Every finding on record at Pasadena Post Acute

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 out of 7 residents (Resident #36) reviewed for infection control. Staff failed to ensure Resident #36's indwelling urinary catheter drainage spout was not touching the floor in the main dining room during lunchtime meal service. This failure could place residents at risk for cross contamination, infection and decline in health. Findings include: Record Review of Resident #36's admission record dated 05/15/2026, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart disease (an umbrella term used for conditions affecting the heart's structure and function), obstructive hydrocephalus (a condition where the normal flow of cerebrospinal fluid [a clear watery liquid that surrounds, cushions and protects the brain and spinal cord] is physically blocked within the brain and cause a buildup of pressure inside the skull), [NAME] Syndrome (a rare hormonal disorder caused by prolonged exposure to excessive levels of cortisol [the body's stress hormone] and obstructive (a blockage that impedes the normal flow of urine) and reflux (urine flowing backwards from the bladder to the kidneys) uropathy (any disease or condition affecting the urinary tract). Record review of Resident's #36's admission MDS dated [DATE] revealed a BIMS score of 9 that suggested moderate cognitive impairment. Section I and Section N revealed Resident #36 had no active infection diagnosis and had not received any medications including antibiotics for infection. Record review of Resident #36's physician order recap report dated 05/15/2026 revealed an order for Insert indwelling urinary catheter, 16 Fr [universal unit of measurement used to describe the outside diameter of a catheter tube], 10 ml balloon size due to urinary retention with closed drainage system every shift. The order was dated as active 04/28/2026 and had no end date. There were no orders for medications or treatments for infections. Observation on 05/14/2026 at 12:28 PM revealed Resident #36 in the main dining room for lunchtime meal service with her lunch tray in front of her. She was observed actively eating and sitting in a wheelchair. Her indwelling urinary catheter bag was hooked to the bottom of the wheelchair, and the drainage spout tubing was resting on the floor. The end of the tubing was uncapped. Observation and interview on 05/14/2026 at 12:34 PM of Resident #36 with RNA C who said Resident #36's catheter spout should not be touching the floor, and she would remove the resident from the dining room and try to fix it. RNA C said that she would try to fix it by hanging the indwelling urinary catheter bag higher on the back of the wheelchair. She said she would also let Resident #36's nurse know because she may need to change the catheter to prevent infection. RNA C said she was not sure who hung the indwelling urinary catheter bag on Resident #36's wheelchair and she thought Resident #36 had just come out of therapy before coming to the dining room. RNA C said they had not noticed when lunch started at 12:00 noon, that the spout from Resident #36's indwelling urinary catheter bag was touching the floor. RNA C said she did not know how long Resident #36's catheter spout had been touching the floor. Observation and interview with LVN B at 12:38 PM on 05/14/2026 in the main dining room who said Resident #36's indwelling urinary catheter bag was hanging too low on the back of her wheelchair, and the spout tubing should not be touching the floor. LVN B said she would notify LVN C who was the charge nurse assigned to Resident #36. She said LVN C could change the residents indwelling urinary catheter bag and tubing, so the resident did not get an infection from it touching and being on the floor. LVN B said while the indwelling urinary catheter bags should be hanging below the resident's bladder to prevent backflow, it should not be touching the floor. She said she did not know who placed the indwelling urinary catheter bag low enough to touch the floor or how long the catheter spout had been touching the floor because she had not noticed it until the surveyor brought it to her attention. Observation and interview with LVN C at 1:21 PM on 05/14/2026 who said Resident #36's indwelling urinary catheter bag tubing and spout should never have been touching the floor because it could cause her to get an infection. LVN C said they did not know who placed the catheter bag that low on the back of Resident #36's wheelchair or how long the indwelling catheter tubing and spout had been touching the floor. LVN C said Resident #36 had an order to change the catheter, which would include all parts of the indwelling urinary catheter, prn and she would also notify the residents MD and RP. Resident #36 refused surveyor observation of change of indwelling urinary catheter bag. Interview with the DON on 05/15/2026 at 09:38 AM who said Resident #36's indwelling urinary catheter tubing/spout, should not have been on the floor or touching the floor. The DON said they had already conducted in-service training with the licensed staff and direct care staff on infection control and indwelling urinary catheter care. The DON said if catheter tubing and spout were on the floor, it could spread infection throughout the facility and or cause Resident #36 to get an infection. The DON said they were the IP for the facility and responsible for the staff training on infection control, which included keeping resident urinary catheter bags, tubing and spouts off of the floor. The DON said they were unsure which CNA had placed Resident #36's indwelling urinary catheter bag low enough on the back of the wheelchair to touch the floor so they in-serviced everyone immediately after the incident was reported on 05/14/2026 by RNA C, LVN B and LVN C. Record review on 5/15/2026 at 10:10 AM of DON/IP in-service training dated conducted on 05/14/2026 by DON/IP and read in part: Urinary Catheter Bag Infection Prevention.Never allow the drainage bag or drainage spout to touch the floor. Record review of facility policy and procedure titled: Infection Prevention and Control Program dated 2001 revealed in part: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary andcomfortable environment and to help prevent the development and transmission of communicable diseases and infections. 2. The program is based on accepted national infection prevention and control standards. Record review of facility policy and procedure titled Catheter Care, Urinary and dated revised September 2014 read in part: Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observations, interviews and record review, the facility failed to adequately allow residents to call for staff assistance from their bedside for four (Resident #1, Resident #5, Resident #9 and Resident #14) out of twenty-five residents for review of resident call systems. The facility failed to ensure call lights were accessible to Resident #1, Resident #5, Resident #9 and Resident #14 while in their beds on 05/12/2026 and 05/13/2026. This failure could place residents at risk of delays in care and emergency assistance. Findings include: A record review of Resident #1's face sheet revealed a [AGE] year-old female with an admission date of 04/21/2026. Resident #1 was diagnosed with Encephalopathy (any disease or disorder that affects brain function), Cerebral Infarction ( occurs when blood flow to a part of the brain is obstructed, leading to tissue death due to lack of oxygen), Pneumonitis Due to Inhalation of Food and Vomit (occurs when food particles, vomit, or stomach contents enter the lungs, causing irritation and inflammation of lung tissue), Sepsis Unspecified Organism (occurs when the body's immune system overreacts to an infection, causing widespread inflammation that can damage tissues and organs) and Cognitive Communication Deficit (occurs when a person's ability to communicate effectively is compromised by impairments in cognitive processes such as attention, memory, and executive function, rather than by problems with speech or language mechanics). A record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 00 or 99 and severely impaired. A record review of Resident #1's care plan dated 04/22/2026 revealed resident requiring one person assist with ADL/Mobility, at risk for falls and pain and a diagnosis of seizure disorder. Resident care plan interventions included encourage to use call light for assistance and call light within reach and answered promptly. A record review of Resident #5's face sheet revealed a [AGE] year-old female with an admission date of 01/08/2026. Resident #5 was diagnosed with Encephalopathy (any disease or disorder that affects brain function), Essential Hypertension (persistent high blood pressure) and Dementia. A record review of Resident #5's MDS dated [DATE] revealed a BIMS score of 09. A record review of Resident #5's care plan dated 04/28/2026 identified resident as a one person assist for ADL/Mobility and fall and pain risk. Interventions included keep call light within reach. A record review of Resident #9's face sheet revealed a [AGE] year old female admitted on [DATE] with a diagnosesis of Rheumatoid Arthritis (a chronic autoimmune disease where your immune system mistakenly attacks the lining of your joints), Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior) and Unspecified Psychosis (a temporary diagnostic label used when a person exhibits clear psychotic symptoms but there is insufficient information to assign a specific psychotic disorder). A record review of Resident #9's MDS dated [DATE] did not record a BIMS score. A record review of Resident #9's care plan dated 03/31/2026 identified her as fall risk. Interventions included keep call light within reach. A record review of Resident #14's face sheet revealed a [AGE] year-old male admitted on [DATE] with a diagnosisis of contractures to both knees, stage 3 pressure ulcers to buttocks, communication deficit and paralysis and weakness to right dominant side. A record review of Resident #14's MDS dated [DATE], revealed that resident was rarely/never understood, somewhat understands others, severely impaired and has a BIMS score of 00 or 99. A record review of Resident #14's care plan dated 05/11/2026 revealed Resident had an unwitnessed fall. Interventions included keep call light within reach. During an observation on 05/12/2026 at 10:20 AM revealed:- Resident #1 was asleep in bed and the call button was observed under the bed.- Resident #5 was in bed and the call button was observed behind her bed.- Resident #14 was asleep in bed and the call button was observed on the floor near his bed. During an observation on 05/13/2026 at 10:07 AM revealed:- Resident #1 was asleep in bed. The Call button was observed behind her bed and on the floor.- Resident #5 was in bed. Her call button was observed hanging down over her bedside tray table. - Resident #9 was observed asleep with her call button coiled on the floor near the headboard of her bed.- Resident #14 was observed asleep with his call button on the floor under his IV pole. During an interview on 05/13/2026 at 11:00 AM with CNA A, she said call buttons were important because they ensure if a resident has a need or an emergency, they can get assistance. She said call buttons should be within reach of the resident. She said they were not supposed to be on the floor. She said if a resident was unable to reach their call button, an incident could happen and she wouldn't know. During an interview on 05/13/2025 at 11:06AM with CNA B, she said call buttons were used in case of emergency or if the residents need help with something. She said call buttons should be located next to residents. She said it's more dangerous for a resident if their call button was under bed or out of reach. She said it could put residents at risk of falls. During an interview on 05/13/2026 at 11:10 AM with Resident #5, she said she was able to pull the cord of the call button from over the bedside tray until she was able to reach and push it for assistance. During an interview on 05/13/2026 at 1:52 PM with the Administrator, he said call buttons were used so residents can request assistance or help. He said call buttons should be within a resident's reach. He said not having a call button in reach of a resident could delay responses in assisting them. He said whether a resident was able to use a call button or not, the expectation was that it is within reach. During an interview on 05/15/2026 at 3:37 PM with the DON, he said call buttons should be within reach of residents when they were in bed. He said call buttons not within reach of residents can cause a delay in care. He said it could also put the resident in danger. A record review of the facility's Answering the Call Light policy dated October 2010 stated, when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interviews, observations and record review, the facility failed to ensure the resident (Resident #14) environment remained as free of accident hazards as is possible over three out of four days to prevent accidents. The facility failed to follow Resident #14's care plan interventions for falls. The failure could place residents at risk of injury, reduced mobility and hospitalization.Findings include: During a record review of Resident #14's face sheet, it was revealed resident was a seventy-two year old male admitted on [DATE] with a diagnoses of contractures to both knees, stage 3 pressure ulcers to buttocks, communication deficit and paralysis and weakness to right dominant side. During a record review of Resident #14's Fall Risk assessment dated [DATE], it was revealed resident was at moderate risk for falls. During a record review of Resident #14's MDS dated [DATE], it was revealed that resident was rarely/never understood, somewhat understands others, severely impaired and had a BIMS of 00 or 99. During a record review of Resident #14's care plan dated 05/11/2026, it was revealed Resident had an unwitnessed fall. Resident goal related to this fall noted he would minimize complications related to the actual fall to the extent possible. Interventions included keep bed in low position with brakes locked.keep call light within reach. During an observation on 05/12/2026 at 10:42 AM Resident #14 was observed lying in bed asleep. Resident's bed was raised approximately two feet above the floor. His call button was on the floor and not within reach. Resident #14 was receiving feeding via gastronomy tube. An oxygen machine was also observed to the left of his bed. Resident #14 did not engage verbally or through gestures due to limited communication ability. During an observation on 05/13/2026 at 10:07 AM, Resident #14 was observed lying in bed. His call light was on the floor under his IV pole. Resident #14's bed was positioned approximately two feet off the floor. During an observation 05/15/2026 at 2:00 PM, Resident #14's bed was observed approximately two feet above the floor. During an interview on 05/15/2026 at 2:08 PM with ADON B, she said interventions were put in place like more frequent rounds and monitoring after Resident #14 had a fall this week. She said not following interventions could place the resident at risk of falling again. During an interview on 05/15/2026 at 2:14 PM with the Administrator, he said following Resident #14's fall on Monday, interventions were put in place to prevent further incidents. He said staff were expected to follow care plan recommendations. He said he wasn't sure why Resident #14's bed had been observed in a higher setting than recommended or the call button was not within reach. He said staff were expected to check on residents at least every two hours. He said failure to follow these interventions could continue to place the resident at risk of additional falls and harm. During an interview on 05/15/2026 at 3:47 PM with the DON, he said interventions had been put in place to prevent further falls by Resident #14. He said in addition to care plan recommendations, staff were expected to increase rounding on the resident. He said checking on the resident about every thirty minutes would be appropriate. He said he wasn't sure why the resident's call button was observed on the floor and out of reach and his bed was not in the lowest position if rounding was being done. He said not following interventions could put the resident in danger. A record review of the facility Falls and Fall Risk Policy dated December 2007, it stated staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling and staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on observations, interviews, and record review the facility failed to prepare food in a form designed to meet individual needs for 5 residents (Resident # 59, 51,88, 23, and 4) reviewed for puree diet. -On 5/13/26 and 5/14/26 the protein puree (A puree diet consists of foods that are blended into a smooth, pudding-like consistency to make eating and swallowing easier for people with chewing or swallowing difficulties) portions of lunch were not the correct texture. This failure had the potential to cause residents on a puree diet to aspirate, choke, or cause weight-loss due to difficulty in consuming meals. Record review of the facility therapeutic diet roster dated 5/12/26 revealed that Resident #'s 59, 51, 88, 23 and 4 required a puree diet. Record review of the menu dated 5/13/26 revealed baked chicken would be served. The menu for 5/14/26 revealed marinated pork loin would be served.Record review of the in-service titled Puree Consistency, dated 5/14/26 revealed that the DM provided training which stated All puree must be smooth without any piece that can be noticed on the tongue, this will prevent resident from choking or aspiration. Puree must look, feel like baby food. Always test and taste all puree to ensure that it is the correct consistency.Observation and interview on 5/13/26 at 10:33 am with the DM and [NAME] A revealed baked chicken puree procedure. [NAME] A followed procedure during pureeing by adding broth into the chicken to thin and using machine to thin. Once pureeing was completed the surveyor observed the texture of the baked chicken and asked if the chicken were pureed enough seeing that the texture could have been pureed a while longer. [NAME] A shook her head and said yes, she took the container of pureed chicken, which was covered in plastic wrap, shook the container and passed the container to the DM. The DM placed the puree chicken on the steam table, took the temperature probe, stirred around the chicken, and took the temperature. The DM said that the facility had 8 residents that required a puree diet, 2 with double portions. Observation of temperature, taste, texture of test tray on 5/13/26 at 12:58 pm with the DM. Surveyors found that the texture of the mashed potatoes and green beans had the texture of baby food. The pureed chicken had the consistency of a tuna or chicken salad and had residual strings or strands of meat when sampled for both surveyors who sampled the pureed baked chicken. The surveyors requested a lunch puree test tray for 5/14/26. Observation and interview on 5/14/26 at 11:30 am with the DM, Administrator and DON of the puree pork loin revealed that the pork loin appeared to be slightly lumpy with the appearance of cooked oatmeal. The puree pork loin was tested by the DM, Administrator, DON and 1 surveyor which all found the texture could be smoother and could see that a resident requiring a puree diet could have the potential to choke. Observation and interview on 5/14/26 at 11:45 am with the DM, Administrator and 2 surveyors, the texture appeared to be smooth like baby food. Both the Administrator and DM said that they could see the difference between the textures of the pureed pork loin, the 2 surveyors also said that there was a difference in the textures. Interview on 5/14/26 at 2:54 pm with the Dietician, she said she heard about puree chicken consistency and only saw the first consistency and second consistency on the pork loin today 5/14/26. She said, the second consistency of the pork loin was smoother, the first consistency of the pork loin could leave residue in the mouth could lead to choking if the residents were determined to need puree diet, Interview on 5/14/26 at 3:59 pm with the Administrator and DON, the Administrator said that they would address the textures of food and that the expectation was that textures were consistent for therapeutic diets. They said the DM was responsible for preparation of foods. During an interview on 5/15/26 at 9:06 am with the DM and [NAME] A , the DM translated for [NAME] A. [NAME] A said she gave the chicken to the DM on 5/13/26, she did not re-puree the chicken. Yesterday 5/14/26, [NAME] A did re-puree the pork after concerns about the texture. She said that she saw a difference in the first puree of pork and the second puree, the second one was really smooth, the first texture was a little thicker, you could see the difference by looking at it. The DM said she had an in-service on puree textures. [NAME] A said she understood that the importance of the texture being smoother. She said if the texture were not smoother, residents could choke. The DM said she trained them (cooks) about aspirating and in the importance of textures. During an interview on 5/15/26 at 4:21 pm with the DON, he said when a specific diet was prescribed, it should be followed. He said puree texture was important to prevent aspiration or choking. Record review of the facility policy and procedure entitled Food and Nutrition Services, dated revised October 2017 read in part. Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Record review of the facility policy and procedure entitled Therapeutic Diets, dated revised October 2017, read in part.A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet.

Based on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for 1 of 8 residents (Resident #1) reviewed for resident assessment. The facility failed to ensure Resident #1's PASRR Level I screening reflected her mental illness diagnosis. This failure could place residents at risk of not receiving specialized services for their mental illness. Findings included: Record review of Resident #1's Admission Record dated 4/3/25 revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, bipolar type (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), anxiety disorder, depression and major depressive disorder severe with psychotic symptoms. Record review of Resident #1's discharge-return anticipated MDS assessment, dated 3/19/25 revealed her cognitive skills for daily decision making were moderately impaired. Record review of Resident #1's care plan dated 4/2/25 indicated she used antidepressant medication related to depression, anxiety, schizoaffective disorder, bipolar type, and major depressive disorder recurrent severe with psychotic symptoms. Record review of Resident #1's PASRR Level I screening dated 8/28/23 indicated there was no evidence or an indicator that the resident had a mental illness. Resident #1 did not have a primary diagnosis of dementia. In an interview on 4/2/25 at 3:49 p.m. the MDS nurse said Resident #1 was positive for mental illness and did not have a dementia diagnosis. She said the (inaccurate) PASRR should have been caught during admission and she would submit another PL1 screening, She said she should have completed an audit of all residents with a schizo diagnosis. She said the purpose of the PASRR screening was to ensure the resident got adequate care and help to go out into the community. In an interview on 4/3/25 at 2:55 p.m. the Administrator said staff should double check the PASRR to ensure no diagnoses were missed. He said the facility did not have a great policy in place but moving forward they would ensure routine audits were completed on PASRRs. He said the purpose of the PASRR screening was to determine if the resident met qualifications for benefits of PASRR. He said he did not believe there was a risk for an inaccurate PASRR screening because the facility had good psych providers to address the residents' needs. Record review of the facility's Admission Criteria policy dated March 2019 read in part, .9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority .

Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when the resident experienced a change in condition for 1 of 8 residents (Resident #55) reviewed for a change in condition. The facility failed to notify the physician when Resident #55 was pocketing Oxycodone pills on [DATE]. Resident #55 was found unresponsive and was sent to the local hospital on [DATE] for respiratory distress. The local hospital sent her to an inpatient behavioral hospital where she was admitted due to worsening of mood and suicidal attempt by drug overdose. An immediate jeopardy (IJ) was identified on [DATE] at 5:21 p.m. While the IJ was lowered on [DATE] at 2:33 p.m., the facility remained out of compliance at a severity level of more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for hospitalization and death. Findings include: Record review of Resident #55's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included quadriplegia C1-C4 incomplete (a spinal cord injury that blocks some, but not all, signals from getting through), major depressive disorder, scoliosis (sideways curvature of the spine or back bone), hypotension (low blood pressure), pain, and polyneuropathy (damage to multiple peripheral nerves). Record review of Resident #55's Hospital Paperwork dated [DATE] revealed she had a past medical history of IV heroin abuse. Record review of Resident #55's Psychiatric Subsequent assessment dated [DATE] read in part, .Review of History: Social Hx: drug use: per chart IV drug abuse Heroin. Pt denied . Record review of Resident #55's annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. She had symptoms of little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, feeling tired or having little energy, poor appetite, or overeating, feeling bad about yourself, and trouble concentrating on things. The total severity score was 21 out of 27 which indicated severe depression. She was dependent on staff for ADLs except for eating and oral hygiene. Record review of Resident #55's Physician Orders for [DATE] included: -Oxycodone 10 mg 1 tablet by mouth every 4 hours as needed for pain, order date [DATE]. Discontinued [DATE] transferred to hospital. Record review of Resident #55's nursing note dated [DATE] at 8:13 a.m. written by LVN P read in part, .Resident is pocketing pills in the mouth and take Oxycodone out per assigned CAN (sic) . Record review of Resident #55's nursing notes from [DATE] - [DATE] revealed there was no further documentation on Resident #55 pocketing pills or notification to the MD. Record review of Resident #55's Medication Administration Record from [DATE] - [DATE] revealed Oxycodone 10 mg give 1 tablet every 4 hours as needed for pain was documented as administered approximately 74 times to Resident #55 by various nurses. Record review of Resident #55's Controlled Drug Administration Record Tablet for Oxycodone 10 mg every four hours as needed for pain dated [DATE] revealed facility staff administered 60 tablets of Oxycodone to Resident #55 between [DATE] - [DATE]. Record review of Resident #55's Controlled Drug Administration Record Tablet for Oxycodone 10 mg every four hours as needed for pain dated [DATE] revealed facility staff administered 48 tablets of Oxycodone to Resident #55 between [DATE] - [DATE]. Record review of Resident #55's nursing note dated [DATE] at 6:07 a.m. written by LVN T revealed the resident was in respiratory distress. Placed O2 at 6L for comfort via NC. O2 saturations at 68%. Record review of Resident #55 's nursing note dated [DATE] at 8:40 a.m. written by RN E revealed CNA walked into the room and found patient unresponsive, was called at 6:40 a.m. to the room and found patient having agonal breaths (abnormal pattern of breathing characterized by labored, gasping breaths that occur because of insufficient oxygen), pupils reactive, and a thready pulse (a weak or absent pulse). The vital signs oxygen saturation at 68%, was not able to get a blood pressure and pulse reading, rapid response activated. At 6:50 a.m. the emergency response arrived; patient transferred to hospital. Record review of Resident #55's local hospital emergency department record dated [DATE] read in part, .stated complaint: suicide attempt; chief complaint: change mental/neuro status . pt found at (nursing facility) by staff as unresponsive with no pulse. Staff began CPR and realized pt had DNR. Staff got pulse back and per medic pt was agonal breathing and had bp of ,d+[DATE] and HR of 74 upon arrival .medication prior to arrival: Naloxone (used for the emergency treatment of known or suspected opioid overdose) Suicide assessment: wish to be dead or to not wake up in the past month: yes; . active suicidal ideation with plan and intent in the past month: yes; . attempted, plan to attempt, or prepared to end life in the past 3 months: yes; . calculated suicide risk level: high risk . emergency notes: This RN did suicide screening on pt. Pt states that she is not active suicidal and does not wish to be dead but wishes that the pain would go away. When asked by this RN if Pt took more Oxycodone than she was supposed to take, Pt said yes. Pt also stated that she never meant to harm herself that she just wanted the pain to go away and that was the reason why she took more Oxycodone than prescribed. Pt denies suicidal ideations at this time . Record review of Resident #55's local hospital record dated [DATE] read in part, .HPI: 46 y/o female with pmh of anxiety, PE, anemia and quadriplegic due to spinal infection with chronic pain admitted after she was found unresponsive at the NH. Per report, CPR initiated, was more awake upon EMS arrival. She was AAOx4 upon arrival to the ER. She reports had taken more pain medication to help control her pain. Denies suicidal ideations, she reports just wanted to end her pain . Diagnosis, Assessment and Plan: 1. Drug overdose- ? suicidal attempt - sitter at bedside, psych consulted . Record review of Resident #55's hospital Psychiatric Evaluation Note dated [DATE] read in part, .Patient evaluated and events noted . one to one sitter at bedside. Patient is alert and oriented x 3, calm, cooperative and pleasant. She stated that the reason that she took too many pills was because she was in pain, she stated that it was not intentional. She denied SIHI (suicidal ideations homicidal ideations) and AVH (auditory verbal hallucinations), no paranoia or delusions elicited . as per the treatment team, patient pocketing her pain medications at the nursing home so she can overdose on medications. Record review of Resident #55's hospital Psychiatric Progress Note dated [DATE] read in part, .calm and polite, denies intent to harm self . Assessment: major depression severe without psychosis, rule out substance abuse . Plan . transfer to inpatient psychiatry once medically cleared, with sitter continue for now . states the overdose was not intentional and was not an attempt. When gently confronted further patient states she takes the medicine for pain. She does not like her nursing home and does not wish to return there. Patient states she only took 10 pills throughout the day . Record review of Resident #55's Application for Emergency Detention dated [DATE] revealed there was reason to believe and belief that Resident #55 evidenced a substantial risk of serious harm to herself because of: pt. overdosed on pills in attempt to commit suicide, pt is anxious and agitation, pt is depressed. The beliefs were based on: pt. insight and judgement limited/poor and pt is a harm to herself. Record review of Resident #55's local hospital record dated [DATE] read in part, Discharge to: psych, facility . discharge date : [DATE] discharge diagnosis: 1.drug overdose/suicidal attempt . Hospital course: .presented after she was found unresponsive after drug overdose as an attempt to suicide. Psych evaluated pt, recommended for inpatient psych transfer . remains stable, will transfer to (behavioral hospital) . Record review of Resident #55's Behavioral Hospital Record dated [DATE] read in part, .reason for Admission . include chief complaint in patient's own words: Patient admitted to inpatient behavioral facility from hospital due to worsening of mood and suicidal attempt by drug overdose. Patient had a long history of mental illness with history of depression and anxiety. As per records patient took 10 pills of oxycodone throughout the day. Patient was pocketing her pain medication at nursing home so that she could overdose on medication . The patient was assessed to be a danger to herself and required inpatient level of care for further evaluation and treatment in a controlled environment. Upon initial evaluation . patient endorsed having depressed mood and anxiety. Patient mentioned I don't want to go back to the same nursing home again which I was staying, I don't like the people there . Patient endorsed feelings of helplessness or hopelessness. Patient reported being compliant with medications prior to arriving to the hospital . Patient is being monitored every 15 for suicidal precautions . Record review of Resident #55's MD progress note dated [DATE] read in part . resident was seen today after recent hospital admission for respiratory distress, and O2 sat of 68 possible due to overdose of pain meds, patient was stabilized, but required inpatient psych due to worsening mood and suspected drug overdose . Diagnosis, assessment and plan: chronic pain: given patient's possible overdose and pocketing of pain meds that sent her to the hospital, I will decrease her oxycodone from every 4 hour to every 6 hour and also continue methadone at her regular dose . She is not getting her vitals done, so I will cut back further on pain meds if I have to. I take this question of overdose very seriously. She is on baclofen (used to treat muscle spasms). I will not add back her tizanidine ( used to treat muscle spasms) at this time . Record review of Resident #55's care plan revisions after her hospital stay on [DATE] revealed Resident #55 had impaired cognitive function and impaired thought processes related to cognitive decline and depression. Increased risk for personality changes, poor judgment, delusions, agitation, withdrawing from social contact, dated [DATE]. Resident #55 had a mood problem related to factors such as loss of independence, short temper, history of behavioral issues, major life changes, depression, little interest/pleasure in doing things. Interventions were to administer medications as ordered, assist the resident to identify strengths, positive coping skills and reinforce these, and educate the resident regarding expectations of treatment, etc, monitor mood to determine if problems seem to be related to external causes; report to MD prn acute episode feelings or sadness; feelings of worthlessness or guilt; report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols, date initiated [DATE]. There was no documentation of Resident #55 pocketing pills, her opioid overdose, or suicidal attempt notated in her clinical record. In an observation and interview on [DATE] at 8:45 a.m. with Resident #55 in her room, she was lying in bed awake. She said she had one previous hospitalization . When asked why she was hospitalized , Resident #55 said what? My overdose? If you are curious about my overdose you can leave. Interview ended. Interview on [DATE] at 9:44 a.m. with LVN T, he said he did not see Resident #55 pocket medications but received a report that Resident #55's Oxycodone was found in a cup before she went to the hospital (on [DATE]). He said after the incident, he started to enforce that the resident swallowed her medication, but she would refuse to open her mouth. He said he ensured she did not pocket the medication, but the resident would get upset because she felt they treated her like a child. He said he could not look in her mouth and would ask if she swallowed the medication. Interview on [DATE] at 10:37 a.m. the NP said a Nurse informed him that Resident #55 overdosed after she went to the hospital. He said he and the MD were trying to wean her down as much as possible. He said after she returned from the hospital, he informed the nurses to watch the resident take her pills and have her open her mouth to show that she swallowed the medication. Interview on [DATE] at 11:04 a.m. with the MD, he said he was not aware that Resident #55 was pocketing pills prior to her incident in November. He said if he was notified, he would have stopped the medication and had a conversation and plan to prevent it. He said when Resident #55 returned from hospital she told him what she did was intentional, she did not want to be here, she wanted to kill herself, and she was angry that she was not successful. He said staff should watch her take her pills and monitor for signs and symptoms. He said signs of oxycodone overdose were lethargy (a feeling of fatigue, tiredness and exhaustion both physically and mentally), hypoxia (below-normal level of oxygen in your blood), and low blood pressure. Interview on [DATE] at 11:55 a.m. with the Unit Manager, she said she was not aware Resident #55 was pocketing pills. She said Resident #55 went into distress and was sent out 911. She said after the resident returned from the hospital the resident told her: I tried to, that was on purpose . I know I messed up and I know why the MD changed the medication to every 6 hours. Interview on [DATE] at 12:33 p.m. with the ADON she said she was not aware Resident #55 was pocketing pills prior to the incident in November. She said they would have notified the doctor and intervened if they knew. She said on the day of the incident, nurses and CNAs called her and said the resident was lethargic and unresponsive and they called 911 immediately. She said the hospital called and were concerned about her mental health. The hospital was not releasing the resident back to the facility and she needed to go to inpatient therapy. The ADON said when the resident returned to the facility the resident said to her you will pay for it, I should have died . She said the resident informed her that she was taking too much and was holding them in, because she wanted to die. She said the resident told her that but then reverted and changed the story to get her way. She said prior to the incident the resident would request that staff leave her pain medication in the room, but the ADON informed staff that could not be done, and staff had to stay in the room to ensure it was swallowed. She said the resident would say she was not a child and would curse and yell at the staff. She said signs of an opioid overdose would include low blood pressure and not arousable. Interview on [DATE] at 1:04 p.m. with the DON, he said he was not aware of Resident #55 pocketing medications. He said he was aware she went to the hospital because she was not responding and was sent to the behavioral hospital. He said he reviewed her clinicals from the behavioral hospital but did not observe any outliers. He said he was not aware of her overdosing or having suicidal thoughts. Interview on [DATE] at 1:49 p.m. with the Administrator, he said he was not aware that Resident #55 was pocketing pills. He said he had no knowledge of a drug overdose or history of suicidal ideation. He said she was unresponsive and was sent to the hospital and then to the behavioral hospital for additional psych help. He said if he was notified of her pocketing pills, he would have notified the MD and investigated. This Surveyor showed the Administrator Resident #55's nursing note from [DATE] about pocketing pills. He said he had not seen the note and was not informed of the incident. Interview on [DATE] at 6:54 p.m. with LVN P, he said on [DATE] CNA V informed him that she saw Resident #55 take her medication (Oxycodone) out of her mouth. He said he did not tell the MD or NP but informed the nurse on the next shift and placed it on the 24-hour report. He said he informed the next shift to be careful when administering medication to Resident #55 and ensure she swallowed the medication with water. He said he went to Resident #55's room to look for the medication but did not see anything. He said Resident #55 denied it, was mad, cussed him out, and thought he was accusing her. He said he did not report it to the physician because he did not have information to give him since he did not see the medication in the room. He said multiple people knew she had medication in her room, but he was the only one to document because he thought it needed to be followed up on. An interview was attempted on [DATE] at 9:42 a.m. with CNA V but was unsuccessful. Record review of the facility's Acute Condition Changes - Clinical Protocol policy dated ,d+[DATE] read in part, .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician 8. The nursing staff will contact the physician based on the urgency of the situation . On [DATE] at 5:21 p.m. the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template was left with the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on [DATE] at 7:30 a.m.: PLAN OF REMOVAL - F580 Immediate actions: o DON and/or designee will educate nurses on [DATE] & [DATE] on physician notification regarding changes in condition and behavior. o Nurses will demonstrate competency in this education by completing a post-education questionnaire. Any nurse who is not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o DON and/or designee will educate nurses on [DATE] & [DATE] to ensure medications are taken appropriately by all residents. o Nurses will demonstrate competency in this education by completing a post-education questionnaire. Any nurse who is not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o DON and/or designee will educate nurses on [DATE] & [DATE] to ensure nurses are able to identify a behavioral or mental health change of condition that would require physician consultation. o Nurses will demonstrate competency in this education by completing a post-education questionnaire. Any nurse who is not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o The Interdisciplinary Team will update resident #55 care plan to include the following interventions: o Ensure resident swallows the medication. o Psych will continue to follow resident. o Notify physician of any change of condition related to suicidal behavior/self-harm. Compliance Date: [DATE] o The Interdisciplinary Team will audit residents' charts and interview alert and oriented residents to ensure that any resident who does display signs and symptoms of suicidal ideation/self-harm have appropriate interventions in place and physicians are notified. Compliance Date: [DATE] o The Interdisciplinary Team will review the 72-hour report to ensure that physicians have been notified of all changes of condition identified in this report. Compliance Date: [DATE] o Unit manager communicated with resident #55 physician regarding behavior, medications, and care plan. Compliance Date: [DATE] MONITORING: Record review of the Competency Assessment for Nurses and Med Aides revealed True/False questions for Notifying Physicians regarding change of condition and suicidal ideation/self-harm, and Ensuring medications are taken appropriately. There was also a Signs and Symptoms MD Notification Guide given to them regarding when to notify the physician. Record review of POR revealed Nurses and Med Aides were educated on Med Administration which discussed: prescription and dosage, route of administration, pocketing medication, patient education, timing, record keeping, monitoring, and storage. Record review of POR revealed Nurses were educated on Managing Suicide and Suicidal Ideation, including signs and symptoms and risk factors. Record review of resident # 55's care plan revealed an updated focus on a Risk for injury to self r/t suicidal ideations initiated [DATE]. Interventions included: Administer medications as ordered, monitor while swallowing medication to ensure she is not pocketing/cheeking medication, Notify physician of any change of condition related to suicidal behavior/self-harm, Nurses and Med Aides will ensure resident swallows the medication and doesn't pocket medications, Pscyh services to continue to follow resident, Refer resident to (name) Psych, and Review prescribed medication side effects. Record review of POR binder revealed a list of 92 residents that the Psychologist assessed on [DATE] and charts reviewed, and none of them had any suicidal ideations/self-harm issues. Social Services Director interviewed every resident able from [DATE] to [DATE] and none showed any signs of suicidal ideation or self-harm. Record review of the change in condition log revealed the IDT reviewed the 72hr report for all residents and found 13 changes in conditions. The MD had been notified with all of the residents. Record review of Resident #55's medical record revealed a progress note from LVN E on [DATE] at 10:54 pm that said she spoke with the MD regarding the resident's medications, behaviors, and plan of care. Parameters were received to hold/not administer Oxycodone if SBP less than 100 or HR less than 55. If resident refused to have BP/HR checked medication would not be administered for resident's safety. MD notified of alleged suicidal ideation attempt and stated he didn't feel it was a threat at this time. Staff would continue to monitor resident for s/s and would notify MD of any issues. Record review of In-services/training revealed Nursing Staff were trained on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. In-services given by the ADON with 17 nurse signatures. Med Aides were in-serviced on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. Training performed by the ADON with 3 med aide signatures. Nurse Aides were in-serviced on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. The ADON performed the in-service with 12 Nurse Aide signatures. There are 15 staff members left to perform in-services with the first shift being the night shift on [DATE]. Interview on [DATE] at 1:25 p.m. LVN O said she had in-services on suicidal ideation: what to look for, what to do, who to report it to, change in condition, and to watch them take the medications. Interview on [DATE] at 1:30 p.m. CNA A said she received in-services on suicidal ideation: to report it to the nurse asap, and to follow up, stay with the resident and not leave them alone, report a change in condition, and to check their mouth. Interview on [DATE] at 1:32 p.m. LVN N said she received in-services on suicidal ideations: to report it asap, don't leave them alone, notify the DON/MD/Admin/RP, and report a change in condition. Interview on [DATE] at 1:36 p.m. RN C said she received in-services on suicidal ideation: monitor the s/s, the med administration for suicidal residents, and change in condition. She also said she received in-services on abuse and the abuse coordinator. Interview on [DATE] at 2:15 p.m. the ADON said there were 15 staff members that still needed to be in-serviced. All have been contacted and know they cannot step foot on the floor until they complete the in-service. The first employee who has not been in-serviced is on the PM shift of [DATE]. He will be in-serviced as soon as he gets to the facility. The facility was notified the IJ was lowered on [DATE] at 2:33 p.m. however, the facility remained out of compliance, at a scope of pattern and a severity level of more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their corrective systems.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #55) reviewed for supervision. -The facility failed to put interventions in place to prevent overdose of medications when Resident #55 was first noticed by the staff on [DATE] pocketing medications including narcotics. Resident #55 was found unresponsive and was sent to the hospital on [DATE] for respiratory distress with a hospital discharge diagnosis of drug overdose/suicidal attempt. An immediate jeopardy (IJ) was identified on [DATE] at 5:21 p.m. While the IJ was lowered on [DATE] at 2:33 p.m., the facility remained out of compliance at a severity level of more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for hospitalization and death. Findings include: Record review of Resident #55's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included quadriplegia C1-C4 incomplete (a spinal cord injury that blocks some, but not all, signals from getting through), major depressive disorder, scoliosis (sideways curvature of the spine or back bone), hypotension (low blood pressure), pain, and polyneuropathy (damage to multiple peripheral nerves). Record review of Resident #55's Hospital Paperwork dated [DATE] revealed she had a past medical history of IV heroin abuse. Record review of Resident #55's Psychiatric Subsequent assessment dated [DATE] read in part, .Review of History: Social Hx: drug use: per chart IV drug abuse Heroin. Pt denied . Record review of Resident #55's Care Plan completed [DATE] revealed she was referred for psychiatry services related to depression . often angry with staff, accuse them of not doing their job, then refuse when they attempt to render care, revised on [DATE]. Interventions were to attend therapy. Resident #55 had a behavior problem related to giving statements about staff that could not be validated, revised on [DATE]. She received antidepressant medication related to depression and neuropathic pain, revised on [DATE]. Interventions included to monitor for target behaviors including self-isolation, refusal of care, poor appetite, insomnia. Report adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thought, withdrawal. There was no documentation on pocketing medications or history of drug use. Record review of Resident #55's annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. She had symptoms of little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, feeling tired or having little energy, poor appetite, or overeating, feeling bad about yourself, and trouble concentrating on things. The total severity score was 21 out of 27 which indicated severe depression. She was dependent on staff for ADLs except for eating and oral hygiene. Record review of Resident #55's Physician Orders for [DATE] included: -Oxycodone 10 mg 1 tablet by mouth every 4 hours as needed for pain, order date [DATE]. Discontinued [DATE] transferred to hospital. Record review of Resident #55's nursing note dated [DATE] at 8:13 a.m. written by LVN P read in part, .Resident is pocketing pills in the mouth and take Oxycodone out per assigned CAN (sic) . Record review of Resident #55's nursing notes from [DATE] - [DATE] revealed there was no further documentation on Resident #55 pocketing pills or notification to the MD. Record review of Resident #55's Medication Administration Record from [DATE] - [DATE] revealed Oxycodone 10 mg give 1 tablet every 4 hours as needed for pain was documented as administered approximately 74 times to Resident #55 by various nurses. Record review of Resident #55's Controlled Drug Administration Record Tablet for Oxycodone 10 mg every four hours as needed for pain dated [DATE] revealed facility staff administered 60 tablets of Oxycodone to Resident #55 between [DATE] - [DATE]. Record review of Resident #55's Controlled Drug Administration Record Tablet for Oxycodone 10 mg every four hours as needed for pain dated [DATE] revealed facility staff administered 48 tablets of Oxycodone to Resident #55 between [DATE] - [DATE]. Record review of Resident #55's nursing note dated [DATE] at 6:07 a.m. written by LVN T revealed the resident was in respiratory distress. Placed O2 at 6L for comfort via NC. O2 saturations at 68%. Record review of Resident #55 's nursing note dated [DATE] at 8:40 a.m. written by RN E revealed CNA walked into the room and found patient unresponsive, was called at 6:40 a.m. to the room and found patient having agonal breaths (abnormal pattern of breathing characterized by labored, gasping breaths that occur because of insufficient oxygen), pupils reactive, and a thready pulse (a weak or absent pulse). The vital signs oxygen saturation at 68%, was not able to get a blood pressure and pulse reading, rapid response activated. At 6:50 a.m. the emergency response arrived; patient transferred to hospital. Record review of Resident #55's local hospital emergency department record dated [DATE] read in part, .stated complaint: suicide attempt; chief complaint: change mental/neuro status . pt found at (nursing facility) by staff as unresponsive with no pulse. Staff began CPR and realized pt had DNR. Staff got pulse back and per medic pt was agonal breathing and had bp of ,d+[DATE] and HR of 74 upon arrival .medication prior to arrival: Naloxone (used for the emergency treatment of known or suspected opioid overdose) Suicide assessment: wish to be dead or to not wake up in the past month: yes; . active suicidal ideation with plan and intent in the past month: yes; . attempted, plan to attempt, or prepared to end life in the past 3 months: yes; . calculated suicide risk level: high risk . emergency notes: This RN did suicide screening on pt. Pt states that she is not active suicidal and does not wish to be dead but wishes that the pain would go away. When asked by this RN if Pt took more Oxycodone than she was supposed to take, Pt said yes. Pt also stated that she never meant to harm herself that she just wanted the pain to go away and that was the reason why she took more Oxycodone than prescribed. Pt denies suicidal ideations at this time . Record review of Resident #55's local hospital record dated [DATE] read in part, .HPI: 46 y/o female with pmh of anxiety, PE, anemia and quadriplegic due to spinal infection with chronic pain admitted after she was found unresponsive at the NH. Per report, CPR initiated, was more awake upon EMS arrival. She was AAOx4 upon arrival to the ER. She reports had taken more pain medication to help control her pain. Denies suicidal ideations, she reports just wanted to end her pain . Diagnosis, Assessment and Plan: 1. Drug overdose- ? suicidal attempt - sitter at bedside, psych consulted . Record review of Resident #55's hospital Psychiatric Evaluation Note dated [DATE] read in part, .Patient evaluated and events noted . one to one sitter at bedside. Patient is alert and oriented x 3, calm, cooperative and pleasant. She stated that the reason that she took too many pills was because she was in pain, she stated that it was not intentional. She denied SIHI (suicidal ideations homicidal ideations) and AVH (auditory verbal hallucinations), no paranoia or delusions elicited . as per the treatment team, patient pocketing her pain medications at the nursing home so she can overdose on medications. Record review of Resident #55's hospital Psychiatric Progress Note dated [DATE] read in part, .calm and polite, denies intent to harm self . Assessment: major depression severe without psychosis, rule out substance abuse . Plan . transfer to inpatient psychiatry once medically cleared, with sitter continue for now . states the overdose was not intentional and was not an attempt. When gently confronted further patient states she takes the medicine for pain. She does not like her nursing home and does not wish to return there. Patient states she only took 10 pills throughout the day . Record review of Resident #55's Application for Emergency Detention dated [DATE] revealed there was reason to believe and belief that Resident #55 evidenced a substantial risk of serious harm to herself because of: pt. overdosed on pills in attempt to commit suicide, pt is anxious and agitation, pt is depressed. The beliefs were based on: pt. insight and judgement limited/poor and pt is a harm to herself. Record review of Resident #55's local hospital record dated [DATE] read in part, Discharge to: psych, facility . discharge date : [DATE] discharge diagnosis: 1.drug overdose/suicidal attempt . Hospital course: .presented after she was found unresponsive after drug overdose as an attempt to suicide. Psych evaluated pt, recommended for inpatient psych transfer . remains stable, will transfer to (behavioral hospital) . Record review of Resident #55's Behavioral Hospital Record dated [DATE] read in part, .reason for Admission . include chief complaint in patient's own words: Patient admitted to inpatient behavioral facility from hospital due to worsening of mood and suicidal attempt by drug overdose. Patient had a long history of mental illness with history of depression and anxiety. As per records patient took 10 pills of oxycodone throughout the day. Patient was pocketing her pain medication at nursing home so that she could overdose on medication . The patient was assessed to be a danger to herself and required inpatient level of care for further evaluation and treatment in a controlled environment. Upon initial evaluation . patient endorsed having depressed mood and anxiety. Patient mentioned I don't want to go back to the same nursing home again which I was staying, I don't like the people there . Patient endorsed feelings of helplessness or hopelessness. Patient reported being compliant with medications prior to arriving to the hospital . Patient is being monitored every 15 for suicidal precautions . Record review of Resident #55's care plan revisions after her hospital stay on [DATE] revealed Resident #55 had impaired cognitive function and impaired thought processes related to cognitive decline and depression. Increased risk for personality changes, poor judgment, delusions, agitation, withdrawing from social contact, dated [DATE]. Resident #55 had a mood problem related to factors such as loss of independence, short temper, history of behavioral issues, major life changes, depression, little interest/pleasure in doing things. Interventions were to administer medications as ordered, assist the resident to identify strengths, positive coping skills and reinforce these, and educate the resident regarding expectations of treatment, etc, monitor mood to determine if problems seem to be related to external causes; report to MD prn acute episode feelings or sadness; feelings of worthlessness or guilt; report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols, date initiated [DATE]. There was no documentation of Resident #55 pocketing pills, her opioid overdose, or suicidal attempt notated in her clinical record. Record review of Resident #55's MD progress note dated [DATE] read in part . resident was seen today after recent hospital admission for respiratory distress, and O2 sat of 68 possible due to overdose of pain meds, patient was stabilized, but required inpatient psych due to worsening mood and suspected drug overdose . Diagnosis, assessment and plan: chronic pain: given patient's possible overdose and pocketing of pain meds that sent her to the hospital, I will decrease her oxycodone from every 4 hour to every 6 hour and also continue methadone at her regular dose . She is not getting her vitals done, so I will cut back further on pain meds if I have to. I take this question of overdose very seriously. She is on baclofen. I will not add back her tizanidine at this time . Record review of Resident #55's Physician Orders for [DATE] included: -Oxycodone 10 mg give 1 tablet by mouth every 4 hours as needed for pain, order date [DATE]. Discontinued on [DATE] due to no vitals given so I need to decrease frequency to ensure safety. -Oxycodone 10 mg give 1 tablet by mouth every 6 hours as needed for pain, order date [DATE]. -Staff, if patient refuses vital checks, then hold pain meds for her safety. We need regular bp checks and oxygen checks per facility protocol and please put them in the computer, one time only for hypoxia for 5 days, order date [DATE], end date [DATE]. -Staff, please obtain hospital discharge summary from patient's admission to the hospital for hypoxia. (This is before she went to [behavioral hospital]) one time only for hypoxia for 5 days, order date [DATE], end date [DATE]. -Vital signs every shift, order date [DATE]. In an observation on [DATE] at 12:20 p.m. Resident #55 was lying in bed asleep with her breakfast tray at the bedside, uneaten. This Surveyor called residents name several times, but resident did not respond. Resident coughed and this Surveyor called her name again, but resident did not respond. In an observation on [DATE] at 1:11 p.m. Resident #55 was asleep in bed. Interview on [DATE] at 1:30 p.m. LVN D said Resident #55 slept on and off. He said she was currently on Oxycodone every 6 hours and asked for it every 6 hours. He said he had to ensure she swallowed the medication because she was not in the past. He said he monitored her respirations to ensure she was not sedated or overly medicated. He said she was getting her Oxycodone every 4 hours but now it was every 6 hours. He said she was hoarding her medications and not taking it and the MD changed it. Interview on [DATE] at 8:45 a.m. with Resident #55 in her room, she said she had one previous hospitalization . When asked why she was hospitalized , Resident #55 said what? My overdose? If you are curious about my overdose you can leave. Interview ended. Interview on [DATE] at 9:44 a.m. with LVN T, he said he did not see Resident #55 pocket medications but received a report that Resident #55's Oxycodone was found in a cup before she went to the hospital (on [DATE]). He said after the incident, he started to enforce that the resident swallowed her medication, but she would refuse to open her mouth. He said he ensured she did not pocket the medication, but the resident would get upset because she felt they treated her like a child. He said he could not look in her mouth and would ask if she swallowed the medication. Interview on [DATE] at 10:37 a.m. the NP said a Nurse informed him that Resident #55 overdosed after she went to the hospital. He said he and the MD were trying to wean her down as much as possible. He said after she returned from the hospital, he informed the nurses to watch the resident take her pills and have her open her mouth to show that she swallowed the medication. Interview on [DATE] at 11:04 a.m. with the MD, he said he was not aware that Resident #55 was pocketing pills prior to her incident in November. He said if he was notified, he would have stopped the medication and had a conversation and plan to prevent it. He said when Resident #55 returned from hospital she told him what she did was intentional, she did not want to be here, she wanted to kill herself, and she was angry that she was not successful. He said staff should watch her take her pills and monitor for signs and symptoms. He said signs of oxycodone overdose were lethargy (a feeling of fatigue, tiredness and exhaustion both physically and mentally), hypoxia (below-normal level of oxygen in your blood), and low blood pressure. Interview on [DATE] at 11:55 a.m. with the Unit Manager, she said she was not aware Resident #55 was pocketing pills. She said Resident #55 went into distress and was sent out 911. She said after the resident returned from the hospital the resident told her: I tried to, that was on purpose . I know I messed up and I know why the MD changed the medication to every 6 hours. Interview on [DATE] at 12:33 p.m. with the ADON she said she was not aware Resident #55 was pocketing pills prior to the incident in November. She said they would have notified the doctor and intervened if they knew. She said on the day of the incident, nurses and CNAs called her and said the resident was lethargic and unresponsive and they called 911 immediately. She said the hospital called and were concerned about her mental health. The hospital was not releasing the resident back to the facility and she needed to go to inpatient therapy. The ADON said when the resident returned to the facility the resident said to her you will pay for it, I should have died . She said the resident informed her that she was taking too much and was holding them in, because she wanted to die. She said the resident told her that but then reverted and changed the story to get her way. She said prior to the incident the resident would request that staff leave her pain medication in the room, but the ADON informed staff that could not be done, and staff had to stay in the room to ensure it was swallowed. She said the resident would say she was not a child and would curse and yell at the staff. She said signs of an opioid overdose would include low blood pressure and not arousable. Interview on [DATE] at 1:04 p.m. with the DON, he said he was not aware of Resident #55 pocketing medications. He said he was aware she went to the hospital because she was not responding and was sent to the behavioral hospital. He said he reviewed her clinicals from the behavioral hospital but did not observe any outliers. He said he was not aware of her overdosing or having suicidal thoughts. Interview on [DATE] at 1:49 p.m. with the Administrator, he said he was not aware that Resident #55 was pocketing pills. He said he had no knowledge of a drug overdose or history of suicidal ideation. He said she was unresponsive and was sent to the hospital and then to the behavioral hospital for additional psych help. He said if he was notified of her pocketing pills, he would have notified the MD and investigated. This Surveyor showed the Administrator Resident #55's nursing note from [DATE] about pocketing pills. He said he had not seen the note and was not informed of the incident. Interview on [DATE] at 6:54 p.m. with LVN P, he said on [DATE] CNA V informed him that she saw Resident #55 take her medication (Oxycodone) out of her mouth. He said he did not tell the MD or NP but informed the nurse on the next shift and placed it on the 24-hour report. He said he informed the next shift to be careful when administering medication to Resident #55 and ensure she swallowed the medication with water. He said he went to Resident #55's room to look for the medication but did not see anything. He said Resident #55 denied it, was mad, cussed him out, and thought he was accusing her. He said he did not report it to the physician because he did not have information to give him since he did not see the medication in the room. An interview was attempted on [DATE] at 9:42 a.m. with CNA V but was unsuccessful. Record review of the facility's Safety and Supervision of Residents policy dated ,d+[DATE] read in part, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Facility Oriented Approach to Safety: .3. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause of the hazards and develop strategies to mitigate or remove the hazards to the extent possible . 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. 5. The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary . Individualized, Resident-Centered Approach to Safety . 2. The IDT shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff . c. providing training, d. ensuring that interventions are implemented; and e. documenting interventions. On [DATE] at 5:21 p.m. the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template was left with the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on [DATE] at 7:30 a.m.: PLAN OF REMOVAL - F689 Date of Compliance: [DATE] Immediate actions: o DON and/or designee will assess resident #55 for change in condition, medication overdose, or thoughts of suicidal ideation/self-harm. o Resident #55 was assessed by the Assistant Director of Nursing and the Social Services Director. There were no indications of depression or suicidal ideations and the resident verbalized that they didn't have any thoughts, intent, method, and/or plan. o DON and/or designee will continue to assess resident #55 for change in condition, medication overdose, or thoughts of suicidal ideation/self-harm 3x weekly for 4 weeks. o Care plan implemented to ensure resident swallows the medication, psych will continue to follow resident, and physicians will be notified of any change of condition related to suicidal behavior/self-harm. o Licensed Phycologist, , will assess resident #55 for suicidal ideation/self-harm on [DATE]. ? Per assessment by psychologist, resident #55 is doing well mentally and has no immediate concerns for her physical or mental wellbeing. She indicated that she loves speaking with her psychology team. Compliance Date: [DATE] o The Interdisciplinary Team will update resident #55 care plan to include the following interventions: o Ensure resident swallows the medication. o Psych will continue to follow resident. o Notify physician of any change of condition related to suicidal behavior/self-harm. Compliance Date: [DATE] o DON and/or designee will check resident #55 room for any pills or medications. Compliance Date: [DATE] o DON and/or designee will educate nurses and medication aides on to ensure medications are taken appropriately by all residents. o Nurses and medication aides will demonstrate competency in this education by completing a post-education questionnaire. Any nurse or medication aide who is not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o DON and/or designee will educate staff to ensure all staff are knowledgeable about mental health/behavioral health needs as well as the reporting guidelines should they identify any concerns. o Staff will demonstrate competency in this education by completing a post-education questionnaire. Any staff not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o DON and/or designee will educate staff to ensure all staff are knowledgeable about signs and symptoms of self-harm or suicidal ideation as well as the reporting guidelines should they identify any concerns. o Staff will demonstrate competency in this education by completing a post-education questionnaire. Any staff not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o The Interdisciplinary Team will audit residents' charts and interview alert and oriented residents to ensure that any resident who does display signs and symptoms of suicidal ideation/self-harm have appropriate interventions in place and physicians are notified. Compliance Date: [DATE] o DON and/or designee will conduct search of resident #55 and their belongings 3x/week for 4 weeks. Compliance Date: [DATE] o Unit manager communicated with resident #55 physician regarding behavior, medications, and care plan. Compliance Date: [DATE] o The Interdisciplinary Team will review progress notes during weekday clinical IDT meeting to identify any residents at risk of suicidal ideation/self-harm. Compliance Date: [DATE] o The Interdisciplinary Team has reviewed policies and procedures regarding self-harm and/or suicidal ideations along with the reporting guidelines once concerns are identified. o 'Depression - Clinical Protocol' o 'Acute Condition Changes - Clinical Protocol' Compliance Date: [DATE] MONITORING: Record review of Resident's progress notes revealed a note from [DATE] at 11:26pm stating Social Services Director and ADON assessed resident and there was no change in condition, no evidence of medication overdose and resident stated she had no current thoughts of suicide or self-harm. Progress note from [DATE] at 11:59 p.m. revealed ADON educated resident to communicate any feeling of sadness/hopelessness along with positive coping mechanisms. Resident was receptive and agreed and continued to deny and symptoms of suicidal ideations or sadness. DON and/or designee will continue to assess resident #55 for change in condition, medication overdose, or thoughts of suicidal ideation/self-harm 3x week for 4 weeks. Record review of audit sheet in POR binder. Licensed Psychologist assessed resident #55 on [DATE] and there were no psychological issues of concern. Record review of resident's care plan revealed an updated focus on a Risk for injury to self r/t suicidal ideations initiated [DATE]. Interventions included: Administer medications as ordered, Monitor while swallowing medication to ensure she is not pocketing/cheeking medication, Notify physician of any change of condition related to suicidal behavior/self-harm, Nurses and Med Aides will ensure resident swallows the medication and doesn't pocket medications, Pscyh services to continue to follow resident, Refer resident to (name) Psych, and Review prescribed medication side effects. Record review of Resident #55's medical record revealed a progress note from [DATE] at 11:26pm stating Social Services Director and ADON went into the resident's room to check for any pills or medications. They did not find any pills laying around on the bedside table, side tables, bed, or any other visible areas. Record review of the Competency Assessment for Nurses and Med Aides revealed True/False questions for Notifying Physicians regarding change of condition and suicidal ideation/self-harm, and Ensuring medications are taken appropriately. There was also a Medication Administration sheet given to them regarding prescription and dosage, route of administration, pocketing medication, patient education, timing, record keeping, monitoring, and storage. Record review of the education given regarding mental health/behavioral health needs included Signs/Symptoms of Suicide, Suicide Risk Factors, and Signs and Symptoms MD Notification Guide. Record review of In-services/training revealed Nursing Staff were trained on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. In-services given by the ADON with 17 nurse signatures. Med Aides were in-serviced on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. Training performed by the ADON with 3 med aide signatures. Nurse Aides were in-serviced on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. The ADON performed the in-service with 12 Nurse Aide signatures. There are 15 staff members left to perform in-services with the first shift being the night shift on [DATE]. Record review of POR binder revealed a list of 92 residents that the Psychologist assessed on [DATE] and charts reviewed, and none of them had any suicidal ideations/self-harm issues. DON and/or designee will conduct search of Resident #55 and their belongings 3x week for 4 weeks. Record review of POR binder revealed Audit Sheet for resident. Record review of Resident #55's medical record revealed a progress note from LVN E on [DATE] at 10:54 p.m. that said she spoke with MD regarding the resident's medications, behaviors, and plan of care. Parameters were received to hold/not administer Oxycodone if SBP less than 100 or HR less than 55. If resident refused to have BP/HR checked medication would not be administered for resident's safety. MD notified of alleged suicidal ideation attempt and stated he didn't feel it was a threat at this time. Staff would continue to monitor resident for s/s and would notify MD of any issues. Record review of IDT meeting sign-in sheets revealed they had a meeting on [DATE] which included the Administrator, DON, ADON, Social Services Director, Staffing Coordinator, Medical Records, Activities, LVN E, Admissions, Director of Maintenance, and Director of Rehab. On [DATE] it was the same people, minus Social Services. On [DATE] it was the same people as [DATE]. On [DATE], the 24hr reports from [DATE] were reviewed for all residents. 3 residents were found to have issues. One c/o not feeling well and had n/v with BLE swelling. His K+ levels were elevated, so he was sent to the hospital. One complained of muscle spasms to L upper chest and had had this before. He requested a muscle relaxer. NP notified and EKG ordered. The last one had a seizure and dislodged PEG tube. All residents were assessed psychologically and had no concerns. Record review of facility's policy and procedures on Depression-Clinical Protocol (revised [DATE]) and Acute Condition Changes-Clinical Protocol (revised [DATE]) were reviewed. Interview on [DATE] at 1:25 p.m. LVN O said she had in-services on suicidal ideation: what to look for, what to do, who to report it to, change in condition, and to watch them take the medications. Interview on [DATE] at 1:30 p.m. CNA A said she received in-services on suicidal ideation: to report it to the nurse as soon as possible, and to follow up, stay with the resident and not leave them alone, report a change in condition, and to check their mouth. Interview on [DATE] at 1:32 p.m. LVN N said she received in-services on suicidal ideations: to report it as soon as possible, don't leave them alone, notify the DON/MD/Admin/RP, and report a change in condition. Interview on [DATE] at 1:33 p.m., the Staffing Coordinator said she received in-services on suicidal ideations, change in condition, and who to report to. Interview on [DATE] at 1:36 p.m. RN C said she received in-services on suicidal ideation: monitor the s/s, the medication administration for suicidal residents, and change in condition. She also said she received [TRUNCATED]

47722 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights and 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 and failed to describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 8 residents (Resident #55) reviewed for care plans. The facility failed to put behavioral interventions in place for Resident #55 when she returned from the behavioral hospital on [DATE] after being treated for drug overdose and suicidal idealation into the care plan. An immediate jeopardy (IJ) was identified on [DATE] at 9:45am. It ws determined that an IJ existed from [DATE] through [DATE]. While the IJ was lowered on [DATE] at 4:08pm, the facility remained out of compliance at a severity level of more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of attaining/maintaining their highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of Resident #55's face sheet dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included quadriplegia C1-C4 incomplete (a spinal cord injury that blocks some, but not all, signals from getting through), major depressive disorder, scoliosis (sideways curvature of the spine or back bone), hypotension (low blood pressure), pain, and polyneuropathy (damage to multiple peripheral nerves). Record review of Resident #55's Hospital Paperwork dated [DATE] revealed she had a past medical history of IV heroin abuse. Record review of Resident #55's Psychiatric Subsequent assessment dated [DATE] read in part, .Review of History: Social Hx: drug use: per chart IV drug abuse Heroin. Pt denied . Record review of Resident #55's annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. She had symptoms of little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, feeling tired or having little energy, poor appetite, or overeating, feeling bad about yourself, and trouble concentrating on things. The total severity score was 21 out of 27 which indicated severe depression. She was dependent on staff for ADLs except for eating and oral hygiene. Record review of Resident #55's local hospital emergency department record dated [DATE] read in part, .stated complaint: suicide attempt; chief complaint: change mental/neuro status (overall condition of nervous system function) . pt found at (nursing facility) by staff as unresponsive with no pulse. Staff began CPR and realized pt had DNR. Staff got pulse back and per medic pt was agonal breathing (abnormal pattern of breathing characterized by labored, gasping breaths that occur because of insufficient oxygen) and had bp of ,d+[DATE] and HR of 74 upon arrival .medication prior to arrival: Naloxone (used for the emergency treatment of known or suspected opioid overdose) Suicide assessment: wish to be dead or to not wake up in the past month: yes; . active suicidal ideation with plan and intent in the past month: yes; . attempted, plan to attempt, or prepared to end life in the past 3 months: yes; . calculated suicide risk level: high risk . emergency notes: This RN did suicide screening on pt. Pt states that she is not active suicidal and does not wish to be dead but wishes that the pain would go away. When asked by this RN if Pt took more Oxycodone than she was supposed to take, Pt said yes. Pt also stated that she never meant to harm herself that she just wanted the pain to go away and that was the reason why she took more Oxycodone than prescribed. Pt denies suicidal ideations at this time . Record review of Resident #55's local hospital record dated [DATE] read in part, .HPI: 46 y/o female with pmh of anxiety, PE, anemia and quadriplegic due to spinal infection with chronic pain admitted after she was found unresponsive at the NH. Per report, CPR initiated, was more awake upon EMS arrival. She was AAOx4 [alert to person, place, time, and situation] upon arrival to the ER. She reports had taken more pain medication to help control her pain. Denies suicidal ideations, she reports just wanted to end her pain . Diagnosis, Assessment and Plan: 1. Drug overdose- ? suicidal attempt - sitter at bedside, psych consulted (mental health consultation) . Record review of Resident #55's hospital Psychiatric Evaluation Note dated [DATE] read in part, .Patient evaluated and events noted . one to one sitter at bedside. Patient is alert and oriented x 3, calm, cooperative and pleasant. She stated that the reason that she took too many pills was because she was in pain, she stated that it was not intentional. She denied SIHI (suicidal ideations homicidal ideations) and AVH (auditory verbal hallucinations), no paranoia or delusions elicited . as per the treatment team, patient pocketing her pain medications at the nursing home so she can overdose on medications. Record review of Resident #55's hospital Psychiatric Progress Note dated [DATE] read in part, .calm and polite, denies intent to harm self . Assessment: major depression severe without psychosis, rule out substance abuse . Plan . transfer to inpatient psychiatry once medically cleared, with sitter continue for now . states the overdose was not intentional and was not an attempt. When gently confronted further patient states she takes the medicine for pain. She does not like her nursing home and does not wish to return there. Patient states she only took 10 pills throughout the day . Record review of Resident #55's Application for Emergency Detention dated [DATE] revealed there was reason to believe and belief that Resident #55 evidenced a substantial risk of serious harm to herself because of: pt. overdosed on pills in attempt to commit suicide, pt is anxious and agitation, pt is depressed. The beliefs were based on: pt. insight and judgement limited/poor and pt is a harm to herself. Record review of Resident #55's local hospital record dated [DATE] read in part, Discharge to: psych, facility . discharge date : [DATE] discharge diagnosis: 1.drug overdose/suicidal attempt . Hospital course: .presented after she was found unresponsive after drug overdose as an attempt to suicide. Psych evaluated pt, recommended for inpatient psych transfer . remains stable, will transfer to (behavioral hospital) . Record review of Resident #55's Behavioral Hospital Record dated [DATE] read reason for Admission: include chief complaint in patient's own words: Patient admitted to inpatient behavioral facility from hospital due to worsening of mood and suicidal attempt by drug overdose. Patient had a long history of mental illness with history of depression and anxiety. As per records patient took 10 pills of oxycodone throughout the day. Patient was pocketing her pain medication at nursing home so that she could overdose on medication . The patient was assessed to be a danger to herself and required inpatient level of care for further evaluation and treatment in a controlled environment. Upon initial evaluation . patient endorsed having depressed mood and anxiety. Patient mentioned I don't want to go back to the same nursing home again which I was staying, I don't like the people there . Patient endorsed feelings of helplessness or hopelessness. Patient reported being compliant with medications prior to arriving to the hospital . Patient is being monitored every 15 for suicidal precautions . Record review of Resident #55's care plan revisions after her hospital stay on [DATE] revealed Resident #55 had impaired cognitive function and impaired thought processes related to cognitive decline and depression. Increased risk for personality changes, poor judgment, delusions, agitation, withdrawing from social contact, dated [DATE]. Resident #55 had a mood problem related to factors such as loss of independence, short temper, history of behavioral issues, major life changes, depression, little interest/pleasure in doing things. Interventions were to administer medications as ordered, assist the resident to identify strengths, positive coping skills and reinforce these, and educate the resident regarding expectations of treatment, etc, monitor mood to determine if problems seem to be related to external causes; report to MD prn acute episode feelings or sadness; feelings of worthlessness or guilt; report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols, date initiated [DATE]. There was no documentation of Resident #55 pocketing pills, her opioid overdose, or suicidal attempt notated in her clinical record. Record review of Resident #55's MD progress note dated [DATE] read in part . resident was seen today after recent hospital admission for respiratory distress, and O2 sat of 68 possible due to overdose of pain meds, patient was stabilized, but required inpatient psych due to worsening mood and suspected drug overdose . Diagnosis, assessment and plan: chronic pain: given patient's possible overdose and pocketing of pain meds that sent her to the hospital, I will decrease her oxycodone from every 4 hour to every 6 hour and also continue methadone at her regular dose . Record review of Resident #55's Physician Orders for [DATE] included: -Oxycodone 10 mg give 1 tablet by mouth every 4 hours as needed for pain, order date [DATE]. Discontinued on [DATE] due to no vitals given so I need to decrease frequency to ensure safety. -Oxycodone 10 mg give 1 tablet by mouth every 6 hours as needed for pain, order date [DATE]. -Staff, if patient refuses vital checks, then hold pain meds for her safety. We need regular bp checks and oxygen checks per facility protocol and please put them in the computer, one time only for hypoxia (below-normal level of oxygen in your blood) for 5 days, order date [DATE], end date [DATE]. -Staff, please obtain hospital discharge summary from patient's admission to the hospital for hypoxia. (This is before she went to [behavioral hospital]) one time only for hypoxia for 5 days, order date [DATE], end date [DATE]. -Vital signs every shift, order date [DATE]. In an observation on [DATE] at 12:20 p.m. Resident #55 was lying in bed asleep with her breakfast tray at the bedside, uneaten. This Surveyor called residents name several times, but resident did not respond. Resident coughed and this Surveyor called her name again, but resident did not respond. In an observation on [DATE] at 1:11 p.m. Resident #55 was asleep in bed. Interview on [DATE] at 1:30 p.m. LVN D said Resident #55 slept on and off. He said she was currently on Oxycodone every 6 hours and asked for it every 6 hours. He said he had to ensure she swallowed the medication because she was not in the past. He said he monitored her respirations to ensure she was not sedated or overly medicated. He said she was getting her Oxycodone every 4 hours but now it was every 6 hours. He said she was hoarding her medications and not taking it and the MD changed it. Interview on [DATE] at 8:45 a.m. with Resident #55 in her room, she said she had one previous hospitalization . When asked why she was hospitalized , Resident #55 said what? My overdose? If you are curious about my overdose you can leave. Interview ended. Interview on [DATE] at 9:44 a.m. with LVN T, he said he had received a report that Resident #55 pocketed her Oxycodone and it was found in a cup before she went to the hospital (on [DATE]). He said after Resident #55 returned to the facility he started to enforce that she swallowed her medication, but she would refuse to open her mouth. He said he ensured she did not pocket the medication, but the resident would get upset because she felt they treated her like a child. He said he could not look in her mouth and would ask her if she swallowed the medication. He said Resident #55 requested her Oxycodone every 6 hours on the dot. He said he checked her respirations, temperature, and oxygen saturations once per shift and the medication aide checked her blood pressure and pulse. He said it was hard to do something different to prevent the incident from happening again because she was still on the same medication and refused for staff to look in her mouth. He said when she first returned from the hospital, she was not on the Oxycodone and her other medications were reduced. He said Resident #55 called the behavioral hospital to get her Oxycodone reinstated. He said he called Resident #55's NP and her MD restarted her Oxycodone but reduced it to every 6 hours instead of every 4 hours. Interview on [DATE] at 10:37 a.m. Resident #55's NP said a Nurse informed him that Resident #55 overdosed after she went to the hospital. He said he and the MD were trying to wean her down on her medication as much as possible. He said after she returned from the hospital, he informed the nurses to watch the resident take her pills and have her open her mouth to show that she swallowed the medication. Interview on [DATE] at 11:04 a.m. with the MD, he said he was not aware that Resident #55 was pocketing pills prior to her incident in November. He said if he was notified, he would have stopped the medication and had a conversation and plan to prevent it. He said he did not receive a discharge summary from the hospital and had to use clues from the discharge instructions on what happened. He said he requested that the facility please get the discharge summary (from the local hospital), but he never received it. He said when Resident #55 returned from the behavioral hospital the resident told him what she did was intentional, she did not want to be here, she wanted to kill herself, and she was angry that she was not successful. He said currently Resident #55 was pleasant and very manipulative and they worked to strike a balance. He said staff should watch her take her pills and monitor for signs and symptoms. He said signs of oxycodone overdose were lethargy, hypoxia, and low blood pressure. He said he made it clear to the facility that he wanted Resident #55 to see a pain medication physician and the facility was supposed to be finding someone. He said he was not worried about it happening again because he had faith in the staff and their eagerness to correct the situation. He said Resident #55 may want to do it again and could possibly get away with pocketing pills later down the road. Interview on [DATE] at 11:55 a.m. with the Unit Manager, she said after Resident #55 returned from the hospital the resident was upset that her pain medications and muscle relaxers were changed. She said the MD was worried about an overdose or the resident trying to kill herself but could not stop the medication because of withdrawals. She said the resident told her: I tried to, that was on purpose . I know I messed up and I know why the MD changed the medication to every 6 hours. Interview on [DATE] at 12:33 p.m. with the ADON she said she was not aware Resident #55 was pocketing pills prior to the incident in November. She said they would have notified the doctor and intervened if they knew. She said on the day of the incident ([DATE]), nurses and CNAs called her and said the resident was lethargic and unresponsive and they called 911 immediately. She said the hospital called and were concerned about her mental health. The hospital was not releasing the resident back to the facility and she needed to go to inpatient therapy. The ADON said when the resident returned to the facility the resident said to her you will pay for it, I should have died . She said the resident informed her that she was taking too much and was holding them in because she wanted to die. She said the resident told her that but then reverted and changed the story to get her way. She said the resident had not voiced suicidal ideations. She said things the facility was doing differently upon her return were as much as the resident permitted and in accordance with her resident rights. She said the facility encouraged her to get up, talked to her, and assessed her pain needs. She said nurses knew to stay in the room to ensure the medication was swallowed. Interview on [DATE] at 1:04 p.m. with the DON, he said he was not aware of Resident #55 pocketing medications. He said if he was aware he would have notified the MD and ensured the nurses made sure she took her pills. He said he was aware she went to the hospital because she was not responding and was sent to the behavioral hospital. He said he reviewed her clinicals from the behavioral hospital but did not observe any outliers. He said he was not aware of her overdosing or having suicidal thoughts. Interview on [DATE] at 1:49 p.m. with the Administrator, he said he was not aware that Resident #55 was pocketing pills. He said he had no knowledge of a drug overdose or history of suicidal ideation. He said she was unresponsive and was sent to the hospital and then to the behavioral hospital for additional psych help. This Surveyor showed the Administrator Resident #55's nursing note from [DATE] about pocketing pills. He said he had not seen the note and was not informed of the incident. He said the facility conducted a care plan meeting in her room the day before Resident #55 was found unresponsive in the facility. He said they gave her the facility's expectations (on call lights) and discussed frequent repositioning needs. He said he did not want her to feel like she was a burden and spoke with her about staff workload. He said Resident #55 was understanding, reasonable, and pleasant during the meeting. Interview on [DATE] at 6:54 p.m. with LVN P, he said on [DATE], CNA V informed him that she saw Resident #55 take her medication (Oxycodone) out of her mouth. He said he did not tell the MD or NP but informed the nurse on the next shift and placed it on the 24-hour report. He said he informed the next shift to be careful when administering medication to Resident #55 and ensure she swallowed the medication with water. He said he went to Resident #55's room to look for the medication but did not see anything. He said Resident #55 denied it, was mad, cussed him out, and thought he was accusing her. He said he did not report it to the physician because he did not have information to give him since he did not see the medication in the room. He said multiple people knew she had medication in her room, but he was the only one to document because he thought it needed to be followed up on. An interview was attempted on [DATE] at 9:42 a.m. with CNA V but was unsuccessful. Interview on [DATE] at 2:43 p.m. the Social Services Director said Resident #55 was on psych services every 14 days. She said she did not review hospital clinicals. She said the resident had no behaviors from her point of view and was not suicidal. She said that information would be in the care plan. Telephone interview on [DATE] at 4:31 p.m. with the MDS Nurse, he said Resident #55 had her annual MDS assessment after she returned from the psych hospital (on [DATE]) and her care plan was updated because the mood and behaviors triggered on the assessment. He said the resident was sent to the hospital and then to psych for behaviors. He said nothing was reported to him on suicidal ideations or overdose. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated ,d+[DATE] read in part, .A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs . 8. The interdisciplinary team should review and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the resident has been readmitted to the facility from a hospital stay . Record review of the facility's Acute Condition Changes - Clinical Protocol policy dated ,d+[DATE] read in part, .5. The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having additional complications . On [DATE] at 9:45am the Administrator was notified of the Immediate Jeopardy (IJ) due to the above failures. The IJ template was left with the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on [DATE] at 3:04pm.: PLAN OF REMOVAL - F656 Date of Compliance: [DATE] Facility Failure The facility failed to put interventions in place for Resident #55 when she returned from the behavioral hospital on [DATE] after being treated for suicidal ideations. Immediate Actions: o DON and/or designee will assess resident #55 for change in condition, medication overdose, or thoughts of suicidal ideation/self-harm. o Resident #55 was assessed [DATE] by the Assistant Director of Nursing and the Social Services Director. There were no indications of depression or suicidal ideations and the resident verbalized that they didn't have any thoughts, intent, method, and/or plan. o Care plan implemented to ensure: -resident swallows the medication, -psych will continue to follow resident, -updates to include status/condition of the resident. -and physicians will be notified of any change of condition related to suicidal behavior/self-harm. o DON and/or designee will educate staff to ensure all staff are knowledgeable about mental health/behavioral health needs as well as the reporting guidelines should they identify any concerns. o Staff will demonstrate competency in this education by completing a post-education questionnaire. Any staff not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o The Interdisciplinary Team will review progress notes during weekday clinical IDT meeting to identify any residents at risk of suicidal ideation/self-harm and update care plan as needed to meet resident's medical, nursing, mental, and psychosocial needs. o The Interdisciplinary Team will review care plans for new admission/readmissions to identify any residents at risk of suicidal ideation/self-harm and update care plan as needed to meet resident's medical, nursing, mental, and psychosocial needs. o DON and/or designee do random check during care plan meetings on resident's care plan to assure that it reflects current condition of resident upon admission, readmission, change in condition with appropriate goals and interventions to meet the resident's medical, nursing, mental and psychological needs. o DON and/or designee will educate staff to ensure all staff are knowledgeable about signs and symptoms of self-harm or suicidal ideation as well as the reporting guidelines should they identify any concerns. o The Interdisciplinary Team audited on [DATE] residents' charts and interview alert and oriented residents to ensure that any resident who does display signs and symptoms of suicidal ideation/self-harm have appropriate interventions in place and physicians are notified. No other residents affected. MONITORING: Record review revealed Resident #55 was assessed on [DATE] by the ADON and the Social Services Director, and there were no indications of depression or suicidal ideations. Record review also revealed the resident verbalized she did not have any thoughts, intent, method, and/or plan. Record review of the care plan revealed: Care plan implemented to ensure: - resident swallows the medication, - psychiatry will continue to follow resident, - updates to include status/condition of the resident. - and physicians will be notified of any change of condition related to suicidal behavior/self-harm. Record review of resident # 55's revised care plan revealed an updated focus on a Risk for injury to self r/t suicidal ideations initiated [DATE]. Interventions included: Administered medications as ordered, monitored while swallowing medication to ensure she was not pocketing/cheeking medication, notified physician of any change of condition related to suicidal behavior/self-harm, Nurses and Med Aides ensured resident swallowed the medication and did not pocket medications, Psychiatry services continued to follow resident, referred resident to (name) Psychiatry, and reviewed prescribed medication side effects. Record review confirmed ADON/Social Services Director assessed resident on [DATE] and there was no evidence of medication overdose, thoughts of suicide or self-harm. Record review confirmed Resident was educated to communicate any feelings of sadness/hopelessness along with positive coping mechanisms. Record review revealed staff were in-serviced on Managing Suicide and Suicidal Ideations and Signs and Symptoms MD Notification Guide. Record review of the facility's in-service meeting dated [DATE] revealed 5 staff were trained on care plans: all clinicals should be reviewed prior to and upon admission for new or readmitting residents. Information for clinicals should be added to care plans and communicated to direct care staff, where appropriate. All condition changes or behaviors should be added to care plans timely. The Inservice was conducted by the Administrator. The comments were that all care plan audits are to be completed by 11:59 p.m. on [DATE], per plan of removal for chart audits. Record review revealed IDT Meeting Sign-In sheets from [DATE]-[DATE]. There were also Change in Condition Monitoring sheets from [DATE]-[DATE] that detailed resident's conditions in the last 24hrs and if they needed to be sent to the hospital or had a change in condition. Record review revealed a list of Admission Care Plan Audits that had been completed from [DATE]-[DATE]. Record review revealed the IDT audited and interviewed resident's on [DATE] to ensure no other residents had signs/symptoms of suicidal ideation/self-harm. According to record review, no other residents were identified. Interview with the Regional MDS Coordinator on [DATE] at 3:48pm, she confirmed they reviewed the baseline/comprehensive care plans as the residents came in and made sure a baseline care plan was in place within 48hrs, to ensure any behaviors were noted on there. She also said they reviewed all care plans every morning in their meeting to ensure they had everything that was needed on them, or they would update them at that time. Interview on [DATE] at 3:52pm with the Social Worker, she confirmed they (IDT) met daily to review admission/readmission notes and updated care plans. She said if the resident was a new admission, everything was triggered and put on a baseline care plan within 48hrs. If the resident was a re-admission, they looked through the hospital discharge notes and added anything new to the comprehensive care plan. She said they had the care plan meeting within 48hrs of the resident being admitted . Interview with the DON on [DATE] at 4:00pm, he revealed when they had new admissions, they ensured a baseline care plan was done within ,d+[DATE]hrs after admission. He also said whenever a resident was sent to the hospital, he ensured the indication was added to the care plan. He said he also spot-checked care plans during the care plan meetings and as residents were discharged and admitted . In an observation on [DATE] at 4:05pm, the facility appeared to be clean with no concerns noted. There were no obvious signs of abuse/neglect noted to residents, and no foul odors noted. There was no yelling/moaning heard from residents and residents appeared to be cheerful and smiling. The facility was notified the IJ was lowered on [DATE] at 4:08pm however, the facility remained out of compliance, at a scope of pattern and a severity level of more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their corrective systems.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 2 (Dryer #1 and Dryer #3) of 3 dryers reviewed for equipment in safe operating condition. -The facility failed to check and clean the lint filters at appropriate times. The facility failed to clean the lint filter in Dryer #1 from 7 a.m. to 1 p.m., which caused a buildup of lint. The facility failed to clean the excess lint in Dryer #3, which caused a build up of lint under the machine. These failures could cause a fire or injury. Findings include: Record review of the facility's Dryer Lint Clean Out Schedule for January 2024, revealed spots for staff to initial every 2 hrs which indicated they cleaned the lint filter, starting at 6:00am to 10:00pm. Initials were missing on 1/6/24 from 4:00pm to 10:00pm, 1/8/24 from 6:00am to 2:00pm, 1/9/24 from 6:00am to 2:00pm, 1/10/24 from 6:00am to 2:00pm, 1/11/24 at 6:00am and 4:00pm to 10:00pm, and on 1/12/24 there were initials for 8:00am and 10:00am. In an observation on 1/12/24 at 12:26pm, Housekeeping Supervisor D removed Dryer #1's lint filter. The lint filter was not clean and had a thick buildup of lint on it and there were clothes running in the dryer. She used a broom to get the lint off and threw it in the trash. Dryer #3 had a whole sheet of lint, the size of the lint filter, floating around under the dryer while there were clothes inside the dryer. There was a sign on Dryer #3 that said to clean the lint filter after every 2 loads. Interview on 1/12/24 at 1:00pm while using Spanish interpreter services, Housekeeping Supervisor D said she had been working at the facility for 2yrs as PRN. She said she was there filling in for another employee who could not make it in. She said she only cleaned the lint filters once per shift. She said the lint filters were already clean when she got to work at 6am by the previous night shift, and then when she left at 3pm she would clean them for the next shift. She did not remember who told her to do it that way but said they had to check the lint filters because they would get reported if they did not. She said 1 load took about 30-40min in the dryer. Housekeeping Supervisor D did not know what would happen if there was too much lint in the filter or if it was underneath the machine. Interview on 1/12/24 at 1:15pm with the Maintenance Director he said the lint filters should be cleaned after every 3-4 loads, or 1.5-2hrs. He said the staff's schedule was from 6:00am to 3pm and 3pm to 11pm. There were no overnight shifts. He also said there was a schedule on the wall that staff were expected to follow which said they were to clean the lint filters every 2hrs. He said he was the one that trained the staff and told them to clean the filters every 2hrs. He said if the lint filters were not cleaned, they could catch fire. Record review of the facility's policy and procedure for Fire Safety and Prevention (revised May 2011) read in part: All personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard. 1. Fire prevention is the responsibility of all personnel, residents, visitors, and the general public. 2. Whoever identifies a fire hazard, or other conditions that could develop into a fire hazard, must report the situation to the department director or Maintenance Director as soon as practical. 3. The following fire safety precautions must be followed in the facility at all times: .Overheating: .b. Keep filters on heating systems, dryers, etc., free of lint .8. The facility will train personnel on fire prevention methods .

Based on observation, interview and record review, the facility failed to ensure the pharmacist's medication regimen review recommendations were reviewed by the resident's attending physician, were documented in the medical record, and what, if any, action had been taken to address them, for 6 of 12 months (February, March, April, May, June, and August 2023) reviewed for pharmacy services. -The facility failed to provide Drug Regimen Review forms that were noted by the MD, for the months of February, March, April, May, June, and August of 2023. The DRR forms were either blank or missing all together. This failure could place residents at risk of adverse reactions to medications, continued used of inappropriate medications, or harm including hospitalization if the MD did not review the DRR forms. Findings Include: In an observation on 1/12/24 at 12:39pm, the Pharmacy binder was missing Drug Regimen Review forms for the months of February, March, April, May, June, and August of 2023. The DRR forms were not filled out by the MD or were missing completely for those months. Interview on 1/12/24 at 12:39pm with the ADON she said she did not have any of the DRR forms from before April 2023 because she did not work at the facility at that time. She said she did not get access to the forms online until May 2023. The ADON said she would go back and look for the forms again, for the 3rd time. Interview with the DON on 1/12/24 at 3:20pm the DON said the pharmacist gave the DRRs to the staff and then they gave them to the MDs when they came in to the facility. He said for the MDs that did not come to the facility often, they would call them over the phone. He said the MD would write on the DRR or the staff would, based off what the MD said in person or over the phone. He said they would note on the DRR if it was per MD or if they spoke to the MD on the phone. He said after they were finished with the DRR's they would put them in the pharmacy binder. He said he did not have the DRR forms for the months before April 2023, and they were in storage and he was attempting to get them. He said the DRR forms for the months after April should have been in the pharmacy binder and he did not know why they were not there. Interview with Pharmacist A on 1/17/24 at 1:21pm, she said she uploads the DRR reports to their portal at the end of the month and sends an email to the facility informing them that they are ready. She said the facility prints out the DRR forms and gives them to the MD to review and then they upload them back to the portal to keep for record. She said she would know if the MD did or did not follow her recommendation by looking in the resident's chart; there should be a note about the pharmacist's recommendation. She said if she did not hear anything regarding a recommendation, she would call the facility, The Pharmacist said she thought she started with the facility about 5-6 months ago and did not know what they were doing with the DRR forms before that. Interview with the ADON on 1/17/24 at 2:01pm the missing DRR forms were requested again. The ADON said the facility did print the DRR forms from the portal and filled them out, but they did not upload them back to the portal like the Pharmacist said. She said the MD/NP entered the information into a progress note. The ADON said they kept the DRR forms even though they cannot find them. Interview with the DON on 1/17/24 at 2:33pm he said they filled out the DRR forms and that they should be here somewhere. He said there should not be 6 months of forms missing and that they should be there somewhere. He said they did not have the DRR forms from before April because they did not work at the facility at that time, and there were some glitches in the portal at some point but he did not remember when. Record review of the facility's policy and procedure on Medication Regimen Reviews (revised May 2019) read in part: The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. 1. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. 2. Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated . 5. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses or without clinical indication; b. medication regimens that appear inconsistent with the resident's stated preferences; c. duplicative therapies or omissions of ordered medications; d. inadequate monitoring for adverse consequences; e. potentially significant drug-drug or drug-food interactions; f. potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences; g. incorrect medications, administration times or dosage forms; or h. other medication errors, including those related to documentation . 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it . 14. The Consultant Pharmacist provides the Director of Nursing Services and Medical Director with a written, signed and dated copy of all medication regimen reports. 15. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. 16. The Consultant Pharmacist submits a quarterly report that includes a summary of key findings from MRRs, including: a. The status of the facility's Pharmaceutical Services; b. Staff performance in complying with regulatory requirements related to medication utilization and monitoring; c. Problem areas and irregularities noted (e.g. documentation errors, medication errors, etc.); d. Recommended solutions for specific problem areas; e. Follow-up reports relative to facility's corrective action related to problem areas; and f. Other pertinent information.

Based on observation, record review and interviews, the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles, including the expiration date for 2 out of 5 residents (Residents #73 and #53) and 1 out of 3 Med Carts (100 Hall Nursing Cart) reviewed for pharmaceutical services. The facility failed to ensure the 100 Hall Nursing Cart did not contain: -20 tabs of Hydroxyzine 10mg (for anxiety or itching from allergic response), that expired on 9/1/23 for Resident #73. -1/2 a bottle of NPH insulin 100u/ml (used to bring blood sugar down), that expired on 1/8/24 for Resident #53. -1/2 of a multi-use bottle of Ibuprofen 200mg tabs, that expired on 10/31/23. These failures could place residents at risk of not receiving therapeutic benefits of the medication, adverse reactions to medications, and hospitalization . Findings include: Resident #73 Record review of Resident #73's face sheet revealed he was a [AGE] year-old male admitted on [DATE] with a diagnosis of unspecified pruritus (itching). Record review of Resident #73's care plan dated 1/7/22, revealed a focus: I receive hydroxyzine for pruritus (initiated 9/27/22). Goal: My pruritus will be relieved with interventions through review date. Interventions: Monitor for S/E including GI upset, N/V, sleepiness and notify MD as indicated. Monitor for targeted behavior or itching. Hydroxyzine per MD orders, for effectiveness and notify MD if medication is not effective. Record review of Resident #73's entrance MDS assessment dated [DATE], revealed he had a BIMS score of 9 out of 15, which indicated moderately impaired cognition. He was not taking the Hydroxyzine at this time. Record review of Resident #73's quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 12 out of 15 which indicated moderately impaired cognition. The diagnoses listed on the MDS included unspecified pruritus (itching). Record review of Resident #73's physician orders revealed the following orders from MD A: -Hydroxyzine Hcl Tablet 10mg, Give 1 tablet by mouth every 6 hours as needed for itching. Ordered 5/19/22 at 5:00pm. -Hydroxyzine Hcl Tablet 10mg, Give 1 tablet by mouth every 6 hours as needed for itching. Ordered 9/9/22 at 4:07pm. -Hydroxyzine Hcl Tablet 10mg, Give 1 tablet by mouth every 6 hours as needed for itching. Ordered 10/5/22 at 11:37am. Record review of Resident #73's September 2022 MAR revealed he took Hydroxyzine 10mg on 9/25/22 at 6:09am. Record review of Resident #73's October 2022 MAR revealed he took Hydroxyzine 10mg on 10/9/22 at 4:32am. In an observation on 1/14/24 at 2:50pm, with LVN T present, a blister pack of Hydroxyzine 10mg with 20 tabs left, was found in the 100-hall nurse cart that had expired on 9/1/23, for Resident #73. Resident #53 Record review of Resident #53's face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original admitted [DATE]. He had a diagnosis of type 2 diabetes mellitus (body does not make insulin or body resists it). Record review of Resident #53's care plan dated 4/13/2020 had a focus: I have Diabetes Mellitus (initiated 9/25/20). Goal: I will have no complications related to diabetes through the review date. Interventions: Diabetes medications as ordered by doctor. Observe/document for side effects and effectiveness, see MARs for dosage/time; Metformin, Novolin, FSBS. Diet per MD orders. HS snack. Educate regarding medications and importance of compliance. Have resident verbally stat an understanding. Educate resident/family/caregiver: Diabetes is a chronic disease, and that compliance is essential to prevent complications of the disease. Review complications and prevention with the resident/family/caregiver. Elicit a verbal understanding from the resident/family/caregiver. Observe/document/report PRN and s/sx of hyperglycemia. Observe/document/report PRN any s/sx of hypoglycemia. Record review of Resident #53's entrance MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated moderately impaired cognition. The MDS had Diabetes Mellitus marked as an active diagnosis. According to the MDS, Resident #53 had received insulin injections for 7 days prior to his admission. Record review of Resident #53's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, which indicated moderately impaired cognition. The MDS revealed a diagnosis of Diabetes Mellitus was marked under active diagnosis. The MDS indicated Resident #53 had received insulin injections for 5 days during the last 7 days. Record review of Resident #53's physician orders revealed an order for NovoLIN N Suspension 100 unit/ml (Insulin NPH), Inject 12u SQ QAM r/t Type 2 DM with diabetic neuropathy. Hold if BS less than 100. Ordered on 4/17/23 at 5:50am by MD B. Record review of Resident #53's January 2024 MAR revealed he received Insulin NPH 12u/ml that had expired on 1/8/24, on 1/9/24-1/14/24. In an observation on 1/14/24 at 2:50pm, with LVN T present, 1/2 a bottle of NPH insulin 100u/ml (used to bring blood sugar down), was found in the 100-hall nurse cart that expired on 1/8/24, for Resident #53. In an observation on 1/14/24 at 2:50pm, with LVN T present, 1/2 of a multi-use bottle of Ibuprofen 200mg tabs, was found in the 100-hall nurse cart that had expired 10/31/23. Interview on 1/14/24 at 3:00pm with LVN T, he said he checked his cart for expired medications once a month. He said the cart should be checked more frequently, at least several times a week, but that did not happen because they were too busy. He said he did not know of a specific policy on how often to check the cart for expired medications. LVN T said if a resident was given an expired medication, the medication would not be as effective, and the resident would not receive the full benefit of the medication. Interview on 1/14/24 at 3:22pm with RN C, she said she was the weekend supervisor. She said the medication carts should be checked daily and she expected staff to check them as such. She said if a resident was given an expired medication, not only would the resident not get the full benefit of the medication, but it could also cause death or hospitalization depending on the type of medication and the seriousness of it. Record review of the facility's policy and procedure on Storage of Medications (revised November 2020) read in part: The facility stores all drugs and biologicals in a safe, secure, and orderly manner .3. The nursing staff is responsible for maintaining medication storage and preparation areas .4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for six (Resident #44, #27, #82, #84, #309, #99) of six residents reviewed for receiving enteral feeding via a pump. -The facility failed to clean enteral feeding pumps and poles, which were dirty on 01/09/24, 01/10/24, and 01/11/24 for Residents #44, #27, #82, #84, #309, and #99. This failure could affect the residents who received their nutritional needs via an enteral feeding pump, by placing them at risk for spreading disease-causing organisms, cross-contamination, and possible infection. Findings include: Observations on 01/09/24 at 9:46 AM, 01/10/24 at 8:50 AM, and 01/11/24 at 1:15 PM of Resident #44 in bed receiving active feeding via peg tube (PEG tubes allow you to receive nutrition through your stomach) revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump. Observations on 01/09/24 at 9:55 AM, 01/10/24 at 8:56 AM, and 01/11/24 at 1:20 PM of Resident #27 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump. Observations on 01/09/24 at 10:05 AM, 01/10/24 at 9:05 AM, and 01/11/24 at 1:25 PM of Resident #82 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump. Observations on 01/09/24 at 10:10 AM, 01/10/24 at 9:10 AM, and 01/11/24 at 1:30 PM of Resident #84 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump. Observations on 01/09/24 at 10:15 AM, 01/10/24 at 9:15 AM, and 01/11/24 at 1:35 PM of Resident #309 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump. Observations on 01/09/24 at 10:20 AM, 01/10/24 at 9:20 AM, and 01/11/24 at 1:40 PM of Resident #99 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; top and bottom of the pump. Record review revealed Resident #44 had a physician's order for nothing by mouth, continuous enteral feeding (intake of food via the gastrointestinal tract), every shift administer Fibersource (or equivalent) at 85 ml/hour via g-tube x 22 hours daily via Dual Flow Pump Water Flush 200 ml via g-tube q6 hours x 22 hours via Dual Flow Pump. Record review of Resident #27's Physician Order on 01/13/24 revealed an order for nothing by mouth, continuous enteral feeding, every shift administer Glucerna 1.5 per PEG via Pump at 65 ml/hour x 22 hours, administer water flush 170 ml/every 4 hours. Record review on 01/13/24 revealed Resident #82 had a physician's order for nothing by mouth, continuous enteral feeding, every shift administer Diabetisource at 60 ml/hour via peg tube x 22 hours Water Flushes 100cc every 4 hours peg tube both via Dual Flow Pump. Record review on 01/13/24 revealed Resident #84 had a physician's order for nothing by mouth, continuous enteral feeding, every shift administer Diabetisource AC (or equivalent Glucerna 1.2) at 75cc/hour via peg tube x 22 hours and H2O Flush 95cc every shift (q12 hours) both Dual Flow Pump. Record review on 01/13/24 revealed Resident #309 had a physician's order for nothing by mouth, continuous enteral feeding, every shift administer Osmolite 1.5 enterally at 50cc/hour x 22 hours and Water Flush at 100 ml q2hours x 22 hours Enterally via Dual Pump. Record review on 01/13/24 revealed Resident #99 had a physician's order for nothing by mouth, continuous enteral feeding, every shift administer Diabetisource AC (or equivalent Glucerna 1.2) at 70 ml/hour via peg tube x 22 hours via Dual Flow Pump and water flush 100 ml q12 hours. Interview and observation on 1/11/24 at 3:45 PM with LVN T, of the condition of the enteral feeding pumps and poles of Residents #27 and #99, LVN T said he was not aware the pumps and poles were dirty. He said everyone is responsible for cleaning the pumps and poles saying, everyone who sees they're dirty should clean them. He said dirty pumps and poles have the potential to make residents sick and get an infection. Interview and observation on 1/11/24 at 4:00 PM with LVN O, of the condition of the enteral feeding pumps and poles of Residents #44, #82, #84, and #309, LVN O said it had not been brought to her attention the pumps and poles were dirty and said she would get them cleaned. She said anyone who sees the pumps and poles dirty has the responsibility of cleaning them. She said dirty pumps and poles can cause residents to get sick and can cause cross contamination. Interview on 01/12/24 at 3:19 PM with the DON, of the condition of the enteral feeding pumps and poles of Residents #44, #27, #82, #84, #309, and #99, DON said nursing staff are responsible for cleaning the pumps and poles. He said poles and pumps have a scheduled cleaning day on Sundays but the cleaning schedule the DON provided says the cleaning day is on Mondays. The DON said the adverse effect of dirty enteral pumps and poles on residents could potentially cause infection. Review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment revised September 2022 revealed, Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation .1. The [NAME] Classification System is used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: a. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue (e.g., urinary catheters) or the vascular system (e.g., intravenous catheters) are considered critical items and must be sterile when used, based on acceptable sterilization procedures. Sterilization destroys all viable microorganisms to prevent disease transmission associated with the use of that item .

Based on observation, interview, and record review, the facility failed to review and revise the care plan after each assessment, including both the comprehensive and quarterly review assessments for 3 out of 7 residents (Residents #305, #28, and #89), reviewed for care plans. The facility failed to: -Update Resident #305's care plan to indicate she communicated with pen/paper due to not being able to speak. -Update Resident #28's care plan to indicate she no longer had a PICC line. -Update Resident #89's care plan to indicate she no longer was on a pureed diet. These failures could place residents at risk for receiving delayed treatment and not obtaining/maintaining their highest practicable wellbeing. Findings include: Resident #305 Record review of Resident #305's face sheet revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of amyotrophic lateral sclerosis ALS, dysphagia, GERD, and gastrostomy. Record review of Resident #305's admission MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. She had a diagnosis of ALS. Record review of Resident #305's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15, which indicated moderately impaired cognition. She had diagnoses of ALS and dysphagia. Record review of Resident #305's care plan dated 6/15/23 revealed nothing about communication or the resident using pen and paper to communicate due to her not being able to speak. In an observation and interview on 1/9/24 at 10:00am, Resident #305 was laying on her back in bed, with a feeding pump at the bedside. The resident was unable to speak and used a piece of paper and a pen to communicate. The family member at bedside said the resident was unable to speak and communicated with the paper and pen. Interview on 1/17/24 at 12:36pm with the MDS Coordinator, he said if a resident used pen/paper to communicate it should be on the care plan. He was not sure why it was not on Resident #305's care plan and would investigate it. The MDS Coordinator stated they updated the care plans daily depending on the status of the resident and quarterly with the MDS assessments. He said if care plans were not updated staff would not have the most up to date information to care for the residents. Resident #28 Record review of Resident #28's face sheet revealed she was a [AGE] year-old female admitted on [DATE] with an original admitted [DATE]. She had diagnoses of chronic kidney disease, urinary tract infection, furuncle of limb, and sleep apnea.\ Record review of Resident #28's Admission MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15, which indicated normal cognition. Two of the diagnoses listed on the MDS were osteomyelitis of right tibia and fibula, and infection/inflammation reaction due to orthopedic prosthetic device/graft. It also revealed she had a surgical wound, was on antibiotics, and was receiving IV medications. Record review of Resident #28's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15, which indicated normal cognition. The MDS revealed nothing was marked under infections for active diagnoses. The MDS indicated Resident #28 was not on any antibiotics or IV medications. Record review of Resident #28's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 out of 15, which revealed moderately impaired cognition. The MDS revealed nothing was marked under infections for active diagnoses. Also, the MDS revealed she was not on IV medications and did not have IV. Record review of Resident #28's care plan dated 2/14/23, revealed a Focus: Resident #28 is on IV medications (Meropenem) via PICC line (Left Upper arm) r/t UTI (initiated 10/25/23). Goal: Resident #28 will not have any complications related to IV therapy through the review date. Interventions: Check dressing daily. Monitor/document/report to MD PRN s/sx of infection at the site: drainage, inflammation, swelling, redness, warmth. Monitor/document/report to MD PRN s/sx of infiltration at the site: Edema at the insertion site, taut or stretched skin, blanching or coolness of the skin, slowing or stopping of the infusion, leaking of IV fluid out of the insertion site. Record review of Resident #28's Physician Orders for January 2024, revealed no orders for a PICC line. In an observation on 1/9/24 at 10:13am, Resident #28 was laying in bed and did not have a PICC line to her left upper arm. Interview on 1/17/24 at 12:36pm with the MDS Coordinator, he said he did not work here in October 2023 when the PICC line was added to Resident #28's care plan. He said the previous MDS Coordinator did not keep up with updating the care plans and he was going through them to update them. He said he would investigate her care plan and fix it. Resident #89 Record review of Resident #89's face sheet revealed she was a [AGE] year-old female admitted on [DATE], with an original admitted [DATE]. She had diagnoses of unspecified dementia, metabolic encephalopathy, muscle weakness, protein-calorie malnutrition, anemia, [NAME], and dysphagia. Record review of Resident #89's Admission MDS assessment dated [DATE], revealed a BIMS score of 00, which indicated it was unable to be performed. The MDS revealed she had diagnoses of protein-calorie malnutrition, and weakness. Under Nutritional Approaches none of the above was marked. Record review of Resident #89's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 7 out of 15, which indicated severely impaired cognition. According to the MDS, she had diagnoses of anemia, non-Alzheimer's dementia, protein-calorie malnutrition, and dysphagia. The MDS revealed the resident was on a mechanically altered diet. Record review of Resident #89's care plan dated 7/20/23, revealed a Focus: Resident #89 has a nutritional problem or potential nutritional problem r/t diet restrictions, dysphagia (initiated 8/1/23, revised 9/18/23). Goal: Resident #89 will comply with recommended diet daily through review date. Interventions: Provide diet as ordered: Pureed diet. RD to evaluate and make diet change recommendation PRN. Record review of Resident #89's Physician Orders revealed an order from MD C on 10/5/23 at 12:34pm for a Regular diet: Mechanical Soft texture, thin liquids consistency. Interview on 1/17/24 at 12:36pm with the MDS Coordinator, he said he did not work at the facility in October of 2023. He said he was working on going through all the resident's care plans to ensure they were updated. Record review of the facility's policy and procedure on Care Plans, Comprehensive Person-Centered (revised March 2022) read in part: A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative. 2. The comprehensive person-centered care plan should be developed within the seven (7) days of the completion of the required MDS assessment .6. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible .7. When possible, interventions should address the underlying source(s) of the problem. 8. The interdisciplinary team should review and update the care plan: a. When there has been a significant change in the resident's condition. b, When the resident has been readmitted to the facility from a hospital stay. c. At least quarterly, in conjunction with the required quarterly MDS assessment .

Based on observation, record review, and interview, the facility failed to serve food in accordance with professional standards for food service safety for two out of two Resident reviewed for food service, in that; -The facility failed to follow proper hand hygiene, sanitation, and food handling practices. This failure could place residents at risk of foodborne illnesses. Findings include: On 01/10/2024 at 12:42 PM Observations showed CNA CC walked to the dining area, applied some sanitizer on her palms and the back of her hands (did not rub her hands together), took a plate from the food cart, and placed it in front of Resident #5. The staff thumb was in direct contact with the Resident's plate eating surface and her long blue painted nail was in the Resident's food. The staff then got another plate from the cart and placed it in front of Resident #39. She touched the Resident's left shoulder and asked if she would like for her to cut her piece of chicken. The staff then cut the Resident's chicken, holding the knife, and fork. Her extremely long painted blue nails were touching the neck and root of the fork. The staff was stopped and interviewed. Interview on 01/10/2024 at 12:47 PM, CNA CC stated she received training on infection control when a Resident had RSV. She said the training was about washing hands and wearing a mask when going to a resident's room. She said that before passing the tray in the dining to the residents, she sanitized her hands and passed the tray. She said that in the training, she was told not to use too much hand sanitizer on her hands. Staff demonstrated how she sanitized her hands by friction her palms and the back of her hands. She said it would be unsanitary if her nails got into the Residents' food/plate, and that was how she knew she did not touch the Residents' food. She said she just cut the meat for Resident #39. She said she did not touch Resident #39's shoulder; she touched her chair. She said she knew the Residents could get sick if they ate contaminated food, but I did not think she contaminated the Residents' food with her nails. She said she usually do not assist residents in the dining area. She said she was a shower tech and would assist with transfer sometimes. Record review showed that in-service on hand hygiene and PPE was completed on 09/13/2023. CNA CC name was not on the list. On 01/11/24 at 10:15 AM the ADON handed in-services document on infection controls/nails/hand hygiene dated 01/10/2024 with two pictures of a pair of hands with long and short nails, respectively, stating, We conducted these yesterday because we saw the same thing you saw. Review of the in-service document dated 01/10/2024 showed 17 staff signatures including CNA CC. Observations on 01/11/2024 at 3:07 PM showed CNA CC had short fingernails. Interview on 01/11/2024 at 3:08 PM, CNA CC said that the Supply/Staffing Coordinator asked her to help in the dining area yesterday (01/10/2024), which was why she was there. She said that yesterday, after the interview, she reported to the ADON that she was interviewed about her nails. She said the ADON told her to cut her nails. She said she answered that she would do her nails next Sunday, but the DON said he would rather have her do it now (01/10/2024), so she left work to get her nails done and returned to work after. She said the ADON did not do any training about infection control or hand hygiene yesterday or today (01/11/2024). She said the DON only told her to cut her nails, that it was in the handbook to keep her nails short, and asked her if she had forgotten, and she said yes, she had forgotten. Interview on 01/17/2024 at 2:08 PM, the ADON stated she monitored the staff throughout the week for compliance with the facility's policy. She said she did not check the staff's nails regularly, but if she observed a non-compliance she addressed immediately, and that was what she did for CNA CC. Review of the part 3 dress code of the facility handbook dated 01/01/2023 read, j. Acrylic and/or long natural nails are an infection risk and are not permitted. According to the TAC 483.60(i)(1)-(2), . Employees should never use bare hand contact with any foods, ready to eat or otherwise. Since the skin carries microorganisms, it is critical that staff involved in food preparation and services consistently utilize good hygienic practices and techniques. Record Review of the facility's Infection Control Policy noted, All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 of 7 residents (Resident #1 and Resident #2) reviewed for ADL care. The facility failed to shower Resident #1 and Resident #2, who were dependent on staff for ADLs, as scheduled. Findings include: Resident #1 Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), gangrene (dead tissue caused by an infection or lack of blood flow), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), acquired absence of right leg below knee, acquired absence of left leg below knee, and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Record review of Resident #1's MDS dated [DATE] revealed he had a BIMS score of 14 (cognitively intact); he did not have hallucinations or delusions; he did not exhibit behaviors related to rejection of care; he required limited physical assistance from one staff member for bed mobility, dressing, personal hygiene, and bathing; he had functional limitations in range of motion of upper extremity (one side); he had functional limitations in range of motion of both lower extremities; he was occasionally incontinent of bowel and bladder; and he had surgical wounds and required wound care. Record review of Resident #1's care plan revised 12/15/2022 revealed he was resistive to care, showers, medications, weights. The goal was for the resident to cooperate with care. Interventions were to allow the resident to make decisions about treatment regime, to provide sense of control, educate resident/family caregivers of the possible outcomes of not complying with treatment or care, encourage as much participation/interaction by the resident as possible, if resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. Further review indicated the resident had an ADL self-care performance deficit due to Schizophrenia. The goal was for the resident to maintain current level of function in ADLs. An intervention was Bathing/Showering: The resident is totally dependent [1 staff to provide shower 3x weekly and as necessary], Personal hygiene Routine: The resident required extensive assist x 1. Observation and interview with Resident #1 on 12/15/2022 at 11:15 a.m. revealed he was alert and oriented. Resident #1 was observed halfway on his bed (top half) and halfway on his motorized wheelchair (bottom half). Both of his legs were amputated below the knee and were dressed and wrapped with an ace bandage. Resident #1's fingers were absent on both hands (the right hand was dressed and bandaged). Resident #1 stated staff had just started giving him showers on the day before (12/14/2022). He said he did not know what happened the day before (12/14/2022) that made staff start giving him showers. He said before that, he only got a shower once per month. He said he had been able to wash himself daily, but before 12/14/2022, he had not received a shower or bed bath more than once per month. He said he assumed staff did not give him showers because they just did not want to. He said he had not experienced any negative outcomes from not receiving regular showers. Record review of Resident #1's, Skin Monitoring: Comprehensive CNA Shower Review sheets for November 2022 and December 2022 revealed the following: *11/02/2022 - No time listed. *11/04/2022 - No time listed. *11/07/2022 - No time listed. *11/09/2022 - No time listed. Charge Nurse C signed as the nurse. *11/11/2022 - No time listed. Refusal indicated. *11/14/2022 - No time listed. *11/16/2022 - No time listed. *11/18/2022 - No time listed. *11/21/2022 - No time listed. Refusal indicated. *11/23/2022 - No time listed. *11/25/2022 - No time listed. *11/30/2022 - No time listed. *12/05/2022 - No time listed. *12/07/2022 - No time listed. Charge Nurse C signed as the nurse. *12/09/2022 - No time listed. Charge Nurse C signed as the nurse. *12/14/2022 - No time listed. Charge Nurse C signed as the nurse. Record review of Resident Council meeting Minutes dated 11/03/2022 at 2:00 p.m. revealed, . B. Nursing: Discussion: room [ROOM NUMBER] B (Resident #1) needs shower . Record review of a Resident Grievance Form dated 12/14/2022 written by the Activities Director revealed on 12/14/2022, at 8:35 a.m., Resident #1 expressed to the Activities Director that he was not receiving showers. Further review of the document revealed, Investigation Findings: Issue was resolved immediately. Resolution: Informed nurse (charge nurse) about concern, she followed up with CNA. CNA provided Resident #1 assistance with his shower. Spoke with Resident #1, he expressed he was ok and thankful for linen change as well . Resident #2 Record review of Resident #2's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with Systemic Lupus Erythematosus (an inflammatory disease caused when the immune system attacks its own tissues), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), chronic inflammatory demyelinating polyneuritis (a slowly developing autoimmune disorder in which the body's immune system attacks the myelin that insulates and protects the body's nerves), neuralgia and neuritis (a type of nerve pain caused by inflammation, injury, or infection [neuritis]), paraplegia (paralysis of the legs and lower body), diabetes mellitus (a group of diseases that result in too much sugar in the blood), morbid obesity (a disorder involving excessive body fat that increases the risk of health problems), and generalized anxiety disorder (severe , ongoing anxiety that interferes with daily activities). Record review of Resident #2's MDS dated [DATE] revealed he had a BIMS score of 15 (cognitively intact); he did not have hallucinations or delusions; he did not exhibit behaviors related to rejection of care; he required extensive physical assistance of at least two staff for bed mobility, and personal hygiene; he required total assistance from at least three staff for transfers; he required extensive physical assistance from at least one staff for bathing, dressing, and toilet use; he ambulated via wheelchair; and he was always incontinent of bowel and bladder. Record review of Resident #2's care plan revised on 12/15/2022 revealed he had behaviors and sometimes refused to be changed after an incontinent episode (Goal: The resident will have fewer episodes of refusing to be changed after incontinent episodes. Interventions: Anticipate and meet the needs of the resident, explain all procedures, if reasonable, discuss the resident's behavior and explain why behavior is inappropriate, intervene as necessary to protect the rights and safety of others); and he has a self-care performance deficit due to recent CVA and paraplegia (Goal: Resident will maintain current level of function. Intervention: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary, the resident is totally dependent on 1 staff to provide shower 3x weekly and as necessary). Observation and interview with Resident #2 on 12/15/2022 at 12:15 p.m. revealed he was alert and oriented. Resident #2 was lying in a low bed. He stated since his room was changed (he was moved to another hall due to renovations), he only received showers about once per month. He said it was harder to shower him because staff had to use a rolling chair. He said his last shower was about a week-and-a-half ago (he did not have the exact date or day of the week). He said he had to beg a staff member from the other side of the building to give him a shower. He said he did not know how long it had been since he had a shower before the last shower. He said his beard was very long and it had never been that long. He said he did not know what to do about the showers because he did not want to complain about it and be known as the mean one. He said he had to live in the facility and did not want a bad reputation. He said he should get showers on Tuesdays, Thursdays, and Saturdays. He said he received a bed bath only once since he was admitted . He said he would love to have three showers per week. He said he had not experienced any negative outcomes due to not having regular showers. Record review of Resident #2's, Skin Monitoring: Comprehensive CNA Shower Review sheets for November 2022 and December 2022 revealed the following: *11/02/2022 - No time listed. CNA A was listed as the CNA. *11/04/2022 - No time listed. *11/07/2022 - No time listed. *11/09/2022 - No time listed. *11/11/2022 - No time listed. *11/14/2022 - No time listed. *11/16/2022 - No time listed. *11/18/2022 - No time listed. *11/21/2022 - No time listed. CNA A was listed as the CNA. *11/23/2022 - No time listed. CNA A was listed as the CNA. *11/24/2022 - No time listed. Bed bath was indicated. *11/25/2022 - No time listed. *11/28/2022 - No time listed. *11/30/2022 - No time listed. *12/02/2022 - No time listed. *12/05/2022 - No time listed. *12/07/2022 - No time listed. *12/09/2022 - No time listed. Charge Nurse C was listed as the nurse. *12/12/2022 - No time listed. *12/14/2022 - No time listed. Record review of Resident Grievance Form dated 11/14/2022 at 3:50 p.m. written by the ADON revealed, Resident (multiple residents) Showers were not conducted . Investigation/Findings: Staff: voiced no laundry clean and available due to renovations is what they were told from the weekend . In an interview with the ADON on 12/15/2022 at 12:30 p.m., she stated the facility had some issues regarding showers about two months ago (October 2022)., but they were resolved. She said a few of the facility's new staff were not giving showers. She said all even numbered rooms get showered on Mondays, Wednesdays, and Fridays (A beds on the 6:00 a.m. - 2:00 p.m. shift and B beds on the 2:00 p.m. - 10:00 p.m. shift) and the odd numbered rooms get showered on Tuesdays, Thursdays, and Saturdays (A beds on the 6:00 a.m. - 2:00 p.m. shift and B beds on the 2:00 p.m. - 10:00 p.m. shift). She said most of the residents have preferences about which staff they want to shower them and will refuse showers from anybody else. She said some of the residents have refused showers when she (the ADON) offered. She said she educated staff in October 2022 regarding showers, and it seemed like the problem resolved. In an interview with the Unit Manager, the Social Worker, and the Activities Director on 12/15/2022 at 2:00 p.m., the Activities Director said on the day before, 12/14/2022, she went by to check on Resident #1 and he expressed he was not getting his showers. The Activities Director said she approached the Charge Nurse to get him a shower. The Activities Director said Resident #1 did not say how long he had not had a shower. The Activities Director said last month (November 2022), during a resident council meeting, Resident #1 said he had not had a shower. The Unit Manager said the Activities Director notified her and she spoke to the CNA (she did not say what CNA) on the hall. The Unit Manager said the CNA was getting someone else ready for a shower at that time, but the CNA gave him a shower after that. The Unit Manager said she spoke to Resident #1 afterwards and he was thankful. The Unit Manager said Resident #1 never mentioned how long it had been since he had a shower. The Unit Manager said the CNA who gave Resident #1 his shower was PRN. The Unit Manager said it was the responsibility of the CNA to make sure each resident received their showers as scheduled. The Unit Manager said the CNAs brought the shower form to the charge nurses on each hall for them to sign. The Unit Manager said if a resident refused a shower, they try to encourage the resident and talk to family. The Unit Manager said the nurses had binders with lists of each residents' shower schedule. The Unit Manager said most residents had preferences as to which staff they wanted to shower them. The Unit Manager said she had knowledge of Resident #1 refusing showers several times. The Unit Manager said she had not noticed anybody who was not getting showers as they should. The Social Worker said none of the residents had complained to her about showers. In an interview with the Charge Nurse B on 12/15/2022 at 2:15 p.m., she stated each CNA should give resident shower sheets to their nurse after each shower for them to sign. She said the CNA should document on the sheet if the shower was refused, or if a bed bath was given. She said if a refusal was not noted on the shower sheet form, that meant the shower was given. She said there was a line on the sheet for the CNA to document what time the shower was given, but the CNAs may forget to complete the time. In a telephone interview with CNA A on 12/15/2022 at 2:30 p.m., she stated she worked the 6:00 p.m. - 2:00 p.m. shift. She said she always made sure all of her residents received showers as scheduled on her shift. She said if the shower sheet did not indicate the shower was refused, that meant the CNA forgot to document the shower was given. She said she usually tried to document that the shower was given, refused, or if a bed bath was given. She said she would usually tell the nurse if a shower could not be completed so they could make sure the next shift gave the shower. She said if there was an actual shower sheet without a documented refusal, the shower was given. She said she never showered Resident #1 or Resident #2 because they were both B beds who were showered during the 2:00 p.m. - 10:00 p.m. shift. In a telephone interview with Charge Nurse C on 12/15/2022 at 2:45 p.m., she stated when the CNAs gave showers, they gave the shower sheets to each nurse for them to sign. She said she had no knowledge of any resident not receiving showers as scheduled. She said after the CNA did their jobs, she just signed the sheets. Record review of In-Service Sign-In Sheet dated 10/03/2022 revealed all CNAs and nurses were educated. The document read, Training: All CNAs must use assignment sheet/form located in the CAN assignment form binder and all point-of-care's must be completed. Shower sheets must be completed Record review of facility policy, Bath, Shower/Tub revised February 2018 revealed, Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . Documentation: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual (s) who assessed the resident with the shower/tub bath . 5. If the resident refused the showers/tub bath, the reason (s) why and the intervention taken. 6. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath .

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 2 of 18 residents reviewed for care plan accuracy (Residents # 6, # 46). The facility failed to revise comprehensive care plans to reflect the reevaluation of visitation recommended by CMS for Residents # 6 and # 46 This failure placed residents at risk of not having their needs met and social isolation which could lead to a diminished quality of life. Findings include: Resident # 6 Record review of the face sheet for Resident # 6 revealed a [AGE] year-old female, admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 6's quarterly MDS dated [DATE] revealed a BIMS Summary score of 13, indicating intact cognition in cognitive skills for daily decision making, usually understood and usually understands, limited to extensive assistance required for Activities of Daily Living and incontinent of bladder and bowel. Record review of Resident # 6's comprehensive care plan, initiated and revised 1/8/21, revealed the resident had restricted visitation secondary to COVID-19 precautions, with interventions including providing alternative methods of communicating with family and friends. Observation of Resident # 6 on 10/4/22 at 1:25 p.m. revealed she was in her wheelchair in her room, watching TV. Interview at that time revealed she was fine, and she could have visitors now that the virus had cleared up. Resident # 46 Record review of Resident # 46's face sheet on 10/5/22 revealed a [AGE] year-old male, admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 46's quarterly MDS dated [DATE] revealed a BIMS Summary score of 10, indicating moderately impaired cognitive skills for daily decision making, usually understood and usually understands, extensive to total assistance required for activities of Daily Living, and incontinent of bowel and bladder. Record review of Resident # 46's care plan, initiated 3/17/20 and revised 3/17/20, revealed restricted visitation secondary to COVID-19 precautions with intervention including to provide alternative method of communicating with family and friends. Observation of Resident # 46 on 10/4/22 at 10:10 a.m. revealed he was in bed, alert and oriented, and did not speak due to a healing stoma (a surgical opening in the neck for a [CONDITION(S)] (a tube to assist with breathing). He was able to make his needs known and nodded his head when asked if he could have visitors. Interview with the DON on 10/6/22 at 9:40 a.m. revealed there were no visitor restrictions for COVID-19 in the building currently. The DON said the care plans needed to be revised to remove the visitor restriction for COVID-19 since they could accept all visitors according to CMS guidelines. She said the care plans should have all been revised when CMS lifted the visitor restriction. The DON stated the previous MDS Coordinator left last week, and she had missed creating and updating a lot of care plans, so an MDS Nurse who worked here before had come back this week to help with the care plans since they needed to be accurate for the resident's care. Interview with the Infection Preventionist on 10/6/22 at 9:55 a.m. revealed there were no visitor restrictions in the facility due to COVID-19. Record review of the COVID-19 Response for Nursing Facilities dated 6/27/22 revealed, in part: .the latest guidance on visitation .is now allowed for all residents at all times, per CMS. A facility policy on care plans was not available by the time of exit.

Based on observation, interview, and record review the facility failed to serve food under sanitary conditions in 1 of 1 kitchen. Staff was not wearing a hair net or a mask. 3 large baking sheets containing carbon build-up were stacked against each other Large and medium steam table pans stacked on rack contained moisture and water on the inside and food particles on the inside Open packaged meat, in a 2-door refrigerator, was not labeled, was not in a sealed container. Corn in sealed zip lock bag, in a 2-door refrigerator, was not labeled or dated. [MEDICATION(S)] wrapped in clear plastic wrap, in a 2-door refrigerator, was not dated. Two, 1-gallon zip lock bags containing cheese, in a 2 door refrigerator, were not sealed closed and were not dated. 52 4oz glasses stacked together on rack, were stored wet. 48 8oz glasses stacked together on rack, were stored wet These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations and interview on 08/01/21, the following was noted in the kitchen: *at 8:45 AM Dishwasher-E was not wearing a hair net or a mask. He said his mask was in his pocket and puts it on when he leaves the kitchen. He said the dietary manager locks the office when she leaves, and he was not able to get a hair net. At 8:57 AM, the dishwasher was observed entering the dietary manager's office and exiting; putting on a hair net. *at 9:08 AM Cook-G said the dietary manager was not here. Upon identifying to the cook: carbon build up on 3 large baking sheet stacked together on a rack, 3 large and 2 medium steam table pans stacked together on a rack with moisture and water on the inside of the pans, food particles on the inside of 2 of the large steam table pans. One 24 count muffin pan, on a rack, contained food particles on the inside of 5 muffin cups. Cook-G said I see what you are saying. I have been here 8 years and it has built up over the years. I don't know what to say, I will let the dietary manager know. *at 9:13 AM An open package of meat in the 2-door refrigerator in the kitchen, was unlabeled and was not enclosed in a sealed container. One, 1-gallon size zip lock bag containing corn was not labeled; Two, 1-gallon size zip lock bags containing cheese were not sealed or dated. Cook-G said they had no dates on them and the bags should be closed. She said she will let the dietary manager know. *at 9:45 AM on 8/01/21, Observed 6 sandwiches on a lined baking sheet, in the 2-door refrigerator in the kitchen. The dates written on the paper lining the pan was, 7/21/21 and 7/28/21. These dates indicate the sandwiches were made on 7/21/21 and are 12 days old; as of 8/01/21. On a follow-up visit and interview on 8/01/21 at 12:25 PM Cook-H said the sandwiches were [MEDICATION(S)] sandwiches and they were made yesterday. She said they can use sandwiches up to 7 days but most of the time they only kept them up to 2-3 days. Observation and interview on at 9:50 AM 52 4oz glasses stacked on top of each other, on a tray, were wet with water and moisture on the inside. 48 8 oz glasses were stacked on top of each, on a tray, were wet with water and moisture on the inside. Cook-G said we do have the drying mats, but they are all over the place. She said, I know the glasses are supposed to be put up dry. Observation and interview on at 10:52 AM Dish washer-E said he did not stack the glasses. He said Dietary Aide-F stacked them. During an interview at 10:53 AM, Dietary Aide-F said she stacked the glasses, but she will move them to another tray before using them. Dietary Aide-F said she has not been in-serviced on how to store things. Observation and interview on 11:31 AM Revisited a rack in the kitchen where the baking sheets, steam table pans, and muffin pan were stored. The Dietary Manager removed 3 uncleaned baking sheets, 5 steam table pans and 1 muffin pan, placing them in the 3-compartment sink. The Dietary Manager observed the 2-door refrigerator containing the: unlabeled and undated bag of corn, the open undated, unlabeled and unsealed package of meat, the 2 unsealed, undated bags of cheese and the undated [MEDICATION(S)] wrapped in plastic wrap. The Dietary Manager said, things have to be labeled, dated and sealed. The Dietary Manager said she has not in-serviced the staff and she said sandwiches can be kept up to 10 days. During an interview with the Dietary Manager, on 08/03/21 at 9:42 AM, she said she did not have any documentation that staff had been in-serviced on kitchen sanitation. *at 2:21PM on 08/03/21, the Dietary Manager provided policies on Ware washing, dated 9/2017 and Storage: Cold Food Storage, dated 4/2018. The documents provided did not address the life span of ready to eat sandwiches, made onsite at the facility or a timeline of discardment. Review of the TFER 2015, page 72, section 228.75(g)(B) revealed marking the date or day of preparation with a procedure to discard the food on or before the last day or date the food must be consumed .

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests, and the physical, mental, and psychosocial well-being of 6 of 6 residents in group meeting(Resident #s 1, 6, 11, 41, 62 and 72) and for 1 of 1 residents (Resident #79)reviews for activities. The facility failed to have scheduled activities for residents on the weekends. The facility did not provide ongoing activities for Resident #79. These failures could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: 1.Face Sheet and Care Plans dated 8/2/2021 Resident #79 is a [AGE] year-old female admitted to facility 10/18/2017 with re-admission on 11/18/2020. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress Notes dated 4/15/2019 at 17:49 indicated Resident#79 Resident #79 went to Walmart shopping outing which she bought McDonalds meal which she eat before loading back onto the bus. Progress Note dated 2/3/2020 at 14:21 (Activity Note) indicated Resident#79 is alert able to make her needs known, Enjoys watching TV in her room, word search puzzle books, socializing with others when they stop by her room, she continue to wear her glasses to view her favorite TV shows the westerns, and like listening to the oldies country music, she will be encouraged to be engage in small community interest, she will be assist as needed by staff. Progress Note date 10/26/2020 at 14:42 indicated, Resident #79 enjoyed seeing and talking with her daughter on a zoom call about 3 weeks ago, she was so happy to see and talk with her. She expressed that she was doing alright. Resident#79 enjoys watching TV and socializing with other residents. She was provide with an activity box of word search, puzzle books, adult coloring book and color pins. Seems to be doing ok no concerns at this interview. Interview with Resident #79 on 8/1/2021 at 8:56 a.m. she said she would like to attend activities but the CNA's don't get her up, and stated she does not do anything in the bed either. During an interview on 8/1/2021 at 9:00 am with CNA(J) said that resident #79 very seldom gets out of bed and she sleeps most of time, she said she does not see her doing any activities, and she did not think watching TV was a real activity. During an interview with resident #79 on 8/2/2021 at 10:20 am, she said, she would like to get up and do activities, During an interview on 8/2/2021 at 10:30am with ADON, she said, resident #79 doesn't like to get up and also said that she does not like to be bothered too much, doesn't like even for you to change the water bottle on her oxygen. During an interview on 8/3/2021 at 2:30 pm, Activity Director (AD) said she only worked Monday through Friday as the AD. She said for the weekend activities, she leaves word search puzzles and a few games on a table for the residents to do independently or the CNA/Nurses can get for the residents Record review of the activity Calendar for June 2021 revealed the following: Sunday 6/6, 6/13, 6/20, 6/27 Independent Activities TV WORSHIP 8:00 Rise and Shine 10:00 Table Puzzling 2:00 Cards and Dominoes 3:00 Music Tunes Saturday 6/5,6/12,6/19 and 6/26 Independent Activities TV WORSHIP 8:00 Rise and Shine 10:00 Table Puzzling 2:00 Activity Cart of Games 7:00 My Favorite TV Movie Record review of the activity calendar for July 2021 revealed the following: *Sunday 7/4,7/11,7/18 and 7/25 Independent activities TV Worship Service 8:00 Rise and Shine 10:00 Table Puzzling 2:00 Cards/Dominoes 3:00 Music Tunes Saturday 7/3, 7/10,7/17 7/24 and 7/31 Independent activities TV Worship Service 8:00 Rise and Shine 10:00 Table Puzzling 2:00 Health Bingo on 7/10 7:00 My Favorite TV Movie Record review of the activity Calendar for August 2021 revealed the following: Sunday 8/1, 8/8, 8/15,8/22 and 8/29 Independent Activities: 7:30 Rise and Shine/Coffee 9:00 Monopoly Game (was not on cart 8/1/2021) 10:00 Table Puzzling 2:00 Cards/Dominoes (not on Cart 8/1/2021) 3:00 Music Tunes During an review of resident #79, Care Plan dated 12/19/2018 revised on 10/26/2020 indicated in order to participate fully in activities, I need help gathering supplies for the activity In order to participate fully in activities, I need reminders o go to the activities I enjoy, In order to participate in fully activities, I need encouragement to go to activities I enjoy. Provide in room activities: Crossword and word search. Policy Revised Resident Assessment and Care Planning dated May 2021 indicated #1 The resident and/or the resident's representative is informed that he or she has the right to participate the development of the comprehensive care plan including the right to participate in the care planning process. #5 the care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes or a change in condition. At a minimum, the care plan is updated quarterly. 2.During an observation on (Sunday) 8/1/21 at 8:15 a.m. to 2:00 p.m. revealed there were no activities. During a group interview on 8/2/21 at 10:00 a.m., Resident #s 1, 6, 11, 41, 62 and 72 said there were no organized activities on Saturdays and Sundays. The residents complained of occasional boredom because of the lack of activities. Resident #62 said there was activities listed on the activity calendar, but it was not being done and she said might as well take a black marker and scratch through it. During an interview on 8/2/2021 at 10:17 a.m., the staffing Director said there was not a staff assigned to assisting with activities during the week or on the weekends. During an interview on 8/3/21 at 12:59 p.m. The Activity Director said she worked Monday through Friday 8 a.m. to 5 p.m. and maybe one weekend a month. AD said she was not aware the activities listed on calendar was not activities and was not aware the listed activities on calendar was not being done . She said she expected for the Aides to assist with activities on the weekends, but she never followed up to make sure they were being done. AD described tv worship as a reminder to watch a church service on TV on your own, rise and shine was drinking coffee while eating breakfast, monopoly game and table puzzles were left on an activity cart for residents to play on their own , but did not have an assigned staff to initiate the weekend activities or gather residents to come to weekend activities. AD said they currently did not have a Monopoly game or Dominoes on the activity cart at this time., she said the games went missing and plans on replacing the missing games. She said she did not know why she continued listing the games on the activity calendar and she did not have the games available. During an interview on 8/3/21 at 5:16 p.m. The Administrator said she was not aware weekend activities were not being done and acknowledges the activities listed on calendar could be better. Record Review of the revised activities program policy dated February 2017 indicated The facility provides an activities program designated to meet the interests, preferences, and physical, mental, and psychosocial well-being of each resident as indicated on the comprehensive assessment and care plan. The activities program is staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident. Individual (one-on-one) and group activities, plus one and off-site activities are included in the activities program.

Based on interview and record review, the facility failed to provide to demonstrate a response and rationale for resident council concerns and requests, for 4 of 7 months reviewed for resident council. (January, May, June and July 2021) The facility did not respond to the resident council regarding concerns voiced during January, May, June and July 2021 monthly council meetings. This failure could place residents at risk of not getting their needs met and decreased resident rights. Findings included: During a group interview on 8/2/21 at 10:00 a.m., Resident #s 1, 6, 11, 41, 62 and 72 said they said that staff did not follow up with their concerns/complaints from resident council meetings. Also, facility staff were not letting them know how their concerns were being addressed after a council meeting. Record review of the Resident council minutes dated 1/7/21 indicated: New Business- B. Nursing - One Concern (no further details provided) Resident council minutes dated 5/6/21 indicated: Old Business - Departmental responses approved per resident request of last meeting (review concern forms); was left blank unanswered. New Business - A. Administration -Smoke breaks are late (instructed to complete concern form for specific concern) B. Nursing - staff assisting residents/call lights late (instructed to complete concern form for specific concern) C. Dietary - Food is cold/ residents asking for salads late (instructed to complete concern form for specific concern) I. Maintenance - TV remotes not working/need remotes (instructed to complete concern form for specific concern) Resident council minutes dated 6/4/21 indicated: Old Business - Departmental responses approved per resident request of last meeting (review concern forms), was checked No. New Business B. Nursing - Call lights/ staff assisting (instructed to complete concern form for specific concern). C. Dietary -cold food/ same food every week. (instructed to complete concern form for specific concern) Record review of an undated resident council concern follow-up form addressed to DON with the nursing department regarding June 4, 2021 resident council meeting indicated: Concern - Smoke breaks are late; Action Take - Blank (no response); signature and date - Blank (no response); Resident feels concerns has been sufficiently addressed - Blank (no response); Administrator signature and date - Blank (no response). Record review of an undated resident council concern follow-up form addressed to the laundry department regarding June 4, 2021 resident council meeting indicated: Concern - belongings from laundry not getting back; Action Take - Blank (no response); signature and date - Blank (no response); Resident feels concerns has been sufficiently addressed - Blank (no response); Administrator signature and date - Blank (no response). Record review of the Resident council minutes dated 7/21/21 indicated: Old Business - Departmental responses approved per resident request of last meeting (review concern forms); was left blank unanswered. During an interview on 8/3/21 at 2:08 p.m. The AD said she did not consistently follow up with resident council concerns. She said she was the only one who had the Resident Council concern forms, and after the meetings she was supposed to complete the forms, make a copy and give to the department head to follow up. The AD said she did not have most of the Resident council concern forms either she did not do it, or the department did not give it back to her. She said she should have done a better job with doing the resident council concern forms. During an interview on 8/3/21 at 5:16 pm., the Administrator said she was not aware resident council grievances was not being addressed. She said she expected for AD to handle it. The administrator said she did not sign off on the resident council concern form because she never saw it. Record review of the revised customer experience made simple, Chapter: Resident Rights policy dated June 2021 indicated The center actively resolves concerns submitted orally or in writing to any member of the center's staff.Grievance Official - The administrator acts as the grievance official and is responsible for: overseeing the grievance/concern process; receiving and tracking all concerns through to conclusion, and leading or delegating any necessary investigation by the center; . A=Action 1. Staff receiving the concern should acknowledge receipt of concern, immediately notify the Grievance Official and initiate an investigation.

Based on observation, interview and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 1 of 7 residents (Resident #79) reviewed for call light use, in that: Residents #79's call light was not within reach. This failure could place residents at risk of not receiving care or attention as needed. Findings: Record review of Resident #79's face sheet dated 8/2/2021 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #79's care plan revised 01/8/2019 revealed she was at risk for falls due to: History of falls, weakness, and cognitive impairment. The facility interventions were to include: The Resident needs a safe environment with even floors free from adequate, glare-free light, a working and reachable call light, the bed in low position at night, personal items in reach. During an observation and interview on 8/1/2021 at 10:30 AM with resident #79, her call light was on the floor and out of reach from the resident. Resident #79 said I would like to get up and need assistance many times, but I can't get to my call light, I usually have to yell for assistance when I need it. During an interview on 08/01/2021 at 10:31 AM with CNA J, who was called to residents #79 room by this surveyor, she was asked, how would you make sure that this resident needs were being taken care of, she said, that the residents call light should be attached to her where she could reach it, but I see she can't reach it right now, because call light is on the floor. Both CNA and Surveyor observed resident #79 call light on the floor beside residents bed. CNA J said, I know it's our responsibility to make sure call lights are in reach. During an observation and interview with the resident on 8/3/2021 at 12:30 PM the call light and bed controls were both on the floor. During an interview on 08/3/2021at 4:00 PM, the DON stated call lights should be attached near the residents or within residents' reach at all times when a resident is in bed. It is all staff responsibility to make sure call lights are in reach. Record review of the undated facility policy titled Nursing Rounds/Licensed Staff revealed: FUNDAMENTAL INFORMATION: Purpose: The routine resident check involves entering the resident's room o To ensure the safety and comfort of the resident o To assist in continuity of care o To identify potential change in condition PROCEDURE 3. Note the following o Call light is within the resident's reach

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the prepartion of residents to be active partners and effectively transition them to post-discharge care for 1 of 4 residents (CR #1) reviewed for discharge process. The facility failed to ensure CR #1 was provided effective discharge planning when he discharged , per administration's directive, on the same day he eloped and was found off facility premises. CR #1 was discharged to a private apartment without staff arranging the medical care services of a Home Health Agency to monitor his blood sugars and wound care, without providing CR#1's physician ordered medications and administration instructions and without providing wound care instructions and supplies. CR#1 was found alone in his apartment, deceased lying on the floor six days after being discharged from the facility. Medications were found in the apartment that belonged to another resident who resided at the discharging facility. Upon recognition of the medication error, the facility failed to ensure the wrong medications were retrieved, and the correct medications were provided. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to monitor the effectiveness of the Plan of Removal. This failure could affect any resident in the facility and placed them at risk of improper discharge, unmet needs, injury and death. Findings include: CR #1 Record review of CR #1's face sheet revealed the 61year-old resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of hospital records dated [DATE] revealed CR #1 had been transferred to the hospital after having being found unconscious in his apartment with a blood sugar reading of 700. (Normal blood sugar levels range from 70- 140). Record review of CR #1's H & P conducted by the physician on [DATE] read in part . insulin-dependent but non-compliant with medications .recent orthodontic surgery with removal of teeth .Patient is seen today for evaluation and management of uncontrolled diabetes .sacral wound .wakes easily to name, and responds with ,[DATE] word remarks that are appropriate to conversation. He engages with provider, makes his needs known but is not able to give a reliable history of his health or hospitalization .previously ambulatory with walker .unsteady gait appears catchetic and frail .sacral wound reported patient did not allow inspection. Record review of the admission MDS with an ARD of [DATE] revealed CR #1 scored an 8 on the BIMS indicating he had moderate cognitive impairment. The review further revealed the resident required 2 person assist for bed mobility, hygiene and transfers and that he required only set up assistance for ambulation. The review further revealed the resident had demonstrated verbal behaviors towards others and that he did not require the use of a wheelchair, walker or other assistive ambulatory device. The review revealed the resident was frequently incontinent of both bowel and bladder. Record review of physician's orders [REDACTED].#1 revealed the following orders: Insulin [MEDICATION NAME] Solution 100 unit/ml Inject 10 unit subcutaneously at bedtime Hold for BS <150, for type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. Insulin [MEDICATION NAME] Solution 100 Unit/ML Inject 30 unit subcutaneously in the morning Hold for BS < 150, for diabetes mellitus with diabetic [MEDICAL CONDITION]. Humalog KWIK Pen Solution Pen-Injector 100 unit/ML (Insulin [MEDICATION NAME]) Inject as per sliding scale: If ,[DATE]=5 units, ,[DATE]=7 unit; ,[DATE]=9 units; ,[DATE] = 11 units Call MD if BS < 70 or >400, subcutaneously before meals, for type 2 diabetes mellitus with diabetic kidney disease. FSBS q am before meals Notify MD of BS <60 or >300, for diabetes management. FSBS q am in the morning Notify MD of BS<60 or >300, for diabetes management. License nurse to monitor: Sacral pressure: for any abnormalities or changes to surrounding skin q shift. Ensure dressing is intact. Document plus sign for no observed changes and a minus sign for any observed changes and notify MD and document findings every shift for monitoring, (for sacral wound management). Sacral unstageable wound .Cleanse with NS/WC, apply santyl/aginate and cover with dry absorptive dressing every day shift for unstageable wound. Atorvastin Calcium Tablet 10 mg Give 1 tablet by mouth at bedtime, for hypertension. [MEDICATION NAME] Tablet 20 mg Give 1 tablet one time a day, for gastro-[MEDICAL CONDITION] reflux disease. [MEDICATION NAME] (rDNA) Kit 1 mg Inject 1 ml intramuscularly every 1 hours as needed for 1ml IM prn BS less than 60 if patient unable to swallow, for diabetes mellitus with ketoacidodosis without coma. [MEDICATION NAME] HCL Tablet 50 mg Give 2 tablets one time a day Hold for SBP <110 or P< 60. Give 2 tablets total dose, for hypertension. [MEDICATION NAME] Tablet 50 mg Give 1 tablet every 12 hours Hold for SBP < 110 or Pulse < 60, for hypertension. Senna Tablet 8.6 mg Give 2 tablets by mouth every 24 hours as needed for constipation QHS prn. [MEDICATION NAME] HCL Tablet 100 mg Give 1 tablet by mouth one time a day, for [MEDICAL CONDITION] with acute exacerbation. Record review of CR #1's nursing notes dated [DATE] completed by the wound nurse read , Received no documentation concerning the wound from the hospital . The review revealed the wound nurse contacted the hospital but they could not provide documentation regarding CR #1's wound. The wound nurse documented, Wound is currently unstageable with white tissue covering the base. Wound care doctor to eval. Treatment orders in place. Record review of CR #1's nurses' note dated [DATE] revealed the resident succeeded in exiting the facility unaccompanied and was found in the parking lot at the facility. Record review of CR #1's nurses' note dated [DATE] read in part, At 5:20 AM .my attention was drawn that resident has left the facility unaccompanied and unauthorized. After a search of the nearby surrounding (sic), I called the DON and the Administrator to notify them. Most of the night staff went about searching for the resident until he was found at 6:50AM . The review also revealed the Responsible Party was contacted and the resident was provided with a wanderguard. Record review of Social Services notes dated [DATE] 08:40 am written by the facility's social worker revealed the DON informed her that CR #1 was to be discharged to either of 2 named skilled nursing facilities each with a secure unit. Record review of Social Services notes dated [DATE] 09:12am read, Resident's RP/(family member) stated that she wants to take resident home with home health. Record review of CR #1's nursing notes dated [DATE] 10:56 AM written by the ADON read, Spoke with this residents RP about his recent elopement attempts. She was made aware tht (sic) this resident was not hurt and was easily retrieved back to the facility. She was also made aware that he needed to be safer at a secure unit and this company had several to choose from. She said no to that idea and that she would prefer to get home health and take him home. I said that would be fine but it needs to happen today. So the SW was notified and spoke to the RP as well. We will continue to monitor this situation. Resident is safe and secure in his room at this time. He is in bed with the covers pulled p (sic) over his head. Record review of CR #1's nursing notes dated [DATE] 4:29pm written by the ADON read, Resident was discharged home with his RP. (family member) verbalized understanding of how to admisister (sic) medications to him. His vital signs at the time of his departure were ,[DATE] (blood pressure) . and O2 sat 99% on room air. Record review of physician's orders [REDACTED].#1 revealed the following orders: D/C home with medications. Home Health Nursing Services Order date [DATE]. Place wanderguard on right ankle and watch its functioning every shift for Wandering/Elopement- Order Date [DATE]. Record review of CR #1's nursing notes dated [DATE] 8:59pm written by the ADON read, On [DATE]st, order received for resident to be discharged to home with home health. Resident's (RP) was made aware of pending discharge. Sw made aware to set up home health services. Per the Sw, resident left the building with his (family member) and didn't have his medications. The SW states that she called the (family member) to come back to come pick up the medications. She in-turn told the Med Aide to bag up his meds for discharge. Later he came with the medications in a plastic bag and gave them to me. The Rp returned and was standing at the door, so I gave her the package and asked her if she was familiar with his medications or did she have a question about how to administer them? She responded no that she'd given them before and she understood how to give them. She took the medications and left. About 30 minutes later the med aide said that he needed the package of meds back because he'd given the wrong residents meds. The charge nurse was informed and he called leaving a voice message. I called twice and got her the second time. I apologized for the inconvenience and asked her to bring the medications back. I informed her that a mistake had been made and she'd been given the wrong medications. She moaned about it a little bit but promised to bring them back. The evening charge nurse was instructed to look out for her return as she was to bring the meds back to us. Record review of the Discharge Plan and Summary dated [DATE] revealed CR #1 was going home with home health. Two family members were listed as available to help resident. The question relative to resident's level of consciousness/cognition was answered by a check by Intermittent confusion or fluctuations in consciousness. Record review of the document entitled, Physician Discharge Summary dated [DATE] read in part, .Final [DIAGNOSES REDACTED].He remained confused during stay mainly oriented to self, sometimes place, never time .patient discharged home. A telephone interview was conducted with CR #1's Nurse Practitioner on [DATE] at 1:30 PM. She stated she did not discharge him as he was not ready to discharge. She stated she was surprised to learn he had been discharged and believes the physician would agree with her. She stated the plan was for CR #1 to eventually transfer to a Personal Care Home as he required someone to take care of his medications. She stated CR #1 did not have the capability of managing his medications and required someone to do so. With regard to his ambulatory capacity she stated the resident could walk but had an unsteady gait and was somewhat frail. Record review of an Internal Investigation and Attestation dated [DATE], revealed the document was type-written and was a synopsis of questions from a regional operations employee posed to the social worker. The review further revealed the social worker having stated she sent referrals to 2 separate home health agencies. The review revealed that Home Health Agency #1 accepted CR #1 on [DATE] and that Home Health agency #2 did not accept the resident because they required a signature from the physician. According to the document the Social Worker contacted Home Health Agency #1 on [DATE] and she was advised the agency could not work with the resident due to his insurance. The review further revealed that the Social Worker also contacted Home Health Agency #2 which had denied services on [DATE] and the Social Worker was informed the agency could not work with the resident due to his insurance. The document also read, in part, No other insurance companies were contacted and (family member) was left voicemails to attempt to notify her. Social Worker was unable to document on the resident's chart the above attempts The review also revealed that the Social Worker did not inform the DON nor the Administrator of the information obtained. The Social Worker initialed this document. Record review of Social Services Progress Notes dated March and [DATE] revealed no documentation of home health agencies being contacted or clinicals having been sent to home health agencies. A telephone interview was conducted on [DATE] at 9:00 PM with the facility's social worker. The social worker stated that she learned in the early morning staff meeting on [DATE] that CR #1 had eloped and the facility's administration did not want him to remain at the facility. She stated the ADON called the family and she herself attempted to set up home health for the resident. She stated that home health services with Home Health Care Agency #1 were pending due to the agency requiring a script signature from the doctor. She stated the other agency did not accept the resident but the resident was pending with the other agency. The social worker further stated that the Administrator and the DON wanted him gone. She stated she was told to get the Medication Aide to bag up the prescriptions which she did. She stated she recalled the resident and knew that he lived alone. She further stated she sent both home health agencies fax sheet, face sheet, medication list, doctor's documentation notes and thought she did so on [DATE]. She stated she was absent on [DATE]st and 2nd and she was terminated on the 8th. A telephone interview was conducted on [DATE] at 11:00 AM with an employee of Home Health Agency #1. The employee stated that the facility's social worker called them 2 days in a row. She stated that the second day the social worker called, the social worker had to be reminded that she had already been informed the agency could not accept the resident due to insurance. She stated that the referral was received by the agency on [DATE] and the social worker called them the following day questioning the agency refusing the resident's Medicaid coverage. The agency employee stated the coverage did not extend to skilled nursing assistance which the resident required. A telephone interview was conducted on [DATE] at 12:00 Noon with Home Health Agency #2. The employee from the agency stated they received clinicals from the social worker on [DATE] but they could not accept the resident as there was no signed physician's orders [REDACTED]. Record review of the document entitled Internal Investigation Statement and Attestation dated [DATE] regarding the statement provided to the Corporate Officer by the Medication Aide was reviewed. The document read that the following medications were erroneously sent home with the resident and his family member abiraterone, atorvastin, [MEDICATION NAME], bicalutamide, [MEDICATION NAME], losartan, [MEDICATION NAME] and tamulosin. A telephone interview was conducted on [DATE] at 2:00 PM with the Medication Aide. He stated that the facility's social worker came to him on [DATE] and asked him to prepare a resident's medications as he was being discharged . He stated she stated Mr. (NAME REDACTED) the surname of Resident #2. He stated he went to Resident #2, who was alert and oriented, and asked him if he was discharging today and he replied that yes he was. He stated he went and prepared the bag of medications for Resident #2 and took it to the ADON. Later that day about 4:00 PM Resident #2 asked for his meds and was informed they were upfront. Resident #2 went to the front of the building requesting his meds and then came back and stated the ADON wanted to see him, (the Medication Aide). He stated he went up front and was asked whose medications were in the bag and he informed her they were Resident #2's medications. He further stated he was informed by the Charge Nurse on duty that CR #1's family member had been contacted and would bring the medications right back. Record review of the physician's orders [REDACTED].#2: Abiraterone Acetate tablet 250 mg for malignantneoplasm of prostate. Bicalutamide Tablet 50 mg for malignant neoplasm of of prostate. [MEDICATION NAME] Tablet 5 mg for malignant neoplasm of prostate. Tamsulosin HCL Capsule 0.4mg for malignant neoplasm of prostate. [MEDICATION NAME] ER Tablet 30 mg for pain. [MEDICATION NAME] HCL Tablet 50 mg for pain. Atorvastin Calcium Tablet 80 mg for [MEDICAL CONDITION]. [MEDICATION NAME] Tablet 10 mg for muscle spasm. Benzoate Capsule 200 mg for cough. [MEDICATION NAME] HCL Tablet 10 mg (a muscle relaxant). [MEDICATION NAME] Capsule 100 mg for [MEDICAL CONDITION]. Losartan Potassium Tablet 50 mg for hypertension. [MEDICATION NAME] ER Tablet 24 hour 90 mg for hypertension. A telephone interview was conducted with the former ADON on [DATE] at 4:06 PM. She stated that CR #1 eloped early on the morning of [DATE] and this was the resident's second attempt. They wanted the resident to be in a secure unit or somewhere safer. The Responsible Party offered to take the resident home. Following his discharge she realized his medications were not sent with him. She spoke to the Medication Aide and informed him to get the medications ready to go. She stated she herself was seated in the front at the desk monitoring the entrance when the family member came and she gave the bag of medications to her. She stated she asked the family member if she had any questions about the medications and she replied she did not. She stated she did not see a medication list with the medications. She stated a short time later the Medication Aide returned and asked for the medications back as they were medications belonging to another resident with a similar name. She stated she called the family member and apologized asking her to please return them to the facility and exchange them for the correct medications. She stated that the Charge Nurse called the family member but there was no answer. She stated she instructed the Charge Nurse to look out for the family member and she herself left for the day. She stated she thought the issue was taken care of. A telephone interview was conducted on [DATE] at 2:00 PM with Charge Nurse B. He stated he was not present at the facility at the time of the incident and stated he was at home. He further stated no one informed him to contact the family of CR #1 regarding medications. Interview on [DATE] at 9:30 AM with the DON revealed that a medication inventory list should have been sent with the resident's medications. She further stated that the facility does not send narcotics with the resident at the time of discharge. She said narcotics have to be ordered from a pharmacy that is convenient to the family/resident. She further stated that had she been informed that the wrong medications had been sent with the resident, she herself would have delivered the correct medications and retrieved those of Resident #2. A telephone interview was conducted on [DATE] at 4:58 PM with Wound Nurse C. Wound Nurse C stated she was familiar with CR #1's sacral wound. She stated it was still unstageable but getting better. She stated she was one of 2 wound care nurses. Both do work together and in CR #1's case, he was often resistant to care to have the cream applied and the dressing changed but they were able to work with him to get him to cooperate. A telephone interview was conducted on [DATE] at 5:05 PM with Wound Care Nurse D. Wound Care Nurse D stated the wound was unstageable but looked like it was closing up a bit and was looking better. She stated the resident was often uncooperative. They could perform wound care-changing the dressing and applying the cream very easily if he was asleep but frequently it took the 2 of them up to 30 minutes to redirect him into cooperating. She stated she was surprised to learn that the resident had discharged on [DATE]st without wound care instructions. She was told by the ADON that the family was returning for medications so she placed wound care instructions in the bag. A telephone interview was conducted on [DATE] at 1:50 PM with CR #1's Responsible Party (RP). RP stated that she was contacted by the facility on [DATE] and informed that her CR #1 had left the facility. She stated he walked almost to the freeway, a distance of 5 to 6 miles from the facility. She stated the facility told her he had to be discharged or they were going to place him in a secure unit. She further stated she did not feel he needed to be in a secure unit as he lived by himself. She was told that if she was coming to get him she had to be at the facility by 2:00 PM. She stated she picked CR #1 up and the Social Worker gave her 2 numbers for home health agencies but no one ever called. She stated she went back to pick up his medications and then received messages that they were the wrong medications. She stated she asked CR #1 who insisted the medications were correct and so she did not go pick up the other bag of medications. When asked about CR #1 living alone, She stated that she paid a resident who lives on the same hall to knock on his door and check on him each morning. She stated she did have family to help take care of him but he wanted to go back to his own apartment as he was used to living alone. She stated that she got a call from the neighbor one day at which time he informed her CR #1 was on the floor. She stated that she advised him to call 911. The police then informed her he had passed away. She stated the bag she was given contained a lot of medications and was heavy. She stated one of the medications was a muscle relaxant. She wonders if CR #1 took the wrong medications and this is what caused him to pass away. She further stated this is not right and my (family member) should be here today. Interview on [DATE] at 9:45 AM with the Administrator and the DON revealed they first learned of the resident's demise from a phone call from the police on [DATE]. Both the DON and the Administrator stated the police requested medication records which they provided. The Administrator stated that they turned in a self-report to the State Agency and initiated an internal investigation at that time. The Administrator stated they terminated the employment of the ADON and also of the Social Worker. The DON stated they were informed the Social Worker instructed the Medication Aide to get the medications for a resident using Mr. (NAME REDACTED) CR #1's surname. The Med Aide got the medications together and gave them to the ADON. CR #1 had already left with his family member when they realized the medications had not been sent with the resident and the family member so she was contacted and returned to get the medications. The medications provided were those of Resident #2 whose first name is the same as CR #1's surname. The DON stated that to the best of her knowledge no itemized medication list was provided with the medications that were given to the family member of CR #1. The DON stated that if someone had informed her the wrong medications were given to the family, she herself would have gone to retrieve the incorrect medications and deliver the correct ones. The Administrator stated that the facility's social worker who is responsible for planning a safe and orderly discharge for residents, failed to complete the home health referrals and did not document her efforts in the chart. An interview was conducted on [DATE] at 11:45am with the DON. At that time CR #1's elopement attempts were reviewed. The DON stated that CR #1 was exit seeking. They were concerned he would leave the facility overnight as he had early that one morning. She stated it was felt the resident would be better placed at a secure unit. She further stated they could not take the risk CR #1 would elope during the night. She further stated the RP did not want CR #1 to be transferred and she preferred to take CR #1 home with home health care services. A telephone interview was conducted on [DATE] at 9:00 PM with HPD Officer who arrived on the scene of CR #1's apartment when summoned by the 911 call. He stated CR #1 was pronounced deceased at the scene at his apartment where he resided alone. The HPD Officer responded to questions regarding medications found in the apartment. He stated that medications discovered and bagged up and taken were medications with the names of both CR #1 and Resident #2. Record review of the written policy entitled Transfer & Discharge Procedure Operations , read in part, Transfer and discharge procedures must provide sufficient preparation and orientation of the resident to ensure a safe, orderly transfer or discharge from the facility .Discharge indicated movement of a resident to a non-institutional setting, such as home, without expectation of return .The Interdisciplinary Team (IDT) should evaluate the resident's discharge potential based on a clinical assessment of the resident's status .Preparation and Orientation includes .orienting resident's caregivers to resident's daily patterns the physician provides a discharge order . Review of the written policy entitled, Resident Discharge with Medications read in part, 1 An order is obtained from the resident's physician to discharge or transfer the resident with all medications where permissable by State Law. 2. The resident is evaluated by the licensed nurse and the Interdisciplinary Team (IDT) to determine if the resident is able to properly store and self-administer ordered medications. 3. If the resident is unable to self-administer medications, an authorized caregiver will assume responsibility of the resident's medications at the time of transfer or discharge and must sign the Post Discharge Plan of Care (Briggs). 4. Medications released to the resident or resident caregivers are documented . On [DATE] at 11:50 AM, the Administrator and the DON were notified of Immediate Jeopardy (IJ) and an IJ Template was provided. A Plan of Removal was requested at that time. The final plan of removal was accepted on [DATE] at 2:33 PM after revisions were made. The Plan of Removal included the following: Plan to Remove Immediate Jeopardy Pasadena Care Center [DATE] Admission/Transfer/Discharge Pasadena Care Healthcare Center respectfully submits this plan of removal to abate the allegations of Immediate Jeopardy identified on [DATE] for Admissions/Transfer/Discharge. Immediate Action: -In-services were immediately initiated on [DATE] and completed on [DATE] by 7:00 PM by the Director of Nursing on the following topics to include transfer and discharge procedures, residents discharging home with medications, name alerts, medication reconciliation, (cross reference0, medication pass verification, resident discharge audit. All licensed nurses and Medication Aides were educated on the following and completed on [DATE] by 7:00 pm. Discharge Process: On [DATE] a discharge review was completed for all residents discharged in the past 30 days to ensure that home health care services was in place at the time of discharge. On [DATE] the facility completed an Ad Hoc Quality Assurance Meeting (4 point plan) conducted by the District Director of Clinical Services. meeting participants included the Interdisciplinary Team Members; Administrator, Director of Nursing, Medical Director, MDS Coordinator and Unit Managers. On [DATE] and ongoing the Director of Nurses/Designee review discharges from prior day to include family notification, physician notification, discharge order(s), discharge nurse notes, and medication reconciliation. On [DATE] the Nurse responsible for failing to ensure reconciliation of medications was suspended pending investigation. This nurse was terminated on [DATE] for failure to follow facility discharge policy. On [DATE] the Social Worker was terminated for failure to follow discharge policy related to verification of home health care services. Beginning [DATE] and ongoing for the next 30 days the Director of Nursing or designee will review the Interdisciplinary Team including the Administrator during the daily stand down meetings residents who have been discharged have the following completed: Verification of Home Health Care Services Verification that residents received the correct medications @ the time of discharge Verifications and cross checking of residents names Medication Reconcilation Verification of safe discharge location/environment On [DATE] Licensed Nurse and Medication Aides were re-educated by the Director of Nursing on the following topics to include transfer and discharge procedures of residents discharging home with medications, name alerts, medication reconciliation, (cross reference) medication pass verification, resident discharge audit. This will be completed by [DATE] by 2:00 pm. On [DATE] The Director of Nursing or designee Educated Licensed Nurses on the facility's policy on Transfer and Discharge Procedure to include Emergency Discharge and Family/Resident Education. This will be completed by [DATE] by 2:00 pm. On [DATE] and ongoing for the next 30 days the Director of Nursing or designee will Audit Resident discharged to home to include the following: Resident's Name discharge date Family Education/Training Discharge Location Physician Notification Administrator/Director of Nursing Notification Medications Reconciliation On [DATE] The Administrator Educated the Director of Nursing, Unit Manager, and other nurse managers on the process of referring home health services, as well as DME's, (sic), and other referrals to ensure safe discharge in the absence of the Social Worker. The Unit Manager will be responsible for arranging home health services in the absence of Social Worker. This process will be verified by the Director of Nursing and Reviewed by the Administrator Monitoring included: Record review was conducted of the facility's in-services that had been conducted. The review revealed that the facility initiated in-service education of staff on [DATE] and completed in-services on [DATE]. Documentation of the following in service topics were reviewed: Resident Discharge conducted by DON on [DATE]. Transfer and Discharge conducted by DON on [DATE]. Transfer and Discharge Procedure conducted by the DON on [DATE] Emergency Discharge Procedure: conducted by the DON on [DATE] Resident Discharge with Medication conducted by DON on [DATE]. Family /Resident Education conducted by the DON on [DATE] Name Alert conducted by DON on [DATE] and on [DATE] Resident Discharging Home with Medications conducted by DON on [DATE]. Documentation conducted by DON on [DATE]. Resident Discharge Audit conducted by DON on [DATE]. Medication Reconciliation with Resident Discharge conducted by DON on [DATE]. Medication Checks & The 8 Rights conducted by DON by on [DATE]. Record review of the Written Policies and Procedures utilized in the in-services were reviewed. These are: Documentation Operations 4 Clinical Operations Chapter Nursing Operations. Resident Di (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 of 15 residents reviewed for Administration (CR#1, CR#3, CR#2 and Resident #4). The Administrator failed to: Monitor the DON to ensure that nursing staff were assessing residents properly and that nursing staff were following policy and procedures in regard to wound prevention, skin assessments and change in conditions. The DON failed to: -Supervise and train the nursing staff to ensure they were performing proper and timely skin assessments per facility policy and ensure staff competency. -Supervise and train nursing staff in performing activities of daily living. -Supervise and train nursing staff for residents with changes in condition. -Utilize resources from the facility's corporate office to ensure staff were trained and competent to assess for changes in condition and perform proper and timely skin assessments. These failures resulted in an IJ on 12/11/18. While the IJ was removed on 12/13/18 the facility remained out of compliance at a scope of widespread and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 4 residents, requiring 2 residents to be hospitalized , and placed them at risk of not being provided with appropriate and timely medical intervention and prevention of pressure wounds resulting in decline in their quality of care, quality of life, hospitalization and possible death. Findings include: Interview with RN B on 12/07/2018 at 11:27AM he said that if there was a change in condition in a resident that the CNA's should notify the nurses and were supposed to fill out the Stop and Watch form. RN B went on to say that staff did not use the form very often. Interview with the DON on 12/10/2018 at 2:30PM, the surveyor asked what type of systems were in place to prevent skin breakdown/pressure wounds. DON said that there were policy's and procedures in place. DON said that there was a skin management system at each nurse's station and it addressed each staging of a wound and the nurses were to follow the skin management system. DON said the nurses should always notify the physician once a skin issue is noted. DON said all residents with wounds were seen by the wound care nurse and wound care physician. Interview with Wound Care Nurse on 12/10/2018 at 3:30PM. Surveyor asked Wound Care Nurse what type of training she had regarding wound care. She said she provided wound care at other facilities prior to becoming a Wound Care Nurse at the current facility. Wound Care Nurse said she took an online course for wound care and had a certificate at home. In an interview with RN B on 12/10/2018 at 3:35PM, he was asked by surveyor what type of wound care training he had prior to providing wound care at the facility. RN B said he did hands on training with the wound care physician and the wound care nurse at the facility. In an interview with the DON on 12/10/2018 at 4:45PM, she said the daily nursing skilled notes and the head to toe weekly skin assessment were the same and the nurses should be performing a complete assessment on both which included skin. In an interview with the Wound Care Nurse on 12/11/2018 at 3:20PM, she said she started in wound care in California and when she came to the current facility that the DON watched her perform a wound care. Wound Care nurse said she did not remember if there was a skills check off prior to providing wound care. Wound Care Nurse said she was responsible for training RN B but she did not do a skills check off with him. In an interview with LVN H on 12/11/2018 at 3:35PM, she said that the nurse responsible for the resident was supposed to be responsible for the Weekly Skin Assessments but sometimes the nurses did not have time to do it, so the nurse manager (RN B) was responsible for doing them. Surveyor asked LVN H how she obtained information when filling out the Daily Nursing Skilled form and she said she generally knew everything about her residents and she did a quick assessment and asked the residents questions. LVN H was asked how she knew if there was any skin issues with the residents and she said that the nurses depend on the CNA's to tell them if there was a change in condition or a change in skin. LVN H said the CNA's usually let the nurses know if there was a problem with the residents. In an interview with LVN F on 12/12/2018 at 3:30PM, she said she was not sure who was responsible for weekly head to toe skin checks and she had only been working at the facility for a little over a month. In an interview with Corporate Staff on 12/13/2018 at 10:40AM, she said the Wound Care Nurse had been suspended a pending investigation. She said that inconsistencies had been found regarding the Wound Care Nurse's work. Corporate Staff said that the facility's Registered Nurses had been trained on providing wound care and had been checked off on their skills. In an interview with DON on 12/13/2018 at 12:55PM, she said that Braden Assessments should be performed on Admission, 1 every week for 3 weeks following admission, quarterly, with a significant change and with any new wounds. In an interview with the Administrator on 12/11/2018 at 4:21PM she said she thought the immediate Jeopardy came about because the facility failed in 2 areas. She said that a sharp debridement should not have been performed on CR#1 who was on [MEDICATION NAME] and nursing staff should have stopped the [MEDICATION NAME] when she continued to bleed. Administrator said that there was a delay in notifying the physician of CR#1's bleeding and she should have been sent out within 24 hours of the debridement. She said that the wound care nurse and RN B should not have let the bleeding go on and they both needed advanced training in wound care. Administrator said she was not sure if the wound on CR#1 could have been prevented. Administrator said the facility had policies and procedures in place for prevention of pressure ulcers. Administrator said that the facility had 2 meetings a day where they addressed all issues regarding policies and residents. In an interview with the DON on 12/11/2018 at 4:16PM, she said that she felt that the facility did what they could to prevent the pressure wound for CR#1. DON said maybe they could have ordered CR#1 a specialty mattress sooner. The DON said that there were policies and procedures that the facility followed for prevention of wounds. DON said that the regional office, sister facilities and consultants were all available to staff for education and assistance when needed. The DON provided an in service conducted on 12/12/2018 regarding the policy and procedure on the skin management system and general change in condition, which included the following areas: 1. Change in Residents' condition related to wounds; or any general change of condition . 2. Notifying physician of any changes in condition including skin condition. 3. Reviewing head to toe skin assessments and weekly wound documentation; Providing proper and timely documentation of skin assessments, and wound care on the Head to Toe Record, SBAR, Weekly Skin Pressure Log, and the plan of care. CR #1 Record review of CR#1's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was identified as high risk for developing pressure ulcers and required extensive assistance of 2 people for bed mobility, transfers, dressing, toilet use and personal hygiene. She was receiving an anticoagulant medication, [MEDICATION NAME]. CR #1 was care planned for anticoagulant therapy and included interventions for monitoring PT/INR results and monitor for changes in condition. She was care planned for pressure ulcer development and interventions included frequent repositioning, good nutrition, weekly and full-body skin assessments. CR #1 had a skin assessment completed on 9/24/18 that noted a rash to her groin area and folds to abdomen. No wounds were identified. There were no further skin assessments until 10/26/18. On 10/26/18, a skin assessment indicated she had a new pressure ulcer (unstageable) on her left buttock. There was no documentation that showers were completed for CR #1 on numerous days in (MONTH) and (MONTH) (YEAR). The Wound Care Physician visited CR #1 on 11/7/18 and debrided the wound on her left buttock. On the following 2 days, it was noted that the wound was bleeding. The physician was not consulted. On 11/10/18, CR #1 was send to the hospital due to the bleeding from the left buttock wound. CR #1 was admitted to the hospital on [DATE] and the physician noted the following: feces were noted in CR #1's skin folds that was difficult to remove, her PT/INR value was 8.6, vitamin K and fresh frozen plasma was administered, she had a stage IV necrotic wound on her left buttock and one on her left ankle, and she had surgery to reroute her bowels using a [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. CR#3 Record review of clinical face sheet for CR#3 revealed a [AGE] year-old male with an admission date of [DATE]. [DIAGNOSES REDACTED]. He required extensive assistance of one person for bed mobility, dressing, toilet use and personal hygiene. CR #3 starting taking Bactrim DS 800-160mg (an antibiotic medication) for a [DIAGNOSES REDACTED]. The medication was started on 11/3/18. On 11/4/18 at 9:15pm, a nurse noted CR #3 complained of soreness to his leg. A skin assessment was not completed. On 11/4/18 at 11:59pm, a nurse noted CR #3's family member called the facility to report they were worried about CR #3 because the [MEDICAL CONDITION] was spreading. The nurse looked at CR #3's skin and saw redness and rashes on his left leg spreading to his neck and face. The physician was consulted and CR #3 was sent to the hospital. CR #3 was admitted to the hospital on [DATE] and was diagnosed with [REDACTED]. CR #2 Record review of clinical face sheet for CR#2 revealed a [AGE] year-old male with an admission date of [DATE] and an original admission date of [DATE]. [DIAGNOSES REDACTED]. He required extensive assistance of one person for toilet use and personal hygience and required supervision for transfers. CR #2 had a Stage II wound on his left ankle that was identified on 6/18/18. He was care planned for the wound and interventions included air mattress to bed, boot to left foot and wound care physician visits once weekly. Record review of skin assessments dated 10/31/18 and 11/18/18 revealed there was no assessment of the wound on CR #3's ankle. On 11/19/18, it was found that CR #2's wound on his left ankle progressed to a Stage IV wound. A pressure relieving mattress and cushion were ordered. He was discharged to another facility. Resident #4 Record review of face sheet for Resident #4 revealed a [AGE] year-old male with an admission date of [DATE]. [DIAGNOSES REDACTED]. He required extensive assistance of two people for bed mobility, transfers and personal hygiene. He was identified as at risk for pressure ulcers and care planned for the pressure ulcer development. Interventions included full-body skin assessments weekly, float heels while in bed, pressure reducing device in bed and assist with repositioning. Skin assessments for Resident #4 revealed he did not have impairment to skin on 12/1/18, 12/3/18 and 12/4/18. On 12/5/18, the facility identified that Resident #4 had a deep tissue injury to his right buttock and a Stage II wound on his left buttock. There were no further assessments of the wounds. Refer to F684 and F686 for more detailed information. The Administrator was notified on 12/11/2018 at 3:20PM of the IJ situation identified due to the above failures and a plan of removal (POR) was requested. The POR was received and after multiple revisions it was accepted on 12/13/2018 at 12:05PM. Plan of Removal On (MONTH) 12, (YEAR) (Facility Staff), MSN, APRN, ANP-C, Nurse Practitioner educated the Director of Nursing, District Nurses, and Registered Nurses on the procedures regarding skin assessments, including proper staging, documentation, reporting to physician and proper documentation of wounds. A 100% head to toe Assessments for all residents will begin on (MONTH) 11, (YEAR) and will be completed by (MONTH) 12, (YEAR) by Registered Nurses. The Director of Nursing will notify the physician immediately regarding any changes with new skin conditions. The Registered Nurses will document the condition of skin on Weekly Skin Pressure Record. Nursing staff will be educated by (MONTH) 12, (YEAR) by the Director of Nurses, and District Clinical Director regarding the Policy and Procedure on the skin management system and general change of condition, to include the following areas listed below; 1. Change in Residents' condition related to wounds; or any general change of condition . 2. Notifying physician of any changes in condition including skin condition. 3. Reviewing head to toe skin assessments and weekly wound documentation; Providing proper and timely documentation of skin assessments, and wound care on the Head to Toe Record, SBAR, Weekly Skin Pressure Log, and the plan of care. The Resident Care Specialists will be educated by the Director of Nursing on reporting any change of condition including skin condition and document on the stop and watch form and notify the Licensed Nurse of the change. On (MONTH) 11, (YEAR) the District Clinical Director validated the skill and competencies of the treatment nurse(s) to include staging, change in residents' condition, skin assessment and documentation on Weekly Skin Pressure Record. 4. Residents at risk for pressure ulcers will be evaluated upon admission. The Charge Nurse will assure that the plan of care is updated to reflect that the interventions are implemented. The Director of Nursing will validate the Treatment Nurses performance on return demonstration monthly for the next 3 months; weekly for the 1st month, bi-weekly for the second month; and monthly for the third month. The District Clinical Director will educate the nursing staff by (MONTH) 12, (YEAR) on the policy pertaining to Anticoagulant Therapy. The Assistant Director of Nursing will perform a record review of residents receiving anticoagulants by (MONTH) 12, (YEAR) and document findings on anticoagulant therapy log. Any deviations will be reported to the physician immediately for follow-up and treatment. The Resident Care Specialists will be trained by (MONTH) 12, (YEAR) or before returning to work on the Policy and Procedure regarding repositioning, incontinent care and bathing every month for the next 3 months to validate understanding with these practices. The Director of Nursing or designee will monitor the change of condition /skin condition and residents on anti-coagulant therapy daily in the morning meeting. On (MONTH) 11, (YEAR) an AD Hoc Sub-Committee of the Quality Assurance and Performance Improvement Committee will meet to discuss, approve and implement the plan. The surveyor monitored the POR and included the following: Interview with different staff including nursing staff from multiple shifts on 12/13/2018 revealed they had been in-serviced on change of condition, notifying physician of change in condition, skin assessments and weekly reviews. Observations on 12/13/18 revealed nurses were observed performing complete skin assessments, appropriately on residents. Record review of in-services conducted included abuse/neglect policy, skin management, genral change in condition, and documentation on weekly skin assessments. Record review of the forms revealed that in-services were conducted on all three shifts with the nursing staff attending. As of 12/13/18 most of the staff had been in-serviced. During the monitoring phase, interviews were conducted by the surveyors on different shifts with the nursing staff, nurse management, and CNA's. All interviewed staff verbalized up to date knowledge on new laboratory procedures, abuse and neglect, and resident rights. Observations were conducted during the monitoring phase of the eight residents that were identified with concerns related to laboratory services and no concerns were noted. The Administrator was informed on 12/13/2018 at 3:05PM that the IJ was removed; however the facility remained out of compliance at a level of wide spread and a severity of actual harm that was not immediate jeopardy due to the facility needing more time to train the staff and monitor the plan for effectiveness.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 3 of 10 (CR#1, CR#2 and Resident #4) reviewed for pressure ulcers in that: The facility failed to put preventative measures in place to prevent pressure ulcer development for CR #1 after she was identified as high risk of developing pressure ulcers. Facility staff were not routinely repositioning or bathing CR #1. She developed a necrotic Stage IV pressure ulcer on her left buttock and a necrotic Stage IV DTI wound on her left ankle in the facility. The facility failed to assess and care for CR #1's wounds effectively. She was admitted to the hospital with [REDACTED]. The facility failed to ensure CR #1's skin was kept clean and dry and ensure she was bathed routinely. CR #1 was admitted to the hospital with [REDACTED]. The facility delayed putting interventions in place and failed to assess CR #2's wound to left lateral ankle to ensure the wound did not worsen. The facility failed to put preventative measures in place for Resident #4. Who developed a stage II pressure ulcer in the facility. -The facility failed to ensure the licensed staff providing wound care were knowledgeable and competent in the identification, assessment, documentation and treatment of [REDACTED]. The facility failed to ensure skin assessments were completed per the resident's plan of care for CR #1, CR #2 and Resident #4. An Immediate Jeopardy (IJ) was identified on 12/11/2018. While the IJ was removed on 12/13/2018, the facility remained out of compliance at a severity level of Actual harm that is not immediate jeopardy and a scope of pattern due to needing to train staff and monitor their implementation of the Plan to Remove the Immediate Jeopardy. These failures affected 3 residents requiring one resident to be hospitalized and surgical rerouting of bowels and placed 2 additional residents at risk for worsening pressure ulcers, new pressure ulcers, infections and potential life-threatening complications. Findings include: CR#1 Record review of CR#1's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was discharged to the hospital on [DATE]. Record review of a Braden Scale assessment dated [DATE] revealed CR #1 was at high risk for developing pressure ulcers. Record review of CR#1's admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. MDS further revealed that CR#1 required extensive assistance with 2-person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. Resident was frequently incontinent of bladder and always incontinent of bowel. MDS did not reveal a [DIAGNOSES REDACTED]. She was at risk of developing pressure ulcers. Record review of Care Plans for CR#1 revealed the following care plans: Incontinent of bowel dated 08/14/2018 with a revision date of 08/17/2018. Interventions: check resident frequently and assist with toileting as needed, provide loose fitting and easy to remove clothing, provide peri-care after each incontinent episode . Receives anticoagulant therapy related to [MEDICAL CONDITION] dated 08/17/2018. Interventions: administer anticoagulant medications as ordered by physician, Labs [MEDICATION NAME] time (PT) and International Nationalized Ratio (INR), report abnormal labs to physician, observe/document/report as needed adverse reactions of anticoagulant therapy; blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs . Needs assistance with activities of everyday living because I have impaired mobility, muscle weakness and am morbidly obese dated 08/29/2018. Interventions: need assistance x 1-2 for toileting, need assistance for bed mobility, encourage active participation in tasks, provide cuing with tasks as needed, head to toe skin checks every week and as needed, observe for redness, open areas, scratches, cuts, bruises, and report changes to nurse. -Impaired cognitive function/dementia or impaired thought process related to dementia dated 09/01/2018 with a revision date of 09/14/2018. Interventions: administer medications as ordered, ask yes/no questions, use resident's preferred name, identify yourself at each interaction . Potential for pressure ulcer development related to incontinence, impaired mobility, [MEDICAL CONDITION], moisture associated skin problems and diabetes mellitus dated 08/30/2018. Interventions: Administer treatments as ordered and observe for effectiveness. Assist CR #1 with 1-2 to reposition and/or turn at frequent intervals to provide pressure relief, complete full body check weekly and document, educate the resident/family as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Impaired circulation related to elevated cholesterol dated 08/17/2018 with a revision date of 08/28/2018. Interventions: elevate legs when resting, encourage routine physical exercise, weekly skin checks and notify physician of abnormal findings. Record review of Head to Toe Skin Checks for CR#1 dated 09/24/2018 performed by RN B revealed the following which read in part . Rash to groin area and folds in abdomen, treatment continues. No wounds noted on Head to toe skin Assessment. Record review of CR #1's clinical record revealed there were no skin assessments between 9/24/18 and 10/26/18. In an interview on 11/20/2018 at 2:00PM, the Director of Nurses (DON), surveyor asked for CR #1's for bath/shower sheets. DON said that the facility did not use them and the certified nurse aides (CNA) used the computer system and document their daily tasks. Record review of the activities of daily living form for CR#1 printed from the computer revealed a key which read in part: ADL (activities of daily living) Bathing Bathing: Self Performance-How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) 0 Independent-no help 1 Supervision- oversight help only 2 Physical help limited to transfer only 3 Physical help in part of bathing activity 4 Total dependence 8 Activity itself did not occur or family and /or non-facility staff provided care 100% of the time for that activity NR Response Not Required . Toilet Use: Support Provided-How resident uses the toilet room, comode, bedpan, or urinal; trnasfers on/off toilet; cleanses self after elemination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bed pan, urinal, bedside commode, catheter or ostomy bag 0 No set up of physical helpf from staff 1 Setup help only 2 One person physical assist 3 Two+ persons physical assist 8 ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time NR Response Not Required Record review of activities of daily living form printed from the computer provided by facility for CR #1 dated 10/10/2018-10/25/2018, revealed no documentation that baths/showers were provided for the following days, instead an '8' was documented for the following days indicating that a bath/shower did not occur: 10/10/2018 10/11/2018 10/12/2018 10/13/2018 10/14/2018 10/15/2018 10/16/2018 10/17/2018 10/18/2018 10/19/2018 10/20/2018 10/21/2018 10/22/2018 10/23/2018 10/24/2018 The activities of daily living form for CR#1 further revealed the following: Toileting for the following days had an '8' documented, which indicated that toileting did not occur on the following days: 10/10/2018 10/13/2018 10/14/2018 10/20/2018 Record review of Head to Toe Skin Checks dated 10/26/2018 for CR#1 written by Wound Care Nurse read in part . New pressure ulcer. Left buttock wound (pressure). Measurements 6 cm (Length) X 3 cm (width) X 0.1 cm (depth). Unstageable, slough and necrotic tissue observed to wound bed with moderate serous drainage. Redness to sacral area. Record review of CR #1's Care plan dated 10/26/18 read in part, Unstageable wound to left buttock dated 10/26/2018. Interventions: Air mattress, have staff reposition routinely, have therapy team assist with repositioning of resident routinely, will receive treatment by wound care nurse as ordered by the wound care physician, will receive wound visits by the wound care physician weekly. Record review of Head to Toe Skin Checks for CR#1 dated 10/29/2018 written by wound care nurse read in part . New other issue. Deep tissue injury (DTI) to left ankle and right ankle, redness to sacral, groin and vaginal area and abdominal folds. Left buttock, pressure. 6cm Length X 3cm width X 0.1 depth. Unstageable. Right ankle (outer), pressure 2cm X 1.5cm X 0.0 depth. Left ankle (outer), pressure. 1.5cm Length X 1.5 Width X 0.0 Depth. Record review of CR #1's clinical record revealed no further assessment of wound on 10/2918, including a description of the wound bed, tissue, surrounding skin and any pain issues. Record review of Head to Toe Skin checks for CR#1 dated 10/31/2018 written by wound care nurse read in part . Existing Pressure Ulcer. Unstageable left buttock, left lateral ankle and right lateral ankle. Left lateral ankle, pressure. Length 2.0cm X 1 width X 0.0 depth, unstageable. Right lateral ankle, pressure. Length 3.0cm X 1.0cm width X 0.0cm depth, unstageable. Left buttock, 8 cm X 8cm X 0.0, unstageable. Record review of CR #1's clinical record revealed no further assessment of wound on 10/31/18, including a description of the wound bed, tissue, surrounding skin and any pain issues. Record review of CR #1's physician's orders [REDACTED]. -Pressure relieving mattress every shift for preventative with an order date of 08/10/2018 -[MEDICATION NAME] tablet 3mg with an order date of 10/24/2018- give 3mg by mouth one time a day for blood clot prevention. -Soft booties to bilateral feet order date of 10/30/2018. -Apply skin prep to right lateral ankle, apply dressing every 2 days every shift every 2 days for deep tissue injury order date of 10/30/2018. -Santyl ointment 250unit/gram, apply to left lateral ankle topically every day shift for unstageable wound, cover with dry dressing with an order date of 11/02/2018. -Dakins solution 0.25%, apply to left buttock topically every day shift for stage III and then calcium alginate and dry dressing with an order date of 11/09/2018. Record review of the physician order [REDACTED].#1 did not reveal any orders for wound care nutritional supplements. Record review of activities of daily living form provided by facility, for CR #1 dated 10/26/2018-11/10/2018, revealed no documentation that baths/showers were provided for the following days, instead an '8' was documented for the following days indicating that a bath/shower did not occur: 10/26/2018 10/28/2018 10/29/2018 10/31/2018 11/01/2018 11/02/2018 11/03/2018 11/04/2018 11/05/2018 11/06/2018 11/07/2018 11/08/2018 11/09/2018 The activities of daily living form for CR #1 further revealed the following: Toileting for the following days had an '8' documented, which indicated that toileting did not occur on the following days: 10/26/2018 10/31/2018 11/09/2018 In an interview with DON on 12/07/2018 at 2:09PM, she said that CNA's had been documenting 8's (did not occur) for showers if the residents received a bed bath instead of a shower and they did not know that if the resident was bathed that it should be documented as given and not documented as an 8. DON was asked about missing skin sheets and she was not able to answer as to why the skin sheets were not completed weekly for CR#1 as ordered. Interview with CR#1's responsible party (RP) 11/20/2018 at 1:39PM, she said that she visited CR#1 on a weekly basis and would find CR#1 in clothes, diapers and sheets that were saturated in feces. RP said that the facility would bathe her only once a week and not per schedule or as needed. RP said that CR#1 was not able to use her hands and was not able to make her needs known but was more alert and verbal upon admission to the facility. CR#1 was not able to use a call light and was dependent on staff at the nursing home for activities of daily living. RP said that CR#1 did not have any wounds when she went into the facility and felt that the wound could have been prevented if she (CR#1) was cared for properly. RP did not want CR#1 to return to the nursing facility as she was scared for CR#1's physical health and the decline of health if she returned. RP said that the hospital was trying to place CR#1 in a wound care facility where she could receive treatment for [REDACTED]. In an interview with the Wound Care Nurse on 11/20/2018 at 4:25PM regarding CR#1, she said that she initially called CR#1's pressure wound (buttock), a stage II when it was noticed by staff. Wound Care Nurse said that the very next day that CR#1 was seen by wound care physician and she had immediate skin breakdown overnight. Wound Care nurse said she obtained an order for [REDACTED].#1 received an air mattress the same day. Surveyor asked the wound care nurse why the resident did not have an air mattress previously and she said that she did not know why she did not have one and was not sure if one had been previously ordered. Wound care nurse said the following day that CR#1 had deep tissue injuries to bilateral ankles and a pus pocket to the left buttock and it oozed out when the wound care physician saw her. Wound Care Nurse said the wound care physician saw her Wednesday (11/07/2018) before she was discharged to the hospital on Saturday (11/10/2018). Wound Care nurse said CR#1 would complain of pain upon touch and she did not like to be repositioned. Interview with CNA G on 12/07/2018 at 12:24PM, she said that CR#1 was very nice and she was a sweetheart and never refused care. CNA G said that sometimes CR#1 would not want to be completely turned but would allow staff to use pillows and wedges. CNA G said when she did not want to be turned it was because she was in pain. CNA G said she would notify the nurse in charge if resident was in pain. CNA G said CR#1 was a big lady and she would call other CNA's to assist her with turning the resident. CNA G said it would usually take 3 CNA's to turn CR#1. CNA G said if CR#1 was in pain that she would wiggle around in bed and sometimes end up on her back. In an interview with the DON on 12/07/2018 at 12:56PM she said that residents must meet certain criteria before they can be approved for a specialty mattress. DON said that all the mattresses at the facility are pressure relieving mattresses and that to receive a low air loss mattress or air fluid mattress the criteria had to be met. DON was not able to say what the criteria was and said that it was at the nurse's station. DON said CR#1 did receive a specialty mattress the day she was seen by the Wound Care Physician and her wound was debrided (11/7/18). In an interview with LVN E on 12/10/2018 at 4:20PM, she said CR#1 was confused, never refused care and if she did not feel like being turned/repositioned during her shift (2pm-10pm), that CR#1 would let staff use pillows or wedges to reposition her. In an interview on 12/11/2018 at 3:35 PM with LVN H, she said CR#1 would refuse care sometimes but not all the time. LVN H said on occasion CR#1 would not want to be turned and staff would only turn her once during a shift. Record review of Wound Evaluation and Management Summary dated 11/07/2018 performed by Wound Care Physician for CR#1 which read in part . (CR#1) has multiple wounds. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. (CR#1) has an unstageable DTI of the right lateral ankle of at least 7 days duration. There is no exudate. Stage 3 Pressure Wound of the Left Buttock. Wound size 8cm (length) X 8cm (Wide) X 5cm (deep). Duration of >7 days. Exudate, moderate serous. Thick adherent devitalized necrotic tissue 30%. Granulation tissue 70% .Surgical Excisional Debridement Procedure Note: the wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION NAME]. Then with clean surgical technique, 15 blade was used to surgically excise 19.2cm2 of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissue was observed. Hemostasis was achieved, and a clean dressing was applied .Dressing treatment plan: [REDACTED]. Dry protective dressing apply once daily for 23 days. Dakins solution apply once daily for 30 days. Wet to moist, apply once daily for 30 days. Interview with Wound Care Physician on 12/12/2018 at 12:00PM, he said that he saw CR#1 for the first time on Wednesday (11/08/2018) and CR#1's pressure wound was infected, and foul smelling and it needed to be debrided. Wound Care Physician said CR#1 was a bariatric patient and 4 CNA's helped move CR#1 into position so he could assess CR#1 and provide care. Wound Care physician said the wound care nurse was responsible for dressing the wound daily and he believed she provided care appropriately. Wound Care Physician said he could not say if the pressure wound would ever heal and CR#1 was no longer at the facility. Wound Care Physician asked surveyor if CR#1 was on an air mattress prior to developing a wound and was informed by surveyor that CR#1 was not on an air mattress prior to wound development. Wound Care Physician asked if CR#1 should have been on an air mattress and surveyor responded that she could not advise the physician but did inform him that CR#1's Braden Score was High Risk on admission. Wound Care Physician said he did make sure that an air mattress was ordered following the debridement and would make sure that he ordered air mattresses for his bariatric residents in the future. Wound Care Physician said the issue was unfortunate. Record review of nurse note on 11/10/2018 at 2:44PM written by RN B read in part, (CR#1) has had almost constant bleeding since Wednesday 11/08/2018. It has been controlled at times but due to her weight, the fact that she is on [MEDICATION NAME], I find it necessary to send her to the hospital FOR SAFETY. Nurse is in process of getting her sent to an emergency department for further treatment and stabilization. In an interview with RN B on 11/20/2018 at 5:00PM, he said on Saturday (11/10/2018), one of the nurses asked him to look at the wound because it was still bleeding, and CR #1 was on [MEDICATION NAME]. RN B said CR #1 had a bloody diaper and he (RN B) did not want to deal with it, so he called to have her transferred to the hospital. RN B said that he removed the packing from the wound that was wet/bloody and put a pressure dressing on it. RN B said the sacral pressure wound was not gushing but was more like a steady trickling. Record review of emergency room report dated 11/10/2018 at 3:49 PM for CR#1 read in part . [AGE] year-old female with history of dementia, diabetes mellitus, hypertension (HTN) and [MEDICAL CONDITION] presents to the emergency department from nursing facility in need of wound care. Per emergency medical services (EMS), Resident #1 has wounds to her buttocks. They state 3 days ago the wound doctor was there and scraped the wound. EMS states the wound has been bleeding since .Currently on [MEDICATION NAME]. She has several wounds on buttocks. One deep and packed soaked with blood. The blood is trickling from the wound. Feces was seen in fold of skin in flank and back. Wound cleaned with 100 cubic centimeters (cc) of normal saline and covered with pressure dressings with 4x4 and gauze. Primary impression: Supratherapeutic INR. Secondary Impression: Acute [MEDICAL CONDITION], urinary tract infection and wound infection. Record review of emergency room re-evaluation physician note dated 11/10/2018 at 7:24PM for CR#1 read in part . Spoke with hospital personnel and information given. Personnel states will send to appropriate department since Adult Protective Services (APS) does not handle issues with nursing homes directly. Record review of hospital history and physical dated 11/10/2018 at 7:27PM for CR#1 which read in part . [AGE] year-old female presented from nursing facility with bleeding of sacral wound. Per Emergency Medical Services (EMS). Wound care at the facility tended to wound 3 days ago and it has been bleeding constantly since then. In the emergency room (ER), the wound was unpacked, and a large clot fell out. It was oozing per ER physician. It was repacked. (CR#1's) INR was noted to be 8.6 and 5mg of vitamin K was given along with fresh frozen plasma . (normal parameters for INR is between 2.0 and 3.0 for individuals taking an anticoagulant medication.) (CR #1) was started on [MEDICATION NAME] and [MEDICATION NAME] and admitted to medicine with wound care consultation. General appearance was noted as agitated, altered mental status, chronically ill appearing, awake, no respiratory distress .Diagnoses, Assessment and Plan: [AGE] year-old woman with type II diabetes mellitus (DM), [MEDICAL CONDITION] and on [MEDICATION NAME], dementia with worsening sacral wound, supratherapeutic INR, acute kidney injury (AKI) and urinary tract infection [MEDICAL CONDITION]. Record review of hospital physician wound care note for CR#1 dated 11/12/2018 at 5:56PM read in part . Diagnoses, Assessment and Plan: Left buttock wound necrotic stage IV. No active bleeding. Lateral left ankle necrotic stage IV. Continue packing wound with Dakins moistened Kerlix. Record review of hospital physicians daily report for CR#1 dated 11/19/2018 at 2:16PM read in part . Diagnosis, assessment and Plan: 1. [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] from sacral wound ulcer, urine culture is positive for Extended Spectrum Beta-lactamase (ESBL), Escherichia Coli (E. Coli) and [DIAGNOSES REDACTED]. Changed to [MEDICATION NAME] and [MEDICATION NAME]. Diverting [MEDICAL CONDITION] done on 11/12/2018, sacral wound with continued drainage. 2. Acute [MEDICAL CONDITION] secondary to #1- resolved, at baseline. 3. Supratherapeutic INR (8.6)- resolved after vitamin k and fresh frozen plasma. INR dropped 1.5. Will continue to hold [MEDICATION NAME] given bleeding sacral wound. Monitor hemoglobin and hematocrit (H&H). 4. Acute kidney injury on admission- unclear etiology, baseline creatinine of 0.7 in (MONTH) at another hospital. 5. Urinary tract infection 6. [MEDICATION NAME]- likely in setting of poor nutrition. Nutrition consultation. 7. Non-insulin dependent diabetes mellitus (NIDDM) type 2 8. [MEDICAL CONDITION]- rate controlled with intravenous (IV) beta blocker. Holding anticoagulants as above. Observation and attempted interview with CR#1 at hospital on [DATE] at 2:30PM revealed she had her eyes closed, laying in bariatric bed with low air loss mattress. Intravenous fluids hanging. Resident was not responding to verbal stimuli. Interview with hospital nurse on 11/20/2018 at 2:35PM, she said that CR#1 was rarely alert and usually does not respond to verbal or tactile stimuli since admission to the unit. Interview with hospital physician by phone on 11/30/2018 at 11:45AM, she said she was happy that someone was following up on CR #1. Hospital physician said the pressure ulcer to Resident #1's sacral region did not happen overnight or the same day. She said the wound had been there for some time. She said CR#1 was morbidly obese and was unable to care for herself and believed she was not being turned or repositioned like she was supposed to. Hospital physician said she believed that the pressure ulcer was preventable. She said the pressure ulcer was from the resident constantly lying and being left on her back. She said CR#1 was not cared for by the facility and that when she presented to the emergency room , it was difficult to care for her wound as there was a buildup of fecal material in the folds of CR#1's skin and wound area. She said that she and an emergency room nurse tried to remove the fecal material, but the majority could not be removed because the fecal material was built up over several days and CR#1 was not properly cleaned. Hospital Physician said that CR#1 had to receive a thorough bath to remove the fecal build up. She said that if CR#1 had been cared for that she would not have had a buildup of fecal material in her skin folds nor would she have developed the pressure wound. In an interview with CR#1's RP via telephone on 12/10/2018 at 11:30AM, she said that CR#1 was not doing well and was currently at a long-term acute care hospital. RP said CR#1 was no longer eating and the physician had recommended the insertion of a gastric tube for feedings because CR#1 had declined so much. RP said that the physician at the long-term care hospital also recommended that she (RP) considered putting CR#1 on hospice. RP said she was waiting for her other family member from out of town to come in so they could discuss hospice and the gastric tube. RP said that she would never had let her (family member) be admitted to the nursing home if she knew that CR#1 would not be cared for and that she would deteriorate in less than a few months. RP said that CR#1 was nonresponsive, not eating, had a pressure ulcer and now they had to consider hospice for CR#1 because of the lack of treatment at the nursing home. CR#2 Record review of clinical face sheet for CR#2 revealed a [AGE] year-old male with an admission date of [DATE] and an original admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of Minimum Data Set for CR#2 dated 08/07/2018 revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. MDS further revealed CR#2 required extensive assistance with once person physical assist for toilet use and personal hygiene. CR#2 required supervision with one person assist for transfer. CR#2 was always incontinent of bladder. MDS indicated that CR#2 had a [DIAGNOSES REDACTED].#2 had two Stage IV pressure ulcers. MDS indicated that the largest Stage IV pressure wound measurements were: Length 3.5cm Width 3.7cm Depth 0.3cm MDS did not mention where the largest pressure ulcer was located. MDS revealed blanks/no check marks in the areas labeled, 'Pressure reducing device for chair' and 'Pressure reducing devices for bed.' Record review of Care Plans for CR #2 revealed the following care plans which read in part: New Stage II to my left lateral ankle, dated 06/18/2018 with a target date of 11/13/2018. Stage II has now progressed to a stage IV. Interventions: Air Mattress to bed, boot to left foot, Santyl as ordered, will receive visits by the wound physician once a week. At risk for nutritional problem dated 06/30/2017 with a target date of 11/13/2018. Interventions: Multivitamin, vitamin C, report any signs or symptoms of dysphagia, pocketing, refusing to eat or appears concerned during meals. Dependent on staff for meeting emotional, intellectual, physical and social needs initiated on 02/13/2017 with a target date of 11/13/2018. Interventions: Staff to converse with (CR#2) while providing care, encourage family involvement, avoid scrubbing, pat dry skin, requires extensive to total assistance by staff with bathing/showering, requires extensive assistance by 1-2 staff to turn and reposition in bed. Record review of Medication Review Report for CR#2 dated 12/13/2018 revealed the following physician orders, which read in part: Carbohydrate Controlled Diet, Regular texture, regular consistency with an order date of 11/19/2018 Pressure relieving cushion every shift for prevention dated 11/19/2018 Pressure relieving mattress every shift dated 11/19/2018 Record review of CR #2's physician's orders [REDACTED]. Multiple Vitamin Tablet- 1 tablet by mouth in the morning for health supplement with a start date of 11/16/2018 Pressure relieving cushion every shift for prevention with an order date of 11/19/2018 Pressure relieving mattress every shift for prevention with an order date of 11/19/2018 Change stage 4 to left lateral ankle with normal saline, pat dry and apply skin prep. Calcium alginate (add collagen powder) and dry dressing until resolved. Every day shift for wound healing, with an order date of 10/18/2018. Cleanse stage 4 to right heel with normal saline, pat dry and apply calcium alginate (add collagen powder) with dry dressing daily until resolved, every day shift with an order date of 10/18/2018 and a discontinue date of 11/08/2018. Record review of CR #2's MAR and TAR dated (MONTH) (YEAR) revealed medications and treatments were administered as ordered. Record review of Skin-Head to Toe Skin Checks form for CR#2 dated 10/31/2018 revealed there was no documentation on form other than nails cleaned and trimmed. The rest of the form was left blank. There was no assessment of the wound on his left ankle. Record review of Nursing Admission Data Collection form for CR#2 dated 11/15/2018 indicated that CR#2 did not have any skin issues. Record review of Nutrition Status Review dated 11/19/2018 for CR#2 read in part: controlled carbohydrate diet, regular texture, regular consistency. Report further revealed CR#2 had a Stage IV pressure ulcer to right heel and a Stage IV pressure ulcer to left lateral ankle. Interview with Wound Care Nurse on 11/20/2018 at 3:08 PM, she said CR#2 had developed two pressure ulcers while at the facility and the one to the Right Heel had resolved on 11/20/2018 but the one to the left ankle was a stage IV and had not resolved. Interview with Wound Care Nurse on 12/10/2018 at 11:01AM, she said that CR#2 was recently discharged from the facility to another facility and was still being treated for [REDACTED]. Resident #4 Record review of face sheet for Resident #4 revealed a [AGE] year-old male with an admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of Care Plans for Resident #4 revealed the following which read in part . Activities of daily living self- care performance deficit related to Dementia, limited mobility with an initiated date of 11/10/2016 and a revision date of 07/09/2018. Interventions: assist with activities of daily living as needed, use standard wheelchair for mobility and require assistance being propelled through out the facility, and keep call light in reach. Potential for pressure ulcer development related to immobility, incontinence, and impaired cognition dated 11/10/2016 with a revision date of 07/09/2018. Interventions: Complete a full body check weekly and document, float heel at all times while in bed, follow facility policies for the prevention/tre

Based on observations, interviews and record review, the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 6 residents reviewed for quality of care. (CR #1 and CR #3) The facility failed to ensure CR #1 was not at risk for bleeding before or after debridement of the wound to her left buttock. CR #1, who was on an anticoagulant medication and at risk of bleeding, continued taking the medication before and after the procedure. The facility failed to timely identify and assess CR #1 when she had a change of condition following debridement of the wound to her left buttock. The wound bled for 3 days. CR #1 was admitted to the hospital with [REDACTED]. The facility failed to immediately consult CR #1's physician when she had a change a condition following debridement of the wound to her left buttock. The facility failed to intervene when CR #3 had a change of condition related to [MEDICAL CONDITION] on his leg. The facility failed to consult CR# 3's physician when he had a change of condition, which led to a delay in care that resulted [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on 12/11/2018. While the IJ was removed on 12/13/2018, the facility remained out of compliance at a severity level of Actual harm that is not immediate jeopardy and a scope of pattern due to requiring more time to train staff and monitor the Plan to Remove the Immediate Jeopardy for effectiveness. These failures affected two residents requiring hospitalization and placed them at risk of decline in health and decline in quality of life. Findings include: CR #1 Record review of CR#1's clinical face revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. CR #1 was discharged on [DATE]. Record review of CR #1's admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. MDS noted a [DIAGNOSES REDACTED]. MDS further revealed that CR #1 required extensive assistance with 2-person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. Resident was frequently incontinent of bladder and always incontinent of bowel. MDS did not reveal a [DIAGNOSES REDACTED]. She was at risk of developing pressure ulcers and recieved an anticoagulant 7 days in a week. Record review of Care Plans for CR #1 which read in part . Needs assistance with activities of everyday living because I have impaired mobility, muscle weakness and am morbidly obese dated 08/29/2018. Interventions: need assistance x 1-2 for toileting, need assistance for bed mobility, encourage active participation in tasks, provide cuing with tasks as needed, head to toe skin checks every week and as needed, observe for redness, open areas, scratches, cuts, bruises, and report changes to nurse . Impaired cognitive function/dementia or impaired thought process related to dementia dated 09/ 8 with a revision date of 09/14/2018. Interventions: administer medications as ordered, ask yes/no questions, use resident's preferred name, identify yourself at each interaction. Receives anticoagulant therapy related to [MEDICAL CONDITION] dated 08/17/2018. Interventions: administer anticoagulant medications as ordered by physician, Labs [MEDICATION NAME] time (PT) and International Nationalized Ratio (INR), report abnormal labs to physician, observe/document/report as needed adverse reactions of anticoagulant therapy; blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs . Unstageable wound to left buttock dated 10/26/2018. Interventions: Air mattress, have staff reposition routinely, have therapy team assist with repositioning of resident routinely, will receive treatment by wound care nurse as ordered by the wound care physician, will receive wound visits by the wound care physician weekly. Record review of Physician order [REDACTED].#1 dated 11/20/2018 revealed the following orders: -Give Vitamin K 5mg by mouth for critical lab INR 10.0 with an order date of 10/15/2018. -Observation: anticoagulant medication-observe for side effects: discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, nose bleeds with an order date of 08/10/2018. -[MEDICATION NAME] 3mg =give 3mg by mouth one time a day for blood clot prevention with an order date of 10/24/2018. - PT/INR Labs drawn every Monday. -Dakins Solution 0.25%- Apply to left buttock topically every day shift for stage 3 and then calcium alginate and dry dressing with an order date of 11/09/2018. Record review of Medication Administration Record [REDACTED] [MEDICATION NAME] tablet 3mg ([MEDICATION NAME] Sodium)- give 3mg by mouth one time a day for blood clot prevention with and order date of 10/24/2018. Further review revealed [MEDICATION NAME] tablet 3mg was given by mouth on the following days: 11/01/2018 11/02/2018 11/03/2018 11/04/2018 11/05/2018 11/06/2018 11/07/2018 11/08/2018 11/09/2018 Record review of Head to Toe Skin checks dated 10/31/2018 written by wound care nurse read in part . Existing Pressure Ulcer. Unstageable left buttock, left lateral ankle and right lateral ankle. Left lateral ankle, pressure. Length 2.0cm X 1 width X 0.0 depth, unstageable. Right lateral ankle, pressure. Length 3.0cm X 1.0cm width X 0.0cm depth, unstageable. Left buttock, 8 cm X 8cm X 0.0, unstageable. Record review of Wound Evaluation and Management Summary dated 11/07/2018 performed by Wound Care Physician for CR #1 which read in part . (CR#1) has multiple wounds. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. Stage 3 Pressure Wound of the Left Buttock. Wound size 8cm (length) X 8cm (Wide) X 5cm (deep). Duration of >7 days. Exudate, moderate serous. Thick adherent devitalized necrotic tissue 30%. Granulation tissue 70% .Surgical Excisional Debridement Procedure Note: the wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION NAME]. Then with clean surgical technique, 15 blade was used to surgically excise 19.2cm2 of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissue was observed. Hemostasis was achieved, and a clean dressing was applied .Dressing treatment plan: [REDACTED]. Dry protective dressing apply once daily for 23 days. Dakins solution apply once daily for 30 days. Wet to moist, apply once daily for 30 days. In an interview with Wound Care physician on 12/12/2018 at 12:00PM, he said he saw CR#1 and performed a debridement. He said he performed the debridement on the first day he saw her as the pressure ulcer was infected. Wound Care Physician said the wound was foul smelling and infected. He said it took 4 CNA's to help position her for debridement. Physician said that he packed the wound following the debridement and made sure there was hemostasis before leaving. Wound Care Physician said he did not receive any calls from the facility following the debridement to notify him of any bleeding. He said he believed some shearing occurred that made it start bleeding on Saturday. Wound Care Physician said he was aware that CR#1 was on [MEDICATION NAME] when he performed the debridement. In an interview with the Wound Care Nurse on 11/20/2018 at 4:25PM regarding CR#1, she said that CR #1 had deep tissue injuries to bilateral ankles and a pus pocket to the left buttock and it oozed out when the wound care physician saw her. Wound Care Nurse said the wound care physician saw her the Wednesday (11/07/2018) before she was discharged to the hospital on Saturday (11/10/2018). Wound care nurse said she did not notice any bleeding following wound care and nurses did not notify her of any bleeding. Record review of nursing notes for CR #1 written by Licensed Vocational Nurse (LVN) A read in part . 11/10/2018 at 9:29AM (CR #1's) physician notified of resident's wound care and bleeding from it. New orders received for STAT complete blood count (CBC) and [MEDICATION NAME] time (PT) and International Nationalized Ratio. Record review of nurse note on 11/10/2018 at 2:44PM written by RN B read in part, (CR#1) has had almost constant bleeding since Wednesday 11/08/2018. It has been controlled at times but due to her weight, the fact that she is on [MEDICATION NAME], I find it necessary to send her to the hospital FOR SAFETY. Nurse is in process of getting her sent to an emergency department for further treatment and stabilization. Record review of nurse note dated 11/10/2018 at 6:41PM written by LVN A for CR #1 read in part . Lab called and gave critical INR results 8.2. In an interview with RN B on 11/20/2018 at 5:00PM, he said the wound care physician came on Wednesday (11/07/2018) and I heard the nurses say she was bleeding after wound care. I put a dressing on her and that was on 11/07/2018 (Wednesday). He said on Saturday (11/10/2018), one of the nurses asked him to look at the wound because it was still bleeding, and CR #1 was on [MEDICATION NAME]. RN B said CR #1 had a bloody diaper and he (RN B) did not want to deal with it, so he called to have her transferred to the hospital. RN B said that he removed the packing from the wound that was wet/bloody and put a pressure dressing on it. RN B said the sacral pressure wound was not gushing but was more like a steady trickling. RN B said he could not confirm if the wound was bleeding on Thursday or Friday as he did not work on those days. RN B was asked about his nurse note that was written on 11/10/2018 and said CR#1 had constant bleeding since 11/07/2018. RN B said he was not sure why he wrote that, but he did not work on Thursday or Friday but maybe he heard nurses say that CR #1 had been bleeding for 3 days. In an interview with LVN A on 11/20/2018 at 5:47PM via telephone, she said that CR #1 was having bleeding to her sacral wound and she said it was continuous. LVN A said she was not sure how long it had been bleeding but it had been bleeding for a while. LVN A said she called CR #1's primary physician and received orders for Stat blood work which included Complete Blood Count (CBC), [MEDICATION NAME] Time (PT) and International Nationalized Ratio (INR). LVN A said orders were followed and she notified RN B of the continuous bleeding of the sacral wound. Record review of emergency room report dated 11/10/2018 at 3:49 PM for CR #1 read in part . [AGE] year-old female with history of dementia, diabetes mellitus, hypertension (HTN) and [MEDICAL CONDITION] presents to the emergency department from nursing facility in need of wound care. Per emergency medical services (EMS), CR #1 has wounds to her buttocks. They state 3 days ago the wound doctor was there and scraped the wound. EMS states the wound has been bleeding since. (CR#1) is a baseline per nursing home. Currently on [MEDICATION NAME]. She has several wounds on buttocks. One deep and packed soaked with blood. The blood is trickling from the wound. Feces was seen in fold of skin in flank and back. Wound cleaned with 100 cubic centimeters (cc) of normal saline and covered with pressure dressings with 4x4 and gauze. Primary impression: Supratherapeutic INR. Secondary Impression: Acute [MEDICAL CONDITION], urinary tract infection and wound infection. Record review of emergency room re-evaluation physician note dated 11/10/2018 at 7:00PM for CR#1 read in part . Telephone call to nursing home. They state they ordered STAT labs and got a call back saying the patient has an INR of 8.2. (normal parameters for INR is between 2.0 and 3.0 for individuals taking an anticoagulant medication.) Record review of emergency room re-evaluation physician note dated 11/10/2018 at 7:24PM for CR#1 read in part . Spoke with hospital personnel and information given. Personnel states will send to appropriate department since Adult Protective Services (APS) does not handle issues with nursing homes directly. Record review of hospital history and physical dated 11/10/2018 at 7:27PM for CR #1 which read in part . [AGE] year-old female presented from nursing facility with bleeding of sacral wound. Per Emergency Medical Services (EMS). Wound care at the facility tended to wound 3 days ago and it has been bleeding constantly since then. In the emergency room (ER), the wound was unpacked, and a large clot fell out. It was oozing per ER physician. It was repacked. Resident #1's INR was noted to be 8.6 and 5mg of vitamin K was given along with fresh frozen plasma. CR#1 was started on [MEDICATION NAME] and [MEDICATION NAME] and admitted to medicine with wound care consultation. General appearance was noted as agitated, altered mental status, chronically ill appearing, awake, no respiratory distress .Diagnoses, Assessment and Plan: [AGE] year-old woman with type II diabetes mellitus (DM), [MEDICAL CONDITION] and on [MEDICATION NAME], dementia with worsening sacral wound, supratherapeutic INR, acute kidney injury (AKI) and urinary tract infection [MEDICAL CONDITION]. Record review of hospital physician wound care note for CR#1 dated 11/12/2018 at 5:56PM read in part . Diagnoses, Assessment and Plan: Left buttock wound necrotic stage IV. No active bleeding. Lateral left ankle necrotic stage IV. Continue packing wound with Dakins moistened Kerlix. Record review of hospital physicians daily report for CR #1 dated 11/19/2018 at 2:16PM read in part . Diagnosis, assessment and Plan: 1. [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] from sacral wound ulcer, urine culture is positive for Extended Spectrum Beta-lactamase (ESBL), Escherichia Coli (E. Coli) and [DIAGNOSES REDACTED]. Changed to [MEDICATION NAME] and [MEDICATION NAME]. Diverting [MEDICAL CONDITION] done on 11/12/2018, sacral wound with continued drainage. 2. Acute [MEDICAL CONDITION] secondary to #1- resolved, at baseline. 3. Supratherapeutic INR (8.6)- resolved after vitamin k and fresh frozen plasma. INR dropped 1.5. Will continue to hold [MEDICATION NAME] given bleeding sacral wound. Monitor hemoglobin and hematocrit (H&H). 4. Acute kidney injury on admission- unclear etiology, baseline creatinine of 0.7 in (MONTH) at another hospital. 5. Urinary tract infection 6. [MEDICATION NAME]- likely in setting of poor nutrition. Nutrition consultation. 7. Non-insulin dependent diabetes mellitus (NIDDM) type 2 8. [MEDICAL CONDITION]- rate controlled with intravenous (IV) beta blocker. Holding anticoagulants as above. Observation and attempted interview with CR#1 at hospital on [DATE] at 2:30PM revealed she had her eyes closed, laying in bariatric bed with low air loss mattress. Intravenous fluids hanging. Resident was not responding to verbal stimuli. Interview with hospital nurse on 11/20/2018 at 2:35PM, she said that CR#1 was rarely alert and usually does not respond to verbal or tactile stimuli and had been that way since she was admitted to the unit. In an interview with CR#1's RP via telephone on 12/10/2018 at 11:30AM, she said that CR#1 was not doing well and was currently at a long-term acute care hospital. RP said CR#1 was no longer eating and the physician had recommended the insertion of a gastric tube for feedings because CR#1 had declined so much. RP said that the physician at the long-term care hospital also recommended that she (RP) considered putting CR#1 on hospice. RP said she was waiting for her other family member from out of town to come in so they could discuss hospice and the gastric tube. RP said that she would never had let her (family member) be admitted to the nursing home if she knew that CR#1 would not be cared for and that she would deteriorate in less than a few months. RP said that CR#1 was nonresponsive, not eating, had a pressure ulcer and now they had to consider hospice for CR#1 because of the lack of treatment at the nursing home. CR#3 Record review of clinical face sheet for CR#3 revealed a [AGE] year-old male with an admission date of [DATE]. [DIAGNOSES REDACTED]. CR #3 was discharged on [DATE]. Record review of significant change Minimum Data Set ((MDS) dated [DATE] for CR#3 revealed a Brief Interview of Mental Status (MDS) score of 15, which indicated no cognitive impairment. CR #3 required extensive assistance with one-person physical assist for bed mobility, dressing, toilet use, and personal hygiene. Record review of care plans for CR #3 revealed the following: -Activities of daily living self-care performance deficit related to motor vehicle accident and status [REDACTED]. Interventions: Limited assistance by 1 staff to turn and reposition in bed as necessary. Needs limited extensive assist by 1 staff with bathing, dressing and toileting. -Infection of wound dated 08/30/2018. Interventions: administer antibiotic as per physician orders, follow facility policy and procedures for line listing, summarizing and reporting infections. -Actual skin impairment to skin integrity of the hip and scrotum dated 06/29/2018. Interventions: Encourage good nutrition, use lotion, keep skin clean and dry. Record review of Medication Administration Record [REDACTED]. Record review of the American Academy of Dermatology website https://www.aad.org/public/diseases/rashes/[MEDICAL CONDITION] (undated) revealed [MEDICAL CONDITION] is a bacterial infection of the skin. The first signs of infection include red, swollen skin that is warm or tender. Without treatment, the infection can spread quickly. The bacteria may travel to lymph nodes and into the bloodstream. This can lead to a blood infection or permanently damage lymph vessels . Record review of nurse note dated 11/04/2018 at 9:15PM for CR#3 and written by LVN A read in part . Resident continues on Bactrim DS for [MEDICAL CONDITION] to leg. Complains of soreness to leg. No distress noted. Record review of nurse note dated 11/04/2018 at 11:59PM for CR#3 written by LVN C read in part . Received call from family members stated that they are worrying about their loved one's status. [MEDICAL CONDITION] is spreading all over his body, and they want to send resident to hospital immediately. Went into CR#3's room for assessment. Redness/rashes spread from left leg all the way to the neck and face. His left side of body is red and warm. CR#3 stated that he has to go to the hospital today and he is not feeling sick right now. Record review of CR #3's clinical record revealed no further assessment of his skin. Record review of nurse note for CR#3 written by LVN C dated 11/05/2018 at 12:10AM read in part . (Late Entry) Placed call to physician and spoke to on call physician. Received order to send resident to the hospital. Interview with Director of Nurses (DON) on 11/20/2018 at 5:30PM, she said that CR#3 was a very vocal resident and made his needs known. DON said that if staff were not doing what he needed that he would call her cell phone and let her know. DON said she knew that CR#3 did not have [MEDICAL CONDITION] on Friday (11/02/2018) when she was at the facility. DON said he could not have had it long because it happened on Saturday (11/03/2018). DON said she was not sure what happened between the 2 hours from when LVN A checked on him and LVN C checked on him. DON said she personally saw him on Friday and he did not complain of pain, no issues with [MEDICAL CONDITION] or rashes. Interview with LVN A on 11/20/2018 at 5:47PM via phone. She said that she went into CR#3's room around 9:00PM on 11/04/2018 and checked on CR#3 and he was fine and did not have any problems. Surveyor asked LVN A if she performed an assessment of CR#3 and she said No that she did not perform a complete head to toe assessment, but she looked at him when she talked to him and he looked fine. Attempted interviews with LVN C on 11/20/2018 at various times by phone throughout investigation. Message left. Call not returned. Record review of hospital emergency room physician assessment for CR#3 dated 11/05/2018 at 1:20AM read in part . [AGE] year-old male who presents to the emergency department from nursing home with [MEDICAL CONDITION] in left leg and [MEDICAL CONDITION] per emergency medical services (EMS). Per EMS, the [MEDICAL CONDITION] on the left leg was treated a month ago with antibiotics and never fully got better. CR#3 was placed on Bactrim on 11/02/2018. On arrival to the emergency department (ED), the patient complained of vomiting, chills, fever and intermittent shortness of breath that he associates with [MEDICAL CONDITION]. On the way to the ED, the patient states he had blurry and double vison . Clinical Impression: Primary Impression- septic Shock. Secondary Impressions- Acute [MEDICAL CONDITIONS] of leg, elevated troponin. Record review of hospital physician history and physical for CR#3 dated 11/05/2018 at 3:51AM read in part . [AGE] year-old male who presented from nursing home with complaint of general malaise, nausea and vomiting. In the past 4 days he had been feeling bad with fevers, chills, nausea, vomit and dizziness. He was talking to his family member who is a nurse out of state and she told him to have the facility staff send him to the emergency room for evaluation. In emergency room blood pressure 66/47 which did not adequately respond to 30cc/kilogram (kg) intravenous fluid resuscitation. A left intra jugular central line was placed and pressors were started. He was initiated on [MEDICATION NAME] and [MEDICATION NAME]. admitted to medicine for septic shock due to [MEDICAL CONDITION] . Diagnoses, Assessment & Plan: 1. Septic Shock, [MEDICAL CONDITION], present on admission. Pressor support to maintain blood pressure. Continue [MEDICATION NAME] and [MEDICATION NAME]. Follow up blood culture. Wound care consult for left lower extremity wound. 2. Acute [MEDICAL CONDITION] present on admission. Nephrology consulted. 3. [MEDICAL CONDITION] Fibrillation 4. Elevated troponin 5. Hypertension-avoid antihypertensives in shock state 6. Non-eschimic [DIAGNOSES REDACTED] Record review of hospital discharge assessment for CR#3's written by hospital physician on 11/12/2018 read in part . Discharge Diagnoses 1. [MEDICAL CONDITION] and septic shock secondary to [MEDICAL CONDITION] that was present on admission, weaned off pressors. 2. Left lower extremity [MEDICAL CONDITION], on antibiotics 3. Acute [MEDICAL CONDITION] that has resolved 4. History of chronic [MEDICAL CONDITION] 5. Troponin leak secondary to [MEDICAL CONDITION] and septic shock 6. Nonischemic [DIAGNOSES REDACTED] . The Administrator was notified on 12/11/2018 at 3:20PM of the IJ situation due to the above failures and a plan of removal (POR) was requested. The POR was received and after multiple revisions it was accepted on 12/13/2018 at 12:05PM. Plan of Removal On (MONTH) 12, (YEAR) (Staff Member), MSN, APRN, ANP-C, Nurse Practitioner educated the Director of Nursing, District Nurses, and Registered Nurses on the procedures regarding skin assessments, including proper staging, documentation, reporting to physician and proper documentation of wounds. A 100% head to toe Assessments for all residents will begin on (MONTH) 11, (YEAR) and will be completed by (MONTH) 12, (YEAR) by Registered Nurses. The Director of Nursing will notify the physician immediately regarding any changes with new skin conditions. The Registered Nurses will document the condition of skin on Weekly Skin Pressure Record. Nursing staff will be educated by (MONTH) 12, (YEAR) by the Director of Nurses, and District Clinical Director regarding the Policy and Procedure on the skin management system and general change of condition, to include the following areas listed below; 1. Change in Residents' condition related to wounds; or any general change of condition . 2. Notifying physician of any changes in condition including skin condition. 3. Reviewing head to toe skin assessments and weekly wound documentation; Providing proper and timely documentation of skin assessments, and wound care on the Head to Toe Record, SBAR, Weekly Skin Pressure Log, and the plan of care. The Resident Care Specialists will be educated by the Director of Nursing on reporting any change of condition including skin condition and document on the stop and watch form and notify the Licensed Nurse of the change. On (MONTH) 11, (YEAR) the District Clinical Director validated the skill and competencies of the treatment nurse(s) to include staging, change in residents' condition, skin assessment and documentation on Weekly Skin Pressure Record. 4. Residents at risk for pressure ulcers will be evaluated upon admission. The Charge Nurse will assure that the plan of care is updated to reflect that the interventions are implemented. The Director of Nursing will validate the Treatment Nurses performance on return demonstration monthly for the next 3 months; weekly for the 1st month, bi-weekly for the second month; and monthly for the third month. The District Clinical Director will educate the nursing staff by (MONTH) 12, (YEAR) on the policy pertaining to Anticoagulant Therapy. The Assistant Director of Nursing will perform a record review of residents receiving anticoagulants by (MONTH) 12, (YEAR) and document findings on anticoagulant therapy log. Any deviations will be reported to the physician immediately for follow-up and treatment. The Resident Care Specialists will be trained by (MONTH) 12, (YEAR) or before returning to work on the Policy and Procedure regarding repositioning, incontinent care and bathing every month for the next 3 months to validate understanding with these practices. The Director of Nursing or designee will monitor the change of condition /skin condition and residents on anti-coagulant therapy daily in the morning meeting. On (MONTH) 11, (YEAR) an AD Hoc Sub-Committee of the Quality Assurance and Performance Improvement Committee will meet to discuss, approve and implement the plan. The surveyor monitored the POR and included the following: Interview with different staff including nursing staff from multiple shifts on 12/13/2018 revealed they had been in-serviced on change of condition, notifying physician of change in condition, skin assessments and weekly reviews. Observations on 12/13/18 revealed nurses were observed performing complete skin assessments, appropriately on residents. Record review of in-services conducted included abuse/neglect policy, skin management, general change in condition, and documentation on weekly skin assessments. Record review of the attendance forms revealed that in-services were conducted on all three shifts with the nursing staff attending. As of 12/13/18 most of the staff had been in-serviced. During the monitoring phase, interviews were conducted by the surveyors on different shifts with the nursing staff, nurse management, and CNA's. All interviewed staff verbalized up to date knowledge on new laboratory procedures, abuse and neglect, and resident rights. Observations were conducted during the monitoring phase of the eight residents that were identified with concerns related to laboratory services and no concerns were noted. The Administrator was informed on 12/13/2018 at 3:05PM that the IJ was removed; however the facility remained out of compliance at a level of pattern and a severity of actual harm that was not immediate jeopardy due to the facility needing more time to train the staff and monitor plan for effectiveness.

Based on observation, interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for one (Resident #1) of six residents reviewed quality of care as evidence by: The facility failed to coordinate, schedule or transport Resident #1 to his orthopedic, trauma surgeon and cardiology follow-up appointments after discharge from hospital as indicated in discharge summary. The facility failed to assess and treat Resident #1's leg after being admitted with a leg brace. Resident #1 developed two new wounds at the facility on his leg, a Stage III and Stage IV wound. The facility failed to assess, treat and consult Resident #1's physician for four days after the wounds were discovered at an orthopedic physician appointment. These failures affected 1 resident and could place all 66 residents who are receiving preventive skin care causing additional wounds, harm, and injury. Findings Included: Intake# 6 Record review of Resident #1's face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Hospital Discharge Records dated 06/26/18 revealed, .Wound Care: keep splint/dressing, clean, dry, and intact until follow up appointment. Do not shower till follow up appointment. Please take medications as prescribed. Do not drive or operate heavy equipment while on narcotics .Follow Up Appointment: Dr. Orthopedics in 1 week, trauma surgery in 2 weeks, cardiology in 2 weeks, PCP in 1 week. Admission [DIAGNOSES REDACTED]. joint disruption, b. acetabular posterior column fracture with an associated [MEDICATION NAME] fracture component, c. a complex distal femur fracture (which I believe is open), d. an acute on chronic tibial plateau fx/injury, inability to coagulate, type I or II open fracture of distal end of left femur, unspecified fracture morphology, initial encounter . Record review of Resident #1's Progress Notes dated 06/29/18 revealed Addendum to admission note: resident had brace to left leg in which he said on admission was not to be removed. On visit today by treatment nurse to provide treatment to 51 staples to left hip, this nurse observed dressing sticking from under resident leg brace to left leg. Resident still said this brace can not be removed. This nurse informed him that she noticed a dressing and more staples under this brace and asked if it was okay just to open the brace. Resident agreed to allow this nurse to open the leg brace. Once opened, this nurse observed 56 staples to left leg and knee area. Staples were cleaned and xeroform and dry dress was applied. Will have md see resident in am. Brace remains to left leg and brace was closed back up by this nurse properly. Will continue to monitor . Record review of Resident #1's Progress Notes dated 06/29/18 revealed Skin/Wound Note: Staples cleaned with NS, pat dry and xeroform was applied at this time. Covered with dry dressing. No drainage or signs/symptoms of infection observed. Will continue every 2 days until order is changed. Wound MD will be in to see resident on wed. Resident will have visit by primary MD as well Record review of Resident #1's MDS dated [DATE] Resident #1 had a BIMS of 15, indicating no cognitive impairment. In an interview on 08/30/18 at 10:36 AM the Social Worker stated Resident #1 was going to be discharged by the facility on 07/17/18 but was not because the discharge would have been unsafe. She said she did not set up the appointments or transportation. She was not sure about Resident #1's cardiologist appointment. She said one of Resident #1's appointments was set up for the wrong physician so they had to reschedule. The appointment was sent for wound care physician instead of the surgeon. In an interview on 08/30/18 at 10:50 AM Restorative Aide stated the nurses set up the appointments and a form was sent to the corporate office. She said once the form was approved she scheduled transportation. In an interview on 08/30/18 at 11:25 AM the DON stated the facility had issues with getting Resident #1 to his ortho appointments because they could not get his appointment cleared through insurance. She said his appointments were in Galveston, and the facility could take a resident in the van if needed. She said Resident #1 could not go in the van because he was non-weight baring. She said insurance was not set up yet for transportation. She said the physician at the facility (PCP) and Wound Care Physician were in contact with his outside physician's to reschedule appointments. In an interview on 08/30/18 at 12:20 PM the DON stated Resident #1 had an ortho appointment set for 7/31/18 but was rescheduled due to being in Galveston and it would cost too much money. She said transportation had to be approved by the facility's corporate office. She said he went to his Ortho appointment on 08/07/18 and 08/13/18. Resident #1 was seen for wound consultation on 07/03/18 and his surgeon/ortho physician was consulted about progress over the phone. She said Resident #1 would not let anyone take off his brace and did not want to get out of bed. His staples were removed on 07/19/18 at the facility by his physician. Resident #1 was supposed to be discharged on [DATE] but did not occur because it would have been an unsafe discharge. Since that occurred his appointments were scheduled for a later time. In an interview on 08/30/18 at 2:53 PM the DON stated Resident #1's cardiologist appointment was on hold due to his insurance. She said he did not want to go to the cardiologist's offices they are trying to send him to. She said they were looking into 3 other places to send him. In an interview on 09/04/18 at 1:58 PM the DON stated Resident #1 was scheduled for 7/10/18 but he was non-weight baring and could not be placed in a wheel chair. He did not qualify for a stretcher so the appointment had to be reschedule. The staples he had were removed from the facility. Resident #1 was to be discharged on [DATE] but was not and his appointment was scheduled for 8/1/18. Record review of Resident #1's Physician order [REDACTED]. Record review of Resident #1's TAR dated 8/2018 revealed he was receiving wound care as ordered by the physician. Record review of Resident #1's Progress Notes dated 08/15/18 revealed Wound MD in to see resident today on 08-15-18 concerning post surgical wound of left leg that measures 5.5x1x0.2cm, granulation 50% and 50% skin. MD wants to continue with calcium alginate and dry dressing every 2 days. Wound MD also noted new stage 3 to left calf that measures 2x1x0.2 that occurred from medical device brace to left foot. Resident informed of new occurrence, no odor or signs and symptoms of infection noted. Area is red and shear in color with bleeding noted. Will continue to monitor and treat Record review of Resident #1's orthopedic physician appointment notes dated 08/23/18 revealed Additional Notes: I did not trial fit knee brace because the patient has a 2'' diameter ulcer over his fibular head area that smelt very bad and was red and discolored and hot to the touch. I will proceed with an authorization, however I did call him an ambulance to seek medical attention at a hospital ER . Record review of Resident #1's Hospital Discharge Records dated 08/23/18 revealed, [MEDICATION NAME]-clavulanate ([MEDICATION NAME]) 875-125 mg per tablet, take 1 tablet by mouth 2 times a daily for 10 days. Record review of Resident #1's Physician order [REDACTED]. Record review of Resident #1's MAR indicated [REDACTED]. Start date 08/24/18 and given thru 08/30/18. In an interview on 09/04/18 at 12:50 PM the ADON stated Resident #1 came back to the facility with the prescription for antibiotics. She was not aware of any wound cultures being completed due to this occurring at the hospital. In an interview on 09/04/18 at 2:08 PM MA D stated Resident #1 came back to the facility the night of 08/23/18 after his appointment. He was given his night medication and he went to bed. The nurse on duty ordered his medication for antibiotics. In an interview on 09/04/18 at 2:15 PM LVN C stated when Residents come back from the hospital staff complete a skin assessment, review paperwork from the hospital, call physician and follow orders. In an interview on 09/04/18 at 2:26 PM LVN E stated Resident #1 did not want to be touched so he did not complete an assessment after Resident #1 came back from the hospital. Resident #1 came back with a prescription and it was filled. He was not aware Resident #1 came back from his appointment on 08/23/18 with a new wound. He said Resident #1 did not say anything about the new wound. In an interview on 09/04/18 at 12:44 PM LVN C stated Resident #1 went out to an ortho appointment and came back with the antibiotics from the hospital. She said he came back to the facility on the 2-10 pm shift. Resident #1 had on a leg brace and staff were not taking it off for wound care. She said the facility was waiting for his follow up appointment. Resident had issues with transportation, and corporate wanted him to go to a physician closer to the facility. Record review of Resident #1's Care Plan dated 08/27/18 revealed Resident #1 had a new wound to left lateral leg near knee that measure 4x3cm. Staff are to report signs and symptoms of warmth, redness, drainage, odor and/or infection immediately to the nurse so physician can be notified, and treatment can begin. Record review of Resident #1's Care Plan dated 08/27/18 revealed Resident #1 had a stage 3 to the left calf from medical device. Staff are to report signs and symptoms of warmth, redness, drainage, odor and/or infection immediately to the nurse so physician can be notified, and treatment can began. Record review of Resident #1's Progress Notes dated 08/27/18 revealed: This nurse has been informed today by resident of a new wound located to his left leg, near his knee that measures 4x3cm, slough observed to center of wound with pink surrounding. Wound MD notified immediately and gave order for santyl and calcium alginate with dry dressing daily. Resident went out to an appointment on Thursday 08/23/18 to get measured for knee brace and it was then, per resident that he says the wound was observed, but wound nurse was just made aware of issue today 8/27/18. Wound MD was just in to see resident on 08/22/18 concerning post surgical wound of left leg that measures 4.5 x 4.5 x 0.2 cm, granulation 40% and 50% skin. MD wants to continue with calcium alginate and dry dressing every 2 days. Wound MD noted new stage 3 to left leg calf that measures 5x2x0.2cm that occurred from medical device brace to left foot on 08/15/18 and has since been treated, but no other new areas were noted from medical device since then or on 8-22-18. Resident aware of continued treatment. This nurse also noticed today that he has a new grey softer brace now, his previous brace was black. Will continue to treat and monitor Record review of Resident #1's Care Plan dated 08/30/18 revealed Resident #1 had an infection of wound. Staff are to observe/document/report to MD PRN for signs and symptoms of urinary tract infection. Observe/document/report to MD signs and symptoms of [MEDICAL CONDITION]. Record review of Resident #1's Progress Notes dated 08/30/18 at 11:01 AM revealed: Wound MD is to see resident today 08/29/18 concerning wound to left skin 5x1x0.2 (50% granulation and skin noted) moderate drainage, stage 3 to left interior calf wound 3x2x0.2cm (10% necrotic tissue and 90% granulation) moderate drainage noted, also to superior calf wound stage 4 3.5 cm x 3.5cm x 0.4cm which was cause by medical device . Wound MD will be by to visit again on Wednesday Record review of Resident #1's Physician order [REDACTED]. Observation on 08/30/18 at 9:15 AM revealed large amount of dry and wet blood on Resident #1's sheets and leg brace to left leg which was open. Bandage to left lateral leg and left calf. In an interview on 08/30/18 at 9:15 AM Resident #1 stated he had not been able to see the cardiologist since admitted to the facility. He said he did not go to his appointment to the orthopedic physician until 6 weeks after discharge from hospital. He said he was supposed to go within a week. He said the staff have not been coming into the room to reposition him so he had acquired two new wounds to his leg. He said his leg has been bleeding since yesterday. He said for a couple of weeks, the staff never looked under his brace which caused him to acquire 2 additional wounds. In an interview on 08/30/18 at 9:20 AM LVN A stated staff have not got a chance to change Resident #1's sheets because they were passing trays or they were waiting on the wound care nurse. The wound care physician was at the facility yesterday and treated his leg. She said the bleeding happened a lot after the wound care physician leaves. Record review of Resident #1's Progress Notes dated 08/30/18 at 10:02 AM revealed Summoned to residents room by nurse to perform treatment to residents wound to left knee, lateral leg and calf. Treatments are done every 2 days, however blood noted on brace and per residents request for treatments to be performed. Request honored. Calcium Alginate and dry dressing used, (foam dressing to calf). Brace removed and cleaned appropriately due to infection control. Skin asses in the process, no new skin issues noted. Resident denies pain. Brace will be replaced once it has properly air dried. Resident aware . In an interview on 08/30/18 at 10:10 AM the Wound Nurse stated she found out about the wound to Resident #1's left calf around 8/15/18 which was caused by his leg brace. Resident #1 would not take off his brace. Once the brace was taken off they saw the wound. Resident #1 was sent to an appointment on 8/23/18 to be fitted for a new brace. She said they found out about the wound to his left lateral leg on 08/27/18 when the resident told her about the new wound. She was not aware an additional wound was found on 08/23/18 when Resident #1 went to an appointment. Resident #1 had a black knee brace that was circular which was switched out with a foam brace. She said the wound care physician was at the facility yesterday and had been monitoring the wounds. She said she put a wedge under Resident #1's leg to try and relieve the pressure on his leg. In an interview on 09/04/18 at 12:25 PM the Wound Nurse stated the wound physician came on 8/15/18 and Resident #1 had blood on his sheets. Resident #1 had a new stage 3 wound to left leg. An assessment was completed and no additional wounds were found. She said nobody told her Resident#1 went to the hospital and was not aware that Resident #1 was taking antibiotics for wound infection. She found out when resident told her about the new wound. She said the wound physician was not aware he was taking medication for infection of wound. Based on CMS 672 dated 08/30/18 revealed the facility census was 100.

Based on observations, interviews and record reviews, the facility failed to investigate all incidents of injuries of unknown origin and were reported to the State Agency in accordance with State Law for 1 of 18 residents, (Resident #5) reviewed for abuse and neglect. The facility failed to investigate injuries for Resident #5 that resulted in fractures of the leg, wrist and elbow which caused pain. The facility failed to report that resident #5 sustained fractures of the right arm, left leg and right wrist. An Immediate Jeopardy (IJ) was identified on 10/12/17. While the IJ was lowered on 10/15/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed 102 additional residents who reside at the facility at risk of abuse, neglect, decrease in quality of life and injuries. Intake# 7 Findings included: Resident #5 Record review of face sheet for Resident #5 revealed a year [AGE] year old male admitted to the facility on [DATE] and a readmission date of [DATE]. Resident #5 had the following Diagnoses: [REDACTED]. Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 06, which indicated severe impairment. Resident #5 required extensive assistance with two person physical assistance for bed mobility and transfer. Resident #5 required extensive assistance with one person physical assist for dressing, toilet use and personal hygiene. MDS revealed Resident #5 was always incontinent of bowel and bladder. Record review of Care Plans for Resident #5 revealed the following: Dated 06/07/16 with a revision date of 10/02/17- Problem: Resident #5 had an Activities of daily living (ADL's) self-care performance deficit. He required the presence and assistance of two staff members for ADL's. Interventions included: Resident needed one staff member to provide bath/shower, required extensive assistance of two staff members to turn and reposition in bed and for dressing. Dated 06/07/16 with revision date of 02/22/17- Problem: Communication, Primary language was Spanish. Resident did speak some English. Interventions included: Anticipate and meet needs. Discuss with resident/family concerns or feelings regarding communication difficulty. Dated 09/09/16 with a revision date of 02/22/17. Problem: Incontinent of bowel and bladder. Interventions: Check and change frequently. Dated 09/26/17 with a revision date of 10/02/17. Problem: Potential/Actual Pain related to [DIAGNOSES REDACTED]. Interventions included- Observe for signs and symptoms of verbal and non-verbal indications of pain at each medication pass and periodically. Dated 09/29/17- Resident #5 complained of left knee pain. Interventions included: . Order received to send resident to hospital. Stat x-ray ordered for left knee which resulted in left tibia fracture and follow up with orthopedic physician. Dated 10/02/17- Problem: Left tibia (shin bone) fracture and right upper extremity fracture. Interventions include: Anticipate and meet needs. Two staff presence and assist with my adls. Follow physician's orders [REDACTED]. See physician's orders [REDACTED]. Dated 10/02/17- Problems: Osteopenia and a risk for fractures. Interventions included: Give Calcium per physician orders. Give [MEDICATION NAME] as needed for pain. Required two staff members for adls. Record review of nurse notes completed by LVN CC on 09/26/17 at 7:02 AM (late entry for 09/26/17 at 4:00 AM) read in part . Staff aid (CNA Q) went into Resident #5's room to provide care and to wrap up our second round for the shift. Staff aid tried to reposition patient in order to ascertain a comfortable position to change his diaper, as she rolled resident to his side Resident #5 began shouting am gonna fall and gonna fall while leaning next to his side rail. Staff aid rushed on other side of the bed, she held resident firmly while preventing him from falling out of bed. This writer overheard a loud voice coming from the room and quickly rushed to the room. Resident was held firmly while two person staff slowly repositioned resident to the center of the bed and to a comfortable position. Will continue to monitor. Further record review of LVN CC's nurse note dated 09/26/2017 at 7:02 AM revealed no head to toe assessment was completed following Resident #5's fall. Record review of Incident Investigation worksheet dated 09/29/17 revealed the following: On 09/26/17 at 4:00 AM Certified Nursing Assistant (CNA) Q was providing care and repositioning. Resident #5 assumed he was falling out of bed and began screaming. Charge Nurse CC came in and repositioned Resident #5. The resident did not fall. Resident did complain of pain. On 09/28/17 Resident #5 complained of pain to his leg and back. Charge Nurse CC ordered an x-ray and there was a fracture to the tibia. There was osteopenia noted on the x-ray. There were no witnesses to the incident. There was no alleged perpetrator. Record review of Provider Investigation Report dated 09/29/17 revealed the following: The incident occurred on 09/26/17 at 4:00 AM in Resident #5's room. Resident #5 was being repositioned per CNA Q at approximately 4:00 Am. Resident #5 made a quick motion as to get up and caused his near falling from the bed. X-ray conducted on 09/28/17 and received on 09/29/17, which revealed a [MEDICAL CONDITION] tibia. X-ray showed soft tissue swelling and angulation diffuse osteopenia. Resident #5 was transferred to the hospital on [DATE] and returned to facility (date not listed) with a soft cast to follow-up with the orthopedic specialist. CNA Q was provided a 1:1 in-service training (training not specified). Staff were in-serviced on Abuse and Neglect and lifting and transferring. Observation and interview on 10/10/17 at 2:15 PM with Resident #5 revealed his responsible party (RP) at bedside. Resident #5 had a bright green cast to his right arm from his wrist up to his mid-upper arm and a bright green cast on his left leg that covered his foot and went up to mid-thigh. Interview conducted in English (resident is bilingual) at same time with Resident #5, he said that about a week ago a CNA was cleaning him and turned him to the left quickly and he fell off the bed and landed on the floor. Interview with Resident #5's RP on 10/10/17 at 2:19 PM, he said that he noticed Resident #5's left leg was swollen on 09/28/17 and he notified staff. The RP said he was upset because Resident #5 had been complaining of pain to his left leg and staff did not assess his leg or they would have noticed the swelling. The RP said that Resident #5 said he fell from the bed when a CNA was changing him and they have both told management that he fell from the bed, but no one was listening. The RP said he was scared to complain too much as he does not want them to kick Resident #5 out of the facility as he could not care for him at home but wanted Resident #5 taken care of correctly. In an interview with Resident #5's roommate on 10/11/17 at 11:10 AM, he said that he was in bed when he heard a noise and heard Resident #5 crying. Resident #5's roommate said he got out of bed and put himself in his wheelchair and saw Resident #5 on the floor between the bed and the wall and a CNA was in the room with him. The Roommate said he went in the hall and told the black guy to come help. The black guy asked what happened and I told him Resident #5 fell on the floor. The roommate said the black guy put on gloves and closed the curtain around Resident #5. The roommate said he moved the curtain and watched the CNA and the black guy pick up Resident #5 and put him back in bed. Interview on 10/11/17 at 1:06PM with Licensed Vocational Nurse (LVN) C, Unit Coordinator, revealed she was in her office on 09/26/17 at about 7:30 AM and LVN MM came into her office and said that Resident #5 said he had a fall. LVN C said that she did not speak Spanish but that LVN MM speaks a little Spanish. LVN C said that Resident #5 said he fell out of the bed on the side near the wall. LVN C said she told Resident #5 and LVN MM that Resident #5 could not have fallen on that side as that was where his electric wheelchair was kept. LVN C said she asked the roommate what happened and the roommate said he went to go get help and kept changing his story about what happened. LVN C said that she (LVN C) and LVN MM asked CNA ZZ to translate for them. LVN C said that CNA ZZ translated for Resident #5 and that CNA ZZ said that Resident #5 said he did not fall but was going to roll out of bed but CNA Q yelled for help and CNA Q and LVN CC were able to reposition Resident #5 in bed. In a telephone interview with CNA Q on 10/11/17 at 2:00 PM CNA Q said she was in Resident #5's room, changing his sheets. CNA Q said she had a feeling he might fall and as soon as she thought that he turned and started to fall but she was able to catch him. CNA Q said Resident #5 had one leg dangling off the edge of the bed. CNA Q said she was stalky and ws 6' 2.5 tall and held on to him for dear life until LVN CC came in and assisted her in repositioning him back in bed. CNA Q said that the incident occurred on Tuesday (09/26/17). CNA Q said she did not drop Resident #5 and that Tuesday (09/26/17) was the first time she had ever worked with a little person. CNA Q said that Resident #5 speaks English. CNA Q said that LVN CC checked him out. CNA Q said that Resident #5 kept saying that he fell earlier during the previous shift at 8:00 PM but he did not fall on her shift. CNA Q said she was not suspended pending investigation. In a telephone interview on 10/11/17 at 2:38 PM with LVN MM, she said that she worked the day shift following the incident earlier in the morning. LVN MM said that she was told by Resident #5 a black lady was changing him and dropped him on the floor and a male nurse came to help him. LVN MM said Resident #5 was complaining of pain to his legs during her (LVN MM) shift. LVN MM said she told staff to do an incident report and she ordered x-rays of Resident #5's hips and they were negative. LVN MM said that LVN C said she spoke to the nurse and CNA involved and the CNA said Resident #5 slid off the bed but she caught him and he did not hit the floor. LVN MM said she is not currently working at the facility as she could not deal with the facility at this time. LVN MM did not elaborate on why she could not deal with the facility and needed a break at this time. LVN MM said that she kept telling staff that the incident needed to be investigated and reported. In an interview via telephone on 10/11/17 at 2:46 PM with LVN CC, he said that roughly at 4:00 AM, CNA Q was cleaning up Resident #5 and Resident #5's roommate called him (LVN CC) to come into the room. LVN CC said when he entered the room that Resident #5 was hanging off the bed and CNA Q was holding his upper body on the bed. LVN CC said the CNA Q and he (LVN CC) grabbed him and repositioned him on the bed. LVN CC said Resident #5 did not complain of pain but he was holding his arm on the right side and he was frightened. When asked if an assessment was completed, LVN CC said he completed an assessment in the nurse notes. LVN CC said the physician was not called as Resident #5 did not fall. In an interview on 10/11/17 at 3:00 PM with CNA ZZ, he said that Resident #5 told him that a CNA was changing him and she rolled him over and he fell out of the bed and hit the floor. CNA ZZ said that he told LVN MM exactly what Resident #5 told him and she told the office staff. CNA ZZ said he was not sure what the outcome was but said that the office staff called and spoke to the staff involved. CNA ZZ said he also interviewed Resident #5's roommate and his roommate said that a CNA was changing resident and turned him and he fell out of the bed and landed on the floor. In an interview with the Director of Nurses (DON) on 10/11/17 at 5:00 PM, she said that she was notified of the x-ray with the tiabial fracture on 09/29/17. The DON said she was not aware of the situation involving Resident #5 until 09/29/17. The DON said she was out of the facility for training with the Administrator. The DON said as soon as she became aware of the situation and the x-ray on 09/29/17, she notified the Administrator. The DON said that it was her understanding that the 10 PM- 6 AM shift on 09/26/17 was performing a bed linen change and Resident #5 yelled he was falling and CNA Q called for help. Charge Nurse CC came into the room to assist and they put him in bed. The DON said CNA Q and Charge Nurse CC said Resident #5 did not fall. The DON said that an in-service for positioning and proper techniques had been performed for all staff. When asked if CNA Q was suspended pending investigation the DON said no one was suspended as she didn't think she needed to take CNA Q off the schedule pending investigation. The DON was asked how often were head to toe assessments completed and the DON said weekly. When DON was asked if someone should have noticed the swelling to Resident #5's leg, she said it should have been noticed by somebody during changing. The DON said Resident #5 was a 2 person assist with all care. In an interview with Resident #5's Nurse Practitioner (NP) on 10/12/17 at 9:50 AM, she said that Resident #5 and his roommate said he had a fall but staff at the facility said he did not have a fall. The NP said that Resident #5's RP complained of knee swelling to the resident's left knee. The NP said that Resident #5 had decreased range of motion to his left knee and was crying in pain. The NP said that Resident #5 had a trace amount of swelling to the left knee. The NP said she ordered a STAT x-ray on 09/28/17 and was notified of the results on 09/29/17. The NP said she was not sure why the staff did not notify her of the x-ray result confirming a [MEDICAL CONDITION] until 09/29/17. The NP said that Resident #5 would not be able to injure himself and would not receive those types of injuries with resident care. In an interview with the facility Administrator on 10/12/17 at 10:20 AM, she said that she was not in the building when the incident occurred with Resident #5. The Administrator said she was at a seminar with the DON. The Administrator said she received a text from LVN C that Resident #5 almost fell out of the bed but didn't fall. The Administrator said that the DON received the x-ray report on 09/29/17 that confirmed a [MEDICAL CONDITION] and informed her (Administrator) of the x-ray report. The Administrator said she interviewed LVN CC and CNA Q about the incident and started the investigation. CNA Q said Resident #5 made a motion like he was going to fall off the bed and CNA Q ran to catch him. The Administrator said that LVN CC said that Resident #5 was not on the floor when he entered the room but that his legs were dangling off the bed and CNA Q was at the bedside holding Resident #5. The Administrator said that Resident #5 was Spanish speaking only and that there was staff that spoke Spanish. The Administrator was asked if the facility used a language line for residents who did not speak English and she said that the facility did not. Administrator was asked if the fracture to Resident #5's radial neck (right elbow) and the possible hairline fracture at the right wrist had been investigated and the Administrator said she had just started working on the investigation as Resident #5 was recently seen by the orthopedic specialist on 10/05/17. In an interview with the DON on 10/12/17 at 10:45 AM, she said that it was the charge nurses responsibility to follow up on all STAT orders and if results were not received in 6 hours, the charge nurse should call for results. Observation and interview with Resident #5 on 10/12/17 at 11:00 AM revealed Resident #5 sitting in his electric wheelchair in dining area. Interview at same time with Resident #5, he said that when he fell from the bed to the floor he experienced pain to his right arm, left leg, and back. Resident #5 said he tried to tell the nurse, the black guy that helped the CNA put him back in bed, but the nurse wouldn't speak to him or ask him about his pain. Resident #5 said he was crying when he landed on the floor because he was scared and he was experiencing pain. Resident #5 said that he continues to experience pain to his arm, leg and back since the fall. Record review of Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet Dispersable 50 MG- give 2 tablets by mouth every 8 hours as needed for chronic pain. Further review of MAR for 09/01/2017-09/30/2017 revealed Resident #5 was not medicated for pain on the following days: 09/26/2017 09/27/2017 Record review of MAR for 10/01/2017-10/31/2017 revealed the following orders: [MEDICATION NAME] HCI tablet 50 mg-Give 50 MG by mouth every 6 hours as needed for upset stomach related to chronic pain. [MEDICATION NAME] HCI Tablet Dispersable (dose not legible)-Give 2 tablets by mouth every 8 hours as needed for pain related to chronic pain. Further review of MAR for 10/01/2017-10/31/2017 revealed Resident #5 was not medicated for pain on the following days: 10/07/2017 10/08/2017 In an interview on 10/12/17 at 3:40 PM via phone with facility Medical Director who was also Resident #5's physician, he said that he had been Resident #5's physician for a long time. The Medical Director said he did not receive a call on 09/26/2017 about a fall but did receive a call about Resident #5's hip pain and an x-ray of the hips was ordered. The Medical Director said that Resident #5 had [DIAGNOSES REDACTED] and brittle bones but for those type of injuries to occur he would have had to have fallen or received rigorous care. The Medical Director confirmed that Resident #5 had minimal movement and could not have self-inflicted injuries. The Medical Director also confirmed that Resident #5 did speak English. Record review of nurse notes completed by LVN C (Unit Coordinator) dated 09/26/17 at 10:17 AM read in part . 'I was called into Resident #5's room because he was saying that he was turned too rapid and fell out of the bed. His nurse and myself went in to assess him. He was complaining of pain and said that he had fallen. After talking with him for 10 minutes his story kept changing. He couldn't tell us what side of the bed he fell out of and one story the CNA dropped him then the next no one was there, then it was a woman and then it was a man. We had another Hispanic staff to come and translate for us and he said he fell and a black man came to help put him back in bed. Even when interviewing the roommate the stories changed. I called the only male staff who worked last night which was the nurse and he said the CNA was turning Resident #5 and he started to fall but she held on to him and did not let him fall and called for help and he went in to help her. Resident #5 did not ever hit the floor.' Record review of nurse notes written by LVN MM on 09/26/17 at 2:43 PM read in part . Resident #5 complained of pain to bilateral hips. X-ray of bilateral hips done, awaiting orders. Per resident during incontinent care, rolled out of bed on to floor then resident changed story to- I don't know what happened, didn't remember, then stated the male nurse assisted him to bed unable to remember what side of bed he rolled out of and if he hit anything, medicated with PRN for pain, will continue to monitor. Record review of LVN G's nurse note dated 09/28/17 at 2:26 PM read in part . Resident #5 reports pain to left lower leg per RP, RP at bedside, Nurse Practitioner in facility, assessed resident, [MEDICAL CONDITION] noted from knee to ankle, Nurse Practitioner ordered STAT x-ray to left knee along with STAT labs, call placed for STAT x-ray and call placed to lab for STAT labs, RP aware of orders, will continue to monitor. Record review of Progress Note completed by Nurse Practitioner for Resident #5 dated 09/28/17 read in part . History of Present Illness: Patient is awake, alert appears to have chronic cognitive deficits. Patient's RP reported patient had a fall about 2 days ago. Unclear about nursing documentation, patient's bilateral and hip x-ray done, no fracture or acute distress. Today patient's brother presented at bedside reporting left knee pain, patient cannot move left leg. Upon exam, decreased range of motion, crying in pain. He denies any shortness of breath or chest pain. Patient does not appear in any distress. Vital signs were stable. Record review of Nurse Practitioner's orders dated 09/28/17 revealed orders for the following: CBC, CMP STAT, Pain left knee, left knee x-ray STAT, swelling and pain. Tylenol 325 mg (2 tablets) twice daily scheduled for 3 days. Record review of STAT x-ray of left knee dated 09/28/17 at 3:18 PM read: Findings- There is a [MEDICAL CONDITION] tibia. There is soft tissue swelling and angulation diffuse osteopenia is noted. Conclusion- [MEDICAL CONDITION] tibia. There is a notation on the right lower corner of report that reveals the facility staff notified the physician of the fracture on 09/29/17 at 11:00 AM. Record review of physician order [REDACTED]. Record review of nurse note dated 09/29/17 at 2:40 PM read: Resident was medicated for pain with Tylenol by mouth, will continue to monitor. Record review of x-ray reports from hospital dated 09/29/17 revealed the following: X-ray tibia/fibula. Impression: Limited. Likely mildly displaced, medial plateau fracture extending into the tiabial metaphysis. X-ray Forearm. Impression: Negative examination of the right forearm. X-ray right elbow. Impression: Limited. Contour abnormality of the radial head, which could represent fracture. Record review of nurse note dated 09/29/17 at 9:55 PM read: Resident #5 admitted from Hospital under the service of the Medical Director. Resident accompanied with RP and two ambulance attendants. Admission diagnoses; fractured extremity lower and fractured extremity upper, skin- no new skin condition noted. Complain about pain at this time. Tylenol 650 mg given. Continue to monitor. Record review of LVN C's written statement dated 09/28/17 read in part . Nurse called me into Resident #5's room and said Resident #5 said he had a fall. He first said he fell to the left side of the bed and I said he couldn't have fallen there because he has a large motorized wheelchair there. Resident #5 then said he fell on the other side but Resident #5 and roommate kept changing the details and then he said he didn't fall. That is when we got another staff who spoke fluent Spanish and he said he didn't fall and a black man came to help him. Record review of CNA Q's written statement dated 09/29/17 read in part . Making my rounds on Sept. 26, 17 with Resident #5. I looked at his sheets which appeared to need changing. So I attempted to change his sheet, turn him a little on the side. Next thing I know he put his leg across as to get up. I ran to hold him to prevent his falling. I then told his roommate to please go get the nurse. The nurse came to assist me. We both repositioned him in the center of the bed. Resident did not complain of anything at this time. On last round, Approximately 5:15 AM, I changed resident and resident did not complain of anything at this time. Record review of LVN CC's written statement dated 09/29/17 read in part . The incident occurred Tuesday morning at 4:00 AM. I heard staff calling for help. Upon arrival to the room staff was firmly holding resident on right side of the bed and trying to prevent him from falling off the bed. Resident's leg was sort of dangling. This writer immediately rushed in the room and assisted staff and repositioned resident to the center of the bed and to a more comfortable position. Resident denied pain on assessment, no injury was noted. Record review of report from Orthopedic Specialist for Resident #5 dated 10/05/17 read in part . Presents today in a motorized wheelchair with traumatic right wrist and left leg pain for 2 weeks. The patient resides at facility and states he fell out of his bed. Patient was seen at the hospital where x-rays were taken (not available) of the leg and right wrist. His left leg and right wrist was placed in a temporary splint but he removed his wrist splint last night. Patient complains of no pain at the wrist but has throbbing pain at the elbow. Patient has increased pain at the medial aspect of the elbow with extending it. Patient was right hand dominant. He additionally has left leg pain following his fall. His pain was felt throughout the lower leg. He has increased pain with cold air and reports paresthesia on his left toes. No previous surgeries on the left leg or right wrist. He has been taking [MEDICATION NAME] daily. X-ray results performed at Orthopedics office dated 10/05/17 revealed the following findings: 2 radiologic views of the left tib/fib (lower leg bones), taken in the office today demonstrate a non-displaced tibia fracture at the junction of the metaphysis and diaphysis proximally. 2 radiologic views of the right elbow, taken in the office today demonstrate a radial neck fracture. 3 radiologic views of the right wrist, taken in the office today demonstrate a possible hairline fracture at the level of the wrist. Record review of Abuse and Neglect Prohibition dated January 17 provided by facility read in part . Each resident has the right to be free from mistreatment, neglect, abuse, exploitation, involuntary seclusion, corporal punishment, physical or chemical restraint not required to treat the resident's medical symptoms, injuries of unknown origin, and misappropriation of resident property. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident. Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Injuries of an unknown origin may occur as a result of neglect. Prevention: 1. The facility will address all concerns in accordance with Truly Listening to Our Customers policy. Residents, families, and staff will be able to report incidents and concerns without fear of retribution. The Administrator was notified on 10/12/17 at 12:20pm of the IJ due to the above failures and a Plan of Removal (PoR) was requested. A PoR was received and after several revision, a PoR was accepted on 10/15/17 at 11:45am. The PoR included in part: All licensed nursing staff (RN/LVN), including the DON was re-educated on Incident Assessment and Physician Notification by the District Nurses. The training included: assessing the resident for injury to include skin check, to check the resident's limbs for strength, range of motion, swelling and obvious deformity, notifying the physician and responsible party. If a STAT x-ray/lab is ordered results should be obtained within 4-6 hours and if it is not then the nurse manager is to call the lab directly for results. The physician should be notified for any changes from the patient's baseline. A pain assessment should be conducted and pain medication given as ordered. The patient should be monitored for 72 hours or longer if needed, after an incident/accident. This training started on 10/12/17 at 4:00pm and was completed by 10/13/17 at 2:00pm. Any staff failing to attend the scheduled training will not be able to work until their training was complete. The DON/designee will monitor the completion of incident assessment and physician notification by reviewing documentation in the medical record system. A review will occur during the morning clinical meeting. On October 12, 2017 Ad Hoc subcommittee of the Quality Assurance & Performance Improvement Committee met to discuss, approve and implement the removal plan. Beginning 4:30 p.m., October 13, 2017 facility management will be re-educated on Abuse/Neglect including investigation and reporting. Education will be provided by District Nurses and VP of Clinical Services. The education to include the following: Abuse & Neglect Prohibition to include investigating and reporting. Facility management, after receiving training, will in turn train all facility staff. Training will be conducted and lead by the Administrator. All staff in-service will be conducted Saturday, October 14, 2017 at 2:00 p.m. and concluded at 3:00 p.m. Staff failing to attend the scheduled educations will not be able to work until education is completed. The Plan of Removal was monitored until the IJ was lowered: Record review of the in-service training provided to staff revealed that all staff were trained or retrained in the following: -All CNAs were trained in abuse and neglect. The training was completed 10/14/17. CNAs from different shifts were interviewed and able to explain the training they received. They were aware of the types of abuse and what neglect was, who to report abuse/neglect to and when to report it. -All licensed nursing staff (RN/LVN), including the DON was re-educated on Incident Assessment and Physician Notification. Random interviews were conducted during the monitoring. Staff indicated that they attended these training sessions. They were able to describe the training they received and that training reflected correct techniques. Observations were conducted during the monitoring. No additional concerns were identified between the acceptance of the PoR and the lowering of the IJ. The Administrator was informed on 10/16/17 at 11:45am that the IJ was lowered; however the facility remained out of compliance at a level of pattern and a severity actual harm that is not immediate jeopardy due to the facility needing more time to ensure that the plan of removal was effective. The facility 672, dated 10/10/2017 listed a census of 103.

Based on observation, interview and record review, the facility failed to ensure 1 of 18 residents (Resident #5) reviewed for abuse and neglect was free from abuse and neglect. -The facility failed to ensure Resident #5 was assessed and received medical treatment following a fall that resulted in fractures to resident's right arm and left leg. -The facility failed to ensure Resident # 5 received adequate pain assessment and pain control following a fall and fractured right arm and left leg. -The facility failed to notify Resident #5's physician after resident #5 had a fall with injuries. -The facility failed to notify Resident #5's physician of STAT x-ray results. An Immediate Jeopardy (IJ) was identified on 10/12/17. While the IJ was lowered on 10/15/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed 102 additional residents who reside at the facility at risk of abuse, neglect, decrease in quality of life and injuries. Intake# 7 Findings included: Resident #5 Record review of face sheet for Resident #5 revealed a year [AGE] year old male admitted to the facility on [DATE] and a readmission date of [DATE]. Resident #5 had the following Diagnoses: [REDACTED]. Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 06, which indicated severe impairment. Resident #5 required extensive assistance with two person physical assistance for bed mobility and transfer. Resident #5 required extensive assistance with one person physical assist for dressing, toilet use and personal hygiene. MDS revealed Resident #5 was always incontinent of bowel and bladder. Record review of Care Plans for Resident #5 revealed the following: Dated 06/07/16 with a revision date of 10/02/17- Problem: Resident #5 had an Activities of daily living (ADL's) self-care performance deficit. He required the presence and assistance of two staff members for ADL's. Interventions included: Resident needed one staff member to provide bath/shower, required extensive assistance of two staff members to turn and reposition in bed and for dressing. Dated 06/07/16 with revision date of 02/22/17- Problem: Communication, Primary language was Spanish. Resident did speak some English. Interventions included: Anticipate and meet needs. Discuss with resident/family concerns or feelings regarding communication difficulty. Dated 09/09/16 with a revision date of 02/22/17. Problem: Incontinent of bowel and bladder. Interventions: Check and change frequently. Dated 09/26/17 with a revision date of 10/02/17. Problem: Potential/Actual Pain related to [DIAGNOSES REDACTED]. Interventions included- Observe for signs and symptoms of verbal and non-verbal indications of pain at each medication pass and periodically. Dated 09/29/17- Resident #5 complained of left knee pain. Interventions included: . Order received to send resident to hospital. Stat x-ray ordered for left knee which resulted in left tibia fracture and follow up with orthopedic physician. Dated 10/02/17- Problem: Left tibia (shin bone) fracture and right upper extremity fracture. Interventions include: Anticipate and meet needs. Two staff presence and assist with my adls. Follow physician's orders [REDACTED]. See physician's orders [REDACTED]. Dated 10/02/17- Problems: Osteopenia and a risk for fractures. Interventions included: Give Calcium per physician orders. Give [MEDICATION NAME] as needed for pain. Required two staff members for adls. Record review of nurse notes completed by LVN CC on 09/26/17 at 7:02 AM (late entry for 09/26/17 at 4:00 AM) read in part . Staff aid (CNA Q) went into Resident #5's room to provide care and to wrap up our second round for the shift. Staff aid tried to reposition patient in order to ascertain a comfortable position to change his diaper, as she rolled resident to his side Resident #5 began shouting am gonna fall and gonna fall while leaning next to his side rail. Staff aid rushed on other side of the bed, she held resident firmly while preventing him from falling out of bed. This writer overheard a loud voice coming from the room and quickly rushed to the room. Resident was held firmly while two person staff slowly repositioned resident to the center of the bed and to a comfortable position. Will continue to monitor. Further record review of LVN CC's nurse note dated 09/26/2017 at 7:02 AM (late entry for 09/26/2017 at 4:00 AM) did not reveal an assessment for Resident #5 following the fall. Record review of Incident Investigation worksheet dated 09/29/17 revealed the following: On 09/26/17 at 4:00 AM Certified Nursing Assistant (CNA) Q was providing care and repositioning. Resident #5 assumed he was falling out of bed and began screaming. LVN CC came in and repositioned Resident #5. The resident did not fall. Resident did complain of pain. On 09/28/17 Resident #5 complained of pain to his leg and back. LVN CC ordered an x-ray and there was a fracture to the tibia. There was osteopenia noted on the x-ray. There were no witnesses to the incident. There was no alleged perpetrator. Record review of Provider Investigation Report dated 09/29/17 revealed the following: The incident occurred on 09/26/17 at 4:00 AM in Resident #5's room. Resident #5 was being repositioned per CNA Q at approximately 4:00 Am. Resident #5 made a quick motion as to get up and caused his near falling from the bed. X-ray conducted on 09/28/17 and received on 09/29/17, which revealed a [MEDICAL CONDITION] tibia. X-ray showed soft tissue swelling and angulation diffuse osteopenia. Resident #5 was transferred to the hospital on [DATE] and returned to facility (date not listed) with a soft cast to follow-up with the orthopedic specialist. CNA Q was provided a 1:1 in-service training (training not specified). Staff were in-serviced on Abuse and Neglect and lifting and transferring. Observation and interview on 10/10/17 at 2:15 PM with Resident #5 revealed his responsible party (RP) at bedside. Resident #5 had a bright green cast to his right arm from his wrist up to his mid-upper arm and a bright green cast on his left leg that covered his foot and went up to mid-thigh. Interview conducted in English (resident is bilingual) at same time with Resident #5, he said that about a week ago a CNA was cleaning him and turned him to the left quickly and he fell off the bed and landed on the floor. Interview with Resident #5's RP on 10/10/17 at 2:19 PM, he said that he noticed Resident #5's left leg was swollen on 09/28/17 and he notified staff. The RP said he was upset because Resident #5 had been complaining of pain to his left leg and staff did not assess his leg or they would have noticed the swelling. The RP said that Resident #5 said he fell from the bed when a CNA was changing him and they have both told management that he fell from the bed, but no one was listening. The RP said he was scared to complain too much as he does not want them to kick Resident #5 out of the facility as he could not care for him at home but wanted Resident #5 taken care of correctly. In an interview with Resident #5's roommate on 10/11/17 at 11:10 AM, he said that he was in bed when he heard a noise and heard Resident #5 crying. Resident #5's roommate said he got out of bed and put himself in his wheelchair and saw Resident #5 on the floor between the bed and the wall and a CNA was in the room with him. The Roommate said he went in the hall and told the black guy to come help. The black guy asked what happened and I told him Resident #5 fell on the floor. The roommate said the black guy put on gloves and closed the curtain around Resident #5. The roommate said he moved the curtain and watched the CNA and the black guy pick up Resident #5 and put him back in bed. Interview on 10/11/17 at 1:06PM with Licensed Vocational Nurse (LVN) C, Unit Coordinator, revealed she was in her office on 09/26/17 at about 7:30 AM and LVN MM came into her office and said that Resident #5 said he had a fall. LVN C said that she did not speak Spanish but that LVN MM speaks a little Spanish. LVN C said that Resident #5 said he fell out of the bed on the side near the wall. LVN C said she told Resident #5 and LVN MM that Resident #5 could not have fallen on that side as that was where his electric wheelchair was kept. LVN C said she asked the roommate what happened and the roommate said he went to go get help and kept changing his story about what happened. LVN C said that she (LVN C) and LVN MM asked CNA ZZ to translate for them. LVN C said that CNA ZZ translated for Resident #5 and that CNA ZZ said that Resident #5 said he did not fall but was going to roll out of bed but CNA Q yelled for help and CNA Q and LVN CC were able to reposition Resident #5 in bed. In a telephone interview with CNA Q on 10/11/17 at 2:00 PM CNA Q said she was in Resident #5's room, changing his sheets. CNA Q said she had a feeling he might fall and as soon as she thought that he turned and started to fall but she was able to catch him. CNA Q said Resident #5 had one leg dangling off the edge of the bed. CNA Q said she is stalky and is 6' 2.5 tall and held on to him for dear life until LVN CC came in and assisted her in repositioning him back in bed. CNA Q said that the incident occurred on Tuesday (09/26/17). CNA Q said she did not drop Resident #5 and that Tuesday (09/26/17) was the first time she had ever worked with a little person. CNA Q said that Resident #5 speaks English. CNA Q said that LVN CC checked him out. CNA Q said that Resident #5 kept saying that he fell earlier during the previous shift at 8:00 PM but he did not fall on her shift. CNA Q said she was not suspended pending investigation. In a telephone interview on 10/11/17 at 2:38 PM with LVN MM, she said that she worked the day shift following the incident earlier in the morning. LVN MM said that she was told by Resident #5 a black lady was changing him and dropped him on the floor and a male nurse came to help him. LVN MM said Resident #5 was complaining of pain to his legs during her (LVN MM) shift. LVN MM said she told staff to do an incident report and she ordered x-rays of Resident #5's hips and they were negative. LVN MM said that LVN C said she spoke to the nurse and CNA involved and the CNA said Resident #5 slid off the bed but she caught him and he did not hit the floor. LVN MM said she is not currently working at the facility as she could not deal with the facility at this time. LVN MM did not elaborate on why she could not deal with the facility and needed a break at this time. LVN MM said that she kept telling staff that the incident needed to be investigated and reported. In an interview via telephone on 10/11/17 at 2:46 PM with LVN CC, he said that roughly at 4:00 AM, CNA Q was cleaning up Resident #5 and Resident #5's roommate called him (LVN CC) to come into the room. LVN CC said when he entered the room that Resident #5 was hanging off the bed and CNA Q was holding his upper body on the bed. LVN CC said the CNA Q and he (LVN CC) grabbed him and repositioned him on the bed. LVN CC said Resident #5 did not complain of pain but he was holding his arm on the right side and he was frightened. When asked if an assessment was completed, LVN CC said he completed an assessment in the nurse notes. LVN CC said the physician was not called as Resident #5 did not fall. In an interview on 10/11/17 at 3:00 PM with CNA ZZ, he said that Resident #5 told him that a CNA was changing him and she rolled him over and he fell out of the bed and hit the floor. CNA ZZ said that he told LVN MM exactly what Resident #5 told him and she told the office staff. CNA ZZ said he was not sure what the outcome was but said that the office staff called and spoke to the staff involved. CNA ZZ said he also interviewed Resident #5's roommate and his roommate said that a CNA was changing resident and turned him and he fell out of the bed and landed on the floor. In an interview with the Director of Nurses (DON) on 10/11/17 at 5:00 PM, she said that she was notified of the x-ray with the tiabial fracture on 09/29/17. The DON said she was not aware of the situation involving Resident #5 until 09/29/17. The DON said she was out of the facility for training with the Administrator. The DON said as soon as she became aware of the situation and the x-ray on 09/29/17, she notified the Administrator. The DON said that it was her understanding that the 10 PM- 6 AM shift on 09/26/17 was performing a bed linen change and Resident #5 yelled he was falling and CNA Q called for help. LVN CC came into the room to assist and they put him in bed. The DON said CNA Q and LVN CC said Resident #5 did not fall. The DON said that an in-service for positioning and proper techniques had been performed for all staff. When asked if CNA Q was suspended pending investigation the DON said no one was suspended as she didn't think she needed to take CNA Q off the schedule pending investigation. The DON was asked how often were head to toe assessments completed and the DON said weekly. When DON was asked if someone should have noticed the swelling to Resident #5's leg, she said it should have been noticed by somebody during changing. The DON said Resident #5 was a 2 person assist with all care. In an interview with Resident #5's Nurse Practitioner (NP) on 10/12/17 at 9:50 AM, she said that Resident #5 and his roommate said he had a fall but staff at the facility said he did not have a fall. The NP said that Resident #5's RP complained of knee swelling to the resident's left knee. The NP said that Resident #5 had decreased range of motion to his left knee and was crying in pain. The NP said that Resident #5 had a trace amount of swelling to the left knee. The NP said she ordered a STAT x-ray on 09/28/17 and was notified of the results on 09/29/17. The NP said she was not sure why the staff did not notify her of the x-ray result confirming a [MEDICAL CONDITION] until 09/29/17. The NP said that Resident #5 would not be able to injure himself and would not receive those types of injuries with resident care. In an interview with the facility Administrator on 10/12/17 at 10:20 AM, she said that she was not in the building when the incident occurred with Resident #5. The Administrator said she was at a seminar with the DON. The Administrator said she received a text from LVN C that Resident #5 almost fell out of the bed but didn't fall. The Administrator said that the DON received the x-ray report on 09/29/17 that confirmed a [MEDICAL CONDITION] and informed her (Administrator) of the x-ray report. The Administrator said she interviewed LVN CC and CNA Q about the incident and started the investigation. CNA Q said Resident #5 made a motion like he was going to fall off the bed and CNA Q ran to catch him. The Administrator said that LVN CC said that Resident #5 was not on the floor when he entered the room but that his legs were dangling off the bed and CNA Q was at the bedside holding Resident #5. The Administrator said that Resident #5 was Spanish speaking only and that there was staff that spoke Spanish. The Administrator was asked if the facility used a language line for residents who did not speak English and she said that the facility did not. Administrator was asked if the fracture to Resident #5's radial neck (right elbow) and the possible hairline fracture at the right wrist had been investigated and the Administrator said she had just started working on the investigation as Resident #5 was recently seen by the orthopedic specialist on 10/05/17. In an interview with the DON on 10/12/17 at 10:45 AM, she said that it was the charge nurses responsibility to follow up on all STAT orders and if results were not received in 6 hours, the charge nurse should call for results. Observation and interview with Resident #5 on 10/12/17 at 11:00 AM revealed Resident #5 sitting in his electric wheelchair in dining area. Resident #5, said that when he fell from the bed to the floor he experienced pain to his right arm, left leg, and back. Resident #5 said he tried to tell the nurse, the black guy that helped the CNA put him back in bed, but the nurse wouldn't speak to him or ask him about his pain. Resident #5 said he was crying when he landed on the floor because he was scared and he was experiencing pain. Resident #5 said he continued to have pain to his arm, back, and leg following the fall. Record review of Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet Dispersable 50 MG- give 2 tablets by mouth every 8 hours as needed for chronic pain. Further review of MAR for 09/01/2017-09/30/2017 revealed Resident #5 was not medicated for pain on the following days: 09/26/2017 09/27/2017 Record review of MAR for 10/01/2017-10/31/2017 revealed the following orders: [MEDICATION NAME] HCI tablet 50 mg-Give 50 MG by mouth every 6 hours as needed for upset stomach related to chronic pain. [MEDICATION NAME] HCI Tablet Dispersable (dose not legible)-Give 2 tablets by mouth every 8 hours as needed for pain related to chronic pain. Further review of MAR for 10/01/2017-10/31/2017 revealed Resident #5 was not medicated for pain on the following days: 10/07/2017 10/08/2017 In an interview on 10/12/17 at 3:40 PM via phone with facility Medical Director who was also Resident #5's physician, he said that he had been Resident #5's physician for a long time. The Medical Director said he did not receive a call about a fall on 09/26/2017 but did receive a call about Resident #5's hip pain and an x-ray of the hips was ordered. The Medical Director said that Resident #5 had [DIAGNOSES REDACTED] and brittle bones but for those type of injuries to occur he would have had to have fallen or received rigorous care. The Medical Director confirmed that Resident #5 had minimal movement and could not have self-inflicted injuries. The Medical Director also confirmed that Resident #5 did speak English. Record review of nurse notes completed by LVN C (Unit Coordinator) dated 09/26/17 at 10:17 AM read in part . 'I was called into Resident #5's room because he was saying that he was turned too rapid and fell out of the bed. His nurse and myself went in to assess him. He was complaining of pain and said that he had fallen. After talking with him for 10 minutes his story kept changing. He couldn't tell us what side of the bed he fell out of and one story the CNA dropped him then the next no one was there, then it was a woman and then it was a man. We had another Hispanic staff (CNA ZZ) to come and translate for us and he said he fell and a black man came to help put him back in bed. Even when interviewing the roommate the stories changed. I called the only male staff who worked last night which was the nurse and he said the CNA was turning Resident #5 and he started to fall but she held on to him and did not let him fall and called for help and he went in to help her. Resident #5 did not ever hit the floor.' Record review of nurse notes written by LVN MM on 09/26/17 at 2:43 PM read in part . Resident #5 complained of pain to bilateral hips. X-ray of bilateral hips done, awaiting orders. Per resident during incontinent care, rolled out of bed on to floor then resident changed story to- I don't know what happened, didn't remember, then stated the male nurse assisted him to bed unable to remember what side of bed he rolled out of and if he hit anything, medicated with PRN for pain, will continue to monitor. Record review of LVN G nurse's note dated 09/28/17 at 2:26 PM read in part . Resident #5 reports pain to left lower leg per RP, RP at bedside, Nurse Practitioner in facility, assessed resident, [MEDICAL CONDITION] noted from knee to ankle, Nurse Practitioner ordered STAT x-ray to left knee along with STAT labs, call placed for STAT x-ray and call placed to lab for STAT labs, RP aware of orders, will continue to monitor. Record review of Progress Note completed by Nurse Practitioner for Resident #5 dated 09/28/17 read in part . History of Present Illness: Patient is awake, alert appears to have chronic cognitive deficits. Patient's RP reported patient had a fall about 2 days ago. Unclear about nursing documentation, patient's bilateral and hip x-ray done, no fracture or acute distress. Today patient's brother presented at bedside reporting left knee pain, patient cannot move left leg. Upon exam, decreased range of motion, crying in pain. He denies any shortness of breath or chest pain. Patient does not appear in any distress. Vital signs were stable. Record review of Nurse Practitioner's orders dated 09/28/17 revealed orders for the following: CBC, CMP STAT, Pain left knee, left knee x-ray STAT, swelling and pain. Tylenol 325 mg (2 tablets) twice daily scheduled for 3 days. Record review of STAT x-ray of left knee dated 09/28/17 at 3:18 PM read: Findings- There is a [MEDICAL CONDITION] tibia. There is soft tissue swelling and angulation diffuse osteopenia is noted. Conclusion- [MEDICAL CONDITION] tibia. There is a notation on the right lower corner of report that reveals the facility staff notified the physician of the fracture on 09/29/17 at 11:00 AM. Record review of physician order [REDACTED]. Record review of nurse note dated 09/29/17 at 2:40 PM read: Resident was medicated for pain with Tylenol by mouth, will continue to monitor. Record review of x-ray reports from hospital dated 09/29/17 revealed the following: X-ray tibia/fibula. Impression: Limited. Likely mildly displaced, medial plateau fracture extending into the tiabial metaphysis. X-ray Forearm. Impression: Negative examination of the right forearm. X-ray right elbow. Impression: Limited. Contour abnormality of the radial head, which could represent fracture. Record review of nurse note dated 09/29/17 at 9:55 PM read: Resident #5 admitted from Hospital under the service of the Medical Director. Resident accompanied with RP and two ambulance attendants. Admission diagnoses; fractured extremity lower and fractured extremity upper, skin- no new skin condition noted. Complain about pain at this time. Tylenol 650 mg given. Continue to monitor. Record review of LVN C's written statement dated 09/28/17 read in part . Nurse called me into Resident #5's room and said Resident #5 said he had a fall. He first said he fell to the left side of the bed and I said he couldn't have fallen there because he has a large motorized wheelchair there. Resident #5 then said he fell on the other side but Resident #5 and roommate kept changing the details and then he said he didn't fall. That is when we got another staff who spoke fluent Spanish and he said he didn't fall and a black man came to help him. Record review of CNA Q's written statement dated 09/29/17 read in part . Making my rounds on Sept. 26, 17 with Resident #5. I looked at his sheets which appeared to need changing. So I attempted to change his sheet, turn him a little on the side. Next thing I know he put his leg across as to get up. I ran to hold him to prevent his falling. I then told his roommate to please go get the nurse. The nurse came to assist me. We both repositioned him in the center of the bed. Resident did not complain of anything at this time. On last round, Approximately 5:15 AM, I changed resident and resident did not complain of anything at this time. Record review of LVN CC's written statement dated 09/29/17 read in part . The incident occurred Tuesday morning at 4:00 AM. I heard staff calling for help. Upon arrival to the room staff was firmly holding resident on right side of the bed and trying to prevent him from falling off the bed. Resident's leg was sort of dangling. This writer immediately rushed in the room and assisted staff and repositioned resident to the center of the bed and to a more comfortable position. Resident denied pain on assessment, no injury was noted. Record review of report from Orthopedic Specialist for Resident #5 dated 10/05/17 read in part . Presents today in a motorized wheelchair with traumatic right wrist and left leg pain for 2 weeks. The patient resides at facility and states he fell out of his bed. Patient was seen at the hospital where x-rays were taken (not available) of the leg and right wrist. His left leg and right wrist was placed in a temporary splint but he removed his wrist splint last night. Patient complains of no pain at the wrist but has throbbing pain at the elbow. Patient has increased pain at the medial aspect of the elbow with extending it. Patient was right hand dominant. He additionally has left leg pain following his fall. His pain was felt throughout the lower leg. He has increased pain with cold air and reports paresthesia on his left toes. No previous surgeries on the left leg or right wrist. He has been taking [MEDICATION NAME] daily. X-ray results performed at Orthopedics office dated 10/05/17 revealed the following findings: 2 radiologic views of the left tib/fib (lower leg bones), taken in the office today demonstrate a non-displaced tibia fracture at the junction of the metaphysis and diaphysis proximally. 2 radiologic views of the right elbow, taken in the office today demonstrate a radial neck fracture. 3 radiologic views of the right wrist, taken in the office today demonstrate a possible hairline fracture at the level of the wrist. Record review of Abuse and Neglect Prohibition dated January 2017 provided by facility read in part . Each resident has the right to be free from mistreatment, neglect, abuse, exploitation, involuntary seclusion, corporal punishment, physical or chemical restraint not required to treat the resident's medical symptoms, injuries of unknown origin, and misappropriation of resident property. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident. Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Injuries of an unknown origin may occur as a result of neglect. Prevention: 1. The facility will address all concerns in accordance with Truly Listening to Our Customers policy. Residents, families, and staff will be able to report incidents and concerns without fear of retribution. The Administrator was notified on 10/12/17 at 12:20pm of the IJ due to the above failures and a Plan of Removal (PoR) was requested. A PoR was received and after several revision, a PoR was accepted on 10/15/17 at 11:45am. The PoR included in part: All licensed nursing staff (RN/LVN), including the DON was re-educated on Incident Assessment and Physician Notification by the District Nurses. The training included: assessing the resident for injury to include skin check, to check the resident's limbs for strength, range of motion, swelling and obvious deformity, notifying the physician and responsible party. If a STAT x-ray/lab is ordered results should be obtained within 4-6 hours and if it is not then the nurse manager is to call the lab directly for results. The physician should be notified for any changes from the patient's baseline. A pain assessment should be conducted and pain medication given as ordered. The patient should be monitored for 72 hours or longer if needed, after an incident/accident. This training started on 10/12/17 at 4:00pm and was completed by 10/13/17 at 2:00pm. Any staff failing to attend the scheduled training will not be able to work until their training was complete. The DON/designee will monitor the completion of incident assessment and physician notification by reviewing documentation in the medical record system. A review will occur during the morning clinical meeting. On October 12, 2017 Ad Hoc subcommittee of the Quality Assurance & Performance Improvement Committee met to discuss, approve and implement the removal plan. Beginning 4:30 p.m., October 13, 2017 facility management will be re-educated on Abuse/Neglect including investigation and reporting. Education will be provided by District Nurses and VP of Clinical Services. The education to include the following: Abuse & Neglect Prohibition to include investigating and reporting. Facility management, after receiving training, will in turn train all facility staff. Training will be conducted and lead by the Administrator. All staff in-service will be conducted Saturday, October 14, 2017 at 2:00 p.m. and concluded at 3:00 p.m. Staff failing to attend the scheduled educations will not be able to work until education is completed. The Plan of Removal was monitored until the IJ was lowered: Record review of the in-service training provided to staff revealed that all staff were trained or retrained in the following: -All CNAs were trained in abuse and neglect. The training was completed 10/14/17. CNAs from different shifts were interviewed and able to explain the training they received. They were aware of the types of abuse and what neglect was, who to report abuse/neglect to and when to report it. -All licensed nursing staff (RN/LVN), including the DON was re-educated on Incident Assessment and Physician Notification. Random interviews were conducted during the monitoring. Staff indicated that they attended these training sessions. They were able to describe the training they received and that training reflected correct techniques. Observations were conducted during the monitoring. No additional concerns were identified between the acceptance of the PoR and the lowering of the IJ. The Administrator was informed on 10/15/17 at 11:45am that the IJ was lowered; however the facility remained out of compliance at a level of pattern and a severity actual harm that is not immediate jeopardy due to the facility needing more time to ensure that the plan of removal was effective. The facility 672, dated 10/10/2017 listed a census of 103.

Based on observation, interview, and record review, the facility failed to consult with the resident physician immediately when the resident experienced a significant change in condition for one of 10 residents (Resident #5) reviewed for notification of changes. -The facility failed to immediately consult with Resident #5's Physician when resident had a fall on 09/26/2017. Resident #5 fell from his bed onto the floor during care. Two days later the facility consulted with the Resident's physician who ordered a STAT x-ray. Twenty-four hours after the x-ray was taken the facility notified the physician of the results. Resident #5 was sent to the hospital for evaluation for a fractured left leg. Resident #5 also had a fractured right arm at the wrist and the elbow. An Immediate Jeopardy (IJ) was identified on 10/12/17. While the IJ was lowered on 10/15/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed 102 additional residents who reside at the facility at risk of their physician not being consulted/notified of changes. Intake# 7 Findings included: Resident #5 Record review of face sheet for Resident #5 revealed a year [AGE] year old male admitted to the facility on [DATE] and a readmission date of [DATE]. Resident #5 had the following Diagnoses: [REDACTED]. Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 06, which indicated severe impairment. Resident #5 required extensive assistance with two person physical assistance for bed mobility and transfer. Resident #5 required extensive assistance with one person physical assist for dressing, toilet use and personal hygiene. MDS revealed Resident #5 was always incontinent of bowel and bladder. Record review of Care Plans for Resident #5 revealed the following: Dated 06/07/16 with a revision date of 10/02/17- Problem: Resident #5 had an Activities of daily living (ADL's) self-care performance deficit. He required the presence and assistance of two staff members for ADL's. Interventions included: Resident needed one staff member to provide bath/shower, required extensive assistance of two staff members to turn and reposition in bed and for dressing. Dated 06/07/16 with revision date of 02/22/17- Problem: Communication, Primary language was Spanish. Resident did speak some English. Interventions included: Anticipate and meet needs. Discuss with resident/family concerns or feelings regarding communication difficulty. Dated 09/09/16 with a revision date of 02/22/17. Problem: Incontinent of bowel and bladder. Interventions: Check and change frequently. Dated 09/26/17 with a revision date of 10/02/17. Problem: Potential/Actual Pain related to [DIAGNOSES REDACTED]. Interventions included- Observe for signs and symptoms of verbal and non-verbal indications of pain at each medication pass and periodically. Dated 09/29/17- Resident #5 complained of left knee pain. Interventions included: . Order received to send resident to hospital. Stat x-ray ordered for left knee which resulted in left tibia fracture and follow up with orthopedic physician. Dated 10/02/17- Problem: Left tibia (shin bone) fracture and right upper extremity fracture. Interventions include: Anticipate and meet needs. Two staff presence and assist with my adls. Follow physician's orders [REDACTED]. See physician's orders [REDACTED]. Dated 10/02/17- Problems: Osteopenia and a risk for fractures. Interventions included: Give Calcium per physician orders. Give [MEDICATION NAME] as needed for pain. Required two staff members for adls. Record review of nurse notes completed by LVN CC on 09/26/17 at 7:02 AM (late entry for 09/26/17 at 4:00 AM) read in part . Staff aid (CNA Q) went into Resident #5's room to provide care and to wrap up our second round for the shift. Staff aid tried to reposition patient in order to ascertain a comfortable position to change his diaper, as she rolled resident to his side Resident #5 began shouting am gonna fall and gonna fall while leaning next to his side rail. Staff aid rushed on other side of the bed, she held resident firmly while preventing him from falling out of bed. This writer overheard a loud voice coming from the room and quickly rushed to the room. Resident was held firmly while two person staff slowly repositioned resident to the center of the bed and to a comfortable position. Will continue to monitor. Record review of Incident Investigation worksheet dated 09/29/17 revealed the following: On 09/26/17 at 4:00 AM Certified Nursing Assistant (CNA) Q was providing care and repositioning. Resident #5 assumed he was falling out of bed and began screaming. LVN CC came in and repositioned Resident #5. The resident did not fall. Resident did complain of pain. On 09/28/17 Resident #5 complained of pain to his leg and back. LVN CC ordered an x-ray and there was a fracture to the tibia. There was osteopenia noted on the x-ray. There were no witnesses to the incident. There was no alleged perpetrator. Record review of Provider Investigation Report dated 09/29/17 revealed the following: The incident occurred on 09/26/17 at 4:00 AM in Resident #5's room. Resident #5 was being repositioned per CNA Q at approximately 4:00 Am. Resident #5 made a quick motion as to get up and caused his near falling from the bed. X-ray conducted on 09/28/17 and received on 09/29/17, which revealed a [MEDICAL CONDITION] tibia. X-ray showed soft tissue swelling and angulation diffuse osteopenia. Resident #5 was transferred to the hospital on [DATE] and returned to facility (date not listed) with a soft cast to follow-up with the orthopedic specialist. CNA Q was provided a 1:1 in-service training (training not specified). Staff were in-serviced on Abuse and Neglect and lifting and transferring. Observation and interview on 10/10/17 at 2:15 PM with Resident #5 revealed his responsible party (RP) at bedside. Resident #5 had a bright green cast to his right arm from his wrist up to his mid-upper arm and a bright green cast on his left leg that covered his foot and went up to mid-thigh. Interview conducted in English (resident is bilingual) with Resident #5, he said that about a week ago a CNA was cleaning him and turned him to the left quickly and he fell off the bed and landed on the floor. Interview with Resident #5's RP on 10/10/17 at 2:19 PM, he said that he noticed Resident #5's left leg was swollen on 09/28/17 and he notified staff. The RP said he was upset because Resident #5 had been complaining of pain to his left leg and staff did not assess his leg or they would have noticed the swelling. The RP said that Resident #5 said he fell from the bed when a CNA was changing him and they have both told management that he fell from the bed, but no one was listening. The RP said he was scared to complain too much as he does not want them to kick Resident #5 out of the facility as he could not care for him at home but wanted Resident #5 taken care of correctly. In an interview with Resident #5's roommate on 10/11/17 at 11:10 AM, he said that he was in bed when he heard a noise and heard Resident #5 crying. Resident #5's roommate said he got out of bed and put himself in his wheelchair and saw Resident #5 on the floor between the bed and the wall and a CNA was in the room with him. The Roommate said he went in the hall and told the black guy to come help. The black guy asked what happened and I told him Resident #5 fell on the floor. The roommate said the black guy put on gloves and closed the curtain around Resident #5. The roommate said he moved the curtain and watched the CNA and the black guy pick up Resident #5 and put him back in bed. Interview on 10/11/17 at 1:06PM with Licensed Vocational Nurse (LVN) C, Unit Coordinator, revealed she was in her office on 09/26/17 at about 7:30 AM and LVN MM came into her office and said that Resident #5 said he had a fall. LVN C said that she did not speak Spanish but that LVN MM speaks a little Spanish. LVN C said that Resident #5 said he fell out of the bed on the side near the wall. LVN C said she told Resident #5 and LVN MM that Resident #5 could not have fallen on that side as that was where his electric wheelchair was kept. LVN C said she asked the roommate what happened and the roommate said he went to go get help and kept changing his story about what happened. LVN C said that she (LVN C) and LVN MM asked CNA ZZ to translate for them. LVN C said that CNA ZZ translated for Resident #5 and that CNA ZZ said that Resident #5 said he did not fall but was going to roll out of bed but CNA Q yelled for help and CNA Q and LVN CC were able to reposition Resident #5 in bed. In a telephone interview with CNA Q on 10/11/17 at 2:00 PM CNA Q said she was in Resident #5's room, changing his sheets. CNA Q said she had a feeling he might fall and as soon as she thought that he turned and started to fall but she was able to catch him. CNA Q said Resident #5 had one leg dangling off the edge of the bed. CNA Q said she is stalky and is 6' 2.5 tall and held on to him for dear life until LVN CC came in and assisted her in repositioning him back in bed. CNA Q said that the incident occurred on Tuesday (09/26/17). CNA Q said she did not drop Resident #5 and that Tuesday (09/26/17) was the first time she had ever worked with a little person. CNA Q said that Resident #5 speaks English. CNA Q said that LVN CC checked him out. CNA Q said that Resident #5 kept saying that he fell earlier during the previous shift at 8:00 PM but he did not fall on her shift. CNA Q said she was not suspended pending investigation. In a telephone interview on 10/11/17 at 2:38 PM with LVN MM, she said that she worked the day shift following the incident earlier in the morning. LVN MM said that she was told by Resident #5 a black lady was changing him and dropped him on the floor and a male nurse came to help him. LVN MM said Resident #5 was complaining of pain to his legs during her (LVN MM) shift. LVN MM said she told staff to do an incident report and she ordered x-rays of Resident #5's hips and they were negative. LVN MM said that LVN C said she spoke to the nurse and CNA involved and the CNA said Resident #5 slid off the bed but she caught him and he did not hit the floor. LVN MM said she is not currently working at the facility as she could not deal with the facility at this time. LVN MM did not elaborate on why she could not deal with the facility and needed a break at this time. LVN MM said that she kept telling staff that the incident needed to be investigated and reported. In an interview via telephone on 10/11/17 at 2:46 PM with LVN CC, he said that roughly at 4:00 AM, CNA Q was cleaning up Resident #5 and Resident #5's roommate called him (LVN CC) to come into the room. LVN CC said when he entered the room that Resident #5 was hanging off the bed and CNA Q was holding his upper body on the bed. LVN CC said the CNA Q and he (LVN CC) grabbed him and repositioned him on the bed. LVN CC said Resident #5 did not complain of pain but he was holding his arm on the right side and he was frightened. When asked if an assessment was completed, LVN CC said he completed an assessment in the nurse notes. LVN CC said the physician was not called as Resident #5 did not fall. In an interview on 10/11/17 at 3:00 PM with CNA ZZ, he said that Resident #5 told him that a CNA was changing him and she rolled him over and he fell out of the bed and hit the floor. CNA ZZ said that he told LVN MM exactly what Resident #5 told him and she told the office staff. CNA ZZ said he was not sure what the outcome was but said that the office staff called and spoke to the staff involved. CNA ZZ said he also interviewed Resident #5's roommate and his roommate said that a CNA was changing resident and turned him and he fell out of the bed and landed on the floor. In an interview with the Director of Nurses (DON) on 10/11/17 at 5:00 PM, she said that she was notified of the x-ray with the tiabial fracture on 09/29/17. The DON said she was not aware of the situation involving Resident #5 until 09/29/17. The DON said she was out of the facility for training with the Administrator. The DON said as soon as she became aware of the situation and the x-ray on 09/29/17, she notified the Administrator. The DON said that it was her understanding that the 10 PM- 6 AM shift on 09/26/17 was performing a bed linen change and Resident #5 yelled he was falling and CNA Q called for help. LVN CC came into the room to assist and they put him in bed. The DON said CNA Q and LVN CC said Resident #5 did not fall. The DON said that an in-service for positioning and proper techniques had been performed for all staff. When asked if CNA Q was suspended pending investigation the DON said no one was suspended as she didn't think she needed to take CNA Q off the schedule pending investigation. The DON was asked how often were head to toe assessments completed and the DON said weekly. When DON was asked if someone should have noticed the swelling to Resident #5's leg, she said it should have been noticed by somebody during changing. The DON said Resident #5 was a 2 person assist with all care. In an interview with Resident #5's Nurse Practitioner (NP) on 10/12/17 at 9:50 AM, she said that Resident #5 and his roommate said he had a fall but staff at the facility said he did not have a fall. The NP said that Resident #5's RP complained of knee swelling to the resident's left knee. The NP said that Resident #5 had decreased range of motion to his left knee and was crying in pain. The NP said that Resident #5 had a trace amount of swelling to the left knee. The NP said she ordered a STAT x-ray on 09/28/17 and was notified of the results on 09/29/17. The NP said she was not sure why the staff did not notify her of the x-ray result confirming a [MEDICAL CONDITION] until 09/29/17. The NP said that Resident #5 would not be able to injure himself and would not receive those types of injuries with resident care. In an interview with the facility Administrator on 10/12/17 at 10:20 AM, she said that she was not in the building when the incident occurred with Resident #5. The Administrator said she was at a seminar with the DON. The Administrator said she received a text from LVN C that Resident #5 almost fell out of the bed but didn't fall. The Administrator said that the DON received the x-ray report on 09/29/17 that confirmed a [MEDICAL CONDITION] and informed her (Administrator) of the x-ray report. The Administrator said she interviewed LVN CC and CNA Q about the incident and started the investigation. CNA Q said Resident #5 made a motion like he was going to fall off the bed and CNA Q ran to catch him. The Administrator said that LVN CC said that Resident #5 was not on the floor when he entered the room but that his legs were dangling off the bed and CNA Q was at the bedside holding Resident #5. The Administrator said that Resident #5 was Spanish speaking only and that there was staff that spoke Spanish. The Administrator was asked if the facility used a language line for residents who did not speak English and she said that the facility did not. Administrator was asked if the fracture to Resident #5's radial neck (right elbow) and the possible hairline fracture at the right wrist had been investigated and the Administrator said she had just started working on the investigation as Resident #5 was recently seen by the orthopedic specialist on 10/05/17. In an interview with the DON on 10/12/17 at 10:45 AM, she said that it was the charge nurses responsibility to follow up on all STAT orders and if results were not received in 6 hours, the charge nurse should call for results. Observation and interview with Resident #5 on 10/12/17 at 11:00 AM revealed Resident #5 sitting in his electric wheelchair in dining area. Interview at same time with Resident #5, he said that when he fell from the bed to the floor he experienced pain to his right arm, left leg, and back. Resident #5 said he tried to tell the nurse, the black guy that helped the CNA put him back in bed, but the nurse wouldn't speak to him or ask him about his pain. Resident #5 said he was crying when he landed on the floor because he was scared and he was experiencing pain. In an interview on 10/12/17 at 3:40 PM via phone with facility Medical Director who was also Resident #5's physician, he said that he had been Resident #5's physician for a long time. The Medical Director said he did not receive a call about a fall but did receive a call about Resident #5's hip pain and an x-ray of the hips was ordered. The Medical Director said that Resident #5 had [DIAGNOSES REDACTED] and brittle bones but for those type of injuries to occur he would have had to have fallen or received rigorous care. The Medical Director confirmed that Resident #5 had minimal movement and could not have self-inflicted injuries. The Medical Director also confirmed that Resident #5 did speak English. Record review of nurse notes completed by LVN C (Unit Coordinator) dated 09/26/17 at 10:17 AM read in part . 'I was called into Resident #5's room because he was saying that he was turned too rapid and fell out of the bed. His nurse and myself went in to assess him. He was complaining of pain and said that he had fallen. After talking with him for 10 minutes his story kept changing. He couldn't tell us what side of the bed he fell out of and one story the CNA dropped him then the next no one was there, then it was a woman and then it was a man. We had another Hispanic staff to come and translate for us and he said he fell and a black man came to help put him back in bed. Even when interviewing the roommate the stories changed. I called the only male staff who worked last night which was the nurse and he said the CNA was turning Resident #5 and he started to fall but she held on to him and did not let him fall and called for help and he went in to help her. Resident #5 did not ever hit the floor.' Record review of nurse notes written by LVN MM on 09/26/17 at 2:43 PM read in part . Resident #5 complained of pain to bilateral hips. X-ray of bilateral hips done, awaiting orders. Per resident during incontinent care, rolled out of bed on to floor then resident changed story to- I don't know what happened, didn't remember, then stated the male nurse assisted him to bed unable to remember what side of bed he rolled out of and if he hit anything, medicated with PRN for pain, will continue to monitor. Record review of LVN G nurse's note dated 09/28/17 at 2:26 PM read in part . Resident #5 reports pain to left lower leg per RP, RP at bedside, Nurse Practitioner in facility, assessed resident, [MEDICAL CONDITION] noted from knee to ankle, Nurse Practitioner ordered STAT x-ray to left knee along with STAT labs, call placed for STAT x-ray and call placed to lab for STAT labs, RP aware of orders, will continue to monitor. Record review of Progress Note completed by Nurse Practitioner for Resident #5 dated 09/28/17 read in part . History of Present Illness: Patient is awake, alert appears to have chronic cognitive deficits. Patient's RP reported patient had a fall about 2 days ago. Unclear about nursing documentation, patient's bilateral and hip x-ray done, no fracture or acute distress. Today RP presented at bedside reporting left knee pain, patient cannot move left leg. Upon exam, decreased range of motion, crying in pain. He denies any shortness of breath or chest pain. Patient does not appear in any distress. Vital signs were stable. Record review of Nurse Practitioner's orders dated 09/28/17 revealed orders for the following: CBC, CMP STAT, Pain left knee, left knee x-ray STAT, swelling and pain. Tylenol 325 mg (2 tablets) twice daily scheduled for 3 days. Record review of STAT x-ray of left knee dated 09/28/17 at 3:18 PM read: Findings- There is a [MEDICAL CONDITION] tibia. There is soft tissue swelling and angulation diffuse osteopenia is noted. Conclusion- [MEDICAL CONDITION] tibia. There is a notation on the right lower corner of report that reveals the facility staff notified the physician of the fracture on 09/29/17 at 11:00 AM. Record review of physician order [REDACTED]. Record review of nurse note dated 09/29/17 at 2:40 PM read: Resident was medicated for pain with Tylenol by mouth, will continue to monitor. Record review of x-ray reports from hospital dated 09/29/17 revealed the following: X-ray tibia/fibula. Impression: Limited. Likely mildly displaced, medial plateau fracture extending into the tiabial metaphysis. X-ray Forearm. Impression: Negative examination of the right forearm. X-ray right elbow. Impression: Limited. Contour abnormality of the radial head, which could represent fracture. Record review of nurse note dated 09/29/17 at 9:55 PM read: Resident #5 admitted from Hospital under the service of the Medical Director. Resident accompanied with RP and two ambulance attendants. Admission diagnoses; fractured extremity lower and fractured extremity upper, skin- no new skin condition noted. Complain about pain at this time. Tylenol 650 mg given. Continue to monitor. Record review of LVN C's written statement dated 09/28/17 read in part . Nurse called me into Resident #5's room and said Resident #5 said he had a fall. He first said he fell to the left side of the bed and I said he couldn't have fallen there because he has a large motorized wheelchair there. Resident #5 then said he fell on the other side but Resident #5 and roommate kept changing the details and then he said he didn't fall. That is when we got another staff who spoke fluent Spanish and he said he didn't fall and a black man came to help him. Record review of CNA Q's written statement dated 09/29/17 read in part . Making my rounds on Sept. 26, 17 with Resident #5. I looked at his sheets which appeared to need changing. So I attempted to change his sheet, turn him a little on the side. Next thing I know he put his leg across as to get up. I ran to hold him to prevent his falling. I then told his roommate to please go get the nurse. The nurse came to assist me. We both repositioned him in the center of the bed. Resident did not complain of anything at this time. On last round, Approximately 5:15 AM, I changed resident and resident did not complain of anything at this time. Record review of LVN CC's written statement dated 09/29/17 read in part . The incident occurred Tuesday morning at 4:00 AM. I heard staff calling for help. Upon arrival to the room staff was firmly holding resident on right side of the bed and trying to prevent him from falling off the bed. Resident's leg was sort of dangling. This writer immediately rushed in the room and assisted staff and repositioned resident to the center of the bed and to a more comfortable position. Resident denied pain on assessment, no injury was noted. Record review of report from Orthopedic Specialist for Resident #5 dated 10/05/17 read in part . Presents today in a motorized wheelchair with traumatic right wrist and left leg pain for 2 weeks. The patient resides at facility and states he fell out of his bed. Patient was seen at the hospital where x-rays were taken (not available) of the leg and right wrist. His left leg and right wrist was placed in a temporary splint but he removed his wrist splint last night. Patient complains of no pain at the wrist but has throbbing pain at the elbow. Patient has increased pain at the medial aspect of the elbow with extending it. Patient was right hand dominant. He additionally has left leg pain following his fall. His pain was felt throughout the lower leg. He has increased pain with cold air and reports paresthesia on his left toes. No previous surgeries on the left leg or right wrist. He has been taking [MEDICATION NAME] daily. X-ray results performed at Orthopedics office dated 10/05/17 revealed the following findings: 2 radiologic views of the left tib/fib (lower leg bones), taken in the office today demonstrate a non-displaced tibia fracture at the junction of the metaphysis and diaphysis proximally. 2 radiologic views of the right elbow, taken in the office today demonstrate a radial neck fracture. 3 radiologic views of the right wrist, taken in the office today demonstrate a possible hairline fracture at the level of the wrist. The Administrator was notified on 10/12/17 at 12:20pm of the IJ due to the above failures and a Plan of Removal (PoR) was requested. A PoR was received and after several revision, a PoR was accepted on 10/15/17 at 11:45am. The PoR included in part: All licensed nursing staff (RN/LVN), including the DON was re-educated on Incident Assessment and Physician Notification by the District Nurses. The training included: assessing the resident for injury to include skin check, to check the resident's limbs for strength, range of motion, swelling and obvious deformity, notifying the physician and responsible party. If a STAT x-ray/lab is ordered results should be obtained within 4-6 hours and if it is not then the nurse manager is to call the lab directly for results. The physician should be notified for any changes from the patient's baseline. A pain assessment should be conducted and pain medication given as ordered. The patient should be monitored for 72 hours or longer if needed, after an incident/accident. This training started on 10/12/17 at 4:00pm and was completed by 10/13/17 at 2:00pm. Any staff failing to attend the scheduled training will not be able to work until their training was complete. The DON/designee will monitor the completion of incident assessment and physician notification by reviewing documentation in the medical record system. A review will occur during the morning clinical meeting. On October 12, 2017 Ad Hoc subcommittee of the Quality Assurance & Performance Improvement Committee met to discuss, approve and implement the removal plan. Beginning 4:30 p.m., October 13, 2017 facility management will be re-educated on Abuse/Neglect including investigation and reporting. Education will be provided by District Nurses and VP of Clinical Services. The education to include the following: Abuse & Neglect Prohibition to include investigating and reporting. Facility management, after receiving training, will in turn train all facility staff. Training will be conducted and lead by the Administrator. All staff in-service will be conducted Saturday, October 14, 2017 at 2:00 p.m. and concluded at 3:00 p.m. Staff failing to attend the scheduled educations will not be able to work until education is completed. The Plan of Removal was monitored until the IJ was lowered: Record review of the in-service training provided to staff revealed that all staff were trained or retrained in the following: -All CNAs were trained in abuse and neglect. The training was completed 10/14/17. CNAs from different shifts were interviewed and able to explain the training they received. They were aware of the types of abuse and what neglect was, who to report abuse/neglect to and when to report it. -All licensed nursing staff (RN/LVN), including the DON was re-educated on Incident Assessment and Physician Notification. Random interviews were conducted during the monitoring. Staff indicated that they attended these training sessions. They were able to describe the training they received and that training reflected correct techniques and physician notification. Observations were conducted during the monitoring. No additional concerns were identified between the acceptance of the PoR and the lowering of the IJ. The Administrator was informed on 10/16/17 at 11:45am that the IJ was lowered; however the facility remained out of compliance at a level of pattern and a severity actual harm that is not immediate jeopardy due to the facility needing more time to ensure that the plan of removal was effective. The facility 672, dated 10/10/2017 listed a census of 103.

Based on observation, interview and record review the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for 1 of 18 residents, Resident #5 reviewed for abuse and neglect in that: The Administrator failed to start an investigation after Resident #5 had a fall that resulted in an arm, leg fracture and wrist fracture. CNA Q was not suspended pending investigation of injuries of Resident #5. -The facility failed to ensure Resident #5 was assessed and received medical treatment following a fall that resulted in fractures to resident's right arm and left leg. Resident #5 fell from his bed onto the floor during care. Two days later the physician ordered a STAT x-ray. Twenty four hours after the x-ray was taken the facility notified the physician of the results. Resident #5 was sent to the hospital for evaluation for a fractured left leg. Resident #5 also had a fractured right arm at the wrist and the elbow. -The facility failed to ensure Resident # 5 received adequate pain assessment and control following a fall and fractured right arm and left leg. An Immediate Jeopardy (IJ) was identified on 10/12/17. While the IJ was lowered on 10/15/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed 102 additional residents who reside at the facility at risk of abuse, neglect, decrease in quality of life and injuries. Intake# 7 Findings included: Record review of Abuse and Neglect Prohibition dated January 2017 provided by facility read in part . Each resident has the right to be free from mistreatment, neglect, abuse, exploitation, involuntary seclusion, corporal punishment, physical or chemical restraint not required to treat the resident's medical symptoms, injuries of unknown origin, and misappropriation of resident property. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident. Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Injuries of an unknown origin may occur as a result of neglect. Prevention: 1. The facility will address all concerns in accordance with Truly Listening to Our Customers policy. Residents, families, and staff will be able to report incidents and concerns without fear of retribution. Protection: 1. The facility will protect residents from harm during the investigation. Investigation: 1. The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property in accordance with state law. 2. Any employee alleged to be involved in an instance(S) of abuse and /or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. 3. The facility will report all investigative findings to the state within 5 working days of the incident. Reporting and Response: a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the management staff becomes aware of the allegation; or b. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after management staff becomes aware of the allegation. Resident #5 Record review of face sheet for Resident #5 revealed a year [AGE] year old male admitted to the facility on [DATE] and a readmission date of [DATE]. Resident #5 had the following Diagnoses: [REDACTED]. Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 06, which indicated severe impairment. Resident #5 required extensive assistance with two person physical assistance for bed mobility and transfer. Resident #5 required extensive assistance with one person physical assist for dressing, toilet use and personal hygiene. MDS revealed Resident #5 was always incontinent of bowel and bladder. Record review of Care Plans for Resident #5 revealed the following: Dated 06/07/16 with a revision date of 10/02/17- Problem: Resident #5 had an Activities of daily living (ADL's) self-care performance deficit. He required the presence and assistance of two staff members for ADL's. Interventions included: Resident needed one staff member to provide bath/shower, required extensive assistance of two staff members to turn and reposition in bed and for dressing. Dated 06/07/16 with revision date of 02/22/17- Problem: Communication, Primary language was Spanish. Resident did speak some English. Interventions included: Anticipate and meet needs. Discuss with resident/family concerns or feelings regarding communication difficulty. Dated 09/09/16 with a revision date of 02/22/17. Problem: Incontinent of bowel and bladder. Interventions: Check and change frequently. Dated 09/26/17 with a revision date of 10/02/17. Problem: Potential/Actual Pain related to [DIAGNOSES REDACTED]. Interventions included- Observe for signs and symptoms of verbal and non-verbal indications of pain at each medication pass and periodically. Dated 09/29/17- Resident #5 complained of left knee pain. Interventions included: . Order received to send resident to hospital. Stat x-ray ordered for left knee which resulted in left tibia fracture and follow up with orthopedic physician. Dated 10/02/17- Problem: Left tibia (shin bone) fracture and right upper extremity fracture. Interventions include: Anticipate and meet needs. Two staff presence and assist with my adls. Follow physician's orders [REDACTED]. See physician's orders [REDACTED]. Dated 10/02/17- Problems: Osteopenia and a risk for fractures. Interventions included: Give Calcium per physician orders. Give [MEDICATION NAME] as needed for pain. Required two staff members for adls. Record review of nurse notes completed by LVN CC on 09/26/17 at 7:02 AM (late entry for 09/26/17 at 4:00 AM) read in part . Staff aid (CNA Q) went into Resident #5's room to provide care and to wrap up our second round for the shift. Staff aid tried to reposition patient in order to ascertain a comfortable position to change his diaper, as she rolled resident to his side Resident #5 began shouting am gonna fall and gonna fall while leaning next to his side rail. Staff aid rushed on other side of the bed, she held resident firmly while preventing him from falling out of bed. This writer overheard a loud voice coming from the room and quickly rushed to the room. Resident was held firmly while two person staff slowly repositioned resident to the center of the bed and to a comfortable position. Will continue to monitor. Further record review of LVN CC's nurse note dated 09/26/2017 at 7:02 AM did not reveal a head to toe assessment following Resident #5's fall. Record review of Incident Investigation worksheet dated 09/29/17 revealed the following: On 09/26/17 at 4:00 AM Certified Nursing Assistant (CNA) Q was providing care and repositioning. Resident #5 assumed he was falling out of bed and began screaming. LVN CC came in and repositioned Resident #5. The resident did not fall. Resident did complain of pain. On 09/28/17 Resident #5 complained of pain to his leg and back. LVN CC ordered an x-ray and there was a fracture to the tibia. There was osteopenia noted on the x-ray. There were no witnesses to the incident. There was no alleged perpetrator. Record review of Provider Investigation Report dated 09/29/17 revealed the following: The incident occurred on 09/26/17 at 4:00 AM in Resident #5's room. Resident #5 was being repositioned per CNA Q at approximately 4:00 Am. Resident #5 made a quick motion as to get up and caused his near falling from the bed. X-ray conducted on 09/28/17 and received on 09/29/17, which revealed a [MEDICAL CONDITION] tibia. X-ray showed soft tissue swelling and angulation diffuse osteopenia. Resident #5 was transferred to the hospital on [DATE] and returned to facility (date not listed) with a soft cast to follow-up with the orthopedic specialist. CNA Q was provided a 1:1 in-service training (training not specified). Staff were in-serviced on Abuse and Neglect and lifting and transferring. Observation and interview on 10/10/17 at 2:15 PM with Resident #5 revealed his responsible party (RP) at bedside. Resident #5 had a bright green cast to his right arm from his wrist up to his mid-upper arm and a bright green cast on his left leg that covered his foot and went up to mid-thigh. Interview conducted in English (resident is bilingual) at same time with Resident #5, he said that about a week ago a CNA was cleaning him and turned him to the left quickly and he fell off the bed and landed on the floor. Interview with Resident #5's RP on 10/10/17 at 2:19 PM, he said that he noticed Resident #5's left leg was swollen on 09/28/17 and he notified staff. The RP said he was upset because Resident #5 had been complaining of pain to his left leg and staff did not assess his leg or they would have noticed the swelling. The RP said that Resident #5 said he fell from the bed when a CNA was changing him and they have both told management that he fell from the bed, but no one was listening. The RP said he was scared to complain too much as he does not want them to kick Resident #5 out of the facility as he could not care for him at home but wanted Resident #5 taken care of correctly. In an interview with Resident #5's roommate on 10/11/17 at 11:10 AM, he said that he was in bed when he heard a noise and heard Resident #5 crying. Resident #5's roommate said he got out of bed and put himself in his wheelchair and saw Resident #5 on the floor between the bed and the wall and a CNA was in the room with him. The Roommate said he went in the hall and told the black guy to come help. The black guy asked what happened and I told him Resident #5 fell on the floor. The roommate said the black guy put on gloves and closed the curtain around Resident #5. The roommate said he moved the curtain and watched the CNA and the black guy pick up Resident #5 and put him back in bed. Interview on 10/11/17 at 1:06PM with Licensed Vocational Nurse (LVN) C, Unit Coordinator, revealed she was in her office on 09/26/17 at about 7:30 AM and LVN MM came into her office and said that Resident #5 said he had a fall. LVN C said that she did not speak Spanish but that LVN MM speaks a little Spanish. LVN C said that Resident #5 said he fell out of the bed on the side near the wall. LVN C said she told Resident #5 and LVN MM that Resident #5 could not have fallen on that side as that was where his electric wheelchair was kept. LVN C said she asked the roommate what happened and the roommate said he went to go get help and kept changing his story about what happened. LVN C said that she (LVN C) and LVN MM asked CNA ZZ to translate for them. LVN C said that CNA ZZ translated for Resident #5 and that CNA ZZ said that Resident #5 said he did not fall but was going to roll out of bed but CNA Q yelled for help and CNA Q and LVN CC were able to reposition Resident #5 in bed. In a telephone interview with CNA Q on 10/11/17 at 2:00 PM CNA Q said she was in Resident #5's room, changing his sheets. CNA Q said she had a feeling he might fall and as soon as she thought that he turned and started to fall but she was able to catch him. CNA Q said Resident #5 had one leg dangling off the edge of the bed. CNA Q said she is stalky and is 6' 2.5 tall and held on to him for dear life until LVN CC came in and assisted her in repositioning him back in bed. CNA Q said that the incident occurred on Tuesday (09/26/17). CNA Q said she did not drop Resident #5 and that Tuesday (09/26/17) was the first time she had ever worked with a little person. CNA Q said that Resident #5 speaks English. CNA Q said that LVN CC checked him out. CNA Q said that Resident #5 kept saying that he fell earlier during the previous shift at 8:00 PM but he did not fall on her shift. CNA Q said she was not suspended pending investigation. In a telephone interview on 10/11/17 at 2:38 PM with LVN MM, she said that she worked the day shift following the incident earlier in the morning. LVN MM said that she was told by Resident #5 a black lady was changing him and dropped him on the floor and a male nurse came to help him. LVN MM said Resident #5 was complaining of pain to his legs during her (LVN MM) shift. LVN MM said she told staff to do an incident report and she ordered x-rays of Resident #5's hips and they were negative. LVN MM said that LVN C said she spoke to the nurse and CNA involved and the CNA said Resident #5 slid off the bed but she caught him and he did not hit the floor. LVN MM said she is not currently working at the facility as she could not deal with the facility at this time. LVN MM did not elaborate on why she could not deal with the facility and needed a break at this time. LVN MM said that she kept telling staff that the incident needed to be investigated and reported. In an interview via telephone on 10/11/17 at 2:46 PM with LVN CC, he said that roughly at 4:00 AM, CNA Q was cleaning up Resident #5 and Resident #5's roommate called him (LVN CC) to come into the room. LVN CC said when he entered the room that Resident #5 was hanging off the bed and CNA Q was holding his upper body on the bed. LVN CC said the CNA Q and he (LVN CC) grabbed him and repositioned him on the bed. LVN CC said Resident #5 did not complain of pain but he was holding his arm on the right side and he was frightened. When asked if an assessment was completed, LVN CC said he completed an assessment in the nurse notes. LVN CC said the physician was not called as Resident #5 did not fall. In an interview on 10/11/17 at 3:00 PM with CNA ZZ, he said that Resident #5 told him that a CNA was changing him and she rolled him over and he fell out of the bed and hit the floor. CNA ZZ said that he told LVN MM exactly what Resident #5 told him and she told the office staff. CNA ZZ said he was not sure what the outcome was but said that the office staff called and spoke to the staff involved. CNA ZZ said he also interviewed Resident #5's roommate and his roommate said that a CNA was changing resident and turned him and he fell out of the bed and landed on the floor. In an interview with the Director of Nurses (DON) on 10/11/17 at 5:00 PM, she said that she was notified of the x-ray with the tiabial fracture on 09/29/17. The DON said she was not aware of the situation involving Resident #5 until 09/29/17. The DON said she was out of the facility for training with the Administrator. The DON said as soon as she became aware of the situation and the x-ray on 09/29/17, she notified the Administrator. The DON said that it was her understanding that the 10 PM- 6 AM shift on 09/26/17 was performing a bed linen change and Resident #5 yelled he was falling and CNA Q called for help. LVN CC came into the room to assist and they put him in bed. The DON said CNA Q and LVN CC said Resident #5 did not fall. The DON said that an in-service for positioning and proper techniques had been performed for all staff. When asked if CNA Q was suspended pending investigation the DON said no one was suspended as she didn't think she needed to take CNA Q off the schedule pending investigation. The DON was asked how often were head to toe assessments completed and the DON said weekly. When DON was asked if someone should have noticed the swelling to Resident #5's leg, she said it should have been noticed by somebody during changing. The DON said Resident #5 was a 2 person assist with all care. In an interview with Resident #5's Nurse Practitioner (NP) on 10/12/17 at 9:50 AM, she said that Resident #5 and his roommate said he had a fall but staff at the facility said he did not have a fall. The NP said that Resident #5's RP complained of knee swelling to the resident's left knee. The NP said that Resident #5 had decreased range of motion to his left knee and was crying in pain. The NP said that Resident #5 had a trace amount of swelling to the left knee. The NP said she ordered a STAT x-ray on 09/28/17 and was notified of the results on 09/29/17. The NP said she was not sure why the staff did not notify her of the x-ray result confirming a [MEDICAL CONDITION] until 09/29/17. The NP said that Resident #5 would not be able to injure himself and would not receive those types of injuries with resident care. In an interview with the facility Administrator on 10/12/17 at 10:20 AM, she said that she was not in the building when the incident occurred with Resident #5. The Administrator said she was at a seminar with the DON. The Administrator said she received a text from LVN C that Resident #5 almost fell out of the bed but didn't fall. The Administrator said that the DON received the x-ray report on 09/29/17 that confirmed a [MEDICAL CONDITION] and informed her (Administrator) of the x-ray report. The Administrator said she interviewed Charge Nurse CC and CNA Q about the incident and started the investigation. CNA Q said Resident #5 made a motion like he was going to fall off the bed and CNA Q ran to catch him. The Administrator said that Charge Nurse CC said that Resident #5 was not on the floor when he entered the room but that his legs were dangling off the bed and CNA Q was at the bedside holding Resident #5. The Administrator said that Resident #5 was Spanish speaking only and that there was staff that spoke Spanish. The Administrator was asked if the facility used a language line for residents who did not speak English and she said that the facility did not. Administrator was asked if the fracture to Resident #5's radial neck (right elbow) and the possible hairline fracture at the right wrist had been investigated and the Administrator said she had just started working on the investigation as Resident #5 was recently seen by the orthopedic specialist on 10/05/17. In an interview with the DON on 10/12/17 at 10:45 AM, she said that it was the charge nurses responsibility to follow up on all STAT orders and if results were not received in 6 hours, the charge nurse should call for results. Observation and interview with Resident #5 on 10/12/17 at 11:00 AM revealed Resident #5 sitting in his electric wheelchair in dining area. Interview at same time with Resident #5, he said that when he fell from the bed to the floor he experienced pain to his right arm, left leg, and back. Resident #5 said he tried to tell the nurse, the black guy that helped the CNA put him back in bed, but the nurse wouldn't speak to him or ask him about his pain. Resident #5 said he was crying when he landed on the floor because he was scared and he was experiencing pain. Record review of Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet Dispersable 50 MG- give 2 tablets by mouth every 8 hours as needed for chronic pain. Further review of MAR for 09/01/2017-09/30/2017 revealed Resident #5 was not medicated for pain on the following days: 09/26/2017 09/27/2017 Record review of MAR for 10/01/2017-10/31/2017 revealed the following orders: [MEDICATION NAME] HCI tablet 50 mg-Give 50 MG by mouth every 6 hours as needed for upset stomach related to chronic pain. [MEDICATION NAME] HCI Tablet Dispersable (dose not legible)-Give 2 tablets by mouth every 8 hours as needed for pain related to chronic pain. Further review of MAR for 10/01/2017-10/31/2017 revealed Resident #5 was not medicated for pain on the following days: 10/07/2017 10/08/2017 In an interview on 10/12/17 at 3:40 PM via phone with facility Medical Director who was also Resident #5's physician, he said that he had been Resident #5's physician for a long time. The Medical Director said he did not receive a call about a fall on 09/26/2017 but did receive a call about Resident #5's hip pain and an x-ray of the hips was ordered. The Medical Director said that Resident #5 had [DIAGNOSES REDACTED] and brittle bones but for those type of injuries to occur he would have had to have fallen or received rigorous care. The Medical Director confirmed that Resident #5 had minimal movement and could not have self-inflicted injuries. The Medical Director also confirmed that Resident #5 did speak English. Record review of nurse notes completed by LVN C (Unit Coordinator) dated 09/26/17 at 10:17 AM read in part . 'I was called into Resident #5's room because he was saying that he was turned too rapid and fell out of the bed. His nurse and myself went in to assess him. He was complaining of pain and said that he had fallen. After talking with him for 10 minutes his story kept changing. He couldn't tell us what side of the bed he fell out of and one story the CNA dropped him then the next no one was there, then it was a woman and then it was a man. We had another Hispanic staff to come and translate for us and he said he fell and a black man came to help put him back in bed. Even when interviewing the roommate the stories changed. I called the only male staff who worked last night which was the nurse and he said the CNA was turning Resident #5 and he started to fall but she held on to him and did not let him fall and called for help and he went in to help her. Resident #5 did not ever hit the floor.' Record review of nurse notes written by LVN MM on 09/26/17 at 2:43 PM read in part . Resident #5 complained of pain to bilateral hips. X-ray of bilateral hips done, awaiting orders. Per resident during incontinent care, rolled out of bed on to floor then resident changed story to- I don't know what happened, didn't remember, then stated the male nurse assisted him to bed unable to remember what side of bed he rolled out of and if he hit anything, medicated with PRN for pain, will continue to monitor. Record review of LVN G's nurse note dated 09/28/17 at 2:26 PM read in part . Resident #5 reports pain to left lower leg per RP, RP at bedside, Nurse Practitioner in facility, assessed resident, [MEDICAL CONDITION] noted from knee to ankle, Nurse Practitioner ordered STAT x-ray to left knee along with STAT labs, call placed for STAT x-ray and call placed to lab for STAT labs, RP aware of orders, will continue to monitor. Record review of Progress Note completed by Nurse Practitioner for Resident #5 dated 09/28/17 read in part . History of Present Illness: Patient is awake, alert appears to have chronic cognitive deficits. Patient's RP reported patient had a fall about 2 days ago. Unclear about nursing documentation, patient's bilateral and hip x-ray done, no fracture or acute distress. Today patient's brother presented at bedside reporting left knee pain, patient cannot move left leg. Upon exam, decreased range of motion, crying in pain. He denies any shortness of breath or chest pain. Patient does not appear in any distress. Vital signs were stable. Record review of Nurse Practitioner's orders dated 09/28/17 revealed orders for the following: CBC, CMP STAT, Pain left knee, left knee x-ray STAT, swelling and pain. Tylenol 325 mg (2 tablets) twice daily scheduled for 3 days. Record review of STAT x-ray of left knee dated 09/28/17 at 3:18 PM read: Findings- There is a [MEDICAL CONDITION] tibia. There is soft tissue swelling and angulation diffuse osteopenia is noted. Conclusion- [MEDICAL CONDITION] tibia. There is a notation on the right lower corner of report that reveals the facility staff notified the physician of the fracture on 09/29/17 at 11:00 AM. Record review of physician order [REDACTED]. Record review of nurse note dated 09/29/17 at 2:40 PM read: Resident was medicated for pain with Tylenol by mouth, will continue to monitor. Record review of x-ray reports from hospital dated 09/29/17 revealed the following: X-ray tibia/fibula. Impression: Limited. Likely mildly displaced, medial plateau fracture extending into the tiabial metaphysis. X-ray Forearm. Impression: Negative examination of the right forearm. X-ray right elbow. Impression: Limited. Contour abnormality of the radial head, which could represent fracture. Record review of nurse note dated 09/29/17 at 9:55 PM read: Resident #5 admitted from Hospital under the service of the Medical Director. Resident accompanied with RP and two ambulance attendants. Admission diagnoses; fractured extremity lower and fractured extremity upper, skin- no new skin condition noted. Complain about pain at this time. Tylenol 650 mg given. Continue to monitor. Record review of LVN C's written statement dated 09/28/17 read in part . Nurse called me into Resident #5's room and said Resident #5 said he had a fall. He first said he fell to the left side of the bed and I said he couldn't have fallen there because he has a large motorized wheelchair there. Resident #5 then said he fell on the other side but Resident #5 and roommate kept changing the details and then he said he didn't fall. That is when we got another staff who spoke fluent Spanish and he said he didn't fall and a black man came to help him. Record review of CNA Q's written statement dated 09/29/17 read in part . Making my rounds on Sept. 26, 17 with Resident #5. I looked at his sheets which appeared to need changing. So I attempted to change his sheet, turn him a little on the side. Next thing I know he put his leg across as to get up. I ran to hold him to prevent his falling. I then told his roommate to please go get the nurse. The nurse came to assist me. We both repositioned him in the center of the bed. Resident did not complain of anything at this time. On last round, Approximately 5:15 AM, I changed resident and resident did not complain of anything at this time. Record review of LVN CC's written statement dated 09/29/17 read in part . The incident occurred Tuesday morning at 4:00 AM. I heard staff calling for help. Upon arrival to the room staff was firmly holding resident on right side of the bed and trying to prevent him from falling off the bed. Resident's leg was sort of dangling. This writer immediately rushed in the room and assisted staff and repositioned resident to the center of the bed and to a more comfortable position. Resident denied pain on assessment, no injury was noted. Record review of report from Orthopedic Specialist for Resident #5 dated 10/05/17 read in part . Presents today in a motorized wheelchair with traumatic right wrist and left leg pain for 2 weeks. The patient resides at facility and states he fell out of his bed. Patient was seen at the hospital where x-rays were taken (not available) of the leg and right wrist. His left leg and right wrist was placed in a temporary splint but he removed his wrist splint last night. Patient complains of no pain at the wrist but has throbbing pain at the elbow. Patient has increased pain at the medial aspect of the elbow with extending it. Patient was right hand dominant. He additionally has left leg pain following his fall. His pain was felt throughout the lower leg. He has increased pain with cold air and reports paresthesia on his left toes. No previous surgeries on the left leg or right wrist. He has been taking [MEDICATION NAME] daily. X-ray results performed at Orthopedics office dated 10/05/17 revealed the following findings: 2 radiologic views of the left tib/fib (lower leg bones), taken in the office today demonstrate a non-displaced tibia fracture at the junction of the metaphysis and diaphysis proximally. 2 radiologic views of the right elbow, taken in the office today demonstrate a radial neck fracture. 3 radiologic views of the right wrist, taken in the office today demonstrate a possible hairline fracture at the level of the wrist. The Administrator was notified on 10/12/17 at 12:20pm of the IJ due to the above failures and a Plan of Removal (PoR) was requested. A PoR was received and after several revision, a PoR was accepted on 10/15/17 at 11:45am. The PoR included in part: All licensed nursing staff (RN/LVN), including the DON was re-educated on Incident Assessment and Physician Notification by the District Nurses. The training included: assessing the resident for injury to include skin check, to check the resident's limbs for strength, range of motion, swelling and obvious deformity, notifying the physician and responsible party. If a STAT x-ray/lab is ordered results should be obtained within 4-6 hours and if it is not then the nurse manager is to call the lab directly for results. The physician should be notified for any changes from the patient's baseline. A pain assessment should be conducted and pain medication given as ordered. The patient should be monitored for 72 hours or longer if needed, after an incident/accident. This training started on 10/12/17 at 4:00pm and was completed by 10/13/17 at 2:00pm. Any staff failing to attend the scheduled training will not be able to work until their training was complete. The DON/designee will monitor the completion of incident assessment and physician notification by reviewing documentation in the medical record system. A review will occur during the morning clinical meeting. On October 12, 2017 Ad Hoc subcommittee of the Quality Assurance & Performance Improvement Committee met to discuss, approve and implement the removal plan. Beginning 4:30 p.m., October 13, 2017 facility management will be re-educated on Abuse/Neglect including investigation and reporting. Education will be provided by District Nurses and VP of Clinical Services. The education to include the following: Abuse & Neglect Prohibition to include investigating and reporting. Facility management, after receiving training, will in turn train all facility staff. Training will be conducted and lead by the Administrator. All staff in-service will be conducted Saturday, October 14, 2017 at 2:00 p.m. and concluded at 3:00 p.m. Staff failing to attend the scheduled educations will not be able to work until education is completed. The Plan of Removal was monitored until the IJ was lowered: Record review of the in-service training provided to staff revealed that all staff were trained or retrained in the following: -All CNAs were trained in abuse and neglect. The training was completed 10/14/17. CNAs from different shifts were interviewed and able to explain the training they received. They were aware of the types of abuse and what neglect was, who to report abuse/neglect to and when to report it. -All licensed nursing staff (RN/LVN), including

Based on interview and record review, the facility ensure 1 of 5 (Resident #1), residents recived adequate supervision and assistance to prevent accidents reviewed for accidents and supervisions, in that: Resident #1 was transferred by CNA (Certified Nurse Aide) A alone resulting in a fall. He was transferred to a local hospital and diagnosed with [REDACTED]. This failure affected one resident and could place 73 additional residents at risk of falls/accidents who required transfer assistance. Findings include: Incident Intake # 8 Complaint Intake # 6 Resident #1 Record review of the face sheet of the clinical chart for Resident #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS (Minimum Data Set) dated 2/2/17 revealed Resident #1 had moderate cognitive impairment. MDS further revealed, Resident #1 required extensive assistance with two person physical assist for bed mobility, transfer, and dressing. Record review of Care Plans revealed the following care plans: Resident #1 had an actual fall with no injury, related to poor balance dated 05/24/2016. Resident was found kneeling on his knees on floor mat. Interventions- Continue interventions on the at-risk plan. Encourage resident to ask for assistance. Actual fall on 10/04/2016 with bruising to left lower back related to poor balance dated 05/24/2017 with a revision date of 04/18/2017. Interventions- Interdisciplinary referral: physical therapy, occupational therapy, restorative nursing, social services dated 05/24/2016 with a revision date of 08/08/2016. Place frequently used items in reach dated 05/24/2016. Physical Therapy Consult for strength and mobility dated 05/24/2016. Had a fall on 12/18/2016 (un-witnessed resident was picked up by other residents family members in patio area) no injury noted related to poor balance, impaired communication and unsteady gait. Interventions- Interdisciplinary referral: physical therapy, occupational therapy, restorative nursing, social services dated 05/24/2016 with a revision date of 08/08/2016. Place frequently used items in reach dated 05/24/2016. Physical Therapy Consult for strength and mobility dated 05/24/2016. Actual fall on 04/09/2017 without injury while staff was transferring related to poor balance and impaired cognition dated 05/24/2016 with a revision date of 04/15/2017. Interventions- Interdisciplinary referral: physical therapy, occupational therapy, restorative nursing, social services dated 05/24/2016 with a revision date of 08/08/2016. Place frequently used items in reach dated 05/24/2016. Physical Therapy Consult for strength and mobility dated 05/24/2016. Risk for falls related to impaired mobility, transfer skills, history of Cerebrovascular accident with right hemi, refusal of care at times dated 05/25/2016 with a revision date of 12/07/2016. Interventions- Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Record review of the Situation, Background, Assessment and Recommendation (SBAR) Form dated 4/9/17 at 1:33 pm, completed by a Registered Nurse revealed Resident #1 had experienced a fall while being transferred by a CNA. The report read in part, .resident leg became twisted under him during transfer causing him to fall. Landed on employee 5. Things that make the condition or symptom better are 2 person transfer . The review further revealed Resident #1 had a history of [REDACTED]. SBAR noted that Resident #1 had not had this condition, symptom, or sign before. Vital signs were; blood pressure 144/71, pulse 73, respirations 16, temperature 96.8. SBAR revealed that there was no change in mental status, functional status, and respiratory status, abdominal or genitourinary status. Pain status was not addressed on SBAR. No bruising noted on SBAR. Record review of handwritten statement, not dated, written by CNA A read, On April 8 at 1:23 PM I was transferring .from the bed to his wheelchair. He is usually extensive one person assist. Ever since switching rooms he now transfers on his weaker side. So as I turned to pivot with him into the chair, his weaker leg did not move causing us both to stumble and fall on the floor, having him land on me. Record review of the document entitled, Provider Investigation Report dated 4/18/17 revealed on 4/17/17 Resident #1's family member called to the attention of staff, the presence of a bruise on the resident's right lower extremity. Resident #1 was assessed and was noted to have a bruise to the anterior right lower shin area. Resident denied pain to the area. Resident was transferred to hospital for evaluation and treatment. Resident did not recall injury. Report further revealed that statements were obtained from staff members working to determine if resident had any additional falls. Staff were in-serviced on proper transfer techniques, reporting of incidents and follow up documents. Record review of nurse note dated 04/17/2017 at 2:33 pm revealed: Resident has a bruise to the anterior right lower shin area, physician called , x-ray to right lower extremity, resident denies pain, ecchymosis related to past fall healing evidenced by significant decrease in size of bruise. Record review of the radiology report dated 4/17/17 read, .Results There is diffuse bone demineralization. There is a displaced fracture involving the distal tibia shaft and a comminuted fracture involving the proximal fibula metaphysis. Conclusion: Acute proximal fibula and distal shaft fractures . Record review of nurse note dated 04/17/2017 at 2:35 pm revealed: Resident has a bruise to the anterior right lower shin area, physician called , x-ray to right lower extremity, resident denies pain, ecchymosis related to past fall healing evidenced by significant decrease in size of bruise. Record review of nurse note dated 04/18/2017 at 1:39 pm read: Patient refused medication. Notified charge nurse. Record review of nurse note dated 04/18/2017 at 2:04pm read: Received x-ray results for this resident and NP for physician here and stated resident had fracture of R tibia. Received orders to send resident to hospital for further evaluation. Resident refused to come inside. Notified family at this time and family came to facility. Talked to resident and he is compliant at this time. Awaiting ambulance for transportation. Interview on 4/20/17 at 1:45 PM with CNA A revealed she was with Resident #1 on 4/9/17. She stated she believed the date was actually 4/8/17 at which time she was attempting to transfer the resident from his bed to his wheelchair. She stated that the bed he is now in has him transferring on his weaker side, his right side rather than his left side. She reported his leg didn't pivot and they went back with all his weight on her all the way to the floor. She stated she was careful to hold his head as they went down. She stated she immediately got a nurse to come to the room to examine the resident. CNA A was questioned about her length of employment at the facility, the training she had received and her knowledge of the resident. CNA stated she had been employed at the facility since some-time in March 2017 and was trained by an employee who was no longer at the facility. She stated she was familiar with Resident #1 and although he frequently refused care, he would allow her to perform care and services for him. She reported that Resident #1 refused to go to the hospital following the results of the x-ray having being received and the family had to come to the facility to persuade the resident to go. She stated she was told Resident #1 was a 1 person physical assist and that she was wearing her gait belt at the time the transfer was conducted. Record review was conducted of the personnel file for CNA A. The review revealed the employee, who was hired on 3/7/17, had a current CNA certification and there were no barriers to her employment. The review further revealed CNA A had received some initial training and orientation. There was no documentation of any skills check having been performed with CNA A to ensure she was trained on the accurate and proper techniques for various types of transfers. In an interview on 4/20/17 at 4:15 PM the Director of Nurses (DON) she stated the skills checklist should have been in the personnel file for CNA A. Record review of documentation for in-services revealed the following in-services were provided by the facility for the staff: Transfer In-service dated 04/09/2017 Gait Belts In-service dated 04/18/2017 Follow- up Documentation dated 04/18/2017 Transfers and Gait Belts dated 04/18/2017 Reporting All Injuries dated 04/18/2017 According to the facility's CMS 672, 74 residents required transfer assistance