Every finding on record at River Bend Healthcare

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 24 residents ( residents #7, #13 and #21) reviewed for comprehensive person-centered care plans. 1.The facility failed to ensure a care plan was developed to address Resident #7's oxygen therapy. 2.The facility failed to ensure a care plan was developed to address Resident #13's anticoagulant. 3. The facility failed to ensure a care plan was developed to address Resident #21's need to have her apical pulse checked. This failure could place residents at risk of not receiving the type of care required and result in unmet needs.Findings included: 1.Record review of Resident #7's electronic face sheet dated 02/11/2026 reflected a [AGE] year-old female admitted [DATE], diagnoses included: pneumonia (severe lung infection caused by bacteria, viruses or fungi that inflames the air sacs filling them with fluid or pus), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), depression (feelings of severe despondency and dejection) and obstructive sleep apnea (a serious disorder where breathing repeatedly stops and starts during sleep because throat muscles relax and block the airway). Record review of Resident #7's quarterly MDS assessment dated [DATE] reflected she understood and was understood by others, with a BIMS of 7 indicating severe cognitive impairment. She required moderate assistance with ADLs. She had an active diagnosis of pneumonia and was on oxygen therapy. Record review of Resident #7's comprehensive care plan dated 01/20/2026 reflected Problem, has altered respiratory status/difficulty breathing r/t sleep apnea. Record review reflected oxygen therapy was not noted in the care plan. Record review of Resident #7's active orders as of: 02/11/2026 reflected O2 at 2L-5L/min via N/C PRN for dyspnea (difficulty breathing) and titrate O2 level as needed related to pneumonia, start date 01/07/2026. During an observation on 02/10/2026 at 1:00 p.m., Resident #7 was in the dining room eating lunch, with oxygen infusing via N/C. Observation revealed the portable oxygen tank's gauge setting was set at 3L/min. During an interview on 02/10/2026 at 1:05 pm, Resident #7 stated she used her oxygen to help her breath. 2. Record review of Resident #13's face sheet dated 2/13/2026 revealed a [AGE] year-old female, admitted on [DATE], diagnoses included: Alzheimer's disease (a progressive brain disorder that causes cognitive decline, memory loss, and behavioral changes), chronic atrial fibrillation (a heart rhythm where the upper chambers of the heart quiver instead of beating effectively), and chronic obstructive pulmonary disease (an incurable lung disease that damages airway causing difficulty breathing). Record review of Resident #13's comprehensive MDS dated [DATE] revealed a BIMS score of 10, indicative of moderate cognitive impairment. Record review revealed she required maximal assistance with her ADLs and the anticoagulant was checked. Record review of Resident #13's care plan dated 11/20/2025, revealed the anticoagulant Eliquis was not care planned. Record review of Resident #13's physician orders dated 10/31/2025 revealed an order for Eliquis 5mg for atrial fibrillation twice daily that started on admission [DATE]. Record review further revealed on 12/31/2025 the Eliquis dosage was decreased to 2.5 mg twice daily. Record review of Resident #13's hospital record dated 12/14/2025 revealed Resident #13 was admitted to the hospital for bleeding in her stools and was previously admitted for gastrointestinal bleeding (part of the digestive tract that includes throat, stomach, small and large intestines) according to her medical history. Interview on 2/13/2025 at 12:09 p.m. the MDS Coordinator confirmed the anticoagulant was not care planned for Resident #13. The MDS Coordinator said it was important to have an accurate care plan because it would alert staff who provided care for Resident #13 that she was at risk of bleeding. The MDS Coordinator said the care plan was a tool to identify the residents and the care the residents needed. 3. Record review of Resident #21's electronic face sheet dated 02/10/2026 reflected an [AGE] year-old female admitted on [DATE], diagnoses included: dysphagia (difficulty swallowing), presence of a cardiac pacemaker (an implanted, small device under the chest skin, connected to the heart by wires, used to manage slow, fast, or irregular heartbeats) and depression (feelings of severe despondency and dejection). Record review of Resident #21's quarterly MDS assessment dated [DATE] reflected she understood and was understood by others, with a BIMS of 10 indicating moderately impaired cognition. Record review reflected she required moderate assistance ADLs and had an active diagnosis of heart failure (a chronic, progressive condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen). Record review of Resident #21's comprehensive care plan dated 02/02/2026 reflected Problem, has a pacemaker, interventions monitory vital signs every shift. Resident #21's comprehensive care plan did not reflect she required an apical pulse (a direct, central measurement of the heart's rate and rhythm, typically taken by listening with a stethoscope over the apex of the heart). Record review of Resident #21's active physician orders dated 02/02/2026 reflected Pacemaker: Check apical pulse every shift for monitoring. During an observation on 02/10/2026 at 10:30 a.m., Resident #21 was sitting in her room in a chair. Observation revealed pacemaker monitor box with a heart symbol lit up and sitting on the bedside table. During an interview on 02/10/2026 at 10:35 am, Resident #21 stated the nurses listened to her heart with a stethoscope each shift. During an interview on 02/13/2026 at 11:53 am, the MDS Nurse stated she worked for the facility for three months and walked into a mess. She stated the care plans were not the previous person's focus for a long time, and resident care plans were not done. She stated she started working on MDS's and worked on care plans but had more to do. The MDS Nurse stated Resident #7's oxygen therapy, Resident #13's anticoagulant and Resident #21's apical pulse needed to be reflected in their comprehensive person-centered care plans. She stated she was responsible for the comprehensive person-centered care plans, but the interdisciplinary team contributed to the development of the care plan. She stated it was important for the care plan to be developed and kept updated because the care plan reflected the residents' care and if it were not current a resident could miss the care they needed. During an interview on 02/13/2026 at 3:03 pm, the RNC stated the previous MDS Nurse was terminated because she was not doing her job. She stated the ADM was accountable for the previous MDS nurse's performance and was aware of the care plan issues. She stated the IDT was trying to catch up on care plans but was aware the facility was non-compliant. During an interview on 02/13/2026 at 3:20 pm, the ADM stated the IDT were responsible for sections of a resident's care plan. He stated he was aware the facility had a problem with care plan development and updates. He stated the comprehensive care plan described the residents and what care they required related to orders, needs, and preferences. He stated the needed care for a resident could be missed or inaccurate if the care plan was not accurate. During an interview on 02/13/2026 at 3:30 pm, the DON stated care plans were developed by a team, and nursing care issues were developed by the nurses. The DON stated when the comprehensive care plan was not current, missed problems or interventions, required care could be overlooked, leading to a decline in resident conditions and resulting in missed communication to direct care providers. Record review of the facility's policy and procedure titled Comprehensive Care Plans dated 2025 reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observations and interviews, the facility failed to ensure the menus were followed and documented any substitutions made to the menus for 1 of 1 menus reviewed for accuracy. The facility failed to follow the recipe requirements to make enough food to be served on the menu. This failure could place residents at risk for inadequate nutritional needs.Findings included: During an observation on 2/11/2026 at 12:40 p.m., the menu posted in the dining room was Dijon pork loin, sweet potato casserole, dinner roll, and cream pie. During an observation and interview on 2/11/2026 at 1:13 p.m. the surveyor requested policies from the DM. The RD and the DM were observed walking from the freezer with bags of frozen chicken strips to cook for the lunch meal. The DM said they ran out of the food cooked for lunch and needed to fix the chicken strips for the rest of the residents that did not get the meal on the menu. During an interview on 2/11/2026 at 1:15 p.m., the [NAME] said some of the food was made for pureed and the mechanical soft and it wasn't enough for the regular diets. The [NAME] said it was important to follow the recipe for meals to make sure everyone received the food they needed and to follow the menu posted because that was what the residents expected to receive. During an interview on 2/11/2026 at 1:25 p.m., with the DM and the RD, the RD said they ran out of food due to a portion of the food was used to make the pureed diets and mechanical soft diets. The RD said the cook did not follow the recipe and that was the issue. The DM and the RD said an in-service would be done with the cooks for following the recipes for the menus posted. Record review of the facility policy titled, Food Preparation Guidelines, dated 2025, stated, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and dehydration status. Under Policy Explanation and Compliance Guidelines #1 stated The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes; #2 (b) stated, Preparing foods as directed.

Based on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 15 staff (LVN I) reviewed for Administration. The facility failed to ensure LVN I's nursing license was current since [DATE]. This failure could place residents at risk of not receiving their care from a licensed nurse when required.The findings were: Review of the licensure and training for the facility staff revealed LVN I's hire date was [DATE]. The background and EMR checks were completed on [DATE]. TB screening was completed on [DATE], and new hire competency checklist was completed on [DATE]. Review of the Texas BON website for nursing verification on [DATE] at 5:10 p.m. athttps://txbn.boardsofnursing.org/licenselookup/Home/Index revealed LVN I's nursing license was in delinquent status and had expired on [DATE]. Further review at https://www.nursys.com/LQC/LQCSearch.aspx revealed LVN I had been an LVN in Tennessee from [DATE] to [DATE], and an LVN in Texas from [DATE] to [DATE], and an LVN in [NAME] from [DATE] to [DATE], and an LVN in Arizona from [DATE] to [DATE]. LVN I had no disciplinary actions on her licenses. LVN I was a licensed nurse from 1972 to 2024 which was 52 years. Review of training for LVN I revealed she successfully completed all required training with the facility in the past year including ANE prevention and reporting on [DATE] and [DATE]. Further review revealed behavioral health fundamentals, compliance and ethics essentials, dementia care for nursing facilities, emergency preparedness, essential communication skills for healthcare professionals, fall prevention, HIPAA best practices, HIV, infection prevention, QAPI, resident rights, and restraint reduction in nursing facilities training was completed on [DATE]. In a joint interview on [DATE] at 5:00 p.m. with the Administrator, RNC, and DON. The Administrator stated he was unsure exactly what happened as the new company took over in January of 2025 and he does not have access to any of the previous owner's files or time sheets. The RNC stated they created a QAPI action plan and the Administrator had spoken to LVN I and she was unaware her license had expired. The Administrator stated LVN I was removed from the schedule. The DON and RNC stated there were no concerns with LVN I's nursing care, but they were also reviewing the EHR's of the residents to verify. In an interview on [DATE] at 8:50 a.m. the Administrator stated LVN I was formally suspended and further action was pending. The Administrator stated LVN I previously worked at another facility with the ADON and LVN I thought that her license was good. The Administrator stated LVN I worked approximately 57 shifts since this company took over and he was not the Administrator at the time but was told there was mass confusion at the time. The Administrator stated the new company took over in January of 2025 and he would print LVN I's time sheets from that time until now but had no access to her time sheets prior to that. The Administrator stated HRD was not checking LVN I's license status as expected but the issue was corrected. In an interview on [DATE] at 10:17 a.m., the HRD stated she was in this position for one year and was previously a hospitality aide and receptionist for one year with the prior company. The HRD stated she was trained on how to check backgrounds and licensing and was supposed to do it monthly. The HRD stated she had no employee list that she went by and was still receiving employee files from the previous owners in April of 2025 and May of 2025 and the files were just shoved in boxes all over the facility and she had been sorting through them all and organizing them so she had no idea she was missing LVN I's monthly checks. The HRD stated she had a calendar she used to ensure her monthly checks were completed but did not have LVN I's information. The HRD stated the Administrator made her a spreadsheet of all employees and checks she needed to do and was working with her to ensure it was all completed. The HRD stated the previous Administrator had not gone over these items with her and she felt comfortable that she would be able to complete them all from here on out. The HRD stated the Administrator will be reviewing the checks with her monthly and he was going to train her on how to send out notifications when expiration dates are approaching. In an interview on [DATE] at 11:40 a.m., the RNC stated they checked through the EHR's and there were no issues identified with the care provided by LVN I. The RNC further stated an ADHOC-QAPI meeting was held and included the Administrator, DON, Medical Director, and herself on [DATE] and a plan of action was created and reviewed and updated on [DATE]. In a telephone interview on [DATE] at 12:46 p.m., LVN I stated she previously worked at another facility in November of 2024 and had a coworker help her renew her license online because she was not tech savvy and she had submitted her renewal online and paid with her credit card. LVN I stated she checked the website after, and her license was showing renewed. LVN I stated when the previous company hired her, they also checked her license, and it was showing as current and not expired in December of 2024, so she thought there were no issues. LVN I stated she find her credit card receipt from that long ago but contacted the BON today ([DATE]) and was informed her license renewal did not go through because the payment was declined. LVN I stated she did not have the same email anymore and she did not see any notifications, so she thought it was current. LVN I stated she was waiting for the BON to contact her back to tell her what she needed to renew her license. LVN I apologized and stated she really thought her license was current and that she had been a nurse for a long time and had not lost any of her nursing skills since her license had expired. In an interview on [DATE] at 3:30 p.m., the DON stated possible consequences of facility nurses not having current licenses could be that care would be provided by unlicensed staff. The facility policy on license verification with a copyright of 2025 indicated all personnel that require a license or certification shall be verified through the appropriate issuing agency. 1. The Human Resources Director, or designee, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. 3. Any licensed/certified employee is responsible for maintaining continuing education hours as required for current licensure/certification status. 4. Any licensed/certified employee is responsible for submitting verification of licensure/certification renewal to Human Resources prior to Expiration.

Based on observations, interviews and record reviews, the facility failed to establish and maintain, an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 3 of 7 residents (Residents #3, #33, and #69) reviewed for infection control. 1. The facility failed to ensure Resident #3 was on contact precautions per CDC guidelines and facility policy. 2. The facility failed to ensure the DON put on a gown when he performed wound care for Resident #33 who was on EBP. 3. The facility failed to change gloves during incontinent care for Resident #69. 4. The facility failed to ensure the residents clean clothing was covered when delivering to the residents on 2/11/26. These failures could place residents at risk of cross contamination and infections.Findings included: 1. Record review of Resident #3's face sheet, dated 2/11/26, revealed the resident was an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included displaced bicondylar fracture of right tibia subsequent encounter for closed fracture with routine healing(Involves both the inner and outer condyles/plateau of the proximal tibia and the bones have moved, and is critical for knee joint stability), presence of right artificial knee joint (has undergone a total or partial right knee replacement), infection following a procedure, deep incisional surgical site (infection to a surgical site), and Staphylococcal arthritis right knee (infection where Staphylococcus aureus bacteria invaded the joint space). Record review of Resident #3's quarterly MDS, dated [DATE], revealed the resident had clear speech, was able to understand others and was understood by others, and had no hearing or vision deficits. The resident had a BIMS score of 10 out of 15 indicating moderate cognitive impairment. The resident had no ROM impairments to her upper or lower extremities and used a manual wheelchair. The resident required substantial/maximal assistance - helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for toileting, showers, and personal hygiene. The resident required partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for upper and lower body dressing, and all transfers. Record review further revealed the resident was frequently incontinent of urine and always incontinent of bowel. Record review of Resident #3's care plan, dated 2/10/26, revealed a problem initiated on 9/24/25 and revised on 2/11/26 the resident was on contact isolation for MRSA interventions included educate resident/representative on techniques to prevent infection, such as handwashing, adequate rest, nutrition, and avoidance of crowds initiated on 9/25/25, educate the resident/RP in infection control practices initiated on 9/25/25, initiate the appropriate contact isolation precautions initiated on 9/25/25 and revised on 2/11/26, and staff to follow precautions, including proper hand washing techniques, donning, doffing PPE's to minimize microorganism transmission initiated on 9/25/25 and revised on 2/11/26. Record review of Resident #3's physician orders revealed an order with a start date of 12/24/25 for EBP- staff to utilize gowns and gloves for high contact resident care activities r/t wound. Record review of Resident #3's physician orders revealed an order with a start date of 12/24/25, for PPE required for high resident contact care activities. EBP are indicated for residents with any of the following: Infection or colonization with a CDC targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Record review of the facility undated weekly skin report supplied to surveyors revealed Resident #3 with a surgical wound to her right inferior knee with a start date of 10/7/25 with measurements of 0.5x0.7x0.8 (cm) with tunneling noted 2.4cm and undermining (tissue destruction extends beneath the intact skin at the wound margins) 2.4cm with heavy serosanguineous (pale pink to light red ) drainage and on antibiotics for MRSA for right knee hardware infection and the physician was notified on 2/6/26. Record review of Resident #3's physician orders revealed an order dated 2/3/26 for wound care for surgical wound to right inferior knee. Cleanse with Vashe (wound cleanser), pat dry with 4x4 gauze, apply calcium alginate (medical dressing for moderate to heavily exudating wounds) to wound bed, cover with ABD (abdominal) pad, wrap with kerlix, secure with Coban (self-adherent wrap) as needed for wound contamination or saturation. Record review of Resident #3's physician orders revealed an order with a start date of 2/11/26 for contact isolation for MRSA. Record review of Resident #3's hospital paperwork revealed physician documentation on 11/20/25 the resident's surgical wound was growing MRSA and on 11/21/25 that the resident's knee joint aspiration revealed it was also growing MRSA now. Record review of Resident #3's lab results reported on 11/21/25 revealed the wound was positive for Staphylococcus aureus- many, Staphylococcus spp (species) (types of Bacteria) – many, and Methicillin positive for resistance. Record review of Resident #3's EHR revealed the resident had received IV antibiotics to treat the MRSA and had transitioned to PO antibiotics. There were no issues or concerns noted with clinical treatment of the wound or the MRSA of the wound. In an observation on 2/10/26 at 10:00 a.m., Resident #3's room had an EBP sign on the door and a PPE cart outside of her room. There was no sign indicating contact precautions. In an observation and interview on 2/11/26 at 10:30 a.m., Resident #3 was in bed watching television, the resident was alert and oriented to person and place. The resident stated the facility staff changed her dressing daily and more frequently if it was wet, but she was unable to answer how often the drainage leaked through the dressing. The dressing to the resident's right knee was observed to be clean, and dry when the resident moved her covers. In an observation and interview on 2/13/26 at 11:20 a.m. wound care was completed for Resident #3 by the DON, assisted by the ADON. The DON stated the regular wound care nurse was off today and when she was off, he was the wound care nurse and had experience. Resident #3 was on contact precautions and there were no issues observed following contact precautions and PPE. Wound care was completed as ordered with no issues. The wound was observed to be just below the resident's knee and was circular and small approximately 1/4 inch or smaller than a dime with no redness, but moderate swelling observed of the resident's entire knee area to include the wound. A small amount of clear drainage was noted on the wound. The DON stated the wound had been improving and was smaller with less drainage than previously. In an interview on 2/13/26 at 3:30 p.m. the DON stated Resident #3's wound continued to improve but was not healed. The DON stated the resident completed six weeks of IV antibiotics and transitioned to PO antibiotics. The DON stated he understood the resident should have been on contact precautions versus EBP due to the possibility of drainage coming through the dressing, the possibility of the resident touching the contaminated dressing and other things in her environment. The DON stated the possible consequences of the resident not being on contact precautions were possible transmission and infection control issues. Review of the CDC website on 2/13/26 at 3:00 p.m. at https://www.cdc.gov/mrsa/hcp/infection-control/index.html dated 6/27/25 Infection Control Guidance: Preventing Methicillin-resistant Staphylococcus aureus (MRSA) in Healthcare Facilities. Progress to reduce MRSA infections in healthcare facilities has slowed. More action by healthcare facilities can prevent more MRSA infections. The prevention of MRSA infections is a priority for CDC. CDC recommends Contact Precautions for patients with MRSA. Review of the CDC website on 2/13/26 at 3:10 p.m. at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html dated 6/28/24 revealed Frequently asked questions about using enhanced barrier precautions in nursing homes to prevent MDROs. 4. When should nursing home staff use Contact Precautions versus Enhanced Barrier Precautions for a resident with a MDRO? Contact Precautions are recommended if the resident has acute diarrhea, draining wounds, or other sites of secretions or excretions that are unable to be covered or contained. Review of the facility policy on transmission-based (isolation) precautions with copyright date of 2025 indicated . 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2. The facility will use standard approaches, as defined by the CDC, for Transmission- Based Precautions: airborne, contact, and droplet precautions. Staphylococcal disease; major skin, wound, or burn contact precautions until drainage stops or can be contained by a dressing. 2. Record review of Resident #33's electronic face sheet, dated 02/11/2026, reflected a [AGE] year-old male admitted [DATE]. His diagnoses included: pressure ulcer of right hip (localized damage to the skin and underlying tissue), acute hematogenous osteomyelitis (a rapid-onset infection of the bone and bone marrow caused by bacteria traveling through the bloodstream), anemia (a medical condition defined by a lack of enough healthy red blood cells or hemoglobin to carry adequate oxygen to the body's tissues) and type 2 diabetes mellitus (a chronic condition where the body does not produce enough insulin or cannot properly use the insulin it makes). Record review of Resident #33's admission MDS assessment dated [DATE] reflected he understood and was able to understand. He scored 14 of 15 on his BIMS which signified his cognitive status was intact. He required moderate assistance with his ADLs. He was noted to have a pressure ulcer. Record review of Resident #33's comprehensive person-centered care plan dated 12/26/2025 reflected Problem, risk for infection-EBP, Enhanced Barrier Precautions at all times, Interventions, Staff is to wear PPE's for all contact with resident as long as the resident is on EBP precautions, for things such as dressing, changing linens, transfers, providing hygiene, and wound care. Record review of Resident #33's Active Orders as of: 02/11/2026 reflected Enhanced Barrier Precautions: Staff to utilize gowns and gloves for high contact resident care activities r/t wounds, start date 01/16/2026. Observation on 02/12/2026 at 09:11 a.m., the DON performed wound care and dressing change for Resident #33 revealed the DON followed the physician orders Cleanse hip surgical wound with VASHA (type of wound cleanser), pat dry with 4X4 gauze. Apply skin prep to peri wound. Apply barrier cream to peri wound. Apply SANTYL (a prescription medication used to remove dead tissue from chronic skin ulcers) to wound bed, pack wound bed with VASHE soaked gauze. Cover with border dressing using aseptic technique. The DON washed hands, put on clean gloves, took off old dressing. Removed gloves, washed hands, and cleaned wound as prescribed. Observation revealed the DON did not put on a gown. During an interview on 02/12/2026 at 09:45 a.m., the DON stated he knew he should have put on the gown and forgot, he stated the EBP was to prevent the spread of MDRO's. He stated he was trained in putting on a gown for direct care and did not know why he forgot. He stated cross contamination could occur and cause infection. Interview on 2/13/2026 at 09:30 am with Resident #33, he stated he received wound care since admission. He stated staff wore gowns on Tuesdays when the doctor came with them otherwise, they only wore gloves. During an interview on 02/13/2026 at 3:03 pm, the RNC stated it was important for the staff to follow EBP and infection control procedures because when they do not, a spread of bacteria could cause cross contamination and infection. During an interview on 02/13/2026 at 3:20 pm, the ADM stated he was trained as an ICP and said staff needed to follow infection control policies and procedures to prevent the spread of infections. Record review of the DON's Competency Assessment dated 10/10/25, titled PPE reflected he was trained on the use of PPE. Record review of the DON's training record dated 02/13/2026 reflected he had training titled Infection Prevention Fundamentals on 02/22/2025. Record review of the facilities policy and procedure titled Enhanced Barrier Precautions dated 2025 reflected It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Implementation of Enhanced Barrier Precautions: High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing briefs, wound care: any skin opening which required a dressing. Record review of the facilities policy and procedure titled Infection Prevention and Control Program dated 2025 reflected This facility has established and maintained an infection control prevention and control program designed to provide a sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 3. Record review of Resident #69's face sheet dated 2/13/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included dementia (a significant decline in memory, thinking, behavior, and daily function), cognitive communication deficit (an impairment in communication), and depression (mood disorder that causes persistent feeling of sadness and loss of interest). Record review or Resident #69's care plan dated 11/19/2025 revealed Resident #69 was care planned for refusing care, dementia, and falls. Record review of Resident #69's quarterly MDS dated [DATE] revealed he had a BIMS score of 4, indicative of moderate cognitive deficit. Observation on 02/12/2026 at 10:50 a.m. Lead CNA C and CNA D performed incontinent care for Resident #69. CNA D assisted with repositioning the resident while Lead CNA C cleaned him. When Lead CNA C finished his front area, she assisted him to turn to his left side and started to clean without changing her gloves. When asked by the surveyor about not changing her gloves, she then switched with CNA D and CNA D cleaned his buttocks. When CNA D finished, she grabbed a clean brief to put on the resident without changing her gloves. Interview on 2/12/2026 at 11:05 a.m. CNA D said she had training at a previous facility for infection control practices and said she had the in-service about 4-5 months ago when she first started. CNA C said she had infection control in-service in October. Lead CNA C said it was important to maintain infection control to prevent cross-contamination and infection to the residents. CNA D said residents could get urinary tract infections if you do not change gloves and follow infection control practices. Record review on 2/13/2026 at 11:15 a.m. of infection control training revealed CNA C and CNA D received in-service for infection control on 2/13/2026. Record review of the facility's policy and procedure titled, Infection Prevention and Control Program, dated 2025, reflected, This facility has established and maintained an infection control prevention and control program designed to provide a sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 4. In an observation and interview on 2/11/26 at 8:55 a.m. on 500-hall LS H was observed delivering clean resident clothing using a hanging rack with a basket underneath it on wheels to hold the resident's clothing. LS H was observed entering several resident rooms on 500 hall. Further observation revealed LS H left the residents' clothing on the rack in the hallway, LS H entered resident rooms to deliver clean clothes and observed the clothing on hangers marked with room numbers. Further observation revealed LS H exited her 4th room at the end of the hall and walked away pushing the clean laundry on the uncovered cart. LS H stated she was delivering clean laundry to the residents. LS H stated she was unsure if the clean laundry should be covered and stated this was the way they always did it. LS H stated this was the way she was trained to deliver clothing and was never trained to cover the clean linen when delivering them to the facility halls. Review of staff training for LS H revealed she was trained on delivering clean linens and clothing on 7/8/25. In an interview on 2/13/26 at 3:30 p.m., the DON stated the possible consequences of not keeping the clean laundry covered when delivering was possible cross contamination. Record review of the facility policy on handing clean linen with copyright 2025 indicated . 4. Clean linen must be transported by methods that ensure cleanliness and protect from dust and soil during intra or inter-facility loading, transport, and unloading. Clean linen shall be delivered to resident care units on covered linen carts with covers down.

Based on observations, interviews and record reviews, the facility failed to ensure residents had the right to reside and received in the facility with a reasonable accommodation of resident needs and preferences for 1 of 6 residents (Resident #6) reviewed for call lights. The facility failed to ensure Resident #6's call light was in reach.This failure could place residents at risk for falls, delay of care, and decreased the ability of independent functioning, dignity, and well-being. Record review of Resident #6's face sheet dated 2/13/2026 revealed a [AGE] year-old male, admitted on [DATE] with diagnoses included major depressive disorder (a mood disorder with persistent sadness, a loss of interest that impacts daily functioning), pseudobulbar affect (a neurological condition that causes sudden uncontrollable or inappropriate laughing or crying), and vascular dementia (progressive decline in thinking skills caused by blockage or reduction of blood flow to the brain).Record review of Resident #6's care plan dated 11/20/2025 revealed he was care planned for risk of falls with intervention for call light to be within reach and physical behaviors with a history of harm to others with interventions to provide physical and verbal cues to alleviate anxiety and encourage to seek staff when agitated.Record review of Resident #6's quarterly MDS dated [DATE] revealed a BIMS score of 3, indicative of severe cognitive impairment. Resident #6 required max assist with all ADLs. Observation and interview on 02/10/2026 at 11:31 a.m. Resident #6 was in his room, reclined in his wheelchair reclined with his glasses in his right hand which was contracted. He said he wanted his glasses off. He had a full beard and when asked about shaving, he replied, I don't want to. His clothing was clean and there were no foul odors in the room. Resident #6 had boots on his feet to protect his heels and a Hoyer lift sling was underneath him in the wheelchair. His call light was in the middle of the bed, not in reach. Resident #6 was able to only answer questions with very few words or not at all. He was on EBP with PPE outside the door and a sign posted. Interview on 02/10/2026 at 11:45 p.m. the DON said it was important for the call light to be within reach for the residents because it allowed the residents to call for assistance when needed and there could be an emergency for the resident. The DON said an in-service for call lights would be done immediately.Telephone interview on 2/13/2026 at 3:26 p.m. CNA E said she forgot to put the call light next to Resident #6 when they were done placing him in the chair with the Hoyer lift. She said she knew the call light should have been within his reach. She said it was important for the residents to have the call light within reach because there could be an emergency or needed something, and without it, they were not able to call for help. CNA E said she was trained on call light placement within the residents' reach.Record review of the facility policy titled Call Lights: Accessibility and Timely Response dated 2025 stated: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Under Policy Explanation and Compliance Guidelines, #5 stated: Staff will ensure the call light is within reach of resident.

Based on observation, interviews and record reviews, the facility failed to ensure comprehensive care plans were developed within seven days of the completion of the comprehensive assessment and were reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 resident of 24 residents (Resident #62) reviewed for care plans. The facility failed to ensure Resident #62's comprehensive person-centered care plan was revised after the quarterly MDS assessment to reflect she was incontinent of bowel and bladder. This failure could place residents at risk of a lack of assistance with care.Findings included: Record review of Resident #62's electronic face sheet dated 02/11/2026 reflected an [AGE] year-old female admitted [DATE], diagnoses included: acute cystitis without hematuria (a sudden, localized bacterial infection of the bladder, causing inflammation without visible blood in the urine), sepsis (a life-threatening emergency response to infection where the immune system releases chemicals that trigger widespread inflammation, leading to tissue damage, organ failure and potential death), depression (feelings of severe despondency and dejection) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Record review of Resident #62's five-day MDS assessment dated [DATE] reflected she understood and was understood by others, with a BIMS of 5, severe cognitive impairment. Record review further reflected she was dependent on staff for ADLs, and always incontinent with bowel and bladder. Record review of Resident #62's comprehensive care plan dated 12/23/2025 reflected Problem, has an ADL self-care performance deficit r/t impaired balance, interventions, toilet use, able to assist with parts of ADL, requires assist x1 for transfers on/off toilet. During an observation on 02/12/26 at 09:11 a.m., CNA F and CNA G performed incontinent care for Resident #62. During an interview on 02/13/2026 at 11:53 am, the MDS Nurse stated she worked for the facility for three months. She stated the care plans were not done previously. She stated she started working on MDS's and has worked on care plans but had more to do. She stated Resident #7's oxygen therapy, Resident #13's anticoagulant and Resident #21's apical pulse needed to be reflected in their comprehensive person-centered care plans. She stated the MDS Nurse was responsible for the comprehensive care plans, but the interdisciplinary team contributed to the development of the care plan. She stated it was important for the care plan to be developed and kept updated because the care plan reflected the residents and if it were not current a resident could miss the care they needed. During an interview on 02/13/2026 at 3:03 p.m., the RNC stated that the previous MDS nurse was terminated because she was not doing her job. She stated the ADM was accountable for the MDS nurse performance and was aware of the care plan issues. She stated the IDT was trying to catch up on care plans but was aware the facility was non-compliant. During an interview on 02/13/2026 at 3:20 pm, the ADM stated the IDT were responsible for sections of a resident's care plan. He stated he was aware the facility had a problem with care plan development and updates. He stated the comprehensive care plan described the residents and what care they required related to orders, needs, and preferences. He stated the needed care for a resident could be missed or inaccurate if the care plan was not accurate. During an interview on 02/13/2026 at 3:30 pm, the DON stated care plans were developed by a team, and nursing care issues were developed by the nurses. The DON stated when the comprehensive care plan was not current, missed problems or interventions, required care could be missed and there could be a decline in resident conditions and result in missed communication to direct care providers. Record review of the facility's policy and procedure titled Comprehensive Care Plans, dated 2025, reflected the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: A box in the freezer with a bag of bread sticks were open to air.Four plastic seasoning bottles on a shelf in the kitchen area were opened, and seasoning was on the holes that dispense the seasoning, preventing them from closing.A sugar container had a scoop on the inside of the container. These failures could place residents at risk for food borne illness.Findings included:Observation and interview on 2/10/2026 at 9:30 a.m. the walk-in freezer had a box with a bag of opened breadsticks. The DM said the last time the breadsticks were used was last Monday (2/2/2026). Observation and interview on 2/10/2026 at 9:33 a.m. the dry food storage had a container of sugar with the scoop left inside of the container. The DM said the scoop should not be left inside the container and he removed the container from the dry storage area.Observation on 2/10/2026 at 9:36 a.m. the kitchen area had a shelf with four bottles of seasoning opened with seasoning stuck around the area of the holes used to dispense the seasoning, preventing the tops from closing.Observations and interviews on 2/11/2026 at 1:13 p.m. with the [NAME] and the RD, the [NAME] wore gloves to serve food on the plates. The [NAME] touched the plate warmer unit to open the door and retrieved a plate for serving, touching the inside of the plate. The [NAME] grabbed the plate's base to place the plate in position to be covered by a food dome. The [NAME] then grabbed the dietary slip to read and proceeded to serve food on the plates, with her thumb on the surface of the plate where food would be placed. The [NAME] served three plates in the same manner until the surveyor asked the question about correct handling and serving of the plates. The RD said, I sanitized the outside of the plate warmer box and plates could not be handled without touching the rim of the plate or the inside of the plate! It's not like she touched the place in the middle! You don't eat on the side of the plate, on the rim anyway! The lip of the plate was not a surface where food would be, so it was not a problem!Interview on 2/12/2026 at 8:59 a.m. the DM said it was important to serve food safely to prevent the residents from getting sick and to prevent food borne illness. He said the person serving the food on the plate should not touch anything else when placing food on the plates. The DM said the inside of the plate should not be touched because it could cause cross contamination and the residents could get sick. The DM said it was important to store food safely to prevent food borne illness to the residents and the food in the freezer should be stored safely to protect the food from getting freezer burned to include items been closed correctly because that could destroy the nutrients of the food. The DM said they did not have a facility policy for the correct way to handle plates when serving food.Record review of the facility policy titled, Food Storage dated 12/01/2011 stated: All food will be stored according to the state and Federal Food Codes. The section under Guidelines1 . Dry storage rooms stated. Scoops are stored and covered in a protected area near the food containers.Record review of the facility policy titled: Food Preparation and Guidelines dated 2025 stated under Policy Explanation and Compliance Guidelines #2 Food shall be prepared by methods that conserve nutritive value, flavor and appearance. This includes but is not limited to: (a) Storing food in a manner to minimize exposure to light and air.Record review of the FDA Food Code under FDA/Food Safety Guidelines on Plate Handling: stated in part. The top, inside, or rim of a plate that will come into contact with food should never be touched and When serving, hold plates hold plates by the bottom on the outer edge (underside) only.

Based on observations, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal.The facility failed to close the door on the dumpster.This failure could place the residents at risk of pest and rodents that could cause contamination of foods stored in the kitchen, infection and illness.Findings included:Observation on 2/10/2026 at 9:40 a.m. there was only one dumpster for the facility with doors on the top only, and the door to the dumpster was opened.During an interview on 2/12/2026 at 8:59 a.m. the DM said the dumpsters should be closed after use to prevent rodents and pests from invading the dumpsters and the facility's food to prevent causing food borne illness for the residents. Record review of the facility policy titled Garbage Receptacles dated 6/1/2019 stated: The facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. Under Outdoor receptacles stated: lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors and lids kept closed.

Based on interviews and record reviews, the facility failed to ensure a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care were developed and implemented within 48 hours of a resident's admission and included the minimum healthcare information necessary to properly care for residents, for 1 of 3 residents, (Resident #2), reviewed for comprehensive resident centered care plan. The facility failed to develop interventions for Resident #2's intravenous access when he was admitted on [DATE]. This failure could place residents at risk for harm by not having interventions in place to support their healthcare needs.The findings included: A record review of Resident #2's admission record dated 11/25/2025 revealed an admission date of 9/13/2025 and a discharge date of 10/11/2025 with diagnoses which included sepsis (a life-threatening medical emergency where the body has an overwhelming and damaging immune response to an infection). A record review of Resident #1's admission MDS assessment dated [DATE], revealed the MDS nurse assessed Resident #2 on 9/27/2025 as an [AGE] year-old male admitted for rehabilitation care for a urinary tract infection. Resident #2 was assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment. Section M skin conditions revealed, check all that apply . application of nonsurgical dressings . was unchecked and none of the above were provided . was checked. Resident #2 was receiving antibiotics. A review of section O, special treatments, procedures, and programs, revealed check all of the following treatments, procedures, and programs that were performed on admission . IV medications (intravenous, administering medication or fluids directly into a person's bloodstream through a needle) was unchecked. A record review of Resident #2's Baseline care plan dated 9/16/2025 revealed no interventions to support Resident #1's needs for developing and maintaining intravenous access. A record review of Resident #2's physicians orders dated 9/16/2025 revealed Resident #2 was prescribed to receive meropenem (a potent, broad-spectrum carbapenem antibiotic used to treat severe, often multi-drug resistant, bacterial infections in hospitalized patients) twice daily, intravenously (through a vein). A record review of Resident #2's nursing progress notes revealed LVN A documented on 9/13/2025 at 3:31 PM, Resident was brought to the facility via stretcher, by (name of ambulance service) transport. Resident is alert and oriented to self, . intravenous to left upper arm. During an interview on 11/25/2025 at 1:00 PM, the Administrator, the DON, and the ADON stated Resident #2 was admitted for rehabilitation supports for a urinary tract infection supported by intravenous antibiotics. The DON and the ADON stated a record review of Resident #2's medical records revealed LVN A failed to develop and implement a baseline care plan within 48 hours to support Resident #2's intravenous access which LVN A identified on the admission nursing progress note dated 9/13/2025. The DON and the ADON stated the MDS nurse did assess Resident #2 with having a intravenous access while a Resident, but did not document the intravenous access in Resident #2's care plan template. The Administrator, the DON, and the ADON stated, on 9/15/2025 during their IDT morning meeting, they reviewed all the previous admissions which included a review for care-plan development and implementation to which Resident #2's care plan was not accurately reviewed to reveal the lack of nursing focuses, goals and interventions for Resident #2's intravenous access for his antibiotic medications. The Administrator stated the lack of review could have potential negative outcomes for residents who had needs for support with their healthcare needs. A record review of the facility's Baseline Care Plan / Summary undated policy revealed, Purpose: Promote continuity of care and communication among staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission. Also, to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. Procedure: A baseline care plan for each resident will be developed within 48 hours of the resident's admission to this facility. The baseline care plan will be based on information available from the transferring provider as well as discussions with the Resident / representative. It will include interim approaches for meeting the residents' immediate needs and reflect changes to approaches, as necessary, that occurred before the development of the comprehensive care plan. The baseline care plan will include but not limited to this information needed to care for the Resident: initial goals based on admission orders, instruction needed to provide effective and person-centered care that meets professional standards of quality care; .

Based on interviews and record reviews 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 of 3 residents (Resident #2) reviewed for providing care without a physician's orders. The facility failed to recognize Resident #2 had received medications and fluids through an intravenous access without orders for the intravenous access. This failure could place residents at risk for harm by receiving care without physician's orders. The findings included:[ A record review of Resident #2's admission record dated 11/25/2025 revealed an admission date of 9/13/2025 and a discharge date of 10/11/2025 with diagnoses which included sepsis (a life-threatening medical emergency where the body has an overwhelming and damaging immune response to an infection). A record review of Resident #2's nursing progress notes revealed LVN A documented on 9/13/2025 at 3:31 PM, Resident was brought to the facility via stretcher, by (name of ambulance service) transport. Resident is alert and oriented to self, . intravenous to left upper arm. A record review of Resident #1's admission MDS assessment dated [DATE], revealed the MDS nurse assessed Resident #2 on 9/27/2025 as an [AGE] year-old male admitted for rehabilitation care for a urinary tract infection. Resident #2 was assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment. record review of section M skin conditions revealed, check all that apply . application of nonsurgical dressings . was unchecked and none of the above were provided . was checked. Further review revealed Resident #2 was receiving antibiotics. A review of section O, special treatments, procedures, and programs, revealed check all of the following treatments, procedures, and programs that were performed on admission . IV medications (intravenous, administering medication or fluids directly into a person's bloodstream through a needle) was unchecked. A record review of Resident #2's physicians orders dated 9/13/2025 revealed Resident #2 had no orders for an intravenous access. Further review of physician orders revealed on 9/16/2025 Resident #2 was prescribed to receive meropenem (a potent, broad-spectrum carbapenem antibiotic used to treat severe, often multi-drug resistant, bacterial infections in hospitalized patients) twice daily, intravenously (through a vein). A record review of Resident #2's care plan dated 11/24/2025 revealed no interventions to support Resident #1's needs for developing and maintaining intravenous access. A record review of Resident #2's nursing progress notes revealed LVN B documented on 9/21/2025 at 10:03 AM, Note Text: PIV [peripheral intravenous] to left upper arm dc'd [discontinued] d/t [due to] not flushing. New PIV started with 22g [gauge of needle] intracath to right wrist x 1 attempt. IV antibiotics infusing via new PIV. Will continue to monitor. During an interview on 11/25/2025 at 11:00 AM, LVN B stated he was the nurse for Resident #2 on 9/21/2025, and Resident #2 was prescribed to receive an intravenous antibiotic through the intravenous access on his left upper arm. LVN B stated he could not administer the antibiotic because the intravenous access was occluded (clogged). LVN B stated he removed the intravenous access and instilled a new intravenous access in Resident #2's right wrist and then proceeded to successfully administer Resident #2's antibiotic. LVN B stated he had not checked Resident #2's physicians orders for an intravenous access order, and stated, I assumed he had an order for the IV since he was receiving IV antibiotics . he should have had an order. LVN B stated he had not called the physician to give a report of the discontinued intravenous access and the establishment of a new intravenous access. LVN B stated he believed he did not need to report to the physician because the physician wanted Resident #2 to have an IV since the physician ordered an intravenous antibiotic. During an interview on 11/25/2025 at 1:00 PM, the Administrator, the DON, and the ADON stated Resident #2 was admitted for rehabilitation supports for a urinary tract infection supported by intravenous antibiotics. The DON and the ADON stated a record review of Resident #2's medical records revealed LVN A failed to develop and implement a baseline care plan within 48 hours to support Resident #2 intravenous access which LVN A identified on the admission nursing progress note dated 9/13/2025. The DON and the ADON stated the MDS nurse did assess Resident #2 with having a intravenous access while a Resident but did not document the intravenous access in Resident #2's care plan template. The Administrator, the DON, and the ADON stated, on 9/15/2025 during their IDT morning meeting they reviewed all the previous admissions which included a review for orders and intravenous access however, Resident #2's intravenous access was not reviewed and the order for the intravenous access was not reviewed. The DON stated on 9/16/2025 Resident #2 was prescribed by the physician to receive intravenous antibiotics, and he had not recognized Resident #2 had no order for the intravenous access. The DON stated the admission nurse LVN A was responsible for securing that order since Resident #2 was admitted with the intravenous access. The DON stated the lack of the order should have been reviewed by himself when the antibiotic order was received, and LVN B should have reviewed the order for the intravenous access prior to establishing the new access. The DON stated LVN B was trained and expected to call the physician with the change of condition when he had to discontinue the intravenous access and established a new intravenous access. The Administrator, the DON, and the ADON concurred the failure could have a potential negative outcome for residents receiving care without physician orders. A record review of the facility's undated admission of a Resident policy revealed, Purpose: . Assess residence overall status upon admission . Obtain timely position admission orders including, medications, . Procedure: . Review accompanying documentation from hospital / physician's office for information orders etcetera contact the transferring facility to resolve any questions or to obtain clarification. Contact the attending physician's office as needed for orders, clarification, etcetera . Licensed nurse will contact admitting physician regarding any orders that need clarification and transcribe orders according to facility policy .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 6 residents (Resident #1) reviewed for drug administration. Resident #1 was administered 5 tablets of Carbidopa-Levodopa 25-100mg on 10/21/2025 at noon. The physician order was Carbidopa-Levodopa 25-100mg give 1.5 tablets at 11 a.m. Resident #1 was transferred to the hospital on [DATE] for altered mental status. The noncompliance was identified as PNC. The facility corrected the noncompliance before the survey began.This failure could place residents at risk for not receiving a therapeutic effect or being over-medicated.The findings included:Record review of an undated admission record revealed Resident #1 was an [AGE] year old female, admitted [DATE], with diagnoses that included Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors), fracture of the lower end of right femur (hip fracture), type 2 diabetes (a condition in which the body cannot use insulin correctly and sugar builds up in the blood) and dementia (a general term for impaired ability to remember, think, or make decisions). The admission record revealed Resident #1 had an emergency contact #1 and emergency contact #2 listed with telephone numbers and addresses. Record review of a facility document titled Brief Interview for Mental Status (BIMS) Evaluation, dated 10/17/2025, revealed a BIMS score of 03, indicating severe cognitive impairment. Record review of Resident #1's undated care plan, revealed a care plan that stated Resident #1 had a diagnosis of Parkinson Disease with an intervention to, give medications as ordered by the physician, dated 10/23/2025.Record review of Resident #1's hospital Discharge summary, dated [DATE], revealed an order, Continued carbidopa-levodopa 25-100mg tablet. 5 tab PO daily. Patient Comments: take five (5) tablet (s) by mouth daily. Record review of a hospital discharge document for Resident #1 titled, Home Medication List, dated 10/16/2025, revealed, Continue Medications. These are your current medications to keep taking at home. Further record review revealed, Carbidopa-levodopa 25-100mg tablet. Five tab oral daily. Record review of a facility document titled Drug Regimen Review, revealed Resident #1's name and revealed the regimen review was completed for Resident #1's admission to the facility and the physician or NP were notified of the review on 10/16/2025 at 6:18 p.m. Record review of Resident#1's October 2025 MAR revealed an order, Carbidopa-Levodopa oral tablet 25-100mg (Carbidopa-Levodopa) Give 5 tablets by mouth one time a day for Parkinson's. The start date was 10/17/2025 at 9:00 a.m. and discharge date was 10/20/2025 at 11:11 a.m. The MAR was initialed, indicating the Carbidopa-Levodopa was administered, on 10/17/2025, 10/18/2025, 10/19/2025 and 10/20/2025. An order revealed, Carbidopa Oral tablet 25mg (Carbidopa), Give 1 tablet by mouth two times a day for Parkinsons. One tab at [3 p.m.] & [7:00 p.m.]. The start date was 10/21/2025 at 7:00 p.m. and discharge date was 10/22/2025 at 12:16 p.m. The order was initialed, indicating it was administered, on 10/21/2025 at 4:00 p.m. An order revealed, Carbidopa-Levodopa oral tablet 25-100 mg (Carbidopa-Levodopa) give 1.5 tablet by mouth two times a day for Parkinson's. 1 1/2 tabs at 8:00 a.m. and 11:00 a.m. The start date was 10/21/2025 at 11 a.m. and discharge date was 10/22/2025 at 12:16 p.m. The order was initialed indicating it was administered on 10/21/2025 at 11:00 a.m. Record review of a facility document titled, SNF/NF to Hospital Transfer Form revealed Resident #1 was transferred to the hospital for a med error at 10/21/2025 at 5 p.m. and the document was completed by the ADON. Record review of Resident #1's progress notes, dated 10/21/2025 at 5:31 p.m., by LVN C, revealed, Patient was returning to her room after dinner and this nurse (LVN C) and staff noticed patient had altered mental status and shortness of breath. Patient was unable to hold herself up in her wheelchair. This nurse took patient to her room, administered O2 @ 2L, via nasal canula, this nurse completed a head-to-toe assessment, and this nurse immediately called [ADON]. A progress note dated 10/21/2025 at 5:45 p.m. by the ADON revealed, LATE ENTRY. Resident sent out to [hospital] via stretcher escorted by EMS per [physician] for further evaluation and treatment d/t AMS and changes in vitals. Administrator and DON informed on [sic]incident. Record review of a pharmacy medication packing list, dated 10/20/2025, revealed Resident #1's Carbidopa-Levodopa 25-100mg give 1 tablet at 3 p.m. and 7 p.m. arrived at the facility on 10/20/2025. Record review of a pharmacy blister pack, revealed Resident #1's Carbidopa-Levodopa 25-100mg give 5 tablets daily had 5 tablets in each blister pack and 4 blisters were opened and contained no tablets. Record review of a pharmacy blister pack for Resident #1's Carbidopa 25mg give 1.5 tablet at 8:00 a.m. and 11:00 a.m. had 28 blisters and no blister packs were open, indicating no medication was administered from the blister card. Record review of a pharmacy blister pack for Resident #1's Carbidopa-Levodopa 25-100mg give 1 tablet at 3:00 p.m. and 7:00 p.m. had 28 blisters and no blister packs were open, indicating no medication was administered from the blister card. During an observation 10/23/2025 at 12:00 p.m., MA A was observed administering two medications to Resident #2. The medications were Baclofen 5 mg scheduled for 12:00 p.m. and Pregabalin 150mg scheduled for 1:00 p.m. MA A was observed comparing the blister pack to the MAR prior to administration to verify medication accuracy. The medication blister pack and the physician order in Resident #2's MAR was observed and the orders matched. Resident #2 was administered the medications and swallowed the medications without complications. During an observation 10/23/2025 at 3:51 p.m., LVN B was observed administering one medication to Resident #3. The medication was Eliquis 5mg scheduled for 3:00 p.m. LVN B was observed comparing the blister pack to the MAR prior to administration to verify medication accuracy. The medication blister pack and the physician order in Resident #3's MAR was observed and the orders matched. Resident #3 was administered the medications and swallowed the medications without complications. During an observation 10/23/2025 at 3:55 p.m., LVN B was observed administering one medication to Resident #4. The medication was Eliquis 5mg scheduled for 4:00 p.m. LVN B was observed comparing the blister pack to the MAR prior to administration to verify medication accuracy. The medication blister pack and the physician order in Resident #4's MAR was observed and the orders matched. Resident #4 was administered the medications and swallowed the medications without complications. During an observation 10/23/2025 at 4:40 p.m., Resident #1, was observed lying in a hospital bed asleep with an IV in the left forearm. Resident #1 presented comfortable and did not display any signs of distress. Resident #1 did not wake up or arouse to verbal stimuli and was not able to be interviewed. During an interview on 10/23/2025 at 12:08 p.m., MA A, stated she administered medications to Resident #1 on 10/18/2025 and 10/19/2025. MA A stated Resident #1 had an order for Carbidopa-Levodopa and the administration instructions were to administer 5 tablets once a day. MA A stated she administered the medication to Resident #1 around 9:00 a.m. on 10/18/2025 and 10/19/2025. During an interview 10/23/2025 at 4:35 p.m., the Hospital RN, stated Resident #1 was admitted to the hospital with a diagnosis of an overdose of the medication Carbidopa. Hospital RN stated Resident #1 was very drowsy and received a nutritional supplement by IV for nutrition. The Hospital RN stated there was not a discharge plan at that time. During an interview with LVN C, 10/24/2025 at 9:24 a.m., LVN C stated Resident #1 admitted to the facility from the hospital around 5:00 p.m. on 10/16/2026. LVN C stated Resident #1 admitted with discharge orders from the hospital and LVN C texted the hospital orders to the (NP) G, who approved the orders, and the orders were entered into the EMR for administration. LVN C stated Resident #1 was admitted to the facility with a bottle of Carbidopa-Levodopa that contained tablets and was the supply Resident #1 used at home. LVN C stated she administered Resident #1's 5 tablets from that bottle on the morning of 10/17/2025 and Resident #1's blister pack from the pharmacy arrived at the facility later on 10/17/2025. LVN C stated she administered Carbidopa-Levodopa to Resident #1 on 10/20/2025 from the pharmacy blister pack. LVN C stated NP G approached her with Resident #1's RP on 10/20/2025 and NP G stated she was going to change Resident #1's administration times for the Carbidopa-levodopa and discontinue the order for the five tablets to be administered at one time, once a day. LVN C stated NP G gave the order to administer 1.5 tablets at 8 a.m. and 11 a.m. daily and one tablet at two separate times in the afternoon. LVN C stated NP G said to start the new administration of the Carbidopa-levodopa on 10/21/2025. LVN C stated she entered the new orders into Resident #1's EMR to start on 10/21/2025 at 11 a.m. and LVN C sent the order to the pharmacy to get new blister packs. LVN C stated the blister pack on the medication cart contained five pills per blister for the daily administration and the new blister packs would have 1 or 1.5 tablets per blister. LVN C stated she placed a sticker on the old administration blister pack that read, change in direction and indicated that the order for the medication changed. LVN C stated when a medication aide or nurse observed a change in direction sticker on a blister pack, that person should review the MAR, change in the order, and administer the medication according to the administration record. LVN C reviewed Resident #1's MAR and stated she entered a new Carbidopa-levodopa order for one tablet at 3 p.m. and 7 p.m. with a start date of 10/21/2025. LVN C stated she was not sure why the time for administration on the MAR was 3:00 p.m. and 4:00 p.m. LVN C stated MA D notified LVN C the Carbidopa-Levodopa showed up on her MAR for administration at 4 p.m. so MA D gave Resident #1 one tablet of Carbidopa-levodopa from Resident #1's personal medication bottle that was on the medication cart. LVN C stated MA D showed LVN C the blister pack that had five pills to be administered and told LVN C the blister pack did not match the order to administer one tablet and the order was to administer at 7 p.m. but appeared in her EMR for administration at 4 p.m. LVN C stated when MA D administered one tablet of the medication around 4 p.m., MA D noted a change in condition of Resident #1. LVN C stated she called MA F who administered medications to Resident #1 on the morning of 10/21/2025 and MA F stated she gave Resident #1 five tablets of the Carbidopa-Levodopa at 8 a.m. and 11 a.m. on the morning of 10/21/2025 and used the blister pack with the 5 tablets per administration that had a change of direction sticker on it indicating the order had changed. LVN G stated she went to assess Resident #1 and Resident #1 was observed to be lethargic and not responding when spoken to. LVN C stated she notified the ADON of Resident #1's change in condition and that MA F stated she administered a total of 10 tablets of Carbidopa-levodopa to Resident #1 that morning (10/21/2025). LVN C stated the physician was notified and Resident #1 was transferred to the hospital for evaluation. During an interview on 10/24/2025 at 9:29 a.m., MA D stated Resident #1 had a blister pack on the medication cart with 5 tablets in it to be administered at once and MA D observed that Resident #1's order was to administer 1 tablet, so MA D got 1 tablet out of Resident #1's personal medication bottle on the medication cart. MA D stated she then notified LVN C the medication administration orders did not match the blister pack, and the order was scheduled for 7 p.m. but showed up on the MAR for administration at 4 p.m. MA D stated LVN C called MA F while MA D was at the nurses station and LVN C asked MA F what Resident #1 was administered that morning. MA D stated LVN C stated, Are you sure you gave her two doses of the 5 pills at 8 a.m. and 11 a.m.? MA D stated LVN C hung up the telephone and told the ADON the same information. MA D stated when she administered Resident #1's medication around 4 p.m., Resident #1 was awake and appeared confused but did not appear different from her baseline. MA D said between 4:30 p.m. and 5:00 p.m., Resident #1 was observed not responding to staff and was assessed by the nurses. MA D stated the correct blister packs with the correct dosage had arrived from the pharmacy and were on the cart, just not in the right place when she administered the 1 tablet at 4 p.m. on 10/21/2025. During an interview on 10/24/2025 at 9:31 a.m., RN E, stated LVN C completed Resident #1's medication regimen review with the physician on the day of Resident #1's admission. RN E stated she worked the night shift and reviewed the orders. RN E stated she read the order for the Carbidopa-levodopa 5 tablets daily and called the hospital to question the accuracy of the order. RN E stated she spoke to a nurse at the hospital on [DATE] about the medication dosage .and the person she spoke to said that was how the medication was administered at the hospital. RN E stated she called the on-call physician number and spoke to a Nurse Practitioner. RN E states she told the NP the medication was usually administered at separate times throughout the day but Resident #1's order was for all five tablets to be administered at one time. RN E stated she told the on-call NP that she verified with the hospital that was how the medication was being administered. RN E stated the on-call NP did not change the order and stated she would let the facility physician or NP know so they could review it on the next visit.During an interview on 10/24/2025 at 11:32 a.m., MA F stated she was assigned to administer medications to Resident #1 on 10/21/2025. MA F stated she administered the Carbidopa-Levodopa around 12:00 p.m. to Resident #1 and stated, I pulled the blister pack and did what the blister pack told me. MA F stated she did not see a change in direction sticker and followed the instructions on the blister pack. MA F denied giving the medication at 8 a.m. and stated the medication only appeared on her MAR for administration around 11:00 a.m. MA F stated she felt the nurse should have informed her there was a change in the administration order. MA F stated she looked at the order on the MAR as well and stated for proper medication administration, a person has to compare the order on the MAR to the blister pack and notify the nurse if there was a discrepancy in the orders. MA F stated she did not recall the order on the MAR being different than the order on the blister pack. MA F stated LVN G called her on 10/21/2025 around 4:30 pm. and asked MA F what she administered to Resident #1 that morning and MA F said she told LVN G that she administered 5 tablets of the Carbidopa-Levodopa around noon. During an interview on 10/24/2025 at 12:30 p.m., MA A stated she administered Resident #1's Carbidopa-Levodopa from Resident #1's blister pack on 10/18/2025 and 10/19/2025. During an interview on 10/24/2025 at 12:54 p.m., NP G stated she was notified of Resident #1's hospital discharge orders and gave the order to resume the medications prescribed from the hospital. NP G stated she met with Resident #1's RP on 10/20/2025 at the facility and reviewed the medications. NP G stated the responsible party explained how Resident #1 was administered the Carbidopa-Levodopa at home and stated, it was odd to me that she was getting 5 at once but her bottle from home said 5 tabs a day as well. NP G stated she talked to LVN C and changed the order to reflect new administration times throughout the day so Resident #1 was not taking the 5 tablets at once. NP G stated 5 tablets a day was not an unusual dose and other people were prescribed the same dosage or more of the pills a day, but the administration was usually throughout the day. NP G stated a person taking 5 tablets of Carbidopa-Levodopa at once would likely not cause any side effects or harm but taking more than that dosage, like a double dose, could cause lethargy (tiredness). NP G stated, if she only received 5 tablets, I do not think that would have had any effect. If she got a double dose of the medication that morning, on 10/21/2025, that could have made her drowsy or incoherent. NP G stated it was important to administer medication as ordered because, you don't want to over or under medicate a patient with a wrong dosage.During an interview on 10/24/2025 at 1:20 p.m. Resident #1's RP stated Resident #1 was taking 5 tablets of Carbidopa-Levodopa at home at scheduled times but stated the bottle from home stated take 5 tablets daily. The responsible party stated the hospital was administering it at scheduled times, but the discharging doctor wrote 5 pills daily without specifying if the tablets should have been administered at separate times throughout the day. The responsible party stated they understood why the facility was following the order as the hospital wrote the order upon discharge from the hospital. The responsible party stated they met with the Nurse Practitioner on 10/20/2025 and explained to her how the medication should be administered throughout the day and said, we got it all straightened out that day. The responsible party stated they were notified on 10/22/2025 by a nurse at the facility that Resident #1 was administered 5 tablets at once on 10/21/2025, had a change in condition, and was transferred to the hospital.During an interview on 10/24/2025 at 2:07 p.m., the ADON stated Resident #1's medications, including the five tablets a day of Carbidopa-Levodopa were reviewed upon admission by the NP and the ADON. The ADON stated, It did seem odd when you look back at it, where was everyone's critical thinking. The ADON stated he became aware of a concern with Resident #1's Carbidopa-Levodopa order when LVN C notified the ADON on the afternoon of 10/21/2025 that Resident #1 had a change in condition and seemed different. The ADON stated LVN C also told the ADON that MA D had reported to LVN C that something was wrong with the administration order of the Carbidopa-Levodopa and it was firing off at 4:00 p.m. instead of 7:00 p.m. and the ADON stated he looked at the blister pack and it was the original blister pack with 5 tablets and it had a change in direction sticker on it. The ADON stated MA D did not give the 5 tablets from the blister pack and followed the order to give one tablet. The ADON stated MA D pulled from the resident's home supply bottle. The ADON stated he instructed LVN C to call MA F and ask what MA F administered and the ADON observed LVN C nodding her head acknowledging that [MA F] gave her 10 pills and that is what I understood but it turns out that she gave her 5 pills instead. The ADON stated he counted the administration doses and determined on 10/21/2025, MA F Resident #1 3.5 tablets over the newly ordered dose amount. The ADON stated the new blister packs were on the medication cart at the time of MA F's medication administration and stated MA F grabbed the wrong blister pack and did not look at the change in direction sticker and did not verify the blister pack instructions matched the MAR. The ADON stated the discontinued blister pack should have been removed at the time the order was changed to avoid any medication errors. The ADON stated when he was notified Resident #1 had a change in condition, he assessed her around 5:00 p.m. on 10/21/2025 and observed her to appear weak and lethargic with altered mental status (confusion). The ADON stated Resident #1 was taken to her room, placed on oxygen, the physician was notified, and Resident #1 was transferred to the hospital for evaluation. The ADON stated it was important to administer medications accurately because, you do not want to give the wrong medication. During an interview on 10/24/2025 at 4:23 p.m., the DON stated when administering a medication, the person administering the medication should follow the five rights of medication pass which included ensuring it was the right patient, correct dosage, correct route for administration and the person should validate the medication blister pack matched the order on the MAR. The DON stated change of direction stickers were used to identify a change in an order and a person administering medication should verify the new order on the MAR was used by checking the order in the EMR. The DON stated he was notified of the medication error for Resident #1 by the ADON on 10/22/2025 and stated they completed a QAPI action plan, initiated in-services with direct care staff and stated there were 34 nurses and medication aides. The DON stated a pharmacy representative completed a cart audit on 10/22/2025 and compared resident orders in EMR to the resident blister packs to ensure accuracy. The DON stated MA F was suspended on 10/22/2025 and terminated on 10/23/2025. The DON stated the Medical Director, who was Resident #1's physician, was notified of the medication error on 10/21/2025. The DON stated residents who received medications from MA F on 10/21/2025 were assessed to ensure there were no additional concerns and none were identified.During an interview on 10/24/2025 at 5:52 p.m., the Administrator stated he was notified of the medication error and hospitalization of Resident #1 on 10/21/2025. The Administrator stated they immediately set up a QAPI plan to ensure residents were free from medication errors. The Administrator stated MA F was suspended pending the investigation into the error and the ADON completed a medication error report and started in-servicing on medication administration safety to include change in direction stickers and abuse and neglect. The Administrator stated they conducted a record review to determine how the medication error occurred and stated their audit revealed the medication was administered from the blister pack on 10/18/2025, 10/19/2025, 10/20/2025 and erroneously on 10/21/2025. The Administrator stated the audit revealed that Resident #1 was given 3.5 tablets of Carbidopa-Levodopa more than should have been administered on the morning of 10/21/2025. The Administrator stated a pharmacy technician completed an audit on all of the blister packs and MARs on 10/22/2025. The Administrator stated the Medical Director and the Ombudsman were notified of the medication error. The Administrator stated 2 additional residents were prescribed Carbidopa Levodopa, Resident #5, and Resident #6. The Administrator stated all levels of things from mild effects to death of a resident could occur when a resident was administered the incorrect medication or dosage. The facility course of action prior to surveyor entrance included:Record review of a facility document provided by the Administrator titled, QAPI Action Plan, revealed, Problem: Medication error by CMA which required a resident to be sent out to local ER for further evaluation and treatment and Goal: To ensure all residents' health and safety by receiving proper care i.e. free from medication errors. The actions included: called 911. Inservice on medication safety and abuse/neglect/exploitation prevention. Suspend CMA for medication error 10/21/2025. Charge nurses to monitor all resident who were in the care of this CMA for change in condition related to medication errors. Notify physician. Notify responsible party in person at the facility. In-service nursing staff on making proper notifications to family members/responsible party. Run medication report for all residents who are on Carbidopa-Levodopa. Document in the clinical record of all residents in the care of this CMA to monitor for s/s of change in condition related to possible medication errors. Nursing administration to verify physician orders related to medications. Resident affected by this incident was sent to hospital per physician order. The document revealed, further investigation revealed: 1. What was the medication error? 10/21/2025 5 tablets administered at 11 a.m. of Carbidopa-Levodopa 25-100mg. 2. What medication? Carbidopa-Levodopa 25-100mg. 3. What was the orders? A. Carbidopa-Levodopa 25-100mg 5 tabs once a day on admission date 10/16/2025. B. Then the order changed on 10/20/2025 to Carbidopa-Levodopa 25-100mg give 1.5 tabs po at [8:00 a.m.] and [11:00 a.m.]. Carbidopa-Levodopa give 1 tab po at [3:00 p.m.] and [7:00 p.m.]. Start date of new order was 10/21/2025. 4. What was the frequency the medication was given? Original order 5 tablets once a day, then 5 tablets in total per day 3 in the morning and 2 at night. 5. What was the number of dosages the medication error occurred? One 10/21/2025 at 11:00 a.m. 6. How many pills did she take over the physician ordered amount? 3.5 tablets.Record review of a facility document titled Medication Error Report, revealed the person completing the report was the ADON on 10/21/2025 and the resident listed was Resident #1. The report listed the medication as Carbidopa-Levodopa 25-100mg and frequency ordered was 1.5 tabs at 8 a.m., 1.5 tabs at 11 a.m., 1 tab at 3:00 p.m. and 1 tab at 7 p.m. Description of the medication error was checked wrong dose. Description of the incident revealed, [MA F] was assigned at 10/21/2025 to Recovery (name of hallway) to administer medications. At 4:30 p.m. [MA D] was to give Resident #1 medication, noticed her condition was different, charge nurse called ADON. Medication Carbidopa-Levodopa was noticed to be wrong at 4:30 p.m. [LVN C] called [MA F] and she admitted to giving 5 pills in the morning, read order incorrectly. [ADON] informed. Date and time error occurred was 11:00 a.m. and date and time error discovered was 4:30 p.m. Immediate action taken revealed, Resident has change in vitals, lethargic, pupils dilated to 6, unable to respond to commands. VS 140/78, 74, RR 14, T 97.8, O2 90% RA, weakness, unable to speak or voice needs. The document revealed the physician was notified at 5:45 p.m. and the family/responsible party were notified at 6:00 p.m. Corrective action taken revealed, administered O2/2L via NC, called 911 immediately, informed [physician] of incident and emergency medical attention. Contributing factors revealed, failure to use 5 rights of proper medication administration. Preventive/Corrective Actions revealed, policy/procedure reviewed, staff counseling or retraining and follow up audits scheduled. Describe planned prevention measures revealed, [MA F called by Staffing Coordinator and informed her of being placed on suspension pending investigation and to immediate termination. Staff will be in-serviced on proper medication administration. Record review of a facility document titled Disciplinary Action Form revealed MA F listed as the employee and date of hire was 01/18/2025. The offenses checked were employee conduct, safety, company philosophy and failure to complete duties as assigned. The new violation information revealed, This letter serves as formal notice of termination of your employment, effective immediately, with [facility], due to a serious medication administration error that resulted in a change in condition for [Resident #1] and Due to the severity of the violation, the company decided to forego the normal disciplinary process and moved to immediate termination. The document, dated 10/22/2025, was signed by MA F and the ADON. Record review of an undated facility staff roster revealed 34 licensed nursing and medication aides. Record review of a facility in-service training, dated 10/22/2025, and titled, Medication Safety & Abuse/Neglect/Exploitation Prevention revealed training included the definition of a medication error, examples of medication errors including giving the wrong dose, clarifying unclear orders, reading labels carefully, and using safety checks like MAR vs. medication label vs. physician order. The in-service included immediate steps to take when a medication error occurs that included assessing and monitoring the patient for adverse effects, notification of the DON, physician, and responsible party. The in-service was signed by 33 direct care staff members and 5 were documented as notified over the phone. Record review of an email from the Administrator to the Ombudsman, dated 10/23/2025 at 11:04 a.m., revealed the Ombudsman was notified of the medication error.Record review of an email dated 10/22/2025 at 4:27 p.m. from the Administrator to HHSC Complaint and Incident Intake revealed the Administrator reported the medication error and hospitalization of Resident #1 to HHSC. Record review of an undated Resident Room Roster, provided 10/24/2025 revealed 18 residents resided on the Recovery hallway.Record review of 10 resident's (Resident #2,7,8,9,10,11,12,13,14,15) revealed a progress note on 10/21/2025 that read, Resident has no s/s or changes with administration of medications.Record review of Resident #5's October medication administration record revealed an order, Carbidopa-Levodopa 25-100mg give 1 tablet by mouth three times a day for Parkinson's Disease The medication was scheduled for 8 a.m., 1 p.m. and 5 p.m. and there were no holes in the MAR.Record review of Resident #6's October medication administration record revealed an order, Carbidopa-Levodopa 25-250 mg. Give 1 tablet by mouth four times a day related to Parkinsonism and was scheduled for 6 a.m., 12 p.m., 6 p.m. and 9 p.m. There were no holes in the MAR. During an interview with MA F, 10/24/2025 at 11:32 a.m., MA F stated she was terminated from her job as a medication aide due to a medication error. During interviews with 1 MA (weekends), 4 LVNs (day shift), 1 RN (night shift) 1 MA (afternoon shift) and 1 MA (day shift and received training by phone) the staff members stated they received training on medication administration including safe administration and using 5 rights of medication administration, change of direction stickers, validating blister pack orders match the physician orders, notifying the physician and charge nurse if orders do not match prior to administration. The staff members received training on abuse and neglect and were able to identify when and who to report allegations of abuse or neglect. During an interview with Resident #5, 10/24/2025 at 5:43 p.m., Resident #5 stated she received her Carbidopa-Levodopa three times a day and stated she had been receiving her medication accurately and on time and expressed no concerns with medication administration. During an interview with Resident #6, 10/24/2025 at 5:48 pm, Resident #6 stated he received his Carbidopa-Levodopa four times a day and expressed no concerns with medication administration. During an observation with LVN J, 10/24/2025 at 5:39 p.m., LVN J pulled Resident #5 and #6 Carbidopa-Levodopa 25-100 mg blister pack from the medication administration cart and Resident 5 and Resident #6's blister pack matched the resident's Carbidopa-Levodopa MAR.

Based on interview and record review, the facility failed to immediately inform the resident's responsible party, consistent with his or her authority, when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 6 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's responsible party when Resident #1 had a medication error, change in condition, and was transferred to the hospital on [DATE]. This failure could place residents at risk of a decreased quality of life or hospitalization resulting in a decline in psychosocial or physical health.The findings included:Record review of an undated admission record revealed Resident #1 was an [AGE] year old female, admitted [DATE], with diagnoses that included Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors), fracture of the lower end of right femur (hip fracture), type 2 diabetes (a condition in which the body cannot use insulin correctly and sugar builds up in the blood) and dementia (a general term for impaired ability to remember, think, or make decisions). The admission record revealed Resident #1 had an emergency contact #1 and emergency contact #2 listed with telephone numbers and addresses. Record review of a facility document titled Brief Interview for Mental Status (BIMS) Evaluation, dated 10/17/2025, revealed a BIMS score of 03, indicating severe cognitive impairment. Record review of Resident #1's undated comprehensive care plan, revealed a care plan that stated Resident #1 had a diagnosis of Parkinson Disease with an intervention, give medications as ordered by the physician, dated 10/23/2025. Record review of an undated facility document titled, SNF/NF to Hospital Transfer Form revealed Resident #1 was transferred to the hospital for a med error at 10/21/2025 at 5:00 p.m. and the document was completed by the ADON. Record review of Resident #1's progress notes dated 10/21/2025 at 5:31 p.m., by LVN C, revealed, Patient was returning to her room after dinner and this nurse (LVN C) and staff noticed patient had altered mental status and shortness of breath. Patient was unable to hold herself up in her wheelchair. This nurse took patient to her room, administered O2 @ 2L, via nasal canula, this nurse completed a head-to-toe assessment, and this nurse immediately called [ADON]. A progress note dated 10/21/2025 at 5:45 p.m. by the ADON revealed, LATE ENTRY. Resident sent out to [hospital] via stretcher escorted by EMS per [physician] for further evaluation and treatment d/t AMS and changes in vitals. Administrator and DON informed on [sic]incident. During an interview on 10/24/2025 at 1:20 p.m., Resident #1's RP, stated the RP arrived at the nursing facility to visit Resident #1 at 10:00 a.m. on 10/23/2025 and were notified by the ADON that Resident #1 was administered five tablets at one time of her Carbidopa-Levodopa instead of following the new order, given by the NP on 10/20/2025, to give one tablet at assigned times. The RP was told Resident #1 was sent to the hospital due to a change in condition. The RP stated no one called or notified the RP or emergency contact on 10/21/2025 when Resident #1 had a change in condition and was sent to the hospital. During an interview on 10/24/2025 at 1:50 p.m., LVN C stated she was the charge nurse for Resident #1 on 10/21/2025 and stated the ADON sent Resident #1 to the hospital and completed the physician notification. LVN C stated she did not call and notify the RP of Resident #1's medication error, change in condition, or transfer to the hospital because she assumed the ADON made the notification. LVN C stated, usually the nurse who sends them out, does the discharge notification and LVN C stated the shift was changing and they had another emergency going on at the same time. LVN C stated responsible parties should be notified of changes at the time of the incident. LVN C stated it was important to notify the responsible party, because something bad can happen and they need to know that their family member is not in the building and headed out to the hospital. LVN C stated she talked to the RP on the morning of 10/22/2025 and the responsible party told LVN C that the responsible party had not been notified of the medication error, change in condition, or transfer to the hospital. During an interview 10/24/2025 at 2:07 p.m., the ADON, stated he was notified by LVN C that Resident #1 had a change in condition on 10/21/2025 around 5:00 p.m. The ADON said he contacted the physician and received an order to send Resident #1 to the hospital. The ADON stated normally it was the charge nurse's responsibility to notify the responsible party at the time of a medication errors, change in condition, and transfers to the hospital. The ADON stated we had so much going on right then that there was a mishap and miscommunication and the RP was not contacted at the time of the medication error, change in condition, and transfer to the hospital. The ADON stated Resident #1's RP arrived at the facility on 10/22/2025 and was notified at that time of Resident #1's medication error, change in condition, and transfer to hospital. The ADON stated it was important to notify the responsible party of changes in order to let them know where their family member is and they need to know from us and not from the hospital. Record review of an undated facility policy titled, Discharge/Transfer of (Voluntary)the Resident, the policy stated, Transfer: 4. Explain transfer and reason to the resident and/or representative or person (s) responsible for care. Record review of a facility document dated 10/22/2025, and titled, In-Service Training: Proper Notification to Responsible Parties Following a Medication Error, stated, Immediate Actions Following Discovery of a Medication Error: 3. Notify the Responsible Party/Resident Representative: a. Must be done promptly after physician notification, especially if the error resulted in or could result in harm.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. 1. The facility failed to ensure 4 pitchers of beverages were covered and dated when prepared. 2. The facility failed to ensure box of powder sugar was dated with open date. 3. The facility failed to ensure opened bag of spaghetti was properly sealed with an opened date. 4. The facility failed to ensure opened bag of elbow noodles was dated with an opened date. 5. The facility failed to ensure food temperatures were taken in a sanitary fashion. 6. The facility failed to ensure staff with facial hair was covered by a hair restraint. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on [DATE] at 9:24 a.m. during the initial tour of the kitchen revealed in the standing refrigerator 3 pitchers of beverages not dated with what looked to be apple juice, orange juice and milk all were approximately ,d+[DATE]th emptied and a large pitcher toward the back with what looked to be a juice with no lid and no date. Further observation during the initial tour of the kitchen revealed in the pantry an opened box of powder sugar half empty with no date as to when it was opened, a 10-pound bag of spaghetti in a zip lock bag with top of bag opened to air not dated as to when it was opened, and a quarter of a bag of elbow macaroni noodles with the open end tied off not dated when opened. During an interview on [DATE] at 9:31 a.m. [NAME] A stated she did not know when the spaghetti and elbow pasta were opened and didnot know when it was used. [NAME] A further stated it should have been dated. [NAME] A stated it was important to date items due to it could be dangerous to serve them not knowing when it was opened, and it could cause sickness. [NAME] A stated she did not prep the juices. During an interview and observation on [DATE]at 9:40 a.m. the DA B stated the drinks should be dated when they were prepared. DA B further stated it could make people sick if they did not know when the juice had been prepared. DA B stated he was not there when juices were prepared, but when he came to work there were already there. DA B removed the beverages from the refrigerator and threw them out. Observation on [DATE] at 4:14 p.m. revealed [NAME] C taking the food temperatures. [NAME] C was observed while taking temperatures of ground meat, beans, and rice would place the digital thermometer in iced water and wipe with napkin then place in the next item to take temperature of the food item. Observation on [DATE] at 4:20 p.m. revealed when the DM when asked how staff typically took the temperature of food, she gathered the items from the table including alcohol swabs, pieces of napkin and the digital thermometer. The DM used the digital thermometer after wiping with alcohol swab took the temperature of puree beans. During an interview on [DATE] at 4:26 p.m. with the DM and [NAME] C the DM stated alcohol swabs should be used when taking temperatures of items due to it would not being sanitary going from one item to another. [NAME] C stated the digital thermometer should be sanitized stating by not sanitizing it could cause contamination of the food. [NAME] C further stated by not sanitizing the thermometer could make residents sick. Observation on [DATE] at 8:30 a.m. revealed [NAME] D not wearing a beard restraint (hair net) with a mustache, beard to his chin and hair along the jaw line while preparing breakfast plates. During an interview and observation on [DATE] at 8:45 a.m. [NAME] D stated he did not normally have facial hair so he does not usually need a beard net. [NAME] D further stated beard nets were worn so hair would not go in the food. [NAME] D was not able to explain the risk of hair going into the food. [NAME] D upset by questions regarding beard restraint, stated he wasn't stupid as he was observed to continue to prepare plates and did not put on beard restraint. [NAME] D finished preparing plates. The DM was observed to then provide [NAME] D with a beard restraint. During an interview on [DATE] at 8:50 a.m. the DM stated the purpose of the beard restraints were to prevent hair from going into the food. The DM further stated they prevent cross contamination of the food. The DM stated by hair getting into the food it could cause residents to get sick or even choke on the hair. During an interview on [DATE] at 3:55 p.m. the DON stated beard restraints were used so hair did not fall in the food. The DON further stated if hair was to get in the food it could cause food contamination and the resident could get sick. During an interview on [DATE] at 12:47 p.m. the DM stated pasta noodles should be stored in a zip lock bag, sealed properly, dated with the opened date. The DM stated sealing dried items prevented contamination and by ensuring the opened date was on items ensued staff knew when it was opened. The DM stated beverages should have lids or be covered with a date it was put in the pitcher. The DM further stated beverages could be in the refrigerator for 3 days from the poor date. She stated by not knowing the date it was poured it could be contaminated and make someone sick. During an interview on [DATE] at 1:45 p.m. with the ADM revealed dried food items should be in a resealable container or in a sealable package with a date. The ADM further stated by dating items when opened was for staff to know it was fresh and not expired. The ADM stated by sealing items keep them from getting pest in them and it would stay fresh. The ADM stated beard guards kept hair from getting in the food. He further stated staff were to wear beard restraints any time they were in the kitchen just like a hair net. The ADM stated beard restraints keep hair out of the food and was important due to the hygiene issue. The ADM stated food temperatures should be taken with a digital thermometer, and an alcohol wipe should be used between food items. Review of facility's policy, Food Receiving and Storage, date revised [DATE], read, Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 6. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such food will be rotated using a first in - first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of facility's policy, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, Policy Statement: Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness., Policy Interpretation and implementation: 12. Hair nets or [NAME] and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, ,d+[DATE].11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, ,d+[DATE] Hair Restraints, ,d+[DATE].11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

44020 Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 11 residents (Resident #6, Resident #22 and Resident #62) reviewed for care plans. 1. The facility failed to ensure Resident #6's care plan reflected his receiving hospice services and did not have an active care plan. 2. The facility failed to ensure Resident #22's care plan reflected his pain management. 3. The facility filed to ensure Resident #62's care plan reflected his full code status, need for assistance with ADLs (activities of daily living), and only communicating in Spanish. These deficient practices place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: 1. Record review of Resident #6's face sheet, dated 12/04/2024, revealed Resident #6 was admitted on [DATE] with a readmitted on 08/22/2024 with diagnoses which included: acute diastolic (congestive) heart failure, chronic atrial fibrillation, unspecified dementia, moderate, without behavioral disturbance, heart failure, hypothyroidism, and hypertension. Record review of Resident #6's Significant change MDS assessment, dated 08/26/2024, revealed Resident #6's BIMS score was 5 for severe cognitive impairment and coded as receiving hospice services while a resident at the facility. Record review of Resident #6's physician order summary report, dated 12/04/2024, read, ADMIT TO [name of hospice service], with an order date of 08/23/2024. Record review of Resident #6's care plan with a closed date of 08/30/2024 and a targeted date 09/04/2024, revealed the care plan was closed and did not have a care plan addressing Resident #6 receiving hospice services. During an interview on 12/03/2024 at 3:32 p.m. with the SW stated the DON would care plan when a resident goes on hospice services. During an interview on 12/03/2024 at 3:55 p.m. the DON stated Resident #6's care plan had been deactivated, did not have a care plan for hospice and did not have an active care plan. The DON further stated Resident #6 not having an active care plan would cause the staff to not be aware of his wishes or how they were to care for him correctly. 2.Record review of Resident #22's face sheet, dated 12/04/2024, revealed the resident was [AGE] years old male and an original admitted [DATE] and re-admitted [DATE] with diagnoses that included pain in left shoulder and muscle wasting and atrophy (muscles to decrease in size and strength). Record review of Resident #22's quarterly MDS, dated [DATE], revealed Resident #22's BIMS score was 15 reflecting his cognitive function was intact. Further record review indicated J0100: Pain Management in the Section J (Health Conditions) was answered the resident received scheduled pain medication as ordered. Record review of Resident #22's physician order, dated 10/31/2024, revealed the resident had the order of Norco (Hydrocodone-Acetaminophen) oral tablet 10-325 mg. Give one tablet by mouth every 6 hours as needed for pain, referral for out-patient rehab for occupational therapy due to shoulder pain, and Monitor level of pain every shift using the following scale: 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain every shift. Record review of Resident #22's nursing note, dated 10/28/2024 and 11/18/2024, revealed the resident was transferred to the local acute hospital due to his shoulder pain per the resident's request. Record review of Resident #22's comprehensive care plan, dated 08/16/2024, revealed there were no care plan regarding pain management. Interview on 12/03/2024 at 1:53 p.m. the DON stated Resident #22 had pain to his left shoulder, and for the pain management, the resident had medications and out-patient therapy, and transferred the resident to the local acute hospital because the resident requested it. IDT discussed the resident's pain. However, the facility did not develop the care plan for pain. Interview on 12/03/2024 at 2:47 p.m. the DON said developing care plans was her responsibility, and forgetting to develop Resident #22's care plan for pain, might cause lack of pain management. 3. Record review of Resident #62's face sheet, dated 12/04/2024, revealed Resident #62 was admitted on [DATE] with a readmitted on 10/19/2024 with diagnoses which included: encounter for orthopedic aftercare following surgical amputation, type 2 diabetes mellitus without complications, polyneuropathy, unspecified, hypertension, acquired absence of right leg below knee, end stage renal disease, unsteadiness of feet, difficulty in walking, not elsewhere classified, and dependence on renal dialysis. Record review of Resident #62's Quarterly MDS assessment, dated 10/26/2024, revealed Resident #62's BIMS score was 11 for moderate cognitive impairment and substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathing self, lower body dressing, sit to lying (the ability to move from sitting on side of bed to lying flat on the bed), and lying to sitting on the side of bed (the ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor and with no back support). Record review of Resident #62's physician order summary report, dated 12/04/2024, read, FULLCODE, with an order date of 09/28/2024. Record review of Resident #62's care plan with a target date of 10/09/2024, revealed the care plan did not address Resident #62's need for assistance with ADLs, code status and only communicating in Spanish. During an interview on 12/01/2024 at 10:52 a.m. Family Member A of Resident #62 stated when she is visiting, she would translate for Resident #62 due to him only speaking Spanish. Family Member A further stated Resident #62's Family Member B was present daily, but she also only spoke Spanish. During an interview and observation on 12/03/2024 at 3:32 p.m. with the SW revealed care plans are done by the DON and if she needs assistance the ADON will help with care plans. The SW further stated the SW was responsible for completing the code status, behaviors and communication in the care plan. The SW stated she would typically care plan a resident speaking only Spanish and code status. The SW was observed reviewing Resident #62's care plan on her computer when she stated Resident #62's care plan did not address his Spanish speaking only nor his code status being full code. The SW stated the importance of the care plan was to show the resident's diagnoses, the nursing he gets, any behaviors he has, and what the staff need to look for when caring for him. The SW stated the importance of the code status being care planned was for staff to know what to do and the resident's wishes for resuscitation or not to be resuscitated. She further stated the importance of care planning his communication would make staff aware of the need possibly for a translator. During an interview on 12/03/2024 at 3:55 p.m. the DON reviewed Resident #62/s care plan on her computer of which she revealed ADLs (activities of daily living), communication and code status were not care planned. The DON further stated ADLs, communication and code status were things that would be care planned. The DON stated the ADLs were not care planned which she felt was odd due to the admission care plan when completed usually triggers them in the comprehensive care plan. The DON further stated Resident #62 only speaking Spanish should have been care planned. The DON stated Resident #62 was Spanish speaking mostly. The DON stated the importance of a care plan was to inform the staff of the needs of the resident, how to care for them and what their wishes were. During an interview on 12/04/2024 at 1:55 p.m. with the ADM revealed the DON, a nurse the facility contracts had been doing the care plans. He further stated when they took over in July it was found the care plans had not been done for residents and the issue was part of QA with the goal of completing them being within 90 days. The ADM further stated he believed they were behind on meeting the 90-day goal. Record review of facility's Care Plans - Comprehensive policy, revision date April 2010, read, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problems areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflects currently recognized standards of practice for problem areas and conditions. 4. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).

42031 44020 Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 4 of 19 residents (Resident #4, Resident #25, Resident #30 and Resident #39) reviewed for care plan revisions. 1. The facility failed to ensure Resident #4's care plan was revised quarterly. 2. The facility failed to ensure Resident #25 care plan was revised after Significant Change in condition and when resident returned from the hospital. 3. The facility failed to ensure Resident #30's care plan was revised or reviewed after the quarterly MDS was completed on 09/25/2024. 4. The facility failed to ensure Resident #39's care plan was revised after revised after re-entry to facility and Significant Change in condition. These deficient practices could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Resident #4's face sheet dated 12/4/2024 revealed the resident was admitted to the facility on [DATE], with readmissions on 8/3/2017, and 5/17/2024. Resident #4's diagnoses included secondary parkinsonism, unspecified (any condition that involves the types of movement problems seen in Parkinson disease but is not Parkinson's disease), chronic kidney disease (chronic progressive loss of kidney function), and repeated falls. Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 7 indicating the resident was severely cognitively impaired. The resident was totally dependent on staff for dressing and footwear, and required partial assistance for eating, showering, and personal hygiene. The resident was always incontinent of urine and frequently incontinent of bowel and was at risk of developing pressure ulcers. Record review of Resident #4's EHR (Electronic Health Record) revealed under the care plan tab there was no current care plan for the resident. Under this care plan tab there were three care plans under history, with the newest care plan with a date initiated on 8/3/2022 with a next review date of 6/9/2024. During an interview on 12/03/2024 at 2:30 p.m. the DON stated she was responsible for updating the care plans and she had a PRN (as needed) RN that assisted her. The DON stated she was not sure why Resident #4 had no current care plan and they must have missed revising it in June of 2024. During an interview on 12/4/2024 at 2:00 p.m. the DON stated it was important for the resident's care plans to be revised and current to ensure they received any needed services. 2. Record review of Resident #25's face sheet, dated 12/04/2024, revealed Resident #25 was originally admitted on [DATE] with an admitted [DATE] with diagnoses which included: acute respiratory failure with hypoxia, end stage renal disease, parkinsonism, major depressive disorder, hyperlipidemia, anxiety disorder, and dependence on renal dialysis. Record review of Resident #25's Significant change MDS assessment, dated 10/18/2024, revealed Resident 25 unable to complete the BIMS interview with long- and short-term memory loss. Record review of Resident #25's care plan revealed a start date of 08/18/2024, target date 11/27/2024 and next review date 09/01/2024 without a review having been completed. During an interview on 12/04/2024 at 1:36 p.m. the DON stated regarding the revision of Resident #25's care plan 08/18/2024 it looked like there were some nursing items updated however, the care plan had not been reviewed or revised for the quarter. The DON further stated the facility had been trying to go through all the care plans because they were not getting done before she came to the facility. The DON stated the importance of revision was to be up to date on the care of the resident for the staff to know how to care for the resident. 3. Record review of Resident #30's face sheet, dated 12/04/2024, revealed the resident was [AGE] years old male and an original admitted [DATE] and re-admitted [DATE] with diagnoses that included: displaced intertrochanteric fracture of left femur (fracture to hip area), heart failure (does not pump enough blood for the body's need), muscle wasting and atrophy (muscles to decrease in size and strength), hypertension (high blood pressure), and chronic obstructive pulmonary disease (restricted airflow and breathing problems). Record review of Resident #30's quarterly MDS, dated [DATE], revealed Resident #30's BIMS score was 15 reflecting his cognitive function was intact. Record review of Resident #30's comprehensive care plan revealed the care plan's start date was 03/24/2024, and next review date for the care plan was 06/04/2024. However, there was no reviewed or revised care plan since 06/04/2024. Interview on 12/03/2024 at 11:07 a.m. the DON stated Resident #30's care plan was not revised or reviewed after the resident's quarterly MDS was completed on 09/25/2024. The facility generally had IDT meeting after completion of quarterly MDS, but the DON did not know what reason she did not revise the resident's care plan. Updating or revising the care plan was IDT and DON's responsibility, and not revising care plan after comprehensive assessment might cause incorrect care to the resident. 4. Record review of Resident #39's face sheet, dated 12/04/2024, revealed Resident #39 was originally admitted on [DATE] with an admitted [DATE] with diagnoses which included: other cerebral infarction, unspecified atrial fibrillation, hemiplegia, unspecified affecting right nondominant side, aphasia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and traumatic subdural hemorrhage without loss of consciousness subsequent encounter. Record review of Resident #39's MDS assessments indicated the following: *Entry MDS completed 09/07/2024 *5-day MDS dated [DATE] *Significant Change MDS assessment, dated 10/18/2024 The Significant Change MDS assessment revealed Resident #39 unable to complete the BIMS interview with long- and short-term memory loss. Record review of Resident #39's care plan revealed a start date of 12/01/2024, target completion date 03/20/2025 without a review having been completed after her return form the hospital. During an interview 12/03/2024 at 3:55 p.m. the DON revealed when Resident #39 returned from the hospital they should have reviewed his care plan. DON further stated they just didn't catch it which was why the care plan had not been revised. Record review of facility's Care Plans - Comprehensive policy, revision date April 2010, read, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problems areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflects currently recognized standards of practice for problem areas and conditions. 4. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). 5. The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; When the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in section 2-44, Care plan completion based on the CAA process is required for OBRA-required comprehensive assessments. It is not required for non-comprehensive assessments (Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records. However, the resident's care plan must be reviewed after each assessment, as required by S483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, record review, and interviews, the facility failed to ensure resident received food prepared in a from designed to meet individual needs for 1 of 2 meals, reviewed for nutrition services. The facility failed to ensure the breakfast meal served on 12/03/2024 had the appropriate consistency for the meat serving for the puree textured diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to choking, poor intake, and/or weight loss. The findings included: Observation on 12/03/2024 at 8:40 a.m. revealed [NAME] D preparing breakfast plates for puree residents with meat (sausage) that appeared grainy, closer to a fine ground meat consistency than a pudding consistency. [NAME] D put gravy over the meat as he served the plates. [NAME] D placed a scoop of the puree meat on a plate when asked about the texture of the meat. The DM then took a plastic spoon and mashed the puree meat. The DM after mashing the meat with a plastic spoon then removed from the serving line and pureed the meat. [NAME] D only had 2 tray tickets remaining when the puree meat was removed from the serving table to be processed more by the DM. Observation, record review and interview on 12/03/2024 at 11:12 a.m. revealed [NAME] D preparing puree chicken fried steak with gravy for the lunch meal using microwave warmed milk as the liquid to assist with the processing of the pureed chicken fried steak. Review of the recipe book read gravy to be used when pureeing the chicken fried steak. [NAME] D stated he did not know to use the recipe book and had been instructed to use milk when preparing the chicken fried steak. During an interview on 12/04/2024 at 12:43 p.m. the DM stated the facility had 9 residents who received puree diets. The DM further stated they are served last. The DM could not recall if any purees had been served however, stated there may be some residents who received a puree diet may have eaten in their room, she was not sure who was present the day before in the dining room for the breakfast meal. During an interview on 12/04/2024 at 12:47 p.m. the DM stated she has not had any in-services regarding training meal texture preparation. The DM stated they had had in-services to follow the recipe when preparing diets. The DM further stated the sausage did look to dry to be pureed consistency. The DM stated puree diets are for residents with swallowing issues. She stated the resident could be at risk of chocking or aspiration by receiving non-puree food. During an interview on 12/04/2024 at 1:40 p.m. the DON stated if the diet was not right consistency a resident could choke on it, and possibly get aspiration pneumonia. During an interview on 12/04/2024 at 1:42 p.m. the DM and DON revealed the facility did not have a policy regarding diet textures and preparation. The DM stated the recipe told staff how to make the puree. During an interview on 12/04/2024 at 1:45 p.m. the ADM stated food consistencies should reflect the order when served. The ADM stated pureed diets should have a pudding consistency. The ADM further stated they do not want residents to suffer aspiration pneumonia if served the wrong diet.

Based on interview and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 10 of 19 staff (CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director) reviewed for training, in that: The facility failed to ensure that CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director had completed their mandatory QAPI annual training. This failure could place residents at risk for care by staff who had been insufficiently trained while working in the facility. The findings included: Record review of the annual staff training information revealed the following staff had not completed their mandatory QAPI annual training requirement: *CNA-K (hired 11/02/2023), *CMA-L (hired 05/09/2023), *CMA-M (hired 11/14/2019), *CMA-N (hired 01/18/2021), *CNA-O (hired01/13/2021), *Hospitality-P (hired09/23/2023), *CNA-Q (hired08/07/2023), *Hospitality-R (hired11/22/2022), *Dietary Manger (02/26/2024), and *Activity Director (hired 11/12/2024). Interview on 12/04/2024 at 1:07 p.m. with Administrator and DON stated CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director did not complete their mandatory QAPI annual training. Further interview with DON stated because the facility Human Resources staff was on vacation at this time, the facility did not know what reason the staff did not take the QAPI annual training. It was Human Resources staff's responsibility, but the staff had just promotion recently to Human Resources from CNA position. The staff might be catching all missing trainings. The possible negative outcome was that they might not know what QAPI was.

Based on interview and record review, the facility failed to ensure compliance and ethics training was completed for 10 of 19 employees (CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director) reviewed for orientation training. The facility failed to ensure that CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director had completed their mandatory ethics training. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of the annual staff training information revealed the following staff had not completed their mandatory ethics annual training requirement t: *CNA-K (hired 11/02/2023), *CMA-L (hired 05/09/2023), *CMA-M (hired 11/14/2019), *CMA-N (hired 01/18/2021), *CNA-O (hired01/13/2021), *Hospitality-P (hired09/23/2023), *CNA-Q (hired08/07/2023), *Hospitality-R (hired11/22/2022), *Dietary Manger (02/26/2024), and *Activity Director (hired 11/12/2024). Interview on 12/04/2024 at 1:07 p.m. with Administrator and DON stated CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director did not complete their mandatory ethics annual training. Further interview with DON stated because the facility Human Resources staff was on vacation at this time, the facility did not know what reason the staff did not take the ethics annual training. It was Human Resources staff's responsibility, but the staff had just promotion recently to Human Resources from CNA position. The staff might be catching all missing trainings. The possible negative outcome was that they might not know the procedures for resolving issues in the facility or how to deal with residents in an appropriate manner.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 19 residents (Residents #34) reviewed for accommodation of needs. The facility failed to ensure Resident #34's call light was within reach while he was positioned in her wheelchair. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries. The findings included: Record review of Resident #34's face sheet, dated 12/04/2024, revealed the resident was [AGE] years old male and an original admitted [DATE] and re-admitted [DATE] with diagnoses that included: Dementia (loss of cognitive function), hemiplegia and hemiparesis (weakness and loss of strength on one side of the body), muscle weakness, muscle wasting and atrophy (muscles to decrease in size and strength), and rhinitis (nasal congestion, sneezing, and itching). Record review of Resident #34's quarterly MDS assessment, dated 11/08/2024, indicated his BIMS score was 99 reflecting he chooses not to participate or gave a nonsensical response. Further record review indicated the resident was dependent (Helper does all of the effort) to toilet hygiene, dressing, personal hygiene, and chair-to-bed transfer. Record review of Resident #34's comprehensive care plan, dated 11/29/2021, reflected [Resident #34] am at risk for falls related to unsteady gait/balance, weakness, and hemiplegia. For intervention - keep call light within reached and encourage to ask for assistance. Observation on 12/02/2024 at 9:16 a.m. revealed Resident #34 was on his wheelchair located in front of his bed in his room, and the call light was on the bed, which was behind him. At 9:18 a.m. revealed Resident #34 said on his wheelchair in his room, Help! Help! However, the resident's voice was very low, so most of staff could not hear the resident's voice. On at 9:25 a.m., CNA-I heard the resident's voice and entered to the resident room to help the resident. Interview on 12/02/2024 at 9:25 a.m. CNA-I stated Resident #34 was on his wheelchair located in front of his bed in his room, and the call light was on the bed, which was behind him. Resident #34 could not reach his call light. The call light should have been within reached all the time. Resident #34 could use the call light to get help. CNA-I did not know what reason the call light was on the bed. CNAs probably forgot putting the call light on him after transferring the resident from the bed to the wheelchair. Interview on 12/02/2024 at 9:38 a.m. with LVN-J stated Resident #34 could use the call light to get help. The call light should have been within reached all the time. Interview on 12/02/2024 at 4:16 p.m. with DON stated Resident #34 could use the call light to get help. The call light should have been within reached all the time per the facility policy, and if Resident #34 could not use the call light because it was not within reached, the resident's care might be delayed. Record review of the facility policy, titled Answering the call light, revised 09/2003, revealed Be sure that the call light is plugged in at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observations, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 19 residents (Residents #34) whose assessments were reviewed, in that: The facility failed to ensure Resident #34's quarterly MDS, dated [DATE], correctly assessed the resident's functional limitation in range of motion status as evidence by coding No impairment to upper extremity. However, Resident #34 had impairment regarding function limitation in range of motion to his left arm. These failures could place residents at-risk for inadequate care and services. The findings were: Record review of Resident #34's face sheet, dated 12/04/2024, revealed the resident was [AGE] years old male and an original admitted [DATE] and re-admitted [DATE] with diagnoses that included: Dementia (loss of cognitive function), hemiplegia and hemiparesis (weakness and loss of strength on one side of the body), muscle weakness, muscle wasting and atrophy (muscles to decrease in size and strength), and rhinitis (nasal congestion, sneezing, and itching). Record review of Resident #34's quarterly MDS assessment, dated 11/08/2024, indicated his BIMS score was 99 reflecting he chooses not to participate or gave a nonsensical response. Further record review indicated GG0115: Functional limitation in range of motion in the Section GG (function abilities and goals) was answered No impairment to upper extremity (shoulder, elbow, wrist, and hand). Record review of Resident #34's comprehensive care plan, dated 11/29/2021, reflected [Resident #34] have an alteration in neurological status related to of stroke with left hemiplegia, pseudobulbar affect, and the intervention was physical therapy and occupational therapy evaluated and treat as ordered. Record review of Resident #34's mobility assessment, dated 08/01/2024, reflected Resident #34's upper extremity (shoulder, elbow, wrist, and hand) had impairment on one side. Observation on 12/02/2024 at 9:28 a.m. indicated Resident #34 was on the bed and had contracture (condition of shortening and hardening of muscle) and limitation in range of motion to his left arm. Interview on 12/03/2024 at 5:17 p.m. the Director of Rehab stated Resident #34 had limitation in range of motion to his left arm due to left arm's contracture since the resident was admitted to the facility on [DATE], and the resident was receiving physical therapy including body stretching and range of motion exercise five times a week since 10/30/2024. Interview on 12/03/2024 at 5:19 p.m. the DON stated Resident #34's quarterly MDS, dated [DATE], was inaccurate regarding No impairment to upper extremity in range of motion because the resident had limitation in range of motion to his left arm. MDS nurse had responsibility to assess the resident accurately. The facility used contracted MDS nurse until hiring full-time MDS nurse, and the contracted MDS nurse should have coded impairment on one side to the resident's function limitation in range of motion to upper extremity. Further interview with the DON stated she did not know what reason the MDS nurses coded it inaccurately, and the inaccurate MDS assessment might cause inaccurate care to the resident. On 12/04/2024 at 1:35 p.m., the surveyor called to the MDS a voice message was left . The MDS nurse did not return phone call prior to exit. Record review of the facility policy, titled Resident assessment instrument, revised 01/2017, revealed The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, . The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS .

Based on observation, interviews, and record reviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed who required having leg rests and foot pedals on their wheel chairs for quality of care. The facility failed to ensure Resident #1 had her leg rests and foot pedals on her wheelchair when she went to an appointment on 04/17/2024 and her unsupported right foot slid off from her other foot which was supporting it and was caught under the moving wheelchair pushed by the Maintenance Director and resulted in a fractured femur (thigh and upper hind limb bone, longest strongest bone in the body) . This deficient practice affects residents in wheelchairs who required assistive devices to support their legs and feet such as leg rests and foot pedals and could result in falls and fractures. The findings included: Record review of Resident #1's electronic face sheet dated 04/27/2024 reflected she was originally admitted to the facility on [DATE]. Her diagnoses included: hypertensive chronic kidney disease (high blood pressure makes it more likely that the kidney disease will get worse and end up with heart problems), rheumatoid arthritis (an autoimmune and inflammatory disease causing inflammation (painful swelling) in the affected parts of the body and mainly attacks the joints), specified disorders of bone density and structure (a disease caused by low bone mass and deterioration of bone structure that causes bone fragility and increases risk of fracture), age-related osteoporosis (deterioration in bone mass and microarchitecture, with increasing risk to fragility fractures) with current pathological fracture right femur (occurs in abnormal bone, typically with normal activity or minimal trauma). Record review of Resident #1's quarterly MDS assessment with an ARD of 02/10/2024 reflected she could usually be understood and could usually understand others. She scored a 13/15 on her BIMS which signified she was cognitively intact. She required the use of a manual wheelchair for mobility. She required moderate assistance with her ADL's and was able with moderate assistance from staff to wheel 50 feet doing half of the effort. Helper lifts, holds trunk or limbs and provides more than half the effort. (Resident has more upper body support) She received a pain medication regimen. She took opioid medication (medication prescribed by the doctor to treat persistent or severe pain). Record review of Resident #1's comprehensive person-centered care plan (undated) reflected Focus, have osteoporosis (a bone disease that develops when bone density and bone mass decreases, or when the structure and strength of bone changes), 4/18/2024, was sent to ER for evaluation and treatment r/t x-rays completed revealed mildly displaced intertrochanteric (Do fracture femur with varus deformity (a deformity involving oblique displacement (broken at an angle, fracture is a straight line that's angled across the width of the bone and usually caused by landing on the bone at an angle, after a fall or hit suddenly from an angle) of part of a limb toward the midline). Interventions/Tasks, use of supportive devices such as splints, braces, canes, crutches, etc. Use of a wheelchair with leg rests and foot pedals was not care planned. Further review reflected Focus, on pain medication therapy, Intervention/Tasks, administer medication as ordered. Record review of Resident #1's MAR dated 04/1/2024 - 04/30/2024 reflected she received Tylenol with Codeine #3 tablet 300-30 (narcotic pain medication) MG, one tablet tid for pain. Original order start date 10/16/2023. She received a dose on April 17th at 08:00 AM prior to going to her hospital appointment to receive her blood transfusion. The order for Tylenol with Codeine #3 was discontinued on 04/20/2024 and new orders for oxycodone HCL (narcotic medication for pain) was ordered when she returned from the hospital. Record review of Resident #1's progress note written by LVN dated 04/17/2024 at 4:45 PM reflected resident arrived via facility w/c van from transfusion c/o pain to lower extremity per CNA. Nurse assessed bilateral lower extremities swollen from sitting up too long. Socks pulled halfway down calf tight around calves. Removed socks, patient stated she felt better repositioned bilateral legs placed on small pillow. Resident requested and received her routine pain medication. Record review of Resident #1's progress note Late Entry dated 04/17/2024 at 09:30 PM written by LVN C reflected Called to room by med aide after neighbor requested and was given prn pain medication for right hip/leg pain. Neighbor reporting that feet were caught up in w/c this am during transport appointment at hospital. Right hip area and right leg swollen. Neighbor calls out in pain on movement. Placed call to Dr .after hr. on call and received order for 2 view hip/femur x-rays. Order completed. ETA couple hours. Record review of Resident #1's Final X-ray Report dated 04/17/2024 reflected significant findings, acute, obliquely oriented, comminuted, mildly displaced intertrochanteric fracture femur with varus deformity. Observation on 04/27/2024 at 09:40 a.m. of Resident #1 revealed she was lying in bed, appeared comfortable, and her wheelchair was at the foot of her bed with leg rests and foot pedals unattached. In an interview on 04/27/2024 at 09:45 a.m. with Resident #1, she stated the man who took her to her blood transfusion appointment was not Van Driver A. She stated the man who took her to get her blood drawn, which happens two to three times a month, did not put on her regular footrests. She stated she always had the leg rests and foot pedals on her wheelchair because she needed them to support her legs. She stated she did not think to tell the man she needed them because she thought it would be her regular van driver. She stated she had to carry her right leg by placing it on top of her left leg and her foot slipped causing her right leg to get stuck under the wheelchair. She stated the man stopped and helped her free her leg, and she was in pain, but not severely hurt. She stated she told the hospital staff about her pain, but it was not addressed. She stated her pain was about a 10 out of 1-10 pain scale, 10 being the highest during her appointment which lasted from 11:00 to when she returned to the facility at 04:30 PM. She stated after she returned to the facility, she told CNA B she was in pain and to tell the nurse. She stated LVN C entered the room and treated her for pain, and later she had an x-ray, and was sent to the hospital where they were unable to treat her due to her blood condition. She stated she was then sent to a Navy hospital, but they could not treat her and then she went back to the local hospital where she was sent back to the facility. An interview on 04/27/2024 at 1:21 PM with CNA D revealed she collaborated with Resident #1 the morning of her appointment and no one told her the resident had an appointment. She stated she did not put on the leg extensions and foot pedals on Resident #1's wheelchair and usually never did. She stated she did not know the resident needed the leg rests and foot pedals. An interview on 04/27/2024 at 3:20 pm with the Maintenance Director revealed he was not the routine van driver, but a backup driver for Van Driver A. He stated he got Resident #1 out of the room on 04/17/2024. He stated he was unaware of who needed leg rests or foot pedals. He stated Resident #1 had no leg rests on her chair. When he arrived at the hospital and put the lift down and got her on the ground, her right leg slipped under her and he kept moving ahead. He stated Resident #1 did not ask him for any footrests prior to leaving. He stated he went to the nurse's station at the facility and obtained paperwork prior to going. He stated Resident #1 was holding both legs up just enough so they were not touching the ground. He stated when Resident #1's right leg went under her wheelchair, she complained of pain and told me it hurt a bit. He stated he had 4 other rides and did not think to tell anyone about the incident. He stated he was not informed Resident #1 needed the leg rests and foot pedals, and that it was not a requirement. He stated it was his fault and he did not think about the incident until the next morning at their meeting when he told the Administrator and was suspended for not reporting the incident immediately. He stated he was trained to report anything, and was so busy, he did not think about reporting it at the time. An interview on 04/28/2024 at 1:42 PM with Van Driver A revealed he worked at the facility for 2 years and had received training on van safety when he was first hired and then after the recent incident with Resident #1. He stated he never took Resident #1 to her appointment without the wheelchair leg rests and foot pedals attached. He stated Resident #1 should always have them on because she was frail. He stated he kept spare leg rests and foot pedals in the van. An interview on 04/28/2024 at 3:41 PM with LVN D revealed she collaborated with Resident #1 and the resident required the leg extenders and foot pedals on because she was frail and needed the support. An interview on 04/28/2024 at 3:47 PM with CNA E revealed she worked at the facility since 2010 and collaborated with Resident #1. She stated Resident #1 needed her leg rests and foot pedals, and the only time they were removed when they took her to the toilet and she never told her she did not want them on the wheelchair. An interview on 04/28/2024 at 4:05 PM with the DON revealed she found out about the incident with Resident #1, and staff were in-serviced immediately about communicating with the resident and putting on leg rests and foot pedals if needed. She stated staff needed to be aware of who required leg rests and foot pedals, and it should be care planned if the resident needed them for support and safety such as Resident #1. She stated accidents could happen and the resident could fall or fracture a limb. Record review of the three van drivers revealed Van Driver A was trained on van safety on his DOH: 07/27/2022 and retrained on 04/18/2024. The Maintenance Director was trained on van safety on his DOH: 12/19/2016 and retrained on 04/19/2024. Van Driver F was trained on her DOH: 07/27/2022 and retrained on 04/18/2024. Record review of the facility policy and procedure titled Safety and Supervision of Residents revised December 2007 reflected Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Record review of the facility policy and procedure titled Preventing Resident Abuse revised April 2014 reflected Encouraging all personnel, residents, family members, visitors, etc. to report any signs or suspected incidents of abuse to facility management immediately. Record review of the facility policy and procedure titled Van Safety Policy dated 01/01/2021 reflected All accidents in company vehicles must be reported immediately .to the administrator to include any driver or passenger injuries.

Based on interview and record review the facility failed to ensure residents were free from any significant medication errors for 1 of 5 residents (Resident #3) reviewed for significant medication errors in that: LVN D mistakenly administered Resident #4's evening medications to Resident #3 on 2/13/23. Resident #3 was transferred to a local hospital for observation the next day, 2/14/23. This deficient practice could affect residents who receive medication from the facility and place them at risk for adverse reactions, decline, and hospitalization . The findings were: Record review of Resident #3's diagnosis sheet, dated 2/16/23, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of urinary tract infection, site not specified, poisoning by unspecified drugs, medicaments [a substance used for medical treatment] and biological substances, accidental (unintentional) subsequent encounter, chronic kidney disease, malignant neoplasm [tumor] of cheek mucosa [inner lining of the cheek], and chronic diastolic (congestive) heart failure. Record review of Resident #3's MDS, dated [DATE], revealed Resident #3 had a BIMS score of 13, signifying little cognitive impairment. Record review of Resident #3's physician orders, dated 2/16/23 revealed the following order dated 7/1/21: HYDROcodone-Acetaminophen [also known as Tylenol #3, a combination of Tylenol and codeine, a narcotic, used to treat mild to moderately severe pain] Tablet 5-325 MG. There are no orders for Xanax [also known as alprazolam, a medication used to treat anxiety and panic disorder] or Lyrica [also known as pregabalin, a medication used to treat nerve pain, seizures and anxiety.] Record review of Resident #3's Controlled Drug Receipt/Record/Disposition Form for Hydrocodone/APAP [APAP is another name for Tylenol or Acetaminophen] 5-325 MG take 1 tablet by mouth every 5 hours as needed for pain, dated 12/23/22, revealed Resident #3's Hydrocodone/Acetaminophen was signed out as given on 2/13/23 at 9:00 p.m. by LVN D. Record review of Resident #3's medication error incident report (also known to the facility as risk management), dated 2/13/23, revealed the following note written by LVN D: this nurse and CMA entered [resident's] room to answer [resident question, what was the round pill I took? This nurse informed [resident,] apap. [Resident acknowledged and accepted.] Record review of Resident #3's medication error incident report, dated 2/13/23 and written by the CNO revealed: Resident transferred to ER for evaluation of treatment due to confusion, change in functional abilities post medication error. Nurse [LVN D] acknowledged med error on 2/13/ 10pm with CNO stated that she [LVN D] thinks that resident took 2 lyrica by mistake. Nurse states she placed roommate's [Resident #4's] pills on the table out side restroom because roommate was in restroom. When roommate [Resident #4] stated she hadn't received her medication nurse questioned [Resident #3] who proceeded to ask what the red capsules were. Nurse was directed to obtain VS [vital signs], call MD on call for directive and complete risk management. Discovery on 2/14 reveals [LVN D's] risk management inconsistent with verbal report. Call and messages to nurse [LVN D] without return call. LVN Position was terminated. Resident received Narcan at hospital. Record review of Resident #3's nursing progress notes revealed a progress note dated 2/14/23 and written by LVN E which read: [Resident #3] stated this morning she is unsure of what pills she took last night and she feels sleepy and weak. Record review of Resident #3's hospital history and physical, dated 2/14/23, revealed the following verbiage: It appears patient has an accidental overdose per facility. They had given her a Xanax pill and Lyrica and she has already take Norco.Assessment/Plan: 1. Accidental drug overdose . Per ED provider and information obtained from [the facility], patient was provided with Xanax and Lyrica unknown why she takes hydrocodone for pain. She is coming back to her baseline.2. Altered mental status . resolving secondary to accidental overdose.] Record review of Resident #4's diagnoses sheet revealed Resident #4 was admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia [low oxygen levels in the blood], hypertensive heart and chronic kidney disease with heart failure with stage 5 chronic kidney disease, or end stage renal disease, unspecified dementia [a general term for impaired ability to remember, think, or make decisions], unspecified severity, with anxiety, and type 2 diabetes mellitus with diabetic neuropathy [nerve damage due to diabetes.] Record review of Resident #4's MDS assessment, dated 1/25/23, revealed Resident #4 had a BIMS score of 15, signifying no cognitive impairment. Record review of Resident #4's physician orders, obtained 2/16/23, revealed Resident #4 had alprazolam oral tablet 0.5 mg ordered on 1/29/23 and Lyrica oral capsule 100 mg ordered on 1/19/23. Record review of Resident #4's Controlled Substance Administration Record of alprazolam tablet 0.5 mg, take 1 tablet by mouth every night at bedtime, dated 2/7/23, revealed Resident #4's alprazolam was administered on 2/13/22 at 9:00 p.m. by LVN D. Record review of Resident #4's Controlled Substance Administration Record of pregabalin cap 100 mg take 2 capsules by mouth every night at bedtime and take 1 capsule by mouth every day, dated 1/20/23, revealed Resident #4's pregabalin was administered on 2/13/23 at 9:00 p.m. by LVN D. Record review of a statement given by CMA F, dated 2/14/23, revealed the following: I went into [Resident #4's] room around 9:45 PM to give her a medication and take her blood pressure. [Resident #4] was in bed and stated the nurse did not give her medication . She was looking for her Lyrica and Xanax. She said the nurse brought them in to her and sat them down and left but she doesn't see them.As I got ready to leave [Resident #3] asked me what the red capsules were she took. I told her I was not sure and could go ask the nurse. Spoke with [LVN D] the nurse and let her know [Resident #3] was asking about the medication she was given. [LVN D] stated she gave her Tylenol. Told her [Resident #4] states she didn't receive her Lyrica. [LVN D] said she set them down on her table. [LVN D] went to the count sheet and said see I signed them out. We went back into their room and let [Resident #4] know she had received her medication. [Resident #4] stated she did not receive them. [Resident #3] said she had taken 2 red pills and asked when they were. [LVN D] stated she'll go talk to [the CNO] who was working on [the other unit.] During an interview on 2/16/23 at 2:07 p.m., LVN E stated she worked the shift after LVN D, on the morning of 2/14/23. LVN E stated, I received report from one of the nurses [LVN D] and it was unclear as to what she [Resident #3] may have taken. [LVN D] told me [Resident #3] may have taken Lyrica that wasn't hers and [LVN D] informed me that the on-call physician had been notified and that [Resident #3] was ok. And so when I went to go assess [Resident #3] she was talking and she was answering questions but she did tell me that she was feeling sleepy and weaker than normal. I notified the MD that we weren't sure what she had taken because at that point we didn't have any clear answers from the nurse. LVN E stated she believed Resident #3 took Resident #4's Lyrica, but she was unsure. During an interview on 2/16/23 at 3:42 p.m., Resident #3 stated she didn't remember the sequence of events that lead to her hospitalization . Resident #3 stated, I took some overdose of medication, they say. I don't remember which I'm taking or what I was taking. On 2/16/23 at 4:33 p.m., an interview was attempted with LVN D but LVN D did not answer. An automated message stated the voice mailbox was not set up and the call disconnected itself. LVN D did not return this surveyor's phone call prior to the end of the investigation. During an interview on 2/17/23 at 8:05 a.m., Resident #4 stated, I saw it all. A nurse came in and told [Resident #3] here's your meds. And she came to me and said, 'here's your meds.' I said 'I don't take those pills.' I looked at the pills and I knew they weren't mine.I take 2 Lyrica and my Xanax at night, and that what I saw them give [Resident #3.] During an interview on 2/17/23 at 7:39 a.m., the CNO stated, I was actually working on the floor on the other side of the building. [LVN D] actually came over to me and told me she thought she made a med error, a bad med error.And [Resident #4] was in the bathroom at the time. [LVN D] put the pills on the table in the bathroom. Then [Resident #4] said she wasn't getting her pills or her meds. [Resident #3] said she had taken 2 red capsules. [LVN D] said it was the Lyrica. I said you need to get vitals [vital signs] and you need to call the on-call physician and we need an incident report.When I went back to review the incident report it was not consistent with what she verbally told me. We've all attempted to contact her and nor did she come into work.[ADON C] went and asked a lot of questions. We went through what she investigated and discussed with the med aide [CMA F] what had happened. During an interview on 2/17/23 at 11:54 a.m., ADON C stated she was informed of the medication error involving Resident #3 on the morning of 2/14/23. ADON C stated, I went to check the incident report. I thought ok, [Resident #3] was given Tylenol. I went to the administration record and I didn't see Tylenol signed out for her . [LVN E] said [Resident #3] is stating she took 2 red pills.Usually red pills are lyrica, not Tylenol. [LVN E] said, 'I think [Resident #3] took her neighbor's medication, because [Resident #4] had scheduled 2 Lyrica and Xanax. ADON C said she reviewed Resident #4's Lyrica and Xanax count sheets to confirm the medications were administered. Record review of a facility policy titled, Administering Medications, dated December 2010, revealed, Medications shall be administered in a safe and timely manner, and as prescribed . The individual administering medications must verify the resident's identity before giving the resident his/her medications . Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services.

Based on observation, interview and record review, the facility failed to implement the facility's policy and procedures to protect residents from neglect for 1 of 5 residents reviewed for neglect (Resident #1) in that: Resident #1's transfer to the hospital was delayed approximately 6 hours after multiple requests by the resident's responsible party after the resident experienced a change in condition. When Resident #1 was finally discharged to the hospital, testing revealed the resident had sustained [MEDICAL CONDITION] Infarction and an Upper Gastro Intestinal Bleeding. This deficient practice could affect the 1 resident with recent change in condition and result in delay in care and treatment. The findings were: Review of Resident #4's face sheet dated 5/17/17 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 15 which indicated intact cognition. The MDS further revealed in section I that the resident had [MEDICAL CONDITION]. Review of Resident #1's Order Summary, order date 7/14/2016, page 2 of 5, revealed the resident's physician gave an order to have the resident's vital signs measured, . one time a day every 14 day(s) . Review of Resident #1's blood pressure readings revealed her last reading was inputted on 1/13/2017. Review of Resident #1's emergency room Clinical Report, dated 4/27/2017, stated, She complains of moderate central chest pain (3 days), currently moderate . Review of Resident #1's Laboratory Report, for a Cardiac Panel upon arrival to the hospital on [DATE] revealed high Tropinin-I and Myoglobin levels, indicating likely [MEDICAL CONDITION] Infarction / Cardiac Damage. Additionally, Resident #1's B-Type Natriuretic Peptide level was recorded at 1257 BNP, with greater than 200 BNP suggestive of [MEDICAL CONDITION]. Review of Resident #1's 4/27/2017 Hospital ECG Report, stated, [MEDICAL CONDITION] FIBRILLATION WITH RAPID VENTRICULAR RESPONSE, ANTHEROSEPTAL, MYCARDIAL INFARCTION, ABNORMAL ECG. Review of Resident #1's Hospital Assessment/Plan, dated 4/28/2017, stated: 1. NSTEMI: Likely due to demand ischemia from profound [MEDICAL CONDITION]. Has underlying severe AS and depressed EF. Will continue conservative therapy, not a candidate for invasive workup at this time. 2. Severe AS with depressed EF. Will repeat echo to evaluate her EF which has been declining. Will check with clinic to see if she has ever followed up with us getting referred to TAVR. She may have missed her window at this point. 3. GI Bleed, [MEDICAL CONDITION]: continue management per the primary service and GI. 4. Afib, rate control is adequate. Not a candidate for anticoagulation. Review of Resident #1's Palliative Care Consult, dated 5/1/2017, revealed the resident received a, .2 unit transfusion of packed red blood cells her condition stabilized her blood pressure is now normal mental status is returned her baseline.(sic) Interview on 5/17/2017 at 12:55 p.m. with the MDS Coordinator confirmed Resident #1's blood pressures were not recorded since 1/13/2017. The MDS Coordinator said she was unsure why there was no record of the resident's blood pressure since that date but she revealed she did see the resident had orders for her blood pressure to be taken and recorded in her physician's orders [REDACTED]. Interview on 5/17/2017 at 1:02 p.m. with the DON revealed, according to her, a former nurse deactivated the vital sign trigger therefore the resident's blood pressure readings were not being recorded in her e-chart. Review of the undated Care Plan revealed she, . Has a communication problem r/t Hearing deficit . and uses Oxygen Therapy r/t Ineffective gas exchange s/t [MEDICAL CONDITION] . The goal was for the resident to . have no s/sx of poor oxygen absorption . Interview on 5/17/2017 at 11:38 a.m. with LVN A revealed Resident #1 was administered Tylenol #3 on 4/26/2017 and believed it was likely for a headache. LVN A said she thought that was odd because Resident #1 would not usually ask for her prn Tylenol #3. LVN A said LVN B told her the resident was discharged because she was desatting (to undergo a decrease in the oxygen saturation level in the hemoglobin) and said the resident's blood pressure was fluctuating, and was presenting with aphib (irregular and often very fast heart rate). Review of Resident #1's 02 Saturation levels on 4/27/2017 revealed oxygen saturation levels were recorded four times between 1:12 p.m. and 1:15 p.m., measuring, 94%, 94%, 94%, and 94% during the four readings that were recorded that day. Review of Resident #1's electronic progress note, dated 4/27/2017, inputted at 17:56 (5:56 p.m.), revealed, At 1610 nurse contacted PCP; neighbor presents with VS 122/54 - 102-24-97.7-SaO2 97%-60% on 3 LPM via N/C. Neighbor started presenting with issues at 0830 (8:30 a.m.) today presenting with lethargy, altered mental status and refusing breakfast. She then presented with desating where she would go 99% down to 82% then to 60% on 3 LPM via NC.(sic) Review of Resident #1's electronic progress note, dated 4/27/2017, inputted at 18:25 (6:25 p.m.), revealed, Neighbor continues to decline presenting with s/s of afib, [MEDICAL CONDITION] and elevated respirations. PCP contacted and nurse also added s/s of dehydration and concentrated urine. Per TORB (Telephone Order, Read Back), neighbor to be sent to (the hospital) for assessment. Family notified. Ambulance dispatched at 1615 (4:15 p.m.). Ambulance arrived at 1715 (5:15 p.m.) with two drivers. Neighbor was loaded on ambulance and departed this facility at 1729 (5:29 p.m.) without incident. Report to (hospital RN) received report from this nurse prior to neighbor departing this facility. Will continue to monitor.(sic) Further interview on 5/17/2017 at 1:02 p.m. with the DON revealed, Resident #1's charted oxygen saturation levels did not reflect the residents 4/27/2017 progress notes that said the residents saturation levels were fluctuating between . 97%-60% on 3 LPM via N/C . the DON said she was not sure. The DON indicated the criteria a resident would meet to be sent to the hospital would be change in condition and an SBAR would be used to determine if the resident could be treated at the facility or would need to be sent to the hospital. The DON indicated after reading the resident's 4/27/2017 progress notes, that according to what was written by LVN B, Resident #1 should have been sent out earlier but said none of this information was mentioned in the morning meeting relative to the resident's condition. The DON said the only thing that was reported to her in the morning meeting was that the resident had a little cough. The DON indicated the breakdown was with the communication between the nurse and management. The DON denied the resident's responsible party would have had to pay a $2000 fee to transport the resident to the hospital and speculated that it would have been covered by the facility. Telephone interview on 5/17/2017 at 2:07 p.m. with Resident #1's Responsible Party revealed the resident was very sick on the day she was discharged to the hospital. He said he told staff to discharge the resident because the resident was not doing well at around 9:30 a.m. on 4/27/2017. The resident's responsible party said he spoke to the resident's daughter who was previously talking on the phone to the resident and she did not sound well. The responsible party said on 4/27/2017 at approximately 10:30 a.m. he called the facility and spoke to LVN B in attempt to get the resident discharged to the hospital but said LVN B informed him that they had to wait on the doctor's order to send the resident to the hospital or it would cost $2000 for the transport. The responsible party said he told them to send her anyway but said the resident was not sent until around 4:30 p.m. He also said he was called by the facility around 11:00 a.m. and was informed the resident was not cooperating and resisting care. The responsible party said he was informed by a doctor at the hospital that the resident had suffered a [MEDICAL CONDITION] while at the facility. Telephone interview on 5/17/2017 at 2:23 p.m. with the complainant revealed he was informed by the facility around 4 p.m. on 4/27/2017 that the resident was having trouble breathing and was not eating. The complainant said he urged the facility to send the resident to the hospital and was told they were working on it. The complainant said he was told by hospital staff that the resident had suffered a [MEDICAL CONDITION] that day and also required 2 liters of blood. Interview and observation of Resident #1 on 5/18/2017 at 10:28 a.m. revealed the resident was living in a different long term care facility after being discharged from the hospital. The resident said she could not recall about the day she was discharged to the hospital except that she was very tired that day and had chest pain. Telephone interview on 5/18/2017 at 1:58 p.m. with the resident's physician, revealed he was called by the facility in the afternoon of 4/27/2017 which prompted him to send the resident to the hospital. He said he knew the resident had a bad heart and a lot of other medical issues. The doctor said the resident was doing remarkably well for what she had been through. Interview on 5/18/2017 at 4:50 p.m. with the DON revealed she performed an audit on all resident vitals in the facility's echarts, after surveyor intervention, to ensure vitals were being accurately recorded in the residents' charts after being informed Resident #1 did not have record of her blood pressure being taken and recorded since 1/13/2017. Interview on 5/19/2017 at 8:09 a.m. with LVN B revealed he felt Resident #1 was, historically lethargic and confused, and claimed she was non-compliant with treatments due to her mental status. He said the resident was at the facility for advanced [MEDICAL CONDITION]. LVN B was asked about the cost of sending a resident to the hospital and replied, . if it is a critical issue, there is no question you call 911. LVN B indicated he did not send the resident to the hospital until late afternoon because she .was a bit more lethargic in the morning, a bit more confused. He said he first encountered the resident's daughter around 9:30 a.m. in the morning and said she wanted to send the resident to the hospital because she was, burning up, but said he was monitoring the resident's temperature and found that the resident's temperatures were not out of her normal range. The nurse indicated he elected not to send the resident to the hospital because he felt it's traumatic for the residents to be sent to the hospital. The nurse implied the resident's oxygen saturation levels were typical, indicating the resident would remove the oxygen cannula at times which would drop her oxygen saturation into the 80s at times but then once the oxygen was put back on the oxygen saturation would be back in the 90s. He said when he called the doctor he informed the doctor that the residents blood pressure and sat levels were fluctuating and she was experiencing [MEDICAL CONDITION](an abnormally rapid heart rate) and [MEDICAL CONDITION] Fibrillation (an irregular and often very fast heart rate. This may cause symptoms like heart palpitations, fatigue, and shortness of breath). He also said the resident was not eating or drinking. LVN B indicated that during the day, he was looking for a reason to send her out but said he could not find a reason until later in the afternoon. He said the only thing the resident was telling him was that she wasn't feeling good but denied she ever complained of chest pain. LVN B said he did not send the resident to the hospital when the resident's family was asking him to send her to the hospital, Because the hospital usually just sends them back. LVN B said he did not have an RN assess the resident, Because she's always busy. The nurse indicated he did not document the times the resident's Oxygen Saturation levels dropped down to the 60s (per his notes) or her fluctuating blood pressure he indicated that it was because he was more concerned with providing the resident with care. The nurse indicated he only documented 4 readings on 4/27/2017 within a 3 minute period (between 1:12 p.m.-1:15 p.m.) because the family was concerned and wanted him to. Interview on 5/19/2017 at 8:50 a.m. with the DON revealed it was not facility policy to refuse to send a resident to the hospital if the resident's family was requesting it. Interview on 6/5/2017 at 2:44 p.m. with CNA C revealed when a resident had a change in condition she would notify the nurse in charge of the resident and tell the nurse what the change was. CNA C indicated she was familiar with Resident #1, claiming the resident never complained much. She said the resident would utilize the call light when in need of assistance but said she was pretty independent. She said in the morning before the resident was discharged , the resident became sick and she had to assist the resident more frequently. She said the resident stopped being able to make it to the bathroom and was found wet in the morning. The CNA said LVN B was under the impression the resident's blood pressure cuff was not working as it was giving an error reading so she said LVN B got a different cuff. The CNA indicated she heard the resident's pressures were fluctuating the morning before the resident was discharged . The CNA said the resident told her that she was asking staff to send her to the hospital but said she felt like no one was listening. The CNA said she believed LVN B called the doctor the first time around 11 a.m. but did not know what the doctor told LVN B. She said LVN B called the doctor a second time that afternoon and said the doctor gave the order to send the resident out. The CNA said the thing that stuck out the most to her was that the resident was not continent on the day of discharge. The CNA also said the resident had complained of pain, guessing that it was chest pain but said she couldn't recall exactly. The CNA indicated the resident was not without her cannula on the day of discharge and was consistently utilizing her oxygen. The CNA said the resident was compliant and would not resist wearing her nasal cannula. Additionally, the CNA indicated staff were not monitoring her oxygen saturation levels until after prompted by the resident's daughter around 11 a.m. The CNA said she noticed the resident seemed to be gasping for air around 10:30 a.m. or 11 a.m. but said she thought the resident was having issues related to her [MEDICAL CONDITION]. She said she asked the resident to eat but said the resident explained to her that she just couldn't. She said the resident explained that she felt something was wrong. The CNA said these details prompted her to tell LVN B that she felt something was not right with the resident. The CNA indicated it was at that point LVN B decided to take the resident's vitals (O2 and blood pressure). She said the LVN was having difficulty getting the readings so he elected to elevate her bed as she seemed to be laboring to breathe when lying flat. The CNA indicated the resident's O2 levels were at that point but she could not recall the exact readings. CNA C was asked if she felt Resident #1 should have been sent to the hospital earlier and stated, If that was my family member, I would say yes. The CNA said when they were finally given the order to send the resident out, LVN B called Southern Cross Ambulance service around 3 p.m. and was told it would be up to a 2 hour wait. The CNA said she asked LVN B if they should call 911 and said LVN B said, no, because he felt he had the resident was stable enough so he elected for the resident to wait on the ambulance service as opposed to calling 911. Interview on 6/5/2017 at 3:22 p.m. with CNA D revealed on the day the resident was discharged , she first noticed the resident's roomate's son was in the resident room that morning and was complaining the room smelled like urine. She said she was surprised to find the resident had wet pull-ups in her trash can which she said was not something the resident would normally do. She said it was the resident's shower day and said the resident not only refused but was lying down and wouldn't get up. She said that was when she notified LVN B and said the resident again refused to shower. CNA D explained she and CNA C were finally able to get the resident to shower but said the resident was not wanting to stand. CNA D said the resident's breathing was labored between 9 a.m. and 10 a.m. CNA D said she and the other CNA explained to LVN B that the resident was not being herself. She said the resident was having a hard time standing which was not normal and indicated LVN B started to assess the resident, and asked for a manual blood pressure cuff because the levels were showing really low on the electronic cuff and said the resident's oxygen levels were really low as well but could not recall the specific readings. Interview on 6/5/2017 at 3:36 p.m. with ADON E revealed she told LVN B to talk to the doctor because Resident #1 was experiencing low oxygen saturation and find out what he wanted to do. The ADON said the resident's doctor ordered the resident be sent to the hospital. The ADON indicated that she did not know why LVN B elected to have Resident #1 transported via the ambulance service as opposed to calling 911. The ADON felt LVN B could have done better and said, If (the ambulance service) could have been to the facility within 20-30 minutes, fine, but indicated 911 should have been called after LVN B was told it would be over an hour before the ambulance would arrive. ADON E indicated the resident's vitals were disabled by an ex facility nurse who updated the resident's orders so the blood pressure request would not prompt staff to take readings. The ADON cited several examples that would constitute a change of condition including, when a resident who is continent becomes incontinent, a resident who normally can walk can no longer walk, and if a resident demonstrates difficulty in breathing. The ADON confirmed all were considered to be a change in condition. Interview on 6/5/2017 at 4:28 p.m. the DON revealed the facility did not have a policy for reporting changes in condition of residents up the chain in command but indicated staff was in receipt of in-servicing regarding change of condition. The DON indicated the CNAs should report a change in condition of a resident immediately to the charge nurse and said a resident's change of condition should go above the charge nurse level if the charge nurse could not handle the injury or if it required discharge to the hospital. The DON indicated a resident's change of condition would be documented in the nurses notes and/or sbar if the resident was discharged to the hospital. The DON indicated the actions she would take if informed of a severe change of condition would be to immediately go to the resident's room, assess the resident, and determine what needs to be done. The DON indicated the facility had not yet addressed the deactivation of orders for residents with staff. Interview on 6/5/2017 at 5:05 p.m. with the ex-staff who allegedly deactivated Resident #1's order for biweekly blood pressure readings and recordings revealed the LVN denied altering or deactivating the resident's orders relative to taking and documenting biweekly blood pressure readings. Review of the facility's Abuse and Neglect - Clinical Protocol, policy, revised 4/2007, section Assessments and Recognition, 1. The nurse will assess the individual and document related findings. Assessment data will include: (d.) Vital signs (e.) Behavior over last 24 hours ., (g) all active diagnoses. Further review revealed, Cause Identification, 1. The staff, with the physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes. Additionally, Treatment/Management, 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. A list of resident discharges for the month of April 2017, provided by the facility, revealed Resident #1 was discharged to the hospital.

Based on observation, interview and record review, the facility failed to implement the facility's policy and procedures to protect residents from neglect for 1 of 5 residents reviewed for neglect (Resident #1) in that: Resident #1's transfer to the hospital was delayed approximately 6 hours after multiple requests by the resident's responsible party after the resident experienced a change in condition. When Resident #1 was finally discharged to the hospital, testing revealed the resident had sustained [MEDICAL CONDITION] Infarction and an Upper Gastro Intestinal Bleeding. This deficient practice could affect the 1 resident with recent change in condition and result in delay in care and treatment. The findings were: Review of the facility's Abuse and Neglect - Clinical Protocol, policy, revised 4/2007, section Assessments and Recognition, 1. The nurse will assess the individual and document related findings. Assessment data will include: (d.) Vital signs (e.) Behavior over last 24 hours ., (g) all active diagnoses. Further review revealed, Cause Identification, 1. The staff, with the physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes. Additionally, Treatment/Management, 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Review of Resident #4's face sheet dated 5/17/17 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 15 which indicated intact cognition. The MDS further revealed in section I that the resident had [MEDICAL CONDITION]. Review of Resident #1's Order Summary, order date 7/14/2016, page 2 of 5, revealed the resident's physician gave an order to have the resident's vital signs measured, . one time a day every 14 day(s) . Review of Resident #1's blood pressure readings revealed her last reading was inputted on 1/13/2017. Review of Resident #1's emergency room Clinical Report, dated 4/27/2017, stated, She complains of moderate central chest pain (3 days), currently moderate . Review of Resident #1's Laboratory Report, for a Cardiac Panel upon arrival to the hospital on [DATE] revealed high Tropinin-I and Myoglobin levels, indicating likely [MEDICAL CONDITION] Infarction / Cardiac Damage. Additionally, Resident #1's B-Type Natriuretic Peptide level was recorded at 1257 BNP, with greater than 200 BNP suggestive of [MEDICAL CONDITION]. Review of Resident #1's 4/27/2017 Hospital ECG Report, stated, [MEDICAL CONDITION] FIBRILLATION WITH RAPID VENTRICULAR RESPONSE, ANTHEROSEPTAL, MYCARDIAL INFARCTION, ABNORMAL ECG. Review of Resident #1's Hospital Assessment/Plan, dated 4/28/2017, stated: 1. NSTEMI: Likely due to demand ischemia from profound [MEDICAL CONDITION]. Has underlying severe AS and depressed EF. Will continue conservative therapy, not a candidate for invasive workup at this time. 2. Severe AS with depressed EF. Will repeat echo to evaluate her EF which has been declining. Will check with clinic to see if she has ever followed up with us getting referred to TAVR. She may have missed her window at this point. 3. GI Bleed, [MEDICAL CONDITION]: continue management per the primary service and GI. 4. Afib, rate control is adequate. Not a candidate for anticoagulation. Review of Resident #1's Palliative Care Consult, dated 5/1/2017, revealed the resident received a, .2 unit transfusion of packed red blood cells her condition stabilized her blood pressure is now normal mental status is returned her baseline.(sic) Interview on 5/17/2017 at 12:55 p.m. with the MDS Coordinator confirmed Resident #1's blood pressures were not recorded since 1/13/2017. The MDS Coordinator said she was unsure why there was no record of the resident's blood pressure since that date but she revealed she did see the resident had orders for her blood pressure to be taken and recorded in her physician's orders [REDACTED]. Interview on 5/17/2017 at 1:02 p.m. with the DON revealed, according to her, a former nurse deactivated the vital sign trigger therefore the resident's blood pressure readings were not being recorded in her e-chart. Review of the undated Care Plan revealed she, . Has a communication problem r/t Hearing deficit . and uses Oxygen Therapy r/t Ineffective gas exchange s/t [MEDICAL CONDITION] . The goal was for the resident to . have no s/sx of poor oxygen absorption . Interview on 5/17/2017 at 11:38 a.m. with LVN A revealed Resident #1 was administered Tylenol #3 on 4/26/2017 and believed it was likely for a headache. LVN A said she thought that was odd because Resident #1 would not usually ask for her prn Tylenol #3. LVN A said LVN B told her the resident was discharged because she was desatting (to undergo a decrease in the oxygen saturation level in the hemoglobin) and said the resident's blood pressure was fluctuating, and was presenting with aphib (irregular and often very fast heart rate). Review of Resident #1's 02 Saturation levels on 4/27/2017 revealed oxygen saturation levels were recorded four times between 1:12 p.m. and 1:15 p.m., measuring, 94%, 94%, 94%, and 94% during the four readings that were recorded that day. Review of Resident #1's electronic progress note, dated 4/27/2017, inputted at 17:56 (5:56 p.m.), revealed, At 1610 nurse contacted PCP; neighbor presents with VS 122/54 - 102-24-97.7-SaO2 97%-60% on 3 LPM via N/C. Neighbor started presenting with issues at 0830 (8:30 a.m.) today presenting with lethargy, altered mental status and refusing breakfast. She then presented with desating where she would go 99% down to 82% then to 60% on 3 LPM via NC.(sic) Review of Resident #1's electronic progress note, dated 4/27/2017, inputted at 18:25 (6:25 p.m.), revealed, Neighbor continues to decline presenting with s/s of afib, [MEDICAL CONDITION] and elevated respirations. PCP contacted and nurse also added s/s of dehydration and concentrated urine. Per TORB (Telephone Order, Read Back), neighbor to be sent to (the hospital) for assessment. Family notified. Ambulance dispatched at 1615 (4:15 p.m.). Ambulance arrived at 1715 (5:15 p.m.) with two drivers. Neighbor was loaded on ambulance and departed this facility at 1729 (5:29 p.m.) without incident. Report to (hospital RN) received report from this nurse prior to neighbor departing this facility. Will continue to monitor.(sic) Further interview on 5/17/2017 at 1:02 p.m. with the DON revealed, Resident #1's charted oxygen saturation levels did not reflect the residents 4/27/2017 progress notes that said the residents saturation levels were fluctuating between . 97%-60% on 3 LPM via N/C . the DON said she was not sure. The DON indicated the criteria a resident would meet to be sent to the hospital would be change in condition and an SBAR would be used to determine if the resident could be treated at the facility or would need to be sent to the hospital. The DON indicated after reading the resident's 4/27/2017 progress notes, that according to what was written by LVN B, Resident #1 should have been sent out earlier but said none of this information was mentioned in the morning meeting relative to the resident's condition. The DON said the only thing that was reported to her in the morning meeting was that the resident had a little cough. The DON indicated the breakdown was with the communication between the nurse and management. The DON denied the resident's responsible party would have had to pay a $2000 fee to transport the resident to the hospital and speculated that it would have been covered by the facility. Telephone interview on 5/17/2017 at 2:07 p.m. with Resident #1's Responsible Party revealed the resident was very sick on the day she was discharged to the hospital. He said he told staff to discharge the resident because the resident was not doing well at around 9:30 a.m. on 4/27/2017. The resident's responsible party said he spoke to the resident's daughter who was previously talking on the phone to the resident and she did not sound well. The responsible party said on 4/27/2017 at approximately 10:30 a.m. he called the facility and spoke to LVN B in attempt to get the resident discharged to the hospital but said LVN B informed him that they had to wait on the doctor's order to send the resident to the hospital or it would cost $2000 for the transport. The responsible party said he told them to send her anyway but said the resident was not sent until around 4:30 p.m. He also said he was called by the facility around 11:00 a.m. and was informed the resident was not cooperating and resisting care. The responsible party said he was informed by a doctor at the hospital that the resident had suffered a [MEDICAL CONDITION] while at the facility. Telephone interview on 5/17/2017 at 2:23 p.m. with the complainant revealed he was informed by the facility around 4 p.m. on 4/27/2017 that the resident was having trouble breathing and was not eating. The complainant said he urged the facility to send the resident to the hospital and was told they were working on it. The complainant said he was told by hospital staff that the resident had suffered a [MEDICAL CONDITION] that day and also required 2 liters of blood. Interview and observation of Resident #1 on 5/18/2017 at 10:28 a.m. revealed the resident was living in a different long term care facility after being discharged from the hospital. The resident said she could not recall about the day she was discharged to the hospital except that she was very tired that day and had chest pain. Telephone interview on 5/18/2017 at 1:58 p.m. with the resident's physician, revealed he was called by the facility in the afternoon of 4/27/2017 which prompted him to send the resident to the hospital. He said he knew the resident had a bad heart and a lot of other medical issues. The doctor said the resident was doing remarkably well for what she had been through. Interview on 5/18/2017 at 4:50 p.m. with the DON revealed she performed an audit on all resident vitals in the facility's echarts, after surveyor intervention, to ensure vitals were being accurately recorded in the residents' charts after being informed Resident #1 did not have record of her blood pressure being taken and recorded since 1/13/2017. Interview on 5/19/2017 at 8:09 a.m. with LVN B revealed he felt Resident #1 was, historically lethargic and confused, and claimed she was non-compliant with treatments due to her mental status. He said the resident was at the facility for advanced [MEDICAL CONDITION]. LVN B was asked about the cost of sending a resident to the hospital and replied, . if it is a critical issue, there is no question you call 911. LVN B indicated he did not send the resident to the hospital until late afternoon because she .was a bit more lethargic in the morning, a bit more confused. He said he first encountered the resident's daughter around 9:30 a.m. in the morning and said she wanted to send the resident to the hospital because she was, burning up, but said he was monitoring the resident's temperature and found that the resident's temperatures were not out of her normal range. The nurse indicated he elected not to send the resident to the hospital because he felt it's traumatic for the residents to be sent to the hospital. The nurse implied the resident's oxygen saturation levels were typical, indicating the resident would remove the oxygen cannula at times which would drop her oxygen saturation into the 80s at times but then once the oxygen was put back on the oxygen saturation would be back in the 90s. He said when he called the doctor he informed the doctor that the residents blood pressure and sat levels were fluctuating and she was experiencing [MEDICAL CONDITION](an abnormally rapid heart rate) and [MEDICAL CONDITION] Fibrillation (an irregular and often very fast heart rate. This may cause symptoms like heart palpitations, fatigue, and shortness of breath). He also said the resident was not eating or drinking. LVN B indicated that during the day, he was looking for a reason to send her out but said he could not find a reason until later in the afternoon. He said the only thing the resident was telling him was that she wasn't feeling good but denied she ever complained of chest pain. LVN B said he did not send the resident to the hospital when the resident's family was asking him to send her to the hospital, Because the hospital usually just sends them back. LVN B said he did not have an RN assess the resident, Because she's always busy. The nurse indicated he did not document the times the resident's Oxygen Saturation levels dropped down to the 60s (per his notes) or her fluctuating blood pressure he indicated that it was because he was more concerned with providing the resident with care. The nurse indicated he only documented 4 readings on 4/27/2017 within a 3 minute period (between 1:12 p.m.-1:15 p.m.) because the family was concerned and wanted him to. Interview on 5/19/2017 at 8:50 a.m. with the DON revealed it was not facility policy to refuse to send a resident to the hospital if the resident's family was requesting it. Interview on 6/5/2017 at 2:44 p.m. with CNA C revealed when a resident had a change in condition she would notify the nurse in charge of the resident and tell the nurse what the change was. CNA C indicated she was familiar with Resident #1, claiming the resident never complained much. She said the resident would utilize the call light when in need of assistance but said she was pretty independent. She said in the morning before the resident was discharged , the resident became sick and she had to assist the resident more frequently. She said the resident stopped being able to make it to the bathroom and was found wet in the morning. The CNA said LVN B was under the impression the resident's blood pressure cuff was not working as it was giving an error reading so she said LVN B got a different cuff. The CNA indicated she heard the resident's pressures were fluctuating the morning before the resident was discharged . The CNA said the resident told her that she was asking staff to send her to the hospital but said she felt like no one was listening. The CNA said she believed LVN B called the doctor the first time around 11 a.m. but did not know what the doctor told LVN B. She said LVN B called the doctor a second time that afternoon and said the doctor gave the order to send the resident out. The CNA said the thing that stuck out the most to her was that the resident was not continent on the day of discharge. The CNA also said the resident had complained of pain, guessing that it was chest pain but said she couldn't recall exactly. The CNA indicated the resident was not without her cannula on the day of discharge and was consistently utilizing her oxygen. The CNA said the resident was compliant and would not resist wearing her nasal cannula. Additionally, the CNA indicated staff were not monitoring her oxygen saturation levels until after prompted by the resident's daughter around 11 a.m. The CNA said she noticed the resident seemed to be gasping for air around 10:30 a.m. or 11 a.m. but said she thought the resident was having issues related to her [MEDICAL CONDITION]. She said she asked the resident to eat but said the resident explained to her that she just couldn't. She said the resident explained that she felt something was wrong. The CNA said these details prompted her to tell LVN B that she felt something was not right with the resident. The CNA indicated it was at that point LVN B decided to take the resident's vitals (O2 and blood pressure). She said the LVN was having difficulty getting the readings so he elected to elevate her bed as she seemed to be laboring to breathe when lying flat. The CNA indicated the resident's O2 levels were at that point but she could not recall the exact readings. CNA C was asked if she felt Resident #1 should have been sent to the hospital earlier and stated, If that was my family member, I would say yes. The CNA said when they were finally given the order to send the resident out, LVN B called Southern Cross Ambulance service around 3 p.m. and was told it would be up to a 2 hour wait. The CNA said she asked LVN B if they should call 911 and said LVN B said, no, because he felt he had the resident was stable enough so he elected for the resident to wait on the ambulance service as opposed to calling 911. Interview on 6/5/2017 at 3:22 p.m. with CNA D revealed on the day the resident was discharged , she first noticed the resident's roomate's son was in the resident room that morning and was complaining the room smelled like urine. She said she was surprised to find the resident had wet pull-ups in her trash can which she said was not something the resident would normally do. She said it was the resident's shower day and said the resident not only refused but was lying down and wouldn't get up. She said that was when she notified LVN B and said the resident again refused to shower. CNA D explained she and CNA C were finally able to get the resident to shower but said the resident was not wanting to stand. CNA D said the resident's breathing was labored between 9 a.m. and 10 a.m. CNA D said she and the other CNA explained to LVN B that the resident was not being herself. She said the resident was having a hard time standing which was not normal and indicated LVN B started to assess the resident, and asked for a manual blood pressure cuff because the levels were showing really low on the electronic cuff and said the resident's oxygen levels were really low as well but could not recall the specific readings. Interview on 6/5/2017 at 3:36 p.m. with ADON E revealed she told LVN B to talk to the doctor because Resident #1 was experiencing low oxygen saturation and find out what he wanted to do. The ADON said the resident's doctor ordered the resident be sent to the hospital. The ADON indicated that she did not know why LVN B elected to have Resident #1 transported via the ambulance service as opposed to calling 911. The ADON felt LVN B could have done better and said, If (the ambulance service) could have been to the facility within 20-30 minutes, fine, but indicated 911 should have been called after LVN B was told it would be over an hour before the ambulance would arrive. ADON E indicated the resident's vitals were disabled by an ex facility nurse who updated the resident's orders so the blood pressure request would not prompt staff to take readings. The ADON cited several examples that would constitute a change of condition including, when a resident who is continent becomes incontinent, a resident who normally can walk can no longer walk, and if a resident demonstrates difficulty in breathing. The ADON confirmed all were considered to be a change in condition. Interview on 6/5/2017 at 4:28 p.m. the DON revealed the facility did not have a policy for reporting changes in condition of residents up the chain in command but indicated staff was in receipt of in-servicing regarding change of condition. The DON indicated the CNAs should report a change in condition of a resident immediately to the charge nurse and said a resident's change of condition should go above the charge nurse level if the charge nurse could not handle the injury or if it required discharge to the hospital. The DON indicated a resident's change of condition would be documented in the nurses notes and/or sbar if the resident was discharged to the hospital. The DON indicated the actions she would take if informed of a severe change of condition would be to immediately go to the resident's room, assess the resident, and determine what needs to be done. The DON indicated the facility had not yet addressed the deactivation of orders for residents with staff. Interview on 6/5/2017 at 5:05 p.m. with the ex-staff who allegedly deactivated Resident #1's order for biweekly blood pressure readings and recordings revealed the LVN denied altering or deactivating the resident's orders relative to taking and documenting biweekly blood pressure readings. A list of resident discharges for the month of April 2017, provided by the facility, revealed Resident #1 was discharged to the hospital.

Based on observation, interview and record review, the facility failed ensure services provided met professional standards of quality for 1 resident (Resident #1) reviewed for professional standards. On 4/27/2017, LVN B delayed Resident #1's discharge to the hospital for approximately 8 hours after the resident was observed having a change of condition and approximately 6 hours after multiple requests by the resident's responsible party. When Resident #1 was finally discharged to the hospital, testing revealed the resident had a [MEDICAL CONDITION] Infarction and an Upper Gastro Intestinal Bleeding. This deficient practice could affect the 1 resident with recent change in condition and result in delay in care and treatment. The findings were: 1. According Texas Board of Nursing, 15.4 In the interest of fulfilling its mission to protect the health, safety, and welfare of the people of Texas through the regulation of nurses, the Board of Nursing (BON), through the Nursing Practice Act and Board Rules, emphasizes the nurse ' s responsibility and duty to the client/patient to provide safe, effective nursing care. Specifically, the following portions of the Board Rules and supporting documents underscore the duty and responsibilities of the LVN and/or the RN to the client/patient: The nurse, by virtue of a rigorous process of education and examination leading to either LVN or RN licensure, is accountable to the Board to assure that nursing care meets standards of safety and effectiveness. (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (iv) implementing appropriate aspects of care within the LVN's scope of practice; and Review of Resident #4's face sheet dated 5/17/17 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 15 which indicated intact cognition. The MDS further revealed in section I that the resident had [MEDICAL CONDITION]. Review of Resident #1's Order Summary, order date 7/14/2016, page 2 of 5, revealed the resident's physician gave an order to have the resident's vital signs measured, . one time a day every 14 day(s) . Review of Resident #1's blood pressure readings revealed her last reading was inputted on 1/13/2017. Review of Resident #1's emergency room Clinical Report, dated 4/27/2017, stated, She complains of moderate central chest pain (3 days), currently moderate . Review of Resident #1's Laboratory Report, for a Cardiac Panel upon arrival to the hospital on [DATE] revealed high Tropinin-I and Myoglobin levels, indicating likely [MEDICAL CONDITION] Infarction / Cardiac Damage. Additionally, Resident #1's B-Type Natriuretic Peptide level was recorded at 1257 BNP, with greater than 200 BNP suggestive of [MEDICAL CONDITION]. Review of Resident #1's 4/27/2017 Hospital ECG Report, stated, [MEDICAL CONDITION] FIBRILLATION WITH RAPID VENTRICULAR RESPONSE, ANTHEROSEPTAL, MYCARDIAL INFARCTION, ABNORMAL ECG. Review of Resident #1's Hospital Assessment/Plan, dated 4/28/2017, stated: 1. NSTEMI: Likely due to demand ischemia from profound [MEDICAL CONDITION]. Has underlying severe AS and depressed EF. Will continue conservative therapy, not a candidate for invasive workup at this time. 2. Severe AS with depressed EF. Will repeat echo to evaluate her EF which has been declining. Will check with clinic to see if she has ever followed up with us getting referred to TAVR. She may have missed her window at this point. 3. GI Bleed, [MEDICAL CONDITION]: continue management per the primary service and GI. 4. Afib, rate control is adequate. Not a candidate for anticoagulation. Review of Resident #1's Palliative Care Consult, dated 5/1/2017, revealed the resident received a, .2 unit transfusion of packed red blood cells her condition stabilized her blood pressure is now normal mental status is returned her baseline.(sic) Interview on 5/17/2017 at 12:55 p.m. with the MDS Coordinator confirmed Resident #1's blood pressures were not recorded since 1/13/2017. The MDS Coordinator said she was unsure why there was no record of the resident's blood pressure since that date but she revealed she did see the resident had orders for her blood pressure to be taken and recorded in her physician's orders [REDACTED]. Interview on 5/17/2017 at 1:02 p.m. with the DON revealed, according to her, a former nurse deactivated the vital sign trigger therefore the resident's blood pressure readings were not being recorded in her e-chart. Review of the undated Care Plan revealed she, . Has a communication problem r/t Hearing deficit . and uses Oxygen Therapy r/t Ineffective gas exchange s/t [MEDICAL CONDITION] . The goal was for the resident to . have no s/sx of poor oxygen absorption . Interview on 5/17/2017 at 11:38 a.m. with LVN A revealed Resident #1 was administered Tylenol #3 on 4/26/2017 and believed it was likely for a headache. LVN A said she thought that was odd because Resident #1 would not usually ask for her prn Tylenol #3. LVN A said LVN B told her the resident was discharged because she was desatting (to undergo a decrease in the oxygen saturation level in the hemoglobin) and said the resident's blood pressure was fluctuating, and was presenting with aphib (irregular and often very fast heart rate). Review of Resident #1's 02 Saturation levels on 4/27/2017 revealed oxygen saturation levels were recorded four times between 1:12 p.m. and 1:15 p.m., measuring, 94%, 94%, 94%, and 94% during the four readings that were recorded that day. Review of Resident #1's electronic progress note, dated 4/27/2017, inputted at 17:56 (5:56 p.m.), revealed, At 1610 nurse contacted PCP; neighbor presents with VS 122/54 - 102-24-97.7-SaO2 97%-60% on 3 LPM via N/C. Neighbor started presenting with issues at 0830 (8:30 a.m.) today presenting with lethargy, altered mental status and refusing breakfast. She then presented with desating where she would go 99% down to 82% then to 60% on 3 LPM via NC.(sic) Review of Resident #1's electronic progress note, dated 4/27/2017, inputted at 18:25 (6:25 p.m.), revealed, Neighbor continues to decline presenting with s/s of afib, [MEDICAL CONDITION] and elevated respirations. PCP contacted and nurse also added s/s of dehydration and concentrated urine. Per TORB (Telephone Order, Read Back), neighbor to be sent to (the hospital) for assessment. Family notified. Ambulance dispatched at 1615 (4:15 p.m.). Ambulance arrived at 1715 (5:15 p.m.) with two drivers. Neighbor was loaded on ambulance and departed this facility at 1729 (5:29 p.m.) without incident. Report to (hospital RN) received report from this nurse prior to neighbor departing this facility. Will continue to monitor.(sic) Further interview on 5/17/2017 at 1:02 p.m. with the DON revealed, Resident #1's charted oxygen saturation levels did not reflect the residents 4/27/2017 progress notes that said the residents saturation levels were fluctuating between . 97%-60% on 3 LPM via N/C . the DON said she was not sure. The DON indicated the criteria a resident would meet to be sent to the hospital would be change in condition and an SBAR would be used to determine if the resident could be treated at the facility or would need to be sent to the hospital. The DON indicated after reading the resident's 4/27/2017 progress notes, that according to what was written by LVN B, Resident #1 should have been sent out earlier but said none of this information was mentioned in the morning meeting relative to the resident's condition. The DON said the only thing that was reported to her in the morning meeting was that the resident had a little cough. The DON indicated the breakdown was with the communication between the nurse and management. The DON denied the resident's responsible party would have had to pay a $2000 fee to transport the resident to the hospital and speculated that it would have been covered by the facility. Telephone interview on 5/17/2017 at 2:07 p.m. with Resident #1's Responsible Party revealed the resident was very sick on the day she was discharged to the hospital. He said he told staff to discharge the resident because the resident was not doing well at around 9:30 a.m. on 4/27/2017. The resident's responsible party said he spoke to the resident's daughter who was previously talking on the phone to the resident and she did not sound well. The responsible party said on 4/27/2017 at approximately 10:30 a.m. he called the facility and spoke to LVN B in attempt to get the resident discharged to the hospital but said LVN B informed him that they had to wait on the doctor's order to send the resident to the hospital or it would cost $2000 for the transport. The responsible party said he told them to send her anyway but said the resident was not sent until around 4:30 p.m. He also said he was called by the facility around 11:00 a.m. and was informed the resident was not cooperating and resisting care. The responsible party said he was informed by a doctor at the hospital that the resident had suffered a [MEDICAL CONDITION] while at the facility. Telephone interview on 5/17/2017 at 2:23 p.m. with the complainant revealed he was informed by the facility around 4 p.m. on 4/27/2017 that the resident was having trouble breathing and was not eating. The complainant said he urged the facility to send the resident to the hospital and was told they were working on it. The complainant said he was told by hospital staff that the resident had suffered a [MEDICAL CONDITION] that day and also required 2 liters of blood. Interview and observation of Resident #1 on 5/18/2017 at 10:28 a.m. revealed the resident was living in a different long term care facility after being discharged from the hospital. The resident said she could not recall about the day she was discharged to the hospital except that she was very tired that day and had chest pain. Telephone interview on 5/18/2017 at 1:58 p.m. with the resident's physician, revealed he was called by the facility in the afternoon of 4/27/2017 which prompted him to send the resident to the hospital. He said he knew the resident had a bad heart and a lot of other medical issues. The doctor said the resident was doing remarkably well for what she had been through. Interview on 5/18/2017 at 4:50 p.m. with the DON revealed she performed an audit on all resident vitals in the facility's echarts, after surveyor intervention, to ensure vitals were being accurately recorded in the residents' charts after being informed Resident #1 did not have record of her blood pressure being taken and recorded since 1/13/2017. Interview on 5/19/2017 at 8:09 a.m. with LVN B revealed he felt Resident #1 was, historically lethargic and confused, and claimed she was non-compliant with treatments due to her mental status. He said the resident was at the facility for advanced [MEDICAL CONDITION]. LVN B was asked about the cost of sending a resident to the hospital and replied, . if it is a critical issue, there is no question you call 911. LVN B indicated he did not send the resident to the hospital until late afternoon because she .was a bit more lethargic in the morning, a bit more confused. He said he first encountered the resident's daughter around 9:30 a.m. in the morning and said she wanted to send the resident to the hospital because she was, burning up, but said he was monitoring the resident's temperature and found that the resident's temperatures were not out of her normal range. The nurse indicated he elected not to send the resident to the hospital because he felt it's traumatic for the residents to be sent to the hospital. The nurse implied the resident's oxygen saturation levels were typical, indicating the resident would remove the oxygen cannula at times which would drop her oxygen saturation into the 80s at times but then once the oxygen was put back on the oxygen saturation would be back in the 90s. He said when he called the doctor he informed the doctor that the residents blood pressure and sat levels were fluctuating and she was experiencing [MEDICAL CONDITION](an abnormally rapid heart rate) and [MEDICAL CONDITION] Fibrillation (an irregular and often very fast heart rate. This may cause symptoms like heart palpitations, fatigue, and shortness of breath). He also said the resident was not eating or drinking. LVN B indicated that during the day, he was looking for a reason to send her out but said he could not find a reason until later in the afternoon. He said the only thing the resident was telling him was that she wasn't feeling good but denied she ever complained of chest pain. LVN B said he did not send the resident to the hospital when the resident's family was asking him to send her to the hospital, Because the hospital usually just sends them back. LVN B said he did not have an RN assess the resident, Because she's always busy. The nurse indicated he did not document the times the resident's Oxygen Saturation levels dropped down to the 60s (per his notes) or her fluctuating blood pressure he indicated that it was because he was more concerned with providing the resident with care. The nurse indicated he only documented 4 readings on 4/27/2017 within a 3 minute period (between 1:12 p.m.-1:15 p.m.) because the family was concerned and wanted him to. Interview on 5/19/2017 at 8:50 a.m. with the DON revealed it was not facility policy to refuse to send a resident to the hospital if the resident's family was requesting it. Interview on 6/5/2017 at 2:44 p.m. with CNA C revealed when a resident had a change in condition she would notify the nurse in charge of the resident and tell the nurse what the change was. CNA C indicated she was familiar with Resident #1, claiming the resident never complained much. She said the resident would utilize the call light when in need of assistance but said she was pretty independent. She said in the morning before the resident was discharged , the resident became sick and she had to assist the resident more frequently. She said the resident stopped being able to make it to the bathroom and was found wet in the morning. The CNA said LVN B was under the impression the resident's blood pressure cuff was not working as it was giving an error reading so she said LVN B got a different cuff. The CNA indicated she heard the resident's pressures were fluctuating the morning before the resident was discharged . The CNA said the resident told her that she was asking staff to send her to the hospital but said she felt like no one was listening. The CNA said she believed LVN B called the doctor the first time around 11 a.m. but did not know what the doctor told LVN B. She said LVN B called the doctor a second time that afternoon and said the doctor gave the order to send the resident out. The CNA said the thing that stuck out the most to her was that the resident was not continent on the day of discharge. The CNA also said the resident had complained of pain, guessing that it was chest pain but said she couldn't recall exactly. The CNA indicated the resident was not without her cannula on the day of discharge and was consistently utilizing her oxygen. The CNA said the resident was compliant and would not resist wearing her nasal cannula. Additionally, the CNA indicated staff were not monitoring her oxygen saturation levels until after prompted by the resident's daughter around 11 a.m. The CNA said she noticed the resident seemed to be gasping for air around 10:30 a.m. or 11 a.m. but said she thought the resident was having issues related to her [MEDICAL CONDITION]. She said she asked the resident to eat but said the resident explained to her that she just couldn't. She said the resident explained that she felt something was wrong. The CNA said these details prompted her to tell LVN B that she felt something was not right with the resident. The CNA indicated it was at that point LVN B decided to take the resident's vitals (O2 and blood pressure). She said the LVN was having difficulty getting the readings so he elected to elevate her bed as she seemed to be laboring to breathe when lying flat. The CNA indicated the resident's O2 levels were at that point but she could not recall the exact readings. CNA C was asked if she felt Resident #1 should have been sent to the hospital earlier and stated, If that was my family member, I would say yes. The CNA said when they were finally given the order to send the resident out, LVN B called Southern Cross Ambulance service around 3 p.m. and was told it would be up to a 2 hour wait. The CNA said she asked LVN B if they should call 911 and said LVN B said, no, because he felt he had the resident was stable enough so he elected for the resident to wait on the ambulance service as opposed to calling 911. Interview on 6/5/2017 at 3:22 p.m. with CNA D revealed on the day the resident was discharged , she first noticed the resident's roomate's son was in the resident room that morning and was complaining the room smelled like urine. She said she was surprised to find the resident had wet pull-ups in her trash can which she said was not something the resident would normally do. She said it was the resident's shower day and said the resident not only refused but was lying down and wouldn't get up. She said that was when she notified LVN B and said the resident again refused to shower. CNA D explained she and CNA C were finally able to get the resident to shower but said the resident was not wanting to stand. CNA D said the resident's breathing was labored between 9 a.m. and 10 a.m. CNA D said she and the other CNA explained to LVN B that the resident was not being herself. She said the resident was having a hard time standing which was not normal and indicated LVN B started to assess the resident, and asked for a manual blood pressure cuff because the levels were showing really low on the electronic cuff and said the resident's oxygen levels were really low as well but could not recall the specific readings. Interview on 6/5/2017 at 3:36 p.m. with ADON E revealed she told LVN B to talk to the doctor because Resident #1 was experiencing low oxygen saturation and find out what he wanted to do. The ADON said the resident's doctor ordered the resident be sent to the hospital. The ADON indicated that she did not know why LVN B elected to have Resident #1 transported via the ambulance service as opposed to calling 911. The ADON felt LVN B could have done better and said, If (the ambulance service) could have been to the facility within 20-30 minutes, fine, but indicated 911 should have been called after LVN B was told it would be over an hour before the ambulance would arrive. ADON E indicated the resident's vitals were disabled by an ex facility nurse who updated the resident's orders so the blood pressure request would not prompt staff to take readings. The ADON cited several examples that would constitute a change of condition including, when a resident who is continent becomes incontinent, a resident who normally can walk can no longer walk, and if a resident demonstrates difficulty in breathing. The ADON confirmed all were considered to be a change in condition. Interview on 6/5/2017 at 4:28 p.m. the DON revealed the facility did not have a policy for reporting changes in condition of residents up the chain in command but indicated staff was in receipt of in-servicing regarding change of condition. The DON indicated the CNAs should report a change in condition of a resident immediately to the charge nurse and said a resident's change of condition should go above the charge nurse level if the charge nurse could not handle the injury or if it required discharge to the hospital. The DON indicated a resident's change of condition would be documented in the nurses notes and/or sbar if the resident was discharged to the hospital. The DON indicated the actions she would take if informed of a severe change of condition would be to immediately go to the resident's room, assess the resident, and determine what needs to be done. The DON indicated the facility had not yet addressed the deactivation of orders for residents with staff. Interview on 6/5/2017 at 5:05 p.m. with the ex-staff who allegedly deactivated Resident #1's order for biweekly blood pressure readings and recordings revealed the LVN denied altering or deactivating the resident's orders relative to taking and documenting biweekly blood pressure readings. A list of resident discharges for the month of April 2017, provided by the facility, revealed Resident #1 was discharged to the hospital.