident altercations and to observe and keep Resident#1 and Resident#2 from close proximity without isolating them. The DON stated that Resident#1 and Resident#2 were roommates, and they got along very well. She stated that one day Resident#1 refused to share something with Resident#2, then Resident #2 said he no longer wanted to share a room with Resident#1, so the facility moved Resident#2 to a different room. The DON stated that after moving rooms the residents still got along, they sat close together. The DON stated that the staff had been in-serviced on abuse and neglect and Resident to resident altercation and de-escalation. DON stated that Resident#1 and Resident#2s care plans were updated. On 10/1/2025 at 2:45pm in an interview with the Administrator revealed that he was notified by LVN A that Resident#1 and Resident#2 had an altercation and Resident#2 had a scratch on his nose that was bleeding. He began an investigation that revealed that Resident#2 went into Resident# 1 room and that was when the altercation happened. He stated that the two residents had been roommates before, and Resident #2 requested to be moved to another room. The administrator stated that after the altercation Resident#1 and Resident#2 were placed one on one supervision until both residents were seen by psyche services that evening and the one-on-one supervision was discontinued. He stated that the staff was in-serviced on abuse prohibition and Resident to Resident de-escalation and altercation. The facility notified the doctor and responsible parties for both Resident#1 and Resident#2. He stated that after the altercation the residents were separated to different sides of the hall to make sure they did not have access to each other. He stated that the next day Resident#1 was transferred to an in-patient rehabilitation for physical therapy, and when he returned the two residents remain of different halls and there have been no incidents between the two residents. He stated that Resident#1 and Resident#2 had no known previous incident with each other. Resident#1 had an incident sometime back, but he was the victim not the aggressor. He stated that both Resident#1 and Resident#2 have not had aggression towards other residents. He stated that the facility conducted safe surveys and there were no identified issues. On 10/1/2025 at 2:56pm in an interview with NP F revealed that she was notified by the facility that Resident#1 and Resident #2 had an altercation. She stated that both residents were on psych services, and she had been seeing them for a while and neither Resident#1 nor Resident#2 presented aggressive behavior previously. She stated that she evaluated Resident#1 and Resident#2 the same day in the evening. She stated that after evaluating Resident#1 and Resident#2 she determined that the incident happened because Resident#1 went to Resident#2 room to get what Resident#1 thought was his personal belongings, because that was his old room. She stated that Resident#1 was asleep and woke up suddenly to find Resident#2 going through his personal belongings, and he reacted aggressively partly due brain injury post stroke. She stated that after evaluating Resident#1 and Resident#2 she discontinued the one-on-one supervision because there was no evidence of danger to themselves, to each other, or to other residents. She stated that she was satisfied with the interventions that the facility took after the altercation including separating the Residents to opposite side of the hall to minimize access to each other. Record review of the facility's policy, Revised Revision/Review Date(s):4.2019; 1.2021; 1.2022; 10.2022 and titled Abuse: Prevention of and Prohibition Against reflected:1.Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.2.If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor, and intervene as necessary to maximize resident health and safety.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and Resident #2) of five residents, reviewed for infection control. 1. The facility failed to ensure LVN A wore the appropriate PPE and performed hand hygiene during wound care for Resident #1. 2. The facility failed to ensure CNA C and CNA D performed hand hygiene during incontinence care for Resident #2. This failure placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Review of Resident #1's Quarterly MDS Assessment, dated 06/24/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were moderately impaired. His diagnoses included high blood pressure. The resident had a Stage III pressure ulcer present on admission. Review of Resident #1's Care Plans reflected:08/20/25 Resident had a pressure ulcer on his sacrum related to disease process.Facility interventions: Use Enhanced Barrier Precautions.Administer treatments as ordered and monitor for effectiveness. An observation and interview on 08/20/25 at 10:15 AM of Resident #1 revealed LVN A was preparing to do wound care. The resident had a Stage III sacral wound. The resident had a sign for EBP posted on the door. There was not a PPE bin by the door. LVN A entered the room and put on gloves. LVN A did not put on a gown. LVN A cleaned the sacral wound. It was surrounded by pink scar tissue. The resident had approximately a quarter-sized open wound. Unknown depth. There were no signs of infection. LVN A did not change gloves or perform hand hygiene after cleaning the wound. LVN A applied collagen and a border gauze to the sacral wound. LVN A removed her gloves and washed her hands. LVN A said EBP required staff to wear a gown, gloves, and a mask. LVN A said she did not know that Resident #1 was on EBP. She also said she had not been trained on EBP. LVN A said the risk to the resident if she did not wear a gown, change gloves, and perform hand hygiene was contamination. LVN A said the resident's wound was healing. An interview on 08/20/25 at 10:30 AM with MA B revealed EBP were used for, infections or something. She said Resident #1 was not supposed to be on EBP. MA B said Resident #1 would need a sign and PPE available if he was on EBP. 2. Review of Resident #2's Quarterly MDS Assessment, dated 05/31/25, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. He was usually understood and usually understood others. His diagnoses included kidney disease and cancer. The resident was dependent on staff for toileting. The resident was frequently incontinent of bowel and bladder. Review of Resident #2's Care Plans reflected:03/13/25 Resident had bowel/bladder incontinence related to disease process.Facility interventions included:Incontinent: Check as required for incontinence. Wash, rinse and dry perineum. An observation on 08/20/25 at 10:35 AM of incontinence care for Resident #2 revealed there was a PPE box outside of the door. There was no EBP sign posted. Resident #2 was lying in bed. He was awake, alert, and oriented. He said he had a wound on his bottom. CNA C and CNA D put on gloves and gowns to provide incontinence care before entering the room. CNA C said the resident was on EBP. CNA C said the sign was posted, but another resident in the facility would walk around and take down the signs. CNA C assisted the resident to turn to his left side. His brief was soiled with bowel movement. CNA C began cleaning the bowel movement. CNA C changed gloves and said I'm supposed to use hand sanitizer, but I don't have it. I'm supposed to use it between each glove change. CNA C changed gloves, but did not perform hand hygiene. The sacral area had two pinpoint openings areas. CNA C cleaned the area thoroughly, removed her gloves, and washed her hands. CNA C put down a clean brief and the resident was turned to his right side. CNA D cleaned the resident's other side of buttocks, and the resident was turned to his back. CNA D cleaned the resident's penis and scrotum. CNA D did not change gloves or perform hand hygiene. CNA D used the soiled gloves to apply cream to the resident's peri-area and fastened the brief. CNA D removed her gloves and washed her hands. An interview on 08/20/25 at 10:55 AM with CNA C revealed she said she did not perform hand hygiene. She said she should have gone in and washed her hands. She said the risk to Resident #2 was a possible transfer of infection. An interview on 08/20/25 at 12:55 PM with CNA D revealed she knew to change gloves and perform hand hygiene during incontinence care. She said she did not because, there was a lot going on. CNA D said the risk to Resident #2 was infection control. An interview on 08/20/25 at 1:10 PM with ADON E revealed she was the infection preventionist. She said EBP were used for residents with wounds, indwelling devices, and tracheostomies. ADON E said EBP were important to reduce risk of spread of infection. ADON E said with EBP, staff were supposed to wear a gown, gloves, and face shield (if spills were possible). She said the staff were trained on EBP in August 2025. ADON E said a resident on EBP was supposed to have a sign on the door and PPE in close proximity. She said Resident #2 did not have a sign posted because another resident in the facility would take the signs down. She said everyone was responsible for ensuring signs were kept posted, and she did not know why the resident did not have a sign posted on 08/20/25. ADON E said staff were supposed to wear appropriate PPE for EBP. ADON E said staff were supposed to change gloves and perform hand hygiene during wound care after cleaning the wound. ADON E said failure to wear appropriate PPE, change gloves, and perform hand hygiene placed the residents at risk for infection. ADON E said if staff were not aware of a resident being on EBP, there was a risk of transmission of infection. Record review of the facility in-service, PPE Donning and Doffing and EBP, dated 08/10/25, reflected:LVN A did not sign the in-service.MA B, CNA C, and CNA D signed the in-service. Record review of the facility in-service, Infection Prevention - Hand Washing/Hand Sanitizer, dated 08/10/25, reflected:LVN A did not sign the in-service.CNA C and CNA D signed the in-service. Record review of the facility policy, IPCP Standard and Transmission - Based Precautions, revised October 2022, reflected: .3. Enhanced Barrier Protection (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDRO's to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. Record review of the facility policy, IPCP Standard and Transmission - Based Precautions, revised October 2022, reflected: When and How to Clean Hands.Before or after caring for someone who is sick.

Based on observation, record review and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE].Based on observation, record review and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE]. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. These failures could affect residents by placing them at risk of allergic reaction, decline in quality of life and death. Findings included: Record review of Resident#1's face sheet revealed, she was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Dementia (decline in cognitive function that affects daily living) in other diseases classified elsewhere, unspecified other severity, with mood disturbance (mental health conditions that primarily affect emotional states), unspecified Dementia, unspecified severity, without behavioral, other disturbance, psychotic disturbance (a condition in which one is unable to distinguish what is and is not real), mood disturbance, and anxiety, erosive (Osteo) arthritis (destruction of joint cartilage and bone erosion), other muscle weakness (Generalized), other unspecified lack of coordination, other personal history of Transient Ischemic attack ( caused by a brief blockage of blood flow to the brain) and cerebral and other infarction without residual deficits (blood flow to a part of the brain is obstructed, leading to tissue death due to lack of oxygen). Record review of Resident#1's MDS, dated [DATE] revealed her BIMS score was undetermined. Resident#1's functional limitation in range of motion reflected impairment on one side, coded for lower extremity (hip, knee, ankle, foot). Resident#1's functional abilities for mobility were undetermined. Record review of Resident#1's care plan, undated revealed, she was at risk for communication problem related to Dementia, at risk for impaired cognitive function/dementia or impaired thought processes r/t long term memory loss, Poor nutrition, short term memory loss, Dementia, and impaired decision making. Resident#1 had bowel/bladder incontinence r/t Alzheimer's, Confusion, Dementia, and impaired Mobility. Record review of Resident#1 EMS report, dated 07/20/25 reflected, Dispatched to nursing home for medical emergency. Upon arrival then [Resident#1] one was found in her wheelchair eyes completely swollen shut and family around her. Family reported that patient was found in her bed, by the family, covered in ants. The [Resident#1]had visible ant bites on her neck, face and eyes. The patient had Alzheimer's and was not able to communicate or provide any information. [Resident#1] was transferred to stretcher by EMS via picking patient up from the wheelchair and placing her on the stretcher. En route to hospital vital perform SPO2, BGL, lung sounds were clear, airway patent. [Resident#1], IV established and right hand 50 milligram of Diphenhydramine given via IV, 2 ants found on patient during transport. Vitals remain stable throughout transportation. Patient transported to [local hospital] for further observation and treatment.Record review of Resident#1's hospital records, dated 07/22/25 reflected, Resident#1 was admitted on [DATE] at 11:28 AM. Per EMS, several small ants were actively crawling around patient. Patient had noted bites around her entire body including her face and neck. Patient had noted eyelid swelling. EMS administered IV Benadryl at 15 mg. Patient's face swollen and red with some insect bites likely allergic reaction from insect bites, will start IV steroids, hydrocortisone and Benadryl cream.Visit diagnosed Insect bite, unspecified site, initial encounter (primary), Urinary tract infection without hematuria, site unspecified Dehydration and Unsatisfactory living conditions. Patient's [family member] also requested new placement to a different facility, case management assisted with placement. [Resident#1] was accepted at another SNF/NF and would be discharged on 07/23/25. Record review of the weekend MOD progress note dated 07/20/25 reflected, Writer was alerted by CNA of rash/swollen eyes. Upon entry to room, no ants present in room, on resident or bed/linen. Resident was removed from area and assessed. Linen had already been removed, bed cleaned, and resident was already showered. Scattered rash like areas noted to body and redness along with bilateral swollen eyes during assessment. Writer notified {medical doctor} made aware of clinical situation and new orders given. Family notified of orders and ER transport. Hydrocortisone cream applied to entire body and PRN pain med and Benadryl administered. EMT present and transferred resident to {local hospital} with family en route. Family provided with Administrator's contact info for any concerns. Record review of the Admin interview with CNA A reflected [CNA A] regarding the incident that took place Sunday 7/20/2025 morning. [CNA A] stated she had been in the room of the affected resident about an hour prior at 8:30 and had checked and changed resident for incontinence. Room was clean, no signs of ants in or around bed or on resident at that time. No signs of clutter in the room or open food to draw pests into the room. Record review of the PCC service Inspection Report dated 4/11/25 reflected, on 05/28/25 the following rooms where treated 106-109 and 405-408 for ants and general pest. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the PCC service Inspection Report dated 07/21/25 reflected the facility was treated for ants on 07/21/25 treated room [ROOM NUMBER] for ants and general pest. On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. Record review of Resident#1 shower sheet, dated 07/20/25 reflected Resident#1 had a scattered rash on chest signed by the weekend MOD and CNA A. Record review of in-service training report dated 07/20/25, titled pest control/homelike environment /abuse prohibition conducted by ED in person and via phone reflected: Summary of in-service reflected: Our residents have the right to a safe, clean comfortable and home like environment. We must be diligent in our processes to ensure this for them. -Rooms need to be clean and free of odors. If you observe issues with cleanliness or odors, you must report it to housekeeping immediately and find the source. Facility needs to be free of pest. If you observe issues with pest control, you must report it to maintenance immediately via MS and notify ED or Maintenance-Facility must monitor food in resident rooms and ensure there aren't items drawing pest attention. If you observe issues, you must report it or correct if able.-Maintenance will adjust interventions as appropriate and as the seasons change. Including checking and treating for ants regularly.-Report to admin and DON if ants observed in residents' room, notify nurse immediately-Head to toe skin assessment to be completed by the nurse on both residents in the room.remove any ants-Remove resident and roommate from the room-check adjacent room for ants, room to be treated for ants,-Resident unable to return to room until treatment and deep cleaning completed During an observation on 07/22/25 at 8:30 am to 9:15 am revealed, the common area, dining area and rm# 301, 302, 303, 304, 305,306,307,308, 309, 310, 311 and 312 were free of ants. In an interview on 07/22/25 at 8:43 am CNA B stated residents in the unit did not eat in their room. CNA B stated snacks were kept in a white container and were given out and staff cleaned up right after. CNA B stated the facility had issues in the past with bugs and they let the MD know. CNA B stated she had not seen ants in Resident#1 room before 07/20/25. CNA B was in serviced over the phone about pest control, resident abuse, homelike environment, and Resident#1 was transported to hospital on [DATE]. In an interview on 07/22/25 at 9:28 am the HKS stated they cleaned and disinfected common areas and resident's rooms daily. HKS stated when notified of a pest sighting, the HKS would first let the MD know. The HKS stated everything would be taken out of the resident's room and washed. The HKS stated Resident#1 room was deep cleaned and then deep cleaned again the following day. The HKS stated she viewed a small number of active and unactive ants in Resident#1 room. In an interview on 07/22/25 at 10:05 am, the MD stated it was reported to him on 07/20/25 that a Resident#1 was bitten by ants. The MD came to the facility and immediately sprayed the Resident#1 room and exterior. The MD stated pest control came out 07/20/25 and 07/21/25 and treated the interior and exterior of the facility. The MD stated the facility had minor problems in the past with residents who had spilled food in their rooms and ants followed the trail. The MD stated staff were supposed to report in MS any pest sighting. MD stated PCC technician came out twice a month to treat the facility. The MD stated the last pest control inspection was on 06/20/25. In an interview on 07/22/25 at 10:20 am the HSW stated Resident #1would be discharged to another SNF/NF. The HSW stated Resident#1's planned discharge was on 07/23/25. In an interview on 07/23/25 at 10:28 am, the HN stated that Resident#1 did not talk and was not ambulatory. The HN stated Resident#1 slept most of the day and a family member had been at her side. The HN stated Resident#1 was in the hospital for an allergic reaction to ant bites from a nursing home. Interview and observation at the local hospital on [DATE] at 10:33 am revealed Resident #1 had bites on her eyelids, face and neck. The Family member stated she visited Resident#1 on the morning of 07/20/25. Resident#1's legs were covered with a blanket and when she moved the blanket ants were crawling on her legs. The Family member stated Resident#1's eyes were swollen shut and there were ants crawling on the wall. The family member stated she went and got CNA A who assisted with Resident#1.Attempted to call LVN I on 07/22/25 at 2:24 pm and did not receive a return call before exit.In an interview on 07/22/25 at 2:30 pm weekend MOD stated LVN I called her about Resident#1 had an allergic reaction to ant bites. The weekend MOD informed the DON about the ant bites. The weekend MOD stated she did a head-to-toe assessment and documented in Resident#1 progress notes the findings. The weekend MOD stated she remember the resident having a rash on her chest and her eyes were swollen. The weekend MOD stated Resident#1 hair was wet and she did not find any ants on her. In an interview on 07/22/25 at 3:36 pm CNA A stated at 8:15 am on 07/20/25 she went into Resident#1's room to provide incontinent care and turned to feed Resident#1 and she would not eat. CNA A stated she did not see any ants in Resident#1's room at that time. CNA A stated the family member came and got her around 10 something. CNA A stated Resident#1's eyes were swollen. CNA A stated she notified LVN I and she called the MD by calling his number. CNA A stated she was in-serviced on 07/20/25 to notified LVN I so they could do a head-to-toe assessment on the resident and roommate. CNA stated Resident#1 was given a shower. CNA A stated no ants were found on the roommate side of the room. CNA A stated nearby rooms should be checked for ants and staff must make sure all food was cleaned up.In an interview on 07/22/25 at 3:40 pm CNA C stated she was not there when the incident happened with Resident#1. CNA C was in-serviced on 07/21/25 on homelike environment, pest control and resident abuse. CNA C stated she had not seen any ants. CNA C stated any sighting of pest should be reported to the MD and tell the nurse so she could do a head-to-toe assessment. Interviews on 07/22/25 from 3:45 pm to 4:10 pm revealed LVN D, CNA E, LVN F, CNA G and LVN H stated if pests were seen, first remove the residents from the room, then the MD and Admin were called, the nurse did a head-to-toe assessment, adjacent rooms were checked for pests, they removed residents' belongings, and the HK deep cleaned the rooms. In an interview on 07/22/25 at 4:12 pm the HK stated if they noticed pests to first notify the MD and then bag residents' items and complete laundry. The HK stated the room was deep cleaned twice and adjacent rooms were checked. In an interview on 07/22/25 at 10:02 am the PCC technician stated the company treated the facility twice a month. PCC stated one exterior treatment would be enough to take care of the ants. PCC technician stated he came in on 07/20/25 and 07/22/25 and treated the interior and exterior of the facility for ants. The PCC technician stated no ants were found in the rooms. The PCC technician stated a lot of things could have led to an ant problem such as the weather. The PCC technician stated little showers and heavy rain caused everything on the ground to move around and food being left out could cause ants. In an interview on 07/22/25 at 4:15 pm the DON and Admin stated the Facility immediately cleared Resident #1, and her bed of ants. Resident #1 was showered and affected areas treated, housekeeping immediately deep cleaned the room, and pest control was called immediately to come and treat the room as well as adjacent rooms. Residents on the hall were checked head to toe for skin assessments, and no other signs of ants or bites were sighted. The DON stated Resident#1 roommate had a head-to-toe assessment and no bites were found on her or in her personal belongings. The DON stated Resident#1 roommate was transferred to 200 hall. Admin stated Pest control treated the exterior of the facility as well as the ant hills on the property. All staff were in-serviced on pest control, safe homelike environment, and abuse prohibition. The MD did exterior rounds of the facility and checked for entrance sights and hills and provided exterior treatment. The PCC Technician came back out the next day for a follow up treatment. Dept heads continue to round twice a day to check for signs of pests. Staff are to notify maintenance via MS and group message as well as the Admin immediately. The DON and Admin stated any pest sighted in the resident rooms will require resident to have a head-to-toe assessment immediately and room deep cleaned. During an observation on 07/22/25 at 4:45 pm the surveyor did an exterior walk through of the facility and ant hills were not noticed at that time of visit. Observed a lot of greenery and shrubbery around the facility. During an observation on 07/22/25 at 5:00 pm, resident rm# 106-109, 206, 211 and 405-408 were checked for ants. The surveyor did not observed pest at the time of visit. During an observation and interview on 07/23/25 at 11:30 am the MD and surveyor did an exterior walk through of the facility. The MD stated ant hills were treated and then knocked down the following day. The MD identified spots where ants had been knocked down and no active ants were observed at the time of the visit. Record review of the PCC service Inspection Report dated 07/21/25 reflected, On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. On 07/21/25 treated room [ROOM NUMBER] for ants and general pest Record review of facility policy titled, safe/comfortable/homelike environment, revised 01/22 revealed: Residents are provided with a safe, clean, comfortable and homelike environment. Record review of a pest contract revealed the agreement was effective October 1, 2021, and reflected .8. Service Provider's Schedule and Availability, service provider shall be reasonably available to the Facility and shall spend sufficient time at the facility premises to fulfill service provider's duties hereunder. Record review of facility policy titled, physical Environment, revised 05/2020 reflected: POLICY:It is the policy of this facility to utilize pesticides and rodenticides in a safe and efficient manner to control pests with the least amount of contamination to the environment.Responsibilities:Facility staff will:1. Report any pest sightings and file a report using the pest observation log.2. Document problems found during inspection and the remedial actions taken.3. Advise staff on preventive measure, unsanitary conditions, etc.4. Secure services of a Pest Control company for routine and PRN services to control pests with the least amount of contamination to the environment.Pest Identification:The following guidelines for pest identification:1. When pests are sighted, determine why the infestation is occurring and advise department on preventive measures.2. Use pesticides only after all other channels of control are exhausted.3. Use pesticides only as a preventive measure and in conjunction with proper mechanical controls.4. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Include the following information:a. Type of problemb. Locationc. Person reporting and time reported.Pest Prevention:The following are guidelines for pest prevention:1. All storage and food preparation areas are to be kept clean. This includes walls, floors, shelving, cabinet tops, sinks, equipment, etc.2. Keep grounds free of trash and brush.3. Keep the dumpster area clean.4. Food stored in resident rooms will be in covered containers.5. Clean up food spills.6. Screen foundation areas with mesh.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The cook failed to sanitize the thermometer between checking breakfast food on 06/20/25. 2. The cook failed to check the temperature of the cinnamon rolls, biscuits and fried eggs before they were served to the residents, These deficient practices could affect residents who received meals and/or snacks from the facility's only kitchen by placing them at risk for cross contamination and other food-borne illnesses. Findings included: Observation on 06/20/25 at 6:48 am to 7:40 am, the [NAME] checked the temperature of the scrambled eggs and wiped the thermometer off with a rag that was seating on the cart beside her. The [NAME] checked the temperature of the oatmeal, grits, puree sausage and puree eggs and did not sanitize the thermometer between checking each item. The [NAME] did not check the temperatures of the cinnamon rolls, biscuits, and fried eggs before being served to the residents on the hallway. Interview on 06/20/25 at 7:40 am, the [NAME] stated she did not sanitize the thermometer between foods because she did not have alcohol swabs, and they were about to serve the residents in the dining hall. Interview on 06/20/25 at 7:55 am, the Dietary Manager stated alcohol swabs were supposed to be kept in the kitchen, and she left out of the kitchen and got some. Interview on 06/20/25 at 9:00 am, the Dietary Manager stated by not wiping the thermometer off with the alcohol swabs between food items could put residents at risk of bacteria and infection The Dietary Manager stated not checking the temperatures of the food could led to illness and death. Dietary Manager stated she was aware of bloody chicken that was served to a resident over the weekend and would be in servicing staff on checking temperatures before serving food. Interview on 06/20/25 at 9:15 am, the DON stated that not wiping the thermometer could cause cross contamination, and not checking the temperatures of the food could cause food to not be cooked all the way. Interview on 6/20/25 at 10:30 am Admin nodded yes and did not respond to risk to resident question. Record review of the facility's policy titled Dietary Services, revised October 2022 reflected: It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. Record review of Safe Food Handling | FDA , updated 03/05/24 ,reflected: Cook to the right temperature Color and texture are unreliable indicators of safety. Using a food thermometer is the only way to ensure the safety of meat, poultry, seafood, and egg products for all cooking methods. These foods must be cooked to a safe minimum internal temperature to destroy any harmful bacteria. Cook eggs until the yolk and white are firm. Only use recipes in which eggs are cooked or heated thoroughly. When cooking in a microwave oven, cover food, stir, and rotate for even cooking. If there is no turntable, rotate the dish by hand once or twice during cooking. Always allow standing time, which completes the cooking, before checking the internal temperature with a food thermometer.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Halls 100 and 400) of 3 halls reviewed for environmental concerns. 1. The facility failed to lock 2 Hoyer lifts , bed with mattress, bed frame in the hallway on 06/19/25 could be a fall risk and injury concern and issue for residents. 2. The facility failed to lock 1 Hoyer lift, bed frame and left pallet seating upright by the storage supply closet on 06/20/25 could be a fall risk and injury concern and issue for residents. This deficient practice could place residents at risk of falls, injuries, and decreased quality of life. The findings included: Observation on 06/19/25 at 10:40 am on hall 100 revealed there was an unlocked bed and unlocked bed frame on hall 100. Observation on 06/19/25 at 10:50 am on hall 400 revealed there was an unlocked Hoyer lift and unlocked bed frame. Interview on 06/19/25 between 1:00 pm to 1:40 pm, CNA D, CNA E and CNA F stated the nursing staff were responsible to lock and store the Hoyer lifts after being used. Observation on 06/20/25 at 8:00 am on Hall 100 revealed a pallet was seating up upright against the wall with two boxes on top on the side of the storage door, and a Hoyer lift, bed frame was left unlocked down the hall. Interview on 06/20/25 at 8:10 am, LVN C stated CNAs were responsible to lock the Hoyer lift and put it away. Interview on 06/20/25 at 9:15 am, the DON stated everyone was responsible to put the Hoyer lift up after it had been used. The DON stated the unlocked equipment in the hallway could be a fall risk and injury concern and issue for residents. Interview on 06/20/25 at 9:22 am, the Central Supplies Coordinator stated normally the Maintenance Director broke the boxes down and took the pallet outside. The Central Supply Coordinator stated residents were not in danger because most of the resident down the hall were in wheelchairs and residents were pushed down the hall by therapy or staff. Interview over the phone on 06/20/25 at 8:32 AM, the Maintenance Director stated it would take a lot for a resident to move an unlocked frame or bed. The Maintenance Director stated he usually took the pallets and boxes out back after supplies were put up. Interview on 6/20/25 at 10:30 am Admin stated ok to the equipment being left unlocked in the hallway and if there were risk to the residents. Record review of facility admission packet, undated reflected, safe environment. You have a right to a safe, clean, comfortable and homelike environment .

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the transmission of disease and infection; maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors; follow accepted national standards; follow a system of surveillance designed to identify possible communicable diseases or infections before they could spread to other persons in the facility; follow standard and transmission-based precautions to prevent spread of infections for twenty eight residents (Residents #1, #6, #7, #8, #10, #11, #13, #15, #19, #20, #27, #28, #38, #41, #44, #48, #49, #52, #54, #55, #57, #60, #63, #64, #66, #69, #71, and #73) of seventy three residents reviewed for infection and two (Resident #1 and #59) of three residents observed for incontinence care and one (Resident #277) of one resident observed for wound care. The facility failed to identify the outbreak, isolate the residents and perform proper hand hygiene as per CDC guidelines. The facility failed to implement and maintain contact precautions. Residents with gastrointestinal symptoms were participating in group meetings and eating food in the dining room with residents that were not sick. Residents with gastrointestinal illness were in their rooms with residents that were not displaying symptoms. The facility failed to perform proper cleaning and decontamination of infected rooms. The facility failed to report the outbreak to the local authority. The facility failed to have a system in place to evaluate and screen employees for nausea, vomiting and diarrhea symptoms. As a result, the facility experienced an outbreak of suspected norovirus beginning on 03/17/25. 2. The facility failed to ensure CNA E changed her gloves and performed hand hygiene while providing incontinence care to Resident #1 on 03/18/25. 3. CNA A failed to wear appropriate PPE when providing incontinent care for Resident #59 who supposed to be on EBP. These failures place the residents at risk of exposure to possible infectious agents. 4. The facility failed to ensure ADON J donned the appropriate PPE during wound care for Resident #277, who was on enhanced barriers precautions, on 03/19/25. 5. The facility failed to implement and train staff on transmission-based precautions for symptomatic residents. These failures placed the residents residing in the facility at risk for the development of GI outbreak and related complications including dehydration and cross-contamination of pathogens and illness. An Immediate Jeopardy was identified on 03/20/25. The IJ template was provided to the facility on [DATE] at 1:40 PM. While the Immediate Jeopardy was removed on 03/24/25, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. Findings Included: 1. Record review of the facility's 24-hour report for 03/17/25 to 03/18/25 reflected Residents #15, #20, #27, #54, #55, #60, #66, and #71 had nausea and vomiting; Resident #19 had vomited twice; Resident #44 had vomited on 03/17/25 and 03/18/2025; Resident #28, #57, and had vomited once; Resident #10 and #11 had diarrhea once and was given Imodium for next diarrhea .; Resident #277 had a new order by physician to test for c.diff [Clostridioides difficile]( a bacterial infection of the colon). Record review of the facility's infection control mapping dated 3/18/25 reflected 21 residents had signs and symptoms of nausea/vomiting or diarrhea. Record review of the facility's 24-hour report dated 03/18/25 to 03/19/25 reflected Resident #7, #15, #27, #32, #50, #54, #56, #64, #60, #71, had nausea, vomiting, and diarrhea. Record review of the facility's 24-hour report dated 03/19/25 to 03/20/25 reflected Resident #8 had an episode of diarrhea; Resident #4 laxative was held due to resident having diarrhea, Resident #51 had vomiting. Resident #41 had a change of condition with diarrhea and new order for Imodium every 6 hours for diarrhea as needed. Resident #57 had administration of laxative held due to diarrhea. Resident #48 had nausea, vomiting, and diarrhea. Record review of the facility's 24-hour report dated 03/20/25 to 03/21/25 reflected Resident #1, #8, #27, #32, #41, #52, #54, #64, were on contact precautions for diarrhea. Resident #277 tested positive for c.diff [Clostridioides difficile]( a bacterial infection of the colon), isolation precautions were in place and she had no diarrhea or gastrointestinal complaints. Resident #48's administration of laxative was held due to loose stool earlier and Zofran was administered. In a confidential group interview on 03/19/25 residents stated that they had experienced loose stools, nausea, and vomiting for the past few days. They stated that they had not been on any isolation precautions, had been given Imodium and Zofran and it helped the symptoms. 2-Record review of Resident #7's Quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cognitive communication deficit, seizure disorder, and a BIMS score of 8 (moderately impaired cognition). Resident #7 was occasionally incontinent of urine and always continent of bowl. Record review of Resident #7's care plan, dated initiated 03/20/25 revealed a focus area of: Risk for infection r/t Active communicable pathogen (GI SYMPTOMS TO INCLUDE: NAUSEA/VOMITING/DIARRHEA) . interventions included educating resident on handwashing, monitoring for signs and symptoms of active infection, and notify physician. Record review of Resident #7's physician orders revealed an order for enhanced barrier precautions with a start date of 02/28/2025 and a wound to her right shin with a start date of 02/13/25. Record review of Resident #7's POC Response History (CNAs documentation in the resident's chart) revealed Resident #7 had episodes of diarrhea on 03/16/2025 at 1:06 PM, 03/17/2025 at 6:44 PM, 03/19/2025 at 3:56 AM, 12:35 PM, and 9:33 PM and on 03/20/2025 at 2:35 PM. Record review of Resident #7's progress note dated 03/15/2025 at 3:52 AM reflected Resident complaining of nausea at this time. Per standing orders Phenergan 12.5 mg given by mouth. NP notified of nausea . Note dated 03/19/2025 at 2:09 AM reflected Resident has been complaining of loose stool this shift. In an attempt to interview Resident #7 on 03/18/2025 at 10:53 AM revealed she was non-interviewable. Observation of Resident #7 on 03/19/2025 at 9:15 AM revealed she was laying in bed asleep and had a brown stain on the seat of her pant. Further observation revealed Occupational Therapist (OT) AE entered Resident #7's room and asked if she was sick and if she wanted to get up for therapy. Resident #7 replied that she was not sick but she did not have breakfast because her stomach hurt and she wanted to go to therapy. In an interview on 03/19/25 at 10 AM with CNA G revealed she stated Resident #7 did not have any episodes of loose stools/diarrhea or vomiting and was able to use restroom herself. She stated nurses were notified for any change of condition. In an interview on 03/19/25 at 11 AM with RN AD revealed she stated Resident #7 did not have any nausea/vomiting/diarrhea and was on enhance barrier precautions due to a wound on her shin. 2-Record review of Resident #48's Quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke and cognitive communication deficit and BIMS score of 12 (moderately impaired cognition). Resident #48 was frequently incontinent of urine and always continent of bowl. Record review of Resident #48's physician orders revealed an order for Zofran dated 07/15/23: Zofran oral tablet 4 mg give by mouth every 4 hours as needed for nausea, and vomiting. Record review of Resident #48's POC Response History (CNAs documentation in the resident's chart) revealed Resident #48 had episodes of diarrhea on 03/19/2025 at 9:37 PM and 03/21/2025 at 1:45 PM and 8:36 PM. Record review of Resident #48's e-MAR dated 03/18/25 through 03/24/25 reflected, Resident#48 was administered Zofran on 3/19/2025 and 03/20/2025. Record review of Resident #48's progress note dated 03/19/2025 at 6:30 PM reflected Resident was given PRN Zofran and standing order Imodium for loose stoolx3 today . Record review of Resident #48's progress note dated 03/20/2025 at 7:18 PM reflected he was administered Zofran for mild nausea and at 7:28 PM resident's Colace for constipation was held due to loose stool earlier. 3-Record review of Resident #13's Quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia, cognitive communication deficit. Resident #13's BIMS score of 2 indicated her cognition was severely impaired. Resident #13 was frequently incontinent of urine and bowel. Record review of Resident #13's care plan dated 11/18/2024 reflected Resident #13 was at risk for impaired cognitive function/dementia or impaired thought process. Record review of Resident #13's progress note dated 03/21/2025 09:34 reflected Resident was having loose stools. Record review of Resident #13's POC Response History (CNAs documentation in the resident's chart) revealed Resident #13 had episodes of diarrhea on 03/18/2025 at 09:18 PM, 03/19/2025 at 02:27 AM, 03/19/2025 at 10:11 AM, 03/20/2025 at 03:47 AM. Record review of Resident #13's physician orders reflected resident #13 had a standing order on 03/18/2025 for Zofran Oral Tablet 4 MG (Ondansetron HCl) Give 4mg by mouth, administered every 4 hours as needed for Nausea and Vomiting, Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 2 mg by mouth every 6 hours as needed for Diarrhea. 4-Record review of Resident #49's Quarterly MDS assessment dated [DATE] reflected she was an [AGE] year-old female with an initial admitted [DATE] with diagnoses included Alzheimer's disease, cognitive communication deficit. Resident #49's BIMS score of 4 indicated her cognition was severely impaired. Resident #49 was occasionally incontinent of urine. Record review of Resident #49's care plan dated 06/09/2022 reflected she was at risk for impaired cognitive function. Record review of Resident #49's progress note dated 03/21/2025 09:02 AM reflected resident is experiencing loose stools during patient care. Record review of Resident #49's POC Response History (CNAs documentation in the resident's chart) revealed Resident #49 had episodes of loose stool/diarrhea on 03/18/2025 at 08:56 PM, 03/19/2025 at 07:27 PM, 03/20/2025 at 10:22 AM and 09:59 PM. Record review of Resident #49's physician orders report reflected Resident #49 had a standing order on 03/18/2025 for Zofran Oral Tablet 4 MG (Ondansetron HCl) Give 4mg by mouth, administered every 4 hours as needed for Nausea and Vomiting, Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 2 mg by mouth every 6 hours as needed for Diarrhea. 5-Record review of Resident #54's Quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an admitted [DATE] with diagnoses included dementia, cognitive communication deficit. Resident #54 was always incontinent of bowel and urine. Record review of Resident #54's care plan dated 03/07/2023 reflected she had ADL self-care performance deficit, cognitive deficit and physical dependence required. Record review of Resident #54's progress note dated 03/18/2025 04:49 AM reflected resident had nausea and vomiting. Record review of Resident #54' POC Response History (CNAs documentation in the resident's chart) revealed Resident #54 had episodes of loose stool/diarrhea on 03/14/2025 at 12:22 AM and 07:33 PM, 03/17/2025 at 01:02 PM, 03/18/2025 at 02:15 AM, 01:59 PM and 08:17 PM. Record review of Resident #54's order summary reflected resident #54 had an as needed standing order on 03/18/2025 for Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 2 mg by mouth every 6 hours as needed for Diarrhea, Zofran Oral Tablet 4 MG (Ondansetron HCl) Give 4 mg by mouth every 4 hours as needed for Nausea and Vomiting. 6-Record review of Resident #73's Quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an admitted [DATE] with diagnoses included dementia, cognitive communication deficit. Resident #73's BIMS score of 3 indicated her cognition was severely impaired. Resident #73 was occasionally incontinent of urine. Record review of Resident #73's care plan dated 02/21/2025 reflected resident had bowel/bladder incontinence related to Dementia. Record review of Resident #73's progress note dated 03/18/2025 04:49 AM reflected resident #73 had nausea and vomiting. Record review of Resident #73' POC Response History (CNAs documentation in the resident's chart) revealed Resident #54 had episodes of loose stool/diarrhea on 03/14/2025 at 12:22 AM and 07:33 PM, 03/17/2025 at 01:02 PM, 03/18/2025 at 02:15 AM, 01:59 PM and 08:17 PM, 03/19/2025 at 01:46 AM and 07:03 PM. Record review of Resident #73's physician orders reflected Resident #73 had standing order on 03/18/2025 for Zofran Oral Tablet 4 MG (Ondansetron HCl) Give 4 mg by mouth every 4 hours as needed for Nausea and Vomiting, Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 2 mg by mouth every 6 hours as needed for Diarrhea. 7-Record review of Resident #69's quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension, and anemia. Resident#69 has a BIMS score of 09/15 indicating moderate cognitive impairment. Record review of Resident #69's care plan, dated 03/20/25, reflected she Focus. Risk for infection r/t Active communicable pathogen (GI SYMPTOMS TO INCLUDE: NAUSEA/VOMITING/DIARRHEA). Goal. Will be free of infection by review date. Will mitigate risk of transmission of a pathogen. Interventions/Tasks. Educate resident/family/caregivers regarding the importance of handwashing. Use soap and water and dry hands using disposable towels. Monitor for sign and symptoms of active infection and notify physician. Record review of Resident #69's physician orders reflected an order dated 03/20/25: Monitor each shift for nausea, vomiting, diarrhea. Notify MD for any of the symptoms. Record review of Resident #69's physician orders reflected an order dated 03/18/25: Zofran oral tablet 4 mg give by mouth every 4 hours as needed for nausea, and vomiting. Record review of Resident #69's physician orders reflected an order dated 03/18/25: Imodium A-D oral tablet 2 mg give by mouth every 6 hours as needed for diarrhea. e-MAR review for Resident#69 dated 03/18/25 through 03/24/25 reflected, Resident#69 was not administered Zofran and Imodium tablets. Record review of Resident #69's POC Response History (CNAs documentation in the resident's chart) dated 03/17/25 through 03/24/25 reflected Resident #69 had two loose stool/diarrhea on 03/18/25, and one loose stool/diarrhea on 03/19/25. 8-Record review of Resident #6's annually MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension, and diabetes mellitus. Resident#6 has a BIMS score of 02/15 indicating sever cognitive impairment. Record review of Resident #6's care plan, dated 02/02/25, reflected she Focus. Has bowel/bladder incontinent r/t Dementia AND Physical ASSIST WITH ADL's. Goal. Will be free from skin breakdown due to incontinence and brief use through the review date. Interventions/Tasks. Incontinent: check as required for incontinence. Wash, rinse and dry perineum Record review of Resident #6's physician orders reflected an order dated 03/20/25: Monitor each shift for nausea, vomiting, diarrhea. Notify MD for any of the symptoms. Record review of Resident #6's physician orders reflected an order dated 03/18/25: Zofran oral tablet 4 mg give by mouth every 4 hours as needed for nausea, and vomiting. Record review of Resident #6's physician orders reflected an order dated 03/18/25: Imodium A-D oral tablet 2 mg give by mouth every 6 hours as needed for diarrhea. e-MAR review for Resident #6 dated 03/18/25 through 03/24/25 reflected, Resident#6 was not administered Zofran and Imodium tablets. Record review of Resident #6's Tasks titled Bowel movement/Bowel continence dated 03/17/25 through 03/24/25 reflected Resident#6 had one loose bowel movement on 03/18/25. 9-Record review of Resident #27's quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension, anemia, and diabetes, mellitus. Resident#27 has a BIMS score of 02/15 indicating sever cognitive impairment. Record review of Resident #27's care plan, dated 02/02/25, reflected she Focus. Has an alteration in gastro-intestinal status r/t diarrhea, nausea, vomiting. Goal. Will remain free from discomfort, complications or s/sx related to gastro-intestinal alterations through review date. Will mitigate risk of transmission of a pathogen. Interventions/Tasks. Contact isolation precautions. Record review of Resident #27's physician orders reflected an order dated 03/20/25: Monitor each shift for nausea, vomiting, diarrhea. Notify MD for any of the symptoms. Record review of Resident #27's physician orders reflected an order dated 03/18/25: Zofran oral tablet 4 mg give by mouth every 4 hours as needed for nausea, and vomiting. Record review of Resident #27's physician orders reflected an order dated 03/18/25: Imodium A-D oral tablet 2 mg give by mouth every 6 hours as needed for diarrhea. e-MAR review for Resident #27 dated 03/18/25 through 03/24/25 reflected, Resident#27 was not administered Zofran and Imodium tablets. Record review of Resident #27's Tasks titled Bowel movement/Bowel continence dated 03/17/25 through 03/24/25 reflected Resident#27 had one loose bowel movement on 03/20/25. Interview on 03/20/25 at 09:40 AM, CNA A denied residents (Resident#6, Resident #59, Resident#27, Resident#69) had diarrhea in the last four days (03/17/25, 3/18/25, 3/19/25, and 3/20/25). She stated she was notified about the residents' symptoms during the shift change and getting report from the outgoing CNAs. CNA A stated do not have any resident with diarrhea in the unit now. Interview on 03/20/25 at 09:45 AM, LVN C denied residents (Resident#6, Resident #59, Resident#27, Resident#69) had diarrhea in the last four days (03/17/25, 3/18/25, 3/19/25, and 3/20/25). She stated there was no residents with diarrhea in the unit in the last four days. She stated residents (Resident#6, Resident #59, Resident#27, Resident#69) complained of nausea, and vomiting. She stated report the signs and symptoms to DON, MD, and family. In an interview on 03/20/25 at 10:58 AM with CNA N revealed she was out sick, and she denied having any gastrointestinal symptoms. She stated she had. 10-Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she was a 94 -year-old female admitted to the facility on [DATE] with diagnoses included dementia and cognitive communication deficit. Resident #1's BIMS score of 9, which indicated Resident #1' cognition was moderately impaired, Resident #1 was incontinent of bowel and bladder. Record review of Resident #1's Nurse note dated 03/18/25 at 7:02 AM reflected, Resident had episode of diarrhea. Medical doctor gave new order to initiate as needed standing order for Imodium 2 mg by mouth administered x 1 for diarrhea. Will continue to monitor. Record review of Resident #1' POC Response History (CNAs documentation in the resident's chart) revealed Resident #1 had one episode of loose stool/diarrhea on 3/18/25 at 7:07 AM and another episode on 3/19/25 at 4:21 AM. Interview on 03/20/19 at 8:40 AM, with CNA E revealed that Resident #1 had diarrhea yesterday, CNA E said she told her charge nurse. She was unaware of Resident #1 having any more symptoms on her shift. Interview on 03/20/25 at 08:59 AM, with LVN I revealed that CNA E, on morning shift on 03/18/25 reported to her Resident #1 had diarrhea. She stated Resident #1 had another episode or diarrhea on 03/19/25. In an observation on 03/18/25 at 09:57 AM, CNA E and CNA F entered Resident #1's room to provide peri care. Both staff washed their hands and put on gloves CNA E unfastened the resident brief and she cleaned her front pubic area with several wipes. CNA E with the soiled gloves on she rolled the resident on her side by pushing her by the back, and the thigh. She removed the soiled brief and discarded it. CNA F held resident. CNA E removed and discarded her gloves, she sanitized hands and donned clean gloves, she wiped the anal area from front to back and then the buttocks, changing to a clean wipe with each swipe. CNA E removes gloves, sanitized hands, and donned clean gloves. She placed a clean draw sheet and brief under the resident. Both staff then rolled the resident over, and CAN F pulled the clean sheet under the resident. the staff closed the resident brief, repositioned her in bed, and covered the resident. Both staff then removed their gloves and washed their hands. In an interview on 03/18/25 at 10:10 AM, CNA E stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA E stated she contaminated Resident #1's shirt when she pushed her by her back with soiled gloves. CNA E stated failing to provide proper care exposed the resident to infections. CNA E stated she did not realize she had soiled gloves on when she pushed resident to turn her on the side. 11-Record review of Resident #59's quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (High blood pressure), anxiety disorder, and non-pressure chronic ulcer right foot (a persistence open sore or wound that develops on the skin, often on the legs .). Resident#59 has a BIMS score of 01/15 indicating sever cognitive impairment. Her Functional Status reflected she was dependent on staff for toileting hygiene including incontinent care. Record review of Resident #59's care plan, dated 02/02/25, reflected she Focus. ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: wounds. Goal. Will be free from complications related to infections through the review date. Interventions/Tasks. Use Enhanced Barrier Precautions. Record review of Resident #59's physician orders reflected an order dated 06/27/24:Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wound, Indwelling medical device, infection and/or MDRO status. Record review of Resident #59's physician orders reflected an order dated 03/20/25: Monitor each shift for nausea, vomiting, diarrhea. Notify MD for any of the symptoms. Record review of Resident #59's physician orders reflected an order dated 03/18/25: Zofran oral tablet 4 mg give by mouth every 4 hours as needed for nausea, and vomiting. Record review of Resident #59's physician orders reflected an order dated 03/18/25: Imodium A-D oral tablet 2 mg give by mouth every 6 hours as needed for diarrhea. e-MAR review for Resident#59 dated 03/18/25 through 03/24/25 reflected, Resident#59 was not administered Zofran and Imodium tablets. Record review of Resident #59's Tasks titled Bowel movement/Bowel continence dated 03/17/25 through 03/24/25 reflected Resident#59 had 2 episodes of loose stool/diarrhea on 03/18/25, and 4 episodes of loose stool/diarrhea bowel movement on 03/19/25. Observation on 03/18/25 at 11:01 AM, of Resident #59's incontinent care, provided by CNA A, revealed CNA A washed hands and donned gloves and no gown. There was a signage and supplies for EBP outside of the Resident#59's room at the left side of the entrance. Interview on 03/18/25 at 11:20 AM, CNA A stated Resident #59 has a wound and that way there was a signage and the supplies for EBP in front of the room. CNA A stated she forget to wear required PPE when she went to provide incontinent care for Resident#59. CNA A the risk to resident development of infection. CNA A stated she had been in serviced on EBP. Record review of of CNA A's competency skills revealed she was competent in prevention and control of infections and donning and doffing PPE . 12-Record review of Resident #277's Comprehensive MDS assessment dated [DATE] reflected she was an 84 -year-old female admitted to the facility on [DATE] with diagnoses included pressure ulcer of sacrum, dementia, and cognitive communication deficit. Resident #1's BIMS score of 15, which indicated Resident #277's cognition was intact, Resident #277 was always incontinent of bowel and bladder. In an observation of wound care on Resident #277 by ADON J on 03/19/25 at 12:06 PM, revealed Resident #277 was on Enhanced barriers precautions. There was signage on the right side of the door that informed visitors/staff she was on enhanced barriers precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. ADON J placed gauze, pair of scissors, a calcium alginate dressing (a soft comfortable, highly absorbent dressing), wound cleanser and dry dressing on the bed side table after she cleaned it. ADON J entered the resident's room without any form of PPE, there was PPE cart outside the door of the room. She washed her hand and donned clean gloves and she proceeded to wound care for Resident #277 without wearing gown. She performed wound care without other concerns, she washed hands and left the room. In an interview with ADON J on 03/19/25 at 12:30 PM, she stated she was supposed to wear gown and gloves when providing wound care to resident on enhanced barrier precaution and stated she had failed to do that. She stated failing to wear the proper PPE during wound care created a risk of cross contamination. 13-Record review of Resident #28's Quarterly MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die), dementia, and need for assistance with personal care. Resident #28's BIMS score of 3, which indicated Resident #28' cognition was severely impaired. Record review of Resident #28's nurse's note dated 03/17/25 at 11:46 PM, reflected, Vomiting x1 noted. Medical doctor notified. Record review of Resident #28's nurse's note dated 03/11/25 at 6:56 AM, reflected, Resident had episode of diarrhea. Medical doctor gave new order to initiate as needed standing order for Imodium 2 mg by mouth. Administered x 1 for diarrhea. Will continue to monitor. Record review of Resident #28's POC Response History (CNAs documentation in the resident's chart) revealed Resident #28 had one episode of diarrhea on 3/18/25 at 7:07 AM. Interview on 03/20/25 at 8:59 AM, with CNA F revealed she worked on 03/18/25 on the 6 AM to 2 PM shift on hall 100. She stated Resident #28 had diarrhea when she changed her in the morning. She stated she reported it to the nurse. Interview on 03/20/25 at 8:59 AM, with LVN I revealed on 03/18/25 in the morning she was told by the CNA F that Resident #28 had diarrhea. She stated she notified the physician and received order to give Imodium and to continue to monitor for symptoms. 14-Record review of Resident #63's quarterly MDS assessment dated [DATE] reflected she was a 75-year- old female admitted to the facility on [DATE] with diagnoses included hypertension (elevated blood pressure), osteoarthritis and bipolar disorder. She was cognitively impaired. Review of Resident #63's nurse's note dated 03/18/25 at 6:55 AM, revealed Resident #63 had episode of diarrhea. Medical doctor gave new order to initiate as needed standing order for Imodium 2 mg by mouth. Administered x1 for diarrhea. Will continue to monitor. Record review of Resident #63's POC Response History (CNAs documentation in the resident's chart) revealed Resident #63 had one episode of diarrhea on 3/18/25 at 6:48 AM, and at 6:28 PM and on 3/19/25 at 4:11 PM. Interview on 03/20/25 at 8:59 AM, with CNA F revealed she worked on 03/18/25 on the 6 AM to 2 PM shift on hall 100. She stated Resident #63 had a large loose stool when she changed her in the morning. She stated she reported it to the nurse. Interview on 03/20/25 at 8:59 AM, with LVN I revealed on 03/18/25 in the morning she was told by the CNA F that Resident #63 had diarrhea. She stated she notified the physician and received order to give Imodium and to continue to monitor for symptoms. In an interview with the DON on 03/18/25 at 12:53 PM, she stated she was aware that some residents had symptoms of diarrhea, nausea and vomiting since last night. She stated nurses notified the physician and received order for medication and monitoring. She stated the facility do not isolate residents with symptoms of diarrhea and vomiting if they had less than 3 episodes in 24 hours. In an interview with the Medical Director on 03/18/25 at 03:05 PM, he stated the nurse called him yesterday to report residents with gastrointestinal symptoms (diarrhea, vomiting and nausea). He stated, Norovirus going around. He stated he treated symptoms with medication, and he stated residents with symptoms should isolated, and not eating in the dining with other residents. He stated isolation is a standing order for the facility to prevent spread of the infection. In a follow up interview with the DON on 03/18/25 at 03:47 PM, she stated if a resident had symptoms of diarrhea, nausea and vomiting the staff would monitor, follow doctor's orders, and follow facility protocol which was to isolate resident if having more than 3 episodes of diarrhea. In an email from the Administrator on 03/18/25 at 3:05 PM, reflected the following residents had nausea/vomiting/diarrhea symptoms: Resident#8 and #41- as of the end of the day of 03/19/25 there were no additional residents, and one employee, CNA N, was out sick. In an email from the Administrator on 03/20/25 at 9:23 AM, reflected the following residents had nausea/vomiting/diarrhea symptoms was Residents #6, #10, #11, #15, #19, #20, #27, #28, #44, #50, #54, #60, #63, #66, #71, #73, and the physicians, including the Medical Director, had been notified and orders were given for Zofran 4 mg every 4 hours as needed, for vomiting/nausea and Imodium 2mg as needed for diarrhea episode. Further review revealed Resident #7 and Resident 48 was not included in tracking list. In a phone interview on 03/20/25 at 10:58 AM, CNA N revealed she was out sick and she denied having any ga [TRUNCATED]

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, as based on the comprehensive assessment of the resident; in that: The facility failed to promptly identify and intervene for complications of acute hyperglycemia (high blood sugar) for one (Resident #1) of 22 residents reviewed for hyperglycemia related to type 2 diabetes, resulting in the family calling 911 to transport the resident to the hospital. This failure could place residents at risk for delayed interventions in treatment when glucose levels spike or drop due to underlining conditions. Moreover, this failure is likely to cause severe injury, serious harm, serious impairment, or death in residents with medical histories positive for sepsis, chronic kidney disease, infections, cancer, and diabetes. This failure resulted in the identification of Immediate Jeopardy (IJ) on 10/27/2023 at 5:30 PM. While the immediacy was removed on 10/30/2023 at 8:15 PM, the facility remained out of compliance at scope of isolated and a severity level of actual harm due to the facility's need to monitor the implementation of the plan of removal). Findings included: Record review of Resident #1's history and physical, dated 6/16/2022, revealed she was admitted to the facility on [DATE] from home. She was an [AGE] year-old female with a medical history of dementia, cognitive communication deficits, BIMS 0, hypertension, type 2 diabetes, chronic kidneys disease and dysphagia. Review of Resident #1's care plan, reflected the following: Date revised: 02/07/23, Focus: [Resident #1] has Diabetes Mellitus r/t diabetes mellitus d/t underlying condition with diabetic neuropathy. Goal: Will have no complications related to diabetes through the review date. Interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor. Check skin when assisting with ADLS . Review of Resident #1's physician orders on 10/25/2023 at 2:00 PM revealed physician order dated 6/16/2022, reflected blood glucose checks one time a day in the AM, one a week on Wednesday. The order was entered by the facility's previous ADON and reported orders received by phone. Resident #1's September and October 2023 MAR reflected the resident had blood sugars greater than 200 on the following dates: 9/24/2023 3:28 PM - BS 258 checked by LVN B (Agency Nurse) 9/25/2023 11:35 AM - BS 340 checked by LVN A Record review of the MAR dated 09/25/23 Wound care doctor here making rounds, continue wound care, chest x-ray obtained significant findings, right pleural effusion orders sent to doctors' PA await orders. 10/18/2023 8:56 AM - BS 226 checked by LVN A Record review of the MAR revealed that the Blood Glucose was Monitored BS 226.0 - 10/18/2023 08:56 blood glucose level at baseline, well controlled Teachings/Education was not provided regarding Blood Glucose levels. Vital Signs do not show any fluctuations from baseline that require intervention(s) Record review of hospital records, dated 10/23/23, reflected Resident #1 was transported to the emergency department by EMS for hyperglycemia and a foul-smelling sacral decubitus ulcer (pressure injury). Hospital records reflected Resident #1 had a glucose level of 724. Resident #1 was given IV fluid bolus and started on a broad-spectrum vancomycin (antibiotic) and ceftriaxone (antibiotic). The hospital records reflected Resident #1 was started on an insulin drip for hyperkalemia (high potassium) and hyperglycemia (elevated blood sugar). In a telephone interview on 10/25/2023 at 10:10 AM EMT A reported on the evening of 10/23/2023 Resident #1's visiting family called 911 out of concern for Resident #1's present conditions of increased confusion, weakness, low appetite, and weight loss. EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. Interview with Resident #1's Family Member on 10/31/23 at 4:00PM revealed on 10/23/2023 at 8:00 PM, Resident #1's visiting family reported to nursing staff their observation of a new wound on the residents' inner thigh and expressed concern about Resident #1's declining condition. Resident #1's family member stated the nurse on duty stated she did not know how the wound occurred and did not seem to care about the symptoms of decline/change of condition. Resident #1's family member stated they reported their concerns to the facility Executive Director (ED) and the ED responded, We don't have a medical license and we can't diagnose her with anything. Resident #1's family member stated they called 911 out of urgent concern for Resident #1's symptoms of increased confusion, weakness, low appetite, and weight loss. They stated that when EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. The family member stated that the ER labs were positive for sepsis and the retest of blood sugar was 724. Resident #1 was admitted to the hospital for 10 days with increased confusion, hyperglycemia (elevated blood sugar), poor wound healing, and septicemia (bacterial blood infection). Interview with Resident #1's family member stated EMS arrived at the facility on 10/23/23 to find the resident with a blood sugar greater than 600. In an interview with the Interim DON on 10/25/2023 at 4:20 PM revealed she never met Resident #1 and was not familiar with her medical history because she started working at the facility on the morning of 10/25/2023. The Interim DON stated she expected for nurses to contact the physician anytime a resident's blood sugar was greater than 200 or lower than 70. DON stated the nurses were expected to monitor and notify the physician when blood sugars were too high because they were the ones doing the finger sticks. In an interview and record review with LVN A on 10/26/2023 at 11:25 AM, LVN A stated she did not notice any change in condition when caring for Resident #1. After record review of the September - October 2023 glucose labs, LVN A identified the spikes in the blood sugar values. When questioned about what parameters of glucose levels should a nurse notify the doctor, LVN A stated values less than 70 or higher than 200 and insulin dependent residents have sliding scale orders. Record review of nursing notes revealed she reported to the RP a decline in the resident's condition for the last 3 weeks but spikes in glucose levels ranging from 226 to 340 were not reported to the RP or the residents' physician as a change in condition. LVN A stated she was following orders to check the residents' glucose once a week. LVN A could not explain why she did not notify the physician of the abnormal results. LVN A stated, I messed up. In an interview and record review with LVN A and MD on 10/26/2023 at 11:40 AM after reviewing Resident #1's glucose monitoring orders, MDS, and Care Plan the MD reported he did not recall initiating the orders as they differed from his usual orders of fasting glucose testing once daily for diabetic patient monitoring. The MD stated, Unless the resident reports an intolerance for daily testing, then I would assess the historical weekly glucose values and hemoglobin A1C results before reducing glucose monitoring days, which would be reduced to testing every other day. The MD stated he had no record of request for changing glucose testing days for Resident #1. Record review of the physician orders revealed the order was initiated by the facility's past ADON. LVN A stated the previous ADON made this once-a-week glucose monitoring change to all the diabetic residents on oral hyperglycemic medications. Review of the facility's policy for Significant Change in Condition, Response, revision dated 06/2019 reflected, the nurse shall use his/her clinical judgment and shall contact the physician based on urgency of the situation. The facility was notified of the identification of an Immediate Jeopardy on 10/27/23 at 5:30PM. The Administrator was provided the immediate jeopardy template on 10/27/23 at 5:30PM. The facility's plan of removal was accepted on 10/28/23 at 9:00AM and included the following: Facility's Plan of Removal Per the information provided in the IJ Template given on 10/27/23, the facility failed to properly identify and intervene for an acute change in a resident's condition related to type two diabetes, resulting in the family calling 911 to transport the resident to the hospital. Immediate Action The Medical Director was notified of IJ on 10/27/2023 at 5:50 pm by the Clinical Resource. Resident 40010 was transferred to the hospital on 10/24/2023. Family and Physician were aware of the transfer. She is not returning to the facility per the family. Train the trainer in-service was given by the Clinical Market Leader and completed for company Directors of Nursing, ADON and Clinical Resources. Training and knowledge checks for change in condition/notifications, blood glucose monitoring orders and signs/symptoms of hypo/hyperglycemia will be completed with all nursing staff. This training will be completed by 10/27/23. This training will be provided by company Directors of Nursing, ADON and Clinical Resources. This training will be completed with all nursing staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. Residents requiring oral hypoglycemic medications were reviewed for orders and glucose monitoring. Each of their physicians were contacted and gave orders for daily blood glucose monitoring. Each resident and/or responsible party were notified and consented to the new orders. Orders were placed. Blood sugar thresholds were added to each resident's chart for additional monitoring through [facility electronic medical record's system] An ad hoc meeting regarding items in the IJ template was completed on 10/27/2023. Attendees will include the Medical Director, Clinical Resources, Administrator, and ADON and included the plan of removal items and interventions. The company Directors of Nursing, ADON or Clinical Resource will verify staff knowledge with 10 nursing staff weekly. The Clinical Resource or ADON will verify blood glucose level documentation daily. Diabetic residents receiving oral hypoglycemics will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions, as necessary. Meetings attendees to include but not limited to the Clinical Resource, ADON, and Administrator. The Clinical Resource and Administrator will be responsible for ensuring this meeting is held weekly. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On 10/30/23, the investigator confirmed the facility had implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Monitoring interviews on 10/28/2023 through 10/30/2023 with 8 staff and 3 agency staff across two shifts to include 6AM-2PM, 2PM-10PM (ADON A, CNA A, CNA B, CNA C, LVN C, LVN D, LVN E, DON, and ED) indicated they had been in-serviced on blood sugar parameters and how to identify and report changes of condition. Review of nursing notes revealed the facility notified physicians of the need to change glucose monitoring to daily testing for residents on oral hyperglycemic medications. Physician orders were updated to test diabetic residents' blood sugars daily; it was documented in the nursing notes that residents/POAs were notified and educated about the glucose monitoring risks and benefits. Interview with Executive Director on 10/30/2023 6:47 PM revealed that he did not feel comfortable with making clinical decisions for residents, he trusted his clinical staff to manage that. He stated After Change in Condition (CIC) training he feels more comfortable and understands the importance more proactive in addressing changes in a residents' condition. He stated When the incident with the Resident #1 happened, the family was very upset, and I felt they wanted more than we could offer. We were giving the best care we could for their mother, but their expectations need to be more realistic. In retrospect I feel the situation could have been handled differently. If they would have given us the opportunity to investigate the issue. We originally thought the family was upset about the wound on their mother's leg, not her symptoms at the time. That's why we only self-reported abuse. We have now changed our blood sugar monitoring protocols so we can catch changes earlier. We have a lot of agency clinical staff, so it is difficult for the nurses to know every resident's norm. While the immediate jeopardy was removed on 10/30/2023 at 8:15 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm, due to the facility's need to implement and monitor the effectiveness of its corrective systems.

Based on interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of 22 residents reviewed for notification of changes. The facility failed to promptly identify and intervene for an acute change in a resident's condition related to type 2 diabetes, resulting in the family calling 911 to transport the resident to the hospital. The resident was admitted to the hospital with increased confusion, poor wound healing, hyperglycemia (elevated blood sugar levels), and septicemia (bacterial blood infection). LVN B (Agency Nurse) failed to consult with the physician or physician assistant when Resident #1's blood sugars were greater than 200 on 9/24/2023. LVN A failed to consult with the physician or physician assistant when Resident #1's blood sugars were greater than 200 on 9/25/2023 and 10/18/2023. This failure could place residents at risk for delayed interventions in treatment when glucose levels spike or drop due to underlining conditions. Moreover, this failure is likely to cause severe injury, serious harm, serious impairment, or death in residents with medical histories positive for sepsis, chronic kidney disease, infections, cancer, and diabetes. This failure resulted in the identification of Immediate Jeopardy (IJ) on 10/27/2023 at 5:30 PM. While the immediacy was removed on 10/30/23 at 8:15 PM, the facility remained out of compliance at a scope of isolated and severity level of actual harm due to the facility's need to monitor the implementation of the plan of removal. Findings included: Record Review of the Resident #1's history and physical, dated 6/16/2022, revealed she was admitted to the facility on [DATE] from home. She was an [AGE] year-old female with a medical history of dementia, cognitive communication deficits, BIMS 0, hypertension, type 2 diabetes, chronic kidneys disease and dysphagia. Record Review of Resident #1's physician orders on 10/25/2023 at 2:00 PM revealed physician order dated 6/16/2022, reflected blood glucose checks one time a day in the AM, one a week on Wednesday. The order was entered by the facility's previous ADON and reported orders received by phone. Record review of Resident #1's September and October 2023 MAR reflected the resident had blood sugars greater than 200 on the following dates: 9/24/2023 3:28 PM - BS 258 checked by LVN B (Agency Nurse) 9/25/2023 11:35 AM - BS 340 checked by LVN A Record review of the MAR dated 09/25/23 Wound care doctor here making rounds, continue wound care, chest x-ray obtained significant findings, right pleural effusion orders sent to doctors' PA await orders. 10/18/2023 8:56 AM - BS 226 checked by LVN A Record review of the MAR revealed that the Blood Glucose was Monitored BS 226.0 - 10/18/2023 08:56 blood glucose level at baseline, well controlled Teachings/Education was not provided regarding Blood Glucose levels. Vital Signs do not show any fluctuations from baseline that require intervention(s) Record review of hospital records, dated 10/23/23, reflected Resident #1 was transported to the emergency department by EMS for hyperglycemia and a foul-smelling sacral decubitus ulcer (pressure injury). Hospital records reflected Resident #1 had a glucose level of 724. Resident #1 was given IV fluid bolus and started on a broad-spectrum vancomycin (antibiotic) and ceftriaxone (antibiotic). The hospital records reflected Resident #1 was started on an insulin drip for hyperkalemia (high potassium) and hyperglycemia (elevated blood sugar). In a telephone interview on 10/25/2023 at 10:10 AM, EMT A reported on the evening of 10/23/2023, Resident #1's visiting family called 911 out of concern for Resident #1's present condition of increased confusion, weakness, low appetite, and weight loss. EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. Interview with Resident #1's Family Member on 10/31/23 at 4:00PM revealed on 10/23/2023 at 8:00 PM, Resident #1's visiting family reported to nursing staff their observation of a new wound on the residents' inner thigh and expressed concern about Resident #1's declining condition. Resident #1's family member stated the nurse on duty stated she did not know how the wound occurred and did not seem to care about the symptoms of decline/change of condition. Resident #1's family member stated they reported their concerns to the facility Executive Director (ED) and the ED responded, We don't have a medical license and we can't diagnose her with anything. Resident #1's family member stated they called 911 out of urgent concern for Resident #1's symptoms of increased confusion, weakness, low appetite, and weight loss. They stated that when EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. The family member stated that the ER labs were positive for sepsis and the retest of blood sugar was 724. Resident #1 was admitted to the hospital for 10 days with increased confusion, hyperglycemia (elevated blood sugar), poor wound healing, and septicemia (bacterial blood infection). Interview with Resident #1's family member stated EMS arrived at the facility on 10/23/23 to find the resident with a blood sugar greater than 600. After hospital admission, ER labs were positive for sepsis and the retest of blood sugar was 724. Resident #1 was admitted to the hospital for 10 days with increased confusion, hyperglycemia (elevated blood sugar), poor wound healing, and septicemia (bacterial blood infection). In an interview with the Interim DON on 10/25/2023 at 4:20 PM revealed she never met Resident #1 and was not familiar with her medical history because she started working at the facility on the morning of 10/25/2023. The Interim DON stated she expected for nurses to contact the physician anytime a resident's blood sugar was greater than 200 or lower than 70. DON stated the nurses were expected to monitor and notify the physician when blood sugars were too high because they were the ones doing the finger sticks. In an interview and record review with LVN A on 10/26/2023 at 11:25 AM, LVN A stated she did not notice any change in condition when caring for Resident #1. After record review of the September - October 2023 glucose labs, LVN A identified the spikes in the blood sugar values. When questioned about what parameters of glucose levels should a nurse notify the doctor, LVN A stated values less than 70 or higher than 200 and insulin dependent residents have sliding scale orders. Record review of nursing notes revealed she reported to the RP a decline in the resident's condition for the last 3 weeks but spikes in glucose levels ranging from 226 to 340 were not reported to the RP or the residents' physician as a change in condition. LVN A stated she was following orders to check the residents' glucose once a week. LVN A could not explain why she did not notify the physician of the abnormal results. LVN A stated, I messed up. In an interview and record review with LVN A and MD on 10/26/2023 at 11:40 AM after reviewing Resident #1's glucose monitoring orders, MDS, and Care Plan the MD reported he did not recall initiating the orders as they differed from his usual orders of fasting glucose testing once daily for diabetic patient monitoring. The MD stated, Unless the resident reports an intolerance for daily testing, then I would assess the historical weekly glucose values and hemoglobin A1C results before reducing glucose monitoring days, which would be reduced to testing every other day. The MD stated he had no record of request for changing glucose testing days for Resident #1. Record review of the physician orders revealed the order was initiated by the facility's past ADON. LVN A stated the previous ADON made this once-a-week glucose monitoring change to all the diabetic residents on oral hyperglycemic medications. Review of the facility's policy for Significant Change in Condition, Response, revision dated 06/2019 reflected, the nurse shall use his/her clinical judgment and shall contact the physician based on urgency of the situation. The facility was notified of the identification of an Immediate Jeopardy on 10/27/23 at 5:30PM. The Administrator was provided the immediate jeopardy template on 10/27/23 at 5:30PM. The facility's plan of removal was accepted on 10/28/23 at 9:00AM and included the following: Facility's Plan of Removal Per the information provided in the IJ Template given on 10/27/23, the facility failed to properly identify and intervene for an acute change in a resident's condition related to type two diabetes, resulting in the family calling 911 to transport the resident to the hospital. Immediate Action The Medical Director was notified of IJ on 10/27/2023 at 5:50 pm by the Clinical Resource. Resident 40010 was transferred to the hospital on 10/24/2023. Family and Physician were aware of the transfer. She is not returning to the facility per the family. Record review of Train the trainer in-service was given by the Clinical Market Leader and completed for company Directors of Nursing, ADON and Clinical Resources. Training and knowledge checks for change in condition/notifications, blood glucose monitoring orders and signs/symptoms of hypo/hyperglycemia will be completed with all nursing staff. This training will be completed by 10/27/23. This training was provided by company Directors of Nursing, ADON and Clinical Resources. This training will be completed with all nursing staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. Record review of all residents requiring oral hypoglycemic medications were reviewed for orders and glucose monitoring. Each of their physicians were contacted and gave orders for daily blood glucose monitoring. Each resident and/or responsible party were notified and consented to the new orders. Orders were placed. Blood sugar thresholds were added to each resident's chart for additional monitoring through [facility electronic medical record's system] An ad hoc meeting regarding items in the IJ template was completed on 10/27/2023. Attendees will include the Medical Director, Clinical Resources, Administrator, and ADON and included the plan of removal items and interventions. The company Directors of Nursing, ADON or Clinical Resource will verify staff knowledge with 10 nursing staff weekly. The Clinical Resource or ADON will verify blood glucose level documentation daily. Diabetic residents receiving oral hypoglycemics will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions, as necessary. Meetings attendees to include but not limited to the Clinical Resource, ADON, and Administrator. The Clinical Resource and Administrator will be responsible for ensuring this meeting is held weekly. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On 10/30/2023, the investigator confirmed the facility had implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Monitoring interviews on 10/28/2023 through 10/30/2023 with 8 staff and 3 agency staff across two shifts to include 6AM-2PM, 2PM-10PM (ADON A, CNA A, CNA B, CNA C, LVN C, LVN D, LVN E, DON, and ED) indicated they had been in-serviced on blood sugar parameters and how to identify and report changes of condition. Review of nursing notes revealed the facility notified physicians of the need to change glucose monitoring to daily testing for residents on oral hyperglycemic medications. Physician orders were updated to test diabetic residents' blood sugars daily; it was documented in the nursing notes that residents/RPs was notified and educated about the glucose monitoring risks and benefits. Interview with Executive Director on 10/30/2023 6:47 PM revealed that he did not feel comfortable with making clinical decisions for residents, he trusted his clinical staff to manage that. He stated After Change in Condition (CIC) training he feels more comfortable and understands the importance more proactive in addressing changes in a residents' condition. He stated When the incident with the Resident #1 happened, the family was very upset, and I felt they wanted more than we could offer. We were giving the best care we could for their mother, but their expectations need to be more realistic. In retrospect I feel the situation could have been handled differently. If they would have given us the opportunity to investigate the issue. We originally thought the family was upset about the wound on their mother's leg, not her symptoms at the time. That's why we only self-reported abuse. We have now changed our blood sugar monitoring protocols so we can catch changes earlier. We have a lot of agency clinical staff, so it is difficult for the nurses to know every resident's norm. While the immediate jeopardy was removed on 10/30/2023 at 8:14PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm, due to the facility's need to implement and monitor the effectiveness of its corrective systems.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents. The facility failed to safely transfer Resident #1 and prevent and injury during the use of the mechanical Hoyer lift, which resulted in the resident sustaining a laceration to the head, requiring six staples at the hospital. This failure could place resident at risk for accidents, injuries, and hospitalization . Findings included: Record review of Resident #1's undated face sheet revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and re-entered on 08/20/23. Her diagnoses included spastic quadriplegic cerebral palsy, muscle weakness, lack of coordination, need for assistance with personal care, flexion deformity of the right elbow, and age-related osteoporosis without current pathological fracture. Record review of Resident #1's quarterly MDS dated [DATE] revealed the resident had a progressive neurological condition, and the BIMS score was blank for her cognitive status assessment. The MDS reflected the resident was totally dependent upon two or more people for transfers, her balance during transitioning was not steady, and she was only able to stabilize with staff assistance. The MDS also reflected the resident had functional limitation in range of motion with impairment to both sides of her upper and lower extremities, and she used a wheelchair for mobility. The resident had no falls or injuries since admission or reentry at the time of the MDS assessment. Record review of Resident #1's undated care plan revealed Resident #1 had actual impairment to skin integrity related to laceration to back of head (staples to the back of the head). The care plan reflected: Goal: Skin injury of the (staples to the back of the head) will be healed by review date. Intervention: Follow facility protocol for treatment of injury. Keep skin clean and dry. Resident requires assistance/ potential to restore function to maximum self-sufficiency for transferring from one position to another related to: Physical limitations **** REQUIRES Hoyer LIFT x 2 person assist w/ all transfers ***** Goals: Will receive the necessary physical assistance. Intervention: Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. ADL Self Care Performance Deficit related to Limited Mobility, Weakness, Cerebral Palsy, Epilepsy. Goal: Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene with modified independence through the review date. Intervention: Staff will provide the level of physical assistance as needed with ADLs Due to selfability may fluctuate; TRANSFER: Requires Mechanical Aid Hoyer lift with 2 person. Has had an actual fall with injury on 9/13/23 - Hoyer lift fall. Goal: SPECIFY: injured areas will resolve without complication by review date. Interventions: checked all Hoyer sling in facility, review all Hoyer lift transfer with therapy, staff re-education and training on Hoyer lift transfer. Record review of incident report dated 09/13/23 revealed Resident #1 had a fall in her room, The report reflected CNAs reported to the charge nurse that Resident #1 was on the floor and that she had fallen from the Hoyer lift. The resident stated she had fallen from the Hoyer lift during transfer from the bed trying to get into the wheelchair. The report reflected: Immediate Action Taken: Resident was assessed and is able to communicate. Resident able to state her name, date, birth, and remembers what she had eaten for breakfast. Vital signs were obtained. 147/85, Heart Rate, R 18, o2 sat 97% RA, Temperature 97.2 MD notified, Called all numbers available for her parents and unable to reach. Voice message left. Resident taken to hospital? [No]; no injuries observed at time of incident. Level of Pain: 4 level of consciousness: Alert Mobility: Wheelchair bound. Predisposing Physiological Factors: None Predisposing Situation Factors: During Transfer. Other info: Two (2) CNAs were transferring resident from bed to electric wheelchair when the Hoyer sling broke. Ther Hoyer sling was taken out of use immediately. Pt transferred to Methodist Dallas via 911. No witnesses found. Record review of pain management review dated 09/13/23 revealed reason for review: change in condition. Resident was able to interview, resident indicated pain, resident rated the intensity of pain at a level 4 aching back pain. Record review of progress note dated 09/13/23 9:02 AM written by RN A revealed CNA B and CNA C reported to charge nurse that resident fell from Hoyer lift while transferring from her bed with an attempt to place her in her mobilized wheelchair. The note reflected Resident #1 was able to communicate and state the same. Resident is alert and oriented to person, place, and time. She was able to state her name, date of birth, and was able to recall what she had for breakfast. The note reflected the resident's vital signs were obtained, and the resident was noted to have bleeding from her the back of her head. A Kerlix bandage was applied for pressure to stop bleeding. The resident also provided with pillows for comfort on floor. The physician and 911 was called for transport to the hospital emergency room . The note reflected the ambulance arrived at 9:15 AM to transport the resident to the hospital. The resident's neck was assessed with no complaints noted. The resident denied pain at first, but then complained of back pain at a level of 4. At 9:20 AM, the resident was transported to ER via emergency services. RN A documented that telephone calls were made to several numbers for resident's parents, and multiple voice messages were left. Record review of progress note date 09/13/23 at 3:19 PM written by LVN D documented that Resident #1 returned from the hospital via stretcher, status post fall with head injury and pelvic pain post-trauma. The note reflected the resident was: alert, spoke in short sentences, coherent, and her oxygen saturation levels were at 98% on room air. The note further reflected: Assisted to bed per 2 Emergency Medical Transport, made comfortable. Head to toe assessment done, noted 8 staples posterior head with swelling. Generalized weakness. Vital Signs 97.9, 81, 20, blood pressure 146/86, Bilateral Breathing Sounds auditable, clear and even. Continue to monitor, 100% of her Diet, fed per staff. No complaint of pain at this time. Record review of hospital records dated 09/13/23 reflected the following: Fall and Head Injury Resident is a [AGE] year old female with history of Cerebral Palsy who presents to the Emergency Department complaint of pain after fall. Emergency Medical Service reports patient was being moved with mechanical lift and fell , striking her head. Reports laceration to posterior head. Resident states she is having diffuse back pain and left leg pain. History limited due to resident distress. 5 cm at scalp Occipital area, standard cleaning with saline to deep dermal/superficial fascia with 6 staples. Record review of In-Service Training Report titled Proper Hoyer Lift dated 09/13/23 included CNA B and CNA C. Record review of Mechanical Lift Proficiency dated 09/13/23 indicated Satisfactory. Prior Mechanical Lift Proficiency was not provided. Interview on 10/18/23 at 9:30 AM with the Administrator revealed he was alerted to the incident during stand up the morning of 09/13/23. The Administrator stated the DON and the ADON stepped out to investigate. The Administrator stated he was told that while transferring Resident #1 out of bed to her wheelchair the strap string broke and feel out from the sling to the floor. The Administrator stated Resident #1 did have an injury of laceration to the back of her head, therefore was sent out to the hospital. He then stated he did investigation to ensure the facility followed protocol and in-service was started. Interview on 10/18/23 at 11:44 AM with Resident #1 revealed she did recall having a fall however did not want to discuss the situation at this time. Interview on 10/19/23 at 7:45 AM with Resident #1 revealed she did not want to discuss the fall with surveyor and stated please call my dad and talk to him about it. Interview on 10/19/23 at 9:23 AM with CNA B revealed she was involved in the transfer with Resident #1, along with CNA C which no longer worked in the facility. CNA B stated both aides were in the room completing the transfer procedure as they normally did when getting Resident #1 out of bed. CNA B stated, the sling looked new, it did not look old or nothing. CNA B stated the sling was placed on the machine, everything was perfect, the hooks were on correctly blue or green at the top of sling near her head and purple at the bottom near her feet. CNA B stated when she lifted Resident #1 from the bed, she did not know what happened. She stated the sling was under the resident's head, but she could not say what happened. CNA B stated she was taking the resident out the bed, and the resident was at bed level, but then she went straight to the floor. CNA B stated she stayed with Resident #1 while CNA C went to get the nurse on duty. CNA B stated she could not describe the condition of the sling after the fall; however, she knew the bottom snapped. CNA B stated she was not paying attention to the sling because she was on the floor assisting the nurse. CNA B stated Resident #1 was calm and talking normal, and she was acting as if she was not hurt. CNA B stated the nurse came in, stopped the bleeding, and wrapped Resident #1's head with a bandage. CNA B stated 911 was called and Resident #1 was transferred to the hospital. CNA B stated it was the responsibility of the CNAs to inspect the Hoyer slings to ensure they were safe to use during transfers, not doing so could result in residents having an injury or fall. Interview on 10/19/23 at 12:22 PM with the ADON revealed he was alerted to Resident #1's fall from one of the aides working with her on the hall at the time. The ADON stated when he entered the room he observed Resident #1 on the floor lying on her back, with her eyes open, alert, with baseline intermit confusion. The ADON stated Resident #1 was responding verbally as the floor nurse was completing her assessment. The ADON stated Resident #1 was bleeding in the back of the head, so the nurse applied pressure to stop the bleeding and he called for 911. The ADON stated emergency services came out quickly to have her transferred to the hospital for further evaluation. The ADON stated his expectation was that nursing staff, the aides, were checking the sling to ensure they were appropriate to use in transfers, and the risk of not doing so would be injuries. ADON did not indicate the condition of the sling. Interview on 10/19/23 at 12:47 PM with RN A revealed she was the responding nurse on the hall when Resident #1 had a fall and injury from the Hoyer. RN A stated she was alerted by CNA C that Resident #1 had fell and was on the floor, RN A stated when she entered the room to see Resident #1 flat on her back, left side of her head was bleeding. RN A stated she did an assessment, called for help to a pressure bandage to stop the bleeding, neuro checks, vitals signs, range of motion, and began asking questions as to what happened. RN A she said during her investigation it was told to her by the aides that the Hoyer sling broke. RN A stated she had the aide call 911 and Resident #1 was sent out to the hospital. RN A stated she did see the sling and it seemed like it was a little old. RN A stated the aides are responsible for ensuring the slings are usable and safe, not doing so would cause injury to the resident. Interview on 10/19/23 at 3:05 PM with the DON revealed she stepped out of the stand-up meeting and saw EMS lights. She stated the Receptionist informed her they were at the facility for Resident #1. The DON stated she then went to Resident #1's room. The DON stated upon her arrival she observed the EMS, ADON, charge nurse, and two aides in the room. Resident #1 was on her back, the charge nurse was wrapping the resident with kurlex, and the Resident #1 was able to respond verbally. The DON stated she asked the aides to write their statements, and she grabbed the sling, and returned to the meeting. She stated she updated the staff as to what was going on. The DON stated she was not able to recall which color loop the resident used. She stated Resident #1 returned to the facility the same day with her family members. She stated the Hoyer slings were being inspected quite a few times prior to resident use. She stated the laundry room washed and inspected the slings before and after cleaning. If a sling was frayed or torn, the sling would be taken out of commission. The nursing staff would also inspect when the sling was taken from the laundry room. The DON stated all of the slings looked as if they were in good working condition and fairly new. The DON stated her expectation of using the sling and Hoyer lift were for the laundry department to follow protocol of washing the slings, hanging them to dry, not placing them in the dryer, and inspecting the slings. After inspection of the damaged sling, the DON stated it appeared that when one colored strap broke with Resident #1, the resident then slipped through another colored strap. The DON stated the sling did not look like it was damaged. Telephone interview on 10/25/23 at 2:24 PM with the DON revealed she wanted to provide additional information regarding the incident. She stated she was told by the Housekeeping Supervisor that CNA C advised her during Resident #1's fall there was only one aide (CNA B) completing the Hoyer lift transfer. The DON stated she was unsure why CNA C had not informed her before. The DON stated the Administrator had the Hoyer sling in his office, but he did not want the sling or other information regarding the sling provided to the surveyor. The DON stated she no longer worked at the facility. Telephone interview on 10/25/23 at 4:53 PM with CNA C revealed CNA B requested her assistance to complete the Hoyer lift transfer for Resident #1. CNA C said she and CNA B entered the room together, and CNA B already had the sling and lift machine in the room. CNA C stated the equipment was inspected by CNA B; therefore, she had not inspected the sling. CNA C stated she attached the sling on the left side, but she could not recall the colors she had applied. She stated she and CNA B lifted and moved the resident in the Hoyer lift towards the wheelchair, but then the resident fell . She stated it happened so fast. CNA C stated she then went to alert RN A and the ADON. Record review of the facility's current, undated Policy: Mechanical Lift and Slings Nursing Policy Manual reflected: The facility will provide for the safety needs of a resident requiring the use of a mechanical lift for transfers. Guideline: Transfer status/Mechanical lift will be maintained in the resident's medical record. Two or more assistants must be used for al mechanical lift transfers. Slings should be evaluated prior to using. Any slings that are frayed or torn will be immediately taken out of service and given to the Director of Nurses Sling loops are color coded to provide guidance to the positioning of the sling. When selecting loops it is importation to know that the colors are used to ensure the same height on each side. For example: the top left and top right should have the same color straps hooked onto the lift. The bottom left and right should have the same color strap used to hook onto lift. You may never have all 4 straps the same color, this could cause the resident to slide out of the sling. When connecting the slings to the lift, the shortest of the straps must be at the back of the resident for support. Training will be provided to staff during orientation, annually and as needed. Record review of the undated Patient Lifts Safety Guide reflected: This guide provides general safety recommendations and is not a replacement for the manufacturer's instructions. Select the Patient's sling size: Assess patient's size, weight and hip measurement. Choose size of sling based on manufacturer recommendation for patient's measurement. Choosing correct sling size is critical for safe patient transfer. Sling too large: Patient may slip out. Sling too small: Patient may fall out. If Between sizes: smaller size may keep patient more secure. Using the wrong sling or attaching the sling incorrectly may cause an accident that can result in serious injury or death. Prepare Equipment: .ensure slings, hooks, chains, straps and supports are available, appropriate and correctly sized. Check lift and sling weight limits. Examine sling and attachment areas for tears, holes and frayed seams. DO NOT USE sling with any signs of wear. Place Patient in Sling: Position center of sling under patient's spine Make sure sling opening is not large enough to let patient slip out or too small to let patient fall out. Use matching loops from each side to ensure sling is balanced. Ensure all clips or loops are secure and will stay attached as patient is lifted. Ensure straps are not twisted. Perform Safety Check: Before lifting the patient, perform safety check . Examine all hooks and fasteners to ensure they will not unhook during use. Double check position and stability of straps and other equipment before lifting patient. Ensure clips, latches and bars are securely fastened and structurally sound. Lift the Patient: Lift patient two inches off the surface to make sure patient is secure. Sling traps are confined by guard on sling bar and will not disengage. Weight is spread out evenly. Patient will not slide out of sling or tip forward or backwards.

Based on interviews and record reviews, the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications for one (Resident #1) of one resident reviewed for feeding tube nutrition and care. LVN C placed a temporary GT after Resident #1's GT dislodged on 11/05/22. LVN C failed to obtain an X-ray confirmation, the most accurate method for tube placement verification. LVN C failed to verify and follow facility policy and procedures for when a GT can be replaced within the facility, by whom, or in the hospital. As of 12/05/22, there was no evidence the facility completed nursing training or competency skills checkoffs with LVN C before or after he placed the GT. No training or in-services were conducted with all nursing staff on GT policy and procedure to prevent a recurrence, in that nurses do not reinsert a GT if clogged, becomes dislodged, or use a foreign object to keep the GT hole open. LVN C continued to work every weekend, double shifts through 12/04/22. Resident #1 was hospitalized and had severe abdominal wall pain with induration (area of hardness or deep thickening of the skin, that can result from edema, inflammation, or infiltration) and cellulitis (common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin of the abdominal wall). These failures resulted in an identification of an Immediate Jeopardy (IJ). The DON and E.D. were notified and an IJ template was provided on 12/05/22 at 4:58 PM. While the IJ was removed on 12/06/22, the facility remained out of compliance at an isolated scope and a severity of actual harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents with enteral feeding tubes or if tubes not designed or intended for enteral feeding are used for replacement at risk of at risk of actual or potential physical harm. Findings included: A record review of Resident #1's Admission MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. Resident #1 had medically complex conditions and diagnoses of DM {a group of diseases that result in too much sugar in the blood}, CAD {a heart disease caused by plaque buildup in the wall of the arteries that supply blood to the heart}, HF {when the heart cannot pump enough blood and oxygen to support other organs in your body}, HTN {High blood pressure that is higher than normal}, ESRD {kidneys no longer function well enough to meet a body's needs}, non-Alzheimer's Dementia {a decline in mental ability severe enough to interfere with daily life - Alzheimer's is a specific disease}, malnutrition, Depression (other than bipolar), and surgical procedure involving PEG tube placement. Resident #1's BIMS score was 03, which indicated severe cognitive impact per staff assessment. The MDS reflected one-person physical assist with bed mobility, locomotion on/off unit, dressing, eating, and personal hygiene. Resident #1 required two-person physical assist with transferring between surfaces and toilet use. The Admission MDS assessment reflected Resident #1 presented with a feeding tube. As of 12/05/22, Resident #1 remained admitted to an acute care hospital. A review of Resident #1's digital care plan indicated: - Focus: Has potential nutritional problem r/t poor intake and presence of peg tube [Initiated: 10/26/22; Revision on: 11/08/22] - Goal: Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date. [Initiated: 11/08/22; Target Date: 11/06/22] Will tolerate ordered diet through the review date [Initiated: 11/08/22; Target Date: 11/06/22] - Interventions: Diet as ordered by the physician. Res is on a MCS, DM2 diet with thin liquids. [Initiated: 10/26/22; Revision on: 11/08/22] Meals in dining room if resident is in agreement. [Initiated: 10/26/22] Monitor and report to MD as needed for any s/s of : decreased appetite, N/V, unexpected weight loss, c/o stomach pain, etc. [Initiated: 10/26/22] Provide assistance (set-up, limited, extensive, total) with meals as needed. [Initiated: 10/26/22] Provide supplements as ordered, Resource 2.0 [Initiated: 10/26/22; Revision on: 11/08/22] A review of Resident #1's clinical physician orders reflected an undated banner Special Instructions: Charge Nurses Res is SKILLED for CELLULITIS TO ABDOMINAL WALL. Pls chart on the infection and site daily and what you are doing to provide care and monitoring at the top of the page. Active clinical physician orders reflected: - Start Date 10/24/22: Enteral Feed orders: - every shift TYPE OF FEEDING TUBE Dx: not eating (d/c date: 10/31/22) - every shift FORMULA: Jevity 1.5 at 40 mL/hr X 22HR to provide 880 cc/cal/day. On at 9PM, Off 8AM for 2 Hrs. Start again 10AM [Hold from 10/31/22 to 11/01/22] (d/c date: 11/02/22) - every shift Check gastric residual prior to each bolus feeding. hold feeding for residual >100 cc and notify MD (d/c date 11/03/22) - every shift check g-tube placement and patency prior to each feeding/flushing/medication administration (d/c date: 11/09/22) - every shift flush tubing with 5 mL-10 mL water between each medication administration [Hold from 10/31/22 to 11/01/22] (d/c date: 11/03/22) - every shift flush G-tube with 30 mL - 50 mL of water before and after medication administration (d/c date: 11/03/22) - every shift mix each medication with 5 - 10 mL of water then administer meds per g-tube (d/c date: 11/03/22) - every shift may crush/combine medication for administration if not contraindicated and mix with 4 oz of water. May use slow push to facilitate consumption (d/c date: 10/31/22) - every shift elevate head of bed at 30-45 degrees while feeding is going on [Hold from 10/31/22 to 11/01/22] (d/c date: 11/09/22) - every shift rinse syringe after each use [Hold from 10/31/22 to 11/01/22] (d/c date: 11/09/22) - every night shift every Wed change syringe [Hold from 10/31/22 to 11/01/22] (d/c date: 11/09/22) - every day shift inspect and monitor gastrostomy stoma for signs & symptoms of local infection such as: redness; pain; tenderness; unusual odor; drainage or discharge; hypergranulation of tissue (an excess of granulation tissue that fills the wound bed to a greater extent than what is required and goes beyond the height of the surface of the wound resulting in a raised tissue mass) surrounding stoma. Notify MD if s/s noted (d/c date: 11/09/22) - Start Date 10/24/22: Cleanse G-tube stoma with NSS, pat dry and apply dry dressing every night shift (d/c date: 10/26/22); Cleanse G-tube stoma with NSS, pat dry and apply dry dressing every 24 hours as needed (d/c date: 10/26/22) - Start Date 10/26/22: Clean G-tube site with NSS, pat dry, cover with dry dressing. Initial and date every night shift and when soiled (d/c date: 11/09/22) - Start Date 11/02/22: Abdomen KUB (X-ray performed to assess the abdominal area for causes of abdominal pain) every shift for pain. [Completed 11/02/22] - Start Date 11/02/22: LCS diet, Mechanical soft texture, thin liquids consistency (d/c date: 11/09/22) - Start Date 11/07/22: Hold G-tube flushes/administration until after KUB completed and reported to provider (Completed; d/c date: 11/09/22) - Start Date 11/07/22: Abdomen KUB STAT for PAIN. [Completed 11/07/22] - Start Date 11/07/22: Send to ER for further evaluation and G-tube replacement Review of nurse daily skilled note dated 11/04/22 at 11:00 AM, entered by LVN D indicated . Overall skin description is clean, dry, and intact . PEG-tube intact and patent. Dressing clean dry and intact. No c/o pain or discomfort. Bowel sounds active in all 4 quadrants. A review of the nurse notes for Resident #1 dated 11/05/22 at 9:08 AM, entered by LVN C, indicated Resident #1 refused medications during the morning med pass. Resident #1 was guarding the GT site and stated, I feel a stabbing pain in my stomach. Upon inspection [by LVN C], GT was missing, and the site was closed. LVN C wrote that Resident #1 said she did not pull GT out and must have come out while she was sleeping. Resident #1 refused PRN pain medication when offered by LVN C. The nurse's note reflected LVN C called the NP and was awaiting a callback. A review of the nurse notes for Resident #1 dated 11/05/22 at 9:34 AM, entered by LVN C, indicated, NP called back new order for STAT KUB order placed online and called into [diagnostic laboratory and imaging service provider]. A review of the nurse notes for Resident #1 dated 11/05/22 at 4:41 PM, entered by LVN C, indicated the NP was called and notified of KUB results: The moderate constipation is unchanged. The gastrostomy tube is not clearly visualized LVN C wrote that new orders were received from NP for GI consult and to place a temp cath to the stoma site. A review of the nurse notes for Resident #1 dated 11/05/22 at 5:28 PM, entered by LVN C indicated temp cath placed, verified by air auscultation. 5 cc residual returned. A review of the nurse notes for Resident #1 dated 11/07/22 at 11:54 AM, entered by LVN A, indicated that Resident #1 was crying and stated that her abdomen hurt around the GT site. LVN A reported concern to MD and received orders to hold GT flush until after KUB. Resident #1 ate 80% of breakfast and tolerated all medications by mouth. A review of the nurse notes for Resident #1 dated 11/07/22 at 1:38 PM, entered by LVN A, indicated Change in Condition: Abdominal pain. LVN A entered another nurse note at 2:23 PM that she canceled the KUB and sent Resident #1 to the ER. A review of the emergency department clinical report dated 11/07/22 indicated Resident #1 had abdominal pain that started with peg tube replacement 11/5/22 and was still present and worsening. A review of hospital medical records for inpatient stays dated 11/07/22 to 11/10/22 indicated [Resident #1] had a PEG tube placed about 4 weeks ago . earlier in the last week pulled the PEG tube out herself. It was placed back in. She [Resident #1] has severe abdominal wall pain with induration (area of hardness or deep thickening of the skin, that can result from edema, inflammation, or infiltration) and cellulitis (common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin of the abdominal wall) . [Admitting physician] will remove the PEG tube today (11/07/22). The medical records revealed a Physical Examination of the abdomen severe tenderness to palpation along the indurated area surrounding the PEG tube insertion site. Abdominal wall PEG tube insertion site and green drainage. Large area of induration [a hardening of an area of the body as a reaction to inflammation] surrounding the PEG tube site. The medical records revealed a diagnostic study, CT of the abdomen and pelvis: . Soft tissue thickening about tube in the abdominal wall with multifocal soft tissue air, correlate for infectious process. Assessment and Plan indicated Abdominal wall cellulitis. To consult infectious disease and general surgery due to CT scan showing pockets of air in the abdominal wall. Start IV antibiotics. Record review of a hospital radiology report for Resident #1 dated 11/07/22 indicated: CT abdomen/pelvis. Admit reason - burning in G-tube and abdominal pain. Findings: G-tube in stomach, no inflated balloon is seen. There is soft tissue thickening about the tube in the abdominal wall . correlate for infectious process. Clinical Impression: Abdominal wall infection Record review of a hospital med/surg inpatient nursing record dated 11/07/22 at 9:20 PM indicated [Resident #1] has an IV device that is saline locked for intermittent infusion therapy . Wound A: peg tube stoma; Surrounding Tissue: excoriated (surface of the skin damaged); Interventions: clean with normal saline, change dressing. ABD dressing applied and secured with tape. Patient is confused and kept on removing the dressing. Additional notes indicated peg tube draining stomach content. Stoma is excoriated and no bleeding. Redness observed under the left breast. Documentation dated 11/07/22 at 10:00 PM indicated patient continued to remove dressing and stoma draining gastric content. Documentation dated 11/0/2022 at 11:00 PM indicated patient voiced pain on her stoma. Instructed not to pull on the stoma. Dressing adjusted. A review of the hospital med/surg discharge form dated 11/10/22 indicated discharge Resident #1 to SNF via ambulance with medication reconciliation and education documents. During an interview on 11/15/22 at 1:28 PM, the DON said that Resident #1 was received as a new admit after receiving a new PEG tube. The DON stated the Dietician decided to stop enteral feedings since Resident #1 was eating food orally and tolerating well. The DON stated a nurse notified her that the PEG tube came out, Resident #1 was sent to the hospital to replace the PEG tube and returned with an infection. The DON said before Resident #1 was readmitted to the SNF, she had pulled the PEG tube out again and was sent back to the hospital. The DON was not present when Resident #1 was sent to the hospital on 11/10/22 or 11/14/22, it was her first day back to work (11/15/22); therefore, had not seen the abdominal wound. An interview and observation on 11/16/22 at 12:07 PM at the hospital revealed Resident #1 in bed receiving incontinent care from a skilled nurse and patient care representative. Resident #1 appeared confused and required cues and prompted to follow instructions. Resident #1's abdomen and left breast fold present skin breakdown with pink/white discoloration and crusting. An approximate 5 cm diameter opening in the mid-upper right abdomen, packed with wound gauze, was observed when the skilled nurse pulled back the dressing for investigator visualization of the wound site. Resident #1 could not hold a meaningful conversation and was considered non-interviewable. During an interview on 11/17/22 at 11:37 AM, ADON M said she was familiar with Resident #1, but was out for family emergency when the resident sent out to the hospital on 11/07/22 and 11/10/22. ADON M stated her understanding of the policy was to notify the MD, and to send the resident to hospital if GT dislodged. ADON M stated she has not trained any nurses, received training, or performed skills check off with nurses on GT placement. ADON M stated she did not think nurses replacing a GT in the facility was part of policy and procedure. ADON M stated during walking rounds on 11/14/22, Resident #1 was observed sitting up to the WC. ADON M said that LVN A had told her about Resident #1's skin condition on return from hospital, 11/11/22 and ADON M wanted to see the wound site during dressing change. ADON M said that she discovered the skin damage surrounding the opening of the old PEG site. ADON M described the skin damage as inflamed, pale discoloration. ADON M stated that she had not received training, trained LVN C or any nurses, or performed a skills check-off with nurses on GT placement. During an interview on 11/17/22 at 12:14 PM, LVN A said that she was familiar with Resident #1. LVN A stated she sent Resident #1 to the hospital on 11/07/22 after the resident was observed in the fetal position, crying, holding stomach, complaining of pain - rated pain level a 12 and a 15, on a scale of 1 - 10. LVN A said that upon assessment, she discovered bulging around the peg site that felt hard to touch. LVN A said that she also noticed the PEG tube was different from the initial PEG tube and noted some dull greenish drainage around the peg insert site. LVN A said after reading progress notes she found that LVN C had replaced the PEG tube after it was pulled out on 11/05/22. LVN A said that she was not aware that LVNs were allowed to replace PEG tubes, never received training, or was checked off for competency in replacing PEG tubes. LVN A said that she notified the NP, called for a KUB as ordered, and the resident was sent to the hospital shortly after. During a telephone interview on 11/17/22 at 2:03 PM, the DON said that she worked with LVN C at another facility and hired him on at this SNF. The DON said that at the other facility, the nurses were allowed to replace PEG tubes, but did not complete competency skills check off for PEG tube placement at this facility. The DON said that she placed a call to LVN C to send a copy of skills check off from other facility. The DON stated that this facility policies allow nurses to place G-tubes as needed. During an interview on 11/17/22 at 2:57 PM, LVN B said she had never replaced, received training or competency skills check off for GT placement. A record review of weekend schedules revealed LVN C worked the weekends of 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. A record review of an In-service Training Report dated 12/01/22, subject: G-Tube, was conducted by ADON M, ADON N, and the DON. There was one resident currently admitted to the facility with a GT. Resident #1 remained in the hospital. The attendance record reflected seven nurses attended - LVN A, LVN D, RN K, LVN G, LVN F, and RN L, who worked the day of the In-service Training. LVN C did not attend on that day. During an interview on 12/05/22 at 9:00 AM, the DON said that she was unaware that LVN C replaced Resident #1's GT prior to surveyor entrance and after reading the 24-hour report for the weekend of 11/05/22 and 11/06/22. The DON said her expectation for the nursing staff was to send residents out and not to replace GT without training and skills check off. The DON said she would conduct training and skills checkoff herself or arrange with an approved trainer to host classes on GT placement. The DON stated the P & P reflected the procedure on GT replacement was to send a resident to the hospital. The DON said that skills training for GT replacement was necessary for competency and to prevent harm to residents. The DON indicated that no trainings or competencies were provided to LVN C. The DON verified LVN C worked each weekend as scheduled following the placement of the temporary catheter - 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. During a phone interview on 12/05/22 at 10:43 AM, the NP said that she received a couple of calls from the SNF regarding Resident #1 pulling her GT out. The NP said that she gave LVN C orders to follow SNF P & P and to send Resident #1 to the hospital. The NP said she did not give LVN C orders to place a temporary cath or temporary GT. The NP stated the risk of PEG tube replacement if a nurse does not have the training or skills is accidental peritoneal (the tissue that lines the abdominal wall and pelvic cavity) placement of the tube. Also, the resident can get an infection or aspirate on stomach contents if the GT is placed incorrectly and used. During a phone interview on 12/05/22 at 11:16 AM, LVN C indicated that Resident #1 did not want to take meds by mouth and asked to be administered by GT. LVN C stated he raised the sheet, discovered that GT was not in place, and found it on the floor beside the bed - the GT bulb still inflated. LVN C stated he did not recall entering an order from the NP to place a temp cath. LVN C said he verified placement by air auscultation and stomach content withdrawal. LVN C said he discovered leaking around the GT site from the end of the temp cath he placed when he assisted Resident #1 up to the wheelchair. LVN C stated the dressing around the GT site was a little saturated with pink colored gastric content from breakfast. LVN C said he retrieved and placed a Lopez Valve Closed Enteral Tube Valve [a three-way stop cock intended for use in conjunction with gastric or feeding tubes and maintains a closed system] at the end of the temp cath to prevent leaking and changed the dressing around the cath insert site. LVN C said he had to change the dressing again after an hour due to leaking. LVN C said that he did not receive training or skills checkoff for temporary cath placement or GT replacement at this SNF. LVN C stated the risk of replacing the GT is inserting it in the wrong place, or the resident could be allergic to the material. LVN C verified working the following weekends: 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. During an interview on 12/05/22 at 12:42 PM, ADON N indicated nursing staff was not allowed to insert/replace a GT. ADON N said he recently conducted an in-service on 12/01/22 with nurses, reviewing the policy that stated nursing staff should not use a DeClogger to clear obstructed GTs, replace, or place foreign objects in GT entry sites to prevent from closing. ADON N stated he had not received training, trained LVN C or any nurses, or performed a skills check-off with nurses on GT placement. During an interview on 12/05/22 at 3:16 PM, LVN D stated she would call the physician if a GT became dislodged. She stated if the physician ordered her to place a temporary catheter, she would find someone to help her as she has never inserted a GT or catheter into a resident's stoma before. LVN D stated she did not know the facility's P&P related to nursing staff inserting a GT. An attempt on 12/06/22 at 4:00 PM to reach the Medical Director by telephone was unsuccessful. Review of the facility's Gastrostomy Tube Nursing Clinical Policy/Procedure, policy number: NCLN; revised 10/2020 indicated the following: Procedures: Daily checklist for gastrostomy tubes: - Check for pain, discomfort, or pressure around the tube site. - Check the tube exit site for skin irritation, inflammation, or other signs of infections, gastric leakage, or feeding formula leakage . - Report Changes in GI Symptoms - Report changes in GI Symptoms to the physician immediately. These symptoms may indicate feeding tube malfunction or improper tube placement. The policy did not reflect procedures for nursing staff to replace a GT after dislodgement. A record review of ASPEN Safe Practices for Enteral Nutrition Therapy practice recommendations and rationale for monitoring the feeding tube https://aspenjournals.onlinelibrary.[NAME].com/doi/epdf/10.1177/0148607116673053 Reflected the following: Auscultation is no longer recommended for checking placement of the feeding tube. Movement of air would likely be heard whether the tube was in the correct or incorrect location. X-ray confirmation is the most accurate method for verification of tube placement when concerns arise regarding dislodgement or placement. The E.D. and DON were notified on 12/05/22 at 4:58 PM that an IJ situation was identified due to the above failures and an IJ template was provided. The facility's Plan of Removal was accepted on 12/06/22 and included: - The facility completed staff education on the facility's policy regarding gastrostomy tubes in that the facility does not allow nurses to reinsert gastrostomy tubes (12/05/22) - An audit of all residents with gastrostomy tubes (12/05/22) - LVN C suspended and will not work until he has met with the DON and received training (12/05/22) - New hire/agency orientation packet enhanced to include the facility's GT policy on dislodgement and methods allowed to clear an obstructed GT (12/05/22) - An ad hoc meeting with QAPI Committee regarding the items in the IJ Template (12/05/22) On 12/06/22 the surveyor confirmed the facility implemented their plan or removal sufficiently to remove the IJ by: Interviews conducted with nurses on 12/06/22 [LVN A at 2:09 PM; LVN D at 2:12 PM; LVN E at 2:16 PM; LVN F at 2:25 PM; LVN G at 2:40 PM; RN K at 3:00 PM; RN I at 3:39 PM; and LVN J at 3:50 PM] indicated they participated in an in-service training about gastrostomy tubes. The nurses stated their understanding of the procedure was to send residents to the hospital, and nurses are not to reinsert a GT. Each nurse said in their own words that they would assess the resident, call the physician, and send the resident out to ER if GT becomes dislodged. On 12/06/22 at 1:50 PM, the E.D. and DON were informed the IJ was removed; however, the facility remained out of compliance at an isolated scope and a severity of actual harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure nurses had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one (Resident #1) of one resident reviewed for monitoring and care of feeding tubes. LVN C placed a temporary GT after Resident #1's GT dislodged on 11/05/22. LVN C failed to obtain an X-ray confirmation, the most accurate method for tube placement verification. LVN C failed to verify and follow facility policy and procedures for when a GT can be replaced within the facility, by whom, or in the hospital. As of 12/05/22, there was no evidence the facility completed nursing training or competency skills checkoffs with LVN C before or after he placed the GT. No training or in-services were conducted with all nursing staff on GT policy and procedure to prevent a recurrence, in that nurses do not reinsert a GT if clogged, becomes dislodged, or use a foreign object to keep the GT hole open. LVN C continued to work every weekend, double shifts through 12/04/22. Resident #1 was hospitalized and had severe abdominal wall pain with induration (area of hardness or deep thickening of the skin, that can result from edema, inflammation, or infiltration) and cellulitis (common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin of the abdominal wall). These failures resulted in an identification of an Immediate Jeopardy (IJ). The DON and E.D. were notified and an IJ template was provided on 12/05/22 at 4:58 PM. While the IJ was removed on 12/06/22, the facility remained out of compliance at an isolated scope and a severity of actual harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for an adverse outcome to resident care or services and may also include the potential for physical and psychosocial harm. Findings included: A record review of Resident #1's Admission MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. Resident #1 had medically complex conditions and diagnoses of DM {a group of diseases that result in too much sugar in the blood}, CAD {a heart disease caused by plaque buildup in the wall of the arteries that supply blood to the heart}, HF {when the heart cannot pump enough blood and oxygen to support other organs in your body}, HTN {High blood pressure that is higher than normal}, ESRD {kidneys no longer function well enough to meet a body's needs}, non-Alzheimer's Dementia {a decline in mental ability severe enough to interfere with daily life - Alzheimer's is a specific disease}, malnutrition, Depression (other than bipolar), and surgical procedure involving PEG tube placement. Resident #1's BIMS score was 03, which indicated severe cognitive impact per staff assessment. The MDS reflected one-person physical assist with bed mobility, locomotion on/off unit, dressing, eating, and personal hygiene. Resident #1 required two-person physical assist with transferring between surfaces and toilet use. The Admission MDS assessment reflected Resident #1 presented with a feeding tube. As of 12/05/22, Resident #1 remained admitted to an acute care hospital. A review of Resident #1's clinical physician orders reflected the following: - Start Date 11/07/22: Hold G-tube flushes/administration until after KUB completed and reported to provider (Completed; d/c date: 11/09/22) - Start Date 11/07/22: Abdomen KUB STAT for PAIN. [Completed 11/07/22] - Start Date 11/07/22: Send to ER for further evaluation and G-tube replacement On 11/05/22, LVN C placed a temporary G-tube after Resident #1's G-tube was dislodged. There was no evidence the facility completed nursing training or competency skills checkoffs with LVN C prior to him placing a G-tube. On 11/07/22, LVN A assessed Resident #1's abdomen after complaints of pain and discovered Resident #1's G-tube had been replaced and there was swelling around the peg site, felt hard to touch. Resident #1 was sent to ER and admitted for abdominal infection related to gastric tube replacement. Review of a nurse progress note for Resident #1 dated 11/05/22 at 9:08 AM, entered by LVN C indicated during morning med pass resident was refusing med pass. When asked what was wrong, she stated, I feel a stabbing pain in my stomach. Resident #1 noted to be guarding at G-tube site upon inspection noted residents g-tube to be missing, site is closed resident stated that she didn't pull it out and that it must have come out when she was sleeping. Asked resident if she would like any prn pain mediation but she refused again med pass. Call made to NP awaiting call back . A review of the nurse note for Resident #1 dated 11/05/22 at 4:41 PM, entered by LVN C, indicated the NP was called and notified of KUB results. LVN C wrote new orders were received from NP for GI consult and to place a temp cath to the stoma site. A review of the nurse note for Resident #1 dated 11/05/22 at 5:28 PM, entered by LVN C indicated temp cath placed, verified by air auscultation. 5 cc residual returned. A record review of Resident #1's physician order did not reflect orders on 11/05/22 for a KUB or to place a temporary gastric tube after Resident #1's G-tube became dislodged. A record review of weekend schedules revealed LVN C worked the weekends of 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. A review of the nurse notes for Resident #1 dated 11/07/22 at 11:54 AM, entered by LVN A, indicated that Resident #1 was crying and stated that her abdomen hurt around the GT site. LVN A reported concern to MD and received orders to hold GT flush until after KUB. Resident #1 ate 80% of breakfast and tolerated all medications by mouth. A review of the nurse note for Resident #1 dated 11/07/22 at 1:38 PM, entered by LVN A, indicated Change in Condition: Abdominal pain. LVN A entered another nurse note at 2:23 PM that she canceled the KUB and sent Resident #1 to the ER. During an interview on 11/17/22 at 12:14 PM, LVN A said that she was familiar with Resident #1. LVN A stated she sent Resident #1 to the hospital on 11/07/22 after the resident was observed in the fetal position, crying, holding stomach, complaining of pain - rated pain level a 12 and a 15, on a scale of 1 - 10. LVN A said that upon assessment, discovered bulging around the peg site that felt hard to touch. LVN A said that she also noticed the PEG tube was different from the initial PEG tube and noted some dull greenish drainage around the peg insert site. LVN A said after reading progress notes she found that LVN C had replaced the PEG tube after it was pulled out. LVN A said that she was not aware that LVNs were allowed to replace PEG tubes, never received training, or was checked off for competency in replacing PEG tubes. LVN A said that she notified the NP, called for a KUB as ordered, and was sent to the hospital shortly after. Review of emergency department clinical report dated 11/07/22 indicated abdominal pain that started with peg tube replacement 11/5/22 and is still present and worsening. During a phone interview on 11/17/22 at 2:03 PM, the DON said that she worked with LVN C at another facility and hired him on at this SNF. The DON said that at the other facility, the nurses were allowed to replace PEG tubes, but did not complete competency skills check off for PEG tube placement at this facility. The DON said that she placed a call to LVN C to send a copy of skills check off from other facility. The DON stated that this facility policies allow nurses to place G-tubes as needed. Review of LVN C's employee records indicated he was hired on January 7, 2022. The file indicated he was appropriately screened prior to hire and all background checks were done according to the law. There was no evidence of training or completed skills checklist in LVN C's personnel file. During an interview on 12/05/22 at 9:00 AM, the DON said that she was unaware that LVN C replaced Resident #1's GT prior to surveyor entrance and after reading the 24-hour report for the weekend of 11/05/22 and 11/06/22. The DON said her expectation for the nursing staff was to send residents out and not to replace GT without training and skills check off. The DON said she would conduct training and skills checkoff herself or arrange with an approved trainer to host classes on GT placement. The DON stated the P & P reflected the procedure on GT replacement was to send a resident to the hospital. The DON said that skills training for GT replacement was necessary for competency and to prevent harm to residents. The DON indicated that no trainings or competencies were provided to LVN C. The DON verified LVN C worked each weekend as scheduled following the placement of the temporary catheter - 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. During a phone interview on 12/05/22 at 10:43 AM, the NP said that she received a couple of calls from the SNF regarding Resident #1 pulling her GT out. The NP said that she gave LVN C orders to follow SNF P & P and to send Resident #1 to the hospital. The NP said she did not give LVN C orders to place a temporary cath or temporary GT. The NP stated the risk of PEG tube replacement if a nurse does not have the training or skills is accidental peritoneal (the tissue that lines the abdominal wall and pelvic cavity) placement of the tube. Also, the resident can get an infection or aspirate on stomach contents if the GT is placed incorrectly and used. During a phone interview on 12/05/22 at 11:16 AM, LVN C indicated that Resident #1 did not want to take meds by mouth and asked to be administered by GT. LVN C stated he raised the sheet, discovered that GT was not in place, and found it on the floor beside the bed - the GT bulb still inflated. LVN C stated he did not recall entering an order from the NP to place a temp cath. LVN C said he verified placement by air auscultation and stomach content withdrawal. LVN C said he discovered leaking around the GT site from the end of the temp cath he placed when he assisted Resident #1 up to the wheelchair. LVN C stated the dressing around the GT site was a little saturated with pink colored stomach content from breakfast. LVN C said he retrieved and placed a Lopez Valve Closed Enteral Tube Valve [a three-way stop cock intended for use in conjunction with gastric or feeding tubes and maintains a closed system] at the end of the temp cath to prevent leaking and changed the dressing around the cath insert site. LVN C said he had to change the dressing again after an hour due to leaking. LVN C said that he did not receive training or skills checkoff for temporary cath placement or GT replacement at this SNF. LVN C stated the risk of replacing the GT is inserting it in the wrong place, or the resident could be allergic to the material. LVN C verified working the following weekends: 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. During an interview on 12/05/22 at 12:42 PM, ADON N indicated nursing staff was not allowed to insert/replace a GT. ADON N said he recently conducted an in-service on 12/01/22 with nurses, reviewing the policy that stated nursing staff should not use a DeClogger to clear obstructed GTs, replace, or place foreign objects in GT entry sites to prevent from closing. ADON N stated he had not received training, trained LVN C or any nurses, or performed a skills check-off with nurses on GT placement. Review of the facility's Gastrostomy Tube Nursing Clinical Policy/Procedure, policy number: NCLN; revised 10/2020 indicated: - Procedures: Daily checklist for gastrostomy tubes: Check for pain, discomfort, or pressure around the tube site. Check the tube exit site for skin irritation, inflammation, or other signs of infections, gastric leakage, or feeding formula leakage. Daily treatment or dressings per physician orders. - Report Changes in GI Symptoms Report changes in GI Symptoms to the physician immediately. These symptoms may indicate feeding tube malfunction or improper tube placement. A record review of ASPEN Safe Practices for Enteral Nutrition Therapy practice recommendations and rationale for monitoring the feeding tube retrieved from https://aspenjournals.onlinelibrary.[NAME].com/doi/epdf/10.1177/0148607116673053 reflected: Auscultation is no longer recommended for checking placement of the feeding tube. Movement of air would likely be heard whether the tube was in the correct or incorrect location. X-ray confirmation is the most accurate method for verification of tube placement when concerns arise regarding dislodgement or placement. - The facility completed staff education on the facility's policy regarding gastrostomy tubes in that the facility does not allow nurses to reinsert gastrostomy tubes (12/05/22) - An audit of all residents with gastrostomy tubes (12/05/22) - LVN C suspended and will not work until he has met with the DON and received training (12/05/22) - New hire/agency orientation packet enhanced to include the facility's GT policy on dislodgement and methods allowed to clear an obstructed GT (12/05/22) - An ad hoc meeting with QAPI Committee regarding the items in the IJ Template (12/05/22) On 12/06/22 the surveyor confirmed the facility implemented their plan or removal sufficiently to remove the IJ by: Interviews conducted with nurses on 12/06/22 [LVN A at 2:09 PM; LVN D at 2:12 PM; LVN E at 2:16 PM; LVN F at 2:25 PM; LVN G at 2:40 PM; RN K at 3:00 PM; RN I at 3:39 PM; and LVN J at 3:50 PM] indicated they participated in an in-service training about gastrostomy tubes. The nurses stated their understanding of the procedure was to send residents to the hospital, and nurses are not to reinsert a GT. Each nurse said in their own words that they would assess the resident, call the physician, and send the resident out to ER if GT becomes dislodged. On 12/06/22 at 1:50 PM, the E.D. and DON were informed the IJ was removed; however, the facility remained out of compliance at an isolated scope and a severity of actual harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure one (Resident #1) of two residents reviewed for quality of care received treatment care in accordance with professional standards of practice in that: The facility failed to notify the physician and obtain wound care orders when Resident #1 was noted with a wound. The facility failed to ensure a wound assessment was performed and documented for Resident #1 for approximately three weeks after the wound was observed and reported to nursing staff. The facility failed to ensure Resident #1 was provided wound care to promote healing. The resident's wound deteriorated, developed an infection that required debridement and treatment with intravenous antibiotic therapy. An Immediate Jeopardy (IJ) was identified on 02/16/22. While the IJ was removed on 02/17/22, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures could affect residents with impaired skin integrity and residents at risk for impaired skin integrity of developing life-threatening infection, which could manifest into other health complications, pain, worsening wounds, and a decreased quality of life. Findings included: Review of Resident #1's undated admission record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Physician's active order summary dated 02/16/22 reflected diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident's BIMS score was 14 indicating intact cognition. The assessment reflected the resident required extensive physical assistance of two persons for bed mobility and transfers, was frequently incontinent of bowel/bladder, required extensive physical assistance of one person for dressing and personal hygiene. Review of Resident #1's care plan dated 12/31/21 revealed the risk of ADL selfcare performance deficit was addressed due to limited mobility, incontinent episodes, weakness, [CONDITION(S)] (stroke) with [CONDITION(S)]/ [CONDITION(S)] (muscle weakness or [CONDITION(S)]) affecting the right non-dominant side. Review of Resident #1's weekly skin assessments revealed on 01/31/22 the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The 02/07/22 assessment was blank and the 02/14/22 weekly skin assessment reflected a 5 by 5-centimeter unstageable (full thickness tissue loss covered by extensive necrotic tissue or eschar) wound to the coccyx was noted. The assessment further reflected infection. The note documented on the assessment reflected area to coccyx with noted discoloration to area, with no odor, small amount serous drainage (drainage composed of red blood cells and blood serum), 100% necrotic (dead tissue cells) tissue noted. Wound MD to eval and Tx upon next visit. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . as needed for soiling or dislodging. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's clinical records revealed prior to 02/14/22 there were no orders for wound care, evidence of physician notification and no documentation or assessment of the wound discovered on 02/14/22. Observation of Resident #1 on 02/16/22 at 9:28 a.m. revealed the resident was awake in bed on an air mattress. The resident was non-verbal when spoken to and a foul odor was noted in the room. Interview with DON on 02/16/22 at 10:06 a.m. revealed on Monday 02/14/22 she was working the floor as the charge nurse when she was informed by CNA B that Resident #1 had a wound. She stated staff told her the resident's wound had been a black DTI approximately 3 weeks ago. She stated there was no documented assessments of the wound, description, physician notification, orders for wound care and no wound care treatments had been provided until 02/14/22. CNA B told the DON she had reported the resident's wound to nursing staff approximately 3 weeks ago. The DON stated the routine day and evening shift nurses were new to the nursing profession and she has learned some nursing staff had been applying barrier cream to Resident #1's wound. The DON further stated LVN C told her about the resident's wound one day when the DON was running down the hallway. Additionally, the DON stated she told LVN C to tell the ADON about the resident's wound. However, LVN C was unable to recall if she had informed the ADON and the ADON stated she was not aware of Resident #1's wound. The DON stated she and other staff stayed at the facility late last night to perform skin sweeps and no residents were found with unidentified wounds. She stated she discovered some weekly skin assessments had not been performed consistently. Resident #1's weekly skin assessment was due during the evening shift and LVN C told the DON she had not had time to perform the assessment. She stated staff in-service training had been initiated and was ongoing. Additionally, The DON stated the WCP saw Resident #1 on 02/15/22 and the resident's wound was assessed to be infected. The resident was receiving Intravenous antibiotic treatment and would possibly have an MRI scan performed next week to determine if [CONDITION(S)] (bone infection) was present. Interview with the WCP on 02/16/22 at 11:47 a.m. revealed she saw Resident #1 on 02/15/21 due to a Stage IV pressure ulcer on the sacrum and she performed a surgical debridement procedure. She stated the resident was started on intravenous antibiotic due to her understanding, for a bad infection. When queried about the resident's current wound and infection being prevented if treatment had been provided sooner, she stated it was hard to know as she did not know the condition of the wound prior to her assessment yesterday. She stated, We don't know what they saw before. She further stated, I would say as soon as you see it treat it. The WCP stated infections can go bad quickly and staff would need to keep an eye on the resident. Review of Resident #1's WCP notes dated 02/15/22 reflected the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound measured 7.6 centimeters by 6.8 centimeter by 1.5 centimeters (length by width by depth) with a heavy amount of serosanguinous exudate and thick adherent necrotic (dead) tissue. The notes reflected a surgical debridement (removal of damaged tissue from a wound) procedure was performed to remove necrotic tissue, thick adherent eschar (Eschar-dark dry dead tissue within a wound). The WCP assessment notes reflected the etiology of the wound would be amended on the follow-up note due to acquisition of new information from the facility's PCP. The WCP note dated 02/22/22 reflected the etiology of Resident #1's wound was due to nutritional compromise and infection. Interview with LVN A on 02/16/22 at 1:10 p.m. revealed she had been a nurse since June 2021, worked the day shift and provided care for Resident #1. She stated approximately one week ago (02/09/22) CNA B informed her Resident #1 required a clean dressing to a wound on the buttocks area. She stated the resident was noted with a flat, pink colored, half dollar sized open area to the buttocks area. She cleansed the wound with normal saline and applied a dry dressing that CNA B told her other nurses used. She stated she did not check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated she did not call the physician or document any assessment of the wound because there had been a dressing on the wound, so she knew it was not a new wound. Interview with CNA B on 02/16/22 at 1:31 p.m. revealed she worked the day shift and provided care for Resident #1. She stated approximately two weeks ago (01/31/22) she reported to an agency nurse (LVN D) that Resident #1 had a wound to the buttocks and there was no dressing in place. She stated the resident had a small red colored open hole on the coccyx. She stated LVN D told her she would take care of it and she assumed she did. The next day while providing care for Resident #1 she informed LVN D again that Resident #1 had no dressing on his open wound and again the nurse told her she would take care of it. On Monday 02/14/22 the resident's wound was covered with a dressing that came off during incontinent care. She stated the wound looked worse than before, was black colored, draining fluid and had a foul odor. CNA B stated she reported the wound again to the DON on 02/14/22 due to the DON was the charge nurse for Resident #1. She further stated the DON was very upset because she was not aware the resident had a wound. Interviews conducted with LVN C on 02/16/22 at 1:43 p.m. and 02/17/22 at 3:12 p.m. revealed she had graduated in November 2021 and working at the facility was her first nursing job. She stated she worked the evening shift and provided care for Resident #1. She stated approximately two weeks ago CNA B informed her that Resident #1's dressing was soiled and needed changing. She observed the resident with a dressing with green drainage covering a small open area on the resident's lower back (sacrum). LVN C stated there was a dressing in place and barrier cream on the wound and she knew green drainage indicated an infection. She stated Resident #1 had experienced bowel incontinence and she cleansed the wound with a pre-moistened incontinent wipe and applied a new dry dressing even though CNA B told her barrier cream was used on the resident's wound. LVN C stated she recalled working with agency nurse, LVN D, but it was never made clear to her which one of them was the nurse in charge. She assumed LVN D was in charge due to having more experience. She further stated one day she informed the DON of Resident #1 having a wound and the DON told her to leave the wound open and the ADON would perform the assessments of residents with wounds. She stated she did not complete the weekly skin assessment for 02/07/22 because she was told by the DON that the ADON would complete assessments of residents with wounds. LVN C stated she had not received proper training at the facility and all she knew to do was administer medications. She stated she did not call the physician, obtain wound care orders or document any assessment of Resident #1's wound because she thought the ADON would take care of it all. Observation of wound care for Resident #1 on 02/16/22 at 2:16 p.m. with the ADON revealed the resident had a large open area to the sacrum with noted tunneling (wound progression that forms passageways underneath the surface of the skin), foul odor and heavy serosanguinous drainage. The wound bed was red colored with some noted necrotic tissue present. The nurse cleansed the wound with normal saline, pat dried and applied Anesept (antibiotic that fights bacteria) and Calcium Alginate silver (absorbent wound dressing) and covered the wound with a protective dressing. Interview with the DON on 02/17/22 at 11:26 a.m. revealed her expectations were that weekly skin assessments would be completed by the end of the shift assigned and if not completed, passed on to the oncoming nurse to complete. She stated the ADON was responsible for ensuring nurses completed all weekly skin assessments and that had not been done. The DON stated her expectation was that when nurses were aware of a resident with a wound, they should contact the physician, obtain treatment orders, and notify the family. She stated CNAs were to complete a stop and watch on the electronic health record when they note a change in a resident of any kind to include skin impairments and report to the charge nurse. The stop and watch information would populate to her (the DON) desktop so that she was informed of changes and staff were to call her for all things. When asked if staff had been trained or provided any education to the stop and watch and calling her, she stated she had provided instructions verbally to nursing staff. The DON further stated if weekly skin assessments were not completed residents could have an area of skin impairment that would not be identified. She stated if residents with impaired skin integrity were not identified it could be a detriment to the resident by causing delayed wound healing and infection. Interview with LVN D on 02/17/22 at 11:38 a.m. revealed she was an agency nurse and had provided care for Resident #1. She stated she worked at the facility sometime during the first week in February 2022. She stated she recalled a CNA telling her Resident #1's dressing to his backside needed changing and that the resident only needed a boarder dressing. She stated she did not recall if she placed a new dressing on the resident or if the CNA replaced the dressing. She stated she did not initially check the TAR or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN D further stated later that same day the CNA told her the resident's dressing needed changing again and that the CNA had already changed it. She then checked Resident #1's TAR and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she never removed the dressing and probably just forgot to look at the resident's wound. She stated she told LVN C Resident #1's wound must have been new as there were no orders and that an RN or physician needed to perform the initial assessment of the wound. She stated it was her understanding that an RN or physician performed initial wound assessments and weekly wound assessments thereafter. LVN D stated she was aware that if a CNA reported a resident had an open wound, she should check the TAR and orders. If there were no orders, she was to call the RN or physician for wound care orders. She stated, In the real world you have help and if time had allowed, she would have done it all, but she had to get the resident's medications out. She stated the hall was heavy and you are the nurse, med staff and treatment nurse. Interview with CNA E on 02/17/22 at 1:12 p.m. revealed she provided care for Resident #1 during the day shift. She stated on Wednesday of last week (02/09/22) she noted the resident had a wound on his bottom. She stated the wound was small, slightly open and dime sized. She stated a rubber type dressing was covering the wound. She stated she reported the wound to her charge nurse, LVN F in the past. She further stated she had observed LVN F apply a wet to dry dressing to the resident's wound when there were no rubber dressings available. Each time she was assigned to the resident a dressing was in place on his bottom. Interview with the ADON on 02/17/22 at 1:27 p.m. revealed she was also responsible for the facility's skin/wound system. She stated she was responsible for checking each day to ensure nurses performed weekly skin assessments. She stated she had not been able to perform her duties associated with the skin/wound system because she had been working the floor as a charge nurse. She stated the last time she checked to ensure weekly skin assessments were being performed was approximately 2-3 weeks ago. Interview with LVN F on 02/17/22 at 2:25 p.m. revealed she had not worked at the facility since the end of January 2022. She stated Resident #1 did not have any wounds prior to her leaving the facility. She denied being informed the resident had a wound or ever providing any wound care for the resident prior to leaving the facility in January 2022. Interview with CNA G on 02/17/22 at 3:12 p.m. revealed she provided care for Resident #1 and recalled sometime at the end of January 2022 the resident had a small open area on his bottom. She stated in February 2022 the resident had a bandage or dressing in place on his bottom. She stated the open area was a small penny sized opening with clear drainage. She further stated she was assigned to provide care for the resident off and on and after approximately 2 weeks she noticed the wound got worse and began to smell bad. She stated she did not report the wound because there was always a dressing in place, and she felt nurses were aware and treating the wound. Review of the facility's policy/procedure entitled Skin Management System revised 12/2019 reflected in part: Residents will have ongoing head to toe assessment done weekly and on an as needed basis. Any new identified areas will be documented, notification to the physician, treatment obtained, and responsible party notified. On 02/17/22 the DON provided a document entitled 5 WHYS TOOL. The document reflected: facility staff failed to provide timely wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator was notified that an Immediate Jeopardy (IJ) was identified on 02/16/22 at 4:12 p.m. The IJ template was provided to the Administrator on 02/16/22. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal was accepted on 02/17/22 at 2:10 p.m. and reflected the following: Immediate Action The Medical Director was notified of IJ on 2/16/2022 at 4:35pm. Skin sweeps of total census initiated 2/15/2022 and will be completed 2/16/2022 by Clinical Resource, MDS Nurse, ADON and DON. Review of all pressure ulcer treatments orders was initiated and will be completed 2/16/2022 by the DON. Wound assessment for Resident # was completed by the Wound Physician on 2/15/2022. Order received to Clean coccyx with normal saline or wound cleaner, pat dry, apply anisept with calcium alginate AG (silver) and dry protective dressing QD and/or prn for soiling or dislodging. Resident # responsible party was notified. Education initiated with Nurses and CNAs that included change in condition procedures for wounds, change in behaviors, refusal of care, notification of changes in condition, wound identification and documentation and abuse /neglect reporting. This education will be included in our new hire orientation to include agency staff. Education was provided by the DON, ADON and Clinical Resources. Education complete for all working Nurses and CNAs on 2/17/2022 and will continue with all newly hired staff, PRN or agency staff prior to the start of their next shift. Identification of Others Affected Currently there are 69 residents residing in the facility. The facility initiated a skin sweep on 2/14/2022 of all residents and will complete 2/16/2022. Skin sweep completed on 2/16/2022, there were no other new pressure ulcers. Systemic Change to Prevent Re-occurrence DON started in-service on 2/15/2022 with facility charge nurses and CNAs on documentation and monitoring skin integrity system along with skin assessments. The training includes use of shower sheets by the CNAs as well as the Stop and Watch Program, reporting new areas to nurses, nurse documentation / treatment / notification of new areas, new admission assessments to occur once a week for four weeks, quarterly, and with any change of condition. In-services included: documenting skin assessments, timely follow up and notification to RP, DON and MD, wound treatments, and abuse / neglect reporting until all applicable personnel educated. In-services will be completed prior to accepting assignments for all charge nurses, nursing assistants, including agency, new hires and PRN staff. This education will be included in the new hire orientation to include agency. Nurses will complete education for skin assessment prior to the start of their next shift. CNAs will also receive education on shower sheets and Stop and Watch program prior to the start of their shift. Shower sheets to be completed by CNA and any new areas to be communicated to Charge Nurse. Skin assessments to be completed by Charge Nurse, document and communicate any new skin changes to physician, responsible party and place on 24 hr. report for DON notification. Skin assessments documented for total census started on 2/15/2022 and to be completed on 2/16/2022. Skin sweep was completed on 2/16/2022 and there were no other new pressure ulcers. Head to toe skin assessments to be conducted weekly on residents ongoing. The ADON will be assigned to wound program to assess skin, complete treatments, and round with the Wound Physician. The Administrator, DON, ADON, MDS and/or designees to attend weekly systems meetings to include the skin integrity system to review skin assessment, status and progression/worsening of current pressure injuries and wounds, review and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. Monitoring Daily review of documented head to toe skin assessments, completed and documented shower sheets (CNA communication sheets) by DON/designee. DON/designee will ensure notifications and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON, (name removed) will monitor 5 nurses weekly for skin assessment and report to the weekly QAPI Committee meeting for 4 weeks, then monthly for 90 days. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monthly QAPI meeting will include skin related conditions such as pressure ulcers. Follow up on IJ Plan of Removal and monitoring will be verified by the DON and the Administrator. The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Interviews conducted with 3 LVNs, 1 RN and 7 CNAs across multiple shifts on 02/17/2 from 2:33 p.m. to 4:40 p.m. revealed the nursing staff verbalized comprehension of the in-service training. They stated they had been in-serviced on what to do in the event a resident experienced a change in condition to include development of or worsening wounds, performing weekly skin assessments according to the schedule and completing a full assessment of noted impaired skin integrity to include measurements, notifying the physician, DON, and the resident's responsible party. CNAs stated they were instructed to use shower sheets to document any impaired skin noted on a resident and report the same to the charge nurse. They were to use the facility's stop and watch system to ensure the DON was aware of any changes in resident status.Based on observation, interview, and record review the facility failed to ensure one (Resident #1) of two residents reviewed for quality of care received treatment care in accordance with professional standards of practice in that: 1. The facility failed to notify the physician and obtain wound care orders when Resident #1 was noted with a wound. 2. The facility failed to ensure a wound assessment was performed and documented for Resident #1 for approximately three weeks after the wound was observed and reported to nursing staff. 3. The facility failed to ensure Resident #1 was provided wound care to promote healing. The resident's wound deteriorated, developed an infection that required debridement and treatment with intravenous antibiotic therapy. An Immediate Jeopardy (IJ) was identified on 02/16/22 . While the IJ was removed on 02/17/22, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures could affect residents with impaired skin integrity and residents at risk for impaired skin integrity of developing life-threatening infection, which could manifest into other health complications, pain, worsening wounds, and a decreased quality of life. Findings included: Review of Resident #1's undated admission record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Physician's active order summary dated 02/16/22 reflected diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident's BIMS score was 14 indicating intact cognition. The assessment reflected the resident required extensive physical assistance of two persons for bed mobility and transfers, was frequently incontinent of bowel/bladder, required extensive physical assistance of one person for dressing and personal hygiene. Review of Resident #1's care plan dated 12/31/21 revealed the risk of ADL selfcare performance deficit was addressed due to limited mobility, incontinent episodes, weakness, [CONDITION(S)] (stroke) with [CONDITION(S)]/ [CONDITION(S)] (muscle weakness or [CONDITION(S)]) affecting the right non-dominant side. Review of Resident #1's weekly skin assessments revealed on 01/31/22 the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The 02/07/22 assessment was blank and the 02/14/22 weekly skin assessment reflected a 5 by 5-centimeter unstageable (full thickness tissue loss covered by extensive necrotic tissue or eschar) wound to the coccyx was noted. The assessment further reflected infection. The note documented on the assessment reflected area to coccyx with noted discoloration to area, with no odor, small amount serous drainage (drainage composed of red blood cells and blood serum), 100% necrotic (dead tissue cells) tissue noted. Wound MD to eval and Tx upon next visit. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . as needed for soiling or dislodging. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's clinical records revealed prior to 02/14/22 there were no orders for wound care, evidence of physician notification and no documentation or assessment of the wound discovered on 02/14/22. Observation of Resident #1 on 02/16/22 at 9:28 a.m. revealed the resident was awake in bed on an air mattress. The resident was non-verbal when spoken to and a foul odor was noted in the room. Interview with DON on 02/16/22 at 10:06 a.m. revealed on Monday 02/14/22 she was working the floor as the charge nurse when she was informed by CNA B that Resident #1 had a wound. She stated staff told her the resident's wound had been a black DTI approximately 3 weeks ago. She stated there was no documented assessments of the wound, description, physician notification, orders for wound care and no wound care treatments had been provided until 02/14/22. CNA B told the DON she had reported the resident's wound to nursing staff approximately 3 weeks ago. The DON stated the routine day and evening shift nurses were new to the nursing profession and she has learned some nursing staff had been applying barrier cream to Resident #1's wound. The DON further stated LVN C told her about the resident's wound one day when the DON was running down the hallway. Additionally, the DON stated she told LVN C to tell the ADON about the resident's wound. However, LVN C was unable to recall if she had informed the ADON and the ADON stated she was not aware of Resident #1's wound. The DON stated she and other staff stayed at the facility late last night to perform skin sweeps and no residents were found with unidentified wounds. She stated she discovered some weekly skin assessments had not been performed consistently. Resident #1's weekly skin assessment was due during the evening shift and LVN C told the DON she had not had time to perform the assessment. She stated staff in-service training had been initiated and was ongoing. Additionally, The DON stated the WCP saw Resident #1 on 02/15/22 and the resident's wound was assessed to be infected. The resident was receiving Intravenous antibiotic treatment and would possibly have an MRI scan performed next week to determine if [CONDITION(S)] (bone infection) was present. Interview with the WCP on 02/16/22 at 11:47 a.m. revealed she saw Resident #1 on 02/15/21 due to a Stage IV pressure ulcer on the sacrum and she performed a surgical debridement procedure. She stated the resident was started on intravenous antibiotic due to her understanding, for a bad infection. When queried about the resident's current wound and infection being prevented if treatment had been provided sooner, she stated it was hard to know as she did not know the condition of the wound prior to her assessment yesterday. She stated, We don't know what they saw before. She further stated, I would say as soon as you see it treat it. The WCP stated infections can go bad quickly and staff would need to keep an eye on the resident. Review of Resident #1's WCP notes dated 02/15/22 reflected the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound measured 7.6 centimeters by 6.8 centimeter by 1.5 centimeters (length by width by depth) with a heavy amount of serosanguinous exudate and thick adherent necrotic (dead) tissue. The notes reflected a surgical debridement (removal of damaged tissue from a wound) procedure was performed to remove necrotic tissue, thick adherent eschar (Eschar-dark dry dead tissue within a wound). The WCP assessment notes reflected the etiology of the wound would be amended on the follow-up note due to acquisition of new information from the facility's PCP. The WCP note dated 02/22/22 reflected the etiology of Resident #1's wound was due to nutritional compromise and infection. Interview with LVN A on 02/16/22 at 1:10 p.m. revealed she had been a nurse since June 2021, worked the day shift and provided care for Resident #1. She stated approximately one week ago (02/09/22) CNA B informed her Resident #1 required a clean dressing to a wound on the buttocks area. She stated the resident was noted with a flat, pink colored, half dollar sized open area to the buttocks area. She cleansed the wound with normal saline and applied a dry dressing that CNA B told her other nurses used. She stated she did not check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated she did not call the physician or document any assessment of the wound because there had been a dressing on the wound, so she knew it was not a new wound. Interview with CNA B on 02/16/22 at 1:31 p.m. revealed she worked the day shift and provided care for Resident #1. She stated approximately two weeks ago (01/31/22) she reported to an agency nurse (LVN D) that Resident #1 had a wound to the buttocks and there was no dressing in place. She stated the resident had a small red colored open hole on the coccyx. She stated LVN D told her she would take care of it and she assumed she did. The next day while providing care for Resident #1 she informed LVN D again that Resident #1 had no dressing on his open wound and again the nurse told her she would take care of it. On Monday 02/14/22 the resident's wound was covered with a dressing that came off [NAME][TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate treatment and services to prevent complications for one (Residents #1) of five residents reviewed for tube feedings. LVN A failed to correctly unclog Resident #1's [DEVICE] when it appeared clogged during a flush. LVN A used a declogger tool incorrectly on Resident #1's [DEVICE] that could have resulted in perforation of the [DEVICE] and/or intestinal wall. LVN A used the tool without training or a physician's order. Following the use of the tool, LVN A failed to complete an assessment on Resident #1 or notify the physician. An Immediate Jeopardy/Immediate Threat was identified on 08/03/20. While the Immediate Jeopardy was removed on 08/04/20, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 08/03/20. These failures placed residents at risk for perforation of the [DEVICE] and/or intestinal wall, replacement of the [DEVICE], hospitalization , or even death. Findings included: Review of Resident #1's MDS assessment, dated 07/28/20, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with a readmission on 07/21/20 from the hospital for [DEVICE] placement. The MDS assessment reflected Resident #1's cognition was severely impaired, and her [DIAGNOSES REDACTED]. The resident required the extensive assistance of two staff for activities of daily living and was totally dependent for eating ([DEVICE]). Review of Resident #1's comprehensive care plan, dated 07/21/20, revealed the resident had a goal for at risk of aspiration due to resident receiving nutrition by [DEVICE]. The care plan reflected no goals or approaches related to the use of a [DEVICE] declogger. Review of Resident #1's physician orders reflected: 07/21/20 100 ML of H20 (water) flushes every 4 hours via [DEVICE]. Further review reflected no physician's orders for use of a [DEVICE] declogger. Review of Resident #1's hospital transfer orders dated 07/21/20 reflected no order for the use of [REDACTED] An observation on 08/03/20 at 12:28 p.m. revealed LVN A administered 100 ML of H20 to Resident #1 through her [DEVICE]. LVN A assessed for [DEVICE] placement and poured water into the 60 ML syringe. The water did not flow into the [DEVICE]. LVN A proceeded to massage the [DEVICE] and then wiggled the [DEVICE]. The water still did not flow into the [DEVICE]. LVN A obtained a declogger from the resident's beside table . LVN A that is then inserted a declogger, a flexible threaded device that is serrated approximately 2 inches at the end, into the [DEVICE] without measuring the length of the [DEVICE], verifying the correct size, and not turning the tool in a clockwise direction during insertion and counter clockwise during removal. Following the use of the tool, LVN A administered 100 ML of H20 without reassessing for placement of the tube. A review of the declogger packaging on 08/03/20 at 2:00 p.m. with the DON revealed the following instructions: (Brand Name) Declogger Rxd only Single use only 1. Determine the size of the gastric-tube 2. Select appropriate size declogger that corresponds to the size of the tube 3. Pause pump 4. Insert the declogger to the blockage and then slowly rotate two times in a clockwise direction and then reverse rotate 2 times in counter clockwise direction while removing it. Do not attempt to force the declogger through the entire blockage 5. Repeat X4 until the stop disk is reached without difficulty 6. Flush tube with 30-60cc of water 7. Once clear reconnect the delivery tube and restart the enteral feed Discard the declogger and document results. An interview with LVN A on 08/03/20 at 12:30 p.m. revealed she had not received any training for the use of a [DEVICE] declogger and this was the first time she had used one. Review of Resident #1's clinical nurses' notes reflected on 08/03/20 at 1:25 p.m. Resident #1's [DEVICE] was intact and patent feed with 100 cc H20 flush every 4 hours. There was no further documentation of an assessment, notification of physician of the use of the declogger, or follow-up of Resident #1's condition in the clinical record. An interview with LVN A on 08/03/20 at 2:20 p.m. revealed she was unaware of the different sizes of [DEVICE] decloggers and she did not know the size or length of Resident #1's [DEVICE]. LVN A stated she was unaware if Resident #1 had a physician's order to use the declogger. LVN A stated if a [DEVICE] was clogged normally she would use warm water, reposition the resident, assess and try again. She stated if that was not successful she would call the physician. LVN A was asked why she did not do that and LVN A said, I do not know. An interview with LVN A on 08/04/20 at 10:25 a.m. revealed she did not call the physician because the [DEVICE] flushed after she used the declogger and the resident did not exhibit any pain. When LVN A was ask why she did not document the use of the declogger, LVN A said, I do not know. When LVN A was ask if she was aware of the potential of the danger using the declogger without training and a physician's order, LVN A said, no. An interview with the DON on 08/03/20 at 1:52 p.m. revealed she did not know what a [DEVICE] declogger was and not seen one before. She stated she was unaware of LVN A using a [DEVICE] declogger on Resident #1. The DON stated she did not know that the declogger was in the building and being used. The DON stated to unclog a [DEVICE], staff should use warm water, massage the tube, and reposition the resident. She stated if the [DEVICE] was still clogged the physician must be notified. When the DON was asked about in-service training and policy and procedure related to the use of a [DEVICE] declogger, she stated there was none. An interview on 08/03/20 at 4:00 p.m. with the Medical Director revealed he was familiar with decloggers, but was not familiar with the specific brand used by LVN A. The Medical Director was informed about what had occurred with Resident #1. The Medical Director reviewed the specific declogger online and stated it was very dangerous to use the declogger and staff could perforate the [DEVICE] or the lining of the stomach. He stated if a [DEVICE] was clogged nursing staff should use warm water, massage the tube, reposition the resident and if that did not work they should notify him. The Medical Director stated he could not understand why a nurse would use the declogger without any training. The Medical Director stated he was not aware Resident #1's [DEVICE] was clogged and that a declogger had been used. He stated he should have been notified so he could make the decision about sending the resident to the hospital. An interview with LVN B on 08/03/20 at 12:55 p.m. revealed she knew what the [DEVICE] declogger was and had she had worked with [DEVICE] residents. LVN B said she had no training and she would not use the declogger even if she did. An interview with LVN C on 08/03/20 at 1:07 p.m. revealed he had worked with Resident #1, knew the declogger was in the facility, in each of the [DEVICE] feeders bedside table, on the medication carts, but had never used one and if you needed one you would ask the central supply staff to order you one if you could not find one. When LVN C was ask if he had received any training concerning the declogger, he asked, You have to have training to use one of those? LVN C stated he had no training to use a [DEVICE] declogger. An interview with LVN D on 08/03/20 at 1:10 p.m. revealed she was aware [DEVICE] decloggers were available but had never used one and had no training for the use of the declogger. An interview with LVN G on 08/03/20 at 3:45 p.m. revealed he was currently taking care of Resident #1. LVN G knew there were decloggers in the building, but he had not been trained on how to use one. LVN G stated that the decloggers were dangerous and he would never use one because how would you know how far to place the declogger in and you could perforate the tube. An interview with LVN E on 08/03/20 at 3:51 p.m. revealed she knew the decloggers were in the building but had not been trained on how to use one. An interview with LVN F on 08/03/20 at 3:53 PM revealed she had not been trained on using a [DEVICE] declogger and had not used one. An interview on 08/03/20 at 4:29 p.m. with LVN G revealed the nurses conducted Walking Rounds, at the change of shift, to discuss each resident. LVN G was asked if he was aware that the previous nurse had trouble with Resident #1's [DEVICE] flush and used a declogger, and he stated he had not been informed. LVN G stated he had assessed Resident #1 at 4:00 p.m. and administered the ordered flush with no problems. An observation on 08/03/20 at 2:30 p.m. revealed the DON removing a declogger from a bedside table of a resident's room on Hall 100. An interview with the DON on 08/03/20 at 2:32 p.m. revealed she was in-servicing the nursing staff on pulling the decloggers from the facility and they were not to be used. The facility did not have policy and procedure to use the declogger and the Medical Director said they were dangerous to use in this environment due to the potential of perforation. The DON stated she had done a full sweep of the building and removed all [DEVICE] decloggers from the treatment carts, medications carts, central supply, and residents' rooms. An interview with the DON on 08/03/20 at 3:22 p.m. revealed she had notified the Central Supply Staff, via sent text message, that she was not to order anymore [DEVICE] decloggers. Review of the article Best practices for unclogging feeding tubes in adults from the Nursing2018 journal, published June 2018, revealed: The American Society for [MEDICATION NAME] and Enteral Nutrition (ASPEN) recommends warm water as the best initial choice for trying to unclog a feeding tube. First, attach a 30- or 60-mL piston syringe to the feeding tube and pull back the plunger to help dislodge the clog. Next, fill the flush syringe with warm water, reattach it to the tube, and attempt a flush. If you continue to meet resistance, gently move the syringe plunger back and forth to help loosen the clog. You can then clamp the tube to allow the warm water to penetrate the clog for up to 20 minutes. Additional second-line interventions include using a commercially available enzyme declogging kit or mechanical declogging device. These also must be used in accordance with facility policy and procedure and only by experienced clinicians. If the tube can't be unclogged by these methods, ASPEN recommends replacing it. Access on 08/17/20 from https://www.nursingcenter.com/journalarticle?Article_ ID= 08&Journal_ID= &Issue_ID= 97 Review of the decloggers manufacture's recommendations on use of the Enteral Feeding Tube Decloggers revealed the following: Instructions on [MEDICATION NAME] Usage: PRECAUTIONS: Prior to any use of the product, the length of the feeding tube should be known. Use a declogger that is shorter than the feeding tube. Caution: Federal law restricts this device to sale by or on the order of a physician. DO NOT ATTEMPT TO FORCE THE DECLOGGER THROUGH THE ENTIRE BLOCKAGE. There are five different sizes and two lengths of the Declogger Proper Usage: You should understand what different occurrences cause clogs in enteral feeding tubes so you know why exactly you are unclogging a tube. Here are some examples: kinks in the lines of the tubes, not flushing after putting medication in, dense formulas, small-bore feeding tubes and slow flowing formula can sometimes cause residue that forms buildup. Gastric acids can mix with the formula when the gastric residuals are being checked. Review of the facility's current policy and procedure entitled Maintaining Patency of A Feeding Tube (Flushing) dated as revised October 2018 revealed the following in regard to clogged feeding tubes: Occlusion or clogged tube procedures 1. Check feeding tube for kinks. A kink is a twist or curl, as in a thread, rope, tube, wire, or hair, caused by its doubling or bending upon itself. 2. Attach sixty (60) cc syringe with plunger and gently pull back on the plunger to dislodge the clog. 3. If blockage remains, draw up 30 cc of warm water into the 60 cc syringe and gently instill water into the tube. Do not force fluid into tube. Gently pull back and forth on the plunger to dislodge the clog. 4. The feeding tube can be milked with fingers from the insertion site to assist in removing the clog. 5. If attempts are not successful, notify the physician. The facility's policy/procedure had no documentation in regard to using or not using a declogger. An Immediate Jeopardy/Immediate Threat was identified on 08/03/20. The Administrator and DON were notified of the Immediate Jeopardy on 08/03/20 at 5:02 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/04/20 at 3:16 p.m. and reflected the following: 1. All nurses will be in-serviced by, Director of Nursing, for notification of decloggers and or any medical device used for those specific purposes will no longer be in facility and will not be allowed to be used in the facility Start Date 8/3/2020 -Completed 8/3/2020 a. Director of Nursing, Assistant Director of Nursing, and designated LVN H pulled all decloggers out of medication rooms, residents' rooms, and medication cart on 8/3/2020 2. All nurses will be in-serviced for [DEVICE] proficiency, care, and how to properly unclog g tubes for patency. If any resistance notify physician and obtain order to send resident out for [DEVICE] replacement. Inservice is being conducted by Director of Nursing, Assistant Director of Nursing, and designated LVN H. Start Date 8/3/2020 -Completed 8/4/2020 a. Room set up was established on 8/3/2020 for nurses to show return demonstration to Director of Nursing and Assistant Director of Nursing. Copy of proficiency check off is attached. 3. Nurses will be monitored of completion of [DEVICE] proficiency check off list Inservice by Director of Nursing, and Administrator. Start 8/3/2020-Completion Date 8/4/2020 a. Nursing staff will be required to attend, and complete proficiency check off on [DEVICE] b. Spreadsheet is being maintained by Administrator and Director of Nursing, will monitor to ensure staff completion of proficiency check off. 4. Central Supply will be in-serviced on not ordering Decloggers and notify (supplier) of blocking order for decloggers. Start Date 8/3/2020- Completed 8/3/2020 a. RN, VP of Clinical Services contacted Supply company and blocked the ordering of DeCloggers Completed 8/3/2020 b. Central Supply will bring nursing supply orders to Director of Nursing, and or designee for approval prior to ordering Completed 8/4/2020 5. Medical Director has scheduled inservice with nursing staff. Scheduled 8/4/2020 at 1:00pm a. Topics: Physician Notification, standing orders for [DEVICE], how to address [DEVICE] patency b. Staff not able to attend will be required to watch recording of Medical Director's training prior to next shift scheduled. Spreadsheet of completion is being maintained by Administrator and Director of Nursing. 6. Plan will be reviewed for the next 6 months during QAPI/QA Monitoring of the facility's Plan of Removal included the following: Interviews were conducted on 08/04/20 starting at 5:00 p.m. and continued through 08/05/20 at 4:50 p.m. with 18 staff members from various shifts regarding in-services which included [DEVICE] proficiency, assessment, care, physician notification, physician orders and how to properly unclog a [DEVICE]. The staff members were able to: Describe the correct process for assessing a [DEVICE]. Describe the process for care of a [DEVICE] Describe the process of how to properly unclog a [DEVICE]. Describe the process of when to call the physician. Describe the process of not treating a resident unless you have a physician order. Interviewed staff members and shifts were: LVN C- worked 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. LVN I- worked 2:00 p.m. to 10:00 p.m. (agency staff) LVN J- worked 10:00 p.m. to 6:00 a.m. LVN K- worked 10:00 p.m. to 6:00 a.m. LVN H- worked all shifts LVN L- worked 6:00 a.m. to 2:00 p.m. LVN M- worked 6:00 am to 2:00 p.m. (agency staff) LVN A - worked 6:00 a.m. to 2:00 p.m. LVN D - worked 6:00 a.m. to 2:00 p.m. LVN B - worked 6:00 a.m. to 2:00 p.m. LVN G - worked 2:00 p.m. to 10:00 p.m. LVN N - worked 2:00 p.m. to 10:00 p.m. RN O- weekend supervisor ADON- worked all shifts LVN Q- worked split shifts LVN R-worked 10:00 p.m. to 6:00 a.m. LVN E-worked 2:00 p.m. to 10:00 p.m. LVN F-worked 2:00 p.m. to 10:00 p.m. An interview with the DON on 08/05/20 at 2:00 p.m. revealed going forward the facility would be following the policy and best practice for assessment and care of residents with [DEVICE]s. She stated the nursing staff would be monitored for following physician orders with continued in-service and observation by the DON and ADON. An interview with the Administrator on 08/05/20 at 4:00 p.m. revealed going forward the facility would be following the policy for care and assessments of [DEVICE]s and the importance of physician orders. She stated she would ensure the facility completed and continued the proficiency training for [DEVICE]s. The Administrator was notified on 08/05/20 at 5:30 p.m., the Immediate Jeopardy was removed. While the immediacy was removed on 08/04/20, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the plan of removal.

Based on observation, interview and record review, the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable; and a resident having pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for five (Residents #10, #9, #1, #11, and #7) of 14 residents reviewed for pressure ulcers. 1. Staff failed to set Resident #10's air loss mattress to the correct weight. The mattress was set for a person weighing 450 pounds, however Resident #10 weighed 185 pounds. Staff failed to discover Resident #10's pressure ulcer on her left heel before it became unstageable. CNA L failed to off load Resident #10's heels correctly. She did not know Resident #10 was at risk for developing pressure ulcers and did not know residents, other than bedfast residents, could be at risk for developing pressure ulcers. RN D failed to monitor CNAs to ensure measures were put in place to prevent Resident #10 , who did not have pressure ulcers when she admitted to the facility, had a history a pressure ulcers on her heels and was at moderate risk for developing pressure ulcers, from developing pressure ulcers. She failed to know which residents, whom she cared for, were at risk for developing pressure ulcers. RN M failed to ensure measures were implemented to prevent Resident #10 from developing pressure ulcers. She failed to know which residents, whom she cared for, were at risk for developing pressure ulcers other than bedfast residents. RN M failed to understand the significance of an unstageable pressure ulcer. Resident #10 developed an unstageable pressure ulcer to her left heel, which caused the resident pain. 2. Staff failed to discover Resident #9's pressure ulcer on his right heel before it became unstageable. Staff failed to have more than one heel protector for Resident #9. RN D failed to monitor CNAs to ensure measures were put in place to prevent Resident #9 , who did not have pressure ulcers when he admitted to the facility and was at high risk of developing pressure ulcers, from developing pressure ulcers. She failed to know which residents, whom she cared for, were at risk for developing pressure ulcers. RN M failed to ensure measures were implemented to prevent Resident #9 from developing pressure ulcers. She failed to know which residents, whom she cared for, were at risk for developing pressure ulcers other than bedfast residents. RN M failed to understand the significance of an unstageable pressure ulcer. Resident #9's unstageable pressure ulcer to his right heel worsened after discovery. 3. Staff failed to have Resident #1 in a bariatric bed, which could accommodate her size better and make turning easier. Staff failed to turn and reposition Resident #1, who was admitted to the facility with no pressure ulcers and was at risk for pressure ulcers. Staff failed to put a pressure relieving cushion on Resident #1's wheelchair even though it was a care plan intervention for her Stage II pressure ulcer. Staff failed to put Resident #1's dressing back on her Stage II pressure ulcer on her right buttocks. Resident #1's Stage II pressure ulcer worsened to a Stage III ulcer, which caused pain. She was placed in a bariatric bed after surveyor inquiry. 4. Staff failed to conduct weekly skin assessments on Resident #11, who was admitted to the facility with no pressure ulcers and was at high risk for developing pressure ulcers. Staff failed to properly off load Resident #11's heels, after the development of unstageable pressure ulcer to her left heel. Staff failed to have heel protectors for Resident #11. Resident #11 developed an unstageable pressure ulcer to her left heel. 5. Staff failed to correctly set Resident #7's air mattress for the appropriate weight. Resident #7 was admitted to the facility with pressure ulcers and was at high risk to develop additional pressure ulcers. Staff failed to turn and reposition Resident #7. Resident #7 developed a Stage II pressure ulcer to her right buttocks and an unstageable pressure ulcer to her left hip. Resident #7's right buttocks wound was actually a Stage IV and was healing from the outside. The New Wound Care Physician would have to open up the new healed skin in order to treat the actual wound bed. An Immediate Jeopardy (IJ) was identified on 06/ 03 /14. While the IJ was removed on 06/06/14, the facility remained out of compliance at severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern," due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 19 residents, who resided on Station 300 where Residents #1, #7, #9, #10, and #11 resided, by placing them at risk for development of pressure ulcers, pain and discomfort, which could result in osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), untreated skin problems and/or death. Findings included: 1. Resident #10 was admitted to the facility on [DATE], according to her MDS assessment, dated 05/15/14. The resident was an [AGE] year-old female, who was alert and oriented and able to make her needs known. She had severe visual impairment and required the total assistance of two persons with transfers and turning in bed. The assistance of one person was required for bathing and incontinent care. The MDS assessment reflected her [DIAGNOSES REDACTED]. She had a history of [REDACTED]. According to the MDS assessment, she had a pressure reducing device for the chair and the bed and was turned and repositioned. She received therapy, and she weighed 185 pounds. The May 2014 CNA ADL Tracking Form reflected Resident #10 was totally dependent on staff with turning from side-to-side, and she required one person's assistance with turning. The form also reflected she was totally dependent for bathing, but it did not reflect the frequency of baths or if bathing occurred. Resident #10's Care Plan, dated 05/15/14, reflected she was at high risk for developing pressure ulcers. The Interventions included repositioning the resident, pressure reducing devices on her bed and chair and a Dietary Consult. Resident #10's Braden Risk Assessment Scale, dated 05/18/14, reflected a score of 12, which indicated the resident was at moderate risk for the development of pressure ulcers. Resident #10's Skin Assessment, dated 05/21/14, reflected she did not have any pressure ulcers or other skin problems. Review of the Non-Pressure Skin Condition Report (form for skin assessment utilized by the facility for weekly skin assessments), dated 05/28/14 revealed an unstageable wound was identified on Resident #10's left heel on 05/28/14. The report reflected her family and physician were notified. Unstageable means full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Stage III or IV. An SBAR (Situation, Background, Assessment, Recommendation)Communication Form, (used by the facility for communication) dated 05/28/14, reflected eschar (thick, dry, black dead tissue) to Resident #10's left heel. The Communication Form also reflected Resident #10's skin was intact, even though she had a pressure ulcer on her left heel. Resident #10's physician's orders [REDACTED]. " Review of Nurse's Notes for Resident #10 from 04/06/14 through 06/03/14 did not reveal documentation of turning the resident, off-loading her heels or the implementation of any other care plan interventions. Observation and interview with Resident #10 on 06/03/14 at 11:30 AM revealed she was wheelchair bound and had a protective boot on her left heel (there was no protective boot on her right heel.) There was no cushion in her wheelchair and there was no pressure relieving mattress on her bed (intervention included on her care plan). Resident #10 revealed she was bathed regularly and they washed her feet and cleaned between her toes. She stated she had a history of [REDACTED]. She revealed her heels were off-loaded, and she was turned when she was in bed. Resident #10 said she spent most of her time in the wheelchair. She stated she was aware of the sore on her foot, and it "hurt really bad. It's the worse pain I ever had." Resident #10 revealed they were giving her pain medication which she reported was effective. (Note: Resident #10 had [DIAGNOSES REDACTED].) Interview with CNA L on 06/03/14 at 12:10 PM revealed she found the wound when she returned to work after four to five days off, and reported it to the nurse. CNA L did not consider Resident #10 to be at risk for pressure ulcers because she was not bedfast. She revealed she thought only bedfast residents were at risk for pressure ulcers, and Resident #10 spent most of her time up in her wheelchair. CNA L stated the boot on her left leg was put on after the wound was identified. CNA L put a thin king sized pillow under the resident's calves to off load her heels. Observation of Resident #10 during the interview revealed her heels were still on the mattress surface after the pillow was placed. Interview with DON A on 06/03/14 at 2:30 PM revealed CNA L was only off for two days. DON A was informed of the information provided by CNA L. Interview with RN D on 06/03/14 at 12:20 PM revealed she discovered the wound on her weekly skin assessment. She stated she did not know about the wound, and she was not aware, without looking at the Braden Scale, the resident was at risk for pressure ulcers. RN D did not know why it was not discovered earlier. She revealed she did not think a CNA reported it to her. When asked how the wound had gotten to that stage without someone seeing it, RN D did not respond. RN D stated she performed the skin assessments every week. She revealed she had not assigned specific tasks such as turning to the CNAs, and she did not monitor preventative measures. An observation on 06/03/14 at 2:30 PM, with Treatment Nurse C, of Resident #10's wound revealed the wound, which was on the medial aspect of her left heel, was covered in eschar and measured 2.8 cm x 2.5 cm as measured by Treatment Nurse C. Treatment Nurse C revealed the physician's orders [REDACTED]. She stated she almost quit when she found out about the wound. Treatment Nurse C revealed she assisted the physician wound consultant on 06/02/14 at 8:00 PM when the physician checked the resident's wound. On 06/03/14 at 2:55 PM, an interview with RN M revealed she was not aware of Resident #10's wound previously. She could not identify the residents who were at risk for pressure ulcers and under her care, except "the obvious" bedfast ones. RN M revealed she did not know why care plan interventions for Resident #10 were not implemented, but they were "not a doctor's order, just on the care plan." RN M was not aware that an unstageable wound was very significant. She stated she thought they healed, and the slough just fell off. RN M did not monitor repositioning of residents. She was not aware Resident #10 only had one boot. Observation of Resident #10 on 06/05/14 at 10:30 AM revealed she was in her wheelchair in her room. She continued to have only one protective boot on. She had a low air loss mattress which was set for a resident weighing 450 pounds according to the setting displayed on the air mattress operating system. Resident #10 weighed 185 pounds according to her MDS assessment, dated 05/15/14. That information was provided to the Regional Vice President of Clinical Services immediately after the observation. 2. Resident #9's Admission Nursing Assessment, completed on readmission, dated 06/24/11, reflected he did not have any pressure ulcers. Resident #9's Braden Risk Assessment Scale, dated 02/07/14, reflected a score of 15, which indicated he was at high risk for development of pressure ulcers. Resident #9's Weekly Pressure Ulcer Record, dated 05/29/14, reflected on 05/01/14, a pressure ulcer was identified on the right heel. The pressure ulcer was unstageable and a possible deep tissue injury, which measured 2.0 cm x 2.2 cm on 05/01/14. Resident #9's Care Plan, dated 05/02/14, reflected he had a deep tissue injury to the right heel. According to the MDS assessment, dated 05/05/14, Resident #9 was a [AGE] year-old male who was alert and able to understand most conversations. He had mobility impairment and required the total assistance of two persons with transfers and one person's assistance for turning in bed. The assistance of one person was required for bathing and incontinent care. The MDS assessment reflected his [DIAGNOSES REDACTED]. Further review of his MDS assessment revealed he was as risk for pressure ulcers and had one unstaged slough/eschar pressure ulcer was present. Pressure relieving devices for the bed and chair and turning and repositioning were identified for skin/ulcer treatment as well as wound care. Resident #9's May 2014 physician's orders [REDACTED]. Observation of Resident #9 on 05/20/14 at 10:15 AM revealed an unstageable pressure ulcer to the right heel which measured 2.0 cm x 2.2 cm, according to Treatment Nurse C. The wound was cleansed and Skin Prep was applied. Observation of Resident #9 on 06/03/14 at 10:15 AM revealed he was on his back, had a heel protector only on his right heel and only his right heel was off loaded. CNA N was in the room and revealed she just completed incontinent care. She stated they only had one heel protector for him. That information was provided to RN D immediately after this observation. Resident #9 did not have pad protectors in his bed, pillows between his legs or a wedge behind his back. The May 2014 CNA ADL Tracking Form reflected Resident #9 was totally dependent on staff with turning from side-to-side, and he required one person's assistance with turning. The form also reflected he was totally dependent for bathing, but it did not reflect the frequency of baths or if bathing occurred. Resident #9's Comprehensive Plan of Care initiated 05/08/14 included risk for skin breakdown due to incontinence and needed assistance with ADLs. Resident #9's Comprehensive Plan of Care, initiated 05/08/14, did not address his unstageable pressure ulcer discovered on 05/01/14. Resident #9's Braden Risk Assessment Scale, dated 05/08/14, reflected a score of 13, which indicated the resident was at high risk for the development of pressure ulcers. There was no documentation of Braden Scale scores monthly as was facility protocol. The facility's current Policy and Procedure for Skin and Wound Management, revised October 2010, reflected the nurses were to complete Braden Risk Assessment Scales monthly on at risk residents. Resident #9's Skin Assessment, dated 05/08/14, reflected the unstageable pressure ulcer to his right heel. There was no Skin Assessment, dated 05/15/14, in Resident #9's clinical record. Resident #9's Physician's Telephone Order, dated 05/20/14, reflected to clean the wound on his right heel with wound cleaner, pat dry, apply collagen dressing, cover with (order did not identify what product to use), change dressing daily and as needed. Resident #9's Skin Assessment, dated 05/22/14, reflected the unstageable pressure ulcer to his right heel. Resident #9's Nurse's Note, dated 05/28/14, reflected an SBAR communication form, dated 05/28/14, for a wound on his right heel. It was an open wound, which was not staged. There was no drainage or odor. Orders were received, the wound care nurse was notified, and they were to get heel protectors. The note was signed by RN D. Resident #9's Physician's Telephone Order, dated 05/28/14, reflected heel protectors. Resident #9's Weekly Pressure Ulcer Record, dated 05/29/14, reflected the unstageable wound and possible deep tissue injury, discovered on 05/01/14 on his right heel, now measured 2.5 cm x 2.0 cm. The Record was completed by Treatment Nurse C. The measurements on 05/01/14 were 2.0 cm x 2.2 cm. Review of the Non-pressure Skin Condition Report for Resident #9 revealed the skin assessment completed on 05/29/14 indicated no skin issues. RN D completed the report. Interview with RN D on 06/03/14 at 12:20 PM revealed she had not assigned specific tasks such as turning to the CNAs, and she did not monitor preventative measures. On 06/03/14 at 2:55 PM, an interview with RN M revealed she could not identify the residents who were at risk for pressure ulcers and under her care, except "the obvious" bedfast ones. RN M was not aware that an unstageable wound was very significant. She stated she thought they healed, and the slough just fell off. RN M did not monitor repositioning of residents. 3. Resident #1's MDS assessment, dated 02/13/14, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. She was alert and oriented and required the assistance of two persons for mobility. She was able to ambulate once out of bed. She required the assistance of two persons for bathing and toileting. She was frequently incontinent. Her [DIAGNOSES REDACTED]. She was 5 foot 3 inches and weighed 315 pounds. She was at risk for pressure ulcers with none present at that time. According to the MDS assessment, she had pressure relieving devices for the bed and chair and was turned every two hours. She was receiving restorative therapy for range of motion and walker training. Resident #1's Non-pressure Skin Condition Report, dated 03/30/14, reflected the skin assessment conducted that day revealed no pressure ulcers. Resident #1's Braden Scale-for Predicting Pressure Score Risk, dated 04/05/14, was 12 which indicated she was at moderate risk for developing pressure ulcers. Resident #1's Non-pressure Skin Condition Report, dated 04/07/14, reflected the skin assessment conducted that day revealed no pressure ulcers. Resident #1's Laboratory reports, dated 04/13/14, reflected a Complete Metabolic Panel, which did not indicate dehydration with Sodium, Potassium and Creatinine within normal limits. (Elevated Sodium, low Potassium and elevated Creatinine are indications of dehydration.) The Report also reflected Total Protein and [MEDICATION NAME] levels, which were within normal range which indicated her nutrition levels were adequate to prevent skin breakdown and promote healing. Resident #1 has a Stage II pressure ulcer on her right buttocks identified on 04/18/14, according to a Wound and Skin Status Report, dated 05/14/14. SBAR Communication Form, dated 04/18/14 identified at 12:30 PM, reflected the CNA reported an opened area on Resident #1's buttocks, the physician was contacted and orders were received. The wound was identified as a Stage II pressure ulcer, which measured 2.0 cm x 2.0 cm. Resident #1's Physician's Telephone Order, dated 04/18/14, reflected to cleanse the Stage II with wound cleanser, pat dry, and apply [MEDICATION NAME] dressing PRN. Resident #1's Nursing Care Plan, dated 04/18/14, reflected the Stage II pressure ulcer on her right buttocks. The Approaches to care included: reposition every two hours and anti-pressure mattress on bed and chair. Observation of wound care to Resident #1 on 05/20/14 revealed a healing Stage III pressure ulcer on her buttocks. The wound was clean with granulation tissue in the wound bed. The surrounding skin was normal in appearance and there was no evidence of infection. A Grievance/Complaint Report, dated 05/01/14, reflected Resident #1 reported the nurse and the treatment nurse refused to put her dressing back on and she called DADS. The resident's complaint was substantiated. According to the report, staff was in-serviced and the grievance was ongoing. There was an In-service Training Report indicating the training was completed for Shower Sheets on 05/09/14 (used for documentation of skin changes during the shower) with signatures from the staff attending (22 participants). Resident #1's weight on 05/06/14 was 322.4 pounds, according to the Weight Change History, dated 05/20/14. Resident #1's Wound and Skin Status Report, dated 05/14/14, reflected the Stage II pressure ulcer on right buttocks was now a Stage III. Observation and interview of Resident #1 at 12:40 PM on 05/07/14 revealed the resident was in bed and was morbidly obese. She stated she weighed 315 pounds. She was in a regular bed which would significantly reduced the space to turn from side to side. She was positioned at least a foot below the top of the bed, slumped over. Her head was leaning to the right side. Her left arm was hanging off the left side of the bed, in between the bed and the bed rail. Resident #1 revealed she told the CNA, the nurse, the administrator and the DON she had a wound "on her butt." She stated it hurt and there was blood when she was assisted from the toilet, but they "didn't do anything." Resident #1 revealed she was not being turned, and she usually stayed up in her chair. She had a motorized bariatric wheelchair, which did not have a pressure relieving device. Resident #1 revealed occasionally she was incontinent, she put her light on and after she waited two to three hours, "she beats on the wall with her bed control to get them to come and take care of her." Resident #1 stated the wound doctor, who saw her yesterday after she told them she had "reported them to the state," told her not to spend all of her time up in the wheelchair. Observation of Resident #1 on 05/07/14 at 3:00 PM revealed she was in her motorized wheelchair going to activities. There was no pressure relieving cushion in her wheelchair. Observation and interview with Resident #1 on 05/09/14 at 10:30 AM revealed she was in a bariatric bed with a low air loss air mattress, which was set according to her weight. She stated it was very comfortable and worked well. She revealed she liked the new treatment nurse and the new DON. During the interview, CNA G came in the room. CNA G stated she did not turn the resident because the resident could turn herself, but was paralyzed and could only turn to one side. CNA G revealed she did not really have anything to do with a resident's skin or wounds. She stated she reported changes in a resident's skin to the nurse. She did not acknowledge reporting this resident's wound. 4. Resident #11's MDS assessment, dated 04/01/14, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. She was cognitively impaired and unable to make her needs known. The resident had severe visual impairment and required the assistance of two persons for turning in bed and transfers from the bed. The assistance of one person was required for bathing and incontinent care. The MDS assessment reflected her [DIAGNOSES REDACTED]. She was at risk for pressure ulcers with none present at that time, and she had a pressure reducing device for her chair and bed. According to Resident #11's Admission Nursing Assessment, dated 03/20/14 when she was admitted from another facility, she did not have any pressure ulcers. Resident #11's Dietician consultation, dated 03/26/14 for Failure to Thrive, recommended multivitamins with minerals, liquid protein 30 ml per day for 30 days for her debilitated state. Resident #11 did not have a Care Plan from admission on 03/20/14 through 04/01/14. Resident #11's Care Plan, completed on 04/01/14, included she was at high risk for developing pressure ulcers. The Approaches included repositioning the resident, pressure reducing devices on her bed and chair and a Dietary Consult. Resident #11's History and Physical, dated 04/02/14, reflected she was medically complex with [DIAGNOSES REDACTED]. Resident #11's Skin Assessment reflected was an assessment was completed on 04/14/14, and she did not have any pressure ulcers. There were no other Skin assessments for Resident #11 between 04/14/14 and 05/08/14 in her clinical record. Resident #11's Skin Assessment reflected a skin assessment was due on 05/08/14, and no pressure ulcers were identified. Resident #11's Braden Scale for Predicting the Risk of Identifying a Pressure Ulcer, dated 05/16/14, reflected a score of 16, which indicated she was at high risk for pressure ulcer development. Resident #11's Physician's Progress Note, dated 05/21/14, reflected her [DIAGNOSES REDACTED]. Resident #11's May 2014 physician's orders [REDACTED]. Weekly skin assessment, if any abnormalities follow the skin protocol." Resident #11's Physician's Telephone Order, dated 05/20/14, reflected to cleanse eschar to the "right" heel with wound cleaner, pat dry, apply skin prep. (Note: This wound was not identified until 05/22/14, according to the SBAR with the same date.) An SBAR, dated 05/22/14, reflected the resident had a "wound to left heel." There were no measurements or additional wound description. The SBAR indicated the wound was possibly a deep tissue injury. An interview with Treatment Nurse C on 06/04/14 at 8:10 AM revealed the wound to Resident #11's left heel was an unstageable pressure ulcer. Resident #11's Nurse's Notes, dated 05/22/14 through 06/03/14, did not reflect any documentation of the unstageable pressure ulcer. Resident #11's Physician's Telephone Order, dated 05/22/14, reflected to cleanse with wound on her left heel with cleaner, apply collagen dressing, cover with dry dressing daily and as needed until healed. The Order also reflected to apply heel protectors. Resident #11's Wound Skin and Status Report, dated 05/29/14, reflected the wound was 2.0 cm x 2.0 cm and was unstageable. Observation of Resident #11 on 06/03/14 at 1:30 PM revealed she was in bed, on her back with her heels only partially off the mattress surface with a thin regular size pillow under calves. The resident was not wearing any heel protectors. She was alert but not able to make her needs known. Interview with RN D on 06/03/14 at 12:20 PM revealed she had not assigned specific tasks such as turning to the CNAs, and she did not monitor preventative measures. On 06/03/14 at 2:55 PM, an interview with RN M revealed she could not identify the residents who were at risk for pressure ulcers and under her care, except "the obvious" bedfast ones. RN M was not aware that an unstageable wound was very significant. She stated she thought they healed, and the slough just fell off. RN M did not monitor repositioning of residents. 5. Resident #7's Weekly Pressure Ulcer Record, dated 04/23/14, reflected on 04/23/14, an unstageable 0.4 cm x 0.6 cm pressure ulcer was identified on her left medial foot. Additionally on 04/23/14, an unstageable pressure ulcer 1.0 cm x 0.2 cm was identified on her right hip. The May 2014 CNA ADL Tracking Form reflected Resident #7 was totally dependent on staff with turning from side-to-side, and she required one person's assistance with turning. The form also reflected she was totally dependent for bathing, but it did not reflect the frequency of baths or if bathing occurred. Resident #7's MDS assessment, dated 05/07/14, reflected the resident was a [AGE] year-old female who was readmitted to the facility in April 2011. She was alert and disoriented and able to make her needs known. She had mobility impairment and required the total assistance of one person with turning in bed, and she was bedfast. The assistance of one person was required for bathing and incontinent care. Her [DIAGNOSES REDACTED]. Her weight was 116 pounds. Further review of the MDS assessment revealed she was at risk for the development of pressure ulcers. There were three pressure ulcers identified as unstageable due to slough/eschar. Pressure relieving devices for her bed and chair and turning and repositioning were identified for skin/ulcer treatment as well as care to wounds and application of dressings. Resident #7's Braden Risk Assessment Scale, dated 05/08/14, reflected a score of 13, which indicated the resident was at high risk for the development of pressure ulcers. Resident #7's Weekly Pressure Ulcer Record, 05/08/14, reflected on 05/08/14, a 1.0 cm x 1.0 cm Stage II pressure ulcer was identified on her right buttocks. Resident #7's Wound Physician's Progress Notes reflected on 05/28/14 her left foot had improved, and the measurements were 1.5 cm x 2.4 cm x 0.3 cm, the depth had not changed, and the surface area was smaller. The Notes reflected the wound had too much hyper-granulation tissue (which meant could not close), but no change in wound care. Her right hip wound was smaller, undermining decreased, measurements were 0.5 cm x 0.4 cm x 1.7 cm. Treatment unchanged. New wound on her left hip which was unstageable, measurements were 2.5 cm x 2.0 cm x 0.2 cm, surface area was (5 cm) squared, 50% granulation tissue and 50% skin, so it was a reopened wound. Observation of Resident #7 on 05/07/14 at 2:30 PM revealed she was bedfast. She was alert and confused. She was oriented x 1. She was on an air mattress which was not set correctly. It was set for a person weighing 200 pounds. Treatment nurse was made aware of the setting Interview with Treatment Nurse C on 05/07/14 at 10:30 AM revealed the wounds identified on 04/23/14, which was her first day as the treatment nurse, were identified by her on her first rounds providing wound care. Observation of Resident #7 05/08/14 at 11:00 AM, 1:00 PM and 3:00 PM revealed she was on her back. Interview with CNA N on 06/03/14 at 10:15 AM revealed she turned residents every two hours. 7. Review of Resident Census and Conditions of Residents provided by DON A on 05/07/14 at 12:10 PM revealed the facility had 20 pressure ulcers and 14 of those were facility acquired. An interview on 05/07/14 at 11:45 AM with DON A revealed this was her third day in the facility. She stated she reviewed the Resident Census and Conditions of Residents on her first day and identified a concern regarding pressure ulcers. She revealed she met with Treatment Nurse C on 05/06/14 and they made rounds looking as this concern. DON A stated they developed a plan of approach. According to her initial observations, the areas of concern were focused on station 200 and station 3

Based on observation, interview and record review, it was determined, the facility failed to provide the necessary goods and services to attain or maintain the highest practicable physical well-being for one (Resident #3) of nine residents reviewed for pain management and for three (Residents #9, #11 and #17) of six reviewed residents for skin breakdown and one for catheters. 1) Staff failed to pre-medicate Resident #3 before wound care and repositioning. 2) Staff failed to assess the effectiveness of Resident #3's pain medication and other interventions to control her pain. These failures resulted in Resident #3 voicing complaints of pain during wound care and repositioning on 01/06/14. 3) LVN Y was unable to accurately document Resident #9's wounds when she was assessing the resident's skin. She was documenting the resident's skin was clear when the resident was still receiving treatments on her wounds. WCN assessed the wound on Resident #9's second right toe as being diabetic because the resident had a [DIAGNOSES REDACTED]. These failures placed Resident #9 at risk for missed treatments and inappropriate treatments resulting in delayed healing. These failures could affect the 59 residents receiving pain medication by placing them at risk for unrelieved pain, discomfort, and a decreased quality of life. 1) LVN X and Y were not aware Resident #11's foley catheter had thick cloudy sediment. Both nurses stated catheter was cheched every shift. 2) Resident #11 had a history of [REDACTED]. The facility failed to properly assess and ensure Resident #11 was free of urinary tract infections. 3) The Wound Care Nurse (WCN) failed to daily observe and change Resident #17's venous ulcer wound dressing when it became soiled as ordered Findings included: 1) Resident #3's Face Sheet, dated 12/04/12, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's MDS assessment, dated 12/03/13, reflected she was totally dependent on two or more staff for bed mobility, and she had occasional pain that did not make it hard to sleep or limit her daily activity. Resident #3 rated her pain during pain interview for MDS as an "8." Resident #3 was on scheduled pain medication and as needed pain medication for breakthrough pain. She was able to understand others, she was able to communicate her needs, was moderately impaired for decision-making, and at times her decisions were poor requiring supervision. Resident #3's undated Care Plan, with an admission date of [DATE], reflected these approaches concerning assistance with bed mobility: 1) She required the limited assistance of one person with bed mobility. 2) She required the extensive assistance of one person with bed mobility. 3) She required the total assistance of one person with bed mobility. Resident #3's undated care plan with an admission date of [DATE], reflected she had an unstageable pressure ulcer, staff was to administer pain medication at least (blank) prior to initiating treatment. Resident #3's undated care plan with an admission date of [DATE], reflected she was experiencing the presence of occasional pain. Resident #3 was experiencing the presence of occasional pain in (blank). Staff was to evaluate Resident #3's pain daily using 1-10 scale. Resident #3's pain goal was (blank), monitor Resident #3's pain for worsening symptoms and report to physician. (Resident #3's) goal for pain is to verbalize full relief of pain and (Resident #3) will verbalize that pain is decreased to goal of 3 or less." Resident #3's undated "pain assessment" sheet reflected she had acute generalized pain morning, afternoon, evening, and night, in her knees and sacrum. Her acceptable pain level was zero and repositioning caused increased pain, and the pain was relieved by repositioning and medication. The pain assessment also reflected Resident #3's description of the pain was an "ache." Resident #3's pain interview, dated 11/26/13, reflected she had pain at an intensity of 10 on scale of one to 10 (with one being no pain and 10 being the worst pain ever experienced). Resident #3's Hospice Interdisciplinary Plan of Care, dated 11/28/13, reflected pain was a problem, and the frequency of the pain was occasionally. Her pain was managed by [MEDICATION NAME] ([MEDICATION NAME]) 5/325mg three times a day and a [MEDICATION NAME] 50 mcg every 72 hours. The medication could be adjusted for comfort during wound care and ADLs. The caregiver (Hospice) teaching to give medication 30 minutes before treatment. Resident #3's November 2013 nurses' MAR pain assessment reflected five doses of [MEDICATION NAME] given (11/24/13, 11/25/13, 11/26/13, 11/28/13, and 11/30/13) no pain assessment was documented, but medication was administered and the effectiveness was not documented even though there was a space for it. Resident #3's pain interview, dated 12/03/13, reflected she had a pain intensity of eight. An untitled document reflected LVN U administered medication to Resident #3 on 12/04/13, but the name of the medication was not on the document. Resident #3's pain interview, dated 12/06/13, reflected she had a pain intensity of eight. Resident #3's December 2013 nurses' MAR indicated [REDACTED]. On 12/07/13, 12/08/13, and 12/09/13, Resident #3 received pain medication prior to wound care. The MAR indicated [REDACTED]. Review of Resident #3's December 2013 pain management flow sheet reflected inconsistent documentation of the pain medications' effectiveness. Resident #3's Weekly Nursing Summaries, dated 12/24/13 and 12/24/13, reflected she was frequently in pain, which she vocalized and demonstrated with facial expressions and protective body movements. Resident #3's Hospice Interdisciplinary Plan of Care, dated 12/26/13, reflected pain was a problem and she demonstrated pain by moaning/crying, restlessness, grimacing, and irritability. The frequency was her pain was identified as occasional that was worsened by movement. The pain was managed by [MEDICATION NAME] 5/325 mg three times per day, and a [MEDICATION NAME] 100 mcg every 72 hours, and [MEDICATION NAME] 0.25 mg - 1.0 ml as needed. The medications were effective, and her comfort was maintained. Caregiver (Hospice) teaching of nonverbal demonstration of pain, and symptoms were managed on current intervention. Resident #3's Hospice Interdisciplinary Care Plan, dated 01/01/14, reflected the same interventions and treatment of [REDACTED]. Resident #3's January 2014 Nurses' MAR indicated [REDACTED]. The assessment for the resident pain by shift reflected the resident has no pain or had two days with pain intensity of five. Resident #3's January 2014 E-MAR reflected administration and follow-up on the doses of [MEDICATION NAME] on 01/01/14, 01/02/14, 01/06/14 (12:27 p.m.), and 01/06/14 (5:03 p.m.). Resident #3's Nurse's Notes, dated 12/29/13 through 01/06/14, reflected Resident #3 had a [DIAGNOSES REDACTED]. Further review inconsistent documentation on 01/02/14 and 01/03/14, of Resident #3 experiencing pain "only when she is repositioned." Resident #3's Nurse's Notes, dated 01/06/14, reflected Resident #3 was in bed, in her room, quiet and calm. The Wound Nurse informed Resident #3 she was going to perform the wound treatment and asked if she was hurting; the resident replied, "No." The Charge Nurse was in the room to assist and she asked the resident if she needed something for pain prior to repositioning, the resident replied, "No." During the treatment process the resident remained calm and complained of no pain, when CNA entered the room to assist with repositioning the resident became angry and started to verbalize pain. Pain medication was administered at that time and the resident was repositioned. Resident #3's January 2014 Physician's Orders reflected she was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The orders also reflected [MEDICATION NAME] (narcotic pain medication) 5-325 mg one tablet by mouth three times a day; [MEDICATION NAME] (narcotic pain medication) Patch 100 mcg apply topically every three days for pain; [MEDICATION NAME] (narcotic pain medication) 20 mg/5 ml solution give 0.25 to 1.0 ml by mouth every hour as needed for pain; and [MEDICATION NAME] (pain medication) 650 mg give one suppository per rectum every four hours as needed for pain. The orders also reflected she needed to be turned every two hours. Further review of the Physician's Orders revealed to clean her sacral wound with normal saline, pat dry, and pack wound cavity with silver alginate and cover with a dry dressing every day and as needed. Resident #3's History and Physical, dated 01/06/14, reflected she was medically complex with pain in her joints and back and to continue medications and Hospice, per family request. Observation on 01/06/14 at 9:30 a.m., during initial tour revealed Resident #3 in bed, lying on her back, asleep on an anti-pressure relieving bed. Interview at that time with LVN T revealed Resident #3 was on Hospice with an unstable pressure ulcer and when she was treated or moved the resident experienced a lot of pain, but this was something that had been ongoing with the pain, since her admission on 11/19/13. LVN T stated Resident #3 only hurts when she was moved, but "we have been giving her pain medication that was scheduled and pain medication as needed when she tells us. Sometimes she tells us she does not need the pain medication and then she will hurt when we are moving her." Observation on 01/06/14 at 12:30 p.m., revealed Resident #3 was on her right side in the bed with CNA O holding her, and the wound nurse was in the bathroom washing her hands. Resident #3 could be heard as the surveyor entered the room through the open door voicing to CNA O to put her on her back because she was having some pain. The surveyor walked around to the opposite side of the bed to see Resident #3's face tensed up with her eyes closed, asking CNA O to please put her on her back because she was having some pain and just wanted to be left alone. CNA O had Resident #3 bundled in blankets and a bed linen trying to hold her on her right side. Resident #3's body was shaking as she was trying to assist CNA O to stay on her right side. The Wound Nurse exited the bathroom and CNA O asked if she could help reposition Resident #3 back onto her back. The Wound Nurse said no not right now, I have got to go get her nurse and get her something for pain, and then I can help you." CNA O stated Resident #3 was like this a lot of the time, anytime she has to be touched to reposition her, or doing her treatment sometimes is really bad. The Wound Nurse came back into the room about two minutes later and Resident #3 was repositioned onto her back. Resident #3 verbalized pain during the repositioning and then stopped when she was on her back. LVN T administered the pain medication to Resident #3 about five minutes after this. Observation on 01/06/14 at 12:40 p.m. and 1:20 p.m., revealed Resident #3 sleeping on her back, in her bed, snoring. Her lunch tray was observed on the bedside table uneatened. Interview on 01/06/14 at 2:45 p.m. with Resident #3 revealed she had periods of time where she was okay, that was when she was still and asleep. Resident #3 stated when the staff had to move her, sometimes it hurt badly. Resident #3 stated she never knew when the pain was going to happen really badly, it just happened. Resident #3 said she felt like she was crazy. The surveyor informed Resident #3 she was in the room after they had completed her treatment, and the resident stated yes that was really bad. Resident #3 revealed sometimes they gave her pain medication and sometimes they did not. Resident #3 stated then sometimes when they gave her the pain medication, they gave it and just started care. Resident #3 explained she would like to visit longer, but she would really like to rest when she was not in pain. The surveyor queried Resident #3 concerning her being observed sleeping instead of eating her lunch and the resident replied she did not eat, she was hurting and she just wanted to sleep. Resident #3 rated her pain as a "7" and after pain medication a "5." Interview on 01/06/14 at 3:25 p.m. with LVN V, charge nurse, revealed she thought Resident #3 should have always received pain medication before any treatment. LVN V stated she never had to do treatments on Resident #3, since the facility had a wound nurse. LVN V stated Resident #3 never really asked her for anything. LVN V revealed the resident really only hurts when you reposition her or have to turn her. When queried LVN V if she gave Resident #3 any pain medication prior to repositioning her, LVN V replied, "I ask the resident if she needs something, but she will tell you no and then she will verbalize a lot of pain." LVN V stated she thought Resident #3 needed to be educated on how to tell staff about her pain, because she was very inconsistent in describing her pain. Interview on 01/06/14 at 3:40 p.m. with CNA DD and CNA EE revealed they both took care of Resident #3. They stated they went in together because it took two people to care for her. CNA DD stated they really dreaded going into the room because she was a really nice lady. CNA EE stated the minute she saw the staff in the room, or if they had to wake her up, she will "shut down" because she knew they were going to have to move her. Both CNAs stated if she could stay in the same position she was great, but if they had to move her, it was bad. CNA DD revealed the pain was the worse around the resident's knees and lower legs. CNA DD stated Resident #3 always apologized to them after care for her complaining. CNA DD revealed it happened almost every time they repositioned her or checked her for an incontinent episode. When asked if the nurses were aware, both CNAs replied yes. When asked what the nurses did about it, the CNAs responded they did not know. They stated all they knew was they "dread" changing her. They revealed they knew it had to be done, but the resident continuing to express pain and sometimes crying really got to them. Observation on 01/07/14 at 10:00 a.m., following surveyor's intervention with Wound Nurse and LVN U, charge nurse, revealed wound care with Resident #3 experiencing limited pain. During the treatment Resident #3 complained of pain three times, once during cleaning and twice during repositioning. Interview on 01/07/14 at 10:30 a.m. with the Wound Nurse, following wound care, revealed Resident #3 was better today because she (Wound Nurse) ensured the staff gave Resident #3 pain medication prior to the treatment. The Wound Nurse stated some of the nurses just did not understand pain and the different types of pain. She stated, she really thought LVN T had given the resident pain medication on 01/06/14. The Wound Nurse said LVN T checked with the resident, who told LVN T she did not need pain medication. The wound nurse revealed she thought LVN T would give Resident #3 the pain medication anyway. The Wound Nurse stated she guessed she would have to follow-up on the pain medication because a nurse in the past told her she (Wound Nurse) could not tell her what to do. The Wound Nurse revealed she also had a nurse ask her why she (the nurse) should give Resident #3 pain medication because she was going to verbalize pain anyway. Interview on 01/07/14 at 10:30 a.m. with the roommate of Resident #3 revealed the resident expressed pain when the staff came in to reposition her. The roommate stated Resident #3 sometimes she thought would make a show of expressing her pain, but when she (the roommate) mentioned this to Resident #3, the resident told her roommate she was just "mean." Interview on 01/07/14 at 10:45 a.m. with LVN U revealed she thought part of Resident #3's pain was fear or anxiety. She stated anytime they moved Resident #3 she would express pain and she thought they were used to her doing that. When asked if she was aware of any medication changes made by Hospice or the last time the Hospice had visited the resident, LVN U replied she did not know the last time the Hospice nurse saw Resident #3. LVN U stated the assessment sheets for pain were in the computer and were in the medication sheets. We are supposed to document both places, but sometimes it was confusing which one to use. Observation and interview on 01/07/14 at 4:00 p.m. of CNA DD and CNA EE repositioning Resident #3 revealed the nurse had already given Resident #3's pain medication before they came in the room. CNA DD stated it did not always happen that way, until surveyor intervention. Resident #3 asked CNA EE if she could hold her hand, so she could squeeze if she started hurting. CNA EE directed the resident to hold onto the gait belt wrapped around her waist instead. During the repositioning Resident #3 clamped her mouth closed, shook, grimaced, verbally expressed pain, and grasped the gait belt. CNA DD and CNA EE repositioned Resident #3 and at one time offered to stop, but the resident agreed to let them finish, even though she was expressing pain during the process. Resident #3 told the CNAs to make sure the nurse gave her some more pain medication after they were finished. CNA DD and CNA EE reported to the charge nurse, Resident #3 had requested more pain medication. LVN HH charge nurse stated he would give the resident some more medication. CNA DD told the charge nurse it was not as bad this time, at least she was not expressing a lot of pain this time. Interview on 01/07/14 at 4:20 p.m. with Resident #3, following repositioning, revealed she was grateful for the surveyor's intervention. Resident #3 stated the surveyor made a difference in her life. She revealed the staff took good care of her, but they really needed to better understand how her pain was sometimes, and because of the surveyor they were getting better. Interview on 01/07/14 at 4:20 p.m. with ADON A revealed she felt the staff was doing a good job with Resident #3's pain management. ADON A stated she reviewed Resident #3's clinical record, and the pain medications had been adjusted in the past, and Hospice was helping with managing her pain. When asked when the last time was the Hospice nurse saw Resident #3, she replied they had contacted Hospice and the Hospice nurse was coming to see Resident #3 and she hoped the Hospice nurse could help them. ADON A said she thought something else needed to be done to assist Resident #3 in managing her pain. ADON A revealed she thought the nurses had become complacent with Resident #3's expressing of pain. She stated she thought the nurses heard Resident #3 complaining about her pain, and they thought well she was just complaining again. ADON A stated the nursing staff was being in-serviced starting that day on pain assessment and how to use the pain assessment sheets. Interview on 01/08/14 at 10:00 a.m. with LVN T revealed she thought Resident #3 would be "better served" if she was given [MEDICATION NAME] more often. She stated the Hospice nurse saw the resident and made changes to her [MEDICATION NAME] pain medication, after all this time. LVN T stated she hoped that would help Resident #3. Resident #3's physician telephone order, dated 01/07/14, reflected to change [MEDICATION NAME] 5/325 mg one tablet by mouth from three times a per day to every four hours while awake for pain. Interview on 01/08/14 at 10:15 a.m. with LVN U revealed the pain management sheets were being used by all the nursing staff now. She stated they were in-serviced on how to assess pain, how to use the pain assessment sheets and to utilize the pain medications that were ordered. An interview on 01/07/14 at 12:50 p.m. with the ADM and DON (a corporate nurse serving in the capacity of interim DON during the survey) revealed when asked if she was informed of the concerns the survey team had with Resident #3's pain management, the DON replied she was not made aware. The ADM stated the issue with Resident #3's pain management was "unacceptable,"the facility was a "work in progress, " and there were problems that needed to be "fixed." When the ADM and DON were informed the facility had problem with pain management in March 2013, the DON stated she was the DON at that time, and she put systems in place, but those systems were not followed. The ADM stated he did not want anyone working in the facility who was insensitive to a resident's pain. The DON stated she believed staff sometimes unintentionally considered a resident's behavior as routine behavior. On 01/07/14 at 5:45 p.m., the ADM and ADON A wanted to discuss Resident #3's pain management. The ADM stated he wanted to "appeal" the SQC because he believed the facility did what the resident's physician ordered. He revealed he did not want to over-sedate Resident #3 or "kill" her with too much pain medication. On 01/08/14 at 6:00 p.m., the ADM stated the DON and he "inherited" the problems in the facility, but they did not "cause it." He stated they were "committed" to fixing the problems, and "We'll fix it." The ADM acknowledged there were a lot of problems in the facility, but he stated he would get them fixed because he wanted this facility to be a good "campus." Interview on 01/09/14 at 2:30 p.m. with LVN HH revealed he always tried to give pain medication to the residents he was responsible for, including Resident #3, but sometimes he got so busy and forgot to follow up and document the results of the pain medication. LVN HH revealed the CNAs he worked with were good about telling him about residents' pain. The controlled drug sign-out sheet for Resident #3 reflected 24 doses of [MEDICATION NAME] were given from 11/24/13 through 01/07/14, and there was either partial documentation or no documentation of a pain assessment and effectiveness of the medication. The facility's in-service reports, dated 01/09/14, reflected an in-service was conducted on 01/09/14 by ADON A for the CNAs and nurses regarding pain management, including assessment and documentation of pain. The facility's current Pain Policy, dated 01/01/14, reflected: "1. It is the intent of...To provide pain management and prevention for residents/patients... 2. Policy Statement: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 3. Procedures: 1. A Pain Assessment/data collection will be conducted by the licensed nurse on admission, with a change of condition... 2. Pain will be monitored and documented by the licensed nurse every shift using an evidence based pain scale or non-verbal pain scale. 3. Pain will be monitored for break through pain, (pain experienced between scheduled doses) a prn (as needed) pain medication is administered as part of the treatment regimen for pain management, pain will be rated before and after administration for the medication note effectiveness will be documented in the medical record... 5. A pain care plan with individual interventions will be initiated for all residents on pain medication, reviewed and updated with new pain, and quarterly. 6. The pain management system will be evaluated weekly in the Risk meeting and monthly at the QAPI (Quality Assurance and Performance Improvement) meeting for trends and follow up. 2) Resident #11's Face Sheet, dated 10/14/13, reflected the resident was an [AGE] year-old female with [DIAGNOSES REDACTED]. Resident #11's MDS assessment, dated 10/21/13, reflected she was frequently incontinent of bladder and always incontinent of bowel. The MDS did not indicate Resident #11 had a catheter. The activities of daly living reflected Resident #11 required extensive assistance with her ADLs. The MDS also reflected her brief interview for mental status assessment (BIMS) was 3, Resident #11 was severely impaired. The care plan dated 10/08/13 reflected Resident #11 was incontinent of urine at times. The approaches identified were: 1) initiate bladder retraining plan based on resident's assessment 2) Observe skin daily for irritation and redness 3) Ongoing assessment of color, clarity and character of resident's urine 4) Assess for symtoms urinary tract infection 5) ....Refer to urologist for evaluation of incontinence. Further review of the care plan did not reflect care for the catheter. An observation on 01/06/14 at 9:25 a.m. revealed Resident #11 lying in bed with the catheter drainage bag at the bedside. The tubing and the urine in the bag were thick with cloudy, whitish sediment. ADON A stated, at that time, the resident was bedfast and mobile via a wheelchair and she was incontinent of bowel and bladder, required total assistance with ADLs, had a catheter, and was alert and oriented to herself. ADON A also stated Resident #11 required assistance with transfers and had a pressure ulcer on her coccyx. Resident #11's Nurse's Notes, dated 12/21/13 at 7:30 p.m. reflected she was receiving antibiotics for treatment of [REDACTED]. The Notes also reflected the urine in the Foley remained "amber with sediment and no odor." Resident #11's Nurse's Notes, dated 12/22/13 at 9:00 a.m., reflected her urine was clear and yellow. Resident #11's Nurse's Notes, dated 12/23/13 at 1:08 p.m., reflected the Foley catheter was intact and patent (not clogged). There was no description of the urine color or a thorough assessment of the resident on antibiotic treatment for [REDACTED]. Resident #11's Nurse's Notes, dated 01/02/14 at 2:05 p.m., reflected her Foley catheter was changed due to leaking, and there was yellow urine returned. The urine was not described as clear or cloudy. Resident #11's Nurse's Notes, dated 01/03/14 at 7:58 a.m., reflected her Foley catheter was readjusted with 5 ml fluid added to the bulb due to the Foley leaking. The Note also reflected the urine was yellow with no other information about the urine and/or odor. Resident #11's January 2014 Physician's Orders did not reflect an order for [REDACTED]. An observation on 01/06/14 at 5:10 p.m. revealed Resident #11's catheter was changed, and the urine was less cloudy, but dark amber urine in the bag. Interview with LVN JJ at that time, revealed the catheter was changed only when it leaked and it frequently leaked. She stated she had not observed the catheter since she came on duty. Interview with ADON A on 01/06/14 at 5:15 p.m. revealed she had seen Resident #11's Foley catheter and it had thick sediments earlier, but she could not remember if she asked the Charge Nurse to change the bag and tubing or not. She stated she did not know why Resident #11 had the Foley catheter. She thought the resident had the Foley catheter because the resident had pressure ulcers on her buttocks. ADON A revealed she was not informed the Foley catheter had thick white sediment in it. Interview with LVN Y on 01/07/14 at 9:30 a.m. revealed an order for [REDACTED]. When asked for the order for the Foley catheter LVN Y if there needed to be a physician's order to insert a Foley catheter before one was placed. Observation of Resident #11 at that time revealed she was in bed. The Foley catheter had dark amber urine with thick, whitish sediments. Resident #11's Urinalysis Results, dated 01/06/14, reflected, "Color/Clarity: was Yellow and Cloudy, protein, 100, blood small, [MEDICATION NAME] positive mucous moderate, Leukocytes was large. These results were normally negative or not seen." Resident #11's Culture and Sensitivity Report, dated 01/10/14, reflected her urine had cultured three organisms: Morganella morganii (gram-negative rod commonly found in the environment and in the intestinal tracts of humans, mammals, and reptiles as normal flora) with a colony count greater than 100,000; Providencia stuartii (gram-negative bacilli that are responsible for a wide range of human infections and commonly found in soil, water, and sewage) with colony count greater than 100,000; and Escherichia coli (gram-negative facultative anaerobic organism, rod-shaped bacterium that is commonly found in the lower intestine Gastrointestinal tract of warm-blooded organisms) with colony count greater than 100,000. Resident #11 was treated with [MEDICATION NAME] 500 mg intramuscular every twelve hours for ten days due to urinary tract infection. Observation on 01/08/14 at 9:15 a.m. revealed Resident #11 was asleep in her bed. The Foley catheter bag was on the floor under her bed. Interviews with the following staff revealed they had not observed any sediment in Resident #11's urine in the catheter tubing and drainage bag: LVN X, charge nurse, on 01/07/14 at 1:30 p.m., LVN Y on 01/07/14 at 9:30 a.m., CNA AA on 01/07/14 at 1:35 p.m., CNA CC on 01/08/14 at 1:00 p.m., and MA FF on 01/08/14 at 3:30 p.m. Interview with ADON A on 01/09/14 at 10:45 a.m. revealed the CNAs were not informing the Charge Nurses of issues including the catheter findings on the floor, and the Charge Nurses were not thoroughly assessing the residents during their shifts when ashed why the staff did not recognize the changes with the catheter. 3) Resident #17's Face Sheet, dated 01/04/14, reflected the resident was a [AGE] year-old female readmitted to the facility on [DATE]. Resident #17's MDS assessment, dated 11/29/13, reflected [DIAGNOSES REDACTED]. Resident #17's Care Plan, dated 11/20/13, reflected the ulcers on the resident's heels were venous related ulcers, and the interventions for the right heel were: 1) Perform treatments per order, if no improvement times two weeks report to the physician, and 2) Monitor areas for increase breakdown, signs and symptoms of infection - report to physician. Resident #17's January 2014 Physician's Orders reflected she was receiving hospice services due to [MEDICAL CONDITION]. The Orders also reflected Resident #17 had treatment orders for bilateral lower extremities. Resident #17's Physician's Orders reflected to clean the resident's wound Monday, Wednesday, Friday and as needed due to dislodgement and/or soilage of dressing. An observation on 01/06/14 at 9:15 a.m. revealed Resident #17 in her Geri-chair watching television. ADON A stated, at that time, Resident #17 was mobile via wheelchair, was incontinent of bowel and bladder, and had a history of [REDACTED]. She stated Resident #17 had pressure ulcers on her heels. An observation on 01/08/14 at 4:40 p.m. revealed Resident #17 had dressings to her heel areas, dated 01/06/14. The dressing on the right heel area, dated 01/06/14, was saturated with black, red and serious drainage. The mattress covering the bed at the foot area was covered with dried red drainage from the dressing. Resident #17 stated the physician had not visited her, but the WCN dressed her wound on 01/07/14. The resident also stated the WCN only changed her dressing three times a

Based on observation, interview and record review, it was determined, the facility failed to ensure one (Resident #11) of six residents reviewed for pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. 1) CNA AA failed to inform the WCN or Resident #11's Charge Nurse when she removed the soiled coccyx pressure ulcer dressing from the resident. 2) CNA AA failed to thoroughly clean Resident #11 after an incontinent episode to prevent infection. 3) The WCN failed to recognize when Resident #11's pressure ulcer had tunneling. Resident #11's coccyx pressure ulcer increased from length 4.0 cm, width 3.0 cm on 01/01/14 to length 5.0 cm, width 3.5 cm, with tunneling at the 5:00 o'clock position 3.2 cm as of 01/08/14. These failures could affect the 17 residents, who had pressure ulcers, including Resident #11, by placing them at risk for developing new or worsening pressure ulcers, Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), untreated skin problems and/or death. Findings included: 1) Resident #11's Face Sheet, dated, 10/14/13, reflected the resident was an [AGE] year-old female, who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11's MDS assessment, dated 10/21/13, reflected she had one Stage IV pressure ulcer, which measured (Length by Width by Depth) 5.0 by 1.7 cm by 3.0 cm with slough (slough is a yellow fibrous tissue that is usually found in a wound bed.) The MDS reflected Resident #11 required extensive assistance of one person with bed mobility, dressing eating and personal hygiene. The MDS also reflected Resident #11 required two staff members for assistance with toileting. Resident #11's Care Plan, dated 10/08/13, reflected she had an unstageable pressure ulcer on her medial thigh/sacral areas. The approaches included: Develop turning/repositioning plan with the resident's input; Resident needs wound care as ordered by the physician; Resident needs two persons to assist with repositioning to avoid skin friction/shearing; Needs a referral to a dietician to evaluate resident nutritional status; Obtain resident's [MEDICATION NAME] level to evaluate protein; Encourage good nutritional intake for healing; Monitor for changes in resident's skin status that may indicate worsening of pressure ulcer; and notify the physician. Resident #11's Care Plan, dated 10/08/13, for a sacral unstageable pressure area reflected the approaches included: " ....4) Assist with turn/repositioning every two hours and as needed. 5) Use padding between pressure areas and positioning every two hours and prn (as needed). 6) Provide pressure relieving device for bed and wheel chair. " Resident #11's Care Plans, dated 10/08/13, did not address the physician's orders [REDACTED]. Resident #11's "Braden scale" (an assessment tool for assessing risk for pressure ulcers) assessment, dated 12/10/13, 12/13/13 and 12/24/13, reflected scores of 13, which indicated the resident was at a low risk for developing pressure ulcers. Resident #11's Weekly Pressure Ulcer Healing Record reflected an onset date of 10/08/13 of the sacral/coccyx pressure ulcer. Resident #11's Weekly Pressure Ulcer Healing Record reflected an entry, dated of 12/18/13, which reflected the pressure ulcer was "unstageable" at 7.2 cm by 3.0 cm by 0.9 cm with large serous drainage with black/brown slough in the wound bed and edges rolled. The weekly pressure ulcer healing record assessment, dated 01/01/14, reflected the coccyx wound was a Stage IV, which measured 4.0 cm by 3.0 cm by 0.5 cm with moderate serous (light bloody drainage) drainage and slough in the bed. The assessment also reflected the wound edges were rolled, and it had 3.0 cm undermining (depth of the wound bed from the edges). Resident #11's Braden Scale assessment, dated 12/31/13 and 01/07/14, reflected scores of 15, which indicated she was not at risk for developing pressure ulcers. Further review of the Braden Scale revealed the assessment was incorrect. The assessment indicated on the risk factors "Moisture, Resident was rarely moist." Resident #11 was observed 01/07/14 at 9:45 a.m. to be incontinent of bowel and had a Foley catheter, indicated before the Foley catheter Resident #11 was incontinent of bowel and bladder. The Braden scale assessment also reflected the resident's nutrition was "Adequate." However, the facility weight record reflected Resident #11 had lost approximately 8 pounds since last months weight record. Resident #11's January 2014 physician's orders [REDACTED]. The order did not indicate the frequency for turning Resident #11. The order further reflected no adult briefs while in bed. Resident #11 was observed on 01/06/14 at 9:25 a.m. lying flat on her back in bed. A pillow was under her heels, and ADON A repositioned the pillows to off-load Resident #11's heels. ADON A stated Resident #11 was mostly bedfast. She was incontinent of bowel and had a catheter. She was alert and oriented to self and required total assistance with her activities of daily living needs. ADON A stated Resident #11 required assistance with transfers and she had a pressure ulcer on her coccyx area. It was pointed out to ADON A on rounds that the resident had a dressing to her left heel area and also a clear dressing to her upper left ankle area, ADON A stated the resident must have had a skin tear, but she was not aware of when it happened. The skin tear area had a long purple red line with some drainage to the upper left ankle area and/or the area to the left heel. An observation of CNA AA and LVN JJ providing incontinent care to Resident #11 on 01/07/14 at 9:45 a.m. revealed when the resident was rolled to her left side to expose her buttocks, there was not a dressing on her coccyx pressure ulcer. When asked about the missing dressing, CNA AA replied "I'm not a nurse." She stated she did not know anything about the dressing. The CNA revealed she took Resident #11's dressing off earlier because there was feces on it. When asked if she notified the nurse, CNA AA replied, "No" and that she was not aware she was supposed to notify her. The CNA cleaned the resident's buttocks from back to front. The pressure ulcer on the resident's coccyx had yellow slough in the bed and the edges were coiled (dead tissue and when coiled the edges cannot come together for wound healing.) After CNA AA finished providing incontinent care to the resident, she was asked why she did not clean the resident's inner thigh and vaginal area. LVN JJ stated, at this time, CNA AA did not clean the areas. CNA AA repositioned the resident on her back and cleaned the inner thigh areas without folding the wash towel. There was fecal material on the wash towel used. During an interview with LVN Y on 01/08/14 at 1:10 p.m., LVN Y stated the CNAs did not report there was no dressing on Resident 11's pressure ulcer or she would have placed a dressing on it until the treatment could be done. On 01/07/14 at 11:30 a.m., the (Interim) DON and ADON A were informed of the incontinent care observation and no dressing on Resident #11's coccyx pressure ulcer. The DON stated she would conduct an in-service immediately. The DON revealed the wound needed to have a dressing at all times to prevent infection and to keep feces from getting into the wound. Further interview with the Interim DON on 01/08/14 at 12:30 p.m. regarding in-services revealed she was busy working on the surveyor identified substandard quality of care, and she asked the ADON to take care of it. An interview with ADON A on 01/08/14 at 12:45 p.m. revealed the DON was supposed to take care of training the staff. ADON A stated she was not asked to provide in-services or informed to do the in-services. An observation on 01/07/14 at 5:10 p.m. revealed the WCN providing wound care to Resident #11. Resident #11 was on her back in bed, and CNA MM rolled the resident to her left side exposing her buttocks for treatment. There was still no dressing on her coccyx pressure ulcer. An interview with the WCN, at that time, revealed staff did not report to her the dressing was off or removed. The coccyx wound had yellow thin slough at 7:00 o'clock to 12:00 o'clock, and the edges were coiled and rolled back. An observation of the Wound Care Physician, assisted by the WCN and CNA MM, assessing Resident #11's wounds on 01/08/14 at 12:45 p.m. revealed there was no dressing on the resident's coccyx pressure ulcer. The physician assessed the coccyx pressure ulcer with tunneling at 6:00 o'clock. http://www.hopkinsmedicine.org/gec/series/wound_care.html reflected Undermining/Tunneling ? Using the "clock concept " (12 o'clock is in the direction of the patient's head and 6 o'clock is toward the feet) ? Where does it start and where does it end (clockwise direction) ? Tunnel depth is at it's deepest point ? Location of deepest point (retrieved on 01/23/14). These were the measurements the Physician called out to the WCN from his assessment on 01/08/14 at 12:45 p.m.: Length = 5.0 cm Width = 3.5 cm Depth = 1.8 cm And tunneling 3.2 cm. at 5:00 o'clock per the physician. After the physician exited the room at 1:00 p.m., the WCN stated Resident #11 had a dressing to the coccyx yesterday and now the dressing was off. She also stated the resident was receiving Hospice services and maybe the hospice staff removed the dressing. When asked if hospice staff was educated in informing the nurse when a dressing was removed, the WCN replied she did not know. (NOTE: The DON was informed of the missing dressing on 01/07/14 at 11:30 a.m., and she stated there would be an in-service to inform the CNAs there should be dressing on any open areas.) Review of the weekly pressure ulcer healing record assessment, dated 01/08/14 reflected the wound was a Stage IV with purulent (pus-filled) drainage and no odor. The assessment did not reflect the measurements or tunneling in the wound. An interview on 01/08/14 at 3:00 p.m. with the WCN revealed when asked about the assessments of Resident #11's pressure ulcer, she replied she was waiting for the physician to complete the documentation. The WCN stated she was not aware of the tunneling in the wound. Review of Resident #11's wound care Physician's assessment documentation dated 01/08/14, revealed the coccyx pressure ulcer measurements were 5.0 cm by 3.5 cm by 1.8 cm with 3.2 cm of tunneling. The assessment documentation reflected the wound had a undermining of "1" and tunneling. <https://www.healthtap.com/user_questions/ -what-is-the-difference-between-undermining-and-tunneling-in-regards-to-stage-4-pressure-ulcers>. "Undermining was when a wound's diameter was wider at its base (deep in the wound) than at the wound's skin edge. For example, the hole in the skin may be 5 mm, but the base of the wound cavity is 1 0mm. Tunneling was when the wound tracks under the skin to another opening in the skin or to a deeper cavity. Tunnels are sometimes referred to as a "sinus" or "tract." (Retrieved on 01/14/14.) 2) Review of the facility's current policy for pressure ulcers and skin care management, dated June 2006, revealed: "POLICY: A resident having a pressure ulcer receives necessary treatment and services to promote healing, prevent infection and reduce risk of further breakdown from developing. Fundamental Information: All residents with pressure ulcers will receive appropriate treatment and services to aid in healing and prevent further breakdown. Routine preventive care includes: Turning and proper positioning Application of pressure relieving or pressure reducing devices Appropriate skin care is provided to keep the skin clean and dry and measure implemented to reduce excessive moisture. PROCEDURE: 2) Implement measure to assist in healing listed in the plan of care. Measures may include: Pressure relieving devices Avoid skin shear and friction Provide treatment that promotes healing Provide appropriate nutrition and vitamins/minerals as needed DOCUMENTATION: 1) The licensed nurse will accurately complete the weekly pressure ulcer report... 4) The licensed nurse will document a complete description of the wound in the clinical record, including measurements, drainage, necrotic tissue, appearance of the wound bed and peri-wound area, residents responses to treatment, i.e. pain, refusal... 6) The interdisciplinary team will initiate and revise the residents care plan for interventions and outcomes." 4) The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the Administrator and dated 01/06/14, reflected 17 residents had pressure ulcers.

Based on observation, interview, and record review, it was determined the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, such as body weight for one (Resident #4) of 12 residents reviewed for nutrition. 1) Staff failed to implement the recommendations made for Resident #4 by the Dietitian after she was consulted by the physician. 2) Staff failed to offer supplements as ordered when she consumed less than 50% of her meals. Resident #4 lost approximately 18.4 pounds since 11/15/13, which placed her at greater risk for debility, pressure ulcers, and deterioration of her physical condition. These failures could affect any the facility's 112 residents placing them at risk for unplanned weight loss. Findings included: 1) Resident #4's MDS assessment, dated 10/25/13, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident#4 was alert with periods of confusion and forgetfulness and she required assistance of one staff member to complete a meal. Resident #4's care plan meeting notes, dated 11/07/13, did not reflect any issues related to weight change/nutrition. Resident #4's undated care plan did not reflect problems, goals, or approaches related to weight/nutrition. Resident #4's Surgeon's Progress Note, dated 08/14/12, reflected he diagnosed her Hernia and offered to perform surgery for [REDACTED]. The note reflected Resident #4 and her family at that time chose to not proceed with the Hernia Repair. Further review of the progress note revealed the surgeon informed Resident #4 and her family that in the future the resident had the option to come and have the hernia repaired, if there were any further complications. The facility's Weight Change History Form reflected Resident #4's weight on the following dates: 11/05/13 113.00 pounds, 12/05/13 113.20 pounds, and 01/05/13 108.00 pounds. Resident #4's Dietary progress note, dated 11/15/15, reflected a weight of 113 pounds, which was a 5.4 pound weight loss in one month. The Dietitian recommended to start Resource 2.0 (dietary supplement) at 90 cc three times a day for 30 days. Resident #4's weekly nursing summaries, dated 11/07/13 through 11/28/13, reflected she was at times independent with eating, at times required supervision, and at other times required limited assistance. There was no documentation concerning a weight change or nutritional approaches. Resident #4's December 2013 physician's orders [REDACTED]. There were no nutritional supplements ordered. Resident #4's weekly nursing summaries, dated 12/05/13 through 01/02/14, reflected she was at times independent with eating and at other times required supervision. There was no documentation concerning a weight change or nutritional approaches. Resident #4's January 2014 physician's orders [REDACTED]. There were no nutritional supplements ordered. An interview on 01/07/14 at 4:00 p.m. with MDS KK revealed the process for weight loss that was recently put in place was the following: the residents were to be weighed by the restorative nurse aide, and any resident with a five-pound or greater weight loss was to be re-weighed, following the review of the weights. Interview on 01/07/14 at 4:30 p.m. with ADON A revealed the nutritional consultants reports were presented to the DON and Administrator at the end of the visit. She stated then the reports were given to the ADONs to follow-up with the physician's telephone orders to give to the nurses to initiate and put in the computer. Observation on 01/06/14 at 9:30 a.m. during initial tour revealed Resident #4 was standing in the doorway of her room, and she was a frail, thin female who was confused. Observation on 01/06/14 at 12:30 p.m. revealed Resident #4 in the dining room sitting at the table, and the lunch meal was served; Resident #4 began to "pick" at the meat on the chicken breast. Resident was assisted to the bathroom at about 12:45 p.m., by the staff and when she returned to the dining room at about 1:00 p.m., she sat down and picked at her meal, and consumed only a few bites of the chicken and drank a cup of coffee. Resident #4's January 2014 Dietary treatment record reflected she ate 50% of her meal at lunch time and there was no documentation for 01/07/14. Interview on 01/08/14 at 2:30 p.m. with LVN T revealed the CNAs record on the meal tickets the percentage of the meal the resident ate and then the nurses record meal percentages on the dietary treatment record. LVN T stated she was aware that sometimes Resident #4 ate poorly, but from reviewing the dietary intake record she ate well. When asked about Resident #4 eating a few bites of chicken on 01/06/14, LVN T replied that intake was more like 10% or even less. LVN T stated she had no idea Resident #4 had lost any weight until today. When asked who followed-up on the nutritional consultant recommendations, LVN T replied the nursing administration reviewed the reports with the recommendations, wrote orders and then brought the orders to the nurses to enter into the computer and initiate the recommendations with the residents. When asked if she recalled ever giving Resident #4 a supplement, LVN T replied "No." Observation on 01/07/14 at 12:40 p.m. revealed Resident #4 in the dining area eating her lunch. Resident #4 only consumed three bites of the pork roast that was served. There were additional desserts available for Resident #4, which she did not eat. Observation on 01/08/14 at 9:00 a.m. of the restorative aide weighing Resident #4 revealed she weighed 100.00 pounds. (Note: Resident #4 weighed 108.00 on 01/05/14, according to the facility's weight change history form.) Interview on 01/08/14 at 9:20 a.m. with the Restorative Nurse Aide revealed he was given the task of getting a baseline weight on all the residents in the facility November 2013 by the former DON. When asked when was the last time the scale was calibrated, the Restorative Nurse Aide replied he did not know. He stated he was to weigh all the residents in the facility and then take his weights to MDS KK, and they would identify who he was to reweigh. Observation on 01/08/14 at 1:00 p.m. revealed Resident #4 packed up her brief case with all the Sweet and Low at the table, ate two bites of the vegetables served, did not eat any spaghetti, ate one bite of bread, and drank two cups of coffee. Resident #4's lunch meal ticket, dated 01/08/14, reflected she consumed 50% of her meal. Interview on 01/08/14 at 2:35 p.m. with CNA P revealed she was able to get Resident #4 to eat some ice cream, and that was why she figured the 50% for the meal intake. CNA P stated she had cared for Resident #4 for some time and she was aware the resident had lost weight back in November, because the resident was skinnier. CNA P revealed Resident #4 would eat off and on. CNA P stated she did not recall ever giving her any supplements at all. CNA P revealed she gave her ice cream if she could get the resident to eat it. Interview on 01/08/14 at 2:40 p.m. with CNA LL revealed she had assisted Resident #4 for almost a year. CNA LL stated Resident #4 ate very well at breakfast, but lunch and supper could be a problem. CNA LL revealed the past few months the resident had been really bad, because she got confused and did not want to eat because she thought she had already eaten and said she was full. CNA LL revealed she tried to give Resident #4 anything she could think of that she might eat, but sometimes she just had to give her coffee because that was all she would take. Resident #4's Dietary Treatment records, dated 11/01/13 through 01/08/14, reflected inconsistent meal documentation which indicated she ate 25% to 100% of meals, with no supplements offered. Resident #4's Medication Administration Record, [REDACTED]. Resident #4's lab results completed on 10/27/13 reflected a [MEDICATION NAME] (a test to determine the protein made by the liver used to determine nutrition) level of 3.8 (normal range 18.0-45.0). A handwritten note found on the lab report reflected to administer the resident Prostat (Protein supplement) 30 cc by mouth twice a day during medication pass. There was no follow-up on the lab results and the resident still remained on the Prostat. Resident #4's physician's telephone order, dated 01/08/14, following the surveyor's intervention, reflected weekly weights, Resource (supplement) 60 cc by mouth three times per day, and [MEDICATION NAME] (antidepressant with appetite stimulant) 7.5 mg by mouth every night. An in-service dated 01/09/14, following the surveyor's intervention, reflected an in-service on nutrition and weight loss for all nursing staff. Contents included: charge nurses must communicate with the RNA regarding a resident's weights. Resident admitted /readmitted must be weighed upon admission and weekly for four weeks or until weight is stable. If significant weight loss is determined physician must be notified, therapy evaluate dietary consult must be done, interventions should be placed immediately. All Residents' intake should be monitored and documented daily, after each meal. Review of the Action Plan dated 01/09/14 provided by the MDS KK reflected: Specific issue: Weight monitoring system needed to be stream lined so that no weight changes or variations would be missed concerning weight loss or gain. Systems needing implementation/repair: What constitutes a need to reweigh after monthly weights have been reported and how to establish a new baseline for those residents with unusual weight variances. Action plan: 1) Review all monthly weights at the weekly meeting the week following monthly weight completion. 2) Any resident with a 5 lb. weight loss or gain to be reweighed 3) If resident is found to have a confirmed weight, alert, those resident placed on weekly weight schedule for the next 4 weeks to re-establish the new current weight for that resident. 4) Physician, family and Registered Dietitian to be notified of any residents with a confirmed weight loss/gain of 5% over a 30 day period and/or a 10 % weight loss/gain over a 180 day period of time from the current month 5) All dietary recommendations to be reviewed and discussed with the MD/Family and completed by nursing staff ... The facility's weight Loss Management Policy dated 04/24/06 and identified as current by ADON A identified: Purpose: It is the policy of this facility to assure that the residents maintaining acceptable parameters of nutritional status.... Procedure: All residents admitted or readmitted to the facility will be weighed upon admission and weekly for four weeks or until weight is stable for four weeks. Residents with a significant weight loss of 5% in 30 days, 7.5% in 90 days or 10% in 180 days will be weighed until the resident's weight is stable for four weeks. If the resident's weight is not stable at the end of the four weeks, weekly weights will continue until the resident's weight is stable. ? Residents with a significant weight loss will be assessed for potential risk factors contributing to the weight loss considering the risk factors for [MEDICAL CONDITION]. ? Significant weight losses will be documented on the Weekly Weight Variance Report weekly until weight is stable ... ? Individual Weekly Weight Tracking will be completed with interventions, response to the interventions and the need to implement further interventions. ? Dietary supplements will be offered to residents who consume 50% or less of each meal. Dietary intake will be documented after each meal. ? The Interdisciplinary Care Plan will reflect the weight loss, goals and interventions and will be evaluated periodically ... Parameters of nutritional status which are unacceptable include unplanned weight loss, as well as other indices such as .... Laboratory tests indicating [MEDICAL CONDITION]. (E.g. serum [MEDICATION NAME] levels) ... Clinical conditions demonstrating that the maintenance of acceptable nutritional status may not be possible include, but not limited to: ? Refusal to eat and refuses other methods of nourishment ... ? Increased nutritional calorie needs associated with pressure ulcers and wound healing ... The CMS Form 672, Resident Census and Conditions of Residents dated 01/06/14 and signed by the Administrator reflected the census was 112 residents.

Based on interview and record review, the facility failed to provide the necessary care and services to maintain the highest physical, mental, and psychosocial well-being for one (Resident #1) of nine residents reviewed for pain management. Staff failed to assess and manage Resident #1's pain after, CNAs B and C got her out of bed against her wishes and during the transfer, they sat her down on her ankle on the floor on 02/07/13. CNAs B and C failed to follow Resident #1's Care Plan when they got her out of bed. Staff failed to inform Resident #1's physician she was continuing to complain of pain and had [MEDICAL CONDITION] to her legs. Physician H failed to order an x-ray of Resident #1's ankle, even though she was complaining of pain after the incident. The facility failed to develop policy/procedures for pain management. These failures resulted in delayed care and treatment for [REDACTED]. These failures could affect the 61 residents who were on a pain management program by placing them at risk for delayed care and treatment, unrelieved pain, anxiety, hopelessness, and depression. Findings included: Resident #1's MDS assessment, dated 12/27/12, reflected the resident was a [AGE] year-old female, who was re-admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. According to Resident #1's MDS assessment, she required extensive assistance of two or more persons for transfers, and she had impairment in both of her lower extremities. The MDS assessment also reflected Resident #1 used a wheelchair. The MDS assessment reflected she was 5 feet tall and three inches and weighed 292 pounds. Resident #1's Care Plan, dated 10/19/11 and last reviewed by the facility on 12/21/12, reflected the resident had chronic leg pain, and the goal was "Will maintain reasonable comfort level daily for the next 90 days." Approaches for her pain included, "1. Assess resident for signs and symptoms of pain or discomfort...3. Administer medications as ordered by the Physician to maintain comfort level. 4. Monitor resident for expressions and symptoms of non-verbal pain. 5. Notify Physician if medication subscribed not effective for pain...." According to Resident #1's Care Plan, she was immobile. Further review of Resident #1's Care Plan revealed she had a history of [REDACTED]. Further review of Resident #1's Care Plan, dated 10/19/11 and last reviewed on 12/21/12, revealed, "Covert/open conflict with staff" and "Hx (History) of accusations toward staff." The Approaches were the following: "1. Conference with nursing staff for evaluation of different roommate. 2. Encourage participation in activities. 3. Encourage family visits. 4. Record and report to MDS prolonged (> 3 days) refusal to socialize with others. 5. Care to be given (with) (two) staff in room." Resident #1's Care Plan dated 03/25/12 reflected an undated, handwritten approach, which indicated Resident #1 did not like to get out of bed. A facility Incident/Accident Report dated 02/07/13 reflected, "CNAs report during transfer from bed to shower chair resident buckled her knees & (and) was assist (sic) to floor by staff. Gait belt in use at time, upon entering room, patient (Resident #1) sitting on floor in front of her bed, gait belt around waist, legs stretches (sic) in front of her. Physician notified. Order for bilateral feet x-ray obtained." The Report also reflected a body diagram and the feet were circled. Further review of the Incident/Accident Report revealed a Care Plan was in place and the resident needed the assistance of two staff for transfers. The Report did not reflect if there were any injuries or why the x-ray of Resident #1's feet was ordered. The Incident/Accident Report follow up Report dated 02/08/13 reflected the resident was stable, her range of motion was within normal limits, she was not complaining of pain or discomfort, she was lowered to the floor by CNAs, and nursing staff will monitor how the resident transfers between surfaces to prevent reoccurrence. Resident #1's Nurse's Notes, dated 02/07/13, reflected, "CNAs X (times) 2 went to pts (sic) (Resident #1's) room to get her up for a shower. CNA states a gait belt was in place & verified. Resident assisted (with) standing (with) help of CNAs X 2. When stood up, resident buckled her knees & CNAS assisted her to floor. Resident sat down (with) her feet underneath her. Tylenol 650 mg PO (by mouth) X2 (two tablets) was given at this time...Addendum Both feet were painful to touch. No immediate swelling or bruising noted...(Physician's Assistant) notified of incident, T/O (telephone order) for x-ray of bilateral feet...." The Note did not reflect how much pain the resident was in or how effective the medication was in relieving her pain. Interview on 03/13/13 at 12:19 PM with LVN A revealed she was Resident #1's charge nurse, when the resident fell . LVN A stated CNAs always got Resident #1 out of bed. LVN A stated she went with CNA B into Resident #1's room and asked the resident if she wanted to get up for a shower. LVN A revealed Resident # 1 agreed for CNAs B and C to get her up. LVN A stated CNAs B and C used the gait belt to transfer Resident #1 from the bed to a standing position. LVN A revealed Resident #1 buckled her legs and CNAs B and C lowered her to the floor. LVN A stated when CNA C touched Resident #1 feet, she stated it was painful. LVN A revealed she gave Resident #1 Tylenol two tablets for pain. LVN A was queried if she assessed Resident #1's pain using the facility's pain assessment tool after she gave Resident #1 Tylenol. LVN A replied, "I asked her about it, but did not write it down." LVN A was queried if she assessed Resident #1 for pain medication effectiveness. LVN A replied, "I asked her about it and did not write it down." Interview on 03/12/13 at 10:23 AM with Resident #1 via telephone revealed she had three [MEDICAL CONDITION] with a recent stroke in 2012. Resident #1 stated she had not gotten out of bed since March 2012. She revealed she told CNAs B and C she could not stand. Resident #1 stated CNAs B and C forced her out of the bed to a standing position, and she fell on the floor and broke two bones in her right leg. Resident #1 revealed her leg was painful when the facility's staff touched it, and she screamed due to pain. Resident #1 stated after the fall, the facility staff told her to get back in bed. Resident #1 stated she had been in severe pain since she fell on [DATE]. The resident stated this was her only fall for 2013. Interview on 03/13/13 at 10:14 AM with CNA B revealed she and CNA C were transferring Resident #1 from her bed to the shower chair on 02/07/13. CNA B stated the resident buckled her legs and the resident could not stand. CNA B revealed she and CNA C lowered Resident #1 to the floor in a kneeling position with her legs underneath her. CNA B stated she brought LVN A to the resident's room. CNA B revealed she noticed bruises on Resident #1's feet three days after the fall. Interview of 03/13/13 at 3:20 PM with CNA C revealed she was assisting CNA B to transfer Resident #1 from bed to shower chair. CNA C stated CNA B put the gait belt around Resident #1's chest. CNA B stated at the count of 3 we are getting Resident #1 out of bed to a standing position on the floor. Resident #1 started going down on her legs. CNA C stated CNA B told her for them to place Resident #1 on the floor due to her back pain. CNA C stated Resident #1's feet were crossed and on the opposite direction when they put her on the floor. CNA C stated it looked like Resident #1 had a sprain or a broken leg. CNA C stated when CNA K tried to get Resident #1 up from the floor, she made some noise like she was hurting. Interview on 03/12/13 at 2:30 PM with Resident #2 revealed she was Resident #1's roommate. Resident #2 stated she was in the room when CNAs B and C came in with a shower chair. Resident #2 revealed Resident #1 told CNAs B and C that she did not want to get out of bed. Resident #2 stated, "(CNA B) and (CNA C) dragged (Resident #1) out of bed and she fell like a ton of bricks." Resident #2 revealed Resident #1 screamed in pain, and CNAs B and C called a male nurse to assist them to put Resident #1 back to bed. Interview on 03/27/13 at 3:10 PM with LVN N revealed Resident #1 stated she did not want to get out of bed. LVN N said Resident #1 preferred bed baths. LVN N revealed Resident #1 was a Hoyer lift transfer. Resident #1's Physician's Progress Note dated 02/07/13, reflected the physician examined her after her fall, she had pain in her left ankle, which she "sat down on," and she had 1 + [MEDICAL CONDITION] in her legs. The Progress Note also reflected Resident #1 had a possible fracture and an x-ray was ordered. Interview on 03/27/13 at 12:20 PM with Physician H revealed he ordered an x-ray of Resident #1's ankle. When asked why he signed the telephone order for the x-ray of her feet, he replied, "I was under the impression that the x-ray of the ankle was taken." Physician H stated he was in the room when the x-ray staff came to Resident #1's room, and he told the x-ray technician to x-ray the resident's ankle. When asked if he saw Resident #1's x-ray result, Physician H replied he had a busy schedule, and he instructed the facility to call in all the x-ray results to him via telephone Physician H revealed NP may have seen the x-ray results. He stated the facility did not notify him Resident #1 was having severe pain, and if had known she was having severe pain, he would have ordered a repeat x-ray or increased the [MEDICATION NAME] dose. Physician H stated the only time the facility called him was on 02/21/13, when Resident #1 was having pain and he ordered [MEDICATION NAME] 50 mg every four hours as needed. Resident #1's Physician's Telephone Order dated 02/07/13 reflected to get an x-ray of the resident's feet and Tylenol 325 mg 2 tablets by mouth for pain and fever. Resident #1's X-Ray Results, dated 02/07/13, reflected, "...No fractures were noted in the bones of the feet. There is no evidence for dislocations or bony destruction. IMPRESSION: 1. Osteopenia. 2. Soft tissue swelling. 3. No acute abnormalities...." Resident #1's February 2013 physician's orders [REDACTED]. Resident #1's February 2013 MAR reflected Tylenol 325 mg 2 tablets was given only on the following days: 02/07/13, 02/27/13, and 02/28/13. Interview of 03/13/13 at 12:15 PM LVN E revealed Resident #1 fell on her off day when she was not in the facility. LVN E stated Resident #1 was complaining of pain frequently during 6:00 AM to 2:00 PM shift. When asked if she assessed the pain and notified the doctor, LVN E replied, "I did not inform the doctor that (Resident #1) was having severe pain. I thought it was her usual pain." LVN E stated Resident #1's legs were bruised and swollen. She also revealed Resident #1 was seen by the physician, when she fell . LVN E stated she was told Resident #1 had a right leg fracture. LVN E stated, "We dropped the ball." Resident #1's Physician's Telephone Order dated 02/21/13 reflected [MEDICATION NAME] 50 mg by mouth every four hours as needed for pain. Resident #1's February 2013 MAR reflected [MEDICATION NAME] was administered on 02/12/13, 02/23/13, 02/24/13, and 02/28/13. Interview on 03/13/13 at 1:46 PM with the DON revealed she received a call on 02/27/13 that Resident #1 complained of not getting her pain medication. The DON stated she went to Resident #1's room after one hour to talk with her. The DON stated Resident #1 had bruises on her ankles, which were bluish-yellow in color from the incident on 02/07/13. The DON stated that she called the physician, and he ordered the pain medication [MEDICATION NAME] (pain and muscle relaxer) for Resident #1. The DON looked at the MAR and stated, "Oh, she had Tylenol. Why were they not giving it to her? I did not know she was on Tylenol." When asked for the pain and procedures regarding pain management, the DON replied, "I do not have policies and procedure for pain management." The DON stated she did not know how the nurses were assessing residents for pain because she had only been there for three weeks. She revealed she would develop a pain assessment tool. A confidential interview revealed Resident #1 called him/her stating she did not want staff to get her out of the bed. He/She called LVN J to instruct staff not to be getting Resident #1 out of bed. The interviewee revealed CNAs B and C forced Resident #1 out of bed and she fell . He/She stated the nurse was not giving Resident #1 her pain medication per the physician's orders [REDACTED]. He/She stated the resident was having pain, and the nurse was late in administering her pain medication. The interviewee revealed he/she called the DON to follow-up with Resident #1's pain medication. He/She stated when he/she visited on 02/19/13, Resident #1 had a blue, yellowish bruise on her right ankle. Interview on 03/12/13 at 3:55 PM with LVN J revealed she was told Resident #1 did not want staff to get her out of bed anymore. LVN J stated she told LVN F, the charge nurse. LVN J said Resident #1 was always in her bed, and she had never seen Resident #1 out of bed, when she worked evening duty. LVN J looked at Resident #1's clinical record and said, "I don't see the Care Plan here. They thin her chart." LVN J stated Resident #1 was on routine pain medication and did not complain of pain. Interview on 03/12/13 at 4:18 PM with LVN F revealed she did not receive any call from LVN J. LVN F stated she had never seen Resident #1 out of bed. LVN F stated Resident #1 was always in her bed. Resident #1's clinical records reflected only one pain assessment dated [DATE]. NP's Progress Note dated 03/06/13 reflected Resident #1 had "usual pain" pain to legs and bruises to ankles were gone. The Note also reflected the resident had 1 + [MEDICAL CONDITION] to her legs. Interview on 03/27/13 at 12:05 PM with NP I revealed the nurses did not notify her Resident #1 was having severe pain. NP I stated Resident #1 always had pain in her legs. NP I revealed the x-ray staff was supposed to do the x-ray of the ankle. NP I stated she thought the x-ray staff took the x-ray of Resident #1's ankle. NP I revealed, "She was bedridden. She never stood up and she never got out of bed." Resident #1's Nurse's Notes dated 03/07/13 reflected she was transferred by ambulance from the nursing facility to a local hospital in Houston, per family request at 11:00 PM for evaluation. The ambulance service's note dated 03/07/13 reflected, "...It was noted that there is a temperature difference between the right and left leg with the right leg being hot to the touch and the left being cool. The patients (sic) right leg according to the pt is the one that hurts the most. pt cannot find a position of comfort for her right leg and the pain radiates distal from her knee...." Further review of the ambulance service's note revealed Resident #1's family wanted the service to transport the resident to the hospital for evaluation of a possible hip injury from a fall. Interview on 03/29/13 at 12:00 PM with Ambulance Staff L revealed Resident #1 complained of pain in her right leg. He stated Resident #1 appeared to have a broken hip because she was not able to lie comfortable on a right position. Staff L revealed the resident's family family requested the resident be sent to the hospital for evaluation. He stated he transported Resident #1 at night time to a Houston Hospital. Ambulance Staff L revealed he called around until he found a hospital that had an orthopedic physician in Houston, and he took the resident to the emergency room . Resident #1's hospital Admission Note, dated 03/08/13, reflected she was admitted to the hospital on that date. Continued interview on 03/12/13 at 10:23 AM with Resident #1 revealed the x-ray taken in the hospital indicated two broken bones. Resident #1's hospital X-Ray Results dated 03/08/13 reflected fractures of the distal fibula and tibia with mild posterior displacement of the distal fracture fragments. Resident #1's hospital Consultation dated 03/08/13 reflected, "...There is also antalgic posturing of the right leg...CLINICAL IMPRESSION: ...4. Recent fall and right leg fracture...." Resident #1's other hospital Consultation dated 03/09/13 reflected, "...she had a fall in the nursing home and she was claiming that she had severe pain in the right leg and lower back...The patient was admitted for treatment. The reason for this consult is mainly pain management. Patient has a long history of other problems including [MEDICAL CONDITION], she has [MEDICAL CONDITION] patient has pain in the right lower extremity. She has some pain in the right rib cage and she has pain in the lower back according to her...IMPRESSION: It is my impression that this patient has pain in the right lower extremity. She has a [MEDICAL CONDITION] and fibula. I am concerned about the rib area. I am going to order right ribcage x-ray and lumbar and dorsal spin x-ray, PA and lateral...." Resident #1's hospital X-Ray Results, dated 03/10/13, reflected her right ankle was fractured. Resident #1's hospital Physician's Progress Note dated 03/11/13 reflected her right ankle x-ray indicated deformity of posterolateral tibia and fibula consistent with trauma and "Some fracture lines still visible...." The Note also reflected Right fibula/tibia oblique fracture. Resident #1's hospital Orthopedic Progress Notes dated 03/12/13 reflected her right ankle was fractured/dislocated. Resident #1's hospital Physician's Progress Note dated 03/12/13 reflected, "...She complains of right leg pain as she mentioned the pain is killing her...." Interview on 03/12/13 at 4:00 PM with RN G from the hospital revealed Resident #1 had [MEDICAL CONDITION] leg. RN G stated Resident #1 was on pain medication, pain management, and antibiotics. The facility's undated CMS Form 672 reflected a total of 125 residents. The facility's list of residents on pain management reflected a total of 61 and bedfast a total of seven residents.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #10) of one resident with a [MEDICAL CONDITION], was provided proper care and treatment of [REDACTED]. The facility failures included: 1) Resident #10 had no orders [MEDICAL CONDITION] since the time of her admission on 07/03/09 until surveyor inquiry on 10/06/10. 2) RN F contaminated sterile gloves while donning them [MEDICAL CONDITION] resulting in cross-contamination. 3) LVN C used her sterile gloves to remove the [MEDICAL CONDITION] sponge and then used unsterile exam gloves to provide treatment for [REDACTED]. 4) The physician-ordered oxygen was not provided on 10/04/10, 10/05/10, 10/06/10, 10/07/10 and 10/08/10. 5) [MEDICAL CONDITION] orders were written on 10/06/10 following surveyor inquiry. The orders did not include: a) the size of the inner/outer cannula, b) whether the equipment to use was disposable, c) how often to [MEDICAL CONDITION] and suctioning, and d) measuring of the resident's oxygenation level. 6) The care plan did not address the resident's needs [MEDICAL CONDITION], goals or approaches/interventions. 7) No training [MEDICAL CONDITION] had been provided to the staff. 8) Nurses were not monitored for technique [MEDICAL CONDITION]. 9) There was no emergency [MEDICAL CONDITION] available in the event Resident #10'[MEDICAL CONDITION] out. On 10/07/10 at 4:05 p.m., these failures resulted in an Immediate Jeopardy (IJ) situation with Substandard Quality of Care (SQC) in the area of Quality of Care for Resident #10. While the IJ was removed on 10/08/10 at 4:00 p.m., the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not actual harm" and a scope of "pattern." The facility had not yet in-serviced all nursing staff, fully implemented its plan and was still monitoring for implementation of its plan. These failures could affect Resident #10 and placed her at risk for the potential of compromised respiratory patency, inadequate oxygenation, and infection due to cross-contamination. Findings included: Resident #10's undated face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [MEDICAL CONDITION] is a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a [MEDICAL CONDITION]. Retrieved on 10/12/10 from http://www.medicinenet.com/[MEDICAL CONDITION]/article.htm Observation on 10/04/10 at 7:59 p.m. revealed Resident #10 was asleep in bed on her back. She was lying in a modified Fowler's position on an alternating pressure mattress with both half side rails in the upright position. Resident #10 had a [MEDICAL CONDITION]. The resident was not receiving oxygen and was breathing room air. Resident #10 had Glucerna 1.2 calories infusing via pump at 65 cc per hour. There was no emergency [MEDICAL CONDITION] replacement tube observed at the bedside. The suction machine container was observed with approximately 400 cc of liquid from previous use of the suction machine. (Every patient with a [MEDICAL CONDITION] should have the following equipment available at the bedside: ? Spare [MEDICAL CONDITION] (Same size and one size smaller).... Retrieved on 10/12/10 from http://www.tracheostomia.com/[MEDICAL CONDITION].pdf) During the initial tour on 10/04/10 at 7:59 p.m., LVN H stated Resident #10 was ambulatory per wheelchair, was continent when toileted, received total assistance with ADLs, was on oxygen, was an insulin-dependent diabetic, was forgetful at times and was alert to person. On 10/05/10 at 9:31 a.m., Resident #10 was observed to be awake, lying in bed and two CNAs were giving her a bed bath. Her tube feeding was hanging and infusing via pump. Resident #10 was on room air without oxygen. Review on 10/06/10 of Resident #10's entire clinical record for all the resident's physician's orders [REDACTED]. There were no orders for the following: (1) size and/or type of [MEDICAL CONDITION], (2) how [MEDICAL CONDITION] was to be performed, (3) suctioning, (4) when the inner cannula was to be changed, and (5) if or how often pulse oxygen levels were to be obtained and what the parameters were to determine the need for oxygen. Review of the September 2010 monthly physician's orders [REDACTED]. Observation on 10/06/10 at 9:14 a.m. of Resident #10 revealed the resident was not receiving any oxygen. At that time, LVN C had informed the surveyor she had already set up the supplies needed [MEDICAL CONDITION], but had not started [MEDICAL CONDITION] so the surveyor could observe the procedure. LVN C was observed at that time providing the [MEDICAL CONDITION]: The [MEDICAL CONDITION] kit was observed to be opened, and a sterile drape had been placed across Resident #10 adjacent to the resident's trach. LVN C donned the sterile gloves and removed the sputum-[MEDICAL CONDITION] sponge and disposable inner cannula, placing them in the red biohazard trash bag. The LVN removed her contaminated gloves. LVN C then applied (non-sterile) exam gloves and performed the entire [MEDICAL CONDITION] care procedure using non-sterile gloves, which included: (1) cleaned the external cannula with pipe cleaners and brush, (2) replaced a new and now contaminated inner cannula into Resident #10's outer cannula, and (3) suctioned Resident #10 three times. LVN C then stuck her un-sterile gloved fingers into the sterile container containing the normal saline she had used when suctioning Resident #10. While suctioning Resident #10, LVN C suctioned going into the trachea and coming out, instead of only when pulling the suction tubing out from the [MEDICAL CONDITION]. At one point, LVN C ran out of non-sterile gloves, returned to the treatment cart and reached into the box of exam gloves for a handful of gloves without washing her hands. Upon completion of the procedure, LVN C picked up the red, biohazard bag, which contained the contaminated supplies, went to the "shower room" and disposed of the supplies. LVN C left the "shower room" and then washed her hands in the clean utility room. When asked about leaving soiled items in the "shower room," LVN C said, "We don't use it as a shower room. It's our dirty utility room." There was no emergency [MEDICAL CONDITION] observed as readily available during this treatment/dressing change. Observation on 10/06/10 at 3:09 p.m. of the 300 hall "shower room," where LVN C disposed of the soiled supplies revealed there was no sink for hand washing. Review of facility in-service training records provided to the surveyor as the facility's complete in-service training records for 2009 and 2010 revealed there had been no training for [MEDICAL CONDITION] care. In an interview on 10/06/10 at 4:15 p.m., the DON was asked how [MEDICAL CONDITION] was to be done on Resident #10. The DON stated, "Every shift, and they change the cannula on the 2-10 shift." On 10/07/10 at 7:00 a.m. a telephone order dated 10/06/10 for Resident #10 reflected: "Trach care QS" and "change inner cannula QD on 2-10 shift & PRN." The orders still did not reflect the size of the trach, whether to use disposable equipment, suctioning or when to suction. Nothing was included about measuring the resident's oxygenation level, when to do it or how frequently to do it and parameters with treatment response. Additionally, there was no order to discontinue the resident's oxygen or to administer oxygen PRN. Observation on 10/07/10 at 9:16 a.m. of Resident #10 revealed the resident was not receiving oxygen as ordered by the physician. RN F was observed at that time providing the [MEDICAL CONDITION] for Resident #10: RN F opened the sterile [MEDICAL CONDITION] care kit and contaminated the sterile package with her bare hands. RN F then laid the sterile gloves on the contaminated package wrapper. RN F donned the sterile gloves as one would put on unsterile examination gloves (touching the tips of her sterile glove to the hand). She then pulled the gloves on without protecting the sterile gloved finger tips beneath the folded flap of the sterile gloves and contaminated the gloves. RN F cleaned the outer cannula with two cotton swabs and the brush from the contaminated [MEDICAL CONDITION] kit. Resident #10 was coughing thick white sputum. RN F cleaned around [MEDICAL CONDITION] normal saline on 4 x 4 sponges. RN F removed the contaminated gloves, washed her hands and applied (unsterile) exam gloves. She then opened the sterile suction kit, which included a plastic-lined box (used to hold the sterile normal saline for clearing the suction catheter and tube following suctioning of the [MEDICAL CONDITION]). RN F pushed the plastic in the box down with her fingers while wearing the unsterile gloves, contaminating the box and poured sterile normal saline into the now contaminated plastic-lined box. RN F removed the exam gloves and washed her hands. RN F again donned and contaminated the sterile gloves as she had previously. RN F suctioned Resident #10 three times. RN F removed her gloves, did not wash her hands and picked up the disposable red, biohazard bag, which held the contaminated supplies. RN F placed the red bag in the trash receptacle on the medication cart and removed her gloves. RN F bagged the sputum-contaminated towel used on Resident #10's chest during the procedure, picked up the disposable red bag from the medication cart and entered the room labeled "shower room." When she left the shower room, RN F picked up a [MEDICAL CONDITION] sponge from the top of the medication cart, applied exam gloves and placed [MEDICAL CONDITION] sponge around and beneath Resident #10's [MEDICAL CONDITION]. RN F removed her gloves, did not wash her hands and went to the linen cart for a towel. The RN said, "We always put a towel around her when she has a lot of secretions." While in Resident #10's room, the RN rearranged the nebulizer treatment apparatus and then washed her hands. There was no emergency [MEDICAL CONDITION] observed as readily available during this treatment/dressing change. Review of Care of the Patient with a [MEDICAL CONDITION] retrieved from http://www.orthonurse.org/education/ce/marapr2k/tracheos/sec5text.htm on 03/19/06 revealed, "Potential Complications: ... Pneumonia: Because the presence of a [MEDICAL CONDITION] bypasses the patient's natural clearing mechanisms, the patient is at high risk for developing pneumonia ...The nurse is in a key position to implement measures to minimize risk. Handwashing and the proper use and cleaning of respiratory equipment are paramount in preventing the spread of infection ...Providing patient hygiene helps prevent the development of pneumonia in a number of ways. Using sterile technique when delivering stoma and tube care can minimize the chance of bacteria [MEDICAL CONDITION] entering the lungs." During an interview on 10/07/10 at 9:51 a.m., ADON G acknowledged she had not observed the nurses [MEDICAL CONDITION] for Resident #10. On 10/07/10 at 12:20 p.m. in interview, the DON stated there had been no in-service training on [MEDICAL CONDITION] care. She further stated she relied on the ADONs to monitor the nurses when they did [MEDICAL CONDITION] care. When the DON was informed ADON G had not observed the nurses perform [MEDICAL CONDITION] care, the DON stated she "did not know that." Review of Resident #10's care plan dated 08/12/09 revealed the following: (1) A communication care plan indicated her speech was impaired due to [MEDICAL CONDITION]/trach. (2) At risk for skin breakdown, irritation and/or infection R/T [MEDICAL CONDITION]. The resident's care plan did not address any other potential problems with regard to Resident #10'[MEDICAL CONDITION] surveyor inquiry. Resident #10's care plan Problem for "At Risk for skin breakdown, irritation and/or infection R/T [MEDICAL CONDITION] and gastrostomy" reflected it was initiated on 08/12/09; reviewed on 10/07/09; and was updated on 10/10/09 to include the Problem of "Non-compliance [MEDICAL CONDITION]- pulls off O2, pulls out inner cannula of [MEDICAL CONDITION]." This care plan Problem was reviewed and continued on 11/11/09 and reviewed and continued x 90 days on 02/10/10; was updated to include an entry beneath the Problem of "Non-compliance [MEDICAL CONDITION]- pulls off O2, pulls out inner cannula of [MEDICAL CONDITION]" which stated, "5/12/10 very rare now - monitor" This same care plan Problem was reviewed and continued x 90 days on 07/28/10. The approaches to these problems included: Trach care QS & PRN; [MEDICAL CONDITION] & PRN; Change/replace inner cannula as ordered & PRN; Change O2 setup as ordered & PRN; Ensure that NS is dated & changed on O2 & humidifier as ordered and PRN. However, review of Resident #10's physician's orders [REDACTED]. In an interview on 10/07/10 at 12:30 p.m., RN E stated there had been no in-services for [MEDICAL CONDITION] care. On 10/07/10 at 3:39 p.m. RN F was asked to show the surveyor where the emergency replacement [MEDICAL CONDITION] was located. RN F stated, "Oh, yes. We have one in her room." The surveyor accompanied RN F to Resident #10's room. RN F rummaged through all the supplies in Resident #10's room and was unable to find the emergency replacement [MEDICAL CONDITION] for Resident #10. RN F then stated, "We have one in Central Supply. The key is on Station One (which was at the opposite end of the nursing facility)." RN F was accompanied to Station One and down the hall to Central Supply. One [MEDICAL CONDITION] tube with inner cannula size 6 was located; however, RN F said, "This is a [MEDICAL CONDITION]- hers (Resident #10) is disposable. We can use this one if she pulls it out, or it comes all the way out. She has coughed it partially out and we have been able to put it back in." (An emergency replacement [MEDICAL CONDITION] is to be used in the event an individual with a [MEDICAL CONDITION] either pulls it out or coughs it out, which could be a life-threatening event.) [MEDICAL CONDITION]: A 2- to 3-inch metal or plastic tube that keeps the stoma and trachea open. Retrieved on 10/12/10 from http://www.medterms.com/script/main/art.asp?articlekey=5833 In medicine, a stoma is an opening, either natural or surgically created (artificial), which connects a portion of the body cavity to the outside environment. Retrieved on 10/12/10 from http://en.wikipedia.org/wiki/Stoma_(medicine) Review of the undated facility [MEDICAL CONDITION] Care policy provided by the DON on 10/06/10 as the current facility policy revealed: A) "...Purpose - The purpose of this procedure is to provide guidelines for [MEDICAL CONDITION] care and for the cleaning and sterilization of reusable metal [MEDICAL CONDITION]. (Resident #10 had a disposable plastic [MEDICAL CONDITION].) B) Equipment and supplies: Gloves; Mask and eyewear (as indicated); Trach-care kit; Hydrogen peroxide; Sterile water or normal saline; Suction catheter; suction machine; Replacement [MEDICAL CONDITION] (as necessary); Gauze dressing; and [MEDICATION NAME] ties. C) Procedure Guidelines - [MEDICAL CONDITION] Care: ...3. Remove old dressings and ties. Pull soiled glove over dressing and discard into appropriate receptacle. 4. Put on fresh gloves. (Note: Sterile gloves must be used for anything other than stoma care.)... ...Miscellaneous: 1. Aseptic technique must be used: (Aseptic technique is a set of specific practices and procedures performed under carefully controlled conditions with the goal of minimizing contamination by pathogens (bacteria). ...The goal of aseptic technique is to protect the patient from infection. Retrieved on 10/12/10 from http://www.healthline.com/galecontent/aseptic-technique) a. During all dressing changes until the [MEDICAL CONDITION] wound has granulated (healed); b. during [MEDICAL CONDITION] changes, either reusable or disposable; c. during endotracheal suctioning. (Endotracheal suctioning (ETS) involves the removal of [MEDICAL CONDITION] (lung) secretions from a patient with an artificial airway in place. Retrieved on 10/12/10 from http://www.ncbi.nlm.nih.gov/pubmed/ 17) ...2. Gloves must be used on both hands during any or all manipulation of the [MEDICAL CONDITION]. Sterile gloves must be used during aseptic procedures. ...6. [MEDICAL CONDITION] care must be provided as needed. However, care must be provided at least twice daily on old, established tracheostomies. [MEDICAL CONDITION] for residents with new sites or infections must be provided at least once on each shift. 7. A replacement [MEDICAL CONDITION] must be available at the bedside at all times. 8. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution must be available at the bedside at all times." Review of the undated facility [MEDICAL CONDITION] Site Care: Tie/Dressing Change and Inner Cannula Care policy provided by the DON on 10/06/10 as the current facility policy revealed: "1. Purpose - a. To ensure patency of the altered airway and minimize potential for infection. ...3. Procedure - a. Disposable inner cannula: ...iv. Change the inner cannula as indicated by presence of secretions." On 10/07/10 at 4:05 p.m., these failures resulted in an IJ situation with SQC in the area of Quality of Care for Resident #10. The ADM and DON were informed of the IJ with SQC at that time. On 10/07/10 at 4:20 p.m., the DON said, "I review admission orders for Resident #10. When asked how long Resident #10 had not been receiving the physician-ordered continuous O2 [MEDICAL CONDITION], the DON stated, "Since she came back from the hospital in April (2010)." On 10/07/10 at 5:00 p.m. RN E and the DON presented an opened [MEDICAL CONDITION] (now unsterile) kit and said, "I knew we did have one. Someone used the inner cannula out of it and did not replace it." On 10/08/10 at 2:00 p.m., RN E was asked if she knew when the [MEDICAL CONDITION] presented on 10/07/10 at 5:00 p.m. had been opened. RN E replied, "We don't know when [MEDICAL CONDITION] was opened. I just found it opened in the med room." The facility's Plan of Removal originally dated 10/07/10 was accepted on 10/08/10. It reflected: 1. Resident #10's physician's orders [REDACTED]. The two nurses (RN F and LVN C) and nurse management were inserviced on [MEDICAL CONDITION] care by a Respiratory therapist. 2. There was only one resident with a [MEDICAL CONDITION] in the facility. 3. Resident #10's attending physician saw her and reviewed his [MEDICAL CONDITION] orders. The orders were care planned. [MEDICAL CONDITION] supplies (replacement trach) were placed and will remain at the bedside. The presence of the supplies were to be verified by the charge nurse on each shift and documented on the respiratory record and monitored by the DON and/or designee. The Central Supplies Clerk was to check [MEDICAL CONDITION] supplies on the hall and in Resident #10's room daily, order as necessary and report to the DON and/or designee. The DON received 'train the trainer' inservice from the Respiratory Therapist on [MEDICAL CONDITION] care. All licensed staff and unlicensed staff will be trained in the care of a resident with a [MEDICAL CONDITION]. PRN employees will be trained before their next working shift. [MEDICAL CONDITION] care training will be added to the New Hire Checklist; Proficiency exams will be completed annually; and will be monitored for completeness by the Human Resources Director. Training will be tracked weekly and monitored by the DON and ADM. Resident #10 was referred to an ENT specialist physician. The Medical Director was notified of the deficient practice. 4. The DON and/or designee will conduct random [MEDICAL CONDITION] proficiency checks for nurses who provide care to this resident q shift for three days then weekly for three months. An inventory checklist completed by the Central Supplies Clerk and the DON will be monitored daily for three days and then weekly for three months by the ADM. Findings were to be submitted to the monthly Quality Assurance meeting and weekly progress and tracking of in-servicing to the Medical Director. On 10/08/10 upon entry into the facility, the DON provided a copy of telephone orders from Resident #10's physician which reflected the following: 10/07/10 Pulse ox q shift and PRN; D/C [MEDICAL CONDITION] continuously; N/O Apply O2 [MEDICAL CONDITION] 4.5 lpm @ 35% humidification/mist if pulse ox < 90%. 10/07/[MEDICAL CONDITION] to be performed q shift & PRN for increased secretions; change inner disposable cannula daily on 2-10 shift; ENT Consult. 10/07/10 [MEDICAL CONDITION] shift & PRN. 10/07/10 [MEDICAL CONDITION] size for replacement is 6 DCT (Disposable cuffed [MEDICAL CONDITION]) Shiley - inner diameter 6.4 mm - outer diameter 10.8 mm. Record review verified inservice training on [MEDICAL CONDITION] Care had begun on 10/07/10 at 7:30 p.m. with 13 direct care staff, which included the DON and nursing administrative staff. A proficiency check list had been completed on the staff with proficiency [MEDICAL CONDITION] demonstrated. On 10/08/10 at 8:30 a.m. training was verified with RN F, who verbalized understanding of [MEDICAL CONDITION] care and aseptic technique. On 10/08/10 at 2:05 p.m. training was verified with LVN C, who verbalized understanding of [MEDICAL CONDITION] care as provided by the inservice. Review of Resident #10's physician's orders [REDACTED]. On 10/08/10 at 8:30 a.m. observation of Resident #10's room revealed a replacement [MEDICAL CONDITION] was taped to the wall above her bed and a manual [MEDICAL CONDITION] resuscitator was hanging in a plastic bag on a nail on the wall above the bed. Two pages of instructions for [MEDICAL CONDITION] care proficiency were encased in sheet protectors and were visible for review. The following respiratory equipment was at the bedside: a suction machine, vent with nebulizer and O2 Concentrator. While the IJ was removed on 10/08/10 at 4:00 p.m., the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not actual harm" and a scope of "pattern." The facility had not yet in-serviced all nursing staff, fully implemented its plan and was still monitoring for implementation of its plan. The ADM and DON were notified at that time. CMS form 672 (Resident Census and Conditions of Residents) dated 10/04/10, completed by the DON reflected one resident had a [MEDICAL CONDITION].

Based on observation, interview and record review, the ADM, the DON and ADON G failed to efficiently and effectively manage facility resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #10) of one resident in the facility with a [MEDICAL CONDITION] (Trach). A) The ADM failed to supervise the DON, who reviewed admission orders [REDACTED]'s needs for [MEDICAL CONDITION] as of 10/07/10. B) The ADM and DON failed to supervise ADON G, who did not monitor and supervise staff during the provision of [MEDICAL CONDITION] (trach) care for Resident #10. The DON thought ADON C was monitoring staff [MEDICAL CONDITION], but she was not. RN F contaminated sterile gloves while donning them [MEDICAL CONDITION]. LVN C used her sterile gloves to remove the soiled [MEDICAL CONDITION] drain sponge and then used unsterile exam gloves to [MEDICAL CONDITION]. C) The ADM, the DON and ADON C failed to apprise staff [MEDICAL CONDITION] and supervise staff in [MEDICAL CONDITION]. There had been no in-services provided to staff [MEDICAL CONDITION]. RN F stated she had not received any training on the provision [MEDICAL CONDITION]. D) The ADM, the DON and ADON C failed to monitor and supervise staff when physician's orders [REDACTED]. E) The ADM, the DON and ADON C did not monitor and supervise staff to ensure Resident #10 had the necessary emergency equipment required at the bedside in the event the resident's cannula came out. On 10/07/10 at 4:05 p.m., these failures resulted in an Immediate Jeopardy (IJ) situation in the area of Administration for Resident #10. While the IJ was removed on 10/08/10 at 4:00 p.m., the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not actual harm" and a scope of "pattern." The facility had not yet in-serviced all nursing staff, fully implemented its plan and was still monitoring for implementation of its plan. These failures could affect Resident #10 and placed her at risk for the potential of compromised respiratory patency, inadequate oxygenation, and infection due to cross-contamination. Findings included: Resident #10's undated face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [MEDICAL CONDITION] is a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a [MEDICAL CONDITION]. Retrieved on 10/12/10 from http://www.medicinenet.com/[MEDICAL CONDITION]/article.htm Observation on 10/04/10 at 7:59 p.m. revealed Resident #10 was asleep in bed on her back. She was lying in a modified Fowler's position on an alternating pressure mattress with both half side rails in the upright position. Resident #10 had a [MEDICAL CONDITION]. The resident was not receiving oxygen and was breathing room air. Resident #10 had Glucerna 1.2 calories infusing via pump at 65 cc per hour. There was no emergency [MEDICAL CONDITION] replacement tube observed at the bedside. The suction machine container was observed with approximately 400 cc of liquid from previous use of the suction machine. (Every patient with a [MEDICAL CONDITION] should have the following equipment available at the bedside: ? Spare [MEDICAL CONDITION] (Same size and one size smaller).... Retrieved on 10/12/10 from http://www.tracheostomia.com/[MEDICAL CONDITION].pdf) During the initial tour on 10/04/10 at 7:59 p.m., LVN H stated Resident #10 was ambulatory per wheelchair, was continent when toileted, received total assistance with ADLs, was on oxygen, was an insulin-dependent diabetic, was forgetful at times and was alert to person. On 10/05/10 at 9:31 a.m., Resident #10 was observed to be awake, lying in bed and two CNAs were giving her a bed bath. Her tube feeding was hanging and infusing via pump. Resident #10 was on room air without oxygen. Review on 10/06/10 of Resident #10's entire clinical record for all the resident's physician's orders [REDACTED]. There were no orders for the following: (1) size and/or type of [MEDICAL CONDITION], (2) how [MEDICAL CONDITION] was to be performed, (3) suctioning, (4) when the inner cannula was to be changed, and (5) if or how often pulse oxygen levels were to be obtained and what the parameters were to determine the need for oxygen. Review of the September 2010 monthly physician's orders [REDACTED]. Observation on 10/06/10 at 9:14 a.m. of Resident #10 revealed the resident was not receiving any oxygen. At that time, LVN C had informed the surveyor she had already set up the supplies needed [MEDICAL CONDITION], but had not started [MEDICAL CONDITION] so the surveyor could observe the procedure. LVN C was observed at that time providing the [MEDICAL CONDITION]: The [MEDICAL CONDITION] kit was observed to be opened, and a sterile drape had been placed across Resident #10 adjacent to the resident's trach. LVN C donned the sterile gloves and removed the sputum-[MEDICAL CONDITION] sponge and disposable inner cannula, placing them in the red biohazard trash bag. The LVN removed her contaminated gloves. LVN C then applied (non-sterile) exam gloves and performed the entire [MEDICAL CONDITION] care procedure using non-sterile gloves, which included: (1) cleaned the external cannula with pipe cleaners and brush, (2) replaced a new and now contaminated inner cannula into Resident #10's outer cannula, and (3) suctioned Resident #10 three times. LVN C then stuck her un-sterile gloved fingers into the sterile container containing the normal saline she had used when suctioning Resident #10. While suctioning Resident #10, LVN C suctioned going into the trachea and coming out, instead of only when pulling the suction tubing out from the [MEDICAL CONDITION]. At one point, LVN C ran out of non-sterile gloves, returned to the treatment cart and reached into the box of exam gloves for a handful of gloves without washing her hands. Upon completion of the procedure, LVN C picked up the red, biohazard bag, which contained the contaminated supplies, went to the "shower room" and disposed of the supplies. LVN C left the "shower room" and then washed her hands in the clean utility room. When asked about leaving soiled items in the "shower room," LVN C said, "We don't use it as a shower room. It's our dirty utility room." There was no emergency [MEDICAL CONDITION] observed as readily available during this treatment/dressing change. Observation on 10/06/10 at 3:09 p.m. of the 300 hall "shower room," where LVN C disposed of the soiled supplies revealed there was no sink for hand washing. Review of facility in-service training records provided to the surveyor as the facility's complete in-service training records for 2009 and 2010 revealed there had been no training for [MEDICAL CONDITION] care. In an interview on 10/06/10 at 4:15 p.m., the DON was asked how [MEDICAL CONDITION] was to be done on Resident #10. The DON stated, "Every shift, and they change the cannula on the 2-10 shift." On 10/07/10 at 7:00 a.m. a telephone order dated 10/06/10 for Resident #10 reflected: "Trach care QS" and "change inner cannula QD on 2-10 shift & PRN." The orders still did not reflect the size of the trach, whether to use disposable equipment, suctioning or when to suction. Nothing was included about measuring the resident's oxygenation level, when to do it or how frequently to do it and parameters with treatment response. Additionally, there was no order to discontinue the resident's oxygen or to administer oxygen PRN. Observation on 10/07/10 at 9:16 a.m. of Resident #10 revealed the resident was not receiving oxygen as ordered by the physician. RN F was observed at that time providing the [MEDICAL CONDITION] for Resident #10: RN F opened the sterile [MEDICAL CONDITION] care kit and contaminated the sterile package with her bare hands. RN F then laid the sterile gloves on the contaminated package wrapper. RN F donned the sterile gloves as one would put on unsterile examination gloves (touching the tips of her sterile glove to the hand). She then pulled the gloves on without protecting the sterile gloved finger tips beneath the folded flap of the sterile gloves and contaminated the gloves. RN F cleaned the outer cannula with two cotton swabs and the brush from the contaminated [MEDICAL CONDITION] kit. Resident #10 was coughing thick white sputum. RN F cleaned around [MEDICAL CONDITION] normal saline on 4 x 4 sponges. RN F removed the contaminated gloves, washed her hands and applied (unsterile) exam gloves. She then opened the sterile suction kit, which included a plastic-lined box (used to hold the sterile normal saline for clearing the suction catheter and tube following suctioning of the [MEDICAL CONDITION]). RN F pushed the plastic in the box down with her fingers while wearing the unsterile gloves, contaminating the box and poured sterile normal saline into the now contaminated plastic-lined box. RN F removed the exam gloves and washed her hands. RN F again donned and contaminated the sterile gloves as she had previously. RN F suctioned Resident #10 three times. RN F removed her gloves, did not wash her hands and picked up the disposable red, biohazard bag, which held the contaminated supplies. RN F placed the red bag in the trash receptacle on the medication cart and removed her gloves. RN F bagged the sputum-contaminated towel used on Resident #10's chest during the procedure, picked up the disposable red bag from the medication cart and entered the room labeled "shower room." When she left the shower room, RN F picked up a [MEDICAL CONDITION] sponge from the top of the medication cart, applied exam gloves and placed [MEDICAL CONDITION] sponge around and beneath Resident #10's [MEDICAL CONDITION]. RN F removed her gloves, did not wash her hands and went to the linen cart for a towel. The RN said, "We always put a towel around her when she has a lot of secretions." While in Resident #10's room, the RN rearranged the nebulizer treatment apparatus and then washed her hands. There was no emergency [MEDICAL CONDITION] observed as readily available during this treatment/dressing change. Review of Care of the Patient with a [MEDICAL CONDITION] retrieved from http://www.orthonurse.org/education/ce/marapr2k/tracheos/sec5text.htm on 03/19/06 revealed, "Potential Complications: ... Pneumonia: Because the presence of a [MEDICAL CONDITION] bypasses the patient's natural clearing mechanisms, the patient is at high risk for developing pneumonia ...The nurse is in a key position to implement measures to minimize risk. Handwashing and the proper use and cleaning of respiratory equipment are paramount in preventing the spread of infection ...Providing patient hygiene helps prevent the development of pneumonia in a number of ways. Using sterile technique when delivering stoma and tube care can minimize the chance of bacteria [MEDICAL CONDITION] entering the lungs." During an interview on 10/07/10 at 9:51 a.m., ADON G acknowledged she had not observed the nurses [MEDICAL CONDITION] for Resident #10. On 10/07/10 at 12:20 p.m. in interview, the DON stated there had been no in-service training on [MEDICAL CONDITION] care. She further stated she relied on the ADONs to monitor the nurses when they did [MEDICAL CONDITION] care. When the DON was informed ADON G had not observed the nurses perform [MEDICAL CONDITION] care, the DON stated she "did not know that." Review of Resident #10's care plan dated 08/12/09 revealed the following: (1) A communication care plan indicated her speech was impaired due to [MEDICAL CONDITION]/trach. (2) At risk for skin breakdown, irritation and/or infection R/T [MEDICAL CONDITION]. The resident's care plan did not address any other potential problems with regard to Resident #10'[MEDICAL CONDITION] surveyor inquiry. Resident #10's care plan Problem for "At Risk for skin breakdown, irritation and/or infection R/T [MEDICAL CONDITION] and gastrostomy" reflected it was initiated on 08/12/09; reviewed on 10/07/09; and was updated on 10/10/09 to include the Problem of "Non-compliance [MEDICAL CONDITION]- pulls off O2, pulls out inner cannula of [MEDICAL CONDITION]." This care plan Problem was reviewed and continued on 11/11/09 and reviewed and continued x 90 days on 02/10/10; was updated to include an entry beneath the Problem of "Non-compliance [MEDICAL CONDITION]- pulls off O2, pulls out inner cannula of [MEDICAL CONDITION]" which stated, "5/12/10 very rare now - monitor" This same care plan Problem was reviewed and continued x 90 days on 07/28/10. The approaches to these problems included: Trach care QS & PRN; [MEDICAL CONDITION] & PRN; Change/replace inner cannula as ordered & PRN; Change O2 setup as ordered & PRN; Ensure that NS is dated & changed on O2 & humidifier as ordered and PRN. However, review of Resident #10's physician's orders [REDACTED]. In an interview on 10/07/10 at 12:30 p.m., RN E stated there had been no in-services for [MEDICAL CONDITION] care. On 10/07/10 at 3:39 p.m. RN F was asked to show the surveyor where the emergency replacement [MEDICAL CONDITION] was located. RN F stated, "Oh, yes. We have one in her room." The surveyor accompanied RN F to Resident #10's room. RN F rummaged through all the supplies in Resident #10's room and was unable to find the emergency replacement [MEDICAL CONDITION] for Resident #10. RN F then stated, "We have one in Central Supply. The key is on Station One (which was at the opposite end of the nursing facility)." RN F was accompanied to Station One and down the hall to Central Supply. One [MEDICAL CONDITION] tube with inner cannula size 6 was located; however, RN F said, "This is a [MEDICAL CONDITION]- hers (Resident #10) is disposable. We can use this one if she pulls it out, or it comes all the way out. She has coughed it partially out and we have been able to put it back in." (An emergency replacement [MEDICAL CONDITION] is to be used in the event an individual with a [MEDICAL CONDITION] either pulls it out or coughs it out, which could be a life-threatening event.) [MEDICAL CONDITION]: A 2- to 3-inch metal or plastic tube that keeps the stoma and trachea open. Retrieved on 10/12/10 from http://www.medterms.com/script/main/art.asp?articlekey=5833 In medicine, a stoma is an opening, either natural or surgically created (artificial), which connects a portion of the body cavity to the outside environment. Retrieved on 10/12/10 from http://en.wikipedia.org/wiki/Stoma_(medicine) Review of the undated facility [MEDICAL CONDITION] Care policy provided by the DON on 10/06/10 as the current facility policy revealed: A) "...Purpose - The purpose of this procedure is to provide guidelines for [MEDICAL CONDITION] care and for the cleaning and sterilization of reusable metal [MEDICAL CONDITION]. (Resident #10 had a disposable plastic [MEDICAL CONDITION].) B) Equipment and supplies: Gloves; Mask and eyewear (as indicated); Trach-care kit; Hydrogen peroxide; Sterile water or normal saline; Suction catheter; suction machine; Replacement [MEDICAL CONDITION] (as necessary); Gauze dressing; and [MEDICATION NAME] ties. C) Procedure Guidelines - [MEDICAL CONDITION] Care: ...3. Remove old dressings and ties. Pull soiled glove over dressing and discard into appropriate receptacle. 4. Put on fresh gloves. (Note: Sterile gloves must be used for anything other than stoma care.)... ...Miscellaneous: 1. Aseptic technique must be used: (Aseptic technique is a set of specific practices and procedures performed under carefully controlled conditions with the goal of minimizing contamination by pathogens (bacteria). ...The goal of aseptic technique is to protect the patient from infection. Retrieved on 10/12/10 from http://www.healthline.com/galecontent/aseptic-technique) a. During all dressing changes until the [MEDICAL CONDITION] wound has granulated (healed); b. during [MEDICAL CONDITION] changes, either reusable or disposable; c. during endotracheal suctioning. (Endotracheal suctioning (ETS) involves the removal of [MEDICAL CONDITION] (lung) secretions from a patient with an artificial airway in place. Retrieved on 10/12/10 from http://www.ncbi.nlm.nih.gov/pubmed/ 17) ...2. Gloves must be used on both hands during any or all manipulation of the [MEDICAL CONDITION]. Sterile gloves must be used during aseptic procedures. ...6. [MEDICAL CONDITION] care must be provided as needed. However, care must be provided at least twice daily on old, established tracheostomies. [MEDICAL CONDITION] for residents with new sites or infections must be provided at least once on each shift. 7. A replacement [MEDICAL CONDITION] must be available at the bedside at all times. 8. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution must be available at the bedside at all times." Review of the undated facility [MEDICAL CONDITION] Site Care: Tie/Dressing Change and Inner Cannula Care policy provided by the DON on 10/06/10 as the current facility policy revealed: "1. Purpose - a. To ensure patency of the altered airway and minimize potential for infection. ...3. Procedure - a. Disposable inner cannula: ...iv. Change the inner cannula as indicated by presence of secretions." On 10/07/10 at 4:05 p.m., these failures resulted in an IJ situation in the area of Administration for Resident #10. The ADM and DON were informed of the IJ with SQC at that time. On 10/07/10 at 4:20 p.m., the DON said, "I review admission orders for Resident #10. When asked how long Resident #10 had not been receiving the physician-ordered continuous O2 [MEDICAL CONDITION], the DON stated, "Since she came back from the hospital in April (2010)." On 10/07/10 at 5:00 p.m. RN E and the DON presented an opened [MEDICAL CONDITION] (now unsterile) kit and said, "I knew we did have one. Someone used the inner cannula out of it and did not replace it." On 10/08/10 at 2:00 p.m., RN E was asked if she knew when the [MEDICAL CONDITION] presented on 10/07/10 at 5:00 p.m. had been opened. RN E replied, "We don't know when [MEDICAL CONDITION] was opened. I just found it opened in the med room." The facility's Plan of Removal originally dated 10/07/10 was accepted on 10/08/10. It reflected: 1. Resident #10's physician's orders [REDACTED]. The two nurses (RN F and LVN C) and nurse management were inserviced on [MEDICAL CONDITION] care by a Respiratory therapist. 2. There was only one resident with a [MEDICAL CONDITION] in the facility. 3. Resident #10's attending physician saw her and reviewed his [MEDICAL CONDITION] orders. The orders were care planned. [MEDICAL CONDITION] supplies (replacement trach) were placed and will remain at the bedside. The presence of the supplies were to be verified by the charge nurse on each shift and documented on the respiratory record and monitored by the DON and/or designee. The Central Supplies Clerk was to check [MEDICAL CONDITION] supplies on the hall and in Resident #10's room daily, order as necessary and report to the DON and/or designee. The DON received 'train the trainer' inservice from the Respiratory Therapist on [MEDICAL CONDITION] care. All licensed staff and unlicensed staff will be trained in the care of a resident with a [MEDICAL CONDITION]. PRN employees will be trained before their next working shift. [MEDICAL CONDITION] care training will be added to the New Hire Checklist; Proficiency exams will be completed annually; and will be monitored for completeness by the Human Resources Director. Training will be tracked weekly and monitored by the DON and ADM. Resident #10 was referred to an ENT specialist physician. The Medical Director was notified of the deficient practice. 4. The DON and/or designee will conduct random [MEDICAL CONDITION] proficiency checks for nurses who provide care to this resident q shift for three days then weekly for three months. An inventory checklist completed by the Central Supplies Clerk and the DON will be monitored daily for three days and then weekly for three months by the ADM. Findings were to be submitted to the monthly Quality Assurance meeting and weekly progress and tracking of in-servicing to the Medical Director. On 10/08/10 upon entry into the facility, the DON provided a copy of telephone orders from Resident #10's physician which reflected the following: 10/07/10 Pulse ox q shift and PRN; D/C [MEDICAL CONDITION] continuously; N/O Apply O2 [MEDICAL CONDITION] 4.5 lpm @ 35% humidification/mist if pulse ox < 90%. 10/07/[MEDICAL CONDITION] to be performed q shift & PRN for increased secretions; change inner disposable cannula daily on 2-10 shift; ENT Consult. 10/07/10 [MEDICAL CONDITION] shift & PRN. 10/07/10 [MEDICAL CONDITION] size for replacement is 6 DCT (Disposable cuffed [MEDICAL CONDITION]) Shiley - inner diameter 6.4 mm - outer diameter 10.8 mm. Record review verified inservice training on [MEDICAL CONDITION] Care had begun on 10/07/10 at 7:30 p.m. with 13 direct care staff, which included the DON and nursing administrative staff. A proficiency check list had been completed on the staff with proficiency [MEDICAL CONDITION] demonstrated. On 10/08/10 at 8:30 a.m. training was verified with RN F, who verbalized understanding of [MEDICAL CONDITION] care and aseptic technique. On 10/08/10 at 2:05 p.m. training was verified with LVN C, who verbalized understanding of [MEDICAL CONDITION] care as provided by the inservice. Review of Resident #10's physician's orders [REDACTED]. On 10/08/10 at 8:30 a.m. observation of Resident #10's room revealed a replacement [MEDICAL CONDITION] was taped to the wall above her bed and a manual [MEDICAL CONDITION] resuscitator was hanging in a plastic bag on a nail on the wall above the bed. Two pages of instructions for [MEDICAL CONDITION] care proficiency were encased in sheet protectors and were visible for review. The following respiratory equipment was at the bedside: a suction machine, vent with nebulizer and O2 Concentrator. While the IJ was removed on 10/08/10 at 4:00 p.m., the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not actual harm" and a scope of "pattern." The facility had not yet in-serviced all nursing staff, fully implemented its plan and was still monitoring for implementation of its plan. The ADM and DON were notified at that time. On 10/08/10 at 11:55 a.m., the ADM was asked, "How do you think this IJ came about?" The ADM answered, "We just let things slip through the cracks. We just were not paying attention." While the IJ was removed on 10/08/10 at 4:00 p.m., the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not actual harm" and a scope of "pattern." The facility had not yet in-serviced all nursing staff, fully implemented its plan and was still monitoring for implementation of its plan. The ADM and DON were notified at that time. CMS form 672 (Resident Census and Conditions of Residents) dated 10/04/10, completed by the DON reflected one resident had a [MEDICAL CONDITION].

Based on observation, interview, and record review, it was determined two (Residents #9 and #13) of twenty-one sampled residents were not provided services in the facility with reasonable accomodations of individual needs and preferences. 1) Resident #9 wanted to be assisted out of bed to use a bedside commode, but staff did not take the resident's request/preference into consideration and they had been using a Hoyer lift to transfer the resident onto a bedpan for toileting. This was the system used for the last five months for Resident #9 when she needed to have a bowel movement. The resident was very upset when describing the procedure and stated she felt it was degrading and very inhumane to be treated that way. 2) Resident #13's motorized wheelchair had been broken for three weeks. Staff were told not to use a Geri-chair for the resident due to his [DIAGNOSES REDACTED]. The resident was told there was no Geri-chair available during the day. In the evening, staff would get the resident up in a Geri-chair. The resident was upset about being restricted to bed during the day. These failures could affect the facility's 44 residents, who were dependent upon staff for transfers, including Residents #9 and #13, affecting their quality of life by remaining in bed, not being able to socialize and be involved in activities, which placed them at risk for a poor quality of life, loss of self-worth and self-esteem and depression. Findings included: 1) Resident #9 was observed during rounds on 10/04/10 at 8:12 p.m. in her room. LVN D stated Resident #9 was alert and oriented to person, place and time. She used a wheelchair for ambulation in her room and required assistance while out of the room. LVN D also stated Resident #9 required the assistance of two staff for transfers, and she required total assistance with ADLs. LVN D stated Resident #9 was bedfast, continent and used the bedpan for bowel movements. Review of the October 2010 physicians' orders revealed she was admitted to the facility on [DATE] with diagnoses, which included: Low Back Pressure Ulcer, Pressure Ulcer Heel, Diabetes, Hypertension, [MEDICAL CONDITIONS] Mild Degree, Chronic [MEDICAL CONDITION], Dysarthria, and [MEDICAL CONDITION]. Review of Resident #9's care plan with a review date of 09/29/10 revealed Resident #9 required the assistance of one for transfers and toileting. There was no care plan, which addressed the resident's use of a bedpan for bowel movements. There was no care plan, which reflected why staff used a Hoyer lift to transfer the resident onto a bedpan. Observation on 10/05/10 at 9:45 a.m. of Resident #9's right heel revealed the pressure ulcer had healed and there was pink skin where the presssure ulcer had been. Resident #9 was interviewed on 10/05/10 at 12:45 p.m. The resident stated staff had been placing her on the bedpan to defecate, because they were afraid of her falling and/or dropping her. Resident #9 stated she would prefer to go to the potty chair or the commode. Resident #9 stated she preferred the bedside commode, because the bathroom commode seat was too low for her. Looking upset, she then put her head down and was wringing her hands as she stated, for the last five months she had to have her bowel movements in that manner. Resident #9 stated she felt it was degrading and very inhumane. She stated she could use the bedside commode if staff would assist her. The resident repeated staff were afraid of dropping her, so they made her use the bedpan. The DON was interviewed on 10/05/10 at 4:05 p.m. The DON stated Resident #9 used the bedpan with a transfer onto the pan via the Hoyer lift. The DON stated the Hoyer lift could not be used in the bathroom, because it could not fit, so they placed the resident on the bedpan. When asked why the Hoyer lift and bedpan was started, the DON stated Resident #9 had refused to ambulate due to the pressure ulcer on her left (sic) heel, but that the pressure ulcer had healed. Nurses notes dated 07/15/10 reflected the resident's "Stage III right heel (pressure ulcer) has closed and healed." Further review of Resident #9's entire clinical record revealed no assessment had been conducted to assess the strength in her legs, and no evidence staff had encouraged the resident to ambulate so that she could use a beside commode or the bathroom toilet. The DON was interviewed again on 10/06/10 at 10:15 a.m. following surveyor intervention regarding Resident #9's situation. The DON reported Resident #9 had been started on a trial toileting program. The DON stated the resident would be evaluated by Physical Therapy and Occupational Therapy. Resident #9 was presently being tried for use of the bedside commode. As a result of surveyor inquiry, the DON stated they were going to reassess all the residents, who were being transferred with the Hoyer lift for toileting. Charge nurse LVN I was interviewed on 10/08/10 at 9:40 a.m. LVN I stated she had been working in the facility for five months and had never seen Resident #9 assisted to a standing position until yesterday (10/07/10). LVN I stated the CNAs told her Resident #9 could stand up, pivot and assist with transferring to the bedside commode. LVN I stated when she first started working in the facility, Resident #9 had a pressure ulcer on her heel, which made it impossible for the resident to stand or ambulate, so she was usually placed on the bedpan. LVN I further stated since the pressure ulcer had healed, staff had not attempted assisting the resident to the bedside commode or the bathroom. Interview with ADON G on 10/08/10 at 9:50 a.m. revealed she had not assessed Resident #9 for bowel toileting and/or bedpan use. ADON G stated she had only assessed Resident #9 for use of the electric wheelchair, because her family brought an electric wheelchair and assisted her into the chair without staff assistance. On 10/07/10 at 7:45 a.m. Resident #9 had a huge smile on her face. She stated she was so happy and was looking for the surveyor to tell her the good news. When asked what the good news was, Resident #9 stated the facility staff had assisted her up to the bedside commode. She then pointed to a bedside commode by the bathroom door. Resident #9 stated staff lowered her bed, she scooted to the side of the bed, and the staff supported her to transfer to the commode seat. Resident #9 stated staff had been afraid she would fall, so had kept her in bed and gave her the bedpan. The resident further stated she went to an exercise class where staff made her stand up. However, her right leg was still weak from her not having stood up in a long time. The resident's face was beaming with joy and happiness during this interview. 2) Resident #13 was observed sitting in a Geri-chair on the facility's patio on 10/04/10 at 8:30 p.m. The resident stated he had difficulty obtaining assistance to get out of bed. Resident #13 further stated his electric wheelchair was in need of repair and staff were not able to assist him out of bed during the daytime hours, because there was no Geri-chair available. The resident then stated he did not enjoy being in bed all day. Additionally, the resident stated he was used to being out of bed and active. According to Resident #13, the only time a Geri-chair was available was during nighttime hours. Review of the face sheet dated 01/15/10 revealed Resident #13, [AGE] years of age, was admitted on [DATE] and readmitted on [DATE]. A Medicare readmission MDS assessment dated [DATE] reflected [DIAGNOSES REDACTED]. The MDS assessment also reflected the resident was totally dependent on two staff for bed mobility and transfers. For locomotion on and off the unit, the resident required minimal assist with supervision and was able to self-wheel in a wheelchair. The resident was awake most of the time during the day and spent more than 2/3 of his time involved in activities and his preferences were: cards, exercise/sports, music, reading/writing, walking/wheeling outdoors, watching TV and talking or conversing. An interview with Resident #13 on 10/05/10 at 9:00 a.m. revealed his electric wheelchair had been broken for two weeks. The resident further stated the facility was going to get it fixed. For the time being, the resident stated he used a Geri-chair when one was available. He added if the staff did not find him a Geri-chair, he would be "stuck in bed all day," and he did not want to be in bed all day. (This last statement was spoken in an angry tone of voice.) An interview on 10/05/10 at 12:20 p.m. was conducted with CNA P concerning Resident #13's electric wheelchair. CNA P stated it had been broken for about three weeks. She further stated three unused electric chairs were in the restorative area but belonged to other residents. CNA P stated ADON T informed her a Geri-chair could not be used for Resident #13. She also stated the resident could not bend due to his diagnoses, and would slide right out of a Geri-chair. On 10/05/10 at 12:50 p.m. LVN S was interviewed in regard to the staff getting Resident #13 into a Geri-chair. LVN S stated there were no orders to get him up, and she added she did not feel it was safe to get him up, because he would slide onto the floor. She was afraid he would slide out of a Geri-chair. A review of the care plan dated 01/28/10 revealed mobility off the unit and transfers out of bed were not addressed. A physician's orders [REDACTED]. 1) Occupational Therapy to evaluate and treat 2) Occupational Therapy daily 5x wk x 30 days for therapeutic exercise, therapeutic activity, neuromuscular re-education, ADLs, safety, group therapy prn, heat/ice prn for decreased coordination. The order was signed by a nurse and the Occupational Therapist Registered. physician's orders [REDACTED]. 1) Resident to be up in Geri-chair with anti skid pad to prevent sliding (while MWC is broken) 2) Res must be supervised @ all times when up in chair and on 10/06/10 Physical Therapy was to evaluate and treat. physician's orders [REDACTED]. The DON was interviewed on 10/05/10 at 3:30 p.m. The DON stated Physical Therapy had assessed Resident #13 and she was waiting for the evaluation. She stated the nurses were afraid to get him up due to his sliding. She further stated she forgot to get back with therapy about anti-skid pad for the Geri-chair. On 10/05/10 at 3:35 p.m. in an interview with the COTA in regard to getting Resident #13 into a Geri-chair, she stated she thought the CNAs had tried to get him up. A PTA was also present during the interview and she stated the resident had not been assessed yet, and it would probably be done tomorrow. On 10/05/10 at 4:40 p.m. the DON stated the occupational therapist said it was "OK" for Resident #13 to be in a Geri-chair. She further stated a quote on the electric wheelchair repair was coming. Interview with the LBSW (Licensed Baccalaureate Social Worker) at 4:45 p.m. on 10/05/10 revealed Resident #13 told her three weeks ago he had called the DME (Durable Medical Equipment) company and told them his electric wheelchair was broken. On 09/30/10 she received a bill for the repair and called the DME company and asked them what was going on. She was told by the DME Resident #13 called them for repairs for his electric wheelchair at the nursing home where he previously lived. The DME would send the bill to the nursing home. She stated she gave the bill to the Adm due to it being a "quality of life issue" and stated, "It's in his hands now." An interview on 10/06/10 at 9:00 a.m. with the DON revealed the Adm was looking into the chair situation. She further stated an anti-skid mat and a Geri-chair were being put together for Resident #13 and staff training had taken place. At 10:00 a.m. on 10/06/10, the Adm stated it appeared the facility was responsible for paying the repairs on Resident #13's electric wheelchair. The Adm stated he was getting a second bid and had called his corporate office. It was observed at this time Resident #13 was in a Geri-chair and being pushed toward the dining room. Resident #13 was observed in his room at 1:10 p.m. on 10/06/10 lying in bed. The resident stated he was happy about being able to get up out of bed. At 1:15 p.m. on 10/06/10, the Adm stated a second estimate for the electric wheelchair repairs would be here today, and he would submit it to the corporate office. The CMS-672 (Resident Census and Conditions of Residents) dated 10/04/10 and provided by the DON reflected 44 residents were dependent on staff for transfers.

Based on observation, interview and record review, the facility failed to ensure a significant change comprehensive assessment was completed when facility staff should have determined there had been a significant change in the residents' physical/mental condition for two (Residents #10 and #14) of 24 sampled residents, whose records were reviewed for changes in condition. Resident #10, who currently had a G/T for her nutritional needs and a [MEDICAL CONDITION] for oxygenation, had experienced a significant change in her cognitive status and transfer and ambulation abilities. Due to the improvement in her cognition, the resident was able to recognize and express a desire for oral intake. The resident had also been on room air since her readmission in April 2010 and had not been dependent on oxygen from an oxygen concentrator. Facility staff were aware of these changes, however no specific interventions such as physical, occupational or speech therapy evaluations/assessments had been implemented. A significant change assessment had not been conducted, which would have automatically resulted in a therapy evaluation/assessment to address the resident's improved condition. Further, a recommendation dated 01/25/10 for a follow-up Modified [MEDICATION NAME] Swallow Study (MBSS), E-Stim treatment, and a referral for an ENT specialist had not been done as of 10/07/10. Resident #14 experienced a decline in condition in the areas of mood/behavior, psychosocial responses to those around her, increased need for assistance with transfers, ambulation and eating. The resident was now totally incontinent. The decline was apparent from the assessments conducted on 12/30/09 and 08/18/10, but these changes did not generate a significant change assessment, and screening by therapy was not identified as a need for the resident. Resident #14 fell on [DATE] and fractured her right leg. These failures could affect the facility's 121 residents, including Residents #10 and #14, and placed them at risk for not receiving the appropriate care and services needed for their current condition, resulting in residents not achieving their optimum potential and no interventions to prevent a further decline in their condition. Findings included: 1) Review of Resident #10's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [MEDICAL CONDITION] is a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a [MEDICAL CONDITION]. Retrieved on 10/12/10 at http://www.medicinenet.com/[MEDICAL CONDITION]/article.htm [MEDICAL CONDITION] is a condition characterized by either partial or total loss of the ability to communicate verbally or using written words and can be temporary or permanent. Retrieved on 10/12/10 at http://medical-dictionary.thefreedictionary.com/[MEDICAL CONDITION] Observation on 10/04/10 at 7:59 p.m. revealed Resident #10 was asleep in bed on her back. She was lying in a modified Fowler's position (elevated head of bed) on an alternating pressure mattress with both half side rails in the upright position. Resident #10 had [MEDICAL CONDITION] was breathing room air. Resident #10 had Glucerna 1.2 cal infusing via pump at 65 cc per hour through a G/T (a tube inserted into the abdomen and used for administration of food, fluids and medications). During the initial tour on 10/04/10 at 7:59 p.m., LVN H stated Resident #10 was ambulatory per wheelchair, was continent when toileted, received total assistance with ADLs, was on oxygen, was an insulin dependent diabetic, was forgetful at times, and was alert to person. LVN C stated, "She wants to eat; but, we can't give her anything, not even coffee on a sponge. She failed her [MEDICATION NAME] swallow. She wants bacon, eggs, toast and coffee." Resident #10's significant change MDS assessment dated [DATE] was compared with the quarterly MDS assessment dated [DATE]. The 07/13/10 quarterly MDS reflected an improvement cognitively from severe impairment to moderate impairment; transfer from the need of extensive assistance of two people to extensive assistance of one person; and ambulation from total assistance of one person to limited assistance of one person. On 10/06/10 at 8:56 a.m. in an interview, the MDS Coordinator stated she did not do a significant change MDS assessment for the improvement in Resident #10's condition, which was reflected on the 07/13/10 quarterly MDS assessment. She stated she "didn't see it as a significant change." Review of Resident #10's care plan revealed no documentation regarding the resident's improved cognition, ability to transfer and ambulate. Additionally, there was no care plan for restoration of normal eating skills. On 10/06/10 at 12:38 p.m. observation of Resident #10 revealed she was alert and sitting in a wheelchair in the hall. She was neatly dressed and groomed. Resident #10 mouthed a verbal response, "Thank You" when told how well she looked. On 10/06/10 at 1:00 p.m. Resident #10 covered [MEDICAL CONDITION] said, "I want to eat." The resident's family member was asked, "Have her daily routines and activities changed in a substantial way since moving here?" The family member responded, "She can't eat. She just wants to eat. That's what she looks forward to - being able to eat again." Review of the MBSS dated 01/25/10 revealed, based on the results of the test, recommendations included: education on hyolaryngeal exercises, E-Stim, and to consider an ENT referral to r/o cricopharyngeal dysfunction." An additional recommendation reflected to repeat the MBSS in 4-6 weeks from 01/25/10 and post dysphagia (difficulty swallowing) treatment. Hyolaryngeal and cricopharyngeal are anatomical muscles within the throat involved with swallowing. Retrieved on 10/12/10 from http://www.hani-shaker.com/Swallowing/Swallowing_anatomy.htm E-Stim - Electrical stimulation to cause a single muscle or a group of muscles to contract. Contracting the muscle via electrical stimulation helps strengthen the affected muscle and promotes blood supply. The physical therapist can change the current setting to allow for a forceful or gentle muscle contraction. Retrieved on 10/12/10 from http://physicaltherapy.about.com/od/abbreviationsandterms/g/EStim.htm On 10/07/10 at 10:00 a.m. the RDO stated the former Speech Therapist (ST), who worked at the facility between January 2010 and June 2010 and provided therapy for Resident #10, "was not trained in Vital Stim (E-Stim). We don't have a machine available to do the treatments." The new RD interjected, "There are alternatives to E-Stim." The RDO further stated if there had been a significant change MDS completed, it would have initiated a therapy screening for Resident #10. In an interview on 10/07/10 at 12:20 p.m., the DON was asked what would have happened if a significant change MDS assessment had been done instead of the quarterly MDS assessment on 07/13/10. The DON stated, "If a significant change had been done for improvement or decline in a resident's (Resident #10) condition, it would have triggered a therapy screening." Review of Resident #10's entire clinical record revealed there was no evidence of the resident being referred for a consult for ENT or follow-up to the 01/25/10 MBSS following post dysphagia treatment until surveyor inquiry on 10/07/10. On 10/08/10 at 8:30 a.m. Resident #10 was observed sitting in a wheelchair in the hall neatly dressed and groomed. She was awake and pleasant on approach. Resident #10 responded to name and recognized the surveyor. She talked through her trach. Glucerna 1.2 cal was infusing via the pump at 65 cc per hour through a G/T. 2) Review of Resident #14's face sheet dated 10/16/09 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Phobia. Observation on 10/04/10 at 7:24 p.m. revealed Resident #14 was asleep in bed on her back with her left leg hanging over the full padded side rail on the right side of the bed. There was an oxygen concentrator with tubing connected to a nasal cannula. The nasal cannula was on the floor. There was a nebulizer apparatus uncovered on the bedside table. The supper tray was on the overbed table at the bedside and was untouched. During the initial tour on 10/04/10 at 7:24 p.m., LVN C stated Resident #14 was ambulatory per wheelchair; was incontinent of bowel and bladder; received total assistance with ADLs; and was alert and oriented to person with confusion, combative behaviors and forgetfulness at times. Additionally, LVN C stated Resident #14 was legally blind, was fed in her room, had full bed rails on both sides of the bed; was on antipsychotic medications and had sustained a recent fall with a fracture. Resident #14's annual comprehensive MDS assessment dated [DATE] was compared with the quarterly MDS assessment dated [DATE]. The 08/18/10 quarterly MDS assessment reflected a decline in mood and behavior patterns from crying up to five days a week to crying daily; transfer assistance from the limited assistance of one person to the total assistance of one person; ambulation assistance from limited assistance of one person to total assistance of one person; eating assistance from the limited assistance of one person to extensive assistance of one person; and from frequently incontinent of urine to totally incontinent of urine. An interview on 10/06/10 at 9:00 a.m. with the MDS Coordinator revealed she did not do a significant change MDS for the decline in Resident #14's condition reflected on the 08/18/10 quarterly MDS assessment. She stated she "didn't see it as a significant change. I just didn't do it." Review of Resident #14's nurses notes dated 09/13/10 at 6:20 p.m. revealed "Res finished supper rolled w/c into room and then to B/R (bathroom) found res lying on B/R floor with head facing sink. Crying and screaming Oh Oh I broke my hip. Rt leg on top of left leg with knot at ___ (upper area of) leg. Scratch on hip. Assisted X3 with blanket roll to lift res. to bed. Rt leg turned inward with knot on ___ (upper area of) leg... (Resident #14 stating) Oh that hurt worse than child birth...." Observation on the following dates and times revealed Resident #14 was in bed with both padded side rails in the upright position: 10/05/10 at 9:38 a.m. and 12:50 p.m.; 10/06/10 at 8:11 a.m., 9:36 a.m. and 10:55 a.m.; 10/07/10 at 9:08 a.m.; and 10/08/10 at 9:00 a.m., 12:00 p.m. and 1:30 p.m. Review of Resident #14's admission orders Bed rest till further notice, Bed alarm on at all times, Keep Rt leg straight." Observation on 10/05/10 at 9:38 a.m. revealed Resident #14 was asleep in bed on her back with the head of the bed elevated approximately 45? with with both padded full length side rails in the upright position. Review of Resident #14's comprehensive care plans dated 02/05/08 revealed no care plan for "Mood and Behavior." The care plan for Physical Functioning (ADLs) was initiated on 02/05/08 and then reviewed and continued with each MDS since that time. The last entry for the Physical Functioning Care plan was dated 8/18/10 and stated "review, cont (continue) X 90 D (90 days)." On 10/07/10 at 10:00 a.m. the RDO stated if there had been a significant change MDS completed, that would have initiated a Therapy screening of residents' with a decline and/or improvement in condition, which would have included Resident #14. On 10/06/10 at 10:55 a.m. during the dressing change to Resident #14's surgical wound (open reduction with internal fixation of her fractured right leg), LVN C stated, "We don't get her up anymore." Prior to the fracture, documentation reflected Resident #14 was up ambulating in a wheelchair. On 10/07/10 at 12:20 p.m. in interview, when asked what would have happened if a significant change MDS had been done instead of the quarterly MDS on 08/18/10, the DON stated, "If a significant change had been done for improvement or decline in a resident's condition, it would have triggered a Therapy Screening". The form CMS-672 (Resident Census and Conditions of Residents) dated 10/4/10 provided by the DON reflected the census was 121.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical and mental well-being for one (Resident #2) of eleven residents reviewed for pain and for one (Resident #3) of seven residents reviewed for incontinence. 1) Resident #2 was not provided with pain medication as ordered by the physician to ensure the resident's pain was controlled. When Resident #2 complained of pain to CNA X on 10/05/10, the CNA failed to report the complaint to the nurse. Resident #2 verbalized pain during wound care on 10/06/10. LVN M continued with the treatment without assessing the resident and/or providing the ordered pain medication, leaving the resident with unrelieved pain. This failure could affect the 26 residents, including Resident #2, who were on a pain management program, and placed them at risk for not having pain medication administered as ordered by the physician, not being assessed for pain and having to endure unrelieved pain. 2) On 10/05/10 and 10/06/10, Resident #3 had hard-formed stool in her anal os (the opening of the rectrum), which the resident was unable to expel and caused her pain due to the pressure in her rectal area. CNA ZZ reported the hard-formed stool to LVN I, only because CNA Y insisted. LVN I administered [MEDICATION NAME]. LVNs I and D did not check the resident for impaction. This failure could affect the 76 residents, who were occasionally or frequently incontinent of bowel, including Resident #3, and placed them at risk for not being assessed timely for constipation/impaction, being provided medication and/or treatment when it could provide relief for the residents and not leave them with unrelieved pain and discomfort. There were no residents on a bowel program. Findings included: 1) Review of Resident #2's Record of admitted d 03/18/09 revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. An interview with LVN W on 10/05/10 at 10:45 a.m. revealed she was the charge nurse on duty responsible for providing care to Resident #2. LVN W stated the resident frequently complained of pain. An observation on 10/05/10 at 1:05 p.m. revealed CNA X responded to Resident #2's call light. The resident informed the CNA his legs hurt. CNA X stated, "You have that (pain) patch on." Resident #2 informed the CNA the patch was not helping and he was still "hurting." CNA X exited the resident's room, went into the hallway and began removing lunch trays from other residents' rooms. On 10/05/10 at 1:30 p.m. the surveyor queried LVN W about Resident #2's earlier complaint of pain at 1:05 p.m. LVN W stated she was not aware of the resident's complaint of pain and had not been informed by CNA X. LVN W stated she would assess the resident and administer pain medication. LVN M was observed providing wound care for Resident #2 on 10/06/10 at 11:40 a.m. The resident was observed with a Stage III pressure ulcer on the right hip. The pressure ulcer was noted with undermining and a large amount of serosanguinous (containing or consisting of both blood and serous fluid) drainage was on the old dressing. LVN M used a small syringe to irrigate the undermining (A hollow area between the skin surface and the wound bed) portion of the pressure ulcer. As the nurse began to pack the pressure ulcer with silver calcium alginate (antimicrobial wound dressing) Resident #2 yelled out, "Oh! That hurts." The surveyor queried LVN M about the administration of pain medication prior to the treatment for [REDACTED].#2 with pain medication at approximately 9:30 a.m. or 10:00 a.m. that morning. When the surveyor pointed out to LVN M the current time was 11:40 a.m., she stated she was unaware it was nearly 12:00 p.m. LVN M made no attempt to stop or interrupt the treatment and continued to pack silver calcium alginate into the pressure ulcer, She then covered the pressure ulcer with a foam dressing. Resident #2 continued to complain of pain throughout the treatment and stated his pain patch "was not doing any good." Review of Resident #2's physician orders [REDACTED]. An interview with LVN M on 10/07/10 at 12:30 p.m. revealed there were no routine pain assessments for Resident #2. LVN M stated the resident was oriented and able to ask for pain medications. According to LVN M, unless a resident had orders for and received pain medication, no routine pain assessments were conducted. The LVN stated she "tried" to notice facial expressions of pain and would ask residents if they were in pain. LVN M did not explain how she determined when to administer pain medication if a resident was not able to verbalize the need for the pain medication. During the interview, LVN M stated, "I guess we could routinely put him (Resident #2) on pain medication" prior to his treatment. Review of Resident #2's care plans revealed a review date of 07/14/10. A care plan addressed the resident's cognitive deficits and impaired decision making abilities. Dementia and [MEDICAL CONDITIONS] were the relating factors. Review of Resident #2's entire clinical record revealed the most recent pain assessment was dated 01/20/10 and reflected the location of the resident's pain was "everywhere." According to the assessment, Resident #2's pain was constant, throbbing and sharp. The assessment further reflected increased movement was an exacerbating factor for Resident #2's pain. Further review of the resident's care plans revealed an interdisciplinary care plan worksheet, which reflected the resident was receiving Hospice services due to End Stage [MEDICAL CONDITION]. The goals listed on this worksheet were the resident and family would experience minimal discomfort and anxiety through the dying phase. Approaches included assessing and managing Resident #2's pain. There were no specific actions or nursing care in the care plan worksheet for achieving the goals. There was no care plan specifically addressing Resident #2's pain. An interview on 10/07/10 at 12:45 p.m. with LVN H revealed she was the MDS Coordinator. LVN H stated she completed pain assessments quarterly. LVN H reviewed Resident #2's clinical record and was unable to locate a current pain assessment (last done 01/20/10) or any care plan related to the resident's pain. During an interview with Resident #2 on 10/07/10 at 1:30 p.m., the resident stated he had a "rough" night the previous night. The resident further stated he experienced pain each time his pressure ulcer was treated. According to the resident, he did not request any pain medication because he thought it had already been administered. Resident #2 stated he was not aware he could have pain medication for breakthrough pain. Prior to exit on 10/08/10 at 4:00 p.m., LVN H prepared and provided a care plan for Resident #2 addressing the resident's chronic pain related to [MEDICAL CONDITION], Neuralgia and Muscle Spasm. The facility's P/P dated May 2009 and entitled "Pain Management" was provided by the DON on 10/07/10 and identified as current. The P/P reflected in part: ...4. The interdisciplinary team will be responsible to develop and assess the effectiveness of interventions at least quarterly. ...8. Routine and PRN medication regimen are to be determined by the physician and are to be tailored to the special needs of that resident. 2) The surveyor observed Resident #3 on rounds on 10/04/10 at 7:25 p.m. in her bed. LVN D told the surveyor Resident #3 was alert and oriented to person, time and place; was bedfast and incontinent of bowel and bladder; was fed by staff and had pressure ulcers on both heels, on top of both ankles and the sacrum. Review of Resident #3's entire clinical record revealed the October 2010 physician orders [REDACTED]. The October 2010 physician's orders [REDACTED]. Resident #3 had a telephone order dated 10/01/10, which reflected a new order for [MEDICATION NAME] (laxative for constipation relief) 17 gm in eight ounces water as needed daily. The surveyor observed CNAs Y and Z providing incontinent care to Resident #3 on 10/05/10 at 2:15 p.m. The surveyor observed Resident #3 was in bed. The resident's hands and feet were observed to be flaccid, straight and elevated on pillows. When the staff rolled Resident #3 to her left side to expose her buttocks, he surveyor observed hard-formed, yellow/brown fecal material in the resident's rectal opening. CNA Z told CNA Y Resident #3 was not incontinent, and CNA Z wiped the buttocks with the wash towel. At that time, the surveyor asked CNA Z to check the resident's rectum. When she checked it, CNA Z told the surveyor Resident #3 was just starting to defecate and would push the stool out. CNA Z described the stool as formed and hard at that time. The surveyor asked the CNAs if they would notify the charge nurse. CNA Z stated "No," because the resident would push the stool out. When CNA Z was asked if Resident #3 was able to push the stool out on command, the CNA stated sometimes the resident could, but most times not. CNA Y insisted CNA Z notify the charge nurse. At that time, CNA Z left the room and came back with the charge nurse, LVN I. LVN I told the CNAs to place Resident #3 on her side to defecate, to give her time and cover her up. LVN I then left the room. LVN D then came into the room stating she was now on duty, turned to the CNAs and told them to place Resident #3 on her left side to make it easier for the resident to defecate. LVN D then left the room. At that time, the surveyor asked Resident #3 what she was feeling in her rectal area. Resident #3 responded she felt pressure and pain from not being able to expel the stool. At 2:30 p.m., LVN I came back to the room with a clear class of water, however, she stated she was giving the resident [MEDICATION NAME] for her constipation. Both LVNs D and I came into the room and left without assessing Resident #3's rectum or checking for impaction. The surveyor observed LVN I providing treatment for [REDACTED]. opening. At 9:20 a.m., LVN I rolled Resident #3 to her side to see the sacrum for treatment. The surveyor observed Resident #3 with hard-formed rounded stool in her rectal opening. LVN I covered Resident #3 up and left the room to obtain towels to clean the feces from the resident. LVN I returned with the towel, grabbed and removed the hard-formed, yellow/brown feces from the resident's rectum and then cleaned the fecal material from the rectal opening with the towel. There was still stool observed in the resident's rectal opening, which stretched it open to approximately six cm around. On inquiry, LVN I told the surveyor Resident #3 would push the stool out later. The LVN continued with the treatment to the sacral pressure ulcer. After the treatment was finished, the surveyor asked LVN I why Resident #3 was so flaccid. LVN I stated the resident's [MEDICAL CONDITION] left her paralyzed. Retrieved on 10/12/10 from http://medical-dictionary.thefreedictionary.com/multiple+[MEDICAL CONDITION]. [MEDICAL CONDITION] (MS) is a chronic [DIAGNOSES REDACTED] disorder affecting movement, sensations, and bodily functions. It is caused by destruction of the myelin insulation covering nerve fibers (neurons) in the central nervous system (brain and spinal cord). MS causes a wide variety of symptoms and can affect vision, balance, strength, sensation, coordination, and bodily functions. Later symptoms may include: Fatigue, Muscle [DIAGNOSES REDACTED] and Stiffness, Tremors, Paralysis, [MEDICAL CONDITION], Pain, Speech or Swallowing Difficulty, Loss of Bowel and Bladder Control, Incontinence, and Constipation. Review of the facility's ADL book with CNA AA and LVN I revealed Resident #3 had a bowel movement on 10/02/10, which was documented as "medium." Resident #3 also had a "small" bowel movement on 10/04/10 per the ADL book. There was no documentation Resident #3 had any bowel movement after having been medicated with [MEDICATION NAME] on 10/05/10. The DON was interviewed on 10/06/10 at 10:15 a.m. The DON told the surveyor the facility had a bowel program, and residents were given stool softeners. The surveyor asked if staff were to check residents for impaction. The DON stated if staff felt the resident was impacted, staff would assess and remove the impaction if able. The surveyor requested the facility policy for constipation and/or removing an impaction. The facility's current P/P on removal of fecal impaction was provided by the DON on 10/06/10 at 12:00 p.m. The undated policy had been copied from the Encyclopedia of Nursing and Allied Health. The DON told the surveyor it was the current policy she used for teaching the staff. Review of the policy revealed fecal impaction removal was to be done manually, by breaking it up and removing the fecal impaction, or mass of hardened, clay-like stool lodged in the rectum. Fecal impaction was the result of extreme constipation. As the patient was unable to expel the stool, it further accumulated into a large, harder mass that is impossible to pass by normal defecation. RN E provided another facility P/P (undated) for "removal of impaction," and said the DON found the P/P in another of the facility's policy book. The policy reflected to remove impacted feces, which cannot be removed with laxatives or enema, the attending physician must be consulted for orders. 3) The form CMS-672 (Resident Census and Conditions of Residents) signed by the DON on 10/04/10 reflected 26 residents were on a pain management program, no residents were on an individually written bowel training program, 76 residents were occasionally or frequently incontinent of bowel and the census was 121.