Every finding on record at Parks Health Center

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 4 residents (Resident #1) reviewed for transfers in that: CNA A transferred Resident #1 with the mechanical lift by herself when it required 2 staff members, the mechanical lift tilted over and Resident #1 was dropped and resulted in a laceration to her head. It was determined a past non-compliance existed from 08/16/2026 to 08/16/2026. The past-non-compliance was determined to have been removed due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation. These failures could place residents at risk of accidents and serious injuries which could result in a reduced quality of life.Findings included: Record review of Resident #1's admission record, dated 08/21/2026, indicated she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and muscle weakness. She was [AGE] years of age. Record review of Resident #1's care plan, revised on 08/2026, indicated in part: Focus: Resident requires transfer assistance r/t musculoskeletal impairment. Will demonstrate the appropriate use of adaptive device(s) to increase ability in bed mobility, transfers, toilet use through the review date. Device(s): mechanical lift. Provide two persons for physical assist with Hoyer(Mechanical lift). Transfer (chair/bed to chair transfer, shower, toilet transfer): requires mechanical aid Hoyer for transfers. Focus - Has had an actual fall on 8/16/26: Fall with injury- Laceration to left side of head. (Laceration to head) will resolve without complication by review date. 8/16/26- Direct care staff education and competencies on Hoyer (Mechanical lift) use and safety. Education provided to staff on transfers. Record review of Resident #1's Quarterly MDS Assessment, dated 05/14/2026, indicated in part: Cognitive skills for daily decision making = Severely impaired - never/rarely made decisions. Mobility devices = Wheelchair. Review of Resident #1's incident report dated 08/16/2026 revealed in part: Nurse was notified by RN B, that resident was noted to be on the floor during transfer. Resident noted to lying on the floor face down with upper extremities under torso, lower extremities extended, sling on resident. Recliner noted to be backwards next to resident. Lift noted to be on top of chair. Fall mat on floor. First aid provided to resident. Resident noted to be bleeding unable to determine immediate source of bleeding. Resident stabilized. Pressure applied to bloody area. Resident alert to self. Able to respond questions at resident's baseline. EMS called via 911. Completed by RN C. Telephone interview on 08/20/2026 at 1:12 PM with CNA A, she said that she had transferred Resident #1 with the mechanical lift by herself on 08/16/2026. The CNA said that she had done it by herself because the other staff would not assist her with transferring the resident. CNA A said that she knew that it was supposed to be 2 staff members when the mechanical lift was being used. The CNA said she had been told that there should always be 2 staff members present. CNA A again said the reason she had not asked for help was because she did not get along with the other staff and did not ask for help. The CNA said that she had attempted to transfer Resident #1 from her bed to her Geri-chair with the mechanical lift when the fall occurred. CNA A said that when she was lowering the resident onto her wheelchair the resident landed on the armrest of the Geri-chair and then the lift fell over with the resident in it. The CNA said she then called for help and the staff came in to assist her with the resident. CNA A said she should have called for a second staff member to be present but she had not. Interview on 08/20/2026 at 4:25 PM, CNA B said whenever she transferred a resident with a mechanical lift she would have another person with her because they were to always be a second person to help with the lift. The CNA said the reason for the second person was for one to maneuver the mechanical lift and the other staff member would help guide the resident as they were hanging on a sling that would suspend from the lift. The CNA said that the mechanical lift that was used when CNA A dropped Resident #1 was the same one she would use to transfer the residents and that it worked just fine. CNA B said she had worked in the same hall as CNA A on the day that Resident #1 had been dropped from the mechanical lift which was Sunday 08/16/2026. CNA B said she was next door to Resident #1's room assisting another resident when CNA A transferred Resident #1 on her own. CNA B said that CNA A had not asked her to assist her with transferring Resident #1 or else she would have assisted her. Interview on 08/20/2026 at 4:34 PM, the DON said it was expected that whenever the mechanical lift was used to transfer a resident that there should always be 2 staff members present. The DON said that the reason for 2 staff members to use the mechanical lift was due to safety reasons and plus their policy also indicated that it took 2 staff members when they used the lift. The DON said that the lift that had been used to transfer Resident #1 had been inspected by the maintenance department and it was found to be safe to use. Interview on 08/20/2025 at 4:54 PM, LVN F said she would monitor the CNAs to make sure they were using the lift appropriately. The LVN said that staff were expected to always have 2 staff present when they used the mechanical lift. LVN F said if a staff member could not find someone else to help then they should not attempt to perform the transfer on their own. LVN F said she very often assisted the CNAs with transferring the residents with the mechanical lift. The LVN said the reason for 2 staff to be present when using the lift was because one of them maneuvered the lift while the other one guided the resident to make sure they would land in the wheelchair or wherever they were transferring the resident to. Telephone interview on 08/21/2026 1:48 PM, RN C said she had worked on the day that Resident #1 had been dropped from the mechanical lift which was 08/16/2026. The RN said she had gone to help as she had heard the resident was on the floor. RN C said Resident #1 was faced down on the floor and that CNA A had not said how the fall happened. The RN said she noticed the Geri-chair was flipped backwards and the mechanical lift was laying against the Geri-chair. RN C said she called RN D to come help as she was the charge nurse for that hall. The RN said they stayed with Resident #1 until EMS arrived and they took her to the ER. Telephone interview on 08/21/2026 at 1:54 PM, RN D said she was the charge nurse on 08/16/2026 when Resident #1 had fallen off the mechanical lift. The RN said that she ran into the resident's room as they had called for help. RN D said she entered the room and saw the mechanical lift on its side resting against the Geri-chair. The RN said that CNA A had transferred Resident #1 from the bed to her Geri-chair. RN D said that CNA A told her that she had transferred the resident by herself. The RN said that there were supposed to be 2 staff members when a mechanical lift was used and CNA A had not done that. RN D said Resident #1 was on the floor and was bleeding from somewhere on her head so they did not want to move here and waited there until EMS got there. The RN said the resident did not suffer any fractures but did have a laceration that required some staples. RN D said Resident #1 returned to the facility that same day. Interview on 08/21/2026 at 3:30 PM, the DON said they had put in place the following things after the fall occurred. She said they had trained all the staff to include the CNAs, nurses and medication aides as they could all help with the transfers. The DON said they conducted return demonstrations and also completed staff competencies. The DON said that they immediately removed CNA A from the floor, suspended her and then terminated her. The DON said they verified the training had been effective by interviewing the residents that required the lift for transfers and verified there were 2 staff present per transfers. The DON said besides having the staff conduct return demonstrations that would also make sure staff understood the reason and importance of always having 2 staff for each transfer. The DON said they had ongoing in-service trainings regarding the use of the lift. The DON said the ADON and the DOR would help with the training of the proper use of the lift. Interview on 08/21/2026 at 4:46 PM, the DOR said they had recently trained all the staff on 08/17/2026 on the safe use of the mechanical lift whenever they transferred Resident #1 or any other residents that required the use of the mechanical lift. The DOR said that they had done all that training due to the incident that had just occurred with Resident #1. The DOR said that CNA A should not have transferred Resident #1 by herself while using the mechanical lift. The DOR said it was expected for the staff to use the mechanical lift and that it always required 2 people whenever the resident was transferred as it was safer that way. Interview on 08/25/2026 at 4:15 PM, the DON said that staff could view the PCC system as to which residents used a lift for transfers. The DON said she believed the failure occurred because CNA A had not thought about safety or using appropriate safety with the proper use of the lift. Interview on 08/25/2026 at 4:22 PM, the Administrator said they had conducted competencies to make sure the staff had been trained in the proper use of the lift. The Administrator said the failure probably occurred because CNA A decided to do the transfer herself and not call for help. Record review of Resident #1's incident report dated 08/16/2026 indicated in part: Nurse was notified by RN C, that resident was noted to be on the floor during transfer. Resident noted to lying on the floor face down with upper extremities under torso, lower extremities extended, sling on resident. Recliner noted to be backwards next to resident. Lift noted to be on top of chair. Fall mat on floor. First aid provided to resident. Resident noted to be bleeding unable to determine immediate source of bleeding. Resident stabilized. Pressure applied to bloody area. Resident alert to self. Able to respond to questions at resident's baseline. EMS called via 911. Nurse x2 remained with resident. Unable to obtain vital signs upon incident. EMS in facility. DON, administrator, resident's daughter, Hospice notified of fall. CNA educated on the importance of using x2 for transfer. Resident transferred to ER for treatment and evaluation. Note completed by RN D. Record review of the skills checklist dated 08/03/2026 indicated that CNA A had been trained on the use of the hydraulic lift by RN C. Record review of Resident #1's hospital record dated 08/16/2026 indicated in part: Admit 08/16/2026 and discharged [DATE]. The patient is a [AGE] years of age female with past medical history (PMH) of advanced Alzheimer's. Sent to the emergency room after a traumatic fall from height. By EMS and family history the patient is non-ambulatory secondary to advances dementia and generalized dementia and generalized weakness and she was being moved using a Hoyer at her nursing home today at 17:20pm (5:20pm). The patient was accidentally dropped from approximately 3 feet, falling on her left side. She is not on blood thinners. 5.3 centimeters nonlinear laceration over the left side temporal scalp with moderate bleeding. The wound was closed with staples - 8 total. Record review of the facility's PIR dated 08/21/2026 indicated in part: Person's involved - Resident #1. Alleged perpetrator CNA A. Description of the allegation: On August 16, 2026 at approximately 6:10 pm Resident #1 sustained an injury during a transfer involving mechanical lifting equipment. Facility staff reported that while transferring the resident from her bed to a recliner, the transfer was not successfully completed. Assessment: Resident was awake, alert and oriented x2, able to answer simple questions and make needs known. No loss of consciousness was observed. Resident sustained a laceration to the posterior scalp requiring 8 staples. In-services were conducted regarding transfer policy and procedures, abuse and neglect prevention and resident rights. In addition, facility-wide audits of clinical staff transfer competencies were completed, including observation and validation of proper transfer techniques. Education was reinforced to ensure safe resident handling practices and compliance with facility policies designed to promote resident safety and prevent recurrence of similar incidents. Record review of the facility's in-service training report dated 08/16/2026 indicated in part: Conducted by ADON. Subject Hoyer lift safety. Summary of in-service. Hoyer safety attachment. Proper transfer, Correct sling size. Correct sling for patient. Sling inspection for frays, tears (wear and tear). Any sling that is old has tears, straps are hard, do not use and take out of circulation, turn into Admin or DON. Hoyer competency. Abuse/neglect and exploitation. Ensure 2 persons/staff participate in all Hoyer lift transfers. All staff that were trained signed the document. (Multiple staff had signed the form). Facility implemented actions: The facility staff were trained on 08/17/2026 on the proper use of the mechanical lift to include always having a second staff member present for all lift transfers and to ask for assistance. This was verified by surveyor during observations of staff transferring a resident with the mechanical lift on 08/20/2026 and 08/21/2026. Review of the facility's undated policy titled Mechanical lift and slings indicated in part: The facility will provide for the safety needs of a resident requiring the use of a mechanical lift for transfers. Transfer status/mechanical lift will be maintained in the resident's medical record. Two or more assistants must be used for all mechanical lift transfers. When connecting the slings to the lift, the shortest of the straps must be at the back of the resident for support. If a problem is encountered with the lift, i.e. lift is making noises, mast is not lifting correctly or there are lose parts, discontinue use immediately, take out of service and notify maintenance. Training will be provided to staff during orientation, annually and as needed.

Based on observation, interview and record review the facility failed to assure drugs and biologicals were stored properly in 1 of 2 medication rooms and failed to store all drugs and biologicals in locked compartments for 1 of 2 treatment carts and 1 of 4 medications carts in that: The refrigerator in the medication room contained 1 opened multi-use vial of Tuberculin PPD (Purified Protein Derivative) that had been opened but no open date was found on it. The treatment nurse failed to ensure the treatment cart was locked when it was left unattended. MA A failed to ensure the medication cart was locked when it was left unattended. These failures could place clients at risk for drug diversion or accidental ingestion and place residents and staff at risk for not getting an accurate screening for Tuberculosis.Findings included: During an observation on [DATE] at 9:03 AM the treatment cart was seen unlocked and unsupervised. The cart contained several treatment supplies such as betadine, ointments, wound care supplies and other items During an interview on [DATE] at 3:02 PM the treatment nurse said she had left to go to the restroom and had left the treatment cart unlocked. The treatment nurse said if the cart was left unlocked and unattended there could be a possibility of a resident getting into the items that were in the cart. During an observation and interview on [DATE] at 9:11 AM the front medication room for halls 1, 2 and 3 was inspected with MA A present. Inside the medication refrigerator was an open vial of Tuberculin and an open date was not found on the vial nor the box. The TB container indicated Once entered, vial should be discarded after 30 days. The MA said she did not administer the TB tests so she would not know anything about the vial not dated. During an observation and interview on [DATE] at 3:35 PM the medication cart for hall 2 and 3 was unlocked and unsupervised. The ADON was made aware and the cart was inspected with the ADON present. Inside the medication drawers were several bottles and bubble packs that contained several medications. The ADON said the medication carts were supposed to be locked if left unattended. The ADON said if the cart was left unlocked and unsupervised a resident could get into the cart and take some of the medications. During an interview on [DATE] at 3:44 PM MA A said she was not aware that she had left the medication cart unlocked. MA A said she usually locked her cart when she stepped away but had forgotten today. The MA said if the cart was left unlocked and unattended then a resident or unauthorized staff could have access to the medications. During an interview on [DATE] at 3:40 PM the DON said it was expected for staff to lock their medication carts when not in use. The DON said if the cart was left unlocked it could lead to a confused resident having access to it or also anyone else could have access to it. The DON said the carts were left unlocked and unattended probably because staff were not paying attention after stepping away from the cart. The DON said they monitored the medication carts throughout the day to make sure they were being locked. The DON said it was expected for the TB solution to be dated when opened to know when it was expired. The DON said the failure probably occurred because someone was in a hurry and did not take the time to date it. The DON said that the ADON inspected the medication room on a daily basis for expired or undated medications. During an interview on [DATE] at 4:04 PM the Administrator said it was expected for staff to lock their medication cart if they were not going to use it. The Administrator said that if the carts were left unlocked and unattended it could possibly lead to a resident getting the items in the cart and cause an injury. The Administrator said the failure probably occurred because the staff got nervous due to the state being in the facility as that would not happen when the state was not in the facility. The Administrator said that the DON, ADON and him performed daily rounds to monitor the facility which included the medication carts. The Administrator said it was expected for staff to date medications when they were opened so they would know when it was expired. The Administrator said the ADON checked the medication room and removed any expired or undated medications. Record review of the facility's undated policy titled Storage of medications revealed in part: Purpose: Ensure that medications are stored in a safe, secure and orderly manner. Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not to be left unattended. Compartments include but are not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes. Multi-dose vials that have been opened or accessed should be dated and discarded within 28 days of opening/initial access unless the manufacturer specifies a shorter or longer date. Record review of the facility's undated policy titled Medication Administration, General revealed in part: Keep the medication cart in view at all times. Lock the cart when not standing next to it or working from it.

Based on observation and interview, 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 sanitation and food storage. 1. The facility failed to ensure temperatures were recorded for the refrigerators, dry storage, warmer oven, and freezers. 2. The facility failed to ensure stored foods were properly stored, labeled, and dated. 3. The facility failed to ensure dietary staff properly wore facial hair restraints. 4. The facility failed to properly clean the blender used to puree food between uses. 5. The facility failed to discard spoiled/out-of-date items. 6. The facility failed to prevent dishes and utensils from being stored face up (open to air contamination). 7. The facility failed to ensure Dietary Staff used proper hand hygiene. These failures could place residents at risk for food-borne illnesses.Findings include: Observation during the initial tour of the kitchen on 01/13/2026 at 9:10 AM, revealed the following:The Dietary Manager had a beard cover on that did not cover his mustache. Refrigerator 1 (next to the ice machine)-the temperature log posted was for December/2025-a pitcher contained a pink liquid without a label/date. Dry Storage-the temperature log posted was for January/2026 and was blank-a brown bag of powdered sugar was opened and not sealed-a brown bag of flour was opened and not sealed-baking soda with an expiration month and day was smeared off, expiration year was 2025-instant dry milk was opened and not sealed-toasted oats cereal was opened and not sealed-frosted flakes cereal was opened and not sealed-crispy rice cereal was opened and not sealed Kitchen-the posted food warmer temperature log was for January/2026 and was blank-serving/cooking utensils and pans were hanging from hooks, open to air, at the end of the steam table-plate covers were faced up, open to the air-steak seasoning spice, opened 4/14/2024 with the expiration date rubbed off-cilantro spice opened 1/20/2024, with best by date 7/30/2025-small disposable bowls and the lids faced up, open to the air-bin of blenders were open to air-2 tea dispensers were faced up and opened to the air-silverware in carrier was opened to the air Serving Line Refrigerator- the temperature log posted was for December/2025-a bag of romaine lettuce had turned brown-a tray of disposable cups with lids contained a white substance and did not have a label or date-a tray of disposable cups with lids contained a green substance and did not have a label or date-grated cheese with an opened date of 1/9/2026 and was not sealed-boiled eggs were not labeled and not dated-a metal bin of sliced jalapenos was not covered Walk-in Refrigerator-a metal bin labeled dinner and dated 1/6/2026, had no use by date-Swiss cheese slices opened 1/7/2026 and were not sealed-a metal bin of fruit cocktail was dated 1/8/2026 During the second observation of the kitchen on 1/14/2025 at approximately 11:07 AM, revealed the following: -The Dietary Manager had a beard cover that did not cover his mustache. -Dietary Aide E returned from outside the kitchen with gloves on. Dietary Aide E did not remove the gloves and perform hand washing. -While plating the food, [NAME] C used the same tongs to plate the meat item-ham and the baked potatoes. In an interview with the Dietary Manager on 01/15/2026 at 3:07 PM, he said there was not a good excuse for all the issues/concerns noted in the kitchen. He said the previous Dietary Manager who was fired 3 weeks ago, had allowed the staff to get lazy and run things however they wanted. The DM said he was having to combat bad behaviors, bad attitudes, and negativity. The DM said the residents were at risk of illness due to spoiled food and cross contamination. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 06/19/2025 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring and administering of all medications to meet the needs of each residents, for 1 of 4 medication carts inspected for controlled medication reconciliation and for 2 of 10 (Residents #24 and #46) residents reviewed for pharmacy services in that: MA B did not document the administration of a controlled medication on the individual controlled medication records after administering it to Residents #12, #13, #15, #21 and #42 on 01/14/2026. MA A failed to administer prescribed medications to Resident #24 and #46 on 1/13/26 when she left medications at bedside unattended. This failure could place residents at risk for medication overdose, medication under-dose, drug diversion and placed residents at risk of not receiving therapeutic doses of prescribed medications.The findings included: RESIDENT #12 Record review of Resident #12's admission record, dated 01/14/2026, indicated she was admitted to the facility on [DATE] with diagnosis of pain. She was [AGE] years of age. Record review of Resident #12's order summary report active orders as of: 01/14/2026 indicated in part: Hydrocodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth four times a day for Pain. Record review of Resident #12's Hydrocodone-Acetaminophen controlled medication record indicated 42 pills and the blister pack had 41 pills. RESIDENT #13 Record review of Resident #13's admission record, dated 01/14/2026, indicated she was admitted to the facility on [DATE] with diagnosis of anxiety disorder. She was [AGE] years of age. Record review of Resident #13's order summary report active orders as of: 01/14/2026 indicated in part: Clonazepam Tablet 0.5 MG Give 1 tablet by mouth 1 time daily and give 2 tablets (1mg) by mouth every day at bedtime. (Clonazepam is a medication used to treat anxiety). Record review of Resident #13's clonazepam controlled medication record indicated 28 pills and the blister pack had 27 pills. RESIDENT #15 Record review of Resident #15's admission record, dated 01/14/2026, indicated she was admitted to the facility on [DATE] with diagnosis of pain. She was [AGE] years of age. Record review of Resident #15's order summary report active orders as of: 01/14/2026 indicated in part: Tramadol oral Tablet 50 MG Give 1 tablet by mouth four times a day for pain. Record review of Resident #15's Tramadol controlled medication record indicated 12 pills and the blister pack had 11 pills. RESIDENT #21 Record review of Resident #21's admission record, dated 01/14/2026, indicated she was admitted to the facility on [DATE] with diagnosis of pain. He was [AGE] years of age. Record review of Resident #21's order summary report active orders as of: 01/14/2026 indicated in part: Acetaminophen-Codeine Oral Tablet 300-60 MG Give 1 tablet by mouth two times a day for Pain. Record review of Resident #21's Acetaminophen-Codeine controlled medication record indicated 32 pills and the blister pack had 31 pills. RESIDENT #42 Record review of Resident #42's admission record, dated 01/14/2026, indicated she was admitted to the facility on [DATE] with diagnosis of anxiety disorder. She was [AGE] years of age. Record review of Resident #42's order summary report active orders as of: 01/14/2026 indicated in part: Xanax Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth two times a day related to otherspecified anxiety disorders. (Xanax medication to treat anxiety). Record review of Resident #42's Alprazolam controlled medication record indicated 12 pills and the blister pack had 11 pills. During an observation and interview on 01/14/2026 at 10:22 AM the medication cart for hall 2 was inspected with MA B present. The controlled medication count for Residents #12, #13, #15, #21 and #42 were found to be incorrect. MA B said she had not signed them out yet and was going to do that later. MA B said she was supposed to sign the medication out as soon as she administered it. MA B said she was in a hurry this morning and did not sign the medication after she admitted them. MA B said her not doing that could lead to a discrepancy during reconciliation of the medications. During an interview on 01/14/2026 at 3:20 PM the ADON said the expectation was for the staff to sign the medication out on the controlled medication book as soon as it was administered. She said the staff should sign the medication out at the time they poured the medication as they might forget to sign it out later. The ADON said if the staff had to leave, the medication count would be incorrect. The ADON said that every morning they would check the controlled medication books to make sure the controlled medications were accounted for. During an interview on 01/15/2026 at 3:48 PM the DON said it was expected for staff to document whenever a controlled medication was administered ASAP. The DON said if the medication was not signed out it could possibly lead to a resident receiving another dose. The DON said that this failure probably happened because the staff were in a hurry and did not sign the medication out right away. The DON said the ADON would check the controlled medication book every morning. During an interview on 01/15/2026 at 4:00 PM the Administrator said it was his understanding that whenever a controlled medication was administered it was supposed to documented on the controlled medication book at that time and not later. The Administrator said that if the controlled medication was not signed as given right away it could possibly lead to medications being stolen. The Administrator said the failure probably occurred because the staff got in a hurry and did not take the time to document the medication as soon as it was administered. The Administrator said the ADON would check the controlled medication book every morning. Medication Unsupervised Resident #24Review of Resident #24 admission Record, dated 1/15/26, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Alzheimer's Disease (neurological disorder causing loss of memory), hypoosmolality (sleeping too much), and hyperlipidemia. Review of Resident #24's Quarterly MDS Assessment, dated 1/1/26 revealed:She had a BIMS score of 13 of 15. (indicating she was cognitively intact) Review of Resident #24's Order Summary, dated 1/15/26, revealed orders:Atorvastatin 20mg (medication to control cholesterol) at bedtime for hyperlipidemiaDonepezil 10 mg (medication to slow symptoms of Alzheimer's disease) at bedtime for dementiaMelatonin 5 mg (supplement to assist with at bedtime for insomnia. There was no order for self-administration. Observation on 1/13/26 at 7:03 p.m. revealed a cup of 3 pills on Resident #24's bedside table. Interview on 1/13/26 at 7:11 p.m. the DON stated she did not know what the pills were, but she would find out. Interview on 1/13/26 at 7:17 p.m. with MA A and the DON, the MA stated Resident #24 usually takes it independently. The DON returned and stated the medications were Donepezil 10 mg, Atorvastatin 20 mg, and Melatonin 5 mg. MA A stated she knew better than to leave the medications unattended. Resident #46 Review of Resident #46's admission Record, dated 1/15/26, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included neuropathy (nerve disfunction causing pain) and Hyperlipidemia. Review of Resident #46's Quarterly MDS Assessment, dated 12/15/25, revealed:Her BIMS score was 15 of 15 (indicating she was cognitively intact). Review of Resident #46's Order Summary, dated 1/15/26, revealed orders:Atorvastatin 80 mg at bedtime for hyperlipidemia beginning 8/7/25.Gabapentin 600 mg (medication used to control nerve pain) 1 tablet at bedtime beginning 8/7/25. There was no order for self-administration. Observation and interview on 1/13/26 at 7:25 p.m. Resident #46 had a cup of 2 pills in a medication cup on the bedside table. MA A told the DON was medication was Gabapentin and Atorvastatin. MA A stated she could not give an excuse she knew better. The DON was aware and stated the medications should not be there. Interview on 1/13/26 at 7:30 p.m. with the Administrator and DON the Administrator stated he understood the medications left out were an issue. Review of the facility's policy and procedure on General Medication Administration, undated revealed:Purpose: Safely and accurately administer physician-ordered medication to each resident. Record review of the facility's undated policy titled Controlled medication counting and logging revealed in part: Policy statement: The facility maintains strict controls over all controlled medications to ensure resident safety, prevent diversions, comply with federal and state regulations and maintain accurate accountability. All controlled medications shall be counted, documented, stored, administered and reconciled according to this policy. Shift-to-shift controlled drug count, counts are conducted at every shift change and cart handoff by the off-going and on-coming nurse together. Administration documentation - controlled medications must be documented immediately after administration on the MAR/eMAR and controlled log.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor and appearance and food and drink that was palatable, attractive and at a safe and appetizing temperature from 61 of 63 residents in the facility. 1. The facility failed to ensure food was not held on the steam table longer than necessary for meal service. 2. The facility failed to ensure pureed foods were prepared according to recipes provided by the dietitian and cooked with large volumes of water. These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: Observation and interview on 01/13/2026 at 9:47 AM revealed two metal containers of cooked broccoli on the steam table. [NAME] C stated the broccoli was for lunch. [NAME] C said the hallway trays were plated at 11:45 AM. Observation and interview on 01/14/2026 at approximately 11:14 AM revealed [NAME] C placed water into the puree blender. She did not measure the water. [NAME] C used the water to puree the meat item-ham. [NAME] C repeated the steps, using unmeasured water to puree mixed greens and sweet potatoes. [NAME] C said she used water to puree everything because the facility did not have recipes for pureed foods. [NAME] C said she judged the thickness by eyeing it. Interview with the Dietary Manager on 01/14/2026 at approximately 11:22 AM, revealed the Dietary Manager said his expectations for placing food on the steam table were: 15 minutes before a meal was served was best and 30 minutes was too early. The Dietary Manager said 30 minutes or longer will alter taste, texture, and nutritional value. Interview with the Dietitian on 01/14/2026 at approximately 11:26 AM, revealed the Dietitian said the facility had recipes for pureed food and using only water would have less nutritive value than following the recipes. Interview with the DM on 01/15/2026 at 3:07 PM, the DM said he had the recipe book for pureed items, and the staff had access to it. The DM said the outcome of using water only for pureed foods would be less nutritional benefits for the residents on pureed diets. He said this could lead to weight loss and malnutrition. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 06/19/2025 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 residents (Resident #15 and Resident #29) reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan regarding oxygen therapy for Resident #15 and Resident #29. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services. Findings include: 1. Record review of Resident #15's admission record, dated 01/15/2026, revealed a [AGE] year-old female with an original admission date to the facility of 07/26/2021 and re-admission on [DATE]. The admission record revealed Resident #15 had diagnoses which included congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), muscle weakness, emphysema (a lung disease that results from damage to the walls of the alveoli in your lungs), and shortness of breath. Record review of Resident #15's Quarterly MDS assessment, dated 12/31/2025, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Section O of the MDS revealed Oxygen Therapy was selected for use while a resident of the facility. Record review of Resident #15's Care Plan, dated 01/15/2026, revealed oxygen was not included in the Care Plan. Record review of Resident #15's order summary, dated 01/16/2026, revealed no orders for oxygen therapy. Observation on 01/13/2026 at 3:14 PM revealed Resident #15 was not in her room. The oxygen concentrator was set at 2.5 liters per minute. Observation and interview on 01/13/2026 at 4:21 PM revealed Resident #15 was in her room with a nasal canula on and the oxygen concentrator on, set at 2.5 liters per minute. Resident #15 said she had to wear oxygen, or she had trouble breathing. Observation on 01/15/2026 at 8:17 AM revealed Resident #15 was asleep in a wheelchair with the nasal canula on and the oxygen concentrator on, set at 2.5 liters per minute. 2. Record review of Resident #29's admission record, dated 01/15/2026, revealed a [AGE] year-old female with an original admission date to the facility of 03/14/2023 and re-admission on [DATE]. The admission record revealed Resident #29 had diagnoses which included asthma (a chronic lung disease characterized by inflammation and narrowing of the airways, making it difficult to breathe), dyspnea (difficult or labored breathing), hypoxemia (low levels of oxygen in the blood), and shortness of breath. Record review of Resident #29's Initial MDS assessment, dated 01/02/2026, revealed the resident had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Section O revealed Oxygen Therapy was selected for use while a resident of the facility. Record review of Resident #29's Care Plan, dated 01/15/2026, revealed oxygen was not included in the Care Plan. Record review of Resident #29's order summary, dated 01/16/2026, revealed no orders for oxygen therapy. Observation on 01/13/2026 at 11:24 AM revealed Resident #29 was wearing a nasal canula and oxygen concentrator , set at 4.0 liters per minute. Observation on 01/15/2026 at 2:08 PM revealed Resident #29 was in bed with nasal canula on and oxygen concentrator on, set at 4.0 liters per minute. During an interview with the DON on 01/15/2026 at 4:10 PM, the DON said she was responsible for ensuring the Care Plans were accurate. The DON said she was not aware the oxygen for both residents was not ordered and was not care planned. The DON said oxygen not being ordered or care planned could cause the residents to not receive adequate oxygen therapy, causing shortness of breath and confusion due to inadequate oxygen levels in the blood. Record review of the facility's, undated, policy titled Respiratory Care revealed 1. A comprehensive assessment will be completed on each resident within 14 days of admission to this facility and periodically as required, including when a significant clinical change in status is identified. 2. The interdisciplinary team, along with the resident/resident representative, will develop a comprehensive care plan including measurable goals and interventions. Record review of the facility's, undated, policy titled Comprehensive Care Plan revealed The Comprehensive Care Plan will be developed within 7 days after completion of the comprehensive assessment.

Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (of 7 residents Resident #15 and Resident #29) reviewed for oxygen management. 1. The facility failed to ensure Resident #15 had an order for oxygen. 2. The facility failed to ensure Resident #29 had an order for oxygen and an Oxygen in Use sign on the doorway. These failures could place residents at risk of not receiving appropriate respiratory care. Findings include: 1. Record review of Resident #15's admission record, dated 01/15/2026, revealed a [AGE] year-old female with an original admission date to the facility of 07/26/2021 and re-admission on [DATE]. The admission record revealed Resident #15 had diagnoses which included congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), muscle weakness, emphysema (a lung disease that results from damage to the walls of the alveoli in your lungs), and shortness of breath. Record review of Resident #15's Quarterly MDS assessment, dated 12/31/2025, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Section O revealed Oxygen Therapy was selected for use while a resident of the facility. Record review of Resident #15's Care Plan, dated 01/15/2026, revealed oxygen was not included in the Care Plan. Record review of Resident #15's order summary, dated 01/16/2026, revealed no orders for oxygen therapy. Observation on 01/13/2026 at 3:14 PM revealed Resident #15 was not in her room. The oxygen concentrator was set at 2.5 liters per minute. Observation and interview on 01/13/2026 at 4:21 PM revealed Resident #15 was in her room with the nasal canula on and the oxygen concentrator was on, set at 2.5 liters per minute. Resident #15 said she had to wear oxygen, or she had trouble breathing. Observation on 01/15/2026 at 8:17 AM revealed Resident #15 was asleep in a wheelchair with nasal canula on and oxygen concentrator on, set at 2.5 liters per minute. 2. Record review of Resident #29's admission record, dated 01/15/2026, revealed a [AGE] year-old female with an original admission date to the facility of 03/14/2023 and re-admission on [DATE]. The admission record revealed Resident #29 had diagnoses which included asthma (a chronic lung disease characterized by inflammation and narrowing of the airways, making it difficult to breathe), dyspnea (difficult or labored breathing), hypoxemia (low levels of oxygen in the blood), and shortness of breath. Record review of Resident #29's Initial MDS assessment, dated 01/02/2026, revealed the resident had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Section O revealed Oxygen Therapy was selected for use while a resident of the facility. Record review of Resident #29's Care Plan, dated 01/15/2026, revealed oxygen was not included in the Care Plan. Record review of Resident #29's order summary, dated 01/16/2026, revealed no orders for oxygen therapy. Observation on 01/13/2026 at 9:30 AM revealed Resident #29 did not have an Oxygen in Use sign on the door. Observation on 01/13/2026 at 11:24 AM revealed Resident #29 was wearing a nasal canula and oxygen concentrator, set at 4.0 liters per minute. Observation on 01/15/2026 at 8:16 AM revealed Resident #29 did not have an Oxygen in Use sign on the door. Observation on 01/15/2026 at 2:08 PM revealed Resident #29 was in bed with the nasal canula and oxygen concentrator on, set at 4.0 liters per minute. During an interview with the DON on 01/15/2026 at 4:10 PM, the DON said oxygen had to be ordered by a physician or a physician's representative. The DON said her expectations were to have an Oxygen in Use sign on the door frame outside every room that had a resident using oxygen inside it. The DON said she and the ADON are responsible for assuring Oxygen in Use signs are placed correctly. The DON said if a resident was on oxygen without an order, the resident may not be getting enough oxygen causing shortness of breath and confusion due to inadequate oxygen levels in the blood. Record review of the facility's, undated, policy titled Resident Smoking and Oxygen Policy revealed Oxygen is administered only under physician orders or in emergencies per facility policy. Oxygen warning signs are posted when oxygen is in use.

Based on observation, interview, and record review, the facility failed to provide daily meals at regular times for 2 of 2 meals (breakfast and lunch) observed for timely meal service. The facility failed to serve the breakfast and lunch meals on 10/15/24, at the specific times posted. This failure could place residents at risk of increased hunger, thirst, frustration, and decreased feelings of self-worth. Findings included: Observation on 10/15/24 at 8:26 a.m. revealed the last resident meal tray in the dining room was served. Observation of the kitchen on 10/15/24 from 11:42 am to 2:30 pm revealed the first lunch tray was plated at 12:10 pm and the last tray at was plated at 2:10 pm to be served to the resident. Record review of the Posted Mealtimes outside the dining room revealed: *Breakfast 7:30 AM Hall Carts 4 - 7 AM Hall Carts 3 - 7:10 AM Hall Carts 2 - 7:15 AM Hall Carts 1- 7:20 AM *Lunch 12:30 Hall Cart 4 - 12:00 PM Hall Cart 3 - 12:15 PM Hall Cart 2 - 12:10 PM Hall Cart 1 - 12:20 PM *Dinner 5:30 Hall Carts 4 5:00 PM Hall Cart 3 5:10 PM Hall Cart 4 5:15 PM Hall Cart 1 5:20 PM During the Confidential Resident Council Meeting on 10/16/24 at 9:51 AM seven, alert lucid residents stated that meals were not always on time. The resident said they had to wait up to 2 hours for a meal because the kitchen also had to cook for the attached Assisted Living. The residents said it happened about once a month. The residents stated it was usually lunch that it happened at and you never knew what time lunch would come out. In an interview on 10/16/24 at 3:10 pm Dietary Manager (DM) stated [NAME] F does not typically cook breakfast, but the morning cook called off. DM stated [NAME] F was off all day because she was normally helping with lunch running the fryer. DM stated she does not think lunch has ever been this late especially since they had moved the mealtimes. DM stated they had moved the mealtimes to allow nursing staff to be available to check meal trays. DM stated they do have four staff for the kitchen hired and in training. DM stated this should allow more staff to cover if someone called off. DM stated she was unavailable to help [NAME] F as she was busy with other things. In an interview on 10/16/24 at 3:24 pm [NAME] F stated she does not normally cook for breakfast and lunch and was thrown off because of it. [NAME] F stated food was not typically late but has never been this late. [NAME] F stated she was the person who normally runs the [NAME] and helped with cooking the trays that are off the alternative menu. [NAME] F stated they were just short staffed because of the other cook called in and the process normally ran smoother than it did. Review of the facilities policy titled Food and Nutritional Services dated October 2017 the policy statement is Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Under policy interpretation and implementation section three states Meals and/or nutritional supplements will be provided within 45 minutes of either resident request of scheduled meal time, and in accordance with resident's medication requirements. Review of In-service with the topic being Hall trays and dining room dated 10/02/2024 reveals objective that states in part All meals should be passed in a timely manner.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents and failed to ensure medications were disposed of when expired for 1 of 3 nurses carts inspected for medication storage. The nurse cart for used for halls one and three had four insulin pens and one insulin vial that had expired as indicated by the manufacturer's recommendations. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an observation and interview on [DATE] at 11:32 AM the nurse medication cart for halls 1 and 3 was inspected with LVN E. On the top drawer of the cart were several insulin pens and one insulin vial. Five of the insulins observed had open dates of [DATE], [DATE], [DATE], [DATE] and [DATE] written on them. The insulin pens indicated Use within 28 days after initial dosage on their label. The insulin vial indicated Discard unused portion 28 days after first opening on the vial's box. LVN E said she had the nurse cart assigned to her today but had not noticed the insulins had expired. LVN E said she probably had not noticed that because she had not had to administer any of them recently. LVN E said it was each nurse's responsibility to date the insulin pens or vials whenever they opened them. LVN E said she did not recall being the one that had opened any of the insulin pens or vial. LVN E said if that insulin was administered to a resident, then it could possibly lead to the insulin not being as effective due to it being expired. LVN E said she would remove those insulins from the cart. During an interview on [DATE] at 03:18 PM the DON was said it was expected for the nurses to date the insulin pens and insulin vials as soon as they opened them. The DON said if an expired insulin was administered it could possibly lead to it not being as effective. The DON said she expected for the nurses to remove the expired insulins and have them replaced with a new one. The DON said she monitored the nurse carts and medication room as needed to check for expired or undated medications. The DON said that from now on they would have someone assigned to check the carts and medication rooms. The DON believed the failure occurred because the nurses failed to remove the insulins from the cart once they were expired. During an interview on [DATE] at 04:25 PM the Administrator said it was expected for the nurses to date the insulins as soon as they opened them. The Administrator said the failure probably occurred because the nurses had not removed the expired insulins. The Administrator said if the nurses used the expired insulin it could lead to ineffective results. Record review of the facility policy titled Medication labeling and storage and dated ,d+[DATE] indicated in part: . The nursing staff is responsible for maintaining medication storage . If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning of destroying these items. Medication labeling - The medication label includes at a minimum: Expiration date when applicable. Multi-dose vials that have been opened or accessed (e.g., needle puncture) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Record review of the facility policy titled Insulin Administration and dated ,d+[DATE] indicated in part: Purpose. To provide guidelines for the safe administration of insulin to residents with diabetes. Check expiration date if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on vial (follow manufacturer recommendations for expiration after opening).

Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the facility's only kitchen were stored and sealed appropriately. These failures could place residents at risk for food-borne illness, and food contamination. Findings include: Observations of the facilities only kitchen on 10/15/24 at 07:00 AM revealed One clear plastic tote, with no lid, that had approximately six different bags of cereal outside of the dry food storage on a rack with clean kitchen utensils. The bags were partly rolled but not sealed. Interview with the Dietary Manager (DM) on 10/16/2024 at 3:10 pm revealed she was aware the staff were keeping the cereal on the clean utensils rack. DM stated she had removed a dry foods rack recently and the staff would put the bow of cereal on this utensil rack because it was closer. DM stated any food items should be labled and dated with the open date. DM stated she had told staff that all food needs to be in the dry food storage. The DM stated the staff would forget to take the box back into the dry food storage. DM stated this was a risk for cross contamination and will educate the staff on the importance of keeping all dry foods in the dry food storage. No policy was available.

Based on interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 2 of 7 residents (Residents #13 and #23) reviewed for accurate medical records. The facility failed to document the pulse of the resident's when the physician's orders documented hold parameters for Residents #13 and #23. This failure placed facility residents at risk for incorrect medication administrations due to misinformation by incomplete and inaccurate medical record. The findings included: Resident #13 Review of Resident #13's Admission Record, dated 10/16/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including congestive heart failure (the heart does not pump blood as well as it should). Review of Resident #13's Initial MDS Assessment, dated 7/19/24, revealed: He scored a 15 of 15 on his mental status exam (indicating he was cognitively intact). Active Diagnosis included Heart Failure and hypertension. Review of Resident #13's Care Plan revealed the following care areas: *Revised on 8/7/24 Resident #13 had Congestive Combined Heart failure. The goal was the resident will be free of peripheral edema (swelling to the legs and hands) through the review date. Identified goals included: Give cardiac medications as ordered. Monitor Vital Signs, notify Medical Doctor of significant abnormalities, *Initiated 8/7/24 The Resident had hypertension related to Congestive Heart Failure. The identified goal was the resident will remain free of complications related to hypertension through the review date. Identified interventions included: Give anti-hypertensive medications as ordered, monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Review of Resident #13's Order Summary Report, dated 10/16/24, revealed orders: Metoprolol Succinate 50 mg Give 1 tablet by mouth one time a day for hypertension, hold for blood pressure less than 110/60 and pulse less than 60. Start date 7/18/24. Review of Resident #13's October 2024 Medication Administration Record(MAR) revealed a row for the blood pressure but no row for the pulse outcomes to be documented. In an interview on 10/16/24 at 4:35 p.m. the DON read Resident #13's order for the Metoprolol including the hold for pulse less than 60. The DON said she did not see a row for the pulse on the MAR. The DON stated she did not know if the staff were holding the medication if the pulse was below 60. The DON stated the ADON put the order in July 2024 and she would talk to her. The DON said she guessed nobody checked for these kinds of errors. The DON said she did not know why the pharmacist did not catch the error because she saw recommendation on blood pressure medications in his recommendations. The DON said she did not know why this was not caught. The DON said she was still new and still working on getting things where she wanted things to be and would do an audit the night of 10/16/24. The DON said the blood pressure cuff took the pulse so she would hope the staff were catching it. Resident #23 Review of Resident #23's Admission Record, dated 10/17/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included hypertension (high blood pressure), atrial fibrillation (irregular heartbeat, usually fast). Review of Resident #23's Quarterly MDS Assessment, dated 8/1/24, revealed: He scored a 14 of 15 on his mental status exam (indicating he was cognitively intact) Active Diagnoses included coronary heart disease (reduced blood flow to heart) and Hypertension. Review of Resident #23's Care Plan documented the following care areas: Revised on 10/12/22 Resident #23 had coronary heart disease related to Atherosclerosis (buildup of plaque in the veins). The Goal was Resident #23 would be free from signs and symptoms of complications of cardiac (heart) problems through the review date. Identified interventions included: Give all cardiac medications as ordered by the physician. Monitor and document side effects. Report adverse reactions to Medical Doctor as needed. Revised on 4/18/24 Resident #23 had history of Hypertension. The Goal was Resident #23 would remain free of complications related to hypertension through the review date. Identified interventions included: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (blood pressure drops when standing) and increased heart rate and effectiveness. Obtain blood pressure readings as per physician's orders. Take blood pressure readings under the same conditions each time. For example, resident is sitting, use right arm. Notify physician of any significant abnormalities. Revised on 10/12/22 Resident #23 is at risk for complications related to Atrial Fibrillation/Flutter. The Goal was Resident #23 would exhibit minimal to no complications related to Atrial Fibrillation/Flutter on an ongoing basis thru the next review date. Identified Goals included: Administer medications as per physician's orders, monitor for effectiveness, Check the resident's vital signs as per physician's orders. Review of Resident #23's Order Summary Report, dated 10/17/24, revealed orders: *Amlodipine Besylate Tablet 5mg Give 1 tablet by mouth one time a day for hypertension, hold if Systolic Blood Pressure < 100. Start Dated 4/4/2024. *Metoprolol Tartrate 25 mg Give 1 tablet by mouth two times a day for hypertension related to Atrial Fibrillation, Hypertension. Hold if Blood Pressure Less than 110/60 or pulse < 60 beats per minute. Start date 3/30/23. Review of Resident #23's October 2024 Medication Administration Record revealed the following:*There was no row for the blood pressure reading for the Amlodipine Besylate Tablet 5mg event though it was checked as given 10/1/24 through 10/16/24. *There was no row for the pulse in the Metoprolol Succinate ER 25mg 0800 even thought it was checked as given 10/1/24 through 10/8. *There was no row for the blood pressure nor the pulse on the 1700 (5 p.m.) row even thought it was checked as given 10/9/24, 10/10/24, 10/12/24 through 10/16/24. In an interview on 10/17/24 at 1:08 p.m. the DON stated the results of the parameter audit was over 20 residents who did not have a row for the pulse parameter on the Medication Administration Record. The DON reminded the surveyor, the blood pressure cuff took the pulse of the resident, so the pulse was taken it just was not documented. Review of a letter written by the resident's doctor / Medical Director, dated 10/17/24, revealed: With all hypertensive medications, blood pressure and pulse needs to be monitored and within parameters set by MD. Although both need to be checked, blood pressure is the more critical value. While the pulse was not documented, while the staff check blood pressure the pulse is also taken by the machine. Review of the facility's policy and procedure on Charting and Documentation, revised July 2017, revealed: All services provided to the resident, progress toward the service plan goals, or any changes in the resident's medical, physical, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation The following information is to be documented in the resident medical record: Objective observations; Medications administered; Treatments or services performed;

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #2, #12 and#66) of 5 residents reviewed for infection control. CNA B failed to change her gloves when going from dirty to clean during peri-care and assisting Resident #12 with her ADLs. CNA B failed to wash her hands after she was finished assisting Resident #12 with personal care and before going on to assist someone else. CNA C failed to wash her hands prior to putting gloves on and assisting Resident #2 with personal care. CNA C failed to change her gloves when going from dirty to clean during peri-care and assisting Resident #2 with her ADLs. LVN D failed to use PPE during wound care performed for Resident #66 as the resident was on EBP precautions. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: Resident #12 Record review of Resident #12's admission record dated 10/16/24 indicated she was admitted to the facility on [DATE] with a diagnosis overactive bladder. She was [AGE] years of age. Record review of Resident #12's care plan dated 06/11/2024 indicated in part: Problem: The resident is incontinent of bowel and bladder. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date An intervention was to Clean peri-area with each incontinence episode. Record review of Resident #12's MDS dated [DATE] indicated in part: BIMS = 6 indicating the resident had severe impairment. Urinary continence = Always incontinent. Bowel continence = Always incontinent . During an observation on 10/15/24 at 09:30 AM CNA B entered the room and after she had washed her hands she put on a pair of new gloves. CNA B undid the resident's brief and with some wet wipes wiped Resident #12's vaginal area. CNA B then turned the resident on her side and wiped the resident's rectal area. CNA B then went to the resident's closet and took some clothes and helped the resident get dressed while she still wore the same gloves that she had performed the peri-care on the resident. While CNA B still wore the same gloves, she assisted Resident #12 to the side of the bed and transferred her to her wheelchair with the sit to stand lift and then removed her gloves. After CNA B assisted Resident #12's she left to throw the trash and then went into another resident's room, and without first sanitizing or washing her hands first she put on a pair of gloves and proceeded to assist another resident. During an interview on 10/15/24 at 11:40 AM CNA B said she had forgotten to change her gloves after she cleaned Resident #12's vaginal and rectal area. CNA B said she should have washed or sanitized her hands before putting on the new pair of gloves. CNA B said she just plain forgot to do those steps. CNA B said she had been trained on handwashing and glove changing. CNA B said if she did not wash her hands or change her gloves at the appropriate time then it could lead to the spread of germs to the residents and other facility staff. Resident #2 Record review of Resident #2's admission record dated 10/16/24 indicated she was admitted to the facility on [DATE] with diagnoses of lack of coordination, stroke, and muscle weakness. She was [AGE] years of age. Record review of Resident #2's care plan dated 04/06/2022 indicated in part: Problem: The resident has New Onset bladder/bowel incontinence r/t Impaired Mobility d/t Right Fibula Fracture. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions were to check resident every 2 hours and PRN as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Record review of Resident #2's MDS dated [DATE] indicated in part: BIMS = 9 indicating the resident was moderately impaired. Urinary continence = Always incontinent. Bowel continence = Always incontinent . During an observation on 10/15/24 at 10:05 AM CNA C entered the resident's room and proceeded to put on a pair of gloves without first washing or sanitizing her hands. CNA C then undid Resident 2's brief and wiped the resident's vaginal area with some wet wipes. CNA C then turned the resident on her side and wiped the resident's rectal area with some wet wipes and then removed the soiled brief. While wearing the same gloves, CNA C took a clean brief and fastened it to the resident. CNA C then assisted Resident #2 to the side of the bed and then with a sit to stand lift transferred the resident to her wheelchair while still wearing the same gloves. During an interview on 10/15/24 at 11:07 AM CNA C said she forgot to wash or sanitize her hands prior to putting on gloves before she assisted Resident #2. CNA C said that she should have changed her gloves and washed her hands before she took the new brief and fastened it to the resident. CNA C said she had not washed her hands or changed her gloves because she had gotten nervous as she was being observed during the personal care of the resident. CNA C said if she did not wash her hands or changed her gloves when needed that could lead to the spread of infections which could affect the residents. During an interview on 10/17/24 at 03:24 PM the DON said it was expected for the CNAs to wash their hands before they performed personal care for any of the residents. The DON said the CNAs were supposed to change their gloves once before they went from dirty to clean. The DON said after the CNA wiped the resident's peri-area they were expected to have removed their gloves, sanitized, or washed their hands, and then put on the new gloves. The DON said if the CNAs did not do those procedures that could lead to cross contamination. The DON said she was the infection preventionist and that staff had been trained on infection control procedures. The DON said they monitored the staff by having conducting rounds and the CNAs received proficiency checks. The DON said the failure probably occurred because the staff got nervous and forgot the steps. During an interview on 10/17/24 at 04:30 PM the Administrator said the CNAs should have washed their hands and changed their gloves at the appropriate times. The Administrator said if the CNAs did not perform these steps, then it could lead to the spread of infections. Resident #66 Record review of 's admission record dated 10/16/24 indicated she was admitted to the facility on [DATE] with diagnoses of stroke, muscle weakness and dementia. She was [AGE] years of age. Record review of Resident #66's care plan dated 09/17/2024 indicated in part: Problem: Risk for infection-EBP Enhanced Barrier Precaution at all times. The resident has a Stage 4 pressure ulcer Goal: Resident will show no s/s of infections through the next review. Resident's area will remain free of infection Interventions: Initiate the appropriate EBP isolation precautions. Staff is to wear PPE's for all contact with resident as long as the resident is on EBP precautions, for things such as dressing, changing linens, transfers, providing hygiene, wound care, device care (or use), bathing or showering, changing briefs or assisting with toileting. Staff to follow standard precautions, including proper hand washing techniques, dining, and doffing PPE's to minimize microorganism transmission. Resident needs weekly evaluation of wound healing. Record review of Resident #66's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making indicated the resident was Severely impaired. Determination of Pressure Ulcer/Injury Risk = Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Does this resident have one or more unhealed pressure ulcers/injuries? Yes. Record review of Resident #66's order summary report dated 10/02/24 indicated in part: C *coccyx stage 4 clean with wound wash or normal saline pat dry with gauze, sprinkle crushed 500 mg Flagyl tablet (antibiotic medication) on wound bed apply collagen powder and alginate cover with bordered gauze dressing. Change if soiled or bandage falls off. Everyday shift for wound management. Order date 10/15/24. *Right and left heel blister apply betadine cover with foam heel protector. Everyday shift for preventative Order date 10/02/24. *PPE required for high resident contact care activities. EBP are indicated for residents with any of the following: Infection or colonization with a CDC targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. every shift. Order date 09/09/24. During an observation on 10/16/24 at 11:42 AM LVN D prepared the supplies on her treatment cart, placed them on a tray and then entered the resident's room. On the resident's door there was a sign that indicated Stop - enhanced barrier precautions everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Wound care: any skin opening requiring a dressing. There was a new a plastic wrapped gown observed on the wall as we entered the resident's room. LVN D entered the room, washed her hands, and put on some gloves then proceeded to perform the wound care. LVN D proceeded and removed the dressing from the resident's coccyx area where the wound was located and performed the wound care to that area and to the resident's heels as well. LVN D only used on pair of gloves during the entire procedure and never put on a gown as indicated on the sign on the door. During an interview on 10/16/24 at 12:04 PM LVN D said that EBP meant that staff was required to wear PPE when they assisted a resident that had things such as catheters and IVs in them. LVN D said she should have used PPE when she performed the wound care for Resident #66 but that she had just forgotten to. LVN D said since she had not applied the EBP when she performed the wound care, she could have transferred whatever infections that resident had to others or introduced some form of infection unto the resident. LVN D said she was aware of the EBP procedure as she had already been trained on the method and when it had to be applied. During an interview on 10/17/24 at 03:22 PM the DON said she had expected for LVN D to have worn PPE when she performed the wound care for Resident #66 since the resident was on EBP precautions. The DON said LVN D had been trained on the use of EBP and when to use it. The DON said the way they monitored staff used EBP when required was by getting them trained and monitored the staff following the procedures. The DON said the failure probably occurred because the LVN got nervous and forgot to put on the gown before she performed the wound care. The DON said if the LVN did not wore PPE it could lead to the spread of infections. During an interview on 10/17/24 at 04:30 PM the Administrator said the LVN was expected to use PPE during the wound care as indicated by EBP procedures. The Administrator said he was not sure why the nurse had not worn the PPE, but they were supposed to, to prevent the spread of infections. Record review of the facility's policy titled Perineal Care and dated 02/2018 indicated in part: Purpose - The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Wash and dry your hands thoroughly. Put on gloves Wash the rectal area thoroughly wiping from the base of the labia towards and extending over the buttocks. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Record review of the facility's policy titled Handwashing/Hand Hygiene and dated 10/2023 indicated in part: Policy statement - This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are trained and regularly in-serviced on the importance of hand hygiene in the preventing the transmission of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for hand hygiene - immediately before touching a resident; after contact with blood, body fluids or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. Single use disposable gloves should be used when anticipating contact with blood or body fluids and when in contact with a resident or the equipment or environment of a resident who is on contact precautions. The use of gloves does not replace hand washing/hand hygiene. Record review of the facility's policy titled Enhanced Barrier Precautions and dated 08/2022 indicated in part: Policy statement. Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: Wound care (any skin opening requiring a dressing). EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.

Based on observation, interview, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents and ensure medications were dated when opened for 1 of 3 nurses' carts (cart for hall 100), 1 of 4 medication carts (cart used for hall 100) and for 1 of 2 medication rooms (Medication room on hall 100) and disposed of when expired and for 1 of 7 residents reviewed Residents (Residents #13) of three residents observed for drug storage in that: The nurses' and medication carts were left unlocked and unsupervised. The medication room had an opened and undated vial of Tuberculin (TB) medication in the refrigerator. The facility failed to ensure Resident #13's 3 vials of breathing treatments were secured. These failures could cause access, loss, diversion, or accidental ingestion of medications and place residents at risk of receiving medications that were expired and not produce the desired effect. The findings included: During an observation and interview on [DATE] at 07:00 AM the nurse cart and medication cart on hall 100 were observed to be unlocked and unattended. Inside the cart were several medications that included over the counter bottles and several blister packs of prescribed medications. The CNAs that were passing by said they did not know who had left the carts unlocked and continued to walk by. After about 15 minutes LVN A was seen walking towards the carts and locking them. During an interview on [DATE] at 07:30 AM LVN A said she was supposed to lock the medication carts whenever she stepped away. LVN A said she had counted the medications with the night nurse, so she was in charge of both the nursing and medication carts, and it was her that had left the carts unlocked and unsupervised. LVN A said she had gotten distracted when one of the CNAs' called for her and she left the carts unlocked to go check what the CNA needed. LVN A said the carts were supposed to be kept locked so that no unauthorized people could get into it. LVN A said if the carts were left unlocked and unsupervised that could lead to drug diversions or someone could take the medications that they shouldn't and get the insulin pens. During an interview on [DATE] at 03:27 PM the DON said it was expected for the nursing staff to lock their carts when they were away from them. The DON said if the carts were left unlocked and unattended a resident could get the medications from the cart and accidentally ingest them or unauthorized staff could take some of the medications which lead to a drug diversion. The DON said the failure probably occurred because the nurse stepped away and forgot to lock the carts. The DON said they monitored the carts to make sure they were locked by conducting rounds. During an interview on [DATE] at 04:34 PM the Administrator said the nursing staff was supposed to lock the carts when they were not being used. The Administrator said if the carts were left unlocked then there were possibilities of drug diversions. The Administrator said the failure probably occurred because the nurse had walked away from the carts and had forgotten to lock them. Record review of the facility policy titled Medication labeling and storage and dated ,d+[DATE] indicated in part: Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Resident #13 Review of Resident #13's Admission Record, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including congestive heart failure (the heart does not pump blood as well as it should). Review of Resident #13's Initial MDS Assessment, dated [DATE], revealed: He scored a 15 of 15 on his mental status exam (indicating he was cognitively intact). Active Diagnosis included Heart Failure and hypertension. Respiratory treatments = Oxygen therapy. Review of Resident #13's Care Plan revealed the following care area: *Revised on [DATE] Resident #13 had Congestive Combined Heart failure. The goal was the resident will be free of peripheral edema (swelling to the legs and hands) through the review date. Identified goals included: Give cardiac medications as ordered. Monitor Vital Signs, notify Medical Doctor of significant abnormalities, *Initiated [DATE] The Resident had hypertension related to Congestive Heart Failure. The identified goal was the resident will remain free of complications related to hypertension through the review date. Identified interventions included: Give anti-hypertensive medications as ordered, monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Review of Resident #13's Order Summary Report, dated [DATE], revealed orders: Ipratropium-Albuterol Solution 0XXX,d+[DATE].5 (mg/mL)3 ML inhale every 4 hours every 4 hours as needed for shortness of breath or wheezing via nebulizer. Start date[DATE] Observation and interview on [DATE] at 10:00 a.m. revealed Resident #13 was out of his room. A Small Volume Nebulizer (breathing treatment) machine on Resident #13's bedside table. On top of it were three vials of a liquid in a tube with do not inject and for inhalation only on the tube. Surveyor asked the charge nurse to identify the tubes. LVN A looked at them and stated, those aren't supposed to be there. LVN A identified the tubes as breathing treatments and quickly added I didn't leave those there. In an interview on [DATE] at 3:11 p.m. the DON stated her expectation for storage of medication was they be secured at all times. The DON stated breathing treatments should be stored in the nurse's medication cart. The DON stated the Charge Nurses were responsible for ensuring medications were put up in the medication carts. The DON said the chances of three vials of breathing treatments being left on the bedside table were that someone could easily ingest it, or it could be given to someone else. The DON looked up the side effects and stated allergic reactions by drinking the breathing treatment included increased blood pressure, muscle cramps or difficulty breathing. The DON said she was not aware of any residents who had orders to be able to self-administer medications. The DON stated Resident #13 would probably be able to physically and mentally, but his breathing treatments were as needed. The DON looked at Resident #13's Treatment Administration Record and stated Resident #13 got a breathing treatment the morning of [DATE] at 1:28 a.m. The DON stated the facility had 4 wanderers, none who lived on Resident #13's hallway. The DON said each room had a manager who did rounds. The DON looked and stated the Administrator was assigned to Resident #13's room. In an interview on [DATE] at 3:38 p.m. the Administrator stated he was manager who did rounds. He stated he was in Resident #13's room on [DATE] and totally missed it, the breathing treatment left in the room. EXPIRED TB VIAL During an observation and interview on [DATE] at 04:58 PM the medication room was inspected with the ADON present. Inside the refrigerator was a TB vial that had been opened but no open date was found on the vial or the box container. The ADON said the nurses were supposed to date the TB vial whenever they opened it. The ADON said they did periodically inspections of the medication room for expired and undated medications. The ADON said there was not a specific person assigned to do the inspection of the medication room. The ADON said if a nurse used the undated TB vial solution, the test could result in a false negative or a false positive result as the solution could be expired but the nurse would be unable to know if the solution was still good or not due to no open date. The TB box container indicated Once entered, vial should be discarded after 30 days. During an interview on [DATE] at 03:18 PM the DON was said it was expected for the nurses to date TB vials as soon as they opened them. The DON said if a nurse performed a TB test on someone and the TB solution might had been expired it could lead to false readings. The DON said she expected for the nurses to remove the undated opened TB vials and have them replaced with a new one. The DON said she monitored the medication room as needed to check for expired or undated medications. The DON said that from now on they would have someone assigned to check the carts and medication rooms. The DON believed the failure occurred because the nurses failed to date the TB vial when they opened it. During an interview on [DATE] at 04:25 PM the Administrator said it was expected for the nurses to date the TB vials as soon as they opened them. The Administrator said the failure probably occurred because the nurse failed to date the TB vial when they opened it. The Administrator said if the nurses used the undated TB it could lead to ineffective results. Record review of the facility policy titled Medication labeling and storage and dated ,d+[DATE] indicated in part: . The nursing staff is responsible for maintaining medication storage . If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning of destroying these items. Medication labeling - The medication label includes at a minimum: Expiration date when applicable. Multi-dose vials that have been opened or accessed (e.g., needle puncture) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Record review of the facility policy titled Insulin Administration and dated ,d+[DATE] indicated in part: Purpose. To provide guidelines for the safe administration of insulin to residents with diabetes. Check expiration date if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on vial (follow manufacturer recommendations for expiration after opening). Record review of the facility policy titled Storage of medications and dated ,d+[DATE] indicated in part: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. Compartments containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for three of three residents (Residents #1, #37, #42) reviewed for food meeting residents' needs, in that: The DM did not puree eggs and ham to a puree consistency as required for Residents #1, #37, #42 who were ordered a pureed diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to choking, poor intake, and/or weight loss. The findings included: Resident #1 Record review of Resident #1's admission record revealed Resident #1 was a [AGE] year-old female with an admitted [DATE]. Resident #1 had medical diagnosis of Dysphagia (Difficulty in swallowing). Record review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #1's Brief Interview for Mental Status (BIMs) score of 03 indicating she was severely impaired cognitively. In Section GG - Functional Abilities and Goals Resident #1 was indicated as dependent in eating. Record review of Resident #1's order summary revealed an order for a regular diet Pureed texture, thin consistency, large protein portions with breakfast and lunch related to dysphagia, and Nurse to supervise that aids are assisting resident with feeding before meals for weight loss. Record review of Resident #1's Care plan dated 10/17/24 revealed The resident is on a pureed regular diet with goals and interventions of The resident will have adequate nutrition and fluid intake through the next review date. Dietary Manager to monitor and discuss for food preferences. Resident #37 Record review of Resident #37's admission record revealed Resident #37was a [AGE] year-old female with an admitted [DATE]. Resident #37 had medical diagnosis of Dysphagia (Difficulty in swallowing),. Record review of Resident #37's Annual Minimum Data Set (MDS) dated 9.18.2024 revealed Resident #37's Brief Interview for Mental Status (BIMs) score of 12 indicating she is cognitively intact. In Section GG - Functional Abilities and Goals Resident #37 is indicated as needing supervision or touching assistance in eating. Record review of Resident #37's order summary revealed an order for a Regular diet Pureed texture, Thin consistency. Record review of Resident #37's Care plan dated 10/17/24 revealed The resident has an ADL self-care performance deficit r/t Musculoskeletal impairment with goals and interventions of The resident will improve current level of function in ADLs through the review date. EATING: The resident requires set up and clean up from staff for meals. Resident #42 Record review of Resident #42's admission record revealed Resident #42 is a [AGE] year-old female with an admitted [DATE]. Resident #42 had medical diagnosis of Dysphagia (Difficulty in swallowing. Record review of Resident #42's Annual Minimum Data Set (MDS) dated 9.12.2024 revealed Resident #1's Brief Interview for Mental Status (BIMs) was not scored because the resident is rarely or never understood. In Section GG - Functional Abilities and Goals Resident #42 is indicated as needing supervision or touching assistance in eating. Record review of Resident #42's order summary revealed an order for a Regular diet Pureed texture, Thin consistency ordered on 09/26/24. Record review of Resident #42's Care plan dated 06/11/24 revealed The resident is on a regular diet with goals and interventions of The resident will have adequate nutrition and fluid intake through the next review date. Dietary Manager to monitor and discuss for food preferences. Observation on 10/15/24 at 8:26 a.m. the three resident's were eating meal trays that were severed labeled as puree. The puree trays revealed the ham had the consistency of a mechanical soft diet with gravy on top and served with regular consistency eggs. Further observation revealed the only difference from the puree trays and the regular and mechanical tray was the puree food was served with gravy. In an interview on 10/15/24 at 8:34 a.m. LVN A stated the mechanical soft tray, and the puree tray did look the same. LVN A stated no one on the puree diets had problems swallowing the mechanical soft breakfast meat. LVN A stated there were three residents with a puree diet. In an interview on 10/16/24 at 3:10 pm the Dietary Manager (DM) was shown a picture of the puree tray that was served and stated she did not think the food appeared to be puree texture and appeared closer to mechanical soft. The DM stated she was unsure why the tray was approved by nursing staff who was supposed to check trays. The DM stated she will ensure there was a training on proper meal textures and checking trays. In an interview on 10/16/24 at 3:24 pm [NAME] F stated she thought the blender was not working this morning, so she attempted to puree the meat by smashing the meat down to a smoother consistency and added milk to the eggs to make them softer in consistency. [NAME] F stated she had the lid to the blender misaligned and it was working properly. [NAME] F stated that she thought the puree was soft enough to be safe. In an interview on 10/16/24 at 3:40 pm DON was shown a picture puree breakfast tray and stated she did not think the food appeared to be mechanical soft in texture. DON stated the nursing staff and the staff who are assisting in feeding the residents should all know the difference in diet textures. DON stated she was unsure why the kitchen served this as puree. DON stated often times the resident family members will bring food to these residents that are on puree, and they will cut them into small pieces and the residents are able to eat them. DON stated this may be why the staff felt comfortable feeding that tray to the puree resident. DON stated the staff still should follow diet orders. DON stated she was not aware of any of the residents choking or aspirating due to food texture. DON stated she will ensure there was an in-service done on appropriate diet consistencies. Review of In-service with the topic being Hall trays and dining room dated 10/02/2024 reveals objective that states in part The nurse at all meals should verify tickets. The diet orders should match the meal is served. Review of the facilities policy titled Food and Nutritional Services dated October 2017 the policy statement is Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Under policy interpretation and implementation sections 7 states food and nutritional services staff will inspect food trays to ensure that the correct mail is provided to each resident, the food appears palatable and attractive, and is served at a safe and appetizing temperature. (Subsection a) If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff with report it to the Food Service Manager so that a new food tray can be issued.

48043 Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 4 Medication Carts and 1 of 2 Medication Storage Rooms reviewed for pharmacy services. 1. The facility failed to ensure Medication Cart #1 did not include expired Melatonin 1 mg tablets, Pepcid AC 10 mg tablets, Vitamin D3 capsule, Mag Oxide 400 mg tablets, and Timolol Maleate eyedrops. 2. The facility failed to ensure Medication Cart #2 did not include expired Med Honey Gel 15 ml tubes, Iodoform Packing Strips, and Benzoin Tincture Sterile Applicators. 3. The facility failed to ensure the Medication Storage Room did not contain expired Pneumovax 23 Polyvalent Vaccines 0.5 ml single-use syringes. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings Include: In an observation on [DATE] at 9:25 AM, inventory of the Medication Room with LVN C revealed: - ten single-use injection syringes of Pneumovax 23 Polyvalent Vaccine, expired [DATE] In an observation on [DATE] at 10:00 AM, inventory of Medication Cart #1 with LVN A revealed: - one bottle (approximately 90 tablets) of Melatonin 1 mg, expired ,d+[DATE] - one bottle (approximately 90 tablets) Pepcid AC 10 mg, expired ,d+[DATE] - one bottle (approximately 110 tablets) Vitamin D3 125 mcg/5000 IU, expired ,d+[DATE] - one bottle (approximately 120 tablets) of Mag Oxide 400 mg, expired ,d+[DATE] - one bottle (5ml) of Timolol Maleate 0.5% solution, expired ,d+[DATE] In an observation on [DATE] at 10:20 AM, inventory of Medication Cart #2 with LVN A revealed: - two tubes of Med Honey Gel 0.5 fluid ounces (15ml), expired [DATE] - one container of Iodoform Packing Strip ,d+[DATE] x 5 yards, expired [DATE] - one package Benzoin Tincture Sterile Applicator, expired [DATE] In an interview on [DATE] at 9:25 AM, LVN C stated the Central Supply or the nurses checked the medication storage room for expired meds. She also stated the CMA also checked the medication storage room for expired meds. In an interview on [DATE] at 10:20 AM, LVN B stated the nurses checked the medication carts daily for expired meds. LVN B stated they checked dates on everything they opened. In an interview on [DATE] at 1:30 PM, the DON stated the facility just had a mock survey last month and she did not know why there were expired meds. She stated the eyedrops belonged to a patient's family. The DON stated the med aids were supposed to check the med storage rooms the beginning of each month and put anything in the destruction area that was expired or expiring that month. Record review of the facility policy titled Storage of Medications, with a revision date of [DATE], read in part: Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Residents #128) reviewed for care plans. The facility failed to ensure Resident #128 had a care plan in place to address urinary tract infection. This failure could place residents at risk of not receiving individualized care and services to meet their needs. The findings included: Record review of Resident #128's Care Plan, last revised 9/11/23, revealed no care plan for urinary tract infection Record review of Resident #128's Quarterly MDS, dated [DATE], revealed: She had a mental status score of 15 out of 15, which indicated no cognitive impairment. She had no signs or symptoms of delirium. She required extensive assistance with bed mobility, dressing, toileting and personal hygiene, limited assistance with transfers and supervision for all other ADLs. She was occasionally incontinent of bladder. Record review of Resident #128's Admission Record, dated 09/14/2,3 revealed: The resident was a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her admission diagnoses included urinary tract infection (infection of the urinary system), hypotension (low blood pressure), and acute kidney failure (kidneys no longer filtering waste, causing bloods chemical makeup to be out of balance). Record review of Resident #128' Order Summary, dated 9/9/23, revealed the following orders: Admit to skilled care for urinary tract infection. Interview on 9/14/23 at 11:35 AM, the DON stated the new MDS nurse had only been hired a week ago and that was why some care plans were not up to date. The DON stated that she should have caught it on admission. Record review of the facility policy Care Plans, Comprehensive Person-Centered, revision date 3/20/2022 revealed in part: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment

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 for 1(Resident #1) of 2 residents reviewed for infection control practice CNA A and CNA B failed to perform hand hygiene and change gloves while providing incontinence care for Resident #1. These failures placed residents at risk for the spread of infection. Findings included: Review of Resident #1's Face Sheet, dated 01/04/22, revealed Resident #1 was a 78- year-old male admitted to the facility on [DATE] with overactive bladder, cellulitis, benign prostatic hyperplasia, muscle weakness and Parkinson disease. Review of Resident #1's MDS Assessment, dated 12/24/22, revealed she required extensive assistance with most activity of daily living (ADLs) and one-person assist. Resident #1's MDS reflected he was always incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 12/23/22, revealed Resident #1 was care planned for risk or urinary retention and urethral obstruction related to benign prostatic hyperplasia. Observation of Incontinent Care on 01/04/23 for Resident #1 beginning at 1:46 p.m. revealed CNA A and CNA B washed their hands before the start of care for Resident #1. Both CNAs donned gloves. CNA A and CNA B removed the Resident #1's brief which was completely soiled with urine and fecal matter. CNA A wiped the resident from front to back. CNA A was observed not washing her hands, changing gloves, or performing hand hygiene, CNA A proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the Resident #1 and fastened it. Meanwhile, CNA B was assisting CNA A to provide care to Resident #1. She repositioned the resident touching the perineal area. CNA D used the same soiled gloves to fasten the clean brief to the resident. CNA A and CNA B doffed their gloves. Both washed their hands before exiting Resident #1's room. Interview on 01/04/23 at 1:58p.m with CNA A she said she has been employed in the facility for 2 years and received infection control training in May 2022. CNAA stated cross contamination meant mixing clean with dirty. CNAA acknowledged she should have washed hands and changed gloves before retrieving the clean brief and fastening to Resident #1. She said Resident #1 could get sick for not changing gloves. Interview on 01/04/23 at 2:05 p.m. with CNAB revealed she had been employed at the facility for 8 months. She stated cross contamination was not washing hands or changing gloves. CNAA acknowledged she should have changed her gloves and washed her hands before assisting in repositioning and fastening Resident #1's clean brief. Interview on 01/04/22 at 3:2 0p.m., DON acknowledged she was aware of some of the concerns raised about infection control. She said staff were expected to wash hands before any care was provided and changed gloves at appropriate times. DON explained the facility staff receive yearly training on infection control and periodically check on staff if they see issue with the practice. She said LVN B was responsible for infection control and monitors staff. Review of the facility's Handwashing and Hand hygiene policy revised August 2015 reflected, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy interpretation and implementation include the following: 1) All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infection. 2) All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors . 3) Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a) When hands are visibly soiled; and b) After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile.

Based on observation, interview 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 in that: - The facility failed to label, date, and properly seal food items. - The facility failed to discard rancid food items. - The facility's kitchen staff failed to practice proper hand hygiene during meal preparations. - The facility failed to maintain the appropriate sanitizing solution in the red sanitizing bucket. - The facility failed to clean/sanitize countertop preparation areas after each use during meal service. These deficient practices could place residents who received meals prepared from the kitchen and placed them at risk for food borne illness and cross-contamination. Findings include: Observation on [DATE] at 09:20 AM during an initial tour of the kitchen revealed the following: Dietary Manager L and Dining Service Lead J pull their mask down below their mouth when speaking, fully exposing their mouth and nose, touching surfaces in the kitchen and did not use hand sanitizer or wash their hands. Observation at [DATE] at 09:30 AM of the facility's refrigerator revealed: - Eight hardboiled eggs wrapped in cellophane, no date, and no label. -One gallon size container of Catalina dressing, spillage all over the outside with mold. - One foil sheet size pan of cut lettuce, not properly covered, no date. Observation at [DATE] at 09:40 AM of the facility's pantry revealed: - One pack of seasoning open not sealed correctly, not labeled or dated. Observation at [DATE] at 09:55 AM of the facility's freezer revealed: - One sheet of chocolate cake not labeled or sealed. - One clear bag of steak fingers not labeled or dated. - Cutting board on prep counter with several squash sliced, unattended and uncovered. Observed on [DATE] 10:10 AM DA #G, mask was pulled down below her mouth as she licks her fingers to separate the menus while standing in front of the service line, she sees this surveyor and pulls up mask and continues with taping the menus to the shelf of service line, did not wash or sanitize her hands. Observation/Interview on [DATE] at 10:12 AM accompanied by the Dietician revealed there was no available red buckets filled with sanitizer solution. Dietician verbalized there was no sanitizer in the red buckets to sanitize countertops. Observation on [DATE] at 10:25 AM of Sous Chef #M, touching his earpiece with gloved hand and then continues to cut squash without hand sanitizing, washing hands or changing gloves. Interview/Observation on [DATE] at 11:40 AM accompanied with DM # L verbalized chocolate cake dessert in pan not properly wrapped, dated, or labeled, steak fingers in the freezer should be dated and labeled. The DM #L acknowledged chocolate cake desert should be sealed, dated, and labeled. He also verbalized steak fingers should be dated and labeled. DM#L verbalized dressing should have been discarded, He acknowledged serving these foods to the residents could have caused them to get a food borne illness. DM #L verbalized Sous Chef #M should have washed his hands before continuing with food prep. He said the sink is by the dishwasher and the staff should be washing their hands to prevent the food from being contaminated and causing infection to the residents. Observation on [DATE] 01:20 PM with DA#F, demonstrated hand washing, turned water on, soaped hands washed for 10 seconds, rinsed hands, turned water off, then dried her hands. Interview on [DATE] 01:25 PM with DM #L, and Dining Services Lead #J. Dining Services Lead #J verbalized DM #L and Dietician #K had been doing all the in-services, but she was going to start helping them. DM #L verbalized he and the Dietician #K is responsible along with Dining Services Lead #J for monitoring staff regarding hand washing/infection control. DM #L verbalized staff should have mask on correctly at all times and if they touch their mask, they should be washing their hands. Dining Services Lead #J verbalized the residents can get really sick if the food becomes contaminated, even result in death. Interview on [DATE] at 10:45 AM with DM#L verbalized red sanitation buckets should be filled with sanitizer solution in the morning to sanitize the counter tops before and after prep. DM#L verbalized non-sanitized counter tops can contaminate the food, which could cause infection to the residents, and could result in death. DM#L verbalized that himself, Sous Chef #M and Dining Services Lead # J are responsible to monitor staff, but ultimately, himself and Dietician #K are responsible to monitor the staff and do the In-services. Interview on [DATE] at 2:15 PM Interview with Administrator and Cross Healthcare, Administrator verbalized turn warm water on, wet hands, soap and scrub >30 seconds, rinse, dry with paper towel, throw away in trash, new paper towel and turn off faucet. Administrator verbalized DM#L is responsible for monitoring kitchen staff are correctly washing their hands, when to wash their hands, and wearing their masks correctly, then Myself, dietician, and ICP are responsible for monitoring DM#L of his duties. Administrator verbalized not washing hands properly could cause food borne illness and harm to the residents. administrator verbalized the DM #L, is responsible for making sure kitchen staff are sanitizing the countertops, using the red buckets, and sanitizing solution. Administrator verbalized not sanitizing the counter tops again, could cause food borne illness and harm to the residents. Administrator explained the DM#L is responsible for doing a walk through in the kitchen making sure food in the freezer, pantry, and refrigerator are stored, labeled, and dated correctly and throwing away expired foods. Administrator verbalized himself, the dietician and ICP are responsible for monitoring kitchen staff of their duties, he verbalized he does a walk through every week to 2 weeks along with Dietician, and ICP/ADON. Administrator verbalized himself, the DON, and ADON, are all certified for Infection Control Preventionists. Record review of the facility's policy titled, Hand Washing, dated [DATE] read in part .The consultant dietician will monitor each facility to ensure that good hand washing practices are followed. Employees will be in-serviced as needed. The following guidelines should be used to ensure adequate sanitation practices are in place. 3. Hand Washing steps as followed: a. Wet hands and exposed arms with hot water at least 100 F. b. Apply soap. c. Scrub hands, exposed arms, and fingernails for a minimum of twenty seconds being sure to apply a vigorous friction. d. Rinse hands and exposed arms thoroughly under hot running water. e. Dry hands and arms with paper towel. f. Turn off faucet with the paper towel to avoid contaminating hands and discard towel . Record review of the facility's policy titled, Food Storage, dated [DATE] read in part . The consultant dietician will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe for consumption. All food will be stored according to the state Federal Food Codes. The following guidelines should be followed: 1. Dry Storage rooms d. To ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. 2. Refrigerators e. All refrigerated foods are dated, labeled and tightly sealed, include leftovers, use clean, nonabsorbent, covered containers, that are approved for food storage. All leftovers are used within 48 hours. Items that are over 48 hours old discarded. 3. Freezers e. Frozen foods are stored in moisture-proof wrap or containers that are labeled and dated . Record review of the facility's policy titled, Food Preparation & Handling, dated [DATE] read in part .The consultant dietician will monitor the preparation and handling of food items to ensure that all food served by the facility is of good quality and safe for consumption according to the state and Federal Food Codes and HACCP guidelines. The following guidelines should be followed: 1. General Guidelines a. Clean, sanitized surfaces, equipment and utensils are used. b. Hands are properly washed before beginning food preparation . Record review of the facility's In-service titled, Cleaning vs Sanitizing, not dated, read in part . When to clean and sanitize: Everything in your operation must be kept clean, but any surface that comes in contact with food must be cleaned and sanitized . Each time you use them When you are interrupted during a task When you begin working with a different type of food As often as possible, but at least every four hours if items are in constant use .

Based on observations, interview, and record review the facility failed to ensure that 2 (Resident #60 and Resident #33) of 19 residents reviewed for respiratory care was provided care consistent with professional standards of practice in that: Resident # 60's oxygen nasal cannula tubing and water was not changed, labeled and dated and stored according to the facility's policy. Resident # 33's nasal cannula tubing was not changed, labeled and dated and stored according to the facility's policy. This deficient practice could affect 19 residents who received oxygen treatments and result in respiratory infection. Findings include: Record review of Resident #60's face sheet revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #60's care plan dated 06/06/22 indicated, in part: Focus: Altered respiratory status/ difficulty breathing related to [CONDITION(S)]. Goal: no complications related to shortness of breath. Interventions: O2 concentrator with oxygen via nasal cannula at 2-4 liters per minute every 12 hours, as needed, humidified. Record review of Resident #60's medication profile dated 08/31/2022 indicated in part: Oxygen at 2-4 Liter per minute via nasal cannula as needed to maintain oxygen saturations 92% or greater. Record review of MDS dated [DATE] indicated, in part, that Oxygen is required. Record review of Resident #33's face sheet revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #33's care plan dated 05/23/2022 indicated, in part: Focus: Shortness of breath related to Anxiety. Goal: will maintain normal breathing pattern as evidenced by normal skin color, regular respiratory rate/pattern. Interventions: Oxygen concentrator in room and has order for oxygen to be set at 2 liters per minute via nasal cannula as needed to maintain saturations over 90%. Record review of Resident #33's medication profile dated 03/15/2022 indicated in part: Oxygen at 2 liters per minute every 4 hours as needed related to age- related physical debility and hypoxemia (low level of oxygen in blood). Record review of MDS dated [DATE] indicated, in part, that Oxygen is required. During an interview and observation on 08/09/2022 at 4:30 PM of Resident #60's oxygen tubing revealed the water bottle and oxygen tubing connected to oxygen concentrator were dated 07/29/2022 with black marker, showing last date changed. The used nasal cannula was in residents unmade bed. Interview with LVN D stated that tubing is supposed to be changed every Sunday on night shift by the nurse. LVN D stated she will change the tubing and water immediately. During an interview and observation on 08/10/22 02:20 PM of Resident #33 oxygen tubing revealed it to be on the floor, disconnected from the oxygen concentrator, with no dates on tubing. CNA E stated that Resident #33 does not use the oxygen and proceeded to pick up the soiled tubing, rolled up the soiled tubing and placed the soiled tubing on the handle of the concentrator. LVN C stated that tubing should be in a plastic bag and plugged into the machine when not in use. LVN C stated that the tubing on the floor can get bacteria and cause the resident an infection. During an interview with DON on 08/10/2022 at 11:10 AM, the DON stated that oxygen tubing and water should be changed every Sunday night by nurse on duty. DON stated that the Resident #60 does not like staff entering her room at night. DON stated that night shift nurse failed to change the tubing and failed to communicate with day shift about the failure to change tubing. Record review of the facility's policy dated 2001, revised November 2011, titled Respiratory Therapy- Prevention of Infection indicated, in part: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. Change the oxygen cannula and tubing every seven days. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Mark bottle with date and initials upon opening.

Based on observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs and for 1 of 68 residents (Resident #36) reviewed for call lights. The facility failed to have a call light within reach for Resident #36. This failure could place residents at risk for a delay in care and services, increased falls, excessive wait times, pain, and a decreased quality of life. Findings included: Record review of Resident #36's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #36's care plan, revised 07/14/2022, revealed, Focus: High risk for falls related to gait/balance problems and previous falls. Goal: to be free from falls. Interventions: Call light within reach of resident and encourage resident to use the call light for assistance; resident needs prompt response to all requests for assistance; resident needs a safe environment with a working and reachable call light. Record review of Resident #36's MDS, dated [DATE], revealed a BIMS score of 3 which indicated severe cognitive impairment. Further review revealed the resident required extensive assistance from one or more staff members to perform activities of daily living. Observation on 08/08/2022 at 10:30 AM revealed Resident #36's call light cord was wrapped around the left siderail of residents bed and was not within the resident's reach. Resident #36 was sitting in wheelchair in front of his television. During an interview on 08/08/2022 at 10:30 AM with Resident #36, resident states that he cannot use the call light when it's tied up to the arm rails of bed and I am not in bed, I can't reach it. During an interview on 08/08/2022 at 11:00 AM with LVN D, she stated that it is the CNA's responsibility and her responsibility to make sure that the call light is within reach of resident for safety reasons. During an interview on 08/11/22 at 01:00 PM, the DON stated that Resident #36 had been to therapy that morning. DON stated the therapist failed to ensure that call light was within reach of resident. DON stated that she will do an in-service on call lights as soon as possible. Record review of the Answering the Call Light Policies and Procedures dated 2001, revised March 2021 revealed that the purpose of this procedure is to ensure timely responses to the residents requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #3) of 2 residents reviewed for assistance with transfers as evidenced by: Resident #1, required the Hoyer lift for transfers and during a transfer on 8/14/18 Resident #1 fell when the loop tore off the sling causing a right femur fracture. CNA D transferred Resident #3 by wrapping his arms around his chest (bear hug) and picking him up causing a hematoma and bruising to chest and left shoulder. Resident #3 required the Hoyer lift for transfers. This failures placed the residents requiring the Hoyer lift at risk for of injury during transfers. Findings included: RESIDENT #1 Review of Resident 1's electronic face sheet documented he was admitted on (MONTH) (YEAR), re-admitted on [DATE], was [AGE] years of age, [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set assessment dated [DATE] documented in part: Resident #1's a brief interview for mental status documented a score of 09 indicating he was moderate cognitively impaired. Resident #1 required 2 person with extensive assist for bed mobility, transfers and was dependent on staff for bathing. Review of Resident #1's Care Plan dated 8/20/18 documented this in part: Category: Resident #1's physical mobility was impaired related to intellectual disability and altered mental status. Resident #1 requires the Hoyer lift for transfers and needs assist to be propelled in wheelchair due to lower extremity contracted/drop foot bilaterally. Approaches: Assess/record/report to medical director signs of immobility complications, skin breakdown, thrombus formation and mobility status change, assist to transfer using 2 persons for transfer. Use Hoyer lift for all transfers. Review of the incident report dated 8/14/18 at 9:15 AM documented in part: Description of incident: Resident #1 was in a Hoyer being lifted out of the bathtub when the right side of the sling broke. The certified nurse aide (CNA) caught and assisted resident back into the tub. Resident was assisted into another sling by a nurse and 2 CNA's. Notes: After root cause analysis it was determined a sling caused Resident #1's injuries to his bilateral knees. Resident #1 was sent to emergency room for evaluation and treatment, after the results from an x-ray (8/15/18) showed fracture. Resident #1 returned to the facility post surgical intervention . Slings were inspected and were replaced with new slings. Staff was in-serviced to inspect sling prior to using them and throw away any sling that they might have concern over. Review of an x-ray dated 8/15/18 at 10:03 AM documented diffuse soft tissue swelling, angulated [MEDICAL CONDITION] distal femur. Review of the emergency documentation dated 8/15/18 documented in part: Reexamination: Patient (resident #1) was asked twice earlier if he was in pain but stated he was okay. This time when asked patient said he would like to have pain medication. Patient will be admitted and plan on operating after he has cardiac clearance. Medical Decision Making: Even though the patient does not walk he should be admitted to have surgery as it would be better long-term for limb salvage and pain management. Assessment Plan: [MEDICAL CONDITION] femur. During an interview on 11/07/18 at 6:15 PM CNA A said she was the shower aide who gave Resident #1 his shower the night (8/14/18 at 9:45 PM) the sling broke and Resident #1 fell and was injured. CNA A said it was her first day to do showers. She said Resident #1 fights some aides during care but he never fights with her during care because she doesn't give him a hard time. She said they gave Resident #1 a bubble bath that evening. CNA A said when it was time to get Resident #1 out of the tub, she got CNA B to get resident wheelchair in position. CNA A said they were letting the water out of the bathtub and Resident #1 was being lifted from the bathtub using the Hoyer lift when the sling snapped and I mean the sling just snapped and he fell . CNA A said she had never seen anything like that before. CNA A said they (meaning her and CNA B) had looked at the sling before using it and didn't think that it was going to break. CNA A said the sling was an older one that was still being used. CNA A said she had the sling in the water under Resident #1 and as they raised Resident #1 up from the bathtub the sling ripped, the ring stayed attached to the Hoyer lift and the resident went down. She said Resident #1 fell hard into the tub. She said Resident #1 was about 1-2 feet above the bathtub when the sling ripped causing the resident to fall. CNA A said with Resident #1's weight and him being in the air made a really loud thud when Resident #1 hit the tub. CNA A said the nurse came in and it took all three of them to get Resident #1 out of the bathtub. CNA A said the nurse called the doctor and got an x-ray. During an interview on 11/08/18 at 9:00 AM Resident #1 said his leg was broken when he was dropped. Resident #1 said there was one CNA in the shower room with him when he fell . He said he couldn't remember the aide's name. Resident #1 said he was in the Hoyer lift. He said he thought the sling on the Hoyer lift must have been worn out because the sling ripped and he fell . Resident #1 said it hurt really bad when he fell . Resident #1 said he knew it (referring to leg) was broken and he kept telling the staff it was broken. Resident #1 said the staff didn't do anything until the next day. Resident #1 said he worried now when he is being transferred using the Hoyer lift. During an interview on 11/08/18 at 1:31 PM the director of nurses (DON) said he inspected the sling that tore during Resident #1's transfer and said where the loop had been sewn into the sling had separated. The DON said Resident #1 feet hit the bathtub when the sling separated from the loop. The DON said he and the physical therapist went through all the slings and threw out any slings that any had any signs of wear and replaced them with new ones. During an interview on 11/08/18 1:50 PM CNA A said Resident #1 was about one half foot above the bathtub when the sling broke and Resident #1 went down. She said Resident #1's legs hit the bathtub first then his bottom and his feet. CNA A said the loop was all that broke on Hoyer sling. CNA A said Resident #1 said he thought his leg was broken so LVN C called the doctor to get an x-ray. During an interview on 11/08/18 at 3:08 PM LVN (licensed vocational nurse) G said she worked the evening Resident Nelson fell . She said Resident #1 did not fall but the sling did break. She said his legs hit the tub but he was sat down by the aide. RESIDENT #3 Review of Resident #3's electronic face sheet documented he was admitted on [DATE], was [AGE] years of age, was admitted with [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment dated Review of MDS dated [DATE] documented in part: Resident #3 had a BIMS score of 01 indicating he was severely cognitive impaired. Resident #3 required 2 persons with extensive assist for bed mobility, transfers, and hygiene. Review of the Resident #3's care plan dated 11/08/18 documented Resident #3 had a self care deficit and needed supervision and/or assist to complete activities of daily living. Resident #3 required the mechanical lift (Hoyer) and 2 person assist with all transfers. Approach: Hoyer lift for all transfers, leave sling under resident while up, assist him using the Hoyer lift. Review of the Incident Report for Resident #3 dated 9/13/18 documented in part: Description of the Allegation: On 9/09/18 around 10:50 AM, cna's went to get resident #3 up for the day. CNA's noticed a hard raised area to over the right chest and notified the LVN. LVN (LVN no longer works at the facility) assessed, resident noted to a large knot to chest and complaints of bad headache and shortness of breath. Resident #3 physician was notified and new order to send to emergency for evaluation and treatment. Resident #3's son informed nurse that he was informed by the hospital that injury was caused by [MEDICATION NAME] force trauma to the chest. Description of Injury: Right pectoral hematoma to the top of left shoulder. Complaining of pain to chest area. Investigation Summary: After investigation and interview with residents and staff it was determined that CNA D was performing unsafe transfers on residents and was not following care plans. It was undetermined if incident was intentional by the employee. Interview with Resident #3 was not conclusive due Resident #3's [DIAGNOSES REDACTED]. Review of the CT scan dated 9/09/18 documented contusion of right front of thorax. Review of physician's progress notes from the hospital dated 9/09/18 documented in part: Following verbal consent from the family, patient (Resident #3) is sterile prep with alcohol wipes, a 4 inch 18 gauge spinal needle was inserted in chest wall into hematoma underneath pectoral muscle. I (physician) was able to withdraw 5 centimeters of thick clotted blood. but unable to drive any more due to likely age of the hematoma. Review of patient education materials from hospital dated 9/09/18 documented in part: Causes: A contusion is usually caused by a blow, trauma, or direct force to an area of the body. Symptoms: swelling, redness of injured area, discoloration of the injured area, tenderness, soreness of the injured area and pain. Review of a statement written by CNA D , undated, documented he had been a CNA for [AGE] years. CNA D wrote he had used Hoyer lifts in the past and still did but sometimes not in the room if it is to small. CNA D said he gave Resident #3 a hug like a grasp. CNA D said he put his arms under Resident #3's arm pits and gently put him to bed. No problem what so ever. CNA D wrote he would never on purpose hurt a resident. During an interview on 11/06/18 at 2:00 PM the DON said he received a call regarding a raised hard area on Resident #3. The DON said the nurse said the area on Resident #3 chest looked like a boob. The DON said Resident #3 shouldn't have anything like that come up so he had the nurse send Resident #3 out to be evaluated at the hospital. The DON said the son of Resident #3 called and said he was very upset because the hospital said Resident #3's injury was caused by [MEDICATION NAME] trauma. The DON said Resident #3's son said he thought it was the male CNA that hurt his dad. The DON said he had talked to all his staff requiring if Resident #3 had a fall or injury of any type and they all said no. The DON said when he spoke to CNA D and asked him about any injury while transferring resident #3, CNA D said he did not use the Hoyer lift or two persons to transfer Resident #3. The DON said CNA D told him that he just gives Resident #3 a great big bear hug and transfers him. The DON said he asked CNA D why he didn't think transferring Resident #3 that way would cause an injury because he had to squeeze and grip Resident #3 really tight to get him up and transfer Resident #3. The DON said CNA D said Resident #3 didn't scream or act like it hurt him in anyway. The DON said CNA D told him he didn't use the Hoyer lift because it was too time consuming and was hard to maneuver. The DON said CNA D was trained on how to use Hoyer when he was hired. He said CNA D was aware that resident #3 was a two person Hoyer lift because during orientation he was trained and shown what kind of lift every resident required. The DON said when CNA D was hired as with all new staff, physical therapy trains them to use the Hoyer lift properly. He said the CNA care plan documented Resident #3 was a two person Hoyer lift. He said during the investigation he interviewed resident # 6 said she really liked CNA D because he just lifted her and gently put her in bed. The DON said he could not trace Resident #3's injury to anything but CNA D transferring Resident #3 by picking him up in a big bear hug because Resident #3 did not have a fall or any other kind of accident. During an interview on 11/07/18 at 6:02 PM CNA E said she saw CNA D transfer Resident #3 two times. CNA E said CNA D would stand in front of Resident #3 then put his arms around Resident #3 like a bear hug. pick Resident #3 up, pivot Resident #3 and lay him down in bed. CNA E said Resident #3 never moaned or groaned. She said Resident #3 was very cooperative. CNA E said she and another aide were standing next to Resident #3 and they offered to help transfer Resident #3 but CNA D would tell us no he had it. CNA E said they would lift Resident #3's legs into bed. CNA E said she knew resident #3 required the Hoyer lift and so did CNA D. CNA E said they sometimes try to rush and put residents to bed not and do not always use the correct method to transfer residents. CNA E said she could understand how transferring Resident #3 by lifting him in a bear hug could hurt the resident because by using the hug you wont know your arm strength. CNA E said it never occurred to her to inform the DON that CNA D was not using the Hoyer lift to transfer Resident #3. During an interview on 11/07/18 at 6:30 PM CNA F said Resident #3 was a two person Hoyer lift transfer. CNA F said CNA D would transfer Resident #3 by standing in front of Resident #3 and put his arms around Resident #3's chest. She said CNA D would get Resident #3 right under his arms arm pits and lift him up and transfer Resident #3. CNA F said CNA D would always get someone else to come into the room just in case he needed them. CNA F said she only saw CNA D transfer Resident #3 once. CNA F said Resident #3 could not do anything to help with his transfer. CNA F said Resident #3 would only say oh, oh, oh during the transfer. CNA F said the transfer didn't seem to her that it hurt Resident #3. CNA F said CNA D should have used the Hoyer lift to transfer Resident #3. CNA F said she asked CNA D if he thought he should use the Hoyer lift for Resident #3 but CNA D said no this was how he transferred Resident #3. Review of the policy for Lifting Machine, Using a Mechanical dated (MONTH) 1017 documented in part: Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition.

Based on observation, interview and record review the facility failed to maintain patient care equipment in safe operating condition for 1 of 5 residents (Resident #1) reviewed for safe operating equipment in that: The sling on the Hoyer lift broke during a tranfer resulting in Resident #1 receiving a right femur fracture. This deficient practice put residents who utilized the Hoyer lift for transfers at risk of injury. The findings were: Review of Resident 1's electronic face sheet documented he was admitted on (MONTH) (YEAR), re-admitted on [DATE], was [AGE] years of age, [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set assessment dated [DATE] documented in part: Resident #1's a brief interview for mental status documented a score of 09 indicating he was moderate cognitively impaired. Resident #1 required 2 person with extensive assist for bed mobility, transfers and was dependent on staff for bathing. Review of Resident #1's Care Plan dated 8/20/18 documented this in part: Category: Resident #1's physical mobility was impaired related to intellectual disability and altered mental status. Resident #1 requires the Hoyer lift for transfers and needs assist to be propelled in wheelchair due to lower extremity contracted/drop foot bilaterally. Approaches: Assess/record/report to medical director signs of immobility complications, skin breakdown, thrombus formation and mobility status change, assist to transfer using 2 persons for transfer. Use Hoyer lift for all transfers. Review of the incident report dated 8/14/18 at 9:15 AM documented in part: Description of incident: Resident #1 was in a Hoyer being lifted out of the bathtub when the right side of the sling broke. The certified nurse aide (CNA) caught and assisted resident back into the tub. Resident was assisted into another sling by a nurse and 2 CNA's. Notes: After root cause analysis it was determined a sling caused Resident #1's injuries to his bilateral knees. Resident #1 was sent to emergency room for evaluation and treatment, after the results from an x-ray (8/15/18) showed fracture. Resident #1 returned to the facility post surgical intervention . Slings were inspected and were replaced with new slings. Staff was in-serviced to inspect sling prior to using them and throw away any sling that they might have concern over. Review of an x-ray dated 8/15/18 at 10:03 AM documented diffuse soft tissue swelling, angulated [MEDICAL CONDITION] distal femur. Review of the emergency documentation dated 8/15/18 documented in part: Reexamination: Patient (resident #1) was asked twice earlier if he was in pain but stated he was okay. This time when asked patient said he would like to have pain medication. Patient will be admitted and plan on operating after he has cardiac clearance. Medical Decision Making: Even though the patient does not walk he should be admitted to have surgery as it would be better long-term for limb salvage and pain management. Assessment Plan? [MEDICAL CONDITION] femur. During an interview on 11/07/18 at 6:15 PM CNA A said she was the shower aide who gave Resident #1 his shower the night (8/14/18 at 9:45 AM) the sling broke and Resident #1 fell and was injured. CNA A said it was her first day to do showers. She said Resident #1 fights some aides during care but he never fights with her during care because she doesn't give him a hard time. She said they gave Resident #1 a bubble bath that evening. CNA A said when it was time to get Resident #1 out of the tub, she got CNA B to get resident wheelchair in position. CNA A said they were letting the water out of the bathtub and Resident #1 was being lifted from the bathtub using the Hoyer lift when the sling snapped and I mean the sling just snapped and he fell . CNA A said she had never seen anything like that before. CNA A said they (meaning her and CNA B) had looked at the sling before using it and didn't think that it was going to break. CNA A said the sling was an older one that was still being used. CNA A said she had the sling in the water under Resident #1 and as they raised Resident #1 up from the bathtub the sling ripped, the ring stayed attached to the Hoyer lift and the resident went down. She said Resident #1 fell hard into the tub. She said Resident #1 was about 1-2 feet above the bathtub when the sling ripped causing the resident to fall. CNA A said with Resident #1's weight and him being in the air made a really loud thud when Resident #1 hit the tub. CNA A said the nurse came in and it took all three of them to get Resident #1 out of the bathtub. CNA A said the nurse called the doctor and got an x-ray. During an interview on 11/08/18 at 9:00 AM Resident #1 said his leg was broken when he was dropped. Resident #1 said there was one CNA in the shower room with him when he fell . He said he couldn't remember the aide's name. Resident #1 said he was in the Hoyer lift. He said he thought the sling on the Hoyer lift must have been worn out because the sling ripped and he fell . Resident #1 said it hurt really bad when he fell . Resident #1 said he knew it (referring to leg) was broken and he kept telling the staff it was broken. Resident #1 said the staff didn't do anything until the next day. Resident #1 said he worried now when he is being transferred using the Hoyer lift. During an interview on 11/08/18 at 1:31 PM the director of nurses (DON) said he inspected the sling that tore during Resident #1's transfer and said where the loop had been sewn into the sling had separated. The DON said Resident #1 feet hit the bathtub when the sling separated from the loop. The DON said he and the physical therapist went through all the slings and threw out any slings that any had any signs of wear and replaced them with new ones. During an interview on 11/08/18 1:50 PM CNA A said Resident #1 was about one half foot above the bathtub when the sling broke and Resident #1 went down. She said Resident #1's legs hit the bathtub first then his bottom and his feet. CNA A said the the loop was all that broke on Hoyer sling. CNA A said Resident #1 said he thought his leg was broken so LVN C called the doctor to get an x-ray. During an interview on 11/08/18 at 3:08 PM LVN G said she worked the evening Resident #1 fell . She said Resident #1 did not fall but the sling did break. She said his legs hit the tub but he was sat down by the aide. Review of the policy for Lifting Machine, Using a Mechanical dated (MONTH) 1017 documented in part: Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition.

Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse or neglect were reported to the State regulatory agency in accordance with state law, failed to ensure all violations were thoroughly investigated, and failed to prevent further potential abuse while an investigation was in process for 3 of 13 residents reviewed for abuse and neglect (Residents #1, 2, 4) as evidenced by: a) failure to report an allegation of neglect to the State authority and failure to conduct a thorough investigation when Resident #4 fell from a mechanical lift while staff were operating the lift and transferring the resident resulting in a contusion to her head on 9/11/15; b) failure to report an allegation of neglect to the State authority and failure to conduct a thorough investigation when Resident #2 was being pushed by staff in her wheelchair and the mechanical lift sling strap(s) became entangled in the wheel of the wheelchair, throwing Resident #2 forward and out of her chair on 6/17/15. Resident #2 sustained a thigh contusion and possible acute fracture at the tip of the bony stump of her amputated leg, with associated swelling; and c) failure to report an allegation of physical abuse made by Resident #1 to CNA A, CNA B, and Med Aide A on 9/18/15 at approximately 9:30 a.m. to the State authority until 9/22/15; failure to complete a thorough investigation of Resident #1's allegations; and failure to protect Resident #1 during an investigation. The alleged perpetrators continued to work on Resident #1's hall and go in her room throughout the day the allegation was made and through the weekend of 9/19/15 and 9/20/15 which resulted in mental distress to Resident #1. An Immediate Jeopardy (IJ) was identified on 9/23/15 at 12:00 noon regarding a) and b) above. Findings regarding c) were included in the Immediate Jeopardy by notification to the Administrator on 9/25/15 at 1:35 p.m. While the IJ was removed on 9/29/15, the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a pattern. These failures could affect the 13 residents that require a mechanical lift for transferring between surfaces and could affect the total of 71 residents who required assistance with activities of daily living. These failure could result in ongoing abuse or neglect in the facility and result in pain, emotional distress, injury, or death. Findings included: 1. a) A Resident Admission record dated 6/29/15 documented that Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] from another hospital facility. She was referred from a Rehabilitation facility. [DIAGNOSES REDACTED]. b) A Rehabilitation Hospital report dated 6/13/15 documented Resident #4 was admitted there after a right ankle fracture, tibia-fibula and was non-weight bearing. She was admitted to the rehabilitation facility for aggressive physical therapy. Her weakness was due to disuse [DIAGNOSES REDACTED] secondary to the right ankle fracture. The report documented a past medical history of [REDACTED]. c) An MDS Assessment for Resident #4, dated 7/6/15 documented a Brief Mental Status Interview score of 13, indicating Resident #4 was cognitively intact. She had no indicators of [MEDICAL CONDITION] and no behavioral symptoms. The MDS documented that Resident #4 required Extensive assistance (resident involved in activity, staff provide weight-bearing support) of one person for bed mobility; and extensive assistance from two or more persons for transferring, toilet use, and personal hygiene. The MDS documented that Resident #4 had limited range of motion of a lower extremity on one side and used a wheelchair for mobility. She was documented as having a fall during the last month prior to admission. Resident #4 was 57 inches tall and weighed 247 pounds. d) A care plan for Resident #4 with last care conference date of 8/13/15 and next care conference date of 11/11/15 documented a problem on page 2 of 5 with a start date of 7/24/15: Resident must be lifted mechanically AEB (as evidenced by) (sentence was not complete). The goal documented, Resident will not sustain injuries during transfers with mechanical lift in the next 90 days and the approach was, 2 staff members at all times to use the mechanical lift. The care plan had an added intervention dated 9/11/15, Resident has history of falling related to equipment. A goal stated, Resident will remain free from injury. Approaches included encouraging the resident to use environmental devices such as hand grips, hand rails, etc., keeping call light in reach, keeping personal and frequently used items in reach, observing frequently and placing in a supervised area when out of bed; and providing an environment free of clutter. A problem added to the care plan 9/18/15 documented, Resident has a memory/recall problem related to disease process. The goal stated, Resident will not sustain serious injury due to memory/recall deficit. The approaches included ensuring assistive devices (walkers, canes, wheelchairs, etc.) are in good condition, ensure resident areas are free of hazards, provide chair and/or bed alarm if resident requires assistance with transfer, and redirect resident when entering unsafe areas. e) An Occurrence Report for Resident #4 dated 9/11/15 at 1950 (7:50 p.m.) documented Resident #4 had a fall in her room during transfer. Under Nurse's note of what happened the nurse documented, Was called to the room of resident when CNA stated that the resident had fallen when the loop on the lift strap broke, dropping resident to the floor. Head to toe assessment done for injuries. Physician at the facility, notified of fall. Physician instructed to send resident to the hospital to be evaluated. The nurse documented that a head to toe body check revealed no injuries noted. The nurse documented on page 2 under position when found: Transferring resident with Hoyar lift when strap broke. Under Conclusion on page 3 of the report the nurse documented, Resident observed lying on back on the floor after being summoned to the room by CNA after strap broke while transferring resident with Hoyar lift, dropping resident to floor. Page 3 of the report documented that CNAs F and G were transferring the resident at the time of the incident. Under Notifications the nurse documented that the DON was notified 9/10/15 at 1900 (7:00 p.m.) by telephone and the Risk Manager was notified at 1830 (6:30 p.m.) in person. Notification to the Administrator was blank. The nurse documented on page 1 of the report that Resident #4 was sent to the hospital by ambulance at 8:15 p.m. On page 3, under occurrence specific follow up, the nurse documented that a resident fall review was completed, a plan of care for falls was completed, and a fall risk reassessment was N/A (not applicable). f) A nurse's note dated 9/11/15 at 4:35 a.m. documented, Was called to res. room by CNA @ (at) approx. (approximately) 1930 (7:30 p.m.), found res. (resident) lying on her back on floor upon entering room. Informed by CNA that loop on sling broke during transfer causing res. (resident) to fall to floor. Res. A&0 (alert and oriented) x 3 (person, place, and time.) VS (Vital Signs): B/P (blood pressure) 201/113, Pulse 100, Temp. (temperature) 98.3, Resp (Respirations) 22, O2% (Oxygen saturation) 93% RA (room air). C/O (Complaining of) pain to back of head, left hip, and left knee. Dr. (name of physician) in building ordered res. sent out to (name of hospital). (Name of Ambulance) arrived approx. 1945 (7:45 p.m.) left with res. via stretcher at 2000 (8:00 p.m.). g) A nurse's note dated 9/11/15 at 4:39 a.m. documented that Resident #4 had returned from the hospital at approximately 2245 (10:45 p.m.) by stretcher with a [DIAGNOSES REDACTED]. Vital signs were B/P 125/86, Temperature 97.8, Pulse 88, Respirations 18, and oxygen saturation of 98%. h) A hospital emergency physician record and trauma flow sheet documented the resident's arrival at the emergency department as 9/10/15 at 2009 (8:09 p.m.). The chief complaint was fall injury to head. The estimated height of the fall was approximately four feet. The physician documented under Clinical Impression: Contusion: head. A CT scan to the head was negative. No other injuries were identified and the hospital report that Resident #4 was returned to the facility at 10:36 p.m. The primary nurse signed the report and dated it 9/10/15. i) CNA G documented on a statement 9/10/15 (attached to the above report), Was assisting with (Resident #4) transfer from w/c to bed with Hoyar lift. During transfer green loop broke causing resident to fall to the floor. Charge nurse notified immediately and resident transfer to hospital for evaluation. j) A nurse's note dated 9/14/15 at 11:04 a.m. documented that Resident #4's left lower leg was swelling with redness and complaints of pain on that area. The physician was notified and ordered an X-ray. k) A radiology report dated 9/14/15 documented Resident #4 did not reveal any new fractures. l) During an observation on 9/15/15 at 3:25 p.m., CNAs H and I were observed transferring Resident #4 from her wheelchair to bed. The CNAs fastened the sling straps to the Hoyar and began lifting the resident. They then noticed that the resident and her wheelchair were both lifted off of the floor. Resident #4 was suspended in her chair approximately a foot off the floor when the CNAs noticed and lowered the resident back to the floor. The CNAs checked the straps and again began lifting Resident #4 with the mechanical lift, and again lifted Resident #4 and her wheelchair off of the floor approximately a foot. They then lowered the chair back to the floor again. At that time they noted that parts of the sling were caught on the sides of the wheelchair parts where they should not have been, and released the sling from the chair. They began to lift the resident a third time, and the Hoyar lift stopped functioning. The CNAs determined the battery must have gone dead, so they exchanged the Hoyar lift for a different one, and then were able to transfer Resident #4 to bed. During this observation, Resident #4 said she had fallen to the floor the other day and hit the back of her head. Resident #4 was somewhat confused at the time of this observation, as evidenced by talking to a dog in the room that was not there. m) During an interview on 9/22/15 at 3:20 p.m., Resident #4 was less confused than she had been on 9/15/15 and did not appear to be preoccupied outside of the conversation. She said she recalled the fall from the mechanical lift. She said, That was a biggie. It started ripping and I was gone! She said she heard the fabric tearing before she fell . She said, That's scary. She said she hit the back of her head and had a knot on her head afterwards. She said her head made a loud noise, a large crack, when it hit the floor. n) During an observation and interview on 9/22/15 at 3:05 p.m., CNA J said that each resident that required mechanical lifting had a sling in their room, and all extras were placed in the laundry room. CNA J said that if a CNA needed to replace a soiled sling, they would get a clean one from the laundry room. CNA J accompanied the surveyor to the laundry room. Eight slings were in the laundry room on a cart just inside the door. The Hoyar slings were inspected and one of eight slings was found to be worn (appearance of an older sling as the green color was very faded) and it had two tears completely through the fabric that were large (two fingers could fit through one hole, three fingers could fit through the second hole) and easily seen. o) During an interview on 9/22/15 at 3:35 p.m., the torn sling was shown to the DON. When the DON saw the sling, she said, That shouldn't be in there, it should be in the trash. When discussing who was responsible to monitor the condition of the Hoyar slings, the DON said, The CNAs. The DON said that they had checked and made sure that the slings that were in all the residents' rooms were in good condition, but the ones in the laundry room must not have been checked. 2. a) An undated Admission Record documented Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. b) physician's orders [REDACTED].#2's [DIAGNOSES REDACTED]. c) An MDS Assessment for Resident #2 dated 7/29/15 documented Resident #2 had a Brief Interview for Mental Status score of 14, indicating she was cognitively intact. Under Functional Status the assessment documented that Resident #2 required extensive assistance of two persons to transfer between surfaces, limited assistance of one person to dress, extensive assistance of one person to toilet; and was totally dependent with one person assistance for bathing. Resident #2 used a wheelchair for mobility. She had limited range of motion on the lower extremity of one side. d) A care plan for Resident #2 dated 7/16/15 included a problem with a start date of 7/2/15: Resident is limited in wheelchair mobility r/t (related to) BKA ([MEDICAL CONDITION]). The interventions included to instruct in proper use of the wheelchair, maintain body in functional alignment while in wheelchair, and provide adequate rest periods between activities. A problem with a start date of 7/2/15 documented, Resident has history of falling r/t (related to) outside objects. For example Hoyar lift strap being secured, shoe. Approaches were documented as analyze resident's falls to determine pattern/trend; ensure resident is seated properly in wheelchair (resident has habit of placing item in seat of wheelchair behind her); Ensure that equipment is properly used and secure including Hoyar sling straps being secured and not being dragged; keeping call light in reach, well maintained footwear, environment free of clutter; non slip pad in wheelchair, and toileting assistance every two hours and as needed. e) An Occurrence Report dated 6/17/15 at 1830 (6:30 p.m.) documented that Resident #2 had a fall in the common area. The nurse note documented, Resident being propelled in w/c by CNA. Hoyar lift strap became entangled in wheel causing resident to be pulled forward out of wheelchair. The occurrence report documented the position when found was supine (lying on her back). Under Conclusion the ADON documented 6/18/15 at 10:25 a.m. that the ADON was present when the incident occurred, and 9-1-1 was called and the resident transported to the ER. The ADON documented in part, After speaking to nurse and aide that were next to resident when fall occurred, it was determined that the strap of her Hoyar sling was caught in the wheelchair wheel and caused the resident to fall out of chair and hit her left amputated leg. Resident was in a severe amount of pain. No other complaints of pain. Resident did not hit head . Under the heading Staff Interviews, the writer documented, No staff interviews available. Under Recommendations, the writer documented, None. Under Notifications, the writer documented that the Facility Administrator was notified by phone on 6/17/15 at 1854 (6:54 p.m.). The Director of Nursing notification space on the form was not filled in. The Medical Director was notified on 6/17/15 at 1840 (6:40 p.m.) by telephone. f) Nursing notes in Resident #2's computerized record revealed the nurse entered a late entry on 6/18/15 at 2:16 a.m. for the incident on 6/17/15 at 1830 (6:30 p.m.). The note documented that Resident #2 was being pushed in her wheelchair and her foot and the Hoyar sling strap became entangled in the wheel. The nurse documented that Resident pulled from w/c by Hoyar sling to floor, struck left BKA ([MEDICAL CONDITION]). Notified MD and POA. order received and noted to sent to (hospital) via EMS 911. g) A nurse's note on 6/18/15 at 2:19 a.m. documented that on 6/17/15 at 2300 (11:00 p.m.), Resident #2 returned to the facility from the hospital with no new orders, denied pain or distress, and was assisted to bed. h) An Emergency Physician Record dated 6/17/15 documented a chief complaint of fall injury to L (left) thigh stump. The Discharge Summary from the Emergency Department documented a Primary [DIAGNOSES REDACTED]. i) A radiology report for Resident #2 dated 6/17/15 at 2038 (8:38 p.m.) and dictated by the radiologist on 6/18/15 at 10:08 a.m. documented two views of the femur for an indication of left femur pain status [REDACTED]. The findings included: Patient has undergone mid femoral amputation. There appears to be swelling of the soft tissue stump. No prior postoperative image is available for review. The bony stump exhibits focal areas of bone lysis (dissolution of bone that particularly involves the removal or loss of calcium). No active subperisosteal (under the dense layer of vascular connective tissue enveloping the bones except at the surfaces of the joints) new bone is identified to suggest osteo[DIAGNOSES REDACTED] (bone infection). There is an isolated bony density at the tip of the stump which could represent small acute fracture fragment. Conclusion: Above-knee amputation with possible acute fracture fragment at the tip of the bony stump with associated swelling. j) A nurse's note dated 6/19/15 at 1:48 p.m. by the ADON documented that on 6/18/15 she had spoken to Resident #2's family. The ADON documented, Daughter was upset because she couldn't understand that how negligence could just happen and cause her mom to fall to the floor. I apologized to her about the fall but that in no way, shape, or form was this considered negligence considering the aide was pushing the wheelchair and the nurse was standing nearby and I explained to her that the fall was too sudden for us to be able to do anything. I explained to her that the strap that is on the Hoyar sling got caught in the wheelchair wheels and the jerk on the sling, along with the silk gown she was wearing, there was not enough reaction time for us to actually prevent her from falling. I notified her that the aides will be inserviced on hoyers/slings to ensure that any dangling objects are secured and not dangling freely in order to prevent any further incidents like the resident's from happening again . k) During an observation on 9/10/15 at 1:20 p.m., CNAs A and B were observed to transfer Resident #2 from her wheelchair to bed, using a mechanical lift. CNA A was operating the mechanical lift. She was observed to lock the casters of the mechanical lift prior to lifting Resident #2. l) During an interview on 9/10/15 at 1:30 p.m., CNA A was asked why she locked the casters of the mechanical lift prior to lifting. She said she had always wondered about whether she should be doing that or not, but that was the way she had been taught to do it. m) A review of the mechanical lift owner's manual, provided by the Administrator on 9/22/15 at 5:15 p.m. revealed operating instructions included: Page 3: During lifting or lowering, whenever possible, always keep the base of the lift in the widest position with the casters unlocked. Page 8: DO NOT lift a patient with the caster brakes on. Always let the lift find the correct center of gravity. n) During an interview on 9/22/15 at 2:45 p.m., Resident #2 said that the CNA with her on the day of the incident had been a CNA from an agency, not a full time employee of the facility. Resident #2 said it was unfortunate that it happened but she got banged up pretty bad. 3. During an interview on 9/22/15 at 4:00 p.m., the DON and Risk Manager said that the Risk Manager had only been on the job two weeks. When discussing who was responsible to review and follow up on incident reports such as the one for Resident #4 to rule out potential abuse or neglect, the DON said that would be the Risk Manager's job to ensure that the full review process of the incident reports are entered into the computer system, including the follow up and conclusions, but this process had not started yet. The DON said the Risk Manager had only been working on infection control and had not gotten to the incident reporting system yet. The Risk Manager agreed. The DON and Risk Manager said that Resident #4's fall from the Hoyar was not considered as an allegation of neglect or reportable to the State as possible neglect because the sling tearing could not be considered the staff's fault. They also stated they did not understand how Resident #2 falling was reportable as an allegation of neglect, since staff witnessed the fall. They said they spoke with the staff involved to gather information about the falls, but did not initiate an abuse or neglect investigation or report the incidents. 4. During an interview on 9/23/15 at 9:15 a.m., the Administrator said he was aware of Resident #4's fall from the mechanical lift and Resident #2 falling from her chair when the Hoyar straps tangled in her wheelchair. When discussing Resident #4, the Administrator said that the facility had all new slings and that he determined that the new slings were faulty and, We're visiting with the manufacturers. The Administrator said that neither of the falls (Residents #2 and 4) were reported to the State or investigated as a possible allegation of neglect. When discussing whether the accidents were preventable if staff had done something differently and if he saw that as reportable as possible neglect, he said, Depends on the situation. When discussing that both residents were sent to the emergency room , he then stated, I would say yes. The Administrator stated that the department heads talked about the falls in their stand-up meeting. He said he knew that Resident #4's fall was not reported, and he was 99.9% sure that Resident #2's fall was not reported either. He said that the facility planned to start risk meetings to discuss things they need to focus on, do root cause analysis, and identify things. 5. a) An undated face sheet documented Resident #1 was a [AGE] year-old female admitted to the facility 3/23/15 with [DIAGNOSES REDACTED]. An 8/1/15-9/30/15 physician order [REDACTED]. An admission nursing assessment 3/24/15 documented an admitting [DIAGNOSES REDACTED]. b) A Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status score of 13, indicating that she was cognitively intact. The MDS documented there were no potential indicators of [MEDICAL CONDITION] (hallucinations or delusions), there were no physical symptoms directed toward others (such as hitting, kicking, pushing), there were no verbal behavioral symptoms directed toward others (such as threatening others, screaming at others or cursing at others), and there were no other behavioral symptoms not directed toward others (such as hitting or scratching self, pacing, etc). Under Rejection of Care the facility documented that the behavior of rejecting care had not been exhibited. The MDS documented that Resident #1 used a wheelchair for mobility. The MDS documented that Resident #1 required extensive assistance of two people to transfer between surfaces and to provide physical help in part of the bathing activity; and extensive assistance of one person to dress, use the toilet, and help with personal hygiene. The MDS documented under Language that Resident #1's preferred language was Spanish and that the resident did need/want an interpreter to communicate with a doctor or health care staff. c) A Care Plan for Resident #1 with a dated heading of Last Care Conference: 6/25/2015; Next Care Conference: 9/23/2015 did not include any problem statements, goals, or interventions for resisting care, challenging behaviors, or [MEDICAL CONDITION]. The care plan documented that Resident #1 required reminders of the month, day and year due to impaired temporal orientation. A problem with a start date of 3/24/15 documented that Resident #1 did not speak the dominant language of the facility and the approach was that spanish speaking staff would interpret for Resident #1 when needed. The Care Plan did not address activities of daily living (such as what level of assistance would be provided for transferring, toileting, dressing, hygiene, or showering.) A Care Plan for Resident #1 with a dated heading of Last Care Conference: 9/24/15; Next Care Conference: 12/23/15 was un-changed from the previous care conference with regard to the above information. d) An Occurrence Report regarding Resident #1 dated 9/18/15 at 9:30 a.m. documented as reported by the ADON documented the following: Type- Behavior Problem Location- Bathing Room Activity-Sitting Witnesses- CNA B Assigned Caregiver- CNA A Physician called 9/18/15 at 10:00 POA (Power of Attorney) called 9/18/15 at 10:00 Vital Signs: (All marked N/A). Cognition prior to occ (occurrence): Oriented x2 (person and place) Cognition after occ (occurrence): Oriented x2 Injuries: Laceration, left side of lip, 9/18/15 at 0930. Details: Staff member sustained a laceration on her bottom lip to the left side from resident hitting staff member in the mouth with her shoe. Immediate Actions Taken: Redirect, Resident assigned to another aide, Resident education, training re-instruction. On 9/24/15 at 1535 (3:35 p.m.) the ADON added the following to the Occurrence Report: Under Nurse's Note of what happened: This nurse observed resident coming out of shower room and screaming and hollering but quieted down after a few moments. Aides then went to the social worker and wanted to file a grievance against the resident for causing injury to her. Aide was observed to be bleeding from her bottom lip. Under Resident Statement of what happened: Resident stated that the shower was too cold and that she was not going to shower in that cold bathroom, and that she did not hit anyone. Under Witness Statement of what happened: Other Aide (CNA B) witnessed occurrence and stated that resident hit staff member in the mouth with her shoe. Under Behavior Symptom Exhibited: Physical Under Source of Allegation: Other Under Target of Aggression: Resident was aggressive toward staff member and physical. Under Behavior Problem Notifications on 9/18/15 at 9:30 a.m.: Administrator 9/18/15 at 10:30 a.m.; Physician 9/18/15 at 10:00 a.m.; Resident Guardian 9/18/15 at 10:30 a.m. Under General Follow up Procedures entered by the ADON on 9/25/15 at 9:44: This nurse spoke with resident in regards to why she was so upset with her aides that were taking care of her. Resident stated that the aides were trying to giver her a shower in the cold shower room and that she was too cold to take a shower. I asked resident if at any point she hit any of the staff to which she replied that she did not. This nurse then interviewed the two aides that were assigned to care for her that day. CNA A was interviewed and she stated that they were trying to give resident a shower and that when she bent down to take resident's shoe off the resident began hitting her with the shoe and at one point struck her in the face, which busted her lip. Aides then removed resident from shower room and were going to talk to DON to file a grievance against resident for her behavior and her physical attack towards aide. According to (CNA A), Resident #1 told a couple of other aides that she did not want anyone besides hispanic aides taking care of her. Photographs of busted lip on aide were taken and sent to DON. (CNA B) other aide that was with CNA A on this day corroborated the story and events that occurred with resident. Med Aide A was outside in hallway when incident occurred and gave statement as to what I occurred. Per her statement and interview she stated that she observed CNA A and B forcing resident into shower room and as they put her inside she heard resident screaming no repeatedly. As they got out of the shower CNA A asked her to translate what Resident #1 was saying. She had also asked her to tell Resident #1 that she shouldn't be hitting her (CNA A) and that she was going to report her. Resident #1 then told Med Aide A that they were hitting her and that CNA A said that was a lie, and after that the aides took her to her room. On said day another aides was assigned to the resident to avoid further on going issues. DON made aware of issue and Admin. Under Recommendations entered by ADON with a due date of 9/23/15, a date implemented of 9/24/15: It is recommended that CNA A change resident assignments with another staff member to avoid further confrontations with this resident. The Occurrence report documented Notifications on page 4 of 4 as follows: Director of Nursing: 9/18/15 1200 (via) In Person Facility Administrator: 9/18/15 1200 (via) In Person Risk Manager: 9/18/15 1200 (via) In Person Medical Director: 9/18/15 1000 (via) Fax State Agency: (Blank) e) Nursing Notes for Resident #1 had no entries by nursing staff on 9/18/15, 9/19/15, 9/20/15 or 9/21/15. f) A Social Services Note entered into Resident Progress Notes for Resident #1 dated 9/22/15 at 2:16 p.m. documented that on 9/18/15 CNA A came to the SW to write a complaint regarding Resident #1 stating the resident had hit her in the mouth with a shoe. The SW documented that CNAs A and B were in the shower room with Resident #1 and the resident did not want a shower and hit CNA A. She documented CNA A was bleeding from the lip and photos were taken by the AD and sent to the DON. The SW documented that Resident #1 only wanted hispanic CNAs taking care of her which would create a longer waiting time for her needs. The SW documented that, On next day same resident called the same 2 CNAs names while they were taking care of her roommate and she did not wish to leave the room. Statement written by CNAs. On 9/20/15 resident reported to charge nurse at nurse's station that the same 2 aides had poured water on her bed and floor. DON and SW told them to have other aides care for her, that they need to stay out of that room. The SW documented that she spoke with the resident's daughter on 9/21/15 and the resident's daughter .apologized for her mom and cried. The resident's daughter reported to the SW that Resident #1 denied to her daughter that she had done anything against the staff. The SW documented, DON and SW met with her and told her that assault charges could be filed since her mother is in her right mind. Things seemed to settle down quite a bit and (daughter) expressed intense concern for her mom and her recent behaviors g) During an interview on 9/25/15 at 9:15 a.m., when discussing the status of the facility's investigation, the ADON said the report was not complete. The ADON was asked to provide all of the information she had on the incident. The ADON provided the incident report, a statement from CNA A, a statement from Med Aide C, and three written statements of complaint about Resident #1's behavior (after the incident) by the CNAs. CNA A's (undated) statement was as follows: Had taken her shoes off and she hit me in the mouth with her shoe and so we put it in her lap and pushed her back and me and the aide (CNA B) was in there and so then we went to get (the DON). And she told the other aide (CNA D) that she did not want any aide if there was not hispani

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for 3 of 13 residents reviewed for abuse and neglect (Residents #1, 2, and 4) as evidenced by: a) failure to report an allegation of neglect to the State authority and failure to conduct a thorough investigation when Resident #4 fell from a mechanical lift while staff were operating the lift and transferring the resident resulting in a contusion to her head on 9/11/15; b) failure to report an allegation of neglect to the State authority and failure to conduct a thorough investigation when Resident #2 was being pushed by staff in her wheelchair and the mechanical lift sling strap(s) became entangled in the wheel of the wheelchair, throwing Resident #2 forward and out of her chair on 6/17/15. Resident #2 sustained a thigh contusion and possible acute fracture at the tip of the bony stump of her amputated leg, with associated swelling; and c) failure to report an allegation of physical abuse made by Resident #1 to CNA A, CNA B, and Med Aide A on 9/18/15 at approximately 9:30 a.m. to the State authority until 9/22/15; failure to complete a thorough investigation of Resident #1's allegations; and failure to protect Resident #1 during an investigation. The alleged perpetrators continued to work on Resident #1's hall and go in her room throughout the day the allegation was made and through the weekend of 9/19/15 and 9/20/15 which resulted in mental distress to Resident #1. An Immediate Jeopardy (IJ) was identified on 9/23/15 at 12:00 noon regarding Residents #2 and 4. Findings regarding Resident #1 were included in the Immediate Jeopardy by notification to the Administrator on 9/25/15 at 1:35 p.m. While the IJ was removed on 9/29/15, the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a pattern. These failures could affect the 13 residents that require a mechanical lift for transferring between surfaces and could affect the total of 71 residents who required assistance with activities of daily living. These failure could result in ongoing abuse or neglect in the facility and result in pain, emotional distress, injury, or death. Findings included: 1. Review of the facility's policy titled Protection of Residents During Abuse Investigations, revised December 2006 and provided by the DON on 9/29/15 revealed the policy included the following: Under, Policy Interpretation and Implementation page 8: #1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator. b. Should the employee(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents . #2. Within five (5) working days of the alleged incident, the facility will give the resident, the resident ' s representative (sponsor), the ombudsman, state survey and certification agencies, accused individuals, etc., a written report of the findings of the investigation and a summary of corrective action taken to prevent such incident from recurring 2. Review of the facility's policy titled, Reporting Abuse to Facility Management (page 11) revised April 2014 provided by the DON on 9/29/15 revealed it included the following: Under Policy Interpretation and Implementation: #5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or Charge nurse. The following information should be reported: a. the name(s) of the resident(s) to which the abuse or suspected abuse occurred; b. the date and time that the incident occurred; c. where the incident took place; d. the name(s) of the person(s) allegedly committing the incident, if known; e. the names(s) of any witnesses to the incident; f. the type of abuse that was committed (i.e. verbal, physical, sexual, neglect, etc.); and g. Any other information that may be requested by management. #7. Staff members and persons affiliated with this facility shall not knowingly: .b. fail to report an incident of mistreatment or other offense. #8. The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing services must be called at home or must be page and informed of such incident. #9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. #10. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. 3. Review of the facility's policy titled, Reporting Abuse to State Agencies and Other Entities/Individuals revised December 2009, provided by the DON on 9/29/15 revealed it included the following: Under, Policy Interpretation and Implementation: #1. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown sources, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The resident ' s representative (Sponsor) of Record; d. Adult Protective Services; e. Law enforcement officials; f. The resident ' s Attending Physician; and g. The facility Medical Director. 4. a) A Resident Admission record dated 6/29/15 documented that Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] from another hospital facility. She was referred from a Rehabilitation facility. [DIAGNOSES REDACTED]. b) A Rehabilitation Hospital report dated 6/13/15 documented Resident #4 was admitted there after a right ankle fracture, tibia-fibula and was non-weight bearing. She was admitted to the rehabilitation facility for aggressive physical therapy. Her weakness was due to disuse [DIAGNOSES REDACTED] secondary to the right ankle fracture. The report documented a past medical history of [REDACTED]. c) An MDS Assessment for Resident #4, dated 7/6/15 documented a Brief Mental Status Interview score of 13, indicating Resident #4 was cognitively intact. She had no indicators of [MEDICAL CONDITION] and no behavioral symptoms. The MDS documented that Resident #4 required Extensive assistance (resident involved in activity, staff provide weight-bearing support) of one person for bed mobility; and extensive assistance from two or more persons for transferring, toilet use, and personal hygeine. The MDS documented that Resident #4 had limited range of motion of a lower extremity on one side and used a wheelchair for mobility. She was documented as having a fall during the last month prior to admission. Resident #4 was 57 inches tall and weighed 247 pounds. d) A care plan for Resident #4 with last care conference date of 8/13/15 and next care conference date of 11/11/15 documented a problem on page 2 of 5 with a start date of 7/24/15: Resident must be lifted mechanically AEB (as evidenced by) (sentence was not complete). The goal documented, Resident will not sustain injuries during transfers with mechanical lift in the next 90 days and the approach was, 2 staff members at all times to use the mechanical lift. The care plan had an added intervention dated 9/11/15, Resident has history of falling related to equipment. A goal stated, Resident will remain free from injury. Approaches included encrouraging the resident to use environmental devices such as hand grips, hand rails, etc., keeping call light in reach, keeping personal and frequently used items in reach, observing frequently and placing in a supervised area when out of bed; and providing an environment free of clutter. A problem added to the care plan 9/18/15 documented, Resident has a memory/recall problem related to disease process. The goal stated, Resident will not sustain serious injury due to memory/recall deficit. The approaches included ensuring assistive devices (walkers, canes, wheelchairs, etc.) are in good condition, ensure resident areas are free of hazards, provide chair and/or bed alarm if resident requires assistance with transfer, and redirect resident when entering usafe areas. e) An Occurrence Report for Resident #4 dated 9/11/15 at 1950 (7:50 p.m.) documented Resident #4 had a fall in her room during transfer. Under Nurse's note of what happened the nurse documented, Was called to the room of resident when CNA stated that the resident had fallen when the loop on the lift strap broke, dropping resident to the floor. Head to toe assessment done for injuries. Physician at the facility, notified of fall. Physician instructed to send resident to the hospital to be evaluated. The nurse documented that a head to toe body check revealed no injuries noted. The nurse documented on page 2 under position when found: Transferring resident with Hoyer lift when strap broke. Under Conclusion on page 3 of the report the nurse documented, Resident observed lying on back on the floor after being summoned to the room by CNA after strap broke while transferring resident with Hoyer lift, dropping resident to floor. Page 3 of the report documented that CNAs F and G were transferring the resident at the time of the incident. Under Notifications the nurse documented that the DON was notified 9/10/15 at 1900 (7:00 p.m.) by telephone and the Risk Manager was notified at 1830 (6:30 p.m.) in person. Notification to the Administrator was blank. The nurse documented on page 1 of the report that Resident #4 was sent to the hospital by ambulance at 8:15 p.m. On page 3, under occurrence specific follow up, the nurse documented that a resident fall review was completed, a plan of care for falls was completed, and a fall risk reassessment was N/A (not applicable). f) A nurse's note dated 9/11/15 at 4:35 a.m. documented, Was called to res. room by CNA @ (at) approx. (approximately) 1930 (7:30 p.m.), found res. (resident) lying on her back on floor upon entering room. Informed by CNA that loop on sling broke during transfer causing res. (resident) to fall to floor. Res. A&0 (alert and oriented) x 3 (person, place, and time.) VS (Vital Signs): B/P (blood pressure) 201/113, Pulse 100, Temp. (temperature) 98.3, Resp (Respirations) 22, O2% (Oxygen saturation) 93% RA (room air). C/O (Complaining of) pain to back of head, left hip, and left knee. Dr. (name of physician) in building ordered res. sent out to (name of hospital). (Name of Ambulance) arrived approx. 1945 (7:45 p.m.) left with res. via stretcher at 2000 (8:00 p.m.). g) A nurse's note dated 9/11/15 at 4:39 a.m. documented that Resident #4 had returned from the hospital at approximately 2245 (10:45 p.m.) by stretcher with a [DIAGNOSES REDACTED]. Vital signs were B/P 125/86, Temperature 97.8, Pulse 88, Respirations 18, and oxygen saturation of 98%. h) A hospital emergency physician record and trauma flow sheet documented the resident's arrival at the emergency department as 9/10/15 at 2009 (8:09 p.m.). The chief complaint was fall injury to head. The estimated height of the fall was approximately four feet. The physician documented under Clinical Impression: Contusion: head. A CT scan to the head was negative. No other injuries were identified and the hospital report that Resident #4 was returned to the facility at 10:36 p.m. The primary nurse signed the report and dated it 9/10/15. i) CNA G documented on a statement 9/10/15 (attached to the above report), Was assisting with (Resident #4) transfer from w/c to bed with Hoyer lift. During transfer green loop broke causing resident to fall to the floor. Charge nurse notified immediately and resident transfer to hospital for evaluation. j) A nurse's note dated 9/14/15 at 11:04 a.m. documented that Resident #4's left lower leg was swelling with redness and complaints of pain on that area. The physician was notified and ordered an X-ray. k) A radiology report dated 9/14/15 documented Resident #4 did not reveal any new fractures. l) During an observation on 9/15/15 at 3:25 p.m., CNAs H and I were observed transferring Resident #4 from her wheelchair to bed. The CNAs fastened the sling straps to the Hoyer and began lifting the resident. They then noticed that the resident and her wheelchair were both lifted off of the floor. Resident #4 was suspended in her chair approximately a foot off the floor when the CNAs noticed and lowered the resident back to the floor.The CNAs checked the straps and again began lifting Resident #4 with the mechanical lift, and again lifted Resident #4 and her wheelchair off of the floor approximately a foot. They then lowered the chair back to the floor again. At that time they noted that parts of the sling were caught on the sides of the wheelchair parts where they should not have been, and released the sling from the chair. They began to lift the resident a third time, and the Hoyer lift stopped functioning. The CNAs determined the battery must have gone dead, so they exchanged the Hoyer lift for a different one, and then were able to transfer Resident #4 to bed. During this observation, Resident #4 said she had fallen to the floor the other day and hit the back of her head. Resident #4 was somewhat confused at the time of this observation, as evidenced by talking to a dog in the room that was not there. m) During an interview on 9/22/15 at 3:20 p.m., Resident #4 was less confused than she had on 9/15/15 and did not appear to be preoccupied outside of the conversation. She said she recalled the fall from the mechanical lift. She said, That was a biggie. It started ripping and I was gone! She said she heard the fabric tearing before she fell . She said, That's scary. She said she hit the back of her head and had a knot on her head afterwards. She said her head made a loud noise, a large crack, when it hit the floor. n) During an observation and interview on 9/22/15 at 3:05 p.m., CNA J said that each resident that required mechanical lifting had a sling in their room, and all extras were placed in the laundry room. CNA J said that if a CNA needed to replace a soiled sling, they would get a clean one from the laundry room. CNA J accompanied the surveyor to the laundry room. Eight slings were in the laundry room on a cart just inside the door. The Hoyer slings were inspected and one of eight slings was found to be worn (appearance of an older sling as the green color was very faded) and it had two tears completely through the fabric that were large (two fingers could fit through one hole, three fingers could fit through the second hole) and easily seen. o) During an interview on 9/22/15 at 3:35 p.m., the torn sling was shown to the DON. When the DON saw the sling, she said, That shouldn't be in there, it should be in the trash. When discussing who was responsible to monitor the condition of the Hoyer slings, the DON said, The CNAs. The DON said that they had checked and made sure that the slings that were in all the residents' rooms were in good condition, but the ones in the laundry room must not have been checked. 5. a) An undated Admission Record documented Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. b) physician's orders [REDACTED].#2's [DIAGNOSES REDACTED]. c) An MDS Assessment for Resident #2 dated 7/29/15 documented Resident #2 had a Brief Interview for Mental Status score of 14, indicating she was cognitively intact. Under Functional Status the assessment documented that Resident #2 required extensive assistance of two persons to transfer between surfaces, limited assistance of one person to dress, extensive assistance of one person to toilet; and was totally dependent with one person assistance for bathing. Resident #2 used a wheelchair for mobility. She had limited range of motion on the lower extremity of one side. d) A care plan for Resident #2 dated 7/16/15 included a problem with a start date of 7/2/15: Resident is limited in wheelchair mobility r/t (related to) BKA ([MEDICAL CONDITION]). The interventions included to instruct in proper use of the wheelchair, maintain body in functional alignment while in wheelchair, and provide adequate rest periods between activities. A problem with a start date of 7/2/15 documented, Resident has history of falling r/t (related to) outside objects. For example hoyer lift strap being secured, shoe. Approaches were documented as analyze resident's falls to determine pattern/trend; ensure resident is seated properly in wheelchair (resident has habit of placing item in seat of wheelchair behind her); Ensure that equipment is properly used and secure including Hoyer sling straps being secured and not being dragged; keeping call light in reach, well maintained footwear, environment free of clutter; non slip pad in wheelchair, and toileting assistance every two hours and as needed. e) An Occurrence Report dated 6/17/15 at 1830 (6:30 p.m.) documented that Resident #2 had a fall in the common area. The nurse note documented, Resident being propelled in w/c by CNA. Hoyer lift strap became entangled in wheel causing resident to be pulled forward out of wheelchair. The occurrence report documented the position when found was supine (lying on her back). Under Conclusion the ADON documented 6/18/15 at 10:25 a.m. that the ADON was present when the incident occurred, and 9-1-1 was called and the resident transported to the ER. The ADON documented in part, After speaking to nurse and aide that were next to resident when fall occurred, it was determined that the strap of her hoyer sling was caught in the wheelchair wheel and caused the resident to fall out of chair and hit her left amputated leg. Resident was in a severe amount of pain. No other complaints of pain. Resident did not hit head . Under the heading Staff Interviews, the writer documented, No staff interviews available. Under Recommendations, the writer documented, None. Under Notifications, the writer documented that the Facility Administrator was notified by phone on 6/17/15 at 1854 (6:54 p.m.). The Director of Nursing notification space on the form was not filled in. The Medical Director was notified on 6/17/15 at 1840 (6:40 p.m.) by telephone. f) Nursing notes in Resident #2's computerized record revealed the nurse entered a late entry on 6/18/15 at 2:16 a.m. for the incident on 6/17/15 at 1830 (6:30 p.m.). The note documented that Resident #2 was being pushed in her wheelchair and her foot and the hoyer sling strap became entangled in the wheel. The nurse documented that Resident pulled from w/c by Hoyer sling to floor, struck left BKA ([MEDICAL CONDITION]). Notified MD and POA. order received and noted to sent to (hospital) via EMS 911. g) A nurse's note on 6/18/15 at 2:19 a.m. documented that on 6/17/15 at 2300 (11:00 p.m.), Resident #2 returned to the facility from the hospital with no new orders, denied pain or distress, and was assisted to bed. h) An Emergency Physician Record dated 6/17/15 documented a chief complaint of fall injury to L (left) thigh stump. The Discharge Summary from the Emergency Department documented a Primary [DIAGNOSES REDACTED]. i) A radiology report for Resident #2 dated 6/17/15 at 2038 (8:38 p.m.) and dictated by the radiologist on 6/18/15 at 10:08 a.m. documented two views of the femur for an indication of left femur pain status [REDACTED]. The findings included: Patient has undergone mid femoral amputation. There appears to be swelling of the soft tissue stump. No prior postoperative image is available for review. The bony stump exhibits focal areas of bone lysis (dissolution of bone that particularly involves the removal or loss of calcium). No active subperisosteal (under the dense layer of vascular connective tissue enveloping the bones except at the surfaces of the joints) new bone is identified to suggest osteo[DIAGNOSES REDACTED] (bone infection). There is an isolated bony density at the tip of the stump which could represent small acute fracture fragment. Conclusion: Above-knee amputation with possible acute fracture fragment at the tip of the bony stump with associated swelling. j) A nurse's note dated 6/19/15 at 1:48 p.m. by the ADON documented that on 6/18/15 she had spoken to Resident #2's family. The ADON documented, Daughter was upset because she couldn't understand that how negligence could just happen and cause her mom to fall to the floor. I apologized to her about the fall but that in no way, shape, or form was this considered negligence considering the aide was pushing the wheelchair and the nurse was standing nearby and I explained to her that the fall was too sudden for us to be able to do anything. I explained to her that the strap that is on the hoyer sling got caught in the wheelchair wheels and the jerk on the sling, along with the silk gown she was wearing, there was not enough reaction time for us to actually prevent her from falling. I notified her that the aides will be inserviced on hoyers/slings to ensure that any dangling objects are secured and not dangling freely in order to prevent any further incidents like the resident's from happening again . k) During an observation on 9/10/15 at 1:20 p.m., CNAs A and B were observed to transfer Resident #2 from her wheelchair to bed, using a mechanical lift. CNA A was operating the mechanical lift. She was observed to lock the casters of the mechanical lift prior to lifting Resident #2. l) During an interview on 9/10/15 at 1:30 p.m., CNA A was asked why she locked the casters of the mechanical lift prior to lifting. She said she had always wondered about whether she should be doing that or not, but that was the way she had been taught to do it. m) A review of the mechanical lift owner's manual, provided by the Administrator on 9/22/15 at 5:15 p.m. revealed operating instructions included: Page 3: During lifting or lowering, whenever possible, always keep the base of the lift in the widest position with the casters unlocked. Page 8: DO NOT lift a patient with the caster brakes on. Always let the lift find the correct center of gravity. n) During an interview on 9/22/15 at 2:45 p.m., Resident #2 said that the CNA with her on the day of the incident had been a CNA from an agency, not a full time employee of the facility. Resident #2 said it was unfortunate that it happened but she got banged up pretty bad. 6. During an interview on 9/22/15 at 4:00 p.m., the DON and Risk Manager said that the Risk Manager had only been on the job two weeks. When discussing who was responsible to review and follow up on incident reports such as the one for Resident #4 to rule out potential abuse or neglect, the DON said that would be the Risk Manager's job to ensure that the full review process of the incident reports are entered into the computer system, including the follow up and conclusions, but this process had not started yet. The DON said the Risk Manager had only been working on infection control and had not gotten to the incident reporting system yet. The Risk Manager agreed. The DON and Risk Manager said that Resident #4's fall from the Hoyer was not considered as an allegation of neglect or reportable to the State as possible neglect because the sling tearing could not be considered the staff's fault. They also stated they did not understand how Resident #2 falling was reportable as an allegation of neglect, since staff witnessed the fall. They said they spoke with the staff involved to gather information about the falls, but did not initiate an abuse or neglect investigation or report the incidents. 7. During an interview on 9/23/15 at 9:15 a.m., the Administrator said he was aware of Resident #4's fall from the Hoyer and Resident #2 falling from her chair when the Hoyer straps tangled in her wheelchair. When discussing Resident #4, the Administrator said that the facility had all new slings and that he determined that the new slings were faulty and, We're visiting with the manufacturers. The Administrator said that neither of the falls (Residents #2 and 4) were reported to the State or investigated as a possible allegation of neglect. When discussing whether the accidents were preventable if staff had done something differently and if he saw that as reportable as possible neglect, he said, Depends on the situation. When discussing that both residents were sent to the emergency room , he then stated, I would say yes. The Administrator stated that the department heads talked about the falls in their stand-up meeting. He said he knew that Resident #4's fall was not reported, and he was 99.9% sure that Resident #2's fall was not reported either. He said that the facility planned to start risk meetings to discuss things they need to focus on, do root cause analysis, and identify things. 8. a) An undated face sheet documented Resident #1 was a [AGE] year-old female admitted to the facility 3/23/15 with [DIAGNOSES REDACTED]. An 8/1/15-9/30/15 physician order [REDACTED]. An admission nursing assessment 3/24/15 documented an admitting [DIAGNOSES REDACTED]. b) A Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status score of 13, indicating that she was cognitively intact. The MDS documented there were no potential indicators of [MEDICAL CONDITION] (hallucinations or delusions), there were no physical symptoms directed toward others (such as hitting, kicking, pushing), there were no verbal behavioral symptoms directed toward others (such as threatening others, screaming at others or cursing at others), and there were no other behavioral symptoms not directed toward others (such as hitting or scratching self, pacing, etc). Under Rejection of Care the facility documented that the behavior of rejecting care had not been exhibited. The MDS documented that Resident #1 used a wheelchair for mobility. The MDS documented that Resident #1 required extensive assistance of two people to transfer between surfaces and to provide physical help in part of the bathing activity; and extensive assistance of one person to dress, use the toilet, and help with personal hygeine. The MDS documented under Language that Resident #1's preferred language was spanish and that the resident did need/want an interpreter to communicate with a doctor or health care staff. c) A Care Plan for Resident #1 with a dated heading of Last Care Conference: 6/25/2015; Next Care Conference: 9/23/2015 did not include any problem statements, goals, or interventions for resisting care, challenging behaviors, or [MEDICAL CONDITION]. The care plan documented that Resident #1 required reminders of the month, day and year due to impaired temporal orientation. A problem with a start date of 3/24/15 documented that Resident #1 did not speak the dominant language of the facility and the approach was that spanish speaking staff would interpret for Resident #1 when needed. The Care Plan did not address activities of daily living (such as what level of assistance would be provided for transferring, toileting, dressing, hygeine, or showering.) A Care Plan for Resident #1 with a dated heading of Last Care Conference: 9/24/15; Next Care Conference: 12/23/15 was un-changed from the previous care conference with regard to the above information. d) An Occurrence Report regarding Resident #1 dated 9/18/15 at 9:30 a.m. documented as reported by the ADON documented the following: Type- Behavior Problem Location- Bathing Room Activity-Sitting Witnesses- CNA B Assigned Caregiver- CNA A Physician called 9/18/15 at 10:00 POA (Power of Attorney) called 9/18/15 at 10:00 Vital Signs: (All marked N/A). Cognition prior to occ (occurrence): Oriented x2 (person and place) Cognition after occ (occurrence): Oriented x2 Injuries: Laceration, left side of lip, 9/18/15 at 0930. Details: Staff member sustained a laceration on her bottom lip to the left side from resident hitting staff member in the mouth with her shoe. Immediate Actions Taken: Redirect, Resident assigned to another aide, Resident education, training re-instruction. On 9/24/15 at 1535 (3:35 p.m.) the ADON added the following to the Occurrence Report: Under Nurse's Note of what happened: This nurse observed resident coming out of shower room and screaming and hollering but quieted down after a few moments. Aides then went to the social worker and wanted to file a grievance against the resident for causing injury to her. Aide was observed to be bleeding from her bottom lip. Under Resident Statement of what happened: Resident stated that the shower was too cold and that she was not going to shower in that cold bathroom, and that she did not hit anyone. Under Witness Statement of what happened: Other Aide (CNA B) witnessed occurrence and stated that resident hit staff member in the mouth with her shoe. Under Behavior Symptom Exhibited: Physical Under Source of Allegation: Other Under Target of Aggression: Resident was aggressive toward staff member and physical. Under Behavior Problem Notifications on 9/18/15 at 9:30 a.m.: Administrator 9/18/15 at 10:30 a.m.; Physician 9/18/15 at 10:00 a.m.; Resident Guardian 9/18/15 at 10:30 a.m. Under General Follow up Procedures entered by the ADON on 9/25/15 at 9:44: This nurse spoke with resident in regards to why she was so upset with her aides that were taking care of her. Resident stated that the aides were trying to giver her a shower in the cold shower room and that she was too cold to take a shower. I asked resident if at any point she hit any of the staff to which she replied that she did not. This nurse then interviewed the two aides that were assigned to care for her that day. CNA A was interviewed and she stated that they were trying to give resident a shower and that when she bent down to take resident's shoe off the resident began hitting her with the shoe and at one point struck her in the face, which busted her lip. Aides then removed resident from shower room and were going to talk to DON to file a grievance against resident for her behavior and her physical attack towards aide. According to (CNA A), Resident #1 told a couple of other aides that she did not want anyone besides hispanic aides taking care of her. Photographs of busted lip on aide were taken and sent to DON. (CNA B) other aide that was with CNA A on this day corroborated the story and events that occurred with resident. Med Aide A was outside in hallway when incident occurred and gave statement as to what I occurred. P

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the development and promote the healing of pressure sores for 3 of 6 residents reviewed for pressure ulcers. (Residents #5, #10, and #21). a) Resident #10 who was assessed by the facility to be at high risk for developing pressure ulcers developed a facility acquired, unstageable pressure ulcer to his right heel on or about 6/29/15 and also developed an unstageable pressure ulcer on 7/30/15 to his coccyx. The facility failed to prevent the worsening of pressure ulcers which resulted in the pressure ulcers needing surgical debridement and antibiotics to treat a wound infection. b) Resident #21 entered the facility with a pressure sore to the heel for which there were no interventions or treatment identified 9/4/15 - 10/15/15; and developed six additional wounds on the same foot (right foot) between 9/4/15 and 10/15/15 that were not identified, the physician had not been notified, and treatment orders were not received until 10/16/15. Resident #21 was diagnosed with [REDACTED]. c) Resident #5 developed a facility acquired pressure ulcer on her right ankle (unknown date prior to 7/12/15), with signs of infection noted on 7/12/15. The facility failed to implement interventions to prevent Resident #5's pressure ulcer, to conduct weekly skin assessments, to notify the physician or obtain treatment orders for the ulcer until 8/16/15, to obtain orders for antibiotic treatment for [REDACTED]. An Immediate Jeopardy (IJ) was identified on 10/12/15 at 12:10 p.m. While the IJ was removed on 10/20/15, the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a pattern. These failures resulted in pressure sore development and worsening of pressure sores for Residents #5, 10, and 21 and could place the nine residents with pressure ulcers at risk for developing new pressure sores or worsening of existing pressure ulcers. Findings included: 1. Record review of an undated Resident Admission Record (face sheet) showed Resident #10 was admitted on [DATE]. He was [AGE] years old. [DIAGNOSES REDACTED]. 2. Review of nurse's note dated 6/8/15 at 6:05 p.m. showed the resident was admitted , a head to toe assessment was completed, and there were no pressure ulcers identified. 3. Review of the physician's initial history and physical dated 6/11/15 showed the resident had no pressure ulcers. 4. Review of the Minimum Date Set (MDS) assessment dated [DATE] (14 day assessment) noted Resident #10 had one Stage I and was high risk for breakdown. There were no wound infections/antibiotics. 5. Review of physician telephone orders showed - 6/25/15 at 9:53 p.m.- Staples and sutures removed. Zero signs of infection noted. Zero sign of distress. (Note: the staples were from the hip surgery) 6. Review of a faxed note to physician dated 6/29/15 noted- Resident's right foot - [MEDICATION NAME] spray not working. Can we change to [MEDICATION NAME]? 7. Review of physician telephone order dated 6/29/15 at 3:20 p.m. showed- D/C (discontinue) [MEDICATION NAME] spray right heel. New order- cleanse area to right heel with NS and 4X4's, pat dry. Use NS to activate [MEDICATION NAME] dressing. Apply [MEDICATION NAME] to area on heel and cover with 4X4 and wrap with Kerlix dressing. (Note: this was the first documentation of a heel wound). 8. Review of physician progress notes [REDACTED]. He takes dressing away from that.He has been quite uncooperative, otherwise sleepy. 9. Review of the 30 day MDS dated [DATE] noted Resident #10 remained with one Stage 1 pressure sore and no wound infections/antibiotics. 10. Review of physician monthly orders for 8/01/15- 9/30/15 showed treatment orders for the right heel ulcer, (start date 6/29/15). Next to the order was: [DIAGNOSES REDACTED]. 11. Review of nurse's note showed: 7/30/15 at 5:06 p.m.- Called to resident's room by CNA. Observed large area of redness (did not document where this was) measuring 9 cm X 10 cm red scaly area with open area in center measuring 2.5 cm X 2.5 cm X 1 cm depth with yellowish brownish black color. Will continue to monitor. (Note: This was the first documentation of a wound later to be identified as a coccyx wound). 12. Review of a facility occurrence report dated 7/30/15 documented: Called to resident's room by CNA's. Upon assessment observed large area of redness measuring 9 cm X 10 cm red scaled area with open area in center measuring 2.5 cm X 2.5 cm X 1 cm depth with yellow-brownish black color. Cleansed with NS (normal saline) patted dry, applied TAO (triple antibiotic ointment) covered with Allevyn dressing. DON notified. Dr. notified. Responsible party notified by phone. The Pressure Ulcer Details noted the pressure sore was a Stage III house acquired sore. The General Follow-up Procedures (last page of the occurrence report) noted, care plan updated and had N/A (not applicable) checked. Under Root Cause was also N/A. The recommendation noted, Continue wound care on a daily basis. Be sure to measure wound to monitor progress. 13. Review of physician telephone orders dated 7/30/15 noted - the staff notified physician of large red area on coccyx- 9 cm X 10 cm with open area in center of 2.5 cm X 2.5 cm by 1 cm depth. The writer of the telephone order noted; I believe we need a consult for wound care for this along with right heel. The physician signed the fax and noted, wound care consult ok. 14. Review of nurse's note showed: 8/03/15 at 4:54 a.m.- Redness noted to right buttocks. Skin intact and no drainage noted to the area. Will continue to monitor. 8/03/15 at 3:11 p.m.- Resident is taking Keflex 500 mg PO QID (by mouth four times a day) for wound infection as new order for today. Care plan is done. (Note: this was the first documentation of a wound infection; however there was no clarification if the heel or the coccyx ulcer was infected). 15. Review of physician telephone orders dated 8/03/15 showed - staff notified physician of redness noted to right buttock- skin intact- no drainage. 16. Review of Resident #10's care plans: 8/03/15 Unstageable pressure sore to coccyx. The goal was to heal the pressure sore in 90 days. Interventions were: peri care after each incontinent episode, pressure relieving device in wheelchair and bed, examine skin each shift, monitor nutrition and hydration status, turn and reposition every 2 hours and use pillows to prevent skin to skin contact. There was no earlier dated care plan for the pressure sore to the coccyx and there was no pressure sore care plan for the heel. 17. Review of physician telephone orders dated 8/04/14 showed - staff notified physician, the coccyx is unstageable due to presence of necrotic tissue. Measures 4.8 cm X 1.1 cm- for the time being is it ok to use Santyl ointment to wound bed for debridement until wound center is set up. 18. Review of the Significant change assessment dated [DATE] noted Resident #10 had two unstageable pressure sores with suspected deep tissue injury and was on an antibiotic although the section titled infections was not checked. 19. Review of nurse's note showed: 8/05/15 at 9:06 a.m.- Resident continues on Kelflex for wound infection. Wound care to right heel and coccyx per MD order. (There were no measurements of the heel ulcer and only the initial measurement of the coccyx ulcer was located.) 8/05/15 at 10:03 a.m.- New orders per Dr for unstageable wound coccyx. (Note: unstageable is a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed). 8/06/15 at 9:16 a.m.- Resident has wound care appointment on Monday 8/10/15. 20. Review of Resident #10's care plans: Updated care plan for pressure sore dated 8/06/15 noted resident has a pressure ulcer related to debilitative state, poor nutritional status and immobility but does not clarify if this is the ulcer to the heel or the coccyx. The goal was to heal the pressure sore without complications. The approaches were assess and record the condition of the skin surrounding the pressure ulcer, access the ulcer for location, stage size, presence of granulation tissue with each wound care treatment, avoid friction, conduct a systematic skin inspection on shower days, report any breakdown, mechanical soft diet with house supplement, keep skin dry as possible, keep linens dry, keep resident off his back, maintain head of bed at lowest degree possible, observe and report signs [MEDICAL CONDITION]. 21. Review of the local hospital's wound care center notes for Resident #10: 8/10/15 - Resident presented to wound care center today with complaints of non-healing wound to buttock and right heel. Patients daughter states he began to develop ulcers about one month ago. The resident has a sacral extensive ulceration, deep and undermining with no bone exposure. Wound bed with yellowish slough, malodorous. On right heel superficial ulceration. Wound #1- coccyx is an acute necrotic unstageable pressure ulcer. Initial measurements are 6 cm length X 6 cm width X 1 cm depth. Moderate amount of drainage. The wound presents with signs and symptoms of infection. Wound #2 right heel is an acute suspected deep tissue injury pressure ulcer that measures 0.8 cm length X 0.8 cm width X 0.1 cm depth. There is a small amount of drainage. The surrounding skin presents with signs and symptoms of infection. The right foot wound infection that showed few Staph Aureus and was cultured for antibiotic sensitivity. Resident #10 also had an infection to the coccyx ulcer of [MEDICATION NAME] Coli and a sensitivity report was also attached to show what antibiotic would be effective. The assessment also noted the resident experienced constant, sharp pain related to the dressing changes. There was surgical debridement for the coccyx ulcer and a selective debridement for the right heel ulcer. NOTE: The wound care center began measurements of the ulcers at each visit. 22. Review of physician monthly orders for 8/02/15- 9/02/15 showed treatment orders for the right heel ulcer, start date 8/10/15. Next to the order was: [DIAGNOSES REDACTED]. There were orders for wound #2 right heel start date of 9/02/15 with [DIAGNOSES REDACTED]. There was also an order for [REDACTED]. 23. Review of nurses note dated 8/10/15 at 10:44 p.m.- will start on [MEDICATION NAME] (antibiotic) for wound infection. 24. Review of physician progress notes [REDACTED]. 25. Review of nurses note dated 8/18/15 at 1:22 a.m.- Resident had wound care appointment this AM at hospital. (Note: the wound care consult was ordered 7/30/15 for the right heel and the coccyx but was not carried out until 8/10/15). 26. Review of Resident #10's updated care plan for pressure ulcers dated 8/26/15 noted resident has a pressure sore related to immobility (does not clarify is this is the heel or the coccyx). The goal was to heal the ulcer without complications. The only approach was resident will use cushion at all times in wheel chair. The Care Plan did not address the heel ulcer. 27. Review of the Weekly Pressure ulcer Tracking Log for the week of 9/11/15 noted Resident #10 had a Stage III coccyx wound onset day of 7/31/15. The measurements documented: 2.8 cm X 2.3 cm X 1.8 cm. There was an arrow pointing up next to 0.7 cm; an arrow pointing down by 1.6 cm an arrow pointing to the right by 1.8 cm and an arrow pointing to the left by 0.7 cm. Resident #10 also had the right heel ulcer with no onset date and the stage noted healed. 28. During an observation on 10/12/15 at 1:30 p.m., LVN S and the hospice nurse uncovered Resident #10's wound for observation by surveyor. The wound was observed to be a Stage IV pressure ulcer on the coccyx with no surrounding redness. 29. On 10/12/15 at 1:50 p.m. LVN S provided the surveyor a Q-tip wrapper with wound measurements 2.4 x 1.5 x 0.8 Stage III. RESIDENT #21 1. An undated Resident Admission Record documented Resident #21 was admitted to the facility on [DATE] from a hospital. A Physician's report 9/7/15 documented [DIAGNOSES REDACTED]. 2. An MDS assessment for Resident #21 dated 9/11/15 documented he had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. He had no [MEDICAL CONDITION] or behaviors symptoms. He was assessed as totally dependent on one person to assist him with bed mobility, transferring, dressing, toilet use, and personal hygiene. He used a wheelchair for mobility. He was continent of bowel and bladder. The MDS documented that Resident #21 had one Stage 1 unhealed pressure ulcer, and no Stage 2, 3, 4, or unstageable pressure ulcers. Under Other ulcers, wounds, and skin problems the assessment documented he had Moisture associated skin damage. Under, Skin and Ulcer Treatments the assessment documented applications of ointments/medications other than to feet, application of nonsurgical dressings other than to feet, pressure ulcer care, and nutrition or hydration intervention to manage skin problems. 3. Hospital Records documented on a physician's history and physical dated 8/25/15 that Resident #21 was admitted to the hospital 8/25/15 with a change in mental status, [DIAGNOSES REDACTED] and a possible [MEDICAL CONDITION]. A hospital progress note dated 8/26/15 at 1545 (3:45 p.m.) documented, Applied [MEDICATION NAME] AG 4x4 to heel, cover with [MEDICATION NAME] foam, wrap with Kerlix, and secure with [MEDICATION NAME] tape. Date and sign. Change every 3 days or as needed when soiled or wet. A hospital assesssment dated 9/2/15 included, lesion, right heel. A hospital assessment dated [DATE] documented that Resident #21 would be discharged to the nursing facility with [DIAGNOSES REDACTED]. 4. A facility Clinical Admission Assessment dated 9/4/15 at 2:51 p.m. completed by LVN S documented that Resident #21 had one Stage I ulcer, no Stage II, III, or IV ulcers. Under Skin Treatments LVN S checked Ulcer care. Under Foot Problems and Care, LVN S checked, Open [MEDICAL CONDITION] on the foot and Application of dressings. Under Describe alterations in skin integrity further, including site, size, drainage etc, LVN S documented, Pressure sore to right ankle 3 cm x 3 cm. 5. Review of Resident #21's tab Care Plan initially revealed one sheet of paper describing Resident #1's code status. There was not a nursing care plan. Following surveyor inquiries, the facility provided a nursing care plan with a problem of Pressure Ulcer Right Heel dated 10/16/15 that included interventions to assess for cause of pressure ulcer, observe for pressure cause, investigate contributing factors; measure and monitor wound status every week, provide treatment as ordered, monitor for infection, and assess for pain. During an interview on 10/20/15 at 2:00 p.m., the DON said that if there was not an Admission/Acute Care Plan for Resident #21 in the medical record, then there probably was not one. During an interview on 10/20/15 at 2:05 p.m., LVN T, who stated he was a Unit Manager stated that the admitting LVN should have completed an Admission Care Plan for Resident #21. During an interview on 10/20/15 at 2:10 p.m., LVN S said he did not complete an Admission/Acute Care Plan when Resident #21 was admitted because he did not know that he should have. 6. An admission nurse's note by LVN S dated 9/4/15 at 2:28 a.m. documented that Resident #21 was received from the hospital and was oriented x3 (to person place and time). The nurse's note included the following: .Resident has a pressure sore to his right ankle 3 cm x 3 cm in size with bandage in place . 7. Two Physician's Order Reports (consolidated orders) were on record for Resident #21, one was dated 8/5/15 - 9/5/15 and another one dated 9/1/15 - 9/30/15. These orders did not contain an order for [REDACTED]. 8. Two individual physician's orders documented: 9/4/15 at 1:37 p.m. documented: First Aid - may clean with normal saline, apply antibiotic ointment of choice, cover with a dressing. Check wound daily and PRN (as needed). A physician's telephone order created by LVN S dated 9/6/15 at 9:42 a.m. documented, Cleanse pressure sore to right ankle with NS (normal saline), pat and dry, santyl and cover it with allevyn dressing every 3 days. 9. Treatment Flowsheets for Resident #21 dated 9/6/15 - 10/6/15 documented the order to cleanse the pressure sore to right ankle with NS, pat and dry, apply santyl and cover with allevyn dressing every 3 days. Treatment was initialed every three days as being provided, except the initials on 9/12/15 were circled (indicating treatment was not done), with no explanation on the flowsheet. Treatment Flowsheets for Resident #21 provided on 10/16/15 that were dated 10/1/15 - 10/31/15 documented the same order as above (treatment to Resident #21's right ankle) and was initialed as being provided 10/3/15, 10/6/15, and 10/9/15. There was no treatment documented on 10/12/15 or 10/15/15. 10. Nurse's notes from 9/5/15 - 10/14/15 for Resident #21 revealed the following entries relating to pressure sore, wounds, or wound treatment (all notes related to these): 9/18/15 7:15 a.m. - Resident's pressure sore to right ankle noted with wound treatment done and new dressing in placed (sic). Wound is measured to 2.5 cm x 2.0 cm. No drainage noted . (note created by LVN S). 9/27/15 5:28 p.m. - Treatment to lower left heel. Area healing as expected. Moderate amount of drainage noted to old bandage, no foul odor . (Note created by LVN E). 10/1/15 16:18 (4:18 p.m.) - Patient has red blister to the top of the left foot. No drainage or discomfort noted from new area. Dr. (name) (not Resident #21's primary physician) notified of information. No new orders noted at this time. (Note by LVN E). 10/1/15 16:25 (4:25 p.m.) - Patient has clear fluid filled blister to outer left foot. Patient denies having any pain or discomfort to area. (Note by LVN E). 10/3/15 14:10 (2:10 p.m.) - When this nurse changed his dressing to his pressure sore at right ankle, another new blister came out at the same ankle that is not breaking out yet. Two old blisters are still there with the pressure sore at the same ankle. ADON and nurse manager came to see it and we decided to place it OTA (open to air). Denies pain and will continue to monitor. (Note by LVN S). 10/9/15 11:36 a.m. - Resident's pressure sore noted with new dressing in place per order. No drainage noted. Blisters noted around the right ankle and foot. Will continue to monitor. (Note by LVN S). 10/14/15 14:18 (2:18 p.m.) - .Wound dressing intact . 10/16/15 at 13:33 (1:33 p.m.)- Blisters to R foot cleansed with NS. Wet-to-dry bandage applied, secured with conform dressing . A review of a Skin Assessment Form dated 10/13/15 for Resident #21 revealed it included the following regarding the resident's foot: .Blisters x5 top of R (right) foot), l R Heel . 11. During an observation on 10/16/15 at 1:40 p.m., the ADON unwrapped the bandaging for the observation of Resident #21's foot. Resident #21's foot (heel) was observed to be lying on the bed. His heels were not off loaded as prescribed. During the observation Resident #21 said that the nurse had just bandaged his foot today, but he stated, They very seldom put a bandage on it. The ADON identified eight (8) wounds on Resident #21's foot (two that had been identified and six new wounds). There were 4 wounds on the top of his foot, a wound on the inner foot, a wound on the inner ankle, a wound on the right lateral foot, and a wound on the heel. The ADON took measurements of the wounds. When asked what the facility determined caused the wounds, the ADON said she did not know. When asked what the physician's assessment was, the ADON said the physician did not know either. Resident #21 then stated, Because he hasn't seen them yet. 12. Following the above observation, the facility obtained the following physician's order dated 10/17/15 (The order was written on 10/16/15): Cleanse Blisters to Right Foot/top and inner and lateral side with NS, apply TAO and cover with non-adherent dressing daily until resolved. Keflex (Antibiotic) 500 mg po qid x 10 days; [MEDICATION NAME] 500 mg daily x 7. A hand-written note by the physician dated 10/16/15 documented: Pt. re-examined, wound ulcer foot noted. Has mild [MEDICAL CONDITION]/ulcer/blister, see order . 13. During interviews on 10/16/15 at 3:50 p.m. and 10/17/15 at 10:50 a.m. the ADON said that the physician's order that Resident #21 had for treatment of [REDACTED]. She said she had placed him on her pressure ulcer list 9/11/15 as a heel ulcer. When discussing which wound the nurses had been treating, the ADON said, the heel. When discussing how she knew the nurses were treating the resident's heel if the treatment sheet and physician's orders had not identified the heel for treatment, the ADON said, The times I've been there they've treated his heel. The ADON stated the physician had come to the facility the evening of 10/16/15 and looked at Resident #1's foot and prescribed care. She said that Resident #1's heel had some redness, so the physician ordered an antibiotic for ten days. When discussing LVN E's nursing note of 10/1/15 (identification of a fluid filled blister) the ADON said LVN E should have spoken with a physician. The ADON said that on 10/3/15 she had advised the nurses to leave Resident #21's wounds open to air. When discussing why she did not consult with the physician, she said, I didn't see signs of an infection. She said that she should have told them to leave them open to air until they spoke with the physician. When discussing LVN S's note on 10/3/15 identifying a new blister on Resident #21's foot, the ADON said that LVN S should have contacted the physician. 14. A Skin Assessment Form dated 10/19/15 (multiple forms of the same date) identified the following: 1) Right heel: 2.1 cm x 2.5 cm partial thickness wound (pressure ulcer); wound bed has minimal drainage noted, slough and eschar noted on the periwound. Stage: Unstageable slough and or eschar. 2) Right inner ankle: 2.6 cm x 1.4 cm pressure sore. Area is dried blister, no drainage noted. Stage: Inapplicable. 3. Ankle Right Inner: 0.7 cm x 1.0 cm pressure sore. Healing blister, no drainage present. [MEDICATION NAME] present. 4. Right Foot Dorsal (Top): 0.5 cm x 1.0 cm pressure sore. Area is brown in color, no drainage. Blister that is healing and drying up. 5. Right Foot Dorsal: 1.7 cm x 1.8 cm pressure sore. Area is dried blister, no drainage present. 6. Right Foot Dorsal: 0.8 cm x 0.9 cm pressure sore. Dried blood blister, no drainage or open area. 7. Right Foot Dorsal Top: 1.5 cm x 1.7 cm pressure sore; Dried blood blister, no drainage, no open area noted, no sign or symptom of infection. 8. Ankle Right Outer: 0.6 cm x 1.0 cm pressure sore; Area is pink with [MEDICATION NAME] present, no sign or symptom of infection. 15. During an interview on 10/19/15 at 9:45 a.m., LVN S confirmed he was the admitting charge nurse when Resident #21 entered the facility on 9/4/15. LVN S said that the information he placed on the admitting assessment, his nurse's note, and the physician's order was incorrect, because it should have described the pressure on the resident's heel and should have been treatment for [REDACTED]. When asked why he documented ankle when it should have been heel, LVN S said, because that's what the nurse from the hospital said. LVN S said that he had been treating Resident #21's heel with the ankle order. When discussing if he looked at the order when doing the wound treatments and whether he had considered clarifying the order with the physician, LVN S said he did not look at the order when he did wound treatments because he knew what the treatment was. He also stated that the ankle and heel were close together and he did not see much difference. When referring to his nurse's note on 10/3/15 where he continued to refer to the wound as an ankle wound and not a heel wound, LVN S said, I don't know. LVN S said he thought he talked to the physician about treatment and leaving the wounds open to air, but he did not know when it was. When discussing who he should contact if he observed a deterioration of a wound, signs of infection, or a new wound he said he would call the family and tell the ADON. 16. During an interview on 10/19/15 at 11:00 a.m., LVN E said she had been treating Resident #21's heel and documenting treatment of [REDACTED]. When discussing whether the order had been clarified yet, LVN E said that she would do that following this interview. LVN E said she noticed the other blisters coming up on Resident #21's feet several weeks ago. She said she knew that LVN S knew about them so she assumed since he was unit manager that he took care of calling the doctor about them. She said she knew she should have called the physician. 17. A Fax to the physician dated 10/19/15 documented, Can we get a wound care consult at (hospital)? (Resident #21) has quite a bit of slough on wound bed that may require some debridement. The physician wrote Ok on 10/20/15. 18. During an interview on 10/20/15 at 2:30 p.m., Resident #21's physician said that he did not recollect ever being contact that Resident #21 had developed multiple wounds on his foot since admission. The physician said that 10/16/15 was when he became aware. RESIDENT #5 1. A medical record face sheet dated 3/25/15 documented Resident #5 was a [AGE] year-old female admitted to the facility on [DATE]. There was no admitting [DIAGNOSES REDACTED]. 2. An Initial Nursing Assessment dated 3/20/14 documented Resident #5 had no pressure ulcers on admission. 3. An annual history and physical examination [REDACTED]. Resident #5 had a history of [REDACTED]. 4. A physician's visit note for Resident #5, dated 6/11/15 documented Resident #5 had contractures and a deformity in the right lower foot. Her skin showed dryness and scaling in the right lower extremity. The physician documented, We will try local treatments with creme for her feet. 5. A two page Care Plan for Resident #5 dated 6/25/15 documented five problems (not signing out before leaving facility, impaired vision, rudeness to roommate, hearing loss, at risk for nutrition/need to monitor weight.) These were the only care planned services for Resident #5. There were no interventions to monitor skin or to prevent pressure ulcers. 6. An MDS assessment for Resident #5, dated 6/28/15 documented that Resident #5 had no healed or unhealed pressure ulcers. The MDS documented that Resident #5 was at risk for developing pressure ulcers. The assessment documented Resident #5 required only supervision and set-up help for dressing, eating, toilet use, and personal hygiene. She required limited assistance from staff to transfer between surfaces. She used a wheelchair for mobility. Her Brief Interview for Mental Status score was 10 indicating moderate cognitive impairment. 7. Nurse's notes for Resident #5 from 4/25/15 through 9/10/15 included the following entries (all entries that were related to Resident #5's ankle): 6/25/15 3:16 p.m.: Care plan conference call placed to dtr (daughter) with resident in attendance. No real concerns--resident has swollen ankle which was addressed . 7/12/15 4:56 a.m.: .Applied TAO (triple antibiotic ointment) and changed dressing on patient's ankle, no pain or discomfort per patient. 7/20/15 5:41 p.m.: Sore to Rt. ankle 0.25 x 0.5, black escar noted. Reported to (RN), for Tx (treatment) order. Also redness noted to surrounding area, c/o of pain, 0 drainage. Will cont to monitor. 7/23/15 3:45 a.m.: Cont (continue) to monitor right ankle scabbed sore. Non-tender to touch. No foul odor or drainage. 7/23/15 1:32 p.m.: N/C (no complaint) with ankle sore today, moving about with no problems, cont to monitor. 7/24/15 3:26 a.m.: Right ankle dressing c/d/i (clean/dry/intact). No needs or concerns voiced. 8/10/15 2:26 a.m.: .Resident c/o (complaining of) pain to ankle rates pain a 7 on scale of 1-10, bandage on ankle removed and applied new dressing, small amount of drainage noted, prn (as needed) Tylenol given and effective. Will cont to monitor. 8/11/15 10:11 a.m.: N/C (No complaint) of pain with ankle as of this time, moving around residence in w/c with n/c, cont to monitor. 8/15/15 9:58 p.m.: Right ankle ulcer with moist, yellow drainage, area shows no improvement. Will make MD aware. 8/15/15 10:08 p.m.: Right ankle ulcer measures approx. 1.25 cm x 1.25 cm x 0. Diameter red, tender to touch. Scant yellow drainage noted. Surrounding skin is off white in color. 8/16/15 4:18 a.m.: Admin (Administered) Tylenol 325 mg po prn right ankle discomfort, and is fairly effective. Rates pain at 8 on (1-10) pain scale. After med pain at 4 on pain scale. 8/16/15 1:14 p.m.: N.O. (New order) clean abrasion rt (right) ankle with n/s (normal saline), apply tao and foam dressing, monitor daily til resolved, n/c of pain at this time. 8/17/15 4:22 a.m.: N.O. (New order) noted for wound care to right ankle ulcer. Dressing c/d/i (clean/dry/intact). No needs or concerns voiced. 8/17/15 10:07 a.m.: Tx (Treatment) to ankle done tol (tolerated) well. Ankle swollen and tender to touch some redness noted around area. Faxed Dr. with info . 8/18/15 10:27 a.m.: No response from fax, called R. informed area is red around open area and painful, states give her Keflex 500 mg 1 po qid x1 week . 8/19/15 3:28 a.m.: .NAR (no adverse reaction) to Keflex tx (treatment) administered as directed to right ankle . 8/19/15 11:35 a.m, 8/20/15 at 8:51 a.m., 8/24/15 at 8:51 a.m., 8/25/15 at 12:49 a.m.: (all state continued on antibiotic for ankle wound infection.) 8. A review of Resident #5's Treatment Flowsheets revealed the following: July 1 - July 31, 2015: No treatment orders or treatments to right ankle were documented on this nursing flow sheet. A weekly skin assessment was initialed as done on July 1, 8, 22 and 28 but was blank on the 15th. There were no results of full body skin assessments documented in the medical record. 9. Physician's orders for Resident #5, dated 8/1/15 - 9/30/15 included orders for a weekly skin assessment beginning 11/8/14 and open ended. These physician's orders did not include any treatment for [REDACTED]. A physician's telephone order dated 8/16/15 at 12:05 p.m. entered by LVN K documented, Cl

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 7 of 9 residents reviewed for mechanical lifting for transfer (Residents #2, 4, 9, 14, 16, and 17) as evidenced by: a) failure to ensure the mechanical lift sling was in good repair prior to transferring Resident #4 on 9/10/15. Resident #4 fell approximately four feet from the mechanical lift sling when the sling ripped during transfer. She hit her head on the floor, causing a contusion on the back of her head; b) failure to ensure that torn mechanical lift slings were removed from use following Resident #4's injury. A torn sling was observed with a supply of slings available for use to all staff in the laundry room on 9/22/15; c) failure to ensure the mechanical lift straps of Resident #2's sling underneath her in her wheelchair were secured away from the moving wheels when she was being pushed in her wheelchair on 6/17/15. Resident #2's sling straps tangled in the wheels and threw her forward out of her wheelchair onto the floor, resulting in a thigh contusion (bruise) and possible acute fracture at the tip of the bony stump of her amputated leg, with associated swelling; and d) failure to ensure that the mechanical lift sling and straps were properly placed prior to lifting Resident #4 on 9/15/15. CNAs H and I lifted the resident and her wheelchair with the mechanical lift twice in a row prior to correcting the mechanical lift sling and straps, which placed the resident at high risk of a fall from the lift; e) failure to ensure that the mechanical lift sling straps were secured away from wheelchair wheels for Residents #4, 9, 14, 15, 16, and 17, who sat on the slings in their wheelchairs, on 9/23/15, 9/24/15, and 9/29/15 to prevent a similar accident to Resident #2's fall; and f) failure to utilize the risk management system the facility identified as the means in place to address incident/accidents occurring in the facility to identify risks and hazards for residents to prevent accidents. An Immediate Jeopardy (IJ) was identified on 9/23/15 at 12:00 noon. While the IJ was removed on 9/29/15, the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a pattern. These failures could affect the 13 residents that require a mechanical lift for transferring between surfaces and the additional 58 residents at high risk of falls and could result in injuries causing pain, decrease in level of functioning, or death. Findings included: 1. a) A Resident Admission record dated 6/29/15 documented that Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] from another hospital facility. She was referred from a Rehabilitation facility. [DIAGNOSES REDACTED]. b) A Rehabilitation Hospital report dated 6/13/15 documented Resident #4 was admitted there after a right ankle fracture, tibia-fibula and was non-weight bearing. She was admitted to the rehabilitation facility for aggressive physical therapy. Her weakness was due to disuse [DIAGNOSES REDACTED] secondary to the right ankle fracture. The report documented a past medical history of [REDACTED]. c) An MDS Assessment for Resident #4, dated 7/6/15 documented a Brief Mental Status Interview score of 13, indicating Resident #4 was cognitively intact. She had no indicators of psychosis and no behavioral symptoms. The MDS documented that Resident #4 required Extensive assistance (resident involved in activity, staff provide weight-bearing support) of one person for bed mobility; and extensive assistance from two or more persons for transferring, toilet use, and personal hygiene. The MDS documented that Resident #4 had limited range of motion of a lower extremity on one side and used a wheelchair for mobility. She was documented as having a fall during the last month prior to admission. Resident #4 was 57 inches tall and weighed 247 pounds. d) A care plan for Resident #4 with last care conference date of 8/13/15 and next care conference date of 11/11/15 documented a problem on page 2 of 5 with a start date of 7/24/15: Resident must be lifted mechanically AEB (as evidenced by) (sentence was not complete). The goal documented, Resident will not sustain injuries during transfers with mechanical lift in the next 90 days and the approach was, 2 staff members at all times to use the mechanical lift. The care plan had an added intervention dated 9/11/15, Resident has history of falling related to equipment. A goal stated, Resident will remain free from injury. Approaches included encouraging the resident to use environmental devices such as hand grips, hand rails, etc., keeping call light in reach, keeping personal and frequently used items in reach, observing frequently and placing in a supervised area when out of bed; and providing an environment free of clutter. A problem added to the care plan 9/18/15 documented, Resident has a memory/recall problem related to disease process. The goal stated, Resident will not sustain serious injury due to memory/recall deficit. The approaches included ensuring assistive devices (walkers, canes, wheelchairs, etc.) are in good condition, ensure resident areas are free of hazards, provide chair and/or bed alarm if resident requires assistance with transfer, and redirect resident when entering unsafe areas. e) An Occurrence Report for Resident #4 dated 9/11/15 at 1950 (7:50 p.m.) documented Resident #4 had a fall in her room during transfer. Under Nurse's note of what happened the nurse documented, Was called to the room of resident when CNA stated that the resident had fallen when the loop on the lift strap broke, dropping resident to the floor. Head to toe assessment done for injuries. Physician at the facility, notified of fall. Physician instructed to send resident to the hospital to be evaluated. The nurse documented that a head to toe body check revealed no injuries noted. The nurse documented on page 2 under position when found: Transferring resident with Hoyer lift when strap broke. Under Conclusion on page 3 of the report the nurse documented, Resident observed lying on back on the floor after being summoned to the room by CNA after strap broke while transferring resident with Hoyer lift, dropping resident to floor. Page 3 of the report documented that CNAs F and G were transferring the resident at the time of the incident. Under Notifications the nurse documented that the DON was notified 9/10/15 at 1900 (7:00 p.m.) by telephone and the Risk Manager was notified at 1830 (6:30 p.m.) in person. Notification to the Administrator was blank. The nurse documented on page 1 of the report that Resident #4 was sent to the hospital by ambulance at 8:15 p.m. On page 3, under occurrence specific follow up, the nurse documented that a resident fall review was completed, a plan of care for falls was completed, and a fall risk reassessment was N/A (not applicable). f) A nurse's note dated 9/11/15 at 4:35 a.m. documented, Was called to res. room by CNA @ (at) approx. (approximately) 1930 (7:30 p.m.), found res. (resident) lying on her back on floor upon entering room. Informed by CNA that loop on sling broke during transfer causing res. (resident) to fall to floor. Res. A&0 (alert and oriented) x 3 (person, place, and time.) VS (Vital Signs): B/P (blood pressure) 201/113, Pulse 100, Temp. (temperature) 98.3, Resp (Respirations) 22, O2% (Oxygen saturation) 93% RA (room air). C/O (Complaining of) pain to back of head, left hip, and left knee. Dr. (name of physician) in building ordered res. sent out to (name of hospital). (Name of Ambulance) arrived approx. 1945 (7:45 p.m.) left with res. via stretcher at 2000 (8:00 p.m.). g) A nurse's note dated 9/11/15 at 4:39 a.m. documented that Resident #4 had returned from the hospital at approximately 2245 (10:45 p.m.) by stretcher with a [DIAGNOSES REDACTED]. Vital signs were B/P 125/86, Temperature 97.8, Pulse 88, Respirations 18, and oxygen saturation of 98%. h) A hospital emergency physician record and trauma flow sheet documented the resident's arrival at the emergency department as 9/10/15 at 2009 (8:09 p.m.). The chief complaint was fall injury to head. The estimated height of the fall was approximately four feet. The physician documented under Clinical Impression: Contusion: head. A CT scan to the head was negative. No other injuries were identified and the hospital report that Resident #4 was returned to the facility at 10:36 p.m. The primary nurse signed the report and dated it 9/10/15. i) Review of the nurse's note tab of Resident #4's medical record was a four page document and two attached statements (from CNA F and G). The document was titled, Fall Details Report that said (Must be submitted along with a completed Occurrence Report) for Resident #4 dated 9/10/15 at 1930 (7:30). Page one was completed documenting facts about the fall as stated on the incident (fall to ground, lying on back, visually observed 9/10/15 at 1830 (6:30 p.m.). The second page of the document was blank. It included the following headings, Root Cause, Quality Assurance Review, New Medication Change, Change in Resident Condition, Conclusion, Abuse was suspected, yes or no, Notifications, Report Closed. A third page of the document titled, Fall Investigation Report was blank. It included headings of Recent changes to Resident status, Resident state of motion at time of fall (choose one), How many staff were in assistance, and Yes/No to questions of whether a fall risk reassessment, care plan, and fall review were completed. A fourth page titled, Occurrence Investigation Follow up Report was blank. It included Recommendations: assigned to:________; due date:___________; Status: (circle one) Implemented/Pending/Declined; Recommendation:________________. CNA G documented on a statement 9/10/15 (attached to the above report), Was assisting with (Resident #4) transfer from w/c to bed with Hoyer lift. During transfer green loop broke causing resident to fall to the floor. Charge nurse notified immediately and resident transfer to hospital for evaluation. CNA F also documented a statement 9/10/15 that did not include different information from CNA G's statement. j) A nurse's note dated 9/14/15 at 11:04 a.m. documented that Resident #4's left lower leg was swelling with redness and complaints of pain on that area. The physician was notified and ordered an X-ray. k) A radiology report dated 9/14/15 documented Resident #4 did not reveal any new fractures. l) During an observation on 9/15/15 at 3:25 p.m., CNAs H and I were observed transferring Resident #4 from her wheelchair to bed with a mechanical lift. The CNAs fastened the sling straps to the lift and began lifting the resident. They then noticed that the resident and her wheelchair were both lifted off of the floor. Resident #4 was suspended in her chair approximately a foot off the floor when the CNAs noticed and lowered the resident back to the floor. The CNAs checked the straps and again began lifting Resident #4 with the mechanical lift, and again lifted Resident #4 and her wheelchair off of the floor approximately a foot. They then lowered the chair back to the floor again. At that time they noted that parts of the sling were caught on the sides of the wheelchair parts where they should not have been, and released the sling from the chair. They began to lift the resident a third time, and the lift stopped functioning. The CNAs determined the battery must have gone dead, so they exchanged the Hoyer lift for a different one, and then were able to transfer Resident #4 to bed. During this observation, Resident #4 said she had fallen to the floor the other day and hit the back of her head. Resident #4 was somewhat confused at the time of this observation, as evidenced by talking to a dog in the room that was not there. m) During an interview on 9/22/15 at 3:20 p.m., Resident #4 appeared less confused than she had on 9/15/15 and did not appear to be preoccupied outside of the conversation. She said she recalled the fall from the lift. She said, That was a biggie. It started ripping and I was gone! She said she heard the fabric tearing before she fell . She said, That's scary. She said she hit the back of her head and had a knot on her head afterwards. She said her head made a loud noise, a large crack, when it hit the floor. n) During an observation and interview on 9/22/15 at 3:05 p.m., CNA J said that each resident that was mechanically lifted had a sling in their room, and all extras were placed in the laundry room. CNA J said that if a CNA needed to replace a soiled sling, they would get a clean one from the laundry room. CNA J accompanied the surveyor to the laundry room. Eight mechanical lift slings were in the laundry room on a cart just inside the door. The slings were inspected and one of eight slings was found to be worn (appearance of an older sling as the green color was very faded) and it had two tears completely through the fabric that were large (two fingers could fit through one hole, three fingers could fit through the second hole) and easily seen. o) During an interview on 9/22/15 at 3:35 p.m., the torn sling was shown to the DON. When the DON saw the sling, she said, That shouldn't be in there, it should be in the trash. When discussing who was responsible to monitor the condition of the Hoyer slings, the DON said, The CNAs. The DON said that they had checked and made sure that the slings that were in all the residents' rooms were in good condition, but the ones in the laundry room must not have been checked. p) A review of the mechanical lift owner's manual, provided by the Administrator on 9/22/15 at 5:15 p.m. revealed operating instructions included: Under Maintenance Schedule: Check entire sling inventory for fraying, tearing, or excessive wear of any kind and replace any worn or damaged slings with new (brand) slings. 2. a) An undated Admission Record documented Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. b) physician's orders [REDACTED].#2's [DIAGNOSES REDACTED]. c) An MDS Assessment for Resident #2 dated 7/29/15 documented Resident #2 had a Brief Interview for Mental Status score of 14, indicating she was cognitively intact. Under Functional Status the assessment documented that Resident #2 required extensive assistance of two persons to transfer between surfaces, limited assistance of one person to dress, extensive assistance of one person to toilet; and was totally dependent with one person assistance for bathing. Resident #2 used a wheelchair for mobility. She had limited range of motion on the lower extremity of one side. d) A care plan for Resident #2 dated 7/16/15 included a problem with a start date of 7/2/15: Resident is limited in wheelchair mobility r/t (related to) BKA (below the knee amputation). The interventions included to instruct in proper use of the wheelchair, maintain body in functional alignment while in wheelchair, and provide adequate rest periods between activities. A problem with a start date of 7/2/15 documented, Resident has history of falling r/t (related to) outside objects. For example Hoyer lift strap being secured, shoe. Approaches were documented as analyze resident's falls to determine pattern/trend; ensure resident is seated properly in wheelchair (resident has habit of placing item in seat of wheelchair behind her); Ensure that equipment is properly used and secure including Hoyer sling straps being secured and not being dragged; keeping call light in reach, well maintained footwear, environment free of clutter; non slip pad in wheelchair, and toileting assistance every two hours and as needed. e) An Occurrence Report dated 6/17/15 at 1830 (6:30 p.m.) documented that Resident #2 had a fall in the common area. The nurse note documented, Resident being propelled in w/c by CNA. Hoyer lift strap became entangled in wheel causing resident to be pulled forward out of wheelchair. The occurrence report documented the position when found was supine (lying on her back). Under Conclusion the ADON documented 6/18/15 at 10:25 a.m. that the ADON was present when the incident occurred, and 9-1-1 was called and the resident transported to the ER. The ADON documented in part, After speaking to nurse and aide that were next to resident when fall occurred, it was determined that the strap of her Hoyer sling was caught in the wheelchair wheel and caused the resident to fall out of chair and hit her left amputated leg. Resident was in a severe amount of pain. No other complaints of pain. Resident did not hit head . Under the heading Staff Interviews, the writer documented, No staff interviews available. Under Recommendations, the writer documented, None. Under Notifications, the writer documented that the Facility Administrator was notified by phone on 6/17/15 at 1854 (6:54 p.m.). The Director of Nursing notification space on the form was not filled in. The Medical Director was notified on 6/17/15 at 1840 (6:40 p.m.) by telephone. f) Nursing notes in Resident #2's computerized record revealed the nurse entered a late entry on 6/18/15 at 2:16 a.m. for the incident on 6/17/15 at 1830 (6:30 p.m.). The note documented that Resident #2 was being pushed in her wheelchair and her foot and the Hoyer sling strap became entangled in the wheel. The nurse documented that Resident pulled from w/c by Hoyer sling to floor, struck left BKA (below the knee amputation). Notified MD and POA. order received and noted to sent to (hospital) via EMS 911. g) A nurse's note on 6/18/15 at 2:19 a.m. documented that on 6/17/15 at 2300 (11:00 p.m.), Resident #2 returned to the facility from the hospital with no new orders, denied pain or distress, and was assisted to bed. h) An Emergency Physician Record dated 6/17/15 documented a chief complaint of fall injury to L (left) thigh stump. The Discharge Summary from the Emergency Department documented a Primary [DIAGNOSES REDACTED]. i) A radiology report for Resident #2 dated 6/17/15 at 2038 (8:38 p.m.) and dictated by the radiologist on 6/18/15 at 10:08 a.m. documented two views of the femur for an indication of left femur pain status [REDACTED]. The findings included: Patient has undergone mid femoral amputation. There appears to be swelling of the soft tissue stump. No prior postoperative image is available for review. The bony stump exhibits focal areas of bone lysis (dissolution of bone that particularly involves the removal or loss of calcium). No active subperisosteal (under the dense layer of vascular connective tissue enveloping the bones except at the surfaces of the joints) new bone is identified to suggest osteo[DIAGNOSES REDACTED] (bone infection). There is an isolated bony density at the tip of the stump which could represent small acute fracture fragment. Conclusion: Above-knee amputation with possible acute fracture fragment at the tip of the bony stump with associated swelling. j) A nurse's note dated 6/19/15 at 1:48 p.m. by the ADON documented that on 6/18/15 she had spoken to Resident #2's family. The ADON documented, Daughter was upset because she couldn't understand that how negligence could just happen and cause her mom to fall to the floor. I apologized to her about the fall but that in no way, shape, or form was this considered negligence considering the aide was pushing the wheelchair and the nurse was standing nearby and I explained to her that the fall was too sudden for us to be able to do anything. I explained to her that the strap that is on the Hoyer sling got caught in the wheelchair wheels and the jerk on the sling, along with the silk gown she was wearing, there was not enough reaction time for us to actually prevent her from falling. I notified her that the aides will be inserviced on hoyers/slings to ensure that any dangling objects are secured and not dangling freely in order to prevent any further incidents like the resident's from happening again . k) During an observation on 9/10/15 at 1:20 p.m., CNAs A and B were observed to transfer Resident #2 from her wheelchair to bed, using a mechanical lift. CNA A was operating the mechanical lift. She was observed to lock the casters of the mechanical lift prior to lifting Resident #2. l) During an interview on 9/10/15 at 1:30 p.m., CNA A was asked why she locked the casters of the mechanical lift prior to lifting. She said she had always wondered about whether she should be doing that or not, but that was the way she had been taught to do it. m) A review of the mechanical lift owner's manual, provided by the Administrator on 9/22/15 at 5:15 p.m. revealed operating instructions included: Page 3: During lifting or lowering, whenever possible, always keep the base of the lift in the widest position with the casters unlocked. Page 8: DO NOT lift a patient with the caster brakes on. Always let the lift find the correct center of gravity. n) During an interview on 9/22/15 at 2:45 p.m., Resident #2 said that the CNA with her on the day of the incident had been a CNA from an agency, not a full time employee of the facility. Resident #2 said it was unfortunate that it happened but she got banged up pretty bad. 3. a) During an interview on 9/22/15 at 4:00 p.m. CNA N said she had worked at the facility for 3-4 months. She said she had not received any in-service training on use of the mechanical lift since she started working. She said she was not aware of who's responsibility it was to inspect the slings. CNA D was present for this interview and he said he did not know who was responsible to remove worn or torn slings from circulation. He said he doubt it was the laundry, and thought it might be the maintenance department. b) During an interview on 9/23/15 at 9:45 a.m., CNA A said that she was shown how to operate the mechanical lift by another CNA after she was hired. She said she had been at the facility about two months. She said the facility had never assessed her competency at operating the mechanical lift. c) During an interview on 9/23/15 at 10:50 a.m., CNA B said she had been at the facility for two weeks. She said she had used the mechanical lifts to transfer residents. She said she had not participated in an in-service for mechanical lifts and the facility had never assessed her competency at operating the mechanical lift. d) During an interview on 9/23/15 at 11:35 a.m., CNA O said she had worked at the facility three weeks. She said she had worked on three different halls and had operated the mechanical lifts. She said the hall she was working today had four residents that required mechanical lifting. She said she had not had any refresher training on use of the mechanical lift and the facility had never assessed her competency. CNA O said she had heard that Resident #4 fell from the mechanical lift but was never told what caused the fall. e) During an interview on 9/24/15 at 9:40 a.m., CNA H said she had been working in the facility about two months, but she had been a CNA for fourteen years. She said the PTA demonstrated the steps of the mechanical lift. She said she used the mechanical lift and had five residents on her hall for which she used the lift. CNA H said she was confident in her skills but she had worked with other CNAs who did not appear to know how to use the mechanical lifts correctly. When discussing if she was aware of Resident #4's fall from the mechanical lift, CNA H said that she found out about it from the resident. f) In a confidential interview, a staff member stated that on the first day of this investigation, direct care staff were told to go to the PTA (Physical Therapy Assistant) and get a quick refresher on using the mechanical lift because the state was in the building and would be watching them that day. The staff member said a quick training was done during the noon hour by the PTA while the state surveyor was gone to lunch. She said the refresher consisted of the PTA verbally going over the instructions of the mechanical lift with the staff. g) In an interview with the PTA on 9/23/15 at 11:20 a.m., when discussing how the facility ensured staff were trained and competent in operating the mechanical lifts, the PTA said, We have CNAs come in and grab me, and we do a demonstration. I demonstrate for them then they demonstrate for me. When discussing that several interviews revealed staff had not participated in this type of training, he said that he tried to have a session quarterly. He said, I should have one pretty quick stating he had a session in June. The PTA said he gave the staff the competency check lists for that session but the facility could not find them. When discussing the recent incidents regarding Resident #2 being thrown from her wheelchair, and Resident #4 being dropped from the mechanical lift, the PTA said the facility had not asked him to do any additional training or in-service following those incidents. h) In an interview on 9/23/15 at 3:30 p.m., the Maintenance Supervisor said his department was not responsible to monitor the mechanical lift slings or their condition. i) A review of the mechanical lift owner's manual, provided by the Administrator on 9/22/15 at 5:15 p.m. revealed operating instructions included: On Page 3, under Warning!: Never operate the lift unless you have been properly trained on all procedures and safe handling methods. 4. a) Observation on 9/23/15 at 12:17 p.m. revealed Resident #17 was observed in the dining room in a Geri-chair. A mechanical lift sling was underneath him in the chair. The sling strap hung down between the chair frame and the left wheel of the Geri Chair. b) Observation on 9/23/15 at 12:23 p.m. revealed Resident #15 was observed in the dining room sitting on a mechanical lift sling. The sling strap was hanging down next to the large wheel of the wheelchair. c) Observation on 9/23/15 at 12:24 p.m. revealed Resident #4 sitting on a mechanical lift sling in her wheelchair. The sling strap was hanging from the wheelchair and touching the front wheel of her chair. d) Observation on 9/24/15 at 10:45 a.m. revealed Resident #9 was sitting in her wheelchair by the nurse's station. The mechanical lift sling was observed to be bunched up and she was sitting on it. A sling strap was dangling by the right front wheel of the wheelchair. e) Observation on 9/24/15 at 10:50 a.m., Resident #14 was sitting in her wheelchair by the nurse's station. She was sitting on a mechanical lift sling in the wheelchair. The sling straps were dangling by both of the front wheels of the wheelchair. f) Observation on 9/24/15 at 10:55 a.m. revealed Resident #15 was sitting in her wheelchair by the nurse's station. A mechanical lift sling was observed underneath her in the chair. A blanket was across her legs and almost covered the front wheels of the wheelchair. A sling strap was dangling by the left rear wheel of the wheelchair. g) Observation on 9/29/15 at 9:00 a.m., revealed Resident #16 was sitting in her wheelchair in the back dining room by hall #4, almost asleep. A mechanical lift sling was observed underneath her. A sling strap was dangling by the right front wheel of the wheelchair. h) During an interview on 9/27/15 at 12:00 noon, the Administrator said that he was going to ensure staff monitored the sling straps. He said he would have the staff begin documenting it on each shift. 5. During an interview on 9/22/15 at 4:00 p.m., the DON and Risk Manager said that the Risk Manager had only been on the job two weeks. When discussing who was responsible to review and follow up on incident reports to ensure follow through to identifying risk factors and putting intervention in place to prevent falls, the DON said that would be the Risk Manager's job. She said these documents were located in the computer system (referred to as Risk Watch system), including the follow up and conclusions, but this process had not started yet. The DON said the process had not been in place since the last Risk Manager left employment. The DON said the new Risk Manager had only been working on infection control since her hire, and had not gotten to the incident reporting system yet. The Risk Manager agreed. 6. During an interview on 9/23/15 at 9:15 a.m., the Administrator said he was aware of Resident #4's fall from the Hoyer and Resident #2 falling from her chair when the Hoyer straps tangled in her wheelchair. When discussing Resident #4, the Administrator said that the facility had all new slings and that he determined that the new slings were faulty and, We're visiting with the manufacturers. The Administrator did not identify the facility's actions regarding Resident #2's fall. The Administrator stated that the department heads talked about the falls in their stand-up meeting after they occurred. He said that the facility planned to start risk meetings in the future to discuss things they need to focus on, do root cause analysis, and identify things. 7. A Policy titled, Safe Lifting and Movement of Residents revised on October 2009 provided by the DON on 9/28/15 revealed it included the following: Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices . Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints . 8. A Policy titled, Falls and Fall Risk, Managing Revised December 2007 provided by the DON on 9/28/15 revealed it included the following: Policy Statement- Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions . 9. A Policy titled, Assessing Falls and Their Causes Revised October 2010 provided by the DON revealed it included the following: Under, General Guidelines: Falls are a leading cause of morbidity and mortality among the elderly in nursing homes . Residents must be assessed in a timely manner for potential causes of falls. Relevant environmental issues should be addressed promptly 10. The Administrator was notified of an Immediate Jeopardy (IJ) on 9/23/15 at 12:00 noon. 11. The facility's Plan of Removal of Immediate Jeopardy was accepted on 9/29/15 at 3:30 p.m. and included the following: Hired Risk Manager on 9/13/15. DON or designee is responsible and will be monitored weekdays. Incidents/accidents have been placed in Risk Watch within 24 hours of incident beginning 9/14/15 - 9/24/15. The completion date is on

Based on observations, record review and interviews the administration failed to manage the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being for 3 of 13 residents reviewed for abuse and neglect (Residents #1, 2, 4); 7 of 9 residents reviewed for mechanical lift transfers (Residents #2, 4, ); 4 of 6 residents reviewed for pressure sores (Residents 3, 5, 10 and 21) and 2 of 4 residents reviewed for indwelling urinary catheters (Residents #2 and 3) as evidenced by: A) The Administrator, who was the Abuse and Neglect Coordinator for the facility, failed to ensure direct care staff immediately reported allegations of abuse by Resident #1; failed to oversee the actions of the ADON, whom he had appointed to investigate allegations of physical abuse made by Resident #1; and failed to monitor and ensure the ADON implemented the facility's Abuse and Neglect Policies and Procedures to thoroughly investigate and report allegations of alleged abuse and neglect for Residents #1; B) The Administrator and DON failed to direct the Risk Manager to implement the facility's risk management process to identify risks and hazards and implement preventive strategies for Residents #2 and 3, and failed to follow the facility's policies to report these incidents as allegations of neglect to the State authority; C) The Administrator and DON failed to direct the PTA (physical therapist's assistant) to assess competency of Certified Nurse's aides to ensure they were skilled and competent in the use of mechanical lifts, and failed to ensure mechanical lift slings were in good condition prior to and after Resident #4 fell from a lift due to a torn sling; D) The DON and ADON failed to ensure nurses were implementing procedures to accurately identify skin issues or effectively treating and monitoring skin issues for all residents to ensure residents who admitted without pressure ulcers did not develop pressure ulcers, residents with pressure ulcers received prompt treatment by contacting the resident's physician, and services were provided to promote healing for Residents #3, 5, 10, and 21; and E) The DON and ADON failed to ensure nurses were using indwelling urinary catheters for approved [DIAGNOSES REDACTED].#2 and #3. On 9/22/15 at 9:30 a.m., the Administrator was notified that Substandard Quality of Care was identified in the area of quality of care related to facility-acquired pressure sores and for urinary incontinence with no toileting program and the use of indwelling urinary catheters without an appropriate diagnosis. The Administrator was informed that the survey would be extended. On 9/23/15 at 12:00 p.m., The Administrator was notified of an Immediate Jeopardy (IJ) in the areas of Quality of Care (Prevention of Accidents) and Resident Behavior and Facility Practice for Residents #2 and #3. Findings regarding Resident #1 were included in the Immediate Jeopardy by notification to the Administrator on 9/25/15 at 1:35 p.m. On 10/12/15 at 12:10 p.m. the Administrator was notified of an Immediate Jeopardy (IJ) in the area of Quality of Care (Pressure Sores) for Residents #3, 5, and 10. Findings regarding Resident #21 were included in the Immediate Jeopardy by notification to the Administrator on 10/16/15 at 4:30 p.m. The failures regarding abuse and neglect and prevention of accidents could affect the 13 residents that require a mechanical lift for transferring between surfaces and could affect the total of 71 residents who required assistance with activities of daily living and could result in accidents, injury or death; These failures could affect the 6 residents identified by the facility as having pressure sores and result in pain, infection, and illness; The failures to implement interventions to promote urinary continence and failure to prevent the use of catheters when not clinically indicated could affect the 40 incontent residents of the facility and result in preventable incontinence and unnecessary indwelling catheters, and could result in pain and infection. The findings included: ACCIDENTS AND HAZARDS 1. a) A Resident Admission record dated 6/29/15 documented that Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] from another hospital facility. She was referred from a Rehabilitation facility. [DIAGNOSES REDACTED]. A Rehabilitation Hospital report dated 6/13/15 documented Resident #4 was admitted there after a right ankle fracture. An MDS Assessment for Resident #4, dated 7/6/15 documented a Brief Mental Status Interview score of 13, indicating Resident #4 was cognitively intact. The MDS documented that Resident #4 required extensive assistance from two or more persons for transferring. Resident #4 was 57 inches tall and weighed 247 pounds. b) Care plans for Resident #4 date of 8/13/15 documented that Resident #4 required 2 staff to use a mechanical lift for transferring. Interventions added to the care plan on 9/11/15 and 9/18/15 addressed the problem of falls, stating the staff should ensure assistive devices are in good condition. c) An Occurrence Report for Resident #4 dated 9/11/15 at 1950 (7:50 p.m.) documented Resident #4 had a fall in her room during transfer. The report documented that CNAs F and G were transferring her when the mechanical lift sling tore, dropping the resident to the floor. She was sent to the hospital in an ambulance at 8:15 p.m. d) A hospital emergency physician record and trauma flow sheet documented the resident's arrival at the emergency department as 9/10/15 at 2009 (8:09 p.m.). The chief complaint was fall injury to head. The estimated height of the fall was approximately four feet. The physician documented: Contusion: head. f) Review of the nurse's note tab of Resident #4's medical record was a four page document and two attached statements (from CNA F and G). The document was titled, Fall Details Report for Resident #4 dated 9/10/15 at 1930 (7:30). Page one was completed documenting facts about the fall as stated on the incident (fall to ground, lying on back, visually observed 9/10/15 at 1830 (6:30 p.m.). The second, third, and fourth pages of the document were blank where the document has spaces for recommendations following the incident. g) During an observation on 9/15/15 at 3:25 p.m., CNAs H and I were observed transferring Resident #4 from her wheelchair to bed with a mechanical lift. The CNAs were observed to lift the wheelchair with the resident in it twice before they determined the sling was fastened to the wheelchair in places it should not have been. h) During an observation and interview on 9/22/15 at 3:05 p.m., CNA J said that each resident that was mechanically lifted had a sling in their room, and all extras were placed in the laundry room. CNA J said that if a CNA needed to replace a soiled sling, they would get a clean one from the laundry room. CNA J accompanied the surveyor to the laundry room. Eight mechanical lift slings were in the laundry room on a cart just inside the door. The slings were inspected and one of eight slings was found to be worn (appearance of an older sling as the green color was very faded) and it had two tears completely through the fabric that were large (two fingers could fit through one hole, three fingers could fit through the second hole) and easily seen. 2. a) An undated Admission Record documented Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. physician's orders [REDACTED].#2's [DIAGNOSES REDACTED]. b) An MDS Assessment for Resident #2 dated 7/29/15 documented Resident #2 had a Brief Interview for Mental Status score of 14, indicating she was cognitively intact. Under Functional Status the assessment documented that Resident #2 required extensive assistance of two persons to transfer between surfaces. Resident #2 used a wheelchair for mobility. She had limited range of motion on the lower extremity of one side. c) A care plan for Resident #2 dated 7/16/15 included a problem with a start date of 7/2/15: Resident is limited in wheelchair mobility r/t (related to) BKA ([MEDICAL CONDITION]). A problem with a start date of 7/2/15 documented, Resident has history of falling r/t (related to) outside objects. For example Hoyer lift strap being secured, shoe. Approaches included to ensure that equipment is properly used and secure including Hoyer sling straps being secured and not being dragged. d) An Occurrence Report dated 6/17/15 at 1830 (6:30 p.m.) documented that Resident #2 had a fall in the common area. The nurse note documented, Resident being propelled in w/c by CNA. Hoyer lift strap became entangled in wheel causing resident to be pulled forward out of wheelchair. 9-1-1 was called and the resident transported to the ER. f) An Emergency Physician Record dated 6/17/15 documented a chief complaint of fall injury to L (left) thigh stump. The Discharge Summary from the Emergency Department documented a Primary [DIAGNOSES REDACTED]. g) A radiology report for Resident #2 dated 6/17/15 at 2038 (8:38 p.m.) documented findings of: Above-knee amputation with possible acute fracture fragment at the tip of the bony stump with associated swelling. h) A nurse's note dated 6/19/15 at 1:48 p.m. by the ADON documented that on 6/18/15 she had spoken to Resident #2's family and told the family that the aides would be inserviced on Hoyer/slings to ensure that any dangling objects are secured and not dangling freely in order to prevent any further incidents like the resident's from happening again . i) During an observation on 9/10/15 at 1:20 p.m., CNAs A and B were observed to transfer Resident #2 from her wheelchair to bed, using a mechanical lift. CNA A was operating the mechanical lift. She was observed to lock the casters of the mechanical lift prior to lifting Resident #2. During an interview following the transfer, CNA A was asked why she locked the casters of the mechanical lift prior to lifting. She said she had always wondered about whether she should be doing that or not, but that was the way she had been taught to do it. j) A review of the mechanical lift owner's manual, provided by the Administrator on 9/22/15 at 5:15 p.m. revealed operating instructions included: During lifting or lowering, whenever possible, always keep the base of the lift in the widest position with the casters unlocked. Page 8: DO NOT lift a patient with the caster brakes on. Always let the lift find the correct center of gravity. 3. a) During the following interviews, each CNAs reported they had not been checked off by the facility as being competent in using the mechanical lifts: 9/22/15 at 4:00 p.m.: CNA N said she had been at the facility 3-4 months and did not know who should be inspecting the lift slings. CNA D was present and he did not know who was reponsible for inspecting the lift slings. 9/23/15 at 945 a.m.: CNA A was only shown how to use the lift by another CNA. 9/23/15 at 10:50 a.m.: CNA B had been there two weeks and had been using mechanical lifts, but no training by this facility. 9/23/15 at 11:35 a.m.: CNAO had been there three weeks and had operated mechanical lifts. She had heard Resident #4 fell from a lift, but was never told what caused the fall. 9/24/15 at 9:40 a.m.: CNA H had been there two months. She had observed other CNAs who did not know how to operate the mechanical lifts correctly. She found out about Resident #4's fall from the mechanical lift because Resident #4 told her. 4. a) Observation on 9/23/15 at 12:17 p.m. revealed Resident #17 was observed with a mechanical lift sling underneath him in the chair. The sling strap hung down between the chair frame and the left wheel of the Geri Chair. b) Observation on 9/23/15 at 12:23 p.m. revealed Resident #15 in the dining room sitting on a lift sling, and the sling strap was hanging down next to the large wheel of the wheelchair. c) Observation on 9/23/15 at 12:24 p.m. revealed Resident #4 sitting on a mechanical lift sling in her wheelchair, and the sling strap was hanging from the wheelchair and touching the front wheel of her chair. d) Observation on 9/24/15 at 10:45 a.m. revealed Resident #9 was sitting in her wheelchair on a lift sling and the sling strap was dangling by the right front wheel of the wheelchair. e) Observation on 9/24/15 at 10:50 a.m., Resident #14 was sitting in her wheelchair on a mechanical lift sling in the wheelchair, and the sling straps were dangling by both of the front wheels of the wheelchair. f) Observation on 9/24/15 at 10:55 a.m. revealed Resident #15 was sitting in her wheelchair on a lift sling, and the sling strap was dangling by the left rear wheel of the wheelchair. g) Observation on 9/29/15 at 9:00 a.m., revealed Resident #16 was sitting in her wheelchair on a mechanical lift sling, and the sling strap was dangling by the right front wheel of the wheelchair. Interviews with Administrative Staff: 5. In an interview with the PTA on 9/23/15 at 11:20 a.m., when discussing how the facility ensured staff were trained and competent in operating the mechanical lifts, the PTA said, We have CNAs come in and grab me, and we do a demonstration. I demonstrate for them then they demonstrate for me. When discussing that several interviews revealed staff had not participated in this type of training, he said that he tried to have a session quarterly. He said, I should have one pretty quick stating he had a session in June. The PTA said he gave the staff the competency check lists for that session but the facility could not find them. When discussing the recent incidents regarding Resident #2 being thrown from her wheelchair, and Resident #4 being dropped from the mechanical lift, the PTA said the facility had not asked him to do any additional training or in-service following those incidents. 6. During an interview on 9/27/15 at 12:00 noon, when discussing that observations revealed residents' hoyer slings continued to hang near their wheelchair wheels and continued to be a hazard, the Administrator said that he was going to ensure staff monitored the sling straps. He said he would have the staff begin documenting it on each shift. 7. During an interview on 9/22/15 at 4:00 p.m., the DON and Risk Manager said that the Risk Manager had only been on the job two weeks. When discussing who was responsible to review and follow up on incident reports to ensure follow through to identifying risk factors and putting intervention in place to prevent falls, the DON said that would be the Risk Manager's job. She said these documents were located in the computer system (referred to as Risk Watch system), including the follow up and conclusions, but this process had not started yet. The DON said the process had not been in place since the last Risk Manager left employment. The DON said the new Risk Manager had only been working on infection control since her hire, and had not gotten to the incident reporting system yet. The Risk Manager agreed. 8. During an interview on 9/22/15 at 3:35 p.m., the torn sling that was found in the laundry room was shown to the DON. When the DON saw the sling, she said, That shouldn't be in there, it should be in the trash. When discussing who was responsible to monitor the condition of the Hoyer slings, the DON said, The CNAs. The DON said that they had checked and made sure that the slings that were in all the residents' rooms were in good condition, but the ones in the laundry room must not have been checked. 9. During an interview on 9/23/15 at 9:15 a.m., the Administrator said he was aware of Resident #4's fall from the Hoyer and Resident #2 falling from her chair when the Hoyer straps tangled in her wheelchair. The Administrator said that the facility had all new slings and that he determined that the new slings were faulty and, We're visiting with the manufacturers. (The Administrator provided no documentation to support this conclusion). The Administrator did not identify the facility's actions regarding Resident #2's fall. He said that the facility planned to start risk meetings in the future to discuss things they need to focus on, do root cause analysis, and identify things. 10. In an interview on 9/23/15 at 3:30 p.m., the Maintenance Supervisor said his department was not responsible to monitor the mechanical lift slings or their condition. 11. The Administrator was notified of an Immediate Jeopardy (IJ) on 9/23/15 at 12:00 noon. 12. The facility's Plan of Removal of Immediate Jeopardy was accepted on 9/29/15 at 3:30 p.m. and included the following: Hired Risk Manager on 9/13/15. DON or designee is responsible and will be monitored weekdays. Incidents/accidents have been placed in Risk Watch within 24 hours of incident beginning 9/14/15 - 9/24/15. The completion date is ongoing. The responsible persons are charge nurses and will be monitored daily unless reportable event occurs on the weekend, then the Administrator/DON will be notified by phone. Incidents/accidents have been reviewed on a daily basis and entered into Risk Watch; as of 9/14/15 - 9/23/15. Risk Manager reviews entries to make sure reports are entered into system. The completion date is 9/23/15 and ongoing. The charge nurses are responsible and will be monitored by Risk Manager weekdays. Daily entry occurs if reportable event is identified on weekend Administrator and DON are notified. Unusual occurrences have been reported and reviewed in morning meetings and/or by telephone to administrator/DON at the time of occurrence. The completion date is 9/23/15 and ongoing. The DON is responsible and the Administrator or designee will monitor. Hired one Nurse Manager 8/2/15 and second is in interview process to assist with education, oversight and follow up on assigned unit processes implemented with staff. The completion date is 8/2/15. The DON is responsible and will monitor. Risk Watch in-service - Risk Watch Reporter Training conducted for licensed nursing staff to enter incidents/accidents. The completion date is 9/28/15. Risk Watch Training for completion of investigation and follow-up for Nursing leadership completed on 9/28/15 . The administrator of designee will monitor. New slings were changed and confirmed as in good repair for all residents who required slings. Completed on 9/11/15 by the DON. The Risk Manager will monitor for sling condition on a weekly basis. On 9/23/15 extra slings in laundry room were inspected for wear and tear. All slings were in good repair. Completion date was 9/23/15 by the DON. Will be monitored by Environmental Services. Demonstration of the Hoyer lifts by Physical Therapy with return demonstrations of individual staff (CNA) on use of Hoyer lift using check off list conducted. PTA was responsible. PTA completed on 9/28/15. Upon hire and bi-annually. Currently at 25 of 29 CNA ' s completed training. No CNA will be allowed to work with Hoyer lifts on unit until checked off by Physical Therapy. 13. Action Plan verification activities were conducted by two surveyors from 9/25/15 through 9/29/15 and included the following activities: Review of all in-service documentation, review of staff competencies for mechanical lift, review of completed risk-watch report and conclusions, visual inspection of mechanical lift slings in circulation both in resident rooms and laundry room to confirm all in good repair, visual inspection of mechanical lift slings in wheelchairs away from wheels, interviews with nurse aides and nurses to verify in-service understanding, and observation of mechanical lifting of residents. 14. The DON provided a list on 9/10/15 at approximately 1:00 p.m. identifying 13 residents that required a mechanical lift for transferring. The DON documented a total of 71 residents at high risk of falls (which included the 13 requiring mechanical lift) on 9/29/15 at approximately 11:00 a.m. PREVENTION OF ABUSE AND NEGLECT: 1. Interviews about the prevention of abuse and neglect with Administrative Staff regarding Residents #2 and #4 (related to above incidents): During an interview on 9/22/15 at 4:00 p.m., the The DON and Risk Manager said that Resident #4's fall from the mechanical lift was not considered as an allegation of neglect or reportable to the State as possible neglect because the sling tearing could not be considered the staff's fault and because staff witnessed the incident. They said they spoke with the staff involved to gather information about the falls, but did not initiate an abuse or neglect investigation or report the incidents. During an interview on 9/23/15 at 9:15 a.m., the Administrator said that neither of the falls (Residents #2 and 4) were reported to the State or investigated as a possible allegation of neglect. When discussing whether the accidents were preventable if staff had done something differently and if he saw that as reportable as possible neglect, he said, Depends on the situation. When discussing that both residents were sent to the emergency room , he then stated, I would say, yes. 2.a) An undated face sheet documented Resident #1 was a [AGE] year-old female admitted to the facility 3/23/15 with [DIAGNOSES REDACTED]. An 8/1/15-9/30/15 physician order [REDACTED]. An admission nursing assessment 3/24/15 documented an admitting [DIAGNOSES REDACTED]. b) A Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #1 was cognitively intact, had no potential indicators of [MEDICAL CONDITION], there were no physical symptoms directed toward others, there were no verbal behavioral symptoms directed toward others, and there were no other behavioral symptoms not directed toward others. The MDS documented that Resident #1 used a wheelchair for mobility and required extensive assistance of two people to transfer between surfaces and to provide physical help in part of the bathing activity. c) A Care Plan for Resident #1dated 6/25/2015 did not include any problem statements, goals, or interventions for resisting care, challenging behaviors, or [MEDICAL CONDITION]. A Care Plan for Resident #1 dated 9/24/15 was un-changed from the previous care conference with regard to the above information. d) An Occurrence Report regarding Resident #1 dated 9/18/15 at 9:30 a.m. documented that Resident #1 had a behavior on 9/18/15 at 10:00 a.m. and became aggressive and hit CNA A in the mouth with a shoe in the shower room. The report documented that the resident was Redirected and assigned to another aide, and that the the resident was given education, training, and re-instruction. The report documented on 9/24/15 that the resident said it was too cold to shower and denied hitting the staff. The ADON documented that the staff wanted to file a grievance against the resident. The ADON documented interviews with CNAs A and B and the resident on 9/25/15. The ADON's interviews included an interview with Med Aide A who stated she observed CNA A and B forcing resident into shower room and as they put her inside she heard resident screaming No repeatedly. As they got out of the shower CNA A asked her (Med Aide A) to translate what Resident #1 was saying. She had also asked her to tell Resident #1 that she shouldn't be hitting her (CNA A) and that she was going to report her. Resident #1 then told Med Aide A that they were hitting her and that CNA A said that was a lie, and after that the aides took her to her room. CNAs A and B only discussed that Resident #1 had hit CNA A in their interview. The ADON's interview with Resident #1 documented only that she asked the resident if the resident hit CNA A. The ADON's interview did not address Resident #1's allegation on 9/18/15 that CNA A had hit her. She documented the DON, Administrator, and Risk Manager were notified 9/18/15. The space for State notified was blank. Under Recommendations entered by ADON with a due date of 9/23/15, a date implemented of 9/24/15: It is recommended that CNA A change resident assignments with another staff member to avoid further confrontations with this resident. e) A Social Services Note for Resident #1 dated 9/22/15 at 2:16 p.m. documented that on 9/18/15 CNA A came to the SW to write a complaint regarding Resident #1 stating the resident had hit her in the mouth with a shoe. The SW documentation addressed only the resident's behavior as reported by CNA A, and observation of CNA A's lip as it was bleeding. The SW documented that, On next day same resident called the same 2 CNAs names while they were taking care of her roommate and she did not wish to leave the room . On 9/20/15 resident reported to charge nurse at nurse's station that the same 2 aides had poured water on her bed and floor. DON and SW told them to have other aides care for her, that they need to stay out of that room. f) During an interview on 9/25/15 at 9:15 a.m., when discussing the status of the facility's investigation, the ADON said the report was not complete. The ADON was asked to provide all of the information she had on the incident. These reports were the same reports that had been reviewed, above with the addition of written statements from CNA A and CNA B saying Resident #1 hit CNA A. CNA A and CNA B's statements did not address or answer the allegation whether CNA A hit Resident #1. The investigation report did not include a physical assessment of Resident #1 and did not include a statement from or interview with Resident #1. g) During an interview on 9/23/15 at 9:45 a.m., CNA A said that on 9/18/15 at around 9:30 a.m., she and CNA B were taking Resident #1 to the shower room. She said Resident #1 said she did not want to go because it was cold in the shower. CNA A said she went into the shower room and Resident #1 continued to say that she was cold. CNA A said she told Resident #1 she would turn on the two heat lights/lamps in the shower room. CNA A said that Resident #1 was fine with that. CNA A said she and CNA B took Resident #1's clothes off and when she bent down to take Resident #1's shoes off, Resident #1 kicked her in the mouth. CNA A said that she then re-dressed her and put Resident #1's shoes in the resident's lap. CNA A said she told the Administrative staff that Resident #1 had made an allegation that she had hit Resident #1. CNA A said she was not removed from resident care after the allegation was made, and continued to work Resident #1's hall the rest of 9/18/15 (a Friday) and all of the weekend. h) During an interview on 9/23/15 at 10:50 a.m., CNA B said they asked Resident #1 if she would take a shower and the resident refused each time and then finally said yes. CNA B said when they got to the shower, Resident #1 began screaming at the door. CNA B said they attempted to undress Resident #1, she was saying, No, no no. CNA B said that Resident #1 then took off one of her shoes and hit CNA A in the mouth. CNA B said they then took Resident #1 back to her room and reported it to the social worker and DON. CNA B said CNA A did not hit Resident #1. CNA B confirmed that they both continued to work on the same hall, and stated that Resident #1 was calling her names in Spanish. i) During an interview on 9/23/15 at 1:55 p.m., Med Aide A said that she was in the hall and observed the incident with Resident #1. She said that Resident #1 was screaming loudly, No, No, No! as they came down the hall and went into the shower room. Med Aide A said that she continued to hear Resident #1 screaming, No, No, No! in the shower room from the other side of the door. She said she knew Resident #1 made an allegation that CNA A hit her but she did not tell anyone about it that day because she forgot. She said told the ADON about Resident #1's allegation on Saturday morning 9/19/15. j) During interviews on 9/22/15 at 2:20 p.m. and 9/24/15 at 1:45 p.m., Resident #1 said that on 9/18/15 she told CNAs A and B that she did not want to take a shower because the shower room was too cold. She said they took her in the shower room anyway. She said she continued to say she did not want to shower, and she never told them that she would. She said they started undressing her and told her that she was already in the shower room so she was going to take a shower. Resident #1 said she continued to protest and told them over and over she did not want to shower because it was too cold. Resident #1 said that while saying these things, CNA A had her shoe (Resident #1's shoe) in her hand and tapped her (Resident #1's) thigh with the shoe, and Resident #1 said she slapped the CNA's hand away when she did. k) During an interview on 9/25/15 at 11:15 a.m., the DON and the Risk Manager were present. When discussing why the incident report entry was initially made on 9/18/15, but the Nurse's entry on the same incident report describing what happened did not get entered until six days later, the DON and the Risk Manager said they did not know. The DON then stated that the ADON was ill, and that was why the information was entered six days later, and why the investigation was not completed in a timely manner. The DON said she was not aware of the incident until Monday, 9/21/15. She said she never asked the ADON if the alleged perpetrator(s) were suspended. When discussing whether the alleged perpetrator should have been suspended from resident care after the allegation was made, the DON said she should have been suspended on 9/18/15. l) During an interview on 9/25/15 at 12:05 p.m., the Social Worker said she was aware that an incident had occurred on 9/18/15 and took statements from CNAs A and B but did not talk to Resident #1. The Social Worker said, I handled it wrong, I know I did. m) During an interview on 9/25/15 at 1:40 p.m., the Administrator said he was not informed of the incident/allegation of abuse until Monday (9/21/15). He said the ADON was at the facility throughout the weekend and did not know about it. The Administrator said he was of the understanding that the resident was just agitated, and the ADON addressed it by putting the resident with a different aide. The Administrator said the ADON completed the investigation. When discussing whether he had read the investigation, he replied, I've looked through it. When discussing the quality/thoroughness of the investigation, he said he thought the investigation was thorough. n) During an interview on 9/28/15 at 11:10 a.m., the ADON said she was working on the floor on Friday, 9/18/15. The ADON said that she could hear Resident #1 screaming from the shower room while she was at the nurse's station. The ADON said she went down the hall and saw CNA A and B and Resident #1 as they were exiting the shower room. She said Resident #1 said she was okay. The ADON denied Resident #1 told her she had been hit by staff at that time. The ADON said she did not become aware of the allegation until Monday (9/21/15). When discussing that Med Aide A said she told the ADON the allegation on Saturday morning, 9/19/15, the ADON denied that she was at the facility on that day or that she was told. When asked if CNA A was suspended from resident care after the allegation was made, the ADON said she was not. The ADON acknowledged she should have suspended the aides while an investigation was completed. When discussing if she ever asked Resident #1 if she was hi

Based on observation, interview and record review, the facility failed to provide necessary care and services to attain the highest practicable physical, mental and psychological well-being for 2 of 4 Residents (#2 and #3) residents reviewed for indwelling urinary catheters. A) Resident #2 was admitted on [DATE] without an indwelling urinary catheter, but had a catheter inserted on 5/4/15 due to a wound described only as an open area to her left posterior thigh which was documented as resolved on 5/28/15. Resident #2 continued to have an indwelling catheter continuously through 9/29/15 which resulted in Resident #2 suffering painful bladder spasms and a urinary tract infection; B) Resident #3 was admitted to the facility on [DATE] without an indwelling catheter, but had an indwelling Foley catheter placed on 7/3/15 due to a Stage II pressure ulcer to her right glueteal fold which did not clinically indicate the need for a catheter and which resulted in Resident #3 acquiring a urinary tract infection in August 2015. These deficient practices affected Resident #2 and #3 and placed 2 other residents with catheters at risk for abilities to maintain or regain continence, increased the risk for developing of or worsening of a urinary tract infection, [MEDICAL CONDITION], undue pain and discomfort, and possible trauma such as bleeding or accidental removal of the catheters or death. Findings include: RESIDENT #2 1. An undated admission face sheet for Resident #2 documented she was a [AGE] year-old female admitted to the facility on [DATE]. 2. An Initial Nursing Assessment dated 9/12/14 (likely re-admission) documented under Elimination that Resident #2 was continent at least 3x daily. 3. Consolidated Physician's orders for Resident #2 dated 8/1/15 through 9/30/15 documented that Resident #2's [DIAGNOSES REDACTED]. 4. Physician's progress notes from the Physician's assistant dated 5/04/15 documented .Wounds: Pressure area to back of left femur .Insert Foley catheter and leave indwelling and closed drainage system. 5. Nurses notes documented: 5/04/15 at 2:02 p.m. - Refer to dermatologist. May insert Foley catheter until wound resolves. 5/04/15 at 2:27 p.m. - Night nurse informed this nurse that resident had an open area to her left posterior thigh; is open with no drainage noted and no signs/symptoms of infection. Wound bed is red. 5/05/15 at 4:07 p.m. - Foley catheter inserted 16 Fr with 10 cc bulb. 5/05/15 at 4:14 p.m. - New order [MEDICATION NAME] cream apply to peri area BID until issue resolved. 5/05/15 at 6:36 p.m. - Family notified of new order for [MEDICATION NAME] cream and to bring some cotton panties for her, may be having an allergy to pull ups she's been wearing. 6. Progress note from the Physician's assistant dated 5/13/15 documented: .Wounds: Back of left leg (does not address Foley catheter). Progress note from the Physician's assistant dated 5/22/15 documented .The areas on posterior leg and open wounds are showing improvement since Foley catheter inserted, staff report affected areas (unknown word) anterior abdomen .Wounds: Skin area and drying and improving .Continue with Foley catheter . 7. Review of physician orders for Resident #2 dated 8/1/15 through 9/30/15 included an order with a begin date of 5/22/15 and end date as open ended of, Silva Sorb (silver) (OTC/over the counter) gel, extended release; amt: to back of legs and peri; topical. Special Instructions: to back of legs and peri area bid and prn for [DIAGNOSES REDACTED]. 8. Nurses note dated 5/28/15 at 2:13 p.m. - Foley catheter due to be changed 6/05/15. [MEDICATION NAME] cream placed in peri area. Wound on left back of thigh resolved. 9. A review of a Treatment Flow Sheet for Resident #2 dated 5/2/15 - 6/1/15 with page 1 of 1 at the bottom of the page revealed a treatment of [REDACTED]. A hand-written note on the Flow Sheet by LVN P documented, Resolved, DC'd (discontinued) 5/28/15. A review of a Treatment Flow Sheet for Resident #2 dated 6/1/15 - 6/30/15 with page 3 of 5 at the bottom of the page revealed a treatment order same as above, with a hand written note of Resolved under the last treatment documented on 6/6/15. 10. Progress note from the physician assistant for Resident #2 dated 7/1/15 documented:: Physician noted Resident #2 had a urinary tract infection, E.coli (Escherichia coli is a bacterium that can cause serious infections) and was started on antibiotics. 11. Nurses note dated 7/02/15 at 6:42 p.m. - Resident transferred from hospital via ambulance. Head to toe assessment done. Left BKA (below the knee) and excoriation to buttocks noted. Dr. gave new order to apply zinc oxide to buttocks BID (twice a day) and PRN (as needed). 16 Fr Foley in place draining dark yellow urine. 12. Review of physician's orders for Resident #2 dated 8/1/15 through 9/30/15 included an order with a begin date of 7/2/15 and end date as open ended of, [MEDICATION NAME] XL ([MEDICATION NAME] chloride tablet extended release 24 hr; 5 mg once a day. Note: These physician's consolidated orders did not include a physician's order for a Foley catheter or include physician's orders for catheter care. 13. Review of the medical record revealed no physician's consolidated orders for June, July, or August 2015. 14. In an interview on 9/11/15 at 12:50 p.m., the DON there were no consolidated physician's orders completed on any of the residents for June, July, or August 2015 so there would be none for Resident #2. 15. A care plan for Resident #2 dated 7/16/15 included the following: Problem start date: 7/2/15: Urinary incontinence: Functional urinary incontinence r/t immobility (requires the use of Hoyar x2 staff members for transfers. Goal: Resident will not develop skin breakdown related to incontinence Approaches included moisture barrier, check for incontinent episodes at least every two hours, ensure adequate bowel elimination, provide medications as ordered, monitor skin breakdown, and weekly body audit by charge nurse. Problem start date 7/24/15: Resident is at risk for pressure ulcers r/t (related to) immobility/debilitated state. Goal: Resident's skin will remain intact Approaches included to avoid shearing during movement, skin inspections, keep as clean and dry as possible, keep linens clean and dry, maintain head of bed at lowest degree of elevation, provide incontinent care after each incontinent episode ., report signs of skin breakdown, turn and reposition ., use absorbent skin-friendly pads/briefs ., use lifting device such as draw sheet to move resident, and use moisture barrier product . 16. Resident #2's care plan dated 7/16/15 did not address the need or indication for a Foley catheter. 17. Progress notes from the physician's assistant dated 7/23/15 documented .Continues with skin breakdown on buttocks and posterior legs and in abdominal fold .Using [MEDICATION NAME] cream to abd fold and zinc to buttocks. Areas are drying and showing improvement . 18. An MDS Assessment for Resident #2 dated 7/29/15 documented Resident #2 had a Brief Interview for Mental Status score of 14, indicating she was cognitively intact. Under Functional Status the assessment documented that Resident #2 required extensive assistance of two persons to transfer between surfaces, limited assistance of one person to dress, extensive assistance of one person to toilet; and was totally dependent with one person assistance for bathing. Resident #2 used a wheelchair for mobility. She had limited range of motion on the lower extremity of one side. The MDS assessment documented that Resident #2 was frequently incontinent of urine and occasionally incontinent of bowel. The MDS documented that Resident #2 did not have an indwelling catheter. 19. Progress notes from the physician's assistant dated 7/30/15 documented .Staff report is also having issues with bladder cramping and leaking around Foley catheter .Obtain UA (urinalysis) with C&S (culture and sensitivity). Order [MEDICATION NAME] (an [MEDICATION NAME] that prevents spasms in the muscles of the gut and bladder by relaxing them)20 mg tid (three times a day) x 7 (seven) days then dc (discontinue). 20. Nurse's note dated 7/30/15 at 6:55 a.m. - Complains of pain in bladder. Foley patent and draining clear yellow urine. [MEDICATION NAME] given for complaints of anxiety. 21. Review of lab results 7/31/15 for Resident #2 showed Proteus mirabilis positive (a significant urinary tract infection). 22. 7/31/15 at 2:56 a.m. - New order received to obtain UA/ C&S- obtained and sent to lab. New order to start [MEDICATION NAME] 20mg one tablet TID for 7 days for bladder spasms. 23. Nurse's note dated 8/01/15 at 4:18 p.m. - Foley leaking. Changed Foley. Skin red on buttocks near rectum, treated with creams per order. Resident complains of bladder spasms. Nurse's note dated 8/03/15 at 2:22 p.m. - Report result of UA/ C&S- new order for Rocephen 2 grams IM (antibiotic) for 2 days. 24. Review of Daily Skilled Documentation Observation Report documented by licensed nurses revealed they included the following: 8/13/15: Resident #2 did not have any pressure ulcers or rashes. The report showed the resident was frequently incontinent of bowel and bladder and that she used pads and/or a brief. 25. Progress note from the Phsyician assistant dated 8/27/15 documented: Wounds: Rash on posterior legs bilaterally .Continue to medicate rash on legs posterior . (Foley catheter not addressed in note). 26. Nurse's noted dated 9/01/15 at 2:21 a.m. - Resident has open area on frontal gluteal fold. Triple antibiotic placed. 27. Review of Daily Skilled Documentation Observation Report documented by licensed nurse's revealed they included the following: 9/06/15: Resident #2 did not have any pressure ulcers but was checked for abrasions, bruises and open [MEDICAL CONDITION] other than ulcers, rashes or cuts. The report showed the resident was continent of bowel and incontinent of bladder and had an indwelling catheter. 9/13/15: Resident #2 did not have any pressure ulcers (documented under skin integrity section; she had abrasions, bruises/ open [MEDICAL CONDITION] other than ulcers/ and rashes documented under Other skin problems or [MEDICAL CONDITION] present. She was documented as incontinent with an indwelling catheter. 28. Review of nurse's note dated 9/08/15 at 3:52 p.m. - New order front abdominal fold- clean with normal saline, pat dry, place [MEDICATION NAME] powder, place interdry cloth. Review of nurse's note dated 9/16/15 at 2:20 a.m. - Resident continues to have redness open area on frontal abdominal fold. Remove Foley when skin issues resolved. 29. A review of Resident #2's medical record revealed no assessments related to Resident #2's appropriateness for a toileting program, and no assessments related to the use of a Foley catheter. 30. During an interview on 9/11/15 at 10:40 a.m., when the DON provided a list of residents that had catheters, the DON was asked why Resident #2's physician's orders did not include the Foley catheter or catheter care. She said she did not know. 31. During an interview on 9/11/15 at 10:50 a.m., LVN P, who was charge nurse for Resident #2's hall, said she did not know for sure why Resident #2 had a catheter. She said she thought it was due to skin issues related to her brief. She said, I don't know if it is an allergic reaction or not. She said she did not know Resident #2's history well because she had not been working on that hall for very long. When discussing that the physician's orders did not include an order for [REDACTED]. 32. During interviews with Resident #2 on 9/11/15 at 1:00 p.m. and 9/15/15 at 1:15 p.m., She was observed to have a Foley Catheter. When discussing with her why she had a catheter, she said, Because I stayed wet. She said, I was incontinent and I couldn't get them to change me. When asked how often they were providing incontinent care, she said, Not often enough. When asked if she was provided incontinent care at least every two hours, she said she was not. When discussing that the staff had suggested that Resident #2's rashes were a possible allergic reaction to her briefs, Resident #2 said that was not the reason for her rashes. She said she had worn briefs at home and had never had any problems. She said it was the briefs being wet that was the problem. Resident #2 said that before the facility inserted the catheter, she was continent and could ask to go to the restroom when she needed to go. She said she only had one leg, but that leg was strong and she was able to stand and go to the bathroom with assistance of staff. She said, I went one time though but no one came to help me off the commode so I had to use the emergency call light. If I use the call light it takes staff at least 30-40 minutes to respond so I no longer go to the restroom. Now she had a Foley catheter and they were transferring her with a mechanical lift. Resident #2 said she had had the catheter continuously since it was inserted in May 2015. Resident #2 said she had two areas of breakdown on her bottom. She added she was currently in physical therapy three times a week and felt she was getting stronger. Resident #2 complained that the catheter had caused her painful bladder spasms. She said that she would prefer not to have the catheter and to be going to the restroom again. She said, It doesn't take a brain surgeon to get me to the restroom and keep me from wetting myself. 33. In an interview on 9/16/15 at 11:45 a.m., Resident #2 was in her room, in her wheelchair. She said she was waiting for lunch and complained, My bottom is really hurting me, it hurts to sit in this wheelchair for long periods of time. The resident complained she stayed wet most of the time but staff were pretty good at keeping the creams on me for my rash. The resident said staff applied the creams twice a day. The resident added her physician's assistant saw her yesterday and really feels it is best to keep the catheter (Foley) left in until the rash is gone, otherwise it won't heal. The resident added the assistant was a very smart and we better listen to her. RESIDENT #3 1. Review of the undated admission face sheet documented Resident #3 was an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. 2. Record Review of the physician note dated 1/9/15 for Resident #3 noted, Pressure ulcer stage II. 3. An Admission Nursing Assessment for Resident #3 dated 1/15/15 documented that Resident #3 did not admit with a catheter in place. 4. Review of Daily Skilled Documentation Observation Report for Resident #3 noted: 1/15/15 at 8:43 p.m.- (new admit)- Incontinent/Catheter assessment: Frequently incontinent of bladder, occasionally incontinent of bowel, uses pads/brief, no catheter use, requires extensive assist of two people with using the toilet, potential candidate for bowel/bladder retraining, bowel and bladder retraining initiated, toilet schedule initiated, initiate plan of care. NOTE: there was no documentation Resident #3 had a toileting plan initiated nor was the care plan updated to reflect this. 5. Record Review of physician note dated 5/20/15 for Resident #3 showed- No skin breakdown. Diagnostic Impression: UTI, for which she is on Keflex. 6.Review of Resident #3's MDS dated [DATE] showed she was alert and oriented, required total assist of two staff for transfers and total assist of one staff for toileting, was incontinent of bowel and bladder and did not have an indwelling catheter. The resident was not on a toileting program. Additional [DIAGNOSES REDACTED]. Resident #3 was listed as at risk for pressure ulcers but did not have any. 7. Review of Resident #3's care plans documented: Admission Initial Plan of Care 1/15/15 - Pressure ulcer Stage II to right and left buttock. Two staff for transfers. Incontinent of bowel and bladder. Toilet per request, pads/brief. A problem dated 1/15/15 - urinary incontinence related to decreased mobility. The goal: Resident will not develop skin breakdown related to incontinence. The approaches: apply moisture barrier, provide incontinent care after each episode, report any signs of breakdown, weekly skin assessments. 8. Laboratory results for Resident #3 dated 5/8/15 documented a urinary tract infection of Escherichia coli. 9. Review of nurse's notes showed: 7/01/15 at 6:2 a.m.- CNA reported an opened sore to the right upper thigh. Ointment applied. 10. Review of a facility occurrence report dated 7/01/15 (regarding Resident #3): CNA reported an opened sore to the right upper thigh. Wound description: Open area other than ulcer- 1 x 0 x 0 house acquired. General follow up procedures written by ADON and entered 8/11/15 at 10:33 p.m. (41 days after the sore was identified) Resident had an open area to right gluteal fold that was in close proximity to the exterior lining of the brief, resident voids in large amounts and is incontinent. Dr notified of resident's wound and requested for Foley placement until area healed over. During the treatment of [REDACTED]. Recommendation that Foley only be in place until the wound on gluteal fold is resolved as to avoid any unnecessary urinary infections. Once wound is healed, Foley will be removed. 11. Record Review of physician note dated 7/1/15 for Resident #3 showed- She recently had an episode of UTI, which has been resolved. 12. Review of nurse's notes showed: 7/03/15 at 5:46 p.m.- Noted Stage II wound to right gluteal fold. Call placed to dr. New ordered received. OK to place Foley until wound is healed. 16Fr Foley placed. Resident tolerated Foley insertion well. 7/17/15 at 6:54 p.m. - Resident complains of pelvic pain. Changed Foley cath; 16Fr 10ml changed. 7/21/15 at 9:13 a.m.- Continues with Stage II to gluteal fold. Foley cath noted and draining clear yellow urine. 13. A Care Plan dated 7/23/15 included the following: A problem dated 7/24/15 - at risk for pressure ulcers but no documentation that she had a pressure ulcer. The goal: Resident's skin will remain intact. The approaches: avoid shearing the skin, conduct a systematic skin inspection on shower days and as needed, keep clean and dry, report any signs of breakdown, use absorbent-friendly pads/briefs to maintain personal hygiene and dignity, use moisture-barrier products to perineal area. 14. Review of nurse's notes dated 8/10/15 at 2:33 a.m. showed- Foley catheter patent draining clear yellow urine. Denies pain. Continues on antibiotic therapy for UTI (urinary tract infection). NOTE: This was the first mention of a UTI. Review of nurse's note dated 8/29/15 at 12:18 p.m. showed- 16Fr Foley cath placed to aid with healing of open area to right gluteal fold. May remove Foley when resolved. 15. An updated Care Plan documented on 9/10/15 - Resident requires an external catheter related to skin breakdown. The goal: will have 20Fr indwelling catheter care managed appropriately. The approaches: observe for leakage, avoid obstructions in the drainage, change catheter every month. (Note: Problem added by facility following inquiries from surveyor). 16. During an interview on 9/10/15 at 4:25 p.m. the DON said the facility did not have a process or program for assessing residents' needs for a toileting program to promote urinary continence. She said there were no toileting programs in place for any resident at the current time. When discussing why Resident #3 had a Foley catheter, the DON said that Resident #3 had a skin issue in the past, though it was not current. The DON said that Resident #3 had been prescribed Foley catheters off and on for skin issues. She said the skin issues were rash in the folds of her skin. When asked how the facility had tried to prevent the skin rashes and issues, the DON looked through Resident #3's chart and then walked away to attend to another matter. 17. Review of nurse's note dated 9/11/15 at 1:12 a.m. showed- late entry from 9/10/15 at 5:30 a.m. Resident's Foley leaking. Foley removed and re-inserted 20Fr Foley catheter. 18. During an interview on 9/11/15 at 9:25 a.m., the ADON said that Resident #3 had been given a Foley catheter because, She wets constantly and her skin stays macerated. The ADON said that the briefs were the problem and so they had the catheter in and kept briefs off the resident. When told that Resident #3 was observed to be wearing a brief the day before (9/10/15), the ADON said that she was not supposed to be wearing them. When asked if the facility had attempted any other interventions such as underwear with a pad, taking the resident to the restroom more frequently, or changing the resident's brief more frequently, the ADON and DON said they did not know if any other interventions such as regular underwear had been tried. 19. During an observation and interview on 9/11/15 at 1:15 p.m., Resident #3 was observed to have a Foley catheter. When asked why she had a catheter, she said it was because her bottom was sore. She said that she would get sores on the back where her buttocks and thigh met because the brief would rub it and irritate the skin. She said she still wore briefs and was wearing one at this time. She said before she had a catheter, her bottom stayed wet. When asked why, she said that the staff would not change her timely and they would tell her to go to the bathroom in her brief instead of taking her to the restroom. Resident #3 she was continent before the facility inserted the catheter and could tell when she needed to urinate. She said, Trouble is, you lose that sensation with a catheter. Resident #3 was also concerned that since she had a catheter and was transferred with a mechanical lift now instead of getting out of bed, that she would lose her strength and abilities that she once had. 20. On 9/14/15, after surveyor questions regarding Resident #3's indwelling catheter, a physician fax request dated 9/14/15 showed, Request order to discontinue Foley catheter due to no need. The physician replied, OK. 21. An updated care plan dated 9/15/15 showed - Resident #3 had 2 Stage II pressure ulcers, was lifted mechanically and was occasionally incontinent of bowel. (Note: Review of Resident #3's medical record, including all purged files in the medical record overflow, revealed documentation was unclear about Resident #3's history of pressure ulcers, such as when she had them and when they were healed in the past.) 22. Interview on 9/23/15 at 3:00 p.m., Resident #3 was in bed resting. She said she hasn't had any skin breakdown for a while. She added, there's a spot on my backside that breaks open then heals, back and forth. It's very tender back there and can break open easy. I am glad they got that awful catheter out of me. Review of an October 2010 policy, Behavioral Programs and Toileting Plans for Urinary Incontinence noted, in part: - Review the resident's care plan to assess for any special needs of the resident. - Conduct a thorough assessment of the resident and his or her environment to determine factors that may have contributed to any recent decline in urinary incontinence, for example: a change in the resident's medical condition, cognitive status or mobility; new or altered medication regimen; lack of staff familiarity with the resident's usual pattern of voiding; environmental impediments that affect the resident's continence. - Provide treatment and services to address factors that are potentially modifiable such as: manage pain, provide adaptive equipment for residents with mobility problems; remove or improve environmental impediments (lighting, distance to commode); review medication regimen and notify physician with any concerns. - Monitor record and evaluate information about the resident's bladder habits and continence or incontinence including: voiding patterns, associated pain, type of incontinence, level of incontinence and response to specific interventions. - Assess the resident for appropriateness of behavioral programs which promote urinary continence- the resident must possess some skill to be successful with specific interventions attempted. Staff must identify whether the resident can comprehend educational efforts and follow-through with instructions; identify the urge to urinate; potentially learn to control or inhibit the urge to void until reaching a toilet; physically contract the pelvic floor muscles to inhibit the flow of urine, lessen the urgency and respond to prompts to void. - The staff will document the results of the toileting trial in the resident's medical record. Review of a September 2010 policy, Urinary Continence and Incontinence - Assessment and Management noted, in part: - The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible; - Indwelling urinary catheters will be used sparingly, for appropriate indications only. As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence. Examples of such information may include a hospital discharge summary describing placement of an indwelling catheter during a recent hospital stay. Periodically staff will define each individual's level of continence, referring to the criteria in the Minimum Data Set. As part of the assessment, nursing staff will seek and document details related to continence. The nursing staff and physician will identify risk factors for becoming incontinent or for worsening of current incontinence. The evaluation will include a review of medications that might affect continence. If a resident is admitted with a newly placed indwelling catheter, he physician and staff will evaluate the potential for removing it. The physician and staff will address treatable causes or contributing factors related to incontinence. As indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. The physician will identify situations in which an indwelling urethral or suprapubic catheter are indicated, and will document why other alternatives are not feasible. Indwelling catheters shall not be used as a substitute for nursing care of the resident with urinary incontinence. A list of incontinent residents provide by the DON on 9/16/15 showed there were 40 incontinent residents.

Based on observation, interview and record review the facility failed to ensure 2 of 4 Residents (Resident #2 and #3) reviewed for indwelling catheters were not catheterized unless the resident's clinical condition demonstrated that catheterization was necessary; and failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible as evidenced by: A) Resident #2 was admitted on [DATE] without an indwelling urinary catheter, but had a catheter inserted on 5/4/15 due to a wound described only as an open area to her left posterior thigh which was documented as resolved on 5/28/15. Resident #2 continued to have an indwelling catheter continuously through 9/29/15 which resulted in Resident #2 suffering painful bladder spasms and a urinary tract infection; B) Resident #3 was admitted to the facility on [DATE] without an indwelling catheter, but had an indwelling Foley catheter placed on 7/3/15 due to a Stage II pressure ulcer to her right glueteal fold which did not clinically indicate the need for a catheter and which resulted in Resident #3 acquiring a urinary tract infection in August 2015. These deficient practices affected Resident #2 and #3 and placed 2 other residents with catheters at risk for abilities to maintain or regain continence, increased the risk for developing of or worsening of a urinary tract infection, [MEDICAL CONDITION], undue pain and discomfort, and possible trauma such as bleeding or accidental removal of the catheters or death. Findings include: RESIDENT #2 1. An undated admission face sheet for Resident #2 documented she was a [AGE] year-old female admitted to the facility on [DATE]. 2. An Initial Nursing Assessment dated 9/12/14 (likely re-admission) documented under Elimination that Resident #2 was continent at least 3x daily. 3. Consolidated Physician's orders for Resident #2 dated 8/1/15 through 9/30/15 documented that Resident #2's [DIAGNOSES REDACTED]. 4. Physician's progress notes from the Physician's assistant dated 5/04/15 documented .Wounds: Pressure area to back of left femur .Insert Foley catheter and leave indwelling and closed drainage system. 5. Nurses notes documented: 5/04/15 at 2:02 p.m. - Refer to dermatologist. May insert Foley catheter until wound resolves. 5/04/15 at 2:27 p.m. - Night nurse informed this nurse that resident had an open area to her left posterior thigh; is open with no drainage noted and no signs/symptoms of infection. Wound bed is red. 5/05/15 at 4:07 p.m. - Foley catheter inserted 16 Fr with 10 cc bulb. 5/05/15 at 4:14 p.m. - New order [MEDICATION NAME] cream apply to peri area BID until issue resolved. 5/05/15 at 6:36 p.m. - Family notified of new order for [MEDICATION NAME] cream and to bring some cotton panties for her, may be having an allergy to pull ups she's been wearing. 6. Progress note from the Physician's assistant dated 5/13/15 documented: .Wounds: Back of left leg (does not address Foley catheter). Progress note from the Physician's assistant dated 5/22/15 documented .The areas on posterior leg and open wounds are showing improvement since Foley catheter inserted, staff report affected areas (unknown word) anterior abdomen .Wounds: Skin area and drying and improving .Continue with Foley catheter . 7. Review of physician orders for Resident #2 dated 8/1/15 through 9/30/15 included an order with a begin date of 5/22/15 and end date as open ended of, Silva Sorb (silver) (OTC/over the counter) gel, extended release; amt: to back of legs and peri; topical. Special Instructions: to back of legs and peri area bid and prn for [DIAGNOSES REDACTED]. 8. Nurses note dated 5/28/15 at 2:13 p.m. - Foley catheter due to be changed 6/05/15. [MEDICATION NAME] cream placed in peri area. Wound on left back of thigh resolved. 9. A review of a Treatment Flow Sheet for Resident #2 dated 5/2/15 - 6/1/15 with page 1 of 1 at the bottom of the page revealed a treatment of [REDACTED]. A hand-written note on the Flow Sheet by LVN P documented, Resolved, DC'd (discontinued) 5/28/15. A review of a Treatment Flow Sheet for Resident #2 dated 6/1/15 - 6/30/15 with page 3 of 5 at the bottom of the page revealed a treatment order same as above, with a hand written note of Resolved under the last treatment documented on 6/6/15. 10. Progress note from the physician assistant for Resident #2 dated 7/1/15 documented:: Physician noted Resident #2 had a urinary tract infection, E.coli (Escherichia coli is a bacterium that can cause serious infections) and was started on antibiotics. 11. Nurses note dated 7/02/15 at 6:42 p.m. - Resident transferred from hospital via ambulance. Head to toe assessment done. Left BKA (below the knee) and excoriation to buttocks noted. Dr. gave new order to apply zinc oxide to buttocks BID (twice a day) and PRN (as needed). 16 Fr Foley in place draining dark yellow urine. 12. Review of physician's orders for Resident #2 dated 8/1/15 through 9/30/15 included an order with a begin date of 7/2/15 and end date as open ended of, [MEDICATION NAME] XL ([MEDICATION NAME] chloride tablet extended release 24 hr; 5 mg once a day. Note: These physician's consolidated orders did not include a physician's order for a Foley catheter or include physician's orders for catheter care. 13. Review of the medical record revealed no physician's consolidated orders for June, July, or August 2015. 14. In an interview on 9/11/15 at 12:50 p.m., the DON there were no consolidated physician's orders completed on any of the residents for June, July, or August 2015 so there would be none for Resident #2. 15. A care plan for Resident #2 dated 7/16/15 included the following: Problem start date: 7/2/15: Urinary incontinence: Functional urinary incontinence r/t immobility (requires the use of Hoyar x2 staff members for transfers. Goal: Resident will not develop skin breakdown related to incontinence Approaches included moisture barrier, check for incontinent episodes at least every two hours, ensure adequate bowel elimination, provide medications as ordered, monitor skin breakdown, and weekly body audit by charge nurse. Problem start date 7/24/15: Resident is at risk for pressure ulcers r/t (related to) immobility/debilitated state. Goal: Resident's skin will remain intact Approaches included to avoid shearing during movement, skin inspections, keep as clean and dry as possible, keep linens clean and dry, maintain head of bed at lowest degree of elevation, provide incontinent care after each incontinent episode ., report signs of skin breakdown, turn and reposition ., use absorbent skin-friendly pads/briefs ., use lifting device such as draw sheet to move resident, and use moisture barrier product . 16. Resident #2's care plan dated 7/16/15 did not address the need or indication for a Foley catheter. 17. Progress notes from the physician's assistant dated 7/23/15 documented .Continues with skin breakdown on buttocks and posterior legs and in abdominal fold .Using [MEDICATION NAME] cream to abd fold and zinc to buttocks. Areas are drying and showing improvement . 18. An MDS Assessment for Resident #2 dated 7/29/15 documented Resident #2 had a Brief Interview for Mental Status score of 14, indicating she was cognitively intact. Under Functional Status the assessment documented that Resident #2 required extensive assistance of two persons to transfer between surfaces, limited assistance of one person to dress, extensive assistance of one person to toilet; and was totally dependent with one person assistance for bathing. Resident #2 used a wheelchair for mobility. She had limited range of motion on the lower extremity of one side. The MDS assessment documented that Resident #2 was frequently incontinent of urine and occasionally incontinent of bowel. The MDS documented that Resident #2 did not have an indwelling catheter. 19. Progress notes from the physician's assistant dated 7/30/15 documented .Staff report is also having issues with bladder cramping and leaking around Foley catheter .Obtain UA (urinalysis) with C&S (culture and sensitivity). Order [MEDICATION NAME] (an [MEDICATION NAME] that prevents spasms in the muscles of the gut and bladder by relaxing them)20 mg tid (three times a day) x 7 (seven) days then dc (discontinue). 20. Nurse's note dated 7/30/15 at 6:55 a.m. - Complains of pain in bladder. Foley patent and draining clear yellow urine. [MEDICATION NAME] given for complaints of anxiety. 21. Review of lab results 7/31/15 for Resident #2 showed Proteus mirabilis positive (a significant urinary tract infection). 22. 7/31/15 at 2:56 a.m. - New order received to obtain UA/ C&S- obtained and sent to lab. New order to start [MEDICATION NAME] 20mg one tablet TID for 7 days for bladder spasms. 23. Nurse's note dated 8/01/15 at 4:18 p.m. - Foley leaking. Changed Foley. Skin red on buttocks near rectum, treated with creams per order. Resident complains of bladder spasms. Nurse's note dated 8/03/15 at 2:22 p.m. - Report result of UA/ C&S- new order for Rocephen 2 grams IM (antibiotic) for 2 days. 24. Review of Daily Skilled Documentation Observation Report documented by licensed nurses revealed they included the following: 8/13/15: Resident #2 did not have any pressure ulcers or rashes. The report showed the resident was frequently incontinent of bowel and bladder and that she used pads and/or a brief. 25. Progress note from the Phsyician assistant dated 8/27/15 documented: Wounds: Rash on posterior legs bilaterally .Continue to medicate rash on legs posterior . (Foley catheter not addressed in note). 26. Nurse's noted dated 9/01/15 at 2:21 a.m. - Resident has open area on frontal gluteal fold. Triple antibiotic placed. 27. Review of Daily Skilled Documentation Observation Report documented by licensed nurse's revealed they included the following: 9/06/15: Resident #2 did not have any pressure ulcers but was checked for abrasions, bruises and open [MEDICAL CONDITION] other than ulcers, rashes or cuts. The report showed the resident was continent of bowel and incontinent of bladder and had an indwelling catheter. 9/13/15: Resident #2 did not have any pressure ulcers (documented under skin integrity section; she had abrasions, bruises/ open [MEDICAL CONDITION] other than ulcers/ and rashes documented under Other skin problems or [MEDICAL CONDITION] present. She was documented as incontinent with an indwelling catheter. 28. Review of nurse's note dated 9/08/15 at 3:52 p.m. - New order front abdominal fold- clean with normal saline, pat dry, place [MEDICATION NAME] powder, place interdry cloth. Review of nurse's note dated 9/16/15 at 2:20 a.m. - Resident continues to have redness open area on frontal abdominal fold. Remove Foley when skin issues resolved. 29. A review of Resident #2's medical record revealed no assessments related to Resident #2's appropriateness for a toileting program, and no assessments related to the use of a Foley catheter. 30. During an interview on 9/11/15 at 10:40 a.m., when the DON provided a list of residents that had catheters, the DON was asked why Resident #2's physician's orders did not include the Foley catheter or catheter care. She said she did not know. 31. During an interview on 9/11/15 at 10:50 a.m., LVN P, who was charge nurse for Resident #2's hall, said she did not know for sure why Resident #2 had a catheter. She said she thought it was due to skin issues related to her brief. She said, I don't know if it is an allergic reaction or not. She said she did not know Resident #2's history well because she had not been working on that hall for very long. When discussing that the physician's orders did not include an order for [REDACTED]. 32. During interviews with Resident #2 on 9/11/15 at 1:00 p.m. and 9/15/15 at 1:15 p.m., She was observed to have a Foley Catheter. When discussing with her why she had a catheter, she said, Because I stayed wet. She said, I was incontinent and I couldn't get them to change me. When asked how often they were providing incontinent care, she said, Not often enough. When asked if she was provided incontinent care at least every two hours, she said she was not. When discussing that the staff had suggested that Resident #2's rashes were a possible allergic reaction to her briefs, Resident #2 said that was not the reason for her rashes. She said she had worn briefs at home and had never had any problems. She said it was the briefs being wet that was the problem. Resident #2 said that before the facility inserted the catheter, she was continent and could ask to go to the restroom when she needed to go. She said she only had one leg, but that leg was strong and she was able to stand and go to the bathroom with assistance of staff. She said, I went one time though but no one came to help me off the commode so I had to use the emergency call light. If I use the call light it takes staff at least 30-40 minutes to respond so I no longer go to the restroom. Now she had a Foley catheter and they were transferring her with a mechanical lift. Resident #2 said she had had the catheter continuously since it was inserted in May 2015. Resident #2 said she had two areas of breakdown on her bottom. She added she was currently in physical therapy three times a week and felt she was getting stronger. Resident #2 complained that the catheter had caused her painful bladder spasms. She said that she would prefer not to have the catheter and to be going to the restroom again. She said, It doesn't take a brain surgeon to get me to the restroom and keep me from wetting myself. 33. In an interview on 9/16/15 at 11:45 a.m., Resident #2 was in her room, in her wheelchair. She said she was waiting for lunch and complained, My bottom is really hurting me, it hurts to sit in this wheelchair for long periods of time. The resident complained she stayed wet most of the time but staff were pretty good at keeping the creams on me for my rash. The resident said staff applied the creams twice a day. The resident added her physician's assistant saw her yesterday and really feels it is best to keep the catheter (Foley) left in until the rash is gone, otherwise it won't heal. The resident added the assistant was a very smart and we better listen to her. RESIDENT #3 1. Review of the undated admission face sheet documented Resident #3 was an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. 2. Record Review of the physician note dated 1/9/15 for Resident #3 noted, Pressure ulcer stage II. 3. An Admission Nursing Assessment for Resident #3 dated 1/15/15 documented that Resident #3 did not admit with a catheter in place. 4. Review of Daily Skilled Documentation Observation Report for Resident #3 noted: 1/15/15 at 8:43 p.m.- (new admit)- Incontinent/Catheter assessment: Frequently incontinent of bladder, occasionally incontinent of bowel, uses pads/brief, no catheter use, requires extensive assist of two people with using the toilet, potential candidate for bowel/bladder retraining, bowel and bladder retraining initiated, toilet schedule initiated, initiate plan of care. NOTE: there was no documentation Resident #3 had a toileting plan initiated nor was the care plan updated to reflect this. 5. Record Review of physician note dated 5/20/15 for Resident #3 showed- No skin breakdown. Diagnostic Impression: UTI, for which she is on Keflex. 6.Review of Resident #3's MDS dated [DATE] showed she was alert and oriented, required total assist of two staff for transfers and total assist of one staff for toileting, was incontinent of bowel and bladder and did not have an indwelling catheter. The resident was not on a toileting program. Additional [DIAGNOSES REDACTED]. Resident #3 was listed as at risk for pressure ulcers but did not have any. 7. Review of Resident #3's care plans documented: Admission Initial Plan of Care 1/15/15 - Pressure ulcer Stage II to right and left buttock. Two staff for transfers. Incontinent of bowel and bladder. Toilet per request, pads/brief. A problem dated 1/15/15 - urinary incontinence related to decreased mobility. The goal: Resident will not develop skin breakdown related to incontinence. The approaches: apply moisture barrier, provide incontinent care after each episode, report any signs of breakdown, weekly skin assessments. 8. Laboratory results for Resident #3 dated 5/8/15 documented a urinary tract infection of Escherichia coli. 9. Review of nurse's notes showed: 7/01/15 at 6:2 a.m.- CNA reported an opened sore to the right upper thigh. Ointment applied. 10. Review of a facility occurrence report dated 7/01/15 (regarding Resident #3): CNA reported an opened sore to the right upper thigh. Wound description: Open area other than ulcer- 1 x 0 x 0 house acquired. General follow up procedures written by ADON and entered 8/11/15 at 10:33 p.m. (41 days after the sore was identified) Resident had an open area to right gluteal fold that was in close proximity to the exterior lining of the brief, resident voids in large amounts and is incontinent. Dr notified of resident's wound and requested for Foley placement until area healed over. During the treatment of [REDACTED]. Recommendation that Foley only be in place until the wound on gluteal fold is resolved as to avoid any unnecessary urinary infections. Once wound is healed, Foley will be removed. 11. Record Review of physician note dated 7/1/15 for Resident #3 showed- She recently had an episode of UTI, which has been resolved. 12. Review of nurse's notes showed: 7/03/15 at 5:46 p.m.- Noted Stage II wound to right gluteal fold. Call placed to dr. New ordered received. OK to place Foley until wound is healed. 16Fr Foley placed. Resident tolerated Foley insertion well. 7/17/15 at 6:54 p.m. - Resident complains of pelvic pain. Changed Foley cath; 16Fr 10ml changed. 7/21/15 at 9:13 a.m.- Continues with Stage II to gluteal fold. Foley cath noted and draining clear yellow urine. 13. A Care Plan dated 7/23/15 included the following: A problem dated 7/24/15 - at risk for pressure ulcers but no documentation that she had a pressure ulcer. The goal: Resident's skin will remain intact. The approaches: avoid shearing the skin, conduct a systematic skin inspection on shower days and as needed, keep clean and dry, report any signs of breakdown, use absorbent-friendly pads/briefs to maintain personal hygiene and dignity, use moisture-barrier products to perineal area. 14. Review of nurse's notes dated 8/10/15 at 2:33 a.m. showed- Foley catheter patent draining clear yellow urine. Denies pain. Continues on antibiotic therapy for UTI (urinary tract infection). NOTE: This was the first mention of a UTI. Review of nurse's note dated 8/29/15 at 12:18 p.m. showed- 16Fr Foley cath placed to aid with healing of open area to right gluteal fold. May remove Foley when resolved. 15. An updated Care Plan documented on 9/10/15 - Resident requires an external catheter related to skin breakdown. The goal: will have 20Fr indwelling catheter care managed appropriately. The approaches: observe for leakage, avoid obstructions in the drainage, change catheter every month. (Note: Problem added by facility following inquiries from surveyor). 16. During an interview on 9/10/15 at 4:25 p.m. the DON said the facility did not have a process or program for assessing residents' needs for a toileting program to promote urinary continence. She said there were no toileting programs in place for any resident at the current time. When discussing why Resident #3 had a Foley catheter, the DON said that Resident #3 had a skin issue in the past, though it was not current. The DON said that Resident #3 had been prescribed Foley catheters off and on for skin issues. She said the skin issues were rash in the folds of her skin. When asked how the facility had tried to prevent the skin rashes and issues, the DON looked through Resident #3's chart and then walked away to attend to another matter. 17. Review of nurse's note dated 9/11/15 at 1:12 a.m. showed- late entry from 9/10/15 at 5:30 a.m. Resident's Foley leaking. Foley removed and re-inserted 20Fr Foley catheter. 18. During an interview on 9/11/15 at 9:25 a.m., the ADON said that Resident #3 had been given a Foley catheter because, She wets constantly and her skin stays macerated. The ADON said that the briefs were the problem and so they had the catheter in and kept briefs off the resident. When told that Resident #3 was observed to be wearing a brief the day before (9/10/15), the ADON said that she was not supposed to be wearing them. When asked if the facility had attempted any other interventions such as underwear with a pad, taking the resident to the restroom more frequently, or changing the resident's brief more frequently, the ADON and DON said they did not know if any other interventions such as regular underwear had been tried. 19. During an observation and interview on 9/11/15 at 1:15 p.m., Resident #3 was observed to have a Foley catheter. When asked why she had a catheter, she said it was because her bottom was sore. She said that she would get sores on the back where her buttocks and thigh met because the brief would rub it and irritate the skin. She said she still wore briefs and was wearing one at this time. She said before she had a catheter, her bottom stayed wet. When asked why, she said that the staff would not change her timely and they would tell her to go to the bathroom in her brief instead of taking her to the restroom. Resident #3 she was continent before the facility inserted the catheter and could tell when she needed to urinate. She said, Trouble is, you lose that sensation with a catheter. Resident #3 was also concerned that since she had a catheter and was transferred with a mechanical lift now instead of getting out of bed, that she would lose her strength and abilities that she once had. 20. On 9/14/15, after surveyor questions regarding Resident #3's indwelling catheter, a physician fax request dated 9/14/15 showed, Request order to discontinue Foley catheter due to no need. The physician replied, OK. 21. An updated care plan dated 9/15/15 showed - Resident #3 had 2 Stage II pressure ulcers, was lifted mechanically and was occasionally incontinent of bowel. (Note: Review of Resident #3's medical record, including all purged files in the medical record overflow, revealed documentation was unclear about Resident #3's history of pressure ulcers, such as when she had them and when they were healed in the past.) 22. Interview on 9/23/15 at 3:00 p.m., Resident #3 was in bed resting. She said she hasn't had any skin breakdown for a while. She added, there's a spot on my backside that breaks open then heals, back and forth. It's very tender back there and can break open easy. I am glad they got that awful catheter out of me. Review of an October 2010 policy, Behavioral Programs and Toileting Plans for Urinary Incontinence noted, in part: - Review the resident's care plan to assess for any special needs of the resident. - Conduct a thorough assessment of the resident and his or her environment to determine factors that may have contributed to any recent decline in urinary incontinence, for example: a change in the resident's medical condition, cognitive status or mobility; new or altered medication regimen; lack of staff familiarity with the resident's usual pattern of voiding; environmental impediments that affect the resident's continence. - Provide treatment and services to address factors that are potentially modifiable such as: manage pain, provide adaptive equipment for residents with mobility problems; remove or improve environmental impediments (lighting, distance to commode); review medication regimen and notify physician with any concerns. - Monitor record and evaluate information about the resident's bladder habits and continence or incontinence including: voiding patterns, associated pain, type of incontinence, level of incontinence and response to specific interventions. - Assess the resident for appropriateness of behavioral programs which promote urinary continence- the resident must possess some skill to be successful with specific interventions attempted. Staff must identify whether the resident can comprehend educational efforts and follow-through with instructions; identify the urge to urinate; potentially learn to control or inhibit the urge to void until reaching a toilet; physically contract the pelvic floor muscles to inhibit the flow of urine, lessen the urgency and respond to prompts to void. - The staff will document the results of the toileting trial in the resident's medical record. Review of a September 2010 policy, Urinary Continence and Incontinence - Assessment and Management noted, in part: - The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible; - Indwelling urinary catheters will be used sparingly, for appropriate indications only. As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence. Examples of such information may include a hospital discharge summary describing placement of an indwelling catheter during a recent hospital stay. Periodically staff will define each individual's level of continence, referring to the criteria in the Minimum Data Set. As part of the assessment, nursing staff will seek and document details related to continence. The nursing staff and physician will identify risk factors for becoming incontinent or for worsening of current incontinence. The evaluation will include a review of medications that might affect continence. If a resident is admitted with a newly placed indwelling catheter, he physician and staff will evaluate the potential for removing it. The physician and staff will address treatable causes or contributing factors related to incontinence. As indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. The physician will identify situations in which an indwelling urethral or suprapubic catheter are indicated, and will document why other alternatives are not feasible. Indwelling catheters shall not be used as a substitute for nursing care of the resident with urinary incontinence. A list of incontinent residents provide by the DON on 9/16/15 showed there were 40 incontinent residents.

Based on observation, interview, and record review the Administrator and Director of Nurses (DON) failed to use facility resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 2 of 22 residents (Resident #1 and Resident #2) with full code status. (A) The DON failed to implement and monitor the facility's written policy for cardiopulmonary resuscitation (CPR) for Resident #1 and Resident #2 who were full codes. - Licensed Vocational Nurse (LVN) "A" immediately provided Resident #1, who was a full code resident (required CPR in the event of a cardiorespiratory arrest), cardiopulmonary resuscitation (CPR) and notify the 911 emergency medical service (EMS), the primary physician, and the responsible party on [DATE] when Resident #1 was found unresponsive and had no vital signs. Resident #1 died on [DATE]. - LVN "B" immediately provided Resident #2, who was a full code resident, CPR and notify Resident #2's primary physician on [DATE] when LVN "B" observed Resident #2 was unresponsive. LVN "B" left Resident #2's room to get RN "C". This resulted in a delay in starting CPR. Resident #2 died on [DATE]. This failure to perform CPR on Resident #1 and delaying CPR on Resident #2 who were Full Codes according to the physician's orders [REDACTED]. (B) The Administrator failed to investigate incidents to rule out if abuse or neglect had occurred. On [DATE] an Immediate Jeopardy was identified. On [DATE] the Immediate Jeopardy was lowered to actual harm at a pattern after the facility developed and implemented an action plan to remove the Immediate Jeopardy prior to exit. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. This failure could affect all 20 "full code" residents. For residents who have expressed their choice to receive CPR, this failure could result in the facility not honoring the residents' choices, resulting in death. The findings included: RESIDENT #1 Review of Resident #1's Admission Record documented Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was a [AGE] year old male. A review of Resident #1's clinical record revealed a green sheet with "CPR" at the front of the clinical records . (No Advance Directives or Out of Hospital DNR (Do Not Resuscitate) forms were located in Resident #1's clinical record to express Resident #1's code status choice). A review of Resident #1's start up physician's orders [REDACTED]. Review of Resident #1's Care Plan with start date of [DATE] documented in part: Problem: Resident wishes to be a "FULL CODE." Goal: Resident's wishes will be honored. Approach: 1. Verify wishes quarterly. 2. Resuscitate resident if the need arises. 3. Keep Code status on resident's chart. A review of Resident #1's Declaration of CPR form dated [DATE] it had been signed by Resident #1's wife and she did not want Resident #1 to have CPR. There were no witness signatures on the form making the form incomplete. A review of Resident #1's Patient Transfer Form dated [DATE] documented in part: Transferred to local hospital due to vomiting and diarrhea. Under code status documented "Full Code." A review of Resident #1's Physician's Telephone Orders dated [DATE] documented in part: Readmit to facility and resume all previous orders. Hospice to evaluate and treat. There was no documentation that orders for DNR were written. A review of Resident #1's Physician's Telephone Orders, dated [DATE], documented to admit to hospice for palliative care. There was no documentation that stated DNR on the order. A review of Resident #1's Skilled Daily Nurses Notes dated [DATE] at 6:35 a.m. documented Certified Nurse Aide (CNA) "G" called LVN "A" to resident's room. Upon assessment resident noted with no apical pulse, no respirations, no blood pressure, temperature 92.0 ax (Axillary - under the arm). Skin noted to be "Mottled." ( blood vessel changes in the skin which cause a patchy appearance ) Capillary beds purple. Skin cold to touch. LVN "A" contacted hospice nurse who stated, "I am on my way." "Post Mortal" (postmortem) care provided. Hospice nurse stated, "I will call the family." (There was no documentation that LVN "A" started CPR, called 911, the primary physician, or the responsible party to notify them of Resident #1's change of condition.) A review of Resident #1's Skilled Daily Nurses Notes dated [DATE] at 6:40 a.m. LVN "A" contacted the the facility nurse manager (LVN) on call and the on-call physician for the primary physician to report Resident #1 had deceased . A review of Resident #1's Skilled Daily Nurses Notes dated [DATE] at 7:10 a.m., (35 minutes later) LVN "A" documented hospice nurse in with the family. In an interview on [DATE] at 10:35 a.m. Hospice RN "I" stated Resident #1's wife admitted him to hospice care and had signed an Out of Hospital DNR on [DATE] but Resident #1 died before it could be signed by the primary physician. (Making the form incomplete and not valid) Hospice RN "I" confirmed LVN "A" contacted her and she informed him it was too late to start CPR based on his assessment. Hospice RN "I" acknowledged the DNR order was not in place at the time of Resident #1's death and Resident #1 was still a full code to resuscitate. In an interview on [DATE] at 10:50 a.m. the DON acknowledged LVN "A" should have started CPR, notified 911 EMS, contacted the primary physician and the responsible party of Resident #1's change in condition. The DON stated LVN "A" was no longer working at the facility. In an interview on [DATE] at 2:00 p.m. LVN "A" confirmed he was no longer working for the facility. LVN "A" revealed that on [DATE] he went to Resident #1's room and found Resident #1 with no pulse, heart beat, or respirations. LVN "A"confirmed he was aware Resident #1 was still a full code on [DATE] even though the orders for an (Out of Hospital DNR) had been signed by the family on [DATE] was not back signed by the physician. LVN "A" stated he called the hospice nurse who told him she would be in and notify the family and the physician. LVN "A" acknowledged he did not start CPR, notify 911 EMS, or the responsible party of Resident #1's condition. LVN "A" stated the hospice nurse told him it was too late to start CPR. LVN "A" revealed he contacted the on-call physician of Resident #1 death after the fact. (At 6:40 a.m.) In an interview on [DATE] at 10:25 a.m. a DON from a sister facility, assisting the facility's DON, stated there was hospice information for Resident #1 in his hospice chart that supported the wishes of the family and the staff was aware of the wishes which supported that CPR was not to be initiated. The assisting DON acknowledge an LVN cannot make an determination to not to start or halt CPR. The assisting DON later confirmed the additional hospice information had not been in Resident #1's hospice chart in the facility but had been "given to the facility this morning from the hospice agency". In an interview on [DATE] at 10:30 a.m. the administrator confirmed the incidents involving Resident #1 and Resident #2 had not been investigated prior to the survey and he acknowledged that all incidents must be thoroughly investigated to rule out abuse or neglect and further stated it will be part of the facility's plan of action that the administrator and DON will be notified of each code and when a resident expires. RESIDENT #2 Review of Resident #2's Admission Record documented Resident #2 was admitted to the facility on [DATE]. Resident #2 was a [AGE] year old male. Review of Resident #2's Annual Physical/Initial Intake form, dated [DATE], documented [DIAGNOSES REDACTED]. A review of Resident #2's clinical record revealed a green sheet with "FULL CODE" at the front of the clinical records . No Advance Directives or Out of Hospital DNR forms were located in Resident #2's clinical record to express Resident #2's code status choice. A review of Resident #2's Declaration of CPR form, dated [DATE], it had been signed by Resident #2's daughter documenting that she did not want Resident #2 to have CPR. Review of Resident #2's Care Plan with a print date of [DATE] and a signed date of [DATE] revealed no care plan to address Resident #2's code status choice. A review of Resident #2's start up physician's orders [REDACTED]. A review of Social Service Progress Note dated [DATE] documented the social worker contacted Resident #2's daughter about options for hospice services and code status. The social worker explained to Resident #2's daughter he was a full code and did not have any directives. The social worker explained to Resident #2's daughter that he would remain a full code until a DNR was completed in which the daughter voiced understanding. A review of Resident #2's Skilled Daily Nurses Note, dated [DATE] at 7:00 p.m., RN "C" documented: Called to floor to assess resident. Noted resident to have no pulse, heart beat, pupils fixed, no blood pressure, skin cold to touch. 911 notified. Daughter notified and stated "if he's already gone, no CPR." Resident deceased at 7:00 p.m. Had full code status in chart. Attempted CPR until LVN "B" entered room and told us "She (daughter) doesn't want him touched. She is on her way." Stopped CPR/code procedures. EMS here, informed of daughter's request for no CPR or transport. There was no documentation the primary physician was notified of Resident #2's change in condition until after Resident #2 had died . A review of the EMS Patient Care Record, dated [DATE] at 7:18 p.m., documented Resident #2 in part: 3-Lead ECG (electrocardiogram): Asystole (absence of heartbeat). Mental Status: Unresponsive. Skin: Lividity (settling of the blood in the lower (dependent) portion of the body, causing a purplish red discoloration of the skin). Narrative: Rescue 3 and Engine 3 responded to a priority 1 [MEDICAL CONDITION]. Pt was found Apneic (not breathing) and Pulseless with rigor mortis (muscular stiffening) set in and Lividity was present. Pads were placed on patient and ECG showed Asystole. Strip was printed out and patient was declared deceased and Rescue 3 returned to service. RN signature was obtained on refusal of service for due to no transport. A review of Resident #2's Skilled Daily Nurses Note (not dated or timed) LVN "B" documented: Dr.___ notified, on call for Dr.___ (primary physician) informed her of resident's status. Stated "Ok" and thank you for calling. RN "C" to pronounce. Waiting for family to get to facility, postmortem care done. A review of Resident #2's Expiration Discharge Nurse's Notes, dated [DATE], documented RN "C" pronounced Resident #2's death at 7:10 p.m. and the on-call physician was notified at 8:00 p.m. (50 minutes after Resident #2 had died ). In an interview on [DATE] at 4:50 p.m. RN "C" said on [DATE] about 7:00 p.m. she was on hall 4 passing medications when LVN "B" came down the hall and stated Resident #2 appeared dead. RN "C" stated she grabbed her stethoscope, the crash cart and with two aides went to Resident #2's room. LVN "B" informed RN "C" that Resident #2 was a full code (requiring resuscitation). RN "C" stated she started CPR and LVN "B" went to call 911 and the responsible party. RN "C" revealed LVN "B" returned to the room and stated Resident #2's family does not want CPR. RN "C" stated EMS (emergency medical services) entered Resident #2's room around 7:20 p.m. and took over. The EMT placed ECG pads on Resident #2 and observed a flat line (no heart beats). EMS told RN "C" that Resident #2 was dead and rigor mortis had already set in (explaining when the EMS had leaned Resident #2 up to apply ECG pads he noted rigor mortis). LVN "B" told EMS that the family did not want CPR. RN "C" stated one of the EMS personnel had her sign a piece of paper about not transporting the body. In an interview on [DATE] at 5:35 p.m. LVN "B" revealed she was the charge nurse assigned to Resident #2's care working the 6 p.m. to 6 a.m. shift on [DATE]. LVN "B" stated on [DATE] around 7:00 p.m. CNA "D" informed her that something was wrong with Resident #2. LVN "B" went to resident's room and found him slumped down in the bed with his feet hanging off the bed. LVN "B" stated she helped CNA "D" get him back in bed and then shook him. LVN "B" stated she went down to Hall 4 (LVN "B" left Resident #2 instead of sending an aide which delayed the CPR response time) and got RN "C" who got the crash cart, went to Resident #2's room and started CPR. LVN "B" stated she contacted 911 and Resident #2's responsible party. LVN "B" stated she was on the phone with the responsible party when the EMS arrived and she informed them and RN "C" the family does not want to continue with CPR. LVN "B" stated the EMS were wanting to work the code and asked if the family had a POA (power of attorney) or was there a DNR order. LVN "B" informed the EMS, the family was working on getting a POA and a DNR order. LVN "B" stated she thought the family had obtained a POA and a DNR order but acknowledged there were no POA or DNR orders in Resident #2's chart and the full code should have been completed. LVN "B" stated she contacted the on-call physician around 8:00 p.m. of Resident #2's change of condition. (1 hour after Resident #2 had died ). In an interview on [DATE] at 6:15 p.m. the Administrator and DON acknowledged the LVN "A" should have started CPR on Resident #1 and called 911, the physician and the responsible party on his change of condtion. The Administrator and DON acknowledged the nurses should have called the physician on Resident #2's change of conditions and followed the physician's full code (CPR) order regardless of the family once CPR was started and if there were no DNR orders in Resident #2's records. The DON stated there had been no inservices or training on code status procedures done since January of 2010. In an interview on [DATE] at 8:50 a.m. Resident #2's daughter acknowledged they were in the process of obtaining a POA and getting a DNR order for Resident #2 but they did not get it completed before at the time of Resident #2's cardiopulmonary arrest. The daughter acknowledged that she told nurse to stop CPR if he did not have a heart beat or pulse. On [DATE] at 3:00 p.m. an Immediate Jeopardy was identified related to Resident #1 and Resident #2 and the Administrator and Director of Nurses (DON) were informed. In an interview on [DATE] at 10:25 a.m. CNA "D" said he had worked prn (as needed) at the facility since [DATE]. CNA "D" said he worked on [DATE]. He said about 7:00 p.m. he was putting residents to bed and helping on Hall 3. He said he walked by Resident #2's room and noticed his legs were against the rail with his feet hanging off the bed. He said he went and asked LVN "B" to check on him. He said LVN "B" checked Resident #2, he was unresponsive, then LVN "B" went to get RN "C". He said RN "C" came and LVN "B" went to call 911. CNA "D" said he helped RN "C" put the orange board under the resident. He said then RN "C" covered the residents legs with the sheet. He said RN "C" pushed on the resident's chest 3 or 4 times, took out the balloon thing (ambu bag) and gave him breaths. He said then RN "C" pushed on the residents chest and CNA "F" did the balloon thing. He said RN "C" was still pushing on the resident's chest when the paramedic came. He said the paramedic told her to stop, then he put the pads on the resident that was hooked up to a machine. CNA "D" said he left the room after the paramedics got there. He said no one at the facility had questioned him about this incident. In an interview on [DATE] at 7:02 p.m. CNA "F" acknowledged she worked on [DATE] on the 6 p.m. to 6 a.m. shift. CNA "F" stated she saw Resident #2 alive around 6 p.m. and he was calling out for his daughter. CNA "F" stated around 7 p.m., CNA "D" came up to her and said something was wrong with Resident #2. LVN "B" ran and got RN "C" and the crash cart. CNA "F" stated her, CNA "D" and CNA "H" were in the room and observed Resident #2 was already "blue." RN "C" started CPR and was doing chest compression and CNA "H" was doing the ambu bag (respiratory device) on Resident #2. CNA "F" stated she left the room when the EMS got there but remained outside the door. LVN "B" came into the room and informed the EMT's that the family does not want to continue CPR. CNA "F" stated the EMT "hooked him up" and stated he had been "gone" (deceased ) for a while. In an interview on [DATE] at 2:28 p.m. CNA "H" acknowledged she worked on [DATE] on the 6 p.m. to 6 a.m. shift. CNA "H" stated LVN "B" came and got her and RN "C", got the crash cart and went to Resident #2's room. CNA "H" observed Resident #2 slumped down in the bed and she help to get him repositioned. CNA "H" stated Resident #2 already looked dead and was blue. RN "C" instructed her on how to use an ambu bag while she did chest compressions. CNA "H" stated the EMT's came into Resident #2's room while RN "C" was doing CPR and they stated he was already gone and they were not going to continue CPR. LVN "B" came into the room and stated the family does not want CPR. In an interview on [DATE] at 2:00 p.m. Emergency Medical Technician (EMT) "J" acknowledge he and another EMT "K" were assigned the ambulance run to the facility in regards to Resident #2 [MEDICAL CONDITION] on [DATE] around 7:15 p.m. EMT "J" stated his partner, EMT "K", was first in the resident's room while he was talking to an nurse (LVN "B") who was on the phone with Resident #2's POA. EMT "J" stated he was informed by LVN "B" that the family does not want to continue CPR. EMT "J" asked LVN "B" if the family was the POA and was there a DNR order to stop the code. LVN "B" stated the family was the POA. EMT "J" stated he did not see staff working CPR on Resident #2 when he entered the room and EMT "K" had placed ECG pads on Resident #2 which was showing a flat line (no heart beats). EMT "J" observed Resident #2 on the bed with a CPR board under his back and his shirt was off. EMT "J" stated Resident #2 had "obvious death" signs which included rigormortis of the jaw and the small of the back. EMT "J" stated EMT's can make decisions when obvious death signs are present to pursue or stop CPR. In an interview on [DATE] at 6:45 p.m. EMT "K" acknowledged he and EMT "J" were assigned the ambulance run to the facility in regards to Resident #2 [MEDICAL CONDITION] on [DATE]. EMT "K" stated he was first in the resident's room while his partner was talking to the nurse at the nurses station who was on the phone with the POA. EMT "K" stated there was no "CPR in progress" when he entered Resident #2's room but observed two staff in the room by Resident #2's bed. EMT "K" stated he observed rigor in Resident #2's jaw and back and thought Resident #2 had been gone a while. He stated he applied the ECG pads and noted the flat line and he stated Resident #2 was Asystole. EMT "K" stated a young nurse came in and stated the family who had POA did not want CPR. EMT "K" stated EMT's can make decisions when obvious death signs are present to pursue or stop CPR. In an interview on [DATE] at 4:30 p.m. the primary physician of Resident #1 and Resident #2 acknowledged there were no DNR orders that had been written or signed by him and Resident #1 and Resident #2 were still full codes at the time of their death. The primary physician stated he did not think Resident #1 or Resident #2 were good candidates for CPR but acknowledged the DNR orders were not in place so the nurses should have followed the full code orders. The primary physician stated the nurses were outside of their scope of practice. "They need more training." (On following physician's orders [REDACTED]. During an interview on [DATE] at 12:00 p.m. the Administrator and RN Vice President of Clinical said a formal investigation had not been done. The RN said "we were not aware of the incident and don't know why we would be doing a formal investigation." The Administrator said "we did not do a formal investigation but now we have things in place to catch things in our stand up meetings, 24 hour reports and if a resident dies. (If the facility had done an investigation on Resident #1 it may had prevented the incident with Resident #2). A review of facility's policy, Resident Abuse/Neglect/Exploitation/Misappropriation of Resident Property/Involuntary Seclusion/Corporal Punishment dated [DATE], documented in part: Definitions: "Neglect" means failure to provide goods and services to avoid physical harm, mental anguish, or mental illness. Policy: All incidents including those of unknown origins will be thoroughly investigated. Potential abuse or neglect will be prevented during investigation. Results of investigation will be reported to the Facility Administrator or designee and other officials in accordance with Texas law. A written report, if appropriate, will be sent to the "Texas Department of Human Services (TDHS)" within five (5) days following the verbal report, in accordance with applicable laws. Procedure: The Facility Administrator will conduct an internal investigation into all allegations of abuse, neglect or mistreatment. Member(s) of Administration as representatives of the Quality Assurance Committee will interview the individual(s) involved in the allegation. Results of the interview will be held until all parties have been interviewed. The report will be written by member(s) of Administration and stamped "Committee Privileged." Record review of the facility's Cardiopulmonary Resuscitation (CPR) policy dated [DATE] documented in part: In the case of an un-witnessed resident arrest without an Advance Directive, and the responsible party has not clarified preference, call 911, the physician, and the responsible party. Documentation: Time of arrest, who discovered the resident unresponsive. Resident's condition: (absence of breathing and pulse, other signs/symptoms noted at that time). Any treatment administered to the resident. Time the call was placed to the physician including orders/instructions, 911, and the responsible party. Time CPR initiated and EMS arrived. Resident's condition at the time of transfer to the hospital. A review of the facility's policy, Emergency Physicians' Services dated [DATE], documented in part: Procedure: In a medical emergency when a physician is needed, the attending physician is to be called. If the attending physician cannot be reached, the alternate physician must be called. In the event of a serious emergency when neither of the above can be reached, the Medical Director may be called. On [DATE] at 2:30 p.m., the facility developed and implemented an action plan to remove the immediate jeopardy. The facility's plan was as follows: 1. Resident Rights - failure to notify Physician of Change of Condition. -Nurses will be inserviced immediately on the steps to take when calling a code. -Nurses will complete post test regarding the process of calling a code. -Policy and Procedure for performing a code will be reviewed with the licensed nurses. -Remaining nursing staff will be inserviced on their roll during a code. -CPR training for nurses will be arranged through local qualified personnel/vendor. -Immediate review of charts to insure code status matches orders, required paperwork and care plans. -Review of clinical record within 24 hours, of residents that die to insure Policy and Procedure followed. -Nurses will immediately notify the DON and Administrator by phone, of the death of a resident. -Review current Policy and Procedure regarding CPR and Change of Condition to assure inclusion of the following procedures; screening, training, resident protection, identification, investigation and required reporting. In service direct care staff on changes in Policy and Procedure. -Track CPR certification of licensed nurses to assure current certificates. 2. Administration - monitor the campus in a manner to maintain the highest practicable physical, mental, psychosocial well being. -campus administration will be in-serviced on the requirement of monitoring the campus staff to insure residents receive care that promotes their highest level of independence and well being. -Charge nurses will be in-serviced on reporting/recording a change in residents condition through nurses notes and the 24 hour report. -CNA's will be in-serviced on the reporting of a decline in a residents condition to the charge nurse, inservicing to new staff members during orientation. -SW will follow up with Advance Directive request and immediately inform nursing management/charge nurses of need for DNR order. 3. Resident Assessment - following the Standards of Practice for Nursing or Nurse Practice Act during the performance of CPR. Quality of Care - not following the Standards of Practice for Nursing and the Nurse Practice Act during the performance of CPR. -Licensed Nurses in-serviced immediately on the requirements for performing CPR. -CPR training to be arranged through local qualified vendors for licensed nurse. -New CPR training to be arranged for new charge nurses that do not have current CPR certificates. -Track CPR Certification for Licensed Nurses to assure certification is current. -Nursing Management will communicate changes in Code status through the 24 hour report, Resident's POC, documented status on crash cart. 4. Resident behavior - Reporting Abuse, Neglect. -Nursing staff will be in-serviced on the Policy and Procedure for reporting Abuse and Neglect and a copy will be made available for staff to refer to. -Management staff will be in-serviced on investigating and reporting of Abuse and Neglect. -Nurses will be in-serviced on the Standards of Practice for Nurses and the stipulations of the Nurse Practice Act with regards to the death of resident and performing a code. -Clinical records of residents that die will be reviewed within 24 hours to insure that care and services delivered were appropriate to regulations, physician's orders [REDACTED]. -Inservice direct care staff on Policy and Procedure for identifying and reporting potential abuse/neglect. Observation, interview and record review confirmed the facility began implementation of the plan which reduced the scope and severity to actual harm at a pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The Immediate Jeopardy was lifted [DATE] at 12:00 p.m. Record review of Census Daily Detail dated [DATE] documented the facility had 20 Full Code residents. The facility was given the opportunity to provide additional information during the exit conference on [DATE] and none was provided.

Based on observation, interview, and record review, the facility failed to implement their policy and procedure to prohibit neglect related to Cardiopulmonary Resuscitation (CPR) for 2 of 22 residents (Resident #1 and Resident #2) with full code status. The facility failed to ensure: (A) Licensed Vocational Nurse (LVN) "A" immediately provided Resident #1, who was a full code resident (required CPR in the event of a cardiorespiratory arrest), cardiopulmonary resuscitation (CPR) and notify the 911 emergency medical service (EMS), the primary physician, and the responsible party on [DATE] when Resident #1 was found unresponsive and had no vital signs. Resident #1 died on [DATE]. (B) LVN "B" immediately provided Resident #2, who was a full code resident, CPR and notify Resident #2's primary physician on [DATE] when LVN "B" observed Resident #2 was unresponsive. LVN "B" left Resident #2's room to get RN "C". This resulted in a delay in starting CPR. Resident #2 died on [DATE]. On [DATE] an Immediate Jeopardy was identified. On [DATE] the Immediate Jeopardy was lowered to actual harm at a pattern after the facility developed and implemented an action plan to remove the Immediate Jeopardy prior to exit. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. This failure could affect all 20 "full code" residents. For residents who have expressed their choice to receive CPR, this failure could result in the facility not honoring the residents' choices, resulting in death. The findings included: RESIDENT #1 Review of Resident #1's Admission Record documented Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was a [AGE] year old male. A review of Resident #1's clinical record revealed a green sheet with "CPR" at the front of the clinical records . No Advance Directives or Out of Hospital DNR (Do Not Resuscitate) forms were located in Resident #1's clinical record to express Resident #1's code status choice. A review of Resident #1's start up physician's orders [REDACTED]. Review of Resident #1's Care Plan with start date of [DATE] documented in part: Problem: Resident wishes to be a "FULL CODE." Goal: Resident's wishes will be honored. Approach: 1. Verify wishes quarterly. 2. Resuscitate resident if the need arises. 3. Keep Code status on resident's chart. A review of Resident #1's Declaration of CPR form, dated [DATE], it had been signed by Resident #1's wife and she did not want Resident #1 to have CPR. There were no witness signatures on the form making the form incomplete. A review of Resident #1's Patient Transfer Form, dated [DATE], documented in part: Transferred to local hospital due to vomiting and diarrhea. Under code status documented "Full Code." A review of Resident #1's Physician's Telephone Orders, dated [DATE], documented in part: Readmit to facility and resume all previous orders. Hospice to evaluate and treat. There was no documentation that orders for DNR were written. A review of Resident #1's Physician's Telephone Orders, dated [DATE], documented to admit to hospice for palliative care. There was no documentation that stated DNR on the order. A review of Resident #1's Skilled Daily Nurses Notes, dated [DATE] at 6:35 a.m., documented Certified Nurse Aide (CNA) "G" called LVN "A" to resident's room. Upon assessment resident noted with no apical pulse, no respirations, no blood pressure, temperature 92.0 ax (Axillary - under the arm). Skin noted to be "Mottled." (blood vessel changes in the skin which cause a patchy appearance ) Capillary beds purple. Skin cold to touch. LVN "A" contacted hospice nurse who stated, "I am on my way." "Post Mortal" (postmortem) care provided. Hospice nurse stated, "I will call the family." There was no documentation that LVN "A" started CPR, called 911, the primary physician, or the responsible party to notify them of Resident #1's change of condition. A review of Resident #1's Skilled Daily Nurses Notes, dated [DATE] at 6:40 a.m., LVN "A" contacted the the facility nurse manager (LVN) on call and the on-call physician for the primary physician to report Resident #1 had deceased . A review of Resident #1's Skilled Daily Nurses Notes, dated [DATE] at 7:10 a.m., (35 minutes later) LVN "A" documented hospice nurse in with the family. In an interview on [DATE] at 10:35 a.m. Hospice RN "I" stated Resident #1's wife admitted him to hospice care and had signed an Out of Hospital DNR on [DATE] but Resident #1 died before it could be signed by the primary physician. (Making the form incomplete and not valid) Hospice RN "I" confirmed LVN "A" contacted her and she informed him it was too late to start CPR based on his assessment. Hospice RN "I" acknowledged the DNR order was not in place at the time of Resident #1's death and Resident #1 was still a full code to resuscitate. In an interview on [DATE] at 10:50 a.m. the DON acknowledged LVN "A" should have started CPR, notified 911 EMS, contacted the primary physician and the responsible party of Resident #1's change in condition. The DON stated LVN "A" was no longer working at the facility. In an interview on [DATE] at 2:00 p.m. LVN "A" confirmed he was no longer working for the facility. LVN "A" revealed that on [DATE] he went to Resident #1's room and found Resident #1 with no pulse, heart beat, or respirations. LVN "A" confirmed he was aware Resident #1 was still a full code on [DATE] even though the orders for an (Out of Hospital DNR) had been signed by the family on [DATE] but was not back signed by the physician. LVN "A" stated he called the hospice nurse who told him she would be in and notify the family and the physician. LVN "A" acknowledged he did not start CPR, notify 911 EMS, or the responsible party of Resident #1's condition. LVN "A" stated the hospice nurse told him it was too late to start CPR. LVN "A" revealed he contacted the on-call physician of Resident #1 death after the fact. (At 6:40 a.m.) In an interview on [DATE] at 10:25 a.m. a DON from a sister facility, assisting the facility's DON, stated there was hospice information for Resident #1 in his hospice chart that supported the wishes of the family and the staff was aware of the wishes which supported that CPR was not to be initiated. The assisting DON acknowledge an LVN cannot make an determination to not to start or halt CPR. The assisting DON later confirmed the additional hospice information had not been in Resident #1's hospice chart in the facility but had been "given to the facility this morning from the hospice agency." RESIDENT #2 Review of Resident #2's Admission Record documented Resident #1 was admitted to the facility on [DATE]. Resident #2 was a [AGE] year old male. Review of Resident #2's Annual Physical/Initial Intake form, dated [DATE], documented [DIAGNOSES REDACTED]. A review of Resident #2's clinical record revealed a green sheet with "FULL CODE" at the front of the clinical records . No Advance Directives or Out of Hospital DNR forms were located in Resident #2's clinical record to express Resident #2's code status choice. A review of Resident #2's Declaration of CPR form, dated [DATE], it had been signed by Resident #2's daughter documenting that she did not want Resident #2 to have CPR. Review of Resident #2's Care Plan with a print date of [DATE] and a signed date of [DATE] revealed no care plan to address Resident #2's code status choice. A review of Resident #2's start up physician's orders [REDACTED]. A review of Social Service Progress Note dated [DATE] documented the social worker contacted Resident #2's daughter about options for hospice services and code status. The social worker explained to the daughter that he was a full code and did not have any directives. The social worker explained to Resident #2's daughter that he would remain a full code until a DNR was completed in which the daughter voiced understanding. A review of Resident #2's Skilled Daily Nurses Note, dated [DATE] at 7:00 p.m., RN "C" documented: Called to floor to assess resident. Noted resident to have no pulse, heart beat, pupils fixed, no blood pressure, skin cold to touch. 911 notified. Daughter notified and stated "if he's already gone, no CPR." Resident deceased at 7:00 p.m. Had full code status in chart. Attempted CPR until LVN "B" entered room and told us "She (daughter) doesn't want him touched. She is on her way." Stopped CPR/code procedures. EMS here, informed of daughter's request for no CPR or transport. There was no documentation the primary physician was notified of Resident #2's change in condition until after Resident #2 had died . A review of the EMS Patient Care Record dated [DATE] at 7:18 p.m., documented Resident #2 in part: 3-Lead ECG (electrocardiogram): Asystole (absence of heartbeat). Mental Status: Unresponsive. Skin: Lividity (settling of the blood in the lower (dependent) portion of the body, causing a purplish red discoloration of the skin). Narrative: Rescue 3 and Engine 3 responded to a priority 1 [MEDICAL CONDITION]. Pt was found Apneic (not breathing) and Pulseless with rigor mortis (muscular stiffening) set in and Lividity was present. Pads were placed on patient and ECG showed Asystole. Strip was printed out and patient was declared deceased and Rescue 3 returned to service. RN signature was obtained on refusal of service for due to no transport. A review of Resident #2's Skilled Daily Nurses Note (not dated or timed) LVN "B" documented: Dr.___ notified, on call for Dr.___ (primary physician) informed her of resident's status. Stated "Ok" and thank you for calling. RN "C" to pronounce. Waiting for family to get to facility, postmortem care done. A review of Resident #2's Expiration Discharge Nurse's Notes, dated [DATE], documented RN "C" pronounced Resident #2's death at 7:10 p.m. and the on-call physician was notified at 8:00 p.m. (50 minutes after Resident #2 had died ). In an interview on [DATE] at 4:50 p.m. RN "C" said on [DATE] about 7:00 p.m. she was on hall 4 passing medications when LVN "B" came down the hall and stated Resident #2 appeared dead. RN "C" stated she grabbed her stethoscope, the crash cart and with two aides went to Resident #2's room. LVN "B" informed RN "C" that Resident #2 was a full code (requiring resuscitation). RN "C" stated she started CPR and LVN "B" went to call 911 and the responsible party. RN "C" revealed LVN "B" returned to the room and stated Resident #2's family does not want CPR. RN "C" stated EMS (emergency medical services) entered Resident #2's room around 7:20 p.m. and took over. The EMT placed ECG pads on Resident #2 and observed a flat line (no heart beats). EMS told RN "C" that Resident #2 was dead and rigor mortis had already set in (explaining when the EMS had leaned Resident #2 up to apply ECG pads he noted rigor mortis). LVN "B" told EMS that the family did not want CPR. RN "C" stated one of the EMS personnel had her sign a piece of paper about not transporting the body. In an interview on [DATE] at 5:35 p.m. LVN "B" revealed she was the charge nurse assigned to Resident #2's care working the 6 p.m. to 6 a.m. shift on [DATE]. LVN "B" stated on [DATE] around 7:00 p.m. CNA "D" informed her that something was wrong with Resident #2. LVN "B" went to resident's room and found him slumped down in the bed with his feet hanging off the bed. LVN "B" stated she helped CNA "D" get him back in bed and then shook him. LVN "B" stated she went down to Hall 4 (LVN "B" left Resident #2 instead of sending an aide which delayed the CPR response time) and got RN "C" who got the crash cart, went to Resident #2's room and started CPR. LVN "B" stated she contacted 911 and Resident #2's responsible party. LVN "B" stated she was on the phone with the responsible party when the EMS arrived and she informed them and RN "C" the family does not want to continue with CPR. LVN "B" stated the EMS were wanting to work the code and asked if the family had a POA (power of attorney) or was there a DNR order. LVN "B" informed the EMS, the family was working on getting a POA and a DNR order. LVN "B" stated she thought the family had obtained a POA and a DNR order but acknowledged there were no POA or DNR orders in Resident #2's chart and the full code should have been completed. LVN "B" stated she contacted the on-call physician around 8:00 p.m. of Resident #2's change of condition. (1 hour after Resident #2 had died ). In an interview on [DATE] at 8:50 a.m. Resident #2's daughter acknowledged they were in the process of obtaining a POA and getting a DNR order for Resident #2 but they did not get it completed before at the time of Resident #2's cardiopulmonary arrest. The daughter acknowledged that she told the nurse to stop CPR if he did not have a heart beat or pulse. On [DATE] at 3:00 p.m. an Immediate Jeopardy was identified related to Resident #1 and Resident #2 and the Administrator and DON were informed. In an interview on [DATE] at 10:25 a.m. CNA "D" said he had worked prn (as needed) at the facility since [DATE]. CNA "D" said he worked on [DATE]. He said about 7:00 p.m. he was putting residents to bed and helping on Hall 3. He said he walked by Resident #2's room and noticed his legs were against the rail with his feet hanging off the bed. He said he went and asked LVN "B" to check on him. He said LVN "B" checked Resident #2, he was unresponsive, then LVN "B" went to get RN "C". He said RN "C" came and LVN "B" went to call 911. CNA "D" said he helped RN "C" put the orange board under the resident. He said then RN "C" covered the residents legs with the sheet. He said RN "C" pushed on the resident's chest 3 or 4 times, took out the balloon thing (ambu bag) and gave him breaths. He said then RN "C" pushed on the residents chest and CNA "F" did the balloon thing. He said RN "C" was still pushing on the resident's chest when the paramedic came. He said the paramedic told her to stop, then he put the pads on the resident that was hooked up to a machine. CNA "D" said he left the room after the paramedics got there. In an interview on [DATE] at 7:02 p.m. CNA "F" acknowledged she worked on [DATE] on the 6 p.m. to 6 a.m. shift. CNA "F" stated she saw Resident #2 alive around 6 p.m. and he was calling out for his daughter. CNA "F" stated CNA "D" around 7 p.m. came up to her and said something was wrong with Resident #2. LVN "B" ran and got RN "C" and the crash cart. CNA "F" stated her, CNA "D" and CNA "H" were in the room and observed Resident #2 was already "blue." RN "C" started CPR and was doing chest compression and CNA "H" was doing the ambu bag (respiratory device) on Resident #2. CNA "F" stated LVN "B" came into the room and informed the EMT's the family does not want the CPR continued. CNA "F" stated she left the room when the EMS got there but remained outside the door. CNA "F" stated the EMT "hooked him up" and said he had been "gone" (deceased ) for a while. In an interview on [DATE] at 2:28 p.m. CNA "H" acknowledged she worked on [DATE] on the 6 p.m. to 6 a.m. shift. CNA "H" stated LVN "B" came and got her and RN "C", got the crash cart and went to Resident #2's room. CNA "H" observed Resident #2 slumped down in the bed and she help to get him repositioned. CNA "H" stated Resident #2 already looked dead and was blue. RN "C" instructed her on how to use an ambu bag while she did chest compressions. CNA "H" stated the EMT's came into Resident #2's room while RN "C" was doing CPR and they stated he was already gone and they were not going to continue CPR. LVN "B" came into the room and stated the family does not want CPR. In an interview on [DATE] at 2:00 p.m. Emergency Medical Technician (EMT) "J" acknowledge he and another EMT "K" were assigned the ambulance run to the facility in regards to Resident #2's [MEDICAL CONDITION] on [DATE] around 7:15 p.m. EMT "J" stated his partner, EMT "K", was first in the resident's room while he was talking to a nurse (LVN "B") who was on the phone with Resident #2's POA. EMT "J" stated he was informed by LVN "B" that the family does not want to continue CPR. EMT "J" asked LVN "B" if the family was the POA and was there a DNR order to stop the code. LVN "B" stated the family was the POA. EMT "J" stated he did not see staff working CPR on Resident #2 when he entered the room and EMT "K" had placed ECG pads on Resident #2 which was showing a flat line (no heart beats). EMT "J" observed Resident #2 on the bed with a CPR board under his back and his shirt was off. EMT "J" stated Resident #2 had "obvious death" signs which included rigor mortis of the jaw and the small of the back. EMT "J" stated EMT's can make decisions when obvious death signs are present to pursue or stop CPR. In an interview on [DATE] at 6:45 p.m. EMT "K" acknowledged he and EMT "J" were assigned the ambulance run to the facility in regards to Resident #2's [MEDICAL CONDITION] on [DATE]. EMT "K" stated he was first in the resident's room while his partner was talking to the nurse at the nurses station who was on the phone with the POA. EMT "K" stated there was no "CPR in progress" when he entered Resident #2's room but observed two staff in the room by Resident #2's bed. EMT "K" stated he observed rigor in Resident #2's jaw and back and thought Resident #2 had been gone a while. He stated he applied the ECG pads and noted the flat line and he stated Resident #2 was Asystole. EMT "K" stated a young nurse came in and stated the family who had POA did not want CPR. EMT "K" stated EMT's can make decisions when obvious death signs are present to pursue or stop CPR. In an interview on [DATE] at 6:15 p.m. the Administrator and DON acknowledged the LVN "A" should have started CPR on Resident #1 and called 911, the physician and the responsible party on his change of condition. The Administrator and DON acknowledged the nurses should have called the physician on Resident #2's change of conditions and followed the physician's full code (CPR) order regardless of the family once CPR was started and if there were no DNR orders in Resident #2's records. The DON stated there had been no inservices or training on code status procedures done since January of 2010. In an interview on [DATE] at 4:30 p.m. the primary physician of Resident #1 and Resident #2 acknowledged there were no DNR orders that had been written or signed by him and Resident #1 and Resident #2 were still full codes at the time of their death. The primary physician acknowledged the DNR orders were not in place so the nurses should have followed the full code orders. The primary physician stated the nurses were outside of their scope of practice. "They need more training." (On following physician's orders [REDACTED]. A review of facility's policy, Resident Abuse/Neglect/Exploitation/Misappropriation of Resident Property/Involuntary Seclusion/Corporal Punishment dated [DATE], documented in part: Definitions: "Neglect" means failure to provide goods and services to avoid physical harm, mental anguish, or mental illness. Record review of the facility's Cardiopulmonary Resuscitation (CPR) policy dated [DATE] documented in part: In the case of an un-witnessed resident arrest without an Advance Directive, and the responsible party has not clarified preference, call 911, the physician, and the responsible party. Documentation: Time of arrest, who discovered the resident unresponsive. Resident's condition: (absence of breathing and pulse, other signs/symptoms noted at that time). Any treatment administered to the resident. Time the call was placed to the physician including orders/instructions, 911, and the responsible party. Time CPR initiated and EMS arrived. Resident's condition at the time of transfer to the hospital. On [DATE] at 2:30 p.m., the facility developed and implemented an action plan to remove the immediate jeopardy. The facility's plan in part was as follows: 1. Resident Rights - failure to notify Physician of Change of Condition. -Nurses will be inserviced immediately on the steps to take when calling a code. -Nurses will complete post test regarding the process of calling a code. -Policy and Procedure for performing a code will be reviewed with the licensed nurses. -Remaining nursing staff will be inserviced on their roll during a code. -CPR training for nurses will be arranged through local qualified personnel/vendor. -Immediate review of charts to insure code status matches orders, required paperwork and care plans. -Review of clinical record within 24 hours, of residents that die to insure Policy and Procedure followed. -Nurses will immediately notify the DON and Administrator by phone, of the death of a resident. -Review current Policy and Procedure regarding CPR and Change of Condition to assure inclusion of the following procedures; screening, training, resident protection, identification, investigation and required reporting. In service direct care staff on changes in Policy and Procedure. -Track CPR certification of licensed nurses to assure current certificates. 2. Administration - monitor the campus in a manner to maintain the highest practicable physical, mental, psychosocial well being. -campus administration will be in-serviced on the requirement of monitoring the campus staff to insure residents receive care that promotes their highest level of independence and well being. -Charge nurses will be in-serviced on reporting/recording a change in residents condition through nurses notes and the 24 hour report. -CNA's will be in-serviced on the reporting of a decline in a residents condition to the charge nurse, inservicing to new staff members during orientation. -SW will follow up with Advance Directive request and immediately inform nursing management/charge nurses of need for DNR order. 3. Resident Assessment - following the Standards of Practice for Nursing or Nurse Practice Act during the performance of CPR. Quality of Care - not following the Standards of Practice for Nursing and the Nurse Practice Act during the performance of CPR. -Licensed Nurses in-serviced immediately on the requirements for performing CPR. -CPR training to be arranged through local qualified vendors for licensed nurse. -New CPR training to be arranged for new charge nurses that do not have current CPR certificates. -Track CPR Certification for Licensed Nurses to assure certification is current. -Nursing Management will communicate changes in Code status through the 24 hour report, Resident's POC, documented status on crash cart. -Nurses will be in-serviced on the Standards of Practice for Nurses and the stipulations of the Nurse Practice Act with regards to the death of resident and performing a code. -Clinical records of residents that die will be reviewed within 24 hours to insure that care and services delivered were appropriate to regulations, physician's orders [REDACTED]. Observation, interview and record review confirmed the facility began implementation of the plan which reduced the scope and severity to actual harm at a pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The Immediate Jeopardy was lifted [DATE] at 12:00 p.m. Record review of Census Daily Detail dated [DATE] documented the facility had 20 Full Code residents. The facility was given the opportunity to provide additional information during the exit conference on [DATE] and none was provided.

Based on observation, interview, and record review, it was determined the facility failed to implement their prevention of Abuse and Neglect Policies and Procedures to ensure incidents related to facility failure resulting in neglect was thoroughly investigated and reported to the State survey agency. The facility failed to implement their written policy and procedure related to Cardiopulmonary Resuscitation for 2 of 22 residents (Resident #1 and Resident #2) with full code status. The facility failed to ensure: (A) Licensed Vocational Nurse (LVN) "A" immediately provided Resident #1, who was a full code resident (required CPR in the event of a cardiorespiratory arrest), cardiopulmonary resuscitation (CPR) and notify the 911 emergency medical service (EMS), the primary physician, and the responsible party on [DATE] when Resident #1 was found unresponsive and had no vital signs. Resident #1 died on [DATE]. (B) LVN "B" immediately provided Resident #2, who was a full code resident, CPR and notify Resident #2's primary physician on [DATE] when LVN "B" observed Resident #2 was unresponsive. LVN "B" left Resident #2's room to get RN "C". This resulted in a delay in starting CPR. Resident #2 died on [DATE]. (C) The above two incidents were investigated by the facility. The facility did not interview or take written statements from staff, residents, or visitors who may had knowledge of the incidents. The facility failure to investigate the first incident involving Resident #1 could have resulted in the second incident involving Resident #2. (D) The incidents were reported to the State Agency. On [DATE] an Immediate Jeopardy was identified. On [DATE] the Immediate Jeopardy was lowered to actual harm at a pattern after the facility developed and implemented an action plan to remove the Immediate Jeopardy prior to exit. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. This failure could affect all 20 "full code" residents. For residents who have expressed their choice to receive CPR, this failure could result in the facility not honoring the residents' choices, resulting in death. The findings included: A review of facility's policy, Resident Abuse/Neglect/Exploitation/Misappropriation of Resident Property/Involuntary Seclusion/Corporal Punishment dated [DATE], documented in part: Definitions: "Neglect" means failure to provide goods and services to avoid physical harm, mental anguish, or mental illness. Policy: All incidents including those of unknown origins will be thoroughly investigated. Potential abuse or neglect will be prevented during investigation. Results of investigation will be reported to the Facility Administrator or designee and other officials in accordance with Texas law. A written report, if appropriate, will be sent to the "Texas Department of Human Services (TDHS)" within five (5) days following the verbal report, in accordance with applicable laws. Procedure: The Facility Administrator will conduct an internal investigation into all allegations of abuse, neglect or mistreatment. Member(s) of Administration as representatives of the Quality Assurance Committee will interview the individual(s) involved in the allegation. Results of the interview will be held until all parties have been interviewed. The report will be written by member(s) of Administration and stamped "Committee Privileged." Record review of the facility's Cardiopulmonary Resuscitation (CPR) policy dated [DATE] documented in part: In the case of an un-witnessed resident arrest without an Advance Directive, and the responsible party has not clarified preference, call 911, the physician, and the responsible party. Documentation: Time of arrest, who discovered the resident unresponsive. Resident's condition: (absence of breathing and pulse, other signs/symptoms noted at that time). Any treatment administered to the resident. Time the call was placed to the physician including orders/instructions, 911, and the responsible party. Time CPR initiated and EMS arrived. Resident's condition at the time of transfer to the hospital. RESIDENT #1 Review of Resident #1's Admission Record documented Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was a [AGE] year old male. A review of Resident #1's clinical record revealed a green sheet with "CPR" at the front of the clinical records . No Advance Directives or Out of Hospital DNR (Do Not Resuscitate) forms were located in Resident #1's clinical record to express Resident #1's code status choice. A review of Resident #1's start up physician's orders [REDACTED]. Review of Resident #1's Care Plan with start date of [DATE] documented in part: Problem: Resident wishes to be a "FULL CODE." Goal: Resident's wishes will be honored. Approach: 1. Verify wishes quarterly. 2. Resuscitate resident if the need arises. 3. Keep Code status on resident's chart. A review of Resident #1's Declaration of CPR form, dated [DATE], it had been signed by Resident #1's wife and she did not want Resident #1 to have CPR. There were no witness signatures on the form making the form incomplete. A review of Resident #1's Patient Transfer Form, dated [DATE], documented in part: Transferred to local hospital due to vomiting and diarrhea. Under code status documented "Full Code." A review of Resident #1's Physician's Telephone Orders dated [DATE] documented in part: Readmit to facility and resume all previous orders. Hospice to evaluate and treat. There was no documentation that orders for DNR were written. A review of Resident #1's Physician's Telephone Orders, dated [DATE], documented to admit to hospice for palliative care. There was no documentation that stated DNR on the order. A review of Resident #1's Skilled Daily Nurses Notes, dated [DATE] at 6:35 a.m., documented Certified Nurse Aide (CNA) "G" called LVN "A" to resident's room. Upon assessment resident noted with no apical pulse, no respirations, no blood pressure, temperature 92.0 ax (Axillary - under the arm). Skin noted to be "Mottled." (blood vessel changes in the skin which cause a patchy appearance ) Capillary beds purple. Skin cold to touch. LVN "A" contacted hospice nurse who stated, "I am on my way." "Post Mortal" (postmortem) care provided. Hospice nurse stated, "I will call the family." (There was no documentation that LVN "A" started CPR, called 911, the primary physician, or the responsible party to notify them of Resident #1's change of condition.) A review of Resident #1's Skilled Daily Nurses Notes, dated [DATE] at 6:40 a.m., LVN "A" contacted the the facility nurse manager (LVN) on call and the on-call physician for the primary physician to report Resident #1 had deceased . A review of Resident #1's Skilled Daily Nurses Notes, dated [DATE] at 7:10 a.m., (35 minutes later) LVN "A" documented hospice nurse in with the family. In an interview on [DATE] at 10:35 a.m. Hospice RN "I" stated Resident #1's wife admitted him to hospice care and had signed an Out of Hospital DNR on [DATE] but Resident #1 died before it could be signed by the primary physician. (Making the form incomplete and not valid) Hospice RN "I" confirmed LVN "A" contacted her and she informed him it was too late to start CPR based on his assessment. Hospice RN "I" acknowledged the DNR order was not in place at the time of Resident #1's death and Resident #1 was still a full code to resuscitate. In an interview on [DATE] at 10:50 a.m. the DON acknowledged LVN "A" should have started CPR, notified 911 EMS, contacted the primary physician and the responsible party of Resident #1's change in condition. The DON stated LVN "A" was no longer working at the facility. In an interview on [DATE] at 2:00 p.m. LVN "A" confirmed he was no longer working for the facility. LVN "A" revealed that on [DATE] he went to Resident #1's room and found Resident #1 with no pulse, heart beat, or respirations. LVN "A" confirmed he was aware Resident #1 was still a full code on [DATE] even though the orders for an (Out of Hospital DNR) had been signed by the family on [DATE] but it was not back signed by the physician. LVN "A" stated he called the hospice nurse who told him she would be in and notify the family and the physician. LVN "A" acknowledged he did not start CPR, notify 911 EMS, or the responsible party of Resident #1's condition. LVN "A" stated the hospice nurse told him it was too late to start CPR. LVN "A" revealed he contacted the on-call physician of Resident #1 death after the fact. (At 6:40 a.m.) In an interview on [DATE] at 10:25 a.m. a DON from a sister facility, assisting the facility's DON, stated there was hospice information for Resident #1 in his hospice chart that supported the wishes of the family and the staff was aware of the wishes which supported that CPR was not to be initiated. The assisting DON acknowledge an LVN cannot make an determination to not to start or halt CPR. The assisting DON later confirmed the additional hospice information had not been in Resident #1's hospice chart in the facility but had been "given to the facility this morning from the hospice agency". In an interview on [DATE] at 10:30 a.m. the administrator confirmed the incidents involving Resident #1 and Resident #2 had not been investigated prior to the survey and he acknowledged that all incidents must be thoroughly investigated to rule out abuse or neglect and further stated it will be part of the facility's plan of action that the administrator and DON will be notified of each code and when a resident expires. RESIDENT #2 Review of Resident #2's Admission Record documented Resident #1 was admitted to the facility on [DATE]. Resident #2 was a [AGE] year old male. Review of Resident #2's Annual Physical/Initial Intake form, dated [DATE], documented [DIAGNOSES REDACTED]. A review of Resident #2's clinical record revealed a green sheet with "FULL CODE" at the front of the clinical records . No Advance Directives or Out of Hospital DNR forms were located in Resident #2's clinical record to express Resident #2's code status choice. A review of Resident #2's Declaration of CPR form, dated [DATE], it had been signed by Resident #2's daughter documenting that she did not want Resident #2 to have CPR. Review of Resident #2's Care Plan with a print date of [DATE] and a signed date of [DATE] revealed no care plan to address Resident #2's code status choice. A review of Resident #2's start up physician's orders [REDACTED]. A review of Social Service Progress Note dated [DATE] documented the social worker contacted Resident #2's daughter about options for hospice services and code status. The social worker explained to Resident #2's daughter he was a full code and did not have any directives. The social worker explained to Resident #2's daughter that he would remain a full code until a DNR was completed in which the daughter voiced understanding. A review of Resident #2's Skilled Daily Nurses Note, dated [DATE] at 7:00 p.m., RN "C" documented: Called to floor to assess resident. Noted resident to have no pulse, heart beat, pupils fixed, no blood pressure, skin cold to touch. 911 notified. Daughter notified and stated "if he's already gone, no CPR." Resident deceased at 7:00 p.m. Had full code status in chart. Attempted CPR until LVN "B" entered room and told us "She (daughter) doesn't want him touched. She is on her way." Stopped CPR/code procedures. EMS here, informed of daughter's request for no CPR or transport. There was no documentation the primary physician was notified of Resident #2's change in condition until after Resident #2 had died . A review of the EMS Patient Care Record, dated [DATE] at 7:18 p.m., documented Resident #2 in part: 3-Lead ECG (electrocardiogram): Asystole (absence of heartbeat). Mental Status: Unresponsive. Skin: Lividity (settling of the blood in the lower (dependent) portion of the body, causing a purplish red discoloration of the skin). Narrative: Rescue 3 and Engine 3 responded to a priority 1 [MEDICAL CONDITION]. Pt was found Apneic (not breathing) and Pulseless with rigor mortis (muscular stiffening) set in and Lividity was present. Pads were placed on patient and ECG showed Asystole. Strip was printed out and patient was declared deceased and Rescue 3 returned to service. RN signature was obtained on refusal of service for due to no transport. A review of Resident #2's Skilled Daily Nurses Note (not dated or timed) LVN "B" documented: Dr.___ notified, on call for Dr.___ (primary physician) informed her of resident's status. Stated "Ok" and thank you for calling. RN "C" to pronounce. Waiting for family to get to facility, postmortem care done. A review of Resident #2's Expiration Discharge Nurse's Notes, dated [DATE], documented RN "C" pronounced Resident #2's death at 7:10 p.m. and the on-call physician was notified at 8:00 p.m. (50 minutes after Resident #2 had died ). In an interview on [DATE] at 4:50 p.m. RN "C" said on [DATE] about 7:00 p.m. she was on hall 4 passing medications when LVN "B" came down the hall and stated Resident #2 appeared dead. RN "C" stated she grabbed her stethoscope, the crash cart and with two aides went to Resident #2's room. LVN "B" informed RN "C" that Resident #2 was a full code (requiring resuscitation). RN "C" stated she started CPR and LVN "B" went to call 911 and the responsible party. RN "C" revealed LVN "B" returned to the room and stated Resident #2's family does not want CPR. RN "C" stated EMS (emergency medical services) entered Resident #2's room around 7:20 p.m. and took over . The EMT placed ECG pads on Resident #2 and observed a flat line (no heart beats). EMS told RN "C" that Resident #2 was dead and rigor mortis had already set in (explaining when the EMS had leaned Resident #2 up to apply ECG pads he noted rigor mortis). LVN "B" told EMS that the family did not want CPR. RN "C" stated one of the EMS personnel had her sign a piece of paper about not transporting the body. In an interview on [DATE] at 5:35 p.m. LVN "B" revealed she was the charge nurse assigned to Resident #2's care working the 6 p.m. to 6 a.m. shift on [DATE]. LVN "B" stated on [DATE] around 7:00 p.m. CNA "D" informed her that something was wrong with Resident #2. LVN "B" went to resident's room and found him slumped down in the bed with his feet hanging off the bed. LVN "B" stated she helped CNA "D" get him back in bed and then shook him. LVN "B" stated she went down to Hall 4 (LVN "B" left Resident #2 instead of sending an aide which delayed the CPR response time) and got RN "C" who got the crash cart, went to Resident #2's room and started CPR. LVN "B" stated she contacted 911 and Resident #2's responsible party. LVN "B" stated she was on the phone with the responsible party when the EMS arrived and she informed them and RN "C" the family does not want to continue with CPR. LVN "B" stated the EMS were wanting to work the code and asked if the family had a POA (power of attorney) or was there a DNR order. LVN "B" informed the EMS, the family was working on getting a POA and a DNR order. LVN "B" stated she thought the family had obtained a POA and a DNR order but acknowledged there were no POA or DNR orders in Resident #2's chart and the full code should have been completed. LVN "B" stated she contacted the on-call physician around 8:00 p.m. of Resident #2's change of condition. (1 hour after Resident #2 had died ). In an interview on [DATE] at 6:15 p.m. the Administrator and DON acknowledged the LVN "A" should have started CPR on Resident #1 and called 911, the physician and the responsible party on his change of condition. The Administrator and DON acknowledged the nurses should have called the physician on Resident #2's change of conditions and followed the physician's full code (CPR) order regardless of the family once CPR was started and if there were no DNR orders in Resident #2's records. The DON stated there had been no inservices or training on code status procedures done since January of 2010. In an interview on [DATE] at 8:50 a.m. Resident #2's daughter acknowledged they were in the process of obtaining a POA and getting a DNR order for Resident #2 but they did not get it completed before at the time of Resident #2's cardiopulmonary arrest. The daughter acknowledged that she told the nurse to stop CPR if he did not have a heart beat or pulse. On [DATE] at 3:00 p.m. an Immediate Jeopardy was identified related to Resident #1 and Resident #2 and the Administrator and Director of Nurses (DON) were informed. In an interview on [DATE] at 10:25 a.m. CNA "D" said he had worked prn (as needed) at the facility since [DATE]. CNA "D" said he worked on [DATE]. He said about 7:00 p.m. he was putting residents to bed and helping on Hall 3. He said he walked by Resident #2's room and noticed his legs were against the rail with his feet hanging off the bed. He said he went and asked LVN "B" to check on him. He said LVN "B" checked Resident #2, he was unresponsive, then LVN "B" went to get RN "C". He said RN "C" came and LVN "B" went to call 911. CNA "D" said he helped RN "C" put the orange board under the resident. He said then RN "C" covered the residents legs with the sheet. He said RN "C" pushed on the resident's chest 3 or 4 times, took out the balloon thing (ambu bag) and gave him breaths. He said then RN "C" pushed on the residents chest and CNA "F" did the balloon thing. He said RN "C" was still pushing on the resident's chest when the paramedic came. He said the paramedic told her to stop, then he put the pads on the resident that was hooked up to a machine. CNA "D" said he left the room after the paramedics got there. He said no one at the facility had questioned him about this incident. In an interview on [DATE] at 7:02 p.m. CNA "F" acknowledged she worked on [DATE] on the 6 p.m. to 6 a.m. shift. CNA "F" stated she saw Resident #2 alive around 6 p.m. and he was calling out for his daughter. CNA "F" stated CNA "D", around 7 p.m., came up to her and said something was wrong with Resident #2. LVN "B" ran and got RN "C" and the crash cart. CNA "F" stated her, CNA "D" and CNA "H" were in the room and observed Resident #2 was already "blue." RN "C" started CPR and was doing chest compression and CNA "H" was doing the ambu bag (respiratory device) on Resident #2. CNA "F" stated LVN "B" came into the room and informed RN "C" and the EMTs that the family does not want to continue with CPR. CNA "F" stated she left the room when the EMS got there but remained outside the door. CNA "F" stated the EMT "hooked him up" and stated he had been "gone" (deceased ) for a while. In an interview on [DATE] at 2:28 p.m. CNA "H" acknowledged she worked on [DATE] on the 6 p.m. to 6 a.m. shift. CNA "H" stated LVN "B" came and got her and RN "C", got the crash cart and went to Resident #2's room. CNA "H" observed Resident #2 slumped down in the bed and she help to get him repositioned. CNA "H" stated Resident #2 already looked dead and was blue. RN "C" instructed her on how to use an ambu bag while she did chest compressions. CNA "H" stated the EMT's came into Resident #2's room while RN "C" was doing CPR and they stated he was already gone and they were not going to continue CPR. LVN "B" came into the room and stated the family does not want CPR. In an interview on [DATE] at 2:00 p.m. Emergency Medical Technician (EMT) "J" acknowledge he and another EMT "K" were assigned the ambulance run to the facility in regards to Resident #2's [MEDICAL CONDITION] on [DATE] around 7:15 p.m. EMT "J" stated his partner, EMT "K", was first in the resident's room while he was talking to an nurse (LVN "B") who was on the phone with Resident #2's POA. EMT "J" stated he was informed by LVN "B" that the family does not want to continue CPR. EMT "J" asked LVN "B" if the family was the POA and was there a DNR order to stop the code. LVN "B" stated the family was the POA. EMT "J" stated he did not see staff working CPR on Resident #2 when he entered the room and EMT "K" had placed ECG pads on Resident #2 which was showing a flat line (no heart beats). EMT "J" observed Resident #2 on the bed with a CPR board under his back and his shirt was off. EMT "J" stated Resident #2 had "obvious death" signs which included rigormortis of the jaw and the small of the back. EMT "J" stated EMT's can make decisions when obvious death signs are present to pursue or stop CPR. In an interview on [DATE] at 6:45 p.m. EMT "K" acknowledged he and EMT "J" were assigned the ambulance run to the facility in regards to Resident #2 [MEDICAL CONDITION] on [DATE]. EMT "K" stated he was first in the resident's room while his partner was talking to the nurse at the nurses station who was on the phone with the POA. EMT "K" stated there was no "CPR in progress" when he entered Resident #2's room but observed two staff in the room by Resident #2's bed. EMT "K" stated he observed rigor in Resident #2's jaw and back and thought Resident #2 had been gone a while. He stated he applied the ECG pads and noted the flat line and he stated Resident #2 was Asystole. EMT "K" stated a young nurse came in and stated the family who had POA did not want CPR. EMT "K" stated EMT's can make decisions when obvious death signs are present to pursue or stop CPR. In an interview on [DATE] at 4:30 p.m. the primary physician of Resident #1 and Resident #2 acknowledged there were no DNR orders that had been written or signed by him and Resident #1 and Resident #2 were still full codes at the time of their death. The primary physician acknowledged the DNR orders were not in place so the nurses should have followed the full code orders. The primary physician stated the nurses were outside of their scope of practice. "They need more training."(On following physician's orders [REDACTED]. During an interview on [DATE] at 12:00 p.m. the Administrator and RN Vice President of Clinical said a formal investigation had not been done. The RN said "we were not aware of the incident and don't know why we would be doing a formal investigation." The Administrator said "we did not do a formal investigation but now we have things in place to catch things in our stand up meetings, 24 hour reports and if a resident dies. On [DATE] at 2:30 p.m., the facility developed and implemented an action plan to remove the immediate jeopardy. The facility's plan was as follows: 1. Resident Rights - failure to notify Physician of Change of Condition. -Nurses will be inserviced immediately on the steps to take when calling a code. -Nurses will complete post test regarding the process of calling a code. -Policy and Procedure for performing a code will be reviewed with the licensed nurses. -Remaining nursing staff will be inserviced on their roll during a code. -CPR training for nurses will be arranged through local qualified personnel/vendor. -Immediate review of charts to insure code status matches orders, required paperwork and care plans. -Review of clinical record within 24 hours, of residents that die to insure Policy and Procedure followed. -Nurses will immediately notify the DON and Administrator by phone, of the death of a resident. -Review current Policy and Procedure regarding CPR and Change of Condition to assure inclusion of the following procedures; screening, training, resident protection, identification, investigation and required reporting. In service direct care staff on changes in Policy and Procedure. -Track CPR certification of licensed nurses to assure current certificates. 2. Administration - monitor the campus in a manner to maintain the highest practicable physical, mental, psychosocial well being. -campus administration will be in-serviced on the requirement of monitoring the campus staff to insure residents receive care that promotes their highest level of independence and well being. -Charge nurses will be in-serviced on reporting/recording a change in residents condition through nurses notes and the 24 hour report. -CNA's will be in-serviced on the reporting of a decline in a residents condition to the charge nurse, inservicing to new staff members during orientation. -SW will follow up with Advance Directive request and immediately inform nursing management/charge nurses of need for DNR order. 3. Resident Assessment - following the Standards of Practice for Nursing or Nurse Practice Act during the performance of CPR. Quality of Care - not following the Standards of Practice for Nursing and the Nurse Practice Act during the performance of CPR. -Licensed Nurses in-serviced immediately on the requirements for performing CPR. -CPR training to be arranged through local qualified vendors for licensed nurse. -New CPR training to be arranged for new charge nurses that do not have current CPR certificates. -Track CPR Certification for Licensed Nurses to assure certification is current. -Nursing Management will communicate changes in Code status through the 24 hour report, Resident's POC, documented status on crash cart. 4. Resident behavior - Reporting Abuse, Neglect. -Nursing staff will be in-serviced on the Policy and Procedure for reporting Abuse and Neglect and a copy will be made available for staff to refer to. -Management staff will be in-serviced on investigating and reporting of Abuse and Neglect. -Nurses will be in-serviced on the Standards of Practice for Nurses and the stipulations of the Nurse Practice Act with regards to the death of resident and performing a code. -Clinical records of residents that die will be reviewed within 24 hours to insure that care and services delivered were appropriate to regulations, physician's orders [REDACTED]. -Inservice direct care staff on Policy and Procedure for identifying and reporting potential abuse/neglect. Observation, interview and record review confirmed the facility began implementation of the plan which reduced the scope and severity to actual harm at a pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The Immediate Jeopardy was lifted [DATE] at 12:00 p.m. Record review of Census Daily Detail dated [DATE] documented the facility had 20 Full Code residents. The facility was given the opportunity to provide additional information during the exit conference on [DATE] and none was provided.

Based on observation, interview, and record reviews, it was determined the facility failed to provide 2 ( Resident #1 and Resident #2) of 22 residents who had full code status, the care in a manner that met professional standards of quality. The facility failed to ensure: (A) Licensed Vocational Nurse (LVN) "A" immediately provided Resident #1, who was a full code resident (required CPR in the event of a cardiorespiratory arrest), cardiopulmonary resuscitation (CPR) and notify the 911 emergency medical service (EMS), the primary physician, and the responsible party on [DATE] when Resident #1 was found unresponsive and had no vital signs. Resident #1 died on [DATE]. (B) LVN "B" immediately provided Resident #2, who was a full code resident, CPR and notify Resident #2's primary physician on [DATE] when LVN "B" observed Resident #2 was unresponsive. LVN "B" left Resident #2's room to get RN "C". This resulted in a delay in starting CPR. Resident #2 died on [DATE]. On [DATE] an Immediate Jeopardy was identified. On [DATE] the Immediate Jeopardy was lowered to actual harm at a pattern after the facility developed and implemented an action plan to remove the Immediate Jeopardy prior to exit. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. This failure could affect all 20 "full code" residents currently residing at the facility. For residents who have expressed their choice to receive CPR, this failure could result in the facility not honoring the residents' choices, resulting in death. The findings included: Review of Texas Administrative Code Title 22, Part 11, Chapter 217, Rule 217.12 entitled Unprofessional Conduct dated [DATE] revealed unprofessional conduct were behaviors which included unsafe practice which was defined as carelessly failing to perform nursing in conformity with the standards of minimum acceptable level of nursing practice as set out in Rule 217.11. Review of Texas Administrative Code Title 22, Part 11, Chapter 217, Rule 217.11 entitled Standards of Nursing Practice dated [DATE] revealed all nurses including licensed vocational nurses (LVN) were required to: -- know the rationale for and the effects of medications and treatments and shall correctly administer the same. -- institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications. -- supervise nursing care provided by others for whom the nurse is professionally responsible. -- implement appropriate aspects of care within the LVN's scope of practice. RESIDENT #1 Review of Resident #1's Admission Record documented Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was a [AGE] year old male. A review of Resident #1's clinical record revealed a green sheet with "CPR" at the front of the clinical records . (No Advance Directives or Out of Hospital DNR (Do Not Resuscitate) forms were located in Resident #1's clinical record to express Resident #1's code status choice). A review of Resident #1's start up physician's orders [REDACTED]. Review of Resident #1's Care Plan with start date of [DATE] documented in part: Problem: Resident wishes to be a "FULL CODE." Goal: Resident's wishes will be honored. Approach: 1. Verify wishes quarterly. 2. Resuscitate resident if the need arises. 3. Keep Code status on resident's chart. A review of Resident #1's Declaration of CPR form, dated [DATE], it had been signed by Resident #1's wife and she did not want Resident #1 to have CPR. There were no witness signatures on the form making the form incomplete. A review of Resident #1's Patient Transfer Form, dated [DATE], documented in part: Transferred to local hospital due to vomiting and diarrhea. Under code status documented "Full Code." A review of Resident #1's Physician's Telephone Orders dated [DATE] documented in part: Readmit to facility and resume all previous orders. Hospice to evaluate and treat. There was no documentation that orders for DNR were written. A review of Resident #1's Physician's Telephone Orders, dated [DATE], documented to admit to hospice for palliative care. There was no documentation that stated DNR on the order. A review of Resident #1's Skilled Daily Nurses Notes dated [DATE] at 6:35 a.m. documented Certified Nurse Aide (CNA) "G" called LVN "A" to resident's room. Upon assessment resident noted with no apical pulse, no respirations, no blood pressure, temperature 92.0 ax (Axillary - under the arm). Skin noted to be "Mottled." (blood vessel changes in the skin which cause a patchy appearance ) Capillary beds purple. Skin cold to touch. LVN "A" contacted hospice nurse who stated, "I am on my way." "Post Mortal" (postmortem) care provided. Hospice nurse stated, "I will call the family." (There was no documentation that LVN "A" started CPR, called 911, the primary physician, or the responsible party to notify them of Resident #1's change of condition.) A review of Resident #1's Skilled Daily Nurses Notes, dated [DATE] at 6:40 a.m., LVN "A" contacted the the facility nurse manager (LVN) on call and the on-call physician for the primary physician to report Resident #1 had deceased . A review of Resident #1's Skilled Daily Nurses Notes, dated [DATE] at 7:10 a.m., (35 minutes later) LVN "A" documented hospice nurse in with the family. In an interview on [DATE] at 10:35 a.m. Hospice RN "I" stated Resident #1's wife admitted him to hospice care and had signed an Out of Hospital DNR on [DATE] but Resident #1 died before it could be signed by the primary physician. (Making the form incomplete and not valid) Hospice RN "I" confirmed LVN "A" contacted her and she informed him it was too late to start CPR based on his assessment. Hospice RN "I" acknowledged the DNR order was not in place at the time of Resident #1's death and Resident #1 was still a full code to resuscitate. In an interview on [DATE] at 10:50 a.m. the DON acknowledged LVN "A" should have started CPR, notified 911 EMS, contacted the primary physician and the responsible party of Resident #1's change in condition. The DON stated LVN "A" was no longer working at the facility. In an interview on [DATE] at 2:00 p.m. LVN "A" confirmed he was no longer working for the facility. LVN "A" revealed that on [DATE] he went to Resident #1's room and found Resident #1 with no pulse, heart beat, or respirations. LVN "A" confirmed he was aware Resident #1 was still a full code on [DATE]even though the orders for an (Out of Hospital DNR) had been signed by the family on [DATE] but were not back signed by the physician. LVN "A" stated he called the hospice nurse who told him she would be in and notify the family and the physician. LVN "A" acknowledged he did not start CPR, notify 911 EMS, or the responsible party of Resident #1's condition. LVN "A" stated the hospice nurse told him it was too late to start CPR. LVN "A" revealed he contacted the on-call physician of Resident #1 death after the fact. In an interview on [DATE] at 10:25 a.m. a DON from a sister facility, assisting the facility's DON, stated there was hospice information for Resident #1 in his hospice chart that supported the wishes of the family and the staff was aware of the wishes which supported that CPR was not to be initiated. The assisting DON acknowledge an LVN cannot make an determination to not to start or halt CPR. The assisting DON later confirmed the additional hospice information had not been in Resident #1's hospice chart in the facility but had been "given to the facility this morning from the hospice agency". RESIDENT #2 Review of Resident #2's Admission Record documented Resident #2 was admitted to the facility on [DATE]. Resident #2 was a [AGE] year old male. Review of Resident #2's Annual Physical/Initial Intake form, dated [DATE], documented [DIAGNOSES REDACTED]. A review of Resident #2's clinical record revealed a green sheet with "FULL CODE" at the front of the clinical records . No Advance Directives or Out of Hospital DNR forms were located in Resident #2's clinical record to express Resident #2's code status choice. A review of Resident #2's Declaration of CPR form, dated [DATE], it had been signed by Resident #2's daughter documenting that she did not want Resident #2 to have CPR. Review of Resident #2's Care Plan with a print date of [DATE] and a signed date of [DATE] revealed no care plan to address Resident #2's code status choice. A review of Resident #2's start up physician's orders [REDACTED]. A review of Social Service Progress Note dated [DATE] documented the social worker contacted Resident #2's daughter about options for hospice services and code status. The social worker explained to Resident #2's daughter he was a full code and did not have any directives. The social worker explained to Resident #2's daughter that he would remain a full code until a DNR was completed in which the daughter voiced understanding. A review of Resident #2's Skilled Daily Nurses Note, dated [DATE] at 7:00 p.m., RN "C" documented: Called to floor to assess resident. Noted resident to have no pulse, heart beat, pupils fixed, no blood pressure, skin cold to touch. 911 notified. Daughter notified and stated "if he's already gone, no CPR." Resident deceased at 7:00 p.m. Had full code status in chart. Attempted CPR until LVN "B" entered room and told us "She (daughter) doesn't want him touched. She is on her way." Stopped CPR/code procedures. EMS here, informed of daughter's request for no CPR or transport. There was no documentation the primary physician was notified of Resident #2's change in condition until after Resident #2 had died . A review of the EMS Patient Care Record, dated [DATE] at 7:18 p.m., documented Resident #2 in part: 3-Lead ECG (electrocardiogram): Asystole (absence of heartbeat). Mental Status: Unresponsive. Skin: Lividity (settling of the blood in the lower (dependent) portion of the body, causing a purplish red discoloration of the skin). Narrative: Rescue 3 and Engine 3 responded to a priority 1 [MEDICAL CONDITION]. Pt was found Apneic (not breathing) and Pulseless with rigor mortis (muscular stiffening) set in and Lividity was present. Pads were placed on patient and ECG showed Asystole. Strip was printed out and patient was declared deceased and Rescue 3 returned to service. RN signature was obtained on refusal of service for due to no transport. A review of Resident #2's Skilled Daily Nurses Note (not dated or timed) LVN "B" documented: Dr.___ notified, on call for Dr.___ (primary physician) informed her of resident's status. Stated "Ok" and thank you for calling. RN "C" to pronounce. Waiting for family to get to facility, postmortem care done. A review of Resident #2's Expiration Discharge Nurse's Notes, dated [DATE], documented RN "C" pronounced Resident #2's death at 7:10 p.m. and the on-call physician was notified at 8:00 p.m. (50 minutes after Resident #2 had died ). In an interview on [DATE] at 4:50 p.m. RN "C" said on [DATE] about 7:00 p.m. she was on hall 4 passing medications when LVN "B" came down the hall and stated Resident #2 appeared dead. RN "C" stated she grabbed her stethoscope, the crash cart and with two aides went to Resident #2's room. LVN "B" informed RN "C" that Resident #2 was a full code (requiring resuscitation). RN "C" stated she started CPR and LVN "B" went to call 911 and the responsible party. RN "C" revealed LVN "B" returned to the room and stated Resident #2's family does not want CPR. RN "C" stated EMS (emergency medical services) entered Resident #2's around 7:20 p.m. and took over. The EMT placed ECG pads on Resident #2 and observed a flat line (no heart beats). EMS told RN "C" that Resident #2 was dead and rigor mortis had already set in (explaining when the EMS had leaned Resident #2 up to apply ECG pads he noted rigor mortis). LVN "B" told EMS that the family did not want CPR. RN "C" stated one of the EMS personnel had her sign a piece of paper about not transporting the body. In an interview on [DATE] at 5:35 p.m. LVN "B" revealed she was the charge nurse assigned to Resident #2's care working the 6 p.m. to 6 a.m. shift on [DATE]. LVN "B" stated on [DATE] around 7:00 p.m. CNA "D" informed her that something was wrong with Resident #2. LVN "B" went to resident's room and found him slumped down in the bed with his feet hanging off the bed. LVN "B" stated she helped CNA "D" get him back in bed and then shook him. LVN "B" stated she went down to Hall 4 (LVN "B" left Resident #2 instead of sending an aide which delayed the CPR response time) and got RN "C" who got the crash cart, went to Resident #2's room and started CPR. LVN "B" stated she contacted 911 and Resident #2's responsible party. LVN "B" stated she was on the phone with the responsible party when the EMS arrived and she informed them and RN "C" the family does not want to continue with CPR. LVN "B" stated the EMS were wanting to work the code and asked if the family had a POA (power of attorney) or was there a DNR order. LVN "B" informed the EMS, the family was working on getting a POA and a DNR order. LVN "B" stated she thought the family had obtained a POA and a DNR order but acknowledged there were no POA or DNR orders in Resident #2's chart and the full code should have been completed. LVN "B" stated she contacted the on-call physician around 8:00 p.m. of Resident #2's change of condition. (1 hour after Resident #2 had died ). In an interview on [DATE] at 8:50 a.m. Resident #2's daughter acknowledged they were in the process of obtaining a POA and getting a DNR order for Resident #2 but they did not get it completed before at the time of Resident #2's cardiopulmonary arrest. The daughter acknowledged that she told nurse to stop CPR if he did not have a heart beat or pulse. On [DATE] at 3:00 p.m. an Immediate Jeopardy was identified related to Resident #1 and Resident #2 and the Administrator and Director of Nurses (DON) were informed. In an interview on [DATE] at 10:25 a.m. CNA "D" said he had worked prn (as needed) at the facility since [DATE]. CNA "D" said he worked on [DATE]. He said about 7:00 p.m. he was putting residents to bed and helping on Hall 3. He said he walked by Resident #2's room and noticed his legs were against the rail with his feet hanging off the bed. He said he went and asked LVN "B" to check on him. He said LVN "B" checked Resident #2, he was unresponsive, then LVN "B" went to get RN "C". He said RN "C" came and LVN "B" went to call 911. CNA "D" said he helped RN "C" put the orange board under the resident. He said then RN "C" covered the residents legs with the sheet. He said RN "C" pushed on the resident's chest 3 or 4 times, took out the balloon thing (ambu bag) and gave him breaths. He said then RN "C" pushed on the residents chest and CNA "F" did the balloon thing. He said RN "C" was still pushing on the resident's chest when the paramedic came. He said the paramedic told her to stop, then he put the pads on the resident that was hooked up to a machine. CNA "D" said he left the room after the paramedics got there. In an interview on [DATE] at 7:02 p.m. CNA "F" acknowledged she worked on [DATE] on the 6 p.m. to 6 a.m. shift. CNA "F" stated she saw Resident #2 alive around 6 p.m. and he was calling out for his daughter. CNA "F" stated around 7 p.m., CNA "D" came up to her and said something was wrong with Resident #2. LVN "B" ran and got RN "C" and the crash cart. CNA "F" stated her, CNA "D" and CNA "H" were in the room and observed Resident #2 was already "blue." RN "C" started CPR and was doing chest compression and CNA "H" was doing the ambu bag (respiratory device) on Resident #2. CNA "F" stated she left the room when the EMS got there but remained outside the door. LVN "B" came into the room and informed the EMT's that the family does not want to continue CPR. CNA "F" stated the EMT "hooked him up" and stated he had been "gone" (deceased ) for a while. In an interview on [DATE] at 2:28 p.m. CNA "H" acknowledged she worked on [DATE] on the 6 p.m. to 6 a.m. shift. CNA "H" stated LVN "B" came and got her and RN "C", got the crash cart and went to Resident #2's room. CNA "H" observed Resident #2 slumped down in the bed and she help to get him repositioned. CNA "H" stated Resident #2 already looked dead and was blue. RN "C" instructed her on how to use an ambu bag while she did chest compressions. CNA "H" stated the EMT's came into Resident #2's room while RN "C" was doing CPR and they stated he was already gone and they were not going to continue CPR. LVN "B" came into the room and stated the family does not want CPR. In an interview on [DATE] at 2:00 p.m. Emergency Medical Technician (EMT) "J" acknowledge he and another EMT "K" were assigned the ambulance run to the facility in regards to Resident #2 [MEDICAL CONDITION] on [DATE] around 7:15 p.m. EMT "J" stated his partner, EMT "K", was first in the resident's room while he was talking to an nurse (LVN "B") who was on the phone with Resident #2's POA. EMT "J" stated he was informed by LVN "B" that the family does not want to continue CPR. EMT "J" asked LVN "B" if the family was the POA and was there a DNR order to stop the code. LVN "B" stated the family was the POA. EMT "J" stated he did not see staff working CPR on Resident #2 when he entered the room and EMT "K" had placed ECG pads on Resident #2 which was showing a flat line (no heart beats). EMT "J" observed Resident #2 on the bed with a CPR board under his back and his shirt was off. EMT "J" stated Resident #2 had "obvious death" signs which included rigormortis of the jaw and the small of the back. EMT "J" stated EMT's can make decisions when obvious death signs are present to pursue or stop CPR. In an interview on [DATE] at 6:45 p.m. EMT "K" acknowledged he and EMT "J" were assigned the ambulance run to the facility in regards to Resident #2 [MEDICAL CONDITION] on [DATE]. EMT "K" stated he was first in the resident's room while his partner was talking to the nurse at the nurses station who was on the phone with the POA. EMT "K" stated there was no "CPR in progress" when he entered Resident #2's room but observed two staff in the room by Resident #2's bed. EMT "K" stated he observed rigor in Resident #2's jaw and back and thought Resident #2 had been gone a while. He stated he applied the ECG pads and noted the flat line and he stated Resident #2 was Asystole. EMT "K" stated a young nurse came in and stated the family who had POA did not want CPR. EMT "K" stated EMT's can make decisions when obvious death signs are present to pursue or stop CPR. In an interview on [DATE] at 6:15 p.m. the Administrator and DON acknowledged the LVN "A" should have started CPR on Resident #1 and called 911, the physician and the responsible party on his change of condtion. The Administrator and DON acknowledged the nurses should have called the physician on Resident #2's change of conditions and followed the physician's full code (CPR) order regardless of the family once CPR was started and if there were no DNR orders in Resident #2's records. The DON stated there had been no inservices or training on code status procedures done since January of 2010. In an interview on [DATE] at 4:30 p.m. the primary physician of Resident #1 and Resident #2 acknowledged there were no DNR orders that had been written or signed by him and Resident #1 and Resident #2 were still full codes at the time of their death. The primary physician acknowledged the DNR orders were not in place so the nurses should have followed the full code orders. The primary physician stated the nurses were outside of their scope of practice. "They need more training." (On following physician's orders [REDACTED]. Record review of the facility's Cardiopulmonary Resuscitation (CPR) policy dated [DATE] documented in part: In the case of an un-witnessed resident arrest without an Advance Directive, and the responsible party has not clarified preference, call 911, the physician, and the responsible party. Documentation: Time of arrest, who discovered the resident unresponsive. Resident's condition: (absence of breathing and pulse, other signs/symptoms noted at that time). Any treatment administered to the resident. Time the call was placed to the physician including orders/instructions, 911, and the responsible party. Time CPR initiated and EMS arrived. Resident's condition at the time of transfer to the hospital. A review of the facility's policy, Emergency Physicians' Services dated [DATE], documented in part: Procedure: In a medical emergency when a physician is needed, the attending physician is to be called. If the attending physician cannot be reached, the alternate physician must be called. In the event of a serious emergency when neither of the above can be reached, the Medical Director may be called. A review of the Texas Board of Nursing Board Position Statements 15.2 The Role of the Licensed Vocational Nurse in the Pronouncement of Death documented: LVNs do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas. Regardless of practice setting, the importance of initiating CPR in cases where no clear Do Not Resuscitate (DNR) orders exist is imperative. The Board of Nursing (BON) has investigated cases involving the failure of a LVN to initiate CPR in the absence of a DNR order. It is within the LVN scope of practice as defined by Rule 217.11(1)-(2) (effective [DATE]) and the Interpretive Guideline for LVN Scope of Practice under Rule 217.11 for a LVN to gather data and perform a focused assessment regarding a patient, to recognize significant changes in a patient's condition, and to report said data and observation of significant changes to the physician. The LVN's focused assessment should include nursing observations to determine the presence or absence of the following presumptive or conclusive signs of death: Presumptive Signs of Death ? The patient is unresponsive, ? The patient has no respirations, ? The patient has no pulse, ? Patient's pupils are fixed and dilated, ? The patient's body temperature indicates hypothermia: skin is cold relative to the patient's baseline skin temperature, ? The patient has generalized cyanosis, and Conclusive Sign of Death ? There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin which does blanch with pressure). Upon reporting his/her clinical findings to the physician, and in accordance with facility policy, the LVN may accept reasonable physician's orders [REDACTED].e.: notification of family, postmortem care, documentation; however, a LVN may not accept an order that would require the LVN to " pronounce death, " or to complete the state-required " medical certification " of a death that occurs without medical attendance. Employers are also encouraged to develop policies and procedures directing staff in postmortem care and procedures, including appropriate measures that can be completed while waiting for a return call from the attending physician. The BON has no jurisdiction over physician practice, facility policies, or the laws regulating pronouncement of death in Texas. Additional information on Texas regulations regarding pronouncement of death may be found in Chapters 193 and 671 of the Texas Health and Safety Code, as well as through the Department of State Health Services. A LVN is not responsible for the actions of a physician who elects to pronounce death by remote-means. Physicians are licensed by, and must comply with, rules promulgated by the Texas Medical Board as well as other laws applicable to the physician's practice setting. References: Texas Statutes, Health and Safety Code; http://www.statutes.legis.state.tx.us/ (BVNE Statement adopted ,[DATE]; Revised BON statement ,[DATE]; revised ,[DATE]; ,[DATE];,[DATE]; ,[DATE]) (Reviewed - ,[DATE]) On [DATE] at 2:30 p.m., the facility developed and implemented an action plan to remove the immediate jeopardy. The facility's plan was as follows: 1. Resident Rights - failure to notify Physician of Change of Condition. -Nurses will be inserviced immediately on the steps to take when calling a code. -Nurses will complete post test regarding the process of calling a code. -Policy and Procedure for performing a code will be reviewed with the licensed nurses. -Remaining nursing staff will be inserviced on their roll during a code. -CPR training for nurses will be arranged through local qualified personnel/vendor. -Immediate review of charts to insure code status matches orders, required paperwork and care plans. -Review of clinical record within 24 hours, of residents that die to insure Policy and Procedure followed. -Nurses will immediately notify the DON and Administrator by phone, of the death of a resident. -Review current Policy and Procedure regarding CPR and Change of Condition to assure inclusion of the following procedures; screening, training, resident protection, identification, investigation and required reporting. In service direct care staff on changes in Policy and Procedure. -Track CPR certification of licensed nurses to assure current certificates. 2. Administration - monitor the campus in a manner to maintain the highest practicable physical, mental, psychosocial well being. -campus administration will be in-serviced on the requirement of monitoring the campus staff to insure residents receive care that promotes their highest level of independence and well being. -Charge nurses will be in-serviced on reporting/recording a change in residents condition through nurses notes and the 24 hour report. -CNA's will be in-serviced on the reporting of a decline in a residents condition to the charge nurse, inservicing to new staff members during orientation. -SW will follow up with Advance Directive request and immediately inform nursing management/charge nurses of need for DNR order. 3. Resident Assessment - following the Standards of Practice for Nursing or Nurse Practice Act during the performance of CPR. Quality of Care - not following the Standards of Practice for Nursing and the Nurse Practice Act during the performance of CPR. -Licensed Nurses in-serviced immediately on the requirements for performing CPR. -CPR training to be arranged through local qualified vendors for licensed nurse. -New CPR training to be arranged for new charge nurses that do not have current CPR certificates. -Track CPR Certification for Licensed Nurses to assure certification is current. -Nursing Management will communicate changes in Code status through the 24 hour report, Resident's POC, documented status on crash cart. 4. Resident behavior - Reporting Abuse, Neglect. -Nursing staff will be in-serviced on the Policy and Procedure for reporting Abuse and Neglect and a copy will be made available for staff to refer to. -Management staff will be in-serviced on investigating and reporting of Abuse and Neglect. -Nurses will be in-serviced on the Standards of Practice for Nurses and the stipulations of the Nurse Practice Act with regards to the death of resident and performing a code. -Clinical records of residents that die will be reviewed within 24 hours to insure that care and services delivered were appropriate to regulations, physician's orders [REDACTED]. -Inservice direct care staff on Policy and Procedure for identifying and reporting potential abuse/neglect. Observation, interview and record review confirmed the facility began implementation of the plan which reduced the scope and severity to actual harm at a pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The Immediate Jeopardy was lifted [DATE] at 12:00 p.m. Record review of Census Daily Detail dated [DATE] documented the facility had 20 Full Code residents. The facility was given the opportunity to provide additional information during the exit conference on [DATE] and none was provided.

Based on interview and record review, the facility failed to 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. The facility failed to assess and provide effective pain relief for one of four sampled residents (#9) with pain. The facility failed to: a) Develop and implement effective interventions to relieve pain. Resident #9 experienced back and knee pain routinely but had no routine pain medications ordered to effectively control the pain. The facility failed to reevaluate interventions when proven ineffective and the facility identified the resident experiencing pain; b) Conduct pain assessments. The facility did not assess the resident's pain level prior to administration of PRN (as needed) pain medications; c) Consult with the resident's physician when the pain treatment/management was proven ineffective to allow the physician the opportunity to assess and provide alternatives to relieve the resident's pain. The facility failed to follow up on physician progress notes [REDACTED]. The facility failed to notify the physician when the resident experienced pain that scored greater than 5 for 2 or more days in a row; d) Fully address the resident's pain in the plan of care, to include her chronic, bilateral knee pain. The facility failed to have interventions specific to Resident #9 that fully addressed her pain issues. By failing to assess and provide an appropriate plan of care for pain, the facility contributed to the resident experiencing avoidable moderate to severe pain. Record Review of the form CMS 672 Resident Census and Condition signed by the DON on 7/19/10 revealed there were no residents on a pain management program. Failure to properly assess resident #9 for pain, administer pain medication in a timely manner, and assess the effectiveness of the pain medication contributed to her experiencing unrelieved pain and decline in physical and psychosocial well-being and had the potential to effect all residents with complaints of pain in this same manner. Findings include: 1. Review of Resident #9's clinical record face sheet revealed she, an [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 2. An interview was conducted on 7/21/10 at 4:00 p.m. with Resident #9 and her son, the responsible party. Resident #9 said "Most nights I am still awake until midnight or 1:00 a.m. because of the pain. I can't fall asleep most nights because my knees and back hurt so bad." Resident #9 said the pain was chronic, "nothing new; that she had the pain for years and it bothered her most all days." She said there are times she would like to call her son to "ask him to get the nurses to bring her something (for pain) but she didn't have a phone and it was just too hard to get up, back in her wheelchair and wheel herself to the nurses station to use the phone there." Resident #9 was asked if the surveyor could help her with "just one thing" what would that be. She responded, "if I could just get a little more help because I hurt so bad all the time. They think I can do it all myself so I try but I am afraid of falling and then I really would be hurting." She added, "I took something for pain at home but here I just get something every once in awhile. I guess that's all the doctor thinks I need. I'm not going to complain. I would rather just say everything's fine and let them go on and do their job." Resident #9's son said his mother took [MEDICATION NAME] 7.5 mg twice a day while she was at home. He said his mother lived alone (prior to admitting to the facility) and ambulated with a walker. The resident verified this to be true. The resident's son added that one night in May (2010) he came to visit his mother and she was "hurting real bad." He was informed his mother took [MEDICATION NAME] for the pain so he requested staff call her physician to get an order for [REDACTED]. He said staff later got a clarification order for PRN [MEDICATION NAME]. The surveyor told Resident #9 she had [MEDICATION NAME] ordered "as needed." The resident said, "the staff are awfully busy; they stay that way. I have asked for medicine before but I don't want them to get put out with me. I figure they know what the doctor wants me to have so I just wait for them to help me." Resident #9 then added, "I guess I will be here forever; I will never get to see my home again." 3. Review of Resident #9's Monthly Physician Orders, 7/01/10 - 7/31/10 revealed an additional [DIAGNOSES REDACTED]. Resident #9 had an order dated 4/14/09 for [MEDICATION NAME] 100 milligrams (mg) daily for the [MEDICAL CONDITION]. The only medications ordered for pain were [MEDICATION NAME] 7.5/500 - 1 tablet every 6 hours PRN (as needed) for "pain" and Tylenol 325 mg - 2 tablets every 4 hours PRN, both ordered on admission, 4/14/09. There were no scheduled pain medications ordered. The orders also documented, "assess for pain level every shift and PRN using a scale of 0 -10. If pain level is greater than 5 for 2 consecutive days notify MD." 4. Review of Resident #9's care plan for Pain dated 8/11/09 and updated quarterly thereafter documented the resident had [MEDICAL CONDITION] and Lumbar Disk Disorder but no mention of chronic knee pain. The goals for Resident #9 were: - relieve pain and thereby enhance the quality of life; - improve well being by increasing comfort, reducing depression and anxiety; - optimize the ability to participate and perform ADL's and participate in other activities; - monitor relief of pain and alter treatment as needed; - pain will not be higher than 3 on scale of 1 - 10." The interventions included to assess daily for pain and document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 5. Further review of Resident #9's clinical record documented additional information that revealed the facility failed to properly address and control her pain: a) Rehabilitation Summary- Physical Therapy notes: 12/23/09 - "Patient focus this week is pain control." 12/30/09 - "Patient still with (2 arrows pointed upward to represent more than normal amount of pain) of both knees. Patient would not walk this week second to fearful of falls. Pain is improved with therapy but increases with movement and weight-bearing." 1/06/10 - "Continues to complain of pain to both knees 5/10 (5 on a scale of 1 - 10). Therapy noted significant crepitus (a grating or crackling sound of the joint due to wear and tear with arthritis). Unable to stand with knees fully extended and complains of severe pain." 1/13/10 - "Pain has only mildly decreased over past 4 weeks in both knees despite modalities and exercises. Still unable to tolerate standing. Progress has been minimal." 1/14/10 - "Discharge. Resident made marginal progress in the areas of rolling left to right, sitting balance and standing balance. Resident subjective, complains of bilateral knee pain. Resident knee pain hindered ability to transfer, ambulate and stand. Resident received daily bouts of modalities for pain management but the pain was unable to subside. Resident knee pain prevented resident from ambulating beyond 20 feet. Resident will be placed on restorative nursing program." b) Nursing Rehab/Restorative (RNP) Plan of Care: Dated 5/05/10 - Goals were for Resident #9 to maintain comfort level in both knees (She did not have a comfort level in her knees and could not endure therapy. This is why she was discharged from therapy). Notes for RNP: 5/13/10 - the response to her session was "poorly secondary to her knees hurting." 5/22/10 - the response was the same as 5/13/10 adding "refused therapy on the 21st secondary to her knees hurting to badly." 5/27/10 - the response to her session was "resident refused therapy on the 26th and 27th secondary to her knees hurting too badly." Under the Monthly Review section documented: "Is the plan of care appropriate?" Yes. "Are changes to the RNP recommended?" No. "Are changes recommended to the goals?" No. "Are changes recommended to the approaches?" No. "Continue program? No. "Discharge from RNP?" Yes. c) physician progress notes [REDACTED]." The physician's assessment and plan documented: "[MEDICAL CONDITION]- patient currently not taking much of her [MEDICATION NAME] that she has prescribed. Tell nurses to ask if she needs." d) Monthly Nursing Summary - May 2010 "Recently complains of leg pain. Has new order for [MEDICATION NAME] PRN. Usually Tylenol helps." June 2010 "Has been requesting [MEDICATION NAME] more frequently due to leg pain." e) Pain Flowsheets and MAR's: April 2010: Resident #9 was medicated 5 times this month for pain; headache, toothache, general pain, headache and leg pain. There was no pre-pain or post-pain medication rating documented using the 1 - 10 scale. May 2010: Resident #9 was medicated 8 times this month for pain; all complaints were for leg pain. There was no pre-pain or post-pain medication rating documented, only five times effective or good effect documented. June 2010: Resident #9 was medicated 11 times this month for pain. There was no pre-pain or post-pain medication rating documented. Resident #9 had pain rated on a treatment administration record that ranged from 4 to 6. There were two days in a row the resident had pain at a level of 5 (June 24th and June 25th) and two days in a row where she had a pain level of 6 (June 17th and June 18th). There was no documentation the physician had been notified as per physician orders. July 2010 (to day of survey entrance, 7/19/10): Resident #9 was medicated 10 to 13 times this month for pain (the MAR indicated effective." f) Nurses notes in the current record, 3/08/10 - 6/07/10 documented Resident #9 complained of pain sporadically. 6. In an interview on 7/22/10 at 11:00 a.m. the Therapy Director acknowledged they (therapy department) had to discharge Resident #9 from services due to her severe knee pain. He said, "she constantly complained of knee pain to the point her goals were not being met." He acknowledged she required assistance for all her ADL's. He added that if she "were to be on a good pain control program things would be much better for her and we would be happy to re-evaluate her for therapy." 7. In an interview on 7/22/10 at 11:15 a.m. both Restorative Aides said Resident #9 was discharged from RNP because she could not do the program because she had too much pain with her knees. They both said they would be glad to re-evaluate her once her pain was under control. 8. In an interview on 7/23/10 at 8:30 a.m. both the Director Of Nurses (DON) and the Assistant Director of Nurses (ADON) were present. Both staff said they were unaware Resident #9 took pain medication prior to living at the nursing facility and her son had not informed them. The ADON added, "how are we to know she is in pain if he (the son) doesn't tell us these things." The ADON then asked the surveyor if the resident's physician was aware of her complaints of pain. The ADON was shown the physician progress notes [REDACTED]." After the surveyor showed the aforementioned documentation from the therapist, RNP, nurses notes and pain flow sheets/MAR's they both said, "there was poor communication with this situation." Record Review of the form CMS 672 Resident Census and Condition signed by the DON on 7/19/10 revealed there were 71 residents in the building at the time of the survey. The form also revealed there were no residents on a pain management program. The facility was given the opportunity to provide additional information during the exit conference on 7/23/10 but were unable to do so.