Every finding on record at Parkview Manor Nursing and Rehabilitation

Based on interview, and record review, the facility failed to ensure resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 7 residents (Resident #1) reviewed for abuse. The facility failed to ensure LVN A did not verbally and emotionally intimidate and abuse Resident #1 from 11/10/2025 through 03/04/2026, by speaking rudely to Resident #1, excluding the resident from smoke breaks, restricting Resident #1 from approaching or passing by the nurse's station, and removing Resident #1's smoking items from the nurse's station to keep Resident #1 from approaching the nurse's station. This failure could place residents at risk of abuse, and mental anguish and fearfulness. The findings were: Record review of Resident #1's face sheet dated 03/05/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included obstructive/chronic obstructive pulmonary disease (progressive lung condition that obstructs airflow, primarily caused by long-term exposure to irritants like cigarette smoke) with (acute) exacerbation, paraplegia (paralysis on half the body) status, muscle weakness, major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), nicotine dependence (a chronic brain disorder where tobacco use becomes compulsory, causing intense cravings, failed quit attempts, and severe withdrawal symptom), insomnia (difficulty falling asleep, staying asleep, or waking too early, resulting in poor sleep quality and daytime fatigue), dementia (brain disorders causing cognitive decline-memory loss, confusion, and behavioral changes that interfere with daily life) severity, without behavioral disturbance, and psychotic/anxiety/mood disturbance (disconnection from reality (hallucinations/delusions), often accompanied by severe anxiety and mood shifts (depression/mania), and dependence on wheelchair (an individual's reliance on a wheelchair for mobility due to physical, neurological, or musculoskeletal limitations). Record review of Resident #1's, undated, care plan reflected resident Focus: resident required antidepressant medication for diagnosis of depression date initiated 07/04/2024 and revised on 11/11/2025. Focus: Resident has impaired cognitive function or impaired thought processes due to dementia diagnosis as of initiated/revised date of 07/07/2025. Record review of Resident #1's care plan last updated 11/11/2025 reflected she was a smoker but had not reflected abuse allegations being made. Record review of Resident #1's Quarterly MDS, dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had intact mental cognition. Record review of Resident #1's Progress Note dated, 11/10/2025 at 9:00 p.m. reflected LVN B witnessed an argument and heard LVN A telling Resident #1, You need to get off of my hall and go back down to your room right now. Resident #1 stated she could be down the hall if she wanted to be. LVN stated, I am not your nurse, and I want you off of my hall and don't comeback down here. Resident #1 voiced to LVN B that LVN A popped her in the mouth. LVN B performed a head-to-toe assessment. MD B was notified of incident on 11/10/2025 at 10:30 p.m. Intervention imitated by LVN B was to keep both parties involved in the incident apart. Other information noted LVN A notified the DON of incident. The progress note was reviewed and signed off on by the interim DON on 12/19/2025. Record review of Resident #1's skin assessment, dated 11/10/2025 at 09:30 p.m., reflected the resident's skin was intact, and no s/sx of skin integrity issues. Record review of Resident #1's trauma informed as needed assessment, dated 03/11/2026 at 07:01 p.m., reflected Resident #1 had not experienced any adverse effects from the 11/11/2025 abuse allegation. Record review of a complaint received to Health and Human Services, dated 03/03/2026, reflected LVN A had been very rude and verbally abusive toward Resident #1, had hid the resident's cigarettes, refused to take the resident out on schedule smoke breaks, and would tell the resident she was not allowed and could not come on the 300 hall (location of the nurse's station) which resulted in Resident #1 being scared of LVN A. In an interview on 03/05/2026 at 11:33 a.m., the administrator stated LVN A was terminated on 03/04/2026 after creating a hostile environment at the facility. He stated LVN A called the State Survey Agency on the facility as she was escorted out of the building as retaliation for her termination resulting in this State Survey visit. ADM stated his staff performed resident rounds everyday interviewing and checking on residents including Resident #1 and had not received any reports or complaints of physical, mental, or emotional distress related and felt the residents were safe. In an interview on 03/05/2026 at 3:09 p.m., the housekeeping supervisor stated LVN A began working at the facility in August of 2025, and lacked sincerity when working with the residents. She stated LVN A acted like her work with the facility was just a job and not a place to take care of residents. She stated LVN A was petty with the residents by telling them they could go home if they had not liked something LVN A and done or said. She stated after an allegation of abuse was reported by Resident #1 on 11/10/2025, which named LVN A, LVN A acted differently towards Resident #1 by not allowing the resident to join her for smoke breaks and disappeared becoming unlocatable when it was time to take Resident #1 out on smoke breaks. She stated she continued monitoring LVN A's behavior towards Resident #1 and reported the witnessed occurrences to the ADM. She stated thereafter, Resident #1 avoided LVN A by not going by the nurse's station when LVN A was on shift. Resident #1's family told her Resident #1 had once been a med aide who had worked with LVN A in the past at another facility. She stated that it had been her opinion that the facility had a hard time finding nurses who were willing to work and stay employed with the facility that it was more of a hinderance to lose a nurse than to deal with LVN A's behavior towards Resident #1. She stated the ADM was the facility's abuse coordinator and named the following as forms of abuse: physical, verbal, financial emotional, and sexual. In an interview on 03/05/2026 at 03:46 p.m., Med Aide stated that LVN A was tough as nails, direct, outspoken and bold. She stated that LVN A would not take Resident #1 out for cigarette breaks and LVN A stated that she did not fool with Resident #1 and Resident #1 did not fool (refusing to deal with or engage) with LVN A. She stated she was unaware of the reason for the discord between LVN A and Resident #1. She stated the ADM was the abuse coordinator and named the following as forms of abuse: physical, verbal, sexual, emotional, neglect, and financial. In an interview on 03/05/2026 at 04:45 p.m., director of respiratory therapy stated she witnessed on several occasions LVN A speaking rudely to Resident #1 and had refused and avoided taking Resident#1 out on smoke breaks. The DRT stated Resident #1 had to go a long way around the building to get through to the therapy department to avoid passing LVN A at the nurse's station on the 300-hall. She stated as the easiest route to the therapy department required passing by the nurse's station on the 300-hall. The DRT stated she had to inform Resident #1 not to interact with LVN A to avoid rude treatment and for the resident to direct her needs through the DRT when LVN A was on shift. The DRT stated the ADM and DON had been informed of LVN A's behavior towards Resident #1 several times during the facility's morning meetings and it was her understanding that the ADM and the DON had spoken to LVN A several times regarding her treatment towards Resident #1, but no changes occurred. DRT stated Resident #1 should not have had to avoid staff or any areas staff worked in to avoid rude treatment. She stated LVN A's negativity carried over onto the CNAs making a hostile environment for the staff. She stated the ADM was the abuse coordinator. In an interview on 03/05/2026 at 05:00 p.m., the director of dietary services stated LVN A had an awful character and would hide away making it difficult to find her for meal serving assistance during mealtimes. She stated LVN A was ugly to Resident #1 by denying her smoke breaks and speaking rudely towards the resident. She stated LVN A was a smoker and customary for the smoking staff to take the smoking residents out on breaks. She stated LVN A took several smoke breaks throughout the day but refused to take and/or allow Resident #1 to join her. She stated LVN A's treatment towards the resident began from the first day LVN A began working at the facility until LVN A's last day of employment with the facility. She stated LVN A was fired under the last ownership for poor performance and behavior, began working as an agency nurse at the facility, then had to be walked out when the facility learned she was on shift, and then hired again under the new/current ownership. She stated she was not sure if the new ADM and DON were aware of those occurrences. She stated on 02/27/2026, LVN A spoke loudly and rudely to the ADM and threatened to have someone whoop (inflict physical harm) the ADM which resulted in the employment termination of LVN A. She stated that the ADM was the abuse coordinator for which all allegations of abuse: verbal, physical, sexual, financial, and emotional were reported. She stated the ADM and DON were made aware of LVN A's treatment towards Resident #1, but she stated that she had not seen any changes. In an interview on 03/05/2026 at 05:23 p.m., the DON stated a week prior she had to provide LVN A with a written disciplinary counseling about toning down her attitude, and unprofessional behavior and interactions with the staff. The DON stated she had to redirect LVN A who told Resident #1 she could not drive her motor wheelchair around the nurse's station as LVN A did not want the resident around her after an unsubstantiated abuse allegation on 11/10/2025. She stated Resident #1 had not expressed any concerns since the abuse allegation but could see the energy was different with Resident #1 when LVN A was on shift. She stated therefore they moved Resident #1's cigarettes that had once been stored at the nurses' station to the memory care unit to help Resident #1 avoid LVN A. She stated she felt that was the best course of action to reduce any adverse effects of Resident #1's interactions with LVN A. She stated the ADM was the abuse coordinator and the facility provided ANE in-services monthly and as needed. In an interview on 03/05/2026 at 6:09 p.m., Resident #1 stated she had to avoid going to the nurse's station when LVN A was on shift otherwise LVN A would stop her, grab her electric controller and turn her around. She stated LVN A also refused to take her out on smoke breaks and her cigarettes had to be moved from the nurse's station on the 300-hall because LVN A had not wanted them there. She stated the quickest route to therapy was past the nurse's station on the 300-hall, but when LVN A was on shift, she had to go a longer route to get to therapy to avoid LVN A. She stated LVN A's negative behavior towards her began in November of 2025 when LVN A slapped her in the mouth and she reported the incident to the ADM. She stated at first LVN A's treatment made her feel bad and sad and she would sit at the window watching LVN A and the other resident smoke during smoke breaks she could not go on. She stated another staff had always taken her out thereafter, and other staff and residents encouraged her not to feel bad, but it took a while and took DRT telling her not to listen or pay attention to LVN A's behavior towards her. She stated after a while LVN A's behavior began not to bother her anymore and she adjusted to avoid contact, communication and proximity of LVN A when she was on shift. She stated the ADM was the facility's abuse coordinator. In an interview on 03/11/2026 at 11:13 a.m., the ADM stated there had not been an active social worker on staff with the facility for the last 30-day s or so to ask about Resident #1's psychosocial status since the abuse allegation was made. The ADM stated he was the acting SW until a new hire filled the position. He stated the abuse allegation made against LVN A by Resident #1 on 11/10/2025, was reported to the State Survey Agency in November 2025, investigated and both the facility and the State Surveyor at that time found the allegations to be unsubstantiated. He stated that the facility social worker who no longer works for the facility and himself checked in on Resident #1's psychosocial status after the incident and found that she had no emotional or mental issues as a result of the allegation. He stated no further incidents were reported to him regarding LVN A's treatment or interactions with or towards Resident #1. In an interview on 03/11/2026 at 12:10 p.m., the HS stated LVN A intimidated Resident #1 from the time LVN A began working at the facility by making rude comments to her and restricting her from going near the nurse's station when LVN A was on shift, and making Resident #1 scared to go around LVN A. She stated LVN A would not take Resident #1 out on smoke breaks and expressed Resident #1 was not allowed to come down the hall near the nurse's station when LVN A was on shift. The HS stated she had to take the resident out on smoke breaks as a result. She stated at first, she asked Resident #1 why she was not going down the hall near the nurse's station and Resident #1 would say she was not going anywhere near LVN A, refusing to use LVN A's name. She stated she spoke to Resident #1 about how it made her feel and the resident told her she had not wanted to get anyone in trouble so she would avoid the nurse's station. She told the residents not to worry about getting anyone in trouble. She stated Resident #1 would ride all the way around the other side of the facility to get to an area that was easily accessible by just passing the nurse's station to avoid LVN A. She stated Resident #1's cigarettes had to be removed from the nurse's station to the memory care nurse's station because LVN A made a big deal about them being at the nurse's station and not wanting them there. She stated LVN A was a smoker, would take the other facility's smoking resident out on smoke breaks, but not Resident #1 making another staff have to come off the floor to take Resident #1 out after LVN A finished. She stated it had was discussed in the morning meeting and it had not made sense to have two smoke break times because of LVN A's discontent. She stated nevertheless, two smoke times were initiated. She stated the ADM was the abuse coordinator and named the following as forms of abuse: physical, verbal, sexual, emotional, neglect, and financial. She stated the facility provided ANE in-services monthly and as needed. In an interview on 03/11/2026 at 01:05 p.m., CNA A stated she was aware that LVN A could not get along with Resident #1 but could not provide any specific details or incidents as to why. She stated the ADM was the facility's abuse coordinator and listed the following as forms of abuse: financial, verbal, mental, physical, and sexual. She stated she received her last in-service on ANE on this date. In an interview on 03/11/2026 at 02:56 p.m., the interim DON stated LVN B witnessing LVN A tell Resident #1 as noted in the progress note dated 11/10/2025 at 9:00 p.m. stating Get off my hall and go back down to your room right now was not enough evidence to substantiate any forms of abuse against LVN A. He stated that the ADM was the abuse coordinator who ensured the facility received in-service training on ANE at least monthly but also as needed. In an interview on 03/12/2026 at 12:28 p.m., the ADM stated he was the abuse coordinator and had was notified on 11/11/2025 by the facility's corporate office that Resident #1 made an abuse allegation against LVN A. He stated Resident #1 stated LVN A popped her in the mouth. He stated the facility immediately suspended LVN A at that time and conducted an investigation finding no witnesses to collaborate with the allegations and he had to unsubstantiate the findings. He stated after he was not made aware by the resident or any staff, Resident #1 had issues with LVN A, which intimidated her after the allegations was made. In an interview attempt on 03/13/2026 at 11:28 a.m., the MD left a voicemail message for a return call. No interview was obtained. Record review of ANE in-service training dated 11/11/2025 reflected LVN A signed off on receiving this in-service. Record review of LVN A's employee disciplinary report reflected an infraction that occurred on 02/28/2026 where LVN A created a hostile work environment by behaving in an unprofessional manner towards the ADM. LVN A was terminated effective immediately signed by DON on 03/04/2026. LVN A refused to sign off on the report. Record review of resident-to-resident incidents in-service training dated 03/10/2026 reflected incidents were to be reported to the ADM for investigation. LVN A had not signed off on receiving this in-service. Record review of the facility's, undated, policy titled Abuse/Neglect reflected Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

Based on interview, and record review, the facility failed to ensure a resident who was transferred or discharged had complete and accurate documentation in their clinical records, including required information to support continuity of care for closed record one of 4 residents (CR) reviewed for transfer-discharge. The facility failed to ensure CR's transfer/discharge documentation was completed in a timely manner. This failure had the potential to affect all residents requiring transfer or discharge by increasing the risk of miscommunication, gaps in care, and adverse outcomes. Findings included:Record review of CR's face sheet dated 03/05/2026 reflected an [AGE] year-old female who admitted to the facility on [DATE] with no discharge date noted. CR had diagnoses which included depressive episodes (cause significant distress or impairment but do not meet the full criteria), gastro-esophageal reflux disease without esophagitis (experience chronic heartburn and reflux symptoms), anemia (blood disorder where the body lacks enough healthy red blood cells or hemoglobin, leading to reduced oxygen flow to organs), insomnia, (difficulty falling asleep, staying asleep, or waking too early, resulting in poor sleep quality and daytime fatigue), hyperkalemia (high blood potassium levels that can cause dangerous heart arrhythmias or sudden cardiac arrest), and diaphragmatic hernia (an abnormal opening in the diaphragm allowing abdominal organs (stomach, intestines) to move into the chest cavity without strangulation or tissue death) without obstruction or gangrene (death of body tissue caused by infection or lack of blood flow). Record review of CR's undated, care plan reflected resident CR had dementia problems with communication, and unclear speech, with an ADL self-care performance deficit, and had limited physical mobility, and received antidepressant medication with adverse risks of side effects and reactions. Record review of CR's Quarterly MDS, dated [DATE], reflected, CR had a BIMS score of 04 indicating that CR had mentally impaired cognition. In an interview on 03/05/2026 at 06:42 p.m., Family #1 stated she received a call on 03/04/2025 from LVN A who stated CR #1 was sent to the hospital ER for stroke like symptoms. She stated LVN A reported that the CR had been having s/sx of stroke for the last 24-hours, but nobody informed Family #1. She stated that on 03/05/2026, LVN A told her LVN A went against the facility protocol on 03/04/2026 and called 911 to send CR #1 out for medical attention. She stated LVN A told her she checked on CR at the end of her shift on 03/02/2026 and told the on-coming LVN B to monitor CR for stroke like symptoms. She stated LVN A was off on 03/03/2026 and returned on 03/04/2026 finding that CR's condition had worsened. She stated based on this information a complaint was made to HHSC. She stated on 03/04/2026 it was determined by the hospital CR had a stroke and was med-flight to higher level of care hospital. She stated LVN A later called and stated that LVN A was fired as a result of calling 911 and sending CR out without prior physician consent. She stated at this time she had not received an official call from the facility informing her that the CR had a change in condition nor had anyone from the facility called to check on the CR's status. She stated the hospital physician stated CR would probably not wake up, and if she had, would be paralyzed on her left side and would never speak again. She stated the hospital physician had advised her to consider placing CR on hospice care. In an interview on 03/11/2026 at 12:10 p.m., the HS stated on 03/04/2026 she was not on shift when CR was discharged . She stated on 03/04/2026, LVN A called her informing her of the CR's discharge and how the Med Aid observed CR in and out of consciousness on 03/03/2026 during the first shift. She stated she told LVN A that it could not have been possible for CR to be unconscious throughout both shifts without any nursing staff checking on CR. In an interview on 03/11/2026 at 12:34 p.m., LVN C stated on 03/04/2026 she was off shift and received a call from the DON asking about CR's LVN A discharging CR to the hospital that morning. She stated she told the DON that at the end of her shift on 03/03/2026 Med Aid came to her and stated that Family 2 had concerns that CR was not feeling well. She stated she went to assess CR and found that CR's vitals were fine, and CR was able to state she was fine. She stated she had not spoken to Family 2 about CR status at that time. She stated that LVN D came on shift to relieve her, and she informed LVN D to watch for any changes in CR's condition. She stated she was not aware that CR's clinical chart had no notes of discharge to the hospital. She stated since LVN A was CR's nurse, it would have been LVN A's responsibility to complete CR's discharge documentation summarizing the reason for the discharge, and how CR left the facility. She stated that LVN A had not completed the required discharge documents. In an interview on 03/11/2026 at 02:25 p.m., the Med Aid stated since CR's discharge, she had not seen any clinical notes in CR's records reflecting CR's reason for being sent out of the facility. She stated she would have expected LVN A to complete CR discharge documentation prior to LVN A ending LVN A's shift. In an interview on 03/11/2026 at 02:56 p.m., the interim DON stated on 03/04/2026, the CR was found to have a change of condition that required her immediate transfer by ambulance to a higher level of care facility. He stated as CR's nurse, after completing a physical assessment, SBAR report summarizing CR change of condition that required the ER transfer to a higher level care facility, LVN A should have completed a discharge summary for CR's discharge to reflect on the ADT list required by CMS. He stated LVN A had not completed the SBAR which was unable to trigger the discharge summary report and effected CR's discharge from reflection on the ADT report within the following 24-hours of CR's discharge. He stated that because of LVN A's failure to complete CR's discharge documentation, there were no notes reflecting CR's physician and family contacts or the status of CR's location and current condition. He stated CR's discharge documentation was important for the continuity of CR's care. In an interview on 03/12/2026 at 12:28 p.m., the ADM stated he learned CR discharged CR's hospital on [DATE]. He stated he asked LVN A why the resident was sent out and LVN A stated due to a change in condition. He stated he attempted to get more information from LVN A who was CR's charge nurse and the nurse who discharged CR to the hospital, with no response. He stated on 03/05/2026 Family #3 requested CR's clinical records, but he stated he had provided Family #3 with only the last hospital notes documented in CR's progress notes because he wanted to find out more from his staff the reason for CR's discharge before he released the information. He stated that LVN A had not completed the required change of condition/SBAR documentation that triggered and initiated the discharged documentation as to when, where, and why CR was sent to the hospital to date resulting. He stated charge nurses were responsible for completing a SBAR, skin, and pain assessment in preparation of a resident's discharge out of the facility. He stated failure to complete those assessments resulted in untimely information being reported to CMS. He stated LVN A was terminated on 03/04/2026 at 3:00 p.m. for unrelated issues. In an interview on 03/13/2026 at 02:14 pm., MD B stated on 03/04/2026 at 03:29 p.m., she received a call from LVN A reported CR's eyes were rolling in the back of head and her blood pressure was elevated. MD B directed LVN A send CR out for immediate transfer to the hospital due to stroke like symptoms. Record review of the facility's ADT log, dated 03/04/2026 - 03/11/2025, reflected CR discharged to an acute care hospital on [DATE]. Record review of CR's Discharge summary dated after survey intervention on 03/11/2026 at 08:56 p.m. and signed and completed by interim DON, reflected CR admitted to the facility on [DATE] and was discharged to the hospital on [DATE], due to a change in condition on 03/04/2026.

Based on interview and record review the facility failed to ensure that residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for quality of care. The facility failed to complete a psychosocial assessment after Resident #1 alleged physical abuse. This failure could place residents at risk for potential injuries, physical and/or emotional pain, and hospitalization. The findings included:Record review of Resident #1's face sheet dated 03/05/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included paraplegia (paralysis on half the body) status, (progressive lung condition that obstructs airflow, primarily caused by long-term exposure to irritants like cigarette smoke) with (acute) exacerbation, major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), dementia (brain disorders causing cognitive decline-memory loss, confusion, and behavioral changes that interfere with daily life) severity, and psychotic/anxiety/mood disturbance (disconnection from reality (hallucinations/delusions), often accompanied by severe anxiety and mood shifts (depression/mania), and nicotine dependence (a chronic brain disorder where tobacco use becomes compulsory, causing intense cravings, failed quit attempts, and severe withdrawal symptom). Record review of Resident #1's, undated, care plan reflected resident Focus: Resident has impaired cognitive function or impaired thought processes due to dementia diagnosis as of initiated/revised date of 07/07/2025. Focus: Resident required antidepressant medication for diagnosis of depression date initiated 07/04/2024 and revision on 11/11/2025. Resident #1's care plan had no reflection of an abuse allegation. Record review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS score of 14, which indicated the resident had intact mental cognition. Record review of Resident #1's nursing note, completed by LVN A, dated 11/10/2025 at 07:15 a.m., reflected Resident #1 had a verbal behavior/altercation, while being mentally oriented with no injuries. The behavior/altercation reflected: while escorting Resident #1 out on a smoke break, Resident #1 verbalized being upset the smoke break was late. LVN A informed CR that other assignments had to be completed and when those assignments were complete, LVN A provided Resident #1 with her smoke break. CR began making insulting comments and calling LVN A an nigger bitch,. LVN A requested LVN B take resident out for her smoke break as a result of the behavior at that time as well as during the 3p.m. smoke break that same day. The SW was made aware of CR's behavior. The interim DON signed off on the nurses note dated 12/18/2025. Record review of Resident #1's nursing note, completed by LVN B, dated 11/10/2025 at 09:00 p.m., reflected the resident had a cognition/behavior/agitation event in the hallway when asked about the television LVN A began yelling while on the 300-hall to Resident #1, You need to get off of my hall and go back down to your room right now. Resident stated she could be down the hall if she wanted to be. LVN A stated, I am not your nurse, and I want you off of my hall and don't come back down here. Arguing started and Resident #1 and LVN A went their separate ways with no injuries or pain noted. No s/sx resident had distress/discomfort at time of observed incident. Record review of Resident #1's nursing note, completed by DON, dated 11/10/2025 at 9:30 p.m., reflected: Treatment/New Orders: After occurrence and information Resident #1 voiced LVN A popped her in the mouth. The DON performed a head to toe assessment and informed Resident #1's responsible party (RP), MD B on 11/10/2025 at 9:30 p.m. Intervention: Keep both parties involved in this incident apart. Interim DON signed off on the nurses note dated 12/19/2025 at 11:38 a.m. Record review of Resident #1's nursing note, completed by LVN B dated 11/10/2025 at 09:30 p.m., reflected no adverse skin issues. MD B was informed of CR's weekly skin assessment on 11/12/2025. Record review of Resident #1's nursing note completed by LVN B, dated 11/10/2025 at 09:30 p.m., reflected the resident had a patterned verbal behavior with no adverse mental, emotional, or physical effects. In an interview on 03/11/2026 at 02:56 p.m., the interim DON stated LVN B documented a nursing progress note, dated 11/10/2025 at 9:00 p.m. reflecting that Resident #1 made an allegation that LVN A had popped the resident in the mouth. He stated that neither during nor after the allegations were investigated, had the facility performed a follow-up psychosocial assessment for Resident #1. He stated the importance of a psychosocial assessment was to ensure the resident had not experienced any psychological harm from the event. He stated there were also no risk assessments conducted after the incident. He stated on 03/11/2026 he completed a trauma assessment interview with Resident #1 had expressed no risks other than falls related to the allegation. In an interview on 03/12/2026, at 12:28 p.m., the ADM stated he was unaware the facility had not completed a psychosocial evaluation to ensure Resident #1 had not experienced any adverse effects from her abuse allegation on 11/11/2025. He stated it had been his expectation that the facility's social worker (SW) who was no longer with the facility would have been responsible for initiating that evaluation but was unaware why it had not been. He stated Resident #1 had not expressed to him or any other staff she had issues with LVN A after 11/11/2025. He stated LVN A received disciplinary actions prior to her termination on 03/04/2026, but they were related to her professionalism with and towards staff not residents. Record review of facility's, undated, policy titled Behavior Management Policy reflected: Policy: Behavior management includes the management of anger, confusion, hallucinations, and other behavior by utilizing techniques such as area limitations, self-responsibility, group interactions, limit setting, and behavior modifications depending on individual needs. Behavior changes can be attributed to dementia disorders or psychological conflicts resulting from a loss of control over body, environment, and unmet needs such as pain, hunger, thirst, and toileting. They may include combativeness, arguing, agitation, and aggressiveness. Goals1. The resident will modify behavior for optimal functioning and well-being.

Based on interview and record review, the facility failed to maintain complete and accurate clinical records for resident accordance with professional standards and regulatory requirements for closed record one of 4 residents (CR) reviewed for assessments. The facility failed to complete an incident report reflecting the resident's current condition and care provided after CR had a change in condition which resulted in a hospitalization. This failure had the potential to affect all residents residing in the facility by compromising continuity of care, clinical decision-making, and resident safety. Findings included:Record review of CR's face sheet dated 03/05/2026 reflected an [AGE] year-old female who admitted to the facility on [DATE] with no discharge date noted. Cr had diagnoses which included muscle wasting and atrophy (loss of muscle tissue, causing muscle thinning, weakness, and reduced mobility), other abnormalities of gait and mobility (irregular walking patterns caused by pain, neurological diseases, or musculoskeletal issues, including limping, shuffling, or instability), muscle weakness, dementia (brain disorders causing cognitive decline-memory loss, confusion, and behavioral changes that interfere with daily life), without behavioral/psychotic/mood/anxiety disorders (disconnection from reality, hallucinations/delusions). Record review of CR's undated, care plan reflected resident Focus: CR had an ADL self-care performance deficit, communication, problems with unclear speech and Dementia, but was usually understood and usually understands, limited physical mobility, required antidepressant medication with the risk for side effects/adverse reactions. Record review of CR's Quarterly MDS, dated [DATE], reflected a BIMS score of 04 indicating that CR had impaired mental cognition. In an interview on 03/05/2026 at 06:42 p.m. Family #1 stated she received a call on 03/04/2025 from LVN A who stated CR had stroke like symptoms and was sent to the hospital ER. She stated on 03/04/2026 it was determined by the hospital CR had a stroke and was med-flight to higher level of care hospital. She stated LVN A reported to the facility on [DATE] prior to coming off shift that the CR had been having s/sx of stroke for the last 24-hours, but nobody informed Family #1. She stated that on 03/05/2026, LVN A called and told her when LVN A left shift on 03/02/2026 LVN A told LVN B, the on-coming nurse to monitor CR for stroke like symptoms as she had concerns. She stated LVN A told her she was off shift on 03/03/2026 and returned on 03/04/2026 finding that CR's condition had worsened. She stated at that time, LVN A told her LVN A went against the facility protocol and called 911 to send CR to the ER. She stated LVN A told her LVN A was fired for calling 911 and sending CR to the ER without prior MD consent. She stated based on this information a complaint was made to HHSC. She stated at this time she had not received an official call from the facility informing her that the CR had been discharged with a change in condition nor had anyone from the facility called to check on the CR's status. She stated the higher level of care hospital physician stated CR would probably not wake up, not speak again, and would be paralyzed on her left side. She stated at this time, CR's MD had advised her to consider placing CR with hospice care. In an interview on 03/11/2026 at 12:10 p.m., the HS stated she was not on shift when CR was discharged . She stated on 03/04/2026, she received a call from LVN A informing her CR's discharged and how the Med Aid observed CR in and out of consciousness during the first shift on 03/03/2026. She stated she told LVN A that it could not have been possible for CR to be unconscious throughout both shifts without any nursing/CNAs reporting CR had a change in condition. In an interview on 03/11/2026 at 12:34 p.m., LVN C stated she was off shift on 03/04/2026 when she received a call from the DON asking about CR's change of condition resulting in LVN A discharging CR that morning. She stated on 03/03/2026 the Med Aid came to her and stated that Family 2 had concerns that CR was not feeling well. She stated she assessed CR and found that CR's vitals were fine, and CR stated she was fine. She stated she had not spoken to Family 2 about CR status at that time. She stated that LVN D relieved her shift, and she informed LVN D to watch for any changes in CR's condition. She sated she relayed all this information to the DON during the call. She stated she was not aware that CR's clinical chart had not reflected CR's change of condition on 03/04/2026. She stated LVN A was CR's nurse, and LVN A's responsibility to update and complete CR's change of condition documentation to outline CR's changes, vital signs, MD and RP notification, and subsequence MD orders. She stated that LVN A had not completed the change of condition documents. In an interview on 03/11/2026 at 01:05 p.m., CNA A stated she worked with the CR on 03/03/2026 from 6:00 a.m. - 6:00 p.m. She stated she had changed CR's bed linen, gave her a bed bath, changed her clothing, and brushed CR's hair. She stated the CR had no desire to eat her breakfast meal that morning, which was not abnormal, but accepted and ate her lunch meal, at 2:00 p.m. she laid CR down in her bed for the day. She stated she was off on 03/04/2026 she returned to shift on 03/05/2026, and CR was no longer at the facility. In an interview on 03/11/2026 at 02:25 p.m., the Med Aid stated on 03/03/2026 at 5:00 p.m. she attempted to pass medication to CR while Family #2 was in CR's room ensuring CR ate her dinner on that day, as he often had. She stated CR was asleep and she was unable to pass the medication to CR. She stated before she left the room Family #2 stated he did not like the way CR was looking. She stated she noticed CR appeared to be sleeping, when was not abnormal, but she could see the whites of her eyes showing a bit. She stated she had actually never seen CR's full face while she was asleep because CR always had her hair bonnet pulled down over most of her face when she slept and Med Aid was unaware if that was normal for CR's eyes to look that way. She stated she then asked CNA C how CR looked when she was last checked on and CNA C said CR was fine. She stated then she informed LVN C who was standing by and overheard her speaking to CNA C that CR had not received her medications because she was asleep. She stated LVN C was coming off shift as well, and LVN C informed LVN D who was coming on shift of CR's missed medications. She stated rumor was Family #2 spoke to LVN C about CR's condition, but no one came to check on CR for 12-hours and when LVN A came on shift the morning of 03/04/2026, LVN A found CR's blood pressure at 181/131 which was high and indicated CR was in distress. She stated therefore LVN A called 911 and sent CR out for higher level of care. She stated since CR's discharge, she had not seen and documented nursing notes reflecting what the s/sx CR exhibited or the reasoning for CR being sent out of the facility. She stated she would have expected LVN A to complete documentation to note CR's discharge. In an interview on 03/11/2026 at 02:56 p.m., the interim DON stated on 03/04/2026, the CR was found to have a change of condition that required her immediate transfer by ambulance to a higher level of care facility. He stated as CR's nurse, LVN A should have completed a Sbar (change of condition report) after completing a physical assessment on CR noting the date, time, and details of CR's change in condition that required the emergency transfer to a higher level care facility. He stated the report would have also included CR's vitals at the time of transfer, medications, and notification to CR's MD and her family. He stated as of this date, there was no Sbar, discharge summary, or nursing progress notes detailing or summarizing CR's need for hospital transfer or her condition for transfer to the hospital on [DATE] and he could not say why. He stated failure to complete the SBAR also effected CR showing up on the ADT list and initiating the discharge summary which was required by CMS. He stated it was the DON's responsibility to ensure that the charge nurse/LVN A completed the SBAR. He stated the process had fallen through and the discharge was not reviewed. He stated that based on CR's clinical records, there was no documentation the CR's physician and family were contacted about her discharge and documenting such was important for the continuity of CR's care, so they were to be aware of CR's location and current condition. In an interview on 03/12/2026 at 12:28 p.m., the ADM stated he learned of CR's change of condition hospital discharge on [DATE] and asked LVN A why the resident was sent out. He stated LVN A told him CR had a change of condition. He stated he then spoke to Med Aid who told him that on 03/04/2026, CR had seemed more sleepy than normal. He stated she spoke to LVN C and LVN D who both stated they had not noted anything wrong with CR when they last worked with her on 03/03/2026 into the morning of 03/04/2026. He stated then on 03/05/2026 Family #3 came in and asked for CR's clinical records. He stated he provided Family #3 with only the last hospital notes noted in CR's progress notes and Family #3 requested more details, which he stated he had not provided Family #3 because he wanted to find out from his staff what occurred with CR before he released the information. He stated he attempted to get more information from LVN A who was CR's charge nurse and the nurse who sent CR to the hospital, with no response. He stated in the evening of 03/05/2026 Family #3 came to the facility with a truck to retrieve all of CR's personal belongings. He stated that LVN A had not completed the required change of condition/SBAR documentation as to when, where, and why CR was sent to the hospital to date. He stated LVN A was terminated on 03/04/2026 at 3:00 p.m. for an unrelated issue. He stated charge nurses should be completing a SBAR, skin, and pain assessment at the time when a resident prepared to discharge out of the facility. He stated failure to complete those assessments resulted in untimely information being reported to CMS. In an interview on 03/12/2026 at 03:11 p.m., CNA B stated she worked the evening shift and on 03/03/2026 into 03/04/2026 and had not noticed any changes in condition in CR. In an interview on 03/12/2026 at 03:13 p.m., CNA C stated she had cared for CR on many occasions overnight and was familiar with CR's baseline. She stated on 03/03/2026 into 03/04/2026 she had not noticed any changes in condition that required her to inform CR's nurse. She stated she last saw CR on 03/04/2026 at 5:00 a.m. when providing CR incontinent care, as CR was wet and CR thanked her for the brief change. She stated CR was normally like that and had not looked sick. She stated CR was sleepy but that was normal because she cared for CR throughout the night shift. She stated she had no reports to share with LVN D related to a change in condition. In an interview on 03/13/2026 at 02:14 pm., MD B stated on 03/04/2026 at 03:29 p.m., LVN A called to inform her that while at the facility CR's eyes were rolling in the back of head and her blood pressure was elevated. MD B directed LVN A to call 911 to have CR immediately transferred to the hospital and CR was med-flight to the hospital due to stroke like symptoms. Record review of CR's physician note dated 03/03/2026 at 09:55 a.m., reflected PA-C assessed CR noting no issues and continue to report any s/sx of issues. Record review of CR's March 2026 MAR reflected the CR received her doses of medication on 03/02/2026 and were administered by the Med Aid. Record review of the facility's admissions, transfer, discharges log, dated 03/04/2026 - 03/11/2025, reflected on 03/04/2026 CR discharged to an acute care hospital. Record review of CR's discharge summary date on 03/11/2026 at 08:56 p.m., after survey intervention reflected CR admitted to the facility on [DATE] and was discharged to the ER on [DATE] due to a change in condition on 03/04/2026 signed and completed on 03/11/2026 by interim DON.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #18) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #18's behavior of entering male residents' rooms and taking off her clothes. This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial decline in healthRecord review of Resident #18's face sheet dated 09/05/2025, she was a [AGE] year-old female originally admitted to the facility on [DATE]. Her medical diagnoses included Alzheimer's Disease (a progressive disease affecting memory loss and decline in cognitive abilities), Type 2 diabetes mellitus (high blood sugar), and anxiety disorder (a mental health condition characterized by excessive fear, worry, or dread that interferes with daily life). Record review of Resident #18's Quarterly MDS dated [DATE] reflected a BIMS (short interview to measure cognition) score of 3, indicating severe cognitive impairment. Resident #18 was able to independently ambulate and dress. Record review of Resident #18's progress notes revealed the following behaviors:-3/30/2025 at 5:34pm, Resident #18 was going into other residents' rooms and removing their linen and pillows, she was redirected. -6/16/2025 at 9:11am, Resident #18 was redirected on two occasions from male rooms where she went into rooms and started removing clothes. The resident did not like being taken out but did leave. -7/19/2025 at 5:35pm, Resident #18 continued to remove clothing and was redirected and staff re-dressed her as needed.-8/7/2025 at 3:09pm, Resident #18 was walking in and out of other residents' rooms and taking off her clothes, and she was redirected every 10-15 minutes of that behavior.[Record review of Resident #18's care plan last captured 09/04/2025, revealed she was not care-planned for behaviors of entering male residents' rooms and taking off her clothes. Record review of Resident #18's monthly psychological assessments from March 2025 to August 2025, revealed there were no concerns related to the resident's wellbeing. Observation and interview with Resident #18 on 9/2/2025 at 7:40pm, she stated she liked her sisters and the people that helped her at the facility. Resident #18 was lying in bed, sleeping on her sheets. There were no odors or clutter in Resident #18's room. Interview with LVN C on 9/2/2025 at 7:50pm, she said Resident #18 walked around during the daytime and would take her clothes off in the common areas and Resident #18 had to be redirected. LVN C said the nurses' station was in the center of the unit and they can monitor all residents. Interview with MA P on 9/4/2025 at 11:30am, she said Resident #18 used to be aggressive but had calmed down. Resident #18 had habits of wandering room to room., stripping beds, and undressing herself. Staff knew to redirect Resident #18 out of residents' rooms and getting her to put her clothes back on by offering activities or snacks . MA P said she always redirect the Resident #18. Interview with MDS A on 9/4/2025 at 2:40pm, she said she was in charge of completing resident care plans. MDS A was aware Resident #18 had behaviors of taking off her clothes and going to male residents' rooms. MDS A said the purpose of care plans was so staff could get a better picture of residents' care, and if behaviors were not care-planned, then staff would not know how to fully take care of residents. Interview with the Administrator on 9/5/2025 at 11:13pm, the Administrator said Resident #18's behaviors should have been in her care plan and the care plan gave staff a snapshot of how to take care of residents and were basic instructions on providing care. Care plans were a way for staff to communicate about residents as well. If care plans did not capture a resident's total care, it could put the residents at risk. The Administrator said that MDS A and the MDS Nurse in general were in charge of documenting, but that care planning started with the nurse who was responsible for communicating resident's care with the MDS Nurse. Record review of the facility's Comprehensive Care Plan Nursing Policy and Procedure Manual, undated, revealed in part, Care plans will be person-centered and reflect the resident's goal of admission and desired outcomes .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.

Based on observations, interviews, and record reviews 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 two (Resident #15 and Resident #26 ) of 4 residents reviewed for medication administration. -Resident #15 was given Midodrine for her hypotension (low blood pressure) outside of prescribed parameters on 8/4/2025 at 10:00am and 6:00pm, 8/10/2025 at 10:00am and 8/28/2025 at 10:00am. -Resident #26 was given Carvedilol for his hypotension outside of prescribed parameters on 8/4/2025 at 9:00amThese failures placed residents at risk of not receiving medications as prescribed, decreased therapeutic effects of the medications, risk for drug diversion, delay in medication administration and worsening of their medical conditions.Resident #15Record review of Resident #15's face sheet last captured 09/05/2025, she was a [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses included: metabolic encephalopathy (a brain dysfunction caused by an underlying condition, and could affect mood, thinking, memory or loss of consciousness), Major Depressive Disorder (prolonged sadness which can cause a loss of interest and withdrawal from familiar activities), dementia (loss of cognitive functioning like thinking, reasoning and memory and potential loss of emotional control and personality) and hypotension (low blood pressure). Record review of Resident #15's Quarterly MDS dated [DATE], she had a BIMS score of 00, indicating severe cognitive impairment. Resident #15 required moderate assistance with ADLs like toileting, eating and personal and oral hygiene and was coded as always incontinent of urine and bowel. Record review of Resident #15's care plan last captured 09/05/2025, she was care-planned for adverse medication effect and behavior monitoring initiated 06/09/2025, with interventions including monitoring and accurate documentation of the resident's response to any treatment such as vital signs, progress notes and medication administration records. Record review of Resident #15's Order Summary report captured 09/05/2025, revealed Resident #15 had an order for Midodrine HCl oral Tablet 5 MG, give 1 tablet by mouth two times a day for symptomatic orthostatic hypotension[ when your blood pressure drops suddenly after standing up from a sitting or lying down , causing one to feel dizzy, lightheaded or even faint), hold for SBP <130 (< less than) with a start date of 04/17/2025 . Record review of Resident #15's MAR reflected Resident #15 was given Midodrine HCl oral Tablet 5 MG, give 1 tablet by mouth on 8/4/2025 at 10:00am and 6:00pm, 8/10/2025 at 10:00am and 8/28/2025 at 10:00am, when it was supposed to be held if SBP <130. Observation and attempted interview on 9/3/2025 at 7:52am with Resident #15, revealed she was lying in bed, and appeared in a pleasant mood. Resident #15 was unable to answer questions.Resident #26 Record review of Resident #26's face sheet dated 09/05/2025 reflected a [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE]. His medical diagnoses included chronic venous hypertension (high blood pressure in the veins of the legs), orthostatic hypotension (when someone's blood pressure drops when they are standing up or sitting down), and history of falling. Record review of Resident #26's Comprehensive MDS dated [DATE], revealed he had a BIMS score of 15, indicating high cognitive intactness related to thinking and memory. Record review of Resident #26's care plan last captured 09/05/2025, he was care-planned for having heart failure, hypertension with interventions including monitoring for side effects such as orthostatic hypotension. Record review of Resident #26's Order Summary captured 09/05/2025, revealed he was prescribed Carvedilol Tablet 3.125 MG, give 1 tablet by mouth two times a day for heart failure and hold if SBP less than 100 with a start date of 04/15/2025.Record review of Resident #26's August 2025 MAR revealed he had a blood pressure reading of 93/57 on 08/04/2025 and was given Carvedilol on 08/04/2025 at 9:00am . Record review of Resident #26's progress notes for August 2025, revealed there were no nurses' notes or documentation on Resident #26 taking Carvedilol outside of the parameters. Interview with MA P on 09/04/2025 at 11:30am, she said that she would tell the nurse on duty about residents' vitals that were out of parameter, and the nurse would let MA P know whether to give the medication or not. LVN Z would do vitals and then MA P would come in and give the mediations. MA P did not document telling LVN Z about the vitals but said she did inform LVN Z. Interview with LVN Z on 09/05/2025 at 1:51pm, she said she was not informed about Resident #15's SBP being over 130 and that she should have been notified of the vitals out of parameters. She said that if aides told her about vitals out of parameters LVN Z would review the vitals and re-check resident's vitals again. Resident #15 and Resident #26 had no issue of low blood pressure but that could have happened if they were given her blood pressure medication out of parameters. LVN Z said aides were good about reporting vitals for Resident #26 and that LVN Z checked vitals throughout the day as well. Interview with the DON on 9/5/2025 at 2:27pm, she said that MAs should notify nurses when resident vitals were out of parameters. The MA did not give Resident #26's medications as ordered. If Resident #15's and #26's medications were given when vitals were out of parameters, it could cause the vitals to be increased even more beyond range. The MAs were trained by the DON to give medications, and it would be part of their certificate. The DON said nurses were to document vitals MAs reported to them, and the nurse would report to the physician. Attempted interview with Resident #15's physician on 9/5/2025 at 3:15pm, phone number was left with the physician's office. Phone call was not returned. Record review of the facility's policy on Medication Orders revealed in part, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. The policy did not cover following physician orders. Requested policy on Following Physician Orders on 9/5/2025 at 2:03pm by email from the Administrator and DON, the policy titled Medication Orders was sent.

Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for two (Nurse medication Cart used for hall A and Nurse medication Cart for secured unit) three medication carts reviewed for storage of medications. -The Nurse Cart (unsecured unit) and the Nurse cart (secured unit) had multiple medications open, some had no names and were not dated. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversionObservation of the Nurse Cart for hall A on 09/04/2025 at 1:27 PM revealed the following medications open, with no names and not dated: 1. Mupirocin Ointment USP 2% opened and not dated2. Medi Honey 0.5 fl oz/1.5ml/18 with no resident name, opened and not dated3. Muscle rub net weight 3 oz with no resident name, opened and not dated4. Nystatin cream USP 100,000 um and 30 grams opened and not dated5. Relief Preparation soothing relief 0.9 oz no resident name, opened and not dated6. Mupirocin Ointment 2% net weight 22 gram opened and not dated7. Voltaren Arthritis pain net weight 100 gram no resident name, opened and not dated8. Santyl ointment 250 UM Hg opened and not dated In an interview on 09/04/25 at 1:27PM the ADON said the medications were supposed to have an open date when medications were opened because she didn't want to keep it forever. Observation of the Nurse Cart in the secured unit on 09/04/2025 at 1:48 PM revealed the following medications were open, with no names and not dated:Ketoconazole cream 2% opened and not datedKetoconazole Shampoo 2% opened and not dated In an interview on 09//204025 at 1:48 PM, LVN M stated she always checked the medication cart whenever she worked. She would always place an open date on medications that were opened for therapeutic effectiveness. LVN M stated she would notify the ADON of the medications opened and not dated. During an interview on 9/4/25 at 2:30 PM with the with DON, Regional Nurse and the Administrator, regarding medication storage, when asked about medications not dated when opened for administration the Regional Nurse said the nurses were not supposed to date the ointments. The nurse surveyor asked the Regional Nurse why most of the ointments and gels on nurse's medication carts had open date on it. Record review of the facility policy on Medication Storage PCU027 revised 2025 reflected in part: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Expired Medications and Medications with Shortened Expiration Dates Policy:Ensure that all medications in the facility are rotated and / or reviewed on a consistent basis to prevent having expired medications in the facility.Procedure:3. All medications will be labeled per State Board of Pharmacy Rules and Regulations that includes specific directions pertaining to expired or discarded after language.4. In the event that a medication has a shortened expiration date once opened the medication (open-dated) will be labeled with the date opened and the initials of the nurse. In the event the nurse is unsure if medication has a shortened expiration date that nurse will contact the Pharmacy to clarify or refer to the manufacturer recommendations. All OTC medication may be used until manufacturer's expiration date is reached or per the individual State Board of Pharmacy and State Health Departments rules and regulations.

Based on observation, interview and record review, the facility failed to ensure residents have a right to a dignified existence and treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #15) of 4 residents reviewed for dignity. -Resident #15 was observed eating in the dining room while soiled and staff present did not notice before serving Resident #15 her breakfast. This deficient practice could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment regardless of resident cognition.Record review of Resident #15's face sheet last captured 09/05/2025, she was a [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses included: metabolic encephalopathy (a brain dysfunction caused by an underlying condition, and could affect mood, thinking, memory or loss of consciousness), Major Depressive Disorder (prolonged sadness which can cause a loss of interest and withdrawal from familiar activities), dementia (loss of cognitive functioning like thinking, reasoning and memory and potential loss of emotional control and personality) and hypotension (low blood pressure. Record review of Resident #15's Quarterly MDS dated [DATE], she had a BIMS score of 00, indicating severe cognitive impairment. Resident #15 required moderate assistance with ADLs like toileting, eating and personal and oral hygiene and was coded as always incontinent of urine and bowelRecord review of Resident #15's care plan last captured 09/05/2025, she was care-planned for impaired cognitive function/dementia or impaired thought processes, with interventions keeping the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Resident #15 was also care-planned for ADL self-care performance deficit, with interventions including requiring assistance to use the toilet. Observation and attempted interview on 9/3/2025 at 7:52am with Resident #15, revealed she was lying in bed soiled in urine, and appeared in a pleasant mood. Resident #15 was unable to answer questions. Resident #15 got out of bed and walked without assistance to the dining area in the secured unit for breakfast soiled with urine. LVN E asked Resident #15 to sit down. Resident #15 sat by herself at a table. LVN E brought Resident #15 and set it in front of the resident who began eating her breakfast. Interview with CNA D on 9/8/2025 at 8:00am, she said that she did not see Resident #15 walking soiled from Resident #15's room to the dining room because CNA D was providing showers to another resident. CNA D said if she knew Resident #15 was wet, she would have changed Resident #15 first before bringing her to the dining room for breakfast. Interview with LVN E on 9/8/2025 at 3:20pm, she said she gave Resident #15 her breakfast tray but did not notice Resident #15 was wet and took Resident #15 to her room for incontinent care after surveyor intervention. LVN E came back after completing incontinent care and said that if residents were not changed in a timely manner, they could have skin breakdown. Nurses were responsible for ensuring that CNAs changed residents in a timely manner. Interview with the Administrator and DON on 9/4/2025 at 2:40pm, the DON said that it would be uncomfortable for Resident #15 to eat while soiled and it would affect her dignity. Staff should have redirected Resident #15 to her room and changed the resident. Record review of the facility's policy on perineal care dated 04/27/2022 revealed in part, It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations. Record review of the facility's policy on resident rights, undated, revealed in part, the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . The facility must provide equal access to quality of care .The resident has a right to be treated with respect and dignity, including .3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferencesexcept when to do so would endanger the health or safety of the resident or other residents.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 (Dumpster A) of 1 facility dumpsters observed for proper garbage disposal. -Dumpster A's side door was open with trash inside on 9/2/2025. This failure could place residents at risk of contact with pests and associated diseases. Observation on 9/2/2025 at 6:34pm, revealed the left lid on Dumpster A was open. Interview with the Dietary Manager on 9/2/2025 at 6:35pm, she said the dumpster's lids should be closed at all times. The lids being left open could cause cross contamination, trash could be blown out by the wind and could get in the yard and smell. Animals could also get in the dumpster and could injure staff. The Dietary Manager said that she verbally educated housekeeping and nursing staff to close it, and she would do a formal in-service. Interview with the Administrator and DON on 9/3/2025 at 2:37pm, the Administrator said all staff were responsible for ensuring the dumpsters were closed. The DON said that if the dumpsters were open, it could cause cross-contamination, critters could come and that could affect residents' dignity.A policy on dumpsters was requested from the Dietary Manager on 9/3/2025 at 9:42am. On 9/3/2025 at 10:33pm. The Dietary Manager verbally confirmed the facility did not have a policy on dumpsters.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for physical environment.The facility failed to clean and/or remove ceiling tiles throughout the facility that a had black, moldlike substance on them.This failure could place residents at risk for respiratory issues, infection, and hospitalization.Findings included:In an observation on 8/14/25 the following observations were made of a black, moldlike substance:- 10:23am: Ceiling tiles outside of the Soiled Utility room, across from room [ROOM NUMBER].- 10:31am: Ceiling tiles outside of room [ROOM NUMBER].- 10:33am: Ceiling tiles outside of room [ROOM NUMBER].- 10:35am: Ceiling tiles across from the entrance to the Therapy Gym.- 10:36am: Ceiling tiles over Nurse's Station 3.- 10:47am: Ceiling tiles in the Therapy Room.In an interview on 8/14/25 at 10:36 a.m., LVN W said they did not have a Maintenance Director at the moment and the last one left 2 weeks ago. She said the previous Maintenance Director would empty the air conditioner's drain pan regularly, that was in the attic. She said he would clean the mold with acid and bleach and then replace the tiles in the ceiling. She said he would also clean the walls with bleach/acid and then put new plaster over it and re-paint. LVN W said no one had done any repairs since he left.In an interview on 8/14/25 at 10:45 a.m., the ADM said, How do you know that is black mold, did you test it? after she was shown pictures of what was found.In an interview on 8/14/25 at1:32 p.m., the ADM said they were making repairs as they were made aware. She said they had been fixing issues since the building was bought a year ago, but it took time to get everything done because it was an old building. She said she would have the maintenance people from some of the sister buildings come out and check the blackened areas on the tiles to see if they were mold.In an anonymous interview, it was said if the patch in room [ROOM NUMBER] was pulled back, black mold would be seen all over the beams and the Maintenance Director was told to spray bleach on it, patch the wall and paint it. The anonymous person said the ADM told the Maintenance Director; the smell of paint would cover the mold smell so the residents would stop complaining. The anonymous person said there was black mold everywhere, and the Maintenance Director spent his time bandaging the a/c system and replacing black mold tiles. The anonymous person said the drip pans from the a/c constantly got full and the pans had eroded away so much they were falling apart, causing the drains to clog from the particles and leak water into the ceiling, walls, and light fixtures. The anonymous person said the Maintenance Director was in the attic every day fixing the drains or the stains from the black mold.A policy on Physical Environment was requested and the ADM said they did not have one.Record review of the facility's policy on Resident Rights (no dates) read in part: The resident has a right to a dignified existence.in an environment that promotes maintenance or enhancement of his or her quality of life.The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care.The resident has a right to be treated with respect and dignity, including.The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences .

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for resident abuse. The facility failed to prevent Resident #1 from being physically abused by MA D who hit Resident #1 on the face during patient care on 11/10/2024. The noncompliance was identified as past noncompliance. The noncompliance began on 11/10/2024 and ended on 11/11/2024. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of experiencing and enduring abuse causing a decreased quality of life. Findings included: Record review of Resident#1's face sheet dated 01/24/2025, reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a diagnosis of Unspecified Dementia, Moderate, With Agitation (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). Record review of Resident #1's quarterly MDS assessment, dated 06/26/2024, reflected a BIMS score of 1 out of 15, which indicated the severe cognitive impairment. Further review of Resident #1's MDS reflected the resident needed assistance with ADL care. The MDS did not indicate Resident #1 had a history behaviors experience of hallucinations, or the expression of false beliefs (delusions). Record review of Resident#1's, undated, comprehensive care plan reflected a focus area initiated on 11/08/2024, Resident #1 had impaired cognitive function or impaired thought processes related to diagnosis of Dementia. Interventions: Engage the resident in simple, structured activities that avoid overly demanding tasks. The resident had a history of trauma that may have a negative impact. The trauma is related to: a negative interaction with staff member. Goal: Maintain resident's safety and integrity during post trauma episode, using appropriate interventions. Intervention: If the resident has escalated, if possible do not touch the resident unless necessary for resident's or others safety. Two staff members while providing care. Date Initiated: 11/11/2025. Record review of the provider investigation report dated 11/10/2025 revealed MA D's written statement read in part At 2:23a.m, I heard someone yelling mama I went and checked all the rooms to see who was calling out for help. It was Resident #1. I walked in the room to find her on the floor she was lying flat on her face and her right leg was bent. I called out for the nurse a couple times in the meantime CNA J, and I went back to the room. Resident #1 was still yelling mama we told her we had to wait for the nurse the nurse came asked her was she hurt Resident # 1 said her face and leg hurt me and CNA J started to position her to get her off the floor and she got upset and said to leave her alone because the two boys in the corner would get her up. We told her we would help her. Resident #1 started swinging as we lifted her from the floor. My head was down, and the tip of her hand brushed across my glasses. We got her in bed, and I said you can't be upset. We are trying to help you Record review of LVN C written statement dated 11/10/204 read in part November 10, 2024, at approximately 2:30 a.m. Resident#1 was found lying on her abdomen and her head facing towards the wall resident one did not appear in any distress. Assessment completed Resident#1 was returned to her bed by CNA J and MA Resident#1 was waving her arms in the air trying to be left alone. Resident #1 managed to hit MA D in the face. As a reaction MA D hit Resident#1 in her face Record review of CNA J's written statement dated 11/10/2024 read in part On Saturday night I was called to help MA pick Resident # 1 off the ground we waited until LVN C completed her assessment MA and I proceeded to pick up Resident # 1 She started swinging her hand trying to fight us Resident # 1 hit MA D in the face Resident # 1 was slapped back by MA D Observation and interview on 01/24/2025 at 5:00 p.m., Resident #1 was in bed, and she was dressed in her casual clothes. Resident #1 was not able to say if the staff was abusive to her. Resident #1 was a poor historian. During an interview on 01/24/2025 at 5:30 p.m., the DON stated there was an incident on 11/10/2024 with Resident #1 when MA D along with other staff was attempting to assist the resident off the ground back to bed. At this time the resident proceeded with slapping MA D across the face. The charge nurse witnessed MA D reacted and returned the slap to the resident. DON stated there was no reason for MA D to physically abuse Resident #1. DON stated the Administrator notified by the charge nurse of the incident on 11/10/2024. She stated MA D was suspended immediately on 11/10/2024, pending the facility's investigation. During interviews on 01/24/2025 between 12:47 a.m. and 4:50 p.m., (LVN W, CNA T, and MA C) from day shift were interviewed All staff interviewed were able to verbalize understanding of abuse/neglect in-services received. During an interview on 01/22/2025 at 6:00 p.m., the Administrator stated the facility had QAPI meeting about the incident; staff was in-serviced on abuse/neglect; safe surveys with residents; and the DON would train new staff upon hire on abuse/neglect. Record review reflected the following action were implemented by the facility: On 11/10/2024 immediately after the incident Resident #1 was assessed for pain/Injury/emotional distress - No pain or injury noted; however resident did appear upset per charge nurse. The three staff members (MA D, LVN C, and CNA J) involved were suspended on 11/10/2024, pending facility's investigation. Incident reported to HHSC. 1/1 in servicing regarding reporting of abuse and neglect provided to staff members on 11/10/24 by Administrator. Law enforcement was notified by Administrator on 11/10/24. Resident #1 medical provider and responsible party was made aware of incident on 11/10//24 by Administrator. Risk management assessments completed for all residents on 11/10/24 by DON. Ad hoc QAPI completed on 11/10/24 with IDT team. In servicing initiated on Abuse and neglect on 11/10/24 by Administrator. In servicing initiated on Handling aggressive behaviors by DON 11 /11 /24. Trauma informed care assessment completed by charge nurse on 11/10/24. Resident #1 revised care plan for trauma informed care completed on 11 /11 /24. Resident #1 referred to psych services by DON on 11 /11 /24. Follow up assessment on Resident #1 completed on 11 /11 /24. No indication of pain and emotional distress was noted. State Surveyor verified the following: Record review of MA D employee file reflected the following: DOH: 06/21/2024 and MA D was training on abuse and neglect upon hire. Criminal background checks completed 07/09/2024. HHS check completed 06/28/2024. DOT: 11/10/2024 due to substantiated allegation of physical of abuse. The three staff ((LVN C, CNA J, and MA D) had previously had abuse and neglect training as well as behavior management for residents training prior to 11/10/2024. EMR/Criminal background/License check were current for three staff members (LVN C, CNA J, and MA D) involved. The facility policy on abuse dated 03/09/2018, reflected in part The resident has the right to be free from abuse Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, . and situations that may constitute abuse or neglect to any resident in the facility Physical Abuse: Includes, hitting, slapping, punching, and kicking. It also includes controlling behavior through corporal punishment

Based on observations, interviews and record review the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment for 2 of 2 shower rooms, in that: 1. Shower room [ROOM NUMBER] had an area on tile that had soap scum and hard water stains, the shower mat was dirty with black stains, shower chair back rest had hard water stains, and under shower chair was dirty with reddish substance. 2. Shower room [ROOM NUMBER] had a tile missing, the shower chair under the seat had reddish substance. This failure could affect any resident and contribute to feelings of low self-esteem. The Findings were: 1. Observation on 8/01/2024 at 1:49 PM with Laundry/Housekeeper revealed in Shower room [ROOM NUMBER] had an area on tile that had soap scum and hard water stains, the shower mat was dirty with back stains, shower chair back rest had hard water stains, and under shower chair was dirty with reddish substance. Observation on 8/01/2024 at 2:03 PM with Maintenance Supervisor revealed Shower room [ROOM NUMBER] water temp was 96.8 Degrees Fahrenheit. Interview on 8/01/2024 at 1:50 AM with Laundry/Housekeeper stated Shower room [ROOM NUMBER] had an area on tile that had soap scum, and hard water stains, the shower mat was dirty with back stains, shower chair back rest had hard water stains, and under shower chair was dirty with reddish substance. The housekeeper stated staff clean the shower rooms, but the stains do not come off. Interview on 8/01/2024 at 2:17 PM with Maintenance Supervisor in Shower #1 stated an area on tile that had soap scum, and hard water stains, the shower mat was dirty with back stains, shower chair back rest had hard water stains, and under shower chair was dirty with reddish substance. Housekeeper stated staff clean the shower rooms, but the stains do not come off. Interview on 8/01/2024 at 2:04 PM with the Maintenance Supervisor stated the water temperature near shower #1 was 96.8 Degrees Fahrenheit. 2. Observation on 8/01/2024 at 1:55 PM with Shower room [ROOM NUMBER] had a tile missing, the shower chair under the seat had reddish substance. Observation on 8/01/2024 at 2:03 PM of Maintenance Supervisor (started 2 weeks ago) observed in Shower #2 revealed a tile missing, had tile had mildew build up on vent, the shower chair under the seat had reddish substance. The Maintenance Supervisor stated shower water temp was 96.8 Degrees Fahrenheit. Observation on 8/1/2024 at 2:16 PM with the Maintenance Supervisor of the water heater unit 1 outside near Shower #2 was at 125 Degrees Fahrenheit. Observation of the 2nd water heater, near kitchen was at 100 Degrees Fahrenheit. Interview on 8/01/2024 at 2:17 PM with the Maintenance Supervisor in Shower #2 had tile missing, had mildew build up on vent, shower room water temp was 124.1 Degrees Fahrenheit. The Maintenance Supervisor stated that was too hot, would like it no more than 110 Degrees Fahrenheit Interview on 8/01/2024 at 3:25 PM with the Maintenance Supervisor stated he had not gone in the resident showers. Interview on 8/02/2024 10:45 AM with the HSK D stated she did not lift or clean the mat on floor to clean it and does not clean the tile floor or tiled walls. Interview on 8/02/2024 at 11:21 AM with the ADM/DON stated no residents had any injuries of burn skin due to shower water being too hot. no water temperature logs for the building. The ADM stated the Maintenance Supervisor started 2 weeks ago. Record review of policy Resident Rights revision date 11/28/2016 revealed Safe environment-The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interviews and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of four quarters in 2024 (Quarter 2) reviewed for sufficient nursing staff. According to the PBJ report for Quarter 1 2024 (January 1 through March 31), the facility did not have sufficient weekend staff. This failure could place residents at risk of diminished quality of life and quality of care. Findings: Record review of the CMS PBJ report for Quarter 2 2024 (January 1,2024 through March 31,2024) indicated the facility had excessively low weekend staffing. Record review of the RN staffing hours for January 1, 2024, to March 31, 2024, revealed that there was no RN coverage on 2/10/24, 2/11/2024, 2/25/24,3/23/24,3/24/24,3/30/24, and 3/31/24. August 1, 2024, interview at 11:50 AM: The Director of Nursing (DON) stated that the shortage of weekend RN coverage 2/10/24, 2/11/24, 2/25/24,3/23/24,3/24/24,3/30/24, 3/31/24.was due to the facility's remote location; she added that lack of weekend RN coverage can lead to possibly increased readmission rates. Interview on 8/01/24 at 12:18 PM, with the Administrator stated that no RN coverage was available on 2/10/24, 2/11/24, 2/25/24,3/23/24,3/24/24,3/30/24, and 3/31/24 because the staffing agency contracted could not provide a weekend RN. She stated she currently had an RN weekend position posted, but no one has applied due to the facility's location. Record review of facility policy Departmental Supervision, 2001, revised August 2006, revealed an RN/LPN is on duty 24 hours per day, seven days a week.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that items stored in the walk-in in refrigerator were labeled after opened or prepared. In dry storage a dented can of tomatoes, received date 07/16/24, observed on 07/30/24 on rack with all other can goods to be used. This failure affects the residents who received meals from the kitchen and place them at risk for foodborne illness. Findings included: Observation of the facility's only kitchen on 07/30/2024 at 10:08 AM revealed the facility's dry storage had a can of dented tomatoes, dated 07/16/24, on rack with all other cans. Three trays of unlabeled drinks were observed in the walk-in refrigerator. Milk jug, small jar of jalapeno, small jar of mayonnaise and small squeeze bottle of mayonnaise, all opened, were also observed in the walk-in refrigerator unlabeled with open dates. Interview with the Dietary Manager on 08/01/2024 at 1:45 pm revealed all open foods in the walk-in refrigerator were to be labeled with the date opened. The Dietary Manager also stated that any foods or drinks prepared and then stored in the refrigerator were to be labeled with the date prepared. The Dietary Manager stated that all staff were responsible to label all items before storing them in the refrigerator. The Dietary Manager stated cans were inspected when they were received, and any dented cans were placed on a shelf designated for dented cans. Dented cans were returned to the vendor for credit. The Dietary manager stated that whoever puts the delivery away was responsible to identify any dented cans, but one must have been missed. The Dietary Manager stated, by not labeling open items in the refrigerator or using the dented cans, there could be an increased risk for food born illness. Record review of the policy named Food receiving and storage dated 2022, revealed 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) and 3. Dry foods and good are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, on 04/24/2024, states 3-101.11 Safe, Unadulterated, and Honestly Presented. Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard.

Based on observations, interviews and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 2 shower rooms, in that 1. Shower room [ROOM NUMBER] water temperature was 96.8 Degrees Fahrenheit. 2. Shower room [ROOM NUMBER] water temperature was 124.1 Degrees Fahrenheit. 3. No water temperature logs were kept. This failure could affect any resident and contribute to feelings of low self-esteem. The Findings were: 1. Observation on 8/01/2024 at 2:03 PM with the Maintenance Supervisor revealed Shower room [ROOM NUMBER] water temp was 96.8 Degrees Fahrenheit. Interview on 8/01/2024 at 2:04 PM with the Maintenance Supervisor stated the water temperature near shower #1 was 96.8 Degrees Fahrenheit. 2. Observation on 8/01/2024 at 2:03 PM with the Maintenance Supervisor (started 2 weeks ago) observed in Shower #2 water temperature was 96.8 Degrees Fahrenheit. Observation on 8/1/2024 at 2:16 PM with Maintenance Supervisor of the water heater unit 1 outside near Shower #2 was at 125 Degrees Fahrenheit. Observation of the 2nd water heater, near kitchen was at 100 Degrees Fahrenheit. Interview on 8/01/2024 at 2:17 PM with Maintenance Supervisor in Shower #2 had shower room water temperature was 124.1 Degrees Fahrenheit. The Maintenance Supervisor stated that was too hot,would like it no more than 110 Degrees Fahrenheit Interview on 8/01/2024 at 3:25 PM with Maintenance Supervisor stated he had not gone in the resident showers to take water temperatures. Interview on 8/02/2024 at 11:21 AM with ADM/DON stated no residents had any injuries of burn skin due to shower water being too hot. The ADM stated no water temperature logs for the building. ADM stated the Maintenance Supervisor started 2 weeks ago and was still training. Asked for policies. ADM stated the Maintenance Supervisor was getting trained today. Record review of the incident reports, grievances, and resident council minutes for 6 months revealed no concerns with hot water or cold water during showers. Record review of the policy, Bath, Tub/shower [NAME] dated 2003 revealed 7. run water in the tub and test the temperature with the thermometer to obtain in rand of 98-104 degrees Fahrenheit or run water into the shower and test on the inner arm for comfortable, temperature. Record review of Hot water systems dated [NAME] 2003 revealed 1. The hot water system will be checked weekly for temperature variants. The temperature [NAME] be recorded on the water temperature log weekly and maintained by the Maintenance Supervisor. The facility will be responsible for maintaining at least twelve months of water temperatures logs for review. 3. The following area wills be checked and logged weekly: c. shower temperature. 6. Water temperatures should be maintained at 100 Degrees Fahrenheit, and 110 Degrees Fahrenheit fat maximum. Record review of the policy Resident Rights revision date 11/28/2016 revealed Safe environment-The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on Observations & Interviews, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident # 31) reviewed for call light. The facility failed to ensure Resident # 31's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being. Findings include: Record review of Resident # 31's face sheet dated 7/30/24 revealed a 64 - year old female admitted to the facility on [DATE]. Resident # 31 had diagnoses that included Chronic obstructive pulmonary disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Major Depressive Disorder ( a severe mood disorder that can affect a person's thoughts, feelings, and ability to perform daily activities) and Paraplegia( is a term used to describe the inability to voluntarily move the lower parts of the body). Record review of Resident # 31's Admission MDS assessment dated [DATE] reflected a BIMS score of 13 which suggested intact cognition. under section G, G0300, option # 3, which stated that the patient was unsteady on their feet and required assistance X 2. Record review of Resident 31's care plan dated 7/09/24 did not address the use of call light. Observation and interview on 7/30/24 in Resident # 31's room at 9:45 AM revealed that the call light was found on the floor under the bed. Resident # 31 stated, I would be in a pickle if I need to call for help. Resident # 31 expressed that they did not know how the call light ended up on the floor. On 7/30/24 at 9:50 AM, during an interview, CNA A stated that she was the assigned nursing assistant for Resident #31. She mentioned that she did not know how Resident #31's call light ended up on the floor, but she picked it up and clipped it to Resident #31's bedspread. She also noted that if Resident #31 lacked access to the call light, it could potentially lead to a fall if Resident #31 needed assistance. During an interview with the DON on 7/30/24, at 10:05 AM, she mentioned that she was the assigned nurse for Resident # 31. She emphasized the importance of ensuring that the call light was accessible to all residents, stating that the lack of accessibility to a call light for any resident could lead to a potential negative outcome if assistance is needed. The DON also mentioned that charge nurses currently monitored this task during their morning rounds daily, and she was responsible for overseeing this process. Record review of the facility policy Call System, Resident, dated 2001, revealed call lights are placed within reach of resident.

Based on observation, interview and record review revealed the facility did not provide special eating equipment and utensils for residents who need them for 1 of 1 Residents (Resident #37) who were observed during meal service. Staff failed to ensure Resident #37 had a built-up spoon and a straw. Based on observation, interview and record review revealed the facility did not provide special eating equipment and utensils for residents who need them for 1 of 1 Residents (Resident #37) who were observed during meal service. Staff failed to ensure Resident #37 had a built-up spoon and a straw. This failure could affect residents who depended on assistive devices and infringe on the resident's dignity and feeding independence. The findings were: Record review of Resident #37's face sheet, dated 7/30/24, revealed Resident #37 was an [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #37 was diagnosed with muscle wasting and atrophy and feeding difficulties. Record review of Resident #37's care plan, dated 07/30/2024, revealed Resident #37 has a swallowing problem r/t Dysphasia. Resident #37's care plan also notes all meals to be served on a divided plate. Drinks to be in mug with no ice and a straw. Res. to have built up spoons for all meals. Record review of Resident#37's meal ticket dated 07/30/2024, revealed resident was to receive a built-up spoon and straw with meal tray. Dining observation of the facility's dining room on 07/30/2024 at 11:44 AM revealed Resident #37 was presented her lunch but was not provided a straw or built-up spoon. Resident #37 was provided a regular fork. Interview with Resident #37 on 07/30/2024 at 1:56 PM revealed resident was not provided a built-up spoon or straw at lunch. Resident #37 stated that the built-up spoon was uncomfortable to use, and she did not need a straw anymore. Resident #37 stated she had asked to be given a regular fork a few days before and the facility had not provided the built-up spoon since. Interview with the Dietary Manager on 08/01/2024 at 1:45 PM revealed Resident #37 had requested to get a regular fork instead of the built-up spoon but could not recall the date. The Dietary Manager stated by not providing Resident #37 a built-up spoon or straw Resident #37 could have a difficult time eating and drinking. Record review of facility's policy named Adaptive Eating Devices dated 2012 revealed dietary department: sanitizes the utensils after each use and places the devices on the resident's tray as needed.

Based on observation, interview, and record review the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 (refrigerator in resident room [ROOM NUMBER]-A) of 3 residents' refrigerators reviewed in that: The personal refrigerators in one residents' rooms contained food items which were unlabeled and undated. This failure could place residents at risk of foodborne illness due to consuming foods which are spoiled. The findings were: Observations on 7/30/24 at 9:45 A.M. revealed that the personal refrigerator in resident room [ROOM NUMBER]-A contained sliced summer sausage in an unlabeled and undated zip-lock bag. Further observation on 07/30/2024 at 11:34 a.m. revealed sliced summer sausage in an unlabeled and undated zip-lock bag was still present. During an interview with CNA C on 07/30/24 at 9:50 a.m., CNA C confirmed that the personal refrigerator in resident room [ROOM NUMBER]- A contained sliced summer sausage in an unlabeled and undated zip-lock bag. During an interview with the Director of Nursing on 7/30/24, at 1:20 p.m., the DON confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled foods. The DON stated that the night shift nurses were responsible for overseeing this task, but currently, this was not being monitored. Record review of the facility policy, Foods Brought by Family/Visitors, dated 2001, revised October 2017, revealed, .Perishable foods must be stored in a resealable container tightly fitting lids in refrigerator, container will be labeled with Residents name, the item and use by date.

Based on interview and record review the facility failed to ensure Medical records in accordance with accepted professional standards and practices, were complete and accurately documented for 1 of 5 (Resident #25) residents, in that: Resident #25's care plan meeting was documented as a DNR status and order was a full code status. This failure could result in residents' records not accurately documenting the administration of medications and could result in a decline in heath. The Findings were: Record review of Resident #25' Admission Record dated 8/1/2024 revealed she was admitted on [DATE], re- admitted in 12/28/2022 with a full code status. Record review of Resident # 25's consolidated orders for August 2024 revealed an order for a full code status. Record review of Resident # 25's care plan dated 7/6/2024 revealed she was a full code status. Record review of Resident # 25's care plan conference dated 6/8/2024 revealed she was a DNR. Interview on 8/01/2024 at 12:12 PM with the ADM stated maybe an error on the care plan conference with the MDS signature. no policy on record accuracy. Interview on 8/1/2024 at 1:00 PM with the MDS revealed she lead the care plan conferences and was a mistake. The MDS stated the risk was low to residents because the charge nurses look at code status book for all residents and get updated. The MDS stated the charge nurses look at the orders not the care plan conferences.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 1 of 3 halls (Memory Care Unit) observed for environmental conditions. The facility failed to prevent three of the Memory Care Unit's chairs and sofas' exterior covering from being ripped with the interior stuffing exposed. This failure could place residents at risk of harm from furniture pieces and at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Observation on 4/11/2023 at 7:16 AM of the memory care unit's common room revealed three chairs and sofas were ripped, and the interior stuffing was visible. Residents were seated on the chairs. Interview on 4/12/2023 at 2:41 PM with the AD revealed she was in the Memory Care Unit daily. The AD said the furniture in the Memory Care Unit had been ripped for a couple of months. The AD said the facility was in the process of obtaining new furniture. The AD said she had seen the residents picking at the furniture. The AD said when staff saw the residents picking at the furniture, the staff would redirect the residents. The AD said the staff had attempted to move the residents to ensure they did not continue to pick at the furniture. Interview on 4/12/2023 at 2:54 PM with MA A revealed she worked in Memory Care Unit daily. MA A said the furniture in the Memory Care Unit had been ripped for some time and had in the past two weeks become more ripped. MA A said the residents in the Memory Care Unit would pick at the rips increasing the ripped area. MA A said if the staff observed a resident picking at the furniture the staff would redirect the resident and possibly move the resident. Interview on 4/12/2023 at 8:46 AM with CNA A revealed she had been employed by the facility for eight months. CNA A said the furniture in the common room of Memory Care Unit had been peeling for the entirety of that time. CNA A said there were residents who picked at the peeling furniture. CNA A said she would redirect those residents and move them to another seat Interview with the Admin on 4/12/2023 at 1:17 PM revealed she had ordered replacement couches for the Memory Care Unit common room. The Admin said the replacements would not arrive until 6/2/2023. She said she would provide all communication related to the ripped chairs in the Memory Care Unit concerns she had with the corporate representatives for the facility. Interview on 4/13/2022 at 12:33 PM with the Admin revealed she had been employed as The Admin since 9/27/2022 and received an Administrator's license in August of 2022. The Admin said the furniture in the Memory Care Unit had smaller rips when she was hired, but it had become worse because Memory Care Unit residents would pick at the already open areas. The Admin said that is why the corporate offices agreed to purchase new furniture. The Admin said due to the condition of the furniture and the acuity of the residents in the Memory Care Unit the residents could pick the furniture and put the pieces in their mouths. The Admin said she was not aware of any residents putting furniture pieces in their mouths. Interview on 4/13/2023 at 3:41 PM with The Admin, revealed she would provide all communication related to the ripped furniture concerns in the memory care area she had with the corporate representatives for the facility. Record review of an invoice dated 4/12/2023 revealed the facility ordered six couches and six loveseats from Direct Supply. The delivery date for the couches and loveseats was 6/2/2023. No other documentation related to the furniture in the memory care unit was provided by the facility prior to exit.

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 7 residents (Resident #1 and Resident #2) reviewed for accidents and supervision. 1. The facility failed to provide adequate supervision of Resident #2 in the attached courtyard of the secure unit resulting in an unwitnessed fall in which the resident suffered a fracture to his left femur (hip fracture), decreased range of motion and pain. 2. The facility failed to provide adequate supervision of Resident #1 in the attached courtyard of the secure unit resulting in resident's elopement from an unlocked exterior gate. These failures could affect residents by placing them at risk of minor and major injuries due to inadequate supervision. Findings include: switch order of findings Resident #1 Record review of Resident #1's Admission Records revealed a [AGE] year-old male admitted to the facility on [DATE] with an initial admitted [DATE]. Resident #1's diagnoses included dementia, lack of coordination, unsteadiness on feet, abnormalities of gait and mobility, weakness, [CONDITION(S)] disorder, [CONDITION(S)], diabetes and hypertension (HTN). Record review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], revealed a brief interview of mental status (BIMS) score of 11 out of 15, which indicated he had moderate cognitive impairment. He had not exhibited wandering behavior. He required supervision with no physical help from staff for locomotion off the unit. He required supervision with set up only for bed mobility, transfers, walking in room, walking in corridor, dressing, eating and toilet use. He required two-person physical assist with personal hygiene. He was not steady but able to stabilize without staff assistance for balance during transitions and walking. Record review of Resident #1's care plan, revised on 11/23/20, revealed Resident #1 was an elopement risk as evidenced by admission with history of attempts to leave facility unattended and impaired safety awareness. 11/04/20-walked to city due to lawn service not closing gate. Interventions included; all vendors notified and in-service on contacting facility immediately when equipment requires servicing; assess for fall risk; secure patio-realign gate to close properly; staff to monitor exit doors through shift with close monitoring during generator testing. Resident has low-moderate risk for falls related to (r/t) use of antidepressant medication for [CONDITION(S)] disorder and need for staff supervision with activities of daily living (ADLs). Record review of Resident #1's nursing progress note, dated 11/04/2020 at 2:00 PM, written by former DON, revealed in part .Resident #1 will sit on patio .for extended amount of time with staff checking frequently on resident .lawn service mowed last night while residents were inside eating dinner .Resident #1 stated he pushed on gate door to parking lot with gate opening. Resident stated he wanted to see some friends, so he kept walking. Resident stated he had a friend at City Hall .Friend was aware resident lived at the facility and called to notify .Staff (facility) member placed resident in van to bring back to facility without incident Nursing performed complete assessment .no injuries Record review of the Provider Investigation Report, dated 11/05/2020, documented the distance Resident #1 walked (on 11/04/2020), from the facility to City Hall was 0.61 miles. The report had attached, undated, in services which revealed staff were in serviced on the following topics: outside doors of secure unit should be checked every 2 hours; announcements to be made when generators are tested ; secure unit back gate should not be used as exit/entrance; vendors such as lawn services shall be given instructions how/when to secure . In an observation on 05/26/21 at 09:59 AM revealed Resident # 1 walked outside of his room and out to the attached courtyard, no chimes/alarms played as the resident exited the door. All staff were either with residents in the sitting area or at the nursing station, there were no staff in the area surrounding the exit to the courtyard and there was no staff in the courtyard . In an observation on 05/26/21 at 2:30 PM revealed Resident#1 was in the outside patio sitting on the bench. A staff member was not with him. The gate was locked. In an interview on 05/26/21 at 10:22 AM, Resident #1 did not know what the date was, and he did not remember the incident when he wandered off and walked to City Hall. He said he only stays in the patio with a staff member. In an interview on 05/26/21 at 10:25A with, LVN A revealed Resident #1 was the only resident who really liked to go out to the patio. She stated she will check on him afterwards, if she knew he was out and will keep an eye on him. She does every 2-hour rounds on residents and would check on him. In an interview on 05/27/21 at 9:45 AM with the Activity Director revealed on 11/14/2020 the Administrator instructed her to pick up Resident #1 after receiving a call that the resident was at City Hall. She went to City Hall and drove him back to the facility. She said it was not far but was a bit of a walk from facility to City Hall. Resident #2 Record review of Resident #2's Admission Record revealed an [AGE] year-old male admitted to the facility on [DATE] with an initial admission of 07/10/19. Resident #2's diagnosis included fracture of left femur, left hip pain, urinary tract infection, difficulty walking, [CONDITION(S)], [CONDITION(S)] and collapse; disruptive mood dysregulation disorder, cognitive communication deficit, diabetes, dementia, repeated falls and hypertension. Record review of Resident #2's quarterly MDS, dated [DATE], revealed he required one-person physical assist with locomotion off the unit. He used a wheelchair as a mobility device. Additional active diagnosis included unsteadiness on feet. Record review of Resident #2's care plan, dated 05/16/21, revealed he had an ADL self-care performance deficit r/t dementia, type 2 diabetes, muscle weakness, hypertension and a history of falls. Interventions included: staff will provide frequent visual checks. Resident #2 was an elopement risk r/t dementia Interventions included in part: distract resident from wandering by offering pleasant diversions, monitor for fatigue. Resident #2 was high risk for falls related to history of falls at home, abnormal gait, lack of coordination, muscle weakness and impulsiveness. Interventions included: ensure he is wearing appropriate footwear . when mobilizing in a wheelchair therapy screen and treat; follow facility fall protocol; may have scoop mattress; physical therapy evaluate and treat as ordered; therapy screen per facility protocol; remind and encourage to use his wheelchair. There was no specific instructions about supervision in the courtyard. Record review of Resident#2's hospital records, dated 04/10/21 at 1:45 AM, revealed in part .Resident #2 presented to emergency department (ED) with complaints of fall injury. Details of fall: The patient fell from an upright position, while walking. Onset: the symptoms/episode began/occurred at an unknown time. Associated injuries: The patient sustained left hip, decreased range of motion, painful injury. Associated signs and symptoms: pertinent positives: nausea, vomiting, after manipulating leg and causing pain, occurred on arrival to ED Severity of symptoms: at their worst the symptoms were severe, in the emergency department the symptoms were unchanged .recurrent falls- typically wheelchair bound but forget that due to his dementia-was found away from his wheel chair on the ground complaining of left hip pain preoperative diagnosis; left hip fracture . In an observation on 05/26/21 at 10:08 AM revealed Resident #2 was in the secure unit sitting in a special wheelchair watching tv in the sitting room. He was alert and did not know the current date. When asked if he had fallen recently, he did not reply. He said he did walk with someone's help. In an interview on 05/26/21 at 10:25 AM revealed LVN A was not at the facility when Resident #2 fell , it happened at night. LVN A stated the resident went out the exit door leading to the courtyard . At the time his room was by the side door to the patio. He was moved close to nurses station for staff to keep a close eye on him. Resident #2 has scoop mattress, staff monitor him, he is given reminders and staff complete rounds frequently. In an interview on 05/26/21 at 12:08 PM with the DON revealed during night shifts there was only one nurse and one CNA in the secure unit. The DON said there was no written policy regarding staffing in the secure unit but when the nurse was out of the unit the CNA was expected to observe all residents. The DON said the courtyard doors are unlocked at all times and did not have a chime or alert system . The DON said the CNA was unaware Resident #2 was in the courtyard because she was performing peri care for another resident while the charge nurse was out of the unit. The DON said no alert system was placed on the courtyard door after Resident #2's fall, but staff were in-serviced on the expectation at least one staff member must remain in the unit to observe residents at all times. In a telephone interview on 05/26/21 at 7:20 PM with LVN K revealed Resident #2 fell around midnight on 04/10/21. LVN K said when working the secure unit at night, the nurse always had the responsibility of Hall 1 as well. LVN said when she returned the aide was in another room and when she checked on Resident #2 around 12:30 AM he was gone; she stated I figured he walked by himself. LVN K said the secure unit usually has one aide and one nurse on the night shift. LVN K said residents can go out the doors into the courtyard and the doors are always unlocked. LVN K said staff were expected to conduct rounds on residents every 2 hours, sometimes every hour for high fall risk residents. LVN K said Resident # 2 wandered quite a bit, he will go to the door and not quite get it open and he does this on day shift. LVN K said on the night of the fall, Resident # 2 did not have the wheelchair with him and he was by the back gate. LVN K said residents are allowed to go to the courtyard whenever they want, and as far as she was aware there were no policies which stated otherwise. LVN K said if a resident was in a wheelchair, they didn't let them go outside by themselves due to dementia since the resident might attempt to stand up. LVN K said the gate was checked on night shift every hour to make sure it was locked, and staff previously recorded this on a log and then stopped . LVN K did not know why the gate check logged was stopped. LVN K stated she was usually on the unit 98% of the time. LVN K said the expectation was for the aide not to leave the unit and not sleep while on unit. LVN K said there were about 13-14 residents in the secure unit. In a telephone interview on 05/27/21 at 11:10 PM with CNA R revealed she had just started her rounds and LVN K went to the front (off the secure unit). She did not see Resident #2 in his room and that's when she started to search and found him outside by the gate. She stated Resident #2 got out of bed and walked outside. He was on the ground and the resident said he was hurting. She stated they put him in his wheelchair then put him in the bed. CNA R stated she always did rounds every 2 hours to check on residents. She checked the gate after rounds. Usually they had one of the doors locked and the other one unlocked to keep residents inside but Resident #2 used the unlocked door . She said residents can go out during the day however they could get hurt if they were by themselves. In an interview on 05/26/21 at 09:59 AM with CNA T revealed residents could go in and out of the courtyard and the doors do not have chimes to alert them to residents exiting to the courtyard. CNA T said staff were expected to have eyes on residents at all time . In an interview on 05/26/21 at 10:06 AM with the administrator revealed residents on the secure unit should be watched by staff at all times. The administrator said the facility had chimes on the exit doors to the courtyard in the past, but they kept falling off . The administrator said on paper monitoring the exits with chimes sounds good, but he doesn't think it was a permanent solution . In an interview on 05/26/21 at 01:30 PM with the Administrator revealed there was no requirement staff should be with residents at all times. The Administrator said inadequate supervision of residents in the courtyard places residents at risk of getting lost or having unwitnessed falls. The Administrator said the courtyard has always been an issue , but they do not have enough staff to complete continuous one-on-one monitoring of residents in the courtyard. Record review of the facility's Policy and Procedure for Secure Unit, effective date 01/2011, read in part .Residents eligible for admission to the secure unit will have behaviors exhibited of wandering without intent or elopement attempts, justifying their need for admission Security and safety measures are provided to prevent the residents from harming themselves or others, or leaving designated indoor or outdoor areas without supervision by staff members or other responsible escort to prevent resident from harm to self or leaving designated areas; indoor/outdoor

Based on observation, interview, and record review, the facility failed to effectively maintain an infection prevention and control program designed to help prevent the spread of infections for 13 of 15 residents (Residents #1, #2, #3, #4, #6, #7, #8, #9, #10, #12, #13, #14 and #15) reviewed for infection control and COVID-19. The facility failed to quarantine and cohort residents who were new admissions or residents who returned from the hospital, including Residents #1, #2, #3 and #4. The facility failed to report a positive COVID-19 test result for 3 staff to HHSC and the local health department. The facility failed to have a covid response plan that addressed the separation of residents, PPE usage, and COVID infection control preventive procedures. These failures resulted in an immediate jeopardy on 11/18/20. While the IJ was lowered on 11/20/20 the facility remained out of compliance at a scope of widespread and severity of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures could affect all residents and placed them at risk of exposure to infectious diseases. Findings Include: Resident #4 Record Review of Resident #4's face sheet reveals a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident #4's Treatment Administration Record for November 2020 reveal in part beginning on 11/5/20 resident requires droplet isolation for covid 19 exposure and/or infection in their room until 11/6/20. Record Review of resident #4's Covid test collected on 11/12/20 reveal a positive test result on 11/13/20. Record Review of Progress note for Resident #4 completed by DON on 11/11/20, read in part Performed two Rapid Test on resident - Sofia 2 [MEDICATION NAME] and Abbott BinaxNow COVID-19 Ag Card. Both tests indicated positive test for COVID-19. Nursing also performed Nasal Test to send to (Laboratory) to determine if resident is COVID positive. Resident had sitter in room with both tests performed on sitter. Sitter's result indicated positive on both [MEDICATION NAME] test. Nursing informed another sitter, Sitter A, reported to work on previous day knowing she was sick (afebrile) and was admitted to hospital with COVID symptoms mainly respiratory issues. Nursing aware of health problems until (Sitter B) informed nursing after her two [MEDICATION NAME] positive test. COVID hall has only 1 way in from outside. During an interview with Administrator on 11/13/20 at 1:20 p.m., he said that the [MEDICAL TREATMENT] residents and frequent flyers were on the warm hall. Frequent Flyers were residents who consistently go out to the hospital. He said there was no one on a warm unit or the covid unit. The warm unit had the ability to be closed off. He said Resident #4 nor Resident #3 were on the warm unit. Both residents resided on a general population hall but were on isolation. Resident #4 was on the memory care unit but was moved to other room for isolation. She was never put on the warm unit. She had sitters because she wandered a lot and had falls, and the family wanted her watched around the clock, and if family was willing to pay for sitters the facility allows it. She had 4 sitters total. She had a sitter for 3 months plus, but probably a lot longer than that. Her sitters were trained on covid and wore PPE. They wore cloth or surgical masks. They were also screened coming into the building and received testing as well. Residents #3 and #4 were not placed on the warm unit because they were frequent fliers and coming in and out of the building regularly. The warm unit was designed for [MEDICAL TREATMENT] in the beginning of the pandemic or the ones that were constantly coming in and out. During an interview on 11/13/20 at 1:33 p.m., with CNA D in the memory care unit. He said he had been there about 1.5 years. He said he had not been trained on covid. He knew what s/s of covid were. He was monitoring the residents checking their temperatures. The procedure was if the temp was over 99, then isolate the resident immediately. He would notify the nurse in the memory unit (LVN-B) and she also has another hall too. He said this was the only area he works. He said he learned what a warm unit was this morning and that it for the people on isolation who came back from hospital. He said he was familiar with Resident #4. She had a sitter because she was high fall risk and kept moving around. The sitters started coming last year. The sitters have been coming in the whole pandemic. He said she had 2 sitters. He doesn't know if they came to work sick, but he thought there was no other way Resident #4 would have gotten covid. He said he has been tested and was negative since that happened. Last week he was tested . During an interview on 11/13/20 at 1:43 p.m. with LVN B, she said she worked in the memory care unit and part of the front hall. She monitored residents for s/s whenever she makes rounds or once a shift. Vitals were checked twice a shift. She said she was familiar with Resident #4. She had a sitter because she would not sleep very well and was increased high fall risk and she was so tiny that a fall would be bad. So, the family provided a sitter. The sitters have been coming since before the pandemic started and have remained coming. She had sitters all the time. Quarantining/Isolation units Observation on 11/13/20 at 10:50 a.m. revealed that Resident #4 was on contact isolation due to being a new admission. Resident #4 was not on a designated quarantine hall, but in a room on a hallway with Covid- negative residents. During an interview on 11/13/20 at 10:50 a.m. with CNA B, she said that she did not know where the warm hall was. She said she knew there was a covid hall. New admits were being placed wherever a room was available. She knew a new admit for today was going on a Covid negative hallway. During interview on 11/13/20 at 11:18 a.m. with CNA A, she said she did not know what a warm unit was. She said the Covid unit was on the other side of the building. She was guessing the regular rooms were the warm rooms. She had not been told anything about a warm unit. She said if a resident was new they would put them anywhere and put PPE outside the door. During an interview on 11/13/20 at 11:32 a.m. with CNA C she said, she was not working with anyone on isolation today, but there was a resident in room [ROOM NUMBER] that was on isolation for the last 14 days as new admit. She said she thought the warm unit is the covid. She did not know who the new admits or readmits were. She said new admits go to whatever hall they put them on and then on isolation for 14 days. During an interview on 11/13/20 at 11:51 am with LVN A, she said that she was providing care for any residents on isolation at this time. She did have 2 residents that came off isolation after being a new admit. They were not on a warm hall, they were placed in a single room and PPE bins were outside their door. During an interview on 11/13/20 at 12:00pm, with MA A, she said that she has been here since May this year but was here for 5 years and quit for 2 months. She was aware of the current pandemic. She said she was wearing a cloth mask earlier in the morning. She said the warm unit was on that hall (points to short hall). She said 2 people were on the warm unit. She said they were residents that have come back from hospital. No one was on the covid unit. She said she worked with Resident #3 and he was a new admit. She said she was familiar with Resident #4 and she has sitters due to her being active and unstable. Her family requested it. Resident #1 Record review of Resident #1 face sheet reveal an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1 Physician order [REDACTED]. On 11/17/20 move resident to warm zone for covid + roommate (Resident #7) for 14 days. Record review of Resident #1's Rapid Covid test taken on 11/12/20. Result was not detected. Observation on 11/17/20 at 10:30 a.m. revealed Resident #1, admitted on [DATE], was not on a quarantine hall. She resided in a room on a hallway with Covid- negative residents. She did not have any isolation precaution sign on the door. Observation on 11/17/20 at 10:30 a.m. revealed there was not a designated quarantine/warm unit for new admissions or readmissions in the facility. Resident # 13 Record review of Resident #13's face sheet reveal a [AGE] year-old male admitted on [DATE] and has some of the following diagnoses; covid 19 (11/17/20), mild intellectual disabilities, generalized [MEDICAL CONDITION], hypertension, [DIAGNOSES REDACTED], and contact with and exposure to other [MEDICAL CONDITION] communicable diseases. Record Review of Resident #13's Comprehensive MDS assessment dated [DATE] reveal a BIMS score of 13, indicating he was cognitively intact. Record Review of Resident #13's Physician order [REDACTED]. Record Review of Resident #13's care plan updated 11/19/20 revealed resident was positive for covid. Interventions included all meals, treatments, and activities would be provided in room, employees would be trained on the use of PPE and facility would follow CDC guidelines for possible exposure to covid-19. Record Review of Resident #13's covid test collected on 11/12/20 revealed a positive result on 11/16/20. Observation on 11/17/20 at 10:37 a.m. revealed that Resident #13 had a roommate, Resident #12. Resident #12 remained in the room with the door open and no contact isolation notice or precautions being used. Gown was left on the door for reuse. CNA A removed Resident #12's clothes and personal bottle out of room not in wrap and set clothes on the table in the common area. CNA A was wearing gloves and went to a door (identified later as Hot Unit) and opened it, did not discard PPE or gloves, came back to get the clothes and moved the clothes back to the room. During an interview on 11/17/20 at 10:45 a.m. with CNA-A, she said that she took out Resident #13's clothes from the room. She said she didn't know she couldn't remove clothes. She said DON actually set the clothes on the table in the common area because she didn't know. She picked the clothes up and put them back in the closet. She said she headed to the covid hall and went through warm hall. She said with everything going on, she doesn't know what to do sometimes. She said she took old PPE off and put new PPE on before leaving the room. She said she has not had a recent training. Resident # 8 Record Review of Resident #8's face sheet reveal a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident # 8's Physician order [REDACTED]. Record Review of Resident # 8's Care Plan updated on 11/20/20 reveal resident was covid +. Intervention includes infection control implementations per facility protocol. Record Review of Resident #8's Covid test collected on 11/12/20 reveal a positive result on 11/16/20. Observation on 11/17/20 at 10:40 a.m. that covid positive Resident #8 remained in the room with the door open and without any isolation precautions in place. Observation on 11/17/20 at 10:40 a.m., that the warm unit was not identified with a sign. There was not a door available to close, and the COVID unit was on other side not identified by signs. Resident # 9 Record Review of Resident #9's face sheet revealed a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident #9's Physician order [REDACTED]. Record Review of Resident #9's Care Plan updated on 11/20/20 revealed resident is covid positive requiring droplet isolation. Infection control implementation per facility protocol. Record Review of Resident #9's Covid test collected on 11/12/20 reveal negative test result on 11/16/20. Record review of an in-house rapid test on 11/17/20 revealed a positive result. Observation and interview on 11/17/20, 1:53 p.m., with the DON and he said that another resident tested positive. Resident #9 and there were not any contact isolation procedures implemented nor a notice sign on the door. Resident #2 Record review of Resident #2's face sheet reveal a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Physician order [REDACTED]. on 11/14/20 resident required strict isolation for 14 days in a single occupancy room for 14 days. Record Review of Resident #2 's care plan updated on 11/19/20 revealed resident was at risk for covid 19 infection due to possible exposure. Interventions included all meals, treatments, and activities will be provided in room, employees will be trained on the use of PPE and facility will follow CDC guidelines for possible exposure to covid-19. Record Review of Resident #2's Covid test collected on 11/8/20 reveal on 11/11/20 a negative test result. Resident # 14 Record Review of Resident #14's face sheet reveal an [AGE] year-old male admitted on [DATE] with some of the following diagnoses; contact with and exposure to other [MEDICAL CONDITION] communicable diseases, cardia pacemaker, and history of falling. Record Review of Resident #14's Quarterly MDS dated [DATE] reveal a BIMS score of 8, indicating moderate cognitive impairment. Record review of Resident #14's Physician orders [REDACTED]. Record Review of Resident #14's Care Plan updated 7/28/20 revealed resident has potential exposure to covid due to positive staff member. Interventions included infection control implementations per facility protocol, and droplet isolation. Record Review of Resident #14's covid test collected on 11/12/20 revealed a positive test result on 11/16/20. During an interview and observation with Administrator on 11/17/20 at 10:07 a.m., he said 2 new admits Resident #1 and Resident #2 were in rooms 18A and 39A, which was observed to be in general population areas. He said 3 residents returned positive on the general admission floor after COVID testing on Thursday and Friday 11/12/20 and 11/13/20. Residents #8, #13, and #14 had positive test results. They would be moved to the COVID hall. Gowns were observed hanging on doors of these positive residents for reuse. During an interview with the DON on 11/17/20 at 10:41 a.m. he said new admits were placed on isolation and monitored for 14 days. The facility conducted rapid test on new admits and they currently do not have a Warm Hall. Residents with unknown Covid status were placed in a private room and a test was conducted every 8 hours. Staff were assessed upon entering the building, whenever any staff was experiencing symptoms, a rapid test was conducted. Residents were being assessed for fever, cough, SOB, fatigue, Loss of smell and taste, oxygen saturation every 8 hours. Reporting During an interview with DON and Administrator on 11/13/20 at 9:45 a.m., the DON said that all the staff were being tested for COVID-19 once a week. There were 3 positive staff results at the end of October 2020. The DON said these results were from the rapid test, so he did not report positive test results to HHSC. He said 1 of the 3 staff members was a sitter for Resident #4, one staff member was a driver for the facility, and the other was the new social worker. The administrator said he was responsible for reporting positive COVID-19 test results but because these were rapid tests he did not. PPE/hand hygiene Resident #3 Record Review of Resident #3's face sheet reveal a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident #3's Comprehensive MDS dated [DATE] reveal a BIMS score of 4, indicating severe cognitive impairment and extensive assistance required for ADL assistance. Record Review of Resident #3's physician orders [REDACTED]. Beginning on 11/17/20 monitor for symptoms of covid every 4 hours. Record Review of Resident #3's Care Plan updated on 11/20/20 revealed resident was at risk for covid-19 infection due to possible exposure. Some interventions included all meals, treatments, and activities will be provided in room, employees will be trained on the use of PPE and facility will follow CDC guidelines for possible exposure to covid-19. Record review of Resident #3's covid test collected on 11/12/20 revealed a negative result on 11/16/20. Observation on 11/13/20 at 9:50 a.m., revealed a gown was hung on Resident #3's room for reuse. There was not any name on the hook or gown. Resident #3 was on contact isolation. There were no N95 respirators available in the bin or face shield/goggles. Observation on 11/13/20 at 10:20 a.m. revealed CNA A went into isolation from Resident #3's room wearing a cloth mask to provide care. During an interview on 11/13/20 at 10:50 a.m. with CNA-B, she said that she had been here about a year. The facility did same training on covid and PPE when everything started. She was being tested , she received test 2 times this week. She was wearing a gown. She said she wore a gown when she entered a room. She said she will sometimes discard the gown but has been told she can hang and reuse. She said the procedure was that she hangs her gown on the hook. The hook did not have her name on it. She said she was concerned that she and others are wearing gowns that someone else wore. She said she never knew who wears her gown except in memory care they wear the same gown all day and never take off. During an interview on 11/13/20 at 11:18 a.m. with CNA- A, she said she has been here about 8 years. She has not had any recent training on PPE but has been trained in the past. She said she did not use the gowns hung on the door, she got a fresh one every time because she was not going to put a gown on that someone wore. She said some of the nurses told her to reuse gowns. She said Resident #3 may be on isolation due to wound care infection. She said she was wearing a cloth mask, but she was told today to wear an N95. She said she has provided care for Resident #3 and she wore PPE gown, her cloth mask and gloves. She said she discarded her gown and gloves. She said she was being tested regularly. During an interview on 11/13/20 at 11:32 a.m. with CNA C- she said she has been here almost 9 years. She said she had been trained on covid but have not had any recent training on PPE or covid. She was wearing a cloth mask this morning, but the Administrator gave her N95 after entrance. She said gowns were supposed to be reused. She was not wearing the same gown for all rooms. She said she was supposed to be wearing the same gown for the individual room. Just the for that day. She discarded her gown every time she used it. She said she was told to wear the gown hanging, that someone else wore and then hang it back up. Observation on 11/13/20 at 11:35 a.m. revealed CNA A wearing a gown, N95 and gloves, delivered a tray to Resident #13, came back to the cart and delivered a 2nd tray in room [ROOM NUMBER], with same the gloves and gown. No sanitizing or handwashing. Observation on 11/13/20 at 11:43 a.m. revealed CNA B delivered a meal tray to a resident in room [ROOM NUMBER], then closed the door too room [ROOM NUMBER], then pushed the cart to room [ROOM NUMBER] and served a meal tray to the only resident in 40, and then pushed the care some more and served a meal tray to room [ROOM NUMBER]. She was wearing the same gown and did not sanitized her hands or wash hands. During an interview on 11/13/20 at 11:47 a.m. CNA B said she was aware she was to use hand sanitizer between trays, but hand sanitizer was not available. Soap was available in residents' rooms. During her observation she did not use soap or sanitizer. Observation on 11/13/20 at 11:47 a.m. revealed Hall 3 did not have any sanitizer dispensers. During an interview on 11/13/20 at 11:51 a.m. with LVN A, she said the gowns are hung and used when they going in and out of the room. She is reusing the gown. She said the gowns are disposable. Then she said she hangs new gowns up for next person. When asked why she just said she reuses gowns, she said she doesn't. When asked if she is being told to reuse the gown then she not really. She said she will roll the gown up and stick in pocket sometimes if she needs to reuse so she knows its hers. During an interview on 11/13/20 at 1:33 p.m., with CNA D in the memory care unit He said he had been only wearing the regular surgical masks. He only got an N95 today when the state came. Gowns had not been worn until today either. He said he was confused because they say he was supposed to reuse the gowns, but he did not do that because he did not feel comfortable, so he got a new one every time. There was one biohazard bin by the main door and then in every resident's room. During an interview on 11/13/20 at 2:18 p.m. with the Administrator he said there was not a specific policy on reusing PPE. The same CNA may use the same gown multiple times. Therapy and nurses should re-gown. The same CNA work on the same hall so they should know their own gowns. They were assigned certain halls. They dispose of the gown and get new ones per shift. Every time you go in and out of a room, staff were supposed to re-gown for different rooms. Hands should sanitize before going into one room and then before entering a different room when passing trays. He affirmed that the 300 halls were without sanitizer bins as all the sanitizer bins did fall off. The sanitizer should be at the nurses' station and should be on the cart of the food. The trays should be parked right by the sanitizer on the wall so it was easy to access during the trays. He said he would make sure it gets back up on the wall. Observation on 11/17/20 at 12:04 p.m. of Biohazard waste disposal bags located inside room [ROOM NUMBER] was observed to be full and soiled isolation gowns were falling out of the bag. Observation on 11/17/20 at 1:53 p.m., revealed the DON put on a gown that was hanging on the back of Resident #14's door. He did not put on gloves and did not wear a face shield or goggles. Resident #15 remained in the room. He hung the gown back up on the door and left the room. Observation on 11/17/20 at 1:45 p.m. Staff was observed putting on her gown and gloves without carrying out hand hygiene. She entered room [ROOM NUMBER] where a covid positive resident's roommate, Resident #6, was placed on isolation. No sign was placed at the door and she had no goggles or face shield on. Gloves and gown were doffed inside the resident room and disposed in the Biohazard waste bag located inside the room, she performed hand hygiene upon exiting the room. Observation on 11/17/20 at 2:16 PM of the COVID unit revealed there were no face shields or goggles or N95 masks available in the donning station. During interview and observation on 11/17/20 at 2:35 p.m. with DON, the PPE storage was observed. DON said PPE was stored at the back of the facility, some were kept at the nursing station and Administrator's office. They have about 19,600 gowns and 25 face shields, DON indicated that they were in the process of ordering more face shields and goggles. The central storage location was observed to have adequate, N95, hand sanitizers, and gowns. The DON oversees taking Inventory of PPE on a weekly basis and the Administrator oversaw restocking form a PPE supplying from located in The Woodlands and they get supplies every two weeks. Observation and Interview on 11/18/20 at 12:17 p.m. revealed MA -B was observed putting on Gloves and Gown without conducting Hand Hygiene, she had no face shield on. She was newly employed and have been at the facility for only two weeks. She received training on COVID-19 and was able to identify signs and symptoms. Explained donning and doffing of PPE Correctly. Facility screen for signs and symptoms at the entrance every shift and she was designated to work the warm hall, Hall 2 and Memory care unit. Observation on 11/18/20 at 12:18 p.m. MA B was observed carrying out hand hygiene, picked up Resident #1's food tray and placed it on the isolation PPE cart in front of room [ROOM NUMBER]. She had on N-95, Gloves and gown, No face shield. Resident #1 was on contact isolation precautions. During an interview on 11/18/20 at 2:10 p.m. with DON he said Resident #9's COVID test came out positive. He said he oversaw infection control for the facility. As at 11/18/2020, 8 residents, 2 staffs and 2 sitters have tested positive to COVID-19. All employees and residents have been tested and all the initial testing conducted on 11/13/2020 have been received. Resident #4 was the initial covid case at the facility and her sitter was suspected to have infected her with [MEDICAL CONDITION]. Sitter A was asymptomatic, she suspected she might have contracted [MEDICAL CONDITION] and still came to work. She subsequently became ill and was admitted into the hospital on [DATE]. DON was unsure of Sitter A last day of work but stated that sitters working with Resident #4 worked round the clock. Resident #4 had a fever of 99.0 F and a rapid test was conducted on 11/11/2020 and she tested positive. Sitter B was one of her sitters working with her on that day and her rapid test came out positive as well. Resident #4's room was in Hall 2 and she had no roommate. The facility only utilized Surgical and cloth mask prior to their first confirmed case. There were no COVID-19 Co-horting setup prior to the first covid case. Positive Residents were transferred to the hot zone, beginning on 11/17/20, and their roommate who were exposed were being transferred to the warm zone and monitored for 14 days. The facility was not currently allowing visitations due to them having a positive covid case. Record Review of Interim Guidance for Prevention, Management, and reporting of COVID-19 outbreaks in LRC Facilities procedures read in part, On March 2020, Centers for Medicare and Medicaid Services (CMS), directed all Nursing Facilities to restrict visitors except those deemed medically necessary, and restrict non-essential personnel. Provide Supplies for recommended Infection Prevention and Control Practices, like hand hygiene supplies, and make necessary PPE available. Supplies for performing hand hygiene should be readily available. If COVID-19 is identified in the facility, immediate action must be taken to isolate the covid positive residents away from other residents. Any roommates should be moved and monitored for 14 days. A plan is created for cohorting residents with symptoms of respiratory infection and covid 19 including dedicating staff to work only on affected units. Facility should ensure staff are educate and trained on PPE and infection control and hand hygiene. Nursing facilities are required to report the first confirmed covid -19 positive casein staff or residents, and the first confirmed case after a facility has been without cases for 14 days or more to HHSC. Resident #7 Record Review of resident #7 face sheet reveal an [AGE] year-old female admitted on [DATE] with some [DIAGNOSES REDACTED]. Record Review of Resident #7's Physician order [REDACTED]. 11/17/20, monitor for covid symptoms every 4 hours. Record Review of Resident #7's Care Plan updated on 11/19/20 revealed covid-19 infection due to possible exposure. Some interventions include all meals, treatments, and activities will be provided in room, employees will be trained on the use of PPE and facility will follow CDC guidelines for possible exposure to covid-19. Record Review of Resident # 7's Covid test result taken on 11/12/20 reveal a negative result. Record review of Resident #7's in house rapid test dated 11/19/20 revealed a positive result. Resident #10 Record Review of Resident #10's face sheet reveal a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident #10's Physician order [REDACTED]. Record Review of Resident #10's Care Plan updated on 11/20/20 reveals resident was covid positive and interventions included infection control implementations per facility protocol, and droplet isolation. Record Review of resident #10's covid test taken on 11/12/20 reveal a negative result on 11/16/20. Record review of Resident #7's in house rapid test dated 11/20/20 revealed a positive result. The facility Administrator was notified on 11/18/20 at 3:58 p.m. that an IJ situation had been identified due to the above failures. The IJ template was provided. A Plan of Removal was submitted by the Administrator on 11/18/20. After a revision, the final Plan of Removal was accepted on 11/20/20 at 10:14 AM. The plan of removal included the following: Please accept this Plan of Removal for alleged deficient Immediate Jeopardy imposed on 11/18/20 at Parkview Manor Nursing and Rehabilitation. Immediate action: On 11/18/20 all immediate staff working at the time of the alleged deficient practice were in-serviced on the HHSC COVID response plan by the Administrator/ or designee and the Director of Nursing/ or designee which includes: A) Separation of residents into specific cohorts Positive, Exposed/ or unknown, and Negative. B) Correct screening of employees prior to shift to include questions as outlined in the HHSC COVID response plan. C) Correct PPE needed for each cohort. D) Proper donning and doffing of PPE. E) Hand washing and hygiene. F) Glove usage G) Cross contamination that includes laundry of COVID positive or unknown status of residents. H) Disinfecting of each cohort's rooms and frequency. I) Designated staff to only work with each cohort of residents. In addition, all staff that are not present at the time of in-servicing will be required to be in-serviced prior to their next shift by the DON/ or designee, or the Administrator/ or designee. The facilities staffing contingency plan consist of the utilization of hazard pay for employees working on the COVID positive unit and the unknown status unit. The facility will also utilize agency as needed to help maintain same staff for each cohort. The facility may also offer working bonuses to fill shifts as needed. The facility may also file for request through the HHSC STAR program if needed. Facility was already utilizing hazard pay, bonuses, and agency to enhance staff (TRUNCATED)

Based on Observation, interview and record review, the facility failed to ensure the right to be free from neglect for one of five residents (Resident #1 ) reviewed for abuse/neglect. CNA #1 left Resident #1 alone in her room during a bed bath resulting in the resident falling out of bed, sustaining injuries, including fractures and needed to be sent to the hospital for treatment. This failure affected one resident and could place the other 4 residents who receive bed baths at risk of potential neglect and/or injury. Findings included: Intake # 5/TX 355 Record review of Resident #1's facesheet revealed she was an [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. Record review of Resident #1's Admission MDS dated [DATE] revealed she had severe cognitive impairment with a BIMS score of 0 out of a possible 15. She required extensive assistance of two or more person physical assist for transfers, toilet use, and bed mobility, extensive assistance of one person for dressing and personal hygiene, totally dependent on one person for locomotion off unit and bathing. She had no impairment of her upper and lower extremities. Resident #1 was always incontinent of bowel and frequently incontinent of urine. She did not have pain at time of assessment and unable to determine any falls before admission. Record review of Resident #1's clinical record revealed she did not have a care plan in place at time of the incident. Record review of Resident #1's hospital records revealed she was sent to the emergency roiagnom on [DATE] after a fall with wounds to her left side. She came in after an un-witnessed fall while receiving a bed bath. This document read in part; The nursing home staff stated they were in the process of giving her a bed bath and had to leave it to go get supplies and when they came back she had fallen out of bed and was found on the floor. This document also revealed Resident #1 sustained multiple skin tears to left hand, left fingers, left elbow, laceration to left eyebrow, bruises to bilateral arms and left eye, and swelling to left eye. Record Review of Resident #1's progress note dated 2/15/2017 at 6:15 a.m. read in part; CNA #1 summoned Nurse A to Resident #1's room. CNA #1 reported that Resident #1 was on the floor and that she was giving Resident #1 a bed bath and CNA #1 went to get more towels and when CNA #1 returned, Resident #1 was on the floor next to her bed. Doctor and family notified. Resident #1 sent to the hospital. Further record review of Resident #1's progress notes revealed in part; 2/15/2017 bandages where applied to Resident #1's left side of head, left elbow, and left hand/wrist areas due to only visible areas observed with active bleeding. Recorded Review of Resident #1's Fall Risk assessment dated [DATE] revealed in part; A.- Resident #1 is oriented x3 at all times. 1.- Vital signs Blood Pressure: 160/81, Pulse: 89 beats per minute, Respirations 20, Temperature 99.4 Fahrenheit temporal artery (forehead). .4. - Extremities; Right and left upper and lower extremities weak. Record review of Resident #2's radiology report dated 2/15/2017 revealed in part; There is a mildly displaced fracture through the proximal fifth metacarpal (bones in the hand). There is medial and dorsal dislocation of the fifth middle phalanx with overlap of bones approximately 3-4mm. Further review of Resident #1's radiology report dated 2/15/2017 revealed in part; There is an extra-axial hematoma (a solid swelling of clotted blood within the tissues) along the right front parietal and temporal convexities. The majority of this collection is high density. It measures approximately 9 cm in maximal length and 2cm in maximal thickness. There is prominent early [DIAGNOSES REDACTED] with dilation of the left lateral ventricle particularly the temporal horn. There is left parietal soft tissue swelling and extensive left periorbital soft tissue injury. In an Interview with Nurse B on 2/17/2017 at 10:15 a.m., she stated that she did report the incident to the Administrator. Nurse B said she was the nurse on call when the incident happened. She said she was told by CNA #1 that CNA #1 was going to give Resident #1 a bed bath. Bed was in regular height. CNA #1 had gotten Resident #1 ready for the bed bath when CNA #1 realized she needed more towels. CNA #1 walked to the linen closet located catty-corner to Resident #1's room to get more towels. When CNA #1 came back Resident #1 had fallen onto floor. Nurse B stated CNA #1 should have pressed the call light and asked for assistance. She said CNA #1 is currently suspended. Nurse B had spoken to Resident #1's relative the day before who stated Resident #1 had a broken finger on left hand, skin tear, and hematoma from hitting her head. In an interview with the Administrator on 2/17/2017 at 10:25 a.m., he said Resident #1 was about to get a bed bath and CNA #1 went to the linen closet to get towels. He stated CNA's should not leave resident's alone and CNA's should have all items prepared before starting. Resident #1 fell and bumped her head on bed side table. He said Resident #1's finger was broken. He said the incident was not reported because he didn't think it was reportable. In an Interview on 2/17/2017 10:40 a.m. with CNA #1 was preparing to give Resident #1 a bed bath. She said she left to get more towels upon returning back to the room Resident #1 was on the floor. She said sometimes Resident #1 moves around but she thought Resident #1 would be safe and wouldn't move while she left to get the towels. Observation and interview on 2/17/2017 at 2:45 p.m. revealed that Resident #1 was still in the hospital. Resident #1 was in bed with the hospital nurse holding Resident #1's left arm. Hospital nurse stated they were waiting on the wound care nurse to come redress Resident #1's wounds. In Observing Resident #1's wound, a deep laceration on left hand was noted, bruising on both arms, large bump above left eye. The hospital nurse stated she had a dislocated thumb and a broken finger on her left hand. Record Review of the facility Policy and Procedure with the title Personal Care date unknown read in part . Never leave the resident unattended . In an interview with the Administrator on 2/17/17 at 8:30 am, the facility policy regarding neglect was requested, but not provided by the time of exit. According to the facility's census sheet, there were 5 residents who received bed baths.

Based on observation, interview and record review, the facility failed to immediately consult with the physician concerning a change in condition of one of nine residents (Resident # 1) reviewed for physician consultation. The facility failed to consult with the physician when Resident #1 experienced pain on multiple occasions following a fracture to the resident's right leg. An Immediate Jeopardy was identified on 3/29/16. While the IJ was removed on 3/31/16, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. This failure affected one resident and placed 60 residents who require staff assistance with ADL's at risk of pain, not receiving medical care or adequate assessments, and a decline in their health status. Findings include: Incident # 8 Record review of Resident # 1's medical records revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 1's annual MDS assessment dated [DATE] revealed she sometimes made herself understood and sometimes understands others. She was unable to complete the Basic Interview for Mental Status (BIMS) and her cognitive skills for daily decision making was coded a 3. Severely impaired. She was totally dependent on one person for assistance with bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. She was totally dependent on two persons for assistance with transfers. She had no range of motion impairment in her upper or lower extremities. She was always incontinent of bowel and bladder. She had no pain documented on the pain assessment interview portion of the assessment. She had no falls. She was 64 inches tall and weighed 123 pounds. Record review of Resident # 1's March, 2016 physician's orders [REDACTED]. Not to exceed four grams in a 24 hour period. Further review of the physician's orders [REDACTED].#1 had no other orders for any additional pain medications. Record review of Resident # 1's Progress Notes revealed the following nursing notes: 3/8/16 at 3:59 PM : Reported to this nurse that resident is hollering when right leg or hip is moved. Made slip to have resident seen at (Clinic) asap (as soon as possible) for right hip pain and discomfort. Also faxed (Dr. B) at (Clinic) to inform her of bulge to right hip joint and pain resident c/o (complained of) when moved. Record review of a Nursing Communication Fax signed by LVN B revealed the communication sheet was faxed on 3/8/16 at 2:57 PM to Resident # 1's primary care physician, Dr. B and read, 3/8/16 4:00 PM .Resident is hollering in pain from right hip & right leg. Hip has bulge when moved .Have made appointment slip for resident to be seen ASAP. In a box titled Physician's Section was written Agree and the doctor's signature with further documentation: Appt made for 10th had to reschedule d/t (do to) bad weather. The physician's section was not dated. Further review of Resident #1 ' s progress notes revealed: 3/12/16 at 4:21 AM: Resident continues with bulge Right hip and right knee swelling, leg lays turned inward. Request made for MD appt. 3/12/16 11:17 AM: Resident continues with bulge to right hip joint and right knee is turning inwards at this time. Resident c/o pain and discomfort when transferred and repositioned . 3/13/16 at 5:07 PM: Noted swelling of right knee, right outer thigh discolored and swollen, bulge to right hip joint area. Called (Dr. A) at 440 pm informed him of what is going on said to send out to ER and have resident checked. 4:50 pm Called (family member) informed him what is going on and that resident would be taken by (facility) van to (Hospital) ER (emergency room ) to evaluate and treat. 4:52 pm Spoke with (hospital staff) at (Hospital) ER informed him of right hip, leg, knee and outer thigh concerns and of resident's pain and discomfort noted and worsening. 5:07 pm Called (family member) and let him know that (Staff A)was leaving (facility)in van at this time to take resident to (Hospital) ER. Informed (Staff A) to please stay with resident until family arrived at least due to ER very busy. 5:15 pm Tried to call (Admin) let him know what was going on. Got voice mail left message for him to please call back. 5:16 pm Called (DON) let her know what is going on with resident at this time. Will pass on in report to on coming nurse what is going on. 3/13/16 at 10:22 PM: Returned from (Hospital) via company van with (Staff A). (Staff A) stated family did arrive and were made aware of situation. DX. Distal Right Femur Rx. Non ambulatory, knee immobilizer in place. Orders included f/u (follow up) with (Dr. C) the next Tuesday he comes to (Clinic). Also to f/u with (Dr. B) Appt slips made . Record review of a Radiologist report from the hospital dated 3/13/16 for Resident # 1 revealed, Two view evaluation of the right knee reveals prior right knee arthroplasty with fracture through native bone and migration of the hardware. Fracture seen through the posterior aspect of the distal femur of uncertain duration. The femoral shaft is seen to have shifted medially with respect to the tibial plateau. Soft tissue swelling also noted. Further review of Resident #1's progress notes revealed: 3/16/16 at 5:36 PM: Resident will grimace when being transferred or moved. When asked if she is hurting resident smiles and says no . 3/17/16 at 8:20 AM: Resident was up in w/c grimacing and shifting around in chair gave Tylenol 650 mg scheduled dose then moved resident from W/C to geri chair. Around 9:45 am resident seemed more comfortable. Record review of Resident # 1's Care Plans revealed a care plan dated 3/17/16 read, (Resident # 1) will be free from s/sx (signs and symptoms) of pain during healing process of right femur fx through the next review. Interventions included give pain medications as ordered. Monitor/document side effects and effectiveness (Tylenol) .Handle gently when moving or positioning. Maintain body alignment .(Mechanical) lift for all transfers . Further review of the care plans revealed there was no previous care plan for pain noted in the resident's care plans. Record review of Resident # 1's Pain Assessments in the electronic medical record revealed a pain assessment dated [DATE] at 2:39 PM which read that the resident could verbalize pain, and the verbal pain assessment of pain intensity at the time of the assessment on a scale of 1-10 was a 8.8 ; and during the last 24 hours it was 8.8. The location of the pain was right hip, and right (side) and for the description of the pain aching, sharp, and shooting were checked. The pattern was intermittent with duration of 30 minutes and the pain affected sleep and appetite. Transferring, turning & repositioning, and bathing were checked as causes of the pain. Interventions: scheduled medication with APAP were checked. Record review of Resident # 1's March 2016 MARS revealed her pain level was documented for each scheduled dose of Tylenol at 7:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM daily. On nine days at 7:00 AM she had a pain level of 5 documented. At 11:00 AM she had pain level of 4-5 documented on three days. At 4:00 PM she had a pain level of 3 noted on 3/13/16 and a 5 on 3/21/16. At 8:00 PM a pain level of 4-6 was documented for all but one day in the month. Most of the evenings the pain level was a 5. Record review of Resident #1's progress notes revealed Resident #1 continued to have pain two weeks after being diagnosed with [REDACTED].>3/23/16 12:35 AM: Resident actually talking tonight. When asked Resident if she had pain, she said some when was asked if some needed pain med, she said yes she would appreciate it and when pain med was given she said thank you. 3/27/16 at 3:44 AM: On Pt check at 11 PM resident stated she had pain and when asked if she wanted pain she said yes. Was unable to give pain level. 2 Tylenol 325 mg tabs crushed and given . There was no documentation in Resident #1 ' s medical record concerning the physician being consulted concerning the resident ' s pain. Observation of Resident # 1 on 3/29/16 at 10:55 AM revealed she was seated in a geri-chair in the activity room in front of the television. Resident # 1 appeared to be uncomfortable and was frowning with some facial grimacing. Resident # 1 was alert, but was unable to speak. She had tape on two skin tears on her right forearm which appeared to be almost healed. Observation and interview with Resident # 1 on 3/29/16 at 11:40 AM revealed she appeared distressed and was making facial grimaces as though in a lot of pain. Resident # 1 kept reaching out to the Surveyor. When she was asked if she was okay she shook her head no. LVN D was notified Interview on 3/29/16 at 12:15 PM. LVN D said she had checked on Resident # 1 and she was smiling which indicated she was not in pain. She stated she adjusted the pillow behind her in the geri-chair to make her more comfortable and took her to the dining room. LVN D said she did not work on 3/8/16 or on 3/13/16 when Resident # 1 went out to the hospital. She stated she did work on 3/9 and 3/10/16. She stated she saw a fax that was sent to the doctor's office for an appointment for Resident # 1. She stated Resident # 1 received routine Tylenol for pain. She stated every time she asked Resident #1 if she was in pain she denied it. She stated the only time she had seen her grimacing was a couple of times while she was being transferred. LVN D stated, As far as any pain, it's being controlled with the Tylenol. She stated Med Rec (medical records) makes all of the doctor's appointments. She stated there was a really bad storm the week of 3/8/16 and they rescheduled all of the resident ' s appointments for the next week because it was too bad out to take the residents anywhere. Observation of Resident # 1 on 3/29/16 at 12:44 PM revealed she was seated in the geri-chair in the dining room and LVN D was observed pulling her up in the chair from behind. While the nurse was pulling Resident # 1 up she was observed grimacing a great deal and opened her mouth and kept it opened and was gritting her teeth. Once repositioned Resident # 1 closed her mouth and her facial expression became more relaxed. Observation of Resident # 1 on 3/29/16 at 3:04 PM revealed she was seated in the geri-chair in the activity room. She was asked if she was feeling better and she shook her head no. Resident # 1 was observed to be frowning and kept looking down and appeared to have discomfort. Resident # 1 was unable to respond further to any questions. Interview and record review on 3/29/16 at 1:15 PM Med Rec was asked if she made an appointment for Resident # 1 to see the physician on 3/8/16. She stated she did make an appointment for her. She was observed getting out the appointment book and looking at it. Review of the appointment book revealed Resident # 1's name was not on the appointment schedule in the book during the week of 3/8/16. Med Rec then stated, You know what I really don't think I did. Med Rec said it was because of the storm and she had to reschedule the resident's appointments. She stated the next morning after the resident returned from the hospital she got her scheduled to see the orthopedic doctor on Tuesday, 3/15/16, at the Clinic. Interview on 3/29/16 at 2:06 PM the DON, when she learned that Resident #1 was in pain and had swelling of her leg she said she learned about the resident's pain on 3/9/16. When asked if she notified the Admin, she stated she thought he knew because everyone talked about it in the morning stand up meeting and Med Rec was to make a doctor's appointment for Resident #1. Interview on 3/30/16 at 2:42 PM LVN B looked at the nurse note on 3/8/16 at 3:59 PM and verified she wrote the note. She stated the staff did tell her Resident # 1 was hollering, but she went and assisted staff to transfer Resident # 1 from the shower chair and she was fine. She stated she did not cry out in pain on 3/8/16. Interview on 3/29/16 at 2:22 PM the DON stated she assessed Resident # 1 on 3/9/16 and her hip didn't feel out of place at all. She stated there was a little raised area on the right leg. She stated, I saw no bruise. She didn't cry out when I moved her in the bed. The DON stated Resident #1's doctor's appointment was pending, so she waited to see what the doctor said. She stated when Resident # 1 came back from theER on [DATE] she had scheduled Tylenol. She stated she had orders for the scheduled Tylenol since November 2014. The DON stated, I don't know why the ER doctor did not prescribe something stronger. I think the ER doctor should have prescribed something stronger if they thought she was in pain. But you know, I'm not the doctor. Interview on 3/29/16 at 3:44 P.M.CNA A said on 3/8/16 she helped take care of Resident # 1. She stated as they were rolling her she was making noises like she was in pain. Interview on 3/29/16 at 4:20 PM Med Rec said she called the doctor's office on Wednesday evening, 3/9/16, and scheduled an appointment for Resident # 1 for 3/15/16 to see the orthopedic doctor. She stated when she gets a slip requesting an appointment be made she usually tries to talk to the nurse. Med Rec stated staff did not let her know it was urgent. Record review of the request slip for a doctor's appointment to be scheduled for Resident # 1 read ASAP on the request. Observation of Resident # 1 on 3/30/16 at 10:50 AM revealed Resident #1 smiled when greeted and was trying to talk and said several words that could not be understood. She was seated in the geri-chair in the activity room and had her left foot on the floor. She appeared to be uncomfortable and was grimacing off and on and frowning Interview on 3/30/16 at 11:47 A.M. LVN B stated Resident # 1 had no black and blue marks on 3/8/16. She stated she assisted with transferring her and she was only complaining about pain in the bulging area only. In an interview on 3/30/16 at 11:57 AM the DON stated they do in-services throughout the year regarding notification of the physician. She stated an immobilizer was put into place for Resident # 1 and she has a follow-up appointment with the orthopedic doctor on 4/12/16. She stated They didn't call me for this. She stated she would call the Medical Director if she thought the physician was not responding appropriately. She stated he's a great resource and very helpful. Several attempts were made to contact the night shift nurse LVN C by phone but the numbers provided by the facility were not working numbers. Record review of facility policy, Change in a Resident's Condition or Status revised April 2007 read in part, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . 1.- The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On -Call Physician when there has been: b. A discovery of injuries of an unknown source .d. A significant change in the resident ' s physical/emotional/mental condition; 2. A significant change of condition is a decline or improvement in the resident ' s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .4.- Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status . . The facility Administrator and the Director of Nursing were notified on 3/29/2016 at 2:51 PM that an IJ situation had been identified due to the above failures. The first Plan of Removal was submitted by the Administrator on 3/30/2016. The final Plan of Removal was accepted on 3/31/2016 at 1:05 PM. The Plan of Removal included: 1. An updated pain assessment was completed on 3/17/16 on the resident in question and the MD was notified of the results. The pain assessment was the universal pain assessment tool (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. This assessment will be completed on this resident every shift until further notice and after every PRN pain medication administration. This assessment will be completed by the resident's charge nurse at the time. 2. All nurses were in-serviced to timely notify the resident's MD. If the MD does not assess and/or order interventions, the Medical Director will be notified for orders. In the event that there are no effective responses the resident will be sent to closest emergency room for assessment per nursing judgment. This in-service was started and completed on 3/30/16 by the Regional Director of Operations. 3. Pain assessments on all residents were completed as of 3/30/16. Each pain assessment will be entered into Point Click Care (electronic record software). Any positive finding of active unrelieved pain will be discussed immediately by the IDT that consists of the Administrator, Regional Director, DON, Regional Nurse, and other administrative nurses. Each respective MD will be notified as needed. 4. All staff will be in-serviced on pain assessments and recognition. Tools will include but are not limited to the universal pain assessment tool (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. All nursing staff will be in-serviced over physician notification of pain and follow up. This in-service was started and completed on 3/30/16 by the ADON. Any staff who did not attend this in-service will be required to before they can return to work after this date. 5. All nursing staff were in-serviced by the facility COTA on appropriate transfer techniques. This in-service was started on 3/30/16. All staff will be required to have this in-service before working after 3/30/16. 6. The MD was called on 3/30/16 and a clarification order was obtained for a two person transfer for the resident in question. 7. The plan of care and orders for 100% of the residents was completed to ensure that the correct mode of transfer was accurate. This audit was completed on 3/30/16 by nursing administration. 8. All nursing staff were in-serviced by the Assistant Director of Nurses on following the plan of care for transfers. 9. A 100% audit of all fax notifications was completed by the nursing administration to ensure that all change of conditions were communicated to the MD with appropriate responses and/or interventions. All fax notifications have been removed. All communication will be done via telephone. This was all completed on 3/30/16. 10. The IDT which consist of the Administrator, Director of Nursing, Assistant Director of Nursing, MDS/Care Plan Coordinator, and the care plan nurse will be in-serviced on interventions to be put in place and the plan of care for. This was done by the Regional Nurse and completed as of 3/29/16. · A resident identified with pain · A resident identified with a change of condition 11. After the incident was brought to the attention of the corporate staff on 3/14/16, the Administrator was instructed to self-report to DADS, the corporate team began daily reviewing the 24 hour report and giving directions to nursing administration, and requiring constant follow up. This was began before STATE entered the facility on 3/29/16 and will continue at this time. 12. The corporate nurse and/or weekend RN will be in the building daily until the new DON starts on 4/4/16. 13. The Director of Nursing has been removed from the facility. The Surveyor confirmed the Plan of Removal had been implemented as evident by: Record review of an In-Service sign-in sheet revealed that nine LVN's received training on MD notification of resident change of condition on 3/30/16. Record review of the attached policy updated 3/30/16 read in part, .In the event of any change in a resident's condition (change of condition) you as the nurse are responsible for: Ensuring that the correct MD is notified of the situation. This DOES NOT mean fax the MD. We need a timely response . Record review of In-Service sign-in sheets revealed CNA's, MA's, and nurses on all three shifts received training on pain assessments and medications on 3/29/16; and transfer training including how to look up and follow the resident's plan of care for transferring in the computer on 3/30/16. Record Review of a Course Completion History revealed all staff representing all three shifts had completed a computer course titled Resident Lifting and Transfers on 3/30/16. Record review of a Pain Assessment History Report dated 3/30/16 revealed pain assessments had been completed on all residents in the facility. Interviews conducted on 3/31/16 with nursing staff revealed staff was able to verbalize the information from the recent in-services such as identifying residents with pain, consulting the physician, notifying the DON and Administrator with any resident change in status and safe transferring. The staff stated they were trained on how to look up a resident's care plan on the floor computers to see how they were to be transferred and any special instructions. In an interview with LVN B on 3/31/16 at 2:54 PM she stated the training went over pain assessments and indications of pain, and what staff was to do if there was an increase in pain or a change of condition. She stated staff was to contact the physician and the DON or Administrator. If they cannot get ahold of anyone they were to send the resident out to the hospital emergency room . She stated they would no longer send faxes to the physician. She stated staff were trained on how to look at the computer to tell if a resident was a two person transfer and if the resident had [MEDICAL CONDITION] or a calcium deficiency requiring them to be very delicate. The Administrator, Regional Director of Operations, Regional Nurse and the owner were informed on 3/31/16, at 4:00 PM that the IJ was lowered; however the facility remained out of compliance with a scope identified as pattern and a severity of actual harm that is not an immediate jeopardy due to the facility needing more time to train the staff and monitor the new systems/procedures that were put in place. According to the facility's CMS Form 672 there were 61 residents depend on staff assistance for ADL care.

Based on observation, interview and record review, the facility failed to implement their policy on neglect for one of nine residents (Resident #1) reviewed for neglect. The facility failed to assess Resident #1 who had bulging to her right hip and was in pain for six days and was found to be a distal right femur fracture. The facility failed to effectively control Resident #1's pain when the distal right femur fracture was discovered. The facility failed to follow physician's orders [REDACTED].#1 via two person transfer during which, the resident experienced pain. An Immediate Jeopardy was identified on 3/29/16. While the IJ was removed on 3/31/16, the facility remained out of compliance at a scope identified as pattern and a severity of actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. This failure affected one resident and placed 60 residents who require staff assistance with ADL's at risk of pain, not receiving medical care or adequate assessments, and a decline in their health status. Findings include: Incident # 8 Record review of Resident # 1's medical records revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 1's annual MDS assessment dated [DATE] revealed she sometimes made herself understood and sometimes understands others. She was unable to complete the Basic Interview for Mental Status (BIMS) and her cognitive skills for daily decision making was coded a 3. Severely impaired. She was totally dependent on one person for assistance with bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. She was totally dependent on two persons for assistance with transfers. She had no range of motion impairment in her upper or lower extremities. She was always incontinent of bowel and bladder. She had no pain documented on the pain assessment interview portion of the assessment. She had no falls. She was 64 inches tall and weighed 123 pounds. Record review of Resident # 1's March, 2016 physician's orders [REDACTED]. Not to exceed four grams in a 24 hour period. Further review of the physician's orders [REDACTED].#1 had no other orders for any additional pain medications. Further review of Resident # 1's March, 2016 physician's orders [REDACTED]. The start date was dated 4/29/15. Review of Resident #1's March, 2016 MARs revealed the order for staff to use the mechanical lift for transfers was documented that the lift had been used on both the day and the night shift from 3/01/16-3/29/16. Record review of Resident # 1's Progress Notes revealed the following nursing notes: 3/8/16 at 3:59 PM : Reported to this nurse that resident is hollering when right leg or hip is moved. Made slip to have resident seen at (Clinic) asap (as soon as possible) for right hip pain and discomfort. Also faxed (Dr. B) at (Clinic) to inform her of bulge to right hip joint and pain resident c/o (complained of) when moved. Record review of a Nursing Communication Fax signed by LVN B revealed the communication sheet was faxed on 3/8/16 at 2:57 PM to Resident # 1's primary care physician, Dr. B and read, 3/8/16 4:00 PM .Resident is hollering in pain from right hip & right leg. Hip has bulge when moved .Have made appointment slip for resident to be seen ASAP. In a box titled Physician's Section was written Agree and the doctor's signature with further documentation: Appt made for 10th had to reschedule d/t (do to) bad weather. The physician's section was not dated. Further review of Resident #1 ' s progress notes revealed: 3/12/16 at 4:21 AM: Resident continues with bulge Right hip and right knee swelling, leg lays turned inward. Request made for MD appt. 3/12/16 11:17 AM: Resident continues with bulge to right hip joint and right knee is turning inwards at this time. Resident c/o pain and discomfort when transferred and repositioned . 3/13/16 at 5:07 PM: Noted swelling of right knee, right outer thigh discolored and swollen, bulge to right hip joint area. Called (Dr. A) at 440 pm informed him of what is going on said to send out to ER and have resident checked. 450 pm Called (family member) informed him what is going on and that resident would be taken by (facility) van to (Hospital) ER (emergency room ) to evaluate and treat. 452 pm Spoke with (hospital staff) at (Hospital) ER informed him of right hip, leg, knee and outer thigh concerns and of resident's pain and discomfort noted and worsening. 507 pm Called (family member) and let him know that (Staff A)was leaving (facility)in van at this time to take resident to (Hospital) ER. Informed (Staff A) to please stay with resident until family arrived at least due to ER very busy. 5:15 pm Tried to call (Admin) let him know what was going on. Got voice mail left message for him to please call back. 5:16 pm Called (DON) let her know what is going on with resident at this time. Will pass on in report to on coming nurse what is going on. 3/13/16 at 10:22 PM: Returned from (Hospital) via company van with (Staff A). (Staff A) stated family did arrive and were made aware of situation. DX. Distal Right Femur Rx. Non ambulatory, knee immobilizer in place. Orders included f/u (follow up) with (Dr. C) the next Tuesday he comes to (Clinic). Also to f/u with (Dr. B) Appt slips made . Record review of a Radiologist report from the hospital dated 3/13/16 for Resident # 1 revealed, Two view evaluation of the right knee reveals prior right knee arthroplasty with fracture through native bone and migration of the hardware. Fracture seen through the posterior aspect of the distal femur of uncertain duration. The femoral shaft is seen to have shifted medially with respect to the tibial plateau. Soft tissue swelling also noted. Record review of the Provider Investigation Report revealed Resident #1's injury of unknown origin was reported to DADS on 3/14/16. The Description of the Allegation read, (Resident # 1) was found on 3/8/16 with swelling and bulge to her right leg. She complained of discomfort when staff transferred her or provided personal care. No incident had been reported and no falls reported. On 3/10 Nursing made an appointment with MD for the following week. On 3/13/16 Nurses concerned about swelling on the leg contacted (Dr. A) and the physician told them to send (Resident # 1) to the ER. At 22:17 (Resident # 1) returned from ER with a [DIAGNOSES REDACTED]. At the 3/15/16 appointment the surgeon reported that this was an old fracture that is recurring spontaneously. The family spoke to (facility) on the 15th telling staff that(family) did not want (resident) to have surgery or a pin. She wanted to keep (resident) to be kept in an immobilizer as instructed by the ER doctor (sic). Further review of the facility's investigation revealed written statements were taken on 3/14/16 and 3/15/16 from nine CNA's who had worked with Resident # 1. Seven of these statements revealed the CNA had no knowledge of the injury or how it occurred. Record review of a witness statement signed by CNA A read, This statement is in regard to (Resident # 1) which occurred on 3/8/16? Statement: I (CNA A) noticed her being in pain and saw her right leg and reported it to nurse but didn't witness anything. I haven't worked with her in a while. Record review of a witness statement signed by CNA F read, This statement is in regard to (Resident # 1)Which occurred on 3/8/16. Statement: I (CNA F) didn't witness resident injury to her knee. I only seen the discoloration on Sat. 3/12/16. I asked the charge nurse (LVN B) was it broken. Attached to the DON ' s statement was a typed note which read (Resident #1) has a history of pain. She as (sic) been on Tylenol 650 mg scheduled four times a day since 11/14/14 and it is effective for pain relief. She is able to rest without complications. This statement was signed and dated 3/18/16. Further review of Resident #1's progress notes revealed: 3/15/16 at 3:44 PM: (Clinic Staff) states that at the appointment this morning it was determined that surgery is not an option due to res age and the invasive surgery. She also states that (Dr. C) told her that it was an old fracture that just keeps shattering. She advised that MD wants her to keep knee immobilizer on until next appointment, only to be taken off when in the shower . 3/16/16 at 5:36 PM: Resident will grimace when being transferred or moved. When asked if she is hurting resident smiles and says no . 3/17/16 at 8:20 AM: Resident was up in w/c grimacing and shifting around in chair gave Tylenol 650 mg scheduled dose then moved resident from W/C to geri chair. Around 9:45 am resident seemed more comfortable. Record review of Resident # 1's Care Plans revealed a care plan dated 3/17/16 read, (Resident # 1) has DX of distal right femur fracture DX on 3/13/16. Saw Ortho (Dr. C) on 3/15/16 for F/U. (Dr. C) states it is an old fx that keeps shattering. Not a candidate for surgery d/t (do to) age and invasive procedure. The Goal read (Resident # 1) will be free from s/sx (signs and symptoms) of pain during healing process of right femur fx through the next review. Interventions included give pain medications as ordered. Monitor/document side effects and effectiveness (Tylenol) .Handle gently when moving or positioning. Maintain body alignment .(Mechanical) lift for all transfers . Further review of the care plans revealed there was no previous care plan for pain noted in the resident's care plans. Record review of Resident # 1's Pain Assessments in the electronic medical record revealed a pain assessment dated [DATE] at 2:39 PM which read that the resident could verbalize pain, and the verbal pain assessment of pain intensity at the time of the assessment on a scale of 1-10 was a 8.8 ; and during the last 24 hours it was 8.8. The location of the pain was right hip, and right (side) and for the description of the pain aching, sharp, and shooting were checked. The pattern was intermittent with duration of 30 minutes and the pain affected sleep and appetite. Transferring, turning & repositioning, and bathing were checked as causes of the pain. Interventions: scheduled medication with APAP were checked. Record review of Resident # 1's March 2016 MARS revealed her pain level was documented for each scheduled dose of Tylenol at 7:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM daily. Review revealed the following: On nine days at 7:00 AM she had a pain level of 5 documented. On three days at 11:00 AM she had pain level of 4-5 documented. At 4:00 PM she had a pain level of 3 noted on 3/13/16 and a 5 on 3/21/16. At 8:00 PM a pain level of 4-6 was documented for all but one day in the month. Most of the evenings the pain level was a 5. Record review of Resident #1's progress notes revealed Resident #1 continued to have pain two weeks after being diagnosed with [REDACTED].>3/23/16 12:35 AM: Resident actually talking tonight. When asked Resident if she had pain, she said some when was asked if some needed pain med, she said yes she would appreciate it and when pain med was given she said thank you. 3/27/16 at 3:44 AM: On Pt check at 11 PM resident stated she had pain and when asked if she wanted pain she said yes. Was unable to give pain level. 2 Tylenol 325 mg tabs crushed and given . There was no documentation in Resident #1 ' s medical record where the physician was consulted concerning the pain. Observation of Resident # 1 on 3/29/16 at 10:55 AM revealed she was seated in a geri-chair in the activity room in front of the television. Resident # 1 appeared to be uncomfortable and was frowning with some facial grimacing. Resident # 1 was alert, but was unable to speak. She had tape on two skin tears on her right forearm which appeared to be almost healed. Interview on 3/29/16 at 11:41 AM CNA C said before Resident # 1 went to the ER and they found the fracture, she did notice something was wrong and that the resident was in pain. She stated she reported it to the nurse and asked LVN B to check her. She stated Resident # 1 was a two person transfer and staff did not use the mechanical lift with her. Interview on 3/29/16 at 11:43 AM CNA E said staff never used the mechanical lift for Resident # 1. She stated Resident #1 was a two person transfer with a gait belt. She stated she remembered that Resident # 1 acted like she was in pain on 3/8/16 and they reported it to the nurse. Interview on 3/29/16 at 12:15 PM. LVN D said she had checked on Resident # 1 and she was smiling which indicated she was not in pain. She stated she adjusted the pillow behind her in the geri-chair to make her more comfortable and took her to the dining room. LVN D said she did not work on 3/8/16 or on 3/13/16 when Resident # 1 went out to the hospital. She stated she did work on 3/9 and 3/10/16. She stated she saw a fax that was sent to the doctor's office for an appointment for Resident # 1. She stated Resident # 1 received routine Tylenol for pain. She stated every time she asked Resident #1 if she was in pain she denied it. She stated the only time she had seen her grimacing was a couple of times while she was being transferred. LVN D stated, As far as any pain, it's being controlled with the Tylenol. She stated Med Rec (medical records) makes all of the doctor's appointments. She stated there was a really bad storm the week of 3/8/16 and they rescheduled all of the resident ' s appointments for the next week because it was too bad out to take the residents anywhere. Observation of Resident # 1 on 3/29/16 at 12:44 PM revealed she was seated in the geri-chair in the dining room and LVN D was observed pulling her up in the chair from behind. While the nurse was pulling Resident # 1 up she was observed grimacing a great deal and opened her mouth and kept it opened and was gritting her teeth. Once repositioned Resident # 1 closed her mouth and her facial expression became more relaxed. Interview and record review on 3/29/16 at 1:15 PM Med Rec was asked if she made an appointment for Resident # 1 to see the physician on 3/8/16. She stated she did make an appointment for her. She was observed getting out the appointment book and looking at it. Review of the appointment book revealed Resident # 1's name was not on the appointment schedule in the book during the week of 3/8/16. Med Rec then stated, You know what I really don't think I did. Med Rec said it was because of the storm and she had to reschedule the resident's appointments. She stated the next morning after the resident returned from the hospital she got her scheduled to see the orthopedic doctor on Tuesday, 3/15/16, at the Clinic. Interview on 3/29/16 at 1:25 PM CNA D said she had taken care of Resident # 1, but did not work with her that often. She stated the facility did have a manual mechanical lift in the facility, but staff transferred Resident # 1 using two people and a gait belt. CNA D stated she was surprised that the facility did not have staff start using a mechanical lift transfers with Resident #1 after her leg was fractured. She stated Resident # 1 always says Ow when staff turned her, or she would make faces. She stated she did this before the fracture happened. She stated Resident #1 still had pain. She said Resident #1 appeared to have pain when being turned more so than when being transferred. Interview on 3/29/16 at 2:06 PM the DON when asked, she stated there was a mobile x-ray unit the facility used. When asked why staff did not request an x-ray for Resident # 1 on 3/8/16, she stated, I don't know why the nurse did not call the mobile x-ray. She stated she thought LVN B told her the resident's doctor wanted to see her in the office. She stated staff did not call her. When asked when she learned that Resident #1 was in pain and had swelling of her leg she said she learned about the resident's pain on 3/9/16. When asked if she notified the Admin, she stated she thought he knew because everyone talked about it in the morning stand up meeting and Med Rec was to make a doctor's appointment for Resident #1. Interview on 3/29/16 at 2:14 PM. LVN B by telephone, LVN B said on 3/8/16 she called the doctor's office and talked to one of the assistants requesting that Resident # 1 be seen as soon as possible. She stated she requested an appointment for her. She stated she gave the resident Tylenol and that was controlling the pain. When asked why she did not request an x-ray she responded, Her hip was bulging was my concern. She wasn't crying out in pain. If she was it would've been a clear indication we needed an x-ray. LVN B was asked about the nurse note she wrote on 3/8/16 at 3:59 PM stating the resident was hollering in pain. LVN B asked if Surveyor was sure she wrote that note because she did not remember it. LVN B stated on 3/13/16 the resident ' s leg looked worse and was more swollen and she talked to the doctor on call about it who ordered the resident to be sent to the ER. Interview on 3/30/16 at 2:42 PM LVN B looked at the nurse note on 3/8/16 at 3:59 PM and verified she wrote the note. She stated the staff did tell her Resident # 1 was hollering, but she went and assisted staff to transfer Resident # 1 from the shower chair and she was fine. She stated she did not cry out in pain on 3/8/16. Observation of Resident # 1 on 3/29/16 at 3:04 PM revealed she was seated in the geri-chair in the activity room. She was asked if she was feeling better and she shook her head no. Resident # 1 was observed to be frowning and kept looking down and appeared to have discomfort. Resident # 1 was unable to respond further to any questions. Interview on 3/29/16 at 2:22 PM the DON stated she assessed Resident # 1 on 3/9/16 and her hip didn't feel out of place at all. She stated there was a little raised area on the right leg. She stated, I saw no bruise. She didn't cry out when I moved her in the bed. The DON stated Resident #1's doctor's appointment was pending, so she waited to see what the doctor said. She stated when Resident # 1 came back from theER on [DATE] she had scheduled Tylenol. She stated she had orders for the scheduled Tylenol since November 2014. The DON stated, I don't know why the ER doctor did not prescribe something stronger. I think the ER doctor should have prescribed something stronger if they thought she was in pain. But you know, I'm not the doctor. The DON stated, I did find out about the skin tears and thought they were related. She stated she interviewed the CNA's, but no one knew anything about how it happened. Interview on 3/29/16 at 2:45 PM with the Administrator and the DON, the Administrator stated he was not told anything about Resident # 1 having an injury until 3/14/16. The DON then stated, It was talked about in the morning meeting .maybe you weren't there. The Administrator made no further comment. Interview on 3/29/16 at 3:44 P.M.CNA A said on 3/8/16 she helped take care of Resident # 1. She stated as they were rolling her she was making noises like she was in pain. She stated the color on her right leg did not look right and it was swollen from the knee to her hip. She stated her skin was a yellowish tone on the upper leg. She stated she did not see a dark bruise on her. It was just yellow. She stated they reported it and LVN B told her she was going to fax the doctor. She stated Resident # 1 was a two person assist for everything. She stated they do not use a mechanical lift to transfer her. Interview on 3/29/16 at 4:18 PM the Regional Director of Operations stated the facility called him on 3/14/16 about Resident # 1's fracture. He stated he told them to go ahead and call it in. He stated when he looked at the incident he realized there was a problem. He stated he talked to them about it. Interview on 3/29/16 at 4:20 PM Med Rec said she called the doctor's office on Wednesday evening, 3/9/16, and scheduled an appointment for Resident # 1 for 3/15/16 to see the orthopedic doctor. She stated when she gets a slip requesting an appointment be made she usually tries to talk to the nurse. Med Rec stated staff did not let her know it was urgent. Record review of the request slip for a doctor's appointment to be scheduled for Resident # 1 read ASAP on the request. Observation of Resident # 1 on 3/30/16 at 10:50 AM revealed Resident #1 smiled when greeted and was trying to talk and said several words that could not be understood. She was seated in the geri-chair in the activity room and had her left foot on the floor. She appeared to be uncomfortable and was grimacing off and on and frowning Interview on 3/30/16 at 11:47 A.M. LVN B stated Resident # 1 had no black and blue marks on 3/8/16. She stated she assisted with transferring her and she was only complaining about pain in the bulging area only. In an interview with the DON on 3/30/16 at 11:57 AM she stated they do in-services throughout the year regarding pain, abuse/neglect, and injuries of unknown source, safe transfer and notification of the physician. She stated they have safe transfer training that was conducted by the therapy department with the CNA's. She stated an immobilizer was put into place for Resident # 1 and she has a follow-up appointment with the orthopedic doctor on 4/12/16. The DON stated she could call or text the Medical Director anytime day or night. She stated she would call the Medical Director if she thought the physician was not responding appropriately. The DON stated she had only been working in the facility for about six months. Observation of Resident # 1 being transferred from the geri-chair to the bed was conducted on 3/30/16 at 12:42 PM with CNA C and CNA D in the resident's room. CNA C and CNA D put a gait belt on Resident # 1's waist and each CNA held onto the resident under each arm and pulled her up holding the gait belt in the back and sat her on the bed. They then laid Resident #1 down and log rolled her (one CNA at her shoulders and one CNA at her legs) over onto her right side toward the window. Resident # 1 then rolled herself back over onto her back. She had the immobilizer on her right leg. Resident # 1 was smiling throughout the transfer and did not appear to be in pain at this time. Interview on 3/30/16 at 2:25 PM the Regional Nurse was asked about Resident # 1's orders for a mechanical lift transfer. He stated, That must be an order error. She's not overweight and I don't think she requires a hoyer. The Regional Nurse was asked if a mechanical lift would also be used with someone who is very delicate, having pain and had brittle bones like Resident # 1. The Regional Nurse stated it would be up to the IDT team to determine. He stated staff tried to use the least restrictive method possible. Interview on 3/30/16 at 2:42 P.M. LVN B stated Resident # 1 used to be transferred with a mechanical lift. She stated the order for a mechanical lift transfer needed to be discontinued. She stated, I've been telling them because of her brittle bones they need to do a two person transfer with a gait belt and to be very gentle with her due to her brittle bones. I can go D/C (discontinue) it right now if you want. Several attempts were made to contact the night shift nurse LVN C by phone but the numbers provided by the facility were not working numbers. LVN C had written the nurse note on 3/12/16 at 4:21 AM on 3/29/16 - 4/01/16 . Record review of a physician's orders [REDACTED]. Discontinue Date/Reason read, Patient has always been a safe transfer with 2 people and a gait belt, PCP agrees and dc'd hoyer transfer. In an interview with the Admin on 3/31/16 at 10:36 AM he stated he makes rounds in the facility several times a day every day. He stated he talks to the residents and the staff while he's out walking the floor. He stated this was a big part of his management to walk the floor and talk to residents and staff four to five times a day. He stated every day they have a stand up meeting. He said they had a list of questions they asked that had to do with anything reported in the last 24 hours, complaints, incidents, staffing issues, or needed equipment. He stated prior to the meeting he reviewed the 24 hour report. He stated anything that comes up in the meeting that was not completely addressed already they made an action plan to address it during the day. He stated he also goes through the point click care system (PCC) and checks the alerts and looks at everything: treatments, medication administration, and incident reports. He stated they come out of the meeting with a list of things to follow up on during the course of the day. He stated at 4:00 PM they had a stand down meeting to find out what had been addressed and what had not been addressed. They then take another look at whatever was not addressed. Everything should be addressed before 4:00 PM. In further interview with the Admin he was asked how he thought the IJ came about and if he was aware of the situation. He stated he did not know about the incident with Resident #1 until Monday 3/14/16 and he should have known prior to that. The Admin stated in the daily process, in the PCC they see if a nurse did not follow up on something. He stated the PCC had Administrative alerts and Clinical alerts that come up on the dashboard. He stated it had become part of his daily routine to check it and it was a powerful tool. He stated the facility started on the PCC last summer and were just now mastering it. He stated the daily review of the PCC was critical to staying on top of things. He stated the facility also had been doing a stand down meeting since last December and this had become a powerful tool to ensure that people were working on things. He stated it was crucial to do every day. He stated it still was possible to miss something like what happened with Resident # 1. The Admin stated he may have been out part of that week. He was not sure. The Admin stated they miss things in the PCC. He stated the nurse ' s note were in the PCC. The Admin stated, If anything bad happens in my building it's my fault. I've redoubled my efforts to not miss anything. It's been a learning curve for me. The Admin stated the Corporate Nurse had been very involved in the building, as well as the Regional Director, who was also an LVN, and they were available to all levels of staff. Record review of the facility's policy titled Abuse Investigations revealed in part, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Record review of the facility's policy titled Reporting Abuse to Facility Management revealed it read in part, It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management .Policy Interpretation and Implementation .4. The administrator 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 paged and informed of such incident. Record review of facility policy, Pain Assessment Policy (Revised 3/30/16) revealed, Our pain assessment is the universal pain assessment toll (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. This assessment is located in point click care (PCC). It is the policy of our facility that this assessment will be completed: .After any event that could cause injury/pain to the resident. After any change of condition status Be sure to follow the instructions on the pain assessment with any follow up as indicated by the current pain score. Record review of facility policy, Change in a Resident's Condition or Status revised April 2007 read in part, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . 1.- The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On -Call Physician when there has been: b. A discovery of injuries of an unknown source .d. A significant change in the resident ' s physical/emotional/mental condition; 2. A significant change of condition is a decline or improvement in the resident ' s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .4.- Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status . . The facility Administrator and the Director of Nursing were notified on 3/29/2016 at 2:51 PM that an IJ situation had been identified due to the above failures. The first Plan of Removal was submitted by the Administrator on 3/30/2016. The final Plan of Removal was accepted on 3/31/2016 at 1:05 PM. The Plan of Removal included: 1. An updated pain assessment was completed on 3/17/16 on the resident in question and the MD was notified of the results. The pain assessment was the universal pain assessment tool (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. This assessment will be completed on this resident every shift until further notice and after every PRN pain medication administration. This assessment will be completed by the resident's charge nurse at the time. 2. All nurses were in-serviced to timely notify the resident's MD. If the MD does not assess and/or order interventions, the Medical Director will be notified for orders. In the event that there are no effective responses the resident will be sent to closest emergency room for assessment per nursing judgment. This in-service was started and completed on 3/30/16 by the Regional Director of Operations. 3. Pain assessments on all residents were completed as of 3/30/16. Each pain assessment will be entered into Point Click Care (electronic record software). Any positive finding of active unrelieved pain will be discussed immediately by the IDT that consists of the Administrator, Regional Director, DON, Regional Nurse, and other administrative nurses. Each respective MD will be notified as needed. 4. All staff will be in-serviced on pain assessments and recognition. Tools will include but are not limited to the universal pain assessment tool (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. All nursing staff will be in-serviced over physician notification of pain and follow up. This in-service was started and completed on 3/30/16 by the ADON. Any staff who did not attend this in-service will

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source were immediately reported the administrator of the facility and to other officials in accordance with State law through established procedures for one of nine residents (Resident # 1) reviewed for abuse and neglect. The facility failed to assess Resident #1 who had bulging to her right hip and was in pain for six days and was found to be a distal right femur fracture. The facility failed to effectively control Resident #1's pain when the distal right femur fracture was discovered. The facility failed to follow physician's orders [REDACTED].#1 via two person transfer during which, the resident experienced pain. Staff failed to notify the Administrator of Resident #1's bulging to the right hip and pain when it was discovered on 3/8/16. An Immediate Jeopardy was identified on 3/29/16. While the IJ was removed on 3/31/16, the facility remained out of compliance at a scope identified as pattern and a severity of actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. This failure affected one resident and placed 60 residents who require staff assistance with ADL's at risk of pain, not receiving medical care or adequate assessments, and a decline in their health status. Findings include: Incident # 8 Record review of Resident # 1's medical records revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 1's annual MDS assessment dated [DATE] revealed she sometimes made herself understood and sometimes understands others. She was unable to complete the Basic Interview for Mental Status (BIMS) and her cognitive skills for daily decision making was coded a 3. Severely impaired. She was totally dependent on one person for assistance with bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. She was totally dependent on two persons for assistance with transfers. She had no range of motion impairment in her upper or lower extremities. She was always incontinent of bowel and bladder. She had no pain documented on the pain assessment interview portion of the assessment. She had no falls. She was 64 inches tall and weighed 123 pounds. Record review of Resident # 1's March, 2016 physician's orders [REDACTED]. Not to exceed four grams in a 24 hour period. Further review of the physician's orders [REDACTED].#1 had no other orders for any additional pain medications. Further review of Resident # 1's March, 2016 physician's orders [REDACTED]. The start date was dated 4/29/15. Review of Resident #1's March, 2016 MARs revealed the order for staff to use the mechanical lift for transfers was documented that the lift had been used on both the day and the night shift from 3/01/16-3/29/16. Record review of Resident # 1's Progress Notes revealed the following nursing notes: 3/8/16 at 4:54 AM: 4:45 Resident brought to nurse ' s station with several small skin tears to right outer forearm, largest one 2 cm in length. Using NH (nursing home) protocol, area cleansed NS (normal saline) patted dry, steri strips and TAO (triple antibiotic ointment) applied with dry non-adherent drgs, (dressing) wrapped with kerlix initially. MD faxed. RP (responsible party) notified. 3/8/16 at 3:59 PM : Reported to this nurse that resident is hollering when right leg or hip is moved. Made slip to have resident seen at (Clinic) asap (as soon as possible) for right hip pain and discomfort. Also faxed (Dr. B) at (Clinic) to inform her of bulge to right hip joint and pain resident c/o (complained of) when moved. Record review of a Nursing Communication Fax signed by LVN B revealed the communication sheet was faxed on 3/8/16 at 2:57 PM to Resident # 1's primary care physician, Dr. B and read, 3/8/16 4:00 PM .Resident is hollering in pain from right hip & right leg. Hip has bulge when moved .Have made appointment slip for resident to be seen ASAP. In a box titled Physician's Section was written Agree and the doctor's signature with further documentation: Appt made for 10th had to reschedule d/t (do to) bad weather. The physician's section was not dated. Further review of Resident #1 ' s progress notes revealed: 3/12/16 at 4:21 AM: Resident continues with bulge Right hip and right knee swelling, leg lays turned inward. Request made for MD appt. 3/12/16 11:17 AM: Resident continues with bulge to right hip joint and right knee is turning inwards at this time. Resident c/o pain and discomfort when transferred and repositioned . 3/13/16 at 5:07 PM: Noted swelling of right knee, right outer thigh discolored and swollen, bulge to right hip joint area. Called (Dr. A) at 440 pm informed him of what is going on said to send out to ER and have resident checked. 450 pm Called (family member) informed him what is going on and that resident would be taken by (facility) van to (Hospital) ER (emergency room ) to evaluate and treat. 452 pm Spoke with (hospital staff) at (Hospital) ER informed him of right hip, leg, knee and outer thigh concerns and of resident's pain and discomfort noted and worsening. 507 pm Called (family member) and let him know that (Staff A)was leaving (facility)in van at this time to take resident to (Hospital) ER. Informed (Staff A) to please stay with resident until family arrived at least due to ER very busy. 5:15 pm Tried to call (Admin) let him know what was going on. Got voice mail left message for him to please call back. 5:16 pm Called (DON) let her know what is going on with resident at this time. Will pass on in report to on coming nurse what is going on. 3/13/16 at 10:22 PM: Returned from (Hospital) via company van with (Staff A). (Staff A) stated family did arrive and were made aware of situation. DX. Distal Right Femur Rx. Non ambulatory, knee immobilizer in place. Orders included f/u (follow up) with (Dr. C) the next Tuesday he comes to (Clinic). Also to f/u with (Dr. B) Appt slips made . Record review of a Radiologist report from the hospital dated 3/13/16 for Resident # 1 revealed, Two view evaluation of the right knee reveals prior right knee arthroplasty with fracture through native bone and migration of the hardware. Fracture seen through the posterior aspect of the distal femur of uncertain duration. The femoral shaft is seen to have shifted medially with respect to the tibial plateau. Soft tissue swelling also noted. Record review of the Provider Investigation Report revealed Resident #1's injury of unknown origin was reported to DADS on 3/14/16. The Description of the Allegation read, (Resident # 1) was found on 3/8/16 with swelling and bulge to her right leg. She complained of discomfort when staff transferred her or provided personal care. No incident had been reported and no falls reported. On 3/10 Nursing made an appointment with MD for the following week. On 3/13/16 Nurses concerned about swelling on the leg contacted (Dr. A) and the physician told them to send (Resident # 1) to the ER. At 22:17 (Resident # 1) returned from ER with a [DIAGNOSES REDACTED]. At the 3/15/16 appointment the surgeon reported that this was an old fracture that is recurring spontaneously. The family spoke to (facility) on the 15th telling staff that(family) did not want (resident) to have surgery or a pin. She wanted to keep (resident) to be kept in an immobilizer as instructed by the ER doctor (sic). Further review of the facility's investigation revealed written statements were taken on 3/14/16 and 3/15/16 from nine CNA's who had worked with Resident # 1. Seven of these statements revealed the CNA had no knowledge of the injury or how it occurred. Record review of a witness statement signed by CNA A read, This statement is in regard to (Resident # 1) which occurred on 3/8/16? Statement: I (CNA A) noticed her being in pain and saw her right leg and reported it to nurse but didn't witness anything. I haven't worked with her in a while. Record review of a witness statement signed by CNA F read, This statement is in regard to (Resident # 1)Which occurred on 3/8/16. Statement: I (CNA F) didn't witness resident injury to her knee. I only seen the discoloration on Sat. 3/12/16. I asked the charge nurse (LVN B) was it broken. Attached to the DON ' s statement was a typed note which read (Resident #1) has a history of pain. She as (sic) been on Tylenol 650 mg scheduled four times a day since 11/14/14 and it is effective for pain relief. She is able to rest without complications. This statement was signed and dated 3/18/16. Further review of Resident #1's progress notes revealed: 3/15/16 at 3:44 PM: (Clinic Staff) states that at the appointment this morning it was determined that surgery is not an option due to res age and the invasive surgery. She also states that (Dr. C) told her that it was an old fracture that just keeps shattering. She advised that MD wants her to keep knee immobilizer on until next appointment, only to be taken off when in the shower . 3/16/16 at 5:36 PM: Resident will grimace when being transferred or moved. When asked if she is hurting resident smiles and says no . 3/17/16 at 8:20 AM: Resident was up in w/c grimacing and shifting around in chair gave Tylenol 650 mg scheduled dose then moved resident from W/C to geri chair. Around 9:45 am resident seemed more comfortable. Record review of Resident # 1's Care Plans revealed a care plan dated 3/17/16 read, (Resident # 1) has DX of distal right femur fracture DX on 3/13/16. Saw Ortho (Dr. C) on 3/15/16 for F/U. (Dr. C) states it is an old fx that keeps shattering. Not a candidate for surgery d/t (do to) age and invasive procedure. The Goal read (Resident # 1) will be free from s/sx (signs and symptoms) of pain during healing process of right femur fx through the next review. Interventions included give pain medications as ordered. Monitor/document side effects and effectiveness (Tylenol) .Handle gently when moving or positioning. Maintain body alignment .(Mechanical) lift for all transfers . Further review of the care plans revealed there was no previous care plan for pain noted in the resident's care plans. Record review of Resident # 1's Pain Assessments in the electronic medical record revealed a pain assessment dated [DATE] at 2:39 PM which read that the resident could verbalize pain, and the verbal pain assessment of pain intensity at the time of the assessment on a scale of 1-10 was a 8.8 ; and during the last 24 hours it was 8.8. The location of the pain was right hip, and right (side) and for the description of the pain aching, sharp, and shooting were checked. The pattern was intermittent with duration of 30 minutes and the pain affected sleep and appetite. Transferring, turning & repositioning, and bathing were checked as causes of the pain. Interventions: scheduled medication with APAP were checked. Record review of Resident # 1's March 2016 MARS revealed her pain level was documented for each scheduled dose of Tylenol at 7:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM daily. Review revealed the following: On nine days at 7:00 AM she had a pain level of 5 documented. On three days at 11:00 AM she had pain level of 4-5 documented. At 4:00 PM she had a pain level of 3 noted on 3/13/16 and a 5 on 3/21/16. At 8:00 PM a pain level of 4-6 was documented for all but one day in the month. Most of the evenings the pain level was a 5. Record review of Resident #1's progress notes revealed Resident #1 continued to have pain two weeks after being diagnosed with [REDACTED].>3/23/16 12:35 AM: Resident actually talking tonight. When asked Resident if she had pain, she said some when was asked if some needed pain med, she said yes she would appreciate it and when pain med was given she said thank you. 3/27/16 at 3:44 AM: On Pt check at 11 PM resident stated she had pain and when asked if she wanted pain she said yes. Was unable to give pain level. 2 Tylenol 325 mg tabs crushed and given . There was no documentation in Resident #1 ' s medical record where the physician was consulted concerning the pain. Observation of Resident # 1 on 3/29/16 at 10:55 AM revealed she was seated in a geri-chair in the activity room in front of the television. Resident # 1 appeared to be uncomfortable and was frowning with some facial grimacing. Resident # 1 was alert, but was unable to speak. She had tape on two skin tears on her right forearm which appeared to be almost healed. Interview on 3/29/16 at 11:41 AM CNA C said before Resident # 1 went to the ER and they found the fracture, she did notice something was wrong and that the resident was in pain. She stated she reported it to the nurse and asked LVN B to check her. She stated Resident # 1 was a two person transfer and staff did not use the mechanical lift with her. Interview on 3/29/16 at 11:43 AM CNA E said staff never used the mechanical lift for Resident # 1. She stated Resident #1 was a two person transfer with a gait belt. She stated she remembered that Resident # 1 acted like she was in pain on 3/8/16 and they reported it to the nurse. Interview on 3/29/16 at 12:15 PM. LVN D said she had checked on Resident # 1 and she was smiling which indicated she was not in pain. She stated she adjusted the pillow behind her in the geri-chair to make her more comfortable and took her to the dining room. LVN D said she did not work on 3/8/16 or on 3/13/16 when Resident # 1 went out to the hospital. She stated she did work on 3/9 and 3/10/16. She stated she saw a fax that was sent to the doctor's office for an appointment for Resident # 1. She stated Resident # 1 received routine Tylenol for pain. She stated every time she asked Resident #1 if she was in pain she denied it. She stated the only time she had seen her grimacing was a couple of times while she was being transferred. LVN D stated, As far as any pain, it's being controlled with the Tylenol. She stated Med Rec (medical records) makes all of the doctor's appointments. She stated there was a really bad storm the week of 3/8/16 and they rescheduled all of the resident ' s appointments for the next week because it was too bad out to take the residents anywhere. Observation of Resident # 1 on 3/29/16 at 12:44 PM revealed she was seated in the geri-chair in the dining room and LVN D was observed pulling her up in the chair from behind. While the nurse was pulling Resident # 1 up she was observed grimacing a great deal and opened her mouth and kept it opened and was gritting her teeth. Once repositioned Resident # 1 closed her mouth and her facial expression became more relaxed. Interview and record review on 3/29/16 at 1:15 PM Med Rec was asked if she made an appointment for Resident # 1 to see the physician on 3/8/16. She stated she did make an appointment for her. She was observed getting out the appointment book and looking at it. Review of the appointment book revealed Resident # 1's name was not on the appointment schedule in the book during the week of 3/8/16. Med Rec then stated, You know what I really don't think I did. Med Rec said it was because of the storm and she had to reschedule the resident's appointments. She stated the next morning after the resident returned from the hospital she got her scheduled to see the orthopedic doctor on Tuesday, 3/15/16, at the Clinic. Interview on 3/29/16 at 1:25 PM CNA D said she had taken care of Resident # 1, but did not work with her that often. She stated the facility did have a manual mechanical lift in the facility, but staff transferred Resident # 1 using two people and a gait belt. CNA D stated she was surprised that the facility did not have staff start using a mechanical lift transfers with Resident #1 after her leg was fractured. She stated Resident # 1 always says Ow when staff turned her, or she would make faces. She stated she did this before the fracture happened. She stated Resident #1 still had pain. She said Resident #1 appeared to have pain when being turned more so than when being transferred. Interview on 3/29/16 at 2:06 PM the DON when asked, she stated there was a mobile x-ray unit the facility used. When asked why staff did not request an x-ray for Resident # 1 on 3/8/16, she stated, I don't know why the nurse did not call the mobile x-ray. She stated she thought LVN B told her the resident's doctor wanted to see her in the office. She stated staff did not call her. When asked when she learned that Resident #1 was in pain and had swelling of her leg she said she learned about the resident's pain on 3/9/16. When asked if she notified the Admin, she stated she thought he knew because everyone talked about it in the morning stand up meeting and Med Rec was to make a doctor's appointment for Resident #1. Interview on 3/29/16 at 2:14 PM. LVN B by telephone, LVN B said on 3/8/16 she called the doctor's office and talked to one of the assistants requesting that Resident # 1 be seen as soon as possible. She stated she requested an appointment for her. She stated she gave the resident Tylenol and that was controlling the pain. When asked why she did not request an x-ray she responded, Her hip was bulging was my concern. She wasn't crying out in pain. If she was it would've been a clear indication we needed an x-ray. LVN B was asked about the nurse note she wrote on 3/8/16 at 3:59 PM stating the resident was hollering in pain. LVN B asked if Surveyor was sure she wrote that note because she did not remember it. LVN B stated on 3/13/16 the resident ' s leg looked worse and was more swollen and she talked to the doctor on call about it who ordered the resident to be sent to the ER. Interview on 3/30/16 at 2:42 PM LVN B looked at the nurse note on 3/8/16 at 3:59 PM and verified she wrote the note. She stated the staff did tell her Resident # 1 was hollering, but she went and assisted staff to transfer Resident # 1 from the shower chair and she was fine. She stated she did not cry out in pain on 3/8/16. Observation of Resident # 1 on 3/29/16 at 3:04 PM revealed she was seated in the geri-chair in the activity room. She was asked if she was feeling better and she shook her head no. Resident # 1 was observed to be frowning and kept looking down and appeared to have discomfort. Resident # 1 was unable to respond further to any questions. Interview on 3/29/16 at 2:22 PM the DON stated she assessed Resident # 1 on 3/9/16 and her hip didn't feel out of place at all. She stated there was a little raised area on the right leg. She stated, I saw no bruise. She didn't cry out when I moved her in the bed. The DON stated Resident #1's doctor's appointment was pending, so she waited to see what the doctor said. She stated when Resident # 1 came back from theER on [DATE] she had scheduled Tylenol. She stated she had orders for the scheduled Tylenol since November 2014. The DON stated, I don't know why the ER doctor did not prescribe something stronger. I think the ER doctor should have prescribed something stronger if they thought she was in pain. But you know, I'm not the doctor. The DON stated, I did find out about the skin tears and thought they were related. She stated she interviewed the CNA's, but no one knew anything about how it happened. Interview on 3/29/16 at 2:45 PM with the Administrator and the DON, the Administrator stated he was not told anything about Resident # 1 having an injury until 3/14/16. The DON then stated, It was talked about in the morning meeting .maybe you weren't there. The Administrator made no further comment. Interview on 3/29/16 at 3:44 P.M.CNA A said on 3/8/16 she helped take care of Resident # 1. She stated as they were rolling her she was making noises like she was in pain. She stated the color on her right leg did not look right and it was swollen from the knee to her hip. She stated her skin was a yellowish tone on the upper leg. She stated she did not see a dark bruise on her. It was just yellow. She stated they reported it and LVN B told her she was going to fax the doctor. She stated Resident # 1 was a two person assist for everything. She stated they do not use a mechanical lift to transfer her. Interview on 3/29/16 at 4:18 PM the Regional Director of Operations stated the facility called him on 3/14/16 about Resident # 1's fracture. He stated he told them to go ahead and call it in. He stated when he looked at the incident he realized there was a problem. He stated he talked to them about it. Interview on 3/29/16 at 4:20 PM Med Rec said she called the doctor's office on Wednesday evening, 3/9/16, and scheduled an appointment for Resident # 1 for 3/15/16 to see the orthopedic doctor. She stated when she gets a slip requesting an appointment be made she usually tries to talk to the nurse. Med Rec stated staff did not let her know it was urgent. Record review of the request slip for a doctor's appointment to be scheduled for Resident # 1 read ASAP on the request. Observation of Resident # 1 on 3/30/16 at 10:50 AM revealed Resident #1 smiled when greeted and was trying to talk and said several words that could not be understood. She was seated in the geri-chair in the activity room and had her left foot on the floor. She appeared to be uncomfortable and was grimacing off and on and frowning Interview on 3/30/16 at 11:47 A.M. LVN B stated Resident # 1 had no black and blue marks on 3/8/16. She stated she assisted with transferring her and she was only complaining about pain in the bulging area only. In an interview with the DON on 3/30/16 at 11:57 AM she stated they do in-services throughout the year regarding pain, abuse/neglect, and injuries of unknown source, safe transfer and notification of the physician. She stated they have safe transfer training that was conducted by the therapy department with the CNA's. She stated an immobilizer was put into place for Resident # 1 and she has a follow-up appointment with the orthopedic doctor on 4/12/16. The DON stated she could call or text the Medical Director anytime day or night. She stated she would call the Medical Director if she thought the physician was not responding appropriately. The DON stated she had only been working in the facility for about six months. Observation of Resident # 1 being transferred from the geri-chair to the bed was conducted on 3/30/16 at 12:42 PM with CNA C and CNA D in the resident's room. CNA C and CNA D put a gait belt on Resident # 1's waist and each CNA held onto the resident under each arm and pulled her up holding the gait belt in the back and sat her on the bed. They then laid Resident #1 down and log rolled her (one CNA at her shoulders and one CNA at her legs) over onto her right side toward the window. Resident # 1 then rolled herself back over onto her back. She had the immobilizer on her right leg. Resident # 1 was smiling throughout the transfer and did not appear to be in pain at this time. Interview on 3/30/16 at 2:25 PM the Regional Nurse was asked about Resident # 1's orders for a mechanical lift transfer. He stated, That must be an order error. She's not overweight and I don't think she requires a hoyer. The Regional Nurse was asked if a mechanical lift would also be used with someone who is very delicate, having pain and had brittle bones like Resident # 1. The Regional Nurse stated it would be up to the IDT team to determine. He stated staff tried to use the least restrictive method possible. Interview on 3/30/16 at 2:42 P.M. LVN B stated Resident # 1 used to be transferred with a mechanical lift. She stated the order for a mechanical lift transfer needed to be discontinued. She stated, I've been telling them because of her brittle bones they need to do a two person transfer with a gait belt and to be very gentle with her due to her brittle bones. I can go D/C (discontinue) it right now if you want. Several attempts were made to contact the night shift nurse LVN C by phone but the numbers provided by the facility were not working numbers. LVN C had written the nurse note on 3/12/16 at 4:21 AM on 3/29/16 - 4/01/16 . Record review of a physician's orders [REDACTED]. Discontinue Date/Reason read, Patient has always been a safe transfer with 2 people and a gait belt, PCP agrees and dc'd hoyer transfer. In an interview with the Admin on 3/31/16 at 10:36 AM he stated he makes rounds in the facility several times a day every day. He stated he talks to the residents and the staff while he's out walking the floor. He stated this was a big part of his management to walk the floor and talk to residents and staff four to five times a day. He stated every day they have a stand up meeting. He said they had a list of questions they asked that had to do with anything reported in the last 24 hours, complaints, incidents, staffing issues, or needed equipment. He stated prior to the meeting he reviewed the 24 hour report. He stated anything that comes up in the meeting that was not completely addressed already they made an action plan to address it during the day. He stated he also goes through the point click care system (PCC) and checks the alerts and looks at everything: treatments, medication administration, and incident reports. He stated they come out of the meeting with a list of things to follow up on during the course of the day. He stated at 4:00 PM they had a stand down meeting to find out what had been addressed and what had not been addressed. They then take another look at whatever was not addressed. Everything should be addressed before 4:00 PM. In further interview with the Admin he was asked how he thought the IJ came about and if he was aware of the situation. He stated he did not know about the incident with Resident #1 until Monday 3/14/16 and he should have known prior to that. The Admin stated in the daily process, in the PCC they see if a nurse did not follow up on something. He stated the PCC had Administrative alerts and Clinical alerts that come up on the dashboard. He stated it had become part of his daily routine to check it and it was a powerful tool. He stated the facility started on the PCC last summer and were just now mastering it. He stated the daily review of the PCC was critical to staying on top of things. He stated the facility also had been doing a stand down meeting since last December and this had become a powerful tool to ensure that people were working on things. He stated it was crucial to do every day. He stated it still was possible to miss something like what happened with Resident # 1. The Admin stated he may have been out part of that week. He was not sure. The Admin stated they miss things in the PCC. He stated the nurse ' s note were in the PCC. The Admin stated, If anything bad happens in my building it's my fault. I've redoubled my efforts to not miss anything. It's been a learning curve for me. The Admin stated the Corporate Nurse had been very involved in the building, as well as the Regional Director, who was also an LVN, and they were available to all levels of staff. Record review of the facility's policy titled Abuse Investigations revealed in part, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Record review of the facility's policy titled Reporting Abuse to Facility Management revealed it read in part, It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management .Policy Interpretation and Implementation .4. The administrator 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 paged and informed of such incident. Record review of facility policy, Pain Assessment Policy (Revised 3/30/16) revealed, Our pain assessment is the universal pain assessment toll (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. This assessment is located in point click care (PCC). It is the policy of our facility that this assessment will be completed: .After any event that could cause injury/pain to the resident. After any change of condition status Be sure to follow the instructions on the pain assessment with any follow up as indicated by the current pain score. Record review of facility policy, Change in a Resident's Condition or Status revised April 2007 read in part, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . 1.- The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On -Call Physician when there has been: b. A discovery of injuries of an unknown source .d. A significant change in the resident ' s physical/emotional/mental condition; 2. A significant change of condition is a decline or improvement in the resident ' s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .4.- Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status . . The facility Administrator and the Director of Nursing were notified on 3/29/2016 at 2:51 PM that an IJ situation had been identified due to the above failures. The first Plan of Removal was submitted by the Administrator on 3/30/2016. The final Plan of Removal was accepted on 3/31/2016 at 1:05 PM. The Plan of Removal included: 1. An updated pain assessment was completed on 3/17/16 on the resident in question and the MD was notified of the results. The pain assessment was the universal pain assessment tool (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. This assessment will be completed on this resident every shift until further notice and after every PRN pain medication administration. This assessment will be completed by the resident's charge nurse at the time. 2. All nurses were in-serviced to timely notify the resident's MD. If the MD does not assess and/or order interventions, the Medical Director will be notified for orders. In the event that there are no effective responses the resident will be sent to closest emergency room for assessment per nursing judgment. This in-service was started and completed on 3/30/16 by the Regional Director of Operations. 3. Pain assessments on all residents were completed as of 3/30/16. Each pain assessment will be entered into Point Click Car

Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one of nine (Resident # 1) residents reviewed for quality of care. The facility failed to assess Resident #1 who had bulging to her right hip and was in pain for six days and was found to be a distal right femur fracture. The facility failed to effectively control Resident #1's pain when the distal right femur fracture was discovered. The facility failed to follow physician's orders [REDACTED].#1 via two person transfer during which, the resident experienced pain. An Immediate Jeopardy was identified on 3/29/16. While the IJ was removed on 3/31/16, the facility remained out of compliance at a scope identified as pattern and a severity of actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. This failure affected one resident and placed 60 residents who require staff assistance with ADL's at risk of pain, not receiving medical care or adequate assessments, and a decline in their health status. Findings include: Incident # 8 Record review of Resident # 1's medical records revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 1's annual MDS assessment dated [DATE] revealed she sometimes made herself understood and sometimes understands others. She was unable to complete the Basic Interview for Mental Status (BIMS) and her cognitive skills for daily decision making was coded a 3. Severely impaired. She was totally dependent on one person for assistance with bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. She was totally dependent on two persons for assistance with transfers. She had no range of motion impairment in her upper or lower extremities. She was always incontinent of bowel and bladder. She had no pain documented on the pain assessment interview portion of the assessment. She had no falls. She was 64 inches tall and weighed 123 pounds. Record review of Resident # 1's March, 2016 physician's orders [REDACTED]. Not to exceed four grams in a 24 hour period. Further review of the physician's orders [REDACTED].#1 had no other orders for any additional pain medications. Further review of Resident # 1's March 2016 physician's orders [REDACTED]. The start date was dated 4/29/15. Review of Resident #1's March 2016 MARs revealed the order for staff to use the mechanical lift for transfers was documented that the lift had been used on both the day (6:00 AM - 6:00 PM) and the night (6:00 PM - 6:00 AM) shift from 3/01/16-3/29/16. Record review of Resident # 1's Progress Notes revealed the following nursing notes: 3/8/16 at 4:54 AM: 4:45 Resident brought to nurse ' s station with several small skin tears to right outer forearm, largest one 2 cm in length. Using NH (nursing home) protocol, area cleansed NS (normal saline) patted dry, steri strips and TAO (triple antibiotic ointment) applied with dry non-adherent drgs, (dressing) wrapped with kerlix initially. MD faxed. RP (responsible party) notified. This note was signed by LVN C. 3/8/16 at 3:59 PM : Reported to this nurse (LVN B) that resident is hollering when right leg or hip is moved. Made slip to have resident seen at (Clinic) asap (as soon as possible) for right hip pain and discomfort. Also faxed (Dr. B) at (Clinic) to inform her of bulge to right hip joint and pain resident c/o (complained of) when moved. This note was signed by LVN B. Record review of a Nursing Communication Fax signed by LVN B revealed the communication sheet was faxed on 3/8/16 at 2:57 PM to Resident # 1's primary care physician, Dr. B and read, 3/8/16 4:00 PM .Resident is hollering in pain from right hip & right leg. Hip has bulge when moved .Have made appointment slip for resident to be seen ASAP. In a box titled Physician's Section was written Agree and the doctor's signature with further documentation: Appt made for 10th had to reschedule d/t (do to) bad weather. The physician's section was not dated. Further review of Resident #1 ' s progress notes revealed: 3/12/16 at 4:21 AM: Resident continues with bulge Right hip and right knee swelling, leg lays turned inward. Request made for MD appt. This note was signed by LVN C. 3/12/16 11:17 AM: Resident continues with bulge to right hip joint and right knee is turning inwards at this time. Resident c/o pain and discomfort when transferred and repositioned .This note was signed by LVN B. 3/13/16 at 5:07 PM: Noted swelling of right knee, right outer thigh discolored and swollen, bulge to right hip joint area. Called (Dr. A) at 440 pm informed him of what is going on said to send out to ER and have resident checked. 450 pm Called (family member) informed him what is going on and that resident would be taken by (facility) van to (Hospital) ER (emergency room ) to evaluate and treat. 452 pm Spoke with (hospital staff) at (Hospital) ER informed him of right hip, leg, knee and outer thigh concerns and of resident's pain and discomfort noted and worsening. 507 pm Called (family member) and let him know that (Staff A)was leaving (facility)in van at this time to take resident to (Hospital) ER. Informed (Staff A) to please stay with resident until family arrived at least due to ER very busy. 5:15 pm Tried to call (Admin) let him know what was going on. Got voice mail left message for him to please call back. 5:16 pm Called (DON) let her know what is going on with resident at this time. Will pass on in report to on coming nurse what is going on. This note was signed by LVN B. 3/13/16 at 10:22 PM: Returned from (Hospital) via company van with (Staff A). (Staff A) stated family did arrive and were made aware of situation. DX. Distal Right Femur Rx. Non ambulatory, knee immobilizer in place. Orders included f/u (follow up) with (Dr. C) the next Tuesday he comes to (Clinic). Also to f/u with (Dr. B) Appt slips made . This note was signed by LVN C. Record review of a Radiologist report from the hospital dated 3/13/16 for Resident # 1 revealed, Two view evaluation of the right knee reveals prior right knee arthroplasty with fracture through native bone and migration of the hardware. Fracture seen through the posterior aspect of the distal femur of uncertain duration. The femoral shaft is seen to have shifted medially with respect to the tibial plateau. Soft tissue swelling also noted. Record review of the Provider Investigation Report revealed Resident #1's injury of unknown origin was reported to DADS on 3/14/16. The Description of the Allegation read, (Resident # 1) was found on 3/8/16 with swelling and bulge to her right leg. She complained of discomfort when staff transferred her or provided personal care. No incident had been reported and no falls reported. On 3/10 Nursing made an appointment with MD for the following week. On 3/13/16 Nurses concerned about swelling on the leg contacted (Dr. A) and the physician told them to send (Resident # 1) to the ER. At 22:17 (Resident # 1) returned from ER with a [DIAGNOSES REDACTED]. At the 3/15/16 appointment the surgeon reported that this was an old fracture that is recurring spontaneously. The family spoke to (facility) on the 15th telling staff that(family) did not want (resident) to have surgery or a pin. She wanted to keep (resident) to be kept in an immobilizer as instructed by the ER doctor (sic). Further review of the facility's investigation revealed written statements were taken on 3/14/16 and 3/15/16 from nine CNA's who had worked with Resident # 1. Seven of these statements revealed the CNA had no knowledge of the injury or how it occurred. Record review of a witness statement signed by CNA A read, This statement is in regard to (Resident # 1) which occurred on 3/8/16? Statement: I (CNA A) noticed her being in pain and saw her right leg and reported it to nurse but didn't witness anything. I haven't worked with her in a while. Record review of a witness statement signed by CNA F read, This statement is in regard to (Resident # 1)Which occurred on 3/8/16. Statement: I (CNA F) didn't witness resident injury to her knee. I only seen the discoloration on Sat. 3/12/16. I asked the charge nurse (LVN B) was it broken. Attached to the DON ' s statement was a typed note which read (Resident #1) has a history of pain. She as (sic) been on Tylenol 650 mg scheduled four times a day since 11/14/14 and it is effective for pain relief. She is able to rest without complications. This statement was signed and dated 3/18/16. Further review of Resident #1's progress notes revealed: 3/15/16 at 3:44 PM: (Clinic Staff) states that at the appointment this morning it was determined that surgery is not an option due to res age and the invasive surgery. She also states that (Dr. C) told her that it was an old fracture that just keeps shattering. She advised that MD wants her to keep knee immobilizer on until next appointment, only to be taken off when in the shower . This note was signed by LVN D. 3/16/16 at 5:36 PM: Resident will grimace when being transferred or moved. When asked if she is hurting resident smiles and says no .This note was signed by LVN B. 3/17/16 at 8:20 AM: Resident was up in w/c grimacing and shifting around in chair gave Tylenol 650 mg scheduled dose then moved resident from W/C to geri chair. Around 9:45 am resident seemed more comfortable.This note was signed by LVN B. Record review of Resident # 1's Care Plans revealed a care plan dated 3/17/16 read, (Resident # 1) has DX of distal right femur fracture DX on 3/13/16. Saw Ortho (Dr. C) on 3/15/16 for F/U. (Dr. C) states it is an old fx that keeps shattering. Not a candidate for surgery d/t (do to) age and invasive procedure. The Goal read (Resident # 1) will be free from s/sx (signs and symptoms) of pain during healing process of right femur fx through the next review. Interventions included give pain medications as ordered. Monitor/document side effects and effectiveness (Tylenol) .Handle gently when moving or positioning. Maintain body alignment .(Mechanical) lift for all transfers . Further review of the care plans revealed there was no previous care plan for pain noted in the resident's care plans. Record review of Resident # 1's Pain Assessments in the electronic medical record revealed no pain assessments from 3/1/16 - 3/13/16, when Resident #1 was sent to the hospital. A pain assessment was found dated 3/17/16 at 2:39 PM which read that the resident could verbalize pain, and the verbal pain assessment of pain intensity at the time of the assessment on a scale of 1-10 was a 8.8 ; and during the last 24 hours it was 8.8. The location of the pain was right hip, and right (side) and for the description of the pain aching, sharp, and shooting were checked. The pattern was intermittent with duration of 30 minutes and the pain affected sleep and appetite. Transferring, turning & repositioning, and bathing were checked as causes of the pain. Interventions: scheduled medication with APAP were checked. Record review of Resident # 1's March 2016 MARs revealed her pain level was documented for each scheduled dose of Tylenol at 7:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM daily. Review revealed the following: On nine days at 7:00 AM she had a pain level of 5 documented. On three days at 11:00 AM she had pain level of 4-5 documented. At 4:00 PM she had a pain level of 3 noted on 3/13/16 and a 5 on 3/21/16. At 8:00 PM a pain level of 4-6 was documented for all but one day in the month. Most of the evenings the pain level was a 5. Record review of Resident #1's progress notes revealed Resident #1 continued to have pain two weeks after being diagnosed with [REDACTED].>3/23/16 12:35 AM: Resident actually talking tonight. When asked Resident if she had pain, she said some when was asked if some needed pain med, she said yes she would appreciate it and when pain med was given she said thank you.This note was signed by LVN C. 3/27/16 at 3:44 AM: On Pt check at 11 PM resident stated she had pain and when asked if she wanted pain she said yes. Was unable to give pain level. 2 Tylenol 325 mg tabs crushed and given . This note was signed by LVN C. There was no documentation in Resident #1 ' s medical record where the physician was consulted concerning the pain. Observation of Resident # 1 on 3/29/16 at 10:55 AM revealed she was seated in a geri-chair in the activity room in front of the television. Resident # 1 appeared to be uncomfortable and was frowning with some facial grimacing. Resident # 1 was alert, but was unable to speak. She had tape on two skin tears on her right forearm which appeared to be almost healed. Interview on 3/29/16 at 11:41 AM CNA C said before Resident # 1 went to the ER and they found the fracture, she did notice something was wrong and that the resident was in pain. She stated she reported it to the nurse and asked LVN B to check her. She stated Resident # 1 was a two person transfer and staff did not use the mechanical lift with her. Interview on 3/29/16 at 11:43 AM CNA E said staff never used the mechanical lift for Resident # 1. She stated Resident #1 was a two person transfer with a gait belt. She stated she remembered that Resident # 1 acted like she was in pain on 3/8/16 and they reported it to the nurse. Interview on 3/29/16 at 12:15 PM. LVN D said she had checked on Resident # 1 and she was smiling which indicated she was not in pain. She stated she adjusted the pillow behind her in the geri-chair to make her more comfortable and took her to the dining room. LVN D said she did not work on 3/8/16 or on 3/13/16 when Resident # 1 went out to the hospital. She stated she did work on 3/9 and 3/10/16. She stated she saw a fax that was sent to the doctor's office for an appointment for Resident # 1. She stated Resident # 1 received routine Tylenol for pain. She stated every time she asked Resident #1 if she was in pain she denied it. She stated the only time she had seen her grimacing was a couple of times while she was being transferred. LVN D stated, As far as any pain, it's being controlled with the Tylenol. She stated Med Rec (medical records) makes all of the doctor's appointments. She stated there was a really bad storm the week of 3/8/16 and they rescheduled all of the resident ' s appointments for the next week because it was too bad out to take the residents anywhere. Observation of Resident # 1 on 3/29/16 at 12:44 PM revealed she was seated in the geri-chair in the dining room and LVN D was observed pulling her up in the chair from behind. While the nurse was pulling Resident # 1 up she was observed grimacing a great deal and opened her mouth and kept it opened and was gritting her teeth. Once repositioned Resident # 1 closed her mouth and her facial expression became more relaxed. Interview and record review on 3/29/16 at 1:15 PM Med Rec was asked if she made an appointment for Resident # 1 to see the physician on 3/8/16. She stated she did make an appointment for her. She was observed getting out the appointment book and looking at it. Review of the appointment book revealed Resident # 1's name was not on the appointment schedule in the book during the week of 3/8/16. Med Rec then stated, You know what I really don't think I did. Med Rec said it was because of the storm and she had to reschedule the resident's appointments. She stated the next morning after the resident returned from the hospital she got her scheduled to see the orthopedic doctor on Tuesday, 3/15/16, at the Clinic. Interview on 3/29/16 at 1:25 PM CNA D said she had taken care of Resident # 1, but did not work with her that often. She stated the facility did have a manual mechanical lift in the facility, but staff transferred Resident # 1 using two people and a gait belt. CNA D stated she was surprised that the facility did not have staff start using a mechanical lift transfers with Resident #1 after her leg was fractured. She stated Resident # 1 always says Ow when staff turned her, or she would make faces. She stated she did this before the fracture happened. She stated Resident #1 still had pain. She said Resident #1 appeared to have pain when being turned more so than when being transferred. Interview on 3/29/16 at 2:06 PM the DON when asked, she stated there was a mobile x-ray unit the facility used. When asked why staff did not request an x-ray for Resident # 1 on 3/8/16, she stated, I don't know why the nurse did not call the mobile x-ray. She stated she thought LVN B told her the resident's doctor wanted to see her in the office. She stated staff did not call her. When asked when she learned that Resident #1 was in pain and had swelling of her leg she said she learned about the resident's pain on 3/9/16. When asked if she notified the Admin, she stated she thought he knew because everyone talked about it in the morning stand up meeting and Med Rec was to make a doctor's appointment for Resident #1. Interview on 3/29/16 at 2:14 PM. LVN B by telephone, LVN B said on 3/8/16 she called the doctor's office and talked to one of the assistants requesting that Resident # 1 be seen as soon as possible. She stated she requested an appointment for her. She stated she gave the resident Tylenol and that was controlling the pain. When asked why she did not request an x-ray she responded, Her hip was bulging was my concern. She wasn't crying out in pain. If she was it would've been a clear indication we needed an x-ray. LVN B was asked about the nurse note she wrote on 3/8/16 at 3:59 PM stating the resident was hollering in pain. LVN B asked if Surveyor was sure she wrote that note because she did not remember it. LVN B stated on 3/13/16 the resident ' s leg looked worse and was more swollen and she talked to the doctor on call about it who ordered the resident to be sent to the ER. Interview on 3/29/16 at 2:22 PM the DON stated she assessed Resident # 1 on 3/9/16 and her hip didn't feel out of place at all. She stated there was a little raised area on the right leg. She stated, I saw no bruise. She didn't cry out when I moved her in the bed. The DON stated Resident #1's doctor's appointment was pending, so she waited to see what the doctor said. She stated when Resident # 1 came back from theER on [DATE] she had scheduled Tylenol. She stated she had orders for the scheduled Tylenol since November 2014. The DON stated, I don't know why the ER doctor did not prescribe something stronger. I think the ER doctor should have prescribed something stronger if they thought she was in pain. But you know, I'm not the doctor. The DON stated, I did find out about the skin tears and thought they were related. She stated she interviewed the CNA's, but no one knew anything about how it happened. Interview on 3/30/16 at 2:42 PM LVN B looked at the nurse note on 3/8/16 at 3:59 PM and verified she wrote the note. She stated the staff did tell her Resident # 1 was hollering, but she went and assisted staff to transfer Resident # 1 from the shower chair and she was fine. She stated she did not cry out in pain on 3/8/16. Interview on 3/29/16 at 2:45 PM with the Administrator and the DON, the Administrator stated he was not told anything about Resident # 1 having an injury until 3/14/16. The DON then stated, It was talked about in the morning meeting .maybe you weren't there. The Administrator made no further comment. Observation of Resident # 1 on 3/29/16 at 3:04 PM revealed she was seated in the geri-chair in the activity room. She was asked if she was feeling better and she shook her head no. Resident # 1 was observed to be frowning and kept looking down and appeared to have discomfort. Resident # 1 was unable to respond further to any questions. Interview on 3/29/16 at 3:44 P.M.CNA A said on 3/8/16 she helped take care of Resident # 1. She stated as they were rolling her she was making noises like she was in pain. She stated the color on her right leg did not look right and it was swollen from the knee to her hip. She stated her skin was a yellowish tone on the upper leg. She stated she did not see a dark bruise on her. It was just yellow. She stated they reported it and LVN B told her she was going to fax the doctor. She stated Resident # 1 was a two person assist for everything. She stated they do not use a mechanical lift to transfer her. Interview on 3/29/16 at 4:18 PM the Regional Director of Operations stated the facility called him on 3/14/16 about Resident # 1's fracture. He stated he told them to go ahead and call it in. He stated when he looked at the incident he realized there was a problem. He stated he talked to them about it. Interview on 3/29/16 at 4:20 PM Med Rec said she called the doctor's office on Wednesday evening, 3/9/16, and scheduled an appointment for Resident # 1 for 3/15/16 to see the orthopedic doctor. She stated when she gets a slip requesting an appointment be made she usually tries to talk to the nurse. Med Rec stated staff did not let her know it was urgent. Record review of the request slip for a doctor's appointment to be scheduled for Resident # 1 read ASAP on the request. Observation of Resident # 1 on 3/30/16 at 10:50 AM revealed Resident #1 smiled when greeted and was trying to talk and said several words that could not be understood. She was seated in the geri-chair in the activity room and had her left foot on the floor. She appeared to be uncomfortable and was grimacing off and on and frowning Interview on 3/30/16 at 11:47 A.M. LVN B stated Resident # 1 had no black and blue marks on 3/8/16. She stated she assisted with transferring her and she was only complaining about pain in the bulging area only. In an interview with the DON on 3/30/16 at 11:57 AM she stated they do in-services throughout the year regarding pain, abuse/neglect, and injuries of unknown source, safe transfer and notification of the physician. She stated they have safe transfer training that was conducted by the therapy department with the CNA's. She stated an immobilizer was put into place for Resident # 1 and she has a follow-up appointment with the orthopedic doctor on 4/12/16. The DON stated she could call or text the Medical Director anytime day or night. She stated she would call the Medical Director if she thought the physician was not responding appropriately. The DON stated she had only been working in the facility for about six months. Observation of Resident # 1 being transferred from the geri-chair to the bed was conducted on 3/30/16 at 12:42 PM with CNA C and CNA D in the resident's room. CNA C and CNA D put a gait belt on Resident # 1's waist and each CNA held onto the resident under each arm and pulled her up holding the gait belt in the back and sat her on the bed. They then laid Resident #1 down and log rolled her (one CNA at her shoulders and one CNA at her legs) over onto her right side toward the window. Resident # 1 then rolled herself back over onto her back. She had the immobilizer on her right leg. Interview on 3/30/16 at 2:25 PM the Regional Nurse was asked about Resident # 1's orders for a mechanical lift transfer. He stated, That must be an order error. She's not overweight and I don't think she requires a hoyer. The Regional Nurse was asked if a mechanical lift would also be used with someone who is very delicate, having pain and had brittle bones like Resident # 1. The Regional Nurse stated it would be up to the IDT team to determine. He stated staff tried to use the least restrictive method possible. Interview on 3/30/16 at 2:42 P.M. LVN B stated Resident # 1 used to be transferred with a mechanical lift. She stated the order for a mechanical lift transfer needed to be discontinued. She stated, I've been telling them because of her brittle bones they need to do a two person transfer with a gait belt and to be very gentle with her due to her brittle bones. I can go D/C (discontinue) it right now if you want. Several attempts were made to contact the night shift nurse LVN C by phone but the numbers provided by the facility were not working numbers. Record review of a physician's orders [REDACTED]. Discontinue Date/Reason read, Patient has always been a safe transfer with 2 people and a gait belt, PCP agrees and dc'd hoyer transfer. Record review of facility policy, Pain Assessment Policy (Revised 3/30/16) revealed, Our pain assessment is the universal pain assessment toll (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. This assessment is located in point click care (PCC). It is the policy of our facility that this assessment will be completed: .After any event that could cause injury/pain to the resident. After any change of condition status Be sure to follow the instructions on the pain assessment with any follow up as indicated by the current pain score. Record review of facility policy, Change in a Resident's Condition or Status revised April 2007 read in part, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . 1.- The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On -Call Physician when there has been: b. A discovery of injuries of an unknown source .d. A significant change in the resident ' s physical/emotional/mental condition; 2. A significant change of condition is a decline or improvement in the resident ' s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .4.- Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status . . The facility Administrator and the Director of Nursing were notified on 3/29/2016 at 2:51 PM that an IJ situation had been identified due to the above failures. In an interview with the Admin on 3/31/16 at 10:36 AM he stated he makes rounds in the facility several times a day every day. He stated he talks to the residents and the staff while he's out walking the floor. He stated this was a big part of his management to walk the floor and talk to residents and staff four to five times a day. He stated every day they have a stand up meeting. He said they had a list of questions they asked that had to do with anything reported in the last 24 hours, complaints, incidents, staffing issues, or needed equipment. He stated prior to the meeting he reviewed the 24 hour report. He stated anything that comes up in the meeting that was not completely addressed already they made an action plan to address it during the day. He stated he also goes through the point click care system (PCC) and checks the alerts and looks at everything: treatments, medication administration, and incident reports. He stated they come out of the meeting with a list of things to follow up on during the course of the day. He stated at 4:00 PM they had a stand down meeting to find out what had been addressed and what had not been addressed. They then take another look at whatever was not addressed. Everything should be addressed before 4:00 PM. In further interview with the Admin he was asked how he thought the IJ came about and if he was aware of the situation. He stated he did not know about the incident with Resident #1 until Monday 3/14/16 and he should have known prior to that. The Admin stated in the daily process, in the PCC they see if a nurse did not follow up on something. He stated the PCC had Administrative alerts and Clinical alerts that come up on the dashboard. He stated it had become part of his daily routine to check it and it was a powerful tool. He stated the facility started on the PCC last summer and were just now mastering it. He stated the daily review of the PCC was critical to staying on top of things. He stated the facility also had been doing a stand down meeting since last December and this had become a powerful tool to ensure that people were working on things. He stated it was crucial to do every day. He stated it still was possible to miss something like what happened with Resident # 1. The Admin stated he may have been out part of that week. He was not sure. The Admin stated they miss things in the PCC. He stated the nurse ' s note were in the PCC. The Admin stated, If anything bad happens in my building it's my fault. I've redoubled my efforts to not miss anything. It's been a learning curve for me. The Admin stated the Corporate Nurse had been very involved in the building, as well as the Regional Director, who was also an LVN, and they were available to all levels of staff. The first Plan of Removal was submitted by the Administrator on 3/30/2016. The final Plan of Removal was accepted on 3/31/2016 at 1:05 PM. The Plan of Removal included: 1. An updated pain assessment was completed on 3/17/16 on the resident in question and the MD was notified of the results. The pain assessment was the universal pain assessment tool (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. This assessment will be completed on this resident every shift until further notice and after every PRN pain medication administration. This assessment will be completed by the resident's charge nurse at the time. 2. All nurses were in-serviced to timely notify the resident's MD. If the MD does not assess and/or order interventions, the Medical Director will be notified for orders. In the event that there are no effective responses the resident will be sent to closest emergency room for assessment per nursing judgment. This in-service was started and completed on 3/30/16 by the Regional Director of Operations. 3. Pain assessments on all residents were completed as of 3/30/16. Each pain assessment will be entered into Point Click Care (electronic record software). Any positive finding of active unrelieved pain will be discussed immediately by the IDT that consists of the Administrator, Regional Director, DON, Regional Nurse, and other administrative nurses. Each respective MD will be notified as needed. 4. All staff will be in-serviced on pain assessments and recognition. Tools will include but are not limited to the universal pain assessment tool (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. All nursing staff will be in-serviced over physician notification of pain and follow up. This in-service was started and completed on 3/30/16 by the ADON. Any staff who did not attend this in-service will be required to before they can return to work after this date. 5. All nursing staff were in-serviced by the facility COTA on appropriate transfer techniques.

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of nine residents (Resident #1) reviewed for change of condition and pain management. The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect for Resident # 1. The Administrator failed to supervise the DON to ensure she carried out her responsibilities in the areas of staff training/monitoring, assessment, physician consultation, and reporting potential abuse/neglect, including injuries of unknown source to the abuse coordinator. The DON failed to report, monitor, assess, and consult the physician or otherwise seek medical attention when a resident had increased pain, evidence of an injury of an unknown source, and a change of condition. The DON failed to train nursing staff to report, monitor, assess, and consult the physician or otherwise seek medical attention when a resident had increased pain, evidence of an injury of unknown source, and a change of condition. An Immediate Jeopardy was identified on 3/29/16. While the IJ was removed on 3/31/16, the facility remained out of compliance at a scope identified as pattern and a severity of actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. This failure affected one resident and placed 67 residents in the facility at risk of pain, not receiving medical care or adequate assessments, and a decline in their health status. Findings include: Incident # 8 Record review of Resident # 1's medical records revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 1's March 2016 physician's orders [REDACTED]. The start date was dated 4/29/15. Review of Resident #1's March 2016 MARs revealed the order for staff to use the mechanical lift for transfers was documented that the lift had been used on both the day and the night shift from 3/01/16-3/29/16. Record review of Resident # 1's Progress Notes revealed the following nursing notes: 3/8/16 at 4:54 AM: 4:45 Resident brought to nurse ' s station with several small skin tears to right outer forearm, largest one 2 cm in length. Using NH (nursing home) protocol, area cleansed NS (normal saline) patted dry, steri strips and TAO (triple antibiotic ointment) applied with dry non-adherent drgs, (dressing) wrapped with kerlix initially. MD faxed. RP (responsible party) notified. 3/8/16 at 3:59 PM : Reported to this nurse that resident is hollering when right leg or hip is moved. Made slip to have resident seen at (Clinic) asap (as soon as possible) for right hip pain and discomfort. Also faxed (Dr. B) at (Clinic) to inform her of bulge to right hip joint and pain resident c/o (complained of) when moved. Record review of a Nursing Communication Fax signed by LVN B revealed the communication sheet was faxed on 3/8/16 at 2:57 PM to Resident # 1's primary care physician, Dr. B and read, 3/8/16 4:00 PM .Resident is hollering in pain from right hip & right leg. Hip has bulge when moved .Have made appointment slip for resident to be seen ASAP. In a box titled Physician's Section was written Agree and the doctor's signature with further documentation: Appt made for 10th had to reschedule d/t (do to) bad weather. The physician's section was not dated. Further review of Resident #1 ' s progress notes revealed: 3/12/16 at 4:21 AM: Resident continues with bulge Right hip and right knee swelling, leg lays turned inward. Request made for MD appt. 3/12/16 11:17 AM: Resident continues with bulge to right hip joint and right knee is turning inwards at this time. Resident c/o pain and discomfort when transferred and repositioned . 3/13/16 at 5:07 PM: Noted swelling of right knee, right outer thigh discolored and swollen, bulge to right hip joint area. Called (Dr. A) at 440 pm informed him of what is going on said to send out to ER and have resident checked. 450 pm Called (family member) informed him what is going on and that resident would be taken by (facility) van to (Hospital) ER (emergency room ) to evaluate and treat. 452 pm Spoke with (hospital staff) at (Hospital) ER informed him of right hip, leg, knee and outer thigh concerns and of resident's pain and discomfort noted and worsening. 507 pm Called (family member) and let him know that (Staff A)was leaving (facility)in van at this time to take resident to (Hospital) ER. Informed (Staff A) to please stay with resident until family arrived at least due to ER very busy. 5:15 pm Tried to call (Admin) let him know what was going on. Got voice mail left message for him to please call back. 5:16 pm Called (DON) let her know what is going on with resident at this time. Will pass on in report to on coming nurse what is going on. 3/13/16 at 10:22 PM: Returned from (Hospital) via company van with (Staff A). (Staff A) stated family did arrive and were made aware of situation. DX. Distal Right Femur Rx. Non ambulatory, knee immobilizer in place. Orders included f/u (follow up) with (Dr. C) the next Tuesday he comes to (Clinic). Also to f/u with (Dr. B) Appt slips made . Record review of a Radiologist report from the hospital dated 3/13/16 for Resident # 1 revealed, Two view evaluation of the right knee reveals prior right knee arthroplasty with fracture through native bone and migration of the hardware. Fracture seen through the posterior aspect of the distal femur of uncertain duration. The femoral shaft is seen to have shifted medially with respect to the tibial plateau. Soft tissue swelling also noted. Record review of the Provider Investigation Report revealed Resident #1's injury of unknown origin was reported to DADS on 3/14/16. The Description of the Allegation read, (Resident # 1) was found on 3/8/16 with swelling and bulge to her right leg. She complained of discomfort when staff transferred her or provided personal care. No incident had been reported and no falls reported. On 3/10 Nursing made an appointment with MD for the following week. On 3/13/16 Nurses concerned about swelling on the leg contacted (Dr. A) and the physician told them to send (Resident # 1) to the ER. At 22:17 (Resident # 1) returned from ER with a [DIAGNOSES REDACTED]. At the 3/15/16 appointment the surgeon reported that this was an old fracture that is recurring spontaneously. The family spoke to (facility) on the 15th telling staff that(family) did not want (resident) to have surgery or a pin. She wanted to keep (resident) to be kept in an immobilizer as instructed by the ER doctor (sic). Further review of the facility's investigation revealed written statements were taken on 3/14/16 and 3/15/16 from nine CNA's who had worked with Resident # 1. Seven of these statements revealed the CNA had no knowledge of the injury or how it occurred. Record review of a witness statement signed by CNA A read, This statement is in regard to (Resident # 1) which occurred on 3/8/16? Statement: I (CNA A) noticed her being in pain and saw her right leg and reported it to nurse but didn't witness anything. I haven't worked with her in a while. Record review of a witness statement signed by CNA F read, This statement is in regard to (Resident # 1)Which occurred on 3/8/16. Statement: I (CNA F) didn't witness resident injury to her knee. I only seen the discoloration on Sat. 3/12/16. I asked the charge nurse (LVN B) was it broken. Attached to the DON ' s statement was a typed note which read (Resident #1) has a history of pain. She as (sic) been on Tylenol 650 mg scheduled four times a day since 11/14/14 and it is effective for pain relief. She is able to rest without complications. This statement was signed and dated 3/18/16. Further review of Resident #1's progress notes revealed: 3/15/16 at 3:44 PM: (Clinic Staff) states that at the appointment this morning it was determined that surgery is not an option due to res age and the invasive surgery. She also states that (Dr. C) told her that it was an old fracture that just keeps shattering. She advised that MD wants her to keep knee immobilizer on until next appointment, only to be taken off when in the shower . 3/16/16 at 5:36 PM: Resident will grimace when being transferred or moved. When asked if she is hurting resident smiles and says no . 3/17/16 at 8:20 AM: Resident was up in w/c grimacing and shifting around in chair gave Tylenol 650 mg scheduled dose then moved resident from W/C to geri chair. Around 9:45 am resident seemed more comfortable. Record review of Resident # 1's Pain Assessments in the electronic medical record revealed no pain assessments from 3/1/16 - 3/13/16 when the resident went to the hospital. A pain assessment dated [DATE] at 2:39 PM which read that the resident could verbalize pain, and the verbal pain assessment of pain intensity at the time of the assessment on a scale of 1-10 was a 8.8 ; and during the last 24 hours it was 8.8. The location of the pain was right hip, and right (side) and for the description of the pain aching, sharp, and shooting were checked. The pattern was intermittent with duration of 30 minutes and the pain affected sleep and appetite. Transferring, turning & repositioning, and bathing were checked as causes of the pain. Interventions: scheduled medication with APAP were checked. Record review of Resident # 1's March 2016 MARs revealed her pain level was documented for each scheduled dose of Tylenol at 7:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM daily. Review revealed the following: On nine days at 7:00 AM she had a pain level of 5 documented. On three days at 11:00 AM she had pain level of 4-5 documented. At 4:00 PM she had a pain level of 3 noted on 3/13/16 and a 5 on 3/21/16. At 8:00 PM a pain level of 4-6 was documented for all but one day in the month. Most of the evenings the pain level was a 5. Record review of Resident #1's progress notes revealed Resident #1 continued to have pain two weeks after being diagnosed with [REDACTED].>There was no documentation in Resident #1 ' s medical record where the physician was consulted concerning the pain. Interview on 3/29/16 at 11:41 AM CNA C said before Resident # 1 went to the ER and they found the fracture, she did notice something was wrong and that the resident was in pain. She stated she reported it to the nurse and asked LVN B to check her. She stated Resident # 1 was a two person transfer and staff did not use the mechanical lift with her. Interview on 3/29/16 at 11:43 AM CNA E said staff never used the mechanical lift for Resident # 1. She stated Resident #1 was a two person transfer with a gait belt. She stated she remembered that Resident # 1 acted like she was in pain on 3/8/16 and they reported it to the nurse. Interview on 3/29/16 at 12:15 PM. LVN D said the only time she had seen Resident #1 grimacing was a couple of times while she was being transferred. LVN D stated, As far as any pain, it's being controlled with the Tylenol. She stated Med Rec (medical records) makes all of the doctor's appointments. She stated there was a really bad storm the week of 3/8/16 and they rescheduled all of the resident ' s appointments for the next week because it was too bad out to take the residents anywhere. Observation of Resident # 1 on 3/29/16 at 12:44 PM revealed she was seated in the geri-chair in the dining room and LVN D was observed pulling her up in the chair from behind. While the nurse was pulling Resident # 1 up she was observed grimacing a great deal and opened her mouth and kept it opened and was gritting her teeth. Once repositioned Resident # 1 closed her mouth and her facial expression became more relaxed. Observation, interview and record review on 3/29/16 at 1:15 PM Med Rec was asked if she made an appointment for Resident # 1 to see the physician on 3/8/16. She stated she did make an appointment for her. She was observed getting out the appointment book and looking at it. Review of the appointment book revealed Resident # 1's name was not on the appointment schedule in the book during the week of 3/8/16. Med Rec then stated, You know what I really don't think I did. Med Rec said it was because of the storm and she had to reschedule the resident's appointments. She stated the next morning after the resident returned from the hospital she got her scheduled to see the orthopedic doctor on Tuesday, 3/15/16, at the Clinic. Interview on 3/29/16 at 1:25 PM CNA D said she had taken care of Resident # 1, but did not work with her that often. She stated the facility did have a manual mechanical lift in the facility, but staff transferred Resident # 1 using two people and a gait belt. CNA D stated she was surprised that the facility did not have staff start using a mechanical lift transfers with Resident #1 after her leg was fractured. She stated Resident # 1 always says Ow when staff turned her, or she would make faces. She stated she did this before the fracture happened. She stated Resident #1 still had pain. She said Resident #1 appeared to have pain when being turned more so than when being transferred. Interview on 3/29/16 at 2:06 PM the DON when asked, she stated there was a mobile x-ray unit the facility used. When asked why staff did not request an x-ray for Resident # 1 on 3/8/16, she stated, I don't know why the nurse did not call the mobile x-ray. She stated she thought LVN B told her the resident's doctor wanted to see her in the office. She stated staff did not call her. When asked when she learned that Resident #1 was in pain and had swelling of her leg she said she learned about the resident's pain on 3/9/16. When asked if she notified the Admin, she stated she thought he knew because everyone talked about it in the morning stand up meeting and Med Rec was to make a doctor's appointment for Resident #1. Interview on 3/29/16 at 2:14 PM. LVN B by telephone, LVN B said on 3/8/16 she called the doctor's office and talked to one of the assistants requesting that Resident # 1 be seen as soon as possible. She stated she requested an appointment for her. She stated she gave the resident Tylenol and that was controlling the pain. When asked why she did not request an x-ray she responded, Her hip was bulging was my concern. She wasn't crying out in pain. If she was it would've been a clear indication we needed an x-ray. LVN B was asked about the nurse note she wrote on 3/8/16 at 3:59 PM stating the resident was hollering in pain. LVN B asked if Surveyor was sure she wrote that note because she did not remember it. LVN B stated on 3/13/16 the resident ' s leg looked worse and was more swollen and she talked to the doctor on call about it who ordered the resident to be sent to the ER. Interview on 3/30/16 at 2:42 PM LVN B looked at the nurse note on 3/8/16 at 3:59 PM and verified she wrote the note. She stated the staff did tell her Resident # 1 was hollering, but she went and assisted staff to transfer Resident # 1 from the shower chair and she was fine. She stated she did not cry out in pain on 3/8/16. Interview on 3/29/16 at 2:22 PM the DON stated she assessed Resident # 1 on 3/9/16 and her hip didn't feel out of place at all. She stated there was a little raised area on the right leg. She stated, I saw no bruise. She didn't cry out when I moved her in the bed. The DON stated Resident #1's doctor's appointment was pending, so she waited to see what the doctor said. She stated when Resident # 1 came back from theER on [DATE] she had scheduled Tylenol. She stated she had orders for the scheduled Tylenol since November 2014. The DON stated, I don't know why the ER doctor did not prescribe something stronger. I think the ER doctor should have prescribed something stronger if they thought she was in pain. But you know, I'm not the doctor. The DON stated, I did find out about the skin tears and thought they were related. She stated she interviewed the CNA's, but no one knew anything about how it happened. Interview on 3/29/16 at 2:45 PM with the Administrator and the DON, the Administrator stated he was not told anything about Resident # 1 having an injury until 3/14/16. The DON then stated, It was talked about in the morning meeting .maybe you weren't there. The Administrator made no further comment. Interview on 3/29/16 at 3:44 P.M.CNA A said on 3/8/16 she helped take care of Resident # 1. She stated as they were rolling her she was making noises like she was in pain. She stated the color on her right leg did not look right and it was swollen from the knee to her hip. She stated her skin was a yellowish tone on the upper leg. She stated she did not see a dark bruise on her. It was just yellow. She stated they reported it and LVN B told her she was going to fax the doctor. She stated Resident # 1 was a two person assist for everything. She stated they do not use a mechanical lift to transfer her. Interview on 3/29/16 at 4:18 PM the Regional Director of Operations stated the facility called him on 3/14/16 about Resident # 1's fracture. He stated he told them to go ahead and call it in. He stated when he looked at the incident he realized there was a problem. He stated he talked to them about it. Interview on 3/29/16 at 4:20 PM Med Rec said she called the doctor's office on Wednesday evening, 3/9/16, and scheduled an appointment for Resident # 1 for 3/15/16 to see the orthopedic doctor. She stated when she gets a slip requesting an appointment be made she usually tries to talk to the nurse. Med Rec stated staff did not let her know it was urgent. Record review of the request slip for a doctor's appointment to be scheduled for Resident # 1 read ASAP on the request. Interview on 3/30/16 at 11:47 A.M. LVN B stated Resident # 1 had no black and blue marks on 3/8/16. She stated she assisted with transferring her and she was only complaining about pain in the bulging area only. In an interview with the DON on 3/30/16 at 11:57 AM she stated they do in-services throughout the year regarding pain, abuse/neglect, and injuries of unknown source, safe transfer and notification of the physician. She stated they have safe transfer training that was conducted by the therapy department with the CNA's. She stated an immobilizer was put into place for Resident # 1 and she has a follow-up appointment with the orthopedic doctor on 4/12/16. The DON stated she could call or text the Medical Director anytime day or night. She stated she would call the Medical Director if she thought the physician was not responding appropriately. The DON stated she had only been working in the facility for about six months. Observation of Resident # 1 being transferred from the geri-chair to the bed was conducted on 3/30/16 at 12:42 PM with CNA C and CNA D in the resident's room. CNA C and CNA D put a gait belt on Resident # 1's waist and each CNA held onto the resident under each arm and pulled her up holding the gait belt in the back and sat her on the bed. They then laid Resident #1 down and log rolled her (one CNA at her shoulders and one CNA at her legs) over onto her right side toward the window. Resident # 1 then rolled herself back over onto her back. She had the immobilizer on her right leg. Resident # 1 was smiling throughout the transfer and did not appear to be in pain at this time. Interview on 3/30/16 at 2:25 PM the Regional Nurse was asked about Resident # 1's orders for a mechanical lift transfer. He stated, That must be an order error. She's not overweight and I don't think she requires a hoyer. The Regional Nurse was asked if a mechanical lift would also be used with someone who is very delicate, having pain and had brittle bones like Resident # 1. The Regional Nurse stated it would be up to the IDT team to determine. He stated staff tried to use the least restrictive method possible. Interview on 3/30/16 at 2:42 P.M. LVN B stated Resident # 1 used to be transferred with a mechanical lift. She stated the order for a mechanical lift transfer needed to be discontinued. She stated, I've been telling them because of her brittle bones they need to do a two person transfer with a gait belt and to be very gentle with her due to her brittle bones. I can go D/C (discontinue) it right now if you want. Several attempts were made to contact the night shift nurse LVN C by phone but the numbers provided by the facility were not working numbers. LVN C had written the nurse note on 3/12/16 at 4:21 AM on 3/29/16 - 4/01/16 . Record review of a physician's orders [REDACTED]. Discontinue Date/Reason read, Patient has always been a safe transfer with 2 people and a gait belt, PCP agrees and dc'd hoyer transfer. In an interview with the Admin on 3/31/16 at 10:36 AM he stated he makes rounds in the facility several times a day every day. He stated he talks to the residents and the staff while he's out walking the floor. He stated this was a big part of his management to walk the floor and talk to residents and staff four to five times a day. He stated every day they have a stand up meeting. He said they had a list of questions they asked that had to do with anything reported in the last 24 hours, complaints, incidents, staffing issues, or needed equipment. He stated prior to the meeting he reviewed the 24 hour report. He stated anything that comes up in the meeting that was not completely addressed already they made an action plan to address it during the day. He stated he also goes through the point click care system (PCC) and checks the alerts and looks at everything: treatments, medication administration, and incident reports. He stated they come out of the meeting with a list of things to follow up on during the course of the day. He stated at 4:00 PM they had a stand down meeting to find out what had been addressed and what had not been addressed. They then take another look at whatever was not addressed. Everything should be addressed before 4:00 PM. In further interview with the Admin he was asked how he thought the IJ came about and if he was aware of the situation. He stated he did not know about the incident with Resident #1 until Monday 3/14/16 and he should have known prior to that. The Admin stated in the daily process, in the PCC they see if a nurse did not follow up on something. He stated the PCC had Administrative alerts and Clinical alerts that come up on the dashboard. He stated it had become part of his daily routine to check it and it was a powerful tool. He stated the facility started on the PCC last summer and were just now mastering it. He stated the daily review of the PCC was critical to staying on top of things. He stated the facility also had been doing a stand down meeting since last December and this had become a powerful tool to ensure that people were working on things. He stated it was crucial to do every day. He stated it still was possible to miss something like what happened with Resident # 1. The Admin stated he may have been out part of that week. He was not sure. The Admin stated they miss things in the PCC. He stated the nurse ' s note were in the PCC. The Admin stated, If anything bad happens in my building it's my fault. I've redoubled my efforts to not miss anything. It's been a learning curve for me. The Admin stated the Corporate Nurse had been very involved in the building, as well as the Regional Director, who was also an LVN, and they were available to all levels of staff. Record review of the facility's policy titled Abuse Investigations revealed in part, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Record review of the facility's policy titled Reporting Abuse to Facility Management revealed it read in part, It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management .Policy Interpretation and Implementation .4. The administrator 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 paged and informed of such incident. Record review of facility policy, Pain Assessment Policy (Revised 3/30/16) revealed, Our pain assessment is the universal pain assessment toll (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. This assessment is located in point click care (PCC). It is the policy of our facility that this assessment will be completed: .After any event that could cause injury/pain to the resident. After any change of condition status Be sure to follow the instructions on the pain assessment with any follow up as indicated by the current pain score. Record review of facility policy, Change in a Resident's Condition or Status revised April 2007 read in part, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . 1.- The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On -Call Physician when there has been: b. A discovery of injuries of an unknown source .d. A significant change in the resident ' s physical/emotional/mental condition; 2. A significant change of condition is a decline or improvement in the resident ' s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .4.- Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status . . The facility Administrator and the Director of Nursing were notified on 3/29/2016 at 2:51 PM that an IJ situation had been identified due to the above failures. The first Plan of Removal was submitted by the Administrator on 3/30/2016. The final Plan of Removal was accepted on 3/31/2016 at 1:05 PM. The Plan of Removal included: 1. An updated pain assessment was completed on 3/17/16 on the resident in question and the MD was notified of the results. The pain assessment was the universal pain assessment tool (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. This assessment will be completed on this resident every shift until further notice and after every PRN pain medication administration. This assessment will be completed by the resident's charge nurse at the time. 2. All nurses were in-serviced to timely notify the resident's MD. If the MD does not assess and/or order interventions, the Medical Director will be notified for orders. In the event that there are no effective responses the resident will be sent to closest emergency room for assessment per nursing judgment. This in-service was started and completed on 3/30/16 by the Regional Director of Operations. 3. Pain assessments on all residents were completed as of 3/30/16. Each pain assessment will be entered into Point Click Care (electronic record software). Any positive finding of active unrelieved pain will be discussed immediately by the IDT that consists of the Administrator, Regional Director, DON, Regional Nurse, and other administrative nurses. Each respective MD will be notified as needed. 4. All staff will be in-serviced on pain assessments and recognition. Tools will include but are not limited to the universal pain assessment tool (faces 1-10) and palliative care guidelines-pain assessment for people with cognitive impairment/communication difficulties. All nursing staff will be in-serviced over physician notification of pain and follow up. This in-service was started and completed on 3/30/16 by the ADON. Any staff who did not attend this in-service will be required to before they can return to work after this date. 5. All nursing staff were in-serviced by the facility COTA on appropriate transfer techniques. This in-service was started on 3/30/16. All staff will be required to have this in-service before working after 3/30/16. 6. The MD was called on 3/30/16 and a clarification order was obtained for a two person transfer for the resident in question. 7. The plan of care and orders for 100% of the residents was completed to ensure that the correct mode of transfer was accurate. This audit was completed on 3/30/16 by nursing administration. 8. All nursing staff were in-serviced by the Assistant Director of Nurses on following the plan of care for transfers. 9. A 100% audit of all fax notifications was completed by the nursing administration to ensure that all change of conditions were communicated to the MD with appropriate responses and/or interventions. All fax notifications have been removed. All communication will be done via telephone. This was all completed on 3/30/16. 10. The IDT which consist of the Administrator, Director of Nursing, Assistant Director of Nursing, MDS/Care Plan Coordinator, and the care plan nurse will be in-serviced on interventions to be put in place and the plan of care for. This was done by the Regional Nurse and completed as of 3/29/16. · A resident identified with pain · A resident identified with a change of condition 11. After the incident was brought to the attention of the corporate staff on 3/14/16, the Administrator was instructed to self-report to DADS, the corporate team began daily reviewing the 24 hour report and giving directions to nursing administration, and requiring constant follow up. This was began before STATE entered the facility on 3/29/16 and will continue at this time. 12. The corporate nurse and/or weekend RN will be in the building daily until the new DON starts on 4/4/16. 13. The Director of Nursing has been removed from the facility. The Surveyor monitored the facility to ensure the Plan of Removal had been implemented as evident by: Record review of an In-Service sign-in sheet revealed that nine LVN's received training on MD notification of resident change of condition on 3/30/16. Record review of the attached policy updated 3/30/16 read in part, .In the event of any change in a resident's condition (change of condition) you as the nurse are responsible for: Ensuring that the correct MD is notified of the situation. This DOES NOT mean fax the MD. We need a timely response . Record review of In-Service sign-in sheets revealed CNA's, MA's, and nurses on all three shifts received training on pain assessments and medications on 3/29/16; and transfer training including how to look up and follow the resident's plan of care for transferring in the computer on 3/30/16. Record Review of a Course Completion History revealed all staff representing all three

Based on interview and record review, the facility failed to consult the physician for changes in condition for one of nine residents (CR#1) reviewed for changes in condition as evidenced by: -The facility failed to consult and update CR #1's physician on the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness that lasted on and off for 31 days. -CR #1 was admitted to the hospital with [REDACTED]. CR #1 expired at the hospital after 6 days of admission. An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. This failure affected one former resident (CR#1) who died after being admitted to the hospital and could place 7 residents at the facility identified with infections at risk of not receiving adequate assessments, medical care, pain, decline in their health condition well-being and death. Complaint # 0 Findings include: Record review of the facility face sheet for CR #1 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Admission [DIAGNOSES REDACTED]. CR #1 was sent to the emergency roiagnom on [DATE] for evaluation and treatment of [REDACTED]. CR #1 died at the hospital on [DATE]. Record review of CR #1's quarterly MDS, dated [DATE], revealed CR #1 was not able to complete the interview for BIMS evaluation, she was sometimes able to make herself understood and was sometimes able to understand others. CR #1 required extensive assistance of 2 persons for bed mobility and was total dependent on staff for transfers, toilet use, locomotion and bathing. CR #1 required extensive assistance of one person for dressing and personal hygiene. She required a wheelchair for mobility and was always incontinent of bowel and bladder. The assessment section on swallowing/nutritional status revealed no swallowing disorders and was on a mechanically altered diet. Record review of the facility's weight records for CR #1 revealed weights on: -[DATE] of 160 lbs. -[DATE] of 154 lbs. Record review of CR #1's meal percentages from [DATE] to [DATE] revealed the intake ranged from 25% to 75%. Further record review revealed no meal percentages documented for 16 times for the breakfast and the lunch meals. Record review of the facility's Consulting Dietitian Report for [DATE] to [DATE] revealed she was not evaluated by the dietitian during those dates. Further record review revealed no recommendations for the month of [DATE] for CR #1. In an interview on [DATE] at 2:48 p.m. with the DON, she stated that CR #1 had to be fed and that she was always in the dining room eating and that she noticed changes with her eating 5 to 6 days before she went to the hospital and further said before CR#1 went to the hospital her appetite decreased. Record review of CR #1's Bowel Movement Report recorded by the nursing assistants revealed in part: -[DATE] one episode of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium and one large loose bowel movement. -[DATE] one episode of small and two mediums loose bowel movements. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium, one large loose bowel movement and another medium putty like stool. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] two episodes of medium and one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium and two large loose bowel movements. -[DATE] two episodes of medium and one large loose bowel movement. -[DATE] two episodes of large loose bowel movement. Record review of CR #1's care plan revised [DATE] revealed in part: -Focus: CR #1 has potential fluid deficit related to diuretic use ([MEDICATION NAME]-[MEDICATION NAME] 37XXX,[DATE]mg ordered on [DATE] for [MEDICAL CONDITION]). -Goal: CR#1 will be free of symptoms of dehydration -Interventions: Notify MD if persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours, obtain and monitor laboratories/diagnostic work as ordered. Report results to MD and follow up as indicated. Further record review revealed no information on the entire care plan of CR #1 episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness or interventions to improve, or prevent further decline. Record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 9:33 pm: .CR #1 had loose brown bowel movement with mucous. No foul odor noted. Called Nurse Practitioner on call for MD with orders to monitor bowel movement and to collect a stool specimen. Record review of the verbal MD order dated [DATE] at 9:15 p.m. revealed an order for [REDACTED]. -[DATE] at 12:55 p.m Daily skilled note in part: - G.I.: poor appetite, vomiting, hypoactive bowel sounds. Ate only few bites of lunch today before she made herself vomit -[DATE] at 4:05 p.m. CR #1 has new orders for stool specimen collection to rule out [MEDICAL CONDITION]. Specimen collected and is in med room fridge. Strong/foul odor noted, mucous with seedy appearance noted on the bowel movement. Patient with emesis noted during breakfast and refusal of alternate breakfast as well as lunch . Further record review of Daily skilled note in part: - G.I.: poor appetite, vomiting diarrhea. Increased of bowel, foul odor present, mucous and seedy appearance. -[DATE] at 8:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, diarrhea, hyperactive bowel sounds. CR #1 has been having loose stools. Neuromuscular: Wheelchair - weakness, deterioration. -[DATE] at 09:07 am: CR #1 did not eat breakfast, states I am not hungry. -[DATE] at 12:31 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing, diarrhea. Hyperactive bowel sounds. Neuro/muscular: weakness, deterioration. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 12:46 p.m. read in part: .Draw date: [DATE]. - Stool Culture results: No Salmonella, Shigella, Campylobacter isolated, Pathogenic Escherichia coli or Shiga Toxins 1 or 2 detected. Further record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 5:49 p.m. Daily skilled note in part: - G.I.: diarrhea, hyperactive bowel sounds. Received new order to repeat stool collection for [MEDICAL CONDITION] and culture and sensitivity . Record review of the facility's Complaint Resolution Record dated [DATE], given by CR#1's family member, received by the DON and signed by the Administrator revealed in part: .Resident's Name: CR #1. Staff receiving report: DON. - Concern: Diarrhea for a week, no [MEDICATION NAME] (anti-diarrheal). - Action taken: Explained how [MEDICAL CONDITION] works and contraindication of giving [MEDICATION NAME]. Informed her of negative [MEDICAL CONDITION] result and CR #1 refusing to get up . Further record review revealed that DON signed report on [DATE] and Administrator signed report on [DATE]. Record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 10:23 a.m. Can we have an order to repeat stool specimen collection and testing? Stools are loose/liquid, foamy and seedy appearance. Further record review revealed MD written order dated [DATE] -[MEDICAL CONDITION] and stool for culture and sensitivity. Continued record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 4:45 p.m. Daily skilled note in part: - G.I.: Diarrhea. Night nurse to collect stool for Wednesday. -[DATE] at 2:01 a.m. CR#1 did not produce a bowel movement before laboratory pick up. Further record review of Daily skilled note in part: - Neuromuscular - weakness. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 10:50 a.m. read in part: .for stool specimen drawn [DATE] Specimen unacceptable for testing. Rejected order, routine: - What test was rejected? [MEDICAL CONDITION]. - Reject reason: Please recollect for [MEDICAL CONDITION]. -[DATE] at 3:18 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing and hyperactive bowel sounds. -[DATE] at 6:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake and difficulty chewing. -[DATE] at 4:13 p.m: .CR #1 went to appointment today with new orders for complete metabolic panel to be done on Monday ([DATE]) and to return to clinic in 2 months. Record review of CR #1's comprehensive Metabolic Panel dated [DATE] and faxed to MD on [DATE] at 5:45 p.m. revealed in part: -BUN (blood urea nitrogen, test that reveals how kidneys are working) 38 High (Reference range ,[DATE] mg/dL) -Creatinine (evaluates kidney function) 1.16 (Reference range 0XXX,[DATE].20 mg/dL). Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: Not feeling good. Further record review revealed that Gastrointestinal exam was not conducted by the MD. Continued record review revealed - Assessment [DIAGNOSES REDACTED]. Return to clinic in 2 months. Further record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 10:05 a.m. Daily skilled note in part: - CR #1 has to have extra encouragement during meals to eat. -[DATE] at 6:56 a.m.: CR #1 does not help with being transferred, she is dead weight. Will not stand or pivot to assist with transfers. -[DATE] at 9:40 a.m.: Received an order for [REDACTED]. Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: cough, congestion and nasal drainage. Further record review revealed that Gastrointestinal exam was not conducted by the MD. - [DIAGNOSES REDACTED]. Plan: [MEDICATION NAME] 500 mg by mouth every day for 10 days, chest x-ray and [MEDICATION NAME] 10 mg by mouth for 10 days. Continued record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 10:07 a.m: CR #1 still not eating well. -[DATE] at 10:25 a.m.: CR #1 is not eating well only eating 25% or less of meals. Further record review of the nursing progress notes revealed no MD notification on the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness. -[DATE] at 4:26 p.m: Received fax from CR #1's MD with orders to send CR#1 to the hospital for evaluation and treatment for [REDACTED]. Further record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 7:30 a.m. .CR #1 noted to have watery brown stool. CR #1 also noted to have excoriated buttocks and perineal area. Further record review revealed MD order dated [DATE] at 4:00 p.m. Sent to emergency room for evaluation of possible dehydration and stool for [MEDICAL CONDITION]. Record review of CR #1's Emergency physician record dated [DATE] at 4:47 p.m. revealed in part: .- History of present illness: Generalized weakness. Onset/duration: unknown. History of diarrhea. - Physical exam: lethargic, dry mucous membranes, [MEDICAL CONDITION](fast heart rate).[MEDICAL CONDITION], dehydration. Intravenous fluids Normal Saline bolus of 2000 ml. [MEDICATION NAME] (antibiotic) 1 gram Intravenous and Cefepinie (antibiotic) 1 gram Intravenous. Stool for [MEDICAL CONDITION]. Further record review of CR #1's hospital history and physical dated [DATE] at 10:17 p.m. revealed in part: .Chief complaint: Generalized weakness. [AGE] year old female who present from the nursing home. Family reports diminished appetite. Then over the last day or so developed by the nurses notes, some loose stools associated with some excoriation and a decrease in her normal level of interaction. On [MEDICATION NAME] (antibiotic) 500 mg since [DATE]th for a cough. Vital signs: emergency room blood pressure ,[DATE]. Currently after 3 liters of fluid in the emergency room , blood pressure is very low between ,[DATE] and ,[DATE] with heart rate of 133. Mouth is dry. Abdomen is distended, diffusely tender. She has got some early flexion contractures of her knees and her hips. - Laboratories: [MEDICAL CONDITION] was positive. White blood cells count of 61.3 Critical High (Reference range 4XXX,[DATE].8), BUN (blood urea nitrogen, test that reveals how kidneys are working) 74 Critical High (Reference range ,[DATE] mg/dL) and creatinine (evaluates kidney function) 2.8 (Reference range 0XXX,[DATE].0). - Assessment: 1.- [MEDICAL CONDITION]. She has got 3 liters of fluid in the Emergency Department with improvement of her blood pressure, though is not stabilized at this point. We will continue intravenous fluids overnight tonight. 2.- [MEDICAL CONDITIONS], likely the source of [MEDICAL CONDITION]. We will put her on [MEDICATION NAME] (antibiotic) as well as oral [MEDICATION NAME] (antibiotic). -Did discuss with the daughter that was present this evening that the patient was severely ill and we would have a much clearer picture the next 12 - 24 hours on her ability to survive, given the degree of [MEDICAL CONDITION] and volume resuscitation. 8.- Acute [MEDICAL CONDITION] on top of [MEDICAL CONDITION]. Again due to her dehydration. We will continue fluids. Record review of CR #1's discharge summary from the hospital dated [DATE] at 1:46 p.m. revealed in part: Final discharge Diagnoses: [REDACTED]. - Hospital course: The patient was admitted and started on intravenous [MEDICATION NAME] as well as oral [MEDICATION NAME]. White count was 61,000 on admission. This did slowly improved; however, by mouth intake was extremely poor. Ultimately, the patient continued to decline clinically, having blood pressures that were running lower and urine output that was significantly less despite being on brisk intravenous resuscitation. White counts did improve with the intravenous and oral antibiotics that she was receiving; however, due to her overall decline, I contacted the patient's family to discuss inpatient hospice services. She was admitted to hospice on [DATE]. Further record review of discharge summary dated [DATE] at 1:58 p.m. revealed that CR#1 died in the hospital on [DATE] at 12:16 p.m. In a phone interview on [DATE] at 3:10 p.m. with CR #1's family member, she stated that another family member brought CR #1 to the MD on [DATE] because the family saw how sick CR #1 was and further said She was having diarrhea and was deteriorating. She was eating less and less, her appetite was decreasing, she was really sick until she was sent to the hospital. CR #1 would not move anymore, she was not drinking or eating and she was having severe diarrhea. I was told by the facility that the stool studies were negative but they did not show me any reports. Then when I went to see her at the facility, she did not look good and she was diagnosed at the hospital with [MEDICAL CONDITION]. In an interview on [DATE] at 3:40 p.m. with the DON, she stated that she still did not hear from the laboratory yet about why the stool specimen for CR#1 was rejected on [DATE] and further said I was not aware that the stool specimen was rejected until today when you asked for it. I knew about that there were concerns about CR#1 having loose stools but don't know information in detail. DON further said that she did not know that CR #1 had any problems with her appetite and that she believed that CR #1 was gaining weight. Surveyor requested DON all weights for CR#1. When asked if she was aware that the MD ordered for second time a stool specimen for CR #1 on [DATE], the DON responded I can't say I saw the order. DON did not provide additional weight records for CR #1 to surveyor by the time of exit. In an interview on [DATE] at 3:40 p.m. with the DON, she stated that CR #1 went to the hospital because the MD thought that CR #1 was dehydrated and said CR #1 was on antibiotics for upper respiratory infection, I don't know that she was having loose stools. When asked if she knew what had happened to CR #1, the DON responded She did eventually die, don't know when and did not see a death certificate. She did not come back to the facility. Even though that CR #1's family member works here part time on the weekends, she didn't stay in touch with us. We did not get information about CR #1. We knew CR #1 was in Intensive Care Unit but the hospital would not tell us the reason of her admission. If I was told her [DIAGNOSES REDACTED]. In an interview on [DATE] at 11:31 a.m. with CNA B, she stated that she worked with CR #1 at least twice a week and that the last two weeks before CR #1 went to the hospital, her appetite decreased and that she was more weak and that when CR #1 was up on her chair, she would leaned to the sides and forwards down. When asked about CR #1's stool consistency, CNA B stated her stools were loose. I did report the loose stools to the nurses but I also wrote it on the computer and they are supposed to see it. When asked if she reported CR#1's poor appetite, CNA B responded Nurses knew about her appetite because CR #1 would eat in the dining room. CNA B further said that changes in condition are reported to the nurses verbally and that there was no paper forms to report changes in condition that she was aware of. In an interview on [DATE] at 11:55 a.m. with LVN F, she stated that she was the ADON and wound care nurse. She further stated that CNA's report changes in condition verbally to the nurses and that there was a way in the computer system for CNA's to document changes in condition. LVN F further said that she only heard about CR #1 having diarrhea or loose stools just before she went to the hospital. She continued saying that information on the 24 hour report is reviewed during the morning meetings and that she did not remember any discussion about CR #1's condition. LVN F continued saying that just before CR #1 went to the hospital, they had discussed her poor appetite and eating but nothing about her diarrhea. In an interview on [DATE] at 12:02 p.m. with CNA C, she stated that she was the shower Aide but worked on the floor as well. CNA C further said I gave showers to CR #1 three times a week and I kept telling the nurses about the foul odor and color of her stools. CR #1's stools were yellow, slimy and had the distinctive foul odor, I kept telling the charge nurses about it for about 3 weeks before CR #1 went to the hospital. Every time I would bring her to the shower room, her stools were loose, strong foul odor, runny, slimy and yellow. I would report to the nurses every time. CR #1's appetite declined really bad. Her daughter would come and help her but CR #1 would not eat at all and she started getting the cracks on her mouth. CR #1 started leaning to the sides and then forwards when in the wheelchair during that time that she had the diarrhea and her poor appetite then the facility got an order for [REDACTED]. In an interview on [DATE] at 12:28 p.m. with LVN D, she stated that she was a full time charge nurse and that she worked with CR #1 and that CNA's would report changes in condition verbally to the nurses and that she believed there was a way of documenting changes in condition in the computer system but she was not sure if the staff had been trained about it. LVN D continued saying that she was the nurse that sent CR #1 to the hospital because she was acting abnormal, shaking and was hollering. LVN D further said I believe CR#1 had a negative stool for [MEDICAL CONDITION]. Surveyor asked LVN D to review the records of CR #1 and find the laboratory results that showed that her stools were negative for [MEDICAL CONDITION] and LVN D responded well, I need to go to the laboratory book. Further interview with LVN D, she stated that CR #1 wasn't really eating and was having loose stools and said 3 to 4 weeks before CR #1 went to the hospital, she would not eat. When asked if she notified the MD regarding CR #1's episodes of loose stools and low appetite, LVN D responded we send faxes to the MD, there were faxes. Surveyor asked LVN D to review the records of CR#1 and provide surveyor with documentation about the times the facility notified the MD of CR #1's poor appetite and episodes of loose stools. Further interview and observation at that time, LVN D flipped thru papers and said Well, I am not 100% positive the MD was made aware. I don't remember myself notifying the MD regarding her low appetite or the continuation of the diarrhea, but remember seeing some faxes about CR #1. I don't see them now. In an interview on [DATE] at 12:58 p.m. with LVN E, she stated that she worked with CR #1 and that she was the charge nurse and further said the Aides would tell me that CR #1 was having diarrhea but I asked CR #1's daughter about collecting a stool sample and the daughter refused, I just did not document that information. LVN E continued saying I believe CR #1 went to the doctor but I am not sure if she had any stool sample tested there. CR #1 was also discharged from therapy because she was not cooperating. When asked regarding the nurses notes written by her on [DATE] and [DATE] that talked about CR #1 not eating well, LVN E responded I believe the MD was faxed about it, I remember telling the oncoming nurse about it and to notify the MD about CR #1's not eating but don't remember who was the nurse and I did not checked back to see if the MD was notified. We are lacking on the communication to one and another like for changes in condition, to make sure we follow up on the conditions and notifications to the MD. I don't remember notifying the MD about her appetite and I did not know any information about the stool sample that needed to be recollected again. I believe that's where we need work on because some of the papers just get filed and not followed up. LVN E further said that she was not involved in the care planning of the residents and that LVN A was in charge of updating the care plans for changes in condition and that she did not notify her of CR #1's poor appetite and episodes of loose stools. Further interview on [DATE] at 2:05 p.m. with the DON, she stated that she expected the CNA's to notify the nurses verbally of any changes in condition and that there was no paper form for the CNA's to document changes in condition and that the nurses were supposed to report to the MD changes of condition as soon as possible. DON further stated that she had not done any formal training on [MEDICAL CONDITION] infections, that she only talked to the nurses about it and gave some literature about the infection but did not have a sign in form or course content of the discussion because was more like a conversation. DON continued saying that on September she did a training on abuse and neglect and that she discussed about changes in the condition of the residents because abuse and neglect could lead to a changed in condition on a resident. DON further said that they discussed on the training information about MD notification related to changes in condition and that the main expectation she had from the nurses is that they notify the MD for changes in condition as soon as possible. Continued interview with the DON at that time, she stated that having loose stools was a change in condition that required MD notification. DON further said that she looked at the MD orders every day including the laboratory results and that she does daily rounds including the dining room during most meals. Surveyor asked DON if nurses talked to her about the condition of CR #1 and the DON responded Yes, I talked to them, CR #1 was having some diarrhea, we were concerned about it but it wasn't proven to be [MEDICAL CONDITION]. Continued interview with the DON at that time, when asked how did she think this incident of immediate jeopardy came about, the DON responded It got missed, the laboratory orders, human error but from this second on, I will be all over the charts, I will make 3 copies of the orders and everybody will get copies, we will go over the information on the meetings and will designate the hallways to department heads. When asked if she believed there was a problem with how the facility handled the changes in conditions of the residents, the DON responded CR#1 did not talk, we had to watch her, something was not right, we knew something was going on. Yes, there were things that were missed. When surveyor asked if staff review the bowel record of residents and if she had seen the bowel record of CR#1, the DON responded as she flipped thru CR #1's bowel record documentation I see it, OK, I will have somebody monitoring these records every day. We have shift to shift reports from the nursing staff but there is no system where they can write it down. Loose stools is a change in condition that needed to be reported to the MD in a perfect world. In an interview on [DATE] at 10:05 a.m. with the Administrator, he stated that the main tool the facility has to make sure the needs of the residents are being met is the everyday morning meetings because that where staff review the 24 hour report, orders, laboratory reports and other important information about the residents. He further said that department heads attending the meetings were the DON, Assistant DON, MDS nurse, Care Plan Nurse, dietary, therapy and the wound care nurse. When asked if information regarding the condition of CR #1 was ever discussed on the morning meetings, the Administrator stated what I remember is that she was having difficulty eating and the CNA's were feeding her and I knew that her weight was stable but I do not remember any discussion about her diarrhea or loose stools. I don't remember any specific information about the [MEDICAL CONDITION] or about any laboratory reports. If we had known that her laboratory order was missed, we would had done something. Since yesterday, we put things in place to monitor patients' condition. I was not keeping a task list. Going forward, I will have a task list that will be about who is doing what. We had it but we were not writing information down and by 4:00 p.m. I would forget, but the new plan will be to have a task list. Further interview with the Administrator at that time, he stated that he makes rounds up to 8 times a day on the residents, talks to the residents, the staff and the families. Administrator continued saying that he remembered discussing about CR#1's nutrition but did not remember if the dietitian saw CR #1 before she went to the hospital. Administrator further said that part of the reports they reviewed during the morning meetings was the grievance log. When surveyor asked the Administrator if the department heads had reviewed CR#1's grievance report dated [DATE], received by the DON and signed by him where the family had concerns about CR #1's diarrhea, the Administrator responded as he looked at the grievance report we discussed it, I don't remember what happened, I don't remember what was the plan for the diarrhea. When surveyor asked him, who had signed the grievance report, the Administrator responded that's my signature. Continued interview with the Administrator, when asked how did he think the incident of Immediate Jeopardy came about, he responded we had a problem with the laboratory consistency in the facility, just noticed the problem after this incident. I know there was a problem based on what you guys found. Administrator further stated that he did not remember hearing anything about CR#1's diarrhea or loose stools or that there was a change on her condition prior of CR#1 going to the hospital. When surveyor presented the Administrator with CR #1's bowel movement report and the lack of MD notifications, the Administrator stated as he flipped thru the bowel movement report I see what you are talking about, I only remember conversations about the eating. Normally I don't look at the nursing notes. In retrospect, we will be looking at those notes. I did not realize she had prolonged diarrhea but going forward, we will be looking at everybody. Administrator further said that having a new DON for the last 3 months and the implementation of the new software system in the facility Point Click Care (PCC) could have contributed to the communication problem and further said If we had identified this problem before, our Corporate nurses would have helped us. In further interview on [DATE] at 11:45 a.m. with the DON, when surveyor asked the DON if she had reviewed CR#1's grievance dated [DATE], received by her and signed by the Administrator where the family had concerns about CR #1's diarrhea, the DON responded as she looked at the grievance report This was the family member that does not work here the one that made the grievance and I spoke to her about CR #1's diarrhea and I knew there was a culture but I thought I had seen a negative culture for [MEDICAL CONDITION], well I did not see the report, I thought I read it somewhere and I did my part, I talked to the CNA's regarding incontinent care and turning and repositioning then I called the family back and told her that I had seeing documentation that CR #1 had a negative stool culture for [MEDICAL CONDITION], I read it on the notes . DON continued saying that she did not speak to the dietitian about CR #1's appetite and that the Social Service department was supposed to give a copy of the grievance report to the dietary manager. In a phone interview on [DATE] at 12:10 p.m. with the dietary manager G, she stated that she did not remember information on details regarding CR #1, that she needed to see her computer. She continued saying that she did remember that she was once notified by the nurses that CR #1 had diarrhea and that she provided soups for her. She further stated that she did not remember the dates or who made the report. In a phone interview on [DATE] at 3:30 p.m., Medical Assistant from MD H office, she stated that MD H had left for the day. She further stated that she did not see any laboratory results for [MEDICAL CONDITION] on the records of CR #1. She continued

Based on record review and interview, the facility failed to implement their policy on neglect for one of nine residents (CR #1) reviewed for neglect, as evidenced by: -The facility failed to consult and update CR #1's physician on the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness that lasted on and off for 31 days. -The facility failed to follow up on a second stool specimen for [MEDICAL CONDITION] (a spore-forming bacterium that causes an infectious diarrhea) that the MD had ordered. -The facility failed to develop and place interventions to CR #1's care plan to indicate the loose stools and the development of difficulty chewing, loss of appetite and weakness to improve, or prevent further decline. -CR #1 was admitted to the hospital with [REDACTED]. CR #1 died at the hospital after 6 days of admission. An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. This failure affected one former resident (CR#1) who died after being admitted to the hospital and could place the 66 residents at the facility at risk of not receiving adequate assessments, medical care, pain, decline in their health condition well-being and death. Complaint # 0 Findings include: Record review of the facility face sheet for CR #1 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Admission [DIAGNOSES REDACTED]. CR #1 was sent to the emergency roiagnom on [DATE] for evaluation and treatment of [REDACTED]. CR #1 died at the hospital on [DATE]. Record review of CR #1's quarterly MDS, dated [DATE], revealed CR #1 was not able to complete the interview for BIMS evaluation, she was sometimes able to make herself understood and was sometimes able to understand others. CR #1 required extensive assistance of 2 persons for bed mobility and was total dependent on staff for transfers, toilet use, locomotion and bathing. CR #1 required extensive assistance of one person for dressing and personal hygiene. She required a wheelchair for mobility and was always incontinent of bowel and bladder. The assessment section on swallowing/nutritional status revealed no swallowing disorders and was on a mechanically altered diet. Record review of the facility's weight records for CR #1 revealed weights on: -[DATE] of 160 lbs. -[DATE] of 154 lbs. Record review of CR #1's meal percentages from [DATE] to [DATE] revealed the intake ranged from 25% to 75%. Further record review revealed no meal percentages documented for 16 times for the breakfast and the lunch meals. Record review of the facility's Consulting Dietitian Report for [DATE] to [DATE] revealed she was not evaluated by the dietitian during those dates. Further record review revealed no recommendations for the month of [DATE] for CR #1. In an interview on [DATE] at 2:48 p.m. with the DON, she stated that CR #1 had to be fed and that she was always in the dining room eating and that she noticed changes with her eating 5 to 6 days before she went to the hospital and further said before CR#1 went to the hospital her appetite decreased. Record review of CR #1's Bowel Movement Report recorded by the nursing assistants revealed in part: -[DATE] one episode of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium and one large loose bowel movement. -[DATE] one episode of small and two mediums loose bowel movements. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium, one large loose bowel movement and another medium putty like stool. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] two episodes of medium and one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium and two large loose bowel movements. -[DATE] two episodes of medium and one large loose bowel movement. -[DATE] two episodes of large loose bowel movement. Record review of CR #1's care plan revised [DATE] revealed in part: -Focus: CR #1 has potential fluid deficit related to diuretic use ([MEDICATION NAME]-[MEDICATION NAME] 37XXX,[DATE]mg ordered on [DATE] for [MEDICAL CONDITION]). -Goal: CR#1 will be free of symptoms of dehydration -Interventions: Notify MD if persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours, obtain and monitor laboratories/diagnostic work as ordered. Report results to MD and follow up as indicated. Further record review revealed no information on the entire care plan of CR #1 episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness or interventions to improve, or prevent further decline. Record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 9:33 pm: .CR #1 had loose brown bowel movement with mucous. No foul odor noted. Called Nurse Practitioner on call for MD with orders to monitor bowel movement and to collect a stool specimen. Record review of the verbal MD order dated [DATE] at 9:15 p.m. revealed an order for [REDACTED]. -[DATE] at 12:55 p.m Daily skilled note in part: - G.I.: poor appetite, vomiting, hypoactive bowel sounds. Ate only few bites of lunch today before she made herself vomit -[DATE] at 4:05 p.m. CR #1 has new orders for stool specimen collection to rule out [MEDICAL CONDITION]. Specimen collected and is in med room fridge. Strong/foul odor noted, mucous with seedy appearance noted on the bowel movement. Patient with emesis noted during breakfast and refusal of alternate breakfast as well as lunch . Further record review of Daily skilled note in part: - G.I.: poor appetite, vomiting diarrhea. Increased of bowel, foul odor present, mucous and seedy appearance. -[DATE] at 8:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, diarrhea, hyperactive bowel sounds. CR #1 has been having loose stools. Neuromuscular: Wheelchair - weakness, deterioration. -[DATE] at 09:07 am: CR #1 did not eat breakfast, states I am not hungry. -[DATE] at 12:31 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing, diarrhea. Hyperactive bowel sounds. Neuro/muscular: weakness, deterioration. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 12:46 p.m. read in part: .Draw date: [DATE]. - Stool Culture results: No Salmonella, Shigella, Campylobacter isolated, Pathogenic Escherichia coli or Shiga Toxins 1 or 2 detected. Further record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 5:49 p.m. Daily skilled note in part: - G.I.: diarrhea, hyperactive bowel sounds. Received new order to repeat stool collection for [MEDICAL CONDITION] and culture and sensitivity . Record review of the facility's Complaint Resolution Record dated [DATE], given by CR#1's family member, received by the DON and signed by the Administrator revealed in part: .Resident's Name: CR #1. Staff receiving report: DON. - Concern: Diarrhea for a week, no [MEDICATION NAME] (anti-diarrheal). - Action taken: Explained how [MEDICAL CONDITION] works and contraindication of giving [MEDICATION NAME]. Informed her of negative [MEDICAL CONDITION] result and CR #1 refusing to get up . Further record review revealed that DON signed report on [DATE] and Administrator signed report on [DATE]. Record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 10:23 a.m. Can we have an order to repeat stool specimen collection and testing? Stools are loose/liquid, foamy and seedy appearance. Further record review revealed MD written order dated [DATE] -[MEDICAL CONDITION] and stool for culture and sensitivity. Continued record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 4:45 p.m. Daily skilled note in part: - G.I.: Diarrhea. Night nurse to collect stool for Wednesday. -[DATE] at 2:01 a.m. CR#1 did not produce a bowel movement before laboratory pick up. Further record review of Daily skilled note in part: - Neuromuscular - weakness. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 10:50 a.m. read in part: .for stool specimen drawn [DATE] Specimen unacceptable for testing. Rejected order, routine: - What test was rejected? [MEDICAL CONDITION]. - Reject reason: Please recollect for [MEDICAL CONDITION]. -[DATE] at 3:18 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing and hyperactive bowel sounds. -[DATE] at 6:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake and difficulty chewing. -[DATE] at 4:13 p.m: .CR #1 went to appointment today with new orders for complete metabolic panel to be done on Monday ([DATE]) and to return to clinic in 2 months. Record review of CR #1's comprehensive Metabolic Panel dated [DATE] and faxed to MD on [DATE] at 5:45 p.m. revealed in part: -BUN (blood urea nitrogen, test that reveals how kidneys are working) 38 High (Reference range ,[DATE] mg/dL) -Creatinine (evaluates kidney function) 1.16 (Reference range 0XXX,[DATE].20 mg/dL). Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: Not feeling good. Further record review revealed that Gastrointestinal exam was not conducted by the MD. Continued record review revealed - Assessment [DIAGNOSES REDACTED]. Return to clinic in 2 months. Further record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 10:05 a.m. Daily skilled note in part: - CR #1 has to have extra encouragement during meals to eat. -[DATE] at 6:56 a.m.: CR #1 does not help with being transferred, she is dead weight. Will not stand or pivot to assist with transfers. -[DATE] at 9:40 a.m.: Received an order for [REDACTED]. Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: cough, congestion and nasal drainage. Further record review revealed that Gastrointestinal exam was not conducted by the MD. - [DIAGNOSES REDACTED]. Plan: [MEDICATION NAME] 500 mg by mouth every day for 10 days, chest x-ray and [MEDICATION NAME] 10 mg by mouth for 10 days. Continued record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 10:07 a.m: CR #1 still not eating well. -[DATE] at 10:25 a.m.: CR #1 is not eating well only eating 25% or less of meals. Further record review of the nursing progress notes revealed no MD notification on the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness. -[DATE] at 4:26 p.m: Received fax from CR #1's MD with orders to send CR#1 to the hospital for evaluation and treatment for [REDACTED]. Further record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 7:30 a.m. .CR #1 noted to have watery brown stool. CR #1 also noted to have excoriated buttocks and perineal area. Further record review revealed MD order dated [DATE] at 4:00 p.m. Sent to emergency room for evaluation of possible dehydration and stool for [MEDICAL CONDITION]. Record review of CR #1's Emergency physician record dated [DATE] at 4:47 p.m. revealed in part: .- History of present illness: Generalized weakness. Onset/duration: unknown. History of diarrhea. - Physical exam: lethargic, dry mucous membranes, [MEDICAL CONDITION](fast heart rate).[MEDICAL CONDITION], dehydration. Intravenous fluids Normal Saline bolus of 2000 ml. [MEDICATION NAME] (antibiotic) 1 gram Intravenous and Cefepinie (antibiotic) 1 gram Intravenous. Stool for [MEDICAL CONDITION]. Further record review of CR #1's hospital history and physical dated [DATE] at 10:17 p.m. revealed in part: .Chief complaint: Generalized weakness. [AGE] year old female who present from the nursing home. Family reports diminished appetite. Then over the last day or so developed by the nurses notes, some loose stools associated with some excoriation and a decrease in her normal level of interaction. On [MEDICATION NAME] (antibiotic) 500 mg since [DATE]th for a cough. Vital signs: emergency room blood pressure ,[DATE]. Currently after 3 liters of fluid in the emergency room , blood pressure is very low between ,[DATE] and ,[DATE] with heart rate of 133. Mouth is dry. Abdomen is distended, diffusely tender. She has got some early flexion contractures of her knees and her hips. - Laboratories: [MEDICAL CONDITION] was positive. White blood cells count of 61.3 Critical High (Reference range 4XXX,[DATE].8), BUN (blood urea nitrogen, test that reveals how kidneys are working) 74 Critical High (Reference range ,[DATE] mg/dL) and creatinine (evaluates kidney function) 2.8 (Reference range 0XXX,[DATE].0). - Assessment: 1.- [MEDICAL CONDITION]. She has got 3 liters of fluid in the Emergency Department with improvement of her blood pressure, though is not stabilized at this point. We will continue intravenous fluids overnight tonight. 2.- [MEDICAL CONDITIONS], likely the source of [MEDICAL CONDITION]. We will put her on [MEDICATION NAME] (antibiotic) as well as oral [MEDICATION NAME] (antibiotic). -Did discuss with the daughter that was present this evening that the patient was severely ill and we would have a much clearer picture the next 12 - 24 hours on her ability to survive, given the degree of [MEDICAL CONDITION] and volume resuscitation. 8.- Acute [MEDICAL CONDITION] on top of [MEDICAL CONDITION]. Again due to her dehydration. We will continue fluids. Record review of CR #1's discharge summary from the hospital dated [DATE] at 1:46 p.m. revealed in part: Final discharge Diagnoses: [REDACTED]. - Hospital course: The patient was admitted and started on intravenous [MEDICATION NAME] as well as oral [MEDICATION NAME]. White count was 61,000 on admission. This did slowly improved; however, by mouth intake was extremely poor. Ultimately, the patient continued to decline clinically, having blood pressures that were running lower and urine output that was significantly less despite being on brisk intravenous resuscitation. White counts did improve with the intravenous and oral antibiotics that she was receiving; however, due to her overall decline, I contacted the patient's family to discuss inpatient hospice services. She was admitted to hospice on [DATE]. Further record review of discharge summary dated [DATE] at 1:58 p.m. revealed that CR#1 died in the hospital on [DATE] at 12:16 p.m. In an interview on [DATE] at 1:14 p.m. with the DON, she stated that she did not know what happened to the stool specimen that was supposed to be recollected for CR #1 on [DATE]. She further stated that she did not know why the specimen was rejected by the Laboratory on [DATE] and that she thought that CR #1's stool was negative for [MEDICAL CONDITION] and further said I thought I read somewhere that her stool was negative for [MEDICAL CONDITION]. When asked to look thru CR #1's chart to see if she could find any [MEDICAL CONDITION] laboratory results, the DON responded as she flipped thru the chart It looks that she did not get a [MEDICAL CONDITION] test in the facility. I don't know what happened with the laboratory test for the stool, I will find out. Do not know why was rejected. When asked if CR #1 got her stool collected on [DATE] after the MD gave orders again to check for [MEDICAL CONDITION], DON responded well, there is a nurses note on [DATE] that the stool specimen was not available . DON then left and said she was going to call the laboratory. In an interview on [DATE] at 1:24 p.m. with LVN A, she stated that she was the Care plan nurse and that she would review the care plans every 92 days in the computer and would update the care plans as needed if there is a change in condition on the residents. She further said that there was a communication board in the computer system where the nurses would write information if the residents had a change in condition. LVN A said that also during the morning meetings, the department heads would talk about changes in condition and that she would get the information from there to update the care plans as well. LVN A continued saying that she had spoken to the DON about who would actually be doing changes in the care plans because she was only working part time and that the DON has not come up with a concise decision yet. When asked if CR #1 had any changes in condition that she needed to update on the care plan, LVN A responded CR #1 only had an upper respiratory infection on [DATE] Continued interview with LVN A, she stated that she was not aware of CR #1 having any issues with diarrhea or poor appetite and further said We are in the process with the infection control nurse about how we are going to communicate infections of residents. We have a new tool in the computer system for changes in condition but not sure if staff is really writing on it. In a phone interview on [DATE] at 3:10 p.m. with CR #1's family member, she stated that another family member brought CR #1 to the MD on [DATE] because the family saw how sick CR #1 was and further said She was having diarrhea and was deteriorating. She was eating less and less, her appetite was decreasing, she was really sick until she was sent to the hospital. CR #1 would not move anymore, she was not drinking or eating and she was having severe diarrhea. I was told by the facility that the stool studies were negative but they did not show me any reports. Then when I went to see her at the facility, she did not look good and she was diagnosed at the hospital with [MEDICAL CONDITION]. In an interview on [DATE] at 3:40 p.m. with the DON, she stated that she still did not hear from the laboratory yet about why the stool specimen for CR#1 was rejected on [DATE] and further said I was not aware that the stool specimen was rejected until today when you asked for it. I knew about that there were concerns about CR#1 having loose stools but don't know information in detail. DON further said that she did not know that CR #1 had any problems with her appetite and that she believed that CR #1 was gaining weight. Surveyor requested DON all weights for CR#1. When asked if she was aware that the MD ordered for second time a stool specimen for CR #1 on [DATE], the DON responded I can't say I saw the order. DON did not provide additional weight records for CR #1 to surveyor by the time of exit. Further interview with the DON, she stated that CR #1 went to the hospital because the MD thought that CR #1 was dehydrated and said CR #1 was on antibiotics for upper respiratory infection, I don't know that she was having loose stools. When asked if she knew what had happened to CR #1, the DON responded She did eventually die, don't know when and did not see a death certificate. She did not come back to the facility. Even though that CR #1's family member works here part time on the weekends, she didn't stay in touch with us. We did not get information about CR #1. We knew CR #1 was in Intensive Care Unit but the hospital would not tell us the reason of her admission. If I was told her [DIAGNOSES REDACTED]. DON continued saying that she was not able to find another stool specimen report for CR #1 after it was rejected by the Laboratory on [DATE] and that she did not know why the specimen was rejected by the Laboratory. In an interview on [DATE] at 11:31 a.m. with CNA B, she stated that she worked with CR #1 at least twice a week and that the last two weeks before CR #1 went to the hospital, her appetite decreased and that she was more weak and that when CR #1 was up on her chair, she would leaned to the sides and forwards down. When asked about CR #1's stool consistency, CNA B stated her stools were loose. I did report the loose stools to the nurses but I also wrote it on the computer and they are supposed to see it. When asked if she reported CR#1's poor appetite, CNA B responded Nurses knew about her appetite because CR #1 would eat in the dining room. CNA B further said that changes in condition are reported to the nurses verbally and that there was no paper forms to report changes in condition that she was aware of. In an interview on [DATE] at 11:55 a.m. with LVN F, she stated that she was the ADON and wound care nurse. She further stated that CNA's report changes in condition verbally to the nurses and that there was a way in the computer system for CNA's to document changes in condition. LVN F further said that she only heard about CR #1 having diarrhea or loose stools just before she went to the hospital. She continued saying that information on the 24 hour report is reviewed during the morning meetings and that she did not remember any discussion about CR #1's condition. LVN F continued saying that just before CR #1 went to the hospital, they had discussed her poor appetite and eating but nothing about her diarrhea. In an interview on [DATE] at 12:02 p.m. with CNA C, she stated that she was the shower Aide but worked on the floor as well. CNA C further said I gave showers to CR #1 three times a week and I kept telling the nurses about the foul odor and color of her stools. CR #1's stools were yellow, slimy and had the distinctive foul odor, I kept telling the charge nurses about it for about 3 weeks before CR #1 went to the hospital. Every time I would bring her to the shower room, her stools were loose, strong foul odor, runny, slimy and yellow. I would report to the nurses every time. CR #1's appetite declined really bad. Her daughter would come and help her but CR #1 would not eat at all and she started getting the cracks on her mouth. CR #1 started leaning to the sides and then forwards when in the wheelchair during that time that she had the diarrhea and her poor appetite then the facility got an order for [REDACTED]. In an interview on [DATE] at 12:28 p.m. with LVN D, she stated that she was a full time charge nurse and that she worked with CR #1 and that CNA's would report changes in condition verbally to the nurses and that she believed there was a way of documenting changes in condition in the computer system but she was not sure if the staff had been trained about it. LVN D continued saying that she was the nurse that sent CR #1 to the hospital because she was acting abnormal, shaking and was hollering. LVN D further said I believe CR#1 had a negative stool for [MEDICAL CONDITION]. Surveyor asked LVN D to review the records of CR #1 and find the laboratory results that showed that her stools were negative for [MEDICAL CONDITION] and LVN D responded well, I need to go to the laboratory book. Further interview with LVN D, she stated that CR #1 wasn't really eating and was having loose stools and said 3 to 4 weeks before CR #1 went to the hospital, she would not eat. When asked if she notified the MD regarding CR #1's episodes of loose stools and low appetite, LVN D responded we send faxes to the MD, there were faxes. Surveyor asked LVN D to review the records of CR#1 and provide surveyor with documentation about the times the facility notified the MD of CR #1's poor appetite and episodes of loose stools. Further interview and observation at that time, LVN D flipped thru papers and said Well, I am not 100% positive the MD was made aware. I don't remember myself notifying the MD regarding her low appetite or the continuation of the diarrhea, but remember seeing some faxes about CR #1. I don't see them now. In an interview on [DATE] at 12:58 p.m. with LVN E, she stated that she worked with CR #1 and that she was the charge nurse and further said the Aides would tell me that CR #1 was having diarrhea but I asked CR #1's daughter about collecting a stool sample and the daughter refused, I just did not document that information. LVN E continued saying I believe CR #1 went to the doctor but I am not sure if she had any stool sample tested there. CR #1 was also discharged from therapy because she was not cooperating. When asked regarding the nurses notes written by her on [DATE] and [DATE] that talked about CR #1 not eating well, LVN E responded I believe the MD was faxed about it, I remember telling the oncoming nurse about it and to notify the MD about CR #1's not eating but don't remember who was the nurse and I did not checked back to see if the MD was notified. We are lacking on the communication to one and another like for changes in condition, to make sure we follow up on the conditions and notifications to the MD. I don't remember notifying the MD about her appetite and I did not know any information about the stool sample that needed to be recollected again. I believe that's where we need work on because some of the papers just get filed and not followed up. LVN E further said that she was not involved in the care planning of the residents and that LVN A was in charge of updating the care plans for changes in condition and that she did not notify her of CR #1's poor appetite and episodes of loose stools. Further interview on [DATE] at 2:05 p.m. with the DON, she stated that she expected the CNA's to notify the nurses verbally of any changes in condition and that there was no paper form for the CNA's to document changes in condition and that the nurses were supposed to report to the MD changes of condition as soon as possible. DON further stated that she had not done any formal training on [MEDICAL CONDITION] infections, that she only talked to the nurses about it and gave some literature about the infection but did not have a sign in form or course content of the discussion because was more like a conversation. DON continued saying that on September she did a training on abuse and neglect and that she discussed about changes in the condition of the residents because abuse and neglect could lead to a changed in condition on a resident. DON further said that they discussed on the training information about MD notification related to changes in condition and that the main expectation she had from the nurses is that they notify the MD for changes in condition as soon as possible. Continued interview with the DON at that time, she stated that having loose stools was a change in condition that required MD notification. DON further said that she looked at the MD orders every day including the laboratory results and that she does daily rounds including the dining room during most meals. Surveyor asked DON if nurses talked to her about the condition of CR #1 and the DON responded Yes, I talked to them, CR #1 was having some diarrhea, we were concerned about it but it wasn't proven to be [MEDICAL CONDITION]. Further interview with the DON, she stated that LVN A was in charge of updating the care plans and that care plans were supposed to be updated if the residents had a change in condition. When asked if CR #1's care plan was updated related the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness, the DON said as she flipped thru document I do not see it, I do not see her care plan updated. When asked about who was supposed to collect the specimens for residents and follow up on the laboratory results, the DON said that the night shift nurses were supposed to collect the urine samples and that the stool samples any nurse, as soon as the MD gives the order, any nurse is supposed to collect the specimen as soon as the resident has the bowel movement. When the laboratory sends any document to the facility, the nurses are supposed to follow up with the reports and not to put the reports on the chart until they had finished with the MD notifications and the orders. Continued interview with the DON at that time, when asked how did she think this incident of immediate jeopardy came about, the DON responded It got missed, the laboratory orders, human error but from this second on, I will be all over the charts, I will make 3 copies of the orders and everybody will get copies, we will go over the information on the meetings and will designate the hallways to department heads. When asked if she believed there was a problem with how the facility handled the changes in conditions of the residents, the DON responded CR#1 did not talk, we had to watch her, something was not right, we knew something was going on. Yes, there were things that were missed. When surveyor asked if staff review the bowel record of residents and if she had seen the bowel record of CR#1, the DON responded as she flipped thru CR #1's bowel record documentation I see it, OK, I will have somebody monitoring these records every day. We have shift to shift reports from the nursing staff but there is no system where they can write it down. Loose stools is a change in condition that needed to be reported to the MD in a perfect world. In an interview on [DATE] at 10:05 a.m. with the Administrator, he stated that the main tool the facility has to make sure the needs of the residents are being met is the everyday morning meetings because that where staff review the 24 hour report, orders, laboratory reports and other important information about the residents. He further said that department heads attending the meetings were the DON, Assistant DON, MDS nurse, Care Plan Nurse, dietary, therapy and the wound care nurse. When asked if information regarding the condition of CR #1 was ever discussed on the morning meetings, the Administrator stated what I remember is that she was having difficulty eating and the CNA's were feeding her and I knew that her weight was stable but I do not remember any discussion about her diarrhea or loose stools. I don't remember any specific information about the [MEDICAL CONDITION] or about any laboratory reports. If we had known that her laboratory order was missed, we would had done something. Since yesterday, we put things in place to monitor patients' condition. I was not keeping a task list. Going forward, I will have a task list that will be about who is doing what. We

Based on record review and interview, the facility failed to implement their written policy that prohibited neglect for one of nine residents (CR #1) reviewed for neglect, as evidenced by: -The facility failed to consult and update CR #1's physician on the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness that lasted on and off for 31 days. -The facility failed to follow up on a second stool specimen for [MEDICAL CONDITION] (a spore-forming bacterium that causes an infectious diarrhea) that the MD had ordered. -The facility failed to develop and place interventions to CR #1's care plan to indicate the loose stools and the development of difficulty chewing, loss of appetite and weakness to improve, or prevent further decline. -CR #1 was admitted to the hospital with [REDACTED]. CR #1 died at the hospital after 6 days of admission. An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. This failure affected one former resident (CR#1) who died after being admitted to the hospital and could place the 66 residents residing at the facility at risk of not receiving adequate assessments, medical care, pain, decline in their health condition well-being and death. Complaint # 0 Findings include: Record review of the facility policy and procedure for Recognizing Signs and Symptoms of Abuse/Neglect revised [DATE] read in part: .Our facility will condone any form of resident abuse or neglect. 2.- Neglect is defined as failure to provide goods and services as necessary to avoid physical harm . b.- Signs of / Actual Physical Neglect: Malnutrition and dehydration, Inadequate provision of care .Our residents have the right to be free from neglect Record review of the facility face sheet for CR #1 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Admission [DIAGNOSES REDACTED]. CR #1 was sent to the emergency roiagnom on [DATE] for evaluation and treatment of [REDACTED]. CR #1 died at the hospital on [DATE]. Record review of CR #1's quarterly MDS, dated [DATE], revealed CR #1 was not able to complete the interview for BIMS evaluation, she was sometimes able to make herself understood and was sometimes able to understand others. CR #1 required extensive assistance of 2 persons for bed mobility and was total dependent on staff for transfers, toilet use, locomotion and bathing. CR #1 required extensive assistance of one person for dressing and personal hygiene. She required a wheelchair for mobility and was always incontinent of bowel and bladder. The assessment section on swallowing/nutritional status revealed no swallowing disorders and was on a mechanically altered diet. Record review of the facility's weight records for CR #1 revealed weights on: -[DATE] of 160 lbs. -[DATE] of 154 lbs. Record review of CR #1's meal percentages from [DATE] to [DATE] revealed the intake ranged from 25% to 75%. Further record review revealed no meal percentages documented for 16 times for the breakfast and the lunch meals. Record review of the facility's Consulting Dietitian Report for [DATE] to [DATE] revealed she was not evaluated by the dietitian during those dates. Further record review revealed no recommendations for the month of [DATE] for CR #1. In an interview on [DATE] at 2:48 p.m. with the DON, she stated that CR #1 had to be fed and that she was always in the dining room eating and that she noticed changes with her eating 5 to 6 days before she went to the hospital and further said before CR#1 went to the hospital her appetite decreased. Record review of CR #1's Bowel Movement Report recorded by the nursing assistants revealed in part: -[DATE] one episode of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium and one large loose bowel movement. -[DATE] one episode of small and two mediums loose bowel movements. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium, one large loose bowel movement and another medium putty like stool. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] two episodes of medium and one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium and two large loose bowel movements. -[DATE] two episodes of medium and one large loose bowel movement. -[DATE] two episodes of large loose bowel movement. Record review of CR #1's care plan revised [DATE] revealed in part: -Focus: CR #1 has potential fluid deficit related to diuretic use ([MEDICATION NAME]-[MEDICATION NAME] 37XXX,[DATE]mg ordered on [DATE] for [MEDICAL CONDITION]). -Goal: CR#1 will be free of symptoms of dehydration -Interventions: Notify MD if persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours, obtain and monitor laboratories/diagnostic work as ordered. Report results to MD and follow up as indicated. Further record review revealed no information on the entire care plan of CR #1 episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness or interventions to improve, or prevent further decline. Record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 9:33 pm: .CR #1 had loose brown bowel movement with mucous. No foul odor noted. Called Nurse Practitioner on call for MD with orders to monitor bowel movement and to collect a stool specimen. Record review of the verbal MD order dated [DATE] at 9:15 p.m. revealed an order for [REDACTED]. -[DATE] at 12:55 p.m Daily skilled note in part: - G.I.: poor appetite, vomiting, hypoactive bowel sounds. Ate only few bites of lunch today before she made herself vomit -[DATE] at 4:05 p.m. CR #1 has new orders for stool specimen collection to rule out [MEDICAL CONDITION]. Specimen collected and is in med room fridge. Strong/foul odor noted, mucous with seedy appearance noted on the bowel movement. Patient with emesis noted during breakfast and refusal of alternate breakfast as well as lunch . Further record review of Daily skilled note in part: - G.I.: poor appetite, vomiting diarrhea. Increased of bowel, foul odor present, mucous and seedy appearance. -[DATE] at 8:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, diarrhea, hyperactive bowel sounds. CR #1 has been having loose stools. Neuromuscular: Wheelchair - weakness, deterioration. -[DATE] at 09:07 am: CR #1 did not eat breakfast, states I am not hungry. -[DATE] at 12:31 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing, diarrhea. Hyperactive bowel sounds. Neuro/muscular: weakness, deterioration. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 12:46 p.m. read in part: .Draw date: [DATE]. - Stool Culture results: No Salmonella, Shigella, Campylobacter isolated, Pathogenic Escherichia coli or Shiga Toxins 1 or 2 detected. Further record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 5:49 p.m. Daily skilled note in part: - G.I.: diarrhea, hyperactive bowel sounds. Received new order to repeat stool collection for [MEDICAL CONDITION] and culture and sensitivity . Record review of the facility's Complaint Resolution Record dated [DATE], given by CR#1's family member, received by the DON and signed by the Administrator revealed in part: .Resident's Name: CR #1. Staff receiving report: DON. - Concern: Diarrhea for a week, no [MEDICATION NAME] (anti-diarrheal). - Action taken: Explained how [MEDICAL CONDITION] works and contraindication of giving [MEDICATION NAME]. Informed her of negative [MEDICAL CONDITION] result and CR #1 refusing to get up . Further record review revealed that DON signed report on [DATE] and Administrator signed report on [DATE]. Record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 10:23 a.m. Can we have an order to repeat stool specimen collection and testing? Stools are loose/liquid, foamy and seedy appearance. Further record review revealed MD written order dated [DATE] -[MEDICAL CONDITION] and stool for culture and sensitivity. Continued record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 4:45 p.m. Daily skilled note in part: - G.I.: Diarrhea. Night nurse to collect stool for Wednesday. -[DATE] at 2:01 a.m. CR#1 did not produce a bowel movement before laboratory pick up. Further record review of Daily skilled note in part: - Neuromuscular - weakness. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 10:50 a.m. read in part: .for stool specimen drawn [DATE] Specimen unacceptable for testing. Rejected order, routine: - What test was rejected? [MEDICAL CONDITION]. - Reject reason: Please recollect for [MEDICAL CONDITION]. -[DATE] at 3:18 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing and hyperactive bowel sounds. -[DATE] at 6:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake and difficulty chewing. -[DATE] at 4:13 p.m: .CR #1 went to appointment today with new orders for complete metabolic panel to be done on Monday ([DATE]) and to return to clinic in 2 months. Record review of CR #1's comprehensive Metabolic Panel dated [DATE] and faxed to MD on [DATE] at 5:45 p.m. revealed in part: -BUN (blood urea nitrogen, test that reveals how kidneys are working) 38 High (Reference range ,[DATE] mg/dL) -Creatinine (evaluates kidney function) 1.16 (Reference range 0XXX,[DATE].20 mg/dL). Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: Not feeling good. Further record review revealed that Gastrointestinal exam was not conducted by the MD. Continued record review revealed - Assessment [DIAGNOSES REDACTED]. Return to clinic in 2 months. Further record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 10:05 a.m. Daily skilled note in part: - CR #1 has to have extra encouragement during meals to eat. -[DATE] at 6:56 a.m.: CR #1 does not help with being transferred, she is dead weight. Will not stand or pivot to assist with transfers. -[DATE] at 9:40 a.m.: Received an order for [REDACTED]. Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: cough, congestion and nasal drainage. Further record review revealed that Gastrointestinal exam was not conducted by the MD. - [DIAGNOSES REDACTED]. Plan: [MEDICATION NAME] 500 mg by mouth every day for 10 days, chest x-ray and [MEDICATION NAME] 10 mg by mouth for 10 days. Continued record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 10:07 a.m: CR #1 still not eating well. -[DATE] at 10:25 a.m.: CR #1 is not eating well only eating 25% or less of meals. Further record review of the nursing progress notes revealed no MD notification on the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness. -[DATE] at 4:26 p.m: Received fax from CR #1's MD with orders to send CR#1 to the hospital for evaluation and treatment for [REDACTED]. Further record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 7:30 a.m. .CR #1 noted to have watery brown stool. CR #1 also noted to have excoriated buttocks and perineal area. Further record review revealed MD order dated [DATE] at 4:00 p.m. Sent to emergency room for evaluation of possible dehydration and stool for [MEDICAL CONDITION]. Record review of CR #1's Emergency physician record dated [DATE] at 4:47 p.m. revealed in part: .- History of present illness: Generalized weakness. Onset/duration: unknown. History of diarrhea. - Physical exam: lethargic, dry mucous membranes, [MEDICAL CONDITION](fast heart rate).[MEDICAL CONDITION], dehydration. Intravenous fluids Normal Saline bolus of 2000 ml. [MEDICATION NAME] (antibiotic) 1 gram Intravenous and Cefepinie (antibiotic) 1 gram Intravenous. Stool for [MEDICAL CONDITION]. Further record review of CR #1's hospital history and physical dated [DATE] at 10:17 p.m. revealed in part: .Chief complaint: Generalized weakness. [AGE] year old female who present from the nursing home. Family reports diminished appetite. Then over the last day or so developed by the nurses notes, some loose stools associated with some excoriation and a decrease in her normal level of interaction. On [MEDICATION NAME] (antibiotic) 500 mg since [DATE]th for a cough. Vital signs: emergency room blood pressure ,[DATE]. Currently after 3 liters of fluid in the emergency room , blood pressure is very low between ,[DATE] and ,[DATE] with heart rate of 133. Mouth is dry. Abdomen is distended, diffusely tender. She has got some early flexion contractures of her knees and her hips. - Laboratories: [MEDICAL CONDITION] was positive. White blood cells count of 61.3 Critical High (Reference range 4XXX,[DATE].8), BUN (blood urea nitrogen, test that reveals how kidneys are working) 74 Critical High (Reference range ,[DATE] mg/dL) and creatinine (evaluates kidney function) 2.8 (Reference range 0XXX,[DATE].0). - Assessment: 1.- [MEDICAL CONDITION]. She has got 3 liters of fluid in the Emergency Department with improvement of her blood pressure, though is not stabilized at this point. We will continue intravenous fluids overnight tonight. 2.- [MEDICAL CONDITIONS], likely the source of [MEDICAL CONDITION]. We will put her on [MEDICATION NAME] (antibiotic) as well as oral [MEDICATION NAME] (antibiotic). -Did discuss with the daughter that was present this evening that the patient was severely ill and we would have a much clearer picture the next 12 - 24 hours on her ability to survive, given the degree of [MEDICAL CONDITION] and volume resuscitation. 8.- Acute [MEDICAL CONDITION] on top of [MEDICAL CONDITION]. Again due to her dehydration. We will continue fluids. Record review of CR #1's discharge summary from the hospital dated [DATE] at 1:46 p.m. revealed in part: Final discharge Diagnoses: [REDACTED]. - Hospital course: The patient was admitted and started on intravenous [MEDICATION NAME] as well as oral [MEDICATION NAME]. White count was 61,000 on admission. This did slowly improved; however, by mouth intake was extremely poor. Ultimately, the patient continued to decline clinically, having blood pressures that were running lower and urine output that was significantly less despite being on brisk intravenous resuscitation. White counts did improve with the intravenous and oral antibiotics that she was receiving; however, due to her overall decline, I contacted the patient's family to discuss inpatient hospice services. She was admitted to hospice on [DATE]. Further record review of discharge summary dated [DATE] at 1:58 p.m. revealed that CR#1 died in the hospital on [DATE] at 12:16 p.m. In an interview on [DATE] at 1:14 p.m. with the DON, she stated that she did not know what happened to the stool specimen that was supposed to be recollected for CR #1 on [DATE]. She further stated that she did not know why the specimen was rejected by the Laboratory on [DATE] and that she thought that CR #1's stool was negative for [MEDICAL CONDITION] and further said I thought I read somewhere that her stool was negative for [MEDICAL CONDITION]. When asked to look thru CR #1's chart to see if she could find any [MEDICAL CONDITION] laboratory results, the DON responded as she flipped thru the chart It looks that she did not get a [MEDICAL CONDITION] test in the facility. I don't know what happened with the laboratory test for the stool, I will find out. Do not know why was rejected. When asked if CR #1 got her stool collected on [DATE] after the MD gave orders again to check for [MEDICAL CONDITION], DON responded well, there is a nurses note on [DATE] that the stool specimen was not available . DON then left and said she was going to call the laboratory. In an interview on [DATE] at 1:24 p.m. with LVN A, she stated that she was the Care plan nurse and that she would review the care plans every 92 days in the computer and would update the care plans as needed if there is a change in condition on the residents. She further said that there was a communication board in the computer system where the nurses would write information if the residents had a change in condition. LVN A said that also during the morning meetings, the department heads would talk about changes in condition and that she would get the information from there to update the care plans as well. LVN A continued saying that she had spoken to the DON about who would actually be doing changes in the care plans because she was only working part time and that the DON has not come up with a concise decision yet. When asked if CR #1 had any changes in condition that she needed to update on the care plan, LVN A responded CR #1 only had an upper respiratory infection on [DATE] Continued interview with LVN A, she stated that she was not aware of CR #1 having any issues with diarrhea or poor appetite and further said We are in the process with the infection control nurse about how we are going to communicate infections of residents. We have a new tool in the computer system for changes in condition but not sure if staff is really writing on it. In a phone interview on [DATE] at 3:10 p.m. with CR #1's family member, she stated that another family member brought CR #1 to the MD on [DATE] because the family saw how sick CR #1 was and further said She was having diarrhea and was deteriorating. She was eating less and less, her appetite was decreasing, she was really sick until she was sent to the hospital. CR #1 would not move anymore, she was not drinking or eating and she was having severe diarrhea. I was told by the facility that the stool studies were negative but they did not show me any reports. Then when I went to see her at the facility, she did not look good and she was diagnosed at the hospital with [MEDICAL CONDITION]. In an interview on [DATE] at 3:40 p.m. with the DON, she stated that she still did not hear from the laboratory yet about why the stool specimen for CR#1 was rejected on [DATE] and further said I was not aware that the stool specimen was rejected until today when you asked for it. I knew about that there were concerns about CR#1 having loose stools but don't know information in detail. DON further said that she did not know that CR #1 had any problems with her appetite and that she believed that CR #1 was gaining weight. Surveyor requested DON all weights for CR#1. When asked if she was aware that the MD ordered for second time a stool specimen for CR #1 on [DATE], the DON responded I can't say I saw the order. DON did not provide additional weight records for CR #1 to surveyor by the time of exit. Further interview with the DON, she stated that CR #1 went to the hospital because the MD thought that CR #1 was dehydrated and said CR #1 was on antibiotics for upper respiratory infection, I don't know that she was having loose stools. When asked if she knew what had happened to CR #1, the DON responded She did eventually die, don't know when and did not see a death certificate. She did not come back to the facility. Even though that CR #1's family member works here part time on the weekends, she didn't stay in touch with us. We did not get information about CR #1. We knew CR #1 was in Intensive Care Unit but the hospital would not tell us the reason of her admission. If I was told her [DIAGNOSES REDACTED]. DON continued saying that she was not able to find another stool specimen report for CR #1 after it was rejected by the Laboratory on [DATE] and that she did not know why the specimen was rejected by the Laboratory. In an interview on [DATE] at 11:31 a.m. with CNA B, she stated that she worked with CR #1 at least twice a week and that the last two weeks before CR #1 went to the hospital, her appetite decreased and that she was more weak and that when CR #1 was up on her chair, she would leaned to the sides and forwards down. When asked about CR #1's stool consistency, CNA B stated her stools were loose. I did report the loose stools to the nurses but I also wrote it on the computer and they are supposed to see it. When asked if she reported CR#1's poor appetite, CNA B responded Nurses knew about her appetite because CR #1 would eat in the dining room. CNA B further said that changes in condition are reported to the nurses verbally and that there was no paper forms to report changes in condition that she was aware of. In an interview on [DATE] at 11:55 a.m. with LVN F, she stated that she was the ADON and wound care nurse. She further stated that CNA's report changes in condition verbally to the nurses and that there was a way in the computer system for CNA's to document changes in condition. LVN F further said that she only heard about CR #1 having diarrhea or loose stools just before she went to the hospital. She continued saying that information on the 24 hour report is reviewed during the morning meetings and that she did not remember any discussion about CR #1's condition. LVN F continued saying that just before CR #1 went to the hospital, they had discussed her poor appetite and eating but nothing about her diarrhea. In an interview on [DATE] at 12:02 p.m. with CNA C, she stated that she was the shower Aide but worked on the floor as well. CNA C further said I gave showers to CR #1 three times a week and I kept telling the nurses about the foul odor and color of her stools. CR #1's stools were yellow, slimy and had the distinctive foul odor, I kept telling the charge nurses about it for about 3 weeks before CR #1 went to the hospital. Every time I would bring her to the shower room, her stools were loose, strong foul odor, runny, slimy and yellow. I would report to the nurses every time. CR #1's appetite declined really bad. Her daughter would come and help her but CR #1 would not eat at all and she started getting the cracks on her mouth. CR #1 started leaning to the sides and then forwards when in the wheelchair during that time that she had the diarrhea and her poor appetite then the facility got an order for [REDACTED]. In an interview on [DATE] at 12:28 p.m. with LVN D, she stated that she was a full time charge nurse and that she worked with CR #1 and that CNA's would report changes in condition verbally to the nurses and that she believed there was a way of documenting changes in condition in the computer system but she was not sure if the staff had been trained about it. LVN D continued saying that she was the nurse that sent CR #1 to the hospital because she was acting abnormal, shaking and was hollering. LVN D further said I believe CR#1 had a negative stool for [MEDICAL CONDITION]. Surveyor asked LVN D to review the records of CR #1 and find the laboratory results that showed that her stools were negative for [MEDICAL CONDITION] and LVN D responded well, I need to go to the laboratory book. Further interview with LVN D, she stated that CR #1 wasn't really eating and was having loose stools and said 3 to 4 weeks before CR #1 went to the hospital, she would not eat. When asked if she notified the MD regarding CR #1's episodes of loose stools and low appetite, LVN D responded we send faxes to the MD, there were faxes. Surveyor asked LVN D to review the records of CR#1 and provide surveyor with documentation about the times the facility notified the MD of CR #1's poor appetite and episodes of loose stools. Further interview and observation at that time, LVN D flipped thru papers and said Well, I am not 100% positive the MD was made aware. I don't remember myself notifying the MD regarding her low appetite or the continuation of the diarrhea, but remember seeing some faxes about CR #1. I don't see them now. In an interview on [DATE] at 12:58 p.m. with LVN E, she stated that she worked with CR #1 and that she was the charge nurse and further said the Aides would tell me that CR #1 was having diarrhea but I asked CR #1's daughter about collecting a stool sample and the daughter refused, I just did not document that information. LVN E continued saying I believe CR #1 went to the doctor but I am not sure if she had any stool sample tested there. CR #1 was also discharged from therapy because she was not cooperating. When asked regarding the nurses notes written by her on [DATE] and [DATE] that talked about CR #1 not eating well, LVN E responded I believe the MD was faxed about it, I remember telling the oncoming nurse about it and to notify the MD about CR #1's not eating but don't remember who was the nurse and I did not checked back to see if the MD was notified. We are lacking on the communication to one and another like for changes in condition, to make sure we follow up on the conditions and notifications to the MD. I don't remember notifying the MD about her appetite and I did not know any information about the stool sample that needed to be recollected again. I believe that's where we need work on because some of the papers just get filed and not followed up. LVN E further said that she was not involved in the care planning of the residents and that LVN A was in charge of updating the care plans for changes in condition and that she did not notify her of CR #1's poor appetite and episodes of loose stools. Further interview on [DATE] at 2:05 p.m. with the DON, she stated that she expected the CNA's to notify the nurses verbally of any changes in condition and that there was no paper form for the CNA's to document changes in condition and that the nurses were supposed to report to the MD changes of condition as soon as possible. DON further stated that she had not done any formal training on [MEDICAL CONDITION] infections, that she only talked to the nurses about it and gave some literature about the infection but did not have a sign in form or course content of the discussion because was more like a conversation. DON continued saying that on September she did a training on abuse and neglect and that she discussed about changes in the condition of the residents because abuse and neglect could lead to a changed in condition on a resident. DON further said that they discussed on the training information about MD notification related to changes in condition and that the main expectation she had from the nurses is that they notify the MD for changes in condition as soon as possible. Continued interview with the DON at that time, she stated that having loose stools was a change in condition that required MD notification. DON further said that she looked at the MD orders every day including the laboratory results and that she does daily rounds including the dining room during most meals. Surveyor asked DON if nurses talked to her about the condition of CR #1 and the DON responded Yes, I talked to them, CR #1 was having some diarrhea, we were concerned about it but it wasn't proven to be [MEDICAL CONDITION]. Further interview with the DON, she stated that LVN A was in charge of updating the care plans and that care plans were supposed to be updated if the residents had a change in condition. When asked if CR #1's care plan was updated related the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness, the DON said as she flipped thru document I do not see it, I do not see her care plan updated. When asked about who was supposed to collect the specimens for residents and follow up on the laboratory results, the DON said that the night shift nurses were supposed to collect the urine samples and that the stool samples any nurse, as soon as the MD gives the order, any nurse is supposed to collect the specimen as soon as the resident has the bowel movement. When the laboratory sends any document to the facility, the nurses are supposed to follow up with the reports and not to put the reports on the chart until they had finished with the MD notifications and the orders. Continued interview with the DON at that time, when asked how did she think this incident of immediate jeopardy came about, the DON responded It got missed, the laboratory orders, human error but from this second on, I will be all over the charts, I will make 3 copies of the orders and everybody will get copies, we will go over the information on the meetings and will designate the hallways to department heads. When asked if she believed there was a problem with how the facility handled the changes in conditions of the residents, the DON responded CR#1 did not talk, we had to watch her, something was not right, we knew something was going on. Yes, there were things that were missed. When surveyor asked if staff review the bowel record of residents and if she had seen the bowel record of CR#1, the DON responded as she flipped thru CR #1's bowel record documentation I see it, OK, I will have somebody monitoring these records every day. We have shift to shift reports from the nursing staff but there is no system where they can write it down. Loose stools is a change in condition that needed to be reported to the MD in a perfect world. In an interview on [DATE] at 10:05 a.m. with the Administrator, he stated that the main tool the facility has to make sure the needs of the residents are being met is the everyday morning meetings because that where staff review the 24 hour report, orders, laboratory reports and other important information about the residents. He further said that department heads attending the meetings were the DON, Assistant DON, MDS nurse, Care Plan Nurse, dietary, therapy and the wound care nurse. When asked if information regarding the condition of CR #1 was ever discussed on the morning meetings, the Administrator stated what I remember is that she was having difficulty e

Based on record review and interview, the facility failed to develop a comprehensive care plan, based on a comprehensive assessment, after a change of condition for one of nine residents (CR #1) whose care plans were reviewed. -The facility failed to develop and place interventions to CR #1's care plan to indicate the loose stools and the development of difficulty chewing, loss of appetite and weakness to improve, or prevent further decline. -CR #1 was admitted to the hospital with [REDACTED]. CR #1 died at the hospital after 6 days of admission. An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. This failure affected one former resident (CR#1) who died after being admitted to the hospital and has the potential to affect the 66 residents residing at the facility at risk of not receiving needed care and services based on their assessed needs which could result in inadequate assessments, medical care, pain, decline in their health condition well-being and death. Complaint # 0 Findings include: Record review of the facility face sheet for CR #1 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Admission [DIAGNOSES REDACTED]. CR #1 was sent to the emergency roiagnom on [DATE] for evaluation and treatment of [REDACTED]. CR #1 died at the hospital on [DATE]. Record review of CR #1's quarterly MDS, dated [DATE], revealed CR #1 was not able to complete the interview for BIMS evaluation, she was sometimes able to make herself understood and was sometimes able to understand others. CR #1 required extensive assistance of 2 persons for bed mobility and was total dependent on staff for transfers, toilet use, locomotion and bathing. CR #1 required extensive assistance of one person for dressing and personal hygiene. She required a wheelchair for mobility and was always incontinent of bowel and bladder. The assessment section on swallowing/nutritional status revealed no swallowing disorders and was on a mechanically altered diet. Record review of the facility's weight records for CR #1 revealed weights on: -[DATE] of 160 lbs. -[DATE] of 154 lbs. Record review of CR #1's meal percentages from [DATE] to [DATE] revealed the intake ranged from 25% to 75%. Further record review revealed no meal percentages documented for 16 times for the breakfast and the lunch meals. Record review of the facility's Consulting Dietitian Report for [DATE] to [DATE] revealed she was not evaluated by the dietitian during those dates. Further record review revealed no recommendations for the month of [DATE] for CR #1. In an interview on [DATE] at 2:48 p.m. with the DON, she stated that CR #1 had to be fed and that she was always in the dining room eating and that she noticed changes with her eating 5 to 6 days before she went to the hospital and further said before CR#1 went to the hospital her appetite decreased. Record review of CR #1's Bowel Movement Report recorded by the nursing assistants revealed in part: -[DATE] one episode of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium and one large loose bowel movement. -[DATE] one episode of small and two mediums loose bowel movements. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium, one large loose bowel movement and another medium putty like stool. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] two episodes of medium and one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium and two large loose bowel movements. -[DATE] two episodes of medium and one large loose bowel movement. -[DATE] two episodes of large loose bowel movement. Record review of CR #1's care plan revised [DATE] revealed in part: -Focus: CR #1 has potential fluid deficit related to diuretic use ([MEDICATION NAME]-[MEDICATION NAME] 37XXX,[DATE]mg ordered on [DATE] for [MEDICAL CONDITION]). -Goal: CR#1 will be free of symptoms of dehydration -Interventions: Notify MD if persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours, obtain and monitor laboratories/diagnostic work as ordered. Report results to MD and follow up as indicated. Further record review revealed no information on the entire care plan of CR #1 episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness or interventions to improve, or prevent further decline. Record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 9:33 pm: .CR #1 had loose brown bowel movement with mucous. No foul odor noted. Called Nurse Practitioner on call for MD with orders to monitor bowel movement and to collect a stool specimen. Record review of the verbal MD order dated [DATE] at 9:15 p.m. revealed an order for [REDACTED]. -[DATE] at 12:55 p.m Daily skilled note in part: - G.I.: poor appetite, vomiting, hypoactive bowel sounds. Ate only few bites of lunch today before she made herself vomit -[DATE] at 4:05 p.m. CR #1 has new orders for stool specimen collection to rule out [MEDICAL CONDITION]. Specimen collected and is in med room fridge. Strong/foul odor noted, mucous with seedy appearance noted on the bowel movement. Patient with emesis noted during breakfast and refusal of alternate breakfast as well as lunch . Further record review of Daily skilled note in part: - G.I.: poor appetite, vomiting diarrhea. Increased of bowel, foul odor present, mucous and seedy appearance. -[DATE] at 8:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, diarrhea, hyperactive bowel sounds. CR #1 has been having loose stools. Neuromuscular: Wheelchair - weakness, deterioration. -[DATE] at 09:07 am: CR #1 did not eat breakfast, states I am not hungry. -[DATE] at 12:31 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing, diarrhea. Hyperactive bowel sounds. Neuro/muscular: weakness, deterioration. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 12:46 p.m. read in part: .Draw date: [DATE]. - Stool Culture results: No Salmonella, Shigella, Campylobacter isolated, Pathogenic Escherichia coli or Shiga Toxins 1 or 2 detected. Further record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 5:49 p.m. Daily skilled note in part: - G.I.: diarrhea, hyperactive bowel sounds. Received new order to repeat stool collection for [MEDICAL CONDITION] and culture and sensitivity . Record review of the facility's Complaint Resolution Record dated [DATE], given by CR#1's family member, received by the DON and signed by the Administrator revealed in part: .Resident's Name: CR #1. Staff receiving report: DON. - Concern: Diarrhea for a week, no [MEDICATION NAME] (anti-diarrheal). - Action taken: Explained how [MEDICAL CONDITION] works and contraindication of giving [MEDICATION NAME]. Informed her of negative [MEDICAL CONDITION] result and CR #1 refusing to get up . Further record review revealed that DON signed report on [DATE] and Administrator signed report on [DATE]. Record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 10:23 a.m. Can we have an order to repeat stool specimen collection and testing? Stools are loose/liquid, foamy and seedy appearance. Further record review revealed MD written order dated [DATE] -[MEDICAL CONDITION] and stool for culture and sensitivity. Continued record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 4:45 p.m. Daily skilled note in part: - G.I.: Diarrhea. Night nurse to collect stool for Wednesday. -[DATE] at 2:01 a.m. CR#1 did not produce a bowel movement before laboratory pick up. Further record review of Daily skilled note in part: - Neuromuscular - weakness. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 10:50 a.m. read in part: .for stool specimen drawn [DATE] Specimen unacceptable for testing. Rejected order, routine: - What test was rejected? [MEDICAL CONDITION]. - Reject reason: Please recollect for [MEDICAL CONDITION]. -[DATE] at 3:18 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing and hyperactive bowel sounds. -[DATE] at 6:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake and difficulty chewing. -[DATE] at 4:13 p.m: .CR #1 went to appointment today with new orders for complete metabolic panel to be done on Monday ([DATE]) and to return to clinic in 2 months. Record review of CR #1's comprehensive Metabolic Panel dated [DATE] and faxed to MD on [DATE] at 5:45 p.m. revealed in part: -BUN (blood urea nitrogen, test that reveals how kidneys are working) 38 High (Reference range ,[DATE] mg/dL) -Creatinine (evaluates kidney function) 1.16 (Reference range 0XXX,[DATE].20 mg/dL). Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: Not feeling good. Further record review revealed that Gastrointestinal exam was not conducted by the MD. Continued record review revealed - Assessment [DIAGNOSES REDACTED]. Return to clinic in 2 months. Further record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 10:05 a.m. Daily skilled note in part: - CR #1 has to have extra encouragement during meals to eat. -[DATE] at 6:56 a.m.: CR #1 does not help with being transferred, she is dead weight. Will not stand or pivot to assist with transfers. -[DATE] at 9:40 a.m.: Received an order for [REDACTED]. Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: cough, congestion and nasal drainage. Further record review revealed that Gastrointestinal exam was not conducted by the MD. - [DIAGNOSES REDACTED]. Plan: [MEDICATION NAME] 500 mg by mouth every day for 10 days, chest x-ray and [MEDICATION NAME] 10 mg by mouth for 10 days. Continued record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 10:07 a.m: CR #1 still not eating well. -[DATE] at 10:25 a.m.: CR #1 is not eating well only eating 25% or less of meals. Further record review of the nursing progress notes revealed no MD notification on the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness. -[DATE] at 4:26 p.m: Received fax from CR #1's MD with orders to send CR#1 to the hospital for evaluation and treatment for [REDACTED]. Further record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 7:30 a.m. .CR #1 noted to have watery brown stool. CR #1 also noted to have excoriated buttocks and perineal area. Further record review revealed MD order dated [DATE] at 4:00 p.m. Sent to emergency room for evaluation of possible dehydration and stool for [MEDICAL CONDITION]. Record review of CR #1's Emergency physician record dated [DATE] at 4:47 p.m. revealed in part: .- History of present illness: Generalized weakness. Onset/duration: unknown. History of diarrhea. - Physical exam: lethargic, dry mucous membranes, [MEDICAL CONDITION](fast heart rate).[MEDICAL CONDITION], dehydration. Intravenous fluids Normal Saline bolus of 2000 ml. [MEDICATION NAME] (antibiotic) 1 gram Intravenous and Cefepinie (antibiotic) 1 gram Intravenous. Stool for [MEDICAL CONDITION]. Further record review of CR #1's hospital history and physical dated [DATE] at 10:17 p.m. revealed in part: .Chief complaint: Generalized weakness. [AGE] year old female who present from the nursing home. Family reports diminished appetite. Then over the last day or so developed by the nurses notes, some loose stools associated with some excoriation and a decrease in her normal level of interaction. On [MEDICATION NAME] (antibiotic) 500 mg since [DATE]th for a cough. Vital signs: emergency room blood pressure ,[DATE]. Currently after 3 liters of fluid in the emergency room , blood pressure is very low between ,[DATE] and ,[DATE] with heart rate of 133. Mouth is dry. Abdomen is distended, diffusely tender. She has got some early flexion contractures of her knees and her hips. - Laboratories: [MEDICAL CONDITION] was positive. White blood cells count of 61.3 Critical High (Reference range 4XXX,[DATE].8), BUN (blood urea nitrogen, test that reveals how kidneys are working) 74 Critical High (Reference range ,[DATE] mg/dL) and creatinine (evaluates kidney function) 2.8 (Reference range 0XXX,[DATE].0). - Assessment: 1.- [MEDICAL CONDITION]. She has got 3 liters of fluid in the Emergency Department with improvement of her blood pressure, though is not stabilized at this point. We will continue intravenous fluids overnight tonight. 2.- [MEDICAL CONDITIONS], likely the source of [MEDICAL CONDITION]. We will put her on [MEDICATION NAME] (antibiotic) as well as oral [MEDICATION NAME] (antibiotic). -Did discuss with the daughter that was present this evening that the patient was severely ill and we would have a much clearer picture the next 12 - 24 hours on her ability to survive, given the degree of [MEDICAL CONDITION] and volume resuscitation. 8.- Acute [MEDICAL CONDITION] on top of [MEDICAL CONDITION]. Again due to her dehydration. We will continue fluids. Record review of CR #1's discharge summary from the hospital dated [DATE] at 1:46 p.m. revealed in part: Final discharge Diagnoses: [REDACTED]. - Hospital course: The patient was admitted and started on intravenous [MEDICATION NAME] as well as oral [MEDICATION NAME]. White count was 61,000 on admission. This did slowly improved; however, by mouth intake was extremely poor. Ultimately, the patient continued to decline clinically, having blood pressures that were running lower and urine output that was significantly less despite being on brisk intravenous resuscitation. White counts did improve with the intravenous and oral antibiotics that she was receiving; however, due to her overall decline, I contacted the patient's family to discuss inpatient hospice services. She was admitted to hospice on [DATE]. Further record review of discharge summary dated [DATE] at 1:58 p.m. revealed that CR#1 died in the hospital on [DATE] at 12:16 p.m. In an interview on [DATE] at 1:14 p.m. with the DON, she stated that she did not know what happened to the stool specimen that was supposed to be recollected for CR #1 on [DATE]. She further stated that she did not know why the specimen was rejected by the Laboratory on [DATE] and that she thought that CR #1's stool was negative for [MEDICAL CONDITION] and further said I thought I read somewhere that her stool was negative for [MEDICAL CONDITION]. When asked to look thru CR #1's chart to see if she could find any [MEDICAL CONDITION] laboratory results, the DON responded as she flipped thru the chart It looks that she did not get a [MEDICAL CONDITION] test in the facility. I don't know what happened with the laboratory test for the stool, I will find out. Do not know why was rejected. When asked if CR #1 got her stool collected on [DATE] after the MD gave orders again to check for [MEDICAL CONDITION], DON responded well, there is a nurses note on [DATE] that the stool specimen was not available . DON then left and said she was going to call the laboratory. In an interview on [DATE] at 1:24 p.m. with LVN A, she stated that she was the Care plan nurse and that she would review the care plans every 92 days in the computer and would update the care plans as needed if there is a change in condition on the residents. She further said that there was a communication board in the computer system where the nurses would write information if the residents had a change in condition. LVN A said that also during the morning meetings, the department heads would talk about changes in condition and that she would get the information from there to update the care plans as well. LVN A continued saying that she had spoken to the DON about who would actually be doing changes in the care plans because she was only working part time and that the DON has not come up with a concise decision yet. When asked if CR #1 had any changes in condition that she needed to update on the care plan, LVN A responded CR #1 only had an upper respiratory infection on [DATE] Continued interview with LVN A, she stated that she was not aware of CR #1 having any issues with diarrhea or poor appetite and further said We are in the process with the infection control nurse about how we are going to communicate infections of residents. We have a new tool in the computer system for changes in condition but not sure if staff is really writing on it. In a phone interview on [DATE] at 3:10 p.m. with CR #1's family member, she stated that another family member brought CR #1 to the MD on [DATE] because the family saw how sick CR #1 was and further said She was having diarrhea and was deteriorating. She was eating less and less, her appetite was decreasing, she was really sick until she was sent to the hospital. CR #1 would not move anymore, she was not drinking or eating and she was having severe diarrhea. I was told by the facility that the stool studies were negative but they did not show me any reports. Then when I went to see her at the facility, she did not look good and she was diagnosed at the hospital with [MEDICAL CONDITION]. In an interview on [DATE] at 3:40 p.m. with the DON, she stated that she still did not hear from the laboratory yet about why the stool specimen for CR#1 was rejected on [DATE] and further said I was not aware that the stool specimen was rejected until today when you asked for it. I knew about that there were concerns about CR#1 having loose stools but don't know information in detail. DON further said that she did not know that CR #1 had any problems with her appetite and that she believed that CR #1 was gaining weight. Surveyor requested DON all weights for CR#1. When asked if she was aware that the MD ordered for second time a stool specimen for CR #1 on [DATE], the DON responded I can't say I saw the order. DON did not provide additional weight records for CR #1 to surveyor by the time of exit. Further interview with the DON, she stated that CR #1 went to the hospital because the MD thought that CR #1 was dehydrated and said CR #1 was on antibiotics for upper respiratory infection, I don't know that she was having loose stools. When asked if she knew what had happened to CR #1, the DON responded She did eventually die, don't know when and did not see a death certificate. She did not come back to the facility. Even though that CR #1's family member works here part time on the weekends, she didn't stay in touch with us. We did not get information about CR #1. We knew CR #1 was in Intensive Care Unit but the hospital would not tell us the reason of her admission. If I was told her [DIAGNOSES REDACTED]. DON continued saying that she was not able to find another stool specimen report for CR #1 after it was rejected by the Laboratory on [DATE] and that she did not know why the specimen was rejected by the Laboratory. In an interview on [DATE] at 11:31 a.m. with CNA B, she stated that she worked with CR #1 at least twice a week and that the last two weeks before CR #1 went to the hospital, her appetite decreased and that she was more weak and that when CR #1 was up on her chair, she would leaned to the sides and forwards down. When asked about CR #1's stool consistency, CNA B stated her stools were loose. I did report the loose stools to the nurses but I also wrote it on the computer and they are supposed to see it. When asked if she reported CR#1's poor appetite, CNA B responded Nurses knew about her appetite because CR #1 would eat in the dining room. CNA B further said that changes in condition are reported to the nurses verbally and that there was no paper forms to report changes in condition that she was aware of. In an interview on [DATE] at 11:55 a.m. with LVN F, she stated that she was the ADON and wound care nurse. She further stated that CNA's report changes in condition verbally to the nurses and that there was a way in the computer system for CNA's to document changes in condition. LVN F further said that she only heard about CR #1 having diarrhea or loose stools just before she went to the hospital. She continued saying that information on the 24 hour report is reviewed during the morning meetings and that she did not remember any discussion about CR #1's condition. LVN F continued saying that just before CR #1 went to the hospital, they had discussed her poor appetite and eating but nothing about her diarrhea. In an interview on [DATE] at 12:02 p.m. with CNA C, she stated that she was the shower Aide but worked on the floor as well. CNA C further said I gave showers to CR #1 three times a week and I kept telling the nurses about the foul odor and color of her stools. CR #1's stools were yellow, slimy and had the distinctive foul odor, I kept telling the charge nurses about it for about 3 weeks before CR #1 went to the hospital. Every time I would bring her to the shower room, her stools were loose, strong foul odor, runny, slimy and yellow. I would report to the nurses every time. CR #1's appetite declined really bad. Her daughter would come and help her but CR #1 would not eat at all and she started getting the cracks on her mouth. CR #1 started leaning to the sides and then forwards when in the wheelchair during that time that she had the diarrhea and her poor appetite then the facility got an order for [REDACTED]. In an interview on [DATE] at 12:28 p.m. with LVN D, she stated that she was a full time charge nurse and that she worked with CR #1 and that CNA's would report changes in condition verbally to the nurses and that she believed there was a way of documenting changes in condition in the computer system but she was not sure if the staff had been trained about it. LVN D continued saying that she was the nurse that sent CR #1 to the hospital because she was acting abnormal, shaking and was hollering. LVN D further said I believe CR#1 had a negative stool for [MEDICAL CONDITION]. Surveyor asked LVN D to review the records of CR #1 and find the laboratory results that showed that her stools were negative for [MEDICAL CONDITION] and LVN D responded well, I need to go to the laboratory book. Further interview with LVN D, she stated that CR #1 wasn't really eating and was having loose stools and said 3 to 4 weeks before CR #1 went to the hospital, she would not eat. When asked if she notified the MD regarding CR #1's episodes of loose stools and low appetite, LVN D responded we send faxes to the MD, there were faxes. Surveyor asked LVN D to review the records of CR#1 and provide surveyor with documentation about the times the facility notified the MD of CR #1's poor appetite and episodes of loose stools. Further interview and observation at that time, LVN D flipped thru papers and said Well, I am not 100% positive the MD was made aware. I don't remember myself notifying the MD regarding her low appetite or the continuation of the diarrhea, but remember seeing some faxes about CR #1. I don't see them now. In an interview on [DATE] at 12:58 p.m. with LVN E, she stated that she worked with CR #1 and that she was the charge nurse and further said the Aides would tell me that CR #1 was having diarrhea but I asked CR #1's daughter about collecting a stool sample and the daughter refused, I just did not document that information. LVN E continued saying I believe CR #1 went to the doctor but I am not sure if she had any stool sample tested there. CR #1 was also discharged from therapy because she was not cooperating. When asked regarding the nurses notes written by her on [DATE] and [DATE] that talked about CR #1 not eating well, LVN E responded I believe the MD was faxed about it, I remember telling the oncoming nurse about it and to notify the MD about CR #1's not eating but don't remember who was the nurse and I did not checked back to see if the MD was notified. We are lacking on the communication to one and another like for changes in condition, to make sure we follow up on the conditions and notifications to the MD. I don't remember notifying the MD about her appetite and I did not know any information about the stool sample that needed to be recollected again. I believe that's where we need work on because some of the papers just get filed and not followed up. LVN E further said that she was not involved in the care planning of the residents and that LVN A was in charge of updating the care plans for changes in condition and that she did not notify her of CR #1's poor appetite and episodes of loose stools. Further interview on [DATE] at 2:05 p.m. with the DON, she stated that she expected the CNA's to notify the nurses verbally of any changes in condition and that there was no paper form for the CNA's to document changes in condition and that the nurses were supposed to report to the MD changes of condition as soon as possible. DON further stated that she had not done any formal training on [MEDICAL CONDITION] infections, that she only talked to the nurses about it and gave some literature about the infection but did not have a sign in form or course content of the discussion because was more like a conversation. DON continued saying that on September she did a training on abuse and neglect and that she discussed about changes in the condition of the residents because abuse and neglect could lead to a changed in condition on a resident. DON further said that they discussed on the training information about MD notification related to changes in condition and that the main expectation she had from the nurses is that they notify the MD for changes in condition as soon as possible. Continued interview with the DON at that time, she stated that having loose stools was a change in condition that required MD notification. DON further said that she looked at the MD orders every day including the laboratory results and that she does daily rounds including the dining room during most meals. Surveyor asked DON if nurses talked to her about the condition of CR #1 and the DON responded Yes, I talked to them, CR #1 was having some diarrhea, we were concerned about it but it wasn't proven to be [MEDICAL CONDITION]. Further interview with the DON, she stated that LVN A was in charge of updating the care plans and that care plans were supposed to be updated if the residents had a change in condition. When asked if CR #1's care plan was updated related the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness, the DON said as she flipped thru document I do not see it, I do not see her care plan updated. When asked about who was supposed to collect the specimens for residents and follow up on the laboratory results, the DON said that the night shift nurses were supposed to collect the urine samples and that the stool samples any nurse, as soon as the MD gives the order, any nurse is supposed to collect the specimen as soon as the resident has the bowel movement. When the laboratory sends any document to the facility, the nurses are supposed to follow up with the reports and not to put the reports on the chart until they had finished with the MD notifications and the orders. Continued interview with the DON at that time, when asked how did she think this incident of immediate jeopardy came about, the DON responded It got missed, the laboratory orders, human error but from this second on, I will be all over the charts, I will make 3 copies of the orders and everybody will get copies, we will go over the information on the meetings and will designate the hallways to department heads. When asked if she believed there was a problem with how the facility handled the changes in conditions of the residents, the DON responded CR#1 did not talk, we had to watch her, something was not right, we knew something was going on. Yes, there were things that were missed. When surveyor asked if staff review the bowel record of residents and if she had seen the bowel record of CR#1, the DON responded as she flipped thru CR #1's bowel record documentation I see it, OK, I will have somebody monitoring these records every day. We have shift to shift reports from the nursing staff but there is no system where they can write it down. Loose stools is a change in condition that needed to be reported to the MD in a perfect world. In an interview on [DATE] at 10:05 a.m. with the Administrator, he stated that the main tool the facility has to make sure the needs of the residents are being met is the everyday morning meetings because that where staff review the 24 hour report, orders, laboratory reports and other important information about the residents. He further said that department heads attending the meetings were the DON, Assistant DON, MDS nurse, Care Plan Nurse, dietary, therapy and the wound care nurse. When asked if information regarding the condition of CR #1 was ever discussed on the morning meetings, the Administrator stated what I remember is that she was having difficulty eating and the CNA's were feeding her and I knew that her weight was stable but I do not remember any discussion about her diarrhea or loose stools. I don't remember any specific information about the [MEDICAL CONDITION] or about any laboratory reports. If we had known that her laboratory order was missed, we would had done something. Since yesterday, we put things in place to monitor patients' condition. I was not keeping a task list. Going forward, I will have a task list that will be about who is doing what. We had it but we were not writing information down and by 4:00 p.m. I would forget, but the new plan will be to have a task list. Further interview with the Administrator at that time, he stated that he makes rounds up to 8 times a day o

Based on observation, interview, and record review, the facility failed to provide services in accordance with the written Plan of Care for one of nine residents (CR #1) reviewed for compliance with physician's orders [REDACTED]. -The facility failed to follow up on a stool specimen for [MEDICAL CONDITION] (a spore-forming bacterium that causes an infectious diarrhea) that the laboratory required to be recollected for CR #1 that the MD had ordered. -The facility failed to follow on the second MD order to collect a stool sample to identify [MEDICAL CONDITION] on CR #1 who was having loose stools. -CR #1 was admitted to the hospital with [REDACTED]. CR #1 expired at the hospital after 6 days of admission. An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. This failure affected one former resident (CR #1) who died after being admitted to the hospital and has the potential to affect the 66 residents residing at the facility at risk for not receiving the care and services ordered by the physician and a decline in health status including death. Complaint # 0 Findings include: Record review of the facility face sheet for CR #1 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Admission [DIAGNOSES REDACTED]. CR #1 was sent to the emergency roiagnom on [DATE] for evaluation and treatment of [REDACTED]. CR #1 died at the hospital on [DATE]. Record review of CR #1's quarterly MDS, dated [DATE], revealed CR #1 was not able to complete the interview for BIMS evaluation, she was sometimes able to make herself understood and was sometimes able to understand others. CR #1 required extensive assistance of 2 persons for bed mobility and was total dependent on staff for transfers, toilet use, locomotion and bathing. CR #1 required extensive assistance of one person for dressing and personal hygiene. She required a wheelchair for mobility and was always incontinent of bowel and bladder. The assessment section on swallowing/nutritional status revealed no swallowing disorders and was on a mechanically altered diet. Record review of the facility's weight records for CR #1 revealed weights on: -[DATE] of 160 lbs. -[DATE] of 154 lbs. Record review of CR #1's meal percentages from [DATE] to [DATE] revealed the intake ranged from 25% to 75%. Further record review revealed no meal percentages documented for 16 times for the breakfast and the lunch meals. Record review of the facility's Consulting Dietitian Report for [DATE] to [DATE] revealed she was not evaluated by the dietitian during those dates. Further record review revealed no recommendations for the month of [DATE] for CR #1. In an interview on [DATE] at 2:48 p.m. with the DON, she stated that CR #1 had to be fed and that she was always in the dining room eating and that she noticed changes with her eating 5 to 6 days before she went to the hospital and further said before CR#1 went to the hospital her appetite decreased. Record review of CR #1's Bowel Movement Report recorded by the nursing assistants revealed in part: -[DATE] one episode of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium and one large loose bowel movement. -[DATE] one episode of small and two mediums loose bowel movements. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium, one large loose bowel movement and another medium putty like stool. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] two episodes of medium and one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium and two large loose bowel movements. -[DATE] two episodes of medium and one large loose bowel movement. -[DATE] two episodes of large loose bowel movement. Record review of CR #1's care plan revised [DATE] revealed in part: -Focus: CR #1 has potential fluid deficit related to diuretic use ([MEDICATION NAME]-[MEDICATION NAME] 37XXX,[DATE]mg ordered on [DATE] for [MEDICAL CONDITION]). -Goal: CR#1 will be free of symptoms of dehydration -Interventions: Notify MD if persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours, obtain and monitor laboratories/diagnostic work as ordered. Report results to MD and follow up as indicated. Further record review revealed no information on the entire care plan of CR #1 episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness or interventions to improve, or prevent further decline. Record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 9:33 pm: .CR #1 had loose brown bowel movement with mucous. No foul odor noted. Called Nurse Practitioner on call for MD with orders to monitor bowel movement and to collect a stool specimen. Record review of the verbal MD order dated [DATE] at 9:15 p.m. revealed an order for [REDACTED]. -[DATE] at 12:55 p.m Daily skilled note in part: - G.I.: poor appetite, vomiting, hypoactive bowel sounds. Ate only few bites of lunch today before she made herself vomit -[DATE] at 4:05 p.m. CR #1 has new orders for stool specimen collection to rule out [MEDICAL CONDITION]. Specimen collected and is in med room fridge. Strong/foul odor noted, mucous with seedy appearance noted on the bowel movement. Patient with emesis noted during breakfast and refusal of alternate breakfast as well as lunch . Further record review of Daily skilled note in part: - G.I.: poor appetite, vomiting diarrhea. Increased of bowel, foul odor present, mucous and seedy appearance. -[DATE] at 8:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, diarrhea, hyperactive bowel sounds. CR #1 has been having loose stools. Neuromuscular: Wheelchair - weakness, deterioration. -[DATE] at 09:07 am: CR #1 did not eat breakfast, states I am not hungry. -[DATE] at 12:31 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing, diarrhea. Hyperactive bowel sounds. Neuro/muscular: weakness, deterioration. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 12:46 p.m. read in part: .Draw date: [DATE]. - Stool Culture results: No Salmonella, Shigella, Campylobacter isolated, Pathogenic Escherichia coli or Shiga Toxins 1 or 2 detected. Further record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 5:49 p.m. Daily skilled note in part: - G.I.: diarrhea, hyperactive bowel sounds. Received new order to repeat stool collection for [MEDICAL CONDITION] and culture and sensitivity . Record review of the facility's Complaint Resolution Record dated [DATE], given by CR#1's family member, received by the DON and signed by the Administrator revealed in part: .Resident's Name: CR #1. Staff receiving report: DON. - Concern: Diarrhea for a week, no [MEDICATION NAME] (anti-diarrheal). - Action taken: Explained how [MEDICAL CONDITION] works and contraindication of giving [MEDICATION NAME]. Informed her of negative [MEDICAL CONDITION] result and CR #1 refusing to get up . Further record review revealed that DON signed report on [DATE] and Administrator signed report on [DATE]. Record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 10:23 a.m. Can we have an order to repeat stool specimen collection and testing? Stools are loose/liquid, foamy and seedy appearance. Further record review revealed MD written order dated [DATE] -[MEDICAL CONDITION] and stool for culture and sensitivity. Continued record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 4:45 p.m. Daily skilled note in part: - G.I.: Diarrhea. Night nurse to collect stool for Wednesday. -[DATE] at 2:01 a.m. CR#1 did not produce a bowel movement before laboratory pick up. Further record review of Daily skilled note in part: - Neuromuscular - weakness. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 10:50 a.m. read in part: .for stool specimen drawn [DATE] Specimen unacceptable for testing. Rejected order, routine: - What test was rejected? [MEDICAL CONDITION]. - Reject reason: Please recollect for [MEDICAL CONDITION]. -[DATE] at 3:18 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing and hyperactive bowel sounds. -[DATE] at 6:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake and difficulty chewing. -[DATE] at 4:13 p.m: .CR #1 went to appointment today with new orders for complete metabolic panel to be done on Monday ([DATE]) and to return to clinic in 2 months. Record review of CR #1's comprehensive Metabolic Panel dated [DATE] and faxed to MD on [DATE] at 5:45 p.m. revealed in part: -BUN (blood urea nitrogen, test that reveals how kidneys are working) 38 High (Reference range ,[DATE] mg/dL) -Creatinine (evaluates kidney function) 1.16 (Reference range 0XXX,[DATE].20 mg/dL). Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: Not feeling good. Further record review revealed that Gastrointestinal exam was not conducted by the MD. Continued record review revealed - Assessment [DIAGNOSES REDACTED]. Return to clinic in 2 months. Further record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 10:05 a.m. Daily skilled note in part: - CR #1 has to have extra encouragement during meals to eat. -[DATE] at 6:56 a.m.: CR #1 does not help with being transferred, she is dead weight. Will not stand or pivot to assist with transfers. -[DATE] at 9:40 a.m.: Received an order for [REDACTED]. Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: cough, congestion and nasal drainage. Further record review revealed that Gastrointestinal exam was not conducted by the MD. - [DIAGNOSES REDACTED]. Plan: [MEDICATION NAME] 500 mg by mouth every day for 10 days, chest x-ray and [MEDICATION NAME] 10 mg by mouth for 10 days. Continued record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 10:07 a.m: CR #1 still not eating well. -[DATE] at 10:25 a.m.: CR #1 is not eating well only eating 25% or less of meals. Further record review of the nursing progress notes revealed no MD notification on the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness. -[DATE] at 4:26 p.m: Received fax from CR #1's MD with orders to send CR#1 to the hospital for evaluation and treatment for [REDACTED]. Further record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 7:30 a.m. .CR #1 noted to have watery brown stool. CR #1 also noted to have excoriated buttocks and perineal area. Further record review revealed MD order dated [DATE] at 4:00 p.m. Sent to emergency room for evaluation of possible dehydration and stool for [MEDICAL CONDITION]. Record review of CR #1's Emergency physician record dated [DATE] at 4:47 p.m. revealed in part: .- History of present illness: Generalized weakness. Onset/duration: unknown. History of diarrhea. - Physical exam: lethargic, dry mucous membranes, [MEDICAL CONDITION](fast heart rate).[MEDICAL CONDITION], dehydration. Intravenous fluids Normal Saline bolus of 2000 ml. [MEDICATION NAME] (antibiotic) 1 gram Intravenous and Cefepinie (antibiotic) 1 gram Intravenous. Stool for [MEDICAL CONDITION]. Further record review of CR #1's hospital history and physical dated [DATE] at 10:17 p.m. revealed in part: .Chief complaint: Generalized weakness. [AGE] year old female who present from the nursing home. Family reports diminished appetite. Then over the last day or so developed by the nurses notes, some loose stools associated with some excoriation and a decrease in her normal level of interaction. On [MEDICATION NAME] (antibiotic) 500 mg since [DATE]th for a cough. Vital signs: emergency room blood pressure ,[DATE]. Currently after 3 liters of fluid in the emergency room , blood pressure is very low between ,[DATE] and ,[DATE] with heart rate of 133. Mouth is dry. Abdomen is distended, diffusely tender. She has got some early flexion contractures of her knees and her hips. - Laboratories: [MEDICAL CONDITION] was positive. White blood cells count of 61.3 Critical High (Reference range 4XXX,[DATE].8), BUN (blood urea nitrogen, test that reveals how kidneys are working) 74 Critical High (Reference range ,[DATE] mg/dL) and creatinine (evaluates kidney function) 2.8 (Reference range 0XXX,[DATE].0). - Assessment: 1.- [MEDICAL CONDITION]. She has got 3 liters of fluid in the Emergency Department with improvement of her blood pressure, though is not stabilized at this point. We will continue intravenous fluids overnight tonight. 2.- [MEDICAL CONDITIONS], likely the source of [MEDICAL CONDITION]. We will put her on [MEDICATION NAME] (antibiotic) as well as oral [MEDICATION NAME] (antibiotic). -Did discuss with the daughter that was present this evening that the patient was severely ill and we would have a much clearer picture the next 12 - 24 hours on her ability to survive, given the degree of [MEDICAL CONDITION] and volume resuscitation. 8.- Acute [MEDICAL CONDITION] on top of [MEDICAL CONDITION]. Again due to her dehydration. We will continue fluids. Record review of CR #1's discharge summary from the hospital dated [DATE] at 1:46 p.m. revealed in part: Final discharge Diagnoses: [REDACTED]. - Hospital course: The patient was admitted and started on intravenous [MEDICATION NAME] as well as oral [MEDICATION NAME]. White count was 61,000 on admission. This did slowly improved; however, by mouth intake was extremely poor. Ultimately, the patient continued to decline clinically, having blood pressures that were running lower and urine output that was significantly less despite being on brisk intravenous resuscitation. White counts did improve with the intravenous and oral antibiotics that she was receiving; however, due to her overall decline, I contacted the patient's family to discuss inpatient hospice services. She was admitted to hospice on [DATE]. Further record review of discharge summary dated [DATE] at 1:58 p.m. revealed that CR#1 died in the hospital on [DATE] at 12:16 p.m. In an interview on [DATE] at 1:14 p.m. with the DON, she stated that she did not know what happened to the stool specimen that was supposed to be recollected for CR #1 on [DATE]. She further stated that she did not know why the specimen was rejected by the Laboratory on [DATE] and that she thought that CR #1's stool was negative for [MEDICAL CONDITION] and further said I thought I read somewhere that her stool was negative for [MEDICAL CONDITION]. When asked to look thru CR #1's chart to see if she could find any [MEDICAL CONDITION] laboratory results, the DON responded as she flipped thru the chart It looks that she did not get a [MEDICAL CONDITION] test in the facility. I don't know what happened with the laboratory test for the stool, I will find out. Do not know why was rejected. When asked if CR #1 got her stool collected on [DATE] after the MD gave orders again to check for [MEDICAL CONDITION], DON responded well, there is a nurses note on [DATE] that the stool specimen was not available . DON then left and said she was going to call the laboratory. In an interview on [DATE] at 1:24 p.m. with LVN A, she stated that she was the Care plan nurse and that she would review the care plans every 92 days in the computer and would update the care plans as needed if there is a change in condition on the residents. She further said that there was a communication board in the computer system where the nurses would write information if the residents had a change in condition. LVN A said that also during the morning meetings, the department heads would talk about changes in condition and that she would get the information from there to update the care plans as well. LVN A continued saying that she had spoken to the DON about who would actually be doing changes in the care plans because she was only working part time and that the DON has not come up with a concise decision yet. When asked if CR #1 had any changes in condition that she needed to update on the care plan, LVN A responded CR #1 only had an upper respiratory infection on [DATE] Continued interview with LVN A, she stated that she was not aware of CR #1 having any issues with diarrhea or poor appetite and further said We are in the process with the infection control nurse about how we are going to communicate infections of residents. We have a new tool in the computer system for changes in condition but not sure if staff is really writing on it. In a phone interview on [DATE] at 3:10 p.m. with CR #1's family member, she stated that another family member brought CR #1 to the MD on [DATE] because the family saw how sick CR #1 was and further said She was having diarrhea and was deteriorating. She was eating less and less, her appetite was decreasing, she was really sick until she was sent to the hospital. CR #1 would not move anymore, she was not drinking or eating and she was having severe diarrhea. I was told by the facility that the stool studies were negative but they did not show me any reports. Then when I went to see her at the facility, she did not look good and she was diagnosed at the hospital with [MEDICAL CONDITION]. In an interview on [DATE] at 3:40 p.m. with the DON, she stated that she still did not hear from the laboratory yet about why the stool specimen for CR#1 was rejected on [DATE] and further said I was not aware that the stool specimen was rejected until today when you asked for it. I knew about that there were concerns about CR#1 having loose stools but don't know information in detail. DON further said that she did not know that CR #1 had any problems with her appetite and that she believed that CR #1 was gaining weight. Surveyor requested DON all weights for CR#1. When asked if she was aware that the MD ordered for second time a stool specimen for CR #1 on [DATE], the DON responded I can't say I saw the order. DON did not provide additional weight records for CR #1 to surveyor by the time of exit. Further interview with the DON, she stated that CR #1 went to the hospital because the MD thought that CR #1 was dehydrated and said CR #1 was on antibiotics for upper respiratory infection, I don't know that she was having loose stools. When asked if she knew what had happened to CR #1, the DON responded She did eventually die, don't know when and did not see a death certificate. She did not come back to the facility. Even though that CR #1's family member works here part time on the weekends, she didn't stay in touch with us. We did not get information about CR #1. We knew CR #1 was in Intensive Care Unit but the hospital would not tell us the reason of her admission. If I was told her [DIAGNOSES REDACTED]. DON continued saying that she was not able to find another stool specimen report for CR #1 after it was rejected by the Laboratory on [DATE] and that she did not know why the specimen was rejected by the Laboratory. In an interview on [DATE] at 11:31 a.m. with CNA B, she stated that she worked with CR #1 at least twice a week and that the last two weeks before CR #1 went to the hospital, her appetite decreased and that she was more weak and that when CR #1 was up on her chair, she would leaned to the sides and forwards down. When asked about CR #1's stool consistency, CNA B stated her stools were loose. I did report the loose stools to the nurses but I also wrote it on the computer and they are supposed to see it. When asked if she reported CR#1's poor appetite, CNA B responded Nurses knew about her appetite because CR #1 would eat in the dining room. CNA B further said that changes in condition are reported to the nurses verbally and that there was no paper forms to report changes in condition that she was aware of. In an interview on [DATE] at 11:55 a.m. with LVN F, she stated that she was the ADON and wound care nurse. She further stated that CNA's report changes in condition verbally to the nurses and that there was a way in the computer system for CNA's to document changes in condition. LVN F further said that she only heard about CR #1 having diarrhea or loose stools just before she went to the hospital. She continued saying that information on the 24 hour report is reviewed during the morning meetings and that she did not remember any discussion about CR #1's condition. LVN F continued saying that just before CR #1 went to the hospital, they had discussed her poor appetite and eating but nothing about her diarrhea. In an interview on [DATE] at 12:02 p.m. with CNA C, she stated that she was the shower Aide but worked on the floor as well. CNA C further said I gave showers to CR #1 three times a week and I kept telling the nurses about the foul odor and color of her stools. CR #1's stools were yellow, slimy and had the distinctive foul odor, I kept telling the charge nurses about it for about 3 weeks before CR #1 went to the hospital. Every time I would bring her to the shower room, her stools were loose, strong foul odor, runny, slimy and yellow. I would report to the nurses every time. CR #1's appetite declined really bad. Her daughter would come and help her but CR #1 would not eat at all and she started getting the cracks on her mouth. CR #1 started leaning to the sides and then forwards when in the wheelchair during that time that she had the diarrhea and her poor appetite then the facility got an order for [REDACTED]. In an interview on [DATE] at 12:28 p.m. with LVN D, she stated that she was a full time charge nurse and that she worked with CR #1 and that CNA's would report changes in condition verbally to the nurses and that she believed there was a way of documenting changes in condition in the computer system but she was not sure if the staff had been trained about it. LVN D continued saying that she was the nurse that sent CR #1 to the hospital because she was acting abnormal, shaking and was hollering. LVN D further said I believe CR#1 had a negative stool for [MEDICAL CONDITION]. Surveyor asked LVN D to review the records of CR #1 and find the laboratory results that showed that her stools were negative for [MEDICAL CONDITION] and LVN D responded well, I need to go to the laboratory book. Further interview with LVN D, she stated that CR #1 wasn't really eating and was having loose stools and said 3 to 4 weeks before CR #1 went to the hospital, she would not eat. When asked if she notified the MD regarding CR #1's episodes of loose stools and low appetite, LVN D responded we send faxes to the MD, there were faxes. Surveyor asked LVN D to review the records of CR#1 and provide surveyor with documentation about the times the facility notified the MD of CR #1's poor appetite and episodes of loose stools. Further interview and observation at that time, LVN D flipped thru papers and said Well, I am not 100% positive the MD was made aware. I don't remember myself notifying the MD regarding her low appetite or the continuation of the diarrhea, but remember seeing some faxes about CR #1. I don't see them now. In an interview on [DATE] at 12:58 p.m. with LVN E, she stated that she worked with CR #1 and that she was the charge nurse and further said the Aides would tell me that CR #1 was having diarrhea but I asked CR #1's daughter about collecting a stool sample and the daughter refused, I just did not document that information. LVN E continued saying I believe CR #1 went to the doctor but I am not sure if she had any stool sample tested there. CR #1 was also discharged from therapy because she was not cooperating. When asked regarding the nurses notes written by her on [DATE] and [DATE] that talked about CR #1 not eating well, LVN E responded I believe the MD was faxed about it, I remember telling the oncoming nurse about it and to notify the MD about CR #1's not eating but don't remember who was the nurse and I did not checked back to see if the MD was notified. We are lacking on the communication to one and another like for changes in condition, to make sure we follow up on the conditions and notifications to the MD. I don't remember notifying the MD about her appetite and I did not know any information about the stool sample that needed to be recollected again. I believe that's where we need work on because some of the papers just get filed and not followed up. LVN E further said that she was not involved in the care planning of the residents and that LVN A was in charge of updating the care plans for changes in condition and that she did not notify her of CR #1's poor appetite and episodes of loose stools. Further interview on [DATE] at 2:05 p.m. with the DON, she stated that she expected the CNA's to notify the nurses verbally of any changes in condition and that there was no paper form for the CNA's to document changes in condition and that the nurses were supposed to report to the MD changes of condition as soon as possible. DON further stated that she had not done any formal training on [MEDICAL CONDITION] infections, that she only talked to the nurses about it and gave some literature about the infection but did not have a sign in form or course content of the discussion because was more like a conversation. DON continued saying that on September she did a training on abuse and neglect and that she discussed about changes in the condition of the residents because abuse and neglect could lead to a changed in condition on a resident. DON further said that they discussed on the training information about MD notification related to changes in condition and that the main expectation she had from the nurses is that they notify the MD for changes in condition as soon as possible. Continued interview with the DON at that time, she stated that having loose stools was a change in condition that required MD notification. DON further said that she looked at the MD orders every day including the laboratory results and that she does daily rounds including the dining room during most meals. Surveyor asked DON if nurses talked to her about the condition of CR #1 and the DON responded Yes, I talked to them, CR #1 was having some diarrhea, we were concerned about it but it wasn't proven to be [MEDICAL CONDITION]. Further interview with the DON, she stated that LVN A was in charge of updating the care plans and that care plans were supposed to be updated if the residents had a change in condition. When asked if CR #1's care plan was updated related the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness, the DON said as she flipped thru document I do not see it, I do not see her care plan updated. When asked about who was supposed to collect the specimens for residents and follow up on the laboratory results, the DON said that the night shift nurses were supposed to collect the urine samples and that the stool samples any nurse, as soon as the MD gives the order, any nurse is supposed to collect the specimen as soon as the resident has the bowel movement. When the laboratory sends any document to the facility, the nurses are supposed to follow up with the reports and not to put the reports on the chart until they had finished with the MD notifications and the orders. Continued interview with the DON at that time, when asked how did she think this incident of immediate jeopardy came about, the DON responded It got missed, the laboratory orders, human error but from this second on, I will be all over the charts, I will make 3 copies of the orders and everybody will get copies, we will go over the information on the meetings and will designate the hallways to department heads. When asked if she believed there was a problem with how the facility handled the changes in conditions of the residents, the DON responded CR#1 did not talk, we had to watch her, something was not right, we knew something was going on. Yes, there were things that were missed. When surveyor asked if staff review the bowel record of residents and if she had seen the bowel record of CR#1, the DON responded as she flipped thru CR #1's bowel record documentation I see it, OK, I will have somebody monitoring these records every day. We have shift to shift reports from the nursing staff but there is no system where they can write it down. Loose stools is a change in condition that needed to be reported to the MD in a perfect world. In an interview on [DATE] at 10:05 a.m. with the Administrator, he stated that the main tool the facility has to make sure the needs of the residents are being met is the everyday morning meetings because that where staff review the 24 hour report, orders, laboratory reports and other important information about the residents. He further said that department heads attending the meetings were the DON, Assistant DON, MDS nurse, Care Plan Nurse, dietary, therapy and the wound care nurse. When asked if information regarding the condition of CR #1 was ever discussed on the morning meetings, the Administrator stated what I remember is that she was having difficulty eating and the CNA's were feeding her and I knew that her weight was stable but I do not remember any discussion about her diarrhea or loose stools. I don't remember any specific information about the [MEDICAL CONDITION] or about any laboratory reports. If we had known that her laboratory order was missed, we would had done something. Since yesterday, we put things in place to monitor patients' condition. I was not keeping a task list. Going forward, I will have a task list that will be about who is doing what. We had it but we were not writing information down and by 4:00 p.m. I would forget, but the new plan will be to have a task list. Further interview with the Admini

Based on interview and record review the facility failed to ensure that one of nine residents (CR #1) reviewed for care provided, were provided care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care, as evidenced by: -The facility failed to have a system in place to assess, identify and treat residents with [MEDICAL CONDITION] infections. CR #1 had continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness on and off for 31 days without interventions placed on the care plan to improve or prevent further decline. In addition, the facility failed to follow up on a stool specimen for [MEDICAL CONDITION] (a spore-forming bacterium that causes an infectious diarrhea) that the laboratory required to be recollected for CR #1 that the MD had ordered. The facility failed to follow on the second MD order to collect a stool sample to identify [MEDICAL CONDITION]. --The facility failed to have an effective communication system between nursing assistants, nurses and the MD related to changes in residents' conditions. The MD was not consulted and updated on CR#1's condition. CR #1 was admitted to the hospital with [REDACTED]. CR #1 expired at the hospital after 6 days of admission. An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. This failure affected one former resident (CR#1) who died after being admitted to the hospital and could place 7 residents at the facility identified with infections at risk of not receiving adequate assessments, medical care, pain, decline in their health condition well-being and death. Complaint # 0 Findings include: Record review of the facility face sheet for CR #1 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Admission [DIAGNOSES REDACTED]. CR #1 was sent to the emergency roiagnom on [DATE] for evaluation and treatment of [REDACTED]. CR #1 died at the hospital on [DATE]. Record review of CR #1's quarterly MDS, dated [DATE], revealed CR #1 was not able to complete the interview for BIMS evaluation, she was sometimes able to make herself understood and was sometimes able to understand others. CR #1 required extensive assistance of 2 persons for bed mobility and was total dependent on staff for transfers, toilet use, locomotion and bathing. CR #1 required extensive assistance of one person for dressing and personal hygiene. She required a wheelchair for mobility and was always incontinent of bowel and bladder. The assessment section on swallowing/nutritional status revealed no swallowing disorders and was on a mechanically altered diet. Record review of the facility's weight records for CR #1 revealed weights on: -[DATE] of 160 lbs. -[DATE] of 154 lbs. Record review of CR #1's meal percentages from [DATE] to [DATE] revealed the intake ranged from 25% to 75%. Further record review revealed no meal percentages documented for 16 times for the breakfast and the lunch meals. Record review of the facility's Consulting Dietitian Report for [DATE] to [DATE] revealed she was not evaluated by the dietitian during those dates. Further record review revealed no recommendations for the month of [DATE] for CR #1. In an interview on [DATE] at 2:48 p.m. with the DON, she stated that CR #1 had to be fed and that she was always in the dining room eating and that she noticed changes with her eating 5 to 6 days before she went to the hospital and further said before CR#1 went to the hospital her appetite decreased. Record review of CR #1's Bowel Movement Report recorded by the nursing assistants revealed in part: -[DATE] one episode of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium and one large loose bowel movement. -[DATE] one episode of small and two mediums loose bowel movements. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium, one large loose bowel movement and another medium putty like stool. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] two episodes of medium and one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium and two large loose bowel movements. -[DATE] two episodes of medium and one large loose bowel movement. -[DATE] two episodes of large loose bowel movement. Record review of CR #1's care plan revised [DATE] revealed in part: -Focus: CR #1 has potential fluid deficit related to diuretic use ([MEDICATION NAME]-[MEDICATION NAME] 37XXX,[DATE]mg ordered on [DATE] for [MEDICAL CONDITION]). -Goal: CR#1 will be free of symptoms of dehydration -Interventions: Notify MD if persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours, obtain and monitor laboratories/diagnostic work as ordered. Report results to MD and follow up as indicated. Further record review revealed no information on the entire care plan of CR #1 episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness or interventions to improve, or prevent further decline. Record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 9:33 pm: .CR #1 had loose brown bowel movement with mucous. No foul odor noted. Called Nurse Practitioner on call for MD with orders to monitor bowel movement and to collect a stool specimen. Record review of the verbal MD order dated [DATE] at 9:15 p.m. revealed an order for [REDACTED]. -[DATE] at 12:55 p.m Daily skilled note in part: - G.I.: poor appetite, vomiting, hypoactive bowel sounds. Ate only few bites of lunch today before she made herself vomit -[DATE] at 4:05 p.m. CR #1 has new orders for stool specimen collection to rule out [MEDICAL CONDITION]. Specimen collected and is in med room fridge. Strong/foul odor noted, mucous with seedy appearance noted on the bowel movement. Patient with emesis noted during breakfast and refusal of alternate breakfast as well as lunch . Further record review of Daily skilled note in part: - G.I.: poor appetite, vomiting diarrhea. Increased of bowel, foul odor present, mucous and seedy appearance. -[DATE] at 8:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, diarrhea, hyperactive bowel sounds. CR #1 has been having loose stools. Neuromuscular: Wheelchair - weakness, deterioration. -[DATE] at 09:07 am: CR #1 did not eat breakfast, states I am not hungry. -[DATE] at 12:31 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing, diarrhea. Hyperactive bowel sounds. Neuro/muscular: weakness, deterioration. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 12:46 p.m. read in part: .Draw date: [DATE]. - Stool Culture results: No Salmonella, Shigella, Campylobacter isolated, Pathogenic Escherichia coli or Shiga Toxins 1 or 2 detected. Further record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 5:49 p.m. Daily skilled note in part: - G.I.: diarrhea, hyperactive bowel sounds. Received new order to repeat stool collection for [MEDICAL CONDITION] and culture and sensitivity . Record review of the facility's Complaint Resolution Record dated [DATE], given by CR#1's family member, received by the DON and signed by the Administrator revealed in part: .Resident's Name: CR #1. Staff receiving report: DON. - Concern: Diarrhea for a week, no [MEDICATION NAME] (anti-diarrheal). - Action taken: Explained how [MEDICAL CONDITION] works and contraindication of giving [MEDICATION NAME]. Informed her of negative [MEDICAL CONDITION] result and CR #1 refusing to get up . Further record review revealed that DON signed report on [DATE] and Administrator signed report on [DATE]. Record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 10:23 a.m. Can we have an order to repeat stool specimen collection and testing? Stools are loose/liquid, foamy and seedy appearance. Further record review revealed MD written order dated [DATE] -[MEDICAL CONDITION] and stool for culture and sensitivity. Continued record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 4:45 p.m. Daily skilled note in part: - G.I.: Diarrhea. Night nurse to collect stool for Wednesday. -[DATE] at 2:01 a.m. CR#1 did not produce a bowel movement before laboratory pick up. Further record review of Daily skilled note in part: - Neuromuscular - weakness. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 10:50 a.m. read in part: .for stool specimen drawn [DATE] Specimen unacceptable for testing. Rejected order, routine: - What test was rejected? [MEDICAL CONDITION]. - Reject reason: Please recollect for [MEDICAL CONDITION]. -[DATE] at 3:18 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing and hyperactive bowel sounds. -[DATE] at 6:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake and difficulty chewing. -[DATE] at 4:13 p.m: .CR #1 went to appointment today with new orders for complete metabolic panel to be done on Monday ([DATE]) and to return to clinic in 2 months. Record review of CR #1's comprehensive Metabolic Panel dated [DATE] and faxed to MD on [DATE] at 5:45 p.m. revealed in part: -BUN (blood urea nitrogen, test that reveals how kidneys are working) 38 High (Reference range ,[DATE] mg/dL) -Creatinine (evaluates kidney function) 1.16 (Reference range 0XXX,[DATE].20 mg/dL). Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: Not feeling good. Further record review revealed that Gastrointestinal exam was not conducted by the MD. Continued record review revealed - Assessment [DIAGNOSES REDACTED]. Return to clinic in 2 months. Further record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 10:05 a.m. Daily skilled note in part: - CR #1 has to have extra encouragement during meals to eat. -[DATE] at 6:56 a.m.: CR #1 does not help with being transferred, she is dead weight. Will not stand or pivot to assist with transfers. -[DATE] at 9:40 a.m.: Received an order for [REDACTED]. Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: cough, congestion and nasal drainage. Further record review revealed that Gastrointestinal exam was not conducted by the MD. - [DIAGNOSES REDACTED]. Plan: [MEDICATION NAME] 500 mg by mouth every day for 10 days, chest x-ray and [MEDICATION NAME] 10 mg by mouth for 10 days. Continued record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 10:07 a.m: CR #1 still not eating well. -[DATE] at 10:25 a.m.: CR #1 is not eating well only eating 25% or less of meals. Further record review of the nursing progress notes revealed no MD notification on the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness. -[DATE] at 4:26 p.m: Received fax from CR #1's MD with orders to send CR#1 to the hospital for evaluation and treatment for [REDACTED]. Further record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 7:30 a.m. .CR #1 noted to have watery brown stool. CR #1 also noted to have excoriated buttocks and perineal area. Further record review revealed MD order dated [DATE] at 4:00 p.m. Sent to emergency room for evaluation of possible dehydration and stool for [MEDICAL CONDITION]. Record review of CR #1's Emergency physician record dated [DATE] at 4:47 p.m. revealed in part: .- History of present illness: Generalized weakness. Onset/duration: unknown. History of diarrhea. - Physical exam: lethargic, dry mucous membranes, [MEDICAL CONDITION](fast heart rate).[MEDICAL CONDITION], dehydration. Intravenous fluids Normal Saline bolus of 2000 ml. [MEDICATION NAME] (antibiotic) 1 gram Intravenous and Cefepinie (antibiotic) 1 gram Intravenous. Stool for [MEDICAL CONDITION]. Further record review of CR #1's hospital history and physical dated [DATE] at 10:17 p.m. revealed in part: .Chief complaint: Generalized weakness. [AGE] year old female who present from the nursing home. Family reports diminished appetite. Then over the last day or so developed by the nurses notes, some loose stools associated with some excoriation and a decrease in her normal level of interaction. On [MEDICATION NAME] (antibiotic) 500 mg since [DATE]th for a cough. Vital signs: emergency room blood pressure ,[DATE]. Currently after 3 liters of fluid in the emergency room , blood pressure is very low between ,[DATE] and ,[DATE] with heart rate of 133. Mouth is dry. Abdomen is distended, diffusely tender. She has got some early flexion contractures of her knees and her hips. - Laboratories: [MEDICAL CONDITION] was positive. White blood cells count of 61.3 Critical High (Reference range 4XXX,[DATE].8), BUN (blood urea nitrogen, test that reveals how kidneys are working) 74 Critical High (Reference range ,[DATE] mg/dL) and creatinine (evaluates kidney function) 2.8 (Reference range 0XXX,[DATE].0). - Assessment: 1.- [MEDICAL CONDITION]. She has got 3 liters of fluid in the Emergency Department with improvement of her blood pressure, though is not stabilized at this point. We will continue intravenous fluids overnight tonight. 2.- [MEDICAL CONDITIONS], likely the source of [MEDICAL CONDITION]. We will put her on [MEDICATION NAME] (antibiotic) as well as oral [MEDICATION NAME] (antibiotic). -Did discuss with the daughter that was present this evening that the patient was severely ill and we would have a much clearer picture the next 12 - 24 hours on her ability to survive, given the degree of [MEDICAL CONDITION] and volume resuscitation. 8.- Acute [MEDICAL CONDITION] on top of [MEDICAL CONDITION]. Again due to her dehydration. We will continue fluids. Record review of CR #1's discharge summary from the hospital dated [DATE] at 1:46 p.m. revealed in part: Final discharge Diagnoses: [REDACTED]. - Hospital course: The patient was admitted and started on intravenous [MEDICATION NAME] as well as oral [MEDICATION NAME]. White count was 61,000 on admission. This did slowly improved; however, by mouth intake was extremely poor. Ultimately, the patient continued to decline clinically, having blood pressures that were running lower and urine output that was significantly less despite being on brisk intravenous resuscitation. White counts did improve with the intravenous and oral antibiotics that she was receiving; however, due to her overall decline, I contacted the patient's family to discuss inpatient hospice services. She was admitted to hospice on [DATE]. Further record review of discharge summary dated [DATE] at 1:58 p.m. revealed that CR#1 died in the hospital on [DATE] at 12:16 p.m. In an interview on [DATE] at 1:14 p.m. with the DON, she stated that she did not know what happened to the stool specimen that was supposed to be recollected for CR #1 on [DATE]. She further stated that she did not know why the specimen was rejected by the Laboratory on [DATE] and that she thought that CR #1's stool was negative for [MEDICAL CONDITION] and further said I thought I read somewhere that her stool was negative for [MEDICAL CONDITION]. When asked to look thru CR #1's chart to see if she could find any [MEDICAL CONDITION] laboratory results, the DON responded as she flipped thru the chart It looks that she did not get a [MEDICAL CONDITION] test in the facility. I don't know what happened with the laboratory test for the stool, I will find out. Do not know why was rejected. When asked if CR #1 got her stool collected on [DATE] after the MD gave orders again to check for [MEDICAL CONDITION], DON responded well, there is a nurses note on [DATE] that the stool specimen was not available . DON then left and said she was going to call the laboratory. In an interview on [DATE] at 1:24 p.m. with LVN A, she stated that she was the Care plan nurse and that she would review the care plans every 92 days in the computer and would update the care plans as needed if there is a change in condition on the residents. She further said that there was a communication board in the computer system where the nurses would write information if the residents had a change in condition. LVN A said that also during the morning meetings, the department heads would talk about changes in condition and that she would get the information from there to update the care plans as well. LVN A continued saying that she had spoken to the DON about who would actually be doing changes in the care plans because she was only working part time and that the DON has not come up with a concise decision yet. When asked if CR #1 had any changes in condition that she needed to update on the care plan, LVN A responded CR #1 only had an upper respiratory infection on [DATE] Continued interview with LVN A, she stated that she was not aware of CR #1 having any issues with diarrhea or poor appetite and further said We are in the process with the infection control nurse about how we are going to communicate infections of residents. We have a new tool in the computer system for changes in condition but not sure if staff is really writing on it. In a phone interview on [DATE] at 3:10 p.m. with CR #1's family member, she stated that another family member brought CR #1 to the MD on [DATE] because the family saw how sick CR #1 was and further said She was having diarrhea and was deteriorating. She was eating less and less, her appetite was decreasing, she was really sick until she was sent to the hospital. CR #1 would not move anymore, she was not drinking or eating and she was having severe diarrhea. I was told by the facility that the stool studies were negative but they did not show me any reports. Then when I went to see her at the facility, she did not look good and she was diagnosed at the hospital with [MEDICAL CONDITION]. In an interview on [DATE] at 3:40 p.m. with the DON, she stated that she still did not hear from the laboratory yet about why the stool specimen for CR#1 was rejected on [DATE] and further said I was not aware that the stool specimen was rejected until today when you asked for it. I knew about that there were concerns about CR#1 having loose stools but don't know information in detail. DON further said that she did not know that CR #1 had any problems with her appetite and that she believed that CR #1 was gaining weight. Surveyor requested DON all weights for CR#1. When asked if she was aware that the MD ordered for second time a stool specimen for CR #1 on [DATE], the DON responded I can't say I saw the order. DON did not provide additional weight records for CR #1 to surveyor by the time of exit. Further interview with the DON, she stated that CR #1 went to the hospital because the MD thought that CR #1 was dehydrated and said CR #1 was on antibiotics for upper respiratory infection, I don't know that she was having loose stools. When asked if she knew what had happened to CR #1, the DON responded She did eventually die, don't know when and did not see a death certificate. She did not come back to the facility. Even though that CR #1's family member works here part time on the weekends, she didn't stay in touch with us. We did not get information about CR #1. We knew CR #1 was in Intensive Care Unit but the hospital would not tell us the reason of her admission. If I was told her [DIAGNOSES REDACTED]. DON continued saying that she was not able to find another stool specimen report for CR #1 after it was rejected by the Laboratory on [DATE] and that she did not know why the specimen was rejected by the Laboratory. In an interview on [DATE] at 11:31 a.m. with CNA B, she stated that she worked with CR #1 at least twice a week and that the last two weeks before CR #1 went to the hospital, her appetite decreased and that she was more weak and that when CR #1 was up on her chair, she would leaned to the sides and forwards down. When asked about CR #1's stool consistency, CNA B stated her stools were loose. I did report the loose stools to the nurses but I also wrote it on the computer and they are supposed to see it. When asked if she reported CR#1's poor appetite, CNA B responded Nurses knew about her appetite because CR #1 would eat in the dining room. CNA B further said that changes in condition are reported to the nurses verbally and that there was no paper forms to report changes in condition that she was aware of. In an interview on [DATE] at 11:55 a.m. with LVN F, she stated that she was the ADON and wound care nurse. She further stated that CNA's report changes in condition verbally to the nurses and that there was a way in the computer system for CNA's to document changes in condition. LVN F further said that she only heard about CR #1 having diarrhea or loose stools just before she went to the hospital. She continued saying that information on the 24 hour report is reviewed during the morning meetings and that she did not remember any discussion about CR #1's condition. LVN F continued saying that just before CR #1 went to the hospital, they had discussed her poor appetite and eating but nothing about her diarrhea. In an interview on [DATE] at 12:02 p.m. with CNA C, she stated that she was the shower Aide but worked on the floor as well. CNA C further said I gave showers to CR #1 three times a week and I kept telling the nurses about the foul odor and color of her stools. CR #1's stools were yellow, slimy and had the distinctive foul odor, I kept telling the charge nurses about it for about 3 weeks before CR #1 went to the hospital. Every time I would bring her to the shower room, her stools were loose, strong foul odor, runny, slimy and yellow. I would report to the nurses every time. CR #1's appetite declined really bad. Her daughter would come and help her but CR #1 would not eat at all and she started getting the cracks on her mouth. CR #1 started leaning to the sides and then forwards when in the wheelchair during that time that she had the diarrhea and her poor appetite then the facility got an order for [REDACTED]. In an interview on [DATE] at 12:28 p.m. with LVN D, she stated that she was a full time charge nurse and that she worked with CR #1 and that CNA's would report changes in condition verbally to the nurses and that she believed there was a way of documenting changes in condition in the computer system but she was not sure if the staff had been trained about it. LVN D continued saying that she was the nurse that sent CR #1 to the hospital because she was acting abnormal, shaking and was hollering. LVN D further said I believe CR#1 had a negative stool for [MEDICAL CONDITION]. Surveyor asked LVN D to review the records of CR #1 and find the laboratory results that showed that her stools were negative for [MEDICAL CONDITION] and LVN D responded well, I need to go to the laboratory book. Further interview with LVN D, she stated that CR #1 wasn't really eating and was having loose stools and said 3 to 4 weeks before CR #1 went to the hospital, she would not eat. When asked if she notified the MD regarding CR #1's episodes of loose stools and low appetite, LVN D responded we send faxes to the MD, there were faxes. Surveyor asked LVN D to review the records of CR#1 and provide surveyor with documentation about the times the facility notified the MD of CR #1's poor appetite and episodes of loose stools. Further interview and observation at that time, LVN D flipped thru papers and said Well, I am not 100% positive the MD was made aware. I don't remember myself notifying the MD regarding her low appetite or the continuation of the diarrhea, but remember seeing some faxes about CR #1. I don't see them now. In an interview on [DATE] at 12:58 p.m. with LVN E, she stated that she worked with CR #1 and that she was the charge nurse and further said the Aides would tell me that CR #1 was having diarrhea but I asked CR #1's daughter about collecting a stool sample and the daughter refused, I just did not document that information. LVN E continued saying I believe CR #1 went to the doctor but I am not sure if she had any stool sample tested there. CR #1 was also discharged from therapy because she was not cooperating. When asked regarding the nurses notes written by her on [DATE] and [DATE] that talked about CR #1 not eating well, LVN E responded I believe the MD was faxed about it, I remember telling the oncoming nurse about it and to notify the MD about CR #1's not eating but don't remember who was the nurse and I did not checked back to see if the MD was notified. We are lacking on the communication to one and another like for changes in condition, to make sure we follow up on the conditions and notifications to the MD. I don't remember notifying the MD about her appetite and I did not know any information about the stool sample that needed to be recollected again. I believe that's where we need work on because some of the papers just get filed and not followed up. LVN E further said that she was not involved in the care planning of the residents and that LVN A was in charge of updating the care plans for changes in condition and that she did not notify her of CR #1's poor appetite and episodes of loose stools. Further interview on [DATE] at 2:05 p.m. with the DON, she stated that she expected the CNA's to notify the nurses verbally of any changes in condition and that there was no paper form for the CNA's to document changes in condition and that the nurses were supposed to report to the MD changes of condition as soon as possible. DON further stated that she had not done any formal training on [MEDICAL CONDITION] infections, that she only talked to the nurses about it and gave some literature about the infection but did not have a sign in form or course content of the discussion because was more like a conversation. DON continued saying that on September she did a training on abuse and neglect and that she discussed about changes in the condition of the residents because abuse and neglect could lead to a changed in condition on a resident. DON further said that they discussed on the training information about MD notification related to changes in condition and that the main expectation she had from the nurses is that they notify the MD for changes in condition as soon as possible. Continued interview with the DON at that time, she stated that having loose stools was a change in condition that required MD notification. DON further said that she looked at the MD orders every day including the laboratory results and that she does daily rounds including the dining room during most meals. Surveyor asked DON if nurses talked to her about the condition of CR #1 and the DON responded Yes, I talked to them, CR #1 was having some diarrhea, we were concerned about it but it wasn't proven to be [MEDICAL CONDITION]. Further interview with the DON, she stated that LVN A was in charge of updating the care plans and that care plans were supposed to be updated if the residents had a change in condition. When asked if CR #1's care plan was updated related the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness, the DON said as she flipped thru document I do not see it, I do not see her care plan updated. When asked about who was supposed to collect the specimens for residents and follow up on the laboratory results, the DON said that the night shift nurses were supposed to collect the urine samples and that the stool samples any nurse, as soon as the MD gives the order, any nurse is supposed to collect the specimen as soon as the resident has the bowel movement. When the laboratory sends any document to the facility, the nurses are supposed to follow up with the reports and not to put the reports on the chart until they had finished with the MD notifications and the orders. Continued interview with the DON at that time, when asked how did she think this incident of immediate jeopardy came about, the DON responded It got missed, the laboratory orders, human error but from this second on, I will be all over the charts, I will make 3 copies of the orders and everybody will get copies, we will go over the information on the meetings and will designate the hallways to department heads. When asked if she believed there was a problem with how the facility handled the changes in conditions of the residents, the DON responded CR#1 did not talk, we had to watch her, something was not right, we knew something was going on. Yes, there were things that were missed. When surveyor asked if staff review the bowel record of residents and if she had seen the bowel record of CR#1, the DON responded as she flipped thru CR #1's bowel record documentation I see it, OK, I will have somebody monitoring these records every day. We have shift to shift reports from the nursing staff but there is no system where they can write it down. Loose stools is a change in condition that needed to be reported to the MD in a perfect world. In an interview on [DATE] at 10:05 a.m. with the Administrator, he stated that the main tool the facility has to make sure the needs of the residents are being met is the everyday morning meetings because that where staff review the 24 hour report, orders, laboratory reports and other important information about the residents. He further said that department heads attending the meetings were the DON, Assistant DON, MDS nurse, Care Plan Nurse, dietary, therapy and the wound care nurse. When asked if information regarding the condition of CR #1 was ever discussed on the morning meetings, the Administrator stated what I remember is that she was having difficulty eating and the CNA's were feeding her and

Based on interview and record review, the Administration failed to oversee the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being for one of nine residents (CR#1) reviewed for significant changes in condition and MD notification. -The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect when CR #1's had continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness on and off for 31 days and the MD was not consulted and updated of her condition and Physician orders [REDACTED]. -The Administrator failed to develop a system of communication between the facility and the laboratory to carry out MD orders and a communication system between nursing assistants, nurses and the MD related to changes in residents' conditions. --The Administrator failed to supervise and monitor the DON to ensure she carried out her responsibilities in the areas of assessment and monitoring of medical condition including MD notifications. --The DON failed to train all staff to monitor, assess, and consult physicians concerning [MEDICAL CONDITION] infections and changes in condition. --The DON failed to monitor the nursing staff regarding consulting with the physician when residents had changes on their condition and monitor that nursing staff follows MD orders. An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. This failure affected one former resident (CR#1) who died after being admitted to the hospital and could place 7 residents at the facility identified with infections at risk of not receiving adequate assessments, medical care, pain, decline in their health condition well-being and death. Complaint # 0 Findings include: Record review of the facility face sheet for CR #1 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Admission [DIAGNOSES REDACTED]. CR #1 was sent to the emergency roiagnom on [DATE] for evaluation and treatment of [REDACTED]. CR #1 died at the hospital on [DATE]. Record review of CR #1's quarterly MDS, dated [DATE], revealed CR #1 was not able to complete the interview for BIMS evaluation, she was sometimes able to make herself understood and was sometimes able to understand others. CR #1 required extensive assistance of 2 persons for bed mobility and was total dependent on staff for transfers, toilet use, locomotion and bathing. CR #1 required extensive assistance of one person for dressing and personal hygiene. She required a wheelchair for mobility and was always incontinent of bowel and bladder. The assessment section on swallowing/nutritional status revealed no swallowing disorders and was on a mechanically altered diet. Record review of the facility's weight records for CR #1 revealed weights on: -[DATE] of 160 lbs. -[DATE] of 154 lbs. Record review of CR #1's meal percentages from [DATE] to [DATE] revealed the intake ranged from 25% to 75%. Further record review revealed no meal percentages documented for 16 times for the breakfast and the lunch meals. Record review of the facility's Consulting Dietitian Report for [DATE] to [DATE] revealed she was not evaluated by the dietitian during those dates. Further record review revealed no recommendations for the month of [DATE] for CR #1. In an interview on [DATE] at 2:48 p.m. with the DON, she stated that CR #1 had to be fed and that she was always in the dining room eating and that she noticed changes with her eating 5 to 6 days before she went to the hospital and further said before CR#1 went to the hospital her appetite decreased. Record review of CR #1's Bowel Movement Report recorded by the nursing assistants revealed in part: -[DATE] one episode of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] two episodes of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium and one large loose bowel movement. -[DATE] one episode of small and two mediums loose bowel movements. -[DATE] one episode of medium loose bowel movement. -[DATE] one episode of medium, one large loose bowel movement and another medium putty like stool. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium loose bowel movement. -[DATE] two episodes of medium and one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of large loose bowel movement. -[DATE] one episode of medium and two large loose bowel movements. -[DATE] two episodes of medium and one large loose bowel movement. -[DATE] two episodes of large loose bowel movement. Record review of CR #1's care plan revised [DATE] revealed in part: -Focus: CR #1 has potential fluid deficit related to diuretic use ([MEDICATION NAME]-[MEDICATION NAME] 37XXX,[DATE]mg ordered on [DATE] for [MEDICAL CONDITION]). -Goal: CR#1 will be free of symptoms of dehydration -Interventions: Notify MD if persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours, obtain and monitor laboratories/diagnostic work as ordered. Report results to MD and follow up as indicated. Further record review revealed no information on the entire care plan of CR #1 episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness or interventions to improve, or prevent further decline. Record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 9:33 pm: .CR #1 had loose brown bowel movement with mucous. No foul odor noted. Called Nurse Practitioner on call for MD with orders to monitor bowel movement and to collect a stool specimen. Record review of the verbal MD order dated [DATE] at 9:15 p.m. revealed an order for [REDACTED]. -[DATE] at 12:55 p.m Daily skilled note in part: - G.I.: poor appetite, vomiting, hypoactive bowel sounds. Ate only few bites of lunch today before she made herself vomit -[DATE] at 4:05 p.m. CR #1 has new orders for stool specimen collection to rule out [MEDICAL CONDITION]. Specimen collected and is in med room fridge. Strong/foul odor noted, mucous with seedy appearance noted on the bowel movement. Patient with emesis noted during breakfast and refusal of alternate breakfast as well as lunch . Further record review of Daily skilled note in part: - G.I.: poor appetite, vomiting diarrhea. Increased of bowel, foul odor present, mucous and seedy appearance. -[DATE] at 8:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, diarrhea, hyperactive bowel sounds. CR #1 has been having loose stools. Neuromuscular: Wheelchair - weakness, deterioration. -[DATE] at 09:07 am: CR #1 did not eat breakfast, states I am not hungry. -[DATE] at 12:31 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing, diarrhea. Hyperactive bowel sounds. Neuro/muscular: weakness, deterioration. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 12:46 p.m. read in part: .Draw date: [DATE]. - Stool Culture results: No Salmonella, Shigella, Campylobacter isolated, Pathogenic Escherichia coli or Shiga Toxins 1 or 2 detected. Further record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 5:49 p.m. Daily skilled note in part: - G.I.: diarrhea, hyperactive bowel sounds. Received new order to repeat stool collection for [MEDICAL CONDITION] and culture and sensitivity . Record review of the facility's Complaint Resolution Record dated [DATE], given by CR#1's family member, received by the DON and signed by the Administrator revealed in part: .Resident's Name: CR #1. Staff receiving report: DON. - Concern: Diarrhea for a week, no [MEDICATION NAME] (anti-diarrheal). - Action taken: Explained how [MEDICAL CONDITION] works and contraindication of giving [MEDICATION NAME]. Informed her of negative [MEDICAL CONDITION] result and CR #1 refusing to get up . Further record review revealed that DON signed report on [DATE] and Administrator signed report on [DATE]. Record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 10:23 a.m. Can we have an order to repeat stool specimen collection and testing? Stools are loose/liquid, foamy and seedy appearance. Further record review revealed MD written order dated [DATE] -[MEDICAL CONDITION] and stool for culture and sensitivity. Continued record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 4:45 p.m. Daily skilled note in part: - G.I.: Diarrhea. Night nurse to collect stool for Wednesday. -[DATE] at 2:01 a.m. CR#1 did not produce a bowel movement before laboratory pick up. Further record review of Daily skilled note in part: - Neuromuscular - weakness. Record review of CR #1's Laboratory report revealed in part: -[DATE] at 10:50 a.m. read in part: .for stool specimen drawn [DATE] Specimen unacceptable for testing. Rejected order, routine: - What test was rejected? [MEDICAL CONDITION]. - Reject reason: Please recollect for [MEDICAL CONDITION]. -[DATE] at 3:18 p.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake, difficulty chewing and hyperactive bowel sounds. -[DATE] at 6:49 a.m. Daily skilled note in part: - G.I.: poor appetite, poor fluid intake and difficulty chewing. -[DATE] at 4:13 p.m: .CR #1 went to appointment today with new orders for complete metabolic panel to be done on Monday ([DATE]) and to return to clinic in 2 months. Record review of CR #1's comprehensive Metabolic Panel dated [DATE] and faxed to MD on [DATE] at 5:45 p.m. revealed in part: -BUN (blood urea nitrogen, test that reveals how kidneys are working) 38 High (Reference range ,[DATE] mg/dL) -Creatinine (evaluates kidney function) 1.16 (Reference range 0XXX,[DATE].20 mg/dL). Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: Not feeling good. Further record review revealed that Gastrointestinal exam was not conducted by the MD. Continued record review revealed - Assessment [DIAGNOSES REDACTED]. Return to clinic in 2 months. Further record review of nursing progress notes for CR #1 revealed in part: -[DATE] at 10:05 a.m. Daily skilled note in part: - CR #1 has to have extra encouragement during meals to eat. -[DATE] at 6:56 a.m.: CR #1 does not help with being transferred, she is dead weight. Will not stand or pivot to assist with transfers. -[DATE] at 9:40 a.m.: Received an order for [REDACTED]. Record review of CR #1's MD progress report dated [DATE] revealed in part: - Chief complaint: cough, congestion and nasal drainage. Further record review revealed that Gastrointestinal exam was not conducted by the MD. - [DIAGNOSES REDACTED]. Plan: [MEDICATION NAME] 500 mg by mouth every day for 10 days, chest x-ray and [MEDICATION NAME] 10 mg by mouth for 10 days. Continued record review of the nursing progress notes for CR #1 revealed in part: -[DATE] at 10:07 a.m: CR #1 still not eating well. -[DATE] at 10:25 a.m.: CR #1 is not eating well only eating 25% or less of meals. Further record review of the nursing progress notes revealed no MD notification on the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness. -[DATE] at 4:26 p.m: Received fax from CR #1's MD with orders to send CR#1 to the hospital for evaluation and treatment for [REDACTED]. Further record review of the facility's Nursing Communication fax for CR #1 revealed in part: -[DATE] at 7:30 a.m. .CR #1 noted to have watery brown stool. CR #1 also noted to have excoriated buttocks and perineal area. Further record review revealed MD order dated [DATE] at 4:00 p.m. Sent to emergency room for evaluation of possible dehydration and stool for [MEDICAL CONDITION]. Record review of CR #1's Emergency physician record dated [DATE] at 4:47 p.m. revealed in part: .- History of present illness: Generalized weakness. Onset/duration: unknown. History of diarrhea. - Physical exam: lethargic, dry mucous membranes, [MEDICAL CONDITION](fast heart rate).[MEDICAL CONDITION], dehydration. Intravenous fluids Normal Saline bolus of 2000 ml. [MEDICATION NAME] (antibiotic) 1 gram Intravenous and Cefepinie (antibiotic) 1 gram Intravenous. Stool for [MEDICAL CONDITION]. Further record review of CR #1's hospital history and physical dated [DATE] at 10:17 p.m. revealed in part: .Chief complaint: Generalized weakness. [AGE] year old female who present from the nursing home. Family reports diminished appetite. Then over the last day or so developed by the nurses notes, some loose stools associated with some excoriation and a decrease in her normal level of interaction. On [MEDICATION NAME] (antibiotic) 500 mg since [DATE]th for a cough. Vital signs: emergency room blood pressure ,[DATE]. Currently after 3 liters of fluid in the emergency room , blood pressure is very low between ,[DATE] and ,[DATE] with heart rate of 133. Mouth is dry. Abdomen is distended, diffusely tender. She has got some early flexion contractures of her knees and her hips. - Laboratories: [MEDICAL CONDITION] was positive. White blood cells count of 61.3 Critical High (Reference range 4XXX,[DATE].8), BUN (blood urea nitrogen, test that reveals how kidneys are working) 74 Critical High (Reference range ,[DATE] mg/dL) and creatinine (evaluates kidney function) 2.8 (Reference range 0XXX,[DATE].0). - Assessment: 1.- [MEDICAL CONDITION]. She has got 3 liters of fluid in the Emergency Department with improvement of her blood pressure, though is not stabilized at this point. We will continue intravenous fluids overnight tonight. 2.- [MEDICAL CONDITIONS], likely the source of [MEDICAL CONDITION]. We will put her on [MEDICATION NAME] (antibiotic) as well as oral [MEDICATION NAME] (antibiotic). -Did discuss with the daughter that was present this evening that the patient was severely ill and we would have a much clearer picture the next 12 - 24 hours on her ability to survive, given the degree of [MEDICAL CONDITION] and volume resuscitation. 8.- Acute [MEDICAL CONDITION] on top of [MEDICAL CONDITION]. Again due to her dehydration. We will continue fluids. Record review of CR #1's discharge summary from the hospital dated [DATE] at 1:46 p.m. revealed in part: Final discharge Diagnoses: [REDACTED]. - Hospital course: The patient was admitted and started on intravenous [MEDICATION NAME] as well as oral [MEDICATION NAME]. White count was 61,000 on admission. This did slowly improved; however, by mouth intake was extremely poor. Ultimately, the patient continued to decline clinically, having blood pressures that were running lower and urine output that was significantly less despite being on brisk intravenous resuscitation. White counts did improve with the intravenous and oral antibiotics that she was receiving; however, due to her overall decline, I contacted the patient's family to discuss inpatient hospice services. She was admitted to hospice on [DATE]. Further record review of discharge summary dated [DATE] at 1:58 p.m. revealed that CR#1 died in the hospital on [DATE] at 12:16 p.m. In an interview on [DATE] at 1:14 p.m. with the DON, she stated that she did not know what happened to the stool specimen that was supposed to be recollected for CR #1 on [DATE]. She further stated that she did not know why the specimen was rejected by the Laboratory on [DATE] and that she thought that CR #1's stool was negative for [MEDICAL CONDITION] and further said I thought I read somewhere that her stool was negative for [MEDICAL CONDITION]. When asked to look thru CR #1's chart to see if she could find any [MEDICAL CONDITION] laboratory results, the DON responded as she flipped thru the chart It looks that she did not get a [MEDICAL CONDITION] test in the facility. I don't know what happened with the laboratory test for the stool, I will find out. Do not know why was rejected. When asked if CR #1 got her stool collected on [DATE] after the MD gave orders again to check for [MEDICAL CONDITION], DON responded well, there is a nurses note on [DATE] that the stool specimen was not available . DON then left and said she was going to call the laboratory. In an interview on [DATE] at 1:24 p.m. with LVN A, she stated that she was the Care plan nurse and that she would review the care plans every 92 days in the computer and would update the care plans as needed if there is a change in condition on the residents. She further said that there was a communication board in the computer system where the nurses would write information if the residents had a change in condition. LVN A said that also during the morning meetings, the department heads would talk about changes in condition and that she would get the information from there to update the care plans as well. LVN A continued saying that she had spoken to the DON about who would actually be doing changes in the care plans because she was only working part time and that the DON has not come up with a concise decision yet. When asked if CR #1 had any changes in condition that she needed to update on the care plan, LVN A responded CR #1 only had an upper respiratory infection on [DATE] Continued interview with LVN A, she stated that she was not aware of CR #1 having any issues with diarrhea or poor appetite and further said We are in the process with the infection control nurse about how we are going to communicate infections of residents. We have a new tool in the computer system for changes in condition but not sure if staff is really writing on it. In a phone interview on [DATE] at 3:10 p.m. with CR #1's family member, she stated that another family member brought CR #1 to the MD on [DATE] because the family saw how sick CR #1 was and further said She was having diarrhea and was deteriorating. She was eating less and less, her appetite was decreasing, she was really sick until she was sent to the hospital. CR #1 would not move anymore, she was not drinking or eating and she was having severe diarrhea. I was told by the facility that the stool studies were negative but they did not show me any reports. Then when I went to see her at the facility, she did not look good and she was diagnosed at the hospital with [MEDICAL CONDITION]. In an interview on [DATE] at 3:40 p.m. with the DON, she stated that she still did not hear from the laboratory yet about why the stool specimen for CR#1 was rejected on [DATE] and further said I was not aware that the stool specimen was rejected until today when you asked for it. I knew about that there were concerns about CR#1 having loose stools but don't know information in detail. DON further said that she did not know that CR #1 had any problems with her appetite and that she believed that CR #1 was gaining weight. Surveyor requested DON all weights for CR#1. When asked if she was aware that the MD ordered for second time a stool specimen for CR #1 on [DATE], the DON responded I can't say I saw the order. DON did not provide additional weight records for CR #1 to surveyor by the time of exit. Further interview with the DON, she stated that CR #1 went to the hospital because the MD thought that CR #1 was dehydrated and said CR #1 was on antibiotics for upper respiratory infection, I don't know that she was having loose stools. When asked if she knew what had happened to CR #1, the DON responded She did eventually die, don't know when and did not see a death certificate. She did not come back to the facility. Even though that CR #1's family member works here part time on the weekends, she didn't stay in touch with us. We did not get information about CR #1. We knew CR #1 was in Intensive Care Unit but the hospital would not tell us the reason of her admission. If I was told her [DIAGNOSES REDACTED]. DON continued saying that she was not able to find another stool specimen report for CR #1 after it was rejected by the Laboratory on [DATE] and that she did not know why the specimen was rejected by the Laboratory. In an interview on [DATE] at 11:31 a.m. with CNA B, she stated that she worked with CR #1 at least twice a week and that the last two weeks before CR #1 went to the hospital, her appetite decreased and that she was more weak and that when CR #1 was up on her chair, she would leaned to the sides and forwards down. When asked about CR #1's stool consistency, CNA B stated her stools were loose. I did report the loose stools to the nurses but I also wrote it on the computer and they are supposed to see it. When asked if she reported CR#1's poor appetite, CNA B responded Nurses knew about her appetite because CR #1 would eat in the dining room. CNA B further said that changes in condition are reported to the nurses verbally and that there was no paper forms to report changes in condition that she was aware of. In an interview on [DATE] at 11:55 a.m. with LVN F, she stated that she was the ADON and wound care nurse. She further stated that CNA's report changes in condition verbally to the nurses and that there was a way in the computer system for CNA's to document changes in condition. LVN F further said that she only heard about CR #1 having diarrhea or loose stools just before she went to the hospital. She continued saying that information on the 24 hour report is reviewed during the morning meetings and that she did not remember any discussion about CR #1's condition. LVN F continued saying that just before CR #1 went to the hospital, they had discussed her poor appetite and eating but nothing about her diarrhea. In an interview on [DATE] at 12:02 p.m. with CNA C, she stated that she was the shower Aide but worked on the floor as well. CNA C further said I gave showers to CR #1 three times a week and I kept telling the nurses about the foul odor and color of her stools. CR #1's stools were yellow, slimy and had the distinctive foul odor, I kept telling the charge nurses about it for about 3 weeks before CR #1 went to the hospital. Every time I would bring her to the shower room, her stools were loose, strong foul odor, runny, slimy and yellow. I would report to the nurses every time. CR #1's appetite declined really bad. Her daughter would come and help her but CR #1 would not eat at all and she started getting the cracks on her mouth. CR #1 started leaning to the sides and then forwards when in the wheelchair during that time that she had the diarrhea and her poor appetite then the facility got an order for [REDACTED]. In an interview on [DATE] at 12:28 p.m. with LVN D, she stated that she was a full time charge nurse and that she worked with CR #1 and that CNA's would report changes in condition verbally to the nurses and that she believed there was a way of documenting changes in condition in the computer system but she was not sure if the staff had been trained about it. LVN D continued saying that she was the nurse that sent CR #1 to the hospital because she was acting abnormal, shaking and was hollering. LVN D further said I believe CR#1 had a negative stool for [MEDICAL CONDITION]. Surveyor asked LVN D to review the records of CR #1 and find the laboratory results that showed that her stools were negative for [MEDICAL CONDITION] and LVN D responded well, I need to go to the laboratory book. Further interview with LVN D, she stated that CR #1 wasn't really eating and was having loose stools and said 3 to 4 weeks before CR #1 went to the hospital, she would not eat. When asked if she notified the MD regarding CR #1's episodes of loose stools and low appetite, LVN D responded we send faxes to the MD, there were faxes. Surveyor asked LVN D to review the records of CR#1 and provide surveyor with documentation about the times the facility notified the MD of CR #1's poor appetite and episodes of loose stools. Further interview and observation at that time, LVN D flipped thru papers and said Well, I am not 100% positive the MD was made aware. I don't remember myself notifying the MD regarding her low appetite or the continuation of the diarrhea, but remember seeing some faxes about CR #1. I don't see them now. In an interview on [DATE] at 12:58 p.m. with LVN E, she stated that she worked with CR #1 and that she was the charge nurse and further said the Aides would tell me that CR #1 was having diarrhea but I asked CR #1's daughter about collecting a stool sample and the daughter refused, I just did not document that information. LVN E continued saying I believe CR #1 went to the doctor but I am not sure if she had any stool sample tested there. CR #1 was also discharged from therapy because she was not cooperating. When asked regarding the nurses notes written by her on [DATE] and [DATE] that talked about CR #1 not eating well, LVN E responded I believe the MD was faxed about it, I remember telling the oncoming nurse about it and to notify the MD about CR #1's not eating but don't remember who was the nurse and I did not checked back to see if the MD was notified. We are lacking on the communication to one and another like for changes in condition, to make sure we follow up on the conditions and notifications to the MD. I don't remember notifying the MD about her appetite and I did not know any information about the stool sample that needed to be recollected again. I believe that's where we need work on because some of the papers just get filed and not followed up. LVN E further said that she was not involved in the care planning of the residents and that LVN A was in charge of updating the care plans for changes in condition and that she did not notify her of CR #1's poor appetite and episodes of loose stools. Further interview on [DATE] at 2:05 p.m. with the DON, she stated that she expected the CNA's to notify the nurses verbally of any changes in condition and that there was no paper form for the CNA's to document changes in condition and that the nurses were supposed to report to the MD changes of condition as soon as possible. DON further stated that she had not done any formal training on [MEDICAL CONDITION] infections, that she only talked to the nurses about it and gave some literature about the infection but did not have a sign in form or course content of the discussion because was more like a conversation. DON continued saying that on September she did a training on abuse and neglect and that she discussed about changes in the condition of the residents because abuse and neglect could lead to a changed in condition on a resident. DON further said that they discussed on the training information about MD notification related to changes in condition and that the main expectation she had from the nurses is that they notify the MD for changes in condition as soon as possible. Continued interview with the DON at that time, she stated that having loose stools was a change in condition that required MD notification. DON further said that she looked at the MD orders every day including the laboratory results and that she does daily rounds including the dining room during most meals. Surveyor asked DON if nurses talked to her about the condition of CR #1 and the DON responded Yes, I talked to them, CR #1 was having some diarrhea, we were concerned about it but it wasn't proven to be [MEDICAL CONDITION]. Further interview with the DON, she stated that LVN A was in charge of updating the care plans and that care plans were supposed to be updated if the residents had a change in condition. When asked if CR #1's care plan was updated related the continuous episodes of loose stools and the development of difficulty chewing, loss of appetite and weakness, the DON said as she flipped thru document I do not see it, I do not see her care plan updated. When asked about who was supposed to collect the specimens for residents and follow up on the laboratory results, the DON said that the night shift nurses were supposed to collect the urine samples and that the stool samples any nurse, as soon as the MD gives the order, any nurse is supposed to collect the specimen as soon as the resident has the bowel movement. When the laboratory sends any document to the facility, the nurses are supposed to follow up with the reports and not to put the reports on the chart until they had finished with the MD notifications and the orders. Continued interview with the DON at that time, when asked how did she think this incident of immediate jeopardy came about, the DON responded It got missed, the laboratory orders, human error but from this second on, I will be all over the charts, I will make 3 copies of the orders and everybody will get copies, we will go over the information on the meetings and will designate the hallways to department heads. When asked if she believed there was a problem with how the facility handled the changes in conditions of the residents, the DON responded CR#1 did not talk, we had to watch her, something was not right, we knew something was going on. Yes, there were things that were missed. When surveyor asked if staff review the bowel record of residents and if she had seen the bowel record of CR#1, the DON responded as she flipped thru CR #1's bowel record documentation I see it, OK, I will have somebody monitoring these records every day. We have shift to shift reports from the nursing staff but there is no system where they can write it down. Loose stools is a change in condition that needed to be reported to the MD in a perfect world. In an interview on [DATE] at 10:05 a.m. with the Administrator, he stated that the main tool the facility has to make sure the needs of the residents are being met is the everyday morning meetings because that where staff review the 24 hour report, orders, laboratory reports and other important information about the residents. He further said that department heads attending the meetings were the DON, Assistant DON, MDS nurse, Care Plan Nurse, dietary, therapy and the wound care nurse. When asked if information regarding the condition of CR #1 was ever discussed on the morning meetings, the Administrator stated what I remember is that she was having difficulty eating and the

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent the development of pressure ulcers for 1 of 5 residents (Resident # 62) identified by the facility as high risk for developing a pressure ulcers: - Resident # 62 who was assessed by the facility to be at very high risk for developing pressure ulcers developed an unstagable pressure ulcer to her right heel that required specialized treatment from a outside wound care clinic. This failure affected 1 resident and could place 4 current residents at risk for development of new pressure sores, infection and worsening of current pressure sores. Findings were: Record review of Resident # 62's face sheet revealed she was [AGE] years old and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #62's Braden Scale for Predicting Pressure Sore Risk dated 9/8/2015 revealed she scored a 6. Assessment reference 0.0 to 9.0 Very High Risk. No other Braden Scale assessment was noted in Resident #62's files. Review of Resident #62's quarterly MDS dated [DATE] revealed Resident #62 was severely cognitively impaired. She required extensive assistance of 1 person for bed mobility, dressing and toilet use, total assistance of 2 person for locomotion, personal hygiene and bathing. Resident #62 was always incontinent of both bowel and bladder. This document also revealed Resident #62 did not have a pressure ulcer and she was at risk of developing pressure ulcers. According to this assessment, she was provided a pressure reducing devices for the chair but not the the bed and she was not placed on a turning or repositioning program. Record review of Resident # 62's care plan did not identify her as very high risk for development of pressure ulcers and did not include any preventive measures to prevent the development of pressure sores as indicated on the Braden Scale assessment dated [DATE] and the quarterly MDS dated [DATE]. Review of Resident #62's Nursing progress Note date 10/16/2015 10:28: Res with large amt of bright red blood and mucous to stool with very foul odor this am, night nurse reported stool specimen sent to lab this am to r/o [MEDICAL CONDITION] .10/16/2015 12:47 . start [MEDICATION NAME] 500mg tid x 10 days 10/17/2015 11:38: cont on po [MEDICATION NAME] in tx of diarrhea-like stools, none noted this am, res with redness to per-area, barrier cream applied . res in bed, hob elevated repositioned and propped with pillow. Record review of Resident #62's Weekly Skin assessment dated [DATE] revealed under the section 3. Check if the resident has any of the following, the box labeled No was checked for bruise, skin tear, abrasion, laceration, surgical incision, and rash. Under section h. does the resident have a pressure, venous, arterial, or diabetic ulcer? The box labeled No was checked. Under the section i. Other skin findings, res with redness to peri area was filled in the box. Review of the nursing notes dated 10/18/2015 10:28 read noted fluid-filled blister to right heel. Heel floated on pillow. Bunny boot applies. No loose stool reported Nursing notes dated 10/19/2015 14:52 read Resident has a fluid-filled blister to (R) heel, measuring 6.0 cm x 10.0 cm. No redness noted. Treatment nurse, cleansed with SurePrep, applied gauze padding, wrapped in kerlix . Nursing Communication fax dated 10/19/15 at 2:45p read in part, fluid filled blister to (R) heel 6.0 cm x 10.0 cm. Cleansed with SurePre, padded with gauze and wrapped in kerlix. May we do tx q d? Y, N also applied heel protector and float heel. Y was circled and physician's signature was noted on bottom of the form. Review of Resident #62's care plan revealed pressure area to right heel was added on 10/19/2015 with the following interventions: Ensure heels are floated with the use of pillows. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Monitor dressing every shift to ensure it is intact and adhering. Report loose dressing to treatment or charge nurse. Monitor nutritional status Notify nurse immediately of any new areas of skin breakdown: The resident requires the use of an air mattress. Review of the Nursing Progress Note for 10/20/2015 13:13: F/U blister to (R) heel. Noted copious drainage to gauze dressing & found blister had opened. Treated per order Record review of Resident #62's Weekly Ulcer Assessment dated 10/23/2015 read in part, Location of ulcer: Rt Heel, Date Ulcer Identified: 10/19/2015. Length (cm) 6.0, Width (cm) 10 Depth (cm) - if unable to determine enter UTD: UTD. Wound bed color: Pink. Skin around wound: clear. Pressure reducing devices in place: Air mattress, Pillows to float heels, heel protector were selected. Nutritional Interventions: Vitamin C, Protein supplement were selected. Review of the Medication Review Report and the Medication Administration Report for November 2015 revealed no orders for Vitamin C or Protein supplements. Review of the Nursing Progress Note for 10/24/2015 09:45 : Resident was noted in bed with no heel protectors & dressing to blister to (R) heel partially off. Skin to blister is off. Called clinic to report change. Received new order to clean open area to (R) heel 17:33: Resident up from nap with a change in mood. Attempted to rip off dressing to (R) heel, tore apart heel protector from (L) heel, grabbed & attempted to hit CNA . Review of the Weekly Skin Assessment for 10/24/2015 revealed under section i. Other skin findings: Opened blister to (R) heel w/new treatment in place. was typed in the box. Review of Resident #62's Medication Review Report for November 2015 read in part, Cleanse open area to (R)heel with wound cleanser & pat dry. Apply hydrogel, pad w/gauze, wrap with Kerlix. every day shift order date 10/24/2015 start date 10/25/2015. Cleanse open area to (R) heel with wound cleanser & pat dry. Apply hydrogel, pad w/gauze, wrap w/ Kerlix. every night shift for wound healing order date 10/24/2015 stated dated 10/24/2015. Multivital Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth two times a day for wound healing, order date 10/26/2015 stated dated 10/27/2015. Review of the Nursing Progress Notes 11/4/2015 11:42 : worsening of res pressure ulcer to right heel, asked if could send to wound clinic and asked if Ok for air mattress overlay to help with pressure reduction. 14:02: Ok for appt at wound clinic, air mattress overlay . Review of Resident #62's Medication Review Report for November 2015 read in part, May have pressure relieving mattress order date 11/4/2015. Weekly Skin assessment dated [DATE] yes was selected under section h. Under section i. Other skin findings: Opened blister to (R) heel, 7.9 cm x 6.8 cm w/unstageable ulcer within area - 1.5 cm x 1.9 cm was typed in. Review of the nursing progress note dated 11/11/2015 8:46 read in part, Resident had an appt at Wound Care Specialist for wound to right heel. Returned with new orders for [MEDICATION NAME] 100 mg po BID for 10 days. Wound care is changed to Clean w NS, dry, apply C + Alginate w/Silver, gauze wrap, tape. To be done Monday & Friday by nursing, Wednesday by wound clinic Record review of Resident #62's Weekly Ulcer Assessment dated 11/12/2015 read in part, Location of ulcer: Rt Heel, Date Ulcer Identified: 10/19/2015. Length (cm) 5.4, Width (cm) 6.0 Depth (cm) - if unable to determine enter UTD: UTD. Wound bed color: Pink. Skin around wound: clear. Most sever tissue type present: Eschar - black, brown or tan adhered to the wound bed. Approximate amount of necrosis: 25%. Odor: Mild. Pressure reducing devices in place: Air mattress, wheelchair cushion were selected. Nutritional Interventions: Vitamin C, Protein supplement were selected. Observation of Resident #62 on 11/17/2015 at 9:00 am revealed she was groomed in the memory care unit's activity area in her geri-chair. Her legs were elevated and boots were observed on both feet. Observation of Resident #62 on 11/17/2015 at 12:30 pm revealed her in the memory care unit in her geri-chair with her head down at the dining table. Staff were observed spoon feeding her. Boots were observed on both feet. Review of Resident #62's Medication Review Report for November 2015 read in part, [MEDICATION NAME] Tablet (Multiple Vitamins-Minerals)Give 1 table by mouth two times a day for supplement, order date 11/18/2015 start dated 11/19/2015. In an interview on 11/18/15 at 10:30 AM with LVN M she stated Resident #62 was able to move around but required the staff to turn her. She stated 4 to 5 weeks ago Resident #62 came down with loose stools. They weren't sure if she was contagious and kept her down in her room for a day until the stool report came back. The evening shift noted a fluid filled blister on her right heel. LVN M stated it was an unfortunate incident. Once Resident #62 got the blister is burst and it did not look well. The blister opened and became infected. On 11/4/15 she was ordered an air mattress and on 11/11/15 she started going to the wound care clinic. In an interview with the Regional RN on 11/18/15 at 1:45 PM he stated the Braden scale assessment is used predict which residents are most at risk to develop a pressure ulcer. The care plans should be updated and pressure ulcer prevention protocol should be put in place for those resident who scored high on the assessment. He stated the pressure ulcer prevention protocol consists of weight monitoring, weekly skin assessment, barrier cream and pain monitoring. He stated all of the facility's mattress are pressure reduction. When a resident develops a pressure ulcer they go to the low air loss mattresses. When asked if Resident #62's Braden scale of 6 was high he said yes. When asked what plans were in place he said he will look into it. Review of a handwriting definition for Braden Scale given by the Regional RN read, The Braden scale is used as a tool for predicting Pressure Score risks. After completion the score is intended to implement the care plan triggered by the CAA to put in place interventions to help reduce the risk of pressure sore development. Review of the facility's policy titled, Pressure Ulcer Protocols 12/1/11, read in part, Purpose: Nursing home residents, due to commorbidities and underling clinical conditions, may develop pressure ulcers during their stay at the facility. Standards: Pressure ulcers are defined as ulcerations and/or necrosis of tissue overlying bony prominence that had been subjected to pressure, friction or shear .Process: I. Assessment of Risk: All residents are considered at risk for the development of pressure ulcers. During the admission nursing assessment process, the condition of the resident's skin should be noted . According to Regional RN there were 5 residents who scored high on the Braden scale assessment.

Based on observation, interview and record review, the facility failed to ensure that two staff provided assistance with transfers for one of 12 sampled residents (Resident #1) to prevent an accidental fracture from occurring during a transfer. The failure caused 1 resident a fractured left femur which required an eight day hospital stay and a surgery to insert a rod into the femur and placed 72 residents at risk of not receiving the level of assistance they require with their care which could cause an injury or a decline in their physical condition. Findings include: Intake #'s 8 and 3 Resident #1 Record review of Resident # 1 ' s face sheet revealed she was admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]., and Systemic Lupus [DIAGNOSES REDACTED]tosus. Review of the resident's nurse's notes dated 6/20/2011 revealed the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS assessment dated [DATE] revealed Resident # 1 ' s cognitive skills for daily decision making was severely impaired and the resident was unable to walk. Transfer assistance required by Resident #1 was documented as the resident was total dependent and required two persons physical assist. Record review of Resident # 1 ' s Care Plan dated 4/14/11 revealed the resident was at risk of falls related to history of falls and the identified goal was the resident would remain free of injury from falls during the next 90 days. Interventions to obtain this goal were that two staff were to assist resident to transfer as needed. Record review of Resident #1 ' s Care Plan dated 4/14/11 revealed the resident had a self care deficit with feeding, toileting, bathing, grooming, dressing and transfer. Intervention: was that two staff were to transfer resident at all times and two staff were to assist her in her wheelchair. Record review of the Resident #1's form titled Nurse Aide Information Sheet, undated, revealed "... locomotion wheelchair, assist with transfer with 2 assist..." Record review of the Resident #1's ADL Flow Record revealed documented transfer for June 2011 required total assist and was done by one person on the day shift from June 1, 2011 to June 14, 2011. This record revealed one person transfer was done on the evening shift on June 1, 2, 3, 4, 6, 10, 13, and 14. There was no documentation for June 12, 2011 on the evening shift. Record review of the Facility Provider Investigation Report dated 6/13/2011 for Resident #1 revealed the resident ' s functional ability required total assistance. Record review of the Facility Provider Investigation Report Summary dated 6/13/2011 revealed "...after supper Resident #1 was transferred from the chair to the bed by CNA #4 alone. There were no other transfers of the resident after that. Based on the timing and nature of Resident #1 ' s injuries it was assumed by the DON the injury occurred during the last transfer after supper. resident sustained [REDACTED]. Record review of the Facility Provider Investigation Report dated 6/13/2011 statement provided by the DON revealed CNA #4 transferred Resident #1 by herself from the wheel chair to the bed after supper on June 12, 2011. This was her usual manner. CNA #4 used the " hug " method with a pivot. The resident ' s swollen left leg was discovered on rounds later. Record review of the facility Incident/Accident report dated 6-12-11 for Resident #1 revealed the date and time of incident was 6/12/11 at 8:55 P.M and the resident was transfered to the hospital via ambulance. Record review of the nurse ' s notes dated 6/12/11 at 11:30 P.M. revealed the emergency room doctor notified the facility that Resident #1 was being admitted to the hospital with [REDACTED]. Record review of the resident's medical record revealed [REDACTED]. Record review of the Resident #1's nurse ' s notes dated 6/20/11 at 1:00 P.M. revealed "...report was called to Parkview Manor regarding Resident #1 ' s return to the facility with a Left Femur Fracture with an Open Reduction Internal Fixation..." (a surgical procedure to insert a metal rod in to the fractured femur). Observation on 6/22/11 at 9:40 A.M., during initial tour revealed Resident # 1 in bed sleeping on her back with the head of the bed slightly elevated. The residents legs were bent at the knees and feet were together. The resident woke easily to activity in the room; she smiled to the stimulation but had no verbal response. The resident was clean and groomed. She had four incisions to her left leg. One incision was at her left knee and two incisions were slightly above the left knee. There was one incision on the top of her left thigh. All incisions had staples intact. Observation on 6/22/11 at 2:00 P.M. revealed Resident #1 being transferred into the bed with use of a Hoyer lift. The resident was non verbal but smiled throughout the process. Interview on 6/22/11 at 12:45 P.M. CNA #1 stated on 6/12/2011 Resident #1 was put back to bed by CNA #4. She stated the resident did not stand and needed two people to transfer her. She stated the resident was too heavy for one person transfer. Interview on 6/22/11 at 1:15 P.M. the DON stated Resident #1 was non-weight bearing at this time. She stated on June 12th no staff had assessed any pain in the resident. After supper it was noticed the left leg was swollen after the last transfer into bed. She stated CNA #4 had used the " hug method " to put the resident to bed. The DON stated the resident was on long term Dilantin (medication for seizures) which was bad for the bones. She stated the resident was not on any calcium supplements. Interview on 6/22/11 at 2:10 P.M. CNA #2 stated Resident #1 did not stand or walk. She stated it took two staff to transfer her. Interview on 6/22/11 at 2:25 P.M. CNA #3 stated Resident #1 required two staff to transfer her. She said swelling of the resident ' s leg was noticed during the last rounds for the 2 P.M. to 10 P.M. shift on 6/12/11. Interview on 6/22/11 at 2:45 P.M. LVN #1 stated about 9:00 P.M. on 6/12/11 the CNAs called her to the residents room. The resident ' s leg looked swollen and turned out. The family, Hospice, Administrator and DON were notified. The resident was transferred to the hospital. The resident was non-weight bearing and had required two staff to transfer her. She said the doctor from the hospital had called and said the resident was probably dropped. Interview on 6/22/11 at 3:00 P.M. CNA #4 stated Resident #1 was non weight bearing. She said on 6/12/2011 she transferred the resident the way she always did. She had transferred her alone using the hug method. She said she did nothing different or unusual with the transfer from all the other times she had done the transfer in the past. She said the resident ' s legs were like jelly. CMS form 802 revealed the census was 73 residents.