Every finding on record at Pierremont Healthcare Center

Based on record reviews, observations and interviews the facility failed to provide appropriate infection control practices for 1 (#3) of 1 resident reviewed with an indwelling catheter. The facility failed to provide privacy and use appropriate infection control practices when removing Resident #3's catheter. Findings:Review of facility's Urinary Catheter Policy with a revision date of June 2025 revealed in part;Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections.Preparation: 2. Assemble the equipment and supplies as needed.General Guidelines: 1. Following aseptic techniques of the urinary catheter, maintain a closed drainage system. Use Enhanced barrier precautions. Changing Catheters:Equipment and SuppliesThe following equipment and supplies will be necessary when performing this procedure:1. Wash basin;2. Soap and water;3. Wash cloth;4. Towel;5. Bed protector; and6. Gown, gloves and mask (follow Enhanced Barrier Precautions.)Steps in the Procedure:3. Fill the wash basin one-half (1/20) full of warm water. Place the wash basin on the bedside stand within easy reach.7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry.12. Provide privacy. Cover the resident with a sheet, exposing only the perineal area.Review of 802 Roster Matrix revealed Resident #3 had an indwelling catheter. Review of Resident #3's face sheet revealed initial admission date of 03/20/2026 and a re-entry admission date of 05/18/2026 with the following diagnoses but not limited to muscle weakness (generalized), gram-negative sepsis, bacteremia, sepsis due to enterococcus, and urinary tract infection.Review of Resident #3's June 2026 Physician Orders revealed an order dated 06/09/2026 to change urinary catheter afterwards collect urinalysis with reflex.During an interview on 06/09/2026 at 2:55 p.m. S5 LPN (Licensed Practical Nurse) reported Resident #3 had an order for a culture with catheter change on Resident #3.Observation on 06/09/2026 at 3:00 p.m. revealed S5 LPN, S6 LPN, and S7 CNA (Certified Nurse Assistant) Coordinator failed to close the blinds to the outside to provide privacy for Resident #3. S5 LPN failed to bring a bag to dispose of linen and waste that would be used during procedure. S5 LPN failed to set up a basin with soap and water. S5 LPN removed Resident #3's catheter with assistance from S6 LPN and S7 CNA Coordinator. Further observation revealed Resident #3 had a bowel movement. During perineal care, S6 LPN exited Resident #3's room with the contaminated PPE on to retrieve linen and supplies. S5 LPN failed to cover Resident #3's exposed lower body while awaiting S6 LPN return with linen and supplies. S6 LPN returned to Resident #3's room with the contaminated PPE. During an interview on 06/09/2026 at 3:30 p.m. S3 Infection Control Nurse reported staff should have removed contaminated PPE before exiting a resident's room on EBP. Staff should have brought another bag to dispose of linen and waste used during a catheter change procedure. During an interview on 06/09/2026 at 3:45 p.m. S5 LPN confirmed privacy was not provided to Resident #3 during catheter removal. S5 LPN confirmed a bag to dispose of linen and waste that was used during procedure was not provided. S5 LPN confirmed a basin with soap and water was not set up for the procedure. During an interview on 6/10/2026 at 8:30 a.m. S6 LPN confirmed the contaminated PPE was not removed and disposed of properly when leaving Resident #3's room. S6 LPN confirmed returning with linen and supplies to Resident #3's room with the same contaminated PPE on.

Based on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure:Enhanced Barrier Precautions (EBP) posted outside the resident's room for 1 (Resident #2) of 3 residents reviewed for EBP, Suctioning supplies were stored properly for 1 (Resident #1) of 3 residents who needed respiratory care, including tracheostomy care Findings: Review of the facility's Enhanced Barrier Precautions (EBP) policy dated 04/01/2024 revealed in part:Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employ targeted gown and glove use during high contact resident care activities.EBP are indicated for residents with any of the following:Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.Communication to Staff/Medical Professionals:The facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP. Resident #2 Review of the facility's roster matrix revealed Resident #2 had a tracheostomy. Review of Resident #2's face sheet revealed an admission date to the facility on [DATE] with the following diagnoses but not limited to Malignant Neoplasm of the larynx, Malignant Neoplasm of the supraglottis, acute respiratory failure with hypoxia, tracheostomy, gastrostomy, and acute respiratory distress.Review of Resident #2's current care plan revealed in part, resident required Enhanced Barrier Precaution related to tracheostomy with an intervention to apply signage outside resident room.Observation on 06/08/2026 and 06/09/2026 failed to reveal EBP signage outside Resident #2's room.During an Interview on 06/09/2026 at 1:55 p.m., S3 Infection Control Nurse acknowledged there was no EBP signage outside Resident #2's room but should have been. Resident #1Review of Resident #1's face sheet revealed an initial admission date of 12/23/2024 and a re-entry date of 03/23/2026 with following diagnoses revealed in part but not limited to quadriplegia and tracheostomy status. Review of facility policy on Infection Control with a revision date 06/30/2025 revealed in part:Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observation on 06/08/2026 at 1:00 p.m. revealed Resident #1's yankauer suction was in Resident #1's bedside table drawer without being properly placed in a plastic bag. During an interview on 6/8/2026 at 1:15 p.m. S4 LPN (Licensed Practical Nurse) reported Resident #1's yankauer suction should be stored in a plastic bag and labeled. During an interview on 6/10/2026 at 2:30 p.m. S1 Corporate Nurse reported Resident #1's yankauer suction should be stored in a plastic bag and not just be stored in Resident #1's bedside drawer.

Based on observations and interviews the facility failed to accommodate the needs of 2 (#5, #100) out of 4 (#5, #15, #21, #100) residents reviewed for environment. The facility failed to ensure:Resident #5 had a cord on the wall light next to the bed.Resident #100's bathroom emergency call light was functional.Findings:Resident #5Review of Resident #5's record revealed Resident #5 had a BIMS score of 14 indicating intact cognition. During an interview on 02/10/2026 at 7:59 a.m., Resident #5 reported the wall light next to her bed didn't work. Observation on 02/10/2026 at 7:59 a.m. revealed Resident #5's over-bed light on the wall did not have a pull cord to turn it on. During an interview on 02/10/2026 at 8:17 a.m., S17 CNA confirmed Resident #5's wall light did not have a pull cord to turn it on. Observation on 02/12/2026 at 8:18 a.m. revealed Resident #5's wall light did not have a pull cord to turn it on. During an interview on 02/12/2026 at 8:20 a.m., S17 CNA reported they told S1 Administrator on 02/11/2026 Resident #5's wall light did not have a cord to turn it on.During an interview on 02/12/2026 at 8:58 a.m., S18 Maintenance Supervisor observed Resident #5's wall light and confirmed it was missing the entire light switch and the pull cord that attached to the switch and needed to be repaired. Resident #100Review of Resident #100's 5 Day MDS assessment dated [DATE] revealed Resident #100 had a BIMS score of 11 indicating moderately impaired cognition. Observation on 02/09/2026 at 9:00 a.m. revealed Resident #100's bathroom emergency call light did not activate the call system when pulled. During an interview on 02/09/2026 at 9:00 a.m., Resident #100 reported she used the bathroom for toileting, washing her hands, and brushing her teeth. During an interview on 02/09/2026 at 9:05 a.m., S16 Social Worker entered Resident #100's room, and confirmed Resident #100's bathroom emergency call light did not work. Observation on 02/12/2026 at 9:02 a.m. revealed Resident #100's bathroom emergency call light did not activate the call system when pulled. During an interview on 02/12/2026 at 9:03 a.m., S18 Maintenance Supervisor observed Resident #100's bathroom emergency call light with surveyor and confirmed it did not work and needed to be fixed again or replaced.

Based on record reviews, observations, and interviews, the facility failed to provide services to prevent further contractures and potential decline in range of motion for 2 (#24, #81 ) of 2 residents reviewed for positioning & mobility. Findings: Resident #24 Review of Resident #24's medical record revealed an admit date of 11/01/2019 with diagnoses, including in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and contracture right hand. Review of Resident #24's MDS assessment dated [DATE] revealed a functional status of dependent on dressing, toileting, bed mobility, transfers, shower/bathe, eating and personal hygiene. Review of Resident #24's Physician's orders revealed orders dated 12/31/2025 for resident to wear right elbow extension hand splint, on before breakfast, off after lunch or as tolerated. Resident to receive RNP services at least 6 x week for PROM and splinting due to diagnosis of CVA. Review of Resident #24's comprehensive care plan revealed: Resident at risk for loss of ROM - Splints as ordered. Observation on 02/09/2026 at 8:15 a.m. revealed Resident #24's right hand was contracted. Further observation revealed right hand contracted inward and splint lying on bedside table. Observation on 02/10/26 at 8:30 a.m. revealed Resident #24's right hand was contracted. Further observation revealed right elbow extension hand splint on bedside table. Observation on 02/11/2026 at 9:15 a.m. revealed Resident #24's right hand was contracted. Further observation revealed right elbow extension hand splint on bedside table. During an interview on 02/11/2026 at 11:50 a.m., S4 Restorative Aide reported Resident #24 had orders to place the splint once a day. S4 Restorative Aide confirmed on 02/09/2026 and 02/10/2026 she and the other restorative aide were working on the floors and were unable to apply the splint to Resident #24's right hand. Resident #81 Review of Resident #81's medical record revealed an admit date of 05/17/2024 with diagnoses, including in part: hemiplegia and hemiparesis following cerebral infarction affecting dominant side and right shoulder muscle wasting and atrophy. Review of Resident #81's Quarterly MDS assessment dated [DATE] revealed impairment to ROM to one side of upper extremities and one side of lower extremities. Further review of Resident #81's Quarterly MDS dated [DATE] revealed a functional status of dependent with dressing, toileting, bed mobility, transfers, shower/bath, eating, and personal hygiene. Review of Resident #81's active physician orders revealed in part an order dated 01/02/2026 for resident to have Restorative Nursing Program for passive range of motion to right upper elbow and shoulder, flexion/extension 3 sets of 20 two times a week, and right resting hand splint applied after breakfast and removed after lunch. Review of Resident #81's task section of medical record for past 30 days, 01/14/2026 through 02/11/2026, failed to reveal documentation Resident #81's splint had been applied during the 30 day look back period. Further review of Resident #81's tasks revealed the not applicable box was checked every day during the 30 day look back period for Resident #81's amount of minutes spent providing splint or brace assistance task. An observation on 02/10/2026 at 12:30 p.m. revealed Resident #81 lying in bed without splint in place to right hand. An observation on 02/11/2026 at 10:30 a.m. revealed Resident #81 lying in bed without splint in place to right hand. An observation on 02/12/2026 at 9:00 a.m. revealed resident #81 lying in bed without splint to right hand. During an interview on 02/12/2026 at 9:05 a.m., S4 Restorative Aide reported Resident #81 did not have a splint. During an interview on 02/12/2026 at 9:20 a.m., S14 LPN, on Resident #81's hall, reviewed Resident #81's orders and confirmed Resident #81 did have an order for splint to right hand. During an interview on 02/12/2026 at 9:21 a.m., S14 LPN observed Resident #81 and confirmed Resident #81 did not have a splint in place to right hand.

Based on record reviews, observations, and interviews, the facility failed to provide adequate supervision to prevent accidents and ensure the residents' environment remained free of hazards for 1 (#83) of 1 residents reviewed for smoking. The facility failed to:1. Ensure Resident #83 was supervised while smoking according to the facility's policy and the residents' plan of care;2. Ensure Resident #83's smoking materials were secured according to the facility's policy and the residents' plan of care, and;3. Ensure Resident #83's smoking safety evaluations were conducted quarterly according to the facility's policy. Findings: Review of the Facility Smoking Policy - Supervised and Unsupervised - latest revision date of 07/01/2025 revealed in part:This policy is intended to minimize the risks to residents who smoke, including possible adverse effects on treatment .Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely .If resident is determined to be an Unsafe Smoker then they must be supervised at all times when smoking. Facility staff will keep all smoking supplies and smoking times will be established by the facility and adhered to by the resident. A supervised smoking schedule will be posted and residents will be required to smoke with supervision only, according to the schedule. Resident smoking evaluations will be conducted: admit/readmit, quarterly, change in condition. Review of the facility provided Smoker's list revealed Resident #83 was listed as an unsafe smoker. Review of Resident #83's record revealed an initial admission date of 11/26/2008, a readmission date of 02/09/2009, and diagnoses including: other cerebral infarction due to occlusion or stenosis of small artery, chronic obstructive pulmonary disease, other lack of coordination, unspecified visual disturbance, weakness, and tobacco use.Review of Resident #83's Quarterly MDS dated [DATE] revealed Resident #83 had a BIMS Score of 15 indicating intact cognition.Review of Resident #83's comprehensive care plan revealed in part: the resident is a smoker. Date Initiated: 06/06/2025 - observe clothing and skin for signs of cigarette burns. Date Initiated: 06/06/2025 - The resident requires a smoking apron while smoking. Date Initiated: 06/06/2025 - The resident requires supervision while smoking. Date Initiated: 06/06/2025 - The resident's smoking supplies are stored on med cart. Date Initiated: 06/06/2025. Review of Resident #83's most recent Smoking/Vaping Safety Evaluation dated 06/05/2025 revealed in part: -Can the Resident dispose of ashes or other tobacco-related residue appropriately? = no-Does the Resident have finger dexterity problems? = no-It is confirmed resident is NOT a safe smoker/vaper.-Smoking/Vaping Additional Notes/Comments - Resident has smoking apron that he wears every day. Resident educated at this time and resident's responsible party.Observation on 02/09/2026 at 9:55 a.m. revealed Resident #83 had a cigarette lighter in his lap while seated in his wheelchair wearing a smoking apron. Further observation revealed a pack of cigarettes on Resident #83's bed side table. During an interview on 02/09/2026 at 9:55 a.m., Resident #83 reported he went outside to smoke about 3 times a day. Resident #83 further reported he had burned himself about a year ago and he had to wear the smoking apron ever since then but was still allowed to keep his own smoking supplies. Observation on 02/10/2026 at 3:10 p.m. revealed Resident #83 seated in his wheelchair in his room wearing a smoking apron with a pack of cigarettes and a lighter on the bedside table next to him. Observation on 02/11/2026 at 8:30 a.m. revealed Resident #83 was in bed in his room with a pack of cigarettes and a lighter on the bedside table. Observation on 02/11/2026 at 1:22 p.m. revealed a cigarette lighter on the bedside table in Resident #83's room. Resident #83 was observed to be outside on the patio just outside the end of the hall smoking a cigarette with a smoking apron in place. Further observation revealed another resident, Resident #32, was outside holding two packs of cigarettes and smoking with Resident #83. Further observation revealed no staff member was present outside with Resident #83. During an interview on 02/11/2026 at 1:22 p.m. Resident #83 reported sometimes he was able to light his own cigarette, but usually his friend, Resident #32, would light it for him. Resident #83 reported Resident #32 was holding his pack of cigarettes for him. During an interview on 02/11/2026 at 1:26 p.m. S19 LPN reported unsafe smokers should be supervised when smoking, but she did not know Resident #83's smoking status. During an interview on 02/11/2026 at 1:28 p.m., S3 ADON confirmed the facility policy required unsafe smokers to be supervised when smoking and that smoking supplies be kept by staff. S3 ADON reported Resident #83 did not always have staff supervision when smoking because he wore a smoking apron. S3 ADON further reported staff did not keep Resident #83's smoking supplies because he would get really angry if you tried to take his cigarettes and lighter from him. S3 ADON further confirmed quarterly smoking safety assessments had not been completed for Resident #83 and should have been. During an interview on 02/11/2026 at 1:40 p.m., S5 Corporate Nurse confirmed Resident #83 did not have quarterly smoking safety assessments and should have. S5 Corporate Nurse further confirmed Resident #83 was an unsafe smoker, should not be in possession of his own smoking supplies, and should have staff supervision when smoking. During an interview on 02/11/2026 at 2:00 p.m., S20 LPN/MDS Nurse reported the floor nurses were responsible for performing the quarterly smoking safety assessments. S20 LPN/MDS Nurse further reported Resident #83 refused to give up possession of his smoking supplies and told them he's grown, he's going to smoke when he wants to, and that all they could do was chart it as a behavior.

Based on record review and interview, the facility failed to provide appropriate and sufficient services, treatment and care, based upon current standards of practice and the resident's comprehensive assessment and care plan to prevent urinary tract infections. The facility failed to provide suprapubic catheter care for 1 (#122) of 3 residents reviewed for urinary catheter or UTI.Findings: Review of Resident #122's medical record revealed an admit date of 02/26/2024 and discharge date of 05/06/2025 with the following diagnoses, including in part: quadriplegia C1-C4 complete, other retention of urine, UTI, and neuromuscular dysfunction of bladder unspecified. Review of Resident #122's comprehensive care plan revealed resident has indwelling catheter -suprapubic catheter care as ordered and prn.Review of Resident #122's Physician's orders revealed an order dated 05/15/2024 for suprapubic catheter care every shift and as needed for patency.Review of Resident #122's April 2025 TAR failed to reveal suprapubic catheter care was provided on the following shifts: day shift on 04/04/2025 and 04/23/2025, night shift from 04/01/2025 to 4/04/2025, 04/07/2025 to 04/10/2025, 04/12/2025, 04/14/2025, 04/23/2025 and 04/24/2025.During an interview on 2/10/2026 at 2:30pm S2 DON reviewed Resident #122's April 2025 TAR and acknowledged Resident #122 did not receive suprapubic catheter care on day shift 04/04/2025 and 04/23/2025, night shift from 04/01/2025 to 4/04/2025, 04/07/2025 to 04/10/2025, 04/12/2025, 04/14/2025, 04/23/2025 and 04/24/2025.

Based on record review, observation and interview the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure resident snack/nourishment refrigerators contained sealed, dated, labeled and dated food items from residents. Findings: Review of Policy titled Food: Safe Handling for Foods from Visitors (reviewed 08/08/2025) revealed, in part:Policy StatementResidents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors.Procedures .4. When food items are intended for later consumption, the responsible facility staff member will: .Ensure that the food is stored separate or easily distinguishable from the facility food.Ensure that foods are in a sealed container to prevent cross contamination.Label foods with the resident name and the current date.5. Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and: .Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for >7 days. (Storage of frozen foods and shelf stable items may be retained for 30 days.) Review of the following resident snack/nourishment refrigerators revealed:Hall A-An unsealed, unlabeled and undated carton of a dozen eggs in a plastic grocery bag with [DATE] date on the end of the carton.-A partially used, unsealed, unlabeled and undated 4 ounce container of applesauce.Hall B- Signage on the front of the resident snack/nourishment refrigerator which read Resident Refrigerator Only, Food must be labeled with resident's name and date, Absolutely no employee's food/drinks allowed, and Food will be discarded if not labeled/dated or not resident's food/drink.-A partially used, unlabeled and undated 12 ounce container of chicken salad.-3 partially used, unsealed, unlabeled and undated 4 ounce containers of applesauce.-A partially used, unlabeled and undated 46 ounce carton of cranberry cocktail.-An undated and unlabeled paper plate with food on it and covered in plastic wrap.-A partially used 46 ounce carton of thickened apple juice with Best if used by 12/30/2025 on the side of the carton. During an interview on 2/10/2026 at 7:54 a.m. S2 DON reported the snack/nourishment refrigerators were used for things like residents' personal food for those residents who don't have a refrigerator in their room. Further reported residents were to put name and date before being placed in the refrigerator. Further reported the night shift would check for things outdated and discard. During an interview on 02/10/2026 at 8:10 a.m. S3 ADON observed the items in the Hall B resident snack/nourishment refrigerator and reported the chicken salad, container of applesauce, carton of cranberry cocktail, covered paper plate with food, and thickened apple juice should have been sealed, labeled with resident name and dated when placed in the refrigerator and were not. During an interview on 02/10/2026 at 8:15 a.m. S13 LPN observed the items in the Hall A resident snack/nourishment refrigerator and reported the dozen eggs and applesauce should have been sealed, labeled with resident name and dated when placed in the refrigerator and were not.

Based on record review, observation, and interview, the facility failed to provide appropriate treatment and services for 1 (#90) of 2 (#90, #3) residents reviewed for tube feeding. The facility failed to ensure Resident #90's tube feeding and water bags were labeled correctly.Findings:Review of Resident #90's record revealed an admit date of 04/21/2025 and diagnoses including dysphagia following cerebral infarction, type 2 diabetes mellitus with other specified complication, moderate protein-calorie malnutrition, and encounter for attention to gastrostomy.Review of Resident #90's physician orders revealed orders including:- 01/05/2026 - Enteral feed every shift - Tube Feeding Continuous: Formula Osmolite 1.5 at 60cc/hr for 22 hours and 150cc H20 flush every 4 hrs to allow for ADL care.- 06/09/2025 - Jevity 1.5 maybe used as needed if Osmolite isn't available -04/30/2025 - Enteral Feed - every night shift Change feeding syringe, bag/bottle and tubing every 24 hrs or as directed by product manufacturer.Observation on 02/09/2026 at 10:00 a.m. revealed Resident #90 lying in bed with HOB elevated 30 degrees. Further observation revealed Resident #90 had tube feeding in progress with Jevity 1.5 at 60cc/hr. The container of Jevity and the bag of water for flushes were not labeled with the date and time they were prepared.During an interview on 02/09/2026 at 10:00 a.m., S15 LPN observed Resident #90's Jevity container and bag of water and confirmed they were not labeled and should have been.

Based on record reviews and interviews the facility failed to protect resident's right to be free from physical abuse by a staff member for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents. The deficient practice resulted in actual harm of Resident #1 on 01/10/2025 at 9:15 p.m. when S4 CNA (Certified Nursing Assistant) bent Resident #1's fingers back to her wrist. Resident #1 was assessed by S6 LPN (Licensed Practical Nurse) on the morning of 01/11/2025 and found to have swelling and bruising to her right hand. Resident #1's right hand x-ray dated 01/11/2025 revealed findings consistent with acute fracture of mid aspect of middle phalanx 2nd digit right hand with acute fracture of distal 2nd metacarpal. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Abuse Prohibition Policy dated 05/17/2024 revealed in part: Intent: Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Policy: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Review of Resident #1 Minimum Data Set assessment dated [DATE] revealed a Brief Mental Status of 10 which indicated moderately impaired cognition and was dependent on staff for activities of daily living. Review of Resident #1 progress notes revealed in part a note dated 01/11/2025 at 9:30 a.m. signed per S6 LPN revealed Resident #1 complained of right hand pain to S5 CNA during breakfast service and told S5 CNA not to touch her right hand as it was broken. S5 CNA noted Resident #1's hand to be purplish in color and Resident #1 told her that the big girl pulled her fingers back to her wrist last night when she was changing her and hurt her hand. S6 LPN assessed Resident #1 and noted her right hand to be light purple in color to thumb and fingers and Resident #1 reported to S6 LPN it hurt. Resident #1 further reported to S6 LPN that big girl did it last night when she was changing me by pulling my fingers back to my wrist. Review of the facility's incident report dated 01/11/2025 at 9:45 a.m. regarding Resident #1 reported by S6 LPN revealed: -Description: resident noted to have bruise to right hand. -Resident description: resident states that between 8-9 last night while CNA was changing her the CNA told her to roll over and she was doing the best she could when CNA took her hand and bent her fingers back towards her wrist. -Immediate action taken: assessed from head to toe. Passive range of motion with some difficulty, resident able to use hand to take meds, drink soda, and eat. ___ (mobile imaging provider) notified of need for x-ray to right hand and wrist. -Pain level: 5 -refused ___ per standing orders for pain -Notified: Administrator, DON (Director of Nursing) and MD (Medical Doctor) Review of Resident #1's clinical record revealed x-ray report from ____ (mobile imaging provider) dated 01/11/2025 revealed: Right hand 2 views, osteopenia noted, obliquely oriented fracture demonstrated involving the distal aspect of 2nd metacarpal with some overlap of fracture fragments and displacement. There is also fracture of the mid aspect of the middle phalanx of the 2nd digit. Degenerative changes are noted. Soft tissue swelling noted. Impression: Findings consistent with acute fracture of mid aspect of middle phalanx 2nd digit right hand. Findings consistent with acute fracture of distal 2nd metacarpal. During an interview on 01/23/2025 at 2:15 p.m. Resident #1 reported her hand was broken and indicated her right hand. When asked how she broke her hand Resident #1 reported that big girl was changing me and told me to turn. Resident #1 reported she guessed she did not do it as the girl liked and the girl got mad and grabbed her arm and bent her fingers back. During an interview on 01/23/2025 at 2:26 p.m. S5 CNA reported on 01/11/2025 she was setting up breakfast for Resident #1 and was handing Resident #1 a drink and she reported her hand was broken. S5 CNA reported she assessed Resident #1's hand and it was purplish and swollen from her thumb all the way to the middle finger area. S5 CNA reported she asked Resident #1 what happened and Resident #1 told her that the big girl bent her fingers back to her wrist and broke her hand last night. S5 CNA reported she notified S6 LPN who came and assessed Resident #1 and Resident #1 told S6 LPN the same account of how her hand was hurt and named S4 CNA to S6 LPN and later police. S5 CNA reported she went with Resident #1 to the hospital for evaluation and Resident #1 told the nurses and doctors at the hospital the same account of the incident with her hand. During an interview on 01/27/2025 at 11:20 a.m. S7 CNA reported she worked 01/10/2025 on the 11 p.m. to 7 a.m. shift and was assisting Resident #1 with putting on a gown when Resident #1 complained of pain to her hand and reported the black girl bent her fingers back. S7 CNA reported she did not observe any bruising or swelling and reported to the nurse. During an interview on 01/27/2025 at 11:43AM S8 LPN reported she worked 01/10/2025 on the 11 p.m. to 7 a.m. shift and was asked by S7 CNA to talk to Resident #1. S8 LPN reported Resident #1 told her the girl with long black hair bent her fingers back and she did not want her back in the room. S8 LPN reported she observed no swelling or bruising to Resident #1's hand and Resident #1 could move her fingers without any increase in pain. S8 LPN reported Resident #1 had no complaints regarding her hand throughout the rest of her shift. S8 LPN had knowledge of Resident #1 being resistive to care and indicated without swelling, bruising, and increased pain with movement it was not something she needed to report. S8 LPN reported she was notified of Resident #1 right hand being swollen and bruised when she was called to make a statement on 01/11/2025 the following morning. During a telephone interview on 01/27/2025 at 12:24 p.m. S6 LPN reported on 01/11/2025 S5 CNA told her Resident #1's hand was bruised and purple. S6 LPN reported when she assessed Resident #1 she noted the bruising and swelling to her right hand. S6 LPN reported Resident #1 was using her fingers to eat but did not want her hand touched and reported it was broken. S6 LPN reported Resident #1 told her the big girl S4 CNA last night told her to roll over and got mad and bent her fingers back. S6 LPN reported she notified S3 DON and S1 Administrator who was the Abuse Coordinator. S6 LPN reported Resident #1's doctor was notified and an x-ray was done which indicated Resident #1 hand was broken. S6 LPN reported Resident #1 told the police the same accounts of the incident and called S4 CNA by name to police. During a telephone interview on 01/28/2025 at 9:36 a.m. S4 CNA reported she was not aware of any incident or concern with Resident #1's hand until she was notified by phone on 01/11/2025 that Resident #1 reported the big girl bent her hand back. S4 CNA reported she worked the 3 p.m. to 11 p.m. shift on 01/10/2025 and had not been back to the facility since. S4 CNA reported on her last rounds of the evening 01/10/2025 before the end of her shift she provided pericare to Resident #1 first and worked her way down the hall providing care to other residents. S4 CNA reported she did not go back in Resident #1 room before leaving a little after 11:00 p.m. S4 CNA reported after her final rounds she allows residents to sleep and reported she sat at the nurses station that was just outside Resident #1 door after completion of her rounds until she left for the evening. During an interview on 01/28/2025 at 1:08 p.m. S3 DON reported she was at the facility when she was notified on 01/11/2025 by S1 Administrator who is also the abuse coordinator that Resident #1 told S5 CNA that her fingers were bent back by the big aide. S3 DON reported when she assessed Resident #1 she was using her right hand trying to drink. S3 DON reported Resident #1's right hand was bruised and swollen and Resident #1 reported it hurt to touch it and when she moved it. S3 DON reported Resident #1 said the big aide pulled her hand back. S3 DON asked Resident #1 if she remembered the name of the CNA because there were a lot of big aides. S3 DON reported Resident #1 replied S4 CNA. S3 DON reported Resident #1 reported S4 CNA pulled her hand back on purpose. S3 DON reported she notified S1 Administrator of her assessment and he started the reporting process. S3 DON reported she notified the police, Resident #1's responsible party, and Resident #1's physician was notified. S3 DON reported she did not tell police the accused CNA's name and reported she was in the room when the police questioned Resident #1 and when they asked who bent her fingers back Resident #1 screamed S4 CNA. S3 DON reported Resident #1's account of the incident and who bent her fingers remained consistent. S3 DON reported an x-ray confirmed fracture of Resident #1's hand and Resident #1 was sent to the hospital for evaluation. During an interview on 01/28/2025 at 2:10 p.m. S1 Administrator confirmed he was the facility's abuse coordinator. S1 Administrator reported he was notified by S6 LPN around 9:00 a.m. on the morning of 01/11/2025 that S5 CNA came to her and reported Resident #1 hand was swollen and bruised. S1 Administrator reported Resident #1 told her the big black aide with the long hair hurt her hand and bent her fingers back to her wrist. S1 Administrator reported he notified S3 DON who was already in the building and notified his Regional [NAME] President. S1 Administrator reported S3 DON assessed Resident #1 hand to be swollen and confirmed Resident #1 named S4 CNA as the one who bent her fingers back. S1 Administrator reported the police interviewed Resident #1 and she remained consistent in naming S4 CNA as the one who bent her fingers back. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. Review of the facility's corrective action plan initiated on 01/11/2025 with a completion date of 01/13/2025 consisted of the following: The accused, S4 CNA, was suspended 01/11/2025 and terminated on 01/13/2025. Resident #1 was assessed on 01/11/2025, Police were contacted on 01/11/2025, and X-rays were obtained on 01/11/2025. Resident life satisfaction rounds were completed on 01/11/2025 on residents who resided on Resident #1 hall with no concerns noted. Head to toe assessments were performed on all residents and completed on 01/13/2025. The facility performed an in-service with staff on 01/11/2025 regarding abuse prohibition, resident rights, and call light response with the content of abuse coordinator, when to report abuse, resident's rights, neglect, repositioning and transfers, and signs and symptoms of burnout. Random daily observations of care were initiated on 01/13/2025 with weekly staff checks to identify sign and symptoms of burnout/stress. The monitoring will continue for 30 days with review daily by the DON and the Corporate Clinical Specialist and will be reduced to monthly for 3 months.

Based on record reviews and interviews the facility failed to ensure staff reported alleged violations regarding abuse immediately to the proper facility authority as per facility policy for 1 (#1) of 3 ( #1, #2, #3) sampled residents. Findings: Review of the facility's Abuse Prohibition Policy dated 05/17/2024 revealed in part: Intent: Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Policy: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. Definitions: -Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Physical abuse includes hitting, slapping, kicking, shoving, pinching, and controlling behavior through corporal punishment. Identification: 1. Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately. 4. All incidences of unknown origin will be investigated. Reporting/Response: 1. Any employee who becomes aware of an allegation of abuse, or neglect or misappropriation of resident property shall report the incident to Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. Review of Resident #1 Minimum Data Set assessment dated [DATE] revealed a Brief Mental Status of 10 which indicated moderately impaired cognition and was dependent on staff for activities of daily living. Review of Resident #1 comprehensive care plan revealed in part the following problems with appropriate approaches: resident has activities of daily living self-performance deficit and resident is resistive to care. During an interview on 01/27/2025 at 11:20 a.m. S7 CNA reported she worked 01/10/2025 on the 11 p.m. to 7 a.m shift and was assisting Resident #1 with putting on a gown when Resident #1 complained of pain to her hand and reported the black girl bent her fingers back. S7 CNA reported she did not observe any bruising or swelling and reported to the nurse. During an interview on 01/27/2025 at 11:43AM S8 LPN reported she worked 01/10/2025 on the 11 p.m. to 7 a.m. shift and was asked by S7 CNA to talk to Resident #1. S8 LPN reported Resident #1 told her the girl with long black hair bent her fingers back and she did not want her back in the room. S8 LPN reported she observed no swelling or bruising to Resident #1's hand and Resident #1 could move her fingers without any increase in pain. S8 LPN reported Resident #1 had no complaints regarding her hand throughout the rest of her shift. S8 LPN had knowledge of Resident #1 being resistive to care and indicated without swelling, bruising, and increased pain with movement it was not something she needed to report. S8 LPN reported she was notified of Resident #1 right hand being swollen and bruised when she was called to make a statement on 01/11/2025 the following morning. During an interview on 01/30/2025 at 8:47 a.m. S7 CNA acknowledged she did not suspect abuse when Resident #1 reported the girl bent her fingers back. S7 CNA reported she did not ask if the girl bent her fingers back intentionally and had reported only to the nurse. S7 CNA reported knowledge that suspected abuse was to be reported to the abuse coordinator. During an interview on 01/30/2025 at 9:08 a.m. S8 LPN acknowledged she did not suspect abuse when Resident #1 reported the girl bent her fingers back. S8 LPN reported she did not ask if the girl bent her fingers back intentionally and had not reported the allegation to the abuse coordinator. S8 LPN reported knowledge that suspected abuse was to be reported to the abuse coordinator. During an interview on 01/30/2025 at 9:50 a.m. S1 Administrator, S2 Corporate Clinical Specialist, and S3 Director of Nursing reported any allegation of suspected abuse should be reported immediately to the abuse coordinator. S1 Administrator, S2 Corporate Clinical Specialist, and S3 Director of Nursing acknowledged when Resident #1 reported to staff on 01/11/2025 that the girl bent her fingers back the night before and did not want her in her room again the allegation should have been reported to the abuse coordinator as potential abuse and it was not reported.

Based on record reviews and interviews, the facility failed to ensure baseline care plans had been developed and implemented by failing to identify interventions to minimize falls for 3 (#3, #5, and #6) of 6 sampled residents assessed as being at risk for falls. Findings: Review of Policy titled Fall Prevention Program reviewed 06/10/2024 revealed: Policy: All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. A. Procedure 1. All residents will be screened for risk for falls utilizing the Fall Risk Assessment. This will be done at the time of admission, quarterly, after each fall upon significant change in condition. 2. Residents identified at being at risk will have interventions identified in their plan of care to minimize falls. 3. The following is a list of commonly used interventions that may be considered to minimize falls and injury. a. Visual identifiers b. Resident room is maintained clutter free. c. Bed maintained in low position with bedside mat d. Implement a toileting program e. Maintain call light within reach f. Resident teaching regarding safety g. Involvement in restorative programs h. Utilizing a night light i. Utilizing appropriate footwear j. Utilizing nonskid surfaces k. Utilizing adaptive equipment such as-walker, cane, grab bars, etc. Resident #3 Review of Resident #3's medical record revealed an initial admitted [DATE] with diagnoses that included, in part, Type 2 Diabetes Mellitus, muscle wasting and atrophy not elsewhere classified of right and left shoulder, muscle weakness, unspecified abnormalities of gait and mobility, syncope and collapse, other lack of coordination and spinal stenosis cervical region. Review of Medicare 5 day MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/15/2024 revealed Resident #3 had a BIMS (Brief Interview Mental Status of 13, which indicated Resident #3 was cognitively intact. Review of Resident #3's 12/12/2024 Admit/Readmit Evaluation Fall Scale revealed a score of 50, which indicated Resident #3 was at a high risk for falls. Review of Resident #3's care plans revealed: -A 12/12/2024 Baseline Care Plan that failed to identify interventions to minimize falls. -A Comprehensive Care Plan with potential risk for falls with interventions that were initiated on 12/16/2024. During an interview on 01/08/2024 at 4:10 p.m. S2 Corporate Nurse reported Resident #3's baseline care plan did not identify interventions to minimize falls for Resident #3, who had been assessed to be at risk for falls on admission. Resident #5 Review of Resident #5's medical record revealed an initial admitted [DATE] with diagnoses that included, in part, spinal stenosis, Type 2 Diabetes Mellitus, Muscle wasting and atrophy multiple sites, muscle weakness generalized, other reduced mobility, other lack of coordination, other polyosteoarthritis, essential hypertension, difficulty in walking, other specified arthritis multiple sites, and other idiopathic peripheral autonomic neuropathy. Review of Medicare 5 day MDS with ARD of 12/25/2024 revealed Resident #5 had a BIMS score of 15, which indicated Resident #5 was cognitively intact. Review of Resident #5's 12/20/2024 Admit/Readmit Evaluation Fall Scale revealed a score of 45, which indicated Resident #5 was at high risk for falls. Review of Resident #5's care plans revealed: -A 12/20/2024 Baseline Care Plan that failed to identify interventions to minimize falls. -A Comprehensive Care Plan with potential for falls interventions that were initiated on 12/24/2024. Resident #6 Review of Resident #6's medical record revealed an admitted [DATE] with diagnoses that included, in part, unspecified fracture of left calcaneus subsequent encounter for fracture with routine healing, chronic osteomyelitis with draining sinus left ankle and foot, acute hematogenous osteomyelitis unspecified ankle and foot, muscle weakness, other lack of coordination, and other reduced mobility. Review of Medicare 5 day MDS with ARD of 12/29/2024 revealed Resident #6 had a BIMS score of 15, which indicated Resident #5 was cognitively intact. Review of Resident #6's 12/23/2024 Admit/Readmit Evaluation Fall Scale revealed a score of 35, which indicated Resident #6 was at moderate risk for falls. Review of Resident #6's care plans revealed: -A 12/23/2024 Baseline Care Plan that failed to identify interventions to minimize falls. -A Comprehensive Care Plan with potential for falls and interventions that were initiated on 12/27/2024. During an interview on 01/08/2024 at 3:08 p.m. S2 Corporate Nurse and S1 DON (Director of Nursing) reported Resident #5 and Resident #6's baseline care plan did not identify interventions to minimize falls for Resident #5 and #6, who had been assessed to be at risk for falls upon admission.

Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan with adequate interventions to address resident's medical, physical, mental and psychosocial needs for 1 (#6) of 6 (#1, #2, #3, #4, #5, #6) residents who had a potential for falls. Findings: Review of Policy titled Fall Prevention Program reviewed 06/10/2024 revealed: Policy: All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. A. Procedure 1. All residents will be screened for risk for falls utilizing the Fall Risk Assessment. This will be done at the time of admission, quarterly, after each fall upon significant change in condition. 2. Residents identified at being at risk will have interventions identified in their plan of care to minimize falls. 3. The following is a list of commonly used interventions that may be considered to minimize falls and injury. a. Visual identifiers b. Resident room is maintained clutter free. c. Bed maintained in low position with bedside mat d. Implement a toileting program e. Maintain call light within reach f. Resident teaching regarding safety g. Involvement in restorative programs h. Utilizing a night light i. Utilizing appropriate footwear j. Utilizing nonskid surfaces k. Utilizing adaptive equipment such as-walker, cane, grab bars, etc. Review of Resident #6's medical record revealed an admitted [DATE] with diagnoses that included, in part, unspecified fracture of left calcaneus subsequent encounter for fracture with routine healing, chronic osteomyelitis with draining sinus left ankle and foot, acute hematogenous osteomyelitis unspecified ankle and foot, muscle weakness, other lack of coordination, and other reduced mobility. Review of Medicare 5 day MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/29/2024 revealed Resident #6 had a BIMS (Brief Interview Mental Status) score of 15, which indicated Resident #6 was cognitively intact. Review of Resident #6's 12/23/2024 Admit/Readmit Evaluation Fall Scale revealed a score of 35, which indicated Resident #6 was at moderate risk for falls. Review of Resident #6's Comprehensive Care Plan revealed: -Potential for falls related to gait/balance problems (initiated on 12/27/2024) with 2 interventions 1. Educate resident/family/caregivers about safety reminders and what to do if a fall occurs, 2. PT (Physical Therapy) to evaluate and treat as ordered or prn (as needed). During an interview on 01/08/2024 at 3:50 p.m. S3 MDS Coordinator reviewed Resident #6's Potential for Falls Care Plan and reported she had not added all the appropriate interventions and should have. During an interview on 01/08/2024 at 3:52 p.m. S4 MDS Coordinator reviewed Resident #6's Potential for Falls Care Plan and reported she would add other interventions to the prepopulated ones to include interventions such as bed in low position and call light within reach. S4 MDS Coordinator further reported those items had not been added to Resident #6's comprehensive plan and should have been.

Based on record review and interviews, the facility failed to ensure residents at risk for pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and/or to prevent the development of new ulcers unless the individual's clinical condition demonstrated they were unavoidable for 1 (Resident #25) resident reviewed for transmission based precautions. The deficient practice resulted in an Immediate Jeopardy for Resident #25 on 11/01/2024 when Resident #25 was admitted to the hospital when bilateral heel boot protectors were removed and a border dressing to the left heel dated 5/17 was found to be in place. Resident #25's dressing to his left heel was removed and assessment revealed a large area of superficial ulceration over the dorsal right foot measuring 7.0 cm (centimeter) x 7.0 cm in diameter with numerous areas of superficial ulcerations to dorsal aspect of the right foot, lateral right forefoot, and lateral left forefoot and posterior heel with green purulent drainage expressed from areas. Resident #25 was admitted to ICU (Intensive Care Unit) on 11/01/2024 with diagnoses including in part, sepsis with shock, UTI (Urinary Tract infection) and infected bilateral lower extremity pressure ulcers. An x-ray of Resident #25's left foot revealed possible osteomyelitis of the second digit. Resident #25's bilateral lower extremity wounds required surgical debridement by podiatry. This deficient practice had the likelihood to cause more than minimal harm to the total census of 117 residents receiving weekly skin assessments. S1Administrator and S3Corporate Nurse were notified of the Immediate Jeopardy on 11/15/2024 at 4:50 p.m. The facility presented the following Plan of Removal on 11/15/2024 at 9:43 p.m.: Plan of Removal for wound care: On November 15, 2024, facility administration was made aware of an immediate jeopardy concerning: (1) Failure to complete skin assessments accurately and timely and adequate skin care provided during activities of daily living on Resident #25. Incident specific and immediate actions taken prior to and after IJ notification: 1. Director of Nurses (DON) will in-service licensed nursing staff on completion of weekly skin assessments accurately and timely beginning on November 15, 2024. 2. DON will in-service licensed nursing staff and certified nurse aides on providing skin care during ADLs, emphasizing to remove heel protector boots during bathing beginning on November 15, 2024. 3. Beginning November 15, 2024, Nursing Administration team, which includes DON, Unit Managers, and Treatment Nurse, will conduct facility wide head to toe assessments to ensure skin assessments reflect the current resident's skin status. 4. Unit Managers will provide oversight with licensed nursing staff during weekly skin assessments to validate accuracy of skin assessments and removal of heel protector boots during bathing beginning November 15, 2024. 5. DON will randomly validate accuracy of skin assessments and removal of heel protector boots during bathing twice weekly beginning November 15, 2024. 6. Corporate Clinical Specialist will conduct in-service with the nurse administration team which consists of the following, DON, Unit Managers, and Treatment Nurse, on importance of completing weekly skin assessments accurately and timely and removal of heel protector boots during bathing beginning November 15, 2024. 7. DON will start monitoring to ensure licensed nurses are completing weekly skin assessments accurately and timely beginning November 15, 2024. 8. Baylor weekend nurses, weekend Registered Nurses, and new hires will be in-serviced by DON on performing weekly skin assessments accurately and timely and emphasizing to remove heel protector boots during bathing beginning November 15, 2024 before their next scheduled shift. 9. Resident #25 was assessed by Wound Care Nurse Practitioner, November 15, 2024, and will continue until wound is healed. Seven residents are at risk and will be assessed by Wound Care Nurse Practitioner and will continue on caseload until healed. 10. Any identified issue will be addressed immediately and reported to the Quality Assurance Committee. The facility will ensure the likelihood of serious harm no longer exists beginning November 15, 2024. The Immediate Jeopardy was removed on 11/15/2024 at 10:15 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews and record reviews prior to exit. Findings: Review of the facility's The ________ Skin Integrity Prevention and Treatment Program with a review date of January 2023 revealed in part: ______ Skin Essentials Staff Education is completed via orientation in various methods such as but not limited to in person, virtual live and virtual recorded sessions. Session covers: a. the standards of ________ regarding skin/wound management and prevention b. documentation standards that include guidelines used in assessment and treatment d. best practice formulary approaches for treatment and prevention g. importance of skin integrity quality assurance _____ Skin Essentials Assessment and Documentation Standards include but not limited to: Weekly Skin Integrity Checks: a. weekly assessment looking for new wounds - completed by a licensed nurse b. documented on/in treatment record Review of the facility's _____ Health Pressure Injury Prevention Program with a revision date of September 2024 revealed in part: Standard: All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on the results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or, to treat new/existing pressure injuries. Procedure: 4. All residents will have a head-to-toe assessment (skin check) completed on a weekly basis by a licensed nurse to identify any skin breakdown or at-risk areas for break down. The results of this assessment will be documented in the resident's medical record. 5. If a pressure injury/skin breakdown is identified, the following will be done - a. if new area found - - if pressure injury - complete new wound evaluation/assessment. - if non-pressure area - complete new wound evaluation/assessment. Review of the facility's Bath, Bed policy with a revision date of March 2021 revealed in part: Purpose - The purposes of this procedure are to promote cleanliness, provide comfort and to observe the condition of the resident's skin. Steps in the procedure: Legs and Feet: d. wash the foot e. observe toenails and the skin between the toes for redness and cracking of the skin. f. dry the foot and between the toes carefully. Reporting: 2. Report other information in accordance with facility policy and professional standards of practice. Review of Resident #25's medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses that included, in part, quadriplegia, neuromuscular dysfunction of the bladder, and idiopathic peripheral neuropathy. Review of Resident #25's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed, in part, Resident #25 had a BIMS (Brief Interview of Mental Status) score of 15, indicating intact cognition. Further review Resident #25's Quarterly MDS assessment dated [DATE] revealed Resident #25 had no unhealed pressure ulcers. Review of Resident #25's comprehensive care plan revealed in part, Resident #25 was at risk for pressure ulcers due to impaired mobility, incontinence, and fragile skin with interventions in place for daily observation of skin with routine care. Further review of Resident #25's comprehensive care plan revealed Resident #25 had an ADL self-care performance deficit and required extensive assistance by staff. Review of Resident #25's Physician orders revealed in part: 11/13/2024 Isolation Precautions: Contact related to MRSA (Methicillin-resistant Staphylococcus aureus) every shift. Initials acknowledge the following: Resident remained in room, received all medications, participated in activities, received all meals, when applicable received all rehab services, and received all ADL care, in room entire shift. 02/23/2023 Heel protector boots to float heels bilaterally, as tolerated, every shift. 08/11/2023 Weekly skin checks every Monday for immobility, bedbound, and muscle wasting. Review of S5Wound Care NP's note dated 05/17/2024 revealed in part, Resident #25's pressure wound to left lateral heel was healed, had no s/s (signs and symptoms) of infection and wound care had been discontinued. Review of Resident #25's Weekly Skin Assessment Evaluations from 05/29/2024 - 10/29/2024 revealed no new skin issues had been identified for Resident #25's feet. Further review of Resident #25's Weekly Skin Assessment Evaluations from 05/29/2024 - 10/29/2024 failed to reveal weekly skin assessments were completed during the weeks of: 06/10/2024 - 06/16/2024; 06/17/2024 - 06/23/2024; 06/24/2024 - 06/30/2024; 07/01/2024 - 07/07/2024; 07/15/2024 - 07/21/2024; 07/22/2024 - 07/28/2024, 08/05/2024 - 08/11/2024 and 10/14/2024 - 10/20/2024. Review of Resident #25's October 2024 ADL log revealed Resident #25 had been receiving bed baths, with the last bath documented on 10/28/2024. Review of Resident #25's interdisciplinary notes revealed Resident #25 was transported to ER by stretcher on 10/31/2024 related to issues with his suprapubic catheter. Review of Resident #25's hospital records revealed a Physician's note dated 11/01/2024, which revealed in part, Resident #25's history of present illness included chronic sacral decubitus and bilateral lower extremity pressure ulcers . Resident #25's urinalysis is positive for UTI (urinary tract infection) and Resident #25 has severely infected wounds to bilateral lower extremities with drainage . Resident #25 will be admitted to ICU for sepsis with shock. Further review of Resident #25's hospital records revealed a Podiatric Consultation note dated 11/01/2024, which read in part: Multi-Podus boots to both lower extremities were removed this morning. A border gauze dressing to the left heel marked 5/17 was removed and documented. Large area of superficial ulceration over the dorsal right foot measuring 7.0 cm x 7.0 cm diameter with numerous areas of superficial ulceration to dorsal aspect of the right foot, lateral right forefoot, and lateral left forefoot and posterior left heel. [NAME] purulent drainage expressed from areas . All nonviable tissue was removed with saline soaked gauze with manual means. Purulent drainage was expressed from dorsal right foot and lateral right forefoot. All wounds were debrided of nonviable tissue to good bleeding tissue using scalpel blade and forceps. All xerotic tissue was removed and both feet were irrigated with saline wash. The nursing home was contacted this morning to inquire about dressing to the left heel with a date of May 17th. The nurse at the facility stated she did not realize there was a dressing on his left heel. Photos of the dressing and the foot were taken for documentation. Further review of Resident #25's hospital records revealed an Infectious Disease Consult note dated 11/02/2024 which included the following in part, severely infected wounds to bilateral lower extremities with drainage . left foot wound with heavy growth of Staphylococcus Aureus. X-ray of left foot with possible osteomyelitis of the second digit. Of note, there are pictures in chart from heel ulcer dressing dated back from May 17 that apparently was not removed at nursing home. Further review of Resident #25's hospital records from hospital stay 11/01/2024 - 11/06/2024 revealed in part, black and white pictures of an un-initialed foam border dressing dated 5/17 with soiled areas to the inside of foam border dressing. During an interview on 11/14/2024 at 11:00 a.m., S2DON acknowledged she signed Resident #25's 10/29/2024 skin assessment. S2DON could not confirm if there was a dressing on Resident #25's left heel or if heel boots had been taken off during the assessment. S2DON further acknowledged heel protector boots should be taken off during weekly skin assessments. During an interview on 11/14/2024 at 11:15 a.m., Resident #25 reported when he went to the hospital recently he thought his left heel wound was healed, until the doctor told him they removed a dressing from May from his left foot. Resident #25 further reported his left heel had not had any dressing changes or wound care since healing in May. During an interview on 11/14/2024 at 11:40 a.m., S13CNA (Certified Nursing Assistant) reported Resident #25 was compliant with his baths. During an interview on 11/14/2024 at 11:55 a.m., S12LPN (Licensed Practical Nurse) reported she took a call on 11/01/2024 from a hospital physician who questioned if she was aware Resident #25 had a dressing on his left foot dated 05/17/2024. S12LPN reported she informed the physician she was not aware Resident #25 had a dressing on his left foot. S12LPN reported she was unsure of who placed a dressing on Resident #25's left foot. S12LPN further reported the dressing must have been dated from last wound care visit and left in the room. S12LPN stated someone just probably grabbed it out of his (Resident #25) drawer to use. During a telephone interview on 11/14/2024 at 12:10 p.m., S5Wound Care NP confirmed he closed out Resident #25's left heel pressure wound as healed on 05/17/2024. S5Wound Care NP confirmed all wound care and dressing changes were discontinued on 05/17/2024. S5Wound Care NP reported he was not aware Resident #25's left heel had developed an issue prior to going to the hospital on 10/31/2024. S5Wound Care NP reported good foot care was not being administered if this was the case. S5Wound Care NP reported he could not confirm who applied the dressing or why it was applied to Resident #25's left heel. S5Wound Care NP acknowledged it was not good practice for an opened, dated dressing to be left in a resident's room for future use. S5Wound Care NP acknowledged Resident #25 was very high risk for wounds due to his immobility and history of chronic wounds and should have been monitored closely. During an interview on 11/14/2024 at 3:00 p.m., Resident #25 reported the CNAs do not take his boots off when they are giving him a bed bath and stated they (CNAs) do not want to get my feet wet. Resident #25 reported staff are afraid because I got septic once before from my feet getting too wet. Resident #25 further reported the nurses do not take his boots off during the weekly skin assessments and just look at the tips of his feet during the assessment. Resident #25 was unable to recall the last time his boots were removed prior to his recent hospitalization . During an interview on 11/15/2024 at 7:50 a.m., S4Wound Care Nurse viewed photographs from Resident #25's hospital records and confirmed the dressing removed in the hospital was the same dressing she left at the bedside on 05/17/2024. S4Wound Care Nurse reported dressing was dated and left in opened package which was exposed to air. S4Wound Care Nurse acknowledged the dressing could have remained in place over a long period of time because Resident #25 cannot move his lower extremities and if his boots remained in place, the dressing would not have been disturbed. During an interview on 11/15/2024 at 8:00 a.m., S5Wound Care NP confirmed leaving Resident #25's boots in place could lead to skin breakdown. S5Wound Care NP acknowledged he had not documented any assessments of Resident #25's feet since 05/17/2024. S5Wound Care NP reported residents with weekly skin assessments should have a full head to toe skin assessment. During an interview on 11/15/2024 at 8:45 a.m., S2DON reported she does not review the entire hospital record once a resident is discharged back to the facility and had only reviewed Resident #25's Physician orders. S2DON reported she was not aware Resident #25 had been admitted to ICU and photographs had been taken of Resident #25's wound dressing dated 5/17/2024. S2DON confirmed Resident #25's wound dressing which was removed at the hospital had been placed in the facility. S2DON acknowledged skin assessments should be head to toe and Resident #25's boots should be removed for skin assessments as well as bathing. S2DON reported Resident #25 was compliant with ADL care, including baths. During an interview on 11/15/24 at 9:00 a.m., S6LPN reported on 10/31/2024 Resident #25 was sent to a local hospital for urinary related issues. S6LPN acknowledged she did not assess Resident #25's feet prior to going out and Resident #25 was transported to the ER with bilateral heel protector boots in place. During an interview on 11/15/2024 at 10:35 a.m., S14CNA reported when she last bathed Resident #25 on 10/28/2024, Resident #25 had a large white dressing intact to his left foot, but could not recall the date on the dressing. During an interview on 11/15/2024 at 2:30 p.m., S3Corporate Nurse reported the hall nurses were responsible for weekly skin assessments. S3Corporate Nurse further reported S2DON was responsible for overseeing all nursing staff to ensure proper skin assessments and skin care were performed. During an interview on 11/15/2024 at 4:00 p.m., S2DON acknowledged she was responsible for overseeing the nursing staff for adequate skin assessments and proper skin care. S2DON confirmed Resident #25's wounds had not been identified prior to admission to the hospital and wounds should have been identified through weekly skin assessments and ADL care. During an interview on 11/15/2024 at 5:05 p.m., S3Corporate Nurse acknowledged a process was not in place to ensure accurate, timely skin assessments were being performed weekly and proper skin care was being provided.

Based on record review and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #25) resident reviewed for transmission based precautions. The facility failed to ensure Resident #25 received complete and timely skin assessments and proper ADL (Activities of Daily Living) care. The deficient practice resulted in an Immediate Jeopardy for Resident #25 on 11/01/2024 when Resident #25 was admitted to the hospital when bilateral heel boot protectors were removed and a border dressing to the left heel dated 5/17 was found to be in place. Resident #25's dressing to his left heel was removed and assessment revealed a large area of superficial ulceration over the dorsal right foot measuring 7.0 cm (centimeter) x 7.0 cm in diameter with numerous areas of superficial ulcerations to dorsal aspect of the right foot, lateral right forefoot, and lateral left forefoot and posterior heel with green purulent drainage expressed from areas. Resident #25 was admitted to ICU (Intensive Care Unit) on 11/01/2024 with diagnoses including in part, sepsis with shock, UTI (Urinary Tract infection) and infected bilateral lower extremity pressure ulcers. An x-ray of Resident #25's left foot revealed possible osteomyelitis of the second digit. Resident #25's bilateral lower extremity wounds required surgical debridement by podiatry. This deficient practice had the likelihood to cause more than minimal harm to the total census of 117 residents receiving weekly skin assessments. S1Administrator and S3Corporate Nurse were notified of the Immediate Jeopardy on 11/15/2024 at 4:50 p.m. The facility presented the following Plan of Removal on 11/15/2024 at 9:43 p.m.: Plan of Removal for administration oversight: On November 15, 2024, facility administration was made aware of an immediate jeopardy (IJ) concerning: (1) Failed to administer in a manner to ensure Resident #25 had accurately and timely wound care assessments and proper skin care provided during activities of daily living. Incident specific and immediate actions taken prior to and after IJ notification: The facility failed to ensure accurate and timely weekly wound care assessment as ordered. The resident did not receive accurate and timely skin assessment and proper skin care provided during ADLs. 1. Corporate Clinical Specialist will in-service Administrator, beginning November 15, 2024, on validating weekly skin assessments are accurate and timely and proper skin care during ADLs. 2. Administrator/designee will attend the clinical morning meeting with the administration nurses twice weekly to ensure weekly skin assessments are accurate and timely and proper skin care is provided during ADLs beginning November 15, 2024. 3. Corporate Nurse Specialist will provide oversight that the Administrator has attended the clinical morning meeting and reviewed that weekly skin assessments are accurate and timely and proper skin care provided during ADLs beginning November 15, 2024. 4. Corporate Clinical Specialist will conduct in-service with the nurse administration team on importance of completing weekly skin assessments accurately and timely and removal of heel protector boots during bathing beginning November 15, 2024. 5. Baylor weekend nurses, weekend Registered Nurses, and new hires will be in-serviced by DON (Director of Nursing)/designee on performing weekly skin assessments accurately and timely and emphasizing to remove heel protector boots during bathing beginning November 15, 2024 before their next scheduled shift. 6. DON will in-service Licensed Practical Nurses (LPN)/Unit Managers/Treatment Nurse on completion of weekly skin assessments accurately and timely beginning on November 15, 2024. 7. DON will start monitoring to ensure LPN are completing weekly skin assessments accurately and timely beginning November 15, 2024. 8. DON will in-service LPN and certified nurse aides on providing skin care during ADLs, emphasizing to remove heel protector boots during bathing beginning on November 15, 2024. 9. Beginning November 15, 2024, Nursing Administration Team, which consist of DON, Unit Managers, and Treatment nurse will conduct facility wide head to assessment to ensure skin assessments reflect the current resident's skin status. 10. Unit Managers will provide oversight with LPNs during weekly skin assessments to validate accuracy of skin assessment and removal of heel protector boots during bathing beginning November 15, 2024. 11. DON will randomly validated accuracy of skin assessments and removal of heel protector boots during bathing twice weekly beginning November 15, 2024. 12. Any identified issue will be addressed immediately and reported to the Quality Assurance Committee. The facility will ensure the likelihood of serious harm no longer exists beginning November 15, 2024. The Immediate Jeopardy was removed on 11/15/2024 at 10:15 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews and record reviews prior to exit. Findings, Cross Reference F686 Interviews: During an interview on 11/15/2024 at 2:30 p.m., S3Corporate Nurse reported the hall nurses were responsible for weekly skin assessments. S3Corporate Nurse further reported S2DON was responsible for overseeing all nursing staff to ensure proper skin assessments and skin care were performed. During an interview on 11/15/2024 at 4:00 p.m. S2DON acknowledged she was responsible for overseeing the nursing staff for adequate skin assessments and proper skin care. S2DON confirmed Resident #25's wounds had not been identified prior to admission to the hospital and wounds should have been identified from weekly skin assessments and adl care. During an interview on 11/15/2024 at 5:05 p.m., S3Corporate Nurse acknowledged a process was not in place to ensure accurate, timely skin assessments were being performed weekly and proper skin care was being provided. During an interview on 11/15/2024 at 8:30 p.m. S1Administrator acknowledged the break in the system was not ensuring residents were receiving accurate skin assessments.

Based on observations, interviews, and record reviews the facility failed to provide services that meet professional standards for 2 of 2 (#44, #90) out of a total sample of 28 residents. The facility failed to ensure nurses administered medications and remained with the residents until the medications were taken. Findings: Review of the facility's Medication Administration Policy and Procedure dated 07/08/2024 revealed in part: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and implementation: 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Resident #44 Review of resident #44's medical records revealed an admitted [DATE]. Observation on 11/12/2024 at 08:40 a.m. revealed a medication cup that contained pills left on resident #44's breakfast tray at the bedside for resident #44 to take on his own by S8 LPN (Licensed Practical Nurse). During an interview on 11/12/2024 at 9:30 a.m. Resident #44 reported S8 LPN always left his medications at the bedside for him to take on his own. During an interview on 11/12/2024 at 9:40 a.m. S8 LPN reported she had left resident #44's medications for him to take on his own. S8 LPN reported she did not know if resident #44 had been assessed to give his own medications. Review of resident #44's medical record failed to reveal he had been assessed to self-administer his own medications. Resident #90 Review of resident #90's medical record revealed an admitted [DATE]. Observation on 11/12/2024 at 8:40 a.m. revealed a medication cup that contained pills left on resident #90's over bed table by S8 LPN for him to on his own. During an interview on 11/12/2024 at 9:30 a.m. resident #90 reported S8 LPN always left his medications for him to take on his own. During an interview on 11/12/2024 at 09:45 a.m. S8 LPN reported she left resident #90's medications for him to take on his own. S8 LPN reported she did not know if resident #90 had been assessed to give his own medications. Review of resident #90's medical record failed to reveal he had been assessed to self-administer his own medications.

34708 45317 Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails and failed to obtain informed consent from the resident or resident's representative prior to installation of bed rails for 9 (#8, #9, #16, #39, #44, #90, #94, #108, #368) out of 9 (#8, #9, #16, #39, #44, #90, #94, #108, #368) residents reviewed for bed rails. Findings: Review of the Facility Policy on Physical Restraints and Involuntary Seclusion dated 03/2023 revealed in part: 13. Side rails or side rail assist bars/enablers used as an enabler for mobility or transfers must include: -Side Rail evaluation completed -Assessment of the resident's ability to move about in bed. -Determination of whether the resident is able to use the side rails in turning. -Determination that the patient's/resident's ability to transfer considering that the side rail may add risk to the patients/residents self-transfer -Purpose of bedrail and notation that no appropriate alternative exists -An entrapment risk assessment of the resident and the bedrail -Monitoring and Documentation should include an assessment of the risks vs. benefits that is reviewed with the resident and resident representative, who must give informed consent summarized as -Routine assessment for monitoring of appropriateness -Ensuring informed consent -Ensuring appropriateness of bed -Ensuring ongoing inspection and maintenance Resident #8 Review of Resident #8's medical record revealed a readmitted [DATE] with diagnoses, including but not limited to, epileptic syndromes with seizures of localized onset, lack of coordination, and vascular dementia. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 which indicated moderately impaired cognition. Review of Resident #8's physician's orders revealed an order dated 09/05/2024 for assist bars times 2 related to transfer and/or bed mobility. Review of Resident #8's medical record failed to reveal Resident #8 was assessed for the risk of entrapment from bed rails and failed to reveal an informed consent was obtained from Resident #8 or Resident #8's representative prior to installation of bed rails. During an observation on 11/12/24 at 8:30 a.m. revealed Resident #8 lying in bed with assist rails bilaterally in an up position at head of bed (HOB). During an observation on 11/13/2024 at 2:25 p.m. revealed Resident #8 received assistance with repositioning and Resident #8 was observed holding onto bilateral assist rails which were in an up position. During an observation on 11/14/2024 at 11:00 a.m. revealed Resident #8 lying in bed with bilateral assist rails in an up position at HOB. During an interview on 11/14/2024 at 11:02 a.m. S9 CNA reported Resident #8 used assist rails during repositioning. Resident #9 Review of Resident #9's medical record revealed an admitted [DATE] with diagnoses including, but not limited to, cerebral vascular accident (CVA) with hemiplegia and morbid obesity. Review of Resident #9's five day admission MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. Review of Resident #9's physician's orders revealed an order dated 10/16/2024 for assist bars times 2 to assist with bed mobility/transfer every shift. Review of Resident #9's medical record failed to reveal Resident #9 was assessed for the risk of entrapment from bed rails and failed to reveal an informed consent was obtained from Resident #9 or Resident #9's representative prior to installation of bed rails. During an observation on 11/12/2024 at 10:30 a.m. revealed bilateral assist rails attached to the upper part of Resident #9's bed in an up position. During an interview on 11/12/2024 at 10:30 a.m., Resident #9 reported she used the bilateral assist rails to help position herself in bed. Resident #16 Review of Resident #16's medical record revealed an admitted [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified site and contracture of muscle, multiple sites. Review of Resident #16's quarterly MDS dated [DATE] revealed Resident #16 had a BIMS score of 13, which indicated Resident #16 was cognitively intact. Review of Resident #16's physician orders revealed an order dated 08/29/2023 for assist bars times 2 every shift. Review of Resident #16's medical record failed to reveal Resident #16 was assessed for the risk of entrapment from bed rails and failed to reveal an informed consent was obtained from Resident #16 or Resident #16's representative prior to installation of bed rails. During an observation on 11/12/2024 at 2:00 p.m. revealed Resident #16 asleep in bed with bilateral upper assist bars in use. During an observation on 11/13/2024 at 11:00 a.m. revealed Resident #16 awake in bed with bilateral upper assist bars in use. During an observation on 11/14/2024 at 12:11 p.m. revealed Resident #16 sitting up in bed with bilateral assist bars in use. Resident #39 Review of Resident #39's medical record revealed an admitted [DATE] with a readmitted [DATE]. Resident #39's diagnose included, but not limited to, morbid (severe) obesity due to excess calories, acquired absence of left leg below knee, and dementia in other diseases classified elsewhere. Review of Resident #39's quarterly MDS dated [DATE] revealed Resident #39 had a BIMS score of 8, which indicated Resident #39 had moderately impaired cognition. Review of Resident #39's physician orders revealed an order dated 08/29/2023 for bariatric bed with assist bars times 2 for bed mobility and pressure redistribution mattress to bed every shift. Further review of Resident #39's order revealed an order dated 11/08/2024 for assist bars times 2 to assist with bed mobility/transfer every shift. Review of Resident #39's medical record failed to reveal Resident #39 was assessed for the risk of entrapment from bed rails and failed to reveal an informed consent was obtained from Resident #39 or Resident #39's representative prior to installation of bed rails. During an observation on 11/12/2024 at 2:00 p.m. revealed Resident #39 sitting upright in bariatric bed with bilateral upper quarter side rail in use. During an observation on 11/13/2024 at 11:00 a.m. revealed Resident #39 sitting upright in bariatric bed with bilateral upper quarter side rail in use. During an observation on 11/14/2024 12:13 p.m. revealed Resident #39 sitting upright in bariatric bed with bilateral upper quarter side rails in use. Resident #44 Review of Resident #44's medical record revealed an admitted [DATE] with diagnoses including, but not limited to, idiopathic chronic gout multiple sites, other cerebral infarction, dysphagia, end stage renal disease, and dependence on dialysis. Review of Resident #44's quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition. Review of Resident #44's physician's orders revealed an order dated 09/04/2024 for assist bars times 2 to assist with bed mobility/transfer every shift. Review of Resident #44's medical record failed to reveal Resident #44 was assessed for the risk of entrapment from bed rails and failed to reveal an informed consent was obtained from Resident #44 or Resident #44's representative prior to installation of bed rails. During an observation on 11/12/2024 at 08:40 a.m. revealed Resident #44 had 1 assist rail to the right upper side of the bed in an up position. During an interview on 11/12/2024 at 8:40 a.m., Resident #44 reported he used the assist rail to get up and out of bed. Resident #90 Review of Resident #90's medical record revealed an admitted [DATE] with diagnoses including, but not limited to, stroke with hemiplegia or hemiparesis and seizure disorder Review of Resident #90's quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition. Review of Resident #90's medical record failed to reveal Resident #90 was assessed for the risk of entrapment from bed rails and failed to reveal an informed consent was obtained from Resident #90 or Resident #90's representative prior to installation of bed rails. During an observation on 11/12/2024 at 08:40 a.m. revealed Resident #90 had 1 assist rail to the right upper side of the bed in an up position. During an interview on 11/12/2024 at 8:40 a.m., Resident #90 reported he used the assist rail to get up from bed and to turn and reposition. Resident #94 Review of Resident #94's medical record revealed an admitted [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. Review of Resident #94's quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated severely impaired cognition. Review of Resident #94's medical record failed to reveal Resident #94 was assessed for the risk of entrapment from bed rails and failed to reveal an informed consent was obtained from Resident #94 or Resident #94's representative prior to installation of bed rails. During an observation on 11/12/2024 at 09:50 a.m. revealed Resident #94 had bilateral assist rails in an up position attached to the head of her bed. Resident #108 Review of Resident #108's medical record revealed an admitted [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #108's admission MDS dated [DATE] revealed Resident #108 had a BIMS of 15 which indicated Resident #108 was cognitively intact. Review of Resident #108's physician orders revealed an order dated 11/13/2024 for assist bars times 2 to assist in bed mobility/transfer. Review of Resident #108's medical record failed to reveal Resident #108 was assessed for the risk of entrapment from bed rails and failed to reveal an informed consent was obtained from Resident #108 or Resident #108's representative prior to installation of bed rails. During an observation on 11/12/2024 at 3:00 p.m. revealed Resident #108 asleep in bed with bilateral upper assist rails in use. During an observation on 11/13/2024 at 11:00 a.m. revealed Resident #108 asleep in bed with bilateral upper assist rails in use. During an observation 11/14/2024 12:10 p.m. revealed Resident # 108 siting up in bed with bilateral upper assist rails in use. Resident #368 Review of Resident #368's medical record revealed a readmitted [DATE] with diagnoses, including but not limited to, paranoid schizophrenia, seizures, and Alzheimer's disease. Review of Resident #368's quarterly MDS assessment dated [DATE] revealed a BIMS score of 5 which indicated severely impaired cognition. Review of Resident #368's physician's orders revealed an order dated 09/05/2024 for assist bars times 2 related to transfer and/or bed mobility. Review of Resident #368's medical record failed to reveal Resident #368 was assessed for the risk of entrapment from bed rails and failed to reveal an informed consent was obtained from Resident #368 or Resident #368's representative prior to installation of bed rails. During an observation on 11/12/24 at 1:50 p.m. revealed Resident #368 sitting in wheelchair at bedside. Further observation revealed Resident #368's bed had assist rails bilaterally in an up position at the HOB. During an observation on 11/13/2024 at 1:45 p.m. revealed Resident #368 sitting up in chair at bedside. Further observation revealed Resident #368's bed had assist rails bilaterally in an up position at the HOB. During an observation on 11/14/2024 at 11:10 a.m. revealed Resident #368 sitting up in chair at bedside. Further observation revealed Resident #368's bed had assist rails bilaterally in an up position at the HOB. During an interview on 11/14/2024 at 11:15 a.m. S10 LPN reported Resident #368 used assist rails to help with position changes. During an interview on 11/14/2024 at 3:00 p.m. S3 Corporate Nurse reviewed Resident #8, #9, #16, #39, #44, #90, #94, #108, and #368's medical records and confirmed the residents were not assessed for the risk of entrapment from bed rails and an informed consent was not obtained from the resident or resident's representative prior to installation of bed rails.

Based on record reviews, observations, and interview the facility failed to provide services to prevent further contractures and potential decline in range of motion for 1 (#34 ) of 2 (#34, #90) residents reviewed for limitations in ROM (range of motion). Findings: Review of resident #34's medical record revealed an admitted [DATE] with diagnoses that included cerebral infarction, aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral affecting left non-dominant side, contracture of right knee, contracture of left knee, and other reduced mobility. Review of resident #34's November 2024 physician's orders revealed an order dated 04/05/2024 for resident to wear right resting hand splint and left palmar guard, on before breakfast and off after lunch or as tolerated. Nurse to check skin prior to application and after removal of splint. ROM to be performed prior to application. Nurse to complete in the absence of restorative nurse assistant. Review of resident #34's Comprehensive Plan of Care revealed a problem of activities of daily living self-care performance deficit related to hemiplegia with interventions that included resident has right resting hand splint and left palmar guard for contracture management. During an observation on 11/12/2024 at 10:00 a.m. resident #34's right hand was contracted with no brace or splint in place. Review of resident #34's November 2024 medication administration record failed to reveal documentation of right hand splint and left palmar guard being used as ordered and failed to reveal skin checks being performed as ordered. During an observation on 11/13/2024 at 12:10 p.m. with S11 LPN (Licensed Practical Nurse) revealed resident #34 did not have a splint on her right hand and did not have a palmar guard in her left hand. During an interview on 11/13/2024 at 12:10 p.m. S11 LPN reported she was not aware that resident #34 was to have a right resting hand splint or left palmar guard on her hands. During an observation on 11/15/2024 at 7:50 a.m. revealed resident #34 did not have a splint on her right hand and did not have a palmar guard in her left hand.

Based on observations and interviews the facility failed to ensure the kitchen's dishwasher was working in a safe operating condition. Findings: During a tour of the kitchen on 11/12/2024 at 7:50 a.m. with S7 Dietary Manager revealed the following: Observation of the facility's mechanical dishwasher revealed staff loading dishes in a bin and then running the bin through the dishwasher. The bin is placed on the left side of the mechanical dishwasher and when finished the bin exits the right side. Observed water flowing to the left side of the mechanical dishwasher and staff were having to squeegee the water into the sink. Observed staff had put a blanket behind the sink to help with drainage of the water. Observed the right side of the dishwasher and a gap was between the mechanical dishwasher and the table. This caused water to flow out of the gap and onto the floor. Observed the motor for the mechanical dishwasher and it was covered with a plate lid under the gap where water was running out. During an interview on 11/12/2024 at 8:05 a.m. S7 Dietary Manager reported that she reported the problem with the mechanical dishwasher about the drainage to administration a long time ago and it still has not been fixed. During an interview on 11/12/2024 at 10:05 a.m. S3 Corporate Nurse observed the water from mechanical dishwasher and reported that it needed to be fixed. During an interview on 11/13/2024 at 2:35 p.m. S1 Administrator observed the water drainage from the mechanical dishwasher. S1 Administrator verified the water was not flowing to the sink as it should be and a blanket was placed behind the sink. S1 Administrator verified the water was also dripping on the right side of the mechanical dishwasher and verified a plate lid cover was placed over the motor of the sink due to water dripping.

Based on record reviews and interviews, the facility failed to develop an individualized person-centered plan of care to meet the needs of 1 (#3) of 5 (#1, #2, #3, #4, and #5) residents whose plan of care was reviewed. The facility failed to ensure the plan of care included an accurate assessment for resident #3 by not acknowledging the behaviors exhibited. The facility failed to develop a plan of care and implement interventions to care for resident #3's behaviors. Findings: Review of resident #3's clinical record revealed an admitted to this facility of 03/21/2024. Diagnoses include but not limited to dementia with behavior disturbance, Schizoaffective /Bipolar disorder, insomnia, history of Syphilis, encephalopathy toxic, psychotic disturbance, mood disturbance, anxiety, and cognitive communication deficit. Review of resident #3's MDS (Minimum Data Set) with assessment reference date of 03/29/2024 revealed a BIMS (Brief Interview for Mental Status) Summary Score of 06 which indicates severe cognitive impairment. Review of resident #3's MDS Section E - Behavior failed to reveal physical and verbal behavioral symptoms directed towards others, which included in part cursing at others, and hitting had been exhibited. Further review of resident #3's MDS failed to reveal other behavioral symptoms not directed towards others, which included in part rejection of care, wandering, and disrobing in public, had been exhibited by resident #3 Review of resident #3's Comprehensive Plan of Care failed to reveal interventions were put into place when resident #3 refused ADL Care/Assistance from staff or for other behaviors exhibited. Further review revealed the facility documented resident #3 was an elopement risk, wandered aimlessly and no interventions were listed. Review of the Nurse's Progress notes dated 04/01/2024 at 2:51 p.m. S1 LPN (Licensed Practical Nurse) documented resident #3 is still wearing the same clothes that she had on when admitted . She (resident #3) continues to refuse to allow anyone to assist her with bathing and changing clothes. Resident #3 has dementia and is severely confused. Uses profanity with staff and tells us to get out and leave her alone. During an interview on 04/29/2024 at 1:42 p.m. with resident #3's RP (responsible party) reported resident #3 was admitted to this facility needing care due to dementia. Resident #3's RP reported when she visit resident #3 on 04/02/2024 she still had on the same clothing as when she was transferred on 03/21/2024 to the facility. Resident #3's RP reported that is when she went to the nurse's station and spoke with one of the nurses (name unknown). Resident #3's RP reported that is when she was told her sister had been refusing to take a bath or change her clothing. Resident #3's RP reported no one from the facility had notified her that her sister was refusing care. Resident #3's RP reported if she had known she could have come and helped. During an interview on 04/29/2024 at 3:00 p.m. S2 LPN reported resident #3 was very confused, would refuse care, and wander in and out of other residents' rooms. S2 LPN further reported resident #3 would curse you out and would not let you in her room. During an interview on 04/30/2024 at 10:30 a.m. S3 CNA (Certified Nursing Assistant) reported resident #3 would wander in the hallway and into other residents' rooms. S3 CNA reported resident #3 would refuse to let her give her a bath. S3 CNA reported resident #3 did not want any female staff to do anything for her. S3 CNA reported on the day resident #3 was transferred out to the behavior hospital she was cursing and hit one of the nurses. S3 CNA reported resident #3 became more agitated and combative when she would attempt to bath or change her clothing. During an interview on 04/30/2024 at 10:30 a.m. S4 LPN reported she observed resident #3 and she had behaviors. S4 LPN reported resident #3 wandered in the hallway and into other residents' rooms. S4 LPN reported resident #3 was confused and combative toward the staff. S4 LPN reported even if they think a resident should be placed on the Dementia Unit they can only make those suggestions but it is up to the IDT (Interdisciplinary Team) to have them placed there. S4 LPN reported usually if a resident wanders like resident #3 they are placed on the Dementia Unit. During an interview on 04/30/2024 at 11:10 a.m. S5 LPN reported resident #3 was confused, combative, and would curse at staff. S5 LPN reported resident #3 would wander in the other resident's room and in the hallway. S5 LPN reported resident #3 would remove her clothing and come out in the hallway. During an interview on 04/30/2024 at 1:15 p.m. S6 SS (Social Service) reported she is the one that completed Section E - Behavior of the MDS for resident #3. S6 SS reported she completed Section E - Behavior by doing a 7 day look back period of what the floor nurses chart on each shift. S5 SS reported the Care Plan is completed from the documentation on the MDS. S5 SS reported after reviewing the nurses' documentations on resident #3's Nurse's Progress Notes, S6 SS acknowledged behaviors should have been answered as yes for behaviors.

Based on record review, interviews, and video evidence review the facility failed to ensure 1 (#4) of 1 (#4) residents reviewed for accidents received the necessary supervision and assistive devices to each resident to prevent avoidable accidents including a fall. The deficient practice resulted in actual harm for Resident #4 on 03/19/2024 at 8:11 p.m. when Resident #4 suffered a major injury when he fell out of the bed to the floor when incontinence care was being administered. S2 CNA (Certified Nursing Assistant) was providing incontinence care to Resident #4 and when S2 CNA turned to get an item out of a bedside table drawer, Resident #4 rolled off the bed and to the floor. Resident #4 was sent to a local hospital ER (emergency room ) on 03/19/2024 and the hospital records showed Resident #4 suffered a closed non-displaced fracture of the right patella (kneecap). Resident #4 returned to the facility on [DATE]. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of Resident #4's clinical record revealed the resident had the following diagnoses, in part, hemiplegia and hemiparesis following CVA (Cerebral Vascular Accident) affecting non-dominant side, cerebral infarction, seizures, and muscle weakness. Review of Resident #4's physician orders for March 2024 revealed the following, in part: 11/20/2020 order for assist bars times two to assist with bed mobility/transfer. 06/15/2021 order for fall mat times two every shift. Review of Resident #4's minimum data set assessment dated [DATE] revealed the resident had a BIMS (Brief Interview of Mental Status) of 2, which would indicate the resident was severely impaired. Review of Resident #4's MDS (Minimum Data Set) revealed Resident #4 required total dependence for bed mobility with one person assist. Resident #4 was always incontinent of bowel and bladder. Review of the facility's incident report on 03/20/2024 (entered date) for Resident #4's accident/fall on 03/19/2024 revealed the following, in part: Incident description- Allegation of neglect reported by RP (Responsible Party) of resident. S2 CNA was giving incontinent care to resident and he slipped off the bed. S2 CNA tried to grab him, but couldn't hold him and fell . S2 CNA stated that she went in the room to clean Resident #4 and she cleaned his front first, then as she was cleaning his back, the air-loss mattress aired up and Resident #4 started slipping. S2 CNA tried to grab him, but couldn't hold him up and he fell . S2 CNA stated she went and got her nurse. RP has video of incident from electronic monitoring surveillance. At 2:38 PM today, RP told CCS (unknown abbreviation), that she felt like the accused could have prevented victim's fall and reported incident to Abuse division of LDH (Louisiana Department of Health). Review of Resident #4's progress notes revealed the following, in part: Note on 03/19/2024 at 8:16 p.m. - S2 CNA called writer to room. Resident was lying on the floor on his left side between his bed and roommates' bed. Small amount of blood noted to forehead. Resident complained of bilateral knee pain. Ambulance called to transport resident to ER for evaluation. Pillows applied for resident's comfort during wait. S2 CNA states this happened during incontinence care, she wrote a statement. Writer stayed with resident until ambulance arrived . Complained of hip pain to EMTs (Emergency Medical Technicians). Resident #4 to go to local ER. Note on 03/20/2024 at 1:45 p.m. - Resident #4 returned to the facility from local hospital ER via stretcher per ambulance with two attendants. New orders were noted. Diagnosis: Right Patella Fracture. Review of Resident #4's hospital record dated 03/19/2024 revealed reason for visit was fall. Diagnosis was closed non-displaced fracture of right patella, unspecified fracture morphology, initial encounter. Another diagnosis was pain. Review of the time stamped and dated video footage with audio from the camera located at the head of Resident #4's bed, provided by Resident #4's RP, revealed the following, in part: On 03/19/2024 at 8:09 p.m., S2 CNA at bedside providing incontinence care. On 03/19/2024 at 8:10 p.m., S2 CNA rolled Resident #4 on his right side with Resident #4 on the edge of the mattress and both knees were bent and hanging over the edge of the mattress. S2 CNA was noted cleaning the backside of Resident #4. On 03/19/2024 at 8:11 p.m., S2 CNA, with one hand holding Resident #4 in place, placed a new pad and brief on the bed and rolled Resident #4 on to his back. S2 CNA removed her hand from holding Resident #4's left hip and turned to get supplies from the bedside table drawer. Resident #4 proceeded to roll forward to his right side and fell off the bed and onto the floor. Resident #4 could be heard yelling his knee hurt. During review of the video it was noted that the left assist rail was positioned at the left top corner of Resident #4's mattress and a fall mat was not noted on the floor of the right side of Resident #4's bed. During an interview on 04/02/2024 at 4:00 p.m., Resident #4's RP indicated she saw the video footage of S2 CNA cleaning Resident #4 and when S2 CNA was trying to get something from drawer, Resident #4 fell out of the bed to the floor. The RP verified Resident #4 suffered a right patella fracture. During an interview on 04/03/2024 9:15 a.m., S1 Corporate Nurse reported Resident #4 should have been a two person assist due to his behaviors and mobility issues. She further acknowledged he was too close to the edge of the bed and the assist bars were not in the correct position when the incident occurred. During an interview on 04/03/2024 at 10:50 a.m., S2 CNA reported she gathered all supplies to clean and change Resident #4 on 03/19/2024. S2 CNA further reported after she cleaned Resident #4 she shifted him towards his back and reached for supplies from the bedside drawer. Resident #4 fell out of the bed and to the floor. During an interview on 04/03/2024 at 1:15 p.m., S2 CNA confirmed fall mats were not in place when Resident #4 fell out of the bed on 03/19/2024 and she was not aware that the fall mats were ordered. During an interview on 04/04/2024 at 10:00 a.m. S1 Corporate Nurse verified the problems that led to Resident #4's fall on 03/19/2024 were assist rails were at the top of the bed and not in the correct position, Resident #4 was too close to the edge of the bed while S2 CNA was cleaning him, and supplies were not safely within reach. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice. The facility implemented the following actions to correct the deficient practice with a completion date of 03/23/2024: 1. Resident #4 was sent to a local hospitalER on [DATE] for evaluation. 2. S2 CNA was suspended pending investigation. 3. Nursing staff was in-serviced on 03/21/2024 on positioning residents in bed. 4. S2 CNA was in-serviced on 03/23/2024 on positioning residents in bed. 5. S1 Corporate Nurse monitored fall mat placement weekly throughout the facility since the accident/fall on 03/19/2024. 6. S1 Corporate Nurse verified all total care residents had been changed to two person assist for bed mobility. 7. The 02/23/2024 QAPI (Quality Assurance/Performance Improvement) plan for falls with fracture or injury was revised on 03/21/2024 to include Resident #4. The plan put into place for Resident #4 included making the resident a two person assist, the assist bed rails were moved where the resident can reach them, and fall mats were placed on both sides of residents' bed.

Based on observations, record reviews and interviews, the facility failed to protect the residents' right to be free from physical abuse by staff for Resident #1, free from physical and verbal abuse and psychosocial harm by staff for Resident #5, and free from verbal abuse by staff for Residents #10, #11, and #12 (5 residents) out of 11 (#1, #2, #3, #4, #5, #6, #10, #11, #12, #14 and #15) sampled residents reviewed for abuse. The deficient practice resulted in an Immediate Jeopardy when: 1. On 12/23/2023 at approximately 7:30 p.m., S3CNA (Certified Nursing Assistant) physically abused Resident #1 by hitting Resident #1 on right shoulder and right cheek and slapping Resident #1's lower arm. Resident #1 is cognitively impaired and nonverbal, with the exception of the word Si. Resident #1 is capable of answering questions by nodding yes/no, using hand gestures and saying Si for yes. Resident #1 was able to communicate S3CNA hit her on the right shoulder and twice on the right cheek. Resident #1 acknowledged physical abuse by S3CNA hurt and Resident #1 was afraid of S3CNA. S1Administrator and S2DON (Director of Nursing) were made aware of the abuse on 12/23/2023 when Resident #4, who is cognitively intact, reported having witnessed S3CNA aggressively hit Resident #1 on the right shoulder. After this incident of abuse, staff were not retrained on abuse prevention to include residents with poor cognition, impaired communication, dementia, and behaviors. 2. The immediate jeopardy continued on 01/15/2024 at 10:17 p.m., when S4CNA physically and verbally abused Resident #5, who is cognitively impaired, while providing peri-care. Observation of surveillance video revealed S4CNA aggressively pushed and pulled on Resident #5's contracted left leg to position and reposition Resident #5. S4CNA bent Resident #5's right thumb backwards in a forceful manner, in an attempt to release Resident #5's grip on the handrail. Resident #5 was noted to be in pain and agitated. Resident #5 repeatedly expressed pain to S4CNA during peri-care. Resident #5 yelled in part, G___ d___, don't push on me no more . don't dig your claws into me like that; that hurts . G___ d___, that hurts. S4CNA was heard cursing at Resident #5 and with a raised voice stated in part, Well, roll your a__ over . I'm not going to keep trying to roll you and you steady rolling that way to f___ . Y'all hurting my back with this dumb s____ . I shouldn't have to deal with dumb s___ like this. S1Administrator was made aware of the abuse to Resident #5 by S4CNA, on 01/18/2024, by viewing video surveillance provided by Resident #5's RP (Responsible Party). Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical and verbal abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. After this incident of abuse, staff were not retrained on abuse prevention to include residents with poor cognition, impaired communication, dementia, and behaviors. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to the 118 residents residing in the facility per the Resident Census and Conditions Report dated 01/18/2024. S1Administrator and S2DON were notified of the Immediate Jeopardy on 01/24/2024 at 11:30 a.m. The Immediate Jeopardy was removed on 01/25/2024 at 10:25 a.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings: Review of the facility's Abuse and Neglect Policy, with a revision date of 11/07/2023, revealed in part: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free of abuse, corporal punishment, involuntary seclusion, and financial abuse. Policy: 1. The facility will prohibit neglect, mental and physical abuse of residents. Definitions: Abuse means the willful infliction of injury . pain or mental anguish. Physical Abuse includes hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment. Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend or disability. Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment of depravation Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses, which included in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia, and dysphagia. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 11/04/2023 revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 12 out of 15 indicating moderately impaired cognition. Resident #1 was always incontinent of bowel and bladder and dependent on staff for ADL (Activities of Daily Living) care. Resident #1 required extensive assist by one staff for bed mobility. Review of Resident #1's comprehensive care plan revealed Resident #1 was care planned for a communication problem related to stroke and diagnosis of aphasia, with approaches including staff to speak on an adult level and speak clearly and slower than normal. Resident #1 is able to communicate by gestures with an intervention for staff to validate Resident #1's message by repeating aloud. Resident #1 has impaired cognition with approaches including staff to ask yes/no questions, in order to determine Resident #1's needs. Further review of Resident #1's comprehensive care plan revealed Resident #1 was care planned for physical and verbal, aggressive behaviors with approaches including staff to intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, and if response is aggressive, staff to walk calmly away and approach later. Review of Resident #1's medical record revealed an interdisciplinary note dated 12/23/2023 at 7:39 p.m. by S5LPN (Licensed Practical Nurse) which read in part, Resident #4 wheeled to S5LPN while down the hall passing medication, stating Resident #3 and I (Resident #4) just called S1Administrator because S3CNA hit Resident #1 on the shoulder. Resident #4 stated, Resident #1 also told me (Resident #4), S3CNA slapped Resident #1's face. Review of signed witness statement provided by Resident #1 dated 12/26/2023 revealed in part, S1Admininistrator and S2DON spoke to Resident #1 about the incident with S3CNA. Resident #1 stated S3CNA used the back of her hand to slap Resident #1's right cheek while in the room with S3CNA, alone. Resident #1 is afraid of S3CNA and does not want to work with her again. Resident #1's witness statement was written by S2DON. Review of signed witness statement by Resident #4 dated 12/26/2023 revealed in part, Resident #4 stated she saw S3CNA use the back of her hand to hit Resident #1's arm and tell Resident #1 it was time to get changed. Resident #1did not move and Resident #4 stated S3CNA swung Resident #1 around in wheelchair to take into the room. Review of signed witness statement by S5LPN dated 12/30/2023 revealed in part: S3CNA yelled down the hall stating . Resident #1 is acting up again . I (S5LPN) walked down the hall to speak with Resident #1 who was sitting on the middle of the hall screaming loud and crying . Resident #1 began taking brief off .smearing (bm) bowel movement against the wall and started screaming louder. S5LPN informed S3CNA to leave Resident #1 alone and let resident calm down; then I will speak with Resident #1 again. I (S5LPN) went back down the hall to administer medication . Resident #4 reported S2DON and S1Administrator were notified because she (Resident #4) witnessed S3CNA hit Resident #1. During an interview on 01/18/2024 at 2:00 p.m., Resident #1 responded by nodding yes/no, using gestures and stating Si for yes. Resident #1 nodded head yes and stated Si when asked if she had been taken care of by S3CNA. Resident #1 nodded yes and stated Si when asked if she recalled an incident on 12/23/2023 with S3CNA. Resident #1 took her open right hand and placed it on her right cheek twice to demonstrate where S3CNA had hit her. Resident #1 nodded yes several times, answered Si, Si, and held up two fingers to confirm S3CNA hit her twice on the right cheek. Resident #1 further demonstrated S3CNA hit her on the arm by repeatedly touching her right shoulder. Resident #1 confirmed S3CNA hit her on the right shoulder by nodding yes and answered Si, Si. Resident #1 acknowledged the physical abuse by S3CNA hurt and she was afraid of S3CNA. During an interview on 01/18/2024 at 2:15 p.m., Resident #4 reported she had witnessed S3CNA, during the evening shift, on 12/23/2023, approach Resident #1 in the hall and start smacking Resident #1's right shoulder with the back of S3CNA's hand in a very aggressive manner. Resident #4 further reported S3CNA continued smacking on Resident #1's right arm, swung the wheelchair around, pushed Resident #1 into Resident #1's room, and shut the door. Resident #4 further reported, later into the shift, Resident #1 was sitting in the hall, crying and gesturing at her face. Resident #4 reported Resident #1 replied Si and nodded yes, when asked if S3CNA had hit her on the face. Review of Resident #4's Quarterly MDS dated [DATE] revealed in part a BIMS score of 15 out of 15, indicating intact cognition. During an interview on 01/18/2024 at 4:00 p.m., S2DON reported she was informed of the allegation of abuse on 12/23/2023 when S1Administrator telephoned and merged a call with Resident #4. Resident #4 reported to S2DON and S1Administrator, she had witnessed S3CNA slap Resident #1 on the arm. S2DON reported during an interview with Resident #1, S2DON and S1Administrator, Resident #1 took S1Administrator's hand and placed it on her right cheek to demonstrate where S3CNA had struck her. S2DON acknowledged Resident #1 was afraid of S3CNA. S2DON reported she trusted Resident #4 who had a high BIMS score and believed what Resident #4 had reported. During an interview on 01/22/2024 at 8:00 a.m., S1Administrator reported S3CNA was immediately suspended pending investigation and terminated on 01/02/2024 upon substantiating physical abuse. During an interview on 01/22/2024 at 9:15 a.m., Resident #2 reported he had witnessed S3CNA slap Resident #1's arm on the evening shift of 12/23/2023. Resident #2 reported he was sitting on his bed and had a clear view into Resident #1's room. Resident #2 reported he could hear the slap from across the hall. Review of Resident #2's Annual MDS dated [DATE] revealed in part a BIMS score of 14 out of 15, indicating intact cognition. Review of facility's Life Satisfaction Rounds dated 12/26/2023 revealed in part, Resident #2 answered S3CNA had been rude to and had yelled at Resident #2. Resident #2's comment revealed Resident #2 does not allow S3CNA to provide care. During a telephone interview on 01/23/2024 at 8:50 a.m., S5LPN reported Resident #4 informed her (S5LPN), she had witnessed S3CNA hit Resident #1 on the arm. S5LPN reported she approached Resident #1 for assessment and Resident #1 kept shaking her head no and tapping on her right arm. S5LPN reported Resident #1 was unable to communicate further findings. During an interview on 01/23/2024 at 1:00 p.m., S1Administrator reported decision to terminate S3CNA was based on Resident #4's witnessed account and results of Life Satisfaction Rounds, which had raised concerns regarding S3CNA. Review of in-service dated 12/27/2023 revealed in part, all departments had been educated on facility's general abuse policy. Further review failed to reveal staff had been instructed on allegations of abuse of residents with behaviors, dementia, and residents with impaired cognition. Resident #5 Resident #5 was admitted to the facility on [DATE] with diagnoses, which included in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contracture of left knee, dementia with other behavioral disturbance, schizoaffective disorder, and bipolar II disorder. Review of Resident #5's Quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 03 out of 15, indicating severely impaired cognition. Resident #5 was always incontinent of bowel and bladder and dependent on staff for ADL care. Resident #1 was totally dependent for bed mobility and required two staff assistance. Review of Resident #5's comprehensive care plan revealed in part, Resident #5 was care planned for impaired cognitive function and impaired thought process related to dementia and BIMS score. Approaches included ask yes/no questions in order to determine Resident #5's needs, communicate with necessary cues and stop and return if Resident #5 was agitated. Further review of Resident #5's comprehensive care plan revealed Resident #5 was care planned for socially inappropriate, disruptive behaviors with approaches including, staff to speak in a calm manner, explain all procedures to the resident before starting and allow resident to adjust to changes. During an interview on 01/22/2024 at 8:30 a.m., S1Administrator reported Resident #5's RP came into the office on 01/18/2024 and presented a surveillance video of verbal and physical abuse by S4CNA toward Resident #5 which occurred on 01/15/2024. S1Administrator reported he and S6Corporate Nurse watched the video. S1Administrator acknowledged physical and verbal abuse and identified employee in the video as S4CNA. Review of video with audio, provided by Resident #5's RP, from 01/15/2024 at 10:14:47 p.m. to 01/15/2024 at 10:20:30 p.m. revealed in part: 10:14:54 p.m. S4CNA entered Resident #5's room. Resident #1 was observed to be lying flat in bed covered with blanket. 10:15:29 p.m. S4CNA pulled Resident's #5's blanket back, revealing Resident #5's left knee contracture. S4CNA removed Resident #5's brief. 10:15:41 p.m. S4CNA exited Resident #5's room and Resident #5 was left fully exposed. 10:17:08 p.m. S4CNA returned to Resident #5's room carrying supplies. S4CNA began performing peri-care to Resident #5 from the left side of the bed. 10:17:22 p.m. S4CNA pushed Resident #5's contracted left leg over towards the right side of the bed until Resident #5 was positioned on Resident #5's right side. 10:17:27 p.m. Resident #5 yelled G___ d___, don't push on me no more. S4CNA proceeded to clean Resident #5's buttocks area. 10:17:49 p.m. Resident #5 yelled, Don't dig your claws into me like that. That hurts! 10:18:36 p.m. S4CNA finished cleaning Resident #5 and prepared a new brief. 10:18:49 p.m. S4CNA grabbed Resident #5's contracted left leg and pulled Resident #5 towards the left side of the bed. 10:18:52 p.m. Resident #5 yelled G___ d___ that hurts. S4CNA responded Well, roll your a__ over. 10:18:56 p.m. S4CNA began placing clean brief on Resident #5. S4CNA stated in a raised voice I'm not going to keep trying to roll you and you steady rolling that way to f___. Y'all hurting my back with this dumb s___. 10:19:04 p.m. S4CNA yelled, Roll over . I shouldn't have to deal with dumb s___ like this. 10:19:12 p.m. Resident #5 yelled It hurts and S4CNA replied, G___ d___, you're hurting me too. 10:19:25 p.m. S4CNA walked to the right side of the bed and attempted to roll Resident #5 to his left side. Resident #5 was observed to be gripping the left side rail. S4CNA began pulling Resident #5's fingers back and aggressively bent Resident #5's right thumb in a backward motion. 10:19:41 p.m. Resident #5 yelled G___ d___ that hurts. 10:19:44 p.m. S4CNA replied with a raised voice That's how my back feels. 10:19:59 p.m. S4CNA instructed, with a raised voice, Relax your arm, Resident #5 and S4CNA continued to pull Resident #5's right arm away from left handrail. 10:20:15 p.m. S4CNA stated to Resident #5 You're being such an a__. 10:20:30 p.m. Resident #5 stated, Well, that hurts too. Peri-care was completed. During an interview on 01/22/2024 at 2:40 p.m., Resident #5's RP acknowledged having become more aware of issues with Resident #5's care after installing a camera in Resident #5's room for monitoring. An observation on 01/22/2024 at 4:30 p.m. revealed Resident #5 sitting upright in bed watching television. Resident #5 was observed to be clean, without odors and appeared comfortable. Resident #5 was unable to participate in an interview. During an interview on 01/23/2024 at 1:00 p.m., S1Administrator confirmed, upon review of Resident #5's surveillance video on 01/18/2024, S4CNA was immediately suspended pending investigation. S1Administrator further confirmed the determination was made to substantiate physical and verbal abuse and S4CNA was terminated on 01/22/2024. Review of in-service dated 01/18/2024 revealed in in part, all departments had been educated on facility's general abuse policy. Further review failed to reveal staff had been instructed on allegations of abuse of residents with behaviors, dementia, and residents with impaired cognition. During an interview on 01/24/2024 at 10:00 a.m., S2DON acknowledged training provided to staff after the incidents on 12/23/2023 and 01/15/2024 was on the general abuse policy and failed to address allegations of abuse of residents with behaviors, dementia, and residents with low BIMS scores. S2DON acknowledged both Resident #1 and Resident #5 had exhibited behaviors and acknowledged facility did not have a formal process in place to address the training needs for staff for allegations of abuse toward residents with a low BIMS score or residents with severe behaviors. During an interview on 01/24/2024 at 1:40 p.m., S1Administrator acknowledged staff had not received focused training on abuse for vulnerable residents and should have. S1Administrator confirmed this could have contributed to the abuse circumstances. Resident #10 Review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included in part, encephalopathy, history of septic shock, chronic obstructive pulmonary disease, cerebral vascular accident, type 2 diabetes, cognitive communication deficit, lack of coordination, bipolar disease and essential hypertension. Review of Resident #10's MDS dated [DATE] revealed Resident #10 had a BIMS score of 12 out of 15 indicating moderately impaired cognition. Review of Resident #10's comprehensive care plan revealed in part, Resident #10 was care planned for impaired cognitive function and impaired thought processes related to Resident #10's diagnosis of dementia and BIMS score of 12 with approaches that included in part; give meds as ordered, monitor for side effects and effectiveness, communicate with resident using his name, reorient resident as often as needed, communicate with family as needed, monitor, document and report any changes to resident family and medical doctor. Review of facility's Life Satisfaction Rounds dated 01/24/2024 revealed in part, Resident #10 had reported S8CNA had been verbally abusive. During an interview on 01/29/2024 at 2:00 p.m., Resident #10 reported in the past, S8CNA just went off and yelled at her when Resident #10 asked S8CNA to help her look for something. Resident #10 reported S8CNA was very rude and told her to get the other one to help you look for it. Resident #10 further reported, I called my son on the phone and told him about how rude S8CNA was and during the phone conversation S8CNA kept walking by my door listening to the conversation. Resident #10 further stated S8CNA came into her room a few days later and pointed her finger in her face and yelled at her you know my name, because you talked about me yesterday. Resident #10 stated when S8CNA would come in her room she felt anxious and nervous. Resident #10 stated I told the director of nurses when they came around asking about S8CNA. During a telephone interview on 01/29/2024 at 12:17 p.m., Resident #10's son reported his mother (Resident #10) called him and told him S8CNA had stormed into her room and pointed her finger at her aggressively and had been verbally abusive to her. During an interview on 01/30/2024 at 8:30 a.m., Resident #R19 (Resident #10's roommate) reported S8CNA was rude to Resident #10. Resident #R19 further reported S8CNA yelled at Resident #10 and pointed her finger in Resident #10's face. Resident #R19 stated, S8CNA talked sharp and rough to some residents. Review of Resident #R19's MDS revealed a BIMS score of 15 out of 15 indicating intact cognition. During an interview on 01/30/2024 at 8:00 a.m., S1Administrator reported S8CNA was suspended on 01/24/2024 when Resident #10 made allegations of verbal abuse during Life Satisfaction Rounds. S1Administrator confirmed the alleged verbal abuse was substantiated and S8CNA was officially terminated on 01/29/2024. S1Administrator also confirmed S8CNA should have been retrained on abuse after a previous allegation of abuse. Resident #11 Review of Resident #11's medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses, which included in part, hemiplegia following a cerebral vascular accident, cardiovascular disease, a history of breast cancer, polyneuropathy, seizures, bipolar disease, hypothyroidism, urine retention, contracture, schizophrenia, and essential hypertension. Review of Resident #11's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Review of Resident #11's comprehensive care plan revealed Resident #11 was care planned for an activities of daily living self-care performance deficit with approaches that included in part, active range of motion with care, allow extra time when communicating with resident, one person assistance with bed mobility, transfers, dressing, hygiene and bathing, monitor and document and report any changes and any potential for improvement. Review of facility's Life Satisfaction Rounds dated 01/24/2024 revealed in part, Resident #11 had reported S8CNA had been verbally abusive. During an interview on 01/30/2024 at 8:30 a.m., Resident #11 reported S8CNA was always mad at her. Resident #11 reported in the past when she asked S8CNA to shower her, S8CNA took her to the shower room, closed the door, and began to curse her out. Resident #11 further reported S8CNA told her to shut up when Resident #11 asked S8CNA to move to a different shower chair that was not slippery. Resident #11 stated, I told her she treats me like s___ and S8CNA raised her hand at me as if she was going to hit me and told me I was not going to get no d___ towel. Resident #11 stated S8CNA made me feel very uncomfortable. Resident #11 also reported S8CNA would tap the glass with her hand when Resident #11 attempted to drink wine, causing her to deliberately spill the prescribed wine. Resident #11 further stated, I reported this to administration when they asked me. During an interview on 02/01/2024 at 9:38 a.m., S10CNA reported overhearing Resident #11 say to another staff, S8CNA would make Resident #11 hold her urine and tell Resident #11stop drinking so much. S10CNA also reported Resident #11 had her shower moved to the day shift because S8CNA would go off on Resident #11 when she asked to be showered on the evening shift. During an interview on 01/30/2024 at 8:00 a.m., S1Administrator reported S8CNA was suspended on 01/24/2024 when resident #11 made allegations of verbal abuse during Life Satisfaction Rounds. S1Administrator confirmed the alleged verbal abuse was substantiated and S8CNA was officially terminated on 01/29/2024. S1Administrator also confirmed S8CNA should have been retrained on abuse after a previous allegation of abuse. Resident #12 Review of Resident #12's medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included in part, metabolic encephalopathy, and lack of coordination, gastronomy, muscle wasting left shoulder, cognitive communication deficit, polyneuropathy, major depressive disorder, joint derangement and dysphagia. Review of Resident #12's MDS dated [DATE] revealed Resident #12 had a BIMS score of 15 out of 15 indicating intact cognition. Review of Resident #12's comprehensive care plan revealed Resident #12 was care planned for limited physical mobility with approaches that included in part; resident is dependent on assistance with bed mobility, locomotion, personal hygiene toileting requiring extensive assistance, requiring total assistance with transfers. Review of facility's Life Satisfaction Rounds dated 01/24/2024 revealed in part, Resident #12 had reported S8CNA had been verbally abusive and stated, S8CNA would yell at me. During an interview on 01/30/2024 at 1:45 p.m., Resident #12 reported S8CNA's words were mean all the time. Resident #12 stated, She wouldn't put me to bed when I wanted to go. She would speak rudely to me when I asked to be changed and say I will change you but you will stay in the bed and not get up again. Resident #12 stated, I like to be up in my chair, so I can go and smoke and socialize. When she made me stay in my room I feel isolated. Resident #12 reported she told the director of nurses about S8CNA's mean attitude. During an interview on 01/30/2024 at 8:30 a.m., Resident #R19 reported S8CNA was rude to Resident #12. Resident #R19 reported S8CNA told Resident #12 when she asked to be changed and cleaned up, If I clean you up, I'm not going to get you back up in the chair. Resident # R19 reported Resident #12 wanted to be up in the daytime, but S8CNA told Resident #12 she had to either not be cleaned up or get cleaned up and stay in the bed. Resident #R19 further reported S8CNA had a flip mouth and was always telling residents what she was not going to do. Review of Resident #R19's MDS revealed a BIMS score of 15 out of 15 indicating intact cognition. During an interview on 01/30/2024 at 1:25 p.m., S2DON confirmed Resident #12 reported S8CNA had been rude to her. S2DON reported Resident #12 told her S8CNA yelled at her when it was time for her to be changed, and when it was time for her to go to bed. Resident #12 told S2DON she didn't want to get put down for the night so early, so she didn't go get changed. S2 DON further reported Resident #12 was told by S8CNA, Next time I change you, you will not get back up and you will have to wait until 11pm to be changed. S2DON stated she reported this to the administrator who initiated an investigation. S8CNA had already been suspended on 01/24/2024 and was officially terminated on 01/29/2024. During an interview on 01/30/2024 at 8:00 a.m., S1Administrator reported S8CNA was already suspended on 01/24/2024 when Resident #12 made allegations of verbal abuse during Life Satisfaction Rounds. S1Administrator confirmed the alleged verbal abuse was substantiated and S8CNA was officially terminated on 01/29/2024. S1Administrator also confirmed S8CNA should have been retrained on abuse after a previous allegation of abuse.

I. Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 5 (#1, #5, #10, #11, and #12) of 11 residents (#1, #2, #3, #4, #5, #6, #10, #11, #12, #14 and #15) reviewed for abuse: 1. by failing to ensure a system was in place to protect Resident #1 from physical abuse by staff, Resident #5 from verbal abuse and psychosocial harm by staff, and Residents #10, #11, and #12 from verbal abuse by staff, prevent abuse from happening again and ensure all residents were free from abuse; 2. by failing to ensure a system was in place to provide ongoing staff training to identify vulnerable residents at risk for abuse and address residents with behaviors, dementia, and low BIMS (Brief Interview for Mental Status) scores. The deficient practice resulted in an Immediate Jeopardy when: 1. On 12/23/2023 at approximately 7:30 p.m., S3CNA (Certified Nursing Assistant) physically abused Resident #1 by hitting Resident #1 on right shoulder and right cheek and slapping Resident #1's lower arm. Resident #1 is cognitively impaired and nonverbal, with the exception of the word Si. Resident #1 is capable of answering questions by nodding yes/no, using hand gestures and saying Si for yes. Resident #1 was able to communicate S3CNA hit her on the right shoulder and twice on the right cheek. Resident #1 acknowledged physical abuse by S3CNA hurt and Resident #1 was afraid of S3CNA. S1Administrator and S2DON (Director of Nursing) were made aware of the abuse on 12/23/2023 when Resident #4, who is cognitively intact, reported having witnessed S3CNA aggressively hit Resident #1 on the right shoulder. After this incident of abuse, staff were not retrained on abuse prevention to include residents with poor cognition, impaired communication, dementia, and behaviors. 2. The Immediate Jeopardy continued on 01/15/2024 at 10:17 p.m., when S4CNA physically and verbally abused Resident #5, who is cognitively impaired, while providing peri-care. Observation of surveillance video revealed S4CNA aggressively pushed and pulled on Resident #5's contracted left leg to position and reposition Resident #5. S4CNA bent Resident #5's right thumb backwards in a forceful manner, in an attempt to release Resident #5's grip on the handrail. Resident #5 was noted to be in pain and agitated. Resident #5 repeatedly expressed pain to S4CNA during peri-care. Resident #5 yelled in part, G___ d___, don't push on me no more . don't dig your claws into me like that; that hurts . G___ d___, that hurts. S4CNA was heard cursing at Resident #5 and with a raised voice stated in part, Well, roll your a__ over . I'm not going to keep trying to roll you and you steady rolling that way to f___ . Y'all hurting my back with this dumb s____ . I shouldn't have to deal with dumb s___ like this. S1Administrator was made aware of the abuse to Resident #5 by S4CNA, on 01/18/2024, by viewing video surveillance provided by Resident #5's RP (Responsible Party). Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical and verbal abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. After this incident of abuse, staff were not retrained on abuse prevention to include residents with poor cognition, impaired communication, dementia, and behaviors. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to the 118 residents residing in the facility per the Resident Census and Conditions Report date 01/18/2024. S1Administrator and S2DON (Director of Nursing) were notified of the Immediate Jeopardy on 01/24/2024 at 11:30 a.m. The Immediate Jeopardy was removed on 01/25/2024 at 10:25 a.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings, Cross Reference F600: During an interview on 01/24/2024 at 10:00 a.m., S2DON acknowledged training provided to staff was general abuse policy and failed to address behaviors, dementia, and residents with low BIMS scores. S2DON acknowledged both Resident #1 and Resident #5 had exhibited behaviors and acknowledged facility did not have a formal process in place to assess residents with a low BIMS score or residents with severe behaviors for abuse. During an interview on 01/24/2024 at 1:40 p.m., S1Administrator acknowledged staff had not received focused training on abuse for vulnerable residents and should have. S1Administrator confirmed this could have contributed to the abuse circumstances. II. Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for and for 2 (#16, #17) of 6 (#7, #8, #9, #13, #16, #17) residents reviewed for pressure ulcers. The facility failed to ensure 2 (#16, #17) of 6 (#7, #8, #9, #13, #16, #17) residents received wound care as ordered. The deficient practice resulted in an immediate jeopardy for Resident #16 on 12/15/2023 when S7 Wound Care FNP (Family Nurse Practitioner) assessed Resident #16's sacral wound as deteriorating and with s/s (signs and symptoms) of infection. On 12/15/2023, S7Wound Care FNP wrote a new order to change the wound care treatment and increase the frequency of Resident #16's sacral pressure ulcer wound care dressing changes from M/W/F (Monday/Wednesday/Friday) to every day. The facility did not provide wound care every day as ordered from 12/16/2023 to 12/25/2023 and instead provided wound care on M/W/F from 12/16/2023 to 12/25/2023. No wound care was provided on Wednesday 12/20/2023 and from 12/16/2023 to 12/25/2023 wound care was only provided 3 times. Resident #16 was sent to a local hospital on 12/25/2023 due to sacral wound not healing properly. Resident #16's hospital records for 12/25/2023 indicated Resident #16 presented with sacral wound, low grade fever of 100.4 F (degrees Fahrenheit), and a foul odor was noted to the 6cm (centimeter) decubitus ulcer of the sacrum. Current active problems noted in the hospital records on 12/25/2023 included decubitus ulcer of sacrum stage 4 (acute), fever (acute), leukocytosis (acute), and sepsis (acute). A 12/25/2023 CT (Computed Tomography) of the abdomen pelvis revealed an impression of large right sacral decubitus ulcer extending to the coccyx with some osseous changes suggestive of underlying osteomyelitis. The immediate jeopardy continued for Resident #17 on 01/05/2024 when Resident #17's sacral pressure wound was initially found, wound care orders were received, and wound care orders were not carried out as ordered. The facility did not provide wound care as ordered by: 1. not providing wound care daily as per S7 Wound Care FNP's 01/05/2024 order and instead provided wound care each day Monday through Friday, excluding Saturday and Sundays, from 01/08/2024 to 01/31/2024; 2. not utilizing the ordered 0.125% Dakin's Solution during wound care and instead used 0.25% Dakin's Solution for wound care during the Monday through Friday wound care from 01/08/2024 to 01/31/2024; and 3. not conducting wound care as per S7 Wound Care FNP's 01/26/2024 order by utilizing 1% Flagyl instead of the ordered 0.1% Gentamycin and Santyl for wound care from 01/27/2024 to 01/31/2024. This deficient practice had the likelihood to cause more than minimal harm to the remaining 24 residents receiving wound care as per the Order Type: Wound Orders dated 01/31/2024. S1 Administrator, S6 Corporate Nurse and S2DON were notified of the Immediate Jeopardy on 02/01/2024 at 4:15 p.m. The Immediate Jeopardy was removed on 02/02/2024 at 4:00 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews and record reviews prior to exit. Findings, Cross Reference F686: During an interview on 01/31/2024 at 3:05 p.m. S2DON reported if wound care had been ordered for every day, the wound care should have been conducted every day, Monday through Sunday. S2DON further reported she was not aware that daily wound care was not being conducted on the weekends and not conducting wound care as ordered could result in worsening of a wound. During an interview on 02/05/2024 at 2:13 p.m. S2DON and S6Corporate Nurse reported it was the DON's responsibility for monitoring of wound care and wound care orders and this was not done. During an interview on 02/05/2024 at 2:20 p.m., S1Administrator acknowledged Resident #16 and Resident #17's wounds had worsened. S1 Administrator further reported daily orders should be done every day and it is understandable how a wound could get worse if wound care was not done as ordered. III. Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for and for 2 (#16, #17) of 6 (#7, #8, #9, #13, #16, #17) residents reviewed for wound care staff competency. The facility failed to ensure S9Wound Care Nurse was competent to enter wound care orders accurately and perform wound care as ordered for 2 (#16, #17) of 6 (#7, #8, #9, #13, #16, #17) residents reviewed for wound care. The deficient practice resulted in an immediate jeopardy for Resident #16 on 12/15/2023 when S9Wound Care Nurse failed to enter Resident #16's wound care order timely and accurately leading to a delay in care, resulting in a decline and worsening of Resident #16's sacral pressure ulcer and impending hospitalization on [DATE]. Resident #16's 12/15/2023 wound care order was entered: 1. on 12/20/2023, five days after the order was written, 2. utilizing wound cleanser instead of the ordered 0.125% Dakin's Solution, and 3. with a frequency of M/W/F (Monday/Wednesday/Friday) instead of daily. The immediate jeopardy continued for Resident #17 on 01/05/2024 when S9Wound Care Nurse failed to enter Resident #17's order for wound care treatment and wound care frequency accurately potentially resulting in a worsening of Resident #17's sacral pressure ulcer. Resident #17's 01/05/2024 wound care order was entered: 1.utilizing 0.25% Dakin's Solution instead of the ordered 0.125% Dakin's Solution and 2. with a frequency of every day shift every Monday, Tuesday, Wednesday, Thursday, Friday instead of once daily, to include Saturday and Sunday. This deficient practice had the likelihood to cause more than minimal harm to the remaining 24 residents receiving wound care as per the Order Type: Wound Orders dated 01/31/2024. S1 Administrator, S2DON (Director of Nursing) and S6Corporate Nurse were notified of the Immediate Jeopardy on 02/05/2024 at 3:00 p.m. The immediate jeopardy was removed on 02/06/2024 at 4:00 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through observations, onsite interviews and record reviews prior to exit. Findings, Cross Reference F726: During an interview on 02/05/2024 at 11:51 a.m., S2DON reported it was always S9Wound Care Nurse who entered wound care orders and confirmed there was no process for entering wound care orders when S9 Wound Care Nurse was out. During an interview on 02/05/2024 at 2:13 p.m., S2DON and S6Corporate Nurse reported it was the DON's responsibility for monitoring of wound care and wound care orders and this was not done. During an interview on 02/05/2024 at 2:20 p.m., S1Administrator reported training of S9Wound Care Nurse had been conducted by the prior wound care nurse, S2DON was responsible for monitoring of the wound care nurse and daily orders should be done every day. During an interview on 02/06/2024 at 11:43 a.m., S7Wound Care FNP (Family Nurse Practitioner) reported he had assumed wound care orders were entered correctly and he did not have access to the electronic medical record to see if they had been entered correctly.

Based on observation, record reviews and interviews, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and/or to prevent the development of new ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 2 (#16, #17) of 6 (#7, #8, #9, #13, #16, #17) residents reviewed for pressure ulcers. The deficient practice resulted in an immediate jeopardy for Resident #16 on 12/15/2023 when S7 Wound Care FNP assessed Resident #16's sacral wound as deteriorating and with s/s (signs and symptoms) of infection. On 12/15/2023, S7 Wound Care FNP wrote a new order to change the wound care treatment and increase the frequency of Resident #16's sacral pressure ulcer wound care dressing changes from M/W/F (Monday/Wednesday/Friday) to every day. The facility did not provide wound care every day as ordered from 12/16/2023 to 12/25/2023 and instead provided wound care on M/W/F from 12/16/2023 to 12/25/2023. No wound care was provided on Wednesday 12/20/2023 and from 12/16/2023 to 12/25/2023 wound care was only provided 3 times. Resident #16 was sent to a local hospital on 12/25/2023 due to sacral wound not healing properly. Resident #16's hospital records for 12/25/2023 indicated Resident #16 presented with sacral wound, low grade fever of 100.4 F (degrees Fahrenheit), and a foul odor was noted to the 6cm (centimeter) decubitus ulcer of the sacrum. Current active problems noted in the hospital records on 12/25/2023 included decubitus ulcer of sacrum stage 4 (acute), fever (acute), leukocytosis (acute), and sepsis (acute). A 12/25/2023 CT (Computed Tomography) of the abdomen pelvis revealed an impression of large right sacral decubitus ulcer extending to the coccyx with some osseous changes suggestive of underlying osteomyelitis. The immediate jeopardy continued for Resident #17 on 01/05/2024 when Resident #17's sacral pressure wound was initially found, wound care orders were received, and wound care orders were not carried out as ordered. The facility did not provide wound care as ordered by: 1. not providing wound care daily as per S7 Wound Care FNP's 01/05/2024 order and instead provided wound care each day Monday through Friday, excluding Saturday and Sundays, from 01/08/2024 to 01/31/2024; 2. not utilizing the ordered 0.125% Dakin's Solution during wound care and instead used 0.25% Dakin's Solution for wound care during the Monday through Friday wound care from 01/08/2024 to 01/31/2024; and 3. not conducting wound care as per S7 Wound Care FNP's 01/26/2024 order by utilizing 1% Flagyl instead of the ordered 0.1% Gentamycin and Santyl for wound care from 01/27/2024 to 01/31/2024. This deficient practice had the likelihood to cause more than minimal harm to the remaining 24 residents receiving wound care as per the Order Type: Wound Orders dated 01/31/2024. S1 Administrator, S6 Corporate Nurse and S2 DON (Director of Nursing) were notified of the Immediate Jeopardy on 02/01/2024 at 4:15 p.m. The Immediate Jeopardy was removed on 02/02/2024 at 4:00 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews and record reviews prior to exit. Findings: Review of Pressure Injury Prevention Program policy (reviewed 1-2023) revealed: Standard All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or to treat new/existing pressure injuries. Procedure . 5. If a pressure injury/skin breakdown is identified, the following will be done- . c. Notify MD-obtain treatment orders . e. Update care plan . h. Monitor weekly via weekly wound reporting and skin integrity quality assurance processes . 6. Weekly Wound Assessment . b. If treatment or interventions change or wound presentation is reclassified . update care plan . d. Physician updated . Resident #16 Review of Resident #16's medical record revealed Resident #16 was admitted to the facility on [DATE] and discharged to the hospital on 12/25/2023 and had diagnoses that included, in part, pressure ulcer of coccygeal region, type 2 diabetes mellitus, Alzheimer's disease, dementia, age related physical debility, adult failure to thrive, and unspecified protein-calorie malnutrition. Review of Resident #16's Quarterly MDS (Minimum Data Set) dated 12/16/2023 revealed, in part, Resident #16 had a BIMS (Brief Interview of Mental Status) score of 09, indicating Resident #16 was moderately impaired cognitively. Resident #16's 12/16/2023 Quarterly MDS further revealed Resident #16 was dependent with bed mobility and toilet use and required extensive assistance with eating. Review of Resident #16's December 2023 ________Surgical & Wound care Progress notes/orders revealed the following wound care order change: 12/15/2023 - Acute decline with overt SOI (signs of infection) for Resident #16's Stage 4 pressure ulcer coccyx that was deteriorating and included Wound Orders: Cleanse/irrigate wound with 0.125% Dakin's Solution, apply Silvadene Antimicrobial Cream, cover with dry dressing, change dressing every day and as needed. Review of Resident #16's December 2023 TAR (Treatment Administration Record) revealed wound care had been conducted as per below: 12/20/2023 order for Wound 1: Sacrum; Cleanse with wound cleanser, pat dry, apply Silvadene and cal ag (calcium alginate) and optifoam dressing to area every M/W/F and prn (as needed) for soilage/dislodgement was conducted 12/22/2023 (Friday) and 12/25/2023 (Monday). Review of Resident #16's December 2023 ______ Surgical & Wound Care Progress notes/orders and December 2023 TAR failed to reveal wound care had been conducted as per S7 Wound Care FNP's 12/15/2023 order. Review of Resident #16's Wound Weekly Observation Tools revealed the following wound progression from the wound's identification: 11/21/2023 - Stage 3 Pressure wound on sacrum - 3.0cm (L) (length) X 1.7cm (W) (width) X 0.3cm (D) (depth), First Observation, acquired during resident stay. 11/28/2023 - Stage 3 Pressure wound on sacrum - 3.2cm (L) X 4cm (W) X 0.2cm (D) 12/05/2023 - Stage 3 Pressure wound on sacrum - 3.0cm (L) X 3.8cm (W) X 0.2cm (D) 12/12/2023 - Stage 3 Pressure wound on sacrum - 3.2cm (L) X 3.5cm (W) X 0.2cm (D) 12/19/2023 - Stage 3 Pressure wound on sacrum - 4.5cm (L) X 3.8cm (W) X 0.4cm (D), s/s of infection -increased size/increased drainage/foul odor. Review of Resident #16's Progress Notes revealed a nurse's note dated 12/25/2023 at 08:33 a.m. which read Per S12 MD (medical doctor) Resident #16 is to be sent to the ER (emergency room ) due to sacrum wound not healing properly. During an interview on 01/31/2024 at 2:50 p.m. S9 Wound Care Nurse reviewed orders from Resident #16's 12/15/2023 __________ Surgical & Wound Care progress note and the December 2023 TAR and reported any change in wound care should have been started at least by the day following receipt of a new wound care order. S9 Wound Care Nurse reported the new 12/15/2023 order and wound care had not been conducted daily as ordered and should have been. During a telephone interview on 01/31/2024 at 2:35 p.m. S7 Wound Care FNP reported he had seen Resident #16 on 12/15/2023 and Resident #16 had wound infection and orders for dressing changes had been revised to increase wound care to daily. S7 Wound Care FNP further reported when he ordered wound care to be done daily, it was to be done every day including weekends. During an interview on 01/31/2024 at 3:05 p.m. S2 DON reported S9 Wound Care Nurse had been the wound care nurse for the facility for about a year. S2 DON further reviewed Resident #16's December 2023 TAR and S7 Wound Care FNP's 12/15/2023 progress note and reported wound care had not been conducted as ordered after the 12/15/2023 order from S7 Wound Care FNP and should have been. During a telephone interview on 02/01/2024 at 11:50 a.m. S12 MD reported he would expect an order for daily wound care to be done every day of the week and not conducting daily wound care when ordered that way could have a significant effect on a resident's wound. S12 MD further reported he was told nurses performed residents' wound care on the weekends. Resident #17 Review of Resident #17's medical record revealed Resident #17 was initially admitted to the facility on [DATE] with a re-entry on 07/01/2022. Diagnoses included, in part, Stage 4 pressure ulcer to sacrum, type 2 diabetes, essential (primary) hypertension, moderate protein-calorie malnutrition, vitamin deficiency, anemia, other secondary Parkinsonism, and degenerative disease of nervous system unspecified. Review of Resident #17's Quarterly MDS dated [DATE] revealed Resident #17 had a BIMS score of 10, indicating Resident #17 was moderately impaired cognitively. Resident #17's 12/09/2023 Quarterly MDS further revealed Resident #17 required supervision with two plus person assist with bed mobility and toilet use and was frequently incontinent of both bowel and bladder. Review of Resident #17's January 2024 ________ Surgical & Wound Care Progress notes/ orders revealed the following wound care order changes: 01/05/2024 - Initial Wound Assessment for Stage 4 sacral pressure ulcer - new wound Order: cleanse/irrigate wound with 0.125% Dakin's Solution. Apply 1% Flagyl with Dakin's moist to dry and cover with dry dressing once daily. 01/26/2024 - Wound #1 sacrum - wound orders: cleanse/irrigate wound with 0.125% Dakin's Solution. - 0.1% Gentamicin and Santyl and Dakin's moist to dry cover with dry dressing. Change dressing every day and as needed. Review of Resident #17's January 2024 TAR revealed the following wound care had been conducted: 01/03/2024 - Wound 1: Sacrum: Cleanse with normal saline wound cleanser, pat dry, apply honey cal ag cover with optifoam dressing every M/W/F and prn for soilage/dislodgement - every day shift every Monday, Wednesday, Friday was conducted on Friday 01/05/2024. 01/05/2024 - Wound 1: Sacrum: Cleanse with 0.25% Dakin's, 1% Flagyl and Dakin's moist to dry cover with optifoam dressing every day and prn for soilage/dislodgement - every day shift every Monday, Tuesday, Wednesday, Thursday, Friday was conducted Monday through Friday from 01/08/2024 (Monday) to 01/31/2024 (Wednesday). Review of Resident #17's January 2024 ______Surgical & Wound Care progress notes/orders and January 2024 TAR failed to reveal wound care had been conducted daily as per the 01/05/2024 and 01/26/2024 S7 Wound Care FNP orders and instead wound care was conducted daily Monday through Friday with no dressing changes conducted on Saturdays and Sundays from 01/08/2024 to 01/31/2024. Further review of Resident #17's January 2024 TAR revealed the 01/05/2024 wound orders had been conducted utilizing 0.25% Dakin's Solution instead of 0.125% Dakin's Solution Monday through Friday from 01/08/2024 to 01/31/2024 and the 1/26/2024 wound care order including 0.1% Gentamicin and Santyl had not been conducted. Review of Resident #17's Wound Weekly Observation Tools revealed the following wound progression from the wound's identification: 01/03/2024 - Stage 3 pressure wound on sacrum - 7cm (L) x 5cm (W) x 0.2cm (D) - Overall impression: first observation, no reference. 01/10/2024 - Stage 3 pressure wound on sacrum - 6cm (L) x 6cm (W) x 1.5cm (D) - Infection suspected = yes; foul odor. Overall Impression: unchanged. 01/17/2024 - Stage 3 pressure wound on sacrum - 5.7cm (L) x 5.5cm (D) x 1.3cm (D) - Overall impression- improving. 01/24/2024 - Stage 3 pressure wound on sacrum - 5.2cm (L) x 5cm (W) x1.3cm (D) - Overall impression: unchanged. 01/31/2024 - Stage 3 pressure wound on sacrum - 5.2cm (L) x 7.0cm (W) x1.3cm (D) - Overall impression: worsening. During an interview on 02/01/2024 at 10:50 a.m. S9 Wound Care Nurse acknowledged Resident #17 did not receive wound care/dressing changes daily (7 days a week) as ordered by S7 Wound Care FNP and should have. Observation of Resident #17's wound care on 02/01/2024 at 11:00 a.m. revealed S9 Wound Care Nurse administered 0.25% Dakin's Solution during wound care instead of the 0.125% Dakin's Solution ordered on 01/05/2024 by S7 Wound Care FNP. When questioned by the surveyor, S9 Wound Care Nurse confirmed she had used the 0.25% Dakin's Solution for Resident #17's wound care and acknowledged it did not agree with Resident #17's wound care order and should not have been used. Further observation of the wound cart failed to reveal 0.125% Dakin's Solution for Resident #17. During a telephone interview on 02/01/2024 at 12:20 p.m. S11 MD acknowledged if wound care is ordered daily he expected it to get done daily. During an interview on 02/01/2024 at 1:00 p.m. S2 DON acknowledged Resident #17 had been administered 0.25 % Dakin's Solution since 01/08/2024 and Resident #17 should have been administered 0.125% Dakin's Solution as ordered on 01/08/2024. S2DON confirmed Resident #17 had not been receiving wound care on the weekends as ordered and should have been. During an interview on 02/01/2024 at 1:20 p.m. S9 Wound Care Nurse confirmed Resident #17 had been administered 0.25% Dakin's Solution since wound care began on 01/08/2024 through todays wound care and should have administered the ordered 0.125% Dakin's Solution. During a phone interview on 01/31/2024 at 2:35 p.m. S7 Wound Care FNP reported if wound care is ordered daily the wound care should be done every day. S7 Wound Care FNP further reported he would order wound care daily to be sure it actually got done. During an interview on 01/31/2024 at 3:05 p.m. S2 DON reported if wound care had been ordered for every day, the wound care should have been conducted every day, Monday through Sunday. S2 DON further reported she was not aware that daily wound care was not being conducted on the weekends and not conducting wound care as ordered could result in worsening of a wound. During a telephone phone interview on 02/01/2024 at 11:25 a.m. S7 Wound Care FNP reported he assumed a weekend nurse was conducting wound care on the weekend and if wound care was ordered daily and was not being done daily there is a potential for a negative outcome. During an interview on 02/05/2024 at 2:20 p.m. S1 Administrator acknowledged Resident #16 and Resident #17's wounds had worsened. S1 Administrator further reported daily orders should be done every day and it is understandable how a wound could get worse if wound care was not done as ordered.

Based on record reviews and interviews the facility failed to ensure nursing staff possessed the competency to provide nursing related services as evidenced by failing to enter physician orders as written and provide care as ordered for 2 (#16, #17) of 6 (#7, #8, #9, #13, #16, #17) residents reviewed for pressure ulcers. The deficient practice resulted in an immediate jeopardy for Resident #16 on 12/15/2023 when S9 Wound Care Nurse failed to enter Resident #16's wound care order timely and accurately leading to a delay in care, resulting in a decline and worsening of Resident #16's sacral pressure ulcer and impending hospitalization on [DATE]. Resident #16's 12/15/2023 wound care order was entered: 1. on 12/20/2023, five days after the order was written, 2. utilizing wound cleanser instead of the ordered 0.125% Dakin's Solution, and 3. with a frequency of M/W/F (Monday/Wednesday/Friday) instead of daily. The immediate jeopardy continued for Resident #17 on 01/05/2024 when S9 Wound Care Nurse failed to enter Resident #17's order for wound care treatment and wound care frequency accurately potentially resulting in a worsening of Resident #17's sacral pressure ulcer. Resident #17's 01/05/2024 wound care order was entered: 1.utilizing 0.25% Dakin's Solution instead of the ordered 0.125% Dakin's Solution and 2. with a frequency of every day shift every Monday, Tuesday, Wednesday, Thursday, Friday instead of once daily, to include Saturday and Sunday. This deficient practice had the likelihood to cause more than minimal harm to the remaining 24 residents receiving wound care as per the Order Type: Wound Orders dated 01/31/2024. S1 Administrator, S2 DON (Director of Nursing) and S6 Corporate Nurse were notified of the Immediate Jeopardy on 02/05/2024 at 3:00 p.m. The immediate jeopardy was removed on 02/06/2024 at 4:00 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through observations, onsite interviews and record reviews prior to exit. Findings: Review of Pressure Injury Prevention Program policy (reviewed 1-2023) revealed: Standard All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or to treat new/existing pressure injuries. Procedure . 5. If a pressure injury/skin breakdown is identified, the following will be done- . c. Notify MD-obtain treatment orders . e. Update care plan . h. Monitor weekly via weekly wound reporting and skin integrity quality assurance processes . 6. Weekly Wound Assessment . b. If treatment or interventions change or wound presentation is reclassified . update care plan . d. Physician updated . Resident #16 Review of Resident #16's medical record revealed Resident #16 was admitted to the facility on [DATE] and discharged to the hospital on 12/25/2023 with diagnoses that included, in part, pressure ulcer of coccygeal region, type 2 diabetes mellitus, Alzheimer's disease, dementia, age related physical debility, adult failure to thrive, and unspecified protein-calorie malnutrition. Review of Resident #16's December 2023 ________Surgical & Wound care Progress notes/orders revealed the following wound care order change: 12/15/2023 - Acute decline with overt SOI (signs of infection) for Resident #16's Stage 4 pressure ulcer coccyx that was deteriorating and included Wound Orders: Cleanse/irrigate wound with 0.125% Dakin's Solution, apply Silvadene Antimicrobial Cream, cover with dry dressing, change dressing every day and as needed. Review of Resident #16's medical record revealed the following physician order had been entered and the December 2023 TAR (Treatment Administration Record) revealed the same orders had been conducted: 12/20/2023 Wound 1: Sacrum; Cleanse with wound cleanser, pat dry, apply Silvadene and cal ag (calcium alginate) and optifoam dressing to area every M/W/F and prn (as needed) for soilage/dislodgement, every day shift every Monday, Wednesday, Friday was conducted 12/22/2023 (Friday) and 12/25/2023 (Monday). Review of Resident #16's December 2023 ______ Surgical & Wound Care Progress notes/orders, physician orders entered and the December 2023 TAR failed to reveal wound care orders had been entered timely and as per S7 Wound Care FNP's (Family Nurse Practitioner) 12/15/2023 order. Further review of the December 2024 TAR revealed wound care: 1. had been conducted on M/W/F instead of daily, 2. had been conducted utilizing wound cleanser instead of the ordered 0.125% Dakin's Solution, 3. continued to utilize calcium alginate which was not ordered per the 12/15/2023 order. Review of Resident #16's Wound Weekly Observation Tools revealed the following wound progression from the wound's identification: 11/21/2023 - Stage 3 Pressure wound on sacrum - 3.0cm (centimeter) (L) (length) X 1.7cm (W) (width) X 0.3cm (D) (depth), First Observation, acquired during resident stay. 11/28/2023 - Stage 3 Pressure wound on sacrum - 3.2cm (L) X 4cm (W) X 0.2cm (D) 12/05/2023 - Stage 3 Pressure wound on sacrum - 3.0cm (L) X 3.8cm (W) X 0.2cm (D) 12/12/2023 - Stage 3 Pressure wound on sacrum - 3.2cm (L) X 3.5cm (W) X 0.2cm (D) 12/19/2023 - Stage 3 Pressure wound on sacrum - 4.5cm (L) X 3.8cm (W) X 0.4cm (D), s/s (signs and symptoms) of infection -increased size/increased drainage/foul odor. During an interview on 01/31/2024 at 2:50 p.m. S9 Wound Care Nurse reviewed orders from Resident #16's 12/15/2023 __________ Surgical & Wound Care progress note and the December 2023 TAR and reported any change in wound care should have been started at least by the day following receipt of a new wound care order. S9 Wound Care Nurse further reported the 12/15/2023 wound care order had not been entered timely or accurately and she did not know why she had entered it incorrectly. S9 Wound Care Nurse reported the new 12/15/2023 order and wound care had not been conducted daily as ordered and should have been. During a telephone interview on 01/31/2024 at 2:35 p.m. S7 Wound Care FNP reported he had seen Resident #16 on 12/15/2023 and Resident #16 had wound infection and orders for dressing changes had been revised to increase wound care to daily. During an interview on 01/31/2024 at 3:05 p.m. S2 DON reported S9 Wound Care Nurse had been the wound care nurse for the facility for about a year and it was S9 Wound Care Nurse's responsibility to enter wound care orders into the electronic record. S2 DON further reviewed Resident #16's December 2023 TAR and S7 Wound Care FNP's 12/15/2023 progress note and reported wound care had not been conducted as ordered after the 12/15/2023 order from S7 Wound Care FNP and should have been. During a telephone phone interview on 02/01/2024 at 11:25 a.m. S7 Wound Care FNP reported he assumed a weekend nurse was conducting wound care on the weekend and if wound care was ordered daily and was not being done daily there was a potential for a negative outcome. S7 Wound Care FNP further reported he was unaware Resident #16's wound care was not being done daily. During a telephone interview on 02/01/2024 at 11:50 a.m. S12 MD (Medical Doctor) reported he would expect an order for daily wound care to be done every day of the week and not conducting daily wound care when ordered that way could have a significant effect on a resident's wound. S12 MD further reported he was told nurses performed residents' wound care on the weekends. During an interview on 02/02/2024 at 1:36 p.m. S9 Wound Care Nurse reviewed Resident #16's wound care orders from the 12/15/2024 S7 Wound Care FNP progress note and the December 2024 TAR and confirmed S7 Wound Care FNP orders did not agree with the wound care being conducted and she did not know why it took 5 days for the orders to be entered. S9 Wound Care Nurse further confirmed Resident #16's wound care should have been conducted daily from 12/15/2023 and had not been. Resident #17 Review of Resident #17's medical record revealed Resident #17 was initially admitted to the facility on [DATE] with a re-entry on 07/01/2022. Diagnoses included, in part, Stage 4 pressure ulcer to sacrum, type 2 diabetes, essential (primary) hypertension, moderate protein-calorie malnutrition, vitamin deficiency, anemia, other secondary Parkinsonism, and degenerative disease of nervous system unspecified. Review of Resident #17's January 2024 ________ Surgical & Wound Care Progress notes/orders revealed the following wound care order changes: 01/05/2024 - Initial Wound Assessment for Stage 4 sacral pressure ulcer - new wound Order: cleanse/irrigate wound with 0.125% Dakin's Solution. Apply 1% Flagyl with Dakin's moist to dry and cover with dry dressing once daily. 01/26/2024 - Wound #1 sacrum - wound orders: cleanse/irrigate wound with 0.125% Dakin's Solution. - 0.1% Gentamicin and Santyl and Dakin's moist to dry cover with dry dressing. Change dressing every day and as needed. Review of Resident #17's medical record revealed the following physician orders were entered and the January 2024 TAR revealed the same orders had been conducted: 01/03/2024 - Wound 1: Sacrum: Cleanse with normal saline wound cleanser, pat dry apply honey cal ag cover with optifoam dressing every M/W/F and prn for soilage/dislodgement - every day shift every Monday, Wednesday, Friday and as needed for soilage/dislodgement was conducted on Friday 01/05/2024. 01/05/2024 - Wound 1: Sacrum: Cleanse with 0.25% Dakin's, 1% Flagyl and Dakin's moist to dry cover with optifoam dressing every day and prn for soilage/dislodgement - every day shift every Monday, Tuesday, Wednesday, Thursday, Friday and as needed for soilage/dislodgement was conducted Monday through Friday from 01/08/2024 (Monday) to 01/31/2024 (Wednesday). Further review of Resident #17's January 2024 ______ Surgical & Wound Care progress notes/orders, physician orders entered, and the January 2024 TAR failed to reveal wound care orders had been entered as per S7 Wound Care FNP's 01/05/2024 and 01/26/2024 orders and as a result wound care had not been conducted as per the orders. Review of the January 2024 TAR failed to reveal wound care had been conducted every day as ordered and instead was conducted daily Monday through Friday with no dressing changes conducted on Saturdays and Sundays from 01/08/2024 to 01/31/2024. Further review of the January 2024 TAR revealed the 01/05/2024 and 01/26/2024 wound orders had been entered and conducted utilizing 0.25% Dakin's Solution instead of the ordered 0.125% Dakin's Solution Monday through Friday from 01/08/2024 to 01/31/2024 and the 1/26/2024 wound care order including 0.1% Gentamicin and Santyl had not been entered or conducted. Review of Resident #17's Wound Weekly Observation Tools revealed the following wound progression from the wound's identification: 01/03/2024 - Stage 3 pressure wound on sacrum - 7cm (L) x 5cm (W) x 0.2cm (D) - Overall impression: first observation, no reference. 01/10/2024 - Stage 3 pressure wound on sacrum - 6cm (L) x 6cm (W) x 1.5cm (D) - Infection suspected = yes; foul odor. Overall Impression: unchanged. 01/17/2024 - Stage 3 pressure wound on sacrum - 5.7cm (L) x 5.5cm (D) x 1.3cm (D) - Overall impression- improving. 01/24/2024 - Stage 3 pressure wound on sacrum - 5.2cm (L) x 5cm (W) x1.3cm (D) - Overall impression: unchanged. 01/31/2024 - Stage 3 pressure wound on sacrum - 5.2cm (L) x 7.0cm (W) x1.3cm (D) - Overall impression: worsening. During an interview on 02/01/2024 at 10:50 a.m. S9 Wound Care Nurse acknowledged she had not entered Resident #17's wound care as ordered by S7 Wound Care FNP and it should have been. During a telephone interview on 02/01/2024 at 12:20 p.m. S11 MD acknowledged if wound care was ordered daily he expected it to get done daily. During an interview on 02/01/2024 at 1:00 p.m. S2 DON acknowledged Resident #17's wound care orders had not been entered accurately and Resident #17 had not been receiving wound care on the weekends as ordered and should have been. During an interview on 02/01/2024 at 1:20 p.m. S9 Wound Care Nurse confirmed Resident #17 had been administered 0.25 Dakin's Solution since wound care began on 01/08/2024 through today's treatment on 02/01/2024 instead of the ordered 0.125% Dakin's Solution. During a telephone interview on 01/31/2024 at 2:35 p.m. S7 Wound Care FNP reported when he ordered wound care to be done daily, it was to be done every day including weekends. During an interview on 01/31/2024 at 3:05 p.m. S2 DON reported she was not aware that daily wound care was not being conducted on weekends and if wound care had been ordered daily, the wound care should have been done every day Monday through Sunday. S2 DON further reported not conducting wound care as ordered could result in worsening of a wound. During an interview on 02/01/2024 at 10:45 a.m. S9 Wound Care Nurse reported she would enter wound care orders after the Wound Care Nurse Practitioner's visits and if an order was for every day she would enter the order as Monday, Tuesday, Wednesday, Thursday, and Friday and did not include wound care being conducted on the weekend. During a telephone phone interview on 02/01/2024 at 11:25 a.m. S7 Wound Care FNP reported he assumed a weekend nurse was conducting wound care on the weekend and if wound care was ordered daily and was not being done daily there was a potential for a negative outcome. During an interview on 02/05/2024 at 11:51 a.m. S2 DON reported it was always S9 Wound Care Nurse who entered wound care orders and confirmed there was no process for entering wound care orders when S9 Wound Care Nurse was out. During an interview on 02/05/2024 at 2:13 p.m. S2 DON and S6 Corporate Nurse reported it was the DON's responsibility for monitoring of wound care and wound care orders and this was not done. During an interview on 02/05/2024 at 2:20 p.m. S1 Administrator reported training of S9 Wound Care Nurse had been conducted by the prior wound care nurse, S2 DON was responsible for monitoring of the wound care nurse and daily orders should be done every day. During an interview on 02/06/2024 at 11:43 a.m. S7 Wound Care FNP reported he had assumed wound care orders were entered correctly and he did not have access to the electronic medical record to see if they had been entered correctly.

Based on record review, and interviews, the facility failed to protect resident's right to be free from physical abuse and psychosocial harm by a staff member for 1 (Resident #1) of 5 (Residents #1, #2, #3, #4, #5) sampled residents. This deficient practice resulted in an actual harm for Resident #1 on 4/25/2023 when S7 CNA (certified nursing assistant) physically hit Resident #1 numerous times with a broomstick. Resident #6 was present and witnessed the incident. The facility was not aware of the physical abuse until 4/30/2023 when S7 CNA acknowledged hitting Resident #1 to S5 CNA and S6 CNA. S5 CNA and S6 CNA then reported the incident to S3 LPN (licensed practical nurse). S3 LPN reported the incident to administrative staff. S3 LPN and S11 LPN assessed Resident #1 after learning of the incident and confirmed that S7 CNA had hit Resident #1 with a broomstick. S11 LPN nurse note on 4/30/2023 revealed Resident #1 was in tears as he described being hit. Resident #1 complained of pain to the right upper body, which was reported to be one of the areas S7 CNA hit him with the broomstick, and indicated his pain level was seven out of ten. The facility sent Resident #1 to an acute emergency department for further evaluation. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Abuse Prohibition Policy with review date of 3/2023 revealed in part: Intent: This protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Policy: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property or finances of residents . Definitions: 1. Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 2. Physical abuse includes, hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment . Record review of Resident #1's diagnoses revealed, in part: primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Other diagnoses were dysphagia, abnormalities of gait and mobility, cognitive communication deficit, muscle wasting and atrophy, lack of coordination, need for assistance with personal care. Record review of Resident #1's MDS (minimum data set) dated 4/19/2023 revealed a BIMS (brief interview for mental status) of 12 which is considered to be moderately impaired cognition. Record review of Resident #1's nurse notes revealed a note completed by S11 LPN on 4/30/2023. At 9:00 a.m. Resident #1 stated to nurse that he was beat with a broom stick on the right side of his head, right side of stomach, and right hip by S7 CNA. He continued to state he was continuously beaten several times by a S7 CNA. Resident #1 then proceeded outside to show nurse the broomstick, the broom stick was bent in three different places from the incident. Resident #1 was in tears as he described the beating. Nurse then performed a head to toe assessment. No hematomas, bruising, swelling, or redness. Resident #1 stated he was just having pain on his side, he rated the pain 7 out of 10 on a pain scale. S11 LPN asked when did this happen, he stated Tuesday afternoon 4/25/2023 on 3:00 p.m.-11 shift. Nurse then reported to Medical Doctor, family member, S2 DON (Director of Nursing), S1 Administrator. Nurse also gave a statement to local police. Nurse sent resident #1 to ER (emergency room ) to be examined. Record review of Resident #1's hospital records revealed Resident #1 was admitted to an acuteER on [DATE]. HPI (history of present illness) narrative: [AGE] year old male presents to ED (emergency department) with complaint of headache times five days. Patient states he is experiencing headache and right rib pain. Patient states that he was hit by his nurse at his nursing home with a broomstick on the right side of his head and on his right ribs. Patient states that he has only just now been sent to the ED to be evaluated following this event. Patient states that he is not normally ambulatory. Patient past history recent trauma. Onset: 5 days Severity: Moderate Relieving factors: nothing Associated symptoms: yes, right rib pain Medical decision making (MDM) narrative .deferred CT (computerized tomography) scan, did obtain chest x-ray and review this in ED rib series was reviewed by Radiology and felt to be negative for any associated fractures. Patient was given Motrin in the ED for his headache and repeat evaluations stated he was feeling improved. At this time I see no indication for further labs, imaging, or hospitalization . The police were alerted of the incident prior to the patient's arrival here. Was discharged to home in stable condition. During an interview on 5/15/2023 at 12:40 p.m., Resident #1 confirmed S7 CNA hit him approximately nine times with a broomstick. Resident #1 reported his head was swollen after the incident. Resident #1expressed he is leaving this facility today and going to live with his brother. During an interview on 5/15/2023 at 2:00 p.m., S1 Administrator indicated he was notified on 4/30/2023 about the incident of Resident #1 being abused by S7 CNA on 4/25/2023. S3 LPN reported the incident to S2 DON on 4/30/2023 after Resident #1 told S3 LPN that S7 CNA had hit him with a broom stick. S1 Administrator indicated he completed a SIMS (Statewide Incident Management System) report after being notified. Local Police Department was notified and came to facility on 4/30/2023. Resident #1 went to hospital on 4/30/2023 due to pain related to the incident. Resident #1 told S1 Administrator that S7 CNA hit him about 10 times to the head and right side. Resident #6 confirmed to S1 Administrator that S7 CNA beat Resident #1 with a broom stick and S7 CNA was hitting him hard. S7 CNA called Resident #6's phone and told her not to say that she hit Resident #1 because she didn't want to go to jail. S7 CNA was suspended pending investigation. S7 CNA was terminated on 5/4/2023 when the abuse allegation was substantiated. During an interview on 5/15/2023 at 2:30 p.m., S2 DON indicated she was notified of the abuse allegation for Resident #1 on 4/30/2023 by S3 LPN. S2 DON indicated she talked with Resident #1 on Monday 5/1/2023 and he indicated S7 CNA hit him with a broom stick and he was still hurting and they sent him toER on Sunday 4/30/2023. S2 DON confirmed Resident #6 witnessed the incident. During an interview on 5/15/2023 at 2:45 p.m., Resident #6 acknowledged Resident #1 told Resident #6 to kiss his --- and suck my ----. S7 CNA told Resident #1 not to talk to Resident #6 that way. Resident #1 told S7 CNA Kiss my ---, -----. S7 CNA went and got the broom and started hitting Resident #1. Resident #6 thought S7 CNA was playing at first but then realized she was hitting Resident #1 hard with the broom stick. Resident #6 confirmed S7 CNA called her on her phone and told her not to say anything about the incident because S7 CNA didn't want to go to jail. Review of Resident #6's MDS dated [DATE] revealed Resident #6 had a BIMS score of 15 indicating Resident #6 is cognitively intact. During a telephone interview on 5/16/2023 at 9:30 a.m., S3 LPN confirmed she overheard S5 CNA and S6 CNA on 4/30/2023 talking about S7 CNA hitting Resident #1. S3 LPN indicated S5 CNA and S6 CNA were fearful of S7 CNA and wanted to be anonymous. S3 LPN explained that S7 CNA was bragging to S5 CNA and S6 CNA about the incident. After hearing about the incident S3 LPN went to Resident #1's room and asked him what happened and he told her S7 CNA beat him with a broom. Resident #1 walked out and showed S3 LPN and S11 LPN the broom and told them the dents in the broom stick were from hitting him. During an interview on 5/16/2023 at 10:00 a.m., S5 CNA indicated during shift change around 3:00 p.m. on 4/29/2023 S7 CNA was bragging to her about hitting Resident #1. S7 CNA went and got the broom that she hit Resident #1 with and reenacted how she swung the broom at Resident #1. S5 CNA acknowledged she did not know if S7 CNA was joking at the time or not. S5 CNA confirmed the next day she told S3 LPN that S7 CNA told her she hit Resident #1 with a broom handle. S5 CNA indicated S3 LPN went to Resident #1's room and asked him about the incident, and Resident #1 confirmed S7 CNA hit him with a broom handle. S3 LPN called S2 DON and local police. S5 CNA reported S6 CNA also overheard what S7 CNA said about hitting Resident #1 with the broom handle. During an interview on 5/16/2023 at 10:15 a.m., S6 CNA confirmed she heard S7 CNA talking about hitting Resident #1 with broom stick. During a telephone interview on 5/16/2023 at 1:50 p.m., S7 CNA indicated she had not abused Resident #1. She wouldn't have been able to because her leg was hurting on 4/25/2023. During an interview on 5/16/2023 at 2:45 p.m., Resident #8 indicated he received care from S7 CNA. Resident #8 acknowledged he did not see Resident #1 being abused but he heard about it afterwards. Resident #8 confirmed he previously voiced complaints to S2 DON about S7 CNA not answering call lights timely, late to work many times, and took a lot of breaks during other CNAs breaks. Resident #8 stated S7 CNA was just plain nasty to residents. Resident #8 reported feeling as if S7 CNA had no respect for residents at all. Review of Resident #8's MDS dated [DATE] revealed Resident #8 had a BIMS score of 15 indicating Resident #8 is cognitively intact. Review of the facility's Immediate Plan of Improvement dated 4/30/2023 included: 1. Concern- Resident was physically abused. 2. Corrective actions with completion dates: a. CNA suspended pending investigation, completed 4/30/2023. b. Resident examined by LPN, then transported to acute emergency department for examination, completed 4/30/2023. c. Local Police Department notified and came to facility and investigated incident, Report #_____, completed 4/30/2023. d. Resident checked every 30 minutes on Franklin system for monitoring, completed 5/3/2023. 3. System changes: a. Allegation of abuse reported to SIMS, completed 4/30/2023 b. Staff in-serviced on abuse policy and reporting policy, completed 5/1/2023. c. Life rounds conducted by Social Services, completed 5/1/2023. d. S7 CNA reported to CNA registry for abuse, completed 5/1/2023. e. Ombudsman in-serviced residents on abuse and reporting, completed 5/2/2023. f. CNA terminated for physical abuse after investigation and reported to [NAME] (Louisiana Registry System), completed 5/5/2023. 4. Monitoring Plan: a. Unit Managers/LPNs will make safety check rounds randomly. Weekly times four weeks to ensure residents feel secure in facility, completed 5/29/2023. 5. QA (Quality Assurance) Committee Analysis: a. Compliance will be reviewed in monthly QA meeting and adjustments made as necessary to ensure safety of all residents and if anytime there is a negative finding reported, it will be addressed and monitoring will continue until compliance is achieved. Completed 5/29/2023. Review of the facility's above actions revealed the facility had implemented the training, monitoring and quality control aspects by 5/5/2023 and were continuing to monitor safety of residents as of this survey.

Based on record reviews and interviews, the provider failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to complete daily blood glucose checks per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice led to an immediate jeopardy situation for Resident #35, which began on 06/01/2022 at 6:00 AM due to blood glucose checks not being done as ordered by Resident #35's physician and failing to notify the physician that blood glucose checks were not being done. Resident #35 has severe cognitive impairment and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 was also receiving [MEDICATION(S)] ([MEDICATION(S)]) five milligrams by mouth daily at 8:00 AM from 06/01/2022 through 06/18/2022 to lower blood glucose levels. On 06/18/2022, Resident #35 exhibited altered mental status with vomiting. In route to the hospital, EMS (emergency medical services) obtained a blood glucose level of 41 mg/dl (normal range 70-99 mg/dl [milligrams/deciliter]). Resident #35 was hospitalized with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . After Resident #35 returned to the facility on [DATE], blood glucose checks were not being completed as ordered by the physician on the dates S5LPN was assigned to care for Resident #35 from June 23, 2022 through August 29, 2022. There was no evidence the physician was notified of blood glucose checks not being done and no evidence of repeat attempts to obtain blood glucose checks. The provider was notified of the immediate jeopardy situation involving Resident #35 on 09/01/2022 at 2:33 PM. The provider's plan of removal was received and approved on 09/01/2022 at 3:53 PM. The plan of removal included: Immediate Actions: Nurse involved was suspended pending investigation. Resident #35 was assessed by nurse practitioner on 09/01/2022, and plan of care updated. Systemic Actions: Nursing Administration will complete an audit on 09/01/2022, of all residents with accuchecks (blood glucose checks) to ensure timely checks and follow up. All nurses will be in-serviced on following physician orders, importance of completing accuchecks, and timely notification of physician. The in-service will be initiated on 09/01/2022, and no employees will be allowed to work without receiving the in-service. Monitoring: Nursing Administration will review accuchecks during the daily clinical meetings to ensure compliance with completion, documentation, and physician notification. Any issues identified will be addressed immediately and all findings will be reported to the QA committee for oversight. Findings: Provider's Refusal of Treatment Policy revealed in part: Policy interpretation and implementation: 3. If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences. 8. The attending physician must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the refusal. Record review of Resident #35's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's MDS (Minimum Data Set) dated 05/15/2022 revealed a BIMS (Brief Interview for Mental Status) of 4 indicating Severe Cognitive Impairment. Review of Resident #35's Care Plans revealed the following, in part: Focus: Resident has a history of refusal of medical treatment. Resident refuses accuchecks (blood glucose checks). Resident sometimes refuses to go to physician appointments. Initiated on 11/16/2019. Interventions/Tasks (in part): Monitor and document resident behaviors as they occur. Report any increase in negative behavior to physician. Focus: Resident has diabetes mellitus. Initiated on 11/16/2019. Interventions: diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness; educate regarding medications and importance of compliance, have resident verbally state an understanding; identify areas of noncompliance or other difficulties in resident diabetic management, modify the problem area so that it may be more manageable for the resident/family, provide and document teaching to the resident/family/caregiver identified roadblocks to compliance .Monitor/document/report any signs and symptoms of [CONDITION(S)] .Monitor/document/report any signs and symptoms of [CONDITION(S)] .Administer [MEDICATION(S)] sliding scale per MD (Medical Doctor) orders. Record review of Resident #35's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Blood glucose checks were ordered AC and HS (before meal and hour of sleep). A verbal order to change blood glucose checks to daily to 6:00 AM was initiated on 09/02/2021 at 12:08 PM per verbal order signed by S3MD on 09/14/2021. 2. [MEDICATION(S)] Tablet ([MEDICATION(S)]) Give five milligrams by mouth one time a day related to type 2 diabetes. Original Order date: 06/24/2021; Start Date: 06/25/2021. 3. [MEDICATION(S)] solution 100 unit/ml (milliliter) per sliding scale- start date 09/03/2021- 0-70=0units; 71-200= 0units; 201-250= 4units; 251-300= 6units; 301-350 = 8units; 351-400= 10units follow additional instructions, subcutaneously in the morning related to type 2 diabetes mellitus without complications; if less than 70 and alert give 8 ounces OJ (Orange Juice), for decreased LOC (Level of Consciousness) follow orders and send to ER (emergency room ). If three episodes less than 70 or greater than 200 call MD. During an interview on 09/13/2022 at 3:27 PM, S2Corporate Nurse indicated S29LPN received a verbal order to change Resident #35's ACHS blood glucose checks to once daily in the morning. During an interview on 09/13/2022 at 4:03 PM, S2Corporate nurse indicated S29LPN entered the verbal order to change blood glucose checks to be done daily in the morning on Resident #35's MAR (Medication Administration Record) and S29LPN failed to enter the order in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #35's MAR for June 2022 revealed the following, in part: 1. [MEDICATION(S)] ([MEDICATION(S)]) five milligrams by mouth was administered at 8:00 AM on 06/01/2022 through 06/18/2022. Order date 06/24/2021, discontinue date 06/22/2022. 2. Blood glucose checks scheduled for 6:00 AM were not completed by S5LPN from 06/01/2022 through 06/18/2022. The June 2022 MAR confirmed S5LPN was assigned to care for Resident #35 on the days that blood glucose checks were not completed. The June 2022 MAR documentation by S5LPN revealed June 1, 4, 5, 8, 11, 13, 16 blood glucose values were left blank; June 2, 3, 9, 10, 17, 18 blood glucoses were marked as resident refusal; June 6, 7, 12, 14, 15 blood glucoses were marked as resident sleeping. Review of Resident #35's June 2022 MAR failed to reveal any supportive evidence S5LPN notified the physician or nurse practitioner of Resident #35's refusal for blood glucose check. Further review failed to reveal any other supportive evidence of repeat attempts to obtain blood glucose checks from Resident #35. Record review of Resident #35's nurse notes revealed the following, in part: 06/18/2022 by S35LPN 8:50 PM- Sent resident out for declining altered mental status, and vomiting up her dinner. Call S4Nurse Practitioner, S4Nurse Practitioner gave order to send Resident #35 out to hospital. Call Resident #35's sister, sent text to S2Corporate Nurse at 6:30 PM. 06/22/2022 by S36LPN 9:46 PM- Resident #35 returned from hospital this shift in stable condition per ___ambulance service stretcher. Antibiotics started . [MEDICATION(S)] and [MEDICATION(S)] discontinued. Further record review of Resident #35's nurse notes failed to reveal any supportive evidence S5LPN notified the physician or nurse practitioner of Resident #35's refusal for blood glucose check. Further review also failed to reveal any other supportive evidence of repeat attempts to obtain blood glucose checks from Resident #35. Record review of Resident #35's ambulance service record dated 06/18/2022 revealed the following, in part: Primary impression- altered mental status Chief complaint- AMS (altered mental status) Narrative note - Nurse states that the patient (Resident #35) has been altered since after lunch today. When she was trying to feed the patient dinner she started spitting it out. The nurse states that the patient cannot talk but will nod head yes or no . Vital signs obtained. Cardiac monitor shows [CONDITION(S)]. Patient's blood glucose was 41 mg/dL (milligrams per deciliter). Intraosseous (IO) access in left proximal tibia with D5 (Dextrose 5%) running. Re-checked blood glucose, reading was 55mg/dL. Patient was answering questions PTA (prior to arrival) to ER. Patient was more alert after the D5. Record review of Resident #35's hospital record for 06/18/2022 - 06/22/2022 revealed the following: Emergency Department note 06/18/2022 at 7:54 PM: History of present illness (HPI) revealed a chief complaint of altered mental status; mode of arrival EMS. HPI narrative - See EMS report. [AGE] year old presents to the emergency department with complaints of altered mental status just prior to arrival. Patient was transported from ______. Nursing home staff told EMS she was responding less and was septic. EMS states blood glucose was low en route and administered D5 (Dextrose 5%) with improvement in mental status. Patient was responsive in ED (Emergency Department). Medical decision making narrative - [AGE] year old female sent for altered mental status. Found to be hypoglycemic. Was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is on Sulfonylurea thus would admit for further care and evaluation. Labs and images reviewed. Labs - point of care glucose level was 51 on 06/18/2022 at 7:56 PM. Glucose level was 52 on 06/18/2022 at 8:36 PM. Normal range (70-110). ER (emergency room ) discharge plan 06/18/2022 at 7:49 PM - ER admitted to hospital, inpatient status. Clinical impression [CONDITION(S)], altered mental status. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Tablet ([MEDICATION(S)]) Give five milligrams by mouth one time a day related to type 2 diabetes was discontinued on 06/22/2022 when resident #35 was discharged from the hospital and returned to the facility. 2. [MEDICATION(S)] solution 100 unit/ml (milliliter) per sliding scale- start date 09/03/21- 0-70=0units; 71-200= 0units; 201-250= 4units; 251-300= 6units; 301-350 = 8units; 351-400= 10units follow additional instructions, blood glucose checks subcutaneously in the morning related to type 2 diabetes mellitus without complications; if less than 70 and alert give 8 ounces OJ (Orange Juice), for decreased LOC (Level of Consciousness) follow orders and send to ER (emergency room ). If three episodes less than 70 or greater than 200 call MD. Record review of Resident #35's MAR for June 2022 revealed blood glucose checks scheduled for 6:00 AM was not completed on 06/23/2022. S5LPN marked as resident refusal on 06/23/2022. Further review failed to reveal any supportive evidence S5LPN notified the physician or nurse practitioner of Resident #35's refusal for blood glucose check. Further review also failed to reveal any other supportive evidence of repeat attempts to obtain blood glucose checks from Resident #35. Review of Resident #35's MAR for July 2022 revealed blood glucose checks were scheduled for 6:00 AM daily. S5LPN did not complete blood glucose checks for the resident from 07/07/2022 through 07/14/2022, 07/16/2022 through 07/24/2022, and 07/26/2022 through 07/31/2022. S5LPN charted resident refused on July 7-14, 16, 17, 18, 20, 21, 23, 27, 28, 30 and 31, 2022. S5LPN charted resident sleeping on July 19, 22, 26 and 29, 2022. The July 2022 MAR confirmed S5LPN was assigned to care for Resident #35 on the days that blood glucose checks were not completed. Further review failed to reveal any supportive evidence S5LPN notified the physician or nurse practitioner of Resident #35's refusal for blood glucose check. Further review also failed to reveal any other supportive evidence of repeat attempts to obtain blood glucose checks from Resident #35. Review of Resident #35's MAR for August 2022 revealed glucose checks were scheduled for 6:00 AM daily. S5LPN did not complete blood glucose checks for the resident from 08/01/2022 through 08/29/2022, with the exception of two days that the checks were completed on August 4th and 19th of 2022. S5LPN charted resident refused on August 1, 2, 3, 6, 7, 8, 9, 11, 13, 14, 15, 16, 17, 20, 21, 24, 25, 26, 27, and 28, 2022. S5LPN charted resident sleeping on August 5, 10, 12 and 29, 2022. June 18, 2022 blood glucose value was left blank. The August 2022 MAR confirmed S5LPN was assigned to care for Resident #35 on the days that blood glucose checks were not completed. Further review failed to reveal any supportive evidence S5LPN notified the physician or nurse practitioner of Resident #35's refusal for blood glucose check. Further review also failed to reveal any other supportive evidence of repeat attempts to obtain blood glucose checks from Resident #35. During an attempted interview on 08/30/2022 at 2:25 PM, S5LPN did not answer any questions related Resident #35's blood glucose checks not being completed as ordered. S5LPN repeatedly sated Resident #35 is very combative and aggressive, and will refuse care a lot. During an interview on 08/30/2022 at 2:53 PM, Resident #35 was able to answer simple questions appropriately, voice tone was calm. Resident #35 was not able to answer any questions related to her blood glucose checks. During an interview on 08/30/2022 at 3:05 PM, S29LPN indicated Resident #35 can be aggressive sometimes but will usually calm down easily. S29LPN further indicated she is able to complete the ordered care for Resident #35 including blood glucose checks. During an interview on 08/31/2022 at 2:55 PM, S31CNA (certified nursing assistant) indicated Resident #35 can be aggressive sometimes but if you approach her in a calm manner she will cooperate. S31CNA indicated you have to explain what you are planning to do for Resident #35 before you start providing the care and Resident #35 will usually say ok and allow care to be provided. During a telephone interview on 08/31/2022 at 10:27 AM, Resident #35's physician (S3MD) indicated he had not received any notifications of Resident #35 refusing any treatments/orders. S3MD acknowledged he was not notified of Resident #35 refusing blood glucose checks and Resident #35 needed blood glucose checks daily and should have been notified. During an interview on 08/31/2022 at 11:06 AM, S4NP (Nurse Practitioner) indicated she was not aware Resident #35 was not getting her blood glucose checks, and did not receive any notifications of Resident #35 refusing care or medications. During a telephone interview on 08/31/2022 at 11:33 AM, S3MD indicated if he had known the resident was not getting blood glucose checks as ordered he would have assessed the situation and ordered additional interventions. During an interview on 08/31/2022 at 4:30 PM, S2Corporate Nurse reviewed Resident #35's June 2022 MAR and confirmed S5LPN did not complete any blood glucose checks for Resident #35 from June 1, 2022 through June 18, 2022 as ordered. Resident #35 was sent to a local hospital and was diagnosed to have [CONDITION(S)] after arriving to the hospital. During an interview on 08/31/2022 at 4:50 PM, S2CorporateNurse indicated she reviewed Resident #35's MARs from March-August 2022 and verified S5LPN was not completing blood glucose checks at 6:00 AM as ordered, on any of the MARs during the months of March-August 2022. S2Corporate Nurse indicated S5LPN was charting Resident #35 had either refused, was asleep, or nothing was documented for blood glucose testing. S2Corporate Nurse confirmed S5LPN's documentation for not completing blood glucose checks was not adequate and the checks should have been completed. During an interview on 08/31/2022 at 5:05 PM, S1Administrator indicated he was not aware of S5LPN not completing blood glucose checks as ordered prior to being notified by S2Corporate Nurse on 08/31/2022. S1Administrator verified S5LPN will be suspended and an investigation will be completed. During an interview on 09/12/2022 at 4:28 PM, S33LPN indicated she had cared for Resident #35 when she filled in for the day shift nurse. S33LPN indicated she had given the [MEDICATION(S)] 5 milligrams by mouth to Resident #35 before and she verified she did not review Resident #35's blood glucose checks before administering the medication. S33LPN indicated S5LPN never reported Resident #35 not having blood glucose checks done at 6:00 AM. During an interview on 09/13/2022 at 2:45 PM S29LPN acknowledged she did not verify Resident #35 had her blood glucoses checked prior to administering Resident #35's [MEDICATION(S)] 5 milligrams by mouth at 8:00 AM. S29LPN confirmed when administering diabetic medications to Resident #35 she did not look at previous blood glucose values but relied on what Resident #35 looked like when she was providing care, using nursing judgement. S29LPN indicated she had access to Resident #35 blood glucose checks documented on the MAR, but she never reviewed the MAR. S29LPN indicated she was able to get Resident #35 to receive care and take medications after sitting and talking to her about her family and this would calm the resident and the resident would cooperate with receiving care and medications. During an interview on 09/14/2022 at 7:40 AM, S34LPN indicated she was able to complete the 6:00 AM blood glucose checks for Resident #35 when she cared for her. S34 LPN further indicated that the resident could be aggressive in behaviors, but if you talk to the resident calmly and notify her what care she was going to receive the resident would calm and accept care. During an interview on 09/14/2022 at 4:30 PM S19Unit Manager confirmed Resident #35 resides on the hall that she is responsible for managing. S19Unit Manager acknowledged she is responsible for conducting chart reviews for the residents on her unit. S19Unit Manager confirmed chart reviews were initiated when a nurse fails to administer a medication and/or other orders not completed. S19Unit Manager verified when a nurse fails to administer a medication and/or other orders not completed it shows on S19Unit Manager's computer dash board for review. S19Unit Manager stated she could not recall the last time she completed a chart review on any resident residing on her hall. During an interview on 09/14/2022 at 4:45 PM S2Corporate Nurse confirmed the DON (Director of Nursing) is responsible for making sure the Unit Managers are completing chart reviews. S2Corporate Nurse confirmed she was acting DON from March 2022 - July 2022 and she did not check to ensure chart checks were being done. S2Corporate Nurse indicated she had instructed S19Unit Manager to complete chart checks. During an interview on 09/14/2022 at 4:55 PM S2Corporate Nurse acknowledged if chart checks had been completed for Resident #35 the lack of blood glucose checks would have been discovered and acted upon. S2 Corporate Nurse confirmed if Resident #35 was receiving daily blood glucose checks as ordered it may have prevented Resident #35 becoming hypoglycemic and requiring hospitalization .

Based on record reviews and interviews, the facility failed to be administered in a manner that used resources effectively and efficiently to ensure a resident's daily blood sugar checks were completed as ordered by a physician for 1 (#35) out of 1 (#35) residents reviewed for glucose monitoring. This failed practice led to an immediate jeopardy situation for Resident #35, which began on 06/01/2022 at 6:00 AM due to blood glucose checks not being done as ordered by Resident #35's physician and failing to notify the physician that blood glucose checks were not being done. Resident #35 has severe cognitive impairment and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 was also receiving [MEDICATION(S)] ([MEDICATION(S)]) five milligrams by mouth daily at 8:00 AM from 06/01/2022 through 06/18/2022 to lower blood glucose levels. On 06/18/2022, Resident #35 exhibited altered mental status with vomiting. In route to the hospital, EMS (emergency medical services) obtained a blood glucose level of 41 mg/dl (normal range 70-99 mg/dl [milligrams/deciliter]). Resident #35 was hospitalized with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . After Resident #35 returned to the facility on [DATE], blood glucose checks were not being completed as ordered by the physician on the dates S5LPN was assigned to care for Resident #35 from June 23, 2022 through August 29, 2022. There was no evidence the physician was notified of blood glucose checks not being done and no evidence of repeat attempts to obtain blood glucose checks. The provider was notified of the immediate jeopardy situation involving Resident #35 on 09/15/2022 at 2:30 PM. The provider's plan of removal was received and approved on 09/15/2022 at 6:01 PM. The plan of removal included: Resident #35 was assessed on 09/01/2022 by S4NP (Nurse Practitioner) and a plan of care was updated. S5LPN, employee, has been terminated as of 09/07/2022. On September 6, 2022 S2Coporate Nurse in-serviced S1Administrator and S18DON (Director of Nursing) and Unit Managers on the importance of following physician orders, importance of completing accuchecks, timely notification of physician, and monitoring medications not administrated to ensure proper follow up, interventions and notifications when reviewing Point Click Care Dashboard System, including medication administration record, progress notes, notifications and documentation. An audit was completed on September 2, 2022 of residents with accuchecks to ensure timely checks and follow up. On September 1, 2022 S32RN (Registered Nurse) and S2Corporate Nurse in-serviced nurses on following physician orders, importance of completing accuchecks and timely notification of physician. Staff will not be allowed to work until in-servicing has been completed. In order to monitor current residents for potential risk, S18DON and nursing administration will review accuchecks during the daily meetings to ensure compliance with completion, documentation and physician notification when reviewing Point Click Care Dashboard System. Compliance on reviewing the Point Click Care System, including medication administration record, progress notes, notifications and documentation will be monitored weekly by S2Corporate Nurse until 12/15/2022. Thereafter, QA (Quality Assurance) will monitor quarterly up to a year for compliance of reviewing Point Click Care Dashboard System and following up on identified issues. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA committee. Findings: Cross refer to F684 Provider's Refusal of Treatment Policy revealed in part: Policy interpretation and implementation- 3. If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences. 8. The attending physician must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the refusal. During an interview on 08/31/2022 at 4:30 PM, S2Corporate Nurse reviewed Resident #35's June 2022 MAR and confirmed S5LPN did not complete any blood glucose checks for Resident #35 from June 1, 2022 through June 18, 2022 as ordered. Resident #35 was sent to a local hospital and was diagnosed to have [CONDITION(S)] after arriving to the hospital. During an interview on 08/31/2022 at 4:50 PM, S2CorporateNurse indicated she reviewed Resident #35's MARs from March-August 2022 and verified S5LPN was not completing blood glucose checks at 6:00 AM as ordered, on any of the MARs during the months of March-August 2022. S2Corporate Nurse indicated S5LPN was charting Resident #35 had either refused, was asleep, or nothing was documented for blood glucose testing. S2Corporate Nurse confirmed S5LPN's documentation for not completing blood glucose checks was not adequate and the checks should have been completed. During an interview on 08/31/2022 at 5:05 PM, S1Administrator indicated he was not aware of S5LPN not completing blood sugar checks as ordered prior to being notified by S2Corporate Nurse on 08/31/2022. S1Administrator verified S5LPN will be suspended and an investigation will be completed. During an interview on 09/14/2022 at 4:30 PM S19Unit Manager confirmed Resident #35 resides on the hall that she is responsible for managing. S19Unit Manager acknowledged she is responsible for conducting chart reviews for the residents on her unit. S19Unit Manager confirmed chart reviews were initiated when a nurse fails to administer a medication and/or other orders not completed. S19Unit Manager verified when a nurse fails to administer a medication and/or other orders not completed it shows on S19Unit Manager's computer dash board for review. S19Unit Manager stated she could not recall the last time she completed a chart review on any resident residing on her hall. During an interview on 09/14/2022 at 4:45 PM S2Corporate Nurse confirmed the DON is responsible for making sure the Unit Managers are completing chart reviews. S2Corporate Nurse confirmed she was acting DON from March 2022 - July 2022 and she did not check to ensure chart checks were being done. S2Corporate Nurse indicated she had instructed S19Unit Manager to complete chart checks. During an interview on 09/14/2022 at 4:55 PM S2Corporate Nurse acknowledged if chart checks had been completed for Resident #35 the lack of blood glucose checks would have been discovered and acted upon. S2Corporate Nurse confirmed if Resident #35 was receiving daily blood glucose checks as ordered it may have prevented Resident #35 becoming hypoglycemic and requiring hospitalization . During an interview on 09/15/2022 at 10:30 AM S2Corporate Nurse verified the facility does not have a policy for resident chart reviews. S2Corporate Nurse indicated Unit Managers are responsible for completing a Daily Nursing Management tool that includes, check for any clinic alerts and clear with a progress note. S2Corporate Nurse confirmed S19 Unit Manager did not complete this task for Resident #35.

Based on record reviews and interviews, the facility failed to provide treatment and services for management of pain to a resident with an injury of unknown origin that is consistent with professional standards of practice for 1 (#80) of 3 (#59, #80, #98) residents reviewed for pain management. The deficient practice resulted in an immediate jeopardy situation on 05/5/2021 when S36 RN (Registered Nurse) observed Resident #80 lying on the floor by her bed and instructed S27 CNA (Certified Nursing Assistant) to get the resident off the floor and put her back in her bed. After replacing Resident #80 back in bed, S27 CNA reported to S36 RN that Resident #80's left leg was swollen and she was in pain. S36 RN did not assess Resident #80. Several other staff caring for Resident #80, acknowledged her left leg was swollen and she continued to grimace in pain, moan, yell out, flinch, stiffen up when touched, turned or repositioned while receiving care. On 05/10/2021, S20 NP (Nurse Practitioner) ordered pain medicine that was not administered until 5/11/2021. Resident #80 was transferred to a local hospital on 05/11/2021 where she was found to have an impacted left femoral fracture that was surgically repaired. S1 Administrator was notified of the Immediate Jeopardy on 08/04/21 at 4:48 PM. The Immediate Jeopardy was removed on 05/11/21 at 6:00 PM when the resident was transferred to the hospital. The deficiency remains at a harm for the remaining 99 residents at a risk for injury that may require pain management after a fall. The facility presented an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit: The facility presented an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit: - Corporate Nurse in-serviced S2 Director of Nursing (DON) on policy and procedures for assessing residents' after a fall for pain or injury, along with correlating interventions. - All staff were in-serviced on policy and procedures for assessing residents' after a fall for pain or injury, to include not moving a resident until they are assessed, along with correlating interventions prior to working with residents. - All residents in the facility were rounded on and assessed for pain - The Unit Manager will round on residents and communicate with staff on the floor twice a day during the week and ongoing to ensure pain is assessed, treated and origin of pain is identified. Weekend RN Supervisor will round on residents and communicate with staff on the floor twice a day and report to S2 DON any concerns with falls or pain. S2 DON/designee will be in contact with RN Supervisor once a day on weekends to assure all issues are addressed. - An audit will be completed to review incident reports by S2 DON/designee to ensure no other issues related to falls, pain or injuries occurred. Any issues identified will be addressed immediately by S2 DON/designee. - S2 DON will monitor current residents' incident reports for 30 days beginning 08/04/2021. S35 Corporate Nurse will monitor compliance of S2 DON for 90 days. - QA (Quality Assurance) will monitor quarterly up to a year for compliance. QA committee will meet weekly for eight weeks to review compliance for plan of action. Findings: Review of Facility's Pain Management Program Policy - Assessment and Recognition - revealed: 6) Interdisciplinary committee will make attempts to determine the root cause of pain and collaborate with physician to conduct necessary diagnostics and evaluation to identify potential source of pain and determine plan of care. Review of Resident #80's Medical Records revealed admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #80's MDS (Minimum Data Set) assessment dated [DATE] revealed: Section C: Cognitive Pattern - BIMS 05 (0-7 Severe Cognitive Impairment). Section G: Functional Status - walking in and out of room, locomotion on unit supervision with one person. Review of Resident #80's Comprehensive Care Plan revealed: Potential for pain - anticipate the resident's need for pain and respond immediately to any complaint of pain, monitor/record/report to nurse any signs or symptoms of non-verbal pain: vocalizations (grunting, moaning, yelling out, silence), face (grimacing). Review of Resident #80's Nurses' Note dated 05/11/2021 at 18:00 revealed - Resident sent to ER (emergency room ) per S2 NP (responsible party) orders r/t (related to) acute impacted fracture or chronic healed fracture left femur needs CT (computed tomography) or MRI (magnetic resonance imaging) to better diagnose femur. Resident RP notified. DON notified res transported to hospital via ambulance . Review of Resident #80's NP Progress Notes revealed the following: - 05/10/2021 - HPI (history of present illness): .Resident poor historian. Phone report received 05/07/2021 secondary to LLE (left lower extremity) pain. Staff nurse reports no precipitating factors. States resident has not gotten out of bed for 2 days. Spoke to staff nurse again on 05/08/2021. Resident remains in bed Seen today for face to face evaluation. Apparently resident was involved in a fall 05/05/2021 that was not reported or documented in a timely manner .treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] - 05/11/2021 - HPI: Nurse reports resident continues to grimace and moan with position changes. Swelling noted to coccyx. Review of Resident #80's May 2021 MAR (medication administration record) revealed [MEDICATION(S)] 7.5 mg (milligrams) was ordered on 05/10/2021 by S20 NP and the first dose was administered on 05/11/2021 after receiving the medication from the pharmacy. Review of Resident #80's hospital ER history and physical with an admitted [DATE] read, in part: Chief Complaint - patient presents with hip injury; HPI (history present illness): presented to hospital ER for a fall at her nursing home. Pelvic images (x-ray) had been delayed unfortunately, and patient was subsequently brought to ER for further evaluation . Review of Resident #80's Radiology Report dated 05/11/2021 revealed impressions: sclerotic band in proximal left femoral neck which may represent either an acute impacted fracture or a chronic healed fracture . Observations from 08/03/21 through 08/06/2021 revealed Resident #80 was self-propelling in a wheelchair in room and on hallways. During an interview on 08/04/2021 at 11:25 AM S20 NP reported Resident #80 had a fall that staff did not report to her in a timely manner. S20 NP reported within a couple of days of the apparent fall she was notified Resident #80 was complaining of pain in the hip area and was unable to get out of bed. S20 NP further reported a left hip and femur x-ray was ordered and when it came back normal, stat lab was ordered. S20 NP reported she went back to re-evaluate Resident #80's pain on 05/10/2021 and was told at that time that the Resident #80 had fallen. S20 NP reported she ordered a pelvic x-ray which showed a hip fracture and Resident #80 was transferred to the hospital. During an interview on 08/04/2021 at 12:35 PM S26 LPN (licensed practical nurse) reported on 05/10/2021 Resident #80 was unable walk to the nurses' station and did not want to get out of bed. S26 LPN observed Resident #80 grimace and appear to be in a lot of a pain when moving her. S26 LPN reported S20 NP and S2 DON were notified at that time. S26 LPN acknowledged she thought it was suspicious because this was not Resident #80's norm. During an interview on 08/04/2021 at 1:50 PM S27 CNA reported working on 05/05/2021 3-11 shift with S36 RN. S27 CNA reported S36 RN passed Resident #80's room looked in, then walked down the hallway and told him to get Resident #80 off the floor. S27 CNA further reported S36 RN did not assess Resident #80 prior to him picking up Resident #80 and putting her back to bed. S27 CNA reported Resident #80 stated ouch when he picked her up. S27 CNA reported S36 RN told him two hours later not tell anyone Resident #80 fell because S36 RN didn't want to write an incident report. S27 CNA further reported Resident #80 was in pain with turning, repositioning or receiving incontinent care. During an interview on 08/04/2021 at 4:40 PM S30 LPN reported she worked 05/05/2021 on the 11-7 night shift following the fall. S30 LPN reported she was notified by S32 CNA Resident #80's leg was swollen, warm and Resident #80 was hurting. S30 LPN reported when assessing Resident #80's leg it was swollen, warm and Resident #80 flinched upon being touched and made a negative facial expression which indicated to S30 LPN Resident #80 was hurting. S30 LPN reported after assessing Resident #80 she covered her back up and didn't report her assessment to anyone. During an interview on 08/04/2021 at 2:00 PM S8 LPN reported following 05/05/2021 Resident #80 was not her normal self. S8 LPN reported S20 NP was contacted on 05/07/2021 to request an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . S8 LPN reported she notified S25 Unit Manager and S26 LPN. During an interview on 08/04/2021 at 1:04 PM S2 DON reported she was notified that Resident #80 had a fall. S2 DON stated I've thought she had a fall this whole time. S2 DON reported Resident #80 fell on [DATE] and confirmed Resident #80 laid in bed for six days in pain before going to the hospital. S2 DON confirmed no investigation was conducted, no statements were taken, and no in-services or training was completed following Resident #80's fall. During an interview on 08/04/2021 at 2:08 PM S25 Unit Manager reported S8 LPN notified her Resident #80 fell when S36 RN was working. S25 Unit Manager reported S2 DON became aware of Resident #80's fall on 05/07/2021. During an interview on 08/04/2021 at 2:17 PM S28 CNA reported on 05/06/2021 Resident #80's left leg was swollen and was reported to S8 LPN. S28 CNA reported S8 LPN acknowledged Resident #80's left leg was swollen and S28 CNA stated it looked like it was broken to me. S28 CNA further reported Resident #80 would scream and holler with touch and was in a lot of pain. S28 CNA reported Resident #80 required two person assist with turning due to Resident #80 being in so much pain. S28 CNA further reported prior to the fall Resident #80 walked to the nurse's station and it was not normal for her to lay in bed. During an interview on 08/04/2021 at 4:10 PM S36 RN confirmed upon returning to work a couple of days following the fall, Resident #80 was in pain with no interventions in place to address the pain. S36 RN reported everyone knew Resident #80 was in pain. During an interview on 08/04/2021 at 4:30 PM S29 CNA reported Resident #80 was able to walk prior to the fall. S29 CNA reported Resident #80 yelled out with turning which was not her norm. S29 CNA reported she notified S33 LPN Resident #80 was in pain. S29 CNA confirmed the resident remained in pain with no change until the resident was sent out to the hospital. During an interview on 08/05/2021 at 11:20 AM S24 CNA reported Resident #80 was in pain and saying ouch with turning. S24 CNA further reported Resident #80 was unable to get out of bed which was not her norm. S24 CNA reported S31 WCN (Wound Care Nurse) and S20 NP assessed Resident #80's backside. S24 CNA further indicated she heard S27 CNA report Resident #80 had fallen. During an interview on 08/05/2021 at 11:30 AM S31 WCN reported being present when S20 NP assessed Resident #80. S31 WCN reported Resident #80 had discomfort and upon turning Resident #80 S31 WCN stated she has a fracture. S31 WCN reported Resident #80 flinched when turned a certain way. During an interview on 08/05/2021 at 2:12 PM S34 CNA reported Resident #80 was ambulating and dancing prior to fracture. During an interview on 08/05/2021 at 4:55 S32 CNA reported Resident #80 did not want to get out of bed, be moved or touched at all which was not her norm. S32 CNA reported Resident #80 would stiffen up when she was touched and swelling was noted to Resident #80's leg. S32 CNA reported S30 LPN was notified on the night shift of 05/05/2021.

Based on record review and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all residents residing in the facility. The facility failed to have an effective system in place to ensure 1 (S19) of 37 staff members working in a licensed capacity was licensed to practice nursing in accordance with State laws. This deficient practice had a potential for more than minimal harm for 130 residents who resided in the facility. This deficient practice resulted in an Immediate Jeopardy on [DATE] when S19, who was not a licensed practical nurse, was allowed to work as a licensed practical nurse in the facility providing care, services and/or treatments to the residents in the facility. S19 was employed by the facility as a social worker and a licensed practical nurse from [DATE] through [DATE]. While working as a licensed practical nurse, S19 performed various resident care, services and treatments including the administration of medications, including insulin injections, the initiation of O2 administration, the administration of tube feedings, the insertion of urinary catheters, etc. In addition, S19 received and carried out physicians' orders, including verbal orders. S19 worked on all units of the facility on the 3pm to 11pm shift, the 11pm to 7am, and on a prn (as needed) basis. The Immediate Jeopardy ended on [DATE] when all staff had been in-serviced, residents assessed, and staff working as nurses in the facility licenses were verified. On [DATE] at 2:30 PM, the Administrator was informed of the Past Noncompliance at the Immediate Jeopardy level. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Cross refer to findings at F839 Review of the Facility Policy Licensure, Certification, and Registration of Personnel revealed the following: Employees who require a license, certification, or registration to perform their duties must present such verification with their application for employment .A copy of the current license, certification, or registration number must be filed in the employee's personnel record .A copy of recertification (e.g. annual, bi-annual, etc. as applicable) must be presented to the Human Resources Director/designee upon receipt of such recertification and prior to the expiration of current licensure, certification, and/or registration. During an interview on [DATE] at 2:15 pm, S20 Corporate Human Resources indicated, S19 Un-licensed Nurse was in the corporate system as a Social Worker and did not trigger for a licensure check/verification as a LPN. During an interview on [DATE] at 10:4 am, S2Corporate Nurse verified all nurse's licenses for the facility should have been verified yearly. During an interview on [DATE] at 9:15 am S2 Corporate Nurse acknowledged she had reviewed S19 Un-licensed Nurse personnel record and did not find any licensed practical nurse competency training or any evidence that S19 Un-licensed Nurse was trained by a seasoned nurse prior to working with residents in the capacity of a licensed practical nurse S2 Corporate Nurse further acknowledged S19 Un-licensed Nurse did not have a current CPR certification. During an interview on [DATE] at 3:00 pm, S1 Administrator and S2 Corporate Nurse confirmed that the administrative policies and procedures in place were not effective in ensuring all licensed professional staff had a valid license to practice as a licensed practical nurse in the facility. During an interview on [DATE] at 3:00 pm, S1 Administrator and S2 Corporate Nurse confirmed several actions were initiated as a result of this incident. The facility has implemented the following actions to correct the deficient practice: *Immediate Action Taken: The alleged perpetrator was terminated on [DATE]. *Credential Checks (licensure, certification, and registry checks) were performed on all licensed, certified and or registered professionals throughout the building by facility human resources was completed on [DATE]. *Self- Reported to the State Licensing Agency the allegation by the Administrator on [DATE]. *Notified the Board of Nursing on [DATE] about the unlicensed individual working as a licensed nurse *Investigation initiated on the concern immediately. *Initiated assessment of residents to ensure no adverse effects was completed on [DATE]. *Notify the Medical Directors and all attending physicians of the unlicensed person working as a licensed nurse was completed on [DATE]. *Verified that all users have the appropriate role in the electronic medical record. Monitoring Plan: Credential verification ticklers will be reviewed at least quarterly by the Regional Human Resource Generalist or designee, to ensure that all active staff have appropriate active credentials. All individuals working in positions outside of their normal position will have a review completed by the Regional HR prior to being allowed to work in a capacity that requires specific credentials. QA (Quality Assurance) Committee Analysis: Audit findings and credential tracking will be shared with the QA team at least quarterly. Any concerns will be immediately addressed and deemed necessary by this team. Through record reviews, the surveyor confirmed the following plan of correction components had been implemented and completed: 1. S2 Corporate Nurse verified all nurse's licenses and CNA certifications. 2. All residents, physicians and family members were notified of S19 un-licensed nurse working as a LPN without a license. Resident is responsible parties and family members were notified by phone using the script as below: I was calling to inform you of a situation that occurred at the facility . We had an unlicensed person working as a nurse. In response to this situation, we have done the following; The employee has been terminated from the facility. We are working hand in hand with the police, Board of Nursing and Department of Health and we are fully cooperating with their investigation. All residents are being assessed by Registered Nurses. All physicians have been notified of the situation. Credentials have been verified of all current staff. This has never happened before, and we are taking every step to ensure that it never happens again. 3. A Resident Council meeting was held on [DATE] at 3:00 pm and all residents were notified of S19 un-licensed nurse working in the facility without a valid license. Documentation of resident council meeting revealed the following: Administrator explained to the residents that the police had been contacted because of an employee working in the facility as a nurse without a license. 4. Life Satisfaction rounds were completed on all residents who were able to participate and answer questions. 5. Employee statements were taken during the facility investigation and the employees were interviewed in relation to working with S1 Un-licensed Nurse. 6. Head to Toe assessments were completed on all residents by a registered nurse. 7. In-service was conducted on [DATE] and [DATE] with the Human Resources Director, Department Heads, and Hiring Managers, Nurses and Certified Nursing Assistants and all staff in regard to the following: Topic: Credential Verification Employees working in positions that require credentials must have their credentials verified prior to allowing the employee to work. All verification screening documentation must be in place prior to working. All employees will only perform job functions they are credentialed to perform, (example- You must have a license to be a nurse, You must have proof of CNA certification) Employees must immediately report to administration or DON (director of nurses) if they notice anyone who may display concerns with competence, knowledge of job skills or any concerns related to staff performance. 8. In-service was conducted on [DATE] on Agency Credentialing Verification Process with Human Resources Director on the following: Agency will provide necessary documentation of verification of LPN license. All agency personnel will only perform job functions they are credentialed to perform. Example: You must have a license to be a nurse; you must have proof of CNA certification to perform CNA duties. The surveyor validated the corrective action plan and the date of correction was listed as [DATE] when the facility provided the last in-service education related to the deficient practice.

Based on record review and interview, the facility failed to ensure 1 (S19) of 35 staff members requiring practical nursing licensure was licensed as a practical nurse in accordance with State laws before being allowed to performed the duties of a practical nurse. This deficient practice had a potential for more than minimal harm for 130 residents who resided in the facility. This deficient practice resulted in an Immediate Jeopardy on [DATE] when S19, who was not a licensed practical nurse, was allowed to work as a licensed practical nurse in the facility providing care, services and/or treatments to the residents in the facility. S19 was employed by the facility as a social worker and a licensed practical nurse from [DATE] through [DATE]. While working as a licensed practical nurse, S19 performed various resident care services and treatments including the administration of medications, insulin injections, the initiation of O2 administration, the administration of tube feedings, the insertion of urinary catheters, and etc. In addition, S19 received and carried out physician's orders including verbal orders. S19 worked on all units of the facility on the 3pm to 11pm shift, the 11pm to 7am, and on a prn (as needed) basis. The Immediate Jeopardy ended on [DATE] when all staff had been in-serviced, residents assessed, and staff working as nurses in the facility licenses were verified. On [DATE] at 2:30 PM, the Administrator was informed of the Past Noncompliance at the Immediate Jeopardy level. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the Louisiana Revised Statutes 37:961.3 states, Practical nurse means a person who practices practical nursing and who is licensed to practice in accordance with 37:961. Further review in accordance with 37:961.4, states in part, The practice of practical nursing means the performance for compensation of any acts, not requiring the education, training, and preparation in professional nursing, in the care, treatment or observation of persons who are ill, injured, or infirm and for the maintenance of the health of others and the promotion of health care, including the administration of medications and treatments or in on-job training or supervising licensed practical nurses, subordinate personnel, or instructing patients consistent with the licensed practical nurse's education and preparation, under the direction of a licensed physician, optometrist, or dentist acting individually or in his capacity as a member of the medical staff, or registered nurse. Review of the Facility Policy Licensure, Certification, and Registration of Personnel revealed the following: Employees who require a license, certification, or registration to perform their duties must present such verification with their application for employment .A copy of the current license, certification, or registration number must be filed in the employee's personnel record .A copy of recertification (e.g. annual, bi-annual, etc. as applicable) must be presented to the Human Resources Director/designee upon receipt of such recertification and prior to the expiration of current licensure, certification, and/or registration. Review of the Facility's Competency of Nursing Staff Policy revealed the following: 1. All nursing staff must meet the specific competency requirements of respective licensure and certification requirements defined by State Law. 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: a. Participate in a facility-specific, competency-based staff development and training program. b. Demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plan of care. During an interview on [DATE] at 1:30 p.m. S1 Administrator, S2 DON, and S4 Regional Vice President of Operations revealed that S19 Un-licensed nurse worked in the facility as a licensed practical nurse, without a license from (MONTH) (YEAR) to (MONTH) 2019. S1 Administrator stated an anonymous tip was called into the local Sheriff's Office and the facility was notified that S19 Un-licensed Nurse was working in the facility as a licensed practical nurse without a license. S1 Administrator stated, S19 Un-licensed Nurse was immediately terminated. S4 Regional Vice President of Operations stated I assisted the administrator in completing an investigation to evaluate all shifts worked, residents taken care of, and procedures performed by S19 Un-licensed Nurse during this time frame. S4 Regional Vice President of Operations stated, All staff licenses had been verified. S1 Administrator and S4 Vice President of Operations verified all physicians, residents and family members had been notified of the situation. During an interview on [DATE] at 2:40 pm, S1 Administrator stated S19 Un-licensed Nurse worked her first shift as a LPN (Licensed Practical Nurse) on [DATE]. S1 Administrator further stated, S19 Un-licensed Nurse's license was verified by the Human Resources director at that time but the original copy of her license was not in her personnel file. Review of S19 Un-licensed Nurse personnel record failed to reveal verification of a license to practice as a licensed practical nurse. Review of S19 Un-licensed Nurse personnel record revealed a Quick Confirm License Verification Form dated [DATE] at 1:56 pm with a name that did not match the name on S19 Un-licensed Nurse Driver's License or Social Security Card. Review of the Facility's Nursing Hours Worked Report revealed S19 Un-licensed Nurse had worked a total of 1047.83 hours as a licensed practical nurse. Review of the calendar and list of shift provided to surveyor on [DATE] by S2 Corporate Nurse revealed S19 Un-licensed Nurse worked as a licensed practical nurse without a license on the following dates and shifts: May (YEAR) -11pm to 7pm shift - [DATE], [DATE], [DATE], [DATE], [DATE] June (YEAR)- 11pm to 7pm shift- [DATE], [DATE], [DATE], [DATE], [DATE] July (YEAR)- 7pm to 7am shift-[DATE] July (YEAR)- 11p to 7am shift- [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] August (YEAR)- 11pm to 7am shift- [DATE] September (YEAR)-11pm to 7am shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] October (YEAR)- 3pm to 11pm shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] November (YEAR) -11pm-7am shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], December (YEAR) -11pm to 7am shift- [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] [DATE] -11pm to 7am shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] February ,[DATE]pm to 7am shift- [DATE], [DATE] [DATE]-11pm to 7am shift- [DATE], [DATE], [DATE], [DATE] [DATE]- 3pm to 11pm shift- [DATE] [DATE]-11pm to 7am shift- [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] [DATE]- 11pm to 7am shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] [DATE]- 11pm to 7am shift-[DATE], [DATE], ,[DATE], 19, [DATE], [DATE], [DATE] [DATE]-11pm to 7am shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] [DATE]-3pm to 11pm shift-[DATE], [DATE] [DATE]-11pm to 7am shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE] Review of residents' MARS (Medication Administration Records) from [DATE] to [DATE] revealed S19 Un-licensed Nurse administered medications by mouth and via PEG tube, administered insulin, administered tube feedings, initiated O2 administration, performed urinary catheterization, etc. to residents under her care. Further review revealed S19 Un-licensed Nurse documented the administration and the performance of these various nursing duties/tasks using her initials. Review of residents' Physicians's Orders from [DATE] to [DATE] revealed S19 Un-licensed Nurse received and/or carried out various physicians' orders including verbal orders. These physicians' orders included medications, treatments, tube feedings, residents' code statuses', etc. Furthers review of residents' medical records from [DATE] to [DATE] revealed S19 Un-licensed Nurse documented and completed numerous medical documents including Nurses Notes, MARs, and Treatment Records. During an interview on [DATE] at 2:40 pm, S1 Administrator and S2 Corporate Nurse verified that S19 Un-licensed Nurse worked as a licensed practical nurse on an as needed basis on all units of the facility. During an interview on [DATE] at 9:15 am, S2 Corporate Nurse acknowledged she had reviewed S19 Un-licensed Nurse personnel record and did not find any licensed practical nurse competency training or any evidence that S19 Un-licensed Nurse was trained by a seasoned nurse prior to working with residents in the capacity of a licensed practical nurse. S2 Corporate Nurse further acknowledged S19 Un-licensed Nurse did not have a current CPR (Cardiopulmonary Resuscitation) certification. During an interview on [DATE] at 1:45 pm, S21 Nurse Practitioner indicated she had interacted with S19 Un-licensed nurse when she was working overtime as a licensed practical nurse. During an interview on [DATE] at 3:50 pm, S22 LPN indicated she had worked with S19 Un-licensed Nurse on the unit. S22 LPN further indicated S19 Un-licensed nurse performed all nursing duties including blood glucose checks, subcutaneous insulin administration, tube feedings, etc. During an interview on [DATE] at 4:00 pm, S23 LPN indicated she worked with S19 Un-licensed Nurse and found her to be slow and thought it was due to her being rusty since she had not worked as a licensed practical nurse in a while. During an interview on [DATE] at 4:05 pm, S24 LPN verified S19 Un-licensed nurse relieved him on the 11pm to 7am shift on [DATE]. S24 LPN stated, he asked S19 Un-licensed Nurse, Are you here to relieve me? and she stated yes. S24 LPN further stated he then asked S19 Un-licensed nurse, are you a nurse? and she said yes. During an interview on [DATE] at 12:20 pm, S5 Social Worker indicated S19 Un-licensed Nurse would work as a LPN frequently and would write doctor's orders and sign them and would say she had to sign them because she was a nurse. S5 Social Worker indicated she had no idea S19 Un-licensed nurse did not have a license to practice nursing, but thought she was a Social Worker and a LPN. During an interview on [DATE] at 10:58 am S11 LPN stated The detective called me because S19 Un-licensed Nurse told him that I trained her on the floor as a nurse, which was not true. S11 LPN further stated S19 Un-licensed Nurse often relieved me on 11 to 7 shift and I found it odd that she had problems putting in a catheter and she had problems with sterile technique. I had to put the catheter in when I came in the next day. S11 LPN also indicated that residents complained about S19 Un-licensed Nurse's overall attitude and demeanor. S11 LPN confirmed that the issues with S19 Un-licensed Nurses' performance and the residents' complaints were not reported to anyone at the facility. During an interview on [DATE] at 6:30 am, S26 CNA (certified nursing assistant) stated S19 Un-licensed Nurse frequently had to ask other nurses for answers to things she should have known. S26 CNA indicated on one occasion a resident had trouble breathing and S19 Un-licensed Nurse panicked and did not know what to do and she had to tell S19 Un-licensed Nurse to place the resident on oxygen. S26 CNA confirmed 911 was called and the resident was evaluated by emergency medical staff and remained in the facility. S26 CNA verified that she witnessed S19 un-licensed nurse give medications via PEG (percutaneous endoscopic gastrostomy tube) and administer insulin injections. S26 CNA confirmed she had not reported the issues surrounding S19 Un-licensed Nurse performance to anyone in the facility. During an interview on [DATE] at 6:50 am, S27 CNA indicated when coming on shift to work after S19 Un-licensed Nurse worked, residents' feeding tubes were not reattached properly and residents' beds were soaked in tube feeding. S27 CNA confirmed she had not reported these findings to anyone at the facility. During a phone interview on [DATE] at 9:21 am, S28 Weekend RN (registered nurse) stated As the weekend Registered Nurse I would arrive at facility around 5am and make rounds and would encounter S19 Un-licensed Nurse on whatever unit in the facility she was assigned to. S28 Weekend RN indicated S19 Un-licensed Nurse worked on all units in the facility. S28 Weekend RN further indicated she thought S19 Un-licensed Nurse was rusty or slow due to her working in the Social Service office and not working as a nurse on the floor for a while. During a phone interview on [DATE] at 2:01pm S31 Former Human Resource Director, indicated, a search on the nurse license verification online system revealed three to four names that could have been S19 Un-licensed Nurse. S31 Former Human Resources Director indicated S19 Unlicensed Nurse pointed to one of the names and indicated it was her name. S31 Former Human Resources Director confirmed two copies of the license verification were printed; one copy was given to S19 Unlicensed Nurse and one copy was put with all the other nurses licenses that had been verified. S31 Former Human Resources Director indicated this took place around (MONTH) (YEAR) in preparation for an upcoming annual survey. During an interview on [DATE] at 10:35 am resident #81 confirmed S19 Un-licensed Nurse, gave his medication when working as a nurse. Resident also stated, I was always leery of her doing anything for me because I did not trust her as a social worker. Resident #81 indicated he had heard that S19 Un-licensed Nurse was not a nurse and he was never comfortable with her giving medications. Review of resident #81's Medical record revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating intact cognition. During an interview on [DATE] at 11:00 am Resident #53 stated I never liked S19 Un-licensed Nurse because when my son was dying she compared his death to the death of her dog. Resident #53 further stated, thank god she was not my nurse often. Resident #53 indicated she had heard that she did not have a license to practice nursing and was [MEDICATION NAME] with a dead person's license. Review of resident #53's Medical record revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. During an interview on [DATE] at 12:15 pm, Resident #24 confirmed S19 Un-licensed Nurse worked as a nurse and a Social Worker and gave medications on the unit. Resident #24 stated I don't understand why it was not caught sooner and I heard she will be arrested tomorrow. Review of Resident #24's Medical record revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. During an interview on [DATE] at 4:30 pm resident #76's daughter confirmed S19 Un-licensed Nurse was her mother's nurse on some occasions on the 11pm to 7am shift. Resident #76's daughter indicated S19 Un-licensed Nurse gave Resident #76 breathing treatments, checked her blood sugar and gave her insulin injections. Resident #76's daughter further indicated S19 Un-licensed nurse did not respond to her complaints about care of resident #76. Resident #76's daughter stated I was told by administration staff that she was not actually a nurse. During an interview on [DATE] at 2:15 pm, S20 Corporate Human Resources verified company policy was to verify licensure yearly. S20 Corporate Human Resources indicated S19 Un-licensed Nurse was in the corporate system as a Social Worker and did not trigger for a licensure check/verification as a LPN. During an interview on [DATE] at 3:00 pm, S1 Administrator and S2 Corporate Nurse confirmed several actions were initiated as result of this incident. . The facility has implemented the following actions to correct the deficient practice: *Immediate Action Taken: The alleged perpetrator was terminated on [DATE]. *Credential Checks (licensure, certification, and registry checks) were performed on all licensed, certified and/or registered professionals throughout the building by facility human resources and was completed on [DATE]. *Self- Reported to the State Licensing Agency the allegation by the Administrator on [DATE]. *Notified the Board of Nursing on [DATE] about the un-licensed individual working as a licensed nurse *Investigation initiated on the concern immediately. *Initiated assessment of residents to ensure no adverse effects was completed on [DATE]. *Notify the Medical Directors and all attending physicians of the un-licensed person working as a licensed nurse was completed on [DATE]. *Verify that all users have the appropriate role in the electronic medical record. Monitoring Plan: Credential verification ticklers will be reviewed at least quarterly by the Regional Human Resource Generalist or designee, to ensure that all active staff have appropriate active credentials. All individuals working in positions outside of their normal position will have a review completed by the Regional HR prior to being allowed to work in a capacity that requires specific credentials QA (Quality Assurance) Committee Analysis: Audit findings and credential tracking will be shared with the QA team at least quarterly. Any concerns will be immediately addressed and deemed necessary by this team. Through record reviews, the surveyor confirmed the following plan of correction components had been implemented and completed: 1. S2 Corporate Nurse verified all nurse's licenses and CNA certifications. 2. All residents, physicians and family members were notified of S19 un-licensed nurse working as a LPN without a license. Residents' responsible parties and family members were notified by phone using the script as below: I was calling to inform you of a situation that occurred at the facility . We had an unlicensed person working as a nurse. In response to this situation, we have done the following; The employee has been terminated from the facility. We are working hand in hand with the police, Board of Nursing and Department of Health and we are fully cooperating with their investigation All residents are being assessed by Registered Nurses All physicians have been notified of the situation. Credentials have been verified of all current staff. This has never happened before, and we are taking every step to ensure that it never happens again. 3. A Resident Council meeting was held on [DATE] at 3:00 pm and all residents were notified of S19 un-licensed nurse working in the facility without a valid license. Documentation of resident council meeting revealed the following: Administrator explained to the residents that the police had been contacted because of an employee working in the facility as a nurse without a license. 4. Life Satisfaction rounds were completed on all residents who were able to participate and answer questions. 5. Employee statements were taken during the facility investigation and the employees were interviewed in relation to working with S1 Un-licensed Nurse. 6. Head-to-Toe assessments were completed on all residents by a registered nurse. 7. In-service was conducted on [DATE] and [DATE] with the Human Resources Director, Department Heads and Hiring Managers, Nurses and Certified Nursing Assistants and all staff in regard to the following: Topic: Credential Verification Employees working in positions that require credentials must have their credentials verified prior to allowing the employee to work. All verification screening documentation must be in place prior to working. All employees will only perform job functions they are credentialed to perform, (example- You must have a license to be a nurse, You must have proof of CNA certification) Employees must immediately report to administration or DON (director of nurses) if they notice anyone who may display concerns with competence, knowledge of job skills or any concerns related to staff performance. 8. In-service was conducted on [DATE] on Agency Credentialing Verification Process with Human Resources Director on the following: Agency will provide necessary documentation of verification of LPN license. All agency personnel will only perform job functions they are credentialed to perform. Example: You must have a license to be a nurse; you must have proof of CNA certification to perform CNA duties. The surveyor validated the corrective action plan and the date of correction was listed as [DATE] when the facility provided the last in-service education related to the deficient practice.

Based on observation, interviews, and record reviews, the facility failed to ensure 1 (#42) of 6 (#42, #65, #53, #142, #68, #69) residents reviewed for accidents received adequate supervision to prevent accidents/falls. The deficient practice resulted in actual harm for Resident #42 on 5/16/18 when the resident fell from bed during pericare. Resident #42 required 2 person assistance for bathing/pericare and fell from the bed while receiving pericare by one staff person. On 5/21/18 Resident #42 complained of pain in his right knee and an x-ray was done which noted a femur fracture. Resident #42 was transported and admitted to a local hospital where x-ray confirmed a femur fracture and surgical repair was performed. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of Resident #42's medical record revealed an admission [DIAGNOSES REDACTED]. Review of Resident #42's Minimum Data Set ((MDS) dated [DATE] and MDS dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. The MDS dated [DATE] and 4/13/18 also revealed Resident #42's functional status was total dependence requiring two- person physical assist. Review of Resident #42's Care Plan revealed the following: At risk for falls related to functional [MEDICAL CONDITION] and included approaches of two person assistance for bed mobility, bathing/pericare and transfers. Review of facility's Incident Report dated 5/7/18 for Resident #42 revealed Resident #42 fell face first onto floor from his bed during pericare. Review of documentation of Certified Nursing Assistant (CNA) statement for Resident #42's 5/7/18 fall revealed: S7CNA was doing pericare on Resident #42 around 9:20 pm after cleaning Resident #42. S7CNA statement further revealed that S7CNA positioned Resident #42 on his side as she began to pick up dirty linen. S7CNA then walked to the door notifying S21LPN that Resident #42 was clean and she could give him his suppository. As the nurse headed towards Resident #42's room S7CNA walked directly across the hall to put dirty pads in barrel. As S7CNA walked back to room S21LPN told S7CNA that Resident #42 had fallen from his bed and that he did not want to go to hospital. S7CNA, the nurse, and two nursing assistants from the back hall lifted Resident #42 back into his bed. There weren't any bruises or scratches. Resident #42 appeared to be ok. Review of facility's Incident Report dated 5/16/18 for Resident #42 revealed: During pericare, S8CNA rolled Resident #42 over and due to sinking of bed she was unable to catch him from falling but did soften his fall. No apparent injuries. Review of documentation of Witness Form for incident/accident of 5/16/18 revealed: Witness name of S8CNA-Description of what you saw: S8CNA was in the middle of giving him a bed bath. S8CNA turned him towards the window. He began to slide. S8CNA attempted to catch him, but S8CNA broke his fall as he slid onto the floor. S8CNA was there the whole entire time. S8CNA stuck her head out the door to get the nurse. S8CNA felt so bad and kept apologizing. Notation included-The mattress was drooping off of frame. Nurse was notified and was reported immediately. Review of Resident #42's mobile x-ray results revealed the date of exam 5/21/18; history of pain (due to patient pain level, I could only obtain an Anteroposterior view). IMPRESSION: There is an acute fracture as described above. RIGHT KNEE X-ray Findings: There is an acute [MEDICAL CONDITION] shaft of the right femur. Osteopenia is present. There is 50millimeters (mm) of superior displacement of the distal fragment. There are no gross lytic or blastic [MEDICAL CONDITION] in the bones. There is no dislocation. [MEDICAL CONDITION] changes are present in the right knee. Review of the Hospital Discharge Summary dated 5/24/18 included the following: History of Present Illness: Resident #42 is a [AGE] year-old male who sustained a C5 through 6 neck injury in 2007 motor vehicle accident and has been incomplete C6 [MEDICAL CONDITION] since that time. Patient stated he was at the nursing home and rehab when he was getting bathed in bed, was very sleepy, and he fell off the bed. Patient was seen by local physician who performed a right intramedullary rodding of the femur. Hospital Course: Patient admitted with fractured femur. Patient was taken to the operating room and had Open Reduction Internal Fixation by a local physician. Patient was admitted to floor. Discharge Diagnosis: [REDACTED].>Review of Resident #42's Notes revealed: 5/7/18 at 10:36 pm CNA exited room to dispose of dirty linen. Right before S21LPN reached room, she heard a thud and patient yell out profanity. Entered room to find patient lying face first on floor beside bed. Called nurse practitioner, gave patient status and due to height of fall, she ordered patient to be sent out for x-rays. Notified nurse practitioner that patient does not want to go to hospital at this time. 5/7/18 at 11:33 pm Called _____ ambulance and they will be arriving shortly. Patient gave verbal permission to be sent to hospital. 5/16/18 at 9:45 pm S8CNA was in room performing pericare. At 8:25, she called out from patient's room for nurse ASAP. S21LPN hurried down to room to find patient face down on the floor beside his bed. Patient was alert and says he's okay. States he did not hit his head. S8CNA never left his bedside but when she rolled him toward her his mattress was drooping off of the bed frame and could not stop him from falling. She did lessen the impact of the fall by trying to catch him. S21LPN notified supervisor and nurse practitioner. Nurse Practitioner ordered neuro checks X 24 hours only. S21LPN went back into room to collect next set of neuro checks and patient refused. Patient states It was not her fault, I want a new mattress. S21LPN also urged him to have bed rails put on tomorrow. 5/21/18 at 7:34 am Resident #42 called S22LPN to room. Resident states that he has had pain in his right knee this weekend and that it feels like it's moving up his thigh. S22LPN assessed right knee and noted anterior aspect of right knee with warmth and inflammation in comparison with left knee. Anterior right knee is tender to touch per resident report. Resident states that he believes that this is a result of the falls he has had recently. Nurse Practitioner notified. Awaiting further orders at this time. 5/21/18 at 8:24 am - 7:53 am Order received and noted to get X-ray of right knee per Nurse Practitioner. Call placed to mobile x-ray. Resident #42 notified of X-ray order. 5/21/18 at 10:22am - 9:18 am x-ray tech on unit to obtain X-ray of resident's right knee. Noted a probable fracture of right femur so nurse practitioner notified. 9:24 am Orders received and noted per nurse practitioner to send resident to local hospital emergency room for probable fracture of right femur. 9:51 am ___ Ambulance on unit to transport resident to local hospital ER for evaluation of probable right femur fracture. 10:15 am Received call from mobile x-ray with results of Right Knee X-ray: Acute fracture of distal shaft of right femur. 50 mm of superior displacement. Nurse practitioner notified of X-ray results. Observation on 8/20/18 at 2:00 pm revealed fall mat at bedside and bed in low position. No rails were observed on the bed. During an interview on 08/20/18 at 2:00 pm Resident # 42 stated he was in the hospital in (MONTH) (YEAR) for broken right leg (femur) after falling out of bed. Resident # 42 states that he was being changed and was rolled over and slid off bed. Resident further stated he has fallen out of bed 2 times during his care by staff. During an interview on 8/24/18 at 9:50 am S1CN (corporate nurse) stated that after Resident # 42's fall on 5/7/18 the CNA involved in the incident was in-serviced on Resident # 42's requirement for 2 person assist for bed mobility. S1CN stated that S7CNA was working alone when the fall occurred. The facility has implemented the following actions to correct the deficient practice on 5/16/18: 1. Facility changed Resident #42's mattress and offered to place assist rails on his bed but Resident #42 declined the rails. 2. During the survey, staff on the hall demonstrated knowledge of when to provide 2 person assist when caring for residents. 3. During the survey, the facility demonstrated evidence of adequate supervision to prevent further falls/injuries to Resident #42 and other residents included in the sample. 4. During the survey, the facility demonstrated evidence that the services being rendered to Resident #42, in regards to bathing/pericare, were being provided in accordance with the resident's plan of care. 5. During the survey, staff indicated that they had been trained that Resident #42 required 2 persons to assist with bathing and pericare.

Based on Record Reviews, Interviews, and Review of the Louisiana Administrative Code, Title 46. Professional and Occupational Standards. Part XLVII. Nurses: Practical Nurses, the facility failed to ensure care and services were provided to 1 (#1) of 5 (#1, 2, 3, 4, 5) residents reviewed out of a total sample of 5 residents in accordance with professional standards of quality by failing to ensure that nursing staff: 1. Obtained sliding scale parameters from the physician to establish reference ranges for insulin administration. 2. Monitored a resident's blood glucose levels as ordered by the physician. 3. Transcribed admission orders [REDACTED]. The Immediate Jeopardy (IJ) began for resident #1 on [DATE] at 7:30 p.m. when resident #1 was admitted to the facility with a [DIAGNOSES REDACTED].#1's admission orders [REDACTED]. Resident #1 was found unresponsive on [DATE] at 5:40 a.m., a full code was initiated and 911 was called. S1Administrator was informed of the Immediate Jeopardy situation on [DATE] at 3:50 p.m. and a Plan of Removal was presented by the Administrator which read as follows: 1. Verify transcription of orders by DON (Director of Nursing)/ADON (Assistant Director of Nursing) on all new admits/readmits. 2. All new hires will complete departmental orientation checklist for competency. 3. DON/ADON will review and determine if new hire is competent to manage unit or needs further training and will start over on competency checklist. 4. DON/Corp (Corporate) Nurse is currently in-servicing all nursing staff on Diabetic Care per our policy and procedure. a. Assessment and Recognition which includes all vital signs and finger sticks b. Signs and Symptoms of Hypo/Hyper (glycemia) c. Interventions d. Insulin Delivery e. Documentation 5. Reviewed the diabetic residents with insulin/accuchecks. 6. Removed nurse off floor immediately and is now shadowing LPN (Licensed Practical Nurse). 7. LPN Departmental checklist started on LPN at hand. All nurses will complete LPN Departmental checklist by [DATE]. 8. Admission checklist implemented and reviewed by DON/ADON. 9. Audits being completed daily. Audits and in-services have been provided to surveyor. 10. In-service and training will continue if any other issues are identified. Immediate Plan of Action from incident (Presented as part of the Plan of Removal) Took nurse off the floor/shadowing nurses and signing off on check list when confident. In-serviced all department heads on all broken processes: Please see following: Self reported incident In-serviced all Nursing Staff Did audits, see following/still doing daily audits Re-implemented Licensed Nursing competency checklist Re-implemented admission check list Follow-up daily on all admits/readmits by DON/ADON Have mandatory in-service monthly Have hired Full time Certified Respiratory Therapist Recruiting Nurse Practitioner for Monday through Friday Hired second Medical Director to oversee Ortho and skilled residents Hiring new DON and now recruiting a RN ADON: will have 3 RNs on staff The day of discovery brought in corp RN DON of [AGE] years to oversee nursing Corp Nurse training new ADONs/in-services Going to have Competency checks completed by [DATE] by all nursing staff The facility provided the Plan of Removal on [DATE] and the plan was accepted. The Immediate Jeopardy was lowered to a level of harm for resident #1 when the local fire department personnel was ordered by Dr. 154, at Med Control, to cease efforts. The immediate jeopardy situation was removed on [DATE] at 11:30 a.m. when it was determined by the surveyor that each resident who received insulin had their physician orders [REDACTED].#1's admitting LPN was in progress. The deficient practice continued at a level of more than minimal harm for the remaining 16 (#3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19) residents receiving sliding scale insulin. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standards, Part XLVII. Nurses: Practical Nurses and Registered Nurses, [DATE], Subpart 1. Practical Nurses under Subchapter E. Curriculum Requirements revealed in part ... 3... development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgment, prudence, ethical thinking and behaviors, problem solving, and critical thinking abilities ...7. Principles and Practices of Nursing- presenting the application of concepts which will provide basic principles of Nursing Care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health nursing. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary healthcare team ... Record review revealed resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of resident #1's most recent MDS (Minimum Data Set) dated [DATE] revealed the following: Section I (Active Diagnoses) Hypertension, Diabetes Mellitus, [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION], Asthma ([MEDICAL CONDITION]) or [MEDICAL CONDITION]. Section O (Special Treatments, Procedures, and Programs) - [MEDICAL TREATMENT] while a resident. Review of resident #1's Admission Care Plan revealed the following: Fall risk with approaches including keep call light in reach, encourage use of call light, instruct resident on safety, assess footwear. Nutritional status with approaches including renal diet as ordered, weigh weekly x 4 weeks then monthly, record % of meals consumed, determine likes and dislikes, report problems to charge nurse such as difficulty swallowing or choking. Feeding tubes with note - Not used but present. [MEDICAL TREATMENT] with approaches including monitoring for signs and symptoms of dehydration, labs as ordered. Diabetes with approaches including blood sugar checks every 6 hours per sliding scale, observe for signs or symptoms of [DIAGNOSES REDACTED], nail care per LPN, and labs as ordered. Review of resident #1's transferring facility's Discharge Medication Reconciliation orders dated [DATE] revealed the following: [MEDICATION NAME] 30cc PO every 6 hours [MEDICATION NAME] 200mg PO twice daily [MEDICATION NAME] Flush 10 units every 12 hours Humalog Kwikpen Insulin SQ (Subcutaneous) every 6 hours per sliding scale K-Phos Neutral 2 packets PO twice daily [MEDICATION NAME] 750mg PO every 12 hours Magnesium Oxide PO 1200mg every 8 hours [MEDICATION NAME] 10mg PO twice daily [MEDICATION NAME] 30mg PO daily [MEDICATION NAME] 5mg PO every 8 hours [MEDICATION NAME] 0.125mg PO daily [MEDICATION NAME] 1.25 0.6mg per inhalation every 6 hours [MEDICATION NAME] 10mg PO every 6 hours as needed for pain Further review of the transferring facility's Medication Reconciliation orders failed to reveal orders regarding the rectal tube, urinary catheter, peg tube, or oxygen. Review of resident #1's facility admission orders [REDACTED] [MEDICATION NAME] 30ml PO every 6 hours [MEDICATION NAME] 200mg PO twice daily [MEDICATION NAME] 750mg PO every 12 hours Magnesium Oxide 1200mg PO every 8 hours [MEDICATION NAME] 10mg PO twice daily K-Phos Neutral (no indication of route, amount, how often) Humalog Kwikpen Insulin Subcutaneous every 6 hours per sliding scale Regular Renal Diet Further review of the admission orders [REDACTED]. Further review of resident #1's facility admission orders [REDACTED] [MEDICATION NAME] 10mg, [MEDICATION NAME] 0.125mg, [MEDICATION NAME] 5mg, [MEDICATION NAME] 30mg, [MEDICATION NAME] 10 units, Insulin sliding scale. Review of resident #1's Resident Summary (admit nursing assessment) dated [DATE] revealed initial admission information omitted the time of admission. Further review revealed resident #1 had a rectal tube, urinary catheter, peg tube, and oxygen that were present upon admission and omitted on the transcribed orders. Review of resident #1's [DATE] MAR (Medication Administration Record) revealed the following Humalog sliding scale: Greater than 200 = 3 units Greater than 300 = 6 units Greater than 400 = 9 units Greater than 500 = 12 units and notify MD Further review of the MAR indicated [REDACTED]. Review of resident #1's Nurse's Notes revealed the following: [DATE] - " Resident noted unresponsive by writer. Unable to palpate resident pulse at this time. Resident noted full code. Stat called on resident and CPR per protocol initiated. 911 dialed and called at 0542. Fire department on site/scene at 0550 and takes over with resident. Dr. 154 at ....(Local Hospital) called time of death at 0615. ....(Resident #1's Physician) notified at 0618 with family notified by writer at 0625. "... Review of the local fire department Patient Care Record for resident #1 dated [DATE] revealed the following: ... arrived on scene ... patient unresponsive and not breathing ... Nursing home staff relates that patient was last seen around 2:00 a.m. and when they came to check on patient this morning she was not breathing. CPR was initiated prior to our arrival by nursing home staff. Upon our arrival ... Patient unresponsive and not breathing. CPR taken over by SFD (Local Fire Department)... Oxygen applied and ventilations provided ... Initial EKG rhythm shows asystole ... Patient intubated successfully. Patient administered 3 [MEDICATION NAME] 3 to 5 minutes apart per ACLS protocol. Patients BS (blood glucose) reads Low on the one touch. Patient administered 25 grams D50. Patient remained asystole throughout code with no rhythm changes. Med control contacted and Dr. 154 advised to cease efforts ... During an interview on [DATE] at 3:00 p.m. ....(Central Station Fire Chief) stated when the EMS unit arrived on scene at the facility, resident #1 was unresponsive with CPR in progress. ....(Central Station Fire Chief) further stated the paramedics checked resident #1 ' s blood glucose and obtained a reading of " low " which means the patient ' s blood sugar is lower than the machine will read. During an interview on [DATE] at 8:05 a.m., S12LPN stated she has been an LPN for about 6 years and has worked in the facility for about 4 months. S12LPN stated she worked the 11P-7A shift and was on duty when resident #1 coded at about 5:00 a.m. S12LPN stated the girl from the lab entered resident #1's room to draw labs and came out and told her resident #1 did not look right. S12LPN stated she immediately went into the room, checked resident's pulse and called a STAT code and 911. S12LPN stated she started CPR but said she did not check resident #1's blood glucose level. S12LPN stated she knew resident #1 needed a sliding scale for insulin but never got a blood glucose level on her. S12LPN stated resident #1 was admitted to the facility the night before she coded; she came in at about 8:30 p.m. on the previous nurse S7LPN. S12LPN stated when she came on she saw that an order for [REDACTED]. S12LPN stated resident #1 was in asystole while she had her and stated when EMS (Emergency Medical Service) arrived she left the room because there was not enough space for them to work. S12LPN stated she stood outside resident #1's door and does not know at what point resident #1's blood sugar was checked. S12LPN stated the hospital sent resident's entire chart and resident #1 had a PEG tube but no TF (feedings) were ordered and she was also a new [MEDICAL TREATMENT] patient. S12LPN stated she had not looked at resident #1's MAR yet, before she coded, so she did not know the insulin order was not clarified. S12LPN agreed it is a nursing judgment and the nurses should have obtained a baseline blood glucose level and did not. During an interview on [DATE] at 9:20 a.m., S2DON stated resident #1 was admitted from the hospital around 7:30 p.m. and the facility received faxed orders before resident #1 arrived. S2DON stated she is not sure why S7LPN did not complete transcribing the hospital discharge orders to resident #1's admission Order form and stated "some of the orders were even written as telephone orders". S2DON stated the ADON is responsible for reviewing admission orders [REDACTED] During an interview on [DATE] at 4:00 p.m. S2DON stated S7LPN has only been a nurse for a short time and has only been on the floor for 2 months. S2DON stated S7LPN was trained as the facility normally trains new nurses. When asked if S7LPN has ever admitted a new resident before, S2DON stated " I ' m not sure. " During an interview on [DATE] at 4:04 p.m. S7LPN stated she has been an LPN since [DATE]. S7LPN stated she started orientation on the 200 Hall [DATE] and oriented 2 days on the front 200 Hall and 2 days on the back 200 Hall. S7LPN stated her orientation consisted of shadowing another LPN as well as hands on resident care. S7LPN stated she did not have a good orientation for admissions; she never admitted or assisted with an admission during orientation. S7LPN stated her first admission was her first day on the west wing (300 Hall). S7LPN stated she did not have another nurse with her during the admissions and the only feed-back she received was when the ADON or DON called her to tell her she did not complete part of the admission forms. S7LPN stated she was never given instructions on how to admit a resident. S7LPN stated there was no paperwork signed after her initial orientation on the 200 (Center) Hall indicating she had completed orientation. S7LPN stated she did not have a skills list to identify what skills she needed to learn, her areas of weakness were not identified, and no competency check list was used for her orientation. S7LPN stated she did not have an orientation check list and was not oriented to the west wing until last week after the incident occurred with resident #1. S7LPN stated then she was " pulled off " to orient to the west wing when they devised an orientation check list. S7LPN viewed resident #1's [DATE] MAR (Medication Administration Record) and stated she copied the orders from the hospital discharge orders. S7LPN stated she wrote STAT ...PHCC on the top of the orders she faxed to the pharmacy. S7LPN stated when she saw the order for insulin; she looked for a sliding scale and could not find it in the resident's chart. S7LPN stated she texted Dr.___(resident #1's admitting physician) and asked for a sliding scale but he did not return the text until about 4:00 a.m.. S7LPN stated when she awoke later that morning she texted the insulin sliding scale to the day nurse, S4LPN, and she texted back "Thanks". During an interview on [DATE] at 4:10 p.m., S1Administrator stated S7LPN has been an LPN for 2 months and they pulled her to re-train and will place her in another area because 300 East and West Halls have the residents with the highest level of acuity. During an interview on [DATE] at 9:00 a.m., resident #1's admitting physician was asked if he was notified for an order for [REDACTED]. Dr. ____ (resident #1's admitting physician) was asked if she was a brittle diabetic, what did her blood sugars usually run, was she receiving tube feedings or was she eating, and was she receiving medications that would lower or raise her blood glucose levels? Dr. ___ (resident #1's admitting physician) stated he did not see resident #1 prior to her admission to the facility, but picked her up after she was transferred. Dr. ___ (resident #1's admitting physician) stated the transferring physician should have written instructions to check her blood glucose levels every (frequency)___ as needed and provide a sliding scale on the Discharge Reconciliation form. Dr. ___ (resident #1's admitting physician) stated the admitting nurse should have notified resident #1's transferring physician for the insulin sliding scale. Review of the facility's Diabetes - Clinical Protocol revealed under Glucose Monitoring: 1. The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. 3. Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation.

Based on Record Review and interviews the facility failed to ensure care and services were provided to attain the highest practicable physical, mental and psychosocial well-being for 1(#1) of 5 (#1, 2, 3, 4, 5) resident reviewed for care and services out of a total sample of 5. The facility failed to have a system in place to ensure the nurse: 1. Obtained sliding scale parameters from the physician to establish reference ranges for insulin administration. 2. Monitored a resident's blood glucose levels as ordered by the physician. 3. Transcribed admission orders [REDACTED]. The Immediate Jeopardy (IJ) began for resident #1 on [DATE] at 7:30 p.m. when resident #1 was admitted to the facility with a [DIAGNOSES REDACTED].#1's admission orders [REDACTED]. Resident #1 was found unresponsive on [DATE] at 5:40 a.m., a full code was initiated and 911 was called. S1Administrator was informed of the Immediate Jeopardy situation on [DATE] at 3:50 p.m. A Plan of Removal was presented by the Administrator which read as follows: 1. Verify transcription of orders by DON (Director of Nursing)/ADON (Assistant Director of Nursing) on all new admits/readmits. 2. All new hires will complete departmental orientation checklist for competency. 3. DON/ADON will review and determine if new hire is competent to manage unit or needs further training and will start over on competency checklist. 4. DON/Corp (Corporate) Nurse is currently in-servicing all nursing staff on Diabetic Care per our policy and procedure. a. Assessment and Recognition which includes all vital signs and finger sticks b. Signs and Symptoms of Hypo/Hyper (glycemia) c. Interventions d. Insulin Delivery e. Documentation 5. Reviewed the diabetic residents with insulin/accuchecks 6. Removed nurse off floor immediately and is now shadowing LPN (Licensed Practical Nurse). 7. LPN Departmental checklist started on LPN at hand. All nurses will complete LPN Departmental checklist by [DATE] 8. Admission checklist implemented and reviewed by DON/ADON 9. Audits being completed daily. Audits and in-services have been provided to surveyor. 10. In-service and training will continue if any other issues are identified. Immediate Plan of Action from incident (Presented as part of the Plan of Removal) Took nurse off the floor/shadowing nurses and signing off on check list when confident. In-serviced all department heads on all broken processes: Please see following: Self reported incident In-serviced all Nursing Staff Did audits, see following/still doing daily audits Re-implemented Licensed Nursing competency checklist Re-implemented admission check list Follow-up daily on all admits/readmits by DON/ADON Have mandatory in-service monthly Have hired Full time Certified Respiratory Therapist Recruiting Nurse Practitioner for Monday through Friday Hired second Medical Director to oversee Ortho and skilled residents Hiring new DON and now recruiting a RN ADON: will have 3 RNs on staff The day of discovery brought in corp RN DON of [AGE] years to oversee nursing Corp Nurse training new ADONs/in-services Going to have Competency checks completed by [DATE] by all nursing staff The facility provided the Plan of Removal on [DATE] and the plan was accepted. The Immediate Jeopardy was lowered to a level of actual harm for resident #1 when the local fire department personnel was ordered by Dr. 154, at Med Control, to cease efforts. The immediate jeopardy situation was removed on [DATE] at 11:30 a.m. when it was determined by the surveyor that each resident who received insulin had their physician orders [REDACTED].#1's admitting LPN was in progress. The deficient practice continued at a level of more than minimal harm for the remaining 16 (#3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19) residents receiving sliding scale insulin. Findings: Record review revealed resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of resident #1's most recent MDS (Minimum Data Set) dated [DATE] revealed the following: Section I (Active Diagnoses) Hypertension, Diabetes Mellitus, [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION], Asthma ([MEDICAL CONDITION]) or [MEDICAL CONDITION]. Section O (Special Treatments, Procedures, and Programs) - [MEDICAL TREATMENT] while a resident. Review of resident #1's Admission Care Plan revealed the following: Fall risk with approaches including keep call light in reach, encourage use of call light, instruct resident on safety, assess footwear. Nutritional status with approaches including renal diet as ordered, weigh weekly x 4 weeks then monthly, record % of meals consumed, determine likes and dislikes, report problems to charge nurse such as difficulty swallowing or choking. Feeding tubes with note - Not used but present. [MEDICAL TREATMENT] with approaches including monitoring for signs and symptoms of dehydration, labs as ordered. Diabetes with approaches including blood sugar checks every 6 hours per sliding scale, observe for signs or symptoms of [DIAGNOSES REDACTED], nail care per LPN, and labs as ordered. Review of resident #1's transferring facility's Discharge Medication Reconciliation orders dated [DATE] revealed the following: [MEDICATION NAME] 30cc PO every 6 hours [MEDICATION NAME] 200mg PO twice daily [MEDICATION NAME] Flush 10 units every 12 hours Humalog Kwikpen Insulin SQ (Subcutaneous) every 6 hours per sliding scale K-Phos Neutral 2 packets PO twice daily [MEDICATION NAME] 750mg PO every 12 hours Magnesium Oxide PO 1200mg every 8 hours [MEDICATION NAME] 10mg PO twice daily [MEDICATION NAME] 30mg PO daily [MEDICATION NAME] 5mg PO every 8 hours [MEDICATION NAME] 0.125mg PO daily [MEDICATION NAME] 1.25 0.6mg per inhalation every 6 hours [MEDICATION NAME] 10mg PO every 6 hours as needed for pain Review of resident #1's facility admission orders [REDACTED] [MEDICATION NAME] 30ml PO every 6 hours [MEDICATION NAME] 200mg PO twice daily [MEDICATION NAME] 750mg PO every 12 hours Magnesium Oxide 1200mg PO every 8 hours [MEDICATION NAME] 10mg PO twice daily K-Phos Neutral (no indication of route, amount, how often) Humalog Kwikpen Insulin Subcutaneous every 6 hours per sliding scale Regular Renal Diet Further review of the admission orders [REDACTED]. Further review of the facility admission orders [REDACTED] [MEDICATION NAME] 10mg, [MEDICATION NAME] 0.125mg, [MEDICATION NAME] 5mg, [MEDICATION NAME] 30mg, [MEDICATION NAME] 10 units, Insulin sliding scale. Review of resident #1's Resident Summary (admit nursing assessment) dated [DATE] revealed initial admission information omitted the time of admission. Further review revealed resident #1 had a rectal tube, urinary catheter, peg tube, and oxygen that were present upon admission and omitted on the transcribed orders. Review of resident #1's [DATE] MAR (Medication Administration Record) revealed the following Humalog sliding scale: Greater than 200 = 3 units Greater than 300 = 6 units Greater than 400 = 9 units Greater than 500 = 12 units and notify MD Further review of the MAR indicated [REDACTED]. Review of resident #1's facility admission orders [REDACTED]. Review of resident #1's Nurse's Notes revealed the following: [DATE] - " Resident noted unresponsive by writer. Unable to palpate resident pulse at this time. Resident noted full code. Stat called on resident and CPR per protocol initiated. 911 dialed and called at 0542. Fire department on site/scene at 0550 and takes over with resident. Dr. 154 at ....(Local Hospital) called time of death at 0615. ....(Resident #1's Physician) notified at 0618 with family notified by writer at 0625. "... Review of the local fire department Patient Care Record for resident #1 dated [DATE] revealed the following: ... arrived on scene ... patient unresponsive and not breathing ... Nursing home staff relates that patient was last seen around 2:00 a.m. and when they came to check on patient this morning she was not breathing. CPR was initiated prior to our arrival by nursing home staff. Upon our arrival ... Patient unresponsive and not breathing. CPR taken over by SFD (Local Fire Department)... Oxygen applied and ventilations provided ... Initial EKG rhythm shows asystole ... Patient intubated successfully. Patient administered 3 [MEDICATION NAME] 3 to 5 minutes apart per ACLS protocol. Patients BS (blood glucose) reads Low on the one touch. Patient administered 25 grams D50. Patient remained asystole throughout code with no rhythm changes. Med control contacted and Dr. 154 advised to cease efforts ... During a telephone interview on [DATE] at 3:00 p.m. ....(Central Station Fire Chief) stated when the EMS unit arrived on scene at the facility, resident #1 was unresponsive with CPR in progress. ....(Central Station Fire Chief) further stated the paramedics checked resident #1 ' s blood glucose and obtained a reading of " low " which means the patient ' s blood sugar is lower than the machine will read. During an interview on [DATE] at 8:05 a.m., S12LPN stated she has been an LPN for about 6 years and has worked in the facility for about 4 months. S12LPN stated she worked the 11P-7A shift (11:00 p.m. to 7:00 a.m.) and was on duty when resident #1 coded at about 5:00 a.m. on [DATE]. S12LPN stated the girl from the lab entered resident #1's room to draw labs and came out and told her resident #1 did not look right. S12LPN stated she immediately went into the room, checked resident's pulse and called a STAT code and 911. S12LPN stated she started CPR but said she did not check resident #1's blood glucose level. S12LPN stated she knew resident #1 needed a sliding scale for insulin but never got a blood glucose level on her. S12LPN stated resident #1 was admitted to the facility the night before she coded; she came in at about 8:30 p.m. on the previous nurse S7LPN. S12LPN stated when she came on she saw that an order for [REDACTED].#1 had blood glucose orders yet and the blood glucose check would not have been due until 6:00 p.m. on her shift. S12LPN stated resident #1 was in asystole while she had her and stated when EMS (Emergency Medical Service) arrived she left the room because there was not enough space for them to work. S12LPN stated she stood outside resident #1's door and does not know at what point resident #1's blood sugar was checked. S12LPN stated the hospital sent resident's entire chart and resident #1 had a PEG tube but no TF (feedings) were ordered and she was also a new [MEDICAL TREATMENT] patient. S12LPN stated she had not looked at resident #1's MAR yet, before she coded, so she did not know the insulin order was not clarified. S12LPN agreed it is a nursing judgment and the nurses should have gotten a baseline blood glucose level and did not. During an interview on [DATE] at 9:20 a.m., S2DON stated resident #1 was admitted from the hospital around 7:30 p.m. and the facility received faxed orders before she arrived, on the day of her arrival. S2DON stated she is not sure why S7LPN did not complete transcribing the hospital discharge orders to resident #1's admission Order form and stated "some of the orders were even written as telephone orders". S2DON stated the ADON is responsible for reviewing admission orders [REDACTED] During an interview on [DATE] at 4:00 p.m. S2DON stated S7LPN has only been a nurse for a short time and has only been on the floor for 2 months. S2DON stated S7LPN was trained as the facility normally trains new nurses. When asked if S7LPN has ever admitted a new resident before, S2DON stated " I ' m not sure. " During an interview on [DATE] at 4:04 p.m. S7LPN stated she has been an LPN since [DATE]. S7LPN stated she did not have an orientation check list and was not oriented to the west wing until last week after the incident occurred with resident #1. S7LPN stated she received 4 days of orientation on the 200 Hall and did not receive training on admitting a resident as they did not have any admissions when she was in training. S7LPN stated "I did the best I could". S7LPN viewed resident #1's [DATE] MAR (Medication Administration Record) and stated she copied the orders from the hospital discharge orders. S7LPN stated she wrote STAT ...PHCC on the top of the orders she faxed to the pharmacy. S7LPN stated when she saw the order for insulin; she looked for a sliding scale and could not find it in the resident's chart. S7LPN stated she texted Dr.___(resident #1's physician) and asked for a sliding scale but he did not return the text until about 4:00 a.m.. S7LPN stated when she awoke later that morning she texted the insulin sliding scale to the day nurse, S4LPN, and she texted back "Thanks". During an interview on [DATE] at 4:10 p.m., S1Administrator stated S7LPN has been an LPN for 2 months and they pulled her to re-train and will place her in another area because 300 East and West Halls have the residents with the highest level of acuity. During an interview on [DATE] at 9:00 a.m., resident #1's admitting physician was asked if he was notified for an order for [REDACTED]. Dr. ____ (resident #1's admitting physician) was asked if she was a brittle diabetic, what did her blood sugars usually run, was she receiving tube feedings or was she eating, and was she receiving medications that would lower or raise her blood glucose levels? Dr. ___ (resident #1's admitting physician) stated he did not see resident #1 prior to her admission to the facility, but picked her up after she was transferred. Dr. ___ (resident #1's admitting physician) stated the transferring physician should have written instructions to check her blood glucose levels every (frequency)___ as needed and provide a sliding scale on the Discharge Reconciliation form. Dr. ___ (resident #1's admitting physician) stated the admitting nurse should have notified resident #1's transferring physician for the insulin sliding scale. Review of the facility's Diabetes - Clinical Protocol revealed under Glucose Monitoring: 1. The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. 3. Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation.