Every finding on record at Pleasant Manor Healthcare and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure menus were followed to meet nutritional needs of residents in accordance with established national guidelines for two sampled residents (R50 and R8) reviewed for menus, in that: The facility failed to utilize therapeutic menu extensions for carbohydrate-controlled diets for R50 and R8. The facility failed to follow portion sizes for all diets for two days. These failures had the potential to affect resident's dependent on the facility kitchen for their nutrients as well as 22 residents who had ordered carbohydrate-controlled (CC) diet, placing them at risk of spikes or drops in blood glucose levels and/or weight loss or weight gain Findings included: 1. Review of R50's quarterly MDS with an ARD of 03/30/26 revealed an admission date of 03/07/25 and a BIMS score of five out of 15, indicating R50 was severely cognitively impaired. R50 received a therapeutic diet and had diagnoses of hypertension, hyperlipidemia, and obesity, class three. Review of R50's Diet Order dated 03/07/25 revealed NAS [no added salt]/CC diet, regular texture, thin liquids consistency. Review of R50's Care Plan revised 11/12/25 revealed, Has nutritional problem or potential nutritional problem r/t [related to] obesity, chronic illness, therapeutic diet. An intervention included Provide, serve diet as ordered. Monitor intake and record q [every] meal. Review of R50's Nutrition- Quarterly Evaluation, dated 03/11/26 revealed, Diet Order 2. No Added Salt, 3. Restricted Concentrated Sweets (RCS). Observation on 04/07/26 at 11:50 AM revealed R50 was sitting in the dining room feeding herself lunch. R50 was served a piece of cornbread and a cup of sherbet as the dessert with her meal. Review of the facility's order listing report for diets, dated 04/10/26, provided by the facility, revealed 22 residents were ordered a carbohydrate-controlled (CC) diet. 2. Review of R8's quarterly MDS with an ARD date of 04/01/26 revealed an admission date of 05/16/23 and a BIMS score of one out of 15, indicating R8 was severely cognitively impaired. R8 received a therapeutic diet and had diagnoses of malnutrition, diabetes mellitus, and dysphagia. Review of R8's Care Plan revised 01/02/26 revealed, Has potential nutritional problem R/T obesity, risk for malnutrition identified by completed MNA [mini nutritional assessment], DMII [diabetes mellitus type two], GERD [gastroesophageal reflux disease], bariatric surgery status, therapeutic diet, mechanically altered diet. Review of R8's Diet Order dated 01/07/26, revealed NAS/CC diet, mechanical soft texture, thin liquids consistency. Review of R8's Nutrition- Quarterly Evaluation, dated 03/11/26, revealed, Diet Order 2. No Added Salt, 3. Restricted Concentrated Sweets (RCS), texture 22. Mechanical Soft. Observation on 04/07/26 at 11:56 AM revealed R8 was sitting in the dining room feeding herself lunch. R8 was served a piece of cornbread and a cup of sherbet as the dessert with her meal. Review of the Menu Item Substitution Log, dated 04/07/26, provided by the facility, revealed sherbet was substituted for Butter Bars. The RD approval section was blank. Review of the week two Fall/Winter 2025 Menus Extensions, provided by the facility, revealed CC mechanical soft diets were to receive a half square of a Butter Bar and were not to receive cornbread for that meal. During an interview on 04/10/26 at 12:43 PM, the Certified Dietary Manager (CDM) was asked why the menu extensions that were provided did not have CC diets listed when many residents had diet orders for a CC diet and their MDS triggered for therapeutic diets. The CDM stated, That's because their diets are liberal diets. The CDM deferred to the Registered Dietitian (RD), who was on the phone. The RD stated there should be CC menu extensions and said she would not have signed them without CC diets. The RD then gave the CDM instructions on how to find the CC extensions and print the menus from the computer. During a follow up interview on 04/10/26 at 3:30 PM, the CDM was asked about the portion sizes on the menu extensions that were not followed because of not using the CC diet extensions for lunch on 04/09/26. CDM stated she was not aware that the serving sizes differed for the different diets. 3. Observation on 04/09/26 at 11:41 AM, Dietary Aide (DA) 1 was observed to be plating lunch on the tray line in the kitchen. DA1 was asked how she knew what portion sizes to serve. DA1 stated she checked her book and then pointed to the menu binder. DA1 used an 8-ounce (oz) scoop with a cream-colored handle for the regular entree and 4-oz scoops with green-colored handles for the side dishes and pureed items. Record review of the Fall/Winter 2025 Menu Extensions with the portion sizes revealed:The portion size for the regular/mechanical soft textured chicken spaghetti casserole was 5.3 oz, but 8 oz was served.The portion size for the regular/mechanical soft textured CC chicken spaghetti casserole was 5.3 oz, but 8 oz was served.The portion size for regular pureed meat was 5.3 oz, but 4 oz was served.The portion size for CC pureed meat was 5.3 oz, but 4 oz was served.The portion size for regular/mechanical soft textured CC green peas was 2 oz, but 4oz was served.The portion size for regular pureed peas was 3.25 oz, but 4 oz was served.The portion size for CC pureed peas was 1.25 oz, but 4 oz was served. During a follow up interview on 04/10/26 at 3:30 PM, the CDM was asked about the portion sizes on the menu extensions that were not followed. The CDM stated she was not aware that the serving sizes differed for the different diets. Review of the undated facility policy titled, Section G: Menu Policies, revealed Therapeutic diets, including textured-modified diets, as ordered by the physician and/or Speech Language Pathologist are preplanned by Registered Dietitian Nutritionist (RDN)s and prepared and served using safe, sanitary food practices . 4. The menu change is extended to all therapeutic diets.

Based on observation, interview and record review, it was determined the facility failed to ensure physician-ordered treatment was provided for one (R69) of 27 residents reviewed for quality of care, in that: R69 did not receive the physician ordered treatment on six wounds, on 04/04/26 or 04/05/26. This failure had the potential to cause deterioration in current wounds, infections and pain at the site. Findings include:Review of a face sheet printed 04/09/26 reflected R69 was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to embolism, severe protein calorie malnutrition, difficulty in walking, cognitive communication deficit, cataracts, glaucoma and pressure ulcer of sacral region stage 4. Review of a comprehensive minimum data set (MDS) assessment dated [DATE] for R69 reflected he had a BIMS score of seven indicating cognitive impairment. The assessment reflected R69 had three unstageable pressure injuries presenting as deep tissue injuries that were present upon admission. Review of a care plan report for R69 revealed a focus area of:1. Actual impairment to skin integrity r/t unstageable DTI of the left heel initiated on 02/11/262. Actual impairment to skin integrity r/t unstageable DTI of the right heel initiated 02/11/26.3. Actual impairment to skin integrity r/t non pressure wound of the right lateral ankle initiated on 02/11/26.4. Actual impairment to skin integrity r/t unstageable DTI of the right lateral foot initiated on 2/11/26.5. Actual impairment to skin integrity r/t arterial wound of the right medial ankle initiated on 2/11/26.6. Actual impairment to skin integrity r/t stage 4 pressure injury of the right medial foot initiated on 02/11/26.All focus areas had an intervention that included administer treatments as ordered. Review of an Order Summary Report printed on 04/07/26 for R69 reflected:1. LEFT HEEL: apply betadine every day shift for unstageable DTI2. RIGHT HEEL: apply betadine every day shift for unstageable DTI3. Right lateral ankle cleanse wound cleanser/dry/apply xeroform/apply Abd pad/apply kerlix gauze roll every day shift and as needed for non-pressure wound.4. Right lateral foot cleanse wound cleanser/dry/apply xeroform/apply Abd pad/apply kerlix gauze every day shift and PRN for unstageable DTI.5. Right medial ankle cleanse wound cleanser/dry/apply xeroform/apply Abd pad/apply kerlix gauze every day shift and PRN for arterial wound.6. Right medial foot cleanse w wound cleanser/dry/apply xeroform/apply Abd pad/apply kerlix gauze roll everyday shift and PRN for stage 4 pressure injury. Review of a treatment administration record (TAR) for April 2026 for R69 reflected treatment orders for:LEFT HEEL: apply betadine every day shift for unstageable DTI; RIGHT HEEL: apply betadine every day shift for unstageable DTI; Right Lateral Ankle: cleanse wound cleanser/dry/apply xeroform/apply Abd pad/apply kerlix gauze roll every day shift for non-pressure wound; Right lateral Foot: cleanse wound cleanser/dry/apply xeroform/apply Abd pad/apply kerlix gauze every day shift for unstageable DTI; Right medial ankle: cleanse wound cleanser/dry/apply xeroform/apply Abd pad/apply kerlix gauze every day shift for arterial wound; and Right medial foot cleanse w wound cleanser/dry/apply xeroform/apply Abd pad/apply kerlix gauze roll every day shift for stage 4 pressure injury. Record review of R69's treatment record revealed on 04/04/26 and 04/05/26, the treatments record for all six orders were blank, indicating the treatments were not completed. The nurse that administered medications to R69 on 04/04/26 and 04/05/26 and should have completed the treatments was LVN2. LVN2 no longer worked in the facility. Observation and interview on 04/08/26 at 11:17 AM revealed R69 had a cushioned boot on the right lower extremity that was elevated on a pillow. R69 stated he was not certain what was wrong with his foot, but it had a sore on it that was painful. He stated they had just finished treating it. Observation and interview on 04/09/26 at 11:35 AM with PTA1 revealed he had worked at the facility for 2.5 years. PTA1 stated he started providing treatments to R69 about a week ago, and he did not complete the treatments on the weekends. He stated when R69 was on skilled services, nursing would complete the treatments. During an interview on 04/09/2026 at 12:43 PM with PTA1, he was asked how he communicated with the nursing department regarding R69's treatment. He stated he had spoken with the charge nurse last week. PTA1 confirmed he did not attend the morning meeting with the leadership. He added that his director did that. PTA1 stated the Director of Rehab would fill them in if there was anything brought up in the morning meeting. When asked where the treatments PTA1 completed were documented, he stated it was in NextHealth. PTA1 confirmed therapy did not complete any treatments on the weekends. He stated the nurse was responsible for treatments on the weekends. Interview on 04/09/26 at 1:20 PM with the DON, she revealed the treatment nurse was not available. The DON was asked how nursing and therapy worked together when providing treatment to R69. The DON stated we do not have a plan to how we are going to work with Therapy. She added that everything would have to be revamped. Review of a policy for Wound Care, dated May 2007, provided by the DON as the current policy, reflected, .document treatment given.

Based on interviews and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for qualifications of a Social Worker.The facility, licensed for 121 beds, did not employ a full-time, qualified social worker.This failure could place residents at risk for unmet social services and psychosocial needs. Findings included:Review of the Facility Summary Report from the Texas Unified Licensure Information Portal (TULIP) dated 02/10/2026 reflected the facility had a total licensed capacity of 132 beds.Review of the All-Staff list, undated, provided by the ADM on 03/03/2026 to the state surveyor, revealed the USW next to the job title Licensed Social Worker. Review of the job description for the facility's 'Social Worker' revealed the qualifications for 'Education and/or Experience' included to Hold current license through the state board as a LSW or a higher-level license. This was signed by the USW on 11/12/2024.Review of an email from the HR dated 10/13/2025 revealed a request to the USW for the USW's social worker's license, to which the USW responded that she had not gotten it yet, she would be testing 12/8/2025.In an interview on 03/05/2026 at 2:45 PM with HR, she stated that she had been working at the facility for about 7 years and that she was responsible for hiring. She stated that she was not the one responsible for hiring the USW, however, that was the ADM. She stated that the USW was hired on 11/11/24 by the ADM. She stated that her process for verifying professional licensure for staff in licensed roles such as social work, would be that she checked to see if they had a current license before hiring. She stated that as of now, the USW did not hold a license through the Texas Behavioral Health Executive Council. She stated that the USW was hired under the title 'Licensed Social Worker', and that the minimum qualifications for that position were what was written on the job description. She stated that when the USW was hired, the USW was supposed to obtain her license, but failed the exam in January 2025, and was supposed to retake it soon. In an interview on 03/05/2026 at 2:55 PM with the ADM, he stated that he began his AIT at this facility in January 2024. He stated that he was responsible for hiring the USW in November 2024. He stated that the facility identified the qualified social worker responsible for social services as the USW. He stated that the ADM at a sister facility was a licensed social worker who provided supervision or consultation for the social services program and did not work for this facility everyday as a licensed social worker but provided oversight if needed. He stated that the USW represented herself to residents, families, and staff as a social worker. He stated that he ensured compliance with the qualified social worker position by utilizing the USW as the social worker, and that she was a good social worker, if there were issues, she could call the sister facility ADM for oversight. He stated that the USW signed psychosocial assessments as the social worker, and that she participated in the interdisciplinary team as the social worker. He stated that when the USW failed her licensure exam in January 2025, he told her that she had 1 more chance to pass before they would need to find a qualified candidate. The ADM provided the surveyor with a picture of the USW's Master of Social Work diploma. Review of the facility's policy titled Social Services, Provision of Medically-Related undated, revealed, Social Services is responsible for providing for the medically related social services needs of each resident. It is not required that the social worker provides these services but assures that they are provided. Examples of these services may include but are not limited to the following:a. Transportation,b. Lost or missing items,c. Resident grievances,d. Scheduling appointments,e. Resident errands,f. Satisfaction surveys,g. Faxing request for discharge orders,h. Arranging for equipment needs.

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #13) of 6 residents reviewed for quality of care and change in conditions.The facility failed to obtain daily weights for Resident #13 for the dates of 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/7/26, 2/8/26, 2/9/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/14/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/21/26, 2/22/26, 2/23/26, 2/24/26, 2/28/26, 3/1/26, and 3/3/26.These failures placed residents at risk of weight gain, disease exacerbation, shortness of breath, decreased quality of life, heart problems, such as arrhythmia (irregular heartbeat).Findings included:Review of Resident # 13's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE]. She had the following diagnoses: heart failure, hypertension (elevated blood pressure), chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe), and depression. Resident #13 had a BIMS score of 13, indicating she was cognitively intact. She required partial/moderate assistance with upper and lower body dressing. Resident #13 had shortness of breath or trouble breathing when lying flat and required oxygen therapy. Review of Resident #13's comprehensive care plan reflected Has coronary artery disease, at risk for activity intolerance, impaired circulation, Date Initiated: 06/22/2024 revision on: 10/30/2025. Interventions included: Obtain weight as ordered.Review of Resident #13's Order Summary Report dated 03/03/2026 reflected an order for daily weights to be completed. Notify MD of weight gain of 3 pounds or more in 24 hours every day. Start date 03/29/2025 .Record review of Resident #13's weights and vital signs dated 03/03/2026 reflected the following weights that had been recorded: 2/26/26 -228.5 Lbs. 2/25/2026 -228.0 Lbs. 2/20/2026 -238.5 Lbs. 2/15/2026 - 238.0 Lbs. 2/6/2026 -239.5 Lbs. 2/1/2026- 235.0 Lbs. Record review of Resident #13's weights and vital signs dated 03/03/2026 reflected there were no daily weights recorded for Resident #13 for the dates of 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/7/26, 2/8/26, 2/9/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/14/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/21/26, 2/22/26, 2/23/26, 2/24/26, 2/28/26, 3/1/26, and 3/3/26. In an interview on 03/05/2026 at 8:28 AM, Resident #13 stated sometimes the staff obtained her weight and sometimes they did not. She stated the staff needed to weigh her to monitor the edema (swelling) in her legs because she had heart failure. In an interview on 03/05/2026 at 10:22 AM, the ADON stated the charge nurses were responsible for obtaining daily weights and notifying the physician of any weight variance. She did not know why Resident #13's weight was not obtained daily. The DON monitored the nurses to ensure their work was completed. Risk to residents for not obtaining a daily weight could include excessive edema and shortness of breath. In an interview on 03/05/2026 at 4:32 PM, the CDON stated the charge nurses were responsible for obtaining daily weights. The DON and ADON were responsible for monitoring to ensure weights were being done. They did not get notification for missed weights on their dashboards, and the dashboards were reviewed daily. The nurses needed to notify the doctor of any weight variance specified on the order. The risk to residents not obtaining daily weights could include volume overload. In an interview on 03/05/2026 at 4:59 PM, the ADM stated the CNAs were responsible for daily weights for Resident #13. The CNA reported to the DON. He was not sure how weights were monitored. He stated negative impacts for not obtaining daily weights could be not catching weight gain. In an interview on 03/05/2026 at 05:05 PM with the ADM revealed that failure to notify of a change in the resident's condition could lead to a further decline in the resident's condition. Record review of facility policy titled Quality of Care revised 11/2007, 07/2013, 10/2025 reflected It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biologicals) to meet the needs of each resident for 2 (Resident # 53 and Resident 68) of 6 residents reviewed for pharmaceutical services.The facility failed to ensure Resident #53 had his prescribed Zofran (a medication for nausea) 4mg available for administration. When the facility failed to order it from the pharmacy and Resident #53 administered another resident's medication (Resident #68's Zofran 4 mg tablet).This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications.Findings included:Record review of Resident #53's significant change in status MDS assessment dated [DATE] reflected a[AGE] year-old male who admitted to the facility on [DATE]. He had the following diagnoses: Myocardial infarction (heart attack), Chronic Respiratory failure, muscle weakness, and difficulty walking. Resident #53 had a BIMS score of 15, indicating he was cognitively intact. Resident #53 was receiving hospice services. Record review of Resident #53's order summary report dated 03/04/2026 reflected an order for Zofran (a medication used to treat nausea and vomiting) Oral Tablet 4 MG Give 1 tablet by mouth four times a day for nausea dated 02/19/2026. Record review of Resident #53's medication administration record for February 2026 reflected that he had received 26 doses of Zofran 4mg which had not been delivered from the pharmacy. Record review of Resident #53's medication administration record for March 2026 reflected he had received 7 doses of Zofran 4mg which had not been delivered from the pharmacy. In an interview on 03/04/2026 at 10:30 AM, Resident #53 stated he had been waiting for his nausea medication since last month. He stated he was supposed to take it 4 times a day and they kept telling him the medication was supposed to come in but it had not. Resident #53 stated he was receiving 1/2 of a pill four times a day. He stated he asked where the medication came from and was told by the MA, they had other residents that took the same medication, so they had plenty. Record review of Activity Transaction for facility emergency drug supply for the month of March 2026 reflected that 1 (one) Zofran 4mg had been pulled for administration on 03/04/2026 at 11:51 AM for Resident #53.Record review of Resident #68's quarterly MDS assessment dated [DATE] reflected a[AGE] year-old female who admitted to the facility on [DATE]. She had the following diagnoses: unspecified dementia (a decline in mental abilities), urinary tract infections, unspecified fall, unspecified protein calorie malnutrition. Resident #68 had a BIMS score of 02, indicating severe cognitive impairment.Record review of Resident #68's order summary report dated 03/05/2026 reflected an order for Zofran (a medication used to treat nausea and vomiting) Oral Tablet 4 MG Give 1 tablet by mouth every 8 hours as needed dated 01/14/26.Record review of Resident #68's medication administration record for March 2026 reflected that she had not received any doses of Zofran 4mg. In an observation on 05/05/2026 at 12:00p.m. of Resident #68's Zofran 4mg prescription revealed she had received 30 tablets delivered on 01/14/26. Resident #68 had 1 tablet left in her prescription. Resident #68 could not be interviewed.In an interview and observation on 03/04/2026 at 1:28 PM, revealed the MA was unable to locate Resident #53's Zofran 4mg tablets in the medication cart. She stated it was not there. She stated she signed out for the medication as given because she was told by RN C to do that. She stated she did not actually see the nurse give the medication. She assumed the nurse had pulled the Zofran 4mg tablet for Resident #53 from the emergency kit. She stated on the other days she worked she could not recall who was working and why she had signed out the Zofran 4mg as administered if the medication was not in the building. In an interview on 03/04/2026 at 1:31 PM, RN C stated that she did not give the medication Zofran 4mg to Resident #53. She stated she did not pull the Zofran 4mg tablet from the emergency cart. RN C stated Resident #53 has had not had any Zofran in the building because it was never delivered from the pharmacy after it was ordered. She stated she had not contacted the pharmacy to see why the medication was not delivered. She stated she followed the five rights of medication administration which included the right resident. In an interview on 03/05/2026 at 12:55 PM, the CDON stated that an investigation was initiated into the missing medication for Resident #53. She stated both the MA and RN C were suspended pending investigation. She stated the facility had pulled orders for all residents receiving Zofran 4mg and it was discovered Resident #68 was missing 29 tablets of the Zofran 4mg. Resident #68 had not received any dosages of her Zofran 4mg tablets. In an interview on 03/05/2026 at 1:15 PM, with RN D, case manager with hospice services for Resident #53, stated she was new to this case. She stated she had reported that the Zofran was not available to the facility nurse last week. RN D stated hospice did not order the medication because it was not related to his diagnosis for hospice admission. Hospice did not pay for that medication, so the facility needed to order it from their pharmacy. She stated the resident told her as well that the facility had been giving him someone else's medication. She stated she did talk to the DON and made it clear to her the medication was ordered routine four times daily from the primary care doctor. RN D stated not having the medication available could lead to uncontrolled symptoms such as increased nausea and abdominal pain . In an interview on 03/05/2026 at 1: 23 PM, the facility Pharm stated it was her expectation that the facility order medications for each resident individually, so they were readily available when needed. She stated if medications were not available the nurses should follow up and call the pharmacy to see what was holding up delivery or orders. She stated she was unsure if RN C had notified the pharmacy regarding resident #53's medication. She stated she completed a medication pass with the medication aides and nurses quarterly, at random, to ensure they followed proper medication administration procedures. She stated the nurses had an emergency kit in the facility with commonly used drugs available to get an emergency supply of medication if needed. She stated the negative effects of not having medications available could be exacerbated symptoms including nausea. Sharing medications could lead to medication errors or lack of supply and residents could run out. In an interview on 03/05/2026 at 3:45 PM, the MD stated all residents should be administered their own medications. It was not appropriate to share medications at the nursing facility. He stated sharing medications could lead to medication errors and medication shortages for residents who needed them. In an interview on 03/05/2026 at 4:32 PM, the CDON stated anytime a medication was ordered and hospice was not going to cover the medication they should let the facility know. The nurses should call hospice and the pharmacy to see why the medication for Resident #53 was not in house. The staff were administering Resident #68's Zofran 4mg tablets to Resident #53. The MA should have informed the nurse that the medication was not available. The CDON stated all nursing staff were in-serviced and those involved were reprimanded and terminated. She stated she expected staff to follow up on medications that were not available. Not having medications available could lead to delays in treatments for other residents that needed their medications. The ADON and DON completed system review audits each day, and they received notifications on the dashboards and 24-hour reports for new orders, to follow up on those notifications daily for review of new orders, and pharmacy delivery identifying any complications by receiving or ordering medications.In an interview on 03/05/2026 at 4:59 PM, the ADM stated it was his expectation that medications be administered as ordered. The staff should not be sharing medications, and that was not common practice at the facility. The ADON and DON should mentor the medication aides and nurses to ensure they followed policy for medication administration. The ADM stated negative effects could be other residents would be out of their medications leading to nausea. Record review of facility undated policy titled Ordering and Receiving Medications from The Pharmacy reflected Medications and related products are received from Pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. A licensed nurse: receives medications delivered to the facility and documents delivery on the medication delivery receipt, verifies medications received and directions for use with the medication order form, promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.

Based on interview and record review, the facility failed to ensure residents were free from chemical restraints that were not required to treat the residents' medical symptoms for 1 (Resident #9) of 6 residents reviewed for unnecessary medications.The facility failed to ensure Resident #9's GDR was attempted and non-pharmacological approaches to care were implemented for Quetiapine Fumarate, an antipsychotic medication (drug used to treat psychosis and related mental health conditions by modulating brain neurotransmitters).This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included:Review of Resident #9's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male who admitted to the facility on [DATE]. He had the following diagnoses: unspecified dementia (a decline in mental abilities), other lack of coordination, aphasia (difficulty with speech), dysphagia (difficulty with swallowing), and muscle weakness. Resident #9 had a BIMS score of 04, indicating severe cognitive impairment. Resident #9 was taking an antipsychotic medication on a routine basis. There had been no GDR attempted and no physician documented GDR as clinically contraindicated.Review of Resident #9's comprehensive care plan dated 08/20/2024 and updated 07/06/2025 reflected Psychotropic medications use with a goal Will reduce the use of psychoactive medication through the review date.Review of Resident #9's physician orders dated 03/05/2026 reflected he had an order for Quetiapine Fumarate Oral Tablet 200 MGGive 200 mg by mouth two times a day related to depression. The medication was started on started 06/01/2024.Record review of Resident #9's medical records from 05/2005-03/2026 reflected there had not been a GDR for his Quetiapine Fumarate tablets.Record review of Resident #9's medication administrations record dated March 2026 reflected he was receiving Quetiapine Fumarate Oral Tablet 200 MG tablets two times a day related to depression.Review of Consultant Pharmacist/Physicians Communication dated 05/19/2025 reflected [Resident #9] is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. The physicians' area was blank, regarding if they agreed/disagreed with the GDR.Quetiapine 200mg BID (for depression) reduce to Quetiapine 150mg BID? If dose reduction is contraindicated or resident failed previous reduction attempt, please document below. Signed by the Pharm.In an interview on 03/05/2026 at 3:45 PM, the MD stated he had just started with the facility back in June 2025, and that if a GDR were requested prior to that date, it may not have been addressed. He stated the DON or ADON left all pharmacy recommendations in his box at the nursing home so he could address them on his rounds. He stated he was normally in the building twice weekly. He stated he would have to evaluate Resident #9's medical records and behaviors to determine if a GDR would be beneficial. He stated that by not addressing pharmacy recommended GDR residents may receive medications they possibly do not need.In an interview on 03/05/2026 at 4:32 PM, the CDON stated the pharmacist reviewed and gave recommendations on psychotropic medications, and the nurse practitioner or physician approved or denied medication recommendations after they reviewed the medical record. She stated that nurses followed the doctors' recommendations and noted in the care plan any new orders or changes. A progress note as to why the GR was approved or denied was also entered into the resident's medical record. She was not sure why Resident #9's GDR recommendation was not addressed. She stated the DON was responsible for all follow-ups for pharmacy recommendations. She stated that the GDR not being evaluated could lead to ineffective medication treatment.In an interview on 03/05/2026 at 4:59 PM, the ADM stated the DON/ADON were responsible for monitoring the GDRs, and all pharmacy recommendations, and by not monitoring psychoactive medication recommendations, could lead to residents not having the best quality of life. Record review of facility policy titled Chemical Restraints and Psychotropic Medication Management Original Date: 05.2007 Revision/Review Date(s): 12.2019; 2.2022; 12.2023; 04.2025; 10.2025 reflected: It is the policy of this facility to ensure that residents are free from chemical restraints imposed for purposes of discipline or convenience or that are not required to treat a specific condition as diagnosed and documented in the clinical record. Psychotropic medications shall not be administered for the purpose of discipline or convenience. Based on a comprehensive assessment, the facility will ensure that: Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible to prevent accidents for 1 (Resident #77) of 6 residents reviewed for accidents and hazards.The facility failed to ensure Resident #77 did not keep disposable razors in her possession and use them without supervision. This failure could place residents at risk of cuts or scrapes. Findings included:Review of Resident #77's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female with an original admit date of 12/07/2025 and a re-admission on [DATE]. Resident #77 had the following diagnoses: high blood pressure, renal insufficiency (poor kidney function), hyponatremia (abnormally low sodium level), glaucoma (group of eye diseases that can lead to damage of the optic nerve), muscle weakness, and cognitive communication deficit. In Section GG - Functional Abilities, she was indicated as needing partial/moderate assistance with oral hygiene, upper body dressing, lower body dressing, and personal hygiene. Resident #77 had a BIMS of 12-indicating she had moderately impaired cognition. Review of Resident #77's comprehensive care plan dated 12/17/2025 reflected she was at risk for impaired visual function r/t glaucoma. Her interventions included consulting with eye care practitioner as required and monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. She had another focus area of 'ADL Self Care Performance Deficit r/t weakness, unsteady gait, impaired cognition'. The interventions were that staff would provide the appropriate level of physical assistance with ADLs as needed, and that her self-ability may fluctuate throughout the day.Review of Resident #77's active physician orders as of 03/03/2026 reflected an order for dorzolamide solution .5% related to unspecified glaucoma, and an order for pramipexole Dihydrochloride for tremors. In an observation on 03/03/2026 at 11:45AM, Resident #77 was shaving herself with a disposable razor in one hand, and a handheld mirror in the other, in front of an exit door at the end of her hall, using the outside light to help her see. She was able to shave her chin without staff approaching her for approximately 5 minutes. In an observation and interview on 03/03/2026 at 10:54 AM with Resident #77, she stated that she had glaucoma and she had to use eye drops for it. She stated that she thought the eye drops were causing a skin allergy due to her under eyes being irritated. She was observed sitting in a wheelchair.In a follow-up interview on 03/05/2026 at 9:45 AM with Resident #77, she stated that she had left her tweezers at home, and she preferred to use tweezers to pluck her chin hair. She stated that she kept a plastic bag of disposable razors in her purse, which she showed the surveyor, and the bag contained approximately 5 disposable razors. She asked the surveyor not to take them from her. In an interview on 03/05/2026 at 11:01 AM with CNA D, she stated that when residents admit to the facility the admitting nurse or CNAs would help fill out an inventory sheet of what residents had brought into the facility. She stated that they would inventory what was in a purse if it were valuables such as wallets and jewelry. She stated that due to Resident #77's vision problems she did not think the resident was safe to shave herself, and she was not aware that Resident #77 had disposable razors in her possession and had not previously seen the resident shave herself. In an interview on 03/05/2026 at 10:00 AM with the ADON, she stated that the admitting nurse would take inventory of resident belongings upon a resident admitting to the facility, and that they only inventoried important items like wallets and jewelry. She stated that they had confiscated a couple items from Resident #77 before, and they had not had to confiscate disposable razors, and she was not aware she had them in her possession. She stated that she could have medical supply get tweezers for Resident #77. In an interview on 03/05/2026 at 3:00 PM with the ADM, he stated that the facility will take an inventory sheet, every morning they do angel rounds (walk throughs done by department heads done usually in the mornings) to make sure any hazardous materials are put away. He stated that no one was assigned to check Resident #77's room, so unfortunately daily checks were missed. He stated that he just got back in town and was not familiar with Resident #77. He stated a negative impact of Resident #77 having disposable razors in her possession could be that a cognitively impaired resident could wander into her room and obtain the razors if they were not put up. An email request for a policy pertaining to shaving, and/or self-shaving, and/or assessments for determining safety/supervision for using disposable razors was requested on 03/05/2026 at 9:13 AM, and a policy was not provided.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 (Resident #25) of 6 residents reviewed for comprehensive care plans. The facility failed to care plan Resident #25's verbal behaviors and document interventions to address them.The facility failed to update Resident #65's care plan to reflect he no longer required the use of disposable dinnerware.This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.Findings included:Review of Resident #25's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #25 had the following diagnoses: non-Alzheimer's dementia (a variety of dementia that is not cause by Alzheimer's disease), malnutrition (undernutrition and/or overnutrition), hyperlipidemia (abnormally high levels of lipids in the blood), diabetes mellitus (when the body cannot properly use blood sugar, leading to high blood sugar levels), and anemia (blood disorder characterized by a reduced number of red bloods cells). In Section E - Behavior, Resident #25 was indicated as not exhibiting physical, verbal, or other behavioral symptoms during the look back period. Resident #25's Section C - Cognitive Patterns indicated 'No' that Resident #25's brief interview for mental status should not be conducted because she was rarely/never understood. Review of Resident #25's comprehensive care plan dated 01/14/2026 reflected a focus of At risk for a communication problem r/t hearing deficit and impaired cognition/dementia Interventions included, Anticipate and meet needs. Ensure/provide a safe environment: call light in reach, adequate low glare light, bed in lowest position and wheels locked, avoid isolation. Occupational, physical, speech-language therapy evaluation and treatment per physician orders. Refer to speech therapy for evaluation and treatment as ordered. Resident #25 had a focus of psychotropic medication use, the interventions included to monitor/record occurrences of pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others.Review of Resident #65's face sheet dated 03/05/2026 reflected a 79- year-old-male who was admitted to the facility on [DATE]. His diagnoses included alcohol use (drinking in a manner, situation, amount, or frequency that could cause harm to the person who drinks or to those around them), alcohol polyneuropathy (nerve damage caused by long-term, excessive alcohol consumption, resulting in pain, numbness, and weakness, primarily in the hands and feet), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), type 2 diabetes(condition in the way the body regulates and uses sugar as a fuel).Review of Resident #65's quarterly MDS assessment dated [DATE] reflected a BIMS score of 01, indicating severe cognitive impairment. Section GG (functional abilities) reflected Resident #65 required supervision or touching assistance with eating and used a wheelchair.Review of Resident #65's care plan initiated on 12/12/2022 and revised on 03/03/2026 reflected Resident #65 was care planned for impaired cognitive functions or impaired thought process r/t ETOH induced dementia.2/14/23: drawers with moldy food. Washing dinnerware in toilet. Notified dietary for disposable plates only - (discontinued 3/3/26 (behaviors no longer applicable)6-29-23: Resident observed washing dinnerware in toilet. Dietary informed that resident is to only have disposable dinnerware. (discontinued 3/3/26 (behaviors no longer applicable). Interventions included COMMUNICATION: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. Needs supervision/assistance with all decision making. Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficultyexpressing self, difficulty understanding others, level of consciousness, mental status.Initiated 12/13/2022 and revised 11/21/2025- Focus: ADL Self Care Performance Deficit r/t impaired cognition, ETOH dependance/withdrawal, impaired mobility. Interventions included: Provide with a homelike environmentFocus: initiated 10/10/2023 Focus: At risk for impaired cognitive function/dementia or impaired thought processes r/t dx alcoholic induced dementia.Interventions included: Initiated 10/25/2023- Provide with a homelike environment, initiated 12/20/2022 Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.Review of Resident #65's progress note dated 03/03/2026 reflected, Discussed resident's current behaviors related to washing dishes in his toilet from 2023. Resident has no current behaviors of such. Resident no longer needs Styrofoam plates for meals. Social Services to provide psychosocial support as needed. In an observation on 03/03/2026 at 10:44 AM revealed Resident #25 in her room. She began to scream out, with no other apparent signs of pain or distress, while lying in bed. In an observation on 03/03/2026 at 12:23 PM, Resident# 65 was observed in the dining room being served his lunch on a foam plate.In an observation on 03/04/2026 at 11:00 AM revealed Resident #25 in the sitting room of the facility. She was sitting in her wheelchair with a wedge behind her left side. She was observed grabbing at things that were not visible and occasionally screamed out with no other apparent signs of pain or distress. In an interview on 03/03/2026 at 12:11 PM with LVN A, she stated that Resident #25 had been yelling out since LVN A began working at the facility on 2/1/2026. She stated that Resident #25 was often taken out of her room and put in the living area of the facility to watch television with other residents. She stated that the resident yelled out for no particular reason, and her cognition was very low and she was not able to communicate with staff or residents. In an interview on 03/05/2026 at 9:24 AM with CNA A, she stated that she worked with Resident #25, and that the resident would pull on things, and reach for things that were not there. She stated that staff watched her in case of falls. She stated it was the resident's normal behavior to yell out and there was no particular reason identified. She stated that the resident would just yell and then stop. She stated that some other normal behaviors for Resident #25 were yelling, disrobing, and hanging her feet off the side of her bed. She stated that if the resident yelled out around other residents the staff would take her back to her room. She stated the resident's cognition was not there to participate in activities. In an interview on 03/05/2026 at 9:32 AM with LVN B, she stated she was the charge nurse on Resident #25's hall. She stated that Resident #25 would mumble, but staff were never able to understand her. She stated that yelling had always been Resident #25's normal behavior and LVN B was not sure what the root cause was. She stated that when the resident yelled out, staff would just talk to her, and even though they could not understand her, they tried to have a normal conversation with her. She stated that the care plans were more for the management staff, and DCS did not look at them, but at the tasks on the Kardex (program used for nurses to document tasks). She stated that nurses monitored behaviors. She stated behaviors were communicated in the orders. In an interview on 03/05/2026 at 12:25 PM with the MDSC, she stated that she was responsible for comprehensive care planning. She stated that when completing the MDS assessment, she looked at the progress notes to determine behaviors. She stated that there was an IDT that came together to discuss. She stated she thought that maybe the verbal outbursts by Resident #25 just became so normalized, that the DCS did not document them, therefore she would not be able to mark it as a verbal behavior in the MDS, which would then not translate over to the care plan. She stated that the communication part of the care plan could be more specific to include her verbal outbursts, and any interventions. In an interview on 03/05/2026 at 3:07 PM with the ADM, he stated that his expectation was for resident specific behaviors to be care planned. He stated that direct care nurses attended the morning meetings. He stated that yelling out was a behavior for Resident #25 that they discussed almost every morning, it just failed to be care planned. In an interview on 03/05/2026 at 4:32 PM, the MDSC stated she had worked at the facility for nine months. She stated she was responsible for completing comprehensive care plan and MDS assessments on all residents. She stated the nurses completed acute changes. She stated that she was not aware of any behaviors and that his care plan should have been updated.In an interview on 03/05/2026 at 4:39 PM with the CDON, she stated that Resident #25 was admitted to this facility from a sister facility, and exhibited the behavior of yelling, at that facility as well, so Resident #25 had been yelling out since her admittance to this facility. She stated she did not know what interventions the IDT determined to help manage or reduce Resident #25's yelling. She stated that there were individualized interventions staff should follow when the resident began yelling, she just did not know what they were. She stated that staff were supposed to document what interventions they attempted and whether they were effective in the progress notes. She stated she did not know why the behavior was not addressed in the care plan. She stated that any interventions that worked should be listed in the care plan, even if it was medication. In an interview on 03/05/2026 at 4:40 PM, LVN B stated she had not witnessed Resident #65 exhibiting any behaviors since she started working on the 600 hall in July 2025. She sated if a resident had behaviors, management staff would notify the nursing staff of how long the resident would need to be monitored. She stated Resident #65 was a good resident and she had no issues with his behaviors.In an interview on 03/05/2026 at 5:07 PM, the ADM stated that he had worked at the facility since 2024. When asked how familiar he was with Resident #65, he stated he would have to look at the resident chart. He stated he had not witnessed Resident #65 washing his dinnerware in the toilet. He stated he was not aware Resident #65 was being served meals on a Styrofoam plate. He stated he was unsure how Resident #65's behaviors were being monitored. He stated that the MDSC was responsible for updating the care plan. He could not give an explanation as to why Resident #65's care plan was not updated to reflect his current status. He stated a negative impact of a resident being served off of a foam plate could create the perception of different treatment compared to other residents.In an interview on 03/05/2026 at 5:22 PM, CNA C stated she had worked at the facility for 15 years. She stated she had not witnessed any behaviors from Resident #65 related to him washing dishes in his toilet. She stated she did not know why he would be served meals on a foam plate. She stated Resident #65 ate all his meals in the dining room. She stated if she were to notice any behaviors she would report to her nurse. She stated serving meals on foam plate could affect the resident's dignity as it did not promote a home-like dining environment.Review of the facility's policy titled Comprehensive Person-Centered Care Planning dated 10/2025 reflected, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Based on interview and record review, the facility failed to reassess, report, and document changes in condition in accordance with the person-centered service plan for 1 (Resident #19) of 8 residents who were reviewed for changes in condition.The facility failed to reassess and report Resident #19's blood pressure in accordance with the facility policy.These failures could lead to heart problems, such as arrhythmia (Irregular heartbeat).Findings included: Review of Resident #19's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Congestive Heart Failure, Alzheimer's disease, and muscle weakness. Review of Resident #19's care plan and BIMS Evaluation dated 03/02/2026 reflected that Resident #19 was assessed with a BIMS score of 99, indicating severely impaired cognition. Resident #19's Blood Pressure Summary dated 01/30/2026 at 10:10 reflected Resident #19's blood pressure was 94/39 mmHg, Sitting r/arm (Right arm). The blood pressure medication was ordered: Valsartan Oral Tablet 320 MG [Give 1 tablet by mouth one time a day for HTN (Hypertension), HOLD FOR SBP (Systolic Blood Pressure) LESS THAN 110 OR DBP (Diastolic Blood Pressure) LESS THAN 60)] had been held by MA F. However, no other readings had been taken, except for the one of 94/39 mmHg on 01/30/2026, and no notes of low blood pressure were noted in Resident #19's progress note. In a telephone interview on 03/05/2026 at 11:33 AM with the Hospice Coordinator revealed that there were no changes in condition for Resident# 19, addressed to hospice on 1/30/2026. In an interview on 03/05/2026 at 02:50 PM with LVN E, revealed that at any point, if LVN E found the resident's vital signs were abnormal, she checked the doctor's order, rechecked the vital signs if needed, informed the doctor of the abnormal results, documented it in her progress note, and entered it in PCC. In an interview on 03/05/2026 at 09:30 AM with the DON, revealed that if abnormal vital signs were a change in condition and were outside the parameters, nurses needed to report them to the doctor or the nurse practitioner. Nurses documented changes of condition in PCC. If a medication aide found abnormal findings, they would notify the charge nurse, who would then recheck the vital signs. However, nurses would only report to the doctor or nurse practitioner if the machine was functioning properly and the vital signs were abnormal. In an interview on 03/05/2026 at 09:40 AM with MA F revealed that, whenever MA F observed abnormal vital signs, MA F reported them to the charge nurse. After finding abnormal results, MA F entered her notes in PCC each time. MA F could not recall the significant vital sign changes on 1/30/2026 for Resident #19.In an interview on 03/05/2026 at 09:52 AM with the ADON revealed that at any point, if the medication aides saw a change in condition, such as abnormal vital signs, they notified the charge nurse, who would recheck the vitals. If the abnormality was not due to a machine malfunction, the nurse would notify the doctor. Nurses should document abnormal vital signs in PCC. If it was a hospice patient, then the nurse would notify the hospice provider.In an interview on 03/05/2026 at 01:31 PM, with RN F revealed that no one reported any low blood pressure or changes in condition among residents during her shift on 1/30/2026. At any point, if RN F finds or the CMA reports that the resident's vital signs are abnormal, she checks the doctor's order, rechecks the vital signs if needed, informs the doctor of the abnormal results, documents it in her progress note, and enters it in the PCC. In an interview on 03/05/2026 at 05:05 PM with the ADM, revealed that failure to notify of a change in the resident's condition could lead to a further decline in the resident's condition. Review of an in-service dated 03/04/2026 of the facility policy titled Holding Blood Pressure Meds per parameters, revealed: When a Certified Medication Aide holds a medication because the parameters are low, the Licensed Nurse must be notified and intervene as appropriate (re check vital signs, inform physician/hospice provider.)Review of an in-service dated 03/04/2026 of the facility policy titled Holding Blood Pressure Meds per parameters, revealed: When a Certified Medication Aide holds a medication because the parameters are low, the Licensed Nurse must be notified and intervene as appropriate (re check vital signs, inform physician/hospice provider.).

Based on observation, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 6 residents (Resident's #50, and #20's) reviewed for resident rights.The facility failed to ensure Resident #50 and #20's call lights were within reach on 03/03/2026 and 03/04/2026This failure could place residents at risk of needs not being met.Findings included:Record review of Resident #20's face sheet dated 03/05/2026 reflected the resident was an 83- year-old female admitted on [DATE]. Her diagnoses included Alzheimer's disease (a brain disorder that causes memory and thinking skills to decline over time), repeated falls (falling multiple times, usually within a short period), lack of coordination (uncoordinated movement, coordination impairment, or loss of coordination), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities).Record review of Resident #20's quarterly MDS assessment, dated 02/18/2026 reflected a BIMS score of 00 indicating severe cognitive impairment. Section GG (functional abilities) reflected resident was dependent assistance for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand, rolling from side to side, and all transfers.Record review of Resident #20's care plan dated 11/22/2021 and revised 10/06/2025 reflected [Resident #20] was at risk for communication problem r/t TIAs, dementia, usually understood/understands, difficulty hearing. Goal: [Resident #20] would to be able to make basic needs known on a daily basis through the review date. Interventions included: Call light in reach.Focus: [Resident #20] had ADL Self Care Performance Deficit r/t impaired balance and Dementia. Goal: [Resident #20] would maintain current level of function through the review date. Interventions included: Encourage to use bell to call for assistance. [Resident #20] was at risk for falls r/t incontinence, psychotropic medication use, gait, imbalance and cognitive impairment/dementia. Goal: [Resident #20] would not sustain serious injury through the review date. Interventions included: Be sure the call light is within reach and encourage to use it to call for assistance asneeded and a working and reachable call light.In observation on 03/03/2026 at 11:06 AM, revealed Resident #20 was lying in bed with the covers pulled up to her chest area. The resident did not respond when her name was called. The resident's call light was observed hanging to the right side of the head of her bed, out of the resident's reach. The resident was resting quietly and had no signs of pain or distress.Record review of Resident #50's face sheet dated 03/05/2026 reflected the resident was an [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), abnormalities of gait and mobility (a change in walking patterns), lack of coordination (uncoordinated movement, coordination impairment, or loss of coordination), hypertension (a condition in which the force of the blood against the artery walls is to high), muscle weakness (a, often sudden, reduction in physical strength where muscles cannot contract or function normally, causing difficulty with tasks like lifting or walking). Record review of Resident #50's quarterly MDS assessment dated [DATE] reflected a BIMS score of 04 indicating severe cognitive impairment. Section GG (functional abilities) reflected resident required supervision or touching assistance for toileting hygiene, baths, upper dressing, lower dressing, sit to stand, and chair/bed- to chair transfer. She required setup or clean up assistance for oral hygiene, putting and taking off footwear, personal hygiene, roll left to right, lying to sitting, walking 50 feet, and walking 150 feet. She was independent with eating, bed to lying, toilet transfers, and she used a walker. Record review of Resident #50's care plan dated 03/05/2025 reflected Resident had a risk for fall r/t poor safety awareness and high-risk medication. Goal: Resident #50 would be free of falls through the review date. Interventions included: Be sure the call light is within reach and encourage to use it to call for assistance as needed.In an observation and interview on 03/05/2026 at 11:25 AM, Resident #50's call light was hanging over the left side of the bed rail, and was on the floor. Resident #50 was asked if she could reach the call light and she was unable to reach it. She stated if she needed assistance and was unable to reach her call light she would yell for help.In an interview and observation on 03/03/2026 at 11:20 AM, LVN A stated that all staff that entered the resident's room were responsible for ensuring the call light was within reach. She stated Resident #20's call light should be within reach at all times. She entered Resident# 20's room and observed the resident's call light hanging to the right side of the head of her bed, and out of resident's reach. She stated she did not feel that Resident #20 was capable of pressing the call button, but the call light was not in an appropriate place, and she could not have pressed the button if she tried. She stated she had been trained on call light placement and if a resident did not have their call light in reach, the resident could have fallen or may not have been able to call for help.In an interview on 03/03/2026 at 11:30 AM, CNA B stated that staff should make rounds every two hours or as needed to check to see if a resident needed assistance, ensuring call lights were within reach, and making sure all residents were comfortable. She stated all residents' call lights should be in reach at all times. She stated she had been trained on call light placement and if a resident's call light was out of reach, they could fall trying to get to the light or could not call for help. In an interview on 03/05/2026 at 11:27 AM LVN B stated that staff should make rounds every two hours or as needed to check to see if a resident needs assistance, ensuring call lights were within reach, and making sure all residents were comfortable. She stated residents' call lights should be within reach at all times. She entered Resident #50's room and saw the call light hanging over the left side of the bed rail, on the floor, and out of reach. She stated the resident was capable of pressing the call button, but the call light was not in reach, and she could not have pressed the button if she tried. She stated she had been trained on call light placement and if a resident did not have their call light in reach, the resident could have fallen or may not have been able to call for help.In an interview on 03/05/2026 at 11:45 AM, the CDON stated that all staff that entered the resident's room were responsible for ensuring the call light was within reach. She stated it was her expectation that all residents had their call lights within reach for residents to call for assistance. She stated staff had been trained on call light placement. She stated if a resident call light was out of their reach, they may have had a need that was unmet.In an interview on 03/05/2026 at 1:30 PM, CNA A stated that staff should make rounds every two hours or as needed to check to see if a resident needed assistance, ensuring call lights were within reach, and making sure all residents were comfortable. She stated she was trained on call light placement and if a resident did not have their call light within reach could cause a resident not to be able to call for assistance and result in a fall or resident choking. In an interview on 03/05/2026 at 4:59 PM, the ADM stated staff completed morning rounds to ensure the residents' call lights were within reach. He stated staff had been trained on call light placement. He stated it was his expectation that all residents have their call lights within their reach at all times. He stated if a resident's call light was out of reach they may not receive assistance in a timely manner. Record review of the facility policy titled Call Light/Bell Policy and revised date 08/03/2021; 10.2025 reflected It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures: 1. Answer the light/bell within a reasonable time2.Listen to the resident's request/need.3.Respond to the request. If the item ., not available or you are unable to assist, explain to the resident and notify the charge nurse for further instructions.4.Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment for 1 of 1 facility observed in that:The facility foyer had 2 of 4 skylights in disrepair for an unknown amount of time.This deficient practice could affect residents, staff, or visitors who entered through the facility front doors by placing them at risk of being exposed to leaks or an unsanitary environment. Findings included:In an observation on 03/03/2026 at 9:08 AM the facility foyer revealed 2 of the 4 skylights were broken, with visible holes, that had been repaired with tape that was adhered to the outside of the skylights. The broken shards of skylight were visible underneath the tape.In an interview on 03/03/2026 at 10:50 AM, with the LM, he stated that the skylights in the foyer broke due to wind, and they were hard to replace. He stated he did not remember exactly when the skylights broke, but he thought it was at the beginning of 2026. He stated that he was not sure when the facility's maintenance director got ahold of the contractor to come out to the facility to measure and replace with new skylights. In an interview on 03/04/2026 at 2:37 PM, the ADM stated that the skylights in the foyer had just been fixed. Additionally, he stated that he thought the work order was in their maintenance system but later stated he could not find anything to support they had reached out for the skylights to be fixed before the survey team arrived. He stated that he really did not remember when the skylights broke or when the technician taped over it. He stated that all maintenance concerns should be documented in the TELS system (system used for inputting and tracking maintenance requests), and any immediate concerns should be relayed to the corporate maintenance technician. He stated that the FMD would only report things to him (ADM) if it required immediate attention or work outside of his capability, like from a contractor. In an observation on 03/04/2026 at 3:03 PM of the facility foyer ceiling revealed the 2 previously broken skylights were now in good condition. In an interview on 03/04/2026 at 3:28 PM with the FMD, he stated that on Monday (3/2/2026) he identified the skylights broken in the facility foyer. He stated he reached out to the roofing company who did a measurement, and they came back today (3/4/2026) and installed new skylights. He stated that the skylight was not broken at the beginning of the year. He stated that the tape was put on there by the vendor. He stated he was not sure how the hole got there and he did not put it in the TELS system because he just called the roofing company. He stated that since he started in April 2025, this was the first time any skylights had broken. He stated that the skylight being broken could lead to weather hazards, or birds flying in. Review of the facility policy titled Maintenance/Request for repairs undated, revealed, All requests may be entered into Tels system, this will create a work order. Information will include: repair needs, area in need of repair, and name of staff member requesting repair.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 (Resident #12) of 6 residents reviewed for ADLs.The facility failed to trim and cut Resident #12's fingernails.This failure could place residents at risk of not receiving services/care and decreased quality of life. Findings included:Review of Resident # 12's significant change in status MDS assessment dated [DATE] reflected an [AGE] year-old male who admitted to the facility on [DATE]. He had the following diagnoses: diabetes mellitus (elevated blood sugar), unspecified dementia (a decline in mental abilities), myopathy (a stiffing of the muscles), and unspecified abnormalities of gait and mobility. Resident #12 had a BIMS score of 07, indicating severe cognitive impairment. Resident #12 required partial/moderate assistance with personal hygiene.Review of Resident #12's comprehensive care plan reflected an ADL Self Care Performance Deficit related to neuropathy (nerve pain) and generalized muscle weakness. Date Initiated: 10/22/2020 revision on: 11/18/2022. Interventions included: Staff will physically assist with all ADLs as needed.Review of Resident #12's visual bedside Kardex (a snapshot of requires care for residents) report dated 3/03/2026 reflected staff will physically assist with all ADLs as needed.In an interview and observation on 03/03/2026 at 10:44 AM, Resident #12 had long and jagged fingernails going past his fingertips with black dirt and debris under them. He stated the nurses refused to cut his fingernails and he did not like them long. He was not sure why no one would take care of his fingernails. In an interview on 03/4/2026 at 11:49 AM, CNA A stated she was responsible for the care of Resident #12. She stated he had diagnosis of diabetes and the CNAs were not supposed to clip the nails of diabetic residents. She stated she had not told the nurse Resident #12's fingernails needed to be cut. She stated having fingernails that were long and dirty could result in infection and a lack of dignity for Resident #12. In an interview on 03/04/2026 at 12:03 PM, RN C stated she was just informed today that the nurses were responsible for clipping residents' fingernails. She stated there was no order for nail care that she was aware of. She stated having fingernails that were dirty, long, and jagged could result in skin tears or infection. In an interview on 03/05/2026 at 4:32PM, the CDON stated that if residents were diabetic the CNAs could clean and file fingernails and the nurses were responsible for clipping the fingernails. She stated Resident #12 was not on a scheduled date for trimming fingernails. She stated that on shower days the CNAs should notify the nurse when a resident's fingernails needed to be clipped. She stated nurses should perform a full body head to toe assessment weekly, that should include fingernails, and at that time if the nurses saw residents' fingernails are long, they should be trimmed unless the resident refuses. The only time fingernail care was placed on the care plan was if there was a specific preference on nailcare. The CDON stated the negative impact of long dirty fingernails could be infection.In an interview on 03/05/2026 at 4:59 PM, the ADM stated fingernails should be cleaned when residents were showered. Long jagged fingernails were not acceptable and if the nurses and CNAs saw that, then they needed to clean them. He stated he was not sure who was responsible for nail care. The ADM stated the negative impacts of long dirty fingernails could be infection. Record review of facility policy titled Quality of Care ADL, Services to carry out revised 11/2007, 07/2013, 10/2025 reflected It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene will be provided by qualified staff.

Based on observation, interview, and record review, the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for 1 of 1 facility's reviewed for water leakage.The facility failed to maintain dry, water-leak-free conditions in the facility's only laundry room.This failure could put all residents at risk of infection and laundry service workers at risk for slips and falls.Findings included:In an observation on 03/05/2026 at 12:13 PM, revealed a water leak in a plumbing line on the dirty side of the laundry room, located behind the washing machine. Water was leaking onto the floor of the room, flowing behind the washing machine, along its side, and into the dirty laundry collection room. A blue type of cloth had been placed at the back of the main water-leakage area to soak up the water, and white blankets had been placed at the corners of the washing machine nearest to the main wall of the room to soak up the water from the leakage area. In an interview on 03/05/2026 at 12:15 PM with the Laundry Service Staff I revealed that the recent leak in the laundry area happened last year, around the end of December 2025. At around the same time, Staff I notified the FMD. Since that time, Staff I had been using dry blankets to soak up the water. Staff I stated water leaks from the main water line to the wall behind the washing machine, then flowed through to the side of the washing machine, and sometimes into her work area on the dirty side of the laundry room. Staff I stated FMD was trying to fix it, but it kept leaking. Staff I stated that a negative outcome would be that laundry staff could slip and fall if the water was there and the floor was wet. She stated that if the water stood for too long, it could create mold. In an interview on 03/05/2026 at 12:40 PM, with the FMD revealed that Staff I reported the leakage to him two weeks ago. The FMD stated that at any point, if anything in the facility needed fixing, he took care of it. For the leakage in the laundry area behind the washer, FMD applied Flex Seal spray (black), but it started leaking again. The FMD mentioned that the leak was so minor that it was at the bottom of the pipe and could easily be dried with a dry blanket. The FMD could not address any negative outcomes of the leakage.In an interview on 03/05/2026 at 12:55 PM with the ADM, revealed that the FMD did not need to report any maintenance to the ADM, since the facility had life-safety and maintenance resources in place. However, if anything was more maintenance-intensive, the FMD could let him know. He stated that failing to fix the laundry leak could pose a fall hazard to laundry service staff.In an interview on 03/05/2026 at 12:59 PM with the LM, revealed that the LM's expectations of the facility FMDs were that they fix everything themselves, but if at any point the FMD could not fix something, they could call the LM for help or submit a work order via the Tels system (system used for inputting and tracking maintenance requests),. The LM mentioned that the leak may not require a licensed plumber if they could fix it themselves. He stated it should not take more than two weeks to fix a problem unless the FMD had already tried to fix it and the problem came back. Review of the facility policy titled Maintenance/Request for Repairs, undated, revealed All requests may be entered into Tels system, this will create a work order. All work orders generated in Tels will automatically be sent to maintenance for completion. Review of the facility's maintenance logbook did not address the water leak in the laundry room. The review of the facility's Tels system's Work Order Report did not include a summary of the water leak in the laundry room .Review of the facility policy titled Maintenance/Request for repairs undated, revealed, All requests may be entered into Tels system, this will create a work order. Information will include: repair needs, area in need of repair, and name of staff member requesting repair.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety and sanitation in the facility's only kitchen. The facility failed to ensure all expired pantry items were discarded. This failure could place residents at risk for health complications, foodborne illnesses and decreased a quality of life. Findings include: Observation of the kitchen pantry on [DATE] at 10:28 AM revealed: 1 large container of Italian Seasoning with Rec [DATE], open [DATE] Ex ,d+[DATE] written in black permanent marker on the side. 1 large container of Parsley Flakes with R [DATE] Ex [DATE] written in black permanent marker on the side. 1 container of Ground Cumin Seeds with Rec [DATE] Ex [DATE] written in black permanent marker on the side. 1 container of Ground Turmeric with R [DATE] Ex [DATE] written in black permanent marker on the side. 1 container of Curry Powder with R [DATE] E [DATE] written in black permanent marker on the side. Interview with the DM on [DATE] at 10:34 AM revealed that employees who received the food delivery would label the items received with the received date, date of opening, and expiration date based off the open date if a use by date was not printed on the product. Interview with the ADM on [DATE] at 11:00 AM revealed the facility kitchen follows guidance from the TFER. Review of the FDA 2022 Food Code revealed, ,d+[DATE].18 Disposition of Ready-to-Eat, Time/Temperature Control for Safety Food o Food held beyond its labeled use-by or expiration date, or past the allowed storage time for safety reasons, must be discarded. ,d+[DATE].12 Food Storage Containers Identified with Common Name of Food o This section indirectly reinforces the importance of proper labeling and identifying food to avoid usage of expired or unsafe items. ,d+[DATE].11 Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food o This section states that food that is unsafe, adulterated, or not honestly presented must be discarded. Expired food often falls into this category if it is deemed unsafe. ,d+[DATE].14 Return of Food to Prevent Contamination o This section implies that food returned or deemed unfit for service should be discarded to avoid risks.

Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 1 medication carts and 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure the medication cart and medication room was locked and medications were secure and not accessible to other staff, resident, or visitors while unattended by MA on 01/08/2025. This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles. Findings included: Observation on 01/08/2025 at 9:02 MA B left the medication cart unlocked outside of room [ROOM NUMBER] in the hallway with the keys on top of the cart while she washed hands inside of the restroom and obtained gloves to administer eye drops. Observation on 01/08/25 at 9:05 AM the facility's only medication storage room was unlocked, and no facility staff were present. In an interview on 01/08/2025 at 9:30AM MA B stated she should never walk away from the cart leaving it open with keys on top. She stated she had been trained to never walk away from an unlocked medication cart. She stated she was sidetracked looking for large gloves. MA B stated the negative effects for leaving the cart unlocked could be a resident may take the keys, other could have access to the medications in the cart. MA B stated she had been visually checked off on med pass monthly with the Pharmacist and DON. In an interview on 01/08/25 at 9:17 AM with the DON she stated the medication storage room was supposed to be locked and that another staff member thought the door locked automatically as the doorknob was recently replaced. In an interview on 01/10/25 at 1:31 PM the DON stated it was her expectation for the medication assistants and Nurses to lock the medication cart when unattended. She stated the staff had been instructed to never leave the keys on top of the cart, always keep the keys on their person, and keep the cart locked. She stated the DON and ADON make rounds frequently and monitor staff as well as instruct them through in-services and when they are checked off visually on medication pass. She stated potential negative effects for the leaving the medication cart open could be missing medications, possible drug diversion. Review of the facility's Medication Access and Storage/Drug Destruction Policy revealed: It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observations, interviews, and record review, the facility failed to coordinate assessments with the PASARR program for 1 of 8 Residents (Resident #63) reviewed for PASARR services. 1. The SW failed to assess Resident #63, based on his behaviors, for a referral for PASARR services. 2. The MDSC failed to refer Resident #63 for a Level II PASARR Evaluation by the local LIDDA. This failure placed residents in the facility at risk for exclusion for PASARR Services. Findings Included: RR or Resident #63's AR, dated 1/10/2025, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. RR of Resident #63's Medical Diagnosis, downloaded from PCC on 1/10/2025, reflected Resident #63 was diagnosed with Depression, Unspecified (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life) and Schizophrenia, Unspecified (which was a chronic mental illness that affected a person's thoughts, feelings, and behavior.) RR of Resident #63's BIMS Score assessment, administered on 1/10/2025, reflected a score of 6, which indicated the resident had severe cognitive impairment. RR of Resident #63's CP reflected a Focus area for impaired cognition or impaired thought, initiated on 12/6/2024, R/T disease process. The Goal, revised on 12/29/2024, indicated the resident was supposed to maintain their current level of functioning through 3/5/2025. The Intervention, initiated on 12/6/2024, delegated nursing home to engage in simple structured activities that avoid overly demanding tasks; a Focus area for psychotropic medication, unknown date of initiation, R/T Schizophrenia. The Goal, initiated on 12/13/2024, indicated the resident would not have reactions to antipsychotic drug therapy (Seroquel 25 MG). Antipsychotic was discontinued on 12/19/2024 / Replaced with Anti-Anxiety Drug Therapy (Hydroxyzine 25 MG) The Intervention, initiated on 12/13/2024, delegated nursing home staff to check blood pressure monthly. RR of Resident #63's P-1, located in PCC, reflected a document sent from Resident #63's referring entity. The document was dated 12/5/2024. Page 4 of 12 indicated resident did not have evidence of an MI, ID, or DD. RR of Resident #63's P-1, located in Simple, reflected a document sent from Resident #63's referring entity. The document was dated 12/5/2024. Page 3 of 8 indicated resident did have evidence of an MI. Interview and observation on 1/7/2025 at 12:14 PM with Resident #63 revealed him in bed in his room. He was able to respond to questions, clean, and appropriately dressed. He was new to the facility and stated it was rough getting used to the routine. It was hard remembering who provided which services. Interview and RR on 01/10/25 at 10:56 AM with the SW, revealed that she was the facility designee to collaborate with residents and their PASARR eligibility/referrals. Based on Resident #1's P-1, located in PCC, Resident #63 presented to the facility on [DATE] with a negative P-1, meaning he did not have evidence of a MI, ID, or DD. The SW stated she had spent time with Resident #63, who had exhibited changes in his alertness, orientation, mood, and cognition. She was unaware Resident #63 had diagnosis of Depression, Unspecified and Schizophrenia, Unspecified. Had she been aware of his mental health diagnosis, she would have had him re-assessed by a medical provider and then referred him to the LIDDA for the P-2 evaluation as needed. However, she had not discovered the mental health diagnosis; she had not referred the resident for mental health services; she had not referred the resident for a P-2 evaluation. RR of the resident medical records in PCC did not reveal a P-2 or referral to the LIDDA. Interview and observation on 1/10/25 at 1:21 PM with the MDSC revealed she was the MDSC at the facility until last week, 1/2/2025. She was responsible, along with the SW, for residents and their PASARR eligibility/referrals. She had been trained as an MDSC at the facility, taken on-line training, and completed the classes for CMAC (Certified MDS Assessment Certification.) The facility followed the guidelines in the RAI for PASSAR processing. Observation of the MDSC revealed her search Simple, a 3rd party data base with HHSC and PASARR, for a P-2 for the LIDDA for Resident #63. Instead of a P-2 for the LIDDA, a P-1 was found. The P-1 found in Simple, was different from the P-1 that was found in PCC. The P-1 found in Simple reflected Resident #63 did have evidence of a MI. Based on the P-1 in simple. The MDSC stated, I just did not see it and there should have been a P-2 submitted for the LIDDA. RR of Simple did not reveal a P-2 for Resident #63. Residents who qualified for PASARR services were available to receive NFSS services, such as PT/OT/ST/DME. Residents who were qualified for, but did not receive NFSS services, were placed at risk for a decrease in options for quality of care. Since she had been removed from her position, CMDSC M and CMDSC N oversaw the MDS/PASARR entries. She was unaware of any support structure in place to catch errors in the PASARR process. Interview on 1/10/25 at 2:23 PM with the ADM stated that the SW and the MDSC were responsible for the residents' PASARR eligibility/referrals to the LIDDA. The facility followed the guidelines of the PASARR division. Residents, who benefitted for PASARR services, were eligible for benefit's such, as DME, assistance post DC from the facility with housing, and therapeutic services. Residents who were eligible, but not afforded the opportunity, risked the loss of services provided through the PASRR program. Safeguards in place to ensure residents get linked to PASARR services were team meetings, MDSC checks, morning meetings, and corporate resource personal. In a situation where there were two conflicting P-1s for a resident, the ADM stated the document in Simple would have taken precedence over the one found in PCC. The failure for the SW to assess the resident for MI and make the appropriate referral, along with the MDSC's failure to retrieve the P-1 from Simple, was a process failure. The staff members responsible for the PASARR eligibility/referrals were the SW and the MDSC. RR of the CMS RAI Version 3.0 Manual, dated 10/2024, reflected: Referral for Level II Resident Review Evaluations is required for individuals previously identified by PASRR to have MI, ID, or a related condition in the following circumstances: Referral for Level II Resident Review Evaluations is also required for individuals who may not have previously been identified by PASARR to have MI, ID, or a related condition in the following circumstances: 1. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan furnishing services to attain, or maintain, the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #30) reviewed for comprehensive care plans. The facility failed to care plan Resident #30's high risk of elopement. This failure placed resident at risk of their needs having gone unmet. Findings included: Record review of Resident #30's quarterly MDS assessment dated [DATE], reflected the resident was a [AGE] year-old male with an admitted [DATE]. Resident #30 had diagnoses which included Parkinson's Disease (a neurodegenerative disease primarily of the central nervous system, affecting both motor and non-motor systems), cognitive communication deficit (impairment in thought organization, attention, memory, and safety awareness), hallucinations, and anxiety. The MDS reflected the resident had a BIMS score of 07, which indicated the resident had severe cognitive impairment. Record review of Resident #30's elopement/wandering evaluation dated 10/23/2024 reflected a score of 14, indicating the resident was a high risk of elopement. Record review of Resident #30's care plan dated last revised on 10/13/24 reflected no interventions for elopement or wandering. In an observation on 01/07/25 at 10:53 AM resident #30 was standing in his room watching television. In an interview on 01/08/25 at 01:58 PM with the DON she stated the MDS Coordinator was responsible for creating the care plan. She stated there had recently been a change in the MDS Coordinator because the previous MDS person at the facility did not work out for them, and the DON did not see where Resident 30 had been care planned for elopement. In an interview on 01/10/25 at 10:04 AM with the MDSR she stated that she had held that position since about 2019. She stated she worked as an MDS resource for multiple facilities. She stated that if a resident had any risk of elopement, the resident should be care planned for elopement interventions. Record review of facility policy titled Care and Treatment, Care Planning dated reviewed on 08/2015 reflected, It is the policy of this facility that the interdisciplinary team shall develop a comprehensive care plan for each resident. A comprehensive care plan is developed within seven days of completion of the resident minimum data set.

Based on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #3) reviewed for respiratory care. The facility failed to place Resident #3's oxygen tubing in a bag when not in use. This failure could place residents at risk of not receiving appropriate respiratory care. The findings were: Resident #3 Record review of Resident #3's undated face sheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses of Heart Failure, Acute upper Respiratory Infection, Obstructive Sleep Apnea, and Shortness of Breath. Record review of Resident #3s care plan dated 03/31/2022 reflected she had Chronic Obstructive Pulmonary Disease (a group of lung diseases that make it difficult to breath) her Goal was to be free of signs and symptoms of respiratory infections through review date. Interventions included to give oxygen therapy as ordered by the physician. Record review of Resident #3's quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. Record review of Resident #3's physicians' orders summary dated 01/08/2025 reflected an order to change oxygen tubing and humidifier bottle, clean filter weekly as needed if equipment is used, every night shift, every Sunday. Keep tubing inside plastic bag when not in use dated 04/22/2021. In an observation and interview on 01/07/25 at 11:49 AM Resident #3s oxygen tubing was laying on top of her concentrator out of the bag and not dated. Resident #3 stated for the most part the nurses changed her oxygen tubing weekly. She stated occasionally she got sick and required her oxygen machine due to her respiratory disease. She stated she liked for it to be clean. In an interview on 01/10/25 at 01:25 PM LVN A stated oxygen tubing was supposed to be changed weekly. She stated the tubing should be in a bag when not in use. She stated the nurses had been instructed on changing the tubing and keeping it covered by the DON. She stated there was a physician's order in the computer to change the tubing. Night shift nursing staff were responsible for changing the tubing on Sundays. The risk to residents for having dirty oxygen tubing included respiratory infection. In an interview on 01/10/25 at 1:31 PM the DON stated staff were educated by the DON, ADON and LVN resource team. The DON stated if a resident had respiratory equipment tubing it should have been bagged, even if it was used as needed it should be bagged. She stated negative effects for residents having unbagged oxygen tubing could include respiratory infections. She stated staff were instructed to remove oxygen equipment in rooms if not used. The DON stated the department heads do angel room rounds every morning to monitor for things that could negatively affect the resident. Record review of facility policy titled Oxygen Equipment dated 05/2017 reflected It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable prefilled humidifiers, tubing, masks, and cannulas for residents receiving oxygen. The equipment is to be discarded after use. The facility will maintain clean tanks, connectors, and concentrators. When oxygen mask or cannula is temporarily not being used it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly.

Based on interviews and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 (Resident #26) of 6 residents reviewed for pharmacy services. The facility failed to obtain a stop date for Resident #26's Cipro (an antibiotic used to treat an acute infection) started on 01/01/2025. These failures could place residents at risk of side effects (gastrointestinal upset, multiple drug resistant infections) related to long term antibiotic use. Findings included: Record review of Resident #26's undated face sheet reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses of neuromuscular dysfunction of the bladder (the nerves and muscles that control the bladder aren't working properly), hypertension (elevated blood pressure), legal blindness, and personal history of malignant neoplasm of brain (history of brain cancer). Record review of Resident #26's quarterly MDS dated [DATE] reflected he had short term memory problems. His cognitive skills for daily decision making were severely impaired. The MDS reflected Resident #26 required an indwelling catheter. Record review of Resident #26's care plan dated 01/01/2025 reflected he had a urinary tract infection. The care plan reflected he had started Cipro 500mg active date 01/01/2025 to 01/06/2025. The goal reflected the urinary tract infection will resolve without complications by the review date. Interventions included to give antibiotic therapy as ordered, monitor/document for side effects and effectiveness. Record review of infection surveillance assessment dated [DATE] reflected Resident #26 had a urinary tract infection with an indwelling catheter. He had purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate. The assessment reflected Resident #26 had started Cipro oral tablet 500mg 1 tablet by mouth two times a day for UTI for 5 days. Record review of the progress notes for Resident #26 dated 01/01/2025 reflected he had swelling to penis, small amount of pus noted with no noted odor to area, doctor and RP were notified and a new order for Cipro 500mg, BID x 7 days for UTI and discharge was obtained. The progress note was signed by the DON. Record review of the infection surveillance assessment dated [DATE] reflected Resident #26 had a urinary tract infection with an indwelling catheter. He had other infection of epididymitis (an infection or inflammation of the testis). The assessment reflected Resident #26 had started Levofloxacin Oral (an antibiotic used to treat infection) Tablet 500 MG to start on 01/03/2025, Give 500 mg by mouth one time a day for Bilateral epididymitis (inflammation of the testis) until 01/10/2025. Record review of Resident #26's Physicians order summary dated 01/08/2025 reflected an order for Cipro Oral Tablet 500 MG (Ciprofloxacin HCl an antibiotic), Give 1 tablet by mouth two times a day for UTI, monitor swelling to penis, dated 01/01/2025. The order did not contain a stop date /duration for antibiotic therapy. Record review of Resident #26's Physicians order summary dated 01/08/2025 reflected an order for Levofloxacin Oral (an antibiotic used to treat infection) Tablet 500 MG to start on 01/03/2025, Give 500 mg by mouth one time a day for Bilateral epididymitis (inflammation of the testis) until 01/10/2025. Record review of Resident #26 Medication Administration Record dated 01/08/2025 reflected resident had received 14 doses of Cipro 500mg starting 01/01/2025. Record review of Resident #26 Medication Administration Record dated 01/08/2025 reflected resident had received Levofloxacin Oral Tablet 500 MG (Levofloxacin) Give 500 mg by mouth one time a day for 6 doses. In an interview on 01/10/2025 at 1:25 PM LVN A stated there should be a stop date on all antibiotic orders used for short term treatment of acute infections. She stated the nurses should have clarified the order with doctor. She stated nurses were instructed to get the stop dates on any short-term medications by in-services monthly given by don. LVN A stated she was unsure why a stop date was not obtained at the time of order for the Cipro order. She stated she was unsure what the negative effects of long-term use of Cipro could be, but she could find out the information. In an interview on 01/10/25 at 1:31 PM the DON stated the Cipro for Resident #26 should have been for 5 to 7 days only. She stated the nurses were instructed to obtain a stop date for all antibiotics used for treatment of acute infections at the time of the order being received. She stated the DON and ADON were responsible for the review of orders daily. She stated they review daily for acute changes in residents' condition by looking at daily reports, review electronic medical records dashboard, and clarifying with the doctors for stop dates. The DON stated negative effects for residents that use long term antibiotic could lead to antibiotic resistant infections or intestinal infections. In an interview on 01/10/25 at 1:53 PM the PA stated Cipro for Resident should have been for 7 days. She stated the staff should have obtained a stop date at time the order was given. She stated the Levofloxacin Oral Tablet 500 MG (Levofloxacin) 1 po q day ordered on 1/3/24 was ordered by another practitioner. She stated it was not protocol to have two antibiotics at the same time. She stated the facility should have stopped the cipro once the Levofloxacin order was received. She stated the Levofloxacin was ordered when the urine culture came back. The PA stated orders were given by encrypted text messages services. The orders were given to the DON or nurses. She stated she did not see any negative effects for Resident #26 being on the cipro for the time he was on it. She stated she would have caught the error at his next visit she sees the resident weekly. Record review of facility policy titled Unnecessary Drugs dated 04/2012 and last revised on 11/12/2015 reflected It is the policy of this facility that each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug us any drug when used: For excessive duration.

Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 of 6 residents (Resident #66) reviewed for dignity. The facility failed to promote resident independence and dignity while dining when staff stood over Resident #66 while assisting them to eat on 01/07/25. This failure could have compromised residents' independence and dignity for those who require feeding assistance. Findings included: Record review of Resident #66's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female with an admitted [DATE]. Resident #66 had diagnoses which included Alzheimer's (a type of brain disorder that causes problems with memory, thinking, and behavior), difficulty in walking, muscle weakness, cognitive communication deficit, and osteoporosis (a condition when bone strength weakens and is susceptible to fracture). Resident #66's BIMS score was left blank. The MDS indicated the resident started speech-language and audiology services therapy on 12/09/24 for 4 days a week. Record review of Resident #66's care plan dated last revised 11/20/24 reflected she had a nutritional problem or potential nutritional problem related to disease process and ADL self-care performance deficit. In an observation on 01/07/25 at 01:05 PM Resident #66 was being assisted with her lunch tray by a SLP who was standing over Resident #66 the entire duration of assistance. In an interview on 01/07/25 at 01:20 PM with the SLP she stated she had worked at the facility since September of 2024. She stated that she was conducting an evaluation on Resident #66 due to a recent weight loss. She stated Resident #66 had poor attention span, could feed herself but may require assistance, and she was checking for Dysphasia (a language disorder that affects the ability to produce and understand spoken language). When asked if the SLP had been trained on how to provide feeding assistance she stated Yes, I am sure there was something in the LMS trainings but was unable to recall if she was supposed to sit or stand next to a resident when providing assistance. In an interview on 01/07/25 at 2:15 PM with the DOR she stated she had worked at the facility for 3 years. When asked what her expectation was for feeding assistance, she stated that she would need to be notified by nursing that certain signs were occurring so that an SLP could evaluate the residents' cognition and swallowing. She stated that normally CNA's assist residents with feeding, but it would not be out of the ordinary that SLP's would be available and/or assisting. The expectation would be for the SLP to be seated next to the resident while providing assistance, and they were informed that they should be sitting for respect purposes, but this was not necessarily talked about for the evaluations. Review of the facility's Feeding checklist for training staff revealed The following table lists the steps that are expected of you in order to feed an individual. The table also provides rationales that explain why you perform some of these steps. The use of this content is for educational purposes only and should only be used as a guide in performing the below skill, subject to the terms and conditions of the Master Services Agreement. no instruction for the employee being trained, to sit next to residents while providing feeding assistance was listed.

Based on interview and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation; the facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress for 1 (Resident #1) of 5 residents reviewed for neglect. The facility failed to: 1. ensure Resident #1 was evaluated and treated for urinary retention which led to Resident #1 requiring emptying of her bladder in the emergency department on 01/27/24 2. ensure Resident #1's pain was addressed by providing her prescribed oxycodone for her bilateral (both left and right) ankle fractures and surgery resulting in uncontrolled pain that caused Resident #1 to call 911 for transport to the emergency roiagnom on [DATE] An Immediate Jeopardy (IJ) situation was identified on 01/31/24. While the IJ was removed on 02/01/24, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could led to urinary retention and uncontrolled pain, both of which required medical intervention in the emergency room , and place residents at risk of not having their needs met to reach their highest practicable mental, physical and psycho-social wellbeing. Findings included: Record Review of Resident #1's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of bilateral ankle fracture (post-op), depression, and high blood pressure. Record review of Resident #1's EHR Assessments tab revealed an admission assessment on 01/27/24 revealed a BIMS that was 14 (cognitively intact). Record review of Resident #1's initial care plan effective 01/27/24 at 12:01 am revealed section V, part a. Pain focus: has acute/chronic pain; goal: Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date; Intervention: Administer analgesia medication as per orders & Intervention: Anticipate need for pain relief and respond immediately to any complaint of pain & Intervention: Pain assessment every shift Record review of the January 2024 orders for Resident #1 revealed that she had an order for oxycodone (narcotic pain reliever) 10 mg q4 hrs prn, started 01/26/24 at 1:13 pm. In addition, she had an order for methocarbamol 500 mg q8 prn pain (muscle relaxant). Record review of the January orders for Resident #1 revealed no order for Tylenol. Record review of the January 2024 MAR revealed no administration of methocarbamol nor of oxycodone. Record review of the police department call log printed 01/29/24 revealed that Resident #1 called 911 herself on 01/26/24 at 5:46 pm stating that the bed pan was cutting into her skin, she cannot move and she wanted to go to the ER. During an interview on 01/30/24 at 1:15 pm with DON she said oxycodone was not part of the emergency kit. DON further stated that Resident #1 was not in pain from her ankles, but the nurse could have called the physician for a different pain medicine that was in the emergency kit. During an interview on 01/30/24 at 1:59 pm with LVN A she stated that Resident #1 wanted a foley catheter inserted because she was not able to urinate in the bed pan. LVN A said it was a dignity issue and Resident #1 did not want to urinate in a brief or on the bed pan. LVN A stated that the DON and LVN A and EMS staff spoke to Resident #1 about the dangers of the foley catheter related to infection and after they talked to Resident #1 she declined transport to the emergency department on 01/26/24. LVN A stated Resident #1 was left on the bed pan for 30 minutes on 01/26/24. LVN A said Resident #1 expressed concerns about wearing briefs as a dignity issue and had difficulty using a bed pan. Resident #1 told LVN A that she was uncomfortable using a bed pan due to being continent and requested a foley be placed on 01/27/24. LVN A stated the facility wanted to monitor her due to infection risk of foley. She stated Resident #1 minimally urinated in bed pan on 01/26/24 and aides reported urine in brief on 01/27/24. When asked why the docotr was not asked for a prescription for another pain medicine like hydrocodone to cover until oxycodone arrived LVN could not answer and kept saying the medication was supposed to arrive on the next delivery. During an interview on 01/31/24 at 10:45 am (at a different facility) Resident #1 said she was left on the bed pan for an hour with no one checking on her on her first day at the facility (01/26/24). She stated she had ankle pain in both ankles the entire time she was in the facility. She said she tried to urinate in the bed pan but was not able on 01/26/24. She said she kept trying to urinate in the brief over the night of 01/26/24 and into the morning of 01/27/24 and she was able to urinate at one point. Resident #1 stated she was in so much pain she did not eat on either day she was in the facility and that she stopped drinking in the afternoon of 01/27/24 due to not being able to urinate. She said she was in 10 out of 10 pain from her ankles the entire day of 01/27/24 and as the day progressed the pain in her abdomen from her full bladder increased to 10 out of 10 as well. She said she called out in pain and was tearful while yelling for assistance and she was only given Tylenol which did not help. Resident #1 stated that she told at least 5 staff each day that she was in pain and that her needs were ignored. She said she was told her oxycodone was not available in the facility and it was on order. Resident #1 said she called 911 for help with her pain and was taken to the emergency room where she cried to the doctors and begged not to be sent back to that facility. Record review of the police department call log printed 01/29/24 revealed that Resident #1 called 911 herself on 01/27/24 at 7:05 pm because she was in pain and the facility was not doing anything for her; operator documented the resident was crying on the phone and stated that broken ankles and bladder was what was causing the pain. During an interview with Hospital Nurse 01/30/24 4:00 pm revealed Resident #1 was seen in emergency department 01/27/24 at 7:52 pm for Urinary retention since yesterday (01/26/24) and acute pain after bilateral ORIF of ankles. Resident #1 told Hospital Nurse she had 10 out of 10 pain in bilateral ankles and the facility did not have her pain medicine in stock and gave her Tylenol. In addition, hospital nurse stated that Resident #1 had 593 mls of urine removed and her bladder was distended (over 400 requires emptying per nurse). In addition, the resident tested positive for a UTI which the hospital nurse stated could be caused by or exacerbated by urine retention. Multiple attempts to reach the pharmacy over 3 days were not successful. Record review of the undated facility policy titled Abuse: Prevention and Prohibition Against revealed each resident has the right to be free from abuse, neglect and misappropriation . Record review of the facility policy titled Pain Recognition and Management revealed if pain management is not effective, the MD should be contacted. This was determined to be an Immediate Jeopardy (IJ) on 01/31/24 at 2:30 PM. The ADM and DON were notified and provided with the IJ template on 01/31/24 at 2:43 PM. The following plan of Removal submitted by the facility was accepted on 02/01/24 at 3:14 pm and included: PLAN OF REMOVAL F600: Neglect: In the IJ Template given on 1/31/2024, the facility failed to address Resident #1 pain and urinary retention. 1. The Medical Director was notified of the IJ on 01/31/2024 at 4:00 pm. 2. Train the trainer in-servicing was given to the ED, DON, ADON, MDS Nurse and RN/ED Cluster Partners by the Clinical Resource. The training included regarding abuse and neglect including goods and services needed to address a resident's needs in relation to pain. This was completed on 1/31/24. 3. Verbal and written training and knowledge checks were completed with all staff regarding abuse and neglect including goods and services needed to address a resident's needs in relation to pain. This training was given by the ED, DON, ADON, MDS Nurse Clinical Resource and RN/ED Cluster Partners, was initiated on 1/31/24 will be completed on 2/1/24 with all staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for agency staff/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. 4. An ad hoc meeting regarding items in the IJ templates will be completed on 1/31/24. Attendees will include the DON, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions. 5. The ED or designee will verify staff knowledge on abuse and neglect prevention with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly after the initial training and knowledge checks completed on 2/1/24 and will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance. 6. The DON or designee will monitor q shift pain assessments daily to verify that interventions are in place and pain medications are given appropriately and will monitor new orders and documentation for pain medication availability daily. The DON or designee will monitor MAR and pain medications stored on carts weekly to ensure pain medication availability. These processes were initiated on 1/31/24 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance. 7. Resident requiring pain management will be reviewed during weekly clinical meeting and the Medical Director and Pain Management Physician will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to DON, ADON, Rehab Director, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and pain management is reviewed. This meeting will begin on 01/31/2024 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance. 8. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 1/31/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. MONITORING THE POR: Record review on 02/01/24 of the in-service records revealed in-services on 02/01/24 related to abuse, neglect, and change in condition - pain and urinary retention. Record review of a sign in sheet for a meeting related to the immediate jeopardy were dated 01/31/24 and showed attendance of DON, Medical Director, ADON, Clinical Resource, and Executive Director. Interviews conducted on 02/01/24 between 10:00 am and 12:00 pm with 4 residents revealed no concerns related to neglect, staff assistance, nor with pain. Interviews conducted on 02/01/24 between 1:00 pm and 5:00 pm with 1 housekeeper, 1 LVN, 1 PTA, 1 COTA, 1 ST, and 1 CNA revealed that staff were in-serviced on pain, urinary retention, neglect and abuse. All were able to answer questions appropriately related to notification of and response to resident pain and resident concerns. All were able to answer questions related to reporting neglect and abuse. Interviews conducted on 02/14/24 between 11:00 am and 1:30 pm with DON, ADON and MDS nurse revealed they were in-serviced by the corporate RN related to pain, neglect and urinary retention; this was completed 01/31/24. Record review of all residents admitted since 01/31/24 revealed no pain related deficient practice. Interviews with all of the residents confirmed no pain related issues nor neglect concerns being voiced. Interviews on 02/14/24 between 11:00 am and 1:30 pm with 1 ADON/LVN, 1 LVN, the staffing coordinator, 1 RN and 2 CNAs revealed all have been in-serviced daily since 01/31/24 related to pain (identifying, reporting, following up), neglect (listed all types of neglect and gave examples), and urinary retention (all voiced signs, listening to resident concerns, and reporting to nurse and if no action taken reporting to DON directly). All stated they had been in-serviced on all topics 02/01/24 and now it was being re-iterated. In an interview on 02/14/24 at 11:00 am with DON she stated that every resident had been assessed for pain, pain was added to every care plan, and all residents had standing orders for pain medications that could be used by any nurse for immediate pain concerns. DON stated that all physicians engaged to ensure pain would be addressed for all residents, including new admissions. These procedures were in place by 02/01/24. The ADM was informed the Immediate Jeopardy was removed on 02/01/2024 at 4:15 p.m. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. On 02/14/24, two attempts were made to contact the pharmacy without success (in addition to the attempts earlier).

Based on observation, interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for pain. The facility failed to: 1. ensure Resident #1's prescribed oxycodone was in the facility and provided to Resident #1 for her pain from bilateral broken ankles and surgery An Immediate Jeopardy (IJ) situation was identified on 01/31/24. While the IJ was removed on 02/01/24, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could affect residents by placing them at risk for pain that would prevent residents from achieving their highest practicable physical, mental and psychosocial well-being. Findings included: Record Review of Resident #1's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of bilateral ankle fracture (post-op), depression, and high blood pressure. Record review of Resident #1's EHR Assessments tab revealed an admission assessment of BIMS that was 14 (cognitively intact). Record review of Resident #1's initial care plan effective 01/27/24 at 12:01 am revealed section V, part a. Pain focus: has acute/chronic pain; goal: Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date; Intervention: Administer analgesia medication as per orders & Intervention: Anticipate need for pain relief and respond immediately to any complaint of pain & Intervention: Pain assessment every shift Record review of the January orders for Resident #1 revealed that she had an order for oxycodone (narcotic pain reliever) 10 mg q4 hrs prn, started 01/26/24 at 1:13 pm. In addition, she had an order for methocarbamol 500 mg q8 prn pain (muscle relaxant). Record review of the January MAR revealed no administration of methocarbamol nor of oxycodone. During an interview on 01/31/24 at 10:45 am (at a different facility) with Resident #1 said she was left on the bed pan for an hour with no one checking on her on her first day at the facility (01/26/24) to the point that the metal felt like it was cutting her skin and she could not move from the bedpan which was extremely uncomfortable. She stated she had ankle pain in both ankles the entire time she was in the facility. She said she tried to urinate in the bed pan but was not able on 01/26/24. She said she kept trying to urinate in the brief over the night of 01/26/24 and into the morning of 01/27/24 and she was able to urinate at one point. Resident #1 stated she was in so much pain she did not eat on either day she was in the facility and that she stopped drinking in the afternoon of 01/27/24 due to not being able to urinate. She said she was in 10 out of 10 pain from her ankles the entire day of 01/27/24 and as the day progressed the pain in her abdomen from her full bladder increased to 10 out of 10 as well. She said she called out in pain and was tearful while yelling for assistance and she was only given Tylenol which did not help. Resident #1 stated that she told at least 5 staff each day that she was in pain and that her needs were ignored. She said she was told her oxycodone was not available in the facility and it was on order. Resident #1 said she called 911 for help with her pain and was taken to the emergency room where she cried to the doctors and begged not to be sent back to that facility. Record review of 911 log revealed Resident #1 called 911 herself on 01/26/24 at 5:46 pm stating that the bed pan was cutting into her skin, she cannot move and she wants to go to the ER. During an interview on 01/30/24 at 1:15 pm with DON she said oxycodone was not part of the emergency kit. DON further stated that Resident #1 was not in pain from her ankles, but the nurse could have called the physician for a different pain medicine that was in the emergency kit. In an interview on 01/30/24 at 1:59 pm with LVN A she stated that the DON and LVN A and EMS staff spoke to Resident #1 about the dangers of the foley catheter related to infection and after they talked to Resident #1 she declined transport to the emergency department on 01/26/24. LVN A further stated that Resident #1's oxycodone did not arrive with her other medications on 01/26/24. She contacted the pharmacy as soon as it opened on 01/27/24 at 8:00 am and was told the oxycodone would arrive on the next shipment, around 4:00 pm. The medication did not arrive with the afternoon delivery around 4:00 pm and LVN A contacted the pharmacy again and placed an order for oxycodone STAT and was told it would be 3-4 hours for delivery. LVN A said the resident wouldn't urinate in the urinal due to dignity. She said she did not recall her complaining of ankle pain, but later stated that Resident #1 mentioned her ankle pain the morning of 01/27/24. When asked why the docotr was not asked for a prescription for another pain medicine like hydrocodone to cover until oxycodone arrived LVN could not answer and kept saying the medication was supposed to arrive on the next delivery. Multiple attempts to reach the pharmacy over 3 days were not successful. Record review of 911 log revealed Resident #1 called 911 herself on 01/27/24 at 7:05 pm because she was in pain and the facility was not doing anything for her; operator documented the resident was crying on the phone and stated that broken ankles and bladder is what was causing the pain. Record review of Resident #1's progress notes revealed notes specific to ankle pain on: 01/26/24 1:03 pm (first note on admission) 01/27/24 12:13 pm Pain originates from fracture Located at bilateral ankles Described as ache nonpharmaceutical interventions include elevate and rest Further review revealed a progress note 01/27/24 at 6:00 pm revealed pending pharmacy delivery for Oxycodone 10 mg q4hr PRN, this nurse called in STAT order at 1700 after pharmacy delivered facility meds (resident's medication not present in package), was advised it would be sent on next delivery in 3-4 hours Record review of pain assessment 01/27/24 at 3:36 pm revealed a score of 7. Further review revealed 01/27/2024 6:36 pm used PAINAD and had a score of 2 (1 for being tensed, and 1 for distracted or reassured by voice/touch). Record review of admission assessment titled Pain Management Review revealed resident rated her pain at a 7 and it was in her bilateral ankles. Under staff observation it had checked that Resident #1 Negative verbalizations and vocalizations (e.g., groaning, crying/whimpering, or screaming) This assessment was signed 01/27/24 at 12:11 am. During an interview with Hospital Nurse 01/30/24 4:00 pm revealed Resident #1 was seen in emergency department 01/27/24 at 7:52 pm for Urinary retention since yesterday (01/26/24) and acute pain after bilateral ORIF of ankles. Resident #1 told Hospital Nurse she had 10 out of 10 pain in bilateral ankles and the facility did not have her pain medicine in stock and gave her Tylenol (no order in facility orders for Tylenol). In addition, hospital nurse stated that Resident #1 had 593 mls of urine removed and her bladder was distended (over 400 requires emptying per nurse). In addition, the resident tested positive for a UTI which the hospital nurse stated could be caused by or exacerbated by urine retention. Record review of the facility policy titled Pain Recognition and Management revealed if pain management is not effective, the MD should be contacted. This was determined to be an Immediate Jeopardy (IJ) on 01/31/24 at 2:30 PM. The ADM and DON were notified. The ADM and DON were provided with the IJ template on 01/31/24 at 2:43 PM. The following plan of Removal submitted by the facility was accepted on 02/01/24 at 3:14 pm: PLAN OF REMOVAL F697: Pain Management: In the IJ Template provided on 01/31/2024, the facility failed to administer narcotic medication to Resident #1 as ordered by the Physician. 1. The Medical Director was notified of the IJ on 01/31/2024 at 4:00 pm. 2. Pain assessments were completed for all residents on 1/31/24 and care plans were updated by DON, Cluster RNs and clinical resource RN. Orders for pain assessment for every shift were verified by DON, Cluster RNs and clinical resource RN for all resident on 1/31/24. 3. An ad hoc meeting regarding items in the IJ templates will be completed on 1/31/24. Attendees will include the DON, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions. 4. The DON, ADON, MDS Nurse , RN Cluster Partners were in-serviced by the Clinical Resource RN. The DON, ADON, MDS Nurse , RN Cluster Partners and clinical Resource RN will verify Nurse knowledge with 5 Nurses weekly using the pain management knowledge check and all agency nurses prior to working a shift. This will be completed weekly x 4 weeks after the initial training and knowledge checks completed on 2/1/24. 5. The DON or designee will monitor q shift pain assessments daily to verify that interventions are in place and pain medications are given appropriately and will monitor new orders and documentation for pain medication availability daily. The DON or designee will monitor MAR and pain medications stored on carts weekly to ensure pain medication availability. These processes were initiated on 1/31/24 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance 6. Resident requiring pain management will be reviewed during weekly clinical meeting and the Medical Director and Pain Management Physician will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to DON, ADON, Rehab Director, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and pain management is reviewed. This meeting will begin on 01/31/2024 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance 7. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 1/31/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring: MONITORING THE POR: Record review on 02/01/24 of the in-service records revealed in-services on 02/01/24 related to pain. Record review of 10 residents revealed pain assessments were completed every shift starting 01/31/24 and care plans were updated related to pain for residents with pain concerns. Further review on 02/14/24 revealed no missed pain assessments for any resident. Record review of a sign in sheet for a meeting related to the immediate jeopardy were dated 01/31/24 and showed attendance of DON, Medical Director, ADON, Clinical Resource, and Executive Director. Interviews conducted on 02/01/24 between 10:00 am and 12:00 pm with 4 residents revealed no concerns related to pain. Interviews conducted on 02/01/24 between 1:00 pm and 5:00 pm with 1 housekeeper, 1 LVN (admitting LVN for Resident #1), 1 PTA, 1 COTA, 1 ST, and 1 CNA revealed that staff were in-serviced on pain, urinary retention, neglect and abuse. All were able to answer questions appropriately related to notification of and response to resident pain. Interviews conducted on 02/14/24 between 11:00 am and 1:30 pm with DON, ADON and MDS nurse revealed they were in-serviced by the corporate RN related to pain; this was completed 01/31/24. Record review of all residents admitted since 01/31/24 revealed no pain related deficient practice. Interviews with all of the residents confirmed no pain related issues. In an interview on 02/14/24 at 11:00 am with DON she stated that every resident had been assessed for pain, pain was added to every care plan, and all residents had standing orders for pain medications that could be used by any nurse for immediate pain concerns. DON stated that all physicians engaged to ensure pain would be addressed for all residents, including new admissions. These procedures were in place by 02/01/24. Interviews on 02/14/24 between 11:00 am and 1:30 pm with 1 ADON/LVN, 1 LVN, the staffing coordinator, 1 RN and 2 CNAs revealed all have been in-serviced daily since 01/31/24 related to pain (identifying, reporting, following up), neglect (listed all types of neglect and gave examples), and urinary retention (all voiced signs, listening to resident concerns, and reporting to nurse and if no action taken reporting to DON directly). All stated they had been in-serviced on all topics 02/01/24 and now it is being re-iterated. The ADM was informed the Immediate Jeopardy was removed on 02/01/2024 at 4:15 p.m. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. On 02/14/24, two attempts were made to contact the pharmacy without success (in addition to the attempts earlier).

Based on observation, interview, and record review, the facility failed to ensure residents received care and necessary treatment and services, based on their comprehensive assessments and consistent with professional standards of practice, to prevent pressure ulcers from developing or to promote healing and prevent infection of existing pressure ulcers for two (Residents #39 and #13) of four residents reviewed for pressure ulcers. 1. The facility failed to prevent the condition of Resident #39's Stage IV pressure ulcer on his left heel from worsening. On 05/17/19, 05/18/19 and 05/19/19 the facility failed to ensure Resident #39 received the daily wound care ordered by the wound care physician to the Stage IV pressure ulcer on his left heel. After three days of not receiving treatments the pressure ulcer had increased in size and developed eschar (thick layer of dead tissue) and odor that may indicate infection. 2. The facility failed to apply Resident #39 sponge boot per MD recommendations and ensure interventions when resident refused to wear sponge boot. 3. The facility failed to ensure Resident #13 wore heel protectors while in bed, as ordered by the physician, to help prevent the development of pressure ulcers. An Immediate Jeopardy (IJ) was identified on 05/22/19. While the IJ was removed on 05/24/19 at 9:45 AM, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility monitoring the effectiveness of the Plan of Removal. These failures could place residents at risk for skin breakdown, pressure ulcers, worsening pressure ulcers, infections, and potential life-threatening complications. Findings included: 1. Review of Resident #39's face sheet, dated 5/23/19, reflected the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #39's Quarterly Minimum Data Set (MDS) assessment, dated 3/16/19, reflected he was a [AGE] years old male. He had intact cognitive skills for daily decision making, and Brief Interview for Mental Status (BIMS)score of 15. Resident #39 required moderate to extensive assistance with activities of daily living. He had two unstageable pressure ulcers that were present on admission. Resident's #39 interventions for pressure ulcer treatment and prevention included skin and ulcer treatments, pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, and application of ointments/medications. Review of Resident #39's undated Care Plan reflected: (Resident #39) has an unstageable pressure ulcer to left and right heel . The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Review of Resident #39's consolidated Physicians Orders revealed the following order, start date of 05/15/19: Cleanse unstageable wound to left heel with Normal Saline, pat dry, apply Santyl ointment and calcium alginate and protective dressing every day at bedtime for wound care for 23 Days. According to Drugs.com Santyl is a [MEDICATION NAME] ointment and it digest collagen in necrotic tissue. https://www.drugs.com/drp/[MEDICATION NAME]-santyl-ointment.html (accessed on 06/04/19) According to Vitality Medical Calcium Alginate combines with the fluids in the wound to create a sodium gel that helps speed up the healing of the wound in promoting the wound's autolytic debridement, while also absorbing excess fluid. https://www.vitalitymedical.com/alginate-dressing.html (accessed on 06/04/19) Record review of Resident #39's wound care progress notes for 03/26/19 through 05/14/19 revealed the following: 03/26/19 - pressure ulcer to left heel was unstageable; measured 3 cm x 4 cm ; no change to wound over the past 7 days; treatment remains [MEDICATION NAME] every day. 04/04/19 - Pressure ulcer to left heel was unstageable; measured 3 cm x 4 cm ; no change in wound progress 04/10/19 - Pressure ulcer to left heel was unstageable; measured 3 cm x 4 cm 04/16/19 - Pressure ulcer to left heel was unstageable; measured 5.5 x 4.0 x depth not measurable. Wound has deteriorated over the past 7 days; surgical excisional debridement performed to remove dead tissue and establish the margins of viable tissue. Procedure performed with topical [MEDICATION NAME] for anesthetic, clean surgical technique, Resident tolerated well. Treatment changed to Santyl and calcium alginate QD (every day). 04/23/19 - Pressure ulcer to left heel was unstageable; measured 5.5 x 4.0 x depth not measurable, continue with alginate calcium apply daily for 16 days Santyl. 04/30/19 - Pressure ulcer to left heel was unstageable. Measured 6.5 cm x 4.5 cm x depth not measurable Wound treatment: Alginate calcium and Santyl daily 05/07/19 - Pressure ulcer left heel was unstageable (debrided); measured 4.5 cm x 3.6 cm x depth not measurable. Wound treatment: Apply alginate calcium and Santyl daily for 30 days - (improved) sponge boot was recommended. 05/14/19 - Pressure ulcer left heel was a stage 4 (debrided), measured 5 cm x 3 cm x depth not measurable. Wound treatment: Apply alginate calcium and Santyl daily for 23 days - Improved (sponge boot recommended) Review of Resident #39's Nutrition Services Note, dated 05/16/19, reflected: Res (Resident) has 2 existing unstag (unstageable) pressure injuries (One to his L (left) and R (right) heel)(> (greater than) 120 d (days)) and one newly discovered stg (stage) IV pressure injury (to his first toe). Per latest wound progress report, wound to the L heel is showing signs of improvement and wound to his R heel is not showing signs of improvement. Res states he loves milk, orange juice and eggs. Summary: Res may not be meeting needs on all days related to changes in taste acuity. Rec'd (Recommended) to fortify milk and oatmeal. 2.) Provide milk w/ (with) all meals and omit corn, peas, cucumbers. Observation and interview on 05/19/19 at 10:41 AM revealed Resident #39 was lying in bed, on an air mattress, watching television. Resident #39's feet were observed to be elevated by rolled up blankets. The heel protectors were at the bedside. Resident #39's feet were uncovered, and a dressing to the left heel dated 05/16/19 was observed. The resident revealed he had pressure ulcers to both heels, but only the left heel had a dressing applied to it. He said the staff did not provide wound care daily and the dressing hadn't been changed in several days. In an interview on 05/19/19 at 10:50 AM LVN W stated she was the charge nurse for Resident #39. She said Resident 39's wound care to both heels was to be provided daily per the physician orders. She stated the wound care was scheduled to be completed on the 2 PM-10 PM shift. LVN W confirmed the dressing on Resident #39's foot was dated 05/16/19. LVN W stated she would notify the 2 PM-10 PM charge nurse to change the dressing. Observation and interview on 05/20/19 at 12:43 PM revealed Resident #39 lying in bed with his feet elevated on rolled up blankets. The dressing on his left foot was dated 05/16/19. He stated he did not like the sponge boots that were at the bedside. He stated he did not know why the dressing on the left heel was not being changed. Resident #39 stated at times one of the charge nurses changed the dates on the dressing without providing care to the wound. He was unable to identify that charge nurse by the name, but stated the staff was a female. Review of Resident #39's Treatment Administration Record for (MONTH) 2019 reflected there were no staff initials indicating wound care had been completed on the left heel as ordered on [DATE], 05/12/19, 05/15/19, 05 /18/19, and 05/19/19. It was initialed 05/17/19 the wound care was completed by LVN E. Observation and interview on 05/21/19 at 10:26 AM revealed Resident #39 was lying in bed. The dressing to the left heel was dated 05/20/19. Resident #39 stated the staff changed the dressing yesterday. In an interview on 05/21/19 at 2:21 PM LVN [NAME] revealed she was off on 05/15/19 and 5/16/19 but worked on 05/17/19. LVN [NAME] stated on 05/17/19 she was the charge nurse for Resident #39 on the 2-10 shift when the wound care was scheduled to be completed, but she did not remember if she completed wound care to his left heel. LVN [NAME] stated there were so many things going on 05/17/19. She stated take full responsibility for not doing the wound care. She stated she came back to work yesterday (05/20/19), and she completed the wound care to Resident #39's left heel. She stated she did not see major changes to the wound from last week to yesterday. In an interview on 05/21/19 at 03:18 PM Resident #39's Wound Care Medical Doctor (MD) revealed he had debrided the resident's left heel wound last week on 5/14/19 and ordered the wound care to be completed daily with Santyl. The MD stated the daily use of Santyl was supposed to help improve the wound, but he stated the wound looked worse today. The MD stated Resident #39's left heel wound had eschar tissue on the wound that was not there last week. The MD stated Resident#39 informed him wound care hadn't been completed for five days. The MD stated failure of the facility to provide wound care per the orders could lead to the wound getting worse. Review of Resident #39's Wound Evaluation and Management Summary by MD dated 5/14/19 reflected, Pressure ulcer left heel stage 4 (debrided)- 5 x 3 x not measurable cm. Wound treatment: Apply alginate calcium and Santyl daily for 23 days wound Improved (sponge boot recommended) Review of Resident #39's Wound Evaluation and Management Summary completed by the MD dated 5/21/19, reflected, .a stage 4 pressure wound of the left heel: wound size and surface area had increased, wound had deteriorated. Review of Resident #39's MD wound progress note, dated 05/21/19, revealed: Pressure ulcer to left heel was a stage 4 (debrided) and measured 5 cm x 3.5 cm x depth not measurable. MD removed necrotic tissue and established the margins of viable tissue. Wound treatment orders to apply calcium alginate and Santyl daily for 16 days. MD recommended a sponge boot, and indicated the wound had deteriorated. In an interview on 05/22/19 at 12:10 PM LVN W confirmed she did not complete Resident #39's wound care on 05/19/19 because she was not assigned to that resident. She stated she was assisting the nurse who was assigned to Resident #39 hall and she assumed the nurse (RN G) who was assigned to that hall had completed the wound care. LVN W stated she did not complete the wound care on Resident #39 on 5/19/19 after it was brought to her attention, because the wound care was supposed to be completed on the 2-10 shift, and she was working on the 6-2 shift. Attempts to contact RN G, the nurse assigned to Resident #39 on 05/18/19 and 05/19/19, were unsuccessful. Observation on 05/22/19 at 01:00 PM revealed Resident #39 was receiving wound care. The dressing being removed from the left heel was dated 5/21/19. The wound had necrotic tissues and yellow slough with minimal serous drainage. Resident #39 denied of pain or discomfort during wound care. While the ADON provided wound care, Resident #39 stated at times the staff only changed the date on the dressing without changing the dressing. Resident #39 also stated when the MD saw the resident's wound yesterday the MD stated the wound stunk. In an interview on 05/22/19 at 1:53 PM the DON revealed the nurses on the 6:00 AM to- 2:00 PM shift was responsible for any wound care to the upper body (waist up) and the 2:00 PM to-10:00 PM shift nurses were responsible for wound care to the lower body (waist down). The DON stated she expected the charge nurse to complete the wound care per orders. The DON stated Resident #39's wound wasn't a facility acquired wound and that the resident was admitted with unstageable wounds to both heals. The DON stated she did not think Resident #39's wound was getting worse because wound care was only missed for a short duration and the measurements had only slightly increased. She stated the facility had started investigating because the resident alleged during wound care with ADON the LVN [NAME] only changed the date on the dressing and did not complete the actual wound care. The DON stated Resident #39 had not previously reported the staff not completing wound care. The DON stated the facility was completing a sweep for the residents with and without wounds. The DON stated she interviewed the weekend nurse (RN G), and the weekend nurse stated she did not complete wound care on Resident #39 on 05/18/19 and 05/19/19 . The DON stated RN G did not give a reason why she did not complete the wound care on Resident #39 and she hadn't been back to work. She stated she expected the charge nurses to complete wound care per plan of care and the dressing should be initialed and dated. In an interview on 05/22/19 at 2:50 PM the ADON revealed she had worked in the facility for approximately a year. She stated she wasn't aware of any issues with Resident #39's wound care until today. The ADON stated Resident #39 informed her the nurses were not completing his wound care and would only changed the date on the dressing. The ADON stated Resident #39 was unable to provide the name of the staff who changed the date on the dressing, but he was able to identify the staff if he saw them. The ADON stated she brought LVN [NAME] into Resident #39's room to demonstrate wound care, and the resident was able to identify LVN [NAME] who since had been terminated as the nurse who changed the date on his dressing without performing wound care. The ADON stated Resident #39 was emotional and said he did not want to lose his leg because staff were not completing his wound care. The ADON stated she did not complete rounds with the wound care doctor last week which she normally did, but this week's wound assessment report indicated since last week Resident #39's wound had gotten bigger and had more drainage. The ADON stated during yesterday rounds with the wound care doctor she noted Resident #39's wound had a foul smell compared to previous weeks. She stated yesterday the wound was debrided and the physician ordered for the same treatment to be continued. She stated the facility did not have a treatment nurse and she expected the charge nurses to complete the wound care and the dressing should be initialed and dated. In an interview on 05/24/19 at 1:55 PM the Wound Care MD stated he had documented on Resident #39's wound care report on Tuesday (5/21/19) that the resident's left heel deteriorated due to generalized decline of patient because that was the only choice on the assessment report. The MD stated Resident #39's wound would have declined due to wound care not being provided per ordered. Review of the Facility's policy titled Skin Management, undated, reflected: . Resident having pressure injuries receive necessary treatments and services to promote healing, prevent infection and prevent new pressure injury from developing . The ADM and DON were informed on 05/24/19 09:45 AM that the Immediate Jeopardy was removed and that the facility remained out of compliance at a severity of potential for more than minimal harm and a scope of isolated. An Immediate Jeopardy was identified on 05/22/19 and the ADM and DON were notified on 05/22/19 at 6:08 pm. A plan of removal was requested at that time and the Immediate Jeopardy template provided. The Plan of Removal was accepted on 05/24/19 09:45 AM and reflected: 1. Failure to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing. On Tuesday 5.21.19 the wound care physician made rounds and identified the wound had deteriorated due to generalized decline of patient per physician wound evaluation and management summary dated 5.21.19. On 5.22.19 still day 4, the Interim DON was made aware that during rounds on Sunday the dressing for Resident #39 was dated 5.16.19. and that on Monday 5.20.19. the dressing dated 5.16.19. was still in place. The dressing was changed; The following plan of action outlines immediate interventions employed by the facility to abate any further concerns surrounding the above issue: 1. The employees in question was terminated on 5.22.19. LVN B, licensed nurse who reported documented a dressing change on 5.17.19., and that per resident interview stated the nurse just changed the tape. And who when ask about the date of 5.16.19 on the dressing that was observed on Sunday 5.19.19. that per her documentation was changed on the 17th, upon interview stated, I have been known to write the wrong date. When ask she stated she just made a mistake. She failed to report to administration concern with dressing changes. LVN W, licensed nurse per statement made rounds on Sunday 5.19.19. and validated dressing for Resident #39 was dated 5.16.19, and no further action was taken. This failure to complete the wound care for resident #39 and to immediately notify nurse management delayed the provision of wound care for resident #39. this nurse was also terminated after interview on 5.23.19 validated that she did not notify facility management or do a dressing change. 2. All the residents in the facility on 05.22.19 with a census of 93 were assessed this assessment was documented on The Weekly Skin Check by the Assistant Director of Nursing, Licensed Vocational Nurse K, MDS coordinator, DON, RN interim director of nurses, Licensed Vocational Nurse H, Director of Clinical Operations. One resident was identified with a Fissure intergluteal cleft measuring 3.5 x 0.2 x0 cm. Physician and resident representative were notified and new order to cleanse area with normal saline, apply Hydrogel gel and cover with dressing daily until healed. There were no new pressure wounds identified that were unknown to the facility. 3. Orders were reviewed for the 4 residents with wounds (2 of which admitted with, including JMcM) and each had orders for wound care. 4. All licensed nurses will be in-serviced regarding skin management system to include completion of Braden's - risk assessment, prevention measures, notification requirements, assessment and documentation of wounds, and who to notify if unable to complete an assigned treatment, timely documentation of treatment administration record. Education and Wound Care skills competencies using Wound Care Skill Assessment form will be completed by DON, ADON, and MDS Coordinator, with acknowledgment of additional understanding validated via posttest and completed and graded by the presenter at the time the education is completed. Competencies were initiated on 05.23.19 at 3:45PM and will continue until licensed nurses have documented competencies. Licensed staff who are not available to complete the education and Wound Care Competencies by 12:00PM 5.24.19. will not be allowed to return to work until training and skills competencies complete. A post test will be completed by each attendee with an expected score of 90% or greater to validate competency. Anyone scoring less than 90% will be required to repeat in-service. 5. DON will monitor to ensure education is completed with 100% of licensed staff. All new hire licensed nurses will receive in-service listed above with post-test. An employee roster of all licensed nurses will be maintained and documented to ensure all nurses receive the training. The rosters will be reviewed in QAPI monthly until compliance is achieved. 6. Facility will hold morning clinical meeting with the IDT members including charge nurses. Meeting will be held immediately following the daily stand-up meeting, Monday - Friday. The EMR clinical dashboard will be reviewed during this meeting for missing documentation of ordered treatments. Facility will document any items that need follow-up and assign responsibility using morning clinical meeting form. Those items will be reviewed each afternoon by the DON or designee to validate completion of each item for the monitoring of compliance. Started 5.23.19 and to continue each morning clinical meeting per protocol. This process will be completed each morning ongoing, with no stop date. 7. Charge nurses are assigned to provide wound care per treatment orders. DON, ADON, and MDS Coordinato (nurse management) will be assigned on a rotation basis by the DON Secret Harris to complete the same review on weekends and holidays to validate compliance. Nurse manager assignments from listed above will begin 5.25.19 and continue per morning clinical meeting protocol, the center conducts daily clinical meetings with members of interdisciplinary team (IDT) discussion regarding changes in resident conditions as identified in the 24-hour summary, resident observations and Point Click Care (PCC) alerts and notifications. The Director of Nursing's computer should be connected to the wall monitor for items the IDT needs to review. Both the morning and afternoon clinical meeting are be held at the same time each day. Documented Variances on the morning clinical meeting form will be reviewed for trends, identified trends will be reported to QAPI monthly until considered resolved. 8. AdHoc /QAPI meeting via phone with the Medical Director to inform he is notified of the Immediate Jeopardy; Interim Director of Nurses, Administrator, Director of Clinical Operations, Divisional Vice President of Clinical Operations completed 5.22.19. @ 6:53PM Observation of wound care was completed on 05/24/19 on Residents #40 at 1:44 pm and #39 at 3:29 pm. The old dressing on Resident#39 wound was dated 05/23/19. Wound care was provided per MD orders. Monitoring of the plan of removal revealed: Interviews were conducted on 05/24/19 at 11:01 am - 05/24/19 at 2:45 pm on with 17 nursing staff (12 nurses-LVN A, LVN K, LVN N, RN O, LVN P, RN Q, LVN H, LVN T, LVN U, LVN L, LVN V, and LVN Y) across all three shifts, the weekend and including PRN staff to ensure they had been in-serviced regarding skin management system to include completion of Braden's - risk assessment, prevention measures, notification requirements, assessment and documentation of wounds, and who to notify if unable to complete an assigned treatment, timely documentation of treatment administration record. Staff interviewed verified that had been in-serviced and had received training on Braden's - risk assessment, prevention measures, notification requirements, assessment and documentation of wounds, and who to notify if unable to complete an assigned treatment, timely documentation of treatment administration record. No concerns were identified during monitoring and the facility was able to train all nursing staff that were working during that time. During the course of the monitoring, the facility completed skin checks for 100% of the residents and no additional concerns were identified. Review of the facility's Skin Management policy and procedures, reflected .appropriate measures to promote healing and prevent infection will be provided in accordance wih the residents plan of care. Review of the facility's In-service on Skin Managment systems reflectect, TX should be done and documented timely; if unavailable MD/family/Supervisor notification; Braden scale should be done with change of condition upon admission, quarterly, and PRN; Skin checks should be conducted weekly and change of condition Review of facility's in-service sign in sheets reflected in-service of nursing staff conducted. The ADM and DON were informed on 05/24/19 at 9:45 AM that the Immediate Jeopardy was removed and the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility monitoring the effectiveness of the Plan of Removal. 3. Review of Resident #13's face sheet, dated 05/21/19, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #13's quarterly MDS assessment, dated 02/19/19, revealed his active [DIAGNOSES REDACTED]. The assessment reflected Resident #13 had unclear speech, was rarely/never understood by others, could usually understand others, and his cognition was moderately impaired. Resident #13 required extensive assistance with bed mobility and had impairment to one side on his upper and lower extremities. The assessment further reflected Resident #13 was at risk of developing pressure ulcers/injuries. The assessment reflected no interventions for skin and ulcer/injury treatments were checked as being provided. Review of Resident #13's care plan, undated, revealed the following: Problem (revised on 05/21/19)- The resident has potential for pressure ulcer development and impaired skin integrity r/t immobility and contractures to BLE (bilateral lower extremities) and LUE (left upper extremity). Goal- The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions (initiated 04/18/19)- Follow facility policies/protocols for prevention/treatment of [REDACTED]. Review of Resident #13's BRADEN Scale For Predicting Pressure Sore Risk assessment, dated 04/23/19, revealed the resident was at moderate risk. The assessment reflected Resident #13 was very limited in his ability to change and control his body position. He was unable to make frequent or significant changes independently. Resident #13 was very limited in his ability to respond meaningfully to pressure-related discomfort. The assessment further reflected Resident #13 required moderate to maximum assistance in moving. Review of Resident #13's (MONTH) 2019 consolidated physician orders [REDACTED]. The order reflected the start date was 03/21/19. Observations of Resident #13 revealed the following: -05/20/19 at 1:35 PM: Resident #13 was in bed. The resident was only wearing socks. -05/20/19 at 2:04 PM: Resident #13 was in bed. The resident was only wearing socks. -05/21/19 at 9:34 AM: Resident #13 was in bed. The resident's feet were bare. -05/21/19 at 1:36 PM: Resident #13 was in bed. The resident was only wearing socks. -05/21/19 at 3:40 PM: Resident #13 was in bed. The resident was only wearing socks. -05/22/19 at 9:45 AM: Resident #13 was in bed. The resident was only wearing socks. In an interview on 05/21/19 at 1:39 PM CNA C stated she had worked with Resident #13 since he moved to hall 600. She stated she thought he had been on the hall for about a month. She stated she did not know if the resident was supposed to wear heel protectors. She stated he would not keep them on. She stated she would put socks on his feet. She stated an aide could apply heel protectors, but the nurse would usually put them on. She stated no one had instructed her to apply heel protectors to Resident #13. CNA C stated she could look on the computer in order to know the type of care each resident required. In an interview on 05/21/19 at 2:02 PM LVN A stated Resident #13 had no current wounds. She stated he had an abrasion to his left knee and one to his left lower leg was recently resolved. She stated he was at risk for developing pressure ulcers due to his nutrition and he would scoot around in bed a lot. She stated that could cause [MEDICAL CONDITION] shearing. LVN A stated they previously put heel protectors on the resident, but he would turn to the left and that could cause pressure to his ankle. She stated he would move his right foot frequently and that would cause the heel protector to move off or up the leg. She stated the heel protectors did not stay on so they did not do any good. She stated she had not told the DON about the concern regarding the heel protectors not staying in place. LVN A stated each shift was responsible for applying the heel protectors. She stated the aides also knew to apply the heel protectors, and they were to check placement of heel protectors when making rounds. She stated the nurses were responsible for checking placement of heel protectors, as well. She stated the aides could look up resident care needs in their kiosk (computer system). In an interview on 05/21/2019 at 3:43 PM the ADON stated heel protectors were used when the resident was bed bound to protect their heels. She stated when they are out of bed they do not need the heel protectors. She stated if a resident was not using the heel protectors they (nurses) should be writing a progress note (nurse's note). She stated Resident #13 should have an order for [REDACTED]. In an interview on 05/21/19 at 3:57 PM LVN B stated they had been using heel protectors on Resident #13, but the way he would kick his legs around would mess up the protectors. She stated he had no wounds on either foot. She stated he was able to move his legs around and every time she would go into room the heel protectors would be off or turned around. She stated generally she would apply the heel protectors at the beginning of the shift and he would kick them off so she would leave them off. She stated she spoke to the ADON about the issue a few months ago and thought maybe it would be discussed (among her supervisors) and a determination would be made as to what to do. In an interview on 05/22/19 at 12:50 PM the DON stated she had been at the facility since (MONTH) 2019. She stated she was not aware staff was not applying heel protectors to Resident #13. She stated Resident #13 was at risk of developing pressure ulcers. The DON stated if an intervention was not working the staff should defer to the interdisciplinary team or the doctor. She stated the doctor could give further instruction. In an interview on 05/23/19 at 10:26 AM CNA [NAME] stated Resident #13 had purple heel protectors he would wear to prevent wounds, but he would not keep them on. She stated the aides and the nurses could apply them and he was supposed to wear them while in bed. She stated he would kick them off and he would use his right hand to remove them. She stated staff would reapply them and try to keep them on.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of eight residents reviewed for quality of care related to change of condition and assessment. LVN A failed to recognize and assess Resident #1's significant decline over a 48-hour period and failed to notify the on-call physician and family promptly of the resident's change in condition, including a positive lab culture for e-coli. When Resident #1 began refusing meals, fluids and medications (including a [MEDICATION NAME] antibiotic) for a suspected UTI over a 48 hour period, he began to exhibit signs of actively dying. He was lethargic, apneic, had purplish fingertips, was unable to hold up his head to eat or drink and could not take any medications. The facility sent the resident to the hospital where he was diagnosed with [REDACTED]. The resident died five days later on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated, due to the facility still monitoring the effectiveness of the Plan Removal. These failures could affect residents in the facility by placing them at risk for declining health conditions going unrecognized and unassessed, serious injury, harm and/or death. Findings included: Resident #1's MDS quarterly resident assessment dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. He had hearing impairment, unclear speech and was usually able to be understood and understand others. He had highly impaired vision. His BI[CONDITION] score was a 2, which indicated severe cognitive impairment. He required extensive assistance to total dependence for transfers, incontinence care, bathing, hygiene, dressing and bed mobility. He used a wheelchair for mobility. He received no special treatments or procedures. Resident #1's care plan, with a revision date initiated [DATE] reflected: Acute Care Plan: UTI (Escherichia coli)-My infection will resolve without any complications by [DATE]; Interventions: Hydration program to promote fluid intake, See current orders for treatments and medications, Contact precautions-gown and glove required when providing all direct care and if anticipating coming into contact with surfaces and materials potentially contaminated by the resident. Review of Resident #1's nursing progress notes reflected: [DATE]: Urine collected for UA/CS this shift at 1330. NP informed of color of urine (coffee brown). N/O [MEDICATION NAME] 100mg po BID for 7 days. [DATE] at 19:15 Resident is started on [MEDICATION NAME] antibiotics with NARN for possible UTI, C&S still pending-Resident didn't want to get out of bed-appetite is poor, refused to eat anything substantial, was able to get him to drink PO fluids. [DATE] at 20:15 Resident refused breakfast, lunch and dinner. Snacks offered with refusal, milk shake offered with small amount accepted; refused evening meds, pushing away nurse and medication. [DATE] at 07:24 Resident noted to have redness to R-trochanter region and R-Ankle; areas noted to have blanching < 3 sec; no openings surrounding sites . [DATE] 10:25 Refused all meds attempted x3; refused breakfast attempted x 2 with resident hitting staff away . [DATE] 15:53 (DR) here; assessed resident; monitor areas q shift. (Note: There was no documentation evidence from the physician of a visit with Resident #1) [DATE] 01:36 Remain on [MEDICATION NAME] for [MEDICATION NAME]/UTI day 5 of 7, .refused PO fluids offered. [DATE]: This nurse noted resident spitting water that was offered back out of mouth as well as other fluids and medicine. It appeared the resident was unable to swallow. Resident became still and lethargic at table .This nurse and CNA put resident back to bed. Assessment done and bluish/purple color noted to the tips of bilateral fingers. Resident has A[CONDITION] and not behaving per normal self. Residents eyes appear sunken and resident appears to be actively passing . Review of Resident #1's [DATE] physician's orders [REDACTED]. [MED] 0.4mg at bedtime for prostate, [MED] once a day. [MED] 3.125 twice a day for hypertension. Review of Resident #1's [DATE] MAR indicated [REDACTED] --[DATE] afternoon/evening medications: [REDACTED]. --[DATE] (morning, afternoon and evening medications): [MEDICATION NAME], Eye vitamins, Mouth Rinse, [MEDICATION NAME], Nutritional Supplement, [MEDICATION NAME], Artificial Tears, Aspirin, [MEDICATION NAME], Folic Acid, Lactobacillus, multi-vitamin, [MED], Vitamin 3 and [MED]. Review of Resident #1's Urine Analysis results [DATE] at 1:30 PM reflected Resident #1 had a UTI. The following values were out of reference range: urine color (amber), urine clarity (cloudy), protein +1, UWBC (urine white blood cells) ,[DATE] (Reference range =Negative, URBC (urine red blood cells) >30, Mucous (moderate), UBACT (ursine bacteria) Many, Culture- Yes, WBC Clump- Present. Review of Resident #1's UA Culture and Sensitivity final report received on [DATE] at 8:40 AM reflected it was positive and >100,000 for Escherichia coli (E-coli). A preliminary finding was noted to have been sent electronically to the facility on [DATE] at 10:53 AM, the day prior to receipt of the official report, indicating he was positive for e-coli with the culture report pending at that time. Review of Resident #1's electronic health record revealed no notification to the physician and the family of the abnormal lab and culture results. Observation of Resident #1 on [DATE] at 3:30 PM at the hospital revealed he was asleep in bed. He had a catheter and the urine in catheter bag was a dark amber color. Resident #1 was not responsive and moaned while intermittently awake. He was receiving [MEDICATION NAME] continuously via IV. Interview with Resident #1's MPOA on [DATE] at 3:10 PM at the hospital revealed she was frustrated because the resident had been at the facility for three years and almost every time he had a urinary tract infection, she was the one to have to inform the facility; they do not catch it themselves. She said when she went to visit Resident #1 Thursday, [DATE], he was unable to recognize her. She said even though he had dementia, he knew who she was prior to that day. He would normally say hello, but on Thursday she said all he could do was fidget in his wheelchair. She said he was making noises and letting fluid run out of his mouth. She asked the charge nurse, LVN B, about the resident, and the nurse got the order for the UA and C&S. The MPOA said she felt Resident #1 had a fever, but his temperature was not registering as being elevated. She said LVN B confirmed he felt hot and gave him [MED]. She asked LVN B to call her if there was any decline in the resident's condition because she wanted Resident #1 to go straight to the hospital. To verify that instruction, the MPOA also told the ADM who agreed she would stay on top of the situation. The MPOA said she received a call from LVN B later that afternoon who informed her she got the collection for the UA and it was really dark, and the nurse practitioner had ordered an antibiotic. The MPOA said she told the nurse to let her know if it got any worse. The MPOA said she never received another phone call or message, so she assumed Resident #1 was fine Thursday and Friday. She said over the weekend, no one called her. She said she was unaware Resident #1 had been refusing all meals, fluids and medications over the weekend. The MPOA said she knew the facility was running the urine tests, but no one called her with the results of the UA and no one called about the C&S. Monday morning, [DATE], LVN B called her and informed her when she arrived back at work, and saw Resident #1, she was immediately concerned because she tried to get him to drink and it rolled out of his mouth, so her main concern was getting the antibiotic down him as soon as possible. She tried to grind the antibiotic and put it in applesauce and managed to get the resident to take a little. The NP told the nurse she needed to contact the MPOA to see what she wanted to do. The MPOA said, I'd already told her what I wanted her to do. I told (LVN B) immediately call and get him to hospital. The MPOA said the hospital doctor told her Resident #1's kidneys were shutting down and he was septic throughout his body and, This is why he is dying. Interview with Resident #1's family member at the hospital on [DATE] at 3:25 PM revealed he was the first family member present when Resident #1 arrived at the ER. He said Resident #1's lips were caked with white stuff and the bottom of his teeth were gunky; You couldn't tell if it was his gums or teeth. He said Resident #1's urine was thick and the color of soda. The family member said Resident #1 did not recognize him at the hospital and all the resident could do was cry out. He said one of the EMTs asked to speak to him outside Resident #1's hospital room. She said the EMT told her when they picked him up from the nursing home, they immediately knew he had not had anything to eat or drink by mouth since Friday (3 days prior) by his physical disposition. Interview with the hospital RN on [DATE] at 3:53 PM revealed Resident #1 [MEDICAL CONDITION] that started in his bladder and then moved to the resident of his body. Interview with Resident #1's hospital nursing technician on [DATE] at 3:52 PM revealed she was present at the hospital when Resident #1 was moved to his hospital room from the emergency room . She said his urine was dark tea colored even after the ER had been infusing IV fluids in him for several hours. Interview with the hospital emergency room RN on [DATE] at 4:40 PM revealed she was present when Resident #1 came to the ER from the nursing home. She said he was obviously dehydrated, his eye sockets sunken, his mucous secretions almost non-existent, his ribs and stomach area were sunken-in and he was not alert or oriented. She said he admitted with [MEDICAL CONDITION]. She said they had to administer his medications via an IV and he did not have the capacity to refuse medications due to his cognition. She said the ER doctor who admitted Resident #1 was not available and had already left for the day. Review of the E[CONDITION]/Ambulance report dated [DATE] revealed they arrived priority one to a call of a male who did not eat or drink over the entire weekend. E[CONDITION] arrived on scene to find Resident #1 lying in bed with equal pupils, pale and dry. Primary impression was vascular dehydration. Initial vital signs were taken by E[CONDITION] for Resident #1 that revealed his blood pressure was ,[DATE]. Review of Resident #1's Hospital Records revealed he arrived at theER on [DATE] at 9:35AM and his diagnosis [MEDICAL CONDITION] and acute kidney failure. His blood pressure upon arrival was ,[DATE]. A CBC (Complete Blood Count) lab was ordered upon admission and the results revealed his white blood cell count was high and abnormal at 20.3 (reference range is 4XXX,[DATE]). Initial clinical assessment indicated Resident #1 appeared cachectic (Loss of weight, [MEDICAL CONDITION], fatigue, weakness and significant loss of appetite), dehydrated, uncomfortable and unkempt. His oral mucosa was dry and his skin had poor turgor (skin elasticity). His finger/toes were cold and purple and his skin temperature was cold. [MEDICAL CONDITION] screen was positive and he met SIRS (Systemic [MEDICAL CONDITION] response syndrome) criteria. An interview with Resident #1's MPOA on [DATE] at _8:30AM the resident passed away earlier that morning ([DATE]). An interview with LVN B on [DATE] at 9:20 AM revealed Resident #1 had been sent out to the hospital two days prior on Monday [DATE] for a change of condition. She said Resident #1 had not seemed himself the week prior, so she called the NP on [DATE] who ordered a UA with C&S (urinalysis with culture and sensitivity test). When LVN B obtained the urine sample from Resident #1, she stated it was very dark, so she called the NP and Resident #1 was ordered [MEDICATION NAME] as a [MEDICATION NAME] antibiotic until the culture was received. LVN B stated it usually took three days for the culture to come back, so in the meantime, the staff was trying to push fluids because he was not drinking very much. On Friday, [DATE], LVN B said she was still administering the antibiotics on her 6AM-2PM shift and she was able to get Resident #1 to drink a little bit. She said it was hard to get him to drink water because he was obsessed with coffee and wanted coffee. After Friday, she went home for the weekend. When she came back to start her shift Monday morning, [DATE], she was told by the weekend nurse, who had worked the overnight shift Sunday, that Resident #1 was not eating or drinking over the weekend very much but there were no other concerns. LVN B said when she went to pass medications early on the shift to Resident #1, he was in his wheelchair in the living area of the memory care unit and he was not able to take his medications or drink anything from a glass. She said, He looked bad, apneic (temporary suspension of breathing), and his fingertips were blue, and he was completely different seeming. She said he did not look well and, Honestly, it looked like he was actively dying, and he looked septic. She said he was unresponsive verbally to her. She said she laid him down in his room where she assessed him and took his vital signs. She said she checked his labs for the culture and saw that no one had looked at it over the weekend. She said the culture indicated Resident #1 had e-coli. She notified the doctor and Resident #1 was transferred to the hospital immediately. LVN B said it appeared no one checked the resident's culture nor notified the doctor when it came back positive for e-coli. She said there was no change in condition documentation completed Saturday or Sunday. She said the labs were electronically sent through the online communication portal and were supposed to be checked every day by the nurse. Further interview with LVN B on [DATE] at 9:52 AM revealed she had reviewed the nursing notes for Resident #1 and she pointed out they reflected over the weekend that he had been in bed for a few days prior to being sent out because he had been feeling so bad. She reviewed the notes from Sunday, [DATE], which reflected he was not eating or drinking. There was a note that indicated the nurse on shift at 7:24 AM on [DATE] documented Resident #1 had redness to the R-trochanter (right, outer hip) region and right ankle. LVN B stated that was something that typically started to occur with the skin when a person was starting to die. She said it could happen quickly and could be caused by a resident becoming septic. She said when a critical lab came in, the protocol was to contact the doctor, make a progress note and await further orders. She reviewed Resident #1's urinalysis and said it was positive for infection, as they knew it would be, and it showed abnormalities on most all areas of his lab. An interview with ADON C on [DATE] at 10:12 AM revealed she reviewed the nursing notes from the weekend prior to determine if the LVN A notified the doctor of Resident #1's lab on Sunday, and she could not locate any evidence of physician notification. Interview with LVN A on [DATE] at 12:12 PM revealed he worked Saturday and Sunday ([DATE] - [DATE]) from 6AM-10PM each day. He stated Resident #1 was his typical self; he was refusing meals and he was not wanting to get out of bed. He was drinking a little bit, but not a lot. LVN A said he gave him a health shake twice, and he took about half of one. He said Resident #1 refused all medications, but he was able to give him an antibiotic once on Saturday. Sunday, Resident #1 would not accept medications at all. On Saturday, staff tried to give him a bath; and Sunday, LVN A said he tried to clean him up, but he was fighting and pushing and doing everything he could not to let the staff clean him. LVN A said, It's not typical, but not unusual. He said Resident #1 was on an antibiotic for a UTI and there was no culture for him. If there was culture, LVN A said it would come to the facility via fax. Saturday morning, he said he knew Resident #1 had a lab pending because of documentation from the nurses' report. He said if a culture came in on his shift for a resident, I have to look at it and call the doctor and tell the results, and the doctor will order the antibiotic specific to that culture. And then I will proceed to give that antibiotic within that two- hour window. LVN A said he normally got the labs and cultures faxed but it did not come in on his shifts. He said he was not certain if he could view the lab results on the computer. LVN A said when the DR came into the memory care unit the afternoon of [DATE] for a routine weekend visit to the facility, he told the DR there was a pending culture for Resident #1 and he was on antibiotics and was refusing food. He said the DR said it was fine and he would look at Resident #1 on his way out. LVN A said the protocol when a resident refused medications depended on the delivery route of the mediation. He said with Resident #1, he normally took them whole, but when he began to refuse, LVN A crushed them and tried that way. He also put them in his milkshake, but it did not work. He said the protocol was to write a nursing progress note and after a period of time, if he was doing it for a full second day, LVN A was supposed to make sure the doctor was notified. LVN A said he told the visiting DR that Resident #1 was not accepting anything at all, including the milkshakes, food and everything else, but the DR did not have an issue with the resident refusing medications. LVN A said the DR told him to call him or the MD if anything changed. When questioned about his progress notes Sunday morning and evening that indicated the resident had skin breakdown on his right side, LVN A said he initially thought it was a concern, but after he did a blanching test, he determined the resident was fine because the skin blanched normally. LVN A said Resident #1 did not have the skin issue on Saturday. He said, If I had known his culture came in, I would have called the doctor immediately, not waiting for one (doctor) to come in. I would have found out if an oral or liquid form of antibiotic could be given or send him out to the hospital to give him a different form of antibiotic. An interview with ADON E on [DATE] at 10:15 AM revealed the doctor should have been notified when Resident #1's culture came back positive for e-coli. She said she was at the facility the day Resident #1 was sent to the hospital ([DATE]). She said she came into work and around 7:30 AM and CNA F came and asked her to help transfer Resident #1. When she saw him, he did not appear weak, his transfer into his wheelchair was normal, and he was taken to the dining room for breakfast. CNA F had commented to ADON E that Resident #1 had a bad weekend. ADON E said about an hour later, she saw Resident #1 again and she saw a noticeable change. She said when she saw him after he had been laid down in bed, he the demeanor of his face had changed, he looked weak, she could not get his oxygen saturation on her finger pulse oximeter and pulled back his hands. She said, He just wasn't alert and normally he is alert. She said he was feisty upon tactile stimulation but did not talk. She said he looked weak in his face. ADON E stated that even if a resident was on an antibiotic, they could still become septic. ADON E said Resident #1 refused all medications for Sunday, [DATE] and it was protocol that if a resident refused all medications over three shifts, the doctor was to be notified. She reviewed Resident #1's clinical record and nursing progress notes and said they revealed he refused Saturday evening medications and all three shifts on Sunday. She said there was no documentation the doctor was notified Resident #1 was refusing all medications. Interview with the DR on [DATE] at 2:13 PM revealed he was the weekend doctor and on-call doctor on [DATE] and [DATE]. He did not recall getting notified of any issues with Resident #1 or pending lab and culture results. He stated he normally rounded and visited with nursing staff to see if there were any issues going on and would make notations if there was a problem with a resident. He did not remember being told anything about Resident #1 not eating, drinking or taking medications. The DR said, I did not see him (Resident #1) Sunday. He said he should have seen the culture and sensitivity and recommended the proper antibiotics. The DR said if Resident #1 was not taking his medications, he should have gone out (to the emergency room ). He said his expectation was the charge nurse(s) for Resident #1 should have notified the him and/or the MD and gotten a recommendation. The DR [MEDICAL CONDITION] was a bacterial infection and if it was e-coli not being treated, it would worsen from a UTI to urosepsis. The DR said if he had known Resident #1 was dehydrated, not taking any PO medications, not eating and he was declining, he would have sent him to the hospital where they could place an IV and give him ,[DATE] care; he felt it was a better setting for that. The DR said signs and symptoms [MEDICAL CONDITION] were elevated temperature, maybe [MEDICAL CONDITION], depending on a status change, and if a resident was declining and not eating and had a positive urine culture. The DR said he did not write a progress note on [DATE] because he did not see Resident #1, he was just rounding. Interview with the DCO on [DATE] at 1:02 PM revealed when a culture and lab was completed, it was entered by the lab company into the facility's online e-charting system and the nurse could access and view it. She stated lab results did not come via fax. The DCO said she reviewed Resident #1's UA and culture and sensitivity which indicated it was sent in (in the computer system) Sunday morning, [DATE], in the 8:00 AM hour. She said the purpose of the culture was to show what antibiotic Resident #1 was sensitive to. She looked at the culture and did not see the [MEDICATION NAME] listed as a medication on the culture, which he had been prescribed three days prior as a [MEDICATION NAME], meaning it would have been ineffective in fighting Resident #1's infection. Interview with CNA F on [DATE] at 1:45 PM revealed when she came in Monday morning at 6AM on [DATE] the CNA who had worked the overnight shift and was a new employee told her that Resident #1 did not have a good weekend. She told CNA F he was not feeling well and when they tried to get him up, he did not want to get up. When CNA F went into his room to check on him when her shift started, she could tell he was weak. She asked the ADON E to help transfer him to his wheelchair. She said he was almost a deadlift and it was much harder to transfer him than normal, but he did not seem like he was any pain. She took him to the dining room, but no one could get him to eat. She said Resident #1 always had a grilled cheese for breakfast, and that was offered but he would not eat it. She said he normally fed himself, but he kept his head down and turned his wheelchair around. She tried to give him some water and he spit it out. She said usually he could let the staff know what was wrong, but he was unable to that morning. She asked him if he was tired and wanted to go to bed and he agreed. Once back in bed, CNA F said that was when she and the nurse started noticing his fingers were turning a purple color on the left hand; about two or three fingers. She could tell he was sick and weak because he always drank coffee, but he did not ask for that morning. She said he also was a good eater, so she knew something was wrong. Interview with the ADM on [DATE] at 5:54 PM revealed she thought Resident #1 had looked bad for the past three weeks; his cheeks looked drawn and gaunt, sunken, and it looked like he was losing weight and he was not as robust as he used to be. After he was sent to the ER, the ADM said she looked at his clinical notes and could tell there was a change in condition Sunday [DATE]. She said, For starters, there has never been any skin issues with him. On Sunday morning, the nurse noted he had skin issue on ankle and hip, but he had not had any skin issues, so that was something that concerned me. She also said Resident #1 refusing all three meals was a concern when looking back. She said, Two things that caught my eye were pushing staff away and telling them not to bother him and the skin; that was a big change. The ADM felt Resident #1 had a change of condition Thursday, [DATE], and a worsening of it over the weekend. She said, I think we all knew he had a UTI Thursday. She said LVN A should have notified the DR and sent Resident #1 to the hospital Sunday. She said, Of any of the failures, the lab was the big one. The ADM reviewed the nursing notes and confirmed there was no evidence Resident #1's MPOA was notified of his change in condition. The ADM said the MPOA should have been called. The ADM said the facility had just found out about the labs that had not been checked on Monday, [DATE], so no training had been done yet. Interview with the DON on [DATE] at 6:33 PM revealed LVN A was counseled on not reporting Resident #1's lab to the physician. She said the labs were entered into the computer, and they could also come via fax, but the facility's fax machine had been broken for the past week. The DON said she did not know anything was wrong until Monday, [DATE]. She said from what she knew at the time of interview, Resident #1 had not eaten or drank anything in two days. The DON said neither she or the physician was notified of that fact, and nothing was documented. She said the only mention of a doctor was when the DR visited, who was noted by LVN A to have looked at the resident, but there was not a note from that physician saying he had visited with Resident #1. The DON said when Resident #1's lab came back positive for e-coli, LVN A did not notify anyone and there was no progress note that he told the DR verbally when he came on [DATE]. The DON said she had to trust the nurses to do their job and was very disappointed in the way LVN A did not handle it. She said she called the weekend DR who said he saw the resident, but nothing alerted him because nothing was brought to his attention there was anything urgent to deal with. The DON said, I'm sorry, because if you looked at the resident, he was declining last week. The DON said she was confused because LVN A wrote a nursing note that the DR assessed Resident #1 but there was no physician's note. The DON said her expectation with a resident refusing medication was as soon as they refused, the nurse should notify the physician and RP. She said had the MPOA been notified, she could have talked Resident #1 into taking the medications. If she could not talk him into it, then the facility would need to notify the doctor. She said, A nurse is there to assess the situation. If a resident refused, like a resident with dementia, who is declining .for him to totally refuse, not eat, not drink, not take meds . you call the doctor. The DON said she did not see Resident #1 before he was sent out to the hospital but the reports of white material in and around his mouth, teeth and gums was indicative of thrush, which was caused by an infection. The DON said no training had been done with the nursing staff since Monday [DATE]. She said the lab company had come out a week ago and done an in-service on labs, how to enter labs, how to pull them up on the computer, and how the labs came to the facility. She said she had a hard time getting weekend people to come in and LVN A did not attend. The DON indicated the lab company had come to the facility several days prior to Resident #1's change of condition to in-service nurses on lab notifications, how to retrieve labs in the online system and and where to order labs in the online system. She said LVN A did not attend that training because he is a weekend nurse and had anotehr job during the week. She said when that occurred, the wekeend RN supervisor would conduct the trianing, but the weekend of [DATE]-[DATE], she did not. Review of LVN A's anuual trianing records, which included the annual skills checklist, revealed he did not have a required nursing skills checklist available. An interview with the DON on [DATE] at 2:05PM revealed there was no facility policy on assessment, and provided a Resident Rounds Policy which she said would be used in lieu of an assessments policy. Review of the facility's Resident Rounds policy (undated) reflected, .Procedure: The licensed nurse sees all residents to: 1. Assess and determine nursing care needs, .3. Reports changes in condition to physician and resident representative in a timely manner. Review of the facility's Change in Resident Condition policy (undated) and provided by the DON on [DATE] reflected, It is the policy of this center to ensure the resident receives necessary care as needed by observation, assessment, intervention, and re-evaluation of a change in the resident's physical and/or mental condition; .A significant change in a resident's status is defined as deterioration .in the health, mental, or psychosocial status of the resident. The nurse needs to contact the provider for . 1/ Significant change in the resident's status; .4. Critical laboratory results, 5. Refusal of treatment or medication two (2) or more consecutive times. Documentation regarding the change in condition is documented in the resident record as to date, time(s), all pertinent observations noted and an accurate record of all interventions initiated including the date and time of physician(s) and responsible party (family). An Immediate Jeopardy was identified on [DATE] at 5:13 PM and the ADM and DON were notified on [DATE]. A plan of removal was requested at that time. The Plan of Removal was accepted on [DATE] at 4:45 PM. The facility's plan of removal reflected: 1. All licensed nurses will be in-serviced regarding resident change of condition, use of Interact, SBAR completion, medication refusal, knowledge of obtaining lab results electronically, hydration, signs and symptoms of UTI, abuse/neglect policy, and the notification to Responsible Party/Power of attorney/family and physician. Education will be completed by facility nursing administration with acknowledgment of understanding. Beginning tonight at 9PM and continue until charge nurses have completed training. Nurses after 6AM in the morning will not be allowed to work the floor until training has been completed. 2. Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their educ

Based on observation, interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for one (Resident #1) of five residents reviewed for labs and cultures. The facility failed to check the laboratory system containing Resident #1's lab results from [DATE] to [DATE]. Due to the delay, the physician was not notified and did not order necessary interventions to treat the resident's infection. As a result, the resident was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired in the hospital on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated, due to the facility still monitoring the effectiveness of the Plan Removal This failure could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. Findings included: Resident #1's MDS quarterly resident assessment dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. He had hearing impairment, unclear speech and was usually able to be understood and understand others. He had highly impaired vision. His BI[CONDITION] score was a 2, which indicated severe cognitive impairment. He required extensive assistance to total dependence for transfers, incontinence care, bathing, hygiene, dressing and bed mobility. He used a wheelchair for mobility. He received no special treatments or procedures. Resident #1's care plan, with a revision date initiated [DATE] reflected: Acute Care Plan: UTI (Escherichia coli)-My infection will resolve without any complications by [DATE]; Interventions: Hydration program to promote fluid intake, See current orders for treatments and medications, Contact precautions-gown and glove required when providing all direct care and if anticipating coming into contact with surfaces and materials potentially contaminated by the resident. Review of Resident #1's nursing progress notes reflected: [DATE]: Urine collected for UA/CS this shift at 1330. NP informed of color of urine (coffee brown). N/O [MEDICATION NAME] 100mg po BID for 7 days. [DATE] at 19:15 (5:15PM) Resident is started on [MEDICATION NAME] antibiotics with NARN for possible UTI, C&S still pending-Resident didn't want to get out of bed-appetite is poor, refused to eat anything substantial, was able to get him to drink PO fluids. [DATE] at 20:15 (8:15PM) Resident refused breakfast, lunch and dinner. Snacks offered with refusal, milk shake offered with small amount accepted; refused evening meds, pushing away nurse and medication. [DATE] at 07:24 Resident noted to have redness to R-trochanter region and R-Ankle; areas noted to have blanching < 3 sec; no openings surrounding sites . [DATE] 10:25 Refused all meds attempted x3; refused breakfast attempted x 2 with resident hitting staff away . [DATE] 15:53 (DR) here; assessed resident; monitor areas q shift. (Note: There was no documentation evidence from the physician of a visit with Resident #1) [DATE] 01:36 Remain on [MEDICATION NAME] for [MEDICATION NAME]/UTI day 5 of 7, .refused PO fluids offered. [DATE]: This nurse noted resident spitting water that was offered back out of mouth as well as other fluids and medicine. It appeared the resident was unable to swallow. Resident became still and lethargic at table .This nurse and CNA put resident back to bed. Assessment done and bluish/purple color noted to the tips of bilateral fingers. Resident has A[CONDITION] and not behaving per normal self. Residents eyes appear sunken and resident appears to be actively passing . Review of Resident #1's [DATE] physician's orders [REDACTED]. [MED] 0.4mg at bedtime for prostate, [MED] once a day. [MED] 3.125 twice a day for hypertension. Review of Resident #1's [DATE] MAR indicated [REDACTED] --[DATE] afternoon/evening medications: [REDACTED]. --[DATE] (morning, afternoon and evening medications): [MEDICATION NAME], Eye vitamins, Mouth Rinse, [MEDICATION NAME], Nutritional Supplement, [MEDICATION NAME], Artificial Tears, Aspirin, [MEDICATION NAME], Folic Acid, Lactobacillus, multi-vitamin, [MED], Vitamin 3 and [MED]. Review of Resident #1's Urine Analysis results [DATE] at 1:30 PM reflected Resident #1 had a UTI. The following values were out of reference range: urine color (amber), urine clarity (cloudy), protein +1, UWBC (urine white blood cells) ,[DATE] (reference range =Negative), URBC (urine red blood cells) >30, Mucous (moderate), UBACT (ursine bacteria) Many, Culture- Yes, WBC Clump- Present. Review of Resident #1's UA Culture and Sensitivity final report received on [DATE] at 8:40 AM reflected it was positive and >100,000 for Escherichia coli (E-coli). A preliminary finding was noted to have been sent electronically to the facility on [DATE] at 10:53 AM, the day prior to receipt of the official report, indicating he was positive for e-coli with the culture report pending at that time. Observation of Resident #1 on [DATE] at 3:30 PM at the hospital revealed he was asleep in bed. He had a catheter and the urine in catheter bag was a dark amber color. Resident #1 was not responsive and moaned while intermittently awake. He was receiving [MEDICATION NAME] continuously via IV. Interview with Resident #1's MPOA on [DATE] at 3:10 PM at the hospital revealed she was frustrated because the resident had been at the facility for three years and almost every time he had a urinary tract infection, she was the one to have to inform the facility; they do not catch it themselves. She said when she went to visit Resident #1 Thursday, [DATE], he was unable to recognize her. She said even though he had dementia, he knew who she was prior to that day. He would normally say hello, but on Thursday she said all he could do was fidget in his wheelchair. She said he was making noises and letting fluid run out of his mouth. She asked the charge nurse, LVN B, about the resident, and the nurse got the order for the UA and C&S. The MPOA said she felt Resident #1 had a fever, but his temperature was not registering as being elevated. She said LVN B confirmed he felt hot and gave him [MED]. She asked LVN B to call her if there was any decline in the resident's condition because she wanted Resident #1 to go straight to the hospital. To verify that instruction, the MPOA also told the ADM who agreed she would stay on top of the situation. The MPOA said she received a call from LVN B later that afternoon who informed her she got the collection for the UA and it was really dark, and the nurse practitioner had ordered an antibiotic. The MPOA said she told the nurse to let her know if it got any worse. The MPOA said she never received another phone call or message, so she assumed Resident #1 was fine Thursday and Friday. She said over the weekend, no one called her. She said she was unaware Resident #1 had been refusing all meals, fluids and medications over the weekend. The MPOA said she knew the facility was running the urine tests, but no one called her with the results of the UA and no one called about the C&S. Monday morning, [DATE], LVN B called her and informed her when she arrived back at work, and saw Resident #1, she was immediately concerned because she tried to get him to drink and it rolled out of his mouth, so her main concern was getting the antibiotic down him as soon as possible. She tried to grind the antibiotic and put it in applesauce and managed to get the resident to take a little. The NP told the nurse she needed to contact the MPOA to see what she wanted to do. The MPOA said, I'd already told her what I wanted her to do. I told (LVN B) immediately call and get him to hospital. The MPOA said the hospital doctor told her Resident #1's kidneys were shutting down and he was septic throughout his body and, This is why he is dying. Interview with Resident #1's family member at the hospital on [DATE] at 3:25 PM revealed he was the first family member present when Resident #1 arrived at the ER. He said Resident #1's lips were caked with white stuff and the bottom of his teeth were gunky; You couldn't tell if it was his gums or teeth. He said Resident #1's urine was thick and the color of soda. The family member said Resident #1 did not recognize him at the hospital and all the resident could do was cry out. He said one of the EMTs asked to speak to him outside Resident #1's hospital room. She said the EMT told her when they picked him up from the nursing home, they immediately knew he had not had anything to eat or drink by mouth since Friday (3 days prior) by his physical disposition. Interview with the hospital RN on [DATE] at 3:53 PM revealed Resident #1 [MEDICAL CONDITION] that started in his bladder and then moved to the resident of his body. Interview with Resident #1's hospital nursing technician on [DATE] at 3:52 PM revealed she was present at the hospital when Resident #1 was moved to his hospital room from the emergency room . She said his urine was dark tea colored even after the ER had been infusing IV fluids in him for several hours. Interview with the hospital emergency room RN on [DATE] at 4:40 PM revealed she was present when Resident #1 came to the ER from the nursing home. She said he was obviously dehydrated, his eye sockets sunken, his mucous secretions almost non-existent, his ribs and stomach area were sunken-in and he was not alert or oriented. She said he admitted with [MEDICAL CONDITION]. She said they had to administer his medications via an IV and he did not have the capacity to refuse medications due to his cognition. She said the ER doctor who admitted Resident #1 was not available and had already left for the day. Review of the E[CONDITION]/Ambulance report dated [DATE] revealed they arrived priority one to a call of a male who did not eat or drink over the entire weekend. E[CONDITION] arrived on scene to find Resident #1 lying in bed with equal pupils, pale and dry. Primary impression was vascular dehydration. Initial vital signs were taken by E[CONDITION] for Resident #1 that revealed his blood pressure was ,[DATE]. Review of Resident #1's Hospital Records revealed he arrived at theER on [DATE] at 9:35AM and his diagnosis [MEDICAL CONDITION] and acute kidney failure. His blood pressure upon arrival was ,[DATE]. A CBC (Complete Blood Count) lab was ordered upon admission and the results revealed his white blood cell count was high and abnormal at 20.3 (reference range is 4XXX,[DATE]). Initial clinical assessment indicated Resident #1 appeared cachectic (Loss of weight, [MEDICAL CONDITION], fatigue, weakness and significant loss of appetite), dehydrated, uncomfortable and unkempt. His oral mucosa was dry and his skin had poor turgor (skin elasticity). His finger/toes were cold and purple and his skin temperature was cold. [MEDICAL CONDITION] screen was positive and he met SIRS (Systemic [MEDICAL CONDITION] response syndrome) criteria. An interview with Resident #1's MPOA on [DATE] at 8:30AM the resident passed away earlier that morning ([DATE]). An interview with LVN B on [DATE] at 9:20 AM revealed Resident #1 had been sent out to the hospital two days prior on Monday [DATE] for a change of condition. She said Resident #1 had not seemed himself the week prior, so she called the NP on [DATE] who ordered a UA with C&S (urinalysis with culture and sensitivity test). When LVN B obtained the urine sample from Resident #1, she stated it was very dark, so she called the NP and Resident #1 was ordered [MEDICATION NAME] as a [MEDICATION NAME] antibiotic until the culture was received. LVN B stated it usually took three days for the culture to come back, so in the meantime, the staff was trying to push fluids because he was not drinking very much. On Friday, [DATE], LVN B said she was still administering the antibiotics on her 6AM-2PM shift and she was able to get Resident #1 to drink a little bit. She said it was hard to get him to drink water because he was obsessed with coffee and wanted coffee. After Friday, she went home for the weekend. When she came back to start her shift Monday morning, [DATE], she was told by the weekend nurse, who had worked the overnight shift Sunday, that Resident #1 was not eating or drinking over the weekend very much but there were no other concerns. LVN B said when she went to pass medications early on the shift to Resident #1, he was in his wheelchair in the living area of the memory care unit and he was not able to take his medications or drink anything from a glass. She said, He looked bad, apneic (temporary suspension of breathing), and his fingertips were blue, and he was completely different seeming. She said he did not look well and, Honestly, it looked like he was actively dying, and he looked septic. She said he was unresponsive verbally to her. She said she laid him down in his room where she assessed him and took his vital signs. She said she checked his labs for the culture and saw that no one had looked at it over the weekend. She said the culture indicated Resident #1 had e-coli. She notified the doctor and Resident #1 was transferred to the hospital immediately. LVN B said it appeared no one checked the resident's culture nor notified the doctor when it came back positive for e-coli. She said there was no change in condition documentation completed Saturday or Sunday. She said the labs were electronically sent through the online communication portal and were supposed to be checked every day by the nurse. Further interview with LVN B on [DATE] at 9:52 AM revealed she had reviewed the nursing notes for Resident #1 and she pointed out they reflected over the weekend that he had been in bed for a few days prior to being sent out because he had been feeling so bad. She reviewed the notes from Sunday, [DATE], which reflected he was not eating or drinking. There was a note that indicated the nurse on shift at 7:24 AM on [DATE] documented Resident #1 had redness to the R-trochanter (right, outer hip) region and right ankle. LVN B stated that was something that typically started to occur with the skin when a person was starting to die. She said it could happen quickly and could be caused by a resident becoming septic. She said when a critical lab came in, the protocol was to contact the doctor, make a progress note and await further orders. She reviewed Resident #1's urinalysis and said it was positive for infection, as they knew it would be, and it showed abnormalities on most all areas of his lab. An interview with ADON C on [DATE] at 10:12 AM revealed she reviewed the nursing notes from the weekend prior to determine if the LVN A notified the doctor of Resident #1's lab on Sunday, and she could not locate any evidence of physician notification. An interview with ADON E on [DATE] at 10:15 AM revealed the doctor should have been notified when Resident #1's culture came back positive for e-coli. She said she was at the facility the day Resident #1 was sent to the hospital ([DATE]). She said she came into work and around 7:30 AM and CNA F came and asked her to help transfer Resident #1. When she saw him, did not appear weak, his transfer into his wheelchair was normal, and he was taken to the dining room for breakfast. CNA F had commented to ADON E that Resident #1 had a bad weekend. ADON E said about an hour later, she saw Resident #1 again and she saw a noticeable change. She said when she saw him after he had been laid down in bed, he the demeanor of his face had changed, he looked weak, she could not get his oxygen saturation on her finger pulse oximeter and pulled back his hands. She said, He just wasn't alert and normally he is alert. She said he was feisty upon tactile stimulation but did not talk. She said he looked weak in his face. ADON E stated that even if a resident was on an antibiotic, they could still become septic. ADON E said Resident #1 refused all medications for Sunday, [DATE] and it was protocol that if a resident refused all medications over three shifts, the doctor was to be notified. She reviewed Resident #1's clinical record and nursing progress notes and said they revealed he refused Saturday evening medications and all three shifts on Sunday. She said there was no documentation the doctor was notified Resident #1 was refusing all medications. Interview with LVN A on [DATE] at 12:12 PM revealed he worked Saturday and Sunday ([DATE] - [DATE]) from 6AM-10PM each day. He stated Resident #1 was his typical self; he was refusing meals and he was not wanting to get out of bed. He was drinking a little bit, but not a lot. LVN A said he gave him a health shake twice, and he took about half of one. She said Resident #1 refused all medications, but he was able to give him an antibiotic once on Saturday. Sunday, Resident #1 would not accept medications at all. On Saturday, staff tried to give him a bath; and Sunday, LVN A said he tried to clean him up, but he was fighting and pushing and doing everything he could not to let the staff clean him. LVN A said, It's not typical, but not unusual. He said Resident #1 was on an antibiotic for a UTI and there was no culture for him. If there was culture, LVN A said it would come to the facility via fax. Saturday morning, he said he knew Resident #1 had a pending because of documentation from the nurses' report. He said if a culture came in on his shift for a resident, I have to look at it and call the doctor and tell the results, and the doctor will order the antibiotic specific to that culture. And then I will proceed to give that antibiotic within that two- hour window. LVN A said he normally got the labs and cultures faxed but it did not come in on his shifts. He said he was not certain if he could view the lab results on the computer. LVN A said when the DR came into the memory care unit the afternoon of [DATE] for a routine weekend visit to the facility, he told the DR there was a pending culture for Resident #1 and he was on antibiotics and was refusing food. He said the DR said it was fine and he would look at Resident #1 on his way out. LVN A said the protocol when a resident refused medications depended on the delivery route of the mediation. He said with Resident #1, he normally took them whole, but when he began to refuse, LVN A crushed them and tried that way. He also put them in his milkshake, but it did not work. He said the protocol was to write a nursing progress note and after a period of time, if he was doing it for a full second day, LVN A was supposed to make sure the doctor was notified. LVN A said he told the visiting DR that Resident #1 was not accepting anything at all, including the milkshakes, food and everything else, but the DR did not have an issue the resident was refusing medications. LVN A said the DR told him to call him or the MD if anything changed. When questioned about his progress notes Sunday morning and evening that indicated the resident had skin breakdown on his right side, LVN A said he initially thought it was a concern, but after he did a blanching test, he determined the resident was fine because the skin blanched normally. LVN A said Resident #1 did not have the skin issue on Saturday. He said, If I had known his culture came in, I would have called the doctor immediately, not waiting for one (doctor) to come in. I would have found out if an oral or liquid form of antibiotic could be given or send him out to the hospital to give him a different form of antibiotic. Interview with the DR on [DATE] at 2:13 PM revealed he was the weekend doctor and on-call doctor on [DATE] and [DATE]. He did not recall getting notified of any issues with Resident #1 or pending lab and culture results. He stated he normally rounded and visited with nursing staff to see if there were any issues going on and would make notations if there was a problem with a resident. He did not remember being told anything about Resident #1 not eating, drinking or taking medications. The DR said, I did not see him (Resident #1) Sunday. He said he should have seen the culture and sensitivity and recommended the proper antibiotics. The DR said if Resident #1 was not taking his medications, he should have gone out (to the emergency room ). He said his expectation was the charge nurse(s) for Resident #1 should have notified the him and/or the MD and gotten a recommendation. The DR [MEDICAL CONDITION] was a bacterial infection and if it was e-coli not being treated, it would worsen from a UTI to urosepsis. The DR said if he had known Resident #1 was dehydrated, not taking any PO medications, not eating and he was declining, he would have sent him to the hospital where they could place an IV and give him ,[DATE] care; he felt it was a better setting for that. The DR said signs and symptoms [MEDICAL CONDITION] were elevated temperature, maybe [MEDICAL CONDITION], depending on a status change, and if a resident was declining and not eating and had a positive urine culture. The DR said he did not write a progress note on [DATE] because he did not see Resident #1, he was just rounding. Interview with the DCO on [DATE] at 1:02 PM revealed when a culture and lab was completed, it was entered by the lab company into the facility's online e-charting system and the nurse could access and view it. She stated lab results did not come via fax. The DCO said she reviewed Resident #1's UA and culture and sensitivity which indicated it was sent in (in the computer system) Sunday morning, [DATE], in the 8:00 AM hour. She said the purpose of the culture was to show what antibiotic Resident #1 was sensitive to. She looked at the culture and did not see the [MEDICATION NAME] listed as a medication on the culture, which he had been prescribed three days prior as a [MEDICATION NAME], meaning it would have been ineffective in fighting Resident #1's infection. Interview with CNA F on [DATE] at 1:45 PM revealed when she came in Monday morning at 6AM on [DATE] the CNA who had worked the overnight shift and was a new employee told her that Resident #1 did not have a good weekend. She told CNA F he was not feeling well and when they tried to get him up, he did not want to get up. When CNA F went into his room to check on him when her shift started, she could tell he was weak. She asked the ADON E to help transfer him to his wheelchair. She said he was almost a deadlift and it was much harder to transfer him than normal, but he did not seem like he was any pain. She took him to the dining room, but no one could get him to eat. She said Resident #1 always had a grilled cheese for breakfast, and that was offered but he would not eat it. She said he normally fed himself, but he kept his head down and turned his wheelchair around. She tried to give him some water and he spit it out. She said usually he could let the staff know what was wrong, but he was unable to that morning. She asked him if he was tired and wanted to go to bed and he agreed. Once back in bed, CNA F said that was when she and the nurse started noticing his fingers were turning a purple color on the left hand; about two or three fingers. She could tell he was sick and weak because he always drank coffee, but he did not ask for that morning. She said he also was a good eater, so she knew something was wrong. Interview with the ADM on [DATE] at 5:54 PM revealed she thought Resident #1 had looked bad for the past three weeks; his cheeks looked drawn and gaunt, sunken, and it looked like he was losing weight and he was not as robust as he used to be. After he was sent to the ER, the ADM said she looked at his clinical notes and could tell there was a change in condition Sunday [DATE]. She said, For starters, there has never been any skin issues with him. On Sunday morning, the nurse noted he had skin issue on ankle and hip, but he had not had any skin issues, so that was something that concerned me. She also said Resident #1 refusing all three meals was a concern when looking back. She said, Two things that caught my eye were pushing staff away and telling them not to bother him and the skin; that was a big change. The ADM felt Resident #1 had a change of condition Thursday [DATE] and a worsening of it over the weekend. She said, I think we all knew he had a UTI Thursday. She said LVN A should have notified the DR and sent Resident #1 to the hospital Sunday. She said, Of any of the failures, the lab was the big one. The ADM reviewed the nursing notes and confirmed there was no evidence Resident #1's MPOA was notified of his change in condition. The ADM said the MPOA should have been called. The ADM said the facility had just found out about the labs that had not been checked on Monday, [DATE], so no training had been done yet. Interview with the DON on [DATE] at 6:33 PM revealed LVN A was counseled on not reporting Resident #1's lab to the physician. She said the labs were entered into the computer, and they could also come via fax, but the facility's fax machine had been broken for the past week. The DON said she did not know anything was wrong until Monday, [DATE]. She said from what she knew at the time of interview, Resident #1 had not eaten or drank anything in two days. The DON said neither she or the physician was not notified of that fact, and nothing was documented. She said the only mention of a doctor was when the DR visited, who was noted by LVN A to have looked at the resident, but there was not a note from that physician saying he had visited with Resident #1. The DON said when Resident #1's lab came back positive for e-coli, LVN A did not notify anyone and there was no progress note that he told the DR verbally when he came on [DATE]. The DON said she had to trust the nurses to do their job and was very disappointed in the way LVN A did not handle it. She said she called the weekend DR who said he saw the resident, but nothing alerted him. He said nothing was brought to his attention and there was anything urgent to deal with. The DON said, I'm sorry because if you looked at the resident, he was declining last week. The DON said she was confused because LVN A wrote a nursing note that the DR assessed Resident #1 but there was no physician's note. The DON said her expectation with a resident refusing medication was as soon as they refused, the nurse should notify the physician and RP. She said had the MPOA been notified, she could have talked Resident #1 into taking the medications. If she could not talk him into it, then the facility would need to notify the doctor. She said, A nurse is there to assess the situation. If a resident refused, like a resident with dementia, who is declining .for him to totally refuse, not eat, not drink, not take meds . you call the doctor. The DON said she did not see Resident #1 before he was sent out to the hospital but the reports of white material in and around his mouth, teeth and gums was indicative of thrush, which was caused by an infection. The DON said no training had been done with the nursing staff since Monday [DATE]. She said the lab company had come out a week ago and done an in-service on labs, how to enter labs, how to pull them up on the computer, and how the labs came to the facility. She said she had a hard time getting weekend people to come in and LVN A did not attend. Review of the facility's Lab Policy (undated) and provided by the DON on [DATE] reflected, The licensed nurse will document on the lab tracking form until steps of the tracking are complete .Lab results: Lab results will be reported to the physician, abnormal lab tests will be sent to the physician, Panic/Critical value labs will be called immediately to the physician upon receipt of the panic/critical value lab. Review of the facility's Change in Resident Condition policy (undated) and provided by the DON on [DATE] reflected, The nurse needs to contact the provider for .4. Critical laboratory results. An Immediate Jeopardy was identified on [DATE] at 5:13 PM and the ADM and DON were notified on [DATE]. A plan of removal was requested at that time. The Plan of Removal was accepted on [DATE] at 4:45 PM. The facility's plan of removal reflected: 1. All licensed nurses will be in-serviced regarding resident change of condition, use of Interact, SBAR completion, medication refusal, knowledge of obtaining lab results electronically, hydration, signs and symptoms of UTI, abuse/neglect policy, and the notification to Responsible Party/Power of attorney/family and physician. Education will be completed by facility nursing administration with acknowledgment of understanding. Beginning tonight at 9PM and continue until charge nurses have completed training. Nurses after 6AM in the morning will not be allowed to work the floor until training has been completed. 2. Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. DON will monitor to ensure education is completed with 100% of licensed nurses. All new hire licensed nurses will receive in servicing regarding resident change of condition, use of Interact, SBAR completion, medication refusal, knowledge of obtaining lab results electronically, hydration, signs and symptoms of UTI, abuse/neglect policy, and the notification to Responsible Party/Power of attorney/family and physician. Education will be completed by facility nursing administration with acknowledgment of understanding prior to working the floor. This will be monitored by the DON to ensure 100% completion. Completion date [DATE]. 3. Facility will hold Daily Clinical Meeting with the IDT members, including charge nurses. Meeting will be held immediately following the daily stand-up meeting, Monday - Friday. DON will lead the meeting, and will include review of physician orders, labs, e-Interact assessments, and 24-hour report for resident changes of condition. Facility will document any items that need follow up and assign responsibility using morning clinical meeting form. Those items will be reviewed each afternoon by the DON or designee to validate completion of each item for monitoring of compliance. Completion date [DATE]. 4. Facility will document any items that need follow up and assign responsibility using morning clinical meeting form. Those items will be reviewed each afternoon by the DON or designee to validate completion of each item for monitoring of compliance. Completion date [DATE]. 5. The weekend supervisor will follow the same daily clinical review of 24-hour reports, eInteract assessments, labs, and new physician orders [REDACTED]. Review those changes with the weekend licensed nurses and ensure Responsible Party/Power of attorney/family and physician have been notified. Completion date [DATE]. 6. In the absence of a weekend supervisor,

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #5) of four residents reviewed for pressure ulcers received the necessary treatment and services to promote healing and prevent new pressure ulcers from developing. The facility failed to: 1. Identify Resident #5's Stage II pressure ulcers until surveyor inquiry. 2. Ensure thorough, accurate and complete skin assessments were conducted. 3. Ensure an assessment was conducted when nurses were notified of a change in Resident #5's Stage I pressure ulcer. 4. Ensure the physician was consulted and new treatment orders were received. 5. Ensure the resident was repositioned every two hours. These failures resulted in Resident #5's Stage I pressure ulcer developing into Stage II pressure ulcers, which were not identified by the facility, and placed Resident #5, along with the other six residents identified with pressure ulcers at risk for further deterioration of existing pressure ulcers, the development of new pressure ulcers, pain and discomfort. Findings included: Resident #5 was observed during rounds on 03/19/13 at 9:10 a.m. The resident was sitting in a wheelchair in his room. During this time, the resident stated he had a sore on his "bottom" and needed assistance to the bathroom. At this time CNA A entered the room and informed the surveyor Resident #5 had a reddened area on his "bottom." CNA A stated a moisture barrier ointment was applied to the resident's buttocks each time incontinent care was provided. Monthly physician orders [REDACTED]. [DIAGNOSES REDACTED]. The Admission Nursing Evaluation was dated 02/08/13 and timed 5:55 p.m. The anatomical representation of the resident's body on the evaluation reflected the resident had a reddened Stage I pressure ulcer on the sacrum. The evaluation reflected the treatment record should be reviewed for treatments and measurements. The evaluation further reflected the resident was continent of bowel and bladder. The only MDS assessment available was an admission assessment dated [DATE] (seven days after admission). The MDS assessment reflected the resident was at risk for developing a pressure ulcer and one Stage I pressure ulcer was present at the time of the assessment. The MDS assessment further reflected Resident #5 was frequently incontinent of urine and required the extensive assistance of one person for bed mobility and transfers. According to the MDS assessment, the resident had limitations in range of motion of upper and lower extremities on both sides but received no turning/repositioning for skin/ulcer treatment. The resident's Braden Scale assessments for predicting pressure ulcer risk dated 02/08/13, 02/15/13 and 02/22/13 reflected Resident #5 was rarely moist, walked occasionally but spent most of the time in bed or sitting in a chair, had no limitations in mobility, and was able to make major and frequent position changes without assistance. (The Braden Scale assessment dated [DATE] reflected the resident walked frequently.) The Braden Scale assessment further reflected Resident #5's scores of 22 on 02/08/13, 02/15/13 and 02/22/13 indicated the resident was not at risk for developing a pressure ulcer. According to the legend on the Braden Scale assessment, a score of nine or less indicated a very high risk, a score of 10-12 indicated a high risk, a score of 13-14 indicated a moderate risk and a score of 15-18 indicated at risk. The legend did not address any score above 18. Resident #5's interim plan of care was dated 02/08/13. Under the heading Pressure Ulcer Risk, the goal was to prevent pressure ulcers. Options/interventions to select were to provide pressure device, turn and reposition, inspect skin according to facility protocol and incontinent care. The only options/interventions checked/selected for Resident #5 were to inspect skin according to facility protocol and incontinent care. Under the heading "Pressure Sores," the goal was to reduce the size and facilitate healing. Options/interventions to select were to obtain a device for the bed/chair, treat according to physician orders [REDACTED]. A comprehensive care plan dated 02/11/12 (three days after admission) addressed a Stage I pressure ulcer located on Resident #5's sacrum. The goal was the resident's skin would remain clean and dry, and the pressure ulcer would heal over the next 90 days. There was no documentation to reflect the care plan had been revised or reviewed to address Resident #5's non-healing pressure ulcer. Approaches included performing the treatment as ordered and notifying the physician of no improvement within two weeks, assisting with turning and repositioning every two hours and as needed. Additional care plans provided by the facility on 03/21/13 were dated 02/22/13 and did not address Resident #5's pressure ulcer, the risk for developing a pressure ulcer, or any refusal of care behaviors. Resident #5's Weekly Skin Integrity Review sheets dated from 02/08/13 to 03/15/13 reflected each week, for more than a month, the resident's skin was intact with a 4 centimeter (cm) by 5 cm (length by width) area of redness located on the sacrum. physician's orders [REDACTED]. Resident #5's treatment records for February and March 2013 from 02/08/13 to 03/15/13 reflected the resident was receiving [MEDICATION NAME] (a moisture barrier ointment) to the buttocks and sacrum every shift. On 03/19/13 at 9:25 a.m., Treatment Nurse (TN) B stated Resident #5 was cognitively oriented enough to be interviewed, occasionally incontinent but used a urinal, was able to transfer without assistance and was admitted with redness on his "bottom." TN B further stated the redness was possibly due to pressure, but the resident had no open areas. Resident #5 was observed sitting in a wheelchair in his room on 03/19/13 at 11:58 a.m., 12:15 p.m. and 12:40 p.m. At 4:05 p.m. on 03/19/13, a strong odor of urine was noted in Resident #5's room. The resident was observed during this time still sitting in the wheelchair. At 4:10 p.m. on 03/19/13, the surveyor requested CNA C to check Resident #5 for incontinence. The resident's incontinent brief was observed to be saturated with urine, and a strong odor of urine permeated the room. The resident had also been incontinent of bowel. Resident #5 required maximum assistance from CNA C to stand and transfer to the bathroom and onto the commode. As CNA C was cleansing the resident, the resident complained of being sore on his "bottom." CNA C stated she was not aware of Resident #5 having any sores on his "bottom." CNA C and the surveyor inspected the resident's buttocks during this time. A Stage II pressure ulcer was noted on the resident's buttocks between the upper gluteal folds. Resident #5 was observed sitting in a wheelchair in his room on 03/20/13 at 9:30 a.m., 12:15 p.m., 1:30 p.m. and 2:15 p.m. During the observation at 2:15 p.m., CNA D and CNA E were preparing to provide incontinent care to the resident. The resident had been incontinent of urine and feces and required maximum assistance to stand and transfer. As CNA E cleansed the resident, she stated, the resident's buttocks "looked bad." During this time, there was no dressing on Resident #5's open Stage II pressure ulcer. CNA D stated TN B saw the resident's buttocks "yesterday" (03/19/13) and had instructed him to continue to apply a moisture barrier cream. An interview was conducted with the TN B on 03/20/13 at 4:25 p.m. about the condition of Resident #5's skin. TN B stated the resident's skin was intact except for an area of redness on his buttocks. When queried during this time about the last time she had seen the reddened area, TN B stated she saw it "today" (03/20/13). When queried about assessing the area between the resident's gluteal folds, TN B stated she had not checked between the resident's gluteal folds. A request was made at this time to observe Resident #5's skin with TN B. Observation of Resident #5 with TN B on 03/20/13 at 4:35 p.m. revealed the resident was in bed and had been incontinent of bowel and bladder. As CNA D provided incontinent care, Resident #5 was noted to flinch and moan as the washcloth came in contact with the Stage II pressure ulcer. During this observation, TN B measured an open area with a pink wound bed located on Resident #5's left inner gluteal fold. The area measured 4 cm by 2.5 cm (length by width). TN B cleansed the area with normal saline, applied the collagen wound dressing Puracol, and covered the wound with a dry dressing. During this observation, another open area was noted on the resident's right inner gluteal fold. TN B did not measure or address the second open area other than to ensure the dressing she applied to the left side of Resident #5's buttock covered the right side. During this time TN B stated the facility had standing orders for Stage I and Stage II wound treatments. According to TN B, a moisture barrier ointment was to be used for Stage I pressure ulcers and the collagen dressing Puracol was to be used for Stage II pressure ulcers. LVN F was queried on 03/20/13 at 5:20 p.m. about receiving any report about Resident #5's skin. LVN F stated, during the evening of 03/19/13, CNA C reported the resident had an open area to his buttocks. During this time, the surveyor queried LVN F about her assessment of the area. LVN F stated she did not see or assess the area but instructed CNA C to report the open area to TN B. During an interview with TN B on 03/20/13 at 5:25 p.m., she stated CNA C had not reported to her the open area observed by the surveyor on 03/19/13 at 4:10 p.m. On 03/20/13 at 5:30 p.m., the surveyor informed the DON about Resident #5's open area and the lack of communication. Review of Resident #5's wound treatment and progress records revealed an entry dated 03/20/13. The records reflected on 03/20/13, a Stage II pressure ulcer was identified on the left gluteal fold. The record did not address the open area on the right inner gluteal fold. On 03/21/13 at 10:30 a.m., the surveyors accompanied the Corporate Nurse, TN B and LVN G to Resident #5's room. When the resident was positioned on the left side (facing the wall), his incontinent brief was noted to be moderately saturated with urine. The dressing on the resident's buttocks was removed, and a second Stage II pressure ulcer was noted on the inner right gluteal fold. During this observation, the Corporate Nurse queried TN B about how she had initially measured the area on the inner left buttock. TN B explained she had measured the length of the entire left wound and across (the width) the top of the resident's coccyx. The Corporate Nurse informed TN B the areas represented two separate wounds one between each gluteal fold. The open area on the right inner gluteal fold was noted with a pink center and was oval shaped and was approximately 1 to 2 cm in diameter. TN B did not obtain measurements during this time. An updated Weekly Skin Integrity Review Sheet for Resident #5's was provided by TN B on 03/22/13. The new sheet was dated 03/21/13 and reflected the Stage II pressure ulcer on the right inner gluteal fold had been assessed and measured on 03/21/13. According to the documentation on the sheet, the pressure ulcer measured 1.0 cm by 0.5 cm (length X width). An interview with the DON on 03/22/13 at 9:30 a.m. revealed Resident #5's physician and the Wound Specialist had visited the resident last evening (03/21/13). Physician telephone orders dated 03/21/13 reflected orders to continue using the Puracol dressing to both the left and the right gluteal fold wounds. The orders further reflected, instead of daily treatments, the treatment should be performed every 72 hours and as needed. An interview with the DON on 03/22/13 at 3:00 p.m. revealed there were no standing orders for wound care. She stated if a pressure ulcer was discovered, "We call for treatment from the physician." TN B was queried on 03/22/13 at 3:15 p.m. about whether she had notified Resident #5's physician about the lack of improvement in the Stage I pressure ulcer. TN B stated, after a certain amount of time, typically one month, she would notify the physician. During this interview, TN B confirmed she had not notified the physician or received any orders prior to treating Resident #5's pressure ulcer with the Puracol on 03/20/13. TN B stated, she thought it (the Puracol) was best to use. During this time, the surveyor reminded the nurse Resident #5's weekly skin assessments reflected the same 4 cm in length by 5 cm in width Stage I pressure ulcer to the sacrum since admission over one month ago, 02/08/13. TN B stated she had no explanation why she had not contacted the resident's physician prior to surveyor intervention. During an interview with CNA C on 03/22/13 at 5:25 p.m., she stated she reported Resident #5's Stage II pressure ulcer to LVN F on 03/19/13. She further stated LVN F told her to tell TN B. According to CNA C, when she told TN B on 03/19/13, TN B told her to put "Some cream on it for now." On 03/21/13 at 3:00 p.m., the survey team requested for review the facility's p/p regarding pressure ulcers, including identification of skin risk factors and assessment for treatment and the facility's p/p regarding bowel and bladder incontinence. On 03/22/13 at 9:10 a.m., the ADM provided the survey team with what he stated were the facility's p/p regarding pressure ulcers. He stated it was the current p/p being followed by the facility. Review of the information provided by the ADM revealed the pressure ulcer p/p consisted of educational material about pressure ulcers. There was no facility-specific p/p included with the information provided by the ADM. On 03/22/13 at 9:55 a.m., the Corporate Nurse stated the facility's p/p for pressure ulcers was to use "best practice." When the surveyor asked the Corporate Nurse if there was any p/p in writing to instruct facility employees in providing care for residents with pressure ulcers, the Corporate Nurse again stated the facility used "best practice." An interview was conducted with the DON on 03/22/13 at 3:30 p.m. about the lack of a facility policy/procedure for pressure ulcers and what her expectations were when pressure ulcers showed no improvement. The DON stated she expected nursing staff to notify the physician at least a week after there was no improvement. No evidence of the existence of any written p/p regarding care of residents with pressure ulcers was provided to the survey team as of the Exit Conference on 03/22/13 at 5:45 p.m. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the DON on 03/19/13, reflected seven residents were identified with pressure ulcers (excluding Stage I).