Every finding on record at Pearsall Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Residents #97) reviewed for infection control:During the medication pass, the facility failed to ensure LVN B did not touch the water faucet with his bare hand after washing his hands and wiped the rubber seal to Resident #97's insulin pen with an alcohol swab prior to administering insulin.These failures could place residents at-risk for infection due to improper care practices.The findings included:Record review of Resident #97's face sheet dated 7/16/26 reflected a [AGE] year old male admitted into the facility on [DATE] and re-admitted on [DATE] with diagnoses that included acquired absence of left toes, diabetes (condition in which the body has trouble controlling the amount of sugar in the blood), peripheral vascular disease (poor circulation, usually in the legs, because the blood vessels have become narrowed by fatty deposits), and acquired absence of right leg below the knee.Record review of Resident #97's most recent comprehensive MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills, had a diagnosis of diabetes and was treated with insulin.Record review of Resident #97's Order Summary Report dated 7/16/26 reflected the following:- Lantus 100 unit/ML insulin, inject 30 units subcutaneously two times a day related to diabetes with order date 2/12/26 and no end dateRecord review of Resident #97's comprehensive care plan with revision date 10/31/23 reflected that the resident had diabetes and was at risk for complications with interventions that included administering medications as ordered by the doctor.During the observation of the medication pass on 7/15/26 at 8:31 a.m., LVN B went into Resident #97's bathroom, washed his hands with soap and water and turned off the faucet with his bare hand. After LVN B obtained an accu-check (finger-stick blood glucose test used to measure a person's blood sugar level) from Resident #97, LVN B returned to the medication cart, obtained the resident's insulin pen and inserted a needle into the rubber seal without cleaning the rubber seal first. During an interview on 7/15/26 at 8:54 a.m., LVN B stated after you wash your hands, you should use a paper towel to turn off the faucet because the surface of the handle was contaminated and basically it was reintroducing germs and germs could come in contact with the hands. LVN B stated that the spread of germs could potentially transfer to a resident and make them sick. LVN B stated he did not realize he had washed his hands and turned off the faucet with his bare hand. LVN B stated he believed, since Resident #97's Lantus insulin pen was new, he was not sure the rubber seal had to be cleaned with an alcohol prep. LVN B stated he had skills training within the year, including training on the use of insulin. During an interview on 7/15/26 at 3:55 p.m., the DON stated, when the nurses used an insulin pen to administer insulin to a resident, her expectation was for the nurse to wipe the rubber seal with an alcohol prep before introducing a needle into the seal to prevent spread of infection. The DON stated that LVN B should have turned off the water faucet after washing his hands with a paper towel because it was cross contamination and a break in infection control. The DON stated the nurse could pass an infection to the resident when providing care, in this case administering an insulin injection. The DON stated that the use of gloves did not take the place of washing the hands. Record review of LVN B's Medication Pass Competency Assessment, dated 1/4/26 reflected he had satisfied the requirements for administering insulin injections. LVN B's Medication Pass Competency Assessment included procedures for injections, The rubber septum of the medication vial, whether unopened or previously accessed, is disinfected with alcohol prior to piercing.Record review of the facility document titled Hand Hygiene, date implemented 10/24/22 reflected in part, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub.The use of gloves does not replace hand hygiene.

Based on interviews, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 6 residents (Resident #17) reviewed for resident assessments.The facility failed to ensure Resident #17's MDS assessment dated [DATE] correctly assessed the resident received dialysis treatments.These failures could place residents at risk for inadequate care and services.The findings included:Record review of Resident #17's face sheet dated 7/13/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes (condition in which the body has trouble controlling the amount of sugar in the blood), hyperlipidemia (too much fat in the blood; high cholesterol), peripheral vascular disease (poor circulation, usually in the legs, because the blood vessels have become narrowed by fatty deposits), chronic kidney disease stage 5 (kidney failure; the kidneys have lost nearly all their ability to filter the blood, and dialysis or a kidney transplant may be needed to keep the person alive).Record review of Resident #17's most recent MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making skills and was diagnosed with kidney disease. Resident #17's MDS assessment under Section O, Special Treatments, Procedures, and Programs did not reflect the resident required dialysis treatments.Record review of Resident #17's Order Summary Report dated 7/13/26 reflected the following:- Dialysis, check shunt to left upper arm for signs and symptoms of infection or bleeding every shift with order date 6/3/26 and no end date- Dialysis provided by dialysis clinic Monday, Wednesday, and Friday at 4:00 p.m. with order date 6/3/26 and no end dateRecord review of Resident #17's comprehensive care plan initiated 6/3/26 and revised on 6/24/26 reflected the resident required dialysis treatments related to end stage renal disease with the goal to ensure the resident did not have signs or symptoms of complications from dialysis.During an interview on 7/13/26 at 2:35 p.m., MA A stated Resident #17 had only been admitted to the facility a short time ago, but as far as she knew the resident had been getting dialysis treatments since he had been admitted . MA A stated she was not sure what days or times Resident #17 had dialysis treatments.During an interview on 7/14/26 at 8:11 a.m., Resident #17 stated he was admitted to the facility about three weeks ago and stated he had been receiving dialysis treatments for the past 3 1/2 years. Resident #17 stated he continued with dialysis treatments while at the facility and had a dialysis appointment yesterday, 7/13/26. During an interview on 7/15/26 at 10:20 a.m., LVN B stated Resident #17 had been admitted into the facility for restorative care related to an injury to his right leg. LVN B stated, Resident #17 had been receiving dialysis treatments prior to his admission and continued with treatments while a resident at the facility. LVN B stated Resident #17 had dialysis treatments scheduled on Monday, Wednesday, and Friday and nursing was responsible for obtaining vital signs and filling out the proper documentation prior to the resident going to dialysis treatments. During an interview on 7/15/26 at 10:27 a.m., the MDS nurse, after she reviewed Resident #17's MDS assessment dated [DATE] stated dialysis should have been triggered on the MDS assessment and basically it was an oversight; a data entry error. The MDS nurse stated the accuracy of the MDS was important because it provided an overall picture of the resident, which was then translated into developing the care plan, which helped as a guide for the staff on how to care for the resident.During an interview on 7/15/26 at 10:37 a.m., the DON stated, the importance of the MDS was that it provided a picture of the resident which was used to develop the care plan. The DON stated that the MDS and the care plan help to identify health issues and resident needs and instructs the staff on the type of care they should be providing. The DON stated the facility followed the guidance of the RAI to develop and complete the MDS assessments. Record review of the CMS's RAI Version 3.0 User's Manual dated October 2025, Section O0110: Special Treatments, Procedures, and Programs, O0110J1, Dialysis reflected in part, .Code peritoneal or renal dialysis which occurs at the nursing home or at another facility.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. 1 of 6 residents (Resident #97) reviewed for pharmaceutical services. LVN B did not prime (a safety test used prior to injecting a patient with insulin in which the dosage selector is dialed to waste at least 2 units of insulin and if insulin solution is seen at the tip of the needle it ensures an accurate dose is injected) the insulin pen prior to injecting Resident #97 with insulin. This deficient practice could affect residents who received insulin by a flex pen in the facility by not receiving the intended therapeutic benefit of their medication.The findings included:Record review of Resident #97's face sheet dated 7/16/26 reflected a [AGE] year old male admitted into the facility on [DATE] and re-admitted on [DATE] with diagnoses that included acquired absence of left toes, diabetes (condition in which the body has trouble controlling the amount of sugar in the blood), peripheral vascular disease (poor circulation, usually in the legs, because the blood vessels have become narrowed by fatty deposits), and acquired absence of right leg below the knee.Record review of Resident #97's most recent comprehensive MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills, had a diagnosis of diabetes and was treated with insulin.Record review of Resident #97's Order Summary Report dated 7/16/26 reflected the following:- Lantus 100 unit/ML insulin, inject 30 units subcutaneously two times a day related to diabetes with order date 2/12/26 and no end dateRecord review of Resident #97's comprehensive care plan with revision date 10/31/23 reflected that the resident had diabetes and was at risk for complications with interventions that included administering medications as ordered by the doctor.During an observation on 7/15/26 at 8:31 a.m., LVN B obtained Resident #97's Lantus insulin from the medication cart and inserted a needle into the rubber seal without cleaning it first. LVN B then took the Lantus insulin pen, did not prime the insulin pen, and dialed the dosage to 30 units and injected the resident with the insulin.During an interview on 7/15/26 at 8:54 a.m. LVN B stated he was not familiar with priming an insulin pen and stated, I don't fully know the technology behind priming the (insulin) pen. LVN B stated he had skills training within the year, including training on the use of insulin. During an interview on 7/15/26 at 3:55 p.m., The DON stated that an insulin pen should be primed prior to administering insulin and should be checked for air bubbles because it could cause an adverse effect on the resident and priming the insulin pen ensures the resident received the appropriate dose.Record review of LVN B's Medication Pass Competency Assessment, dated 1/4/26 reflected he had satisfied the requirements for administering insulin injections. Record review of the Lantus package insert, Instruction Leaflet, with revision date 11/2018 reflected in part, .Follow these instructions completely each time you use.to ensure that you get an accurate dose. If you do not follow these instructions you may get too much or too little insulin, which may affect your blood glucose.Always perform the safety test before each injection.Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly.removing air bubbles.Select a dose of 2 units by turning the dosage selector.Hold the pen with the needle pointing upwards.Press the injection button all the way in. Check if insulin comes out of the needle tip.You may have to perform the safety test several times before insulin is seen.Check that the dose window shows '0' following the safety test.Select your required dose.

Based on observation, interview, and record review the facility failed to provide special eating equipment for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals for 1 of 1 resident (Resident #24) reviewed for special eating equipment and assistance when consuming meals.The facility failed to ensure Resident #24 received the physician-ordered slow-flow adaptive drinking cup during the noon meal on 07/13/2026.The failure placed Resident # 24 at risk for aspiration and/or aspiration pneumonia.Record review of Resident #24's face sheet dated 06/11/2024 revealed Resident #24 had a diagnosis including dysphagia (medical term for difficulty swallowing) and a history of stroke (a medical emergency that happens when blood flow to part of the brain stops, causing brain cells to die from lack of oxygen).Record review of Resident #24's physician orders dated 06/11/2024 revealed order for slow-flow adaptive drinking cup with fluids.Record review of Resident #24's care plan dated 11/11/2025 revealed the need for the adaptive drinking cup to promote safe swallowing and reduce the risk of aspiration.Record review of Resident #24's meal ticket revealed Resident #24 required a slow-flow adaptive drinking cup with meals.Observation of meal service on 07/13/26 at 12:15 pm revealed CNA D served Resident #24 cranberry juice in a regular drinking cup. Resident #24 independently lifted the regular drinking cup, drank the cranberry juice, and immediately coughed after swallowing.During an interview with CNA D on 07/13/26 at 12:17 pm CNA D stated Resident #24 should have been provided a slow-flow adaptive drinking cup during the meal. CNA D acknowledged the resident was served the incorrect drinking cup. CNA D stated he could cough and drink too fast.During an interview with LVN C on 07/13/2026 at 12:23pm, LVN C stated she has worked at facility for about 4 years. She stated I look at the slip and make sure it's correct if it's not, I'll ask the kitchen to make the changes or get what is needed. I reviewed [Resident #24's] meal ticket. I didn't see if he had a sippy cup. He should have had a sippy cup. I'm the one responsible for making sure the residents have what is ordered from the doctor for the residents. The order should have been followed. He could aspirate or something.During an interview with SLP on 07/15/2026 at 3:30 pm, SLP stated Resident #24 requires thin liquids with small sips when drinking. I made those recommendations because the smaller the sips are the more the muscles have control to assist with the swallowing process. The SLP stated that due to Resident #24's diagnosis of dysphagia, he should be monitored and have small sips while drinking or he could cough or potentially aspirate and the fluids could go into his lungs. Interview with Director of Nursing on 07/15/26, at 4:45 p.m., the DON stated Resident #24 should have received the physician-ordered slow-flow adaptive drinking cup. The DON stated staff are educated regarding resident's adaptive equipment needs and explained the purpose of the slow-flow adaptive drinking cup is to regulate the rate of fluid intake and promote safer swallowing. The DON further stated failure to provide the ordered slow-flow adaptive drinking cup could increase the resident's risk for aspiration and aspiration pneumonia.Record review of the facility's undated policy titled Adaptive Equipment documented:6. Staff are required to provide adaptive equipment as ordered and ensure residents receive care and services necessary to maintain safety and meet identified needs and individualized care plans to promote resident safety during meals. Staff are expected to provide adaptive devices as ordered and to follow physician orders and individualized care plans to promote resident safety during meals.

Based on interview, observation and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #23) reviewed for hospice services, in that: The facility failed to ensure Resident #23's hospice documents including: The hospice election form and the physician certification and recertification of the terminal illness specific to each patient were present in the hospice binder in the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation. Record review of Resident #23's admission Record dated 07/15/26 revealed a [AGE] year old female admitted to facility 04/01/26. Resident #23's diagnoses included schizophrenia (a chronic brain disorder where individuals interpret reality abnormally), malignant neoplasm of unspecified site of right female breast (a cancerous tumor originating in the right breast), secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes (metastatic cancer meaning cancer cells from a primary tumor have spread to the armpit and upper limb lymph nodes) and mild intellectual disabilities (characterized by an IQ typically between 50 and 70 and significant limitations in adaptive daily living skills). Record review of Resident #23's Significant Change MDS dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Record review of Resident #23's comprehensive care plan revealed she was placed on hospice services with the date initiated on 06/15/26. Record review of Resident #23's Physician Order Summary as of 07/16/26 revealed she was admitted to [Hospice Company] services for malignant neoplasm of the right breast with an order date of 06/12/26. Record review of the hospice binder for Resident #23 on 07/15/26 at 3:00 pm revealed that there were no forms under the tab for Form 3071 and 3074. During initial rounds on 07/13/26 at 10:45 am, Resident #23 was observed visiting with a hospice employee in her room. During an interview on 07/15/26 at 10:55 am, Resident #23 confirmed she had a visitor from hospice. Resident #23 indicated during her conversation that she was pleased with services from the facility and hospice and that she received help when she needed it. During an interview on 07/15/26 at 3:30 pm, DON stated she would have to ask the hospice company why Forms 3071 (Individual Election/Cancellation/Update) and 3074 (Physician's certificate of terminal illness) were not in the hospice binder under the tab marked for these forms since they are responsible for the binder. The DON called the hospice company and they faxed the forms to her. Record review of Hospice Policy revised December 2017 revealed:Our facility contracts for hospice services for residents who wish to participate in such programs. Our facility has entered into a contractual arrangement for hospice services to make sure that residents who wish to participate in a hospice program may do so. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency is developed. The resident's care plan should be revised and updated with changes. All hospice services are provided under contractual arrangement.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 Residents (Resident #9) whose MDS records were reviewed for accuracy. Resident #9's Discharge MDS assessment dated [DATE] incorrectly documented the resident was discharged to a Short-term hospital. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #9's face sheet dated 12/03/2017 revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included: Type 1 diabetes mellitus with ketoacidosis (no insulin with fat burning creating acid buildup), major depressive disorder (persistent feeling of sadness and loss of interest), and anemia (not enough red blood cells to carry oxygen to the lungs). Record review of Resident #9's Discharge MDS assessment, dated 09/26/2025, revealed under section for identification, Discharge Status was coded as being discharged to Short-Term General Hospital. Record Review of Resident #9's Progress note, dated 9/25/2025 at 5:22 pm, it stated, Resident is planning to be discharging home to Arizona tomorrow morning. 12/4/2025 at 9:44 am staff interview with LVN B, stated the resident was discharged home but was coded as discharged to a short-term general hospital. She stated that the MDS was coded incorrectly. 12/4/2025 at 10:22 am Staff interview with Administrator, he stated resident was discharged with family. He was discharged home but coded to short term hospital. He stated a POC has been completed. He also stated that staff education was completed by administrator. Record review of the CMS MDS 3.0 Manual dated October 2025 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. MDS 3.0 is part of that assessment process and is required by CMS .

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #1) of 5 residents reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #1 on 05/23/2025, CNA-A did not clean the resident's buttock area. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #1's face sheet, dated 05/23/2025, revealed the resident was [AGE] years old male, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of dementia (over time destroy nerve cells and damage the brain), bronchitis (inflammation of the lining bronchial tubes), muscle wasting and atrophy (decrease in muscle mass, weakness and tingling in limbs), hypertension (high blood pressures), and anemia (the blood does not have enough healthy red blood cells to carry oxygen). Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 5 out of 15, which indicated the resident had severe cognitive impairment and had frequently urinary incontinence and occasionally bowel incontinence. Record review of Resident #1's comprehensive care plan, dated 03/07/2025, revealed the resident episodes of bowel and bladder incontinence. For intervention - incontinent care at least every 2 hour and clean peri-care with each incontinence episode. Observation on 05/23/2025 at 11:33 a.m. revealed CNA-A removed Resident #1's old and dirty brief and cleaned the resident's suprapubic area, left, right groin area, and the resident's genital area with circular motion, then turned the resident to right side and put the new and clean brief. CNA-A closed the new and clean brief without cleaning Resident #1's buttock area. Interview on 05/23/2025 at 11:45 a.m. CNA- A stated he did not clean Resident #1's buttock area because he was nervous and forgot. CNA-A said he should have cleaned Resident #1's buttock area. CNA-A said he had peri-care training in January 2025. Interview on 05/23/2025 at 1:01 p.m. the ADON stated the DON was on vacation, so the ADON functioned as DON. The ADON said CNA-A should have cleaned Resident #1's buttock area to prevent possible infection. The ADON said she was responsible for providing training related to peri-care and monitoring skill checkoffs. CNA-A had a skill checkoff on 01/14/2025, and CNA-A passed perineal care for male. Record review of the facility policy, titled Incontinent Care Skills Checklist, undated, revealed . 10. With new wipe or cloth, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock. Remove dirty towel.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The FSS did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. Findings included: During an interview on 05/06/2025 at 11:07 AM, the FSS was hired 06/30/22 and stated she was not a certified dietary manager or certified food service manager, and she did not have an associate's or higher degree in food service management or in hospitality. She had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting but had not completed a course of study in food safety management that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. She attempted to become certified but the facility had gone through several consultant RDs and there had not been one assigned to the facility long enough to serve as a preceptor. During an interview on 05/08/2025 at 10:37 AM, the consultant RD stated did not work at the facility full time. She provided approximately 12 - 16 hours of consultative hours to the facility per month. During an interview on 05/08/2025 at 2:20 PM, the Administrator stated he was aware the FSS was not a certified dietary manager, certified food manager and could not produce evidence she completed a course of study including topics integral to maintaining dietary operations and stated he would take care of it. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The FSS did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. Findings included: During an interview on 05/06/2025 at 11:07 AM, the FSS was hired 06/30/22 and stated she was not a certified dietary manager or certified food service manager, and she did not have an associate's or higher degree in food service management or in hospitality. She had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting but had not completed a course of study in food safety management that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. She attempted to become certified but the facility had gone through several consultant RDs and there had not been one assigned to the facility long enough to serve as a preceptor. During an interview on 05/08/2025 at 10:37 AM, the consultant RD stated did not work at the facility full time. She provided approximately 12 - 16 hours of consultative hours to the facility per month. During an interview on 05/08/2025 at 2:20 PM, the Administrator stated he was aware the FSS was not a certified dietary manager, certified food manager and could not produce evidence she completed a course of study including topics integral to maintaining dietary operations and stated he would take care of it. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to maintain the temperature of reach-in cooler #1 at or below 41 degrees F. 2. The facility failed to ensure a package of pork sausage and a package of sliced salami were discarded by their use-by dates. 3. The facility failed to record the temperature of reach-in cooler #1 on the Refrigerator Temperature Record on 05/08/2025. 4. The facility failed to properly sanitize the compartments of the blender used to puree food for modified diets in accordance with manufacturer's instructions. These failures could place residents at risk for food borne illness. The findings included: 1. Observation on 05/06/2025 at 11:12 AM of reach-in cooler #1 revealed the digital display outside the cooler indicated a temperature of 52 degrees F. Further observation inside the cooler revealed an analogue thermometer indicating a temperature of 51 degrees F. The Dietary Refrigerator and Freezer Temperature Record posted on the side of the cooler indicated the internal temperature of the cooler was 40 degrees F on 05/06/2025. There was no time noted on the log. During an interview on 05/06/2025 at 11:13 AM the FSS stated the internal temperature of reach-in cooler #1 was not good, it should be at or below 41 degrees F, and she would speak to the maintenance supervisor. She did not know what time the temperature was taken that morning, but it was taken by the early DA. All kitchen staff was responsible for keeping an eye on the temperatures of the coolers. Staff was trained during meetings twice a month. During an interview on 05/06/2025 at 11:14 AM, DA A stated she had noted the temperature of reach-in cooler #1 was 40 degrees F and recorded this temperature on the log at 5:00 AM that morning. During an interview on 05/06/2025 at 11:32 AM, the Administrator stated all food from reach-in cooler #1 had been discarded and the cooler would not be in use until it was repaired and maintaining the proper temperature. Record review of facility policy 03.003 Food Storage revised 06/01/2019 revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2. Refrigerators. a. Keep fresh meat, poultry, seafood, dairy products and most fresh fruit and vegetables in the refrigerator at an internal temperature of 41 F or less. h. Place a thermometer inside refrigerators near the door where the temperature is warmest. Check the temperature of all refrigerators using the internal thermometer to make sure the temperature stays at 41 F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the refrigerator. i. Record review of Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (2) At 5 C (41 F) or less. 2. Observation on 05/06/2025 at 11:16 AM in the kitchen revealed inside reach-in cooler #2 a package 5 lb. package of pork chorizo sausage that had been opened and was stored in a sealed zip-locked bag. Written in black marker on the zip-locked bag was, Received 4/11/25 and Opened 4/12/25. Observation on 05/06/2025 at 11:25 AM in the reach-in stand-alone refrigerator revealed a package of uncured sliced salami that had been opened and was stored in a sealed zip-locked bag. Written in black marker on zip locked bag was, 12/22/24. During an interview on 05/06/2025 at 11:26 AM, the FSS stated the opened packages of pork sausage and salami should not have been in the cooler and refrigerator and should have been discarded by dietary staff. All staff was trained on proper storage of food upon hire and during bi-monthly training classes. Record review of facility policy 03.003 Food Storage revised 06/01/2019 revealed, e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. 3. Observation on 05/08/2025 at 10:00 AM revealed there was no entry on the Dietary Refrigerator and Freezer Temperature Record posted on the outside of reach-in cooler #1. During an interview on 05/08/2025 at 10:02 AM, the FSS stated DA B worked the early shift that morning and was responsible for recording the temperature on the log. During an interview on 05/08/2025 at 10:05 AM, DA B stated she noted the internal temperature of reach-in cooler #1 at 5:00 AM when she arrived for duty in the kitchen and it was 40 degrees F. She failed to record the temperature on the log because she was in a hurry. She understood the importance of recording the internal temperatures of the cooler on the log, especially since that particular cooler was discovered to have malfunctioned at some point in the morning of 05/06/2025. 4. Observation on 05/08/2025 at 10:20 AM in the kitchen revealed [NAME] C blended spinach in the high-speed blender for residents ordered a pureed-texture diet. Observation on 05/08/2025 at 10:25 AM revealed [NAME] C emptied the contents of the blender in a pan and took the blender and a measuring cup to the three-compartment sink. [NAME] C used a Quaternary Test Kit to test the concentration of sanitizing solution in the third sink. The test strip revealed a concentration of approximately 200 ppm, indicating an adequate concentration of chlorine to sanitize equipment and dishes. [NAME] C washed the measuring cup and blender components (blade, lid, and container) in the first sink, rinsed the cup and blender components in the second sink, and submerged the cup and blender components in the third sink containing the sanitizing solution. [NAME] C removed the measuring cup and blender components from the third sink containing the sanitizing solution immediately after submersion. [NAME] C then took all items back to the preparation table in the kitchen to puree the next menu item. During an interview on 05/08/2025 at 10:30 AM, [NAME] C stated equipment and dishes needed to be submerged in the sanitizing solution for ten seconds. During an interview on 05/08/2025 at 10:38 AM, the FSS stated equipment and dishes needed to be submerged in the sanitizing solution for 30 seconds to absorb the sanitizer. During an interview on 05/08/2025 at 2:00 PM, the administrator stated equipment and dishes needed to be submerged in the sanitizing solution for 60 seconds or per manufacturer's instructions. Record review of the label on the container of Auto-Clor System Solution QA used by the facility revealed, Directions for use: Treated surfaces must remain wet for 60 seconds. Drain thoroughly and allow to air dry before reuse. Record review of facility policy 04.005 Manual Cleaning and Sanitizing of Utensils and Portable Equipment updated 10/10/2018 revealed, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75 F, or iii. Any other chemical sanitizing agent which has been demonstrated to be effective and non-toxic under use conditions and for which a suitable field test is available. Such other sanitizing agents, in-use solutions, shall provide the equivalent sanitizing effect of a solution containing at least 50 parts per million of available chlorine at a temperature not less than 75 F. The concentration and contact time for quaternary ammonium compounds shall be in accordance with the manufacturer's label directions. C. Be sure to cover all surfaces of the utensils and/or equipment with hot water or the sanitizing solution and keep them in contact with it for the appropriate amount of time.

Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #92) of 8 residents reviewed for baseline care plans. The facility failed to include Resident #92's use of antipsychotic medication in his baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included: Record review of Resident #92's Admission Record dated 05/09/2025 revealed he was a [AGE] year-old man admitted [DATE] with diagnoses which included dementia (general term for loss of memory, language, problem-solving and other thinking abilities) and unspecified psychosis (when a person has trouble telling the difference between what's real and what's not). Record review of Resident #92's entry MDS assessment dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment, and was assessed as taking an antipsychotic medication. Record review of Resident #92's Baseline Care Plan initiated 4/1/2025 revealed a problem area for uses antipsychotic medications r/t psychosis with an initiated date of 05/06/2025. Record review of Resident #92's Medication Administration Record for May 2025 revealed an order for OLANZapine Oral Tablet 2.5MG (Olanzapine). Give 1 tablet by mouth at bedtime for psychosis give 1 tablet to equal 2.5mg po at hs. This order for Olanzapine had a start date of 04/01/2025. During an interview with MDS Nurse-D on 05/08/2025 at 11:57 a.m., MDS Nurse-D stated Resident #92 had an order for Olanzapine, an antipsychotic medication on the day he was admitted [DATE], but this was not addressed on his Baseline Care Plan, and was not added to his Care Plan until 05/06/2025. MDS Nurse-D stated Baseline Care Plans should be completed within 48 hours, and include essential information such as fall risk, and Physician Orders which would include the different type of medications taken. She stated it was important to have this information in the Baseline Care Plan to provide staff with all the information needed to meet his needs after his admission. MDS Nurse-D stated that the admitting Nurse was responsible for completing baseline care plans. Interview on 05/09/2025 at 09:13 a.m. with the DON revealed that the admitting Nurse was responsible for completing Baseline Care Plans, and that Resident #92's Baseline Care Plan should have included his use of an antipsychotic medication. The DON stated that the facility was monitoring for side effects of the anti-psychotic medication and providing good care, but through oversight, it just did not make it onto the Baseline Care Plan within the 48 hours, but had been added later. Record review of the facility policy titled Baseline Care Plan reviewed 10/05/2023 revealed The baseline care plan will: a. be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. initial goals based on admission orders. ii. Physician Orders .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #89) reviewed for care plans: The facility failed to ensure Residents #89's Care Plan reflected he should receive PASRR services. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included: Record review of Resident #89's admission record, dated 5/9/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted last on 10/1/24 with diagnoses including major depressive disorder, schizoaffective disorder, insomnia, anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. Record review of Resident #89's quarterly MDS assessment, dated 2/5/25, revealed Resident #89's cognition was fully intact for daily decision making. Record review of Resident #89's Care Plan, revealed a problem area, initiated on 6/13/24 and revised on 2/17/25, for the resident used antipsychotic medication related to schizoaffective, bipolar type, and a history of psychosis with interventions to be evaluated and treated by a mental health service, and monitor/document/report any adverse reactions of antipsychotic medications. The care plan did not indicate if the resident was receiving PASRR services. Record review of Resident #89's document titled PASRR Evaluation, dated 1/17/25, revealed he was evaluated for qualifying mental illness by a qualified mental health professional. During an interview on 5/9/25 at 12:33 p.m. MDS D stated Resident #89 stated she believed the resident had refused PASRR services. MDS D stated she would need to check but if the resident had refused services, they would still need to add it to the care plan, so people are aware that he was positive for services but refused them and the facility had addressed it. During a follow up interview on 5/9/25 at 12:45 p.m. MDS D stated Resident #89 had not refused PASRR services, and they were waiting for services to be implemented after his recent evaluation. MDS D stated he was receiving psychiatric services in the meantime. Record review of the facility's policy, titled Comprehensive Care Plans, dated 10/22/24, stated Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Policy Explanation and Compliance Guidelines: The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed . 3. The comprehensive care plan will describe at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right i:'etlise treatment c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations .

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 1 of 2 residents (Resident #61) reviewed for pressure injuries. The facility nurse did not provide wound care to Resident #61 on the evening of 05/07/2025 as ordered. This failure could place residents at risk of improper wound management, deterioration in existing pressure injuries, infection, and pain. Findings included: Record review of Resident #61's admission record dated 05/08/2025 revealed he was a [AGE] year-old-man initially admitted on [DATE], and readmitted on [DATE] with diagnosis which included: Pressure ulcer of sacral region Stage 4 (most severe type of pressure injury, characterized by full-thickness skin loss located at base of spine, just above buttocks). Record review of Resident #61's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating intact cognition. He was assessed as being dependent (helper does all the effort) for transfers and having a diagnosis of Pressure Ulcer of sacral region, Stage 4. Record review of Resident #61's Comprehensive Care Plan initiated 11/19/2021, revealed a problem area for stage 4 pressure ulcer to sacrum . with interventions which included Administer treatments as ordered and monitor for effectiveness:. Record review of Resident #61's Physician Order Summary dated 05/08/2025 revealed an order to CLEANSE SACRAL STAGE IV PRESSURE ULCER WITH VASHE [cleansing wound solution]. PAT DRY WITH 4X4 GAUZE. APPLY SKIN PREP TO PERI WOUND. PLACE VASHE SOAKED GAUZE IN NEGATIVE SPACE OF SACRAL PRESSURE WOUND. COVER WITH ABD [abdominal] PAD AND SECURE WITH KERLIX TID AND PRN UNTIL HEALED. Order date 05/02/2025. Record review of Resident #61's Treatment Administration Record (TAR) for May 2025 revealed an order to Cleanse sacral stage IV pressure ulcer with VASHE [cleansing wound solution]. Pat dry with 4x4 gauze. Apply skin prep to peri wound. Place VASHE soaked gauze in negative space of sacral pressure wound. Cover with ABD pad and secure with Kerlix [bulky gauze bandage] TID and PRN until healed with start date of 5/2/2025. Further review revealed Resident #61 was to receive this wound treatment at 0800 [8:00a.m], 1400 [2:00p.m.] and 2000 [8:00 p.m.] every day. On 5/7/2025 at 2000 [8:00p.m.], there were no initials to indicate the wound treatment had been completed. Observation on 05/08/2025 at 08:42 a.m. of wound care for Resident #61 provided by LVN-E revealed that Resident #61 had a dressing dated 5/7/2025 over a wound he had on the back of his upper left thigh, but there was no dressing observed over the Stage IV wound on his sacrum. During an interview with LVN-E on 05/08/2025 at 09:48 a.m., LVN-E stated she had removed the dressing over his sacral wound just prior to the State Surveyor observing his wound care, because she had checked to see if he was clean, and found the sacral wound dressing to be soiled with drainage from his wound and she wanted to clean that up before the State Surveyor observed his wound care. LVN-E stated that Resident #61's had orders for his Stage 4 sacral wound to be cleaned and dressed three times a day, and that the dressing that she had removed earlier had been dated 05/07/2025, but had no time on the dressing and had been heavily soiled with drainage. She reviewed Resident #61's treatment record for May and stated that there was no entry for the 2000 [8:00p.m.] dressing change on 05/07/2025, but could not say if that was a documentation error, or the wound care had not been done. Interview with the DON on 05/08/2025 at 11:46 a.m. revealed that she had contacted the Nurse, LVN-F who had been assigned to provide Resident #61's wound care treatment on the evening of 05/07/2025, and LVN-F told her she had not completed his wound care that night because she had gotten busy and forgot, and the DON stated that she had never done that before. The DON stated she notified Resident #61's Physician of this medication error and that he would be going to see the Wound Care Doctor the next day. The DON stated that by not providing wound care to Resident #61's sacral wound as prescribed, it could result in his wound because worse or slowing healing. Telephone interview on 05/08/2025 at 6:00 p.m. with LVN-F revealed she was Resident #61's assigned Nurse on the evening of 05/07/2025, and had not completed his prescribed wound care at 2000 [8:00p.m.] that evening because she had gotten very busy and did not have time to complete. She stated this was the only time she had not been able to complete his wound care as scheduled, and that not providing his wound care as prescribed could result in his pressure ulcer getting worse. Record review of facility policy titled Topical Administration reviewed 10/01/2019, revealed Apply topical treatment (medication and dressing if indicated) as per physician's order

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 3 medication cart (300 Hall medication cart) reviewed for storage of drugs. The Facility failed to provide change direction labels for Resident #86's medication package of sertraline (Sertraline is an SSRI (serotonin reuptake inhibitor) that increases serotonin levels between neurons (nerves) by blocking serotonin from being absorbed.) which had medication order change from 150 mg to 50 mg. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: Observation on 5/8/25 at 08:32 a.m. revealed a package in the 300-hall medication cart contained medication for Resident #86 with a label for 50 mg of sertraline, and instructions to give 1 tab by mouth daily with 100 mg to equal 150 mg. MA J administered 50 mg of sertraline to Resident #86. Record review of Resident #86's physician orders, dated 5/9/25, revealed an order for sertraline 50 mg give 1 tab by mouth one time a day with a start date of 4/4/25 and no end date. During an interview on 5/9/25 at 10:11 a.m. the DON stated staff should place a change in direction sticker on any medications with a change in the order so staff with be altered and not give the wrong amount of medication to the resident. Record review of the facility's policy titled Labeling of Medication, dated 10/01/2019, stated: Policy All drugs and biological in the Facility are labeled in accordance with all Federal and State regulations . A. When there is a change to a physician order, the nurse receiving the order will affix a Direction Change sticker or equivalent to the label if there is no change in the medication. This sticker will be placed so as not to obliterate any other required information on the medication label. B. When such label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the physician's order for current information. C. The dispensing pharmacy is informed prior to the next refill of the prescription so the new container will contain an accurate label .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 8 residents (Residents #69 and #45) reviewed for infection control. 1. The facility failed to ensure CNA -G, after completing peri and foley care for Resident #69, did not replace a bed wedge that had fallen on the floor back onto Resident #69's bed without cleaning/sanitizing it first. 2. The facility failed to ensure RN I changed his gloves and sanitized his hands after removing an old bandage and placing a new bandage, while performing peg tube (an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) site care for Resident #45. These failures could place residents at risk for cross contamination and infection. The finding included: 1. Record review of Resident #69's Admission Record revealed she was an [AGE] year-old woman admitted on [DATE] with diagnoses which included: cerebral infarction (also known as a stroke, which occurs when blood flow to brain is blocked causing brain tissue to die) and neuromuscular dysfunction of bladder (occurs when signals from nervous system to the bladder are disrupted leading to issues with bladder control and emptying). Record review of Resident #69's 5-day MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment and was assessed as being dependent for transfers and toileting hygiene. Record review of Resident #69's Care Plan initiated revealed problem areas which included: need for Enhanced Barrier Precautions due to foley catheter and ulcers, and is at risk for infection (initiated 3/19/2025). Record review of Resident 369's Order Summary dated 05/08/2025 revealed orders including: Foley cath care q shift and PRN Observation on 05/08/2025 at 8:25 a.m. of foley and peri-care for Resident #69 revealed CNA-G and CNA-H both sanitized their hands, put on gown and gloves and then CNA-G prepared the area by unharnessing and removing an oblong wedge that had been attached to the side of Resident #69's mattress with straps, midway along the length of the bed. The wedge dropped onto the floor and CNA-G was then observed to kick the wedge under the bed to clear it from where she was standing. CNA-G and CNA-H then provided foley and peri-care for Resident #69. After completing the peri-care and repositioning Resident #69, CNA-G picked up the wedge from floor underneath Resident #69's bed and placed it back on the bed, midway along the side of the bed, and attached it back to the mattress with harness straps without cleaning or sanitizing the mattress. During an interview with CNA-G on 05/08/2025 at 8:38 a.m., CNA-G stated that normally the bed wedge just hung over the side of the bed by the harness straps after she removed it for peri-care, not touching the floor, but this time the straps released completely and the wedge fell to the floor. She stated she should have cleaned and sanitized the wedge before replacing it on the bed next to Resident #69 because it had come into contact with dirt and germs on the floor. She stated that by not cleaning the wedge after it was on the floor, it could have caused the spread of germs from the floor to Resident #69. During an interview with the DON on 05/08/2025 at 11:46 a.m., the DON stated that CNA-G should have cleaned and sanitized the bed wedge before placing it back on the bed, noting that Resident #69 was on Enhanced Barrier Precautions, which indicated an increased risk of infection, and that placing the dirty wedge back on the bed could increase the risk for spread of infection. The DON stated CNA-G had worked at the facility a long time, and had been trained on infection control. 2. Record review of Resident #45's admission record, dated 5/9/25, revealed a [AGE] year-old female resident was initially admitted on [DATE], and readmitted on [DATE] with diagnoses including dementia, cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced. This prevents brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes.), and dysphagia (difficult swallowing) following cerebral infarction. Record review of Resident #45's Quarterly MDS Assessment, dated 4/2/25, revealed she had severely impaired cognition for daily decision making. Section K revealed the resident had a feeding tube. Record review of Resident #45's Care Plan revealed a problem area, initiated on 4/18/24, the resident required tube feeding related to dysphagia with interventions to Monitor/document/report PRN any signs and symptoms of: aspiration- fever, SOB (shortness of breath), tube dislodged, infection at tube site, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, and dehydration. Record review of Resident #45's Order Summary, dated 5/7/25, revealed an order to cleanse PEG tube site with normal saline and pat dry with 4x4 gauze. Paint with skin prep and leave open to air one time a day, with a start date of 3/10/25, and no end date. During an observation on 5/8/25 at 2:11 p.m. RN-I removed Resident #45's gauze pad from her PEG tube site. The bandage was dated 5/7/25. RN-I discarded the old gauze bandage, with the same gloves, RN-I opened a new package of split gauze, placed it around the residents PEG tube and secured it to the residents abdomen with tape. RN-I did not change his gloves or sanitize his hands after removing the old gauze bandage and applying the new one. During an interview on 5/8/25 at 2:32 p.m. RN-I stated he should have changed his gloves and sanitized his hands after he removed the old bandage and before he applied the new bandage. RN-I stated his hand sanitizer was in his pocket and not accessible during care. RN-I stated he needed to change his gloves and sanitize his hands because you do not know what was on the old bandage, they can get an infection, and become septic (Sepsis occurs when your immune system has a dangerous reaction to an infection. It causes extensive inflammation throughout your body that can lead to tissue damage, organ failure and even death.). During an interview on 5/9/25 at 12:24 p.m. The DON stated staff should remove their gloves, sanitize their hands, and apply new gloves when removing an old bandage and placing a new one on, to prevent infection to the resident. Record review of the facility policy titled Infection Prevention and Control Program implemented 5/13/2023 revealed This facility has established and maintains 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 as per accepted national standards and guidelines. Further review revealed all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Record review of the facility policy titled Hand Hygiene, dated 10/24/22, stated All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . 6. Additional considerations: a. The use of gloves does not replace band hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . 45857

Based on observation, interview and record review the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 22 residents (Resident #44, Resident #47 and Resident #95) reviewed for resident rights. 1. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #44 Representative prior to admitting to a locked unit. 2. The facility failed to find and obtain informed consent from Reasonable and Responsible party for, Resident #47, who did not have the cognitive ability to make medical decisions, who was taking medications for psychiatric diagnosis, and resided in the locked unit. 3. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #95's Representative prior to admitting to a locked unit. This failure could place residents at risk of being unnecessarily confined to a locked unit and receiving medications without their prior knowledge or consent, or that of their responsible party. Findings include: 1. Record review of Record review of Resident #44's face sheet revealed a [AGE] year-old female was admitted on [DATE] with diagnosis that included dehydration, dementia, muscle weakness, generalized anxiety disorder, seizures, insomnia, and cognitive communication deficit. The face sheet also revealed Resident #44 had a Responsible Party that was a family member. Record review of Resident #44's Admission MDS, dated [DATE], indicated Resident #44's cognition was severely impaired. The MDS also indicated Resident #44 was receiving antianxiety medications and antidepressants. Record review of Resident #44's care plan, revised on 03/26/24 did not contain any information about psychiatric diagnosis, the locked unit, or medications for psychiatric diagnosis. Record review of Resident #44's physician orders, dated 03/27/24 revealed orders for: -ADMIT TO GENERATIONS UNIT (same as locked unit) DUE TO RESIDENT DOES BETTER IN STRUCTURED ENVIRONMENT R/T DX DEMENTIA, order date 02/23/24. Record review of Resident #44's clinical records revealed the facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #44's Representative prior to admission to a locked unit. During an interview on 03/28/24 at 1:50 p.m. Medical records clerk stated she was behind on uploading consent into the computer. The clerk looked in her stack of papers and could not find a consent for Resident #44 to reside in the locked unit. During an interview on 03/29/24 at 2:33 p.m. the DON stated the facility requires a consent form be signed by the RP for all residents on the locked unit. 2. Record review of Record review of Resident #47's face sheet revealed a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included mood disorder due to known physiological condition with major depressive like episode, bipolar disorder severe with psychotic features (a mood disorder that features extreme shifts in mood, during which psychosis can occur. People with psychosis experience a disconnected view of reality. It can involve hallucinations and delusions.), insomnia (is a common sleep disorder that can make it hard to fall asleep or stay asleep), generalized anxiety disorder, schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), mild intellectual disabilities, pseudobulbar affect (A nervous system disorder that causes inappropriate involuntary laughing and crying), schizoaffective disorder (A mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), sleep apnea (a is a potentially serious sleep disorder in which breathing repeatedly stops and starts), and cognitive communication deficit. Resident #47 was noted as the Responsible party. No emergency contact was listed. Record review of Resident #47's Annual MDS, dated [DATE], indicated Resident #47's cognition was severely impaired. The MDS also indicated Resident #47 was receiving antipsychotic medications and antianxiety medications. Record review of Resident #47's care plan indicated, revised on 03/27/24 revealed: - Resident #47 has frequent episodes of crying then laughing r/t DX (diagnosis) of PBA (pseudobulbar affect). In addition, she is easily agitated r/t multiple psych DX of Bipolar, Dementia and Psychosis. Risk for complications. Interventions included administer medications per MD orders, monitor for side effects, and refer to psych as needed. - Resident #47 has impaired cognitive function r/t DX of dementia. Risk for complications. Interventions included Administer medications as ordered. Monitor/document for side effects and effectiveness. Cue, reorient and supervise as needed. - Resident #47 has thought process alteration r/t psychological causes aeb res has dx: schizophrenia and schizoaffective d/o (disorder) and takes routine antipsychotic medication. - Resident #47 has a DX of Anxiety. Risk for complications. Interventions included Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Record review of Resident #47's physician orders, dated 03/28/24 revealed orders for: - ADMIT TO GENERATIONS UNIT DUE TO RESIDENT DOES BETTER IN STRUCTURED ENVIRONMENT RELATED TO DX SCHIZOPHRENIA, order date 05/14/2018. - Ativan Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth three times a day for ANXIETY GIVE 1 TAB = 1MG PO TID, order date 05/18/23. - Nuedexta Oral Capsule 20-10 MG (Dextromethorphan HBr-Quinidine Sulfate) Give 1 capsule by mouth every 12 hours for PBA GIVE ONE CAPSULE = 20-10MG PO Q12H, order date of 06/09/23. - Exelon Patch 24 Hour 4.6 MG/24HR (Rivastigmine) Apply 1 patch transdermally one time a day related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE REMOVE PATCH BEFORE APPLYING AND ROTATE SITES and remove per schedule, order date 08/24/17. During an interview on 03/29/24 at 10:13 a.m. Resident #47 pointed to the nurse when asked if she knew what medications she takes. Resident #47 said she did not sign any medication forms and did not know what medications she took. Resident #47 said no one was in charge of her. During an interview on 03/29/24 at 10:21 a.m. LVN D stated she has worked on the locked unit for a while. LVN D stated Resident #47 resided on the unit because she had wandering and exit seeking behaviors. During an interview on 03/29/24 at 10:38 a.m. the SW stated Resident #47 was her own representative. The SW stated Resident #47 resided in the locked unit to avoid overstimulation. The SW stated she did not know who the person listed as guardian on the consent form for the lock unit was. The SW stated she had never know Resident #47 to have a guardian or have any family visitors. The SW stated the nursing staff fills out the medication consent forms. The SW stated she thinks Resident #47 can make her own decisions and she thinks she knows what you are telling her. The SW stated their legal department would ask them to find someone from the community to sign consent of behalf of residents who cannot make their own medical decisions. The SW stated they had attempted this but did not document it anywhere. During an interview on 03/29/24 at 10:43 a.m. ADON A stated Resident #47 was on the locked unit due to exit seeking behavior. ADON A explained she and another nurse signed a medication consent form on the line for the resident representative because the resident verbally agreed but did not want to sign the document. ADON A stated Resident #47 was her own representative and had never seen anyone else since she was admitted being involved in her care. ADON A stated if they encounter a resident, who was not able to make medical decisions for themselves, they could ask the SW to reach out to the family or an RP but in this case she did not because she knew the resident's history. During an interview on 03/29/24 at 12:38 p.m. MDS E stated Resident #47 has always been her own RP and she has never known anyone else to be involved in her care. MDS E stated Resident #47 multiple psychiatric issues and over the years her cognition has lessened by about 40%. During an interview on 03/29/24 at 12:54 p.m. RN F stated Resident #47 was initially on the locked unit due to exit seeking behavior but more recently was there because of her behaviors and did not exit seek as much anymore. RN F Resident #47 could voice her needs well. RN F said her and another nurse signed the consent form on the Resident Representative line as a way to witness the Resident was informed of the medication change and she verbally agreed to it. RN F stated Resident #47 did not know what medication she took but staff would explain what the medication was for and Resident #47 would say OK. RN F said Resident #47 did not have any memory issues. RN F said she was not familiar with a BIMS score and did not know what Resident #47 BIMS score was. During an interview on 03/29/24 at 2:37 p.m. the DON stated Resident #47 was on the locked unit due to wandering and exit seeking behaviors. The DON stated she will still wander if she was in her wheelchair, and she also gets overstimulated with large groups. The DON stated she has never known anyone else to be involved in her care. The DON stated Resident #47 can give her verbal consent and two nurses witness this by signing on the resident representative line on the consent form. The DON stated Resident #47 had dementia but she was not incompetent and can make decisions. The DON stated a resident on a locked unit can sign their own consent for medications and consent to be on the locked unit. The DON stated they reached out to the ombudsman on 03/29/24 for help with resources for resident who need an RP and was given information. The DON stated if Resident #47 had an RP they would have them sign the consent but because she did not have a RP they had residents or staff sign them. Record review of a document titled Consent for the Generations Unit Placement, dated 08/01/2017, revealed a printed name and the word Guardian in parenthesis. This would indicate that this person consented to Resident #47 being on the locked unit and would have been her guardian. Record review of Resident #47's medical records revealed no guardian, emergency contact, or resident representatives was ever listed for Resident #47. Record review of document titled Informed consent for Psychoactive Medications, dated 06/08/23, revealed a section of the document showed the Resident name was printed on the document and there was no signature on the line for the Residents signature. Another section stated Person authorized to consent on behalf of the resident. The Resident's name was printed on the line labeled Responsible Party & Relationship. Two staff signatures were on the line labeled Responsible Party Signature. 3. Record review of Resident #95's face sheet, dated 3/27/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, cognitive communication deficit, lack of coordination, type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), anoxic brain damage (complete lack of oxygen to the brain resulting in death of brain cells due to oxygen deprivation), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Record review of Resident #95's most recent quarterly MDS assessment, dated 3/2/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #95's comprehensive care plan, revision date 10/26/23 revealed the resident had impaired cognitive function/dementia and resided in the Generations Unit (secure unit). Record review of Resident #95's Order Summary Report, dated 3/27/24, revealed the following: - Admit to Generations Unit due to resident does better in a structured environment due to dementia, with order date 10/4/23 and no end date Observation and interview on 3/26/24 at 12:07 p.m., revealed Resident #95 sitting up in bed eating lunch in the secure unit. Resident #95 was unable to determine how long he had been living in the secure unit. During an observation and interview on 3/28/24 at 5:14 p.m., ADON A revealed Resident #95 had been living in the secure unit since he was admitted to the facility on [DATE]. ADON A revealed Resident #95 was placed in the secure unit due to wandering and the need for a structured environment. ADON A revealed, in order for a resident to reside on the secure unit, a consent and a physician's order needed to be obtained. ADON A revealed she could not find a written consent in Resident #95's electronic record for Resident #95 to be in the secure unit. ADON A revealed she had obtained the order for Resident #95 to reside in the secure unit but had delegated obtaining the consent to a charge nurse. ADON A revealed she could not remember which charge nurse she had told to obtain the consent. ADON A revealed, once the consent was obtained, the document would have been uploaded into the resident's electronic record. During an interview on 3/28/24 at 5:27 p.m., the Medical Records Clerk revealed she was responsible for recovering any resident documents that needed to be uploaded into the resident's electronic record. The Medical Records Clerk revealed, any documents that needed to be uploaded into the electronic record were placed in a basket at the nurse's station. The Medical Records Clerk revealed she made daily rounds to the nurse's station to retrieve those records. The Medical Records Clerk revealed she made it a point to upload consents into the record as soon as they became available to her. The Medical Records Clerk revealed she was at least two months behind in her filing, dating back to January 2024. During an interview on 3/28/24 at 5:35 p.m., the DON revealed, a consent and a physician's order needed to be obtained before a resident was allowed to reside in the secure unit. The DON revealed, a telephone consent could be obtained and any consent, including consent to the secure unit, could be secure by the ADON or the charge nurse. The DON revealed, once consent to the secure unit was obtained, it was uploaded into the resident's electronic record. The DON revealed, Resident #95's family requested the resident reside in the secure unit and the consent should have been in the record. The DON revealed, it was their policy to obtain a consent for Resident #95 to reside in the secure unit because they obtained consents for all the other residents in the secure unit. A policy for Resident Rights was requested and not provided. 45857

Based on interview and record review the facility failed to ensure 1(NA A) of 1 Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course. The facility failed to ensure NA G was a certified nursing aide (CNA) within the required time frame. This failure place residents at risk for receiving care from an individual whose skill level was not known. Findings included: Record review of the facility staff roster provided upon entrance revealed: Nurses' Aide G was listed as a Nursing Assistant with an 04/24/2023 hire date. During an interview with HR on 03/29/2024 at 12:15 p.m., HR stated Nurses' Aide G did have a start date of employment at the facility on 04/24/2023 and she did not know if he had taken any type of CNA test for certification but did know Nurses' Aide G was listed on the staff list. During an interview with LVN C on 03/29/2024 at 1:15 pm, she stated that the nurse aide had completed his skills checklist, but she did not know why he had not taken the certification test. During an interview with the DON on 03/29/2024 at 1:18 p.m., she stated that she did not know why the nurse aide had not taken his certification test. She stated that they had been trying to contact the nurse aide, but he was not answering his phone. Nursing facilities must ensure that their temporary nurse aides register for testing and maintain documentation of registration and test dates on file. Any existing temporary nurse aides not certified before May 1, 2024, must complete a traditional Nurse Aide Training and Competency Evaluation Program (NATCEP) to be approved to take an exam and become certified.

Based on observation, interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 24 residents (Resident #95) reviewed for advanced directives, in that: The facility failed to ensure Resident #95's Out-of-Hospital Do Not Resuscitate (OOH DNR) was dated and signed by the physician which made the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident #95's face sheet, dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, cognitive communication deficit, lack of coordination, type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), anoxic brain damage (complete lack of oxygen to the brain resulting in death of brain cells due to oxygen deprivation), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Further review of Resident #95's face sheet revealed the resident was identified as DNR status. Record review of Resident #95's most recent quarterly MDS assessment, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #95's comprehensive care plan, dated [DATE] revealed the resident was DNR status with interventions which included to ensure a signed DNR was in the medical record. Record review of Resident #95's Order Summary Report, dated [DATE] revealed the following: - DNR (Do Not Resuscitate), with order date [DATE] and no end date Record review of Resident #95's OOH DNR, dated [DATE] revealed the Physician's Statement section which required the physician's signature, printed name, date, and license number were blank. Further review of Resident #95's OOH DNR document revealed the section requiring the physician's signature indicating it was acknowledged the document had been properly completed was blank. During an interview on [DATE] at 8:53 a.m., ADON B revealed, the SW initiated the OOH DNR paperwork and was completed as soon as the resident admitted to the facility. ADON B revealed, DNR orders were obtained by nursing staff, but the SW was responsible for obtaining the OOH DNR. During an interview on [DATE] at 9:05 a.m., the DON revealed the SW was solely responsible for completing the OOH DNR paperwork and nursing staff was in charge of putting the orders into the electronic record. During an observation and interview on [DATE] at 9:09 a.m., the SW revealed she was responsible for ensuring the OOH DNR was completed prior to uploading the document into the electronic record for those residents who requested DNR status. The SW stated, after reviewing Resident #95's electronic record, Resident #95 is a DNR, it's a recent code status and I know that because I handled it. The SW confirmed, Resident #95's OOH DNR was missing the physician's signature, printed name, license number and date. The SW stated, it was me that uploaded Resident #95's OOH DNR document and I take full responsibility for that. The SW revealed, the OOH DNR was invalid because of the missing physician information and resulted in Resident #95 would be identified as full code status and would be going against the family's wishes. During an interview on [DATE] at 4:04 p.m., the Administrator revealed, the SW was responsible for ensuring the OOH DNR documents were filled out completely and correctly. The Administrator revealed, not following the OOH DNR would be going against the resident/family's wishes. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. Record review of the facility policy and procedure, titled Communication of Code Status, date implemented [DATE] revealed in part, .It is the policy of this facility to adhere to resident's rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information .

Based on record review and interviews, the facility failed to complete an accurate assessment which reflected the resident's status for 1 of 5 residents (Resident #78) reviewed for unnecessary medications. The facility failed to ensure Resident #78's diagnosis of depression was included in the residents annual MDS assessment on 01/31/2024. This failure could result in inadequate care due to an incomplete assessment of the resident's psychological condition. The findings included: Record review of Resident #78's face sheet, dated 3/28/2024, reflected a [AGE] year-old male resident initially admitted on [DATE], with a primary diagnosis of Type 2 Diabetes (the bodies inability to regulate sugars). Record review of Resident #78's Annual MDS Assessment, dated 1/31/2024, reflected that the resident did not have depression under the section Active Diagnosis. The MDS Assessment further reflected that Resident #78 was cognitively intact. Record review of Resident #78's Order Summary Report, dated 3/28/2024, reflected the resident had an order for Paroxetine 20 mg (an antidepressant used to treat depression) with a start date of 1/12/2024 for treating depression. Record review of Resident #78's Comprehensive Person-Centered Care Plan, dated 3/28/2024, reflected, [Resident #78] uses anti-depressant medication [refer to] insomnia and adjustment disorder. Interview on 3/28/2024 at 1:48 PM, RN H stated Resident #78 was taking Paroxetine for the purpose of treating depression. RN H stated that during a review of Resident #78's MDS Assessment, depression was not identified as an active diagnosis. RN H further stated that the MDS Assessment was completed by the MDS Coordinators and as a charge nurse he did not review them for their accuracy. Interview on 3/28/2024 at 2:00 PM, MDS Coordinator I stated she had reviewed and completed Resident #78's MDS Assessment on 1/12/2024 and had missed indicating Resident #78's depression due to a clerical error. MDS Coordinator I stated the risk associated with insufficiently completing resident assessments could result in residents' actual diagnosis going untreated and a change in condition being missed. Interview on 3/28/2024 at 2:07 PM, the DON stated she was not aware of Resident #78 being treated pharmaceutically for a diagnosis that Resident #78 was not assessed to have. The DON stated this practice has a risk of residents not being assessed adequately and having missed changes in condition. Record review of facility policy titled, Psychotropic Medication, dated 8/15/2022, reflected, 12. Use of psychotropic medications in specific circumstances: . B. Enduring condition (i. e., non-acute, chronic, or prolonged) I. The resident symptoms and therapeutic goals shall be clearly and specifically identified and documented.

Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 1 of 22 residents (Resident #44) reviewed for care plan revisions. 1. The facility failed to ensure Resident #44's care plan was comprehensive and updated to reflect Resident #44 resided on a locked unit, listed her allergies, listed her code status, and contained interventions for her dementia diagnosis. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Record review of Resident #44's face sheet revealed a [AGE] year-old female was admitted on [DATE] with diagnosis that included dehydration, dementia, muscle weakness, generalized anxiety disorder, seizures, insomnia, and cognitive communication deficit. Record review of Resident #44's Admission MDS, dated [DATE], indicated Resident #44's cognition was severely impaired. The MDS also indicated Resident #44 was receiving antianxiety medications and antidepressants. Record review of Resident #44's care plan indicated, revised on 03/26/24 did not contain any information about psychiatric diagnosis, the locked unit, allergies, code status or medications for psychiatric diagnosis. The care plan stated she had dementia but did not contain any interventions. During an interview on 03/29/24 at 2:33 p.m. the DON stated the care plan was missing information and should contain all of the residents needs so staff can provide appropriate interventions. Record review of the facility's policy, titled Comprehensive Care Plans, dated 10/24/22, stated Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident .

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for 1 of 4 residents (#1) in 1 of 5 facility halls (100 hall) reviewed for history of pain and fracture. LVN G and RN F did not ensure an appointment was made to address treatment of [REDACTED]. The appointment with an orthopedic surgeon was made by RN B at Resident #1's [MEDICAL TREATMENT] treatment center. Resident #1 experienced severe pain, sleep disturbances, inability to bear weight on her leg, and inability to use her legs to self propel in her wheelchair.. This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-conpliance prior to the beginning of the survey. The deficient practice resulted in delay of treatment for [REDACTED]. Findings: Review of Resident #1's Physician Orders dated February 2014, revealed she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed she was assessed as: -always understanding others and being understood by others -having no impairment of range of motion limits to the lower extremities -receiving [MEDICAL TREATMENT] -having no history of fractures -having no problems regarding mood/behavior/psychosocial areas In an interview on 02/24/14 at 11:36 a.m., the Administrator said Resident #1's Physician ordered x-rays in January after the resident told him she was in pain. The administrator said the x-rays showed Resident #1 had a [MEDICAL CONDITION] femur. The Administrator said Resident #1 had not experienced any recent incidents or accidents that could have resulted in the fracture. Review of Resident #1's Telephone Physician Orders revealed an order dated 01/10/14 for "pelvis x-ray, DX (diagnosis): pain" and Left "knee x-ray, DX pain." Review of pelvis and left knee x-ray taken on 01/11/14 revealed "acute intertrochanteric fracture proximal left femur" ([MEDICAL CONDITION]) and "unremarkable left knee." Review of Resident #1's Telephone Physician Orders revealed an order dated 01/11/14 for appointment with an orthopedic surgeon "the sooner the better, need to be scheduled." There was another order dated 02/07/14 for "Stat" hip x-ray. Review of Resident #1's Nurses Notes revealed evidence dated 01/11/14 by LVN G regarding an assessment of the resident's fracture site to the left hip. There were no other entries by nursing staff regarding assessment of Resident #1's fracture site. Nurses Notes for Resident #1 from 01/12/14 to 02/10/14 indicated either no pain or no distress and did not specifically address the resident's fracture. Review of a portable left hip x-ray dated 02/07/14 revealed "Left femoral neck intertrochanteric fracture" that was "unchanged compared with 01/11/14 study." Review of a facility Resident Accident or Incident Report dated 02/10/14 revealed the following: -"resident c/o (complained of) pain to L (left) hip @ (at) [MEDICAL TREATMENT] on Friday 2-7-14. Dr. (N) wanted appt. (appointment) made (with) Dr. (T) (ortho). Dr. (M) was also here on 2-7-14 ordered stat (L) hip x-ray. Results received approx (approximately) 2-7-14 8PM (L) femoral neck introchanteric fx (fracture). No follow up was done. 6A-6P charge nurse followed up on 2-10-14. faxed x-ray report. Received orders for direct admit" to hospital. The report was signed by LVN K, the facility QA nurse. Review of nurses' notes from the [MEDICAL TREATMENT] center Resident #1 attended revealed: -01/21/14 by RN B that "pt (patient) c/o (complains of) pain to l (left) groin/hip. md (doctor) orders referral to dr.../ortho eval. (evaluation). pt c/o losing mobility/function/unable to bear wt. orders faxed to (phone number). will f/u (follow up)" -01/28/14 by RN S for "patient pending f/u w(with)/ortho for hip fx." -01/28/14 by RN B for "called dr. (ortho) office. appt (appointment) not scheduled d/t (due to) office does not accept pt. insurance." -02/11/14 by RN B for "received call from Dr. (T) office on 2/10/14. stated pt will be admitted to DT (downtown) hosp DX(diagnosis): fracture femur. Dr. (N) made aware." and "late entry for Friday 2/7/14: appt scheduled for with Dr (T) for ortho eval. spoke with (staff) at MD office. reports faxed from xrays done on 1/11/14. MD office requesting recent xray and orders for stat xray. call NH (nursing home)- spoke with nurse made aware of appt and need for stat xrays." Review of a Situation Background Assessment Recommendation (SBAR) Communication Form dated 02/10/14, revealed LVN A of received a telephone call on 02/07/14 from RN B at the [MEDICAL TREATMENT] center requesting stat x-rays on Resident #1's hips because of the resident's report of pain to the hips while at [MEDICAL TREATMENT]. LVN A wrote that Dr. N at the [MEDICAL TREATMENT] center wanted Resident #1 seen by Orthopedic Surgeon, Dr. T. LVN A wrote that she notified Resident #1's Physician, Dr. M, and obtained orders for the stat x-rays. LVN A wrote that the x-ray results were received at 5:45 p.m. LVN A wrote that she gave report to LVN U. LVN A wrote that she was following up on 02/10/14 to assure the x-ray results had been sent to Dr. T's office. LVN A wrote that she faxed x-ray results to Dr T's office and was informed by Dr. T's office staff of orders by Dr. T to admit Resident #1 to the hospital for evaluation and treatment. LVN A wrote that she contacted Dr. M and notified him of Resident #1's admission to the hospital. LVN A wrote that Resident #1 was transferred to the hospital by ambulance that day. In an interview during an entrance conference on 02/24/14 at 11:36 a.m., the Administrator said Resident #1 had an x-ray in January, 2014 that showed she had a [MEDICAL CONDITION]. The Administrator said Dr. M ordered an appointment with an orthopedic doctor for evaluation and treatment. The Administrator said the appointment was not made because of lack of follow up to make the appointment and to obtain pre-authorization for the appointment. The Administrator said the nurses said they had been communicating with the DON about the need for the appointment and never informed him of the situation. The Administrator said the DON's employment had been terminated and a Corporate QA RN was acting DON until a new DON started employment. In an interview during initial tour on 02/24/14 at 12:45 p.m., LVN A described Resident #1 as alert, oriented, and having good short and long term memory. LVN A said Resident #1 was in the hospital following treatment for [REDACTED]. Observation on 02/24/14 at 4:30 p.m. revealed Resident #1 was lying in bed at a rehabilitation hospital. Resident #1 was positioned on her back with her hands folded over her stomach. Resident #1 was calm and answered questions readily. Resident #1 did not voice her current pain level until questioned specifically about current pain level. Resident #1 did not show signs of current pain; she was not moaning or grimacing. In an interview on 02/24/14 at 4:30 p.m., Resident #1 said she fell in her room at the facility in mid-September, 2013 and was immediately transferred to a hospital emergency room when she reported pain from the fall. X-rays taken at that time showed bruising but no fracture. Resident #1 said she continued to feel pain from the fall and was not able to bear weight on the left leg. Resident #1 said she told Dr. M about pain to the left hip and leg in January, 2014. Resident #1 said Dr. M ordered an x-ray. Resident #1 said LVN G told her the x-ray results showed she had a broken hip and that Dr. M had ordered an appointment for the resident to see an orthopedic doctor. Resident #1 said that approximately 1 month passed by without an appointment made for her to see the orthopedic doctor. Resident #1 said Dr. M saw her again in February, 2014 and asked if her groin still hurt. Resident #1 said after she told Dr. M that she was still feeling pain, more x-rays were obtained that showed she still had a broken hip. Resident #1 said she was transferred to a hospital on a Monday (corresponded to 02/10/14) where she saw Dr. T and had surgery. Resident #1 said the broken hip and the resulting pain affected her "a lot" and described the following: -she told staff at the facility she was in pain -she told LVNs G and P she was in pain and the nurses would give her Tylenol -she told LVNs G and P she couldn't bear weight on her left leg and couldn't turn to her left side while in bed -she was asking for pain medicine once or twice a day -she told LVN G many times that she was in pain, approximately 3 times a week -she asked LVN G about the appointment to see an orthopedic doctor and was told by LVN G the facility was waiting for some information -she told CNAs she was in pain and they would tell the nurses. she said she had to wait a long time, approximately 1 to 1 1/2 hours, to receive pain medicine and tended to wait longer at night. she did not know the names of the nurses on night shifts. Resident #1 described the effects of the broken hip and pain as: -she said she could not bear weight on her left leg -she could not self propel herself in the wheelchair because her groin would hurt -she sometimes could not sleep because of pain in the groin and would cry. She had difficulty finding a comfortable position. -she had to be careful to sit up and lay down because of pain to her left leg. She said CNAs I and E would help her, as well as LVN D during the day and CNA H on nights would help -she said she was bothered by pain when she turned to her left side during incontinent care but would support herself during the care -she said she had trouble transferring from her wheelchair to the shower chair and would have to sit sideways in the shower chair. She said CNA E helped her with showers. -she said pain from her groin/broken hip kept her from moving around and, as a result, she spent time sitting on the edge of her bed -she described the pain caused by the broken hip as a 7 or 8 on a scale of 1 to 10 where 1 was little pain with increasing pain to a level of 10. she described her current post surgery pain as a 10 and was receiving pain medication. Resident #1 said she also told staff, especially [MEDICAL TREATMENT] technician (DT) C, at the [MEDICAL TREATMENT] center that she had hip pain. Resident #1 said the [MEDICAL TREATMENT] center then contacted the facility about the pain she was experiencing. In an interview on 02/25/14 at 6:35 a.m., DT C said she had taken care of Resident #1 for 3 years and that the resident usually came to [MEDICAL TREATMENT] 3 times a week. DT C said prior to a fall in September, 2013, Resident #1 had no pain and could stand up without assistance. DT C said she would guide Resident #1 from her wheelchair to the [MEDICAL TREATMENT] chair because the resident was visually impaired. DT C said toward the end of November, 2013, Resident #1 told her of a fall and resulting pain. DT C said from that time on, Resident #1 required more assistance to stand. DT C said she had to physically lift Resident #1 to help her stand and that, when standing, the resident would place her full weight on her right leg. DT C said Resident #1 told her it hurt to try and bear weight on the left leg. DT C described Resident #1 as very quiet and as a person who rarely vocalized complaints of pain even after the injury. In an interview on 02/25/14 at 6:57 a.m., [MEDICAL TREATMENT] center RN B said that [MEDICAL TREATMENT] center Dr. N referred Resident #1 to an orthopedic doctor on 01/24/14 because the resident was losing mobility. RN B said she first attempted a referral to a doctor who did not accept the resident's insurance. RN B said she scheduled an appointment with Dr. T's office on 02/07/14 and received a call from Dr. T's office to admit Resident #1 to the hospital. In an interviews on 02/25/14 at 7:58 a.m., LVN D said Resident #1 never complained of pain and she did not notice any change in her ability to transfer. LVN D said she was aware of Resident #1's broken hip and the need for an appointment with an orthopedic doctor but assumed the DON was following up on making the appointment. In an interview on 02/25/14 at 8:43 a.m., RN F said she became aware of Resident #1's broken hip on either 01/13/14 or 01/14/14 and told the DON about the issue. RN F said referral process passed to BOM O who in turn told LVN G to schedule the appointment with the orthopedic doctor. RN F said she did not follow up after this time as she felt the DON was then aware of the need for the appointment. RN F said she did not speak with either the Administrator or Dr. M, Resident #1's Physician, when days passed and the resident's appointment was not made. In an interview on 02/25/14 at 12:52 p.m, LVN G said she would ask Resident #1 if she had any pain and, when the resident responded "no," would ask no further questions. LVN G acknowledged she did not ask questions specifically about pain to Resident #1's broken hip. LVN G said she did not recall Resident #1 asking for pain medicine. LVN G said she did not tell the unit nurse manager, RN F, in January, 2014, about Resident #1's hip fracture because she felt the DON would be better able to help make the orthopedic doctor appointment. LVN G said she did not talk to either the Administrator or Dr. M about the need for Resident #1's doctor appointment. LVN G acknowledged that information regarding Resident #1's [MEDICAL CONDITION] and need for orthopedic appointment was not noted every day on the 24 hour report sheet and said she should have written it in the sheet. Interviews with the following facility CNAs revealed they said they were not told by the nurses that Resident #1 had a [MEDICAL CONDITION] and learned of the fracture when Resident #1 was transferred to the hospital in February, 2014. The CNAs said they did not notice any difference in Resident #1's ability to transfer from wheelchair to shower chair and did not recall the resident saying she was in pain. -on 02/25/14 at 8:20 a.m. -- CNA E -on 02/25/14 at 9:14 a.m. -- CNA H -on 02/25/14 at 10:55 a.m. -- CNA I -on 02/25/14 at 3:15 p.m. -- CNA J Telephone calls for interviews were made, unsuccessfully, with the following current or previous staff: -on 02/25/14 at 9:14 a.m. and 11:07 a.m. -- LVN P -on 02/26/14 at 2:13 p.m. -- RN S from [MEDICAL TREATMENT] center In an interview on 02/26/14 at 1:31 p.m., the QA nurse, LVN K, said concerns were brought and presented at morning meetings. LVN K said staff thought the DON was following up on the concern regarding Resident #1's broken hip and need for an orthopedic doctor appointment. LVN K said she remembered the issue was discussed at only one meeting and did not remember the number of mornings the need for the appointment was brought up. LVN K said RN F was responsible for follow up on resident issues on the 100 Hall. In an interview on 02/26/14 at 1:40 p.m., the acting DON said she did not doubt Resident #1 experienced pain and change in mobility from the broken hip. The acting DON said that, as soon as she arrived at the facility and learned of Resident #1's need for follow up with an orthopedic doctor, she began to work on the referral. The acting DON said Dr. N from the [MEDICAL TREATMENT] knew of an orthopedic doctor so the facility worked with the [MEDICAL TREATMENT] center to refer Resident #1 for treatment. In an interview on 02/26/14 at 2:30 p.m., the Social Worker said she attended morning meetings but usually did not stay for the whole meeting. The Social Worker said she found out about Resident #1's broken hip on the day after the resident was transferred to the hospital. The Social Worker said she was not asked to help obtain a pre- authorization for Resident #1's appointment with an orthopedic doctor. In a telephone interview on 02/26/14 at 3:06 p.m., Dr. M said Resident #1 told him in January, 2014, that her leg hurt and the pain went up to her upper leg. Dr. M said he ordered x-rays that revealed a [MEDICAL CONDITION]. Dr. M said he ordered an appointment be made for evaluation and treatment for [REDACTED]. Dr. M said when he did not hear anything from the nurses at the facility, he assumed Resident #1 had been seen by the orthopedic doctor. Dr. M said if facility nurses had told him Resident #1 had not been seen by an orthopedic doctor and was in pain, he would have ordered an immediate transfer to a hospital. In an interview on 02/26/14 at 3:07 p.m., LVN G said she did not remember Resident #1 asking about an appointment with an orthopedic doctor. LVN G said the reason she did not notify Dr. M was that, after she returned to work from a few days off, the notation on the 24 hour report sheet for Resident #1's orthopedic consult was no longer written in. LVN G said she had spoken with the DON about the appointment but was not given any answers by the DON. In a telephone interview on 02/26/14 at 8:05 p.m., the former DON said she first found out about Resident #1's hip fracture in February, 2014, following discovery of the x-rays from 02/07/14. The former DON said copies of the 24 hour report were made and distributed each morning to the Administrator, the DON, nurse managers, and the QA nurse. The former DON said the nurse managers would report on issues for each hall followed by the charge nurses from each hall reviewing the 24 hour report. The former DON said she had not read each 24 hour report entirely. The former DON said she supervised the nursing staff to assure that resident care was provided by performing spot checks on the nurses. The former DON said the spot checks consisted of pulling and reviewing resident charts and reviewing reports. The former DON said she would not routinely speak with residents but would interact with residents regarding concerns they may have had. The former DON said she never spoke with Resident #1. The former DON said she was assumed the nurses were providing care for residents because "other problems" seemed to be taken care of. In a telephone interview on 02/26/14 at 9:16 p.m., LVN U said she took care of Resident #1 on the 100 hall during the night shift (6p.m. to 6a.m.) for 1 and 1/2 months. LVN U said she first learned of Resident #1's broken hip from reading the 24 hour report and did not remember the exact note or if the broken hip was on the right or left side. LVN U said she did not remember giving Resident #1 any pain medication or if the CNAs told her the resident was in pain. LVN U said her assessment of Resident #1's broken hip was to ask the resident if she was experiencing any pain. LVN U said she did not remember Resident #1's answer to the question of pain. LVN U said she performed no further assessments for Resident #1. LVN U said she informed the CNAs caring for Resident #1 of the resident's broken hip. In an interview on 02/27/14 at 8:59 a.m., the BOM said LVN G approached her on 01/20/14 to ask about a pre- authorization for Resident #1's orthopedic doctor consult. The BOM said she called Resident #1's managed medicaid provider and found that the referral for Resident #1 to see the orthopedic doctor required only a doctor to doctor referral. The BOM said she told LVN G that the LVN needed to call Dr. M's office to obtain the referral. The BOM said LVN G told her she, LVN G, would call Dr. M. The BOM said she assumed LVN G had called to obtain the referral. The BOM said she had no further communication with LVN G regarding Resident #1's appointment. In an interview on 02/27/14 at 9:12 a.m., LVN G said she did not follow up on obtaining the appointment for Resident #1's orthopedic consult because the DON knew about it. LVN G said she assessed Resident #1's broken hip by asking if the resident had pain and by sometimes looking at the fracture site. LVN G said she performed no other assessments of Resident #1's broken hip. LVN G acknowledged she should have spoken to the DON, the Administrator, or Dr. M when days passed without an orthopedic appointment for Resident #1. In an interview on 02/27/14 at 11:14 a.m., CNA Q said she worked on the 100 hall and took care of Resident #1 for the previous 2 months. CNA Q said she was not informed by any other CNA or by the nurses that Resident #1 had a broken hip. CNA Q said Resident #1 never complained of pain or gave any non-verbal indication that she was in pain. CNA Q said approximately 1 and 1/2 months before, after she first started to provide care for Resident #1, she asked the resident how much assistance she needed for transfer. CNA Q said Resident #1 told her she could not stand and bear weight on her legs. CNA Q said Resident #1 did not tell her why she could not stand or bear weight. In an interview on 02/27/14 at 11:24 a.m., RN F said she had not conducted an assessment for significant change in condition for Resident #1 because, according to her review of nurses' notes, physician notes, ADL flowsheets, and [MEDICAL TREATMENT] communication sheets, she did not feel the resident had experienced changes in 2 different areas. RN F said records she reviewed for Resident #1 showed the resident had not had a change in mood and still required the assistance of 1 staff member for activities of daily living. RN F said she did not interview Resident #1 regarding sleep changes or changes in the resident's ability to stand and did not perform a physical assessment of the residnt's broken hip. RN F acknowledged that an assessment of Resident #1's broken hip and the impact to her life of the broken hip would require that she speak with and observe the resident. In an interview on 02/27/14 at 11:38 a.m., LVN R said she worked at the facility for approximately 1 year as an assessment nurse. LVN R said she had observed Resident #1 when she provided transportation for the resident to and from [MEDICAL TREATMENT]. LVN R said Resident #1 did not appear to be in pain during transportation. LVN R acknowledged she did not assess Resident #1 in the privacy of her room at the facility. LVN R said Resident #1's assessments were the responsibility of RN F. Review of Resident #1's Skilled MAR (Medication Administration Record) for January, 2014 revealed no evidence of the resident being administered the medication [MEDICATION NAME] (Tylenol) for pain. Review of Resdient #1's Skilled MAR for February, 2014 revealed evidence she was given 650 milligrams of [MEDICATION NAME] one time on 02/01/14 during the 2p.m. to 10p.m. time period. There was no evidence on the MAR indicated [REDACTED]. Review of facility 24 hour report sheets revealed the following notes made for Resident #1: -01/11/14 through 01/28/14 for finding of [MEDICAL CONDITION] and/or need for ortho consult -01/28/14 through 02/09/14 did not include the [MEDICAL CONDITION] or need for ortho consult -02/10/14 for direct admit to hospital under care of Dr. T Review of CMS S&C-05-09 dated 12/16/04, Clarification of Nursing Home Reporting for Alleged Violations of Mistreatment, Neglect, and Abuse, Includeing Injuries of Unknown Source, and Misappropriation of Resident Property revealed the following definition of neglect: -"Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness Review of the facility policy and procedure Change in a Resident's Condition or status, undated, revealed: -"If a change in the resident's physical or mental condition occurs, an assessment of the resident's condition should be conducted." -"Evaluate causes of change and intervene as indicated." -"Evaluate interventions or monitor resident as indicated." Review of the facility job description for Charge Nurse, undated, revealed job duties included: -"Review 24 hour report with incoming and outgoing Charge Nurse." -"Provides and oversees nursing care to assigned residents." -"Identify significant changes in the condition of residents and takes necessary action per facility policies and procedures." Review of the facility job description for Assessment Nurse dated 06/13, revealed job duties included: -"Check 24-hour report to ensure it is complete and reeflects residents requiring follow up due to acute illness, changes in status, incidents and accidents, etc. Target these residents for rounds." -"Perform walk through rounds, target residents that are identified on the 24-hour report." -"All follow-up identified during the morning start-up (meeting) that was unable to be completed prior to the end of the nurse managers' meeting should be given to the SADON (Staffing ADON) or QA for completion." -"Follow-up on residents after the morning meeting to determine if a change in the plan of care is needed." -"Monitor residents for decline in physical function and initiate Part B screens (for Medicare/Medicaid)." Review of the facility job description for Director of Nursing dated 06/13, revealed the job description included: -"Communicate and supervise nursing personnel with respect to professional conduct and counsel employees about job performance as needed." -"Review facility reports (i.e. facility QA reports and Simple CFS reports, etc.)." -"Review resident clinical records." It was determined the facility failure placed Resident #1 in an IJ situation from 01/11/14 through 02/10/14. The facility took the following corrective measures: -An audit was conducted to identify residents that needed to see physicians and appointments made were verified -X-rays were requested for the previous 30 days and reviewed for any needed follow up -Prior authorizations were verified for residents who requied these for their appointments -Nursing staff were given in-services regarding: 1. monitoring of residents with a change of condition and on follow up of all changes of condition until the condition was resolved 2.notification to the DON/Administrator for all changes in condition 3.residents' conditions were not removed from the 24 hour report until conditions resolved The surveyor reviewed residents with histories of pain and fractures. No issues were identified with unresolved pain or fractures. Interviews with the following nurses revealed they received training on follow up for changes of condition: -on 02/25/14 at 7:58 a.m. -- LVN D -on 02/25/14 at 8:49 a.m. -- RN F -on 02/25/14 at 9:35 a.m. -- LVN V -on 02/25/14 at 9:43 a.m. -- LVN A -on 02/25/14 at 1:05 p.m. -- LVN G This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-conpliance prior to the beginning of the survey. According to the CMS 802 provided on 02/24/14, there were 31 residents living on the 100 hall.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for 1 of 4 residents (#1) in 1 of 5 facility halls (100 hall) reviewed for history of pain and fracture. LVN G and RN F did not ensure an appointment was made to address treatment of [REDACTED]. The appointment with an orthopedic surgeon was made by RN B at Resident #1's [MEDICAL TREATMENT] treatment center. Resident #1 experienced severe pain, sleep disturbances, inability to bear weight on her leg, and inability to use her legs to self propel in her wheelchair. This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-conpliance prior to the beginning of the survey. The deficient practice resulted in delay of treatment for [REDACTED]. Findings: Review of CMS S&C-05-09 dated 12/16/04, Clarification of Nursing Home Reporting for Alleged Violations of Mistreatment, Neglect, and Abuse, Includeing Injuries of Unknown Source, and Misappropriation of Resident Property revealed the following definition of neglect: -"Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Review of the Facility Abuse Prohibition Policy and Procedure dated 07/13, revealed the policy was intented to "set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing home regulations as required by law." The policy included the area of training in "recognizing signs/symptoms of abuse" (and neglect). Review of Resident #1's Physician Orders dated February 2014, revealed she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed she was assessed as: -always understanding others and being understood by others -having no impairment of range of motion limits to the lower extremities -receiving [MEDICAL TREATMENT] -having no history of fractures -having no problems regarding mood/behavior/psychosocial areas In an interview on 02/24/14 at 11:36 a.m., the Administrator said Resident #1's Physician ordered x-rays in January after the resident told him she was in pain. The administrator said the x-rays showed Resident #1 had a [MEDICAL CONDITION] femur. The Administrator said Resident #1 had not experienced any recent incidents or accidents that could have resulted in the fracture. Review of Resident #1's Telephone Physician Orders revealed an order dated 01/10/14 for "pelvis x-ray, DX (diagnosis): pain" and Left "knee x-ray, DX pain." Review of pelvis and left knee x-ray taken on 01/11/14 revealed "acute intertrochanteric fracture proximal left femur" ([MEDICAL CONDITION]) and "unremarkable left knee." Review of Resident #1's Telephone Physician Orders revealed an order dated 01/11/14 for appointment with an orthopedic surgeon "the sooner the better, need to be scheduled." There was another order dated 02/07/14 for "Stat" hip x-ray. Review of Resident #1's Nurses Notes revealed evidence dated 01/11/14 by LVN G regarding an assessment of the resident's fracture site to the left hip. There were no other entries by nursing staff from 01/12/14 to 02/10/14 /regarding assessment of Resident #1's fracture site. Nurses Notes for Resident #1 indicated either no pain or no distress and did not specifically address the resident's fracture. Review of a portable left hip x-ray dated 02/07/14 revealed "Left femoral neck intertrochanteric fracture" that was "unchanged compared with 01/11/14 study." Review of a facility Resident Accident or Incident Report dated 02/10/14 revealed the following: -"resident c/o (complained of) pain to L (left) hip @ (at) [MEDICAL TREATMENT] on Friday 2-7-14. Dr. (N) wanted appt. (appointment) made (with) Dr. (T) (ortho). Dr. (M) was also here on 2-7-14 ordered stat (L) hip x-ray. Results received approx (approximately) 2-7-14 8PM (L) femoral neck introchanteric fx (fracture). No follow up was done. 6A-6P charge nurse followed up on 2-10-14. faxed x-ray report. Received orders for direct admit" to hospital. The report was signed by LVN K, the facility QA nurse. Review of nurses' notes from the [MEDICAL TREATMENT] center Resident #1 attended revealed: -01/21/14 by RN B that "pt (patient) c/o (complains of) pain to l (left) groin/hip. md (doctor) orders referral to dr.../ortho eval. (evaluation). pt c/o losing mobility/function/unable to bear wt. orders faxed to (phone number). will f/u (follow up)" -01/28/14 by RN S for "patient pending f/u w(with)/ortho for hip fx." -01/28/14 by RN B for "called dr. (ortho) office. appt (appointment) not scheduled d/t (due to) office does not accept pt. insurance." -evidence dated 02/11/14 by RN B for "received call from Dr. (T) office on 2/10/14. stated pt will be admitted to DT (downtown) hosp DX(diagnosis): fracture femur. Dr. (N) made aware." and "late entry for Friday 2/7/14: appt scheduled for with Dr (T) for ortho eval. spoke with (staff) at MD office. reports faxed from xrays done on 1/11/14. MD office requesting recent xray and orders for stat xray. call NH (nursing home)- spoke with nurse made aware of appt and need for stat xrays." Review of a Situation Background Assessment Recommendation (SBAR) Communication Form dated 02/10/14, revealed LVN A received a telephone call on 02/07/14 from RN B at the [MEDICAL TREATMENT] center requesting stat x-rays on Resident #1's hips because of the resident's report of pain to the hips while at [MEDICAL TREATMENT]. LVN A wrote that Dr. N at the [MEDICAL TREATMENT] center wanted Resident #1 seen by Orthopedic Surgeon, Dr. T. LVN A wrote that she notified Resident #1's Physician, Dr. M, and obtained orders for the stat x-rays. LVN A wrote that the x-ray results were received at 5:45 p.m. LVN A wrote that she gave report to LVN U. LVN A wrote that she was following up on 02/10/14 to assure the x-ray results had been sent to Dr. T's office. LVN A wrote that she faxed x-ray results to Dr T's office and was informed by Dr. T's office staff of orders by Dr. T to admit Resident #1 to the hospital for evaluation and treatment. LVN A wrote that she contacted Dr. M and notified him of Resident #1's admission to the hospital. LVN A wrote that Resident #1 was transferred to the hospital by ambulance that day. In an interview during an entrance conference on 02/24/14 at 11:36 a.m., the Administrator said Resident #1 had an x-ray in January, 2014 that showed she had a [MEDICAL CONDITION]. The Administrator said Dr. M ordered an appointment with an orthopedic doctor for evaluation and treatment. The Administrator said the appointment was not made because of lack of follow up to make the appointment and to obtain pre-authorization for the appointment. The Administrator said the nurses said they had been communicating with the DON about the need for the appointment and never informed him of the situation. The Administrator said the DON's employment had been terminated and a Corporate QA RN was acting DON until a new DON started employment. In an interview during initial tour on 02/24/14 at 12:45 p.m., LVN A described Resident #1 as alert, oriented, and having good short and long term memory. LVN A said Resident #1 was in the hospital following treatment for [REDACTED]. Observation on 02/24/14 at 4:30 p.m. revealed Resident #1 was lying in bed at a rehabilitation hospital. Resident #1 was positioned on her back with her hands folded over her stomach. Resident #1 was calm and answered questions readily. Resident #1 did not voice her current pain level until questioned specifically about current pain level. Resident #1 did not show signs of current pain; she was not moaning or grimacing. In an interview on 02/24/14 at 4:30 p.m., Resident #1 said she fell in her room at the facility in mid-September, 2013 and was immediately transferred to a hospital emergency room when she reported pain from the fall. X-rays taken at that time showed bruising but no fracture. Resident #1 said she continued to feel pain from the fall and was not able to bear weight on the left leg. Resident #1 said she told Dr. M about pain to the left hip and leg in January, 2014. Resident #1 said Dr. M ordered an x-ray. Resident #1 said LVN G told her the x-ray results showed she had a broken hip and that Dr. M had ordered an appointment for the resident to see an orthopedic doctor. Resident #1 said that approximately 1 month passed by without an appointment made for her to see the orthopedic doctor. Resident #1 said Dr. M saw her again in February, 2014 and asked if her groin still hurt. Resident #1 said after she told Dr. M that she was still feeling pain, more x-rays were obtained that showed she still had a broken hip. Resident #1 said she was transferred to a hospital on a Monday (corresponded to 02/10/14) where she saw Dr. T and had surgery. Resident #1 said the broken hip and the resulting pain affected her "a lot" and described the following: -she told staff at the facility she was in pain -she told LVNs G and P she was in pain and the nurses would give her Tylenol -she told LVNs G and P she couldn't bear weight on her left leg and couldn't turn to her left side while in bed -she was asking for pain medicine once or twice a day -she told LVN G many times that she was in pain, approximately 3 times a week -she asked LVN G about the appointment to see an orthopedic doctor and was told by LVN G the facility was waiting for some information -she told CNAs she was in pain and they would tell the nurses. she said she had to wait a long time, approximately 1 to 1 1/2 hours, to receive pain medicine and tended to wait longer at night. she did not know the names of the nurses on night shifts. Resident #1 described the effects of the broken hip and pain as: -she said she could not bear weight on her left leg -she could not self propel herself in the wheelchair because her groin would hurt -she sometimes could not sleep because of pain in the groin and would cry. She had difficulty finding a comfortable position. -she had to be careful to sit up and lay down because of pain to her left leg. She said CNAs I and E would help her, as well as LVN D during the day and CNA H on nights would help -she said she was bothered by pain when she turned to her left side during incontinent care but would support herself during the care -she said she had trouble transferring from her wheelchair to the shower chair and would have to sit sideways in the shower chair. She said CNA E helped her with showers. -she said pain from her groin/broken hip kept her from moving around and, as a result, she spent time sitting on the edge of her bed -she described the pain caused by the broken hip as a 7 or 8 on a scale of 1 to 10 where 1 was little pain with increasing pain to a level of 10. she described her current post surgery pain as a 10 and was receiving pain medication. Resident #1 said she also told staff, especially [MEDICAL TREATMENT] technician (DT) C, at the [MEDICAL TREATMENT] center that she had hip pain. Resident #1 said the [MEDICAL TREATMENT] center then contacted the facility about the pain she was experiencing. In an interview on 02/25/14 at 6:35 a.m., DT C said she had taken care of Resident #1 for 3 years and that the resident usually came to [MEDICAL TREATMENT] 3 times a week. DT C said prior to a fall in September, 2013, Resident #1 had no pain and could stand up without assistance. DT C said she would guide Resident #1 from her wheelchair to the [MEDICAL TREATMENT] chair because the resident was visually impaired. DT C said toward the end of November, 2013, Resident #1 told her of a fall and resulting pain. DT C said from that time on, Resident #1 required more assistance to stand. DT C said she had to physically lift Resident #1 to help her stand and that, when standing, the resident would place her full weight on her right leg. DT C said Resident #1 told her it hurt to try and bear weight on the left leg. DT C described Resident #1 as very quiet and as a person who rarely vocalized complaints of pain even after the injury. In an interview on 02/25/14 at 6:57 a.m., [MEDICAL TREATMENT] center RN B said that [MEDICAL TREATMENT] center Dr. N referred Resident #1 to an orthopedic doctor on 01/24/14 because the resident was losing mobility. RN B said she first attempted a referral to a doctor who did not accept the resident's insurance. RN B said she scheduled an appointment with Dr. T's office on 02/07/14 and received a call from Dr. T's office to admit Resident #1 to the hospital. In an interview on 02/25/14 at 7:58 a.m., LVN D said Resident #1 never complained of pain and she did not notice any change in her ability to transfer. LVN D said she was aware of Resident #1's broken hip and the need for an appointment with an orthopedic doctor but assumed the DON was following up on making the appointment. In an interview on 02/25/14 at 8:43 a.m., RN F said she became aware of Resident #1's broken hip on either 01/13/14 or 01/14/14 and told the DON about the issue. RN F said referral process passed to BOM O who in turn told LVN G to schedule the appointment with the orthopedic doctor. RN F said she did not follow up after this time as she felt the DON was then aware of the need for the appointment. RN F said she did not speak with either the Administrator or Dr. M, Resident #1's Physician, when days passed and the resident's appointment was not made. In an interview on 02/25/14 at 12:52 p.m., LVN G said she would ask Resident #1 if she had any pain and, when the resident responded "no," would ask no further questions. LVN G acknowledged she did not ask questions specifically about pain to Resident #1's broken hip. LVN G said she did not recall Resident #1 asking for pain medicine. LVN G said she did not tell the unit nurse manager, RN F, in January, 2014, about Resident #1's hip fracture because she felt the DON would be better able to help make the orthopedic doctor appointment. LVN G said she did not talk to either the Administrator or Dr. M about the need for Resident #1's doctor appointment. LVN G acknowledged that information regarding Resident #1's [MEDICAL CONDITION] and need for orthopedic appointment was not noted every day on the 24 hour report sheet and said she should have written it in the sheet. Interviews with the following facility CNAs revealed they said they were not told by the nurses that Resident #1 had a [MEDICAL CONDITION] and learned of the fracture when Resident #1 was transferred to the hospital in February, 2014. The CNAs said they did not notice any difference in Resident #1's ability to transfer from wheelchair to shower chair and did not recall the resident saying she was in pain. -on 02/25/14 at 8:20 a.m. -- CNA E -on 02/25/14 at 9:14 a.m. -- CNA H -on 02/25/14 at 10:55 a.m. -- CNA I -on 02/25/14 at 3:15 p.m. -- CNA J Telephone calls for interviews were made, unsuccessfully, with the following current or previous staff: -on 02/25/14 at 9:14 a.m. and 11:07 a.m. -- LVN P -on 02/26/14 at 2:13 p.m. -- RN S from [MEDICAL TREATMENT] center In an interview on 02/26/14 at 1:31 p.m., the QA nurse, LVN K, said concerns were brought and presented at morning meetings. LVN K said staff thought the DON was following up on the concern regarding Resident #1's broken hip and need for an orthopedic doctor appointment. LVN K said she remembered the issue was discussed at only one meeting and did not remember the number of mornings the need for the appointment was brought up. LVN K said RN F was responsible for follow up on resident issues on the 100 Hall. In an interview on 02/26/14 at 1:40 p.m., the acting DON said she did not doubt Resident #1 experienced pain and change in mobility from the broken hip. The acting DON said that, as soon as she arrived at the facility and learned of Resident #1's need for follow up with an orthopedic doctor, she began to work on the referral. The acting DON said Dr. N from the [MEDICAL TREATMENT] knew of an orthopedic doctor so the facility worked with the [MEDICAL TREATMENT] center to refer Resident #1 for treatment. In an interview on 02/26/14 at 2:30 p.m., the Social Worker said she attended morning meetings but usually did not stay for the whole meeting. The Social Worker said she found out about Resident #1's broken hip on the day after the resident was transferred to the hospital. The Social Worker said she was not asked to help obtain a pre- authorization for Resident #1's appointment with an orthopedic doctor. In a telephone interview on 02/26/14 at 3:06 p.m., Dr. M said Resident #1 told him in January, 2014, that her leg hurt and the pain went up to her upper leg. Dr. M said he ordered x-rays that revealed a [MEDICAL CONDITION]. Dr. M said he ordered an appointment be made for evaluation and treatment for [REDACTED]. Dr. M said when he did not hear anything from the nurses at the facility, he assumed Resident #1 had been seen by the orthopedic doctor. Dr. M said if facility nurses had told him Resident #1 had not been seen by an orthopedic doctor and was in pain, he would have ordered an immediate transfer to a hospital. In an interview on 02/26/14 at 3:07 p.m., LVN G said she did not remember Resident #1 asking about an appointment with an orthopedic doctor. LVN G said the reason she did not notify Dr. M was that, after she returned to work from a few days off, the notation on the 24 hour report sheet for Resident #1's orthopedic consult was no longer written in. LVN G said she had spoken with the DON about the appointment but was not given any answers by the DON. In a telephone interview on 02/26/14 at 8:05 p.m., the former DON said she first found out about Resident #1's hip fracture in February, 2014, following discovery of the x-rays from 02/07/14. The former DON said copies of the 24 hour report were made and distributed each morning to the Administrator, the DON, nurse managers, and the QA nurse. The former DON said the nurse managers would report on issues for each hall followed by the charge nurses from each hall reviewing the 24 hour report. The former DON said she had not read each 24 hour report entirely. The former DON said she supervised the nursing staff to assure that resident care was provided by performing spot checks on the nurses. The former DON said the spot checks consisted of pulling and reviewing resident charts and reviewing reports. The former DON said she would not routinely speak with residents but would interact with residents regarding concerns they may have had. The former DON said she never spoke with Resident #1. The former DON said she was assumed the nurses were providing care for residents because "other problems" seemed to be taken care of. In a telephone interview on 02/26/14 at 9:16 p.m., LVN U said she took care of Resident #1 on the 100 hall during the night shift (6p.m. to 6a.m.) for 1 and 1/2 months. LVN U said she first learned of Resident #1's broken hip from reading the 24 hour report and did not remember the exact note or if the broken hip was on the right or left side. LVN U said she did not remember giving Resident #1 any pain medication or if the CNAs told her the resident was in pain. LVN U said her assessment of Resident #1's broken hip was to ask the resident if she was experiencing any pain. LVN U said she did not remember Resident #1's answer to the question of pain. LVN U said she performed no further assessments for Resident #1. LVN U said she informed the CNAs caring for Resident #1 of the resident's broken hip. In an interview on 02/27/14 at 8:59 a.m., the BOM said LVN G approached her on 01/20/14 to ask about a pre- authorization for Resident #1's orthopedic doctor consult. The BOM said she called Resident #1's managed medicaid provider and found that the referral for Resident #1 to see the orthopedic doctor required only a doctor to doctor referral. The BOM said she told LVN G that the LVN needed to call Dr. M's office to obtain the referral. The BOM said LVN G told her she, LVN G, would call Dr. M. The BOM said she assumed LVN G had called to obtain the referral. The BOM said she had no further communication with LVN G regarding Resident #1's appointment. In an interview on 02/27/14 at 9:12 a.m., LVN G said she did not follow up on obtaining the appointment for Resident #1's orthopedic consult because the DON knew about it. LVN G said she assessed Resident #1's broken hip by asking if the resident had pain and by sometimes looking at the fracture site. LVN G said she performed no other assessments of Resident #1's broken hip. LVN G acknowledged she should have spoken to the DON, the Administrator or Dr. M when days passed without an orthopedic appointment for Resident #1. In an interview on 02/27/14 at 11:14 a.m., CNA Q said she worked on the 100 hall and took care of Resident #1 for the previous 2 months. CNA Q said she was not informed by any other CNA or by the nurses that Resident #1 had a broken hip. CNA Q said Resident #1 never complained of pain or gave any non-verbal indication that she was in pain. CNA Q said approximately 1 and 1/2 months before, after she first started to provide care for Resident #1, she asked the resident how much assistance she needed for transfer. CNA Q said Resident #1 told her she could not stand and bear weight on her legs. CNA Q said Resident #1 did not tell her why she could not stand or bear weight. In an interview on 02/27/14 at 11:24 a.m., RN F said she had not conducted an assessment for significant change in condition for Resident #1 because, according to her review of nurses' notes, physician notes, ADL flowsheets, and [MEDICAL TREATMENT] communication sheets, she did not feel the resident had experienced changes in 2 different areas. RN F said records she reviewed for Resident #1 showed the resident had not had a change in mood and still required the assistance of 1 staff member for activities of daily living. RN F said she did not interview Resident #1 regarding sleep changes or changes in the resident's ability to stand and did not perform a physical assessment of the residnt's broken hip. RN F acknowledged that an assessment of Resident #1's broken hip and the impact to her life of the broken hip would require that she speak with and observe the resident. In an interview on 02/27/14 at 11:38 a.m., LVN R said she worked at the facility for approximately 1 year as an assessment nurse. LVN R said she had observed Resident #1 when she provided transportation for the resident to and from [MEDICAL TREATMENT]. LVN R said Resident #1 did not appear to be in pain during transportation. LVN R acknowledged she did not assess Resident #1 in the privacy of her room at the facility. LVN R said Resident #1's assessments were the responsibility of RN F. Review of Resident #1's Skilled MAR (Medication Administration Record) for January, 2014 revealed no evidence of the resident being administered the medication [MEDICATION NAME] (Tylenol) for pain. Review of Resdient #1's Skilled MAR for February, 2014 revealed evidence she was given 650 milligrams of [MEDICATION NAME] one time on 02/01/14 during the 2p.m. to 10p.m. time period. There was no evidence on the MAR indicated [REDACTED]. Review of facility 24 hour report sheets revealed the following notes made for Resident #1: -01/11/14 through 01/28/14 for finding of [MEDICAL CONDITION] and/or need for ortho consult -01/28/14 through 02/09/14 did not include the [MEDICAL CONDITION] or need for ortho consult -02/10/14 for direct admit to hospital under care of Dr. T Review of the facility policy and procedure Change in a Resident's Condition or status, undated, revealed: -"If a change in the resident's physical or mental condition occurs, an assessment of the resident's condition should be conducted." -"Evaluate causes of change and intervene as indicated." -"Evaluate interventions or monitor resident as indicated." Review of the facility job description for Charge Nurse, undated, revealed job duties included: -"Review 24 hour report with incoming and outgoing Charge Nurse." -"Provides and oversees nursing care to assigned residents." -"Identify significant changes in the condition of residents and takes necessary action per facility policies and procedures." Review of the facility job description for Assessment Nurse dated 06/13, revealed job duties included: -"Check 24-hour report to ensure it is complete and reeflects residents requiring follow up due to acute illness, changes in status, incidents and accidents, etc. Target these residents for rounds." -"Perform walk through rounds, target residents that are identified on the 24-hour report." -"All follow-up identified during the morning start-up (meeting) that was unable to be completed prior to the end of the nurse managers' meeting should be given to the SADON (Staffing ADON) or QA for completion." -"Follow-up on residents after the morning meeting to determine if a change in the plan of care is needed." -"Monitor residents for decline in physical function and initiate Part B screens (for Medicare/Medicaid)." Review of the facility job description for Director of Nursing dated 06/13, revealed the job description included: -"Communicate and supervise nursing personnel with respect to professional conduct and counsel employees about job performance as needed." -"Review facility reports (i.e. facility QA reports and Simple CFS reports, etc.)." -"Review resident clinical records." It was determined the facility failure placed Resident #1 in an IJ situation from 01/11/14 through 02/10/14. The facility took the following corrective measures: -An audit was conducted to identify residents that needed to see physicians and appointments made were verified -X-rays were requested for the previous 30 days and reviewed for any needed follow up -Prior authorizations were verified for residents who requied these for their appointments -Nursing staff were given in-services regarding: 1. monitoring of residents with a change of condition and on follow up of all changes of condition until the condition was resolved 2.notification to the DON/Administrator for all changes in condition 3.residents' conditions were not removed from the 24 hour report until conditions resolved The surveyor reviewed residents with histories of pain and fractures. No issues were identified with unresolved pain or fractures. Interviews with the following nurses revealed they received training on follow up for changes of condition: -on 02/25/14 at 7:58 a.m. -- LVN D -on 02/25/14 at 8:49 a.m. -- RN F -on 02/25/14 at 9:35 a.m. -- LVN V -on 02/25/14 at 9:43 a.m. -- LVN A -on 02/25/14 at 1:05 p.m. -- LVN G This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-conpliance prior to the beginning of the survey. According to the CMS 802 provided on 02/24/14, there were 31 residents living on the 100 hall.

Based on observation, interview, and record review the facility failed to provide services that met professional standards of quality for 1 of 4 residents (#1) in 1 of 5 facility halls (100 hall) reviewed for history of pain and fractures. LVN G and RN F did not ensure an appointment was made to address treatment of [REDACTED]. Resident #1 experienced severe pain, sleep disturbances, inability to bear weight on her leg, and inability to use her legs to self propel in her wheelchair. LVN G 's assessment of Resident #1 for pain was limited to a yes/no question regarding pain and assessment of the fracture site was conducted infrequently. LVN G's assessment resulted in delay in identifying the need for prompt treatment of [REDACTED]. RN F was assigned as nurse manager and assessment nurse for Resident #1 and she did not interview the resident nor perform an assessment of Resident #1's [MEDICAL CONDITION] with the result of delay in identifying the need for prompt treatment of [REDACTED]. The DON did not supervise LVN G and RN F following discovery of Resident #1's [MEDICAL CONDITION] in order to assure the nurses made the orthopedic doctor appointment Resident #1 needed for treatment. This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-conpliance prior to the beginning of the survey. The deficient practice resulted in delay of treatment for [REDACTED]. Findings: Review of the Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice revealed standards applicable to all nurses included: -"(M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications;" -"(Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care;" -"U) Supervise nursing care provided by others for whom the nurse if professionally responsible;" Review of CMS S&C-05-09 dated 12/16/04, Clarification of Nursing Home Reporting for Alleged Violations of Mistreatment, Neglect, and Abuse, Includeing Injuries of Unknown Source, and Misappropriation of Resident Property revealed the following definition of neglect: -"Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Review of the facility job description for Charge Nurse, undated, revealed job duties included: -"Review 24 hour report with incoming and outgoing Charge Nurse." -"Provides and oversees nursing care to assigned residents." -"Identify significant changes in the condition of residents and takes necessary action per facility policies and procedures." Review of the facility job description for Assessment Nurse dated 06/13, revealed job duties included: -"Check 24-hour report to ensure it is complete and reeflects residents requiring follow up due to acute illness, changes in status, incidents and accidents, etc. Target these residents for rounds." -"Perform walk through rounds, target residents that are identified on the 24-hour report." -"All follow-up identified during the morning start-up (meeting) that was unable to be completed prior to the end of the nurse managers' meeting should be given to the SADON (Staffing ADON) or QA for completion." -"Follow-up on residents after the morning meeting to determine if a change in the plan of care is needed." -"Monitor residents for decline in physical function and initiate Part B screens (for Medicare/Medicaid)." Review of the facility job description for Director of Nursing dated 06/13, revealed the job description included: -"Communicate and supervise nursing personnel with respect to professional conduct and counsel employees about job performance as needed." -"Review facility reports (i.e. facility QA reports and Simple CFS reports, etc.)." -"Review resident clinical records." Review of the facility policy and procedure Change in a Resident's Condition or status, undated, revealed: -"If a change in the resident's physical or mental condition occurs, an assessment of the resident's condition should be conducted." -"Evaluate causes of change and intervene as indicated." -"Evaluate interventions or monitor resident as indicated." Review of Resident #1's Physician Orders dated February 2014, revealed she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed she was assessed as: -always understanding others and being understood by others -having no impairment of range of motion limits to the lower extremities -receiving [MEDICAL TREATMENT] -having no history of fractures -having no problems regarding mood/behavior/psychosocial areas In an interview on 02/24/14 at 11:36 a.m., the Administrator said Resident #1's Physician ordered x-rays in January after the resident told him she was in pain. The administrator said the x-rays showed Resident #1 had a [MEDICAL CONDITION] femur. The Administrator said Resident #1 had not experienced any recent incidents or accidents that could have resulted in the fracture. Review of Resident #1's Telephone Physician Orders revealed an order dated 01/10/14 for "pelvis x-ray, DX (diagnosis): pain" and Left "knee x-ray, DX pain." Review of pelvis and left knee x-ray taken on 01/11/14 revealed "acute intertrochanteric fracture proximal left femur" ([MEDICAL CONDITION]) and "unremarkable left knee." Review of Resident #1's Telephone Physician Orders revealed an order dated 01/11/14 for appointment with an orthopedic surgeon "the sooner the better, need to be scheduled." There was another order dated 02/07/14 for "Stat" hip x-ray. Review of Resident #1's Nurses Notes revealed evidence dated 01/11/14 by LVN G regarding an assessment of the resident's fracture site to the left hip. There were no other entries by nursing staff regarding assessment of Resident #1's fracture site. Nurses Notes for Resident #1 indicated either no pain or no distress and did not specifically address the resident's fracture. Review of a portable left hip x-ray dated 02/07/14 revealed "Left femoral neck intertrochanteric fracture" that was "unchanged compared with 01/11/14 study." Review of a facility Resident Accident or Incident Report dated 02/10/14 revealed the following: -"resident c/o (complained of) pain to L (left) hip @ (at) [MEDICAL TREATMENT] on Friday 2-7-14. Dr. (N) wanted appt. (appointment) made (with) Dr. (T) (ortho). Dr. (M) was also here on 2-7-14 ordered stat (L) hip x-ray. Results received approx (approximately) 2-7-14 8PM (L) femoral neck introchanteric fx (fracture). No follow up was done. 6A-6P charge nurse followed up on 2-10-14. faxed x-ray report. Received orders for direct admit" to hospital. The report was signed by LVN K, the facility QA nurse. Review of nurses' notes from the [MEDICAL TREATMENT] center Resident #1 attended revealed: -evidence dated 01/21/14 by RN B that "pt (patient) c/o (complains of) pain to l (left) groin/hip. md (doctor) orders referral to dr.../ortho eval. (evaluation). pt c/o losing mobility/function/unable to bear wt. orders faxed to (phone number). will f/u (follow up)" -evidence dated 01/28/14 by RN S for "patient pending f/u w(with)/ortho for hip fx." -evidence dated 01/28/14 by RN B for "called dr. (ortho) office. appt (appointment) not scheduled d/t (due to) office does not accept pt. insurance." -evidence dated 02/11/14 by RN B for "received call from Dr. (T) office on 2/10/14. stated pt will be admitted to DT (downtown) hosp DX(diagnosis): fracture femur. Dr. (N) made aware." and "late entry for Friday 2/7/14: appt scheduled for with Dr (T) for ortho eval. spoke with (staff) at MD office. reports faxed from xrays done on 1/11/14. MD office requesting recent xray and orders for stat xray. call NH (nursing home)- spoke with nurse made aware of appt and need for stat xrays." Review of a Situation Background Assessment Recommendation (SBAR) Communication Form dated 02/10/14, revealed evidence by LVN A of receiving a telephone call on 02/07/14 from RN B at the [MEDICAL TREATMENT] center requesting stat x-rays on Resident #1's hips because of the resident's report of pain to the hips while at [MEDICAL TREATMENT]. LVN A wrote that Dr. N at the [MEDICAL TREATMENT] center wanted Resident #1 seen by Orthopedic Surgeon, Dr. T. LVN A wrote that she notified Resident #1's Physician, Dr. M, and obtained orders for the stat x-rays. LVN A wrote that the x-ray results were received at 5:45 p.m. LVN A wrote that she gave report to LVN U. LVN A wrote that she was following up on 02/10/14 to assure the x-ray results had been sent to Dr. T's office. LVN A wrote that she faxed x-ray results to Dr T's office and was informed by Dr. T's office staff of orders by Dr. T to admit Resident #1 to the hospital for evaluation and treatment. LVN A wrote that she contacted Dr. M and notified him of Resident #1's admission to the hospital. LVN A wrote that Resident #1 was transferred to the hospital by ambulance that day. In an interview during an entrance conference on 02/24/14 at 11:36 a.m., the Administrator said Resident #1 had an x-ray in January, 2014 that showed she had a [MEDICAL CONDITION]. The Administrator said Dr. M ordered an appointment with an orthopedic doctor for evaluation and treatment. The Administrator said the appointment was not made because of lack of follow up to make the appointment and to obtain pre-authorization for the appointment. The Administrator said the nurses said they had been communicating with the DON about the need for the appointment and never informed him of the situation. The Administrator said the DON's employment had been terminated and a Corporate QA RN was acting DON until a new DON started employment. In an interview during initial tour on 02/24/14 at 12:45 p.m., LVN A described Resident #1 as alert, oriented, and having good short and long term memory. LVN A said Resident #1 was in the hospital following treatment for [REDACTED]. Observation on 02/24/14 at 4:30 p.m. revealed Resident #1 was laying in bed at a rehabilitation hospital. Resident #1 was positioned on her back with her hands folded over her stomach. Resident #1 was calm and answered questions readily. Resident #1 did not voice her current pain level until questioned specifically about current pain level. Resident #1 did not show signs of current pain; she was not moaning or grimacing. In an interview on 02/24/14 at 4:30 p.m., Resident #1 said she fell in her room at the facility in mid-September, 2013 and was immediately transferred to a hospital emergency room when she reported pain from the fall. X-rays taken at that time showed bruising but no fracture. Resident #1 said she continued to feel pain from the fall and was not able to bear weight on the left leg. Resident #1 said she told Dr. M about pain to the left hip and leg in January, 2014. Resident #1 said Dr. M ordered an x-ray. Resident #1 said LVN G told her the x-ray results showed she had a broken hip and that Dr. M had ordered an appointment for the resident to see an orthopedic doctor. Resident #1 said that approximately 1 month passed by without an appointment made for her to see the orthopedic doctor. Resident #1 said Dr. M saw her again in February, 2014 and asked if her groin still hurt. Resident #1 said after she told Dr. M that she was still feeling pain, more x-rays were obtained that showed she still had a broken hip. Resident #1 said she was transferred to a hospital on a Monday (corresponded to 02/10/14) where she saw Dr. T and had surgery. Resident #1 said the broken hip and the resulting pain affected her "a lot" and described the following: -she told staff at the facility she was in pain -she told LVNs G and P she was in pain and the nurses would give her Tylenol -she told LVNs G and P she couldn't bear weight on her left leg and couldn't turn to her left side while in bed -she was asking for pain medicine once or twice a day -she told LVN G many times that she was in pain, approximately 3 times a week -she asked LVN G about the appointment to see an orthopedic doctor and was told by LVN G the facility was waiting for some information -she told CNAs she was in pain and they would tell the nurses. she said she had to wait a long time, approximately 1 to 1/2 hours, to receive pain medicine and tended to wait longer at night. she did not know the names of the nurses on night shifts. Resident #1 described the effects of the broken hip and pain as: -she said she could not bear weight on her left leg -she could not self propel herself in the wheelchair because her groin would hurt -she sometimes could not sleep because of pain in the groin and would cry. she had difficulty finding a comfortable position. -she had to be careful to sit up and lay down because of pain to her left leg. she said CNAs I and E would help her, as well as LVN D during the day and CNA H on nights would help -she said she was bothered by pain when she turned to her left side during incontinent care but would support herself during the care -she said she had trouble transferring from her wheelchair to the shower chair and would have to sit sideways in the shower chair. she said CNA E helped her with showers. -she said pain from her groin/broken hip kept her from moving around and, as a result, she spent time sitting on the edge of her bed -she described the pain caused by the broken hip as a 7 or 8 on a scale of 1 to 10 where 1 was little pain with increasing pain to a level of 10. she described her current post surgery pain as a 10 and was receiving pain medication. Resident #1 said she also told staff, especially [MEDICAL TREATMENT] technician (DT) C, at the [MEDICAL TREATMENT] center that she had hip pain. Resident #1 said the [MEDICAL TREATMENT] center then contacted the facility about the pain she was experiencing. In an interview on 02/25/14 at 6:35 a.m., DT C said she had taken care of Resident #1 for 3 years and that the resident usually came to [MEDICAL TREATMENT] 3 times a week. DT C said prior to Resident #1's fall and hip pain, the resident had no pain and could stand up without assistance. DT C said she would guide Resident #1 from her wheelchair to the [MEDICAL TREATMENT] chair because the resident was visually impaired. DT C said toward the end of November, 2013, Resident #1 told her of the fall and the resulting pain. DT C said from that time on, Resident #1 required more assistance to stand. DT C said she had to physically lift Resident #1 to help her stand and that, when standing, the resident would place her full weight on her right leg. DT C said Resident #1 told her it hurt to try and bear weight on the left leg. DT C described Resident #1 as very quiet and as a person who rarely vocalized complaints of pain even after the injury. In an interview on 02/25/14 at 6:57 a.m., [MEDICAL TREATMENT] center RN B said that [MEDICAL TREATMENT] center Dr. N referred Resident #1 to an orthopedic doctor on 01/24/14 because the resident was losing mobility. RN B said she first attempted a referral to a doctor who did not accept the resident's insurance. RN B said she scheduled an appointment with Dr. T's office on 02/07/14 and received a call from Dr. T's office to admit Resident #1 to the hospital. In an interview on 02/25/14 at 8:43 a.m., RN F said she became aware of Resident #1's broken hip on either 01/13/14 or 01/14/14 and told the DON about the issue. RN F said referral process passed to BOM O who in turn told LVN G to schedule the appointment with the orthopedic doctor. RN F said she did not follow up after this time as she felt the DON was then aware of the need for the appointment. RN F said she did not speak with either the Administrator or Dr. M, Resident #1's Physician, when days passed and the resident's appointment was not made. In an interview on 02/25/14 at 12:52 p.m., LVN G said she would ask Resident #1 if she had any pain and, when the resident responded "no," would ask no further questions. LVN G said she did not recall Resident #1 asking for pain medicine. LVN G said she did not tell the unit nurse manager, RN F, in January, 2014, about Resident #1's [MEDICAL CONDITION] because she felt the DON would be better able to help make the orthopedic doctor appointment. LVN G said she did not talk to either the Administrator or Dr. M about the need for Resident #1's doctor appointment. LVN G acknowledged that information regarding Resident #1's [MEDICAL CONDITION] and need for orthopedic appointment was not noted every day on the 24 hour report sheet and said she should have written it in the sheet. In an interview on 02/26/14 at 1:31 p.m., the QA nurse, LVN K, said concerns were brought and presented at morning meetings. LVN K said staff thought the DON was following up on the concern regarding Resident #1's broken hip and need for an orthopedic doctor appointment. LVN K said she remembered the issue was discussed at only one meeting and did not remember the number of mornings the need for the appointment was brought up. LVN K said RN F was responsible for follow up on resident issues on the 100 Hall. In an interview on 02/26/14 at 1:40 p.m., the acting DON said she did not doubt Resident #1 experienced pain and change in mobility from the broken hip. The acting DON said that, as soon as she arrived at the facility and learned of Resident #1's need for follow up with an orthopedic doctor, she began to work on the referral. The acting DON said Dr. N from the [MEDICAL TREATMENT] knew of an orthopedic doctor so the facility worked with the [MEDICAL TREATMENT] center to refer Resident #1 for treatment. In a telephone interview on 02/26/14 at 3:06 p.m., Dr. M said Resident #1 told him in January, 2014, that her leg hurt and the pain went up to her upper leg. Dr. M said he ordered x-rays that revealed a [MEDICAL CONDITION]. Dr. M said he ordered an appointment be made for evaluation and treatment for [REDACTED]. Dr. M said when he did not hear anything from the nurses at the facility, he assumed Resident #1 had been seen by the orthopedic doctor. Dr. M said if facility nurses had told him Resident #1 had not been seen by an orthopedic doctor and was in pain, he would have ordered an immediate transfer to a hospital. In an interview on 02/26/14 at 3:07 p.m., LVN G said she did not remember Resident #1 asking about an appointment with an orthopedic doctor. LVN G said the reason she did not notify Dr. M was that, after she returned to work form a few days off, the notation on the 24 hour report sheet for Resident #1's orthopedic consult was no longer written in. LVN G said she had spoken with the DON about the appointment but was not given any answers by the DON. In an interview on 02/26/14 at 3:18 p.m., RN F said she did not assess Resident #1 for a possible significant change in condition because she did not think the resident met the criteria of change in at least 2 areas of assessment. In a telephone interview on 02/26/14 at 8:05 p.m., the former DON said she first found out about Resident #1's [MEDICAL CONDITION] in February, 2014, following discovery of the x-rays from 02/07/14. The former DON said copies of the 24 hour report were made and distributed each morning to the Administrator, the DON, nurse managers, and the QA nurse. The former DON said the nurse managers would report on issues for each hall followed by the charge nurses from each hall reviewing the 24 hour report. The former DON said she had not read each 24 hour report entirely. The former DON said she supervised the nursing staff to assure that resident care was provided by performing spot checks on the nurses. The former DON said the spot checks consisted of pulling and reviewing resident charts and reviewing reports. The former DON said she would not routinely speak with residents but would interact with residents regarding concerns they may have had. The former DON said she never spoke with Resident #1. The former DON said she was assurred the nurses were providing care for residents because "other problems" seemed to be taken care of. In an interview on 02/27/14 at 8:59 a.m., the BOM said LVN G approached her on 01/20/14 to ask about a pre-authorization for Resident #1's orthopedic doctor consult. The BOM said she called Resident #1's managed medicaid provider and found that the referral for Resident #1 to see the orthopedic doctor required only a doctor to doctor referral. The BOM said she told LVN G that the LVN needed to call Dr. M's office to obtain the referral. The Bom said LVN G told her she, LVN G, would call Dr. M. The BOM said she assumed LVN G had called to obtain the referral. The BOM said she had no further communication with LVN G regarding Resident #1's appointment. In an interview on 02/27/14 at 9:12 a.m., LVN G said she did not follow up on obtaining the appointment for Resident #1's orthopedic consult because the DON knew about it. LVN G said she assessed Resident #1's broken hip by asking if the resident had pain and by sometimes looking at the fracture site. LVN G said she performed no other assessments of Resident #1's broken hip. In an interview on 02/27/14 at 11:14 a.m., CNA Q said she worked on the 100 hall and took care of Resident #1 for the previous 2 months. CNA Q said she was not informed by any other CNA or by the nurses that Resident #1 had a broken hip. CNA Q said Resident #1 never complained of pain or gave any non-verbal indication that she was in pain. CNA Q said approximately 1 and 1/2 months before, after she first started to provide care for Resident #1, she asked the resident how much assistance she needed for transfer. CNA Q said Resident #1 told her she could not stand and bear weight on her legs. CNA Q said Resident #1 did not tell her why she could not stand or bear weight. In an interview on 02/27/14 at 11:24 a.m., RN F said she had not conducted an assessment for significant change in condition for Resident #1 because, according to her review of nurses' notes, physician notes, ADL flowsheets, and [MEDICAL TREATMENT] communication sheets, she did not feel the resident had experienced changes in 2 different areas. RN F said records she reviewed for Resident #1 showed the resident had not had a change in mood and still required the assistance of 1 staff member for activities of daily living. RN F said she did not interview Resident #1 regarding sleep changes or changes in the resident's ability to stand and did not perform a physical assessment of the residnt's broken hip. RN F acknowledged that an assessment of Resident #1's broken hip and the impact to her life of the broken hip would require that she speak with and observe the resident. In an interview on 02/27/14 at 11:38 a.m., LVN R said she worked at the facility for approximately 1 year as an assessment nurse. LVN R said Resident #1's assessments were the responsibility of RN F. Review of facility 24 hour report sheets revealed the following notes made for Resident #1: -01/11/14 through 01/28/14 for finding of [MEDICAL CONDITION] and/or need for ortho consult -01/28/14 through 02/09/14 did not include the [MEDICAL CONDITION] or need for ortho consult -02/10/14 for direct admit to hospital under care of Dr. T It was determined the facility failure placed Resident #1 in an IJ situation from 01/11/14 through 02/10/14. The facility took the following corrective measures: -An audit was conducted to identify residents that needed to see physicians and appointments made were verified -X-rays were requested for the previous 30 days and reviewed for any needed follow up -Prior authorizations were verified for residents who requied these for their appointments -Nursing staff were given in-services regarding: 1. monitoring of residents with a change of condition and on follow up of all changes of condition until the condition was resolved 2.notification to the DON/Administrator for all changes in condition 3.residents' conditions were not removed from the 24 hour report until conditions resolved The surveyor reviewed residents with histories of pain and fractures. No issues were identified with unresolved pain or fractures. Interviews with the following nurses revealed they received training on follow up for changes of condition: -on 02/25/14 at 7:58 a.m. -- LVN D -on 02/25/14 at 8:49 a.m. -- RN F -on 02/25/14 at 9:35 a.m. -- LVN V -on 02/25/14 at 9:43 a.m. -- LVN A -on 02/25/14 at 1:05 p.m. -- LVN G This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-conpliance prior to the beginning of the survey. According to the CMS 802 provided on 02/24/14, there were 31 residents living on the 100 hall.

Based on observation, interview, and record review, the facility failed to ensure each resident was provided with the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (#1) reviewed for history of fracture and pain. LVN G and RN F did not ensure an appointment was made, as ordered by the physician, to address treatment of [REDACTED]. The appointment with an orthopedic surgeon was made by RN B at Resident #1's [MEDICAL TREATMENT] treatment center. Resident #1 experienced severe pain, sleep disturbances, inability to bear weight on her leg, and inability to use her legs to self propel in her wheelchair. This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-conpliance prior to the beginning of the survey. The deficient practice resulted in delay of treatment for [REDACTED]. Findings: Review of Resident #1's Physician Orders dated February 2014, revealed she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed she was assessed as: -always understanding others and being understood by others -having no impairment of range of motion limits to the lower extremities -receiving [MEDICAL TREATMENT] -having no history of fractures -having no problems regarding mood/behavior/psychosocial areas In an interview on 02/24/14 at 11:36 a.m., the Administrator said Resident #1's Physician ordered x-rays in January after the resident told him she was in pain. The administrator said the x-rays showed Resident #1 had a [MEDICAL CONDITION] femur. The Administrator said Resident #1 had not experienced any recent incidents or accidents that could have resulted in the fracture. Review of Resident #1's Telephone Physician Orders revealed an order dated 01/10/14 for "pelvis x-ray, DX (diagnosis): pain" and Left "knee x-ray, DX pain." Review of pelvis and left knee x-ray taken on 01/11/14 revealed "acute intertrochanteric fracture proximal left femur" ([MEDICAL CONDITION]) and "unremarkable left knee." Review of Resident #1's Telephone Physician Orders revealed an order dated 01/11/14 for appointment with an orthopedic surgeon "the sooner the better, need to be scheduled." There was another order dated 02/07/14 for "Stat" hip x-ray. Review of Resident #1's Nurses Notes revealed evidence dated 01/11/14 by LVN G regarding an assessment of the resident's fracture site to the left hip. There were no other entries by nursing staff from 01/12/14 to 02/10/14 regarding assessment of Resident #1's fracture site. Nurses Notes for Resident #1 indicated either no pain or no distress and did not specifically address the resident's fracture. Review of a portable left hip x-ray dated 02/07/14 revealed "Left femoral neck intertrochanteric fracture" that was "unchanged compared with 01/11/14 study." Review of a facility Resident Accident or Incident Report dated 02/10/14 revealed the following: -"resident c/o (complained of) pain to L (left) hip @ (at) [MEDICAL TREATMENT] on Friday 2-7-14. Dr. (N) wanted appt. (appointment) made (with) Dr. (T) (ortho). Dr. (M) was also here on 2-7-14 ordered stat (L) hip x-ray. Results received approx (approximately) 2-7-14 8PM (L) femoral neck introchanteric fx (fracture). No follow up was done. 6A-6P charge nurse followed up on 2-10-14. faxed x-ray report. Received orders for direct admit" to hospital. The report was signed by LVN K, the facility QA nurse. Review of nurses' notes from the [MEDICAL TREATMENT] center Resident #1 attended revealed: -01/21/14 by RN B that "pt (patient) c/o (complains of) pain to l (left) groin/hip. md (doctor) orders referral to dr.../ortho eval. (evaluation). pt c/o losing mobility/function/unable to bear wt. orders faxed to (phone number). will f/u (follow up)" -01/28/14 by RN S for "patient pending f/u w(with)/ortho for hip fx." -01/28/14 by RN B for "called dr. (ortho) office. appt (appointment) not scheduled d/t (due to) office does not accept pt. insurance." -02/11/14 by RN B for "received call from Dr. (T) office on 2/10/14. stated pt will be admitted to DT (downtown) hosp DX(diagnosis): fracture femur. Dr. (N) made aware." and "late entry for Friday 2/7/14: appt scheduled for with Dr (T) for ortho eval. spoke with (staff) at MD office. reports faxed from xrays done on 1/11/14. MD office requesting recent xray and orders for stat xray. call NH (nursing home)- spoke with nurse made aware of appt and need for stat xrays." Review of a Situation Background Assessment Recommendation (SBAR) Communication Form dated 02/10/14, revealed LVN A received a telephone call on 02/07/14 from RN B at the [MEDICAL TREATMENT] center requesting stat x-rays on Resident #1's hips because of the resident's report of pain to the hips while at [MEDICAL TREATMENT]. LVN A wrote that Dr. N at the [MEDICAL TREATMENT] center wanted Resident #1 seen by Orthopedic Surgeon, Dr. T. LVN A wrote that she notified Resident #1's Physician, Dr. M, and obtained orders for the stat x-rays. LVN A wrote that the x-ray results were received at 5:45 p.m. LVN A wrote that she gave report to LVN U. LVN A wrote that she was following up on 02/10/14 to assure the x-ray results had been sent to Dr. T's office. LVN A wrote that she faxed x-ray results to Dr T's office and was informed by Dr. T's office staff of orders by Dr. T to admit Resident #1 to the hospital for evaluation and treatment. LVN A wrote that she contacted Dr. M and notified him of Resident #1's admission to the hospital. LVN A wrote that Resident #1 was transferred to the hospital by ambulance that day. In an interview during an entrance conference on 02/24/14 at 11:36 a.m., the Administrator said Resident #1 had an x-ray in January, 2014 that showed she had a [MEDICAL CONDITION]. The Administrator said Dr. M ordered an appointment with an orthopedic doctor for evaluation and treatment. The Administrator said the appointment was not made because of lack of follow up to make the appointment and to obtain pre-authorization for the appointment. The Administrator said the nurses said they had been communicating with the DON about the need for the appointment and never informed him of the situation. The Administrator said the DON's employment had been terminated and a Corporate QA RN was acting DON until a new DON started employment. In an interview during initial tour on 02/24/14 at 12:45 p.m., LVN A described Resident #1 as alert, oriented, and having good short and long term memory. LVN A said Resident #1 was in the hospital following treatment for [REDACTED]. Observation on 02/24/14 at 4:30 p.m. revealed Resident #1 was lying in bed at a rehabilitation hospital. Resident #1 was positioned on her back with her hands folded over her stomach. Resident #1 was calm and answered questions readily. Resident #1 did not voice her current pain level until questioned specifically about current pain level. Resident #1 did not show signs of current pain; she was not moaning or grimacing. In an interview on 02/24/14 at 4:30 p.m., Resident #1 said she fell in her room at the facility in mid-September, 2013 and was immediately transferred to a hospital emergency room when she reported pain from the fall. X-rays taken at that time showed bruising but no fracture. Resident #1 said she continued to feel pain from the fall and was not able to bear weight on the left leg. Resident #1 said she told Dr. M about pain to the left hip and leg in January, 2014. Resident #1 said Dr. M ordered an x-ray. Resident #1 said LVN G told her the x-ray results showed she had a broken hip and that Dr. M had ordered an appointment for the resident to see an orthopedic doctor. Resident #1 said that approximately 1 month passed by without an appointment made for her to see the orthopedic doctor. Resident #1 said Dr. M saw her again in February, 2014 and asked if her groin still hurt. Resident #1 said after she told Dr. M that she was still feeling pain, more x-rays were obtained that showed she still had a broken hip. Resident #1 said she was transferred to a hospital on a Monday (corresponded to 02/10/14) where she saw Dr. T and had surgery. Resident #1 said the broken hip and the resulting pain affected her "a lot" and described the following: -she told staff at the facility she was in pain -she told LVNs G and P she was in pain and the nurses would give her Tylenol -she told LVNs G and P she couldn't bear weight on her left leg and couldn't turn to her left side while in bed -she was asking for pain medicine once or twice a day -she told LVN G many times that she was in pain, approximately 3 times a week -she asked LVN G about the appointment to see an orthopedic doctor and was told by LVN G the facility was waiting for some information -she told CNAs she was in pain and they would tell the nurses. she said she had to wait a long time, approximately 1 to 1 1/2 hours, to receive pain medicine and tended to wait longer at night. She did not know the names of the nurses on night shifts. Resident #1 described the effects of the broken hip and pain as: -she said she could not bear weight on her left leg -she could not self propel herself in the wheelchair because her groin would hurt -she sometimes could not sleep because of pain in the groin and would cry. She had difficulty finding a comfortable position. -she had to be careful to sit up and lay down because of pain to her left leg. She said CNAs I and E would help her, as well as LVN D during the day and CNA H on nights would help -she said she was bothered by pain when she turned to her left side during incontinent care but would support herself during the care -she said she had trouble transferring from her wheelchair to the shower chair and would have to sit sideways in the shower chair. she said CNA E helped her with showers. -she said pain from her groin/broken hip kept her from moving around and, as a result, she spent time sitting on the edge of her bed -she described the pain caused by the broken hip as a 7 or 8 on a scale of 1 to 10 where 1 was little pain with increasing pain to a level of 10. she described her current post surgery pain as a 10 and was receiving pain medication. Resident #1 said she also told staff, especially [MEDICAL TREATMENT] technician (DT) C, at the [MEDICAL TREATMENT] center that she had hip pain. Resident #1 said the [MEDICAL TREATMENT] center then contacted the facility about the pain she was experiencing. In an interview on 02/25/14 at 6:35 a.m., DT C said she had taken care of Resident #1 for 3 years and that the resident usually came to [MEDICAL TREATMENT] 3 times a week. DT C said prior to a fall in September, 2013, Resident #1 had no pain and could stand up without assistance. DT C said she would guide Resident #1 from her wheelchair to the [MEDICAL TREATMENT] chair because the resident was visually impaired. DT C said toward the end of November, 2013, Resident #1 told her of a fall and resulting pain. DT C said from that time on, Resident #1 required more assistance to stand. DT C said she had to physically lift Resident #1 to help her stand and that, when standing, the resident would place her full weight on her right leg. DT C said Resident #1 told her it hurt to try and bear weight on the left leg. DT C described Resident #1 as very quiet and as a person who rarely vocalized complaints of pain even after the injury. In an interview on 02/25/14 at 6:57 a.m., [MEDICAL TREATMENT] center RN B said that [MEDICAL TREATMENT] center Dr. N referred Resident #1 to an orthopedic doctor on 01/24/14 because the resident was losing mobility. RN B said she first attempted a referral to a doctor who did not accept the resident's insurance. RN B said she scheduled an appointment with Dr. T's office on 02/07/14 and received a call from Dr. T's office to admit Resident #1 to the hospital. In an interview on 02/25/14 at 7:58 a.m., LVN D said Resident #1 never complained of pain and she did not notice any change in her ability to transfer. LVN D said she was aware of Resident #1's broken hip and the need for an appointment with an orthopedic doctor but assumed the DON was following up on making the appointment. In an interview on 02/25/14 at 8:43 a.m., RN F said she became aware of Resident #1's broken hip on either 01/13/14 or 01/14/14 and told the DON about the issue. RN F said referral process passed to BOM O who in turn told LVN G to schedule the appointment with the orthopedic doctor. RN F said she did not follow up after this time as she felt the DON was then aware of the need for the appointment. RN F said she did not speak with either the Administrator or Dr. M, Resident #1's Physician, when days passed and the resident's appointment was not made. In an interview on 02/25/14 at 12:52 p.m., LVN G said she would ask Resident #1 if she had any pain and, when the resident responded "no," would ask no further questions. LVN G acknowledged she did not ask questions specifically about pain to Resident #1's broken hip. LVN G said she did not recall Resident #1 asking for pain medicine. LVN G said she did not tell the unit nurse manager, RN F, in January, 2014, about Resident #1's [MEDICAL CONDITION] because she felt the DON would be better able to help make the orthopedic doctor appointment. LVN G said she did not talk to either the Administrator or Dr. M about the need for Resident #1's doctor appointment. LVN G acknowledged that information regarding Resident #1's [MEDICAL CONDITION] and need for orthopedic appointment was not noted every day on the 24 hour report sheet and said she should have written it in the sheet. Interviews with the following facility CNAs revealed they said they were not told by the nurses that Resident #1 had a [MEDICAL CONDITION] and learned of the fracture when Resident #1 was transferred to the hospital in February, 2014. The CNAs said they did not notice any difference in Resident #1's ability to transfer from wheelchair to shower chair and did not recall the resident saying she was in pain. -on 02/25/14 at 8:20 a.m. -- CNA E -on 02/25/14 at 9:14 a.m. -- CNA H -on 02/25/14 at 10:55 a.m. -- CNA I -on 02/25/14 at 3:15 p.m. -- CNA J Telephone calls for interviews were made, unsuccessfully, with the following current or previous staff: -on 02/25/14 at 9:14 a.m. and 11:07 a.m. -- LVN P -on 02/26/14 at 2:13 p.m. -- RN S from [MEDICAL TREATMENT] center In an interview on 02/26/14 at 1:31 p.m., the QA nurse, LVN K, said concerns were brought and presented at morning meetings. LVN K said staff thought the DON was following up on the concern regarding Resident #1's broken hip and need for an orthopedic doctor appointment. LVN K said she remembered the issue was discussed at only one meeting and did not remember the number of mornings the need for the appointment was brought up. LVN K said RN F was responsible for follow up on resident issues on the 100 Hall. In an interview on 02/26/14 at 1:40 p.m., the acting DON said she did not doubt Resident #1 experienced pain and change in mobility from the broken hip. The acting DON said that, as soon as she arrived at the facility and learned of Resident #1's need for follow up with an orthopedic doctor, she began to work on the referral. The acting DON said Dr. N from the [MEDICAL TREATMENT] knew of an orthopedic doctor so the facility worked with the [MEDICAL TREATMENT] center to refer Resident #1 for treatment. In an interview on 02/26/14 at 2:30 p.m., the Social Worker said she attended morning meetings but usually did not stay for the whole meeting. The Social Worker said she found out about Resident #1's broken hip on the day after the resident was transferred to the hospital. The Social Worker said she was not asked to help obtain a pre-authorization for Resident #1's appointment with an orthopedic doctor. In a telephone interview on 02/26/14 at 3:06 p.m., Dr. M said Resident #1 told him in January, 2014, that her leg hurt and the pain went up to her upper leg. Dr. M said he ordered x-rays that revealed a [MEDICAL CONDITION]. Dr. M said he ordered an appointment be made for evaluation and treatment for [REDACTED]. Dr. M said when he did not hear anything from the nurses at the facility, he assumed Resident #1 had been seen by the orthopedic doctor. Dr. M said if facility nurses had told him Resident #1 had not been seen by an orthopedic doctor and was in pain, he would have ordered an immediate transfer to a hospital. In an interview on 02/26/14 at 3:07 p.m., LVN G said she did not remember Resident #1 asking about an appointment with an orthopedic doctor. LVN G said the reason she did not notify Dr. M was that, after she returned to work from a few days off, the notation on the 24 hour report sheet for Resident #1's orthopedic consult was no longer written in. LVN G said she had spoken with the DON about the appointment but was not given any answers by the DON. In a telephone interview on 02/26/14 at 8:05 p.m., the former DON said she first found out about Resident #1's [MEDICAL CONDITION] in February, 2014, following discovery of the x-rays from 02/07/14. The former DON said copies of the 24 hour report were made and distributed each morning to the Administrator, the DON, nurse managers, and the QA nurse. The former DON said the nurse managers would report on issues for each hall followed by the charge nurses from each hall reviewing the 24 hour report. The former DON said she had not read each 24 hour report entirely. The former DON said she supervised the nursing staff to assure that resident care was provided by performing spot checks on the nurses. The former DON said the spot checks consisted of pulling and reviewing resident charts and reviewing reports. The former DON said she would not routinely speak with residents but would interact with residents regarding concerns they may have had. The former DON said she never spoke with Resident #1. The former DON said she was assumed the nurses were providing care for residents because "other problems" seemed to be taken care of. In a telephone interview on 02/26/14 at 9:16 p.m., LVN U said she took care of Resident #1 on the 100 hall during the night shift (6p.m. to 6a.m.) for 1 and 1/2 months. LVN U said she first learned of Resident #1's broken hip from reading the 24 hour report and did not remember the exact note or if the broken hip was on the right or left side. LVN U said she did not remember giving Resident #1 any pain medication or if the CNAs told her the resident was in pain. LVN U said her assessment of Resident #1's broken hip was to ask the resident if she was experiencing any pain. LVN U said she did not remember Resident #1's answer to the question of pain. LVN U said she performed no further assessments for Resident #1. LVN U said she informed the CNAs caring for Resident #1 of the resident's broken hip. In an interview on 02/27/14 at 8:59 a.m., the BOM said LVN G approached her on 01/20/14 to ask about a pre-authorization for Resident #1's orthopedic doctor consult. The BOM said she called Resident #1's managed medicaid provider and found that the referral for Resident #1 to see the orthopedic doctor required only a doctor to doctor referral. The BOM said she told LVN G that the LVN needed to call Dr. M's office to obtain the referral. The BOM said LVN G told her she, LVN G, would call Dr. M. The BOM said she assumed LVN G had called to obtain the referral. The BOM said she had no further communication with LVN G regarding Resident #1's appointment. In an interview on 02/27/14 at 9:12 a.m., LVN G said she did not follow up on obtaining the appointment for Resident #1's orthopedic consult because the DON knew about it. LVN G said she assessed Resident #1's broken hip by asking if the resident had pain and by sometimes looking at the fracture site. LVN G said she performed no other assessments of Resident #1's broken hip. LVN G acknowledged she should have spoken to the DON, the Administrator or Dr. M when days passed without an orthopedic appointment for Resident #1. In an interview on 02/27/14 at 11:14 a.m., CNA Q said she worked on the 100 hall and took care of Resident #1 for the previous 2 months. CNA Q said she was not informed by any other CNA or by the nurses that Resident #1 had a broken hip. CNA Q said Resident #1 never complained of pain or gave any non-verbal indication that she was in pain. CNA Q said approximately 1 and 1/2 months before, after she first started to provide care for Resident #1, she asked the resident how much assistance she needed for transfer. CNA Q said Resident #1 told her she could not stand and bear weight on her legs. CNA Q said Resident #1 did not tell her why she could not stand or bear weight. In an interview on 02/27/14 at 11:24 a.m., RN F said she had not conducted an assessment for significant change in condition for Resident #1 because, according to her review of nurses' notes, physician notes, ADL flowsheets, and [MEDICAL TREATMENT] communication sheets, she did not feel the resident had experienced changes in 2 different areas. RN F said records she reviewed for Resident #1 showed the resident had not had a change in mood and still required the assistance of 1 staff member for activities of daily living. RN F said she did not interview Resident #1 regarding sleep changes or changes in the resident's ability to stand and did not perform a physical assessment of the residnt's broken hip. RN F acknowledged that an assessment of Resident #1's broken hip and the impact to her life of the broken hip would require that she speak with and observe the resident. In an interview on 02/27/14 at 11:38 a.m., LVN R said she worked at the facility for approximately 1 year as an assessment nurse. LVN R said she had observed Resident #1 when she provided transportation for the resident to and from [MEDICAL TREATMENT]. LVN R said Resident #1 did not appear to be in pain during transportation. LVN R acknowledged she did not assess Resident #1 in the privacy of her room at the facility. LVN R said Resident #1's assessments were the responsibility of RN F. Review of Resident #1's Skilled MAR (Medication Administration Record) for January, 2014 revealed no evidence of the resident being administered the medication [MEDICATION NAME] (Tylenol) for pain. Review of Resdient #1's Skilled MAR for February, 2014 revealed evidence she was given 650 milligrams of [MEDICATION NAME] one time on 02/01/14 during the 2p.m. to 10p.m. time period. There was no evidence on the MAR indicated [REDACTED]. Review of facility 24 hour report sheets revealed the following notes made for Resident #1: -01/11/14 through 01/28/14 for finding of [MEDICAL CONDITION] and/or need for ortho consult -01/28/14 through 02/09/14 did not include the [MEDICAL CONDITION] or need for ortho consult -02/10/14 for direct admit to hospital under care of Dr. T Review of the facility policy and procedure Change in a Resident's Condition or status, undated, revealed: -"If a change in the resident's physical or mental condition occurs, an assessment of the resident's condition should be conducted." -"Evaluate causes of change and intervene as indicated." -"Evaluate interventions or monitor resident as indicated." Review of the facility job description for Charge Nurse, undated, revealed job duties included: -"Review 24 hour report with incoming and outgoing Charge Nurse." -"Provides and oversees nursing care to assigned residents." -"Identify significant changes in the condition of residents and takes necessary action per facility policies and procedures." Review of the facility job description for Assessment Nurse dated 06/13, revealed job duties included: -"Check 24-hour report to ensure it is complete and reeflects residents requiring follow up due to acute illness, changes in status, incidents and accidents, etc. Target these residents for rounds." -"Perform walk through rounds, target residents that are identified on the 24-hour report." -"All follow-up identified during the morning start-up (meeting) that was unable to be completed prior to the end of the nurse managers' meeting should be given to the SADON (Staffing ADON) or QA for completion." -"Follow-up on residents after the morning meeting to determine if a change in the plan of care is needed." -"Monitor residents for decline in physical function and initiate Part B screens (for Medicare/Medicaid)." Review of the facility job description for Director of Nursing dated 06/13, revealed the job description included: -"Communicate and supervise nursing personnel with respect to professional conduct and counsel employees about job performance as needed." -"Review facility reports (i.e. facility QA reports and Simple CFS reports, etc.)." -"Review resident clinical records." It was determined the facility failure placed Resident #1 in an IJ situation from 01/11/14 through 02/10/14. The facility took the following corrective measures: -An audit was conducted to identify residents that needed to see physicians and appointments made were verified -X-rays were requested for the previous 30 days and reviewed for any needed follow up -Prior authorizations were verified for residents who requied these for their appointments -Nursing staff were given in-services regarding: 1. monitoring of residents with a change of condition and on follow up of all changes of condition until the condition was resolved 2.notification to the DON/Administrator for all changes in condition 3.residents' conditions were not removed from the 24 hour report until conditions resolved The surveyor reviewed residents with histories of pain and fractures. No issues were identified with unresolved pain or fractures. Interviews with the following nurses revealed they received training on follow up for changes of condition: -on 02/25/14 at 7:58 a.m. -- LVN D -on 02/25/14 at 8:49 a.m. -- RN F -on 02/25/14 at 9:35 a.m. -- LVN V -on 02/25/14 at 9:43 a.m. -- LVN A -on 02/25/14 at 1:05 p.m. -- LVN G This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-conpliance prior to the beginning of the survey. According to the CMS 802 provided on 02/24/14, there were 31 residents living on the 100 hall.

Based on observation, interview, and record review, the DON failed to administer the faciity in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 4 residents (#1) reviewed for history of pain and fractures. The DON did not supervise LVN G and RN F following discovery of Resident #1's [MEDICAL CONDITION] in order to assure the nurses made the orthopedic doctor appointment Resident #1 needed for treatment. This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-conpliance prior to the beginning of the survey. The deficient practice resulted in delay of treatment for [REDACTED]. Findings: Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed she was assessed as: -always understanding others and being understood by others -having no impairment of range of motion limits to the lower extremities -receiving [MEDICAL TREATMENT] -having no history of fractures -having no problems regarding mood/behavior/psychosocial areas In an interview on 02/24/14 at 11:36 a.m., the Administrator said Resident #1's Physician ordered x-rays in January after the resident told him she was in pain. The administrator said the x-rays showed Resident #1 had a [MEDICAL CONDITION] femur. The Administrator said Resident #1 had not experienced any recent incidents or accidents that could have resulted in the fracture. Review of Resident #1's Telephone Physician order [REDACTED]." Review of pelvis and left knee x-ray taken on 01/11/14 revealed "acute intertrochanteric fracture proximal left femur" ([MEDICAL CONDITION]) and "unremarkable left knee." Review of Resident #1's Telephone Physician order [REDACTED]." There was another order dated 02/07/14 for "Stat" hip x-ray. Review of Resident #1's Nurses Notes revealed evidence dated 01/11/14 by LVN G regarding an assessment of the resident's fracture site to the left hip. There were no other entries by nursing staff regarding assessment of Resident #1's fracture site. Nurses Notes for Resident #1 indicated either no pain or no distress and did not specifically address the resident's fracture. Review of a portable left hip x-ray dated 02/07/14 revealed "Left femoral neck intertrochanteric fracture" that was "unchanged compared with 01/11/14 study." Review of a facility Resident Accident or Incident Report dated 02/10/14 revealed the following: -"resident c/o (complained of) pain to L (left) hip @ (at) [MEDICAL TREATMENT] on Friday 2-7-14. Dr. (N) wanted appt. (appointment) made (with) Dr. (T) (ortho). Dr. (M) was also here on 2-7-14 ordered stat (L) hip x-ray. Results received approx (approximately) 2-7-14 8PM (L) femoral neck introchanteric fx (fracture). No follow up was done. 6A-6P charge nurse followed up on 2-10-14. faxed x-ray report. Received orders for direct admit" to hospital. The report was signed by LVN K, the facility QA nurse. Review of nurses' notes from the [MEDICAL TREATMENT] center Resident #1 attended revealed: -evidence dated 01/21/14 by RN B that "pt (patient) c/o (complains of) pain to l (left) groin/hip. md (doctor) orders referral to dr.../ortho eval. (evaluation). pt c/o losing mobility/function/unable to bear wt. orders faxed to (phone number). will f/u (follow up)" -evidence dated 01/28/14 by RN S for "patient pending f/u w(with)/ortho for hip fx." -evidence dated 01/28/14 by RN B for "called dr. (ortho) office. appt (appointment) not scheduled d/t (due to) office does not accept pt. insurance." -evidence dated 02/11/14 by RN B for "received call from Dr. (T) office on 2/10/14. stated pt will be admitted to DT (downtown) hosp DX(diagnosis): fracture femur. Dr. (N) made aware." and "late entry for Friday 2/7/14: appt scheduled for with Dr (T) for ortho eval. spoke with (staff) at MD office. reports faxed from xrays done on 1/11/14. MD office requesting recent xray and orders for stat xray. call NH (nursing home)- spoke with nurse made aware of appt and need for stat xrays." Review of a Situation Background Assessment Recommendation (SBAR) Communication Form dated 02/10/14, revealed evidence by LVN A of receiving a telephone call on 02/07/14 from RN B at the [MEDICAL TREATMENT] center requesting stat x-rays on Resident #1's hips because of the resident's report of pain to the hips while at [MEDICAL TREATMENT]. LVN A wrote that Dr. N at the [MEDICAL TREATMENT] center wanted Resident #1 seen by Orthopedic Surgeon, Dr. T. LVN A wrote that she notified Resident #1's Physician, Dr. M, and obtained orders for the stat x-rays. LVN A wrote that the x-ray results were received at 5:45 p.m. LVN A wrote that she gave report to LVN U. LVN A wrote that she was following up on 02/10/14 to assure the x-ray results had been sent to Dr. T's office. LVN A wrote that she faxed x-ray results to Dr T's office and was informed by Dr. T's office staff of orders by Dr. T to admit Resident #1 to the hospital for evaluation and treatment. LVN A wrote that she contacted Dr. M and notified him of Resident #1's admission to the hospital. LVN A wrote that Resident #1 was transferred to the hospital by ambulance that day. In an interview during an entrance conference on 02/24/14 at 11:36 a.m., the Administrator said Resident #1 had an x-ray in January, 2014 that showed she had a [MEDICAL CONDITION]. The Administrator said Dr. M ordered an appointment with an orthopedic doctor for evaluation and treatment. The Administrator said the appointment was not made because of lack of follow up to make the appointment and to obtain pre-authorization for the appointment. The Administrator said the nurses said they had been communicating with the DON about the need for the appointment and never informed him of the situation. The Administrator said the DON's employment had been terminated and a Corporate QA RN was acting DON until a new DON started employment. In an interview during initial tour on 02/24/14 at 12:45 p.m., LVN A described Resident #1 as alert, oriented, and having good short and long term memory. LVN A said Resident #1 was in the hospital following treatment for [REDACTED]. Observation on 02/24/14 at 4:30 p.m. revealed Resident #1 was laying in bed at a rehabilitation hospital. Resident #1 was positioned on her back with her hands folded over her stomach. Resident #1 was calm and answered questions readily. Resident #1 did not voice her current pain level until questioned specifically about current pain level. Resident #1 did not show signs of current pain; she was not moaning or grimacing. In an interview on 02/24/14 at 4:30 p.m., Resident #1 said she fell in her room at the facility in mid-September, 2013 and was immediately transferred to a hospital emergency room when she reported pain from the fall. X-rays taken at that time showed bruising but no fracture. Resident #1 said she continued to feel pain from the fall and was not able to bear weight on the left leg. Resident #1 said she told Dr. M about pain to the left hip and leg in January, 2014. Resident #1 said Dr. M ordered an x-ray. Resident #1 said LVN G told her the x-ray results showed she had a broken hip and that Dr. M had ordered an appointment for the resident to see an orthopedic doctor. Resident #1 said that approximately 1 month passed by without an appointment made for her to see the orthopedic doctor. Resident #1 said Dr. M saw her again in February, 2014 and asked if her groin still hurt. Resident #1 said after she told Dr. M that she was still feeling pain, more x-rays were obtained that showed she still had a broken hip. Resident #1 said she was transferred to a hospital on a Monday (corresponded to 02/10/14) where she saw Dr. T and had surgery. Resident #1 said the broken hip and the resulting pain affected her "a lot" and described the following: -she told staff at the facility she was in pain -she told LVNs G and P she was in pain and the nurses would give her Tylenol -she told LVNs G and P she couldn't bear weight on her left leg and couldn't turn to her left side while in bed -she was asking for pain medicine once or twice a day -she told LVN G many times that she was in pain, approximately 3 times a week -she asked LVN G about the appointment to see an orthopedic doctor and was told by LVN G the facility was waiting for some information -she told CNAs she was in pain and they would tell the nurses. she said she had to wait a long time, approximately 1 to 1/2 hours, to receive pain medicine and tended to wait longer at night. she did not know the names of the nurses on night shifts. Resident #1 described the effects of the broken hip and pain as: -she said she could not bear weight on her left leg -she could not self propel herself in the wheelchair because her groin would hurt -she sometimes could not sleep because of pain in the groin and would cry. she had difficulty finding a comfortable position. -she had to be careful to sit up and lay down because of pain to her left leg. she said CNAs I and E would help her, as well as LVN D during the day and CNA H on nights would help -she said she was bothered by pain when she turned to her left side during incontinent care but would support herself during the care -she said she had trouble transferring from her wheelchair to the shower chair and would have to sit sideways in the shower chair. she said CNA E helped her with showers. -she said pain from her groin/broken hip kept her from moving around and, as a result, she spent time sitting on the edge of her bed -she described the pain caused by the broken hip as a 7 or 8 on a scale of 1 to 10 where 1 was little pain with increasing pain to a level of 10. she described her current post surgery pain as a 10 and was receiving pain medication. Resident #1 said she also told staff, especially [MEDICAL TREATMENT] technician (DT) C, at the [MEDICAL TREATMENT] center that she had hip pain. Resident #1 said the [MEDICAL TREATMENT] center then contacted the facility about the pain she was experiencing. In an interview on 02/25/14 at 6:35 a.m., DT C said she had taken care of Resident #1 for 3 years and that the resident usually came to [MEDICAL TREATMENT] 3 times a week. DT C said prior to Resident #1's fall and hip pain, the resident had no pain and could stand up without assistance. DT C said she would guide Resident #1 from her wheelchair to the [MEDICAL TREATMENT] chair because the resident was visually impaired. DT C said toward the end of November, 2013, Resident #1 told her of the fall and the resulting pain. DT C said from that time on, Resident #1 required more assistance to stand. DT C said she had to physically lift Resident #1 to help her stand and that, when standing, the resident would place her full weight on her right leg. DT C said Resident #1 told her it hurt to try and bear weight on the left leg. DT C described Resident #1 as very quiet and as a person who rarely vocalized complaints of pain even after the injury. In an interview on 02/25/14 at 6:57 a.m., [MEDICAL TREATMENT] center RN B said that [MEDICAL TREATMENT] center Dr. N referred Resident #1 to an orthopedic doctor on 01/24/14 because the resident was losing mobility. RN B said she first attempted a referral to a doctor who did not accept the resident's insurance. RN B said she scheduled an appointment with Dr. T's office on 02/07/14 and received a call from Dr. T's office to admit Resident #1 to the hospital. In an interview on 02/25/14 at 8:43 a.m., RN F said she became aware of Resident #1's broken hip on either 01/13/14 or 01/14/14 and told the DON about the issue. RN F said referral process passed to BOM O who in turn told LVN G to schedule the appointment with the orthopedic doctor. RN F said she did not follow up after this time as she felt the DON was then aware of the need for the appointment. RN F said she did not speak with either the Administrator or Dr. M, Resident #1's Physician, when days passed and the resident's appointment was not made. In an interview on 02/25/14 at 12:52 p.m., LVN G said she would ask Resident #1 if she had any pain and, when the resident responded "no," would ask no further questions. LVN G said she did not recall Resident #1 asking for pain medicine. LVN G said she did not tell the unit nurse manager, RN F, in January, 2014, about Resident #1's [MEDICAL CONDITION] because she felt the DON would be better able to help make the orthopedic doctor appointment. LVN G said she did not talk to either the Administrator or Dr. M about the need for Resident #1's doctor appointment. LVN G acknowledged that information regarding Resident #1's [MEDICAL CONDITION] and need for orthopedic appointment was not noted every day on the 24 hour report sheet and said she should have written it in the sheet. In an interview on 02/26/14 at 1:31 p.m., the QA nurse, LVN K, said concerns were brought and presented at morning meetings. LVN K said staff thought the DON was following up on the concern regarding Resident #1's broken hip and need for an orthopedic doctor appointment. LVN K said she remembered the issue was discussed at only one meeting and did not remember the number of mornings the need for the appointment was brought up. LVN K said RN F was responsible for follow up on resident issues on the 100 Hall. In an interview on 02/26/14 at 1:40 p.m., the acting DON said she did not doubt Resident #1 experienced pain and change in mobility from the broken hip. The acting DON said that, as soon as she arrived at the facility and learned of Resident #1's need for follow up with an orthopedic doctor, she began to work on the referral. The acting DON said Dr. N from the [MEDICAL TREATMENT] knew of an orthopedic doctor so the facility worked with the [MEDICAL TREATMENT] center to refer Resident #1 for treatment. In a telephone interview on 02/26/14 at 3:06 p.m., Dr. M said Resident #1 told him in January, 2014, that her leg hurt and the pain went up to her upper leg. Dr. M said he ordered x-rays that revealed a [MEDICAL CONDITION]. Dr. M said he ordered an appointment be made for evaluation and treatment for [REDACTED]. Dr. M said when he did not hear anything from the nurses at the facility, he assumed Resident #1 had been seen by the orthopedic doctor. Dr. M said if facility nurses had told him Resident #1 had not been seen by an orthopedic doctor and was in pain, he would have ordered an immediate transfer to a hospital. In an interview on 02/26/14 at 3:07 p.m., LVN G said she did not remember Resident #1 asking about an appointment with an orthopedic doctor. LVN G said the reason she did not notify Dr. M was that, after she returned to work form a few days off, the notation on the 24 hour report sheet for Resident #1's orthopedic consult was no longer written in. LVN G said she had spoken with the DON about the appointment but was not given any answers by the DON. In an interview on 02/26/14 at 3:18 p.m., RN F said she did not assess Resident #1 for a possible significant change in condition because she did not think the resident met the criteria of change in at least 2 areas of assessment. In a telephone interview on 02/26/14 at 8:05 p.m., the former DON said she first found out about Resident #1's [MEDICAL CONDITION] in February, 2014, following discovery of the x-rays from 02/07/14. The former DON said copies of the 24 hour report were made and distributed each morning to the Administrator, the DON, nurse managers, and the QA nurse. The former DON said the nurse managers would report on issues for each hall followed by the charge nurses from each hall reviewing the 24 hour report. The former DON said she had not read each 24 hour report entirely. The former DON said she supervised the nursing staff to assure that resident care was provided by performing spot checks on the nurses. The former DON said the spot checks consisted of pulling and reviewing resident charts and reviewing reports. The former DON said she would not routinely speak with residents but would interact with residents regarding concerns they may have had. The former DON said she never spoke with Resident #1. The former DON said she was assurred the nurses were providing care for residents because "other problems" seemed to be taken care of. In an interview on 02/27/14 at 8:59 a.m., the BOM said LVN G approached her on 01/20/14 to ask about a pre-authorization for Resident #1's orthopedic doctor consult. The BOM said she called Resident #1's managed medicaid provider and found that the referral for Resident #1 to see the orthopedic doctor required only a doctor to doctor referral. The BOM said she told LVN G that the LVN needed to call Dr. M's office to obtain the referral. The Bom said LVN G told her she, LVN G, would call Dr. M. The BOM said she assumed LVN G had called to obtain the referral. The BOM said she had no further communication with LVN G regarding Resident #1's appointment. In an interview on 02/27/14 at 9:12 a.m., LVN G said she did not follow up on obtaining the appointment for Resident #1's orthopedic consult because the DON knew about it. LVN G said she assessed Resident #1's broken hip by asking if the resident had pain and by sometimes looking at the fracture site. LVN G said she performed no other assessments of Resident #1's broken hip. In an interview on 02/27/14 at 11:24 a.m., RN F said she had not conducted an assessment for significant change in condition for Resident #1 because, according to her review of nurses' notes, physician notes, ADL flowsheets, and [MEDICAL TREATMENT] communication sheets, she did not feel the resident had experienced changes in 2 different areas. RN F said records she reviewed for Resident #1 showed the resident had not had a change in mood and still required the assistance of 1 staff member for activities of daily living. RN F said she did not interview Resident #1 regarding sleep changes or changes in the resident's ability to stand and did not perform a physical assessment of the residnt's broken hip. RN F acknowledged that an assessment of Resident #1's broken hip and the impact to her life of the broken hip would require that she speak with and observe the resident. Review of facility 24 hour report sheets revealed the following notes made for Resident #1: -01/11/14 through 01/28/14 for finding of [MEDICAL CONDITION] and/or need for ortho consult -01/28/14 through 02/09/14 did not include the [MEDICAL CONDITION] or need for ortho consult -02/10/14 for direct admit to hospital under care of Dr. T Review of the Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice revealed standards applicable to all nurses included: -"U) Supervise nursing care provided by others for whom the nurse if professionally responsible;" Review of CMS S&C-05-09 dated 12/16/04, Clarification of Nursing Home Reporting for Alleged Violations of Mistreatment, Neglect, and Abuse, Includeing Injuries of Unknown Source, and Misappropriation of Resident Property revealed the following definition of neglect: -"Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Review of the facility job description for Director of Nursing dated 06/13, revealed the job description included: -"Communicate and supervise nursing personnel with respect to professional conduct and counsel employees about job performance as needed." -"Review facility reports (i.e. facility QA reports and Simple CFS reports, etc.)." -"Review resident clinical records." It was determined the facility failure placed Resident #1 in an IJ situation from 01/11/14 through 02/10/14. The facility took the following corrective measures: -The DON's employment with the faciity was terminated and the DON was referred to the Board of Nursing -An audit was conducted to identify residents that needed to see physicians and appointments made were verified -X-rays were requested for the previous 30 days and reviewed for any needed follow up -Prior authorizations were verified for residents who requied these for their appointments -Nursing staff were given in-services regarding: 1. monitoring of residents with a change of condition and on follow up of all changes of condition until the condition was resolved 2.notification to the DON/Administrator for all changes in condition 3.residents' conditions were not removed from the 24 hour report until conditions resolved The surveyor reviewed residents with histories of pain and fractures. No issues were identified with unresolved pain or fractures. Interviews with the following nurses revealed they received training on follow up for changes of condition: -on 02/25/14 at 7:58 a.m. -- LVN D -on 02/25/14 at 8:49 a.m. -- RN F -on 02/25/14 at 9:35 a.m. -- LVN V -on 02/25/14 at 9:43 a.m. -- LVN A -on 02/25/14 at 1:05 p.m. -- LVN G This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-conpliance prior to the beginning of the survey. According to the CMS 802 provided on 02/24/14, there were 31 residents living on the 100 hall.