Every finding on record at Rosenberg Health & Rehabilitation Center

Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 7 residents (Resident #2) reviewed for pressure ulcers. The facility failed to complete wound assessments for Resident #2's left heel wound that developed in the facility for approximately 5 weeks. This failure placed the resident at risk for infection, impaired healing, further skin breakdown, and delayed identification of changes in wound status.Findings included: Record review of Resident#2's facesheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Type 2 diabetes, heart failure, Chronic Obstructive Pulmonary Disease, and morbid obesity. Record review of Resident #2's admission MDS dated [DATE] revealed BIMS score of 11 out of 15 indicating moderate cognitive impairment. Further review of the MDS revealed he was not at risk for pressure ulcers, he did not have one or more unhealed pressure ulcers, and he had no venous(an open sore, typically located near the ankle, caused by poor blood circulation and high pressure in the leg veins). or arterial ulcers (wounds caused by poor blood circulation to the lower legs and feet) Record review of Resident #2's Care Plan initiated on 5/10/2026 revealed a care area for a stage 2 pressure ulcer (a partial-thickness skin loss involving the outer layer and the middle layer)to the left heel. The interventions included:Administer analgesics as needed for discomfort or pain. If necessary provide pain management prior to dressing changes and repositioning.Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected.Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse.Provide wound care per physician's order. Keep dressing clean, dry, and intact.Replace the dressing as needed for soiling.Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Record review of Resident #2's SBAR dated 4/30/2026 at 4:07pm revealed he had a change in condition of dark discoloration noted to left heel that had not occurred before. The SBAR noted an observation of, skin intact, wound care nurse to follow-up with treatment plan. Heels offloaded. Monitoring ongoing. Additional information noted, Patient noted with dark discoloration to left heel with Skin intact, NP notified. Attempted to update POA but Unsuccessful. Wound care nurse to follow up with treatment plan. Heels offloaded and floated. Monitoring ongoing. Record review of Resident #2's physician note dated 5/3/2026 at 11:43am, revealed the skin examination noted, small open area to left lateral heel, dry flaky skin bottom of bilateral feet. Appropriate wound care orders already in place. Record review of Resident #2's physician orders dated 5/3/2026 revealed an order for Left lateral heel stage 3 pressure ulcer (a deep, crater-like wound that features full-thickness skin loss)- clean with wound cleanser, apply calcium alginate, secure with island dressing one time a day for Wound Care. Record review of Resident #2's May 2026 and June 2026 MAR revealed order for Left lateral heel stage 3 pressure ulcer- clean with wound cleanser, apply calcium alginate, secure with island dressing one time a day for Wound Care ordered on 5/3/2026 was marked completed from 5/5/2026 - 6/9/2026. Record review of Resident #2's Skin check dated 5/5/2026 at 7:55am by Wound Care Nurse revealed no new skin issue's identified but noted skin issue #001 to the right inner forearm. Further review of the skin check assessment revealed no mention of Resident #2's left lateral heel wound. Record review of Resident #2's Skin issue assessment dated [DATE] at 9:28am by Wound Care Nurse revealed Skin Issue #001 to right inner forearm was resolved/healed. Further review of the skin issue assessment revealed no mention of Resident #2's left lateral heel wound. Record review of Resident #2's physician note dated 5/9/2026 at 3:38pm revealed in part, .wound nurse present performing dressing change to left heel. SKIN: Denies rash and pruritus (irritating skin sensation that creates an urge to scratch). Soreness to left heel. SKIN: dry, intact, normal color. Wound to left lateral heel, dressing changed today. Record review of Resident #2's Skin issue assessment dated [DATE] at 7:13am by the Wound Care Nurse revealed no mention of left lateral heel ulcer. Record review of Resident #2's Physician note dated 5/17/2026 at 2:08pm revealed in part, .SKIN: Denies rash and pruritus. Soreness to left heel. SKIN: dry, intact, normal color. Wound to left lateral heel. Record review of Resident #2's Skin Check assessment dated [DATE] at 8:35am by Wound Care Nurse revealed, No skin issues identified. Foot Evaluation completed. No new skin issues identified. Record review of Resident #2's Skin Check assessment dated [DATE] at 2:22pm by Wound Care Nurse revealed, No skin issues identified. Foot Evaluation completed. No new skin issues identified. Record review of Resident #2's Physician note dated 5/30/2026 at 8:08pm revealed in part, .SKIN: Denies rash and pruritus. Soreness to left heel. SKIN: dry, intact, normal color. Wound to left lateral heel. Record review of Resident #2's Skin Check assessment dated [DATE] at 7:21pm by RN A revealed, No skin issues identified. No new skin issues identified. Record review of Resident #2's clinical record from 4/30/2026 - 6/8/2026 revealed no documented assessments of Resident #2's left lateral heel wound. Further review of clinical records revealed only mention of Resident #2's left lateral heel wound was within the physician treatment order from 5/3/2026 indicating it was a stage 3 pressure ulcer, care plan started on 5/10/2026 indicating stage 2 left heel wound, and physician notes documenting a wound to the left heel on 5/3/2026, 5/9/2026, 5/17/2026, and 5/30/2026. Review further revealed no initial assessment of Resident #2 left heel wound to determine size and appearance of wound upon its discovery to determine progression. Interview on 6/9/2026 at 11:00am, the Wound Care Nurse said the protocols are to do weekly skin checks where it is checked if there are any new skin issues. If there is a skin issue, staff will notify her by entering an SBAR and slipping a paper under her door noting the new skin issue. She will then go and evaluate the skin issue and complete an assessment. She notifies the doctor about the skin issue and her assessment and they may go ahead and give treatment orders over the phone and they will be added to be seen by the wound care doctor depending on the severity of the wound. The Wound Care Nurse said if there is a skin issue she enters weekly skin issues assessments until it is resolved. The Wound Care Nurse stated within the skin issue assessment it allows her to enter in the assessment of the wound, including staging, measurements, drainage, etc. The Wound Care Nurse said the Wound Care Doctor comes weekly and she follows along with him to treat and assess the residents he sees. She stated Resident #2 does have a wound on his left lateral heel but he does not see the wound care doctor because the wound was minor. The Wound Care nurse explained that if the wound was small and minor she will do the treatment and assessments and Resident #2's heel wound qualified for this. The Wound Care Nurse recalled the wound started as a popped blister that turned into a small wound. She stated she does his wound treatment every day for left lateral heel wound and though it is minor it something she keeps an eye on due to issues with lower extremity swelling and reopening the wound. She also stated resident would try to propel himself in the wheelchair by pulling himself with his heel causing further breakdown or reopening. The Wound Care Nurse said she had completed assessments of Resident #2's wound in the skin issue assessments but after reviewing his records she stated she did not know why they were not showing. The Wound Care Nurse stated his Skin Assessment was due today, but she just had not entered it yet. She said she will enter the assessment for today on her end and see if it shows up in the record. Record review of Resident #2's Skin Issues assessment dated [DATE] at 11:09am by Wound Care Nurse revealed, Skin Issue: #001: New skin Issue. Location: Right heel. Issue type: Skin tear. Progress: Stable: previously deteriorating wound characteristics plateaued. Wound was present on admission. Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 1 Width (cm): 0.5 Depth (cm): 0 Area (cm2): 1.5 Undermining (occurs when tissue destruction extends beneath the intact skin at the wound margins, creating a hidden pocket or cave-like space beneath the surface): No. Tunneling (an open injury that extends as a narrow passageway or channel beneath the skin into deeper tissues, muscles, or organs): No. Exudate (wound drainage or fluid) amount: Light. Exudate type: Serous (a clear, watery, or slightly yellow plasma-like discharge): clear watery fluid, which is separated from solid elements. Odor after cleansing: None. Surrounding tissue: Intact. Induration: None present. Edema (swelling caused by excess fluid trapped in your body's tissues): No swelling or edema. Dressing appearance: Intact. Dressing saturation: Minimal < 25%. Cleansing solution: Normal saline. Primary dressing: Calcium alginate. Secondary dressing: Foam. frequency of treatment: daily Skin issue education: Treatment of skin issue. Skin issue education: Signs and symptoms of infection. Skin issue education: Dressing change. Interview on 6/9/2026 at 12:06pm, the Wound Care Nurse said she entered Resident #2's wound assessment in his record for today but she could not produce others like it for previous dates or the initial assessment of the wound to determine how the wound started and had progressed since development. Wound Care Nurse said she completed previous assessments but could not explain why they were now missing or not showing in the record. She stated the wound had improved from when it initially began and had resolved but would occasionally reopen depending on if the resident was having increased swelling in his lower extremities. The Wound Care Nurse added she might have accidentally entered the wound was on his right heel instead of his left and stated she would go back and fix the note. Interview on 6/9/2026 at 1:25pm, the NP stated she was aware of a small wound to Resident #2's left heel and stated from her memory the wound was a reoccurring wound. The wound started as a blister and the Wound Care Nurse provided treatment. The wound closes but sometimes reopens from the swelling in his lower extremities. NP denied having recent visualization of the left heel wound. The NP could not speak on the missing assessments of Resident #2's wounds but stated they should be completed because they are used to determine treatment of the wound. The NP stated if there was a new wound, the Wound Care Nurse would call her and report the assessment of the wound, and she would provide a treatment order for the wound until the resident is picked up by the Wound Care Doctor if needed. The NP added the wound assessments are looked at and used by providers during their chart reviews and assessments when deciding if new orders are needed. Interview on 6/9/2026 at 2:05pm, Resident #2 said about three weeks after he was admitted to the facility, he had a blister form on his heel from wearing his shoes. Resident #2 said apparently the back of the shoe was rubbing his heel and caused the blister to form. Resident #2 said there was a lady staff member who accidentally ripped the top skin off the blister, and it caused the wound to open. Resident #2 said he could not see the wound himself, but he could feel it there. Resident #2 said since the blister had opened causing the open wound it had not completely resolved to his knowledge because it continued to hurt when the area was touched and he received wound treatment on it every day. Observation and interview on 6/10/2026 at 12:50pm, Wound Care Nurse removed dressing dated 6/10/2026 from Resident #2's left lateral heel revealing a dime sized opening on his left lateral heel. No visible drainage, redness, or swelling to the area. Wound had a white center and skin looked moistened around the edges of opening due to recent wound treatment performed, inside the wound was dry. Resident #2 voiced that he thought the wound was getting better but stated he could still feel pain in the wound when it is touched. He voiced no pain at the time of the observation. Record review of the facility Skin Management policy last reviewed on 2/10/2020 revealed in part, .3. A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers. Documentation that the skin evaluation was completed and is entered in the Treatment Administration Record. 4. The wound nurse or licensed nurse re assess/ reevaluates pressure ulcers weekly and as clinically indicated. The weekly evaluation/assessment of the pressure ulcer is documented on the pressure ulcer form. 5. A pressure ulcer is classified weekly by using the deepest identified stage and the term healing. 2. Pressure ulcer healing is documented using descriptive characteristics of the wound (i.e., depth, width, presence of granulation tissue, exudate) and by using a PUSH tool a validated pressure ulcer healing tool.

Based on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 3 residents (Resident #1) reviewed for PASARR services. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days following Resident #1's Interdisciplinary Team meeting. This failure placed residents at risk for inadequate care, and losing access to specialized mental health or intellectual disability services.Findings included: Record review of Resident #1's facesheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: quadriplegia (the partial or total paralysis of all four limbs), neuromuscular dysfunction of bladder (brain, spinal cord, or nerve damage disrupts the signals between your nervous system and the urinary tract), major depressive disorder (a severe mood disorder causing persistent feelings of sadness, hopelessness, and a loss of interest in activities), anxiety disorder (mental health conditions characterized by excessive, persistent, and overwhelming worry or fear that interferes with daily activities), and spondylolisthesis (one of the vertebrae in your spine shifts forward over the bone directly beneath it). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating his cognition was intact and used a wheelchair for a mobility device. Record review of Resident #1's Care Plan initiated on 11/3/2025 and last revised on 4/20/2026 revealed a focus area of PASRR Positive: The facility Interdisciplinary Team (IDT) has determined that resident has been deemed PASRR positive on the PASRR evaluation that was conducted by the designated LIDDA/LMHA which may place resident at risk for not having the ordered specialized services provided. PASRR positive status is related to a history of developmental disabilities. Resident receives habilitation coordination, CMWC and independent living skills. The interventions included: Appointed facility staff to schedule IDT meetings as required so that all necessary team members are in attendance. Designated staff member will invite the PASRR representative to quarterly care plan meetings and communicate any changes of condition as needed. Services are being used and will be included in all IDT approaches. Record review of Resident #1's PASRR Comprehensive Service Plan (PCSP) Form dated 3/16/2026 revealed LA - IDD had comments noting Individual and SPT agreed to following services Customized wheelchair, Habilitation Coordination and Independent living skills with LA-IDD signature dated 3/18/2026. Interview and observation on 6/9/2026 at 1:55pm, Resident #1 was in his room visiting with family. Resident #1 was up and in a motorized wheelchair. Resident stated he recently got the wheelchair after a lot of work to get it. Resident stated he was okay and had no complaints, he continued to visit with his visitor. Interview on 6/9/2026 at 3:15pm, PASSR Program Specialist stated that after the facility has an initial IDT meeting and services are agreed upon to request, the facility has 20 days from the date of the meeting to submit the request in the LTC portal for PASRR services. The PASSR Program Specialist stated the facility had not submitted the request within the 20 days of Resident #1's IDT meeting and an email was sent requesting the information be uploaded and still the requests had not been uploaded which placed them in non-compliance. Interview on 6/9/2026 at 3:25pm, the Social Worker stated Resident #1 was already receiving PASRR services of Habilitation Coordination and Independent living skills, however, he was taken off of Hospice a few months ago which was a change in condition and another initial IDT meeting was required. The Social Worker stated at the new initial IDT meeting on 3/16/2026 it was agreed for Resident #1 to receive the same services of Habilitation Coordination and Independent living skills, as well as a motorized wheelchair. The Social Worker said she had not uploaded the IDT service requests to the portal and stated to her knowledge, usually the LIDDA coordinator would upload that information. The Social Worker stated she was not familiar with where the requests should be uploaded and said she had not done this before with their other PASSR residents. The Social Worker did recall getting an email from State Agency PASSR services regarding non-compliance with specialized services requests. The Social Worker said she forwarded the email to their LIDDA coordinator asking for assistance on what to do with the request and her response did not address what and where to submit requests. The Social Worker stated since Resident #1 was receiving the services and had gotten his motorized wheelchair, she figured the matter was taken care of. Record review of email dated 5/20/2026 at 3:45pm from State Agency PASSR services revealed the facility was not in compliance with submitting specialized service request to the LTC portal within 20 days of the IDT meeting. The email requested the information be uploaded within 3 -5 days upon receiving the email. Further review of the email chain showed the Social Worker forwarded the email to the LIDDA Coordinator on 5/21/2026 at 8:36am asking, Are you able to assist me with this? Is Resident #1 receiving specialized services?. The email chain showed a response from LIDDA Coordinator on 5/22/2026 at 9:07am apologizing for delayed response and noted, When he was taken off of hospice care (change of condition), we held a new initial PASSR meeting on 3/16/2026. He is currently receiving the following specialized services: Habilitation Coordination, Independent Living Skills and Customized Wheelchair (which he had already received). Phone interview attempted on 6/9/2026 at 3:46pm with LIDDA Coordinator but there was no answer and a voicemail requesting a return phone call was left. Interview on 6/10/2026 at 11:00am, the Administrator stated after some investigation it appeared Resident #1 got his motorized wheelchair through his insurance which the resident arranged on his own. The administrator stated Resident #1 was originally denied getting the wheelchair through PASSR services back at his first initial IDT meeting and his insurance also denied him the wheelchair because he was on hospice. The Administrator said Resident #1 took himself off hospice so he could get the wheelchair through his insurance. The Administrator stated given that the Resident was already receiving services and the facility saw he had received the motorized wheelchair, this caused some confusion on whether the service requests needed to be submitted in the portal after change in condition IDT meeting. Record review of the facility Preadmission and Screening Resident Review (PASSR) Rules Guidelines last revised on 7/2023 revealed in part, .Facility initiates Specialized Services by submitting request to Agency within 20 days of PCSP meeting.

ACRONYMS:BIMS: Brief Interview of Mental StatusRN: Registered NurseDON: Director of NursingADON: Assistant Director of NursingMDS: Minimum Data SetADM: AdministratorBased on interview and record review, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment to ensure that resident's care plan was reviewed and revised by the interdisciplinary team to address 1 of 4 residents (Resident # 1's) allegation.The facility failed to ensure that Resident # 1's care plan was revised to address her sexual allegation This failure could place 94 residents at risk of being sexually abused.Record review of Resident # 1's admission face sheet dated 01/08/2026, retrieved on 01/28/2026 at 10:17 a.m., revealed she was an [AGE] year-old female who was admitted into the facility on [DATE]. Her diagnoses included: Bipolar disorder (mental health condition characterized by severe mood swings ranging from extreme high to low. Mild cognitive impairment (decline in memory. Thinking, and judgement ranging from mild to severe. Major depressive disorder (mood disorder characterized by persistent sadness, loss of interest and low energy. Anxiety (excessive persistent fear or worry that interferes with daily life). Record review of Resident # 's quarterly MDS dated [DATE], retrieved 01/28/2026 at 10:17 a.m., revealed for section C0500 the resident's BIMS score was 15 indicating the resident was cognitively intact. For section E0100: Behavior, Resident # 1 was coded with no hallucinations or delusions. Record review of Resident # 1's dated 01/08/2026 retrieved on 01/28/2026 at 10:35 a.m., revealed she uses psychotropic medications which included antipsychotics and antidepressants related to her diagnoses of depression and anxiety. This was initiated on 05/14/2025 and revised on 07/15/2025 with goal for Resident #1 to be free from cognitive behavior/behavior impairment. The intervention was -staff to monitor side effects such as, mania, hostility and rage and impulsive behavior and hallucination. In an interview with RN B on 01/28/2026 at 12:41 p.m., she said, she did not know why the care plan for Resident # 1 was not updated after she made the sexual allegation. RN B said the MDS Coordinator and other management staff are responsible for the care plan. She said the nurses are not directly responsible for the care plan. Nurses can see what is on the care plan and implement the orders. In an interview with MDS Coordinator at 2:25 p.m. on 01/28/2026, she said developing and updating the care plan is the responsibility of the MDS Coordinator, the ADON and the DON. She agreed she knew Resident 's sexual abuse incident. She reviewed the care plan for Resident # 1from 09/24/2025 through January 28th, 2026, and said the care plan was not updated to reflect Resident 's allegation of sexual abuse by a staff member. She said, I cannot tell why it was not updated, I do not have an answer to that at this time. In an interview with ADON A, at 04:56 p.m. on 01/28/2026, he said all nurse managers and the MDS Coordinator are responsible for developing and updating the care plans. He said the care plans are updated so staff can better care for the residents. The consequences of failure to update the care plan for Resident # 1 is the fact that the incident might happen again. In an interview with RN A, at 12: 20p.m. on 01/29/2026, she said, people who complete care plans are responsible for updating the care plans when they are supposed to. RN A said care plans should be reviewed and updated after an incident. She said this will enable the team to see what can be improved for the residents who had an incident. If the care plan is not reviewed, things would stay the same or there would be no improvement. RN A said, she does not know why Resident # 1's care plan was not updated. In an interview with the DON at 12:30 p.m. on 01/29/2026, he said the management team is responsible for the development and updating of the care plans. He said when there is an acute change, the nurse managers will update the care plans. The DON said I cannot say why Resident #1 's care plan was not updated. If we did not update the care plan, she can make the same claim. In an interview with the Administrator at 1:03 p.m. on 01/29/2026, he said, care plan development and updates were the responsibility of the MDS Coordinator. He said, he does not know why Resident 's care plan was not updated. Record review of facility's policy of abuse dated 10/24/2022. Policy Statement:-It is the policy of this facility to provide protection for the health, welfare and rights of each resident .that prohibits and prevents abuse.-Sexual abuse is non-consensual sexual contact of any type with a resident.-The facility provides ongoing oversight and supervision of staff in order to assure that it's policies are implemented as written-New and existing staff will be educated on prohibiting and preventing all forms of abuse.

Based on observation, interview and record review, the facility failed to ensure, a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, based on the comprehensive assessment for 1 of 5 residents (CR #1) reviewed for quality of care in that: CR #1 had a palm protector medical device on his contracted left hand for approximately 7 days, resulting in admission to an acute care hospital on [DATE] with left hand pain, cellulitis, and deep, open pressure wound that involved the thenar web space (the space between the index finger and thumb) that appeared chronic with a foul odor. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 11/11/25 and ended on 11/18/25. The facility corrected the noncompliance before the survey began. This deficient practice placed residents at risk of developing avoidable pressure injuries, severe pain, and decreased quality of life. Findings include: Record review of CR #1's admission record generated on 11/19/25 revealed he was admitted to the facility on [DATE] and had diagnoses of hypertensive heart disease without heart failure (heart problems caused by long-term high-blood pressure), metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance from a systemic illness, organ failure or exposure to toxins), cerebral infarction (occurs when a blockage in a brain artery cuts off blood flow, leading to brain tissue death), abnormalities of gait and mobility, contracture of muscle (the permanent tightening of muscles, tendons, and other tissues which causes a joint to shorten and become stiff, limiting movement), dementia (a decline in mental ability, such as memory loss and impaired thinking, that affects daily life) and hemiplegia (paralysis that affects one side of the body). He was [AGE] years old. Record review of CR #1's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 0, indicating he had severe cognitive impairment. He was dependent on staff for eating, hygiene, dressing, and transfers. He was always incontinent of bowel and bladder. He had one stage 4 pressure ulcer /injury (a severe, full-thickness wound that involves damage to underlying bone, muscle or tendon) and was at risk of developing pressure ulcers/injuries. Record review of CR #1's care plan revised on 7/8/25 revealed he had the potential for skin breakdown due to decreased mobility and incontinence. Interventions included reposition frequently, check for wetness and soiling every two hours and provide incontinence care as needed, bathe per schedule, weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity, report new conditions to the physician. Record review of CR #1's care plan revised on 7/16/25 revealed he had an activity of daily living self-care performance deficit related to impaired mobility, contracture of muscles and hemiplegia following a cerebrovascular accident (occurs when blood supply to the brain is blocked or a blood vessel ruptures, leading to brain damage). Interventions included total assistance of two staff for bed mobility and dependent on two staff for personal hygiene and dressing. Record review of CR #1's physician's orders dated November 2025 revealed there were no orders for a palm guard or other medical device (a palm guard is a device used for moderate to severe contractures to help prevent skin breakdown in the palm). Record review of CR #1's Progress Note documenting skin issues dated 11/4/25 revealed Treatment Nurse B indicated CR #1 did not have an external device, and there were no documented skin issues on his left hand. Record review of CR #1's Nurse Progress Note dated 11/6/25 revealed CR #1 was sent to an acute care hospital for g-tube replacement. Record review of CR #1's After Visit Summary from an acute care hospital dated 11/10/25 revealed he had his feeding tube replaced. The summary included instruction for CR #1 to start taking Ceftin (an antibiotic medication), 1 tablet in the morning and 1 tablet in the evening administered by feeding tube for 5 days. Record review of CR #1's nurse progress note dated 11/14/25 revealed NP A visited CR #1 for a readmission evaluation day #3. (CR #1) was sent to (acute care hospital) on 11/6/2025 due to dislodgement of his PEG tube. At the time of hospitalization he was treated with IV antibiotic for elevated WBC count and suspected pneumonia. After stabilization and PEG tube replacement patient is send (sic) back to the facility on [DATE]. Record review of CR #1's Treatment Administration Record dated 11/1/25 to 11/30/25 revealed Treatment Nurse A documented a head-to-toe skin assessment daily between 11/11/25 and 11/14/25 and on 11/17/25. Treatment Nurse A indicated that there were no changes to CR #1's skin integrity. Record review of Resident #1's Progress Note documenting skin issues dated 11/17/25 completed by Treatment Nurse A indicated CR #1 did not have an external device, and there were no documented skin issues on his left hand. Record review of CR #1's nurse progress note dated 11/17/25 at 9:00pm completed by LVN A revealed, During scheduled medication pass at this time, I observed the resident left hand between thumb/index finger was swollen, red with what appeared to be skin tear, (resident) had on a hand brace in between his thumb/index area. At this (sic) I slowly pulled the brace back and noticed dry blood. At this time, I attempted to assess and clean the area, but resident yelled in pain. I provided his schedule (Morphine) 1mL was administered along with all other scheduled medications. Placed call to.(Advanced Nurse Practitioner). Received order to transfer to (acute care hospital). Record review of CR #1's SBAR Communication Form dated 11/17/25 revealed LVN A documented that CR #1 had a swollen left thumb that started on 11/17/25. The form noted things that make the condition or symptom worse are: hand cuff. Things that make the condition or symptom better are: removing the hand cuff. LVN A documented that the hand cuff is very tight between thumb causing swelling. LVN A notified NP B and NP B recommended CR #1 was sent to the hospital. Record review of CR #1's acute care hospital record dated 11/18/25 at 5:01am revealed an inpatient consult to the hospitalist. MD B noted CR #1 was brought to the hospital due to left hand pain and an open wound. Patient was reportedly put in wrist restraints with thumb hole which cut into the thenar surface. Patient noted to have bleeding and reportedly had foul-smelling discharge.had his wound cleaned and dressed. He was then admitted for further workup and management. assessment and plan: Open wound of thumb with complication.cellulitis (a common, deep skin infection caused by bacteria entering through a break in the skin) of finger of left hand, leukocytosis (a condition characterized by a higher-than-normal white blood cell count and is typically a sign of the body responding to an infection, inflammation or injury). Record review of CR #1's acute care hospital record dated 11/18/25 at 12:41pm revealed an inpatient consult to general surgery. During a physical exam, MD C noted CR #1's left hand wound involving the 1st web space was deep and almost to the bone. There was no active bleeding, and the wound appeared somewhat chronic; has a foul smell without purulence (the state of containing or forming pus). MD C noted the evaluation of the hand was limited by the contracted positioning of the digits. The patient is confused and slightly combative on exam. Given the chronicity, we do not recommend closure of this wound, and it should continue to heal by secondary intention. Record review of CR #1's acute care hospital record dated 11/19/25 revealed an inpatient consult for wound care. The document revealed he presented to the hospital with an open wound on his left hand present on admission. The wound on his hand was secondary to restraints. The wrist restraints cut into patient's left thumb. There is a concern for bleeding and malodorous drainage. The wound was described as a linear laceration into the thenar wound bed (sic) pink, moist, wound margin was circumscribed periwound intact (the skin around a wound is healthy, unbroken, and clearly defined without any signs of damage). There is depth to the wound. And the wound extends into patient's R (sic) palm. Contractures noted of the fingers. The document was completed by MD A. Record review of CR #1's acute care hospital record revealed a photo of his left hand (undated). The hand was shaped like a balled-up fist. Someone was pulling the thumb away from his palm area and the inside of the wound was visible. There was a medical device on his hand that wrapped around from underneath and on top of his thumb that extended out to the top of his hand. It was approximately 2 inches wide. The device had a Velcro component, and the tag was visible displaying the brand name. The device was stained with a dark brown substance where it met the thumb. The thenar web space was lacerated and part of the device was in the laceration. His thumb was red, swollen and had a patch of dried blood and some layers of skin were gone. Record review of CR #1's acute care hospital record revealed a photo of his left hand (undated). The hand was shaped like a balled-up fist. There was no device near his thumb. The thenar web space was lacerated and extended down into his hand toward the bone in his thumb. The thumb was lacerated underneath his thumb where it met his wrist. The laceration was covered in red blood. This thumb was red, swollen, and had a patch of dried blood and some layers of skin were gone. In an interview on 11/19/25 at 4:30pm, LVN B said CR #1's left arm and left hand were contracted. He said his left arm was held close to his chest. He said CR #1 liked to be under a blanket because he was cold and did not like when staff moved the blanket. He said he was not aware of CR #1 having a palm guard or other medical device on his hand because he was always covered. In a telephone interview on 11/20/25 at 7:05pm NP A said she saw CR #1 a few times last week. She said when she visited, CR #1 asked if she would pray with him, and she took both of his hands. She said she did not notice anything wrong with his hands during that time. She said, Maybe something happened overnight. She said CR #1 moved his hands a lot. She said she was not informed by a nurse of a wound to his hand. In an interview on 11/19/25 at 4:00pm, Treatment Nurse A stated she completed a skin assessment of CR #1 about 1 to 2 days before he went to the hospital. She said she saw he had a device on his hand but did not remove it to observe his skin. She said at that time, she did not see blood, edema (swelling caused by excess fluid trapped in your body's tissues) or notice any foul odors. In a telephone interview on 11/19/25 at 2:42pm, LVN A said CR #1 did not like to be shuffled around and liked to be covered with a blanket. She said his left arm was contracted. She said it was bent and always resting on his shoulder. CR #1 had a hand splint/device to open his hand to treat a contracture. She said she was unsure who put the device on. She said she had seen him use the device since she started in July 2025. She said she had not received training on the use of devices and did not monitor their use in his treatment record. She said when she worked with CR #1, she looked at the device on his hand but did not notice there was anything wrong before 11/17/25. She said on 11/17/25, she raised his bed so she could administer his medications. She said when she pulled the sheet back, she saw that his hand was swollen and red with dried blood on it. She said she attempted to remove the device and clean it, but he was in a lot of pain. She said she could not determine how bad the wound was, but said the device was stuck in his hand. She said she called NP B and received a recommendation to send him to the hospital. In a telephone interview on 11/21/25 at 11:35am, MD A said she saw CR #1 at the hospital. She said she did not see him immediately on admission, so she did not see the device on his hand. She said she reviewed the pictures of his hand in his medical record. She said the brace may have been too tight and was there for too long, so it would dig into his skin. She said she described the wound as a laceration in her note because she saw him after the device was removed from his hand. She said the wound could have been a medical device related pressure wound. She said she could not get measurements of the wound because of his hand contracture and the pain it would have caused. In an observation on 11/19/25 at 1:20pm at the acute care hospital, revealed CR #1 was lying in a bed with his eyes closed. His left hand had a thick bandage wrapped around it. His arm was positioned on his chest and his hand was near his left collar bone. In an interview on 11/19/25 at 9:26am, the Hospital RN said CR #1 was in their hospital on [DATE] due to a dislodged g-tube. She said when he left on 11/10/25, he had no injuries to his hand. She said when Resident #1 was seen in the hospital on [DATE], a device was on his hand and was deeply embedded in his hand where the device wrapped around his thumb. She said there was no way the injury occurred in one day. In an interview on 11/19/25 at 2:55pm, the DON said he heard about CR #1's injury from a nurse at the hospital. He said someone in therapy placed the palm protector device on Resident #1's left hand on 11/11/25. He said it was determined that the device was left on his hand from 11/11/25 to 11/17/25. He said when they discovered yesterday on 11/18/25 that Resident #1 did not have an order for the device, they initiated a performance improvement plan. He said a device should have an order, care plan and monitoring in place. In an observation and interview on 11/19/25 at 3:07pm, the Therapy Director said she was the only full-time occupational therapist. She said an occupational therapist evaluated a resident to determine a need for a palm protector device. She said she did not recommend a palm protector for CR #1. She said she could not find a recommendation for a palm protector in CR #1's medical record. She said a palm protector was used when a hand was contracted to protect the palm from the fingers. She said they were used from 4 to 8 hours. She said the risk of using it longer would be skin breakdown. The Therapy Director showed the investigator a palm protector. The palm protector was made out of a fleece-like material. It was placed on the hand using a Velcro strap and a hole for the thumb. When placed, there was a pad in-between the palm and the fingers. In an interview on 11/20/25 at 2:22pm, the Therapy Director said when a resident was receiving therapy services, the therapy team monitored the use of a palm guard device, including placed it then removed it. She said if a resident was not receiving therapy services, the nursing staff were responsible for monitoring. She said CR #1 was under the care of hospice and the nurses were required to complete skin checks. In an interview on 11/19/25 at 4:45pm, CNA A said CR #1 required total assistance with care. She said he did not like when they touched his left arm or hand. She said CR #1 had a brace/device on his left hand for about one month. She said it was in place during the entirety of her shifts from 6am-6pm. She said they were not informed of what type of brace it was. She said it was gold in color and would have noticed if it had blood on it. She said she did not notice any type of injury to his hand. In an interview on 11/19/25 at 6:15pm, RN A said CR #1's left hand and arm were contracted, and his arm was pushed against his chest. She said he had a palm guard on his hand to protect his palm from his fingers. She said sometimes she would check to make sure it was not too tight. She said she did not take it off. She said the device was white so it would be noticeable if it was bleeding. She said she did not notice anything wrong with it. She said she did not know who put the device on his hand or when it occurred. In an interview on 11/19/25 at 6:27pm, CNA B said she saw something on CR #1's hand but could not say what it was. She said she did not notice any issues with his contracture or the device. In an interview on 11/20/25 at 3:15pm, COTA A said her responsibilities at the facility were to carry out the occupational therapist's recommendations for residents. She said she did not make recommendations for treatment. She said CR #1 had a palm protector for a while. She said he was on and off therapy services, and at some point it was recommended. She said she did not put the device on CR #1's hand in the last month. She said she would only see a resident if they were on therapy services. She said CR #1 had not been on services for about 2 months. In an interview on 11/20/25 at 3:37pm, the ADON said it was difficult to assess CR #1 because he did not like to be bothered and pulled back from the nurses. He said he did not know about CR #1's device or injury until he was admitted to the hospital. He said residents with recommendations for a brace or a device should have physician's orders, monitoring and updated care plan. In an interview on 11/20/25 at 3:57pm, COTA B said her responsibilities at the facility were to carry out the occupational therapist's recommendations for residents. She said she did not make recommendations for treatment. She said if a resident was seen for contracture management, she would complete hand care, place the recommended device, monitor for the allotted time, then take it off. She said the devices were not available to a resident unless there was a recommendation for one and it was ordered by the rehabilitation department. She said if a resident was on therapy services, the COTA would monitor the device, and if the resident was not on therapy, the nursing staff would monitor the device. She said the device should be monitored to ensure skin damage did not occur. She said she had not seen CR #1 in over a month. In a telephone interview on 11/20/25 at 4:36pm, LVN C said he cared for CR #1 when he returned from the hospital after 11/11/25. He said when CR #1 returned from the hospital, he had a dressing on his left contracted hand. He said when he saw CR #1's hand on or about 11/11/25, his hand was brown in color, but the wound was not open. He said the dressing was clean and NP A assessed him. He said NP A did not say anything or give any orders. He said he thought CR #1 laid on his left side for too long and that could have caused swelling and skin breakdown. When asked if it was possible that the dressing he was referring to was a contracture management device, he said he was not sure, but it could have been. He said he was not sure who put it on CR #1's hand. He said CR #1 had a brace for his hand a few months ago. He said he was admitted from the hospital with an order for antibiotics. He said he thought the antibiotic prescription was for a possible wound infection, but he did not do the admission assessment so he was unsure. In a telephone interview on 11/20/25 at 4:47pm, CNA C said she worked with CR #1 on 11/13/25, 11/14/25, and 11/17/25. She said CR #1 was always lying on his left side and it was contracted. She said on 11/13/25, she noticed he had a splint on his hand. She said on 11/14/25, when she turned him to change his clothing, she noticed his thumb was swollen and reddish-purple in color. She said she opened his hand and saw it was raw and puss was coming out of his hand. She said she told LVN C. She said LVN C told her he was on antibiotics and there was no further discussion. She said when she returned on 11/17/25, the wound on CR #1's hand looked the same as it did on 11/14/25. In an interview on 11/20/25 at 5:36pm, CNA D said he noticed CR #1's hand was contracted and there was a cloth on his hand but did not get close enough to observe it. Record review of the facility's Skin Management Policy dated 2/1/2014 revealed in part, A comprehensive evaluation of a patient's skin status requires evaluations by the nursing staff, registered dietician, social services, activity and rehabilitation team. if new skin alterations of any type are identified through skin observation or skin evaluations/assessments the physician and family is notified. Physician orders are obtained. The patient is reviewed by the interdisciplinary team and a plan of care initiated. It was determined these failures placed CR #1 in an Immediate Jeopardy (IJ) situation from 11/11/25 to 11/18/25. The Administrator was notified and provided with the IJ template 11/19/25 at 7:07pm. The facility took the following action to correct the non-compliance on 11/18/25: Record review of a Performance Improvement Plan dated 11/18/25 revealed an area of concern of the assistive device system, including a resident with a palm protector without an order, palm protector placed on resident without nursing notification, and resident did not have palm protector routinely removed to assess skin integrity. Interventions included an audit of all residents with palm protectors and splints to ensure orders and care plans were in place, staff education, skin sweep, hand roll/splint placement, removal and skin integrity monitoring. Record review of an In-Service document (undated) revealed the therapy department was trained on donning (put on) and doffing (take off) of braces, splints, and palm guards. Record review of an In-Service Training Report dated 11/18/25 revealed nursing and therapy staff were trained on assistive devices, including doctor's orders prior to placement, notification of order and device placement to nursing department and therapy/nursing monitoring as indicated. Record review of an In-Service Training Report dated 11/18/25 revealed nursing staff, including CNAs, nurses and medication aides were trained on notification of changes of condition, including any change to a resident's skin, and reporting the change of condition to the nurse. Record review of an In-Service Training Report dated 11/19/25 revealed the DON educated Treatment Nurse A on skin assessments and removing assistive devices to assess skin integrity. Record review of the facility audit of residents utilizing palm protectors and splints (undated) revealed 7 residents had orders implemented, care plans implemented, and monitoring initiated on their treatment record. In observations on 11/20/25 between 10:46am and 6:55pm, Residents #1, #2 and #3 were not wearing palm protectors or splints. In an interview on 11/19/25 at 5:05pm, the DON said they completed an audit for all braces and therapy devices. He said they added orders and updated the residents' care plans. He confirmed they started training staff last night and trained every shift since then. Record review of Weekly Shower/Bath Skin Check Sheets dated 11/18/25 revealed all residents had their skin assessed for suspicious areas or marks. In an interview on 11/20/25 at 3:37pm, the ADON confirmed the facility completed skin assessments for all residents on 11/18/25. In interviews on 11/20/25 between 11:15am and 536pm with CNA C, CNA D and CNA E, they stated they received training on changes in condition and would report any changes to a residents' skin integrity to the nurse. In interviews on 11/20/25 between 2:22pm and 6:15pm, the Therapy Manager, COTA A, COTA B, ADON, DON, LVN D, LVN E and RN A revealed they received training on assistive devices and could articulate the assistive device procedures, including obtaining an order, following the order including time restrictions for the device and monitoring the use of the device. In an interview on 11/19/25 at 4:00p, Treatment Nurse A said she needed to remove assistive devices to observe the skin integrity of the residents.

Based on observation, interview, and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, encompassing the resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders for 1 of 12 residents (Resident #1) reviewed for behavioral services. The facility failed to ensure Resident #1 received adequate behavioral health care services to prevent and treat substance abuse disorder when Resident #1 frequently signed himself out of the facility to go to nearby stores and consume alcohol, resulting in intoxication, vomiting, and lethargy to the point of falling out of his wheelchair. Resident #1 was also known by staff to sign himself out and smoke marijuana in the community surrounding the facility, resulting in a positive laboratory finding for THC. An IJ was identified on 05/29/2025. The IJ template was provided to the facility on [DATE] at 1:20 p.m. While the IJ was removed on 06/01/2025, the facility remained out of compliance at a scope of pattern with severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents who require behavioral health services at risk not receiving having their needs met and, deterioration of health Findings include: Record review of Resident #1's face sheet dated 05/28/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. He was diagnosed with end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and excess fluid from the body), schizoaffective disorder (a chronic mental illness that combines systems of both schizophrenia and mood disorder), gastro-esophageal reflux (a chronic condition where stomach contents regularly flow back up into the esophagus), history of falling, difficulty walking, diabetes mellitus type II (chronic disease where the body either does not produce enough insulin or cannot properly use the insulin it produces) with hypoglycemia (when blood glucose levels drop too low), essential hypertension (persistently high blood pressure with no identifiable cause), chronic ischemic heart disease (long-term condition where the heart's blood supply is reduced due to a mismatch between oxygen supply and demand), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms in COPD patients), unspecified cirrhosis of liver (a type of chronic, progressive liver disease where healthy liver cells are replaced by scar tissue), acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the cystic duct), dependence on renal dialysis (treatment that cleans the blood when kidneys are unable to do so), and shortness of breath. Resident #1 was his own responsible party. Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); Resident #1 exhibited behaviors related to rejection of care; Resident #1 used a manual wheelchair for mobility; Resident #1 was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers and required supervision or touching assistance for showers/bathing; Resident #1 was always continent of bowel and bladder; and Resident #1 was prescribed anticoagulant and antipsychotic medication. Record review of resident #1's care plan, revised on 05/25/2025 revealed the following care areas: * Behavioral Problem: Resident has a behavior problem as evidenced by: displaying verbal and sexually inappropriate behavior by exposing his private area to female residents and female staff. Goal included: Resident's inappropriate behavior will not result in harm or injury to self or others. Interventions included: Educate resident on the privacy issues associated with his behavior. Encourage as much as possible to detour injury. Intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of other. Resident will be receiving psychiatric visits with [Psychiatric Provider] to monitor his behaviors per physician orders. * Therapeutic Leave: Resident is cognitively able to sign out of the facility and make their own informed decisions while they are out. On 04/10/2025 while on therapeutic leave, resident made the decision to consume alcoholic beverages. Goals included: The resident will follow facility policy for out on pass. The resident will be safe and comfortable while out on pass. Interventions included: Educate the resident/family/caregivers about the potential risks associated with signing out on pass. Educate resident/family/caregivers on the facility's policy for therapeutic leave/out on pass. Resident is reminded of his health issues and treatment regimens and the recommendations to avoid the use of alcoholic beverages. Further review of Resident #1's care plan revealed no care areas, goals, or interventions to address his substance abuse concerns. Record review of Resident #1's nursing progress notes for April 2025 and May 2025 revealed: * On 04/02/2025, at 4:10 p.m., SW B wrote, Resident was educated with Administrator, ADON, DON, and SW on the policies for Therapeutic Leave and the expectations for the resident when he is on Therapeutic Leave. Resident verbalized understanding. * On 04/11/2025, at 12:10 a.m., RN E wrote, Resident came back on pass to the facility with alcohol intoxication, vitals and assessment done. All within normal baseline. NP notified. New order to transfer resident to the hospital for further evaluation but resident refused. Resident was monitored through the shift, comfort care provided to resident satisfaction. * On 04/11/2025, at 11:50 a.m., ADON F wrote, Late Entry: 04/10/2025 at 11:00 p.m. Upon resident's return to the facility, resident arrived propelling himself in his motorized wheelchair. Resident had a slurred speech, he was drooling, smiling, and laughing, slow to respond to questions, and lethargic. Resident said he was tired and wanted to lay down and go to sleep and was assisted back to his room and was unable to stand to assist with his transfer to his bed, so he was transferred to bed with two people assist. In speaking with the resident, he said that he had ingested alcohol, specifically three 40 oz bottles of [brand name of beer] and he would not say if he had ingested any other substances or drinks. Upon assessment by unit nurse, there was no evidence of trauma or physical injuries noted, no indications of any falls or any other incidents at the time of his return. * On 04/12/2025, at 7:17 p.m., LVN A wrote, Police officer called facility and said resident vomited and may have been drinking with his friend and they have called 911 for him to go to the ER and have him evaluated. They then came to the facility, and I gave him a face sheet and medication lists. I accompanied the officer to EMS parked on the street near the facility and found the patient inside the ambulance being attended to by two paramedics with patient leaning to his left side. I placed a call to the Administrator and ADON. Resident apparently signed out at about 12 noon and left the facility with another resident. They apparently went to a nearby store and purchased drinks. He drank until he vomited on himself and became very weak. I asked the paramedics where they were taking him, and they informed me that they were taking him to [a local hospital] ER. NP and RP notified. * On 04/14/2025, at 4:38 p.m., ADON F wrote, Resident was found to be in possession of a cigarette lighter. The resident was educated by the Administrator on the smoking policy and the lighter was placed in the smoker's box for the resident to have access to only when on smoke breaks. The Administrator educated the resident on use of another resident's electric wheelchair and encouraged to use his own, the resident verbalized understanding. * On 04/15/2025, at 2:11 p.m., RN H wrote, Resident signed himself out and came back vomiting. Happened a couple of times. NP notified. Lab work ordered. New order to transfer to ER for further evaluation. * On 04/16/2025, at 5:23 p.m., ADON G wrote, Final lab results received on the drug and alcohol screening, labs placed in NP binder for review . resident remains in the hospital at this time. * On 04/23/2025, at 9:46 p.m., RN E wrote, Resident, who went out on pass, returned to the facility alert but disoriented, drooling from alcohol intoxication also had multiple emesis (vomiting). Resident vitals and assessment done all vital signs were within normal baseline. NP contacted via telehealth/virtual service. New order for Ondansetron 4 MG 1 tablet PO q 6hours as needed . * On 05/01/2025, at 11:59 a.m., the SW wrote, The Social Worker and the Administrator witnessed [Resident #1] taking a power wheelchair without the permission of the resident who owns the power wheelchair. Resident was educated that he cannot take the belongings of other residents while they are out of the facility. Resident was also educated on the importance of not using someone else's wheelchair and the risks that can occur . * On 05/04/2025, at 4:41 p.m., RN H wrote, Resident exchanged wheelchair with his former roommate and resident was educated that it was not safe to do so, resident verbalized understanding. Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/10/2025 at 11:17 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Complaint: Altered Mental Status . Per nurse, patient went out on pass and returned to facility lethargic, drooling from mouth and vomited once one hour ago. Per nurse, patient only knows his name, does not know where he is, and does not know the month, year. States at baseline patient is alert and oriented x 3 (a term that describes a patient's level of consciousness and cognitive function. Patient aware of person, place, and time). Per nurse, patient admitted to drinking 3 bottles of [brand of beer]. Per nurse, patient refused dialysis today and states patient did not go to dialysis yesterday . Patient seen with nurse . Physical Exam: Exam findings per nurse and video observation . Orders: Transfer to ER via 911: AMS/ESRD - missed HD/vomiting/possible alcohol intoxication . Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/23/2025 at 10:02 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Chief Complaint: GI: Vomiting . Nurse notified clinician that the [AGE] year-old-male patient with history of ESRD on dialysis, Schizophrenia, falls, HTN, DM2, went out of the facility for an hour and came back intoxicated. The nurse stated this is a regular occurrence for him. He did have an episode of vomiting. Denies drinking alcohol. Will monitor him for now . Record review of Resident #1's Lab Results Report collected on 04/11/2025 and reported on 04/16/2025 revealed Resident #1 was positive for THC (Cannabis). Record review of Resident #1's, Psychiatric Subsequent Assessment dated 04/24/2025 revealed, . History of Presenting Illness: Last visit was on 03/24/2025 . Collateral Information: On 04/24/2025, I attended a multidisciplinary care conference meeting with the DON, ADON, MDS, administrator, medical records, and SW. The case was discussed in detail, and it was concluded; 1. Patient was sent to the hospital due to after the staff found him at the store unable to move. Patient was under the influence of alcohol. 2. Patient does not follow his dialysis schedule . Record review of Resident #1's, Clinical Treatment Plan Review (Plan of Care) completed by the psychiatric provider and dated 04/29/2025 revealed, . History of Presenting Illness: . Patient was referred to psychological services for: Agitation, Irritability, Memory Loss, Short Term Memory Problems, Long Term Memory Problems, Noncompliance, Resistance to ADL/Medications, Sexually Inappropriate Behavior, Attention Seeking Behavior, Medication Evaluation, Other: Resident is refusing dialysis. In addition, he was touching himself in his genitals in an inappropriate way . Family/Social History: . Patient endorsed history of drug/alcohol abuse . Summary of Progress: Patient has been less active with therapy during this treatment cycle due to a new interpersonal relationship and frequent trips outside the facility . Treatment Plan: Treatment is expected to result in an improvement in condition or prevention of decline that would otherwise be expected. Treatment is expected to help improve patient's emotional, cognitive, social, behavioral functioning symptomatology. Psychotherapy in addition to psychotropic medication is the treatment of choice for this patient . Further review of Resident #1's Clinical Treatment Plan Review (Plan of Care) revealed no mention of a plan to address Resident #1's substance abuse concerns. Record review of Resident #1's, Psychiatric Subsequent Assessment dated 05/01/2025 revealed, . History of Presenting Illness: Last visit was on 04/24/2025 . Further review of Resident #1's, Psychiatric Subsequent Assessment revealed no documentation to show his substance abuse issues were addressed. Record review of Resident #1's, Psychiatric Subsequent Assessment dated 05/28/2025 revealed, . History of Presenting Illness: This is a post hospital follow up. After my last visit the patient was admitted into the hospital due to AMS, and general weakness. Psych meds were not changed. My last visit was on 05/01/2025 . Collateral Information: On 05/28/2025, I attended a multidisciplinary care conference meeting with the ADON, MDS, Medical records, DON, and SW. The case was discussed in detail, and it was concluded: 1. Patient has returned back from the hospital. Patient was drinking and using drugs while out on pass . Observation and interview with Resident #1 on 05/28/2025, at 2:30 p.m. revealed he was in his bed with his eyes closed. Resident #1 opened his eyes and was able to provide his name. Resident #1 stated he lived in the facility a couple of months and living there was alright. He said he went to dialysis. He said he fell out of his wheelchair about six months ago (he did not say why). Resident #1 did not answer questions related to drinking alcohol or taking drugs while outside the facility on pass. He closed his eyes and appeared to be asleep although he responded to questions unrelated to drinking or smoking. In an interview with the SW on 05/28/2025, at 3:24 p.m., she stated Resident #1 was capable of making his own decisions, but he just did not make the right decisions. She said Resident #1 went out on pass and did things he should not do. She said Resident #1 received psychiatric services to see why he refuses dialysis so much. She said she was not sure if Resident #1's substance abuse issues were discussed during his psychiatric sessions. She said Resident #1 was vomiting once due to intoxication. She said the facility staff could not tell Resident #1 what he could and could not do outside of the facility, and they could only educate him. She said Resident #1 knew what he was doing. She said Resident #1 was his own RP and he did not have any family. She said to her knowledge, Resident #1 only went out twice and got drunk, but she was not there on weekends. She said Resident #1's behavior of going out and getting drunk had decreased and he went out a lot less. She said Resident #1 had been sleeping a lot more recently and he had several hospitalizations. She said she spoke to Resident #1 about the risks of him going out drunk. She said possible negative outcomes of Resident #1 leaving the facility and getting drunk were that he could die, get injured, and go to the hospital. In an interview with the Activity Director on 05/28/2025, at 3:45 p.m., she stated Resident #1 was known to take his former roommate's motorized wheelchair. She stated Resident #1 had been caught smoking weed (marijuana) and drinking beer. She said a group of residents were at a nearby store drinking and the store workers called the police. She said the police went to the facility and told them they had to keep the residents from going there, but once they sign out, the residents go their own way. She said the residents needed more things to do inside the facility. She said she left the facility at 5:00 p.m. daily and she had only observed Resident #1 return to the facility intoxicated a couple of times. She said Resident #1 was in the hospital about a week or so and yesterday (05/27/2025) or Monday (05/26/2025), he was sick and throwing up. She said Resident #1 refused dialysis a lot. She said Resident #1 used another resident's motorized wheelchair to go to the store because he could not physically wheel himself out to store in his manual wheelchair. She said Resident #1 kept taking his former roommate's wheelchair, so they moved Resident #1 to another room. She said she had no knowledge of Resident #1 falling out of a wheelchair but about 7-8 months ago, she observed him outside with his manual wheelchair stuck and leaning off a curb. She said she pulled over and pushed his wheelchair all the way back to the facility. She said Resident #1 was leaning over in his wheelchair and he kept saying he was sick. She said she did not know of he was intoxicated at that time. She said the residents had to pass a busy road and cross the road to get to the store. She said it was not safe for the residents to travel that way, but they had their rights. She said the Administrator told the staff that the residents had their rights. In an interview with the Administrator on 05/28/2025, at 4:32 p.m., he stated the residents had rights. He said Resident #1's BIMS score was 15, but he did not make proper decisions. He said the facility staff had to make sure they did not infringe on the residents' rights. He said Resident #1 signed himself out and returned intoxicated between five and seven times. He said he had undocumented conversations with Resident #1 about how unsafe it was for him to leave the facility and get drunk. He said the conversations were not documented because he did not go into the facility's computer system to write progress notes. He stated Resident #1 received psychiatric services, but he sometimes refused to talk or participate during his sessions. He said he was not sure if Resident #1's smoking and drinking were addressed during the sessions. He said addressing Resident #1's smoking and drinking in his psychiatric sessions would be helpful to reinforce what the facility staff try to educate him on related to those behaviors. In a telephone interview with Resident #1's physician on 05/30/2025, at 10:00 a.m., he stated he was familiar with Resident #1, and he was aware the resident frequently went out on pass to drink and smoke. He said Resident #1 denied drinking and smoking, but he had a history of noncompliance with dialysis and medications. He said Resident #1 had recently been admitted to the hospital a lot and once, at the hospital, they found he had taken drugs. He said Resident #1 kept denying, so it was hard to address it. He said the negative outcome of Resident #1's behaviors were that one day, Resident #1 is fine, and then in a couple of days, he signs out and takes something (drugs or alcohol) and something happens that leads him back in the hospital. In an interview with LVN A on 05/31/2025, at 2:11 p.m., he stated on 04/12/2025, around 1:00 p.m., the police called the facility and said Resident #1 had fallen out of his wheelchair and was vomiting at the church next to the facility. He said the police went to the facility and then he (LVN A) followed them to see Resident #1. He said he thought the police saw Resident #1 on the ground and called 911. He said when he arrived at the scene, he saw Resident #1 inside the ambulance. He said Resident #1 said he had gone to the store. He said Resident #1 went to the hospital and returned to the facility about two days later. LVN A said he heard the motorized chair Resident #1 fell out of belonged to his friend. He said Resident never admitted to the drinking and always tried to hide it. He said Resident #1 usually returned to the facility late at night, so he (LVN A) was usually gone by that time (LVN worked the day shift, 7:00 a.m. - 7:00 p.m.). He said the negative outcome of Resident #1's behavior was that he was a dialysis patient and it interfered with his kidneys. He said Resident #1 falling out of the chair while intoxicated and going to the ER was a very negative effect. Record review of the facility's policy, titled, Behavior Management revised on 04/15/2014 revealed, Policy: The purpose of the policy is to optimize the quality of life and function of patients that experience behavioral symptoms that require person centered approaches to meet the health, physical, psychosocial, and behavioral health needs. Fundamental Information: Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for dementia patients. Fundamental principles of care for a patient with behaviors include an interdisciplinary approach that focus on the individualized needs of the patient . Procedure. Determine whether there is a medical, physical, functional, physiological, emotional, psychiatric, social, or emotional cause of the behaviors . Considerations: Person-Centered Care - evaluate if the environment is supportive and promotes comfort toward understanding, preventing, relieving, and recognizes individual needs and preferences . Evaluations are completed on new or worsening behaviors . Identify the frequency, intensity, duration, severity, and impact of behaviors, as well as the location, surroundings, or situation. Identify interventions or approaches to prevent, modify, relieve, or address the behaviors or distress. Patient behaviors or distress are documented as it occurs and the effectiveness of interventions. Individualized Care Plan Approaches - individualized approaches are used as a first line intervention (except in a documented emergency situation or if clinically contraindicated) . Consistent interventions are used that focuses on a patient's individual needs . Monitor and follow-up care plan is done by the interdisciplinary team who reviews the patient's progress towards goals. Summarize effectiveness of non-pharmacological and pharmacological interventions (quarterly and as indicated), for target behaviors and/or psychological symptoms and changes in a resident's level of distress or emergence of adverse consequences. Adjust interventions as needed and identified when care objectives are not met . An IJ was identified on 05/29/2025 at 1:20 p.m. The IJ template was provided to the Administrator on 05/29/2025 at 1:20 p.m. and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 05/31/2025 at 5:20 p.m. Issue Cited: Behavioral Services Failure to provide behavioral services 5/31/25 6. Immediate Action Taken On 5-29-25 resident #1 is currently in hospital for diagnosis of gastroenteritis and ESRD. 2. Identification of Residents Affected or Likely to be Affected: A. On 5/29/25 by 5:15pm DON/designee identified 66 residents are currently on behavioral services. The remaining 32 residents had no noted behaviors on admission or currently to warrant a referral for behavioral services. 3. Actions to Prevent Occurrence/Recurrence: A. On 5/30/25, [Psychiatric Provider] Services begins performing a psych evaluation on those 32 residents identified to establish any behavioral service needs, ongoing. No residents are identified as using drugs/alcohol when leaving the facility. If any of the 32 residents are identified as having a need for psych behavioral services, then care plans will be updated to reflect the behavior services. If any of the 32 residents are found to need behavioral services then [Psychiatric Provider] will treat in-house, and the care plan will be updated and nursing staff will be educated. None of the 32 residents require behavioral services at this time. B. Resident #1 is in hospital currently and has been on behavioral services but frequently refused visits. If and when resident #1 returns, psych behavioral services will be updated with his alcohol/drug behaviors and will be seen for appropriate service needs. Resident #1 has a history of refusing medical care including medications, dialysis, and psych services. If residents' refusals continue to jeopardize their health and the facility can no longer meet their needs, then the facility may discharge per HHSC guidelines. C. On 5/30/25 at 9:00 am the RNC reviewed the Behavioral Management policy, with no revisions made. D. On 5/30/25 by 12:00 PM the DON/ or designee will in-service nurses on Behavior Management policy, to include monitoring of behaviors each shift, documentation of any unsafe behaviors, notify physician of unsafe behaviors for new orders, and notify DON/ or designee of unsafe behaviors, no nurse will be able to work a shift without the in-service. The RNC in-serviced the Administrator/ or designee and DON/ or designee beforehand. On 5/30/25 by 6pm DON/designee in-serviced CNAs on Behavior Management policy including responding to behaviors and notifying charge nurse, no CNA will be able to work a shift without the in-service. E. DON/designee will review future admissions for the need of psych services and notify physician for an order for behavioral services. F. DON/designee will monitor 24-hour report for unsafe behaviors identified daily in morning stand-up meeting. G. All findings will be discussed during the morning stand-up meeting with IDT team and report to QAPI and update plan of correction as needed. H. On 5/29/25 the facility's Administrator/or designee notified the Medical Director regarding the Immediate Jeopardy the facility received related to Failure to Provide Behavioral Services and reviewed plans to sustain compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ___5/31/25_________ Monitoring of the plan of removal included the following: Record review of the facility's plan of removal documentation revealed a complete audit of the building was completed by the RNC on 05/29/2025 and 32 residents who did not receive behavioral health services were identified. Further review of the facility's plan of removal documentation revealed psychiatric evaluations were completed on the 32 residents who did not previously receive behavioral health services beginning on 05/30/2025. No substance abuse issues were identified among the 32 residents evaluated. Record review of the Behavior Management policy revealed it was reviewed by the RNC on 05/29/2025. Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/29/2025 revealed the DON was educated by the RNC on the Behavior Management policy, including monitoring behaviors each shift, documentation of any unsafe behaviors, and notifying the doctor of any unsafe behaviors. Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/30/2025 revealed the facility's nurses were educated by the RNC on the Behavior Management policy, including monitoring behaviors each shift, documentation of any unsafe behaviors, and notifying the doctor and DON of any unsafe behaviors. Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/29/2025 revealed the facility's CNAs were educated by the DON, ADON F and ADON G on the Behavior Management policy, including how to respond to behaviors, redirection, providing a calm environment, and notifying the nurse of unsafe behaviors. Interviews were conducted with staff on 06/01/2025 from 9:30 a.m. until 12:00 p.m. from all shifts (nurses and CNAs worked 12-hour shifts) including the VP of Operations, RNC, DON, ADON F, ADON G, RN H (day shift), Receptionist I, Receptionist J, LVN K (day shift), CNA L (day shift), CNA M (day shift), LVN N (night shift), and CNA O (night shift), to verify the in-services were conducted and to validate the staff understanding of requirements, training material, and expectations. The VP of Operations, RNC, DON, ADON F, ADON G, RN H, Receptionist I, Receptionist J, LVN K, CNA L (day shift), CNA M (day shift), LVN N (night shift), and CNA O were able to explain the importance of identifying and addressing unsafe behaviors (alcohol and drug abuse), notifying the nurses, DON, and physician of unsafe behaviors, documenting behaviors, responding appropriately to residents who exhibit behaviors, and monitoring residents who exhibit behaviors related to alcohol and drug abuse for their entire shift. The RNC was informed the Immediate Jeopardy was removed on 06/01/2025 at 12:09 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a comprehensive care plan including measurable objectives and timeframes to address Resident #1's medical, nursing, and mental and psychosocial needs related to his known history of signing himself out of the facility in a motorized wheelchair that did not belong to him, ambulating to nearby stores to drink alcohol until intoxicated/vomiting/lethargic and smoking marijuana in the surrounding community. As a result, the resident was ordered to be sent to the local ER on several occasions for treatment. An IJ was identified on 05/29/2025. The IJ template was provided to the facility on [DATE] at 1:20 p.m. While the IJ was removed on 05/31/2025, the facility remained out of compliance at a scope of pattern with severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure placed residents with substance abuse issues at risk of sustaining serious injuries from possible accidents/incidents and an exacerbation/deterioration of health and wellness. Findings include: Record review of Resident #1's face sheet dated 05/28/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. He was diagnosed with end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and excess fluid from the body), schizoaffective disorder (a chronic mental illness that combines systems of both schizophrenia and mood disorder), gastro-esophageal reflux (a chronic condition where stomach contents regularly flow back up into the esophagus), history of falling, difficulty walking, diabetes mellitus type II (chronic disease where the body either does not produce enough insulin or cannot properly use the insulin it produces) with hypoglycemia (when blood glucose levels drop too low), essential hypertension (persistently high blood pressure with no identifiable cause), chronic ischemic heart disease (long-term condition where the heart's blood supply is reduced due to a mismatch between oxygen supply and demand), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms in COPD patients), unspecified cirrhosis of liver (a type of chronic, progressive liver disease where healthy liver cells are replaced by scar tissue), acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the cystic duct), dependence on renal dialysis (treatment that cleans the blood when kidneys are unable to do so), and shortness of breath. Resident #1 was his own responsible party. Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); Resident #1 exhibited behaviors related to rejection of care; Resident #1 used a manual wheelchair for mobility; Resident #1 was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers and required supervision or touching assistance for showers/bathing; Resident #1 was always continent of bowel and bladder; and Resident #1 was prescribed anticoagulant and antipsychotic medication. Record review of Resident #1's care plan, revised on 05/25/2025 revealed the following care areas: * Resident has impaired visual function and is at risk for falls, injury, and a decline in functional ability. Goals included: Resident will maintain optimal quality of life and not experience a decline in ADL functional abilities, or an injury related to vision loss. Interventions included: Arrange consultation with eye care practitioner. Assist to ensure glasses are labeled and within reach. * Resistant to Care: Resident is resistant to care and at risk for injury, a decline in functional abilities, and not having his needs met. [He] refuses to take his scheduled medications and refuses to go to his scheduled dialysis days. Goal included: Resident will not be a danger to self or others. Interventions included: If refusals continue, notify MD and family, document in resident records. Give a clear explanation of complications of not having his dialysis. Encourage as much participation as possible. Provide resident with opportunities to make decisions about his treatment. * Falls: Patient is a fall risk due to weakness of both lower extremities. Resident has the potential for falls related to unsteadiness on feet, abnormalities of gait and mobility, unspecified lack of coordination, and generalized weakness. Fall: 01/04/2025, 02/01/2025. Goal included: Resident will not sustain a fall related injury by utilizing fall precautions. Interventions included: Encourage resident not to transfer without assistance. Anticipate and meet the resident's needs. Educate the resident about safety reminders and what to do if a fall occurs. Encourage socialization and activity attendance as tolerated. * Therapeutic Leave: Resident is cognitively able to sign out of the facility and make their own informed decisions while they are out. On 04/10/2025 while on therapeutic leave, resident made the decision to consume alcoholic beverages. Goals included: The resident will follow facility policy for out on pass. The resident will be safe and comfortable while out on pass. Interventions included: Educate the resident/family/caregivers about the potential risks associated with signing out on pass. Educate resident/family/caregivers on the facility's policy for therapeutic leave/out on pass. Resident is reminded of his health issues and treatment regimens and the recommendations to avoid the use of alcoholic beverages. Further review of Resident #1's care plan revealed no care areas, goals, or interventions to address his substance abuse concerns. Record review of Resident #1's, Elopement/Wandering Risk Assessment dated 05/24/2025, completed by LVN A revealed, A. Preliminary Data. 1. Is the resident physically able to leave the facility on their own? Yes. Continue assessment. B. Evaluation. Cognition: 1. Is the resident disoriented to place or intermittently confused? Yes . Further review of the assessment revealed Resident #1 scored a 1, which indicated low/no elopement risk. Record review of Resident #1's nursing progress notes for April 2025 and May 2025 revealed: * On 04/02/2025, at 4:10 p.m., SW B wrote, Resident was educated with Administrator, ADON, DON, and SW on the policies for Therapeutic Leave and the expectations for the resident when he is on Therapeutic Leave. Resident verbalized understanding. * On 04/11/2025, at 12:10 a.m., RN E wrote, Resident came back on pass to the facility with alcohol intoxication, vitals and assessment done. All within normal baseline. NP notified. New order to transfer resident to the hospital for further evaluation but resident refused. Resident was monitored through the shift, comfort care provided to resident satisfaction. * On 04/11/2025, at 11:50 a.m., ADON F wrote, Late Entry: 04/10/2025 at 11:00 p.m. Upon resident's return to the facility, resident arrived propelling himself in his motorized wheelchair. Resident had a slurred speech, he was drooling, smiling, and laughing, slow to respond to questions, and lethargic. Resident said he was tired and wanted to lay down and go to sleep and was assisted back to his room and was unable to stand to assist with his transfer to his bed, so he was transferred to bed with two people assist. In speaking with the resident, he said that he had ingested alcohol, specifically three 40 oz bottles of [brand name of beer] and he would not say if he had ingested any other substances or drinks. Upon assessment by unit nurse, there was no evidence of trauma or physical injuries noted, no indications of any falls or any other incidents at the time of his return. * On 04/12/2025, at 7:17 p.m., LVN A wrote, Police officer called facility and said resident vomited and may have been drinking with his friend and they have called 911 for him to go to the ER and have him evaluated. They then came to the facility, and I gave him a face sheet and medication lists. I accompanied the officer to EMS parked on the street near the facility and found the patient inside the ambulance being attended to by two paramedics with patient leaning to his left side. I placed a call to the Administrator and ADON. Resident apparently signed out at about 12 noon and left the facility with another resident. They apparently went to a nearby store and purchased drinks. He drank until he vomited on himself and became very weak. I asked the paramedics where they were taking him, and they informed me that they were taking him to [a local hospital] ER. NP and RP notified. * On 04/14/2025, at 4:38 p.m., ADON F wrote, Resident was found to be in possession of a cigarette lighter. The resident was educated by the Administrator on the smoking policy and the lighter was placed in the smoker's box for the resident to have access to only when on smoke breaks. The Administrator educated the resident on use of another resident's electric wheelchair and encouraged to use his own, the resident verbalized understanding. * On 04/15/2025, at 2:11 p.m., RN H wrote, Resident signed himself out and came back vomiting. Happened a couple of times. NP notified. Lab work ordered. New order to transfer to ER for further evaluation. * On 04/16/2025, at 5:23 p.m., ADON G wrote, Final lab results received on the drug and alcohol screening, labs placed in NP binder for review . resident remains in the hospital at this time. * On 04/23/2025, at 9:46 p.m., RN E wrote, Resident, who went out on pass, returned to the facility alert but disoriented, drooling from alcohol intoxication also had multiple emesis (vomiting). Resident vitals and assessment done all vital signs were within normal baseline. NP contacted via telehealth/virtual service. New order for Ondansetron 4 MG 1 tablet PO q 6hours as needed . * On 05/01/2025, at 11:59 a.m., the SW wrote, The Social Worker and the Administrator witnessed [Resident #1] taking a power wheelchair without the permission of the resident who owns the power wheelchair. Resident was educated that he cannot take the belongings of other residents while they are out of the facility. Resident was also educated on the importance of not using someone else's wheelchair and the risks that can occur . * On 05/04/2025, at 4:41 p.m., RN H wrote, Resident exchanged wheelchair with his former roommate and resident was educated that it was not safe to do so, resident verbalized understanding. Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/10/2025 at 11:17 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Complaint: Altered Mental Status . Per nurse, patient went out on pass and returned to facility lethargic, drooling from mouth and vomited once one hour ago. Per nurse, patient only knows his name, does not know where he is, and does not know the month, year. States at baseline patient is alert and oriented x 3 (a term that describes a patient's level of consciousness and cognitive function. Patient aware of person, place, and time). Per nurse, patient admitted to drinking 3 bottles of [brand of beer]. Per nurse, patient refused dialysis today and states patient did not go to dialysis yesterday . Patient seen with nurse . Physical Exam: Exam findings per nurse and video observation . Orders: Transfer to ER via 911: AMS/ESRD - missed HD/vomiting/possible alcohol intoxication . Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/23/2025 at 10:02 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Chief Complaint: GI: Vomiting . Nurse notified clinician that the [AGE] year-old-male patient with history of ESRD on dialysis, Schizophrenia, falls, HTN, DM2, went out of the facility for an hour and came back intoxicated. The nurse stated this is a regular occurrence for him. He did have an episode of vomiting. Denies drinking alcohol. Will monitor him for now . Record review of Resident #1's Lab Results Report collected on 04/11/2025 and reported on 04/16/2025 revealed Resident #1 was positive for THC (Cannabis). Observation and interview with Resident #1 on 05/28/2025, at 2:30 p.m. revealed he was in his bed with his eyes closed. Resident #1 opened his eyes and was able to provide his name. Resident #1 stated he lived in the facility a couple of months and living there was alright. He said he went to dialysis. He said he fell out of his wheelchair about six months ago (he did not say why). Resident #1 did not answer questions related to drinking alcohol or taking drugs while outside the facility on pass. He closed his eyes and appeared to be asleep although he responded to questions unrelated to drinking or smoking. In an interview with a random resident on 05/28/2025, at 1:45 p.m., they stated Resident #1 had a known history of taking his former roommate's motorized wheelchair without permission to sign himself out of the facility and drink at nearby stores. The resident stated Resident #1 frequently drank alcohol until he was intoxicated and smoked marijuana in the community around the facility. The resident said one time, Resident #1 was swerving (change or cause to change direction abruptly) all over the sidewalk on his way back to the facility after drinking and fell out of the motorized wheelchair onto the sidewalk. The resident stated the night nurse had to go and find Resident #1 on the sidewalk. In an interview with the SW on 05/28/2025, at 3:24 p.m., she stated Resident #1 was capable of making his own decisions, but he just did not make the right decisions. She said Resident #1 went out on pass and did things he should not do. She said Resident #1 was vomiting once due to intoxication. She said the facility staff could not tell Resident #1 what he could and could not do outside of the facility, and they could only educate him. She said Resident #1 knew what he was doing. She said Resident #1 was his own RP and he did not have any family. She said to her knowledge, Resident #1 only went out twice and got drunk, but she was not there on weekends. She said she was not sure Resident #1's behaviors were addressed on his care plan, but they should have been so all staff are aware of any interventions. She stated she was not responsible for updating resident care plans. She stated she reviewed chart notes and assessed Resident #1's cognition to see if he could make his own decisions. She said Resident #1's BIMS score was high. She said possible negative outcomes of Resident #1 leaving the facility and getting drunk were that he could die, get injured, and go to the hospital. In an interview with the Administrator on 05/28/2025, at 4:32 p.m., he stated the residents had rights. He said Resident #1's BIMS score was 15, but he did not make proper decisions. He said the facility staff had to make sure they did not infringe on the residents' rights. He said Resident #1 signed himself out and returned intoxicated between five and seven times. He said he had undocumented conversations with Resident #1 about how unsafe it was for him to leave the facility and get drunk. He said the conversations were not documented because he did not go into the facility's computer system to write progress notes. He said Resident #1 was still capable of wheeling himself down the road to the store in his own manual wheelchair. He said the residents previously went to the gas station at the end of the street (the residents still had to cross a busy two-lanes road), but the store staff said they could not go there anymore. He said now, the residents go down to a store further down the road. He said he did not know if Resident #1's behaviors were care planned, but they should have been. In an interview with MDS Nurse C on 05/29/2025, at 12:25 p.m., she stated her duties included completing assessments and reviewing/updating resident care plans. She said she was responsible for residents whose last names began with A - K, so she did not update Resident #1's care plan. She said another MDS nurse who worked part-time was responsible for updating Resident #1's care plan. She said the MDS nurses reviewed and updated care plans every three months when they did quarterly MDS assessments. She said she was aware of Resident #1's behaviors related to smoking and drinking, and those behaviors should be a part of his care plan if the incidents happened. She said it was important to address those issues in Resident #1's care plan because if anything happened, they had the information in the care plan to show they were not giving him what he went outside to get (drugs and alcohol). She said negative outcomes of Resident #1's behaviors were possible if the facility did not intervene. She said Resident #1 could have serious health issues if the facility did not intervene. She said a resident's care plan should address all their behaviors. In a telephone interview with Resident #1's physician on 05/30/2025, at 10:00 a.m., he stated he was familiar with Resident #1, and he was aware the resident frequently went out on pass to drink and smoke. He said Resident #1 denied drinking and smoking, but he had a history of noncompliance with dialysis and medications. He said Resident #1 was alert and oriented to be able to sign himself out. He said Resident #1 had recently been admitted to the hospital a lot and once, at the hospital, they found he had taken drugs. He said Resident #1 kept denying, so it was hard to address it. He said the negative outcome of Resident #1's behaviors were that one day, Resident #1 is fine, and then in a couple of days, he signs out and takes something (drugs or alcohol) and something happens that leads him back in the hospital. He said he asks the facility staff to do their best to monitor Resident #1. He said once Resident #1 was off drugs and was perfectly normal, it would be safe for him to be out alone. He stated when Resident #1 was in that state (under the influence of drugs and alcohol), it was not safe for him to be out alone. He said if a resident was alert, oriented, and making the right decisions, you could not tell them they could not go out because that would be restraining them. He said he would imagine it was not safe for Resident #1 to be out like that (under the influence of drugs and alcohol), but he had the right to sign himself out. He said the facility may have to get a contract with Resident #1 to say if he continued with these behaviors, they could not handle his needs because they do not want anything bad to happen. In an interview with the VP of Operations on 05/30/2025, at 10:30 a.m., he stated the Administrator was no longer employed at the facility and Resident #1 called 911 and was transferred to the hospital related to stomach pains on 05/28/2025. In an interview with LVN A on 05/31/2025, at 2:11 p.m., he stated on 04/12/2025, around 1:00 p.m., the police called the facility and said Resident #1 had fallen out of his wheelchair and was vomiting at the church next to the facility. He said the police went to the facility and then he (LVN A) followed them to see Resident #1. He said he thought the police saw Resident #1 on the ground and called 911. He said when he arrived at the scene, he saw Resident #1 inside the ambulance. He said Resident #1 said he had gone to the store. He said Resident #1 went to the hospital and returned to the facility about two days later. LVN A said he heard the motorized chair Resident #1 fell out of belonged to his friend. In a telephone interview with MDS Nurse D on 06/02/2025, at 11:19 a.m., she stated she was responsible for updating care plans for residents whose last names began with J-Z. She said she made sure MDS assessments were done and care plans were updated. She said she got the information to update care plans by reading progress notes, reading physician's orders, talking to staff, and she observed and talked to the residents. She said she observed Resident #1 around the facility, and he was mostly independent. She even though she read through Resident #1's progress notes, she was not aware of his drinking or drug use. She said she knew he signed himself out of the facility because she saw him in the group when they went out. MDS Nurse D then said she heard Resident #1 smoked weed (marijuana). She said smoking marijuana would be something they needed to add to his care plan. She said it was her understanding that the ADON updated anything that was acute (not long-term issues). She said she only worked 20 hours per week, so she was not at the facility most days. She said she was aware of Resident #1's smoking, but not his drinking. She said she only looked at progress notes when it was time to update the MDS assessments. She said she never saw any notes about Resident #1's drinking alcohol. She said she did not have an answer for why she did not address Resident #1's smoking in his care plan. She said the ADON was at the facility more than she was and they should have updated Resident #1's care plan to address his drinking. She said in her opinion, anybody could update the care plan. She said it was important to address Resident #1's behaviors related to smoking and drinking because it was pertinent information and they needed to act on things like that to keep the resident safe. She said the nursing facility was not a place to get drunk and do drugs. She said the IDT needed to get together, call a care plan meeting, talk, and update things to make sure all Resident #1's behaviors were on his care plan. In an interview with ADON F and ADON G on 06/02/2025, at 11:45 a.m., ADON G said MDS Nurse D was not in the building a lot, so she should review progress notes daily to ensure care plans were updated appropriately. ADON F said they handled (updated care plans) regarding things that were acute, but Resident #1's drinking and drug use were not acute because he had those behaviors a while. ADON G said it was important to address those behaviors in the care plan so all staff know what is going on. ADON G said a negative outcome of not having the behaviors care planned would be that the behaviors continued and but the resident's safety at risk. Record review of the facility's policy, titled, Comprehensive care Plans revised on 09/04/2024 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. B. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . d. The resident's goals for admission, desired outcomes, and preferences for future discharge . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . Record review of the facility's policy, titled, Behavior Management revised on 04/15/2014 revealed, Policy: The purpose of the policy is to optimize the quality of life and function of patients that experience behavioral symptoms that require person centered approaches to meet the health, physical, psychosocial, and behavioral health needs. Fundamental Information: Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for dementia patients. Fundamental principles of care for a patient with behaviors include an interdisciplinary approach that focus on the individualized needs of the patient . Procedure. Determine whether there is a medical, physical, functional, physiological, emotional, psychiatric, social, or emotional cause of the behaviors . Considerations: Person-Centered Care - evaluate if the environment is supportive and promotes comfort toward understanding, preventing, relieving, and recognizes individual needs and preferences . Evaluations are completed on new or worsening behaviors . Identify the frequency, intensity, duration, severity, and impact of behaviors, as well as the location, surroundings, or situation. Identify interventions or approaches to prevent, modify, relieve, or address the behaviors or distress. Patient behaviors or distress are documented as it occurs and the effectiveness of interventions. Individualized Care Plan Approaches - individualized approaches are used as a first line intervention (except in a documented emergency situation or if clinically contraindicated) . Consistent interventions are used that focuses on a patient's individual needs . Monitor and follow-up care plan is done by the interdisciplinary team who reviews the patient's progress towards goals. Summarize effectiveness of non-pharmacological and pharmacological interventions (quarterly and as indicated), for target behaviors and/or psychological symptoms and changes in a resident's level of distress or emergence of adverse consequences. Adjust interventions as needed and identified when care objectives are not met . An IJ was identified on 05/29/2025 at 1:20 p.m. The IJ template was provided to the Administrator on 05/29/2025 at 1:20 p.m. and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 05/31/2025 at 10:42 a.m. Issue Cited: Care Plans Failure to develop and implement a comprehensive person-centered care plan 5/30/25 1. Immediate Action Taken On 5-29-25 resident #1 is currently in hospital with diagnosis of gastroenteritis (inflammation of the lining of the stomach and intestines) and ESRD. 2. Identification of Residents Affected or Likely to be Affected: A. On 5/29/25 by 3pm DON/designee identified 11 residents who sign out of the facility independently, had charts reviewed and determined by their capabilities according to their functional ability assessment (MDS section GG), and make their own choices and decisions according to their BIMs, they were reviewed for any behaviors, none were found, and care plan interventions are in place. 2. Actions to Prevent Occurrence/Recurrence: A. On 5/30/25 by 10:00 am the RNC reviewed the policy on Comprehensive Care Plans with no changes made. B. On 5/29/25 by 7:30pm DON/designee reviewed the care plans for those 11 residents identified as independently capable of signing out of the facility and making their own choices and decisions. None were found to have unsafe behaviors. Care plans were reviewed, and no updates were needed. If and when Resident #1 returns from hospital the care plan will be reviewed and updated with any unsafe behavior and the CNAs and Nurses will be in-serviced to the updated care plan at that time by DON/designee. C. On 5/30/25 by 9am the Regional Nurse Consultant in-serviced the IDT on updating comprehensive care plans to include measurable objectives, timeframes, and interventions for those residents identified as independently signing themselves out of the facility with a focus on unsafe behaviors, goals, and interventions while out of facility. The Administrator/ or designee and DON/ or designee were in-serviced by the RNC beforehand. D. DON/designee will monitor comprehensive care plans for all residents identified as capable of signing themselves out of the facility independently for any unsafe behaviors present and report findings to IDT in morning meeting and revise care plans as needed. E. All findings will be discussed during QAPI monthly and plan of care will be revised as needed. F. On 5/29/25 the facility's Administrator/ or designee notified the Medical Director regarding the Immediate Jeopardy the facility received related to Failure to Develop and Implement a Comprehensive Person-Centered Care Plan and reviewed plan to sustain compliance. Monitoring of the plan of removal included the following: Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/30/2025 revealed the IDT team (DON, Activity Director, ADON F, ADON G, MDS Nurse C, Treatment Nurse, , and a representative from the rehabilitation department) was educated by the RNC on comprehensive care plans, including measurable goals and individualized interventions. Record review of the facility's, Comprehensive Care Plans policy revealed it was reviewed by the RNC on 05/29/2025. Record review of the facility's plan of removal documentation revealed the MDS assessments and care plans for all eleven residents identified as independently capable of signing out of the facility and making their own choices and decisions were reviewed by the DON. Interviews were conducted with staff on 05/31/2025 from 10:45 a.m. until 3:00 p.m. from all shifts (nurses and CNAs worked 12-hour shifts) including the VP of Operations, RNC, DON, ADON F, ADON G, LVN A (day shift), MDS Nurse C, RN P (day shift), CNA Q (day shift), RN R (night shift), Receptionist[TRUNCATED]

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a comprehensive care plan including measurable objectives and timeframes to address Resident #1's medical, nursing, and mental and psychosocial needs related to his known history of signing himself out of the facility in a motorized wheelchair that did not belong to him, ambulating to nearby stores to drink alcohol until intoxicated/vomiting/lethargic and smoking marijuana in the surrounding community. As a result, the resident was ordered to be sent to the localER on several occasions for treatment. An IJ was identified on 05/29/2025. The IJ template was provided to the facility on [DATE] at 1:20 p.m. While the IJ was removed on 05/31/2025, the facility remained out of compliance at a scope of pattern with severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure placed residents with substance abuse issues at risk of sustaining serious injuries from possible accidents/incidents and an exacerbation/deterioration of health and wellness. Findings include: Record review of Resident #1's face sheet dated 05/28/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. He was diagnosed with end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and excess fluid from the body), schizoaffective disorder (a chronic mental illness that combines systems of both schizophrenia and mood disorder), gastro-esophageal reflux (a chronic condition where stomach contents regularly flow back up into the esophagus), history of falling, difficulty walking, diabetes mellitus type II (chronic disease where the body either does not produce enough insulin or cannot properly use the insulin it produces) with hypoglycemia (when blood glucose levels drop too low), essential hypertension (persistently high blood pressure with no identifiable cause), chronic ischemic heart disease (long-term condition where the heart's blood supply is reduced due to a mismatch between oxygen supply and demand), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms in COPD patients), unspecified cirrhosis of liver (a type of chronic, progressive liver disease where healthy liver cells are replaced by scar tissue), acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the cystic duct), dependence on renal dialysis (treatment that cleans the blood when kidneys are unable to do so), and shortness of breath. Resident #1 was his own responsible party. Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); Resident #1 exhibited behaviors related to rejection of care; Resident #1 used a manual wheelchair for mobility; Resident #1 was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers and required supervision or touching assistance for showers/bathing; Resident #1 was always continent of bowel and bladder; and Resident #1 was prescribed anticoagulant and antipsychotic medication. Record review of Resident #1's care plan, revised on 05/25/2025 revealed the following care areas: * Resident has impaired visual function and is at risk for falls, injury, and a decline in functional ability. Goals included: Resident will maintain optimal quality of life and not experience a decline in ADL functional abilities, or an injury related to vision loss. Interventions included: Arrange consultation with eye care practitioner. Assist to ensure glasses are labeled and within reach. * Resistant to Care: Resident is resistant to care and at risk for injury, a decline in functional abilities, and not having his needs met. [He] refuses to take his scheduled medications and refuses to go to his scheduled dialysis days. Goal included: Resident will not be a danger to self or others. Interventions included: If refusals continue, notify MD and family, document in resident records. Give a clear explanation of complications of not having his dialysis. Encourage as much participation as possible. Provide resident with opportunities to make decisions about his treatment. * Falls: Patient is a fall risk due to weakness of both lower extremities. Resident has the potential for falls related to unsteadiness on feet, abnormalities of gait and mobility, unspecified lack of coordination, and generalized weakness. Fall: 01/04/2025, 02/01/2025. Goal included: Resident will not sustain a fall related injury by utilizing fall precautions. Interventions included: Encourage resident not to transfer without assistance. Anticipate and meet the resident's needs. Educate the resident about safety reminders and what to do if a fall occurs. Encourage socialization and activity attendance as tolerated. * Therapeutic Leave: Resident is cognitively able to sign out of the facility and make their own informed decisions while they are out. On 04/10/2025 while on therapeutic leave, resident made the decision to consume alcoholic beverages. Goals included: The resident will follow facility policy for out on pass. The resident will be safe and comfortable while out on pass. Interventions included: Educate the resident/family/caregivers about the potential risks associated with signing out on pass. Educate resident/family/caregivers on the facility's policy for therapeutic leave/out on pass. Resident is reminded of his health issues and treatment regimens and the recommendations to avoid the use of alcoholic beverages. Further review of Resident #1's care plan revealed no care areas, goals, or interventions to address his substance abuse concerns. Record review of Resident #1's, Elopement/Wandering Risk assessment dated [DATE], completed by LVN A revealed, A. Preliminary Data. 1. Is the resident physically able to leave the facility on their own? Yes. Continue assessment. B. Evaluation. Cognition: 1. Is the resident disoriented to place or intermittently confused? Yes . Further review of the assessment revealed Resident #1 scored a 1, which indicated low/no elopement risk. Record review of Resident #1's nursing progress notes for April 2025 and May 2025 revealed: * On 04/02/2025, at 4:10 p.m., SW B wrote, Resident was educated with Administrator, ADON, DON, and SW on the policies for Therapeutic Leave and the expectations for the resident when he is on Therapeutic Leave. Resident verbalized understanding. * On 04/11/2025, at 12:10 a.m., RN E wrote, Resident came back on pass to the facility with alcohol intoxication, vitals and assessment done. All within normal baseline. NP notified. New order to transfer resident to the hospital for further evaluation but resident refused. Resident was monitored through the shift, comfort care provided to resident satisfaction. * On 04/11/2025, at 11:50 a.m., ADON F wrote, Late Entry: 04/10/2025 at 11:00 p.m. Upon resident's return to the facility, resident arrived propelling himself in his motorized wheelchair. Resident had a slurred speech, he was drooling, smiling, and laughing, slow to respond to questions, and lethargic. Resident said he was tired and wanted to lay down and go to sleep and was assisted back to his room and was unable to stand to assist with his transfer to his bed, so he was transferred to bed with two people assist. In speaking with the resident, he said that he had ingested alcohol, specifically three 40 oz bottles of [brand name of beer] and he would not say if he had ingested any other substances or drinks. Upon assessment by unit nurse, there was no evidence of trauma or physical injuries noted, no indications of any falls or any other incidents at the time of his return. * On 04/12/2025, at 7:17 p.m., LVN A wrote, Police officer called facility and said resident vomited and may have been drinking with his friend and they have called 911 for him to go to the ER and have him evaluated. They then came to the facility, and I gave him a face sheet and medication lists. I accompanied the officer to EMS parked on the street near the facility and found the patient inside the ambulance being attended to by two paramedics with patient leaning to his left side. I placed a call to the Administrator and ADON. Resident apparently signed out at about 12 noon and left the facility with another resident. They apparently went to a nearby store and purchased drinks. He drank until he vomited on himself and became very weak. I asked the paramedics where they were taking him, and they informed me that they were taking him to [a local hospital] ER. NP and RP notified. * On 04/14/2025, at 4:38 p.m., ADON F wrote, Resident was found to be in possession of a cigarette lighter. The resident was educated by the Administrator on the smoking policy and the lighter was placed in the smoker's box for the resident to have access to only when on smoke breaks. The Administrator educated the resident on use of another resident's electric wheelchair and encouraged to use his own, the resident verbalized understanding. * On 04/15/2025, at 2:11 p.m., RN H wrote, Resident signed himself out and came back vomiting. Happened a couple of times. NP notified. Lab work ordered. New order to transfer to ER for further evaluation. * On 04/16/2025, at 5:23 p.m., ADON G wrote, Final lab results received on the drug and alcohol screening, labs placed in NP binder for review . resident remains in the hospital at this time. * On 04/23/2025, at 9:46 p.m., RN E wrote, Resident, who went out on pass, returned to the facility alert but disoriented, drooling from alcohol intoxication also had multiple emesis (vomiting). Resident vitals and assessment done all vital signs were within normal baseline. NP contacted via telehealth/virtual service. New order for Ondansetron 4 MG 1 tablet PO q 6hours as needed . * On 05/01/2025, at 11:59 a.m., the SW wrote, The Social Worker and the Administrator witnessed [Resident #1] taking a power wheelchair without the permission of the resident who owns the power wheelchair. Resident was educated that he cannot take the belongings of other residents while they are out of the facility. Resident was also educated on the importance of not using someone else's wheelchair and the risks that can occur . * On 05/04/2025, at 4:41 p.m., RN H wrote, Resident exchanged wheelchair with his former roommate and resident was educated that it was not safe to do so, resident verbalized understanding. Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/10/2025 at 11:17 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Complaint: Altered Mental Status . Per nurse, patient went out on pass and returned to facility lethargic, drooling from mouth and vomited once one hour ago. Per nurse, patient only knows his name, does not know where he is, and does not know the month, year. States at baseline patient is alert and oriented x 3 (a term that describes a patient's level of consciousness and cognitive function. Patient aware of person, place, and time). Per nurse, patient admitted to drinking 3 bottles of [brand of beer]. Per nurse, patient refused dialysis today and states patient did not go to dialysis yesterday . Patient seen with nurse . Physical Exam: Exam findings per nurse and video observation . Orders: Transfer to ER via 911: AMS/ESRD - missed HD/vomiting/possible alcohol intoxication . Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/23/2025 at 10:02 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Chief Complaint: GI: Vomiting . Nurse notified clinician that the [AGE] year-old-male patient with history of ESRD on dialysis, Schizophrenia, falls, HTN, DM2, went out of the facility for an hour and came back intoxicated. The nurse stated this is a regular occurrence for him. He did have an episode of vomiting. Denies drinking alcohol. Will monitor him for now . Record review of Resident #1's Lab Results Report collected on 04/11/2025 and reported on 04/16/2025 revealed Resident #1 was positive for THC (Cannabis). Observation and interview with Resident #1 on 05/28/2025, at 2:30 p.m. revealed he was in his bed with his eyes closed. Resident #1 opened his eyes and was able to provide his name. Resident #1 stated he lived in the facility a couple of months and living there was alright. He said he went to dialysis. He said he fell out of his wheelchair about six months ago (he did not say why). Resident #1 did not answer questions related to drinking alcohol or taking drugs while outside the facility on pass. He closed his eyes and appeared to be asleep although he responded to questions unrelated to drinking or smoking. In an interview with a random resident on 05/28/2025, at 1:45 p.m., they stated Resident #1 had a known history of taking his former roommate's motorized wheelchair without permission to sign himself out of the facility and drink at nearby stores. The resident stated Resident #1 frequently drank alcohol until he was intoxicated and smoked marijuana in the community around the facility. The resident said one time, Resident #1 was swerving (change or cause to change direction abruptly) all over the sidewalk on his way back to the facility after drinking and fell out of the motorized wheelchair onto the sidewalk. The resident stated the night nurse had to go and find Resident #1 on the sidewalk. In an interview with the SW on 05/28/2025, at 3:24 p.m., she stated Resident #1 was capable of making his own decisions, but he just did not make the right decisions. She said Resident #1 went out on pass and did things he should not do. She said Resident #1 was vomiting once due to intoxication. She said the facility staff could not tell Resident #1 what he could and could not do outside of the facility, and they could only educate him. She said Resident #1 knew what he was doing. She said Resident #1 was his own RP and he did not have any family. She said to her knowledge, Resident #1 only went out twice and got drunk, but she was not there on weekends. She said she was not sure Resident #1's behaviors were addressed on his care plan, but they should have been so all staff are aware of any interventions. She stated she was not responsible for updating resident care plans. She stated she reviewed chart notes and assessed Resident #1's cognition to see if he could make his own decisions. She said Resident #1's BIMS score was high. She said possible negative outcomes of Resident #1 leaving the facility and getting drunk were that he could die, get injured, and go to the hospital. In an interview with the Administrator on 05/28/2025, at 4:32 p.m., he stated the residents had rights. He said Resident #1's BIMS score was 15, but he did not make proper decisions. He said the facility staff had to make sure they did not infringe on the residents' rights. He said Resident #1 signed himself out and returned intoxicated between five and seven times. He said he had undocumented conversations with Resident #1 about how unsafe it was for him to leave the facility and get drunk. He said the conversations were not documented because he did not go into the facility's computer system to write progress notes. He said Resident #1 was still capable of wheeling himself down the road to the store in his own manual wheelchair. He said the residents previously went to the gas station at the end of the street (the residents still had to cross a busy two-lanes road), but the store staff said they could not go there anymore. He said now, the residents go down to a store further down the road. He said he did not know if Resident #1's behaviors were care planned, but they should have been. In an interview with MDS Nurse C on 05/29/2025, at 12:25 p.m., she stated her duties included completing assessments and reviewing/updating resident care plans. She said she was responsible for residents whose last names began with A - K, so she did not update Resident #1's care plan. She said another MDS nurse who worked part-time was responsible for updating Resident #1's care plan. She said the MDS nurses reviewed and updated care plans every three months when they did quarterly MDS assessments. She said she was aware of Resident #1's behaviors related to smoking and drinking, and those behaviors should be a part of his care plan if the incidents happened. She said it was important to address those issues in Resident #1's care plan because if anything happened, they had the information in the care plan to show they were not giving him what he went outside to get (drugs and alcohol). She said negative outcomes of Resident #1's behaviors were possible if the facility did not intervene. She said Resident #1 could have serious health issues if the facility did not intervene. She said a resident's care plan should address all their behaviors. In a telephone interview with Resident #1's physician on 05/30/2025, at 10:00 a.m., he stated he was familiar with Resident #1, and he was aware the resident frequently went out on pass to drink and smoke. He said Resident #1 denied drinking and smoking, but he had a history of noncompliance with dialysis and medications. He said Resident #1 was alert and oriented to be able to sign himself out. He said Resident #1 had recently been admitted to the hospital a lot and once, at the hospital, they found he had taken drugs. He said Resident #1 kept denying, so it was hard to address it. He said the negative outcome of Resident #1's behaviors were that one day, Resident #1 is fine, and then in a couple of days, he signs out and takes something (drugs or alcohol) and something happens that leads him back in the hospital. He said he asks the facility staff to do their best to monitor Resident #1. He said once Resident #1 was off drugs and was perfectly normal, it would be safe for him to be out alone. He stated when Resident #1 was in that state (under the influence of drugs and alcohol), it was not safe for him to be out alone. He said if a resident was alert, oriented, and making the right decisions, you could not tell them they could not go out because that would be restraining them. He said he would imagine it was not safe for Resident #1 to be out like that (under the influence of drugs and alcohol), but he had the right to sign himself out. He said the facility may have to get a contract with Resident #1 to say if he continued with these behaviors, they could not handle his needs because they do not want anything bad to happen. In an interview with the VP of Operations on 05/30/2025, at 10:30 a.m., he stated the Administrator was no longer employed at the facility and Resident #1 called 911 and was transferred to the hospital related to stomach pains on 05/28/2025. In an interview with LVN A on 05/31/2025, at 2:11 p.m., he stated on 04/12/2025, around 1:00 p.m., the police called the facility and said Resident #1 had fallen out of his wheelchair and was vomiting at the church next to the facility. He said the police went to the facility and then he (LVN A) followed them to see Resident #1. He said he thought the police saw Resident #1 on the ground and called 911. He said when he arrived at the scene, he saw Resident #1 inside the ambulance. He said Resident #1 said he had gone to the store. He said Resident #1 went to the hospital and returned to the facility about two days later. LVN A said he heard the motorized chair Resident #1 fell out of belonged to his friend. In a telephone interview with MDS Nurse D on 06/02/2025, at 11:19 a.m., she stated she was responsible for updating care plans for residents whose last names began with J-Z. She said she made sure MDS assessments were done and care plans were updated. She said she got the information to update care plans by reading progress notes, reading physician's orders, talking to staff, and she observed and talked to the residents. She said she observed Resident #1 around the facility, and he was mostly independent. She even though she read through Resident #1's progress notes, she was not aware of his drinking or drug use. She said she knew he signed himself out of the facility because she saw him in the group when they went out. MDS Nurse D then said she heard Resident #1 smoked weed (marijuana). She said smoking marijuana would be something they needed to add to his care plan. She said it was her understanding that the ADON updated anything that was acute (not long-term issues). She said she only worked 20 hours per week, so she was not at the facility most days. She said she was aware of Resident #1's smoking, but not his drinking. She said she only looked at progress notes when it was time to update the MDS assessments. She said she never saw any notes about Resident #1's drinking alcohol. She said she did not have an answer for why she did not address Resident #1's smoking in his care plan. She said the ADON was at the facility more than she was and they should have updated Resident #1's care plan to address his drinking. She said in her opinion, anybody could update the care plan. She said it was important to address Resident #1's behaviors related to smoking and drinking because it was pertinent information and they needed to act on things like that to keep the resident safe. She said the nursing facility was not a place to get drunk and do drugs. She said the IDT needed to get together, call a care plan meeting, talk, and update things to make sure all Resident #1's behaviors were on his care plan. In an interview with ADON F and ADON G on 06/02/2025, at 11:45 a.m., ADON G said MDS Nurse D was not in the building a lot, so she should review progress notes daily to ensure care plans were updated appropriately. ADON F said they handled (updated care plans) regarding things that were acute, but Resident #1's drinking and drug use were not acute because he had those behaviors a while. ADON G said it was important to address those behaviors in the care plan so all staff know what is going on. ADON G said a negative outcome of not having the behaviors care planned would be that the behaviors continued and but the resident's safety at risk. Record review of the facility's policy, titled, Comprehensive care Plans revised on 09/04/2024 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. B. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . d. The resident's goals for admission, desired outcomes, and preferences for future discharge . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . Record review of the facility's policy, titled, Behavior Management revised on 04/15/2014 revealed, Policy: The purpose of the policy is to optimize the quality of life and function of patients that experience behavioral symptoms that require person centered approaches to meet the health, physical, psychosocial, and behavioral health needs. Fundamental Information: Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for dementia patients. Fundamental principles of care for a patient with behaviors include an interdisciplinary approach that focus on the individualized needs of the patient . Procedure. Determine whether there is a medical, physical, functional, physiological, emotional, psychiatric, social, or emotional cause of the behaviors . Considerations: Person-Centered Care - evaluate if the environment is supportive and promotes comfort toward understanding, preventing, relieving, and recognizes individual needs and preferences . Evaluations are completed on new or worsening behaviors . Identify the frequency, intensity, duration, severity, and impact of behaviors, as well as the location, surroundings, or situation. Identify interventions or approaches to prevent, modify, relieve, or address the behaviors or distress. Patient behaviors or distress are documented as it occurs and the effectiveness of interventions. Individualized Care Plan Approaches - individualized approaches are used as a first line intervention (except in a documented emergency situation or if clinically contraindicated) . Consistent interventions are used that focuses on a patient's individual needs . Monitor and follow-up care plan is done by the interdisciplinary team who reviews the patient's progress towards goals. Summarize effectiveness of non-pharmacological and pharmacological interventions (quarterly and as indicated), for target behaviors and/or psychological symptoms and changes in a resident's level of distress or emergence of adverse consequences. Adjust interventions as needed and identified when care objectives are not met . An IJ was identified on 05/29/2025 at 1:20 p.m. The IJ template was provided to the Administrator on 05/29/2025 at 1:20 p.m. and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 05/31/2025 at 10:42 a.m. Issue Cited: Care Plans Failure to develop and implement a comprehensive person-centered care plan 5/30/25 1. Immediate Action Taken On 5-29-25 resident #1 is currently in hospital with diagnosis of gastroenteritis (inflammation of the lining of the stomach and intestines) and ESRD. 2. Identification of Residents Affected or Likely to be Affected: A. On 5/29/25 by 3pm DON/designee identified 11 residents who sign out of the facility independently, had charts reviewed and determined by their capabilities according to their functional ability assessment (MDS section GG), and make their own choices and decisions according to their BIMs, they were reviewed for any behaviors, none were found, and care plan interventions are in place. 2. Actions to Prevent Occurrence/Recurrence: A. On 5/30/25 by 10:00 am the RNC reviewed the policy on Comprehensive Care Plans with no changes made. B. On 5/29/25 by 7:30pm DON/designee reviewed the care plans for those 11 residents identified as independently capable of signing out of the facility and making their own choices and decisions. None were found to have unsafe behaviors. Care plans were reviewed, and no updates were needed. If and when Resident #1 returns from hospital the care plan will be reviewed and updated with any unsafe behavior and the CNAs and Nurses will be in-serviced to the updated care plan at that time by DON/designee. C. On 5/30/25 by 9am the Regional Nurse Consultant in-serviced the IDT on updating comprehensive care plans to include measurable objectives, timeframes, and interventions for those residents identified as independently signing themselves out of the facility with a focus on unsafe behaviors, goals, and interventions while out of facility. The Administrator/ or designee and DON/ or designee were in-serviced by the RNC beforehand. D. DON/designee will monitor comprehensive care plans for all residents identified as capable of signing themselves out of the facility independently for any unsafe behaviors present and report findings to IDT in morning meeting and revise care plans as needed. E. All findings will be discussed during QAPI monthly and plan of care will be revised as needed. F. On 5/29/25 the facility's Administrator/ or designee notified the Medical Director regarding the Immediate Jeopardy the facility received related to Failure to Develop and Implement a Comprehensive Person-Centered Care Plan and reviewed plan to sustain compliance. Monitoring of the plan of removal included the following: Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/30/2025 revealed the IDT team (DON, Activity Director, ADON F, ADON G, MDS Nurse C, Treatment Nurse, , and a representative from the rehabilitation department) was educated by the RNC on comprehensive care plans, including measurable goals and individualized interventions. Record review of the facility's, Comprehensive Care Plans policy revealed it was reviewed by the RNC on 05/29/2025. Record review of the facility's plan of removal documentation revealed the MDS assessments and care plans for all eleven residents identified as independently capable of signing out of the facility and making their own choices and decisions were reviewed by the DON. Interviews were conducted with staff on 05/31/2025 from 10:45 a.m. until 3:00 p.m. from all shifts (nurses and CNAs worked 12-hour shifts) including the VP of Operations, RNC, DON, ADON F, ADON G, LVN A (day shift), MDS Nurse C, RN P (day shift), CNA Q (day shift), RN R (night shift), Receptionist I, and Receptionist J, to verify the in-services were conducted and to validate the staff understanding of requirements, training material, and expectations. The VP of Operations, RNC, DON, ADON F, ADON G, LVN A, MDS Nurse C, RN P, CNA Q, RN R, Receptionist I, and Receptionist J were able to explain the importance of making sure all care plans were updated to address unsafe behaviors and include measurable objectives, timeframes, and interventions related to those unsafe behaviors. The VP of Operations and RNC were informed the Immediate Jeopardy was removed on 05/31/2025 at 3:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immedi [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, encompassing the resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders for 1 of 12 residents (Resident #1) reviewed for behavioral services. The facility failed to ensure Resident #1 received adequate behavioral health care services to prevent and treat substance abuse disorder when Resident #1 frequently signed himself out of the facility to go to nearby stores and consume alcohol, resulting in intoxication, vomiting, and lethargy to the point of falling out of his wheelchair. Resident #1 was also known by staff to sign himself out and smoke marijuana in the community surrounding the facility, resulting in a positive laboratory finding for THC. An IJ was identified on 05/29/2025. The IJ template was provided to the facility on [DATE] at 1:20 p.m. While the IJ was removed on 06/01/2025, the facility remained out of compliance at a scope of pattern with severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents who require behavioral health services at risk not receiving having their needs met and, deterioration of health Findings include: Record review of Resident #1's face sheet dated 05/28/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. He was diagnosed with end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and excess fluid from the body), schizoaffective disorder (a chronic mental illness that combines systems of both schizophrenia and mood disorder), gastro-esophageal reflux (a chronic condition where stomach contents regularly flow back up into the esophagus), history of falling, difficulty walking, diabetes mellitus type II (chronic disease where the body either does not produce enough insulin or cannot properly use the insulin it produces) with hypoglycemia (when blood glucose levels drop too low), essential hypertension (persistently high blood pressure with no identifiable cause), chronic ischemic heart disease (long-term condition where the heart's blood supply is reduced due to a mismatch between oxygen supply and demand), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms in COPD patients), unspecified cirrhosis of liver (a type of chronic, progressive liver disease where healthy liver cells are replaced by scar tissue), acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the cystic duct), dependence on renal dialysis (treatment that cleans the blood when kidneys are unable to do so), and shortness of breath. Resident #1 was his own responsible party. Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); Resident #1 exhibited behaviors related to rejection of care; Resident #1 used a manual wheelchair for mobility; Resident #1 was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers and required supervision or touching assistance for showers/bathing; Resident #1 was always continent of bowel and bladder; and Resident #1 was prescribed anticoagulant and antipsychotic medication. Record review of resident #1's care plan, revised on 05/25/2025 revealed the following care areas: * Behavioral Problem: Resident has a behavior problem as evidenced by: displaying verbal and sexually inappropriate behavior by exposing his private area to female residents and female staff. Goal included: Resident's inappropriate behavior will not result in harm or injury to self or others. Interventions included: Educate resident on the privacy issues associated with his behavior. Encourage as much as possible to detour injury. Intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of other. Resident will be receiving psychiatric visits with [Psychiatric Provider] to monitor his behaviors per physician orders. * Therapeutic Leave: Resident is cognitively able to sign out of the facility and make their own informed decisions while they are out. On 04/10/2025 while on therapeutic leave, resident made the decision to consume alcoholic beverages. Goals included: The resident will follow facility policy for out on pass. The resident will be safe and comfortable while out on pass. Interventions included: Educate the resident/family/caregivers about the potential risks associated with signing out on pass. Educate resident/family/caregivers on the facility's policy for therapeutic leave/out on pass. Resident is reminded of his health issues and treatment regimens and the recommendations to avoid the use of alcoholic beverages. Further review of Resident #1's care plan revealed no care areas, goals, or interventions to address his substance abuse concerns. Record review of Resident #1's nursing progress notes for April 2025 and May 2025 revealed: * On 04/02/2025, at 4:10 p.m., SW B wrote, Resident was educated with Administrator, ADON, DON, and SW on the policies for Therapeutic Leave and the expectations for the resident when he is on Therapeutic Leave. Resident verbalized understanding. * On 04/11/2025, at 12:10 a.m., RN E wrote, Resident came back on pass to the facility with alcohol intoxication, vitals and assessment done. All within normal baseline. NP notified. New order to transfer resident to the hospital for further evaluation but resident refused. Resident was monitored through the shift, comfort care provided to resident satisfaction. * On 04/11/2025, at 11:50 a.m., ADON F wrote, Late Entry: 04/10/2025 at 11:00 p.m. Upon resident's return to the facility, resident arrived propelling himself in his motorized wheelchair. Resident had a slurred speech, he was drooling, smiling, and laughing, slow to respond to questions, and lethargic. Resident said he was tired and wanted to lay down and go to sleep and was assisted back to his room and was unable to stand to assist with his transfer to his bed, so he was transferred to bed with two people assist. In speaking with the resident, he said that he had ingested alcohol, specifically three 40 oz bottles of [brand name of beer] and he would not say if he had ingested any other substances or drinks. Upon assessment by unit nurse, there was no evidence of trauma or physical injuries noted, no indications of any falls or any other incidents at the time of his return. * On 04/12/2025, at 7:17 p.m., LVN A wrote, Police officer called facility and said resident vomited and may have been drinking with his friend and they have called 911 for him to go to the ER and have him evaluated. They then came to the facility, and I gave him a face sheet and medication lists. I accompanied the officer to EMS parked on the street near the facility and found the patient inside the ambulance being attended to by two paramedics with patient leaning to his left side. I placed a call to the Administrator and ADON. Resident apparently signed out at about 12 noon and left the facility with another resident. They apparently went to a nearby store and purchased drinks. He drank until he vomited on himself and became very weak. I asked the paramedics where they were taking him, and they informed me that they were taking him to [a local hospital] ER. NP and RP notified. * On 04/14/2025, at 4:38 p.m., ADON F wrote, Resident was found to be in possession of a cigarette lighter. The resident was educated by the Administrator on the smoking policy and the lighter was placed in the smoker's box for the resident to have access to only when on smoke breaks. The Administrator educated the resident on use of another resident's electric wheelchair and encouraged to use his own, the resident verbalized understanding. * On 04/15/2025, at 2:11 p.m., RN H wrote, Resident signed himself out and came back vomiting. Happened a couple of times. NP notified. Lab work ordered. New order to transfer to ER for further evaluation. * On 04/16/2025, at 5:23 p.m., ADON G wrote, Final lab results received on the drug and alcohol screening, labs placed in NP binder for review . resident remains in the hospital at this time. * On 04/23/2025, at 9:46 p.m., RN E wrote, Resident, who went out on pass, returned to the facility alert but disoriented, drooling from alcohol intoxication also had multiple emesis (vomiting). Resident vitals and assessment done all vital signs were within normal baseline. NP contacted via telehealth/virtual service. New order for Ondansetron 4 MG 1 tablet PO q 6hours as needed . * On 05/01/2025, at 11:59 a.m., the SW wrote, The Social Worker and the Administrator witnessed [Resident #1] taking a power wheelchair without the permission of the resident who owns the power wheelchair. Resident was educated that he cannot take the belongings of other residents while they are out of the facility. Resident was also educated on the importance of not using someone else's wheelchair and the risks that can occur . * On 05/04/2025, at 4:41 p.m., RN H wrote, Resident exchanged wheelchair with his former roommate and resident was educated that it was not safe to do so, resident verbalized understanding. Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/10/2025 at 11:17 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Complaint: Altered Mental Status . Per nurse, patient went out on pass and returned to facility lethargic, drooling from mouth and vomited once one hour ago. Per nurse, patient only knows his name, does not know where he is, and does not know the month, year. States at baseline patient is alert and oriented x 3 (a term that describes a patient's level of consciousness and cognitive function. Patient aware of person, place, and time). Per nurse, patient admitted to drinking 3 bottles of [brand of beer]. Per nurse, patient refused dialysis today and states patient did not go to dialysis yesterday . Patient seen with nurse . Physical Exam: Exam findings per nurse and video observation . Orders: Transfer to ER via 911: AMS/ESRD - missed HD/vomiting/possible alcohol intoxication . Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/23/2025 at 10:02 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Chief Complaint: GI: Vomiting . Nurse notified clinician that the [AGE] year-old-male patient with history of ESRD on dialysis, Schizophrenia, falls, HTN, DM2, went out of the facility for an hour and came back intoxicated. The nurse stated this is a regular occurrence for him. He did have an episode of vomiting. Denies drinking alcohol. Will monitor him for now . Record review of Resident #1's Lab Results Report collected on 04/11/2025 and reported on 04/16/2025 revealed Resident #1 was positive for THC (Cannabis). Record review of Resident #1's, Psychiatric Subsequent assessment dated [DATE] revealed, . History of Presenting Illness: Last visit was on 03/24/2025 . Collateral Information: On 04/24/2025, I attended a multidisciplinary care conference meeting with the DON, ADON, MDS, administrator, medical records, and SW. The case was discussed in detail, and it was concluded; 1. Patient was sent to the hospital due to after the staff found him at the store unable to move. Patient was under the influence of alcohol. 2. Patient does not follow his dialysis schedule . Record review of Resident #1's, Clinical Treatment Plan Review (Plan of Care) completed by the psychiatric provider and dated 04/29/2025 revealed, . History of Presenting Illness: . Patient was referred to psychological services for: Agitation, Irritability, Memory Loss, Short Term Memory Problems, Long Term Memory Problems, Noncompliance, Resistance to ADL/Medications, Sexually Inappropriate Behavior, Attention Seeking Behavior, Medication Evaluation, Other: Resident is refusing dialysis. In addition, he was touching himself in his genitals in an inappropriate way . Family/Social History: . Patient endorsed history of drug/alcohol abuse . Summary of Progress: Patient has been less active with therapy during this treatment cycle due to a new interpersonal relationship and frequent trips outside the facility . Treatment Plan: Treatment is expected to result in an improvement in condition or prevention of decline that would otherwise be expected. Treatment is expected to help improve patient's emotional, cognitive, social, behavioral functioning symptomatology. Psychotherapy in addition to psychotropic medication is the treatment of choice for this patient . Further review of Resident #1's Clinical Treatment Plan Review (Plan of Care) revealed no mention of a plan to address Resident #1's substance abuse concerns. Record review of Resident #1's, Psychiatric Subsequent assessment dated [DATE] revealed, . History of Presenting Illness: Last visit was on 04/24/2025 . Further review of Resident #1's, Psychiatric Subsequent Assessment revealed no documentation to show his substance abuse issues were addressed. Record review of Resident #1's, Psychiatric Subsequent assessment dated [DATE] revealed, . History of Presenting Illness: This is a post hospital follow up. After my last visit the patient was admitted into the hospital due to AMS, and general weakness. Psych meds were not changed. My last visit was on 05/01/2025 . Collateral Information: On 05/28/2025, I attended a multidisciplinary care conference meeting with the ADON, MDS, Medical records, DON, and SW. The case was discussed in detail, and it was concluded: 1. Patient has returned back from the hospital. Patient was drinking and using drugs while out on pass . Observation and interview with Resident #1 on 05/28/2025, at 2:30 p.m. revealed he was in his bed with his eyes closed. Resident #1 opened his eyes and was able to provide his name. Resident #1 stated he lived in the facility a couple of months and living there was alright. He said he went to dialysis. He said he fell out of his wheelchair about six months ago (he did not say why). Resident #1 did not answer questions related to drinking alcohol or taking drugs while outside the facility on pass. He closed his eyes and appeared to be asleep although he responded to questions unrelated to drinking or smoking. In an interview with the SW on 05/28/2025, at 3:24 p.m., she stated Resident #1 was capable of making his own decisions, but he just did not make the right decisions. She said Resident #1 went out on pass and did things he should not do. She said Resident #1 received psychiatric services to see why he refuses dialysis so much. She said she was not sure if Resident #1's substance abuse issues were discussed during his psychiatric sessions. She said Resident #1 was vomiting once due to intoxication. She said the facility staff could not tell Resident #1 what he could and could not do outside of the facility, and they could only educate him. She said Resident #1 knew what he was doing. She said Resident #1 was his own RP and he did not have any family. She said to her knowledge, Resident #1 only went out twice and got drunk, but she was not there on weekends. She said Resident #1's behavior of going out and getting drunk had decreased and he went out a lot less. She said Resident #1 had been sleeping a lot more recently and he had several hospitalization s. She said she spoke to Resident #1 about the risks of him going out drunk. She said possible negative outcomes of Resident #1 leaving the facility and getting drunk were that he could die, get injured, and go to the hospital. In an interview with the Activity Director on 05/28/2025, at 3:45 p.m., she stated Resident #1 was known to take his former roommate's motorized wheelchair. She stated Resident #1 had been caught smoking weed (marijuana) and drinking beer. She said a group of residents were at a nearby store drinking and the store workers called the police. She said the police went to the facility and told them they had to keep the residents from going there, but once they sign out, the residents go their own way. She said the residents needed more things to do inside the facility. She said she left the facility at 5:00 p.m. daily and she had only observed Resident #1 return to the facility intoxicated a couple of times. She said Resident #1 was in the hospital about a week or so and yesterday (05/27/2025) or Monday (05/26/2025), he was sick and throwing up. She said Resident #1 refused dialysis a lot. She said Resident #1 used another resident's motorized wheelchair to go to the store because he could not physically wheel himself out to store in his manual wheelchair. She said Resident #1 kept taking his former roommate's wheelchair, so they moved Resident #1 to another room. She said she had no knowledge of Resident #1 falling out of a wheelchair but about 7-8 months ago, she observed him outside with his manual wheelchair stuck and leaning off a curb. She said she pulled over and pushed his wheelchair all the way back to the facility. She said Resident #1 was leaning over in his wheelchair and he kept saying he was sick. She said she did not know of he was intoxicated at that time. She said the residents had to pass a busy road and cross the road to get to the store. She said it was not safe for the residents to travel that way, but they had their rights. She said the Administrator told the staff that the residents had their rights. In an interview with the Administrator on 05/28/2025, at 4:32 p.m., he stated the residents had rights. He said Resident #1's BIMS score was 15, but he did not make proper decisions. He said the facility staff had to make sure they did not infringe on the residents' rights. He said Resident #1 signed himself out and returned intoxicated between five and seven times. He said he had undocumented conversations with Resident #1 about how unsafe it was for him to leave the facility and get drunk. He said the conversations were not documented because he did not go into the facility's computer system to write progress notes. He stated Resident #1 received psychiatric services, but he sometimes refused to talk or participate during his sessions. He said he was not sure if Resident #1's smoking and drinking were addressed during the sessions. He said addressing Resident #1's smoking and drinking in his psychiatric sessions would be helpful to reinforce what the facility staff try to educate him on related to those behaviors. In a telephone interview with Resident #1's physician on 05/30/2025, at 10:00 a.m., he stated he was familiar with Resident #1, and he was aware the resident frequently went out on pass to drink and smoke. He said Resident #1 denied drinking and smoking, but he had a history of noncompliance with dialysis and medications. He said Resident #1 had recently been admitted to the hospital a lot and once, at the hospital, they found he had taken drugs. He said Resident #1 kept denying, so it was hard to address it. He said the negative outcome of Resident #1's behaviors were that one day, Resident #1 is fine, and then in a couple of days, he signs out and takes something (drugs or alcohol) and something happens that leads him back in the hospital. In an interview with LVN A on 05/31/2025, at 2:11 p.m., he stated on 04/12/2025, around 1:00 p.m., the police called the facility and said Resident #1 had fallen out of his wheelchair and was vomiting at the church next to the facility. He said the police went to the facility and then he (LVN A) followed them to see Resident #1. He said he thought the police saw Resident #1 on the ground and called 911. He said when he arrived at the scene, he saw Resident #1 inside the ambulance. He said Resident #1 said he had gone to the store. He said Resident #1 went to the hospital and returned to the facility about two days later. LVN A said he heard the motorized chair Resident #1 fell out of belonged to his friend. He said Resident never admitted to the drinking and always tried to hide it. He said Resident #1 usually returned to the facility late at night, so he (LVN A) was usually gone by that time (LVN worked the day shift, 7:00 a.m. - 7:00 p.m.). He said the negative outcome of Resident #1's behavior was that he was a dialysis patient and it interfered with his kidneys. He said Resident #1 falling out of the chair while intoxicated and going to the ER was a very negative effect. Record review of the facility's policy, titled, Behavior Management revised on 04/15/2014 revealed, Policy: The purpose of the policy is to optimize the quality of life and function of patients that experience behavioral symptoms that require person centered approaches to meet the health, physical, psychosocial, and behavioral health needs. Fundamental Information: Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for dementia patients. Fundamental principles of care for a patient with behaviors include an interdisciplinary approach that focus on the individualized needs of the patient . Procedure. Determine whether there is a medical, physical, functional, physiological, emotional, psychiatric, social, or emotional cause of the behaviors . Considerations: Person-Centered Care - evaluate if the environment is supportive and promotes comfort toward understanding, preventing, relieving, and recognizes individual needs and preferences . Evaluations are completed on new or worsening behaviors . Identify the frequency, intensity, duration, severity, and impact of behaviors, as well as the location, surroundings, or situation. Identify interventions or approaches to prevent, modify, relieve, or address the behaviors or distress. Patient behaviors or distress are documented as it occurs and the effectiveness of interventions. Individualized Care Plan Approaches - individualized approaches are used as a first line intervention (except in a documented emergency situation or if clinically contraindicated) . Consistent interventions are used that focuses on a patient's individual needs . Monitor and follow-up care plan is done by the interdisciplinary team who reviews the patient's progress towards goals. Summarize effectiveness of non-pharmacological and pharmacological interventions (quarterly and as indicated), for target behaviors and/or psychological symptoms and changes in a resident's level of distress or emergence of adverse consequences. Adjust interventions as needed and identified when care objectives are not met . An IJ was identified on 05/29/2025 at 1:20 p.m. The IJ template was provided to the Administrator on 05/29/2025 at 1:20 p.m. and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 05/31/2025 at 5:20 p.m. Issue Cited: Behavioral Services Failure to provide behavioral services 5/31/25 6. Immediate Action Taken On 5-29-25 resident #1 is currently in hospital for diagnosis of gastroenteritis and ESRD. 2. Identification of Residents Affected or Likely to be Affected: A. On 5/29/25 by 5:15pm DON/designee identified 66 residents are currently on behavioral services. The remaining 32 residents had no noted behaviors on admission or currently to warrant a referral for behavioral services. 3. Actions to Prevent Occurrence/Recurrence: A. On 5/30/25, [Psychiatric Provider] Services begins performing a psych evaluation on those 32 residents identified to establish any behavioral service needs, ongoing. No residents are identified as using drugs/alcohol when leaving the facility. If any of the 32 residents are identified as having a need for psych behavioral services, then care plans will be updated to reflect the behavior services. If any of the 32 residents are found to need behavioral services then [Psychiatric Provider] will treat in-house, and the care plan will be updated and nursing staff will be educated. None of the 32 residents require behavioral services at this time. B. Resident #1 is in hospital currently and has been on behavioral services but frequently refused visits. If and when resident #1 returns, psych behavioral services will be updated with his alcohol/drug behaviors and will be seen for appropriate service needs. Resident #1 has a history of refusing medical care including medications, dialysis, and psych services. If residents' refusals continue to jeopardize their health and the facility can no longer meet their needs, then the facility may discharge per HHSC guidelines. C. On 5/30/25 at 9:00 am the RNC reviewed the Behavioral Management policy, with no revisions made. D. On 5/30/25 by 12:00 PM the DON/ or designee will in-service nurses on Behavior Management policy, to include monitoring of behaviors each shift, documentation of any unsafe behaviors, notify physician of unsafe behaviors for new orders, and notify DON/ or designee of unsafe behaviors, no nurse will be able to work a shift without the in-service. The RNC in-serviced the Administrator/ or designee and DON/ or designee beforehand. On 5/30/25 by 6pm DON/designee in-serviced CNAs on Behavior Management policy including responding to behaviors and notifying charge nurse, no CNA will be able to work a shift without the in-service. E. DON/designee will review future admissions for the need of psych services and notify physician for an order for behavioral services. F. DON/designee will monitor 24-hour report for unsafe behaviors identified daily in morning stand-up meeting. G. All findings will be discussed during the morning stand-up meeting with IDT team and report to QAPI and update plan of correction as needed. H. On 5/29/25 the facility's Administrator/or designee notified the Medical Director regarding the Immediate Jeopardy the facility received related to Failure to Provide Behavioral Services and reviewed plans to sustain compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ___5/31/25_________ Monitoring of the plan of removal included the following: Record review of the facility's plan of removal documentation revealed a complete audit of the building was completed by the RNC on 05/29/2025 and 32 residents who did not receive behavioral health services were identified. Further review of the facility's plan of removal documentation revealed psychiatric evaluations were completed on the 32 residents who did not previously receive behavioral health services beginning on 05/30/2025. No substance abuse issues were identified among the 32 residents evaluated. Record review of the Behavior Management policy revealed it was reviewed by the RNC on 05/29/2025. Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/29/2025 revealed the DON was educated by the RNC on the Behavior Management policy, including monitoring behaviors each shift, documentation of any unsafe behaviors, and notifying the doctor of any unsafe behaviors. Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/30/2025 revealed the facility's nurses were educated by the RNC on the Behavior Management policy, including monitoring behaviors each shift, documentation of any unsafe behaviors, and notifying the doctor and DON of any unsafe behaviors. Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/29/2025 revealed the facility's CNAs were educated by the DON, ADON F and ADON G on the Behavior Management policy, including how to respond to behaviors, redirection, providing a calm environment, and notifying the nurse of unsafe behaviors. Interviews were conducted with staff on 06/01/2025 from 9:30 a.m. until 12:00 p.m. from all shifts (nurses and CNAs worked 12-hour shifts) including the VP of Operations, RNC, DON, ADON F, ADON G, RN H (day shift), Receptionist I, Receptionist J, LVN K (day shift), CNA L (day shift), CNA M (day shift), LVN N (night shift), and CNA O (night shift), to verify the in-services were conducted and to validate the staff understanding of requirements, training material, and expectations. The VP of Operations, RNC, DON, ADON F, ADON G, RN H, Receptionist I, Receptionist J, LVN K, CNA L (day shift), CNA M (day shift), LVN N (night shift), and CNA O were able to explain the importance of identifying and addressing unsafe behaviors (alcohol and drug abuse), notifying the nurses, DON, and physician of unsafe behaviors, documenting behaviors, responding appropriately to residents who exhibit behaviors, and monitoring residents who exhibit behaviors related to alcohol and drug abuse for their entire shift. The RNC was informed the Immediate Jeopardy was removed on 06/01/2025 at 12:09 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents as was possible for 1 (Resident #1) of 5 residents reviewed for accidents and supervision. -The facility failed to ensure a system was in place to adequately supervise Resident #1 when he left the faciity on [DATE] and did not return. The facility failed to notify law enforcement or conduct a thorough search for Resident #1. As of 03/21/25, the facility did not know Resident #1's whereabouts. An immediate Jeopardy (IJ) was identified on 03/21/25. The IJ Template was provided to the facility on [DATE] at 2:09 p.m. While the IJ was removed on 03/23/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure placed residents at risk for harm, significant injury, or death. The findings included: Record review of Resident #1's Admission Record, dated 03/21/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included candidiasis (fungal infection caused by overgrowth of a type of yeast), cellulitis (serious bacterial infection of the skin), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (one or more cognitive processes involved in communication), and unsteadiness on feet. Record review of Resident #1's physician order's revealed he was taking the following medications: potassium chloride for on Lasix, furosemide for edema, metoprolol succinate for essential (primary) hypertension, melatonin for insomnia, aripiprazole for schizoaffective, atorvastatin calcium for high LDL, ergocalciferol for supplement, trazodone for insomnia, and sertraline HCL related to depression unspecified. Resident's medications were due. Record review of Resident #1's MDS Assessment, dated 02/26/25, revealed a BIMS score of 13, indicating cognition was intact. Further review revealed the resident did not exhibit wandering behavior. The resident was independent (completes activity by himself with no assistance from a helper) with self-care, except shower/bathe self (required supervision or touching assistance) and mobility functional abilities. Record review of Resident #1's Care Plan Report, undated, revealed resident was in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide self-care and discharge planning is not needed. Resident was not care planned for leaving out on pass. Record review of Resident #1's Elopement/Wandering Risk Assessment, dated 03/15/25, reflected Category: Elopement Risk-Low, no plan of care needed .Score: 1.0. Record review of Resident #1's progress notes, entered by ADON B and dated 03/19/25 at 16:20 [4:20 p.m.], revealed Resident left facility out on pass. Record review of Resident #1's progress notes, entered by Nurse A and dated 03/20/25 at 6:42 [a.m.], revealed Resident did not return from off pass. Observation on 03/21/25 at 7:28 a.m. revealed the facility's Sign out Book was on the counter at the Nurse's Station. The Release of Responsibility for Leave of Absence form for Resident #1 was blank. During a telephone interview on 03/21/25 at 9:15 a.m., Nurse A said she was told by Nurse B that Resident #1 went out on pass on 03/19/25. She said she did not see him for her entire shift, 6:00 p.m. to 6:00 a.m., on the 19th. She said she documented in the resident's progress notes that he did not return. She said usually, residents sign out before they go out on pass, and were supposed to sign back in with the date and time. She said Nurse B did not give her any additional information. She said it could be the nurse's responsibility to make sure the resident signed out or any staff who the resident was under and said she was not sure but thinks the receptionist too. During an interview on 03/21/25 at 9:44 a.m., the DON said ADON A and B both reported to her that Resident #1 went out on pass on Wednesday, 3/19, in the afternoon around 4:00 p.m. She said to her knowledge, the resident did not tell anyone he was leaving or where he was going. She said the ADONs did not say when they expected Resident #1 to return. She said she did not know where Resident #1 was currently. She said the resident did not sign out. She said residents should sign out, but she did not believe they were required to say where they were going or who they were leaving with. She said she has been told the resident used a ride service himself to and from the facility in the past. She said the resident had a BIMS score of 13/14, was his own RP, and has family emergency contacts. She said she did not consider Resident #1 leaving the building an emergency at the time. She said residents were allowed to be on pass for 72 hours. She said the resident did not have a telephone. During an interview on 03/21/25 at 9:58 a.m., ADON A, said Resident #1 went out on pass on Wednesday, 3/19/25, and she believed ADON B told her. She said she did not know where the resident went. She said she did not know where the resident was now. She said she would have to check to see if the resident signed out. She said if residents go out on pass, they can stay out for 72 hours, residents let them know where they were going, when they plan to return, and sign back in when they return. She said Resident #1's medications did not go with him as far as she was aware. She said the resident had a high BIMS score, she believed it was a 13 or 14 and was cognitively intact. During an interview on 03/21/25 at 10:11 a.m., ADON B said the Staffing Coordinator/CNA reported to him, the DON, and ADON A that Resident #1 went out on pass. He said she did not say where he was going. He said he did not ask any additional questions. He said he did not know if he signed out. He said he did not know where Resident #1 was currently. He said he did not know if he had any of his medications with him. He said he did not know when Resident #1 was expected to return. He said residents can stay out on pass for up to 72 hours. During an interview on 03/21/25 at 10:51 a.m., the Receptionist said she worked Wednesday the 19th and saw Resident #1 leave the facility. She said the resident asked her if he could go outside and she said she thought he meant to sit outside. She said she asked the Staffing Coordinator/CNA if he was allowed to go outside and she said yes, he was okay and so she let him go outside. She said after she let Resident #1 go outside, she received a telephone call and walked to the hall and told the nurse she had a call. She said when she returned, she sat down, and the Staffing Coordinator/CNA asked her where the resident was, and she said he should be sitting outside. She said the Staffing Coordinator/CNA said he was not out there and asked if he signed the book, and she said no he did not. She said the Staffing Coordinator/CNA told her everyone needed to sign out. She said the Staffing Coordinator/CNA told ADON B and he went to go find the resident on foot, and that was when ADON B was told by another resident that he saw Resident #1 get into a car. She said Resident #1 did not tell her he was going to leave the facility. During an interview on 03/21/25 at 11:01 a.m., the Staffing Coordinator/CNA said she saw Resident #1 go outside and went on the porch and sat in a rocking chair. She said when she went back by, she saw him down the walkway and he got into a white vehicle. She said she notified the ADONs and the DON. She said they said he was out on pass. She said early that morning, 3/19/25, before 7:00 a.m., Resident #1 mentioned wanting to go to another facility and she told him to talk to the social worker. She said she did not know where the resident was now. During an interview on 03/21/25 at 11:11 a.m., the Administrator said he was out on PTO on the 19th and the 20th. He said he was notified that Resident #1 got into a white vehicle and forgot to sign out by the ADONs at approximately 4-5 o'clock, could not recall the day, but wanted to say it was Wednesday, 3/19/25. He said no one knew where he was. He said initially when Resident #1 first left, they tried to find the white SUV to get him to sign out, but they were unsuccessful. He said he would have to review what their Therapeutic Leave policy stated. He said there had not been any other attempts to find him because they knew he left out on pass. He said even if residents leave and forget to sign out, they try to call them or try to see in what general direction they went and try to redirect them to go back and sign out. He said ultimately, Resident #1 had a high enough BIMS score, and the facility did not want to infringe upon his rights. During an interview on 03/21/25 at 12:44 p.m., the DON said she just called the phone number listed for Resident #1 on his face sheet and a family member answered. She said the family member told her she was happy they called her because she had some concerns about a group home he was at previously. She said the resident's sister believed the Owner/Manager of the group home sent someone to pick him up. She said the family member told her the resident made his own decisions. During an interview on 03/21/25 at 1:01 p.m., the Administrator and DON said they just got off the phone with the Owner/Manager of the group home and was told Resident #1 was with her. They said the Owner/Manager told them the resident called her Tuesday, 3/18/25, night and said he wanted to go back and so she sent an Uber to pick him up. They said they asked to speak with the resident but was told she was driving and would have him call them when she got to where she was going. During an interview on 03/25/25 at 10:54 a.m., the Owner/Manager of the group home said Resident #1 was no longer at her personal care home and believed he went to another home. Record review of the facility's Therapeutic Leave policy, revised 07/14/2023, read in part .Compliance Guidelines .13. The resident or resident representative will sign a release form indicating the date and time the resident is leaving, location, (including address if going to a specific residence) of where resident is going, a telephone number where resident can be reached .17. If the resident has not returned from therapeutic leave as expected, the facility will attempt to contact the resident and resident representative and document attempts in the medical record . Record review of the facility's Missing Resident Policy, revised 08/15/23, read in part .Definitions .Elopement occurs when a resident leaves the premises or a safe area without authorization (an order for discharge or leave of absence) and/or any necessary supervision to do so . The Administrator was notified on 03/21/25 at 2:09 p.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 03/22/25 at 2:55 p.m.: Plan of Removal Tag Cited: F-689 Issue Cited: Free of Accidents/Hazards/Supervision Failure to ensure residents receive adequate supervision to prevent elopement 1.Immediate Action Taken On 3/21/25 @ 4:35pm DON/designee located and visited Resident #1 at the Personal Care Home in a nearby city. Resident #1 had a safe discharged to the Personal Care Home on 3/21/25 with the assistance of the Personal Care Home manager and the Administrator delivered all medications. DON evaluated resident #1 at the Personal Care Home to ensure his safety and well-being. The Administrator was responsible for the facility's decision not to call the resident/RP/police. Administrator and DON were in-service by Regional Nurse Consultant on 3/21/25 by 6:00pm on the Missing Resident Policy, which was reviewed on 3/21/25 at 11:41am with no changes made, along with notifying the police/RP/physician and the state agency when resident is not located in the facility or on facility grounds. The nearby hospital should not be contacted. Don/designee will have the 1:1 training with the receptionist on Therapeutic Leave policy and to notify charge nurse of residents that have not returned from leave that day when the receptionist shift is over and the Missing Resident Policy by 3/22/25 at 10 am. Residents therapeutic leave sign out book will be located at receptionist desk on 3/21/25 by 7:30pm, for her/him to know who is leaving. The Charge nurses will be responsible for tracking of the residents leaving after 5:30pm. Don/designee will educate charge nurses on 3/21/25 by 8pm on giving a follow-up call to resident/RP that did not return from therapeutic leave for the day and document in progress notes. Any charge nurse not present will not be allowed to work their next shift until receiving the education. 2. Identification of Residents Affected or Likely to be Affected: A. On 3/21/25 by 11 pm DON/designee will have 100% of resident's Elopement Risk Assessment completed to identify all elopement risk residents. No new resident identified. B. On 3/21/25 by 11pm DON/designee will identify all the residents with the physical ability to have therapeutic leave. 59 residents were identified. 3. Actions to Prevent Occurrence/Recurrence: A. DON/designee will In-service all staff on the Missing Person Policy on 3/21/25 by 7pm. Any staff not present will not be allowed to work their next shift until they have the training. B. DON/designee will In-service all staff on the Therapeutic Leave Policy on 3/21/25 by 7pm. Any staff not present will not be allowed to work their next shift until they have the training. On 3/21/25 at 8:08am the Regional Nurse Consultant emailed the Therapeutic Policy after reviewing, no changes were made. C. Missing Person Drill will be completed and documented with all staff on 3/21/25 by 7pm. Any staff not present will not be allowed to work their next shift until they have the drill. D. The Elopement binder will be updated with any newly identified residents on 3/21/25 by 7pm. E. All the residents identified as Elopement Risk will have their care plans updated by DON/designee on 3/21/25 by 11 pm. F. All residents identified with physical ability for Therapeutic Leave will have their care plan updated by DON/designee on 3/21/25 by 11 pm. G. DON/designee will educate and be completed by 3/22/25 by 4pm, residents/responsible party on the Therapeutic Leave Policy for those residents identified with the physical ability for therapeutic leave. H. Administrator will have an ad hoc meeting with the Medical Director on IJ findings and actions taken will be completed on 3/21/25 by 7:45pm. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ________________. On 03/22/25-03/23/25, the state surveyor monitoring confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: Observation on 03/23/25 at 7:15 a.m. revealed the sign out book was located at the nurse's station. Record review on 03/23/25 revealed, the Regional Nurse Consultant in-serviced the Administrator and the DON on the Missing Person policy on 03/21/25. Record review on 03/23/25 revealed, the Receptionist received 1:1 training on 03/22/25 on the Therapeutic Leave policy and when to notify the charge nurse of residents who have not returned from leave that day when the shift was over. Record review on 03/23/25 of in-service sign in sheet revealed charge nurses were educated on 03/21/25 on follow-up calling the resident/RP who have not returned from Therapeutic Leave and documenting it in the progress notes. Record review on 03/23/25 revealed an Elopement Risk assessment was completed for 100% of the residents on 03/21/25 and no new residents were identified. Record review on 03/23/25 revealed residents with the physical ability to have therapeutic leave was completed on 03/21/25 and 59 residents were identified. Record review of in-service trainings dated 03/21/25 and 03/24/25 revealed 44 staff were in-serviced on the Missing Person and Therapeutic policy. Record review on 03/23/25 of the facility's Elopement binder revealed it was updated. Record review on 03/23/25 of resident Care Plans revealed those who were identified with physical ability for Therapeutic Leave was updated. Record review on 03/23/25 of Therapeutic Leave documentation revealed contact/attempted contact was made with residents/responsible party for those identified with the physical ability for Therapeutic Leave was completed. Record review of Ad hoc sign in sheet on 03/23/23 revealed meeting was completed with the Medical Director on the IJ findings on 03/21/25. Interviews were conducted from 03/22/25 to 03/23/25 with staff from all shifts and all interviewees verbalized an understanding on the Therapeutic Leave and Missing Person policies. Interviewed staff included the Administrator, ADON A, ADON B, Receptionist A, Receptionist B, Nurse C, Nurse D, Nurse E, CNA A, CNA B, CNA C, and CNA D. The Administrator was notified the Immediate Jeopardy was removed on 03/23/2025 at 2:16 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, 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. -Thirteen 8 oz glasses of juice were not labeled and not dated in the facility refrigerator. -Nine 4 oz glasses of apple sauce were not labeled and not dated in the facility kitchen. This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness. Findings included: Observation in the facility kitchen on 2/25/25 at 06:30 am revealed thirteen 8 oz glasses of juice and nine 4 oz glasses of apple sauce were not labeled (attach a label to something) or dated. Interview with the Dietary Manager on 2/26/25 at 4:01 pm, she said she starts her workday by making sure everything is correctly labeled and dated . She said she make sure the date and use by date are on each food item. She said if the item used is not labeled or dated the residents can get sick or have an allergic reaction. Interview with the [NAME] on 2/27/25 at 1:39 pm, she said all food items should be labeled and dated. She said if the items are not labeled and dated, she had no idea how long the item had been sitting there. She said if she was to use the item and it's not dated or labeled it can make the residents sick. Interview with the Tray-aide on 2/27/25 at 1:45 pm, he said all the food items should be labeled and dated always. He said if the items are not labeled and dated, and the food is used it can put the residents at risk of getting sick. Record review of the Facility's Nutrition Policies and Procedures dated December 5, 2017, read in part . proper labeling with an expiration or use by date .

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 garbage dumpsters (dumpsters #1 and #2) reviewed for disposal of garbage. The facility failed to ensure 2 of 2 dumpster lids were secured. This failure could place residents at risk of infection for exposure to germs and diseases carried by rodents from improperly disposed garbage. Finding included: Observation on 2/25/25 at 7:15 am revealed Dumpster #1 and Dumpster #2 had their lids completely open with the garbage exposed. The cook said they were not the only ones using the dumpsters in the facility. Interview with the Nutrition Director on 2/26/25 at 4:01 pm, she said she had worked at the facility for seven years. The Nutrition Director said the dietary staff were responsible for the dumpster lids remaining closed. She said if the dumpster lid was open the residents are at risk for potential rodents that could come into the building and make the residents sick. Interview with the [NAME] on 2/27/25 at 1:39 pm, she said she had worked at the facility for eight months. She said the kitchen staff responsible for making sure the dumpster lids closed. She said when the lid of the dumpster did not close it can cause the rodents, flies, and gnats to enter the facility which can cause the residents to become sick. Interview with the Tray-Aide on 2/27/25 at 1:45pm, he said he had worked for the facility for one year. He said the kitchen responsible for the dumpster lids remaining closed. He said if the dumpster lids remain open it can put the residents at risk. He said the resident can be put at risk once rodents surround the dumpster. He said the residents can get rabies and become sick. Record review of the Facility's Nutrition Policies and Procedures dated December 2017 read in part . dumpsters must be covered with lids . dumpster doors and lids must be kept closed when not in use . Record review of the Facility's Food-Related Garbage and Rubbish Disposal policy, revised April 2006 revealed . 2. All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be covered when stored or not in continuous use. 5. Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin. 7. Outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter.

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 5 residents (Resident #27) reviewed for pharmacy services. The facility failed to acquire and administer Resident #27's scheduled dose of Clonazepam for several days. This failure could place residents at risk of decreased therapeutic efficiency and a poor quality of life. The Findings were: Record review of Resident #27's face sheet, dated 02/27/25, revealed [AGE] year-old male resident who was admitted to the facility on [DATE] with diagnoses including Respiratory failure, Cerebral infarction (blood flow to brain is interrupted causing the brain tissue to die), depression, and Schizophrenia (Mental disorder that affects a person's ability to think, feel, or behave clearly). Record review of Resident # 27's annual MDS dated [DATE], revealed Resident #27 had a BIMS summary score of an 8, indicating moderate cognitive impairment. His behavior symptoms include Hallucinations and delusions that are directed towards self and others. Record review of Resident #27's comprehensive care plan revealed the resident has a behavior problem as evidence by increased audio and visual hallucinations which caused increase confused thought process. His interventions included to administer medication as ordered, approach resident in a calm manner, call by name, speak slowly, and maintain eye contact, talk to resident while providing cares, allow time for a response, and do not rush. Resident #27 was also care planned for cognitive impairment. He has a history of schizophrenia which causes him to have a cognitive deficit. His interventions included Administer medications per physician's orders and monitor for unusual/adverse reactions and effectiveness. Report abnormal findings to the physician and Provide instructions using a clear voice and simple sentences and repeat as needed. Record review of Resident #27's physician orders for February 2025 revealed Clonazepam oral tablet 0.5 MG. Give 0.5 mg by mouth three times a day for anxiety. Record review of Resident #27's February 2025 MAR revealed Clonazepam oral tablet 0.5 MG. was not administered as ordered on 02/12/25, 02/13/25, and 02/14/25 due to the medication being on hold. Record review of behavior monitoring from 02/10-02/25/25 revealed no increased episodes of inappropriate behaviors or interventions required while on psychoactive medication. Record review of nurse's progress note on 02/13/25 at 7:42 PM revealed that the MA notified LVN N of the Clonazepam script for Resident # 27. She said the MA informed her of the need to notify the pharmacy. A call was placed to MD office, and she spoke with the receptionist regarding the resident's Clonazepam order. He then stated that he would let the MD know about it. Record review of nurse's progress notes dated 02/15/25, 02/16, 02/18, 02/19, and 02/21/25 with nursing staff (MA and LVN) noting resident's refusal of medications with education provided. Observation on 02/26/25 at approximately 2:00 PM. Resident #27 was sitting in his wheelchair in the front lobby. He was observed staring at the ceiling and talking to himself. He was non-verbal when asked questions. Resident stared at surveyor during the attempted interview. Observation on 02/27/25 at 11:28 AM in the 3rd hall. The resident was in his wheelchair. Resident #27 was without signs of aggressive behavior or staring at the ceiling. He was still non-verbal when the surveyor spoke to the resident. Interview on 02/27/25 at 12:31 PM with CNA D who had worked at the facility for 2 years. She said that she was familiar with Resident #27. She the resident's behaviors had constantly changing with good and bad days since she had worked at the facility, including cursing and staring at the ceiling; however, he was easily redirected. She said the resident was combative only with staff and refused services such as showers. She denied witnessing him being a threat to himself or others. Interview on 02/27/25 at 1:55 PM with MA B, who had been working at the facility for 6 months. She said she was trained on what to do with missing/unavailable medications during onboarding. She said Resident #27 medications were on hold because he did not have a prescription. She said she informed LVN N that the medication was unavailable, and she contacted the doctor and sent a message to the pharmacy. She said she could not get the medications from the e-kit, and only the nurses could pull medications from the e-kit. She said LVN N could not get Resident #27 medication from the e-kit because there was no triplicate. She said the resident would refuse medications frequently, he was educated on his refusal, but he was his own responsible party. She said the risk of the resident not getting his medication as ordered was his condition could worsen. Interview on 02/27/25 at 2:01 PM LVN N, who had been working at the facility for 2 months. She said she was familiar with Resident #27. She said she contacted the pharmacy and the physician's office regarding his medication. She said she left a message with the receptionist, who said she would let the physician know he needed a script to administer the Clonazepam. She said MA B notified her twice that the medication was not received. She said she contacted the physician's office again without a response. She said the 3rd time, she contacted the on-call physician group who gave the pharmacy the information needed to fill the prescription. She said she could not pull the ordered medication from the e-kit without 1st having a triplicate from the doctor. She said the resident was currently receiving the medication as ordered. She was not able to provide a risk for him not receiving his medication. Interview on 02/27/25 at 2:18 PM with ADON A, who said that the nurses can get medication out of the e-kit. He said Clonazepam was one of the medications available in the e-kits . He said the process was that if a medication were unavailable due to the pharmacy, the MA would inform the nurse, who could obtain the medication for the e-kit and follow-up with the physician. He said some nurse pulled the Clonazepam from the e-kit, but other nurses did not. He said he was responsible for pulling the report of medication availability in the e-kit. ADON A said LVN W was one of the nurses who obtained Resident #27's Clonazepam from the e-kit and administered his medication per the inventory report. Telephone interview on 02/27/25 at 2:25 PM with the consulting pharmacy. Pharmacist B said he received an initial order for Clonazepam 0.5 mg. on 02/17/25 in electronic medical record. He said he needed a script before he was able to dispense the medication, and the MD needed to sign-off on the medication before approving the Clonazepam. The medication was not filled until 02/24/25; however, the Clonazepam was available in the e-kit for administration. Attempted telephone interview on 02/27/25 at 3:43 PM with Dr A. The surveyor left a voicemail message with contact information. Attempted telephone interview on 02/27/25 at 3:45 PM with Dr. D. The surveyor left a voicemail message with contact information. Attempted telephone interview X's 2 on 02/27/25 at 3:51 PM with LVN W. The surveyor left a voicemail message with contact information. Interview on 02/27/25 at 4:36 PM with the interim DON, who started at the facility on 02/12/25. She said the resident had a recent inpatient stay at a psychiatric facility, and the hospital discontinued all his medications and restarted him on new meds to include Clonazepam. She said she was unsure of his behaviors and thought his baseline consisted of auditory and visual hallucinations. She said the Clonazepam was ordered 3 x' s a day for anxiety. She said he started receiving the Clonazepam as ordered on 02/24/25. She said her expectation was that the staff follows the physician orders and call to notify the pharmacy and physician if a medication was not received. She said some medications are in the e-kit, and the nurses can pull meds from the e-kit until the pharmacy delivers the meds. She said the risk of not receiving his antianxiety meds was an increased risk for inappropriate behaviors. She said she conducted an in-service today regarding the unavailable medications and the e-kit. Interview on 02/27/25 at 4:48 PM with the administrator, who said his expectation was to contact the pharmacy for medication that was ordered but unavailable. He said there should be a collaborative effort between the inpatient psych facility and psych physicians. He said the risk of not administering the Clonazepam could manifest in an was an episodic break. Interview on 02/27/25 at 4:51 PM with the regional nurse, who said the staff was trained on medication administration during on-boarding to include a competency check-off, and staff are periodically in-serviced by the pharmacy consultant. She said the risk of not administering the medication as ordered could have an adverse effect. She said the medication was in the e-kit and the staff should have followed-up with the pharmacy and notified the physician. Interview on 02/27/25 at 5:25 PM with Dr. D's assistant, who said he was seen on 02/13/25 when Resident #27 was discharged from the inpatient facility. She said the Clonazepam started while in the inpatient facility. She said the resident had a history of refusing meds, and the MD was aware on his 02/13/25. She said the staff kept in contact with the MD regularly to discuss any changes in behaviors. Interview on 02/28/25 at 10:47 AM with Dr. D, he said Resident #27 was non-compliant with his medication and had been on several different medication regimens. He said the medication was not ordered by him but by the inpatient facility when he was discharged from the facility. He said the resident was on Abilify, but the clonazepam would have helped with his anxiety and should have been administered as ordered. Dr D. said the risk of not getting his medication was increased behaviors. He said the resident was not a harm to others, and a long-term care facility was an appropriate setting. Record review of the Facility's Medication -Treatment Administration and Documentation Guidelines, revision date 2/2/2014, read in part . Process 4. Administer the medication according to the physician order .

Based on observation, interview, and record review, the facility failed to establish a grievance policy to ensure the prompt resolution of all grievances for 1 of 3 (Resident#1) residents reviewed for grievances. -The facility failed to establish a grievance policy that includes the right to obtain a written decision regarding a resident's grievance. -The facility did not provide a written decision to Resident #1 who filed grievances. These failures could place residents at risk for feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness. Findings included: Observation on 09/27/2024 at 2:01p.m., of the posting near the Receptionist area titled Abuse, Neglect and Grievances revealed the posting included the Administrator's name, title, and phone number. Record Review of Resident #1's face sheet, dated 9/27/2024, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record Review of Resident #1's quarterly MDS assessment, dated 8/13/2024, revealed Resident #1 had a BIMS score of 15 out of 15 which indicated Resident #1 was cognitively intact. Record Review of Resident #1's care plan initiated 12/09/2023 and revised on 12/11/2023 revealed the following: Focus: Resident is in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide selfcare and discharge planning is not needed. Either the family or the resident has requested that questions regarding return to the community only be asked on comprehensive assessments.Goal: Resident and family's wishes will be honored through next review date. Interventions: Observe for change in conditions that may affect long-term care goals and notify the physician and responsible party as needed. Discuss the need for continuing long-term care placement with the resident or family as indicated or requested. Encourage and allow the resident or family to discuss feelings and concerns regarding long-term care placement. Discuss with the resident or family the level of care that would be needed to safely return to an assisted living facility, group home, or the community when indicated or requested. Record Review of the facility's Grievance log (June 2024 to September 2024) revealed Resident#1 filed a grievance on 09/03/2024 and 09/04/2024 with the facility that included patient care and medication administration. The resolution date for the grievance was 09/03/2024 and 09/04/2024 and documentation revealed that the resident was verbally informed of their decision regarding the grievance by the DON, SW, Administrator, but no documentation of written notification was given to Resident #1 or Resident #1's representative. In an interview on 09/27/2024 at 9:30a.m., Resident #1 stated that she had filed two grievances with the facility on 09/03/24 and 09/04/24. Resident #1 stated she had made several attempts with the SW and the Administrator to request copies that the grievance was concluded but had not received any documentation. Resident#1 stated she was told by the Administrator that it was the company's policy not to provide written documentation of the decision regarding the grievance. Resident#1 stated she had filed grievances regarding insulin administration and patient care, and it was her right to view the resolution of the grievances. Resident#1 stated she felt ignored not getting written decisions about her grievances. In an interview on 09/27/2024 at 11:46a.m., with the Administrator, he stated the grievance form was an internal document. Resident/family and not even state Surveyor can have access to the grievance form. It's company's policy. Surveyor asked what if the resident/family or Surveyor request to see the documentation of the decision regarding the grievance. The Administrator stated, they can't. In an interview on 09/27/2024 at 1:10p.m., The SW stated Resident#1 had requested written explanation of the findings of the grievance several times. SW stated she did not give Resident #1 a written explanation of the findings of the grievance. SW stated they had a meeting with Resident#1, Regional Administrator, Administer and her as witness of the conversation. The Regional Administrator explained to the resident normally it's not what we practice. Grievance form is more of internal document, so it is not uploaded to the resident's file. It's not a medical record. SW stated the grievances form goes in the grievance file and when state surveyors ask for it, she was to give it in the form of the grievance log. SW said that a possible negative outcome for not giving a resident written notification for a filed grievance would be that a resident may not feel that the grievance was resolved. In an interview on 09/27/2024 at 1:50 p.m., Interim DON stated the Administrator was the facility's abuse coordinator. Interim DON stated the process for grievance was interview staff/resident, investigate, resolve, and provide explanation to the resident if alert and or family. Interim DON stated, I don't think there is anything that would be preventing us from giving a copy. Interim DON stated that a possible negative outcome for not providing written documentation of the resolution would be that the resident would feel a lapse of communication in the facility, that a resident may forget that they were talked to about the grievance and feel that their grievance was not heard. Record Review of facility's Grievance Policy (Revision Date: 11/19/2016, 7/22/2023) reflected in part: .The Administrator (grievances officer) is responsible for the following: Validates designee follows up with the resident/family regarding resolution or explanation. Ensure that residents either individually or through postings throughout the facility are aware of: The right to file grievances orally, or in writing in the language he/ she understands, The right to file grievances anonymously, The contact information of grievance official Ensure that the grievance officer's information is posted to include: his/her name, business address (mailing and e-mail) and business phone number. A reasonable expected time frame for completing the review of the grievance. The contact information of independent entities with which grievances may be filed. E.g.: The pertinent state agency, Quality improvement Organization, State Survey Agency and State Long Term Care Ombudsman program or protection and advocacy system. Provide a copy of the grievance policy to the resident upon request . The grievance policy did not mention the right to obtain a written decision regarding his or her grievance.

Based on interview and record review, the facility failed to ensure that each resident receives, and the facility provides food that accommodates resident allergies, intolerances, and preferences for 1 (Resident #2) of 5 residents reviewed, in that: [NAME] A denied Resident #2, the 2 cheese flour tortillas requested on his breakfast meal ticket every morning. This failure could place residents at risk for decreased quality of life and weight loss. Findings included: Record review of Resident #2's face sheet revealed a sixty-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses was Parkinson's Disease (disorder that affects the nervous system and the parts of the body controlled by the nerves), kidney failure, reduced mobility, and obesity. Record review of Resident #1's MDS assessment completed 07/03/24 revealed a cognitive score of a 15 (cognitively intact) out of 15. Cognitive functioning in relation to eating revealed that supervision and set up was required during meals. Record review of Resident #2's care plan revised 01/14/20 that he was a regular diet, regular texture, and was to receive large portions. Interventions were to provide and serve diet as orders. In an interview on 08/21/24 at 12:26 p.m., Resident #2 stated he had a problem with his meal ticket. He explained that every morning he was supposed to receive two flour tortillas with cheese but he never got them. Instead, he said he would be given two slices of toast. On the ticket, he explained that this order is always highlighted at the bottom and he informed DM A and the Admin about this occurrence. He could not detail how long his food preference had been denied, but he stated that it had been a long time. He felt that this was being done on purpose and it made him mad. In an interview on 08/21/24 at 12:31 p.m., DM A was asked to go through the breakfast meal tickets to view what is requested by Resident #2. At the bottom of the meal ticket, it stated that he was to receive two flour tortillas with cheese and it was highlighted in green. She stated that he told her on 08/20/24 that he had not been receiving his tortillas and she had an in-service with [NAME] A. The in-service instructed her to follow exactly what was on the ticket. [NAME] A was sent home on 08/20/24 due to insubordination. DM A stated that the dietary staff have to give the residents what they have requested. In an interview on 08/21/24 at 1:30 p.m., [NAME] A stated it was her fault that Resident #2 had not gotten his flour tortillas and she recognized that. She then stated that she did not know that he had cheese tortillas on his ticket because another dietary staff would read it out to her while she plated. She stated that on the morning on 08/21/24, the order for the tortillas was on the ticket but it was not read out to her. When asked when he liked those tortillas, she stated that he wanted them Monday-Sunday. She explained that some days he would want multiple tortillas but when they would bring his plate back, they would still be on his plate uneaten. She stated that going forward, she is going to start giving him the requested cheese tortillas. In an interview on 08/21/24 at 2:22 p.m., DM A stated that on 08/20/24, she asked [NAME] A to make a requested item for a different resident and she stated she was not going to do it. She did not know what was wrong with [NAME] A, but she was sent home for insubordination. On the morning of 08/21/24, she asked [NAME] A if Resident #2 had his two cheese flour tortillas. She said no and [NAME] A was written up. DM A stated that every day, extra requests are highlighted on the ticket and she knew it be a fact that the dietary aid read the ticket out to her in full. She did not know why she did not make the tortillas for Resident #2. When told that [NAME] A denied knowing that Resident #2 requested the tortillas but later stated that he would not eat them, DM A stated Exactly. If he she didn't know he wanted them, then how does she know that he does not eat them?. In an interview on 08/21/24 at 3:57 p.m., the Admin stated that Resident #2 told him on Friday that he had not been receiving his tortillas from his meal ticket. He told me to look at his meal ticket and it said that he was to receive two flour tortillas. He stated that he went to dietary and the DM said she would handle it, but apparently he did not receive flour tortillas on 08/21/24 or 08/20/24. Record review of the Employment Action/Disciplinary Notice Form dated 08/21/24 revealed that [NAME] A was written up because Resident #2 had not received his 2 flour tortillas as it was written his tray ticket. The summary stated that her behavior was not acceptable and it would not be tolerated. Record review of the Culinary Specialist Job responsibilities (not dated) displayed that they were to prepare quality food and baked goods according to the planned menu.

Based on interviews and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents hazards and supervision, in that: The facility failed to ensure Resident #1's noodles were served at the appropriate temperature, which resulted in a burn to the palm of her hand. The failure could place residents at risk of experiencing accidents, injuries, and/or death. Findings Included : Resident #1 Record review of the face sheet for Resident #1 revealed a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting diagnoses was epilepsy (neurological condition that causes unprovoked, recurrent seizures), unsteadiness on feet, seizures, unspecified convulsions, and dementia (memory loss). Record review of Resident #1's MDS assessment completed 05/31/24 revealed a cognitive score of a 10 (moderately impaired) out of 15. Cognitive functioning in relation to eating revealed that supervision and set up was required during meals. Record review of Resident #1's care plan revised 06/10/19 displayed that she had a diagnosis of seizures and took anticonvulsant medications which placed the resident at risk for falls and Injury. Focus initiated on 8/19/24 revealed that she was at risk for injury related to preparing and transporting hot liquids without staff assistance. Interventions were for staff to assist Resident #1 with preparation and delivery of hot liquids and to educate nursing and dietary staff on the proper temperature for meal requests. Record review of the accident report dated 08/19/24 stated that Resident #1 had red discoloration on her hand due to transporting a cup of noodles to her room after lunch. Inservice's were started on 08/19/24 and the dietary staff was educated on safe hot beverage handling. Education had begun for nurses and CNA's on the microwave and hot beverage policy and abuse and neglect. In an interview on 08/21/24 at 12:00 p.m., DA B stated that on 08/19/24, Resident #1 came to the kitchen and requested that she warmed up her cup of ramen noodles in the microwave. She stated that the kitchen staff was instructed not to warm up outside food in the kitchen, but DM A gave her permission to do so this time. She explained that she warmed the cup of noodles in the microwave for exactly one minute and 30 seconds. She stated that other residents were also at the kitchen door so she did not give Resident #1 the cup of noodles immediately out of the microwave, but she was cautious when doing so. She explained that Resident #1 was an independent eater, but she did shake on her hands and arm. When she handed her the cup, she gave it to her in her hand. DA B stated that she was not a cook and only the cooks would check the temperatures on food. Her role in the kitchen was to wrap napkins and she tended to trays . In an interview on 08/21/24 at 1:04 p.m., Resident #1 stated that on the day she burned her hand, she stated that she went to the kitchen with her cup of instant noodles. She stated that when the dietary aid gave her the noodles, she shoved it into her hand. This made the water spill out and burn the palm of her hand. She explained that she shook and when they normally warmed up her noodles, they gave it to her with a tray. She stated that her hand felt better today, but it was hurt badly a few days prior. In an observation on 08/21/24 at 1:05 p.m., the instant cup of noodles from Resident #1 was reviewed. Packaging directions read to fill the cup with boiling hot water and let them stand for 3 minutes with the lid on the cup. Warning label instructed to be cautious, hot; handle with care especially when serving children. In an interview on 08/21/24 at 2:22 p.m., DM A stated that in regard to Resident #1, DA B should have given the noodles to her on a tray because she would shake. DM A stated that after the incident, she asked DA B that if she knew Resident #1 shook, why she did not give her the noodles on a tray. DA B responded that she was not thinking. DM A stated she would have never given her the noodles without a tray and she instructed her to give out a tray in the future, however the protocol had changed and they were no longer allowed to warm up resident food inside of the kitchen. In an interview on 08/21/24 at 3:57 p.m., the Admin stated that the incident with Resident #1 happened on 08/19/24. When he saw her, she was walking down the hallway near the nurses station after lunch. She looked shaky and agitated and when he observed her hand, he could see that her right hand was a lot more red than her left. When asked what happened, Resident #1 stated that she burned her hand on a cup of noodles. She stated that when the dietary aid handed her the noodles, she handed it to her more than gently so the noodles slushed out of the cup and burned her hand. There were also noodles hanging off the side of the cup. Resident #1 told him that she normally received a tray during this handoff. Admin stated that a new policy was implemented where only nurses were allowed to heat up things in the microwave. All staff had not completed the in-service, but they were in the process of updating everyone of the new procedures. He also followed up with wound care and the burn did not result in a wound, only redness. In an interview on 08/21/24 at 4:15 p.m., the WCN stated that she was called to assess Resident #1's hand on 08/19/24. She explained that the palm of her hand was reddened but it didn't blister. Resident #1 stated her hand hurt and the wound was treated with an order of Silvadene cream and was wrapped up. She monitored the wound daily and told Resident #1 to let the charge nurse know if she was in pain. The wound care doctor was in the facility earlier the morning of 08/21/24 and said that the burn had resolved, and he discharged the order for the cream because the redness was gone. In an interview on 08/21/24 at 4:24 p.m., RN A stated that when she saw Resident #1 on 08/19/24, she was in the hallway talking to the Admin and she said she had burned her hand with the cup of noodles. RN A assessed her hand, and it was red. She offered her Tylenol for pain and when she checked on Resident #1 15 minutes later, she denied anymore pain. She described the injury on her right hand as red in discoloration but there were no tears. RNA Stated that she worked on 08/19/24 and 08/20/24, and when she checked on her on 08/20/24, she denied pain and pain medication. She stated the wound care doctor reviewed her hand and stated that everything was good. Record review of the facility's Food and Safety sanitation policy reviewed 07/22/21 revealed: a. Proper reheating- foods reheated in the microwave over must be reheated in a uniform manner so that all parts are heated to 165 degrees F. The food will be rotated or stirred, covered, and the allowed to sit for 2 minutes. b. Personal Hygiene Practices- thorough hand washing is required (but not limited to) the following situations: after coughing, sneezing, or touching hair or face. Food handling: Food service employees will minimize bare hand contact with food that is ready to eat. Except when washing fruits and vegetables, food service employees may not contact exposed, ready to eat food with their bare hands, Instead, suitable utensils such as deli tissue, tongs, single use gloves, or dispensing equipment must be utilized.

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 in 1 of 1 (DA A) kitchen staff reviewed for dietary services . During lunch, DA A failed to wear gloves and properly clean his hands during service while he touched his face mask, key chain, and rubbed his eyes. This failure could place residents at risk for injury and food borne illness during food preparation and services. Findings included : In an observation and interview on 08/21/24 at 12:13 p.m., DA A was tasked with taking the finished plates off the hot line and putting them on the trays inside of the food cart. DA A was the only kitchen staff observed without gloves. During service, DA A touched his face mask covering his mouth. When he spoke, DA A used his bare hand to pull the mask down and speak with other kitchen staff. He bent over and grabbed the bottom of his shirt and pulled it up to his eye, which exposed his bare back and boxers. He used the shirt to wipe his eyes then dropped the bottom of his shirt and continued to grab trays off the line and place them on the cart. DA A stated that he had been working in the kitchen for 8 months and expressed that if he was supposed to be wearing gloves, he had not worn any since his initial employment and no one had enforced it. He explained that the reason he kept touching his face mask was because his glasses pushed it down and he was aware that there was Covid inside of the facility. During the interview, with his bare hands, DA A touched his pants, arm, jewelry, key chain, and scratched his hair underneath his hair net. As he waited for the next line of plates, he was asked if he was supposed to touch different items outside of the plates and cart during services, which he responded I guess not while dropping the key chain. When asked if touching the different items could lead to cross contamination, he responded I guess so. The interview was ended In an interview on 08/21/24 at 12:22 p.m., DM A was made aware that DA A was not wearing gloves or washing his hands and touched multiple unclean services while preparing lunch, she stated that she would let him know. She walked over and instructed him to wash his hands and told him to put gloves on. He walked to the sink to wash his hands and grabbed a new pair of gloves after. She stated that he knew he should have worn gloves during service. In an interview on 08/21/24 at 2:22 p.m., DM A stated that she would talk to DA A about not being sanitary during service and he would be in-serviced. She explained that the harm in having poor sanitary practices in the kitchen would be cross contamination. If DA A was sick and did not wash his hands, he could have passed it to someone else, especially with Covid in the building. She also felt that he needed to review the training given during the food handlers training. Record review of the facility's Food and Safety sanitation policy reviewed 07/22/21 revealed: a. Proper reheating- foods reheated in the microwave over must be reheated in a uniform manner so that all parts are heated to 165 degrees F. The food will be rotated or stirred, covered, and the allowed to sit for 2 minutes. b. Personal Hygiene Practices- thorough hand washing is required (but not limited to) the following situations: after coughing, sneezing, or touching hair or face. c. Food handling: Food service employees will minimize bare hand contact with food that is ready to eat. Except when washing fruits and vegetables, food service employees may not contact exposed, ready to eat food with their bare hands, Instead, suitable utensils such as deli tissue, tongs, single use gloves, or dispensing equipment must be utilized.

Based on observations, interviews, and record review, 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 diseases and infection for 1 of 2 residents (Resident #1) reviewed for infection control. -The facility failed to ensure CNA J performed hand hygiene during incontinent care on Resident #1. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. Findings included: Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit (trouble reasoning and making decisions while communicating) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #1's Quarterly MDS assessment, dated 07/26/2024, revealed the BIMS score was 05 out of 15, which indicated her cognition was severely impaired. The MDS revealed she was dependent on staff with toileting, shower/baths, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS revealed . Record review of Resident #1's care plan, initiated 02/17/2024 and revised on 06/06/24 revealed the following: Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to muscle weakness. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Bed Mobility: total x 1 assist. Transfers: total x 1 assist. Eating: set-up/ clean up Toileting: dependent x 1 assist. Ambulation: n/a. Wheelchair: independent short distances --mostly propelled per staff. Dressing: dependent x 1 assist. Personal Hygiene: dependent x 1. Bathing: dependent x 1 assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Encourage resident to participate to the fullest extent possible with each interaction and praise when attempts are made. Observation on 08/16/24 at 12:16 p.m., revealed CNA J provided Resident #1 with incontinence care. CNA J did not complete hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. CNA J unfasten Resident #1's brief and tucked it under the resident's buttocks. CNA J turned the Resident over and did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus. CNA J removed the soiled brief and discarded it into the trash can sitting near resident's foot of bed. CNA J wiped twice, removed her soiled gloves without washing or sanitizing her hands donned clean gloves. CNA J completed incontinent care and with the same soiled gloves touched the Resident's clean dress, brief, and sheets . In an interview on 08/16/24 at 2:08 p.m., with CNA J, she said she started working full time at the facility last month. She said she did not recall doing CNA competency checks for incontinent care. CNA J said not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-services on infection control at the time of hire. In an interview on 8/16/24 at 2:15 p.m., with the Wound Care Nurse, she said CNA J should have either washed or sanitized her hands in between gloves change as it placed the resident at risk for infections. In an interview on 8/16/24 at 3:06p.m., with ADON B, she said she was the facility's infection preventionist. She said she provided mandatory infection control in-service to staff monthly, quarterly and as needed. She said CNA J was new to the building but not to long term care. She said staff should wash/sanitize their hands upon entering a resident's room, in between glove changes, and before leaving the resident's room. In an interview on 08/16/24 at 4:48p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care each time they perform incontinent care. She said Wound Care Nurse brought it to her attention that CNA J failed to performed hand hygiene during incontinent care on Resident#1. She said the CNA should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said these failures were risk for infection control . Record review of facility's In-Service Program Attendance Record dated 8/14/2024 revealed Topic: Hand Hygiene was signed by CNA J. Record review of facility's Hand Hygiene Policy (Date implemented: 11/12/2017) revealed read in part: .Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6.Additional considerations: a. The use of antimicrobial-impregnated wipes (i.e. towelettes) are not a substitute for using an alcohol-based hand rub or antimicrobial soap. b. The use of gloves does not replace hand washing. Wash hands after removing gloves . Record review of facility's infection control Guidelines (Revision Date: 9/22/2015) revealed read in part: .Anticipated Outcome: The purpose of this policy is to reduce and prevent the spread of infections by the use of evidence based techniques established infection control policies and procedures. 3.Hand Hygiene Protocol: a. Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty. b. Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing care to patients in isolation. c. For routine patient care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact. d. Hands shall be washed in accordance with our facility's established hand washing procedure .

Based on observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 resident (Resident #1) reviewed for incontinent care. -The facility failed to ensure CNA J properly cleaned Resident #1 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown, and a decreased quality of life. Findings included: Record review of the admission sheet (undated) for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which include alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit (trouble reasoning and making decisions while communicating) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the BIMS score was 05 out of 15, which indicated she was severely impaired cognitively. The MDS revealed she was dependent on staff with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent. Section H0400: Bowel Incontinence was coded (3) always incontinent. Record review of Resident #1's care plan, initiated 02/17/2024 and revised on 06/06/24 revealed the following: Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to muscle weakness. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Bed Mobility: total x 1 assist. Transfers: total x 1 assist. Eating: set-up/ clean up Toileting: dependent x 1 assist. Ambulation: n/a. Wheelchair: independent short distances --mostly propelled per staff. Dressing: dependent x 1 assist. Personal Hygiene: dependent x 1. Bathing: dependent x 1 assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Encourage resident to participate to the fullest extent possible with each interaction and praise when attempts are made. Observation on 08/16/24 at 12:16 p.m., revealed CNA J provided Resident #1 with incontinence care assisted by Wound Care Nurse. CNA J removed Resident #1's brief and tucked it under the resident's buttocks. CNA J turned the Resident over and did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus. In an interview on 08/16/24 at 2:08 p.m., with CNA J, she said she started working full time at this facility last month. CNA J said she did not spread Resident #1's labia and clean the resident's meatus during incontinent care because I changed her diaper before breakfast around 8am. She said the failure placed the resident at risk for infections. In an interview on 08/16/24 at 4:48p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care each time they perform incontinent care. She said CNAs were provided training and competency check offs upon hire, quarterly and as needed. No policy on peri care was provided on exit. Record review of facility's Nursing Peri-Care Performance Criteria revealed read in part: .FEMALE 10. Positions waterproof pad under buttocks. 11. Helps to flex knees and spread legs apart. Notes limitation in positioning. 12. Cleanses the upper thighs. 13. Separates labia minora to expose urethral meatus and maintains hand position while cleansing. 14. Cleanse in one direction from clean to dirty. 15. Cleanse each side of labia maiora. 16. Wipe in the direction from perineum to rectum. 17. Use a separate wipe for each stroke and discard. 18. Discard gloves , hand sanitize or wash hands and apply a clean set of disposable gloves. 19. Dries perinea! area thoroughly using a different section of the towel for each stroke. 20. Asks patient/resident to lower legs and assume side lying position. Assists as necessary.

Based on record review and interviews, the facility failed to develop and implement an effective discharge process that focused on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition them to post discharge care for 2 of 3 residents (CR # 1 and #2) reviewed for an effective discharge process. -CR#1 was discharged on [DATE] and a discharge summary was not completed. -CR#2 was discharged on [DATE] and a discharge summary was not completed. These failures could affect residents who are discharged from the facility by not providing a recapitulation of the residents stay and a final summary of the residents' status for any continuation of care that may be required. Findings included: CR#1 Record review of CR#1's face Sheet (undated) revealed, a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: cerebral infarction (refers to damage to tissue in the brain due to a loss of oxygen to the area), cerebral edema (swelling of the brain), and moyamoya disease (disorder of blood vessels in the brain). CR#1 was discharged on [DATE]. Record review of CR#1's Care Plan initiated 11/19/2020 and updated on 05/30/2024 revealed the following: Focus: Resident has an ADL Self Care Performance Deficit and was at risk for not having their needs met in a timely manner. Goal: Resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date. Interventions: Transfers: Per Hoyer x 2-person Record review of CR#1's Discharge MDS dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognitively. Further review of Section A0310. Types of Assessment: F. Entry/discharge reporting coded-10: Discharge assessment-return not anticipated. Section A2105. Discharge Status coded-04: Short-Term General Hospital Record review of CR#1's Social Worker notes dated 5/13/2024 at 12:04pm revealed read in part: .Social Worker spoke to [name] who is the RP and family member for [CR#1]. SW asked if he would like for a referral to be submitted to [facility name], and he stated that he would like the referral to be sent. Referral to [facility name] was sent to [name], the admissions coordinator . Record review of CR #1's clinical record revealed no evidence of discharge planning and no discharge assessment. Record review and interview on 06/21/24 at 1:37p.m., RN AA said nurses initiated the discharge summary and the DON reviewed and signed for completion. RN AA reviewed CR#1's electronic medical records with the State Surveyor. RN AA said, I don't see the discharge Summary for CR#1. Record review and interview on 06/21/24 at 2:30p.m., ADON B said at the time of discharge nurses entered the DC orders and filled out the Discharge Summary form. The State Surveyor reviewed CR#1's EMR with ADON B. ADON B said she completed the functional abilities and goals discharge form today (6/21/24) but failed to complete the Discharge summary and plan of care form. ADON B said the expectation for the nurses were to fill these forms out within 24 to 72 hours of discharge. CR#2 Record review of CR#2's face Sheet (undated) revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: heart failure ( a condition that develops when your heart doesn't pump enough blood for your body's needs), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). CR#2 was discharged on [DATE]. Record review of CR#2's Care Plan initiated 01/19/2024 and updated on 06/05/2024 revealed the following: Focus: Resident was in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide selfcare and discharge planning was not needed. Goal: Resident and families wishes will be honored through the next review date. Interventions: Observe for change in conditions that may affect long-term care goals and notify the physician and responsible party as needed. Record review of CR#2's Discharge MDS dated [DATE] revealed Section A0310. Types of Assessment: F. Entry/discharge reporting coded-10: Discharge assessment-return not anticipated. Section A2105. Discharge Status coded-04: Short-Term General Hospital. Record review of CR#2 nurses noted dated 06/04/24 at 8:35p.m., revealed read in part: .Res found smoking marijuana in his car at the parking lot. Administrator confronted the res about this behavior, and the res was little aggressive. Administrator called 911. The police arrived, upon searching the res car, the police discovered that the res had a firearm in his car per Administrator. The police took the res. The writer notified the Md . Record review of CR #2's clinical record revealed no evidence of discharge planning and no discharge assessment. Record review and interview on 06/21/24 at 3:05p.m., ADON A said prior to being planned/unplanned discharge nurses initiated the discharge summary and each discipline were responsible for completing their own part. ADON A said he expected the interdisciplinary discharge summaries to be completed and sent with the resident at the time of discharge. ADON A said discharge assessments were important to be completed so the resident would know his or her limitations, and recommendations from other departments for example PT for discharge. ADON A said, usually the DON was responsible for closing out discharge documents, but the DON had been out for couple of days in training. ADON A said the ADONs and nurses could also go in assessments and complete/close the forms as well. ADON A said he completed the functional abilities and goals discharge form, discharge summary and plan of care form for CR#2 today (6/21/24). In an interview on 06/21/24 at 3:38p.m., with the Administrator, she said she reviewed CR#1's Social Worker's notes and CR#1 was transferred to another facility. She said, I don't know where CR#2 went after the law enforcement took him from the facility. Record review of facility's Discharge Planning policy dated (12/6/2016) revealed read in part: .Discharge Summary: Post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services .

Based on observation, interview, and record review the facility failed to ensure the resident's environment remained as free as possible of accident hazards and each resident received adequate supervision to prevent accident for 1 (CR #1) of 4 residents reviewed for adequate supervision. The facility failed to provide adequate supervision and training of the staff when they incorrectly used Hoyer lift while transferring CR#1 from a shower chair to her bed on 05/02/2024. This failure placed residents living in the facility at risk of harm due to avoidable accidents by staff not properly using equipment when transferring residents from shower chair. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses include cerebral infarction with aphasia, contracture unspecified joint, cognitive communication deficit, Type 2 Diabetes Mellitus with Hyperglycemia. Review of CR #1's MDS (Minimum Data Set) dated January 24, 2024, section C revealed a BIMS (Brief Interview for Mental Status) score of 13. Section G regarding resident's Activities of Daily Living (ADL) Assistance revealed resident needs supervision and two persons assisting with bed mobility, transferring and toilet use. It also revealed resident requires, two-person assistance with dressing, and personal hygiene. Record review of CR #1's care plan dated 09/04/2023 revealed: Focus: I have an ADL Self Care Performance Deficit and is at risk for not having my needs met in a timely manner. Performance deficit is related to generalized weakness/impaired mobility. Goal number 1: I will maintain a sense of dignity by being clean, dry, odor free, and well groomed. Goal number 2: I will participate to the best of my ability and maintain current level of functioning with activities of daily living (ADL) Goal number 3: I will improve current level of function in bed mobility, Transfer, Dressing, Toilet use, and Personal Hygiene. -Interventions: 1. Bed mobility assist 1 person. 2. Transfer per Hoyer 2 person assist. 3. Eating supervision and setup. 4. Toileting assist 1 person. Record review of CR #1's progress notes dated 5/02/24 revealed LVN A recorded CR#1 was being transferred from her shower chair via Hoyer with two staff present, and CR#1 slipped out of the Hoyer and fell to the floor and sustained a laceration to her right upper eye. Record review of facility's grievance log from February 2024 to April 2024 revealed no concerns regarding Hoyer transfers from CR #1 or family members. Record review of facility maintenance director statement dated 5/02/24 revealed that the Hoyer Lift that was used during the incident with CR#1 had been repaired on 3/21/24. The repair was the replacement of the left rear caster. Therefore, the Hoyer lift was in good working order when it was used during the incident involving CR#1 on 5/02/2024. Record review of ADON-B's statement dated 5/03/24 revealed that she stated I ADON on 5/02/24 did apprehend the Hoyer Sling that was being used by CNA x2 during the transfer day of accident. In my professional opinion, The Hoyer Sling loops upon my inspection, did not seem to be torn or ripped. All three loops were intact, and color for each loop x3 was visible. The Hoyer Sling that was used was Large/blue. Record review of CNA A's statement dated 5/02/24 revealed she and CNA B were getting CR#1 out of the shower chair with the Hoyer lift and the legs of the lift were wide open and the straps were secure. CR#1 was wiggling, CNA B was on the left side, and I was moving the lift. I stopped the lift to try and catch but she fell . CNA B dropped to her knees and told me to go get help and bring her some towels. Record review of CNA B's statement dated 5/02/24 revealed she a CNA A went to put the resident in bed with the Hoyer lift. CR#1 was in the Hoyer lift the legs were wide open I was on the right side and CNA A was on the left side. Resident started moving CNA A asked her to stop and that when the resident fell , and I tried to catch her. I feel to my knees trying to catch the resident. I told CNA A to go get help and bring me some towels because the resident was bleeding from her head. Interview with CNA C on 5/03/24 at 12:30pm, she stated she does know CR#1 and that she has never had a problem with tCR#1 moving while CR#1 was being transferred. CNA C also said that even if the CR#1 was moving that CR#1 should not have fallen fall. CNA C said that CR#1 should not fallen if the Hoyer lift was being used correctly and that staff must know which Slings to use and staff must know how to secure the straps to the Hoyer lift. Interview with CNA-A on 5/03/24 at 1:25pm she stated that the none of the straps from the Hoyer lift came undone during the incident. Interview with CNA D on 5/03/24 at 1:34pm, she stated she does know CR#1 and that she has never had a problem with tCR#1 moving or anything of that nature when CR#1 was being transferred. CNA D went on to say that there was no reason for CR#1 to have fallen when the Hoyer lift was being used and that the only way CR#1 would have fallen was if the Hoyer Slings are not secured properly to the Hoyer lift. Interview with ADON A on 5/03/24 at 2:02pm, he stated that safety was the most important reason why the Hoyer lift was used when transferring a resident. He stated that the Hoyer lift was designed to prevent injury to residents and staff when the resident must be transferred and that the only way that a resident should fall out of a Hoyer was if there was a malfunction with the lift or sling, but if there isn't a malfunction the resident should not fall. Interview with ADON B on 5/03/24 at 2:21pm, she stated that there was nothing wrong with Sling during here preliminary investigation of CR#1 falling out of a Hoyer lift The sling did not have any rips, or tears. She stated the Hoyer lift itself was working properly. She stated that the Sling had multiple colors to show staff how to secure the sling to the Hoyer lift. She stated that it was extremely difficult for a resident to fall out of a Hoyer lift. Interview with Administrator on 5/03/24 at 2:42pm, she stated that to my knowledge it is impossible for a resident to fall out of a Hoyer lift if it is working properly. She stated that if the Sling is secured properly and that the Hoyer Lift itself is not malfunctioning the resident should not fall. She went on to state that the Hoyer Lift was designed for the safety of the resident and staff. Interview with Resident#1 on 5/07/24 at 10:20 am, she stated that she does not remember what happened the day of her accident. She stated that she does not remember falling. She stated that she remembers being in the Hospital and that she had a cut on her eye and that her head hurts sometimes. Observation on 5/07/24 at 11:50am, CNA D and CNA B performed a Hoyer lift transfer from bed to wheelchair. The CNA s performed the transfer without any problems. They explained to Resident#1 hat they were going to do, provided privacy for the resident, secured the Sling to the Hoyer lift, and placed the resident into a wheelchair. Record review of facility's Mechanical Lift policy dated February 2022 revealed the guideline on facility response to moving obese or immobile residents: 1. Verify Physician orders. 2. Introduce self, explain procedure, and provide privacy. 3. Raise bed to highest point possible making sure wheels are locked. 4. Second employee to assist by standing on the opposite side of bed and roll resident toward second employee. 5. Position Sling with the head section of the sling under the resident's neck, the spine covered, and leg sections fit under thigh to the inside of the leg. 6.Position lift in the center of bed, adjusting the leg of the lift if needed with the handle toward the feet and the wide part and shoulder level. 7.Connect sling straps attachment points to the spreader bar. 8. Fold resident's arms on chest and instruct to keep arms close to body for safety. 9. Lift with handset control and adjust to comfortable position for transfer. 10. To return to bed or lower to chair, move lift to desired position with the hand set control, when fully supported by bed/chair disconnect the sling straps, move the lift out of the way and remove sling.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 25 of 30 residents (Resident #204, #206, #92, #78, #9, #77, #73, #67, #39, #71, #74, #75, #20, #7, #44, #36, #50, #14, #30, #16, #82, #88, #70, #94, and #38) reviewed for infection control. The facility failed to ensure that Residents (#44, #36, #50, #14, #30, #16, #82, #88, #70, #94, and 38) who received negative COVID test results were not accommodated in a shared room alongside Residents(Resident #92, #78, #9, #77, #73, #39, #71, #74, #75, #20 and #7) who had tested positive for COVID 19 and were identified as droplet isolation precaution Residents. The facility failed to ensure transmission-based precaution protocols evidenced in the inadequate placement of notices and insufficient provision of Personal Protective Equipment (PPE) in the vicinity of residents' rooms or within their immediate proximity for the following residents: (Resident 71), (Resident #20), (Resident #74), (Resident #42), (Resident #75), (Resident #39), (Resident #67), (Resident #73), (Resident #7), (Resident #77), (Resident #9), (Resident #78), (Resident #92), (Resident #206), and (Resident #204). The facility failed to ensure that staff (CNA T and CNA J) implemented appropriate use of PPE and transmission-based precautions prior to enter and exiting residents' (Resident #91, #80, #74, #71, #77, and #92) rooms. The facility failed to ensure staff (CNA T, CNA J and ADON A) wash or sanitize hands after providing care to Residents (Resident #91, #80, #71, #74, #77, #92, and #352) rooms. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:45p.m. While the IJ was removed on [DATE] at 2:05p.m, the facility remained out of compliance at a scope of pattern and a severity level of Actual harm that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures have the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings included: Record review of Resident #204's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #206's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #92's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #78's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #9's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #77's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #73's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #67's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #39's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #71's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #74's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #75's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #20's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #7's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #82's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old with primary diagnosis of metabolic encephalopathy (a problem in the brain, caused by a chemical imbalance in the blood). Record review of Resident #44's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old with a primary diagnosis of polyosteoarthritis (a common type of arthritis that affects many joints at once, causing pain, swelling, and stiffness). Record review of Resident #36's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old with primary diagnosis of Chronic Kidney Disease (occurs when a disease or condition impairs kidney function). Record review on [DATE] of lab results and clinical charts for Residents #204, #206, #92, #78, #9, #77, #73, #67, #39, #71, #74, and #75 revealed positive COVID 19 nasal swab results dated [DATE]; and indicated the identified residents were all under droplet isolation precautions. Record review on [DATE] of lab results and clinical charts for Residents #44, #50, #14, #30, #16, #83, #88, #70, 94, and #38 revealed negative COVID 19 nasal swab results dated [DATE]. Record review on [DATE] of lab results and clinical chart for Resident #20 revealed positive COVID 19 nasal swab results dated [DATE]; and indicated the identified resident was under droplet isolation precautions. Record review on [DATE] of lab results and clinical chart for Resident #36 revealed negative COVID 19 nasal swab results dated [DATE]. Record review on [DATE] of lab results and clinical chart for Resident #7 revealed positive COVID 19 nasal swab results dated [DATE]; and indicated the identified resident was under droplet isolation precautions. Record review on [DATE] of lab results and clinical chart for Resident #82 revealed negative COVID 19 nasal swab results dated [DATE]. Record review of facility's infection control tracking and trending log dated [DATE] revealed no documented tracking of Staff and Residents who tested positive for the COVID19 for the month of [DATE]. Record review on [DATE] at 4:00 pm the facility furnished test outcomes from [DATE]st, 23rd, and 26th, 2023, indicating positive COVID 19 test results for 14 residents (Residents #204, #206, #92, #78, #9, #77, #73, #67, #39, #71, #74, #75, #20, #36, and #7). Record review resident roster and observations on [DATE] revealed that these identified positive COVID 19 residents resided in various location on all designated halls (100 hall, 200 hall, 300 hall, 500 hall, and 600 hall) reserved for the facility's residents, and were accommodated in a shared room alongside Residents (#44, #36, #50, #14, #30, #16, #82, #88, #70, #94, and 38) who had tested negative for COVID 19 as of [DATE]. Observation, record review and interview on [DATE] at 09:30am revealed that there were no droplet isolation precaution postings and insufficient PPE observed in or around Resident #71's room and the door. Resident #71 resided on the 100 hall of the facility, in shared room [ROOM NUMBER] with Resident #44. Both Resident #71 and Resident #44 were observed inside the designated room # 1 with the room door open at that time. Resident #71 was lying in bed without a facemask. Resident # 44 was sitting in a chair without a facemask. Resident #44 was interviewed at the time of observation and stated that he had tested negative for COVID 19 last week on [DATE] but was told that he had to continue to cohort with Resident #71 who had tested positive on the same date ([DATE]). Resident #44 stated that he was not provided a facemask and was afraid that would get sick from Resident #71. Resident # 44 stated that he had shared the concern with the facility staff, but various unidentified staff never provided him with a facemask and told him that he had to continue to reside in the room with positive COVID 19 Resident #71. Observation on [DATE] at 12:15PM revealed Resident #19 in her room being fed by Staff Z. Staff Z had a surgical mask on. In an interview with Staff Z at 12:15 PM, he said he does not know if Resident #19 was positive for Covid or not. Interview conducted on [DATE], at 9:13 am, ADON B stated that the administrator was absent due to a doctor's appointment. ADON B also reported the presence of active COVID-19 cases within the facility; initially detected on [DATE]. ADON B stated he was uncertain regarding the number of residents and staff who tested positive for COVID-19 and was also unsure about the total number of residents tested for the virus. Interview on [DATE] at 9:29 am, Nurse A, the nurse assigned to hall 6, stated that only rooms [ROOM NUMBER] on the 600 hall and were COVID 19 Isolation rooms. Nurse A stated that they were out of supplies and administration staff had not restocked the PPE. It was not identified how long the facility had been out of supplies. Interview with the DON, on [DATE] at 1:00pm stated she and the Administrator were informed by the Regional Nurse on [DATE] that Residents who tested positive for COVID 19 should remain in the rooms with those residents who had tested negative for COVID 19. The DON also revealed that she had been out of the facility since [DATE], as the DON, ADON A, and ADON B tested positive for COVID on [DATE]. She stated that she returned to the facility on [DATE] just prior to the interview. The DON also revealed that Resident #19 was positive with COVID. Observation on [DATE] at 1:30PM, revealed two facility staff moving residents from the 100 halls. Both staff had a face max on no other form of PPE was observed. In an interview with the two staff on at 2:30PM, Staff X and staff Y said they were asked by the facility Administrator to move all the covid positive residents to the 200 halls with the positive residents and leave the negative residents in their room. Staff Y said he tested positive on [DATE]. He said he had some symptoms flue-like on [DATE] and took covid test on [DATE]. He said the test was positive for covid. He said at that time, he called the facility to inform the DON and Administrator that he had Covid. He said he was asked to stay home for 5 days. He said he came back to work on [DATE] During the Resident Council Meeting on [DATE] at 2:30 p.m., Resident #28, was very emotional after learning that there were several people in the facility with COVID. His eyes started watering and he said, I have been in the hospital for 5 months and almost died . I have seen people die around me, and they aren't telling us anything. Resident #59 said, there is no designated COVID hall, and they are not transferring people out of rooms who are negative and COVID is spreading. Resident #17 said, Yes, it's spreading, and I don't have my 2nd COVID Booster. Record review on [DATE], of clinical chart revealed that Residents (#28, #59, and 17) who attended the Resident Council meeting was pending COVID results in Point Click Care. Interview on [DATE] at 3:00 pm with the Administrator and IP A (also identified as ADON A) who stated that had been trained on transmission-based precautions and is responsible for the tracking a trending of communicable diseases within the facility. Documentation of the IP A's trainings was requested at the time of the interview. Interview [DATE] at 4:45 pm with Nurse A, the nurse assigned to hall 6, stated she worked part time at the facility for 1 Year. She stated that she had not complete COVID 19 training but had been trained on airborne precautions. Nurse A stated that the person who initially set up the COVID Isolation rooms, did not set them up correctly. She stated there were negative and positive residents in the same room, and the risk of having them in same room can cause a spread in COVID 19 to other residents. Nurse A stated that not washing and sanitizing hands and having the correct PPE could also cause spread in COVID 19. Interview on [DATE] at 3:42 pm, CNA O stated that she started working at the facility one month ago. CNA O stated that she completed skill competencies and training with a nurse upon hire, but she was not able to articulate or identify what competencies and training were completed. CNA O stated that the supply person or administration staff would normally stock the door with PPE each morning. CNA O stated that the correct PPE was not provided or stoked on the door yesterday, [DATE] morning when she was entering and exiting rooms and no bags were in rooms for doffing PPE. Interview with the Administrator on [DATE] at 4:00 pm, the administrator revealed updated information regarding the facility' s identified Infection Preventionist. The Administrator stated that IP A had not completed the CDC required training, Nursing Home Infection Preventionist Training Course. The Administrator stated that as of [DATE] the DON was the designated the IP. The Administrator state that no one had been monitoring the tracking and trending of the COVID 19 infection in the facility. The Administrator stated that she DON and ADON A had been out sick for at least 5 days since both had tested positive on [DATE]. Record review on [DATE] at 4:00 pm the facility furnished test outcomes from [DATE]st, 23rd, 26th, and 28th 2023, indicating positive COVID 19 test results for 29 residents. The total number of COVID 19 positive Residents had doubled from the previous test results. Interview on [DATE] at 4:12 pm with the Administrator and the DON, the Administrator stated that they would be moving residents that are negative out of rooms with individuals who are positive and notifying families. The Administrator stated that this process is late due to the misinterpretation of the policy, and the information that they received from the Regional Nurse consultant who advised the Administrator and the DON to not designate a hot zone (a designated hall for COVID positive residents) and to not move negative residents who were placed in cohort rooms with COVID positive residents. Interview on [DATE] at 4:25 with the Regional Nurse who stated that she informed the Administrator to isolate, place signage on doors, and test on days 1,3, and 5. She stated that on [DATE], she informed the Administrator and the DON to keep positive COVID residents in a cohort room with negative COVID because the negative residents had already been exposed to positive residents. Regional Nurse stated that this was the facility policy. During the interview, the Regional Nurse and the surveyor team reviewed facility's policy titled Novel Coronavirus Prevention and Response Section 8, Procedure when COVID -19 is suspected or confirmed, Letter F, page 5 indicated Do NOT cohort residents with other residents with COVID 19 infection unless they are also confirmed to have COVID 19 infection through testing. Regional Nurse stated that she had previously, on [DATE] misinterpreted the policy and had advised the Administrator and the DON based on the initial previous interpretation of the written policy. The Regional Nurse stated that she had been trained on transmission-based precautions and is responsible for the tracking a trending of communicable diseases within the facility. The Regional Nurse stated as result of her misadvising the Administrator and the DON the facility staff and Residents were placed at risk for being infected with COVID 19. Observation on [DATE] at 5:00 am, CNA T was observed entering droplet precaution room [ROOM NUMBER] without Personal Protective Equipment (PPE) and proceeded to administer incontinent care to Resident #91 while wearing gloves. Subsequently, after concluding the care, CNA T neglected to remove the gloves, sanitize or wash her hands before attending to Resident #80, assisted in adjusting the resident in bed. She returned to the designated clean linen cart with contaminated gloved hands, removed linen, and interacted with the cart without prior hand hygiene. Using the same contaminated gloves, CNA T proceeded to touch the doorknob of room [ROOM NUMBER], then entered room [ROOM NUMBER] without additional PPE (N95, gown, and face shield), continuing to provide incontinent care and emptied Resident #71's urinal. Following this, CNA T omitted hand washing and proper hand hygiene measures before attending to Resident #74, assisted the resident with a blanket. Droplet precaution room [ROOM NUMBER] door remained open. Interview on [DATE] at 5:43 am, CNA T expressed uncertainty regarding why PPE was not utilized, and hand hygiene practices were neglected. CNA T stated that Residents #91, #81, #71 and #74 were on Droplet Precautions due to testing positive for COVID 19. CNA T also acknowledged the risk of infection transmission in the absence of proper PPE and hand hygiene measures. CNA mentioned undergoing infection control training previously but was unable to articulate the specifics or content of the training provided. CNA T stated that she had received training on providing incontinent care to Residents. Observation on [DATE] at 5:05am, CNA J was observed entering identified Droplet Precaution rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) without the appropriate Personal Protective Equipment (PPE), including face shields, N95 masks, and gowns, while providing incontinent care to Residents #77 in room [ROOM NUMBER] and Resident #92 in room [ROOM NUMBER]. Upon exiting room [ROOM NUMBER], proper hand hygiene measures were not implemented. CNA J did not wash or sanitize her hand after exiting Residents #77 room before she provided care to Resident #92. Interview on [DATE] at 5:15am, CNA J acknowledged the error of failing to don PPE and wash hands. CNA J stated that Resident #77 and Resident #92 were on Droplet Precautions due to testing positive for COVID 19. She verbalized an understanding that the transmission of infection can occur when PPE and hand hygiene protocols were not followed. She stated that such error put residents and staff at risk for infection. CNA J mentioned receiving infection control training, some time ago, but was unable to specify the content covered during the training sessions. Interview on [DATE] at 8:11AM, the DON stated Resident #50 and Resident #83 were newly diagnosed as COVID positive as of [DATE]. The DON stated they should have followed the same protocol as before; it worked before. The DON stated the facility should have followed CDC guidelines not to room negative residents with positive residents. The DON stated they kept the negative and positive residents together because the Administrator and the DON were instructed to do so, by the Regional Nurse. The DON continued and stated that the Regional Nurse rationale was that the residents were already exposed and there was no reason to move them. The DON stated that the system failure placed Residents were placed at risk for being infected with COVID 19. The DON stated that the facility was working to ensure that all isolated rooms were stocked with proper PPE and signage. The surveyor informed the DON that staff had been observed entering rooms without PPE and was not implementing hand hygiene before and after care. The surveyor inquired but the DON's expectation related that to hand hygiene and the donning PPE. The DON stated that staff had been in-serviced and trained on proper hand hygiene and PPE. The surveyor required documentation of staff trainings. Interview on [DATE] at 12:00pm, the Administrator stated staff were notified of the COVID 19 outbreak on [DATE]. The Administrator stated that she was not able to verify how the staff was notified and who notified staff. The Administrator stated the floor nurses were monitoring residents for signs/symptoms and were made aware they were responsible, and doctors' orders to assess all residents for signs and symptoms had been added to the PCC. The Administrator could not articulate a plan to mitigate the risk at the time of the meeting. The Administrator stated that the Epidemiology Department had not been notified of the COVID 19 outbreak at the time of the interview. The Administrator did not reveal why the information had not been reported. The Administrator stated that the Business Office Manager is responsible for reporting to Epidemiology Department. Interview on [DATE] at 12:40, the Business office Manager stated that she was made aware of COVID positive residents at the facility on [DATE] when she returned to work. She stated that she had been out of the facility the previous week due to a personal family member's death. She stated that in her absence, the Administrator is supposed to report COVID 19 to the health department. Business office Manager stated that a report was submitted to the health department on [DATE] that included 14 residents who tested positive for COVID 19 on [DATE] and not for the total 29 residents that were currently in the building. The facility failed to provide failed to provide proof of in-services and staff training for infection control and transmission-based precaution requested on [DATE], [DATE], and [DATE] at various times. requested as of [DATE]. Thes was determined to be an immediate jeopardy (IJ) on [DATE] due to the above failures. The administrator was notified and provided the IJ template on [DATE] at 1:45p.m. The immediacy was lowered on Sunday, [DATE] at 2:05p.m. with the facility Administrator and DON, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal - Infection Prevention and Control 1. Immediate Action Taken A. On [DATE] the DON/designee moved all COVID positive residents to hall 200 that will serve as a dedicated COVID unit for all residents who are COVID Positive. B. On [DATE] roommates with high exposure to COVID positive residents are being monitored every shift by license nurse for signs/symptoms of COVID with documentation on LN MAR. All other residents are being monitored for signs/symptoms of COVID through License Nurse rounds during shift. Asymptomatic residents with a higher-risk exposure, will have a series of 3 viral tests for SARS-CoV-2 infection. Testing will be done immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. (This will typically be at day 1 (when day of exposure is day0), day 3, and day 5). Then testing will be repeated every ,d+[DATE] days until no new cases are identified for at least 14 days. C. On [DATE] residents in Isolation for COVID had appropriate signage placed on door (Contact Isolation signage, Droplet Isolation signage, and Donning and Doffing PPE signage) to alert staff of required PPE. D. On [DATE] residents who tested positive for COVID, had physician notification and orders received to place residents in Droplet Isolation. Each resident in Isolation had appropriate and adequate PPE outside of each room. This will be replenished as needed E. On [DATE] the DON who is currently the designated Infection Preventionist for the facility received 1:1 education on the Infection Preventionist Job duties that include: Education, training, experience, or certification in infection control and prevention. Completed specialized training in infection prevention and control through accredited continuing education. Develop and implement an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infections to provide a safe, sanitary, and comfortable environment. Establish facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff, and visitors. Develop and implement written policies and procedures in accordance with current standards of practice and recognized guidelines for infection prevention and control. Oversee the facility's antibiotic stewardship program. Oversee resident care activities that increase risk of infection (i.e., use and care of urinary catheters, wound care, incontinence care, skin care, point-of-care blood testing, and medication injections). Lead the facility's Infection and Prevention Control Committee. Develop action plans to address opportunities for improvement. Participate on the facility's QAA Committee. Perform duties as assigned. F. The Infection Preventionist will use a system of surveillance to utilized prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards G. On [DATE] the facility assigned dedicated staff to the COVID unit. This will be ongoing until outbreak is over to the extent possible 2. Identification of Residents Affected or Likely to be Affected: A. On all other residents were tested for COVID-19 with only 1 other resident identified who tested COVID positive. Total COVID-19 residents 29. 3.Actions to Prevent Occurrence/Recurrence: A. On [DATE] the DON/Designee started In-Service education with all staff on the Coronavirus Prevention and Response Plan that: Prompt identification, treatment to prevent the spread, source control, community surveillance, signs/symptoms to report and notify physician, testing considerations, response to an Outbreak, Hospital Admission Levels prevention, interventions to prevent respiratory germs into the facility, procedure when COVID-19 is suspected or confirmed, Managing /staff with High Exposure, return to work criteria for HCP and duration of transmission-based precautions for residents. This education will be completed on [DATE] at 7:30 pm, and no staff will be allowed to work until they have completed this education. This education will be provided to all newly hired staff ongoing. B. On [DATE] the DON/Designee started In-Service education with all staff on Transmission-Based Precautions Policy that: Defines different Isolation Precautions, standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission, when to Initiation of Transmission-Based Precautions, Discontinuation of Transmission-Based Precautions, Recommended PPE for each type of precaution. This education will be completed on [DATE] at 7:30 pm, and no staff will be allowed to work until they have completed this education. This education will be provided to all newly hired staff ongoing. C. On [DATE] the DON/Designee started In-Service education with all staff Hand Hygiene Policy that: D. Defines what hand hygiene is, when to perform hand hygiene versus using alcohol-base hand rub, technique, when to change gloves. This education will be completed on [DATE] at 7:30 pm, and no staff will be allowed to work until they have completed this education. This education will be provided to all newly hired staff ongoing. E. On [DATE] the DON/Designee started skills validation reviews with all staff on Hand Hygiene and the Use of PPE. These skills competencies will be completed on [DATE] at 7:30 pm, and no staff will be allowed to work until they have completed this education. These skills competencies will be provided to all

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and timeframes to meet residents' physical, mental and psychosocial needs for 1 of 10 residents (CR#1) reviewed for care plans. The facility failed to implement CR #1's care plan, which included 1:1 monitoring for a history of diet noncompliance, to ensure he ate nothing by mouth. On [DATE], CR #1 was unsupervised during a meal and ate food that was not compliant with his diet, resulting in his death after a choking incident. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:55 p.m. While the IJ was removed on [DATE] at 4:42pm, the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents with no food by mouth (NPO) diet at risk of choking or death. Findings included: Record review of a list of NPO (no food by mouth) residents provided by DON listed 10 residents that were not able to eat any food by mouth. Record review of CR#1' face sheet revealed a [AGE] year-old male that was admitted to the facility on [DATE], CR#1 had diagnoses which included: Cerebral Palsy (a disorder of movement, muscle tone, or posture), Dysphagia (difficulty swallowing, a common complication with cerebral palsy), Gastrostomy tube(a tube inserted through the belly that brings nutrition directly to the stomach), pneumonitis due to the inhalation of food and vomit( inflammation in lung tissue), Schizoaffective Disorder(a mental health disorder in which there is a combination of symptoms of schizophrenia and mood disorder), and epilepsy(a disorder in which cell activity in the brain is disturbed, causing seizures). Record review of CR#1's quarterly MDS assessment dated [DATE] revealed under Section C500- Brief Interview of mental status was 14 (indication of cognitvely intact). Section E- Behavior revealed A. Physical Behaviors (such as hitting and kicking)- directed towards others, B. Verbal behaviors towards others (such as screaming/using profanity), C. Other behaviors towards self (such as rummaging, pacing) were all coded as (1) - meaning behaviors of this type occurred 1 to 3 days. Section GG0120- Mobility Devices revealed a manual wheelchair was used. Section GG0130- Functional ability coded A. Eating (01)- coded for dependent on helper for all efforts. K0520- Nutritional Approaches revealed B. Feeding Tube was used for nutritional needs. Record review of MDS dated [DATE] revealed CR#1 was discharged due to death in facility. Record review of care plan date initiated and revised on [DATE] revealed CR#1 has behavior problem as evidenced by noncompliant with NPO (nothing by mouth). CR#1 takes food from trays, takes water pitchers and water in them and goes to machine and buys soda. CR#1 will have no signs and symptoms of aspiration and noncompliance will decrease through target date of [DATE]. Interventions: educate the resident on possible outcomes, minimize potential for noncompliant behavior and CR#1 requires 1:1 monitoring. Record review of physician order dated [DATE] revealed CR#1 had a pureed texture, mildly thick-nectar consistency. Record review of physician order dated [DATE] revealed CR#1 had a pureed texture, thin liquid consistency. Record review of physician order dated [DATE] revealed CR#1 had an NPO texture diet until additional swallow evaluations related to Dysphagia, unspecified. G-tube would be used for nutritional needs. Record review of physician order dated [DATE] revealed CR#1 had an NPO diet texture (Nothing by mouth) Record review of nursing progress note dated [DATE] written by RN A revealed CNA A heard someone coughing. CNA A investigated and learned that it was CR#1. CNA A asked if CR#1 had eaten any food. CR#1 shook his head no. She asked again and he said yes. CNA A called for help and RN A began the Heimlich maneuver. RN A swept his mouth and then began to suction. Some food particles were removed. RN A then provided oxygen at 100% and no vitals could be palpated. The Heimlich maneuver was unsuccessful, 911 was called and nurses began to provide Cardiopulmonary resuscitation. CR#1 became cyanotic (turning blue) and unresponsive. Emergency Medical Services (EMS) arrived and continued cardiopulmonary resuscitation and CR#1 left the facility via ambulance. Record review of Emergency Medical Service report dated [DATE] at 18:16 (6:16 p.m.) the local EMS was dispatched to a choking call that was upgraded to a cardiac arrest with law enforcement and fire department. Upon arrival CR#1 was laying supine on the floor. There were three staff members in the room performing Cardiopulmonary resuscitation. One male was ventilating with a self-inflating resuscitator bag connected to oxygen. There was a female performing chest compressions, and another female at the feet of the patient. Staff reported that they found CR#1 choking. Staff performed the Heimlich maneuver without success. CR#1 was apneic and pulseless. Medic took over from staff. Assessment revealed CR#1 airway was completely obstructed with what appeared to be chewed up banana. Cardiac monitor revealed asystole (a type of cardia arrest, which is when the heart stops beating entirely. CR#1 was taken to a local hospital via stretcher. CR#1 remained asystole throughout patient care. Interview with DON on [DATE] at 1:49 p.m. she stated CR#1 care plan included 1:1 monitoring since he tried to take regular food from residents and vending machines and attempted to eat by mouth although he had a G-tube. She said staff such as CNA's, nurses, housekeeping and restorative aides were used to sit with him to prevent him from taking regular diet food. She said she was not sure of the date that the 1:1 ended. CR#1 was said to be doing much better with seeking food so at some point the monitoring ended. She said that the updates to care plans were made by the MDS nurse. Interview with the Administrator on [DATE] at 3:46 p.m. revealed CR#1 was being redirected with activities due to his behaviors. She said that he was on 1:1 monitoring for both hitting his head and seeking regular food although he had a G-tube. She said he had no behaviors for a while. She could not recall how long it had been since his last behavior. She said she continued to bring him into her office to listen to music and even moved his room across from her office so at mealtimes she could watch him. She said on [DATE] CR#1 took a dinner roll from his roommate (Resident #2) and ate some of it causing him to choke. She said that he was not currently on 1:1 monitoring because it had been a long time since he had any behaviors. She could not recall when the monitoring stopped. She said the staff were doing the best they could because they were not able to get CR#1 discharged or transferred to another facility. Other facilities would not admit him due to behaviors, G-tube, or previous nursing facilities stays. She said she do not know why the care plan had not been updated. Interview with RN A on [DATE] at 4:31 p.m., revealed to her to state on [DATE] she heard CNA A calling for help after learning that CR#1was cough and possibly choking. She said that she began trying the Heimlich maneuver and was unsuccessful. She swept his mouth for food and then suctioned. She stated that very little food particles came up. She stated that she had help from two other nurses. She said CR#1 was turning blue, and she gave him oxygen. She said that CPR was initiated, and EMS took over when they arrived. She said that CR#1 was constantly trying to get regular food from other residents' plates. She said he would get angry if anyone tried to stop him from acquiring regular food although he had a G-tube. Interview with CNA A on [DATE] at 4:47 p.m., states she said CR#1 had a G-tube and would take other residents' food. She said he was able to walk a little and would sneak into other resident rooms for their food. She said that the Administrator had informed all staff to pay attention to him and make sure he did not take other people's food. She said usually when they (CNA's) pass the trays they would keep the cart further away from him so he would not try to get food while they are with other residents. She stated that the Administrator did an in-service about 2 or 3 weeks ago and informed them that he still had an NPO - nothing by mouth diet. She said she provided 1:1 monitoring for CR#1 for several months around June/[DATE] and it ended sometime in July or August. She said she could not remember. She said she would sit in his room and make sure he did not get regular food and was not hitting his head. She said he would get upset if anyone took regular food away from him and he would pull out his g-tube and they had to call 911. She said that he would pull out the G-tube because he wanted to eat. She said on [DATE] at approximately 6 p.m. she heard someone coughing and immediately went to CR#1's room and looked at Resident #2's tray. She noticed the dinner roll was not there. She asked him if he ate something he nodded no. She said she asked again CR#1 did you eat something, and he nodded up and down as to say yes and pointed to his roommate's tray. She does not know why the roommate did not stop him from taking his dinner roll. She said she did not ask Resident #2. She said she called the nurse right away. RN A started the Heimlich maneuver, she swept his mouth, and another nurse came into the room to assist RN A. She left the room when they started working on him. Interview with MDS nurse on [DATE] at 1:25pm, revealed her to state CR#1 was on 1:1 monitoring when he was admitted . She said she had been employed at the facility since [DATE]. She said she participated in care plan meetings and provided MDS quarterly, upon significant change and readmissions for all residents of the facility. She said sometimes it took a while to make updates because there were so many residents. She could not explain why CR#1's care plan had an intervention 1:1 staff monitoring due to him trying to take food. She said if she recall correctly, he had not attempted to take or eat regular diet food and it should have been removed off the interventions. Record review of the Comprehensive care plans policy dated [DATE] stated it is the policy of this facility to develop and implement a comprehensive person-centered car plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy explanation and Compliance Guidelines included: 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Record review of the MDS nurse job description revealed responsibilities included MDS completion in a timely, accurate documentation-supported and case mix optimized manner; development of individualized care plans reflective of the residents' status; oversight of the resident care data collection tool; coordination of assessments and services by other clinical departments; liaison to rehab team; audit and survey preparation, implementation and response; managed care clinical authorizations and justifications. The Administrator and DON were notified of an IJ on [DATE] at 2:55pm, due to the above failure. The Administrator was given a copy of the Immediate Jeopardy template and Plan of Removal (POR) was requested. The following plan of removal submitted was accepted on [DATE] at 2:06pm. 1. Immediate Action Taken A. Resident # 1 expired in facility on [DATE] B. 100% audit of all resident's care plans were reviewed to ensure that appropriate interventions to reflect care that resident is receiving. This audit was conducted by MDS nurse and will be completed by 10:00 am on [DATE] 2. Identification of Residents Affected or Likely to be Affected: A. 100% audit of all resident's care plans were reviewed to ensure that appropriate interventions to reflect care that resident is receiving. This audit was conducted by MDS nurse and will be completed by 10:00 am on [DATE]. One other resident was identified as having the potential for taking food or fluids from meal trays. This resident's care plan was updated on [DATE] will appropriate interventions, and does not require 1:1 supervision per the Interdisciplinary Care Plan Team. The C.N.A.'s Kardex has been updated to identify this potential issue. B. On [DATE] 10 residents were identified as being NPO. MDS Nurse/Designee reviewed and revised care plans of these 10 residents if applicable 3.Actions to Prevent Occurrence/Recurrence: A. Care plans will be updated and reviewed weekly by Interdisciplinary care team during the care plan Meeting to validate that all goals and interventions are resident specific. The weekly care plan conference meeting will be conducted on [DATE]. B. Regional Reimbursement nurse will complete random weekly audits of care plan interventions to validate that goals and interventions reflect each resident's need. C. All care plan reviews and updates will be discussed monthly in QAPI D. On [DATE] DON/Designee began in-service education with all licensed nurses and C.N.A.'s on following care plans. This education will be completed by 10:00am [DATE]. No license nurse or C.N.A. will be allowed to work until this education has been completed. 4. On [DATE] the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to care plans and reviewed plan to sustain compliance Date Facility Asserts Likelihood for Serious Harm No Longer Exists: _____[DATE]____________ Monitoring of the plan of removal included the following: Interviews with two CNA's and three nurses between [DATE]-[DATE] revealed they had been trained on following care plans. Staff stated they were clear on the expectation to follow care plans and reporting and documenting changes in mental or physical conditions to nurses on duty, DON and/or Administrator. Record review of care plans for the 10 identified residents with NPO diets revealed no concerns were found. Record review of Resident #3's face sheet, MDS, nursing progress notes and care plans were reviewed due to resident identified as having the potential for taking food off the food trays. A family care plan meeting was held with FM on [DATE] and there was a plan to prevent resident from receiving food that was not the accurate consistency. Record review of weekly care plan meeting sign-in revealed it was held on [DATE]. The DON and Regional Nurse Consultant were informed the Immediate Jeopardy was removed on [DATE] at 4:42 p.m. The facility remained out of compliance at a severity level of isolated and a scope and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective system that were put into place.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision to ensure CR#1 ate nothing by mouth when he had a Gastrostomy tube (G-tube) for enteral feedings due to dysphagia and history of aspiration/choking. On [DATE], CR #1 was unsupervised during a meal and ate food that was not compliant with his diet, resulting in his death after a choking incident. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:55 p.m. While the IJ was removed on [DATE] at 4:42pm, the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents at risk of injuries due to lack of supervision by facility staff. Findings Included: Record review of CR#1's undated face sheet revealed a [AGE] year-old male that was admitted to the facility on [DATE]. CR#1 had diagnoses which included: Cerebral Palsy (a disorder of movement, muscle tone, or posture), Dysphagia (difficulty swallowing, a common complication with cerebral palsy), Gastrostomy tube(a tube inserted through the belly that brings nutrition directly to the stomach), pneumonitis due to the inhalation of food and vomit( inflammation in lung tissue), Schizoaffective Disorder(a mental health disorder in which there is a combination of symptoms of schizophrenia and mood disorder), and epilepsy(a disorder in which cell activity in the brain is disturbed, causing seizures). Record review of CR#1's quarterly MDS assessment dated [DATE] revealed under Section C500- Brief Interview of mental status was 14 (which indicated cognitively intact). Section E- Behavior revealed A. Physical Behaviors (such as hitting and kicking)- directed towards others, B. Verbal behaviors towards others (such as screaming/using profanity), C. Other behaviors towards self (such as rummaging, pacing) were all coded as (1) - meaning behaviors of this type occurred 1 to 3 days. Section GG0120- Mobility Devices revealed a manual wheelchair was used. Section GG0130- Functional ability coded A. Eating (01)- coded for dependent on helper for all efforts. K0520- Nutritional Approaches revealed B. Feeding Tube was used for nutritional needs. Record review of care plan initiated and revised on [DATE] revealed CR#1 has behavior problem as evidenced by noncompliant with NPO (nothing by mouth). CR#1 takes food from trays, takes water pitchers and water in them and goes to machine and buys soda. CR#1 will have no signs and symptoms of aspiration and noncompliance will decrease through target date of [DATE]. Interventions: educate the resident on possible outcomes, minimize potential for noncompliant behavior and CR#1 requires 1:1 monitoring. Record review of physician order dated [DATE] revealed CR#1 had a pureed texture, mildly thick-nectar consistency. Record review of physician order dated [DATE] revealed CR#1 had a pureed texture diet with thin liquid consistency. Record review of physician order dated [DATE] revealed CR#1 had an NPO texture diet until additional swallow evaluations related to Dysphagia. Record review of physician order dated [DATE] revealed CR#1 had an NPO diet texture (Nothing by mouth) Record review of a nursing progress note written by RN A dated [DATE] revealed CNA A heard someone coughing. CNA A investigated and learned that it was CR#1. CNA A asked if CR#1 had eaten any food. CR#1 shook his head no. She asked again and he said yes. CNA A called for help and RN A began the Heimlich maneuver. RN A swept his mouth and then began to suction. Some food particles were removed. RN A then provided oxygen at 100% and no vitals could be palpated. The Heimlich maneuver was unsuccessful, 911 was called and nurses began to provide Cardiopulmonary resuscitation. CR#1 became cyanotic (turning blue) and unresponsive. Emergency Medical Services (EMS) arrived and continued cardiopulmonary resuscitation and CR#1 left the facility via ambulance. Record review of room change for CR#1 revealed multiple changes occurred due to readmissions and for monitoring. CR#1 most recent room change was on [DATE]. Record review of Emergency Medical Service report dated [DATE] at 18:16 (6:16pm) the local EMS was dispatched to a choking call that was upgraded to a cardiac arrest with law enforcement and fire department. Upon arrival CR#1 was laying supine on the floor. There were three staff members in the room performing Cardiopulmonary resuscitation. One male was ventilating with a self-inflating resuscitator bag connected to oxygen. There was a female performing chest compressions, and another female at the feet of the patient. Staff reported that they found CR#1 choking. Staff performed the Heimlich maneuver without success. CR#1 was apneic and pulseless. Medic took over from staff. Assessment revealed CR#1 airway was completely obstructed with what appeared to be chewed up banana. Cardiac monitor revealed asystole (a type of cardia arrest, which is when the heart stops beating entirely. CR#1 was taken to a local hospital via stretcher. CR#1 remained asystole throughout patient care. Record review of a speech therapy evaluation and treatment plan for certification dates [DATE]-[DATE] revealed: Current Referral: Reason for referral were CR#1 risk of aspiration, nursing staff reported consistent coughing/choking with puree/thin liquids diet. Treatment approaches: Evaluation of speech sound production and language assessment, evaluation of oral and pharyngeal swallow function. Initial assessment: The [NAME] Assessment of swallow ability ([NAME]) consisted of 24 clinical items comprised of four main components: (1) general patient examination (alertness and cooperation), (2) oral preparation phase (saliva, lip, seal, and tongue movement), (3) oral phase (gag reflex and palatal movement), (4) pharyngeal (cough reflex and voluntary cough). [NAME] are interpreted as no abnormality (=178), mild dysphagia (,d+[DATE]) severe dysphagia (=138). The risks of aspiration were defined based on the total scores. CR#1 score was 130 which meant severe dysphagia. CR#1 had speech therapy 3 times per week for 5 weeks. The recommendation for CR#1 was no food by mouth (NPO) diet. Record review of speech therapy CR#1 treatment plan for [DATE]-[DATE] changed from 3 times per week to 4 times per week. CR#1 would remain on a NPO diet based upon his evaluation. Interview with the DON on [DATE] at 1:49 p.m., revealed her to state that CR#1 was his own RP. She said they had been trying to get him a guardian. However, he had a Brief Interview of Mental status (BIM) of 14- (which meant cognitively intact). She said that he had multiple speech evaluations and swallow studies between [DATE] -[DATE] in which the recommendation was no food by mouth or NPO. She said CR#1 wanted to eat food from his roommate and off other trays as he found them. She said he was placed on 1:1 monitoring due to this behavior. She said she learned in [DATE] that CR#1 had been admitted from a group home. At the group home, CR#1 was said to have swallowed bleach, and this added to his swallowing issues. She said that he was placed on 1:1 monitoring as an intervention. She said 1:1 was provided by CNA's, nurses, housekeeping for a month or more. She said his behavior got better, then he started pulling out his G-tube. Interview with the Speech therapist on [DATE] @ 3:13 p.m. revealed she began working at the facility in [DATE]. She said the most recent evaluation on CR#1 was [DATE]-[DATE]. She said dysphasia, communication and auditory services were provided. Trials of various consistencies were done such as, pudding moderately thick, thin, and multiple others were tried with CR#1. He had therapy 3-times per week for ,d+[DATE] minutes. She said signs/symptoms of aspiration were discussed and CR#1 sometimes he did not follow her instructions. She said CR#1 was impulsive, she would cue him to only take 1 sip of a liquid and he would take ,d+[DATE] sips and start coughing. She said she took breaks and would sometimes work with him on safety. She said she educated CR#1 on bolus and holding liquids in his mouth and demonstrated swallowing hard. She said 1-step directions were given so they were easier to follow. She said the trials for various consistencies did not do well. She said he would start coughing which indicated to her that thin nor thickened could be tolerated. She said he was on an NPO diet. She stated that orders were put in PCC and all nurses where all nursing staff are aware of changes in d orders and plan of treatment. Interview with the Administrator on [DATE] at 3:46 p.m. revealed that CR#1 was being redirected with activities due to his behaviors. She said that he was on 1:1 monitoring for both hitting his head and seeking regular food although he had a G-tube. She said he had not sought food or had any other behaviors in a while. She could not recall how long it had been since his last behavior. She said she continued to bring him into her office to listen to music and even moved his room across from her office so at breakfast and lunch mealtimes she could watch him. She said she had watched him for several weeks and as needed. Also, that she had staff (CNA, RN, Housekeeping) all to monitor him for several months. She said he was not on 1:1 monitoring because it had bee a long time since he had any behaviors. She said that it was believed that on [DATE] CR#1 took a dinner roll from his roommate (Resident #2) and ate some of it causing him to choke. She said that he was not currently on 1:1 monitoring because it had been a long time since he had any behaviors. She said he had been moved several times to be closest to the nursing station so they could monitor him. Interview with RN A on [DATE] at 4:31 p.m., revealed to her to state on [DATE] she heard CNA A calling for help after learning that CR#1was coughing and possibly choking. She said that she began trying the Heimlich maneuver and was unsuccessful. She swept his mouth for food and then suctioned. She stated that very little food particles came up. She stated that she had help from two other nurses. She said CR#1 was turning blue, and she gave him oxygen. She said that CPR was initiated, and EMS took over when they arrived. She said that CR#1 was constantly trying to get regular food from other residents' plates. She said he would get angry if anyone tried to stop him from acquiring regular food although he had a G-tube. Interview with CNA A on [DATE] at 4:47 p.m., said CR#1 had a G-tube but would take other residents' regular food. She said he was able to walk a little and would sneak into other resident rooms for their food and tried to get food off his roommate's tray. She said that the Administrator had informed all staff to pay attention to him and make sure he did not take other residents' food. She said usually when CNA's pass the trays, they would keep the cart further away from him so he would not try to get food while they were with other residents. She stated that the Administrator did an in-service about 2 or 3 weeks ago and informed them that he still had an NPO - nothing by mouth diet. She said she provided 1:1 monitoring for CR#1 for several months around June/[DATE] and it ended sometime in July or August. She said she could not remember. She said she would sit in his room and make sure he did not get regular food and was not hitting his head. She said he would get upset if anyone took regular food away from him and he would pull out his g-tube and they had to call 911. She said that he would pull out the G-tube because he wanted to eat. She said on [DATE] at approximately 6 p.m. she heard someone coughing and immediately went to CR#1's room and looked at Resident #2's tray. She noticed the dinner roll was not there. She asked him if he ate something, and he nodded no. She said she asked again CR#1 did you eat something, and he nodded up and down as to say yes and pointed towards his roommate. She does not know why the roommate did not stop him from taking his dinner roll. She said she did not ask Resident #2. She said she called the nurse right away because CR#1 was choking. RN A started the Heimlich maneuver, she swept his mouth, and another nurse came into the room to assist RN A. She left the room when they started working on him. Interview with Resident #2 on [DATE] @ 2:25 p.m., he questioned whether he was in trouble because CR#1 took his dinner roll. He said he did not give it to him. He said on the day that this incident occurred, CR#1 was standing near his bed acting like he was watching his television. He said he asked CR#1 why he was not looking at his own television. He said when he started doing something in his bed, he noticed that his dinner roll was gone. He said he looked at his roommate (CR#1) and he was chewing something. He said then he began to cough, and then staff came in to find out what was going on. He said he left the room because staff were working on him. Resident #2 said CR#1 had been his roommate for about 2 months. He said that CR#1 was constantly trying to stash food. He said that if he knew he could not eat and still tried, maybe he wanted to choke and die. He said he would do things to cause himself harm. Interview with Dietary Manager, on [DATE] @ 2:40 p.m., revealed her to state she has been employed at the facility for 7 years. She said that CR#1 was NPO and had a G-tube. She said staff informed her that he would try to grab food off trays in the hall and she began having them bring the carts back to the kitchen as soon as the meals had been passed out to the residents, and they tried to ensure trays were not left in residents' rooms after residents with regular diets were done eating. She said that she stopped putting self-serve coffee out for residents to prevent CR#1 from getting coffee. Interview with the FM on [DATE] at 3:20 p.m., revealed that CR#1 passed away on [DATE]. She said that it was her understanding that CR#1 passed away from choking on a dinner roll that he had taken from another resident's tray. She said it was difficult to find a nursing facility closer to where his family resided. She said since he had a G-tube, and bad behaviors such as hitting, spitting, and trying to eat other residents' food made it difficult and several facilities would not admit him. She said the medical examiner told her on [DATE] CR#1 passed away from choking and was going to prepare his death certificate. As of this interview, she had not received it. Record review of the facility's abuse, neglect and exploitation policy revealed it to state it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of resident property. Record review of incidents, accidents and supervision policy stated it is the policy of this facility to provide an environment that is free of hazards over which the facility has control and provides supervision and assistive devices to each residet to prevent avoidable accidents. The Administrator and DON were notified of an Immediate Jeopardy on [DATE] at 2:55 p.m., due to the above failure. The Administrator was provided with a copy of the IJ template, and a plan of removal (POR) was requested. The following plan of removal submitted by the facility was accepted on [DATE] at 2:06pm. 1. Immediate Action Taken A. Resident # 1 expired in facility on [DATE] B. On [DATE] the DON/designee completed rounds throughout the facility to identify other residents who have potential for taking food or fluids from other meal trays. One other resident was identified as having the potential for taking food or fluids from meal trays. This resident's care plan was updated on [DATE] will appropriate interventions. The C.N.A.'s Kardex has been updated to identify this potential issue. C. On [DATE] the DON/Designee started in-service education with all licensed nurses and C.N.A.'s on the Comprehensive Care Plan Policy which guides the Interdisciplinary Care Team on: measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed, Care Plans will be update or revised as applicable at least quarterly and as needed base on resident care changes, Care Plan interventions flow to Kardex system that provides directions to C.NA.'s on care resident requires. This will be completed on [DATE] at 10;00 am and no licensed nurse or C.N.A. will be allowed to work until they have received this education. 2. Identification of Residents Affected or Likely to be Affected: A. On [DATE] the DON/designee completed rounds throughout the facility to identify other residents who have potential for taking food or fluids from other meal trays. One other resident was identified as having the potential for taking food or fluids from meal trays. This resident's care plan was updated on [DATE] will appropriate interventions. The C.N.A.'s Kardex has been updated to identify this potential issue 3.Actions to Prevent Occurrence/Recurrence: A. On [DATE] DON/Designee started in-service education on with all staff on: Emergency Response to Choking Training on Heimlich Maneuver Minimizing accessibility to food and liquids (busing table in D/R once a resident has completed a meal, covers for carts out in hallway to minimize a resident's accessibility) This training will be completed on [DATE] by 7:00 pm. No staff member will be allowed to work until this training has been completed. B. Department managers will be assigned daily to monitor meal service to ensure that carts out in the hallway are not accessible to the residents during mealtimes. The schedule of meal monitoring will be the responsibility of the administrator, and this will be reviewed daily during morning meetings. On [DATE] the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Accidents and Supervision to sustain compliance Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ________[DATE]_______ Monitoring of this plan of removal included the following: Observation on [DATE] revealed of facility management in the dining room monitoring residents during lunch. Observation on [DATE] revealed of plastic cart covers that zipped to cover entire cart. Interviews with three CNA's and two nurses between [DATE]-[DATE] on morning, evening and overnight shifts revealed that they had been in-serviced on emergency response to choking, Heimlich maneuver training, and minimizing accessibility to food after mealtimes. They stated that they understood the procedure in an emergency. They would call the charge nurse or any nurse available in an emergency and follow the chain of command for reporting the events to the Administrator, DON, and family members. A subsequent interview with the DON on [DATE]@2:15 p.m. revealed her to state the Heimlich maneuver training had been completed as well as emergency response to choking. She said no staff were permitted to work until they had been trained. She said she had three that would receive training when they came back to work on the following week. Record review of training on [DATE] of Heimlich maneuver revealed that LVN A provided Heimlich maneuver training . The DON and Regional Nurse Consultant were informed the Immediate Jeopardy was removed on [DATE] at 4:42 p.m. The facility remained out of compliance at a severity level of isolated and a scope and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective system that were put into place.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control, in that: -Wound Care Nurse failed to perform hand hygiene when moving from a dirty to clean while performing Resident #1's wound care. This failure could place residents at risk for infections. Findings included: Record review of the admission sheet (undated) for Resident #1 revealed he was [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 4 (deep wound reaching the muscles, ligaments, or bones), paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs) and neuromuscular dysfunction of bladder (a problem in your brain, spinal cord, or central nervous system makes you lose control of your bladder). Record review of Resident#1's Quarterly MDS dated [DATE] revealed BIMS score of 15 out of 15 indicating intact cognition. Further review of Section M0150. Risk of Pressure Ulcers/Injuries- Is this resident at risk of developing pressure ulcers/injuries? Coded- Yes. M0210. Unhealed Pressure Ulcers/Injuries-Does this resident have one or more unhealed pressure ulcers/injuries? Coded- Yes. M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Number of Stag 3 Pressure ulcers coded-2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry coded-2. D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 Pressure ulcers coded-2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry coded 2. Record review of Resident#1's care plan initiated 09/27/2023 and revised on 10/03/2023 revealed the following: Focus: Pressure ulcer: Stg 4 R ischium Resident has a pressure ulcer and is at risk for infection, pain, and a decline in functional abilities. Goal: Resident's pressure ulcer will show signs of healing through next week date. Target Date: 01/09/2024. Interventions: Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. Record review of Resident #1's physician order dated 11/15/23 revealed an order to cleanse stage 4 to the R ischium with NS or skin cleanser pat dry apply collagen then gauze moistened with vashe solution cover with dry dressing change qd/PRN every day shift. Observation and interview on 11/20/23 at 10:15a.m., with Resident #1 revealed he was resting on an air mattress. He said, facility was not providing proper wound care. I asked to be sent to the hospital and found out that my wounds were infected with MRSA. Observation on 11/20/23/06/22 at 10:30 a.m., revealed Wound Care Nurse performing wound care on Resident #1 assisted by CNA A. Prior to start of the treatment, Resident #1 was assisted onto his left side. Observation revealed a dressing dated 11/19/23 on a wound to the R ischium area approximately 3 cm in diameter. Wound Care Nurse did not clean the R ischium from the inside to out. Wound Care nurse then removed her soiled gloves, without sanitizing/washing her hands, donned new gloves and continued the wound care treatment. Wound Care Nurse applied collagen then gauze moistened with vashe hypochlorous acid solution (wound cleanser) and covered with dry dressing. In an interview on 11/20/23 at 12:15 p.m., with the Wound Care Nurse, she said the resident was on isolation for MRSA to the wound. She said she was nervous she should have performed hand hygiene before donning (putting) clean gloves as it placed the risk for cross contamination and infections to the wound. She said the company that provided the wound care supplies came to the facility on Friday (11/17/23) and did competency check off with her. She said she signed in-service on infection control a week ago she could not recall the exact date. In an interview on 11/20/23 at 2:39p.m., with the DON, she said she expected staff to follow standard infection control techniques. To perform handwashing before the treatment, if hands become soiled, between gloves change, and after as it placed risk for infections. She said staff were provided training on infection control and hand hygiene on the 15th of this month. She said Wound care company representative did Wound Care Nurse's competency check off last Friday (11/17/23). She said, I spot checked Wound Care Nurse in October 3 weeks ago or a month ago can't recall the exact date. She said the potential risk to resident due to this failure was cross contamination. Record review of facility's Wound Management policy (Revision Date: 2/7/2019) revealed read in part: .Anticipated Outcome: To promote wound healing of various types of wounds and provide evidence-based treatments in accordance with current standards of practice and physician orders. Process: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . Record review of facility's Hand Hygiene policy (Date Implemented: 11/12/2027) revealed read in part: .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: 1. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 6. Additional considerations: b. The use of gloves does not replace hand washing. Wash hands after removing gloves . Record review of facility's Infection Prevention and Control Program policy (Date implemented: 10/24/2022) revealed read in part: .Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 4. Standard Precautions: b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures .

Based on observation, interview, and record review, the facility failed to ensure resident's right to be free from neglect for 1 resident (Resident #1) of 10 residents reviewed for neglect in that: 1. The facility failed to have an effective system in place to monitor for STAT diagnostic/laboratory results, 2. The facility failed to ensure staff were trained on where to check for and follow up on diagnostic/laboratory results. 3. The facility failed to have a communication system in place to ensure timely continuity of care and interventions/treatment. 4. The facility failed to report to the ordering physician Resident #1's stat x-ray results of a fracture to the right hip, femur, and pelvis in a prompt manner. An IJ was identified on 05/26/2023. The IJ template was provided to the facility Administrator on 05/26/2023 at 5:50pm. While the Administrator was notified at 11:50am on 05/29/2023 that the IJ was removed, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner. This failure resulted in delayed diagnosis of sacral osteomyelitis and antibiotic administration for Resident #1 with the potential to place residents who received diagnostic testing at risk for neglect, delayed treatment, and hospitalization . Findings: Resident #1 Record review of Resident #1's face sheet dated 05/12/2023 revealed an [AGE] year-old male admitted to the NF on 04/02/2023 with the following diagnoses; cerebral infarction (disrupted blood flow to the brain), respiratory failure, hypertension (high blood pressure), dysphagia (difficulty swallowing), functional quadriplegia (loss of control of both arms and both legs), type two diabetes mellitus, heart disease, sacral (below the spine and above the tailbone) ulcer stage 4, pressure ulcer of left ankle, renal (kidney) disease, tracheostomy (opening created at the front of the neck so that a tube can be inserted in the windpipe to help one breathe), gastrostomy (opening in the stomach done surgically for the introduction of food), and colostomy (surgical operation creating an opening in the abdomen/stomach to expel waste). Record review of Resident #1's admission assessment MDS dated [DATE] revealed BIMS score of 9 (cognition moderately impaired). Further review revealed that resident was totally dependent on staff with assistance of activities of daily living. Record review of Resident #1's Nursing progress Notes dated 05/04/2023 documented by the Wound Care Nurse revealed in part: .Resident visited per wound care docotor this a.m., upon observation stage 4 of the sacrum shows signs of improvement .Arterial wound of L(left) second toe is currently stable .wound has no noted exudate with 100% necrotic eschar noted to wound bed, tratement order for site continue as ordered, arterial wound of the L (left) 3rd toe is also stable .wound has no noted exudate with 100% necrotic eschar noted to wound bed, treatement order continue as ordered .no signs of infection noted to sites . Record review of Resident #1's Care Plan dated 05/12/2023 revealed that resident was being care planned for falls and ADL performance deficit related to: impaired mobility and limited ROM. Record review of Resident #1's Physician Progress Notes dated 05/04/2023 revealed in part: .chief complaint/nature of presenting problem: Patient reports severe pain in right hip, right femur, patient has severe chronic comorbidities, patient's right lower extremity is seen over the left lower extremity. Patient appears more alert and verbal today, reports significant discomfort to the right hip, right femur . Record review of Resident #1's Physician orders revealed the following orders: -Dated 05/04/2023 X-ray right hip, pelvis, right femur STAT (right away) -Dated 05/04/2023 Tylenol Extra Strength tablet 500mg 1 tablet every 8 hours for pain for 7 days crush via peg. Record review of Resident #1's MAR for the month of May 2023 revealed that the NF was administering Tylenol extra strength as ordered by the physician. Record review of Resident #1's STAT X-ray results of the right hip, pelvis, right femur dated 05/04/2023 revealed in part: .Age-indeterminate (the radiologist cannot tell based on the x-rays alone if it is new or old) avulsion fracture at greater trochanter (any of two bones by which muscles are attached to the upper part of the thigh bone) of femur is noted. No other acute fracture or dislocation . Record review of the NF 24-hour communication dated 05/04/2023 was documented that the STAT X-ray was done of the right hip, pelvis, and femur (there was no mention that the physician was notified of results). Further review of the 24-hour communication on 05/06/2023 was documented that Resident #1 refused dialysis, G-tube (gastrostomy) and trach (tracheotomy) care; colostomy bag changed. There was no further documentation regarding the results of Resident #1's STAT right hip X-ray or if the physician and been notified. Further review of the results of Resident #1's STAT X-ray results of right hip, pelvis, right femur dated 05/04/2023 revealed that the weekend supervisor initialed on 05/07/2023 and that she notified the physician on 05/07/2023 with orders to send Resident #1 out for treatment and evaluation. Record review of the NF Staff Time Sheet dated 05/04/2023 revealed that LVN F clocked in to work at 5:48pm and LVN C clocked in to work at 7:19pm. Interview on 05/17/2023 at 4:15 pm via phone, LVN C said he worked on 05/04/2023 6pm-6am and was Resident #1's nurse. LVN C said he was not aware that Resident #1 had an X-ray done on his right hip. LVN C said he worked at the NF on a PRN basis and did not recall that he had received in report that resident had STAT X-ray done on right hip. LVN C said he received and gave shift report using the 24-hour communication form. Interview on 05/28/2023 at 11:30 am via phone, LVN D said she was working on 05/04/2023 6am-6pm shift and that she was Resident #1's nurse on that day. LVN D said Resident #1's doctor came to the NF on 05/04/2023 and that she remembered resident complaining of pain to his right hip. LVN D said the NP had also come to the NF on 05/04/2023 and gave orders on multiple residents. LVN D said LVN C were the nurses to relieve her but were running late for work. Therefore, she had to give report to LVN F who was working another hall. LVN D said LVN F was upset that he had to take report for LVN C, and she just gave LVN F a verbal report not using the 24-hour communication form. LVN D said although she did not mention in her verbal report to LVN F that Resident #1 had a STAT order for an X-ray of the right hip that had been done, she did write it on the 24-hour communication form. LVN D said she knew she was supposed to utilize the 24-hour communication form, it was just a lot happening on 05/04/2023. Interview on 05/28/2023 at 12:37 pm, LVN F said he worked at the NF part time during the evening shift 6pm-6am. LVN F said the normal process when clocking in to work was to count the narcotics cart. LVN F said he completed walking rounds along with verbal report utilizing the 24-hour report form. LVN F said he did not recall receiving a report from LVN D nor giving report to LVN C regarding Resident #1. Record review of Resident #1's Nursing Progress Notes revealed the following documented by LVN D dated 05/04/2023 at 8:19 am: incomplete documentation that read .9:49 am patient refused . 05/05/2023 documented by LVN C revealed in part at 7:11am: .Refused dialysis MD/RP aware . 05/05/2023 documented by LVN O at 2:15pm: .Resident refused dialysis. NP aware and educated patient about the importance of hemodialysis. Nurse attempted 3 times. Resident still refused . 05/07/2023 documented at 10:13 am by Weekend Supervisor read in part: .Physician notified regarding x-ray results. Received new order to send out for evaluation of fracture. Resident resting quietly in bed at this time denies pain . Record review of Resident #1's hospital records dated 05/07/2023 revealed in part: XXX[AGE] year-old male who is bedbound, was sent from NH for evaluation of right hip pain. X-ray at outside facility was questionable for right hip fracture. Upon examination it was noted necrotic (death of living tissue) changes in his left 2nd and third toes. He also has a stage 4 sacral decubitus ulcer. CT pelvis was completed rising suspicion for sacral osteomyelitis (infection of bone). He did not meet the suspicion for sepsis .Right hip pain likely referred pain. No CT evidence of fracture .Noted Orthopedic Surgery input. No need for surgical intervention for hip or femur. Will start on empiric (therapy begun on the basis of a clinical or educated guess) Zyvox and Levaquin (antibiotics) . Interview on 05/12/2023 at 11:14 am, The Administrator said Resident #1 was still in the hospital in ICU. The Administrator said she was not at the NF regarding the incident with Resident #1 and that she started working at the NF on 05/08/2023. The Administrator said she found out later the STAT X-rays done on Resident #1 right hip revealed a fracture. Further interview with the Administrator said she was not aware that there had been a delay in reporting Resident #1's STAT X-ray results of the right hip done on 05/04/2023 to the doctor until 05/07/2023. Interview on 05/12/2023 at 3:42 pm, The Weekend Supervisor said she worked only on the weekends double shift 6am-10pm. The weekend supervisor said when she saw Resident #1's X-ray results of the right hip at the nurse's station on 05/07/2023, she was not sure if the physician had been notified and therefore texted the doctor on 05/07/2023. The weekend supervisor said when she contacted Resident #1's doctor, he had not been notified of the STAT X-ray results that he had ordered on 05/04/2023 until she had presented the results to him on 05/07/2023. The weekend supervisor said the doctor gave her orders to send Resident #1 out to the hospital for further evaluation and treatment. The weekend supervisor said she received reports on the residents at the NF from the ADON through text or facetime. The weekend supervisor said the ADON never mentioned to her that a STAT X-ray of the right hip, right femur, and pelvis had been ordered on Resident #1. The weekend supervisor said when she called the ADON on 05/07/2023, the ADON told her that she was not aware that a STAT X-ray had been order for Resident #1. The weekend supervisor said the nurses on duty on the weekend were not aware that a STAT X-ray of the right hip had been ordered on Resident #1. The weekend supervisor said she went to Resident #1's room to see if resident was in pain. She said resident said he was not in any pain. Interview on 05/12/2023 at 4:40pm, LVN A said she worked Hall 500 and that Resident #1 resided on Hall 600. LVN A said when she reported to work, she went and checked on the residents before taking a verbal report from the nurse. LVN A said when she takes a verbal report from the nurse, she also utilized the 24-hour report sheet to ensure she was receiving all needed information to ensure the continuity of care. LVN A said not all the nurses utilized the 24-hour report sheet. LVN A said the 24-hour communication report sheet was kept at the nurse's station in a binder. Interview on 05/12/2023 at 4:55pm, the ADON said the doctor was making rounds at the NF on 05/04/2023 and Resident #1 said he was in pain. The ADON said the doctor ordered an X-ray of the right hip on Resident #1. The ADON said honestly, she did not know that there had been a delay in notifying the physician regarding Resident #1 X-ray results taken of the right hip on 05/04/2023. The ADON said the X-ray of Resident #1's right hip was ordered STAT. The ADON said that radiology came to the NF late on 05/04/2023. The ADON said the nurses should have caught that and it should have been discussed in the shift-to-shift report. The ADON said when the weekend supervisor called her on 05/07/2023 she told the weekend supervisor to call the doctor. The ADON said there was a different DON working at the NF at that time of when the STAT X-ray was ordered for Resident #1. The ADON said she attended the morning meetings and that Resident #1's STAT X-rays done on 05/04/2023 (Thursday) was never discussed in the following morning meeting on 05/05/2023. Further interview with the ADON said the reason Resident #1's STAT X-ray of the right hip, pelvis, and femur was not discussed was because the NF Administrator was late arriving at the NF, and it was her last day working at the NF. Therefore the morning meeting on 05/05/2023 did not happen. The ADON said the NF at the time did not have a permanent DON as well, but an interim DON. The ADON said the NF did not have a policy that the nurses had to document on the 24-hour communication report sheet as a form of communication regarding the residents care. Further interview on 05/12/2023 at 5:15 pm, the Administrator said regarding Resident #1, the NF had done in-services on abuse and neglect when she began work on 05/08/2023, documentation, level of pain assessment, shift reporting, notifying the Administrator/DON/Doctor before sending a resident out to the hospital. Further interview with the Administrator said the Regional Director of Operations called the incident regarding Resident #1 into the state and that the Regional Director of Operations was the one that completed the facility incident investigation regarding Resident #1 STAT X-ray results of fracture on right hip, right pelvis and femur. The Administrator was unable to provide a specific date as to when the Regional Director of Operations called the incident in to the state. Interview on 05/12/2023 at 5:15pm. the DON said she started working at the NF on 05/08/2023 and what she knew about Resident #1 was that resident had a lot of contractures and complained of pain. The DON said the nurse medicated the resident for pain but it was not effective, and the doctor said to send resident to the hospital to be evaluated. The DON said it was discovered at the hospital that Resident #1 had a fracture but could not say where the fracture was. The DON said when Resident #1 went to the hospital on 05/07/2023 the nurses called the hospital to see how the resident was doing. The DON said that was when the NF found out that Resident #1 had a fracture. The DON said she never read the NF Incident Investigation Report regarding Resident #1. Interview on 05/17/2023 at 9:30 am via phone, Radiology said a STAT X-ray was done on Resident #1's right hip on 05/04/2023 and the results were called to the NF on 05/04/2023 spoke to a Staff Member XX. Radiology said they did not get a last name or title. Radiology said the results were verbally given to Staff Member XX at 9:54 pm and faxed to the NF on 05/04/2023. Radiology said the STAT X-ray results were faxed again to the NF on 05/07/2023 at 11:28am. Interview on 05/17/2023 at 10:00am the Administrator said the NF had 3 fax machines in the NF Further interview 05/17/2023 at 2:13 pm, the Administrator said the NF did not have an employee by the name of [Staff Member XX] that worked at the NF. Observation on 05/17/2023 at 12:00 pm revealed Resident #1 on Hall-600 sitting in a Geri-chair that was in a reclined positioned. Resident was easily aroused and denied any pain at that time. Interview on 05/17/2023 at 12:50 pm via phone Physician A of Resident #1 revealed he reviewed Resident #1' s hospital records on 05/16/2023. Physician A said the hospital records reached the conclusion, after a CT scan of the right pelvis, that resident did not have a fracture. Physician A said while Resident #1 was at the hospital, Resident #1 was seen by the Orthopedic doctor. Physician A said Resident #1 had multiple comorbidities and his prognosis was poor. Physician A said Resident #1 was a good candidate for hospice, but the family of the resident would have to make that choice. The physician said because resident had been assessed by the hospital would base his plan of care off the hospital conclusion and continue to monitor Resident #1. Attempted interview via phone on 05/17/2023 at 1:47 pm with LVN O; no answer. Interview on 05/17/2023 at 2:15 pm, the DON said the nurses were supposed to do verbal reports and look at the 24-hour communication report on the computer. The DON said the NF trying to get rid of paper, using only the computer to document resident care. The DON said she would have to look at the computer to see if the staff was charting on the 24-hour form on the computer. The DON said a STAT order should be followed up in 2 hours if results were not received. The DON said some of the nurses were timid when it came to calling the physician and not all nurses use critical thinking. The DON said she would be doing further in-service with staff on a lot of issues including notifying the doctor whenever there was a change in a resident (s) condition. The DON said she spoke with the Regional Nurse who informed her that whenever there is a change in a resident condition, the nurses should be using and INTERACT form. The DON said she had not been privy to reviewing the form, but it seems to be like a glorified SBAR. The DON said she had not reviewed Resident #1's chart at all because she had been busy with training and doing in-services with the Nursing Staff. The DON said the Administrator had reviewed Resident #1's medical records. The DON said she had learned that the NF had 3 different fax machines that consisted of an e-fax (send to the computer), fax in the medication room, and work room (copy room). The DON said she was unsure where the results for diagnostic testing would be faxed. The DON said it was the nurses that completed shift reports as well as the ADONs that was supposed to be reviewing the 24-hour communication form. The DON said the ADON was supposed to bring the 24-hour communication report sheet to the morning meetings. The DON said it was ultimately the DON that ensured that the 24-hour communication forms were being done. The DON said the 24-hour communication form was another form of communication that was relied upon to ensure the continuity of care for the residents. Further interview on 05/17/2023 at 2:32 pm, The Administrator said when a resident had to be discharged to the hospital, she would do a look back for the past 72-hours that included reviewing the 24-hour communication reports that were kept in a binder at the nurse's station. The Administrator said she also reviewed what was documented in PCC to ensure that residents care was being met. The Administrator was not able to answer that if she had done those things, why did she not see that there was a delay in notifying Resident #1's physician of STAT X-ray results of the right hip. The Administrator said it was the ADONs that were responsible for reviewing the 24-hour communication form which were brought to the morning meetings to be further discussed. The Administrator said she was told by the ADON that all diagnostic results was faxed to the medication fax room (. The Administrator said even if a diagnostic result went to another fax room, the staff should have been following up on Resident #1's STAT X-ray results that were taken on 05/04/2023. Interview on 05/17/2023 at 2:55 pm, LVN E said she thought the NF had 1 fax machine which was in the copy room. LVN E said diagnostics were good about calling the NF on anything that was critical and having the person's name who they spoke to; including the time they spoke with that person. Interview on 05/17/2023 at 3:54 pm, the DON said the Weekend Supervisor was supposed to get the resident reports from the DON or ADON when they reported to work. The DON said she did not think that the NF had a permanent DON at the time of the incident regarding Resident #1, but an interim DON. Interview on 05/27/2023 at 11:13 am, the Weekend Supervisor said she normally checked the fax machine in the copy room [ROOM NUMBER]-4 times while on duty. The Weekend Supervisor said STAT diagnostic testing should followed up in 2 hours for the results. The weekend supervisor said the laboratory was good about calling the NF with lab results but was not sure about radiology. The weekend supervisor said she was not sure how Resident #1 STAT X-ray results of the right hip went un-reported to Resident #1's physician. The weekend supervisor said the NF neglected to report to Resident #1's physician, right away, the results of resident STAT X-rays done on the resident's right hip. The Weekend Supervisor said resident was placed at risk for pain and further injury of the right hip. A call was placed to LVN O on 05/27/2023 at 12:12pm with a female answering the phone denying that they were LVN O. It was confirmed with the NF that the number provided to the surveyor for LVN O was the number that they had on file for LVN O. Attempted an interview on 05/27/2023 at 12:44pm via phone with LVN O; no answer, left voicemail with a call back number. Interview on 05/27/2023 at 12:30pm, the ADON said LVN O was an agency nurse. Interview on 05/27/2023 at 12:25 pm, LVN B said she worked at the NF PRN. LVN B said she worked at the NF over a year ago and had just started working back at the NF. LVN B said she did not know how many fax machines that the NF had. LVN B said she believed that diagnostic test results were retrieved from the fax machine in the medication room. LVN B said no one at the NF had in serviced her on all fax machine locations or how often to follow-up for diagnostic results. Interview on 05/28/2023 at 11:20 am, the DON said the NF failed to follow up on Resident #1's STAT X-ray of right hip and report to the physician in a timely manner. The DON said the NF was not following their process. The DON said there was unstable staffing. The DON said there was no consistency with communication among the nursing staff regarding resident care. Interview on 05/29/2023 at 11:08 am, the Administrator said when agency nurses worked at the NF, it was not a guarantee that they will be back the next day and things will go missed. The Administrator said the NF did not have any systems in place to follow-up on STAT Labs/diagnostic testing. The Administrator said everybody was just doing their own thing and not communicating with each other using the 24-hour communication form consistently regarding the residents' care, not following up regarding test results, and reporting the findings to the physician. Further interview with the Administrator said she did not do an investigation regarding Resident #1 stat x-ray of the right hip not being reported to the physician in a prompt manner because the Regional Director of Operations said that he would do the investigation. Interview on 05/29/2023 at 12:55pm The Regional Director of Operations said regarding Resident #1's stat x-ray of the right hip not being reported to the attending physician at the NF in a prompt manner, said he called the incident in to the state and told the Administrator to do the facility investigation. Record review of the NF Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/2022 revealed in part: .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing an implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Neglect means failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of the NF policy on Clinical Practice Guidelines Facility 24 Hour Report revised 02/04/2022 revealed in part: .It is the policy of this facility to record relevant information on a 24-hour report form in order to promote continuity of care. The report form will be completed daily for a 24-hour period .Each nurse is responsible for reviewing the information on the shift report at the beginning of his/her shift to identify and prioritize resident needs. The ADON or designee, will review 24-hour shift reports daily in order to identify and prioritize resident needs . An IJ was identified on 05/26/2023. The IJ template was provided to the facility Admministrator on 05/26/2023 at 5:50pm. While the Administrator was notified on 05/29/2023 at 11:50am that the IJ was removed, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner. PLAN OF REMOVAL F600 Name of facility Date: 05/26/2023 Immediate Action The DON or designee immediately reviewed all residents with recent Diagnostic testing to ensure that timely follow up on results of diagnostic testing, and physician notification were implemented if needed. No other issues identified. This was completed 05/26/2023. The DON or designee immediately reviewed the 24 -hour nurse report to validate communication system is in use by licensed nurse to ensure continuity of care, treatment, and interventions as applicable. This was completed on 05/26/2023. The DON or designee immediately validated that all licensed nurses were knowledgeable on location of fax machine designated to receive diagnostic results including frequency by providing in-service education. This was completed 05/27/2023. No licensed nurse will be allowed to work after 05/27/2023 until they have completed this education. The DON or designee immediately implemented the Diagnostic Tracking tool on 05/27/2023 to effectively monitor diagnostic orders, results of diagnostic testing, and notification of Physician. Facilities Plan to ensure compliance quickly DON/designee began education Immediately on: Diagnostic Tracking Guidelines Education with all licensed nurses including post-test Use of Diagnostic Tracking tool to have an effective system in place to monitor for STAT diagnostic/laboratory results Abuse and Neglect Education with all licensed nurses including post-test 24 Hour Report entry Guidelines Education to have a communication system in place to ensure timely continuity of care and interventions/treatment Documentation Guidelines Education Notification of Change in Condition Education including post-test This education began 5/26/2023 and will end 5/27/2023. Any licensed nurse who has not received this education and post-test will not be allowed to work until this is completed. The facility's Medical Director was notified of the Immediate Jeopardy on 5/26/2023. On 5/27/2023 the facility will conduct an Ad Hoc QAPI meeting to review areas cited and plan for sustaining compliance. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following monitoring: Interview on 05/28/2023 at 1:45 pm, the Weekend Supervisor said she had been in-service in the following areas: abuse/neglect, handwashing, how to access all diagnostic testing by looking in the computer to review and track physician orders. The weekend supervisor said by looking at the tracker, she could see if the order had been processed. That way, she could call the physician/doctor with the results in a timely manner. The weekend supervisor said she had also received in-service on receiving a verbal report using the 24-hour communication form from the unit nurses at the beginning of the shift and at the end of shift and her report would be provided to the ADON. The weekend supervisor said she had been in-serviced on all fax locations at the NF with the copy room being the fax machine for diagnostic results. Interview on 05/28/2023 at 1:50 pm, RN I worked the 6am-6pm shift said she had been in-service on the following: abuse/neglect, tracking ordered diagnostic testing in the system and checking to see if the physician was notified of the results, documentation on all diagnostic testing in PCC and that the physician was notified, shift reporting providing a verbal report are porting using the 24-hour communication form, and the location of the fax machines at the NF. Interview on 05/28/2023 at 2:03 pm, LVN E said she worked the 6am-6pm shift and had been in-serviced on all diagnostic testing, hand washing, abuse and neglect, notifying the physician in a timely manner on STAT diagnostic test results, checking on ordered diagnostic testing to ensure the order had been done and results provided to the physician, documentation, shift reporting using the 24-hour report form. Interview on 05/28/2023 at 2:15 pm, LVN S said she worked full time at the NF 6am-6pm shift. LVN S said she received in-service on abuse and neglect, how to track ordered diagnostic testing in the computer using the tracker, reporting the test results to the physician and notifying the RP as well, document care provided to the residents in the Nursing Progress Notes in PCC as well as documenting on the 24-hour communication form, location of the fax machines at the NF, shift to shift report using the 24-hour communication form. Interview on 05/28/2023 at 2:20 pm, LVN J said she worked the 6am-2pm shift and been in-serviced in the following areas: abuse and neglect, change in resident condition notifying and the RP, documentation, how to track all diagnostic testing using the tracker in the computer to see if the test had been done and reporting results to the physician, verbal shift to shift report with the 24-hour communication form, and location of fax machines with the test results being found on the fax machine in the copy room. Interview on 05/28/2023 at 8:55 pm, LVN G said she worked at the NF part-time 6pm-6am shift. LVN G said she had received in-service on abuse and neglect, communicating all diagnostic testing results to the physician in a prompt manner, verbal shift to shift reporting using the 24-hour communication form, and location of fax machines with the copy room being the fax machine for designated diagnostic test results, and being sure to document actions taken in the care of the resident in PCC and on the 24-hour communication form. Interview on 05/28/2023 at 9:02 pm, LVN K said she worked at the NF full time 6pm-6am. LVN K said she had been in-serviced on abuse and neglect, 24-hour communication shift to shift report, tracking STAT diagnostic testing as well as all diagnostic testing reporting to the doctor in a timely fashion, notifying the family when there is a change in the resident condition as well as the doctor, fax machine locations, and documentation. Interview on 05/28/2023 at 9:15 pm, LVN L said she worked at the NF full time on the 6:00pm-6am shift. LVN L said she had been in-serviced on location of the fax machines with the copy room being the designated fax machine for diagnostic testing, documenting when a resident experience a change in condition notifying the physician and the RP and what was done, being sure to document on the 24-hour communication form, using the 24-hour communication form when giving verbal shift to shift report, reporting all diagnostic testing results to the physician in a timely manner, how to use the tracker in the computer to track diagnostic testing, abuse and neglect. Interview on 05/28/2023 at 9:35pm LVN C, said he had been in-serviced on reporting all diagnostic testing results to the doctor in a timely manner, documenting in PCC and on the 24-hour communication form relaying the information in shift report, documenting when there was a change in resident (s) condition, location of the fax machines, and how to track the results of ordered diagnostic [TRUNCATED]

Based on observation, interview, and record review the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician order for 1 (Resident #1) of 10 residents reviewed for radiology services in that: -The facility failed to report Resident #1's stat x-ray results of a fracture of the right hip, femur, and pelvis in a prompt manner. An IJ was identified on 05/26/2023. The IJ template was provided to the facility Administrator on 05/26/2023 at 5:50pm. While the Administrator was notified on 05/29/2023 at 11:50am that the IJ was removed, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner. This failure has the potential to place residents who receive diagnostic testing for delayed treatment and hospitalization s. Findings: Resident #1 Record review of Resident #1's face sheet dated 05/12/2023 revealed an [AGE] year old male admitted to the NF on 04/02/2023 with the following diagnoses; cerebral infarction (disrupted blood flow to the brain), respiratory failure, hypertension (high blood pressure), dysphagia (difficulty swallowing), functional quadriplegia (loss of control of both arms and both legs), type two diabetes mellitus, heart disease, sacral (below the spine and above the tailbone) ulcer stage 4, pressure ulcer of left ankle, renal (kidney) disease, tracheostomy (opening created at the front of the neck so that a tube can be inserted in the windpipe to help one breathe), gastrostomy (opening in the stomach done surgically for the introduction of food), and colostomy (surgical operation creating an opening in the abdomen/stomach to expel waste). Record review of Resident #1's admission assessment MDS dated [DATE] revealed BIMS score of 9 (cognition moderately impaired). Further review revealed that resident was totally dependent on staff with assistance of activities of daily living. Record review of Resident #1's Care Plan dated 05/12/2023 revealed that resident was being care planned for falls and ADL performance deficit related to: impaired mobility and limited ROM. Record review of Resident #1's Physician Progress Notes dated 05/04/2023 revealed in part: .chief complaint/nature of presenting problem: Patient reports sever pain in right hip, right femur, patient has severe chronic comorbidities, patient's right lower extremity is seen over the left lower extremity. Patient appears more alert and verbal today, reports significant discomfort to the right hip, right femur . Record review of Resident #1's Physician orders revealed the following orders: -Dated 05/04/2023 X-ray right hip, pelvis, right femur STAT (right away) Record review of Resident #1's MAR for the month of May 2023 revealed that the NF was administering Tylenol extra strength as ordered by the physician. Record review of Resident #1's STAT X-ray results of the right hip, pelvis, right femur dated 05/04/2023 revealed in part: .Age-indeterminate (the radiologist cannot tell based on the x-rays alone if it is new or old) avulsion fracture at greater trochanter of femur is noted. No other acute fracture or dislocation . Record review of the NF 24-hour communication form dated 05/04/2023 was documented that the STAT X-ray was done of the right hip, pelvis, and femur but not that the physician was notified of results. Further review of the 24-hour communication on 05/06/2023 was documented that Resident #1 refused dialysis, G-tube (gastrostomy)and trach (tracheotomy) care; colostomy bag changed. There was no further documentation regarding the results of Resident #1's STAT right hip X-ray or if the physician and been notified. Further review of the results of Resident #1's STAT X-ray results of right hip, right pelvis, and right femur dated 05/04/2023 revealed that the weekend supervisor initialed on 05/07/2023 that she notified the physician on 05/07/2023 with orders to send Resident #1 out for treatment and evaluation. Record review of the NF Staff Time Sheet dated 05/04/2023 revealed that LVN F clocked in to work at 5:48pm and LVN C clocked in to work at 7:19pm. Interview on 05/17/2023 at 4:15pm via phone LVN C said he worked on 05/04/2023 6pm-6am and was Resident #1's nurse. LVN C said he was not aware that Resident #1 had an X-ray done on his right hip. LVN C said he worked at the NF on a PRN basis and did not recall that he had received in report that resident had STAT X-ray done on right hip. LVN C said he received and gave shift report using the 24-hour communication form. Interview on 05/28/2023 at 11:30am via phone LVN D said she was working on 05/04/2023 6am-6pm shift and that she was Resident #1's nurse on that day. LVN D said resident doctor came to the NF on 05/04/2023 and that she remembered resident complaining of pain to his right hip. LVN D said the NP had also come to the NF on 05/04/2023 and gave orders on multiple residents. LVN D said LVN C was the nurse to relieve her, but was running late for work therefore, she had to give report to LVN F who was working another hall. LVN D said LVN F was upset that he had to take report for LVN C, and she just gave LVN F a verbal report not using the 24-hour communication form. LVN D said although she did not mention in her verbal report to LVN F that Resident #1 had a STAT order for an X-ray of the right hip that had been done, she did write it on the 24-hour communication form. LVN D said she knew she was supposed to utilize the 24-hour communication form it was just a lot happening on 05/04/2023. Interview on 05/28/2023 at 12:37pm LVN F said he worked at the NF part time the evening shift 6pm-6am. LVN F said the normally process when clocking in to work at the NF was to count the narcotic cart. LVN F said he done walking rounds along with verbal report utilizing the 24-hour report form. LVN F said he did not recall receiving report from LVN D nor giving report to LVN C regarding Resident #1. Record review of Resident #1's Nursing Progress Notes revealed the following documented by LVN D dated 05/04/2023 at 8:19am documentation incomplete read as follows: .9:49am patient refused . 05/05/2023 documented by LVN C revealed in part at 7:11am: .Refused dialysis MD/RP aware . 05/05/2023 documented by LVN O at 2:15pm Resident refused dialysis. NP aware and educated patient about the importance of hemodialysis. Nurse attempted 3 times. Resident still refused . 05/07/2023 documented at 10:13am by weekend supervisor read in part: .Physician notified regarding x-ray results. Received new order to send out for evaluation of fracture. Resident resting quietly in bed at this time denies pain . Record review of Resident #1's hospital records dated 05/07/2023 revealed in part: XXX[AGE] year-old male who is bedbound, was sent from NH for evaluation of right hip pain. X-ray at outside facility was questionable for right hip fracture. Upon examination it was noted necrotic (death of living tissue) changes in his left 2nd and third toes. He also has a stage 4 sacral decubitus ulcer. CT pelvis was completed rising suspicion for sacral osteomyelitis (infection of bone). He did not meet the suspicion for sepsis .Right hip pain likely referred pain. No CT evidence of fracture .Noted Orthopedic Surgery input. No need for surgical intervention for hip or femur. Will start on empiric (therapy begun on the basis of a clinical or educated guess) Zyvox and Levaquin (antibiotics) . Interview on 05/12/2023 at 11:14am Administrator said Resident #1 was still in the hospital in ICU. The Administrator said she was not at the NF regarding the incident with Resident #1 and that she started working at the NF on 05/08/2023. The Administrator said she found out later the STAT X-rays done on Resident #1 right hip revealed a fracture. Further interview with the Administrator said she was not aware that there had been a delay in reporting Resident #1's STAT X-ray results of the right hip done on 05/04/2023 to the doctor until 05/07/2023. Interview on 05/12/2023 at 3:42pm The Weekend Supervisor said she worked only on the weekends double shift 6am-10pm. The Weekend Supervisor said when she saw Resident #1's X-ray results of the right hip at the nurse's station on 05/07/2023, she was not sure if the physician had been notified and therefore text the doctor on 05/07/2023. The Weekend Supervisor said when she contacted Resident #1's doctor, he had not been notified of the STAT X-ray results that he had ordered on 05/04/2023 until she had presented the results to him on 05/07/2023. The Weekend Supervisor said the doctor gave her orders to send Resident #1 out to the hospital for further evaluation and treatment. The Weekend Supervisor said she received report on the residents at the NF from the ADON through text or facetime. The Weekend Supervisor said the ADON never mentioned to her that a STAT X-ray of the right hip, right femur, and pelvis had been ordered on Resident #1. The Weekend Supervisor said when she called the ADON on 05/07/2023, the ADON told her that she was not aware that a STAT X-ray had been order for Resident #1. The Weekend Supervisor said the nurses on duty on the weekend were not aware that a STAT X-ray of the right hip had been ordered on Resident #1. The Weekend Supervisor said she went to Resident #1's room to see if resident was in pain. She said resident said he was not in any pain. Interview on 05/12/2023 at 4:40pm LVN A said she worked Hall 500 and that Resident #1 resided on Hall 600. LVN A said when she reported to work, she observed the residents first before taking a verbal report from the nurse. LVN A said when she took a verbal report from the nurse, she also utilized the 24-hour report sheet to ensure she was receiving all needed information to ensure the continuity of care. LVN A said not all the nurses utilized the 24-hour report sheet. LVN said the 24-hour report sheet was kept at the nurse's station in a binder. Interview on 05/12/2023 at 4:55pm ADON said the doctor was making rounds at the NF on 05/04/2023 and Resident #1 said he was in pain. The ADON said the doctor ordered an X-ray of the right hip on Resident #1. The ADON said honestly, she did not know that there had been a delay in notifying the physician regarding Resident #1 X-ray results taken of the right hip on 05/04/2023. The ADON said the X-ray of Resident #1's right hip was ordered STAT. The ADON said that radiology came to the NF late on 05/04/2023. The ADON could not give the time that Radiology came to the NF to do an X-ray of Resident #1's right hip. The ADON said the nurses should have caught that and it should have been discussed in shift-to-shift report. The ADON said when the weekend supervisor called her on 05/07/2023 regarding Resident #1's X-ray of the right hip she told the weekend supervisor to call the doctor. The ADON said there was a different DON working at the NF at that time when the STAT X-ray was ordered for Resident #1 right hip. The ADON said she attended the morning meetings and that Resident #1 STAT X-rays done on 05/04/2023 (Thursday) was never discussed in the following morning meeting on 05/05/2023. Further interview with the ADON said the reason Resident #1's STAT X-ray of the right hip, pelvis, and femur was not discussed was because the NF Administrator was late arriving at the NF, and it was her last day working at the NF therefore the morning meeting on 05/05/2023 did not happen. The ADON said the NF at the time did not have a permanent DON as well, but an interim DON. The ADON said the NF did not have a policy that the nurses had to document on the 24-hour communication report sheet as a form of communication regarding the resident (s) care. Further interview on 05/12/2023 at 5:15pm Administrator said regarding Resident #1, the NF had done in-services on abuse and neglect, documentation, level of pain assessment, shift reporting, notifying the Administrator/DON/Doctor before sending a resident out to the hospital. Further interview with the Administrator said the Regional Director of Operations called the incident regarding Resident #1 into the state and that the Regional Director of Operations was the one that done the facility incident investigation regarding Resident #1 STAT X-ray results of a fracture to resident right hip. Interview on 05/12/2023 at 5:15pm DON said she started working at the NF on 05/08/2023 and what she knew about Resident #1 was that resident had a lot of contractures and complained of pain. The DON said the nurse did medicate resident for pain but was not effective and the doctor said to send resident to the hospital to be evaluated. The DON said it was discovered at the hospital that Resident #1had a fracture but could not say where the fracture was. The DON She said when Resident #1 went to the hospital on 05/07/2023 the nurses called the hospital to see how resident was doing. The DON said that was when the NF found out that Resident #1 had a fracture. The DON said she never read the NF Incident Investigation Report regarding Resident #1. Interview on 05/17/2023 at 9:30am via phone Radiology regarding Resident #1 said a STAT X-ray was done on resident right hip on 05/04/2023 and the results were called to the NF on 05/04/2023 spoke to a staff member XX. Radiology said they did not get a last name or title. Radiology said the results were verbally given to XX at 9:54pm and faxed to the NF on 05/04/2023. Radiology said the STAT X-ray results were faxed again to the NF on 05/07/2023 at 11:28am. Interview on 05/17/2023 at 10:00am the Administrator said the NF had 3 fax machines in the NF that consisted of the following: 1)Copy Room 2)Medication Room 3)e-fax Further interview 05/17/2023 at 2:13pm the Administrator said the NF did not have an employee by the name of XX that worked at the NF. Observation on 05/17/2023 at 12:00pm Resident #1 on Hall-600 sitting in a Geri-chair that was in a reclined positioned. Resident was easily aroused and denied any pain at the present time. Interview on 05/17/2023 at 12:50pm via phone Physician A of Resident #1 at the NF said regarding Resident #1 he reviewed resident hospital records on 05/16/2023. Physician A said the hospital records reached the conclusion after a CT scan of the right pelvis was done that resident did not have a fracture. Physician A said while resident was at the hospital was seen by the Orthopedic doctor. Physician A said resident had multiple comorbidities and prognosis was poor, resident was a good candidate for hospice, but the family of resident would have to make that choice. Physician A said because resident had been assessed by the hospital would base his plan of care off the hospital conclusion and continue to monitor Resident #1. Attempted interview via phone on 05/17/2023 at 1:47pm with LVN O; no answer. Interview on 05/17/2023 at 2:15pm DON said the nurses supposed to do verbal report and use their computer looking at the 24-hour communication report on the computer. The DON said the NF trying to get rid of paper using only the computer to document resident care. The DON said she would have to look at the computer to see if the staff was charting on the 24-hour form on the computer. The DON said a STAT order should be followed up in 2 hours if results not received. The DON said some of the nurses are timid when it came to calling the physician and that not all nurses use critical thinking. The DON said she would be doing further in-service with staff on a lot of issues including notifying the doctor whenever there was a change in a resident (s) condition. The DON said she spoke with the Regional Nurse who informed her that whenever there is a change in a resident condition the nurses should be using and INTERACT form. The DON said she had not been privy to reviewing the form, but it seems to be like a glorified SBAR. The DON said she had not reviewed Resident #1's chart at all because she had been busy with training and doing in-services with the Nursing Staff when she started working at the NF on 05/08/2023. The DON said the Administrator had reviewed Resident #1's medical records. The DON said she learned today that the NF had 3 different fax machines that consisted of an e-fax (send to the computer), fax in the medication room, and work room (copy room). The DON said she was unsure where the results for diagnostic testing would be faxed too. The DON said it was the nurses that done shift report as well as the ADON's that was supposed to be reviewing the 24-hour communication form. The DON said the ADON supposed to bring the 24-hour communication report sheet to the morning meetings. The DON said it was ultimately the DON that ensure that the 24-hour communication forms were being done. The DON said the 24-hour communication forms was another form of communication that was relied upon to ensure the continuity of care for the residents. Further interview on 05/17/2023 at 2:32pm Administrator said when a resident had to be discharged to the hospital, she would do a look back for the past 72-hours that included reviewing the 24-hour communication reports that were kept in a binder at the nurse's station. The Administrator said she also reviewed what was documented in PCC to ensure that residents care was being met. The Administrator was not able to answer that if she done these things why did she not see that there was a delay in notifying Resident #1's physician of STAT X-ray results of the right hip? The Administrator said it was the ADON's that were responsible for reviewing the 24-hour communication form which were brought to the morning meetings to be further discussed. The Administrator said she was told by the ADON that all diagnostic results was faxed to the medication fax room (281-633-9594). The Administrator said even if a diagnostic result went to another fax room, the staff should have been following up on Resident #1's STAT X-ray results that were taken on 05/04/2023. Interview on 05/17/2023 at 2:55pm LVN E said she thought the NF had 1 fax machine which was in the copy room. LVN E said diagnostics were good about calling the NF on anything that was critical and got the person's name who they spoke too including the time they spoke with that person. Interview on 05/17/2023 at 3:54pm DON said the weekend supervisor supposed to get report from the DON or ADON when they report to work. The DON said she did not think that the NF had a permanent DON at the time of the incident regarding Resident #1, but an interim DON. Interview on 05/27/2023 at 11:13am Weekend Supervisor said she normally checked the fax machine in the copy room [ROOM NUMBER]-4 times while on duty. The Weekend Supervisor said STAT diagnostic testing she followed up in 2 hours for the results. The weekend supervisor said laboratory was good about calling the NF with lab results but was not sure about radiology. The Weekend Supervisor said she was not sure how Resident #1 STAT X-ray results of the right hip went un-reported to Resident #1's physician. The Weekend Supervisor said the NF neglected to report to Resident #1's physician right away the results of resident STAT X-rays done on resident right hip. The Weekend Supervisor said this placed resident at risk for pain and further injury of the right hip. A call was placed to LVN O on 05/27/2023 at 12:12pm with a female answering the phone denying that they were LVN O. It was confirmed with the NF that the number provided to the surveyor for LVN O was the number that they had on file for LVN O. Interview on 05/27/2023 at 12:30pm ADON said LVN O was an agency nurse. Attempted interview on 05/27/2023 at 12:44pm via phone with LVN O, no answer, left voicemail with a call back number. Interview on 05/27/2023 at 12:25pm LVN B said she worked at the NF PRN. LVN B said she worked at the NF over a year ago and had just started working back at the NF. LVN B said she did not know how many fax machines that the NF had. LVN B said she believed that diagnostic test results were retrieved from the fax machine in the medication room. LVN B said no one at the NF had in serviced her on all fax machine locations at the NF or how often to follow-up for diagnostic results. Interview on 05/28/2023 at 11:20am DON said she thought the immediate jeopardy occurred because the NF failed to follow up on Resident #1's STAT X-ray of right hip and report to the physician in a timely manner. The DON said the NF was not following their process. The DON said another reason she believes was due to unstable staffing not that she was blaming the previous DON. The DON said there was no consistency with communication among the nursing staff regarding Resident #1's care. Interview on 05/29/2023 at 11:08am Administrator said IJ occurred at the NF because when agency nurses work at the NF not a guarantee that they will be back the next day and things will go missed. The Administrator said the NF did not have any systems in place to follow-up on STAT Labs/diagnostic testing. The Administrator said everybody was just doing their own thing and not communicating with each other using the 24-hour communication form consistently regarding the resident (s) care, not following up regarding test results, and reporting the findings to the physician. Record review of the NF Policy on Diagnostic's Tracking Guidelines dated 08/2013 revealed in part: Purpose: To establish a clinical practice model to track the completion, reporting and monitoring of diagnostic tests (labs, x-rays, Doppler studies etc.) and results .Abnormal Radiology results are communicated to the physician or medical director immediately . Record review of the NF policy on Clinical Practice Guidelines Facility 24 Hour Report revised 02/04/2022 revealed in part: .It is the policy of this facility to record relevant information on a 24-hour report form in order to promote continuity of care. The report form will be completed daily for a 24-hour period .Each nurse is responsible for reviewing the information on the shift report at the beginning of his/her shift to identify and prioritize resident needs. The ADON or designee, will review 24-hour shift reports daily in order to identify and prioritize resident needs . An IJ was identified on 05/26/2023. The IJ template was provided to the facility on [DATE] at 5:50pm. While the IJ was removed on 05/29/2023, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner. PLAN OF REMOVAL F 773 Name of facility Date: 5/26/2023 Immediate action: The DON or designee immediately reviewed all residents with recent Diagnostic testing to ensure that timely follow up on results of diagnostic testing, and physician notification were implemented if needed. No other issues identified. This was completed 5/26/2023 The DON or designee immediately reviewed the 24 -hour nurse report to validate communication system is in use by licensed nurse to ensure continuity of care, treatment, and interventions as applicable. This was completed 5/26/2023 The DON or designee immediately validated that all licensed nurses were knowledgeable on location of fax machine designated to receive diagnostic results including frequency by providing in-service education. This was completed 5/27/2023. No licensed nurse will be allowed to work after 5/27/2023 until they have completed this education. The DON or designee provided 1:1 education with ADON and all charge nurses that failed to update the 24-hour report regarding the impending results of the stat X-Ray and for not following up on results timely. This was completed 5/27/2023. The DON or designee immediately validated that facility did not fail to notify physician regarding any recent diagnostic testing. This was completed 5/27/2023. Facilities Plan to ensure compliance quickly DON/designee began education Immediately with all licensed nurses on: Reviewing the 24-hour report in morning meeting Policy & Procedure: Diagnostic Tracking Guidelines Education with all licensed nurses including post-test Use of Diagnostic Tracking tool to have an effective system in place to monitor for STAT diagnostic/laboratory results for timely tracking of Diagnostic testing 7 days a week. All ordered diagnostic testing will be recorded on the tracking log in the 24- hour report book, and reviewed 3 times a shift by charge nurses/ADON until results are received and Physician notification of results. If stat results not received within 4 hours, physician will be notified for appropriate orders The lab tracking log will be reviewed in the daily morning meeting and on weekends by the weekend supervisor. Policy & Procedure: Abuse and Neglect Education with all licensed nurses including post-test Policy & Procedure: 24 Hour Report entry Guidelines Education to have a communication system in place to ensure timely continuity of care and interventions/treatment Policy & Procedure: Documentation Guidelines Education Policy & Procedure: Notification of Change in Condition Education including post-test Beginning 5/27/2023 DON or designee will provide this education to all licensed Agency staff, PRN staff, and new hires prior to working On 5/27/2023 the DON or designee will provide 1:1 education with the weekend supervision on all education to ensure oversight of systems on weekends This education began 5/26/2023 and will end 5/27/2023. Any licensed nurse who has not received this education and post-test will not be allowed to work until this is completed. The facility DON or designee conducted a root cause analysis on 5/27/2023 and will take to QAPI committee for review The facility's Medical Director was notified of the Immediate Jeopardy on 5/26/2023. On 5/27/2023 the facility will conduct an Ad Hoc QAPI meeting to review areas cited and plan for sustaining compliance. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 05/28/2023 at 1:45pm Weekend supervisor said she had been in-service in the following areas: abuse/neglect, handwashing, how to access all diagnostic testing by looking in the computer to review and track physician orders. The weekend supervisor said by looking at the tracker, she could see if the order had been processed that way, she could call the physician/doctor with the results in a timely manner. The weekend supervisor said she had also received in-service on receiving a verbal report using the 24-hour communication form from the unit nurses at the beginning of the shift and at the end of shift and her report would be provided to the ADON. The weekend supervisor said she had been in-serviced on all fax locations at the NF with the copy room being the fax machine for diagnostic results. Interview on 05/28/2023 at 1:50pm RN I worked the 6am-6pm shift said she had been in-service on the following: abuse/neglect, tracking ordered diagnostic testing in the system and checking to see if the physician was notified of the results, documentation on all diagnostic testing in PCC and that the physician was notified, shift reporting providing a verbal report are porting using the 24-hour communication form, and the location of the fax machines at the NF. Interview on 05/28/2023 at 2:03pm LVN E said she worked the 6am-6pm shift and had been in-serviced on all diagnostic testing, hand washing, abuse and neglect, notifying the physician in a timely manner on STAT diagnostic test results, checking on ordered diagnostic testing to ensure the order had been done and results provided to the physician, documentation, shift reporting using the 24-hour report form. Interview on 05/28/2023 at 2:15pm LVN S said she worked full time at the NF 6am-6pm shift. LVN S said she received in-service on abuse and neglect, how to track ordered diagnostic testing in the computer using the tracker, reporting the test results to the physician and notifying the RP as well, document care provided to the residents in the Nursing Progress Notes in PCC as well as documenting on the 24-hour communication form, location of the fax machines at the NF, shift to shift report using the 24-hour communication form. Interview on 05/28/2023 at 2:20pm LVN J said she worked the 6am-2pm shift and been in-serviced in the following areas: abuse and neglect, change in resident condition notifying and the RP, documentation, how to track all diagnostic testing using the tracker in the computer to see if the test had been done and reporting results to the physician, verbal shift to shift report with the 24-hour communication form, and location of fax machines with the test results being found on the fax machine in the copy room. Interview on 05/28/2023 at 8:55pm LVN G said she worked at the NF part-time 6pm-6am shift. LVN G said she had received in-service on abuse and neglect, communicating all diagnostic testing results to the physician in a prompt manner, verbal shift to shift reporting using the 24-hour communication form, and location of fax machines with the copy room being the fax machine for designated diagnostic test results, and being sure to document actions taken in the care of the resident in PCC and on the 24-hour communication form. Interview on 05/28/2023 at 9:02pm LVN K said she worked at the NF full time 6pm-6am. LVN K said she had been in-serviced on abuse and neglect, 24-hour communication shift to shift report, tracking STAT diagnostic testing as well as all diagnostic testing reporting to the doctor in a timely fashion, notifying the family when there is a change in the resident condition as well as the doctor, fax machine locations, and documentation. Interview on 05/28/2023 at 9:15pm LVN L said she worked at the NF full time on the 6:00pm-6am shift. LVN L said she had been in-serviced on location of the fax machines with the copy room being the designated fax machine for diagnostic testing, documenting when a resident experience a change in condition notifying the physician and the RP and what was done, being sure to document on the 24-hour communication form, using the 24-hour communication form when giving verbal shift to shift report, reporting all diagnostic testing results to the physician in a timely manner, how to use the tracker in the computer to track diagnostic testing, abuse and neglect. Interview on 05/28/2023 at 9:35pm LVN C said he had be in-serviced on reporting all diagnostic testing results to the doctor in a timely manner, documenting in PCC and on the 24-hour communication form relaying the information in shift report, documenting when there was a change in resident (s) condition, location of the fax machines, and how to track the results of ordered diagnostic testing in the computer. Interview on 05/29/2023 at 9:00am LVN H said he worked the 6:00pm-6:00am shift part time at the NF and been in-service in the following areas: abuse and neglect, timeliness of report STAT diagnostic testing results to the physician, following up on all diagnostic testing results by tracking the ordered test results in the computer, location of all fax machines at the NF and the one designated for diagnostic testing results, verbal shift to shift report using the 24-hour communication form, documenting in PCC (Nursing Progress Notes) actions taken regarding the care of the resident (s). On 05/29/2023 at 11:50am the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a [TRUNCATED]

Based on observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 3 of 15 residents (CR #1, Resident #2, Resident #3) reviewed for quality of care. 1. The facility failed to assess, identify and monitor CR#1's change in condition (low b/p , low O2 saturation, lethargy and frequent toileting ) for prompt intervention. 2. The facility failed to ensure CR#1's comprehensive assessment to include all vital signs and SBAR were checked following his change in condition. 3. The facility medication aides failed to notify nursing staff that CR#1 was not administered his hypertensive medications all day due to low blood pressures. 4. The facility medication aide, MA C, failed to notify the nurse that Resident #2 had elevated blood pressure so a comprehensive assessment could be completed. 5. The facility nurse, LVN D, failed to complete a comprehensive assessment on Resident #3 when she was notified the resident's blood pressure was elevated. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:15 PM. While the IJ was removed on [DATE] at 9:30 AM, the facility remained out of compliance at a scope of a pattern and severity of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for inadequate care, infections or decline in health. Findings include: Record review of CR#1's face sheet revealed a [AGE] year old male admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 was discharged on [DATE]. Record review of CR#1's MDS, dated [DATE], revealed CR#1 had a BIMS of 13, which meant he had little to no cognitive impairment. CR#1 required supervision and set up for transfers and toilet use. CR#1 required total dependence for bathing with two-person support. CR#1 required wheelchair for mobility. Record review of CR#1's physician orders, dated ,d+[DATE], revealed [MEDICATION(S)] tablet 10 MG, Give 1 tablet by mouth in the morning for [CONDITION(S)] Hold for SBP < 120, start date [DATE];[MEDICATION(S)] HCL tablet 25 MG, give by mouth every 8 hours for [CONDITION(S)] hold if SBP < 120 start date [DATE];[MEDICATION(S)] tablet 20 MG Give 20 MG by mouth in the morning for [CONDITION(S)], hold if SBP < 120 or HR < 60, start date [DATE];[MEDICATION(S)] [MEDICATION(S)] tablet 50 MG Give 50 MG by mouth every 12 hours for [CONDITION(S)], Hold for SBP < 120,start date [DATE] . Record review of CR#1's MAR dated ,d+[DATE] revealed the following: -On [DATE] CR #1's BP was ,d+[DATE] at 9:00 AM. CR#1 was not administered [MEDICATION(S)] tablet 10 mg. -On [DATE] CR #1's BP was ,d+[DATE] at 9:00 AM. CR#1 was not administered [MEDICATION(S)] tablet 20 mg. -On [DATE] CR #1's BP was ,d+[DATE] at 9:00 AM. CR#1 was not administered [MEDICATION(S)] [MEDICATION(S)] tablet 50 mg. - On [DATE] CR #1's BP was ,d+[DATE] at 9:00 PM. CR#1 was not administered medication [MEDICATION(S)] [MEDICATION(S)] tablet 50 mg. On [DATE] CR #1's BP was ,d+[DATE] at 12:00 AM. CR#1 was not administered [MEDICATION(S)] HCL tablet 25 mg. On [DATE] CR #1's BP was ,d+[DATE] at 8:00 AM. CR#1 was not administered [MEDICATION(S)] HCL tablet 25 mg. On [DATE] CR #1's BP was ,d+[DATE] at 4:00 PM. CR#1 was not administered [MEDICATION(S)] HCL tablet 25 mg. Record review of CR#1's Care Plan, dated [DATE], revealed CR#1 had hypertension and was at risk for fluctuations in blood pressure. Staff were to administer antihypertensive medications as ordered, monitor for side effects such as [CONDITION(S)], headache, [CONDITION(S)], chest pain, and decreased heart rate ([CONDITION(S)]). Staff were to monitor/document/report to physician as needed any signs or symptoms of malignant hypertension: headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, [CONDITION(S)], or difficulty breathing. Staff were to monitor for [CONDITION(S)] and document when present and notify physician of changes in severity of [CONDITION(S)] as needed. CR#1 used oxygen therapy routinely or as needed and was a risk for ineffective gas exchange. This was related to dx of [CONDITION(S)] and heart failure. Staff were to administer medications as ordered by the physician and monitor/document any side effects and effectiveness. Staff were to administer oxygen therapy per physician's order and monitor for signs and symptoms of respiratory distress and report to the physician as needed. Record review of CR#1's Progress Notes, dated [DATE] at 2:08 PM, revealed .resident complaining of episodes of SOB , O2 sats at 92% on RA , new order noted per NP .to begin O2 at ,d+[DATE]L PRN for episodes of SOB and to obtain CXR to rule out abnormalities, O2 initiated, sats increased to 98% on 2 liters with no distress noted, will continue to monitor, attempted to notify family contact .per telephone to inform of new orders, no answer left message requesting call back, will continue to monitor . Written by Treatment Nurse Record review of CR#1's Progress Notes, dated [DATE] at 12:05 AM, revealed .Resident was found on the floor, at the entrance of his toilet door. Face down, he was assessed head to toe, he said that he did not hit his head. No bruises noticed. His O2 was 87 with nasal canola and ,d+[DATE] with Non breathable. And 911 was called, resident was sent to the ER . Response: BP ,d+[DATE] PULSE 60 BS 120 . Written by LVN A In an interview on [DATE] at 12:52 PM, the Treatment Nurse stated on [DATE] MA A reported CR#1 had shortness of breath. CR#1 did not seem like he was in any distress, he said he had a previous order for O2 before. CR#1 did not have an order in the system, so she called the NP to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP ordered a chest x-ray which was routine and was not a stat order. She was not sure if the chest x-ray was completed . In an interview on [DATE] at 1:08 PM, MA A stated she was passing medication when she noticed CR#1 had problems breathing so she went to get the nurse . The nurse went to get O2 for CR#1 his O2 stat was 92%. When she came back later, CR#1 was sitting in his wheelchair and CR#1 stated he was okay. She stated the respiratory distress occurred between 9:15 AM to 9:30 AM she remembered because she was signing off on his medications. She went back at 1:00 PM to administer medications to the roommate and she saw CR#1 and he was fine. In an interview on [DATE] at 3:09 PM, CNA A stated she helped staff clean up CR#1 after his fall on [DATE]. She had to help hold the resident up because he was so weak. She had to hold his legs up to help clean him up and give him a bed bath. CR#1's brief was full of BM . He did not usually use the bathroom on himself and went to the bathroom. CNA B told LVN A CR#1 was weak. CR#1 usually did things for himself. The CNA A and CNA B gave CR#1 a bath around 8 PM. She did not witness CR#1's fall that night. He fell around 9 PM. His O2 stat dropped after the fall and he was treated by LVN A. CR#1 went to the hospital around 11 PM . In a telephone interview on [DATE] at 5:38 PM, LVN A stated when she did rounds around 6pm on [DATE], CR#1 was sitting in his wheelchair watching television. Later she saw his call light on, went and saw him on the toilet and she cleaned him and put him in his chair. Later that night his light was on again while she was taking care of another resident. When she went into the room, she found CR#1 on the floor and she called for help. She asked CR#1 if he was okay. CR#1 told her he was trying to stand up and fell . She checked CR#1's head, he reported he did not hit his head. She then started to do more assessments on him. CR#1 was transferred from the wheelchair to the bed. His O2 stat was low so she called the NP. CR#1 received O2 via nasal cannula, so it was changed to non-rebreather mask. The nurse aides helped clean him up. The NP told her to monitor him but since he was breathing with his accessory muscles, she called 911. She had checked on him three times during her shift and completed checks on his blood sugar. She was not aware CR#1 was weak that night or when he had a bath, CR#1 was cleaned up after the fall. She was not aware of any issues during the shift. CR#1 did have three BM's during her shift and needed help. He usually did things for himself . In an interview on [DATE] at 3:25 PM, CNA B stated CR#1 was always continent. LVN A told her she helped CR#1 in the bathroom earlier and he had diarrhea. CR#1 fell around 9 PM or 10 PM . She had to help clean up CR#1 after he had his fall. CR#1 had BM all over him. The nurse aides had to give him a bed bath. In an interview on [DATE] at 3:46 PM, MA B stated CR#1 was okay when she worked with him on [DATE] during the 2 PM to 10 PM shift. CR#1's blood pressure was low , and he was not given his blood pressure medication. CR#1's did not show any other adverse symptoms or was sick. She went to administer his medication around 9:00 PM . She thought the nurse knew his blood pressure was low. She could not remember if she reported it to the nurse. Medication Aides were supposed to tell the nurse when a resident's blood pressure was low. She did not know CR#1 was sick because nobody reported that to her. She did not usually work with CR#1. In an interview on [DATE] at 3:55 PM, MA A stated if a resident's blood pressure was below the parameter their medication was withheld. She did not report to the nurse that CR#1's blood pressure was below the parameters and he was not given his blood pressure medications . She was giving out medications and noticed CR#1 could not breath, during the excitement she forgot to mention CR#1 was not given his blood pressure medications because of his blood pressure . She worked with him during the 6 AM to 2 PM shift. In an interview on [DATE] at 4:05 PM, the DON stated the medication aides were supposed to inform the nurses when a resident missed a medication and if vitals were below the parameters, so an assessment could be completed on the resident. The physician may need to be notified based on the assessment. She was not aware of the situation with CR#1. She had been working with the staff on these issues and in-serviced them. It was important to notify the physician so the resident could get proper treatment and care . In an interview on [DATE] at 5:09 PM, LVN A stated she was not aware CR#1 was not given his medications. The nurse aides were busy, so she had to clean CR#1 up while he was on the toilet a few times during the shift. She did notice there was some loose stool on the toilet, but she did not get to see his BM because he had flushed the toilet when she came to help clean him. She was not sure if the resident had diarrhea. She did not call the physician because she did not see his stools. CR#1 was found face down later that night near bathroom. His O2 stats were low and he was breathing with his accessory muscles . CR#1 went to the hospital and 6 hours later she was informed he expired. In an interview on [DATE] at 2:59 PM, NP A stated she was not aware CR#1's blood pressure was below the parameters and he was not given his blood pressure medication on [DATE]. CR#1's blood pressure was usually high. On [DATE] she received a call about CR#1's O2 stat being 92% and he had shortness of breath. He had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He was fine that day. She ordered a chest x-ray for the resident to determine if he had any heart failure, staff did not call her back with anything. He was just seen by the physician the day before and [MEDICATION(S)] was ordered for his [CONDITION(S)]. The nurses would use their nursing judgement to determine when to call her. Depending on CR#1's signs and symptoms after assessment she could determine a treatment plan. If they had any questions they should have called. She was called around 12 PM that day regarding CR#1's shortness of breath. In an interview on [DATE] at 11:15 AM, the Treatment Nurse stated she was not aware CR#1's blood pressure was below the parameter and he did not get his medications. In an interview on [DATE] at 12:18 PM, the Physician stated CR#1 was on a diuretic medication for his [CONDITION(S)], in the past he would be non-compliant. He had some shortness of breath on [DATE] and a chest x-ray was ordered, he was sent to the hospital after the fall. He was not aware of him not getting any hypertensive medications due to his blood pressure being below the parameters, it was good they did not give them due to his blood pressure being below the parameters. The facility may have told the NP. She gave the order for the O2 and chest x-ray after his shortness of breath . In an interview on [DATE] at 4:02 PM, LVN C stated if a resident had shortness of breath, she would apply O2 and send them out to the hospital if they did not have a history of SOB. The nurse would complete a full assessment on the resident. The nurse would call the physician to see what orders they wanted to implement or if they wanted to send the resident out . A lot of the nurses at the facility didn't completed full assessments. They just said the person was always like that or that was just a behavior . In an interview on [DATE] at 4:10 AM, LVN B stated if a resident had SOB the nurse was supposed to get vital signs, complete an assessment and call the NP . If the situation was critical then they called 911 and told the NP. Staff were supposed to complete an SBAR . If a resident was sent out by 911 then the nurse would not do an SBAR. In an interview on [DATE] at 4:15 PM, the DON stated depending on the resident if they had SOB the nurse would do a full assessment. The nurse would complete a full set of vitals . The nurses may not know what a full assessment meant being that they were LVN's. The nurses needed to call the physician and have the vitals ready to communicate them to the physician . Record review of CR#1's Clinical Records revealed there was not SBAR Assessment or comprehensive assessment completed for CR#1's shortness of breath (SOB) on [DATE]. Record review of CR#1's Hospital Records, dated [DATE] revealed .the patient was brought to the ER via ambulance from .SNF with altered mental status, [CONDITION(S)] on his bilateral lower extremities, and an unwitnessed fall at the facility according to the staff, the patient has been altered for approximately 20 minutes .BP ,d+[DATE] Temperature 90.3 F .pulse 57 bpm .respirations 30 .SpO2 93% .Clinical impression .Severe septic with shock, altered mental status and acute cardiovascular failure, respiratory failure and renal failure, adult failure to thrive, acute generalized weakness, [CONDITION(S)] of the right lower leg and left lower let (groin and pannus), acute urinary tract infection with [MEDICATION(S)] and hematuria associated with indwelling catheter, moderate hypothermia with [CONDITION(S)], no hypothermia secondary to immersion or exposure, [CONDITION(S)] . Record review of Resident #2's face sheet revealed a [AGE] year old male admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's MDS, dated [DATE], revealed Resident #2 had a BIMS of 14, which meant he had little to no cognitive impairment. Record review of Resident #2's Care Plan, dated [DATE], revealed Resident #2 had hypertension and was at risk for fluctuations in blood pressure. Staff were to administer antihypertensive medications as ordered, monitor for side effects such as [CONDITION(S)], headache, [CONDITION(S)], chest pain, and decreased heart rate. Staff were to check vital signs as ordered and as needed. Check blood pressure prior to the administration of antihypertensive medications. Record review of Resident #2's Physician Orders, dated ,d+[DATE], revealed .[MEDICATION(S)] HCL tablet 50 MG give 1 tablet by mouth three times a day related to essential primary hypertension .give every 8 hours .start date [DATE] Record review of Resident #2's Medication Administration Record, dated [DATE], revealed .[MEDICATION(S)] HCL tablet 50 MG give 1 tablet by mouth three times a day related to essential primary hypertension .give every 8 hours start date [DATE] . Administration times 1:00 AM, 9:00 AM, and 5:00 PM. On [DATE] for 5:00 PM Resident #2's B/P was ,d+[DATE] and his Pulse was 96 . Observation on [DATE] at 3:05 PM revealed Resident #2 laid in bed and received O2 via nasal cannula at 2 ,d+[DATE] liters. During medication pass MA C administered [MEDICATION(S)] 50 mg tab , [MEDICATION(S)] HCL administered once in each eye once . In an interview on [DATE] at 3:08 PM, MA C stated Resident #2's blood pressure was high , so it was okay to give him his blood pressure medications early. She stated she would report this to the nurse. In an interview on [DATE] at 4:36 PM, LVN D stated she was not aware Resident #2's B/P was elevated. Normally if a resident's blood pressure was high, she looked at orders, then called the physician to see if they wanted to give a one-time order of the medication. She did an assessment on the resident after the medication was given , she went back 30 minutes after to see if the medication worked. She did not have to do an assessment before. The facility trusted the medication aides' vitals , so she just did the assessment after the medication was administered. In an interview on [DATE] at 4:45 PM, MA C stated the staff could give a medication one hour before or after. If the B/P was high the staff spoke with the nurse and the nurse would advise the medication aide if the medication could be given early . She understood it was given early and she did not call to tell the nurse Resident #2's B/P was elevated and it was her mistake . Resident #2's B/P was always high the nurses told the medication aides to give the medication early if the blood pressure was high. She was just going off of previous instructions . Record review of Resident #3's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's MDS, dated [DATE], revealed she had a BIMS of 15, which meant she had no cognitive impairment. Record review of Resident #3's care plan, dated [DATE], revealed Resident #3 had hypertension and was at risk for fluctuations in blood pressure. Staff were to administer antihypertensive medications as ordered and monitor for side effects such as [CONDITION(S)], headache, [CONDITION(S)], chest pain, and decreased heart rate. Staff were to check vitals as ordered and as needed. Check blood pressure prior to administration of antihypertensive medications. Staff were to monitor/document/report to the physician as needed any signs or symptoms of malignant hypertension: headache, visual problems, confusion, disorientation, lethargy, nauseas, and vomiting, irritability, [CONDITION(S)] or difficulty breathing. Record review of Resident #3's physician orders, dated ,d+[DATE], revealed .[MEDICATION(S)] HCL Tablet 25 mg give 1 tablet by mouth two times a day related to essential (primary) hypertension .Hold for SBP < 120 or HR < 60 .start date [DATE] .[MEDICATION(S)] tablet 20 mg give 1 tablet by mouth two times a day related to essential (primary) hypertension .Hold for SBP < 110 or HR < 60 .start date [DATE]. Record review of Resident #3's medication administration record dated ,d+[DATE] revealed .[MEDICATION(S)] HCL Tablet 25 mg give 1 tablet by mouth two times a day related to essential (primary) hypertension .Hold for SBP < 120 or HR < 60 .start date [DATE] Administration times 10:00 AM, 6:00 PM. There was no documentation for medication administration on [DATE] for [MEDICATION(S)] HCL at 6:00 PM. Record review of Resident #3's medication administration record, dated ,d+[DATE], revealed .[MEDICATION(S)] tablet 20 mg give 1 tablet by mouth two times a day related to essential (primary) hypertension .Hold for SBP < 110 or HR < 60 .start date [DATE] Administration times 10:00 AM, 6:00 PM. There was no documentation for medication administration on [DATE] for 6:00 PM. Observation on [DATE] at 3:19 PM revealed Resident #3 laid in bed, the residents B/P was taken lying down in bed, her blood pressure was ,d+[DATE] and her pulse 74 bpm which was taken by MA C. In an interview on [DATE] at 3:20 PM, MA C stated Resident #3's blood pressure was high and she would notify the nurse to see if she could get the medication early . Observation and interview on [DATE] at 3:34 PM, LVN D was observed to ask Resident #3 was she okay from the doorway and left the room without doing an assessment. LVN D stated the physician gave permission for a one-time administration of [MEDICATION(S)] 25 mg for Resident #3, the order would be changed to 3 times a day . Observation on [DATE] at 3:35 PM revealed MA C administered [MEDICATION(S)] 25 mg and [MEDICATION(S)] 20 mg during medication pass. In an interview on [DATE] at 4:36 PM, LVN D stated Resident #3 had a one-time order for [MEDICATION(S)] 25 mg. The policy at the facility was for medication to be given either an hour before or an hour after. The physician did not give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility trusted the medication aides' vitals , she just did the assessment after the medication was administered. In an interview on [DATE] at 5:01 PM, the ADON stated staff were able to give the medication an hour before or an hour after the administration . If the medication was given early the nurse was supposed to call the physician first. If the B/P was high the nurse would ask when the B/P was taken and check orders, administer medication then do an assessment for effectiveness. Policy wise he was not sure if the nurse did an assessment after they were made aware a resident's B/P was elevated. The nurse would ask the medication aide the B/P, if they said the person was sweating then the nurse would do an assessment . In an interview on [DATE] at 5:08 PM, MA D stated the facility policy was for a medication to be given an hour before an hour after the administration time. If the resident wanted the medication early, she would inform the nurse. If the B/P was high the medication aide notified the nurse to find out if a PRN could be given or what instructions should be given. In an interview on [DATE] at 5:25 PM, LVN E stated if the MA did B/P checks and it was elevated they reached out to the physician. The nurse should go to the room do an assessment and give the physician a report and follow on whatever orders were given . If a one-time dose was given, then the nurse did a follow up assessment. The staff went to the MAR and viewed what time the medication was given to determine when it needed to be administered. In an interview on [DATE] at 5:35 PM, the DON stated the staff could administered the medication one hour after or before the medication could be administered or given. If the MA told the nurse the B/P was elevated the nurse needed to assess the resident first, then the nurse would notify the physician so they could receive orders and follow the physician orders. After the medication was given then the staff would follow up with an assessment. All the staff had been trained when to give a medication per the time it was scheduled, the time to give a medication was documented on the MAR . Record review of the facility policy titled Physician Monitoring Orders, dated [DATE], revealed . Residents' health conditions are monitored and physicians are updated about change in health status . The Licensed Nurse participates in the evaluation process identifying and reporting any alterations in patient responses to therapeutic interventions in comparison to expected outcomes . Monitoring means to observe and check the progress, to keep under systematic review, to report patient response (especially when expected outcomes show patient progress in not improving) .When receiving a physician order to monitor a resident change in condition , clarify the patient monitoring order with directions; include guidance to explain the physicians' order Record review of the facility policy titled Vital Signs, dated [DATE], revealed . 5. Nurse Aides and Med Aides report to the Nurse vital signs that require physician notification .6. The Nurse notifies Physician if vital signs are abnormal for the patient or as ordered by the physician Record review of the facility policy [CONDITION(S)] Management, dated ,d+[DATE], revealed .It is the policy of this facility to provide emergent care for residents who experience seizures to prevent or minimize serious injuries, maintain a patent airway and to minimize complications .Seizures are defined as a sudden alteration in normal brain activity that causes distinct changes in behavior and body function . 11. Provide oxygen during the [CONDITION(S)] in color changes. Observe entire body, type and progression of body movements (tonic or clonic) and specific area(s) of the body involved .12. Monitor vital signs and neurological signs. 13. Notify physician. 14. Reassesses resident's environment . Record review of the facility policy titled Notification of Changes, dated [DATE], revealed .To provide guidance on when to communicate acute changes in status to MD, NP , and /responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: 3. A significant change in physical, mental or psychological status of the resident .Policy Explanation and Compliance Guidelines .6. The facility documents resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurses Progress Note or Telephone Order Form (physician/family notice) as appropriate . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:15 PM. The The Administrator and the DON were notified. The DON was provided with the IJ template on [DATE] at 4:32 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 4:49 PM: Plan of Removal An audit of the medication administration records was completed by the DON/designee on [DATE] to identify antihypertensive medications and all Residents were evaluated and assessed for change of condition on [DATE] by the Clinical Team which included the /Regional Nurse Consultant/DON/ADON/MDS Nurse. Any resident on antihypertensive medication with omissions or with blood pressures outside the parameters: o The DON/designee will complete a resident evaluation for change of condition using the Physical Evaluation tool [DATE]. o The physician will be notified by the DON/designee if there is a change of condition using the Interact protocols with specific signs and symptoms observed. o A Medication Error report will be completed The DON /designee will provide training to the Nurses and Nurse aides on the following topics and a post test will be completed: a) Clinical Practice Guideline: Notification of Change of Condition a. Nurse aides were educated on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. Communication will be evidenced by the Nurse aides documenting in Point of Care assessment tool via the Kiosk of their observations to the Nurse. The DON and Administrator will ensure 100% compliance each day of their observations to ensure effective communication to Licensed Nurses of their observations. b. The Nurses will use the Interact Change of Condition When to report to MD/NP/PA for any observation noted out of normal parameters. The Nursing team will call the MD/NP/PA and additionally also have available (Telehealth) 6p-6a and on weekends for additional and immediate assessment using the Interact S-Bar and Inter-act - Change of Condition. b) Clinical Practice Guideline: Following Physician Orders/Monitoring. All nurses will be re-educated on our policy of following Physician Monitoring orders. The Licensed Nurse participates in the evaluation process identifying and reporting any alterations in patient responses to therapeutic interventions in comparison to expected outcomes. Monitoring means to observe and check the progress, to keep under systematic review based on the physician parameters. c) Clinical Practice Guidelines: Vital Signs The Nurse (Nurse A) was re-educated one on one for failure to document her assessment appropriately. The Nurse (Nurse B) re-educated one on one of the 'comprehensive assessment' that would have included an Interact S-Bar, vital signs and continued monitoring. The Medication Aide who was aware of change in blood pressure with parameters but did not report it to the nurse was suspended pending investigation on [DATE]. All Nurses and Medication Aides will be educated on the importance of reporting vitals outside normal limits started on [DATE] by the DON. All medications with Physician orders to monitor parameters will have a specific order on the Medication Administration Record to call the Physician based on his pre-established parameters for Nurses to report to the MD/PA/NP. Specifically, when a BP is outside of normal parameters with an order to notify the Physician the Nurse will clearly verbalize /determine the residents name, room number, and diagnosis. Where there are no specific parameters to monitor the Nurses will follow the Interact 4 protocol for blood pressure. The nurse will first recheck the b/p using a manual apparatus blood pressure cuff to ensure accuracy and report observation. The nurse will specifically: Repeat any prescribed orders back to the physician or health care provider. Use clarification questions to avoid misunderstandings. Enter the order into the medical record. Write a telephone order or verbal order including date, time, name of the resident, the complete order and sign the name of the physician or Health Care provider and Nurse. Transcribe order on appropriate documents MAR/TAR /24 Hour report. The Physician will sign the order on his or her next visit or within regulatory timeframes. Finally, follow-thru with new order by making appropriate observations contact or notify lab or pharmacy Re-educate the Clinical Team on Improving Nursing Communication from shift to shift by the following: Use of 24-Hour Report and or Crisis Charting with identified Change of Condition and monitoring on relevant information which include change of conditions and assessment need. Nurses going off duty will review residents on 24-

Based on interview and record review the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status, that was a deterioration in health, mental, or psychosocial status in either a life threatening condition or clinical complications for 1 of 15 residents (CR#5) reviewed for resident rights. The facility failed to ensure CR#5's physician was notified when there was a change in condition on 08/27/21 after CR #5 had a [CONDITION(S)]. An Immediate Jeopardy (IJ) was identified on 10/28/21 at 1:59 PM. While the IJ was removed on 10/30/21 at 2:28 PM, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for delays in life saving treatments and care which could result in clinical complications and/or death. Findings include: Record review of CR#5's face sheet revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#5 was discharged on [DATE] . Record review of CR#5's MDS, dated [DATE], revealed CR#5 had a BIMS of 2, which meant he had severe cognitive impairment. CR#5 required limited assistance with one-person physical assist with bed mobility and transfers. Record review of CR#5's Physician Orders, dated 08/26/21, revealed .[MEDICATION(S)] tablet 1000 mg ([MEDICATION(S)]) give 1 tablet by mouth two times a day related to [CONDITION(S)]. Start date 07/24/2021 Record review of CR#5's care plan, dated 09/23/19, revealed he had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to administer medications and anticonvulsants as ordered and monitor and document for effectiveness and side effects. Staff were to obtain, and monitor lab work and diagnostic test as ordered then report the results to the physician when available and follow up as needed. Staff were to monitor for warning signs prior to seizures and notify the physician of [CONDITION(S)] activity. After a [CONDITION(S)] staff were to turn resident on side with head back, hyper-extended to prevent aspiration, keep airway open after [CONDITION(S)], measure vital signs, complete neuro checks, and notify physician. Monitor for [CONDITION(S)], headache, altered loss of consciousness, paralysis, weakness and pupillary changes. Record review of CR#5's Progress Notes, dated 07/15/21, revealed .Nursing Note Data: Fall Action: This writer was notified of patient laying on the floor by another staff. Upon entering Patient's room, noted patient lying on his stomach in front of his bed, losing consciousness, with his body stiffed and jerking movement of extremities for 1 minute and clenching his teeth. Patient unable to explain what happened. Writer with other staff members slowly roll him over on the left side, with w/c hair removed out of the way. Nurse's assessment done after episode of Jerking stopped. V/S checked respiration 21, HR , 76, B/P 151/86, T -97.0, O2 sat 99 via room air. He was assisted to bed by 4 staff . No Visual injury noted this time, he denies pain. Roommate stated he fell from his w/c to the floor, while having a jerking movement. RP notified, NP called spoken with on the phone, received order to transfer patient to .Hospital .for further Eval due to fall with head hitting the floor. FMR transport called, was told P/U will be in 30 min . He is currently lying in bed with even and unlabored breathing, watching TV. Response: He is transported to the Hospital . Record review of CR#5's hospital records, dated 07/15/21, revealed he was diagnosed with subdural hematoma, history of [CONDITION(S)] disease, history of craniotomy, diffuse focal neurological deficit, history of kidney disease, personal history of fall, [CONDITION(S)], and [CONDITION(S)] . Record review of CR#5's progress note, dated 08/26/21, revealed .Staff alerted by resident's roommate that resident had a [CONDITION(S)] and fell from his bed and onto the floor. Upon assessment resident noted to have bleeding from his left brow and top of his scalp. Resident alert and showed no s/s of pain or distress. Resident non-verbal but does make eye contact when spoken too. Due to resident's history of seizures, head injury and inability to verbalize pain or discomfort, 911 notified for transport at this time. DON and administrator in facility and aware of incident. Resident's . notified of incident and transfer. EMT personnel arrived in facility at approximately 1155 and transported resident to .hospital- .without incident. PCP notified of incident and transfer at this time. Spoke with .at .ER and notified of transfer. No further issues noted at this time . Written by LVN C Record review of CR#5's progress note, dated 08/27/21, revealed .Data: Alerted by therapist that resident was having a [CONDITION(S)]. Action: Approached resident's room and monitored resident laying in bed. Safe without any noted injury. [CONDITION(S)] activity lasted less than 1 minute. Response: Resident monitored. V/S stable. Resident alert and left resting in bed. Called hospital lab to request results from resident's [MEDICATION(S)] level from yesterday's ER visit. Will increase monitoring. Call light left within reach . Written by LVN C Record review of CR#5's clinical records revealed there was not an SBAR completed after his [CONDITION(S)] on 08/27/21. Record review of CR#5's progress note, dated 08/31/21, revealed .Data: Resident's .requested resident not go to .hospital . Notified .NP who gave order to go to . Called ER and gave report to . FMR updated for transfer details. Returned called to daughter to update with hospital details Written by LVN C Record review of CR#5's SBAR, dated 08/31/21, revealed .Situation .1. The change in condition, symptoms, or signs I am calling about is/are AMS , [CONDITION(S)] .2. This started on: 08/30/2021 .8. Other relevant information: Lethargic. Usually non-verbal but ability to make gestures and cues. Not attempting either at this time .Background .1. Mental Status Changes .1d. decreased consciousness (sleepy, lethargic) .Assessment (RN ) or Appearance (LPN ) .LPN .Multiple [CONDITION(S)], AMS .Request .1b. Lab work .1f. Transfer to the hospital .2. Nursing Notes .Notified PCP of change received order to send to ER for evaluation and tx . Notified . of change and transfer. FMR called and requested to transfer to hospital .Report called to .ER. Awaiting transport at this time .called and notified of facility and time . There were not vitals documented for 10/31/21. Written by LVN C Record review of CR#5's clinical records revealed CR#5 did not have any documented neuro-checks on 08/27/21, 08/28/21, 08/29/21 and 08/30/21. Record review of CR#5's clinical records revealed CR#5 did not have any documented follow up assessments on 08/27/21, 08/28/21, 08/29/21 and 08/30/21 . Record review of CR#5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#5's death certificate, with an issue date of 09/21/21, revealed CR#5's cause of death was complications of [MEDICATION(S)] head trauma . In an interview on 10/06/21 at 11:59 AM, LVN C stated she was on floor when CR#5 had the fall on 08/26/21 after a [CONDITION(S)]. CR#5 was non-verbal, had a small laceration on the head, she sent him out to hospital immediately. His [MEDICATION(S)] levels were checked at the hospital and he had a CT scan on 08/26/21. It looked like he hit his head on the dresser next to his bed during the fall on 08/26/21. CR#5's bed was in the low position during the fall on 08/26/21 . CR#5 was a very tall man and when he started having seizures he would fall over. She would check on him to make sure he was in a low position during the shift. She called the hospital on 8/27/21 for [MEDICATION(S)] level and they were in the therapeutic range. CR#5 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 10/06/21 at 12:15 PM the DON stated CR#5 had a fall and was bleeding so he was sent out 911 to be evaluated on 08/26/21 . He was sent back to the facility , all his tests were negative. CR#5 was not responding appropriately so he was sent out again on 08/31/21. During the fall on 08/26/21 his bed was in the lowest position. He would not have fallen out of bed, if he did not have a [CONDITION(S)]. He did not have any fractures . In a telephone interview on 10/26/21 at 4:30 PM, LVN C stated she thought she completed an assessment and documented the vitals when CR#5 was sent to the hospital on 08/31/21. She did complete an SBAR. The documentation maybe on paper or his Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#5 was sent out to the hospital for a non-medical emergency. On 08/27/21 CR#5 had a [CONDITION(S)]; she did an assessment but was not sure where the documentation was. She thought she called the NP regarding the [CONDITION(S)] on 08/27/21. The nurse on duty that night before CR#5 was sent out was LVN A, she did several vitals on him the night of 08/30/21. In a telephone interview on 10/26/21 at 4:57 PM, LVN A stated she did vitals on CR#5 the morning before he left to the hospital on 08/31/21. He was not his normal self and she told the on-coming nurse, LVN C, he was not his normal self. The vitals were normal. When she came onto her shift CR#5 was in bed and she did not wake him up. CR#5 was sent out to the hospital on the morning shift on 08/31/21. She went into the room to give his roommate medications and CR#5 was sleep at the time during her shift. CR#5 usually fist bumped with her in the morning, but he did not respond and was not his normal self. She did do vitals on him on 08/27/21 when she was awaiting on the labs from the hospital for his [MEDICATION(S)] levels when he fell on [DATE] . She did not know where the vital were located for 08/31/21. In an interview on 10/26/21 at 5:18 PM, the DON stated if a resident had a [CONDITION(S)] staff were to protect the resident , take vitals, notify the physician , call 911 if the [CONDITION(S)] did not stop. If the resident was not sent out to the hospital by 911 then they would do an SBAR. That was the communication tool to give the physician all the information to possibly get new orders or labs. The physician would make the call if the person needed to be sent out. In an interview on 10/27/21 at 12:15 PM, NP B stated she was not contacted on 08/27/21 regarding CR#5's [CONDITION(S)]. Based on the resident's condition and vitals she would have instructed the facility to give a one-time dose of [MEDICATION(S)], order labs for [MEDICATION(S)] level, or send out to the hospital if the resident had continuous seizures. If the resident was stable, then the nurse would monitor the vitals. She was notified of the seizures on08/26/21 and 08/31/21 , she had the resident sent to the hospital. It was reported CR#5 had another [CONDITION(S)] and was lethargic on 08/31/21. Record review of CR#5's hospital records, dated 08/31/21, revealed CR#5 was diagnosed with subarachnoid hemorrhage, seizures, and COVID-19. Record review of the facility policy titled [CONDITION(S)] Management, dated 12/2007, revealed .13. Notify physician. 14. Record review of the facility policy titled Notification of Changes, dated 07/13/15, revealed .To provide guidance on when to communicate acute changes in status to MD, NP, and /responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: 3. A significant change in physical, mental or psychological status of the resident . 6. The facility documents resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurses Progress Note or Telephone Order Form (physician/family notice) as appropriate . This was determined to be an Immediate Jeopardy (IJ) on 10/28/21 at 1:59 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on 10/28/21 at 2:11 PM. The following Plan of Removal was submitted and accepted on 10/29/21 at 11:35 AM: All Residents with a fall in the last 30 days and residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . o The physician will be notified by the DON/designee if there is a change of condition using the Interact protocols with specific signs and symptoms observed. o The DON/designee will complete a resident bedside environment evaluation on residents with falls in the last 30 days including those with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] o The Fall Risk Assessment will be reviewed, evaluated for additional interventions to help reduce falls and injury during a fall. The at Risk for Falls care plan will be updated by the DON/designee. The DON /designee will provide training to the Nurses and Nurse aides on the following topics and a post test will be completed: a) Clinical Practice Guideline: Notification of Change of Condition in-services completed on 10/22/2021 and 10/23/2021 a. Nurse aides were educated on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. Communication will be evidenced by the Nurse aides documenting in Point of Care assessment tool via the Kiosk of their observations to the Nurse. The DON and Administrator will ensure 100% compliance each day of their observations to ensure effective communication to Licensed Nurses of their observations. b. The Nurses will use the Interact Change of Condition When to report to MD/NP/PA for any observation noted out of normal parameters. The Nursing team will call the MD/NP/PA and additionally also have available Third Eye Health (Telehealth) 6p-6a and on weekends for additional and immediate assessment using the Interact S-Bar and Inter-act - Change of Condition. b) Clinical Practice Guideline: 1) Accident and Supervision Policy 2) Post Fall Interventions All licensed nurses and nurse aides will be in-serviced on identifying hazard(s) and risk(s), evaluating and evaluating hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s) and monitoring for effectiveness and modifying interventions when necessary. The Regional Nurse and Clinical Leadership DON/ADON or designee will conduct the training for identifying hazards and potential risk. Physical Therapy will screen and evaluate falls and Equipment as part of IDT in post fall assessment. Maintenance will evaluate hazards as part of Post Fall Assessment with the inter-disciplinary team and review systemic concerns as part of monthly QAPI . The Nurses will be trained on immediate post fall interventions to consider during the bedside evaluation to prevent the reoccurrence of falls. The immediate intervention is used to update the care plan by the licensed Nurse. The licensed Nurse communicates the immediate intervention to the nurse aide and enters the intervention on the 24 Hr . Report. o The post fall interventions will be evaluated by the DON/designee who will individualize the care plan based on resident diagnoses, assessment, individual needs and physician orders. o After each fall the DON/designee reviews and evaluates the Fall Evaluation and updates based on the individualized assessment. o The DON/designee update the Resident Care Tool with post fall interventions based on physician orders, diagnosis, assessment and individualized needs of the resident. c) Clinical Practice Guidelines: Vital Signs, Documentation Guidelines, Neuro Check Policy All nurses will be in-serviced on the guidelines for the measurement, reporting of vital signs. documentation of an assessment related to change of condition. Neuro checks protocol training for residents that experience head trauma will be completed for the nurses by the DON/designee. d) [CONDITION(S)] Care All nurses and nurse aide will be in serviced on the important steps to help someone who is having any type of [CONDITION(S)] by the DON/designee. The steps are a protocol that will be used to individualize the care plan of a resident with a [CONDITION(S)] diagnosis. o Stay with the person and call for help o Send first responder to call 911 o Ease the person to the floor if standing o Turn the person gently onto one side to help breathing. o Clear the area around the person of anything hard or sharp to prevent injury o Take off their eyeglasses. o Loosen ties or anything around their neck that may make it hard to breathe. o Try to time the [CONDITION(S)]. o Notify the physician (included in physician change of condition notification) Individualized [CONDITION(S)] interventions are communicated to the nurse aides using the Resident Care Tool. The DON/ADON review and update the Resident Care Tool based on physician orders, resident change of condition and intervention discussed during the IDT Facility Morning Meeting e) Residents with a change of condition including falls will be reviewed in the Morning IDT Meeting with a follow up discussion by the IDT Team about the resident's condition in the Afternoon Meeting. a. The DON/designee will complete the QAPI Acute Condition Change Tool, oversee and monitor resident changes of condition. b. The Administrator will validate that the Morning IDT Meeting and the Afternoon IDT Meeting consistently take place. c. The DON/designee will review change of condition documentation monitoring d. The DON/ADON are responsible for validating that i. post fall interventions are in place and ii. Neuro checks are implemented as indicated iii. a post fall bedside evaluation was completed, iv. review interventions implemented and v. evaluate intervention effectiveness review o Annual skill reviews on 1) supervision and accident policy, 2) vital signs and documentation guidelines 3) training on physician notification of changes will be completed for the nurses and aides as appropriate by the DON/designee o New hires (licensed nurses, on 1) supervision and accident policy, 2) vital signs and documentation guidelines 3) training on physician notification of changes the DON/Designee. An audit will be completed by the DON/designee on residents with a change of condition including falls as follows o Five residents weekly for four weeks (which will include any resident with a fall, sent to ER or hospital, or with unusual circumstances then; o Four residents weekly for two weeks then; o Three residents a week for one week. All nursing staff will participate in in-service trainings and post testing prior to assuming duties at the facility. Corrective actions will be completed by 10/29/2021 . Surveyor Monitored the plan of removal as follows: Observations were started on 10/29/21 at 3:17 PM and continued through 10/30/21 at 1:45 PM. Observation of Resident #9, Resident #8, Resident #2, and Resident #10's bedrooms revealed the beds were in lowest position, residents with safety helmet were being implemented while out of bed, and the room was free of clutter and hazards. Interviews were started on 10/29/21 at 12:44 PM and continued through 10/30/21 at 2:20 PM with 25 staff across all three shifts, including weekdays, weekends and multiple departments. The staff interviewed regarding the plan of removal: MA A, MA E, CNA I, CNA J, CNA D, Staffing Coordinator, RN D, LVN C, LVN K, CNA L, MDS Coordinator, Therapy Director, Physical Therapist, MA B, ADON, DON, CNA K, LVN A, LVN M, Transportation, Administrator, LVN G, LVN F, RN B, RN A. All staff interviewed verbalized adequate understanding of plan of remove training received. Record review of the facility in-service sheets, dated 10/22/21, 10/23/21, 10/28/21 and 10/29/21, revealed staff were in-serviced on falls, accident, supervision, seizures, vitals, neuro checks, clinical documentation, nurse meeting regarding interact 4.0, SBAR Notification, vital signs, change of condition, following physician orders and monitor. Record review of the facility POR binder revealed the facility completed a 30-day audit of residents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility POR binder revealed the facility completed individualized [CONDITION(S)] interventions on the Resident Care Tool and updated this on 10/29/21. Record review of Care Plans for Resident #9, Resident #8, Resident #2, and Resident #10 revealed care plans were individualized. The Administrator and the DON were informed the Immediate Jeopardy was removed on 10/30/21 at 2:28 PM. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (CR #1 and CR #2) of thirteen residents reviewed quality of care. - The physician was not consulted for 4 hours after LVN A, and the DON identified a change in condition to include increased lethargy and unresponsiveness in CR #1. The resident was not transferred to the hospital until the NP was called to report a critical Potassium lab of 6.1 -CR #1 was admitted to the hospital [DATE], had to be intubated, and was diagnosed with [REDACTED]. - The physician was not informed of CR #2's change in condition on [DATE] to include not eating and not feeling well. - CR #2 passed away on [DATE] in the facility. These failures resulted in an IJ on [DATE]. While the IJ was lowered on [DATE] the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected two discharged resident and placed 18 residents in hall 4 and 5 at risk of a delay of appropriate medical treatment and a worsening of a resident's condition. Findings included: CR #1 Record review of CR #1's Face Sheet documented he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of CR #1's [DATE] Admission MDS documented, in part: - His scored a 7 of 15 on his mental status exam (indicating moderate cognitive impairment) - He needed supervision of 1 staff for locomotion and eating - He needed extensive assistance and 1 staff physical assist with activity of daily living. Record review of CR #1's care plan dated [DATE] CR #1 was able to effectively communicate the presence of pain and will notify staff when he had pain. Record review of Nurse's Notes documented, lab result for Potassium (K) level (normal reference level is from 3XXX,[DATE].2) in part: - [DATE] at 2:56 p.m. K level was 6.5 (critical level) NP was notified and repeat K lab ordered. -[DATE] at 3:35 p.m. K level was 6.7 (critical level) NP was notified and [MEDICATION NAME] ordered and given. - [DATE] at 2:45 a.m. CR #1 was up yelling out for help -[DATE] at 8:00 pm NP was notified of Potassium level of 5.8 (high) in the facility and [MEDICATION NAME] 15 g/60 ml one time ordered and given. NP ordered a repeat of K level in a.m . - [DATE] at 1:50 p.m. K level was 6.1 (critical) and NP was notified at 2:00 p.m. and ordered Resident #1 transferred to a local hospital. Record review of CR #1's Nurse's Notes documented in part: -[DATE] 12 am Resident observed sitting up by the nurses' station. Stated he wanted to go to bed .yelling from his room, trying to get out of bed .continues to yell waking other residents up .was brought back out of the room in wheelchair .will continue to monitor . - [DATE] at 2:45 a.m. CR #1 was up yelling out help me, get me out of the snow. Resident confused .got resident out of bed in to the lobby .will continue to monitor . - [DATE] at 10:00 a.m. CR #1 lethargic, assessed, stable vital signs blood pressure ,[DATE], Pulse 73, Respiration 19 and oxygen saturation to room air was 97%. - [DATE] at 2:00 p.m. Received critical lab value and NP will send resident to ER, responsible party notified and message left on the answering machine. Record review of CR #1's emergency care center triage report dated [DATE] had documented arrival time and date was [DATE] at 3:39 p.m. with chief complaint of [DIAGNOSES REDACTED], [MEDICAL CONDITION]. Further review of attending physician notes in emergency documented, in part: History of present illness: Due to the patient's abnormal vitals, he was transferred to the emergency room where his blood pressure was found to be ,[DATE]. CR #1 currently remains intubated, he did receive a fluid bolus. CR #1 was diagnosed with [REDACTED]. In an interview with LVN A on [DATE] at 1:20 p.m. she said CR #1 was up and down the hall in his wheelchair and was able to make his needs known. LVN A said that on [DATE] at 10:00 a.m. CR #1 was not looking well. LVN A said she did not notify CR #1's physician or NP when CR #1 was not looking well because his vital signs was stable. LVN A said a critical lab of Potassium was called by the lab on [DATE] at 1:50 p.m. and she then called the NP, that ordered CR #1 to be transferred to the hospital. LVN A said she called the first number on the face sheet to informed CR #1's family about his change of condition. She said she did not realized it was CR #1's cell phone number. LVN A said that she first called the ambulance service to pick up the resident. When they did not show up, she then called 911. Observation of CR #1 on [DATE] at 1:36 p.m. in the hospital, CR #1 was lying in bed alert but not not responsive verbally. He had a naso-gastric tube through right nares with [MEDICATION NAME] via pump at 40 cc/hr. CR #1 had oxygen at 3L/min via nasal cannula. The hospital nurse said at the time of the observation that CR #1 was extubated on [DATE] and only open his eyes sometimes when called by name. During an interview on [DATE] at 2:50 p.m. with the DM, she said that breakfast was served in the facility from 7:30 a.m. to 7:45 a.m. During an interview on [DATE] at 1:54 p.m. the DON said he remembered that before or after breakfast on [DATE] CR #1 he just was not himself and not responding. The DON said he asked LVN A about CR #1's based line. The DON said he noticed the changes on CR #1's condition that morning and asked LVN A to send him out to the hospital. The DON said he did not know that CR #1 was not send out until that afternoon. The DON asked the nurse surveyor: Are we talking about the same CR #1. I thought CR #1 was sent out to the hospital earlier The DON said CR #1 had a wheelchair and moved independently and was able to make his needs known. During an interview on [DATE] at 9:37 a.m. the NP said she was called sometime in [DATE] in the afternoon regarding CR #1's potassium level that was high and he was lethargic. NP said she ordered for CR #1 to be transferred to the hospital. NP said she was already taking care of CR #1 for high K level earlier. The NP confirmed that nobody in the facility had called her that morning to inform her that the resident had a change in condition. During an interview on [DATE] at 2:00 p.m. CNA B said she had worked with CR #1 all the time. She said CR #1 was alert and able to make needs known, he would eat by himself, propels himself on the wheelchair. CR #1 only needed help with transfer from bed to wheelchair. During an interview on [DATE] at 2:26 p.m. CNA C said she had worked with CR #1, he was very alert and he call for help when he wants to use the restroom or adjust his leg on the wheelchair. During an interview on [DATE] at 10:40 a.m. MA A said she saw CR #1 that morning of [DATE] at 9:00 a.m. She said he was not looking like himself and CR #1 said he was not feeling well. MA A said she reported it to LVN A. MA A said prior to CR #1's change in condition, he was very active and knew what he wanted. During an interview on [DATE] at 2:00 p.m. CNA A said she took care of CR#1 on 200 hall on [DATE]. She said she arrived at work at around 9:00 a.m. because she was working a double shift. CNA A said CR #1 was always awake and able to make needs but on [DATE] CR #1 was not sitting straight on his wheelchair, he was slumping over to his right side, not looking well and that she reported this to LVN A. On [DATE] at 11:47 am a family member contacted the State Agency to inform that CR #1 passed away in the hospital on [DATE]. CR #2: Record review of CR #2's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of CR #2's admission MDS assessment dated [DATE] revealed CR #2's BIMS (Brief Interview for Mental Status) score of 3 of 15 indicating severely impaired decision skills. Resident #2 bed mobility coded as extensive assistance needed, eating coded as extensive assistance. Continued review of admission MDS assessment dated [DATE] revealed CAA triggers for nutritional status. Record review of CR #2's care plan with date (unknown) revealed unplanned weight loss care planned. Care plan for unplanned weight loss read: Focus: Unplanned weight loss related to dementia and impaired wound decline, on puree diet with nectar thicken liquids. Goal: Will receive adequate nutrition and fluid intake and weight will stabilize over the next 90days. Approach: Serve diet as ordered and offer subs if < 75% is eaten monitor intake, weight monthly. Record review of CR #2's nursing notes dated [DATE] revealed the resident had a meal intake of < 20%. Further record review of nursing notes revealed continuous monitoring for intake and decline in activities for CR #2. There was no documentation the physician was notified or consulted of the changes in condition or that the guardian was notified. Record review of the 24 hour report worksheet dated [DATE] revealed a note to monitor CR #2's meal intake. Further record review of CR#2's nurses' notes between [DATE] to [DATE] revealed no other nursing note of monitoring CR #2's change in condition, monitoring for follow-up concerning CR #2 complaint of not feeling well or not eating well. Record review of CR#2's nursing note revealed on [DATE] at 11:30A.M. CR#2 was declared deceased . Physician and guardian were notified. There were no other notes related to CR #1's passing. In an interview with RN A on [DATE] at 5:08 P.M revealed CR #2 meal intake declining was reported to him by CNA D. He said he wrote the nursing note and a note in the 24 hour report worksheet. Further interview with RN A he said he verbally pass CR #2's decline in meal intake and condition to the oncoming nurse for the second shift, however he said he did not report to change or condition to the physician or the resident's guardian. RN A said he did not assess the resident. In an interview with RN A on [DATE] at 12:10 P.M revealed RN A was called into CR#2's for full code of CR#2 until confirmation of DNR was given. Further interview with RN A revealed CR#2 was taking her last breathes upon his entry in to CR#2's room. In an interview with CNA D on [DATE] at 10:26 A.M she said that she notified LVN B on [DATE] of CR #2's decline and not eating all of her food and CR #2 said she was not feeling well. CNA D said CR #2 normally ate all of her food except vegetables and CR #2 started refusing to eat. CNA D said that after notifying LVN B about CR #2 not eating she then told RN A of CR#2 not eating. In an interview with the DON on [DATE] at 10:12 A.M. he said he was not notified of CR #2 decline in meal intake. Further interview with the DON revealed he was not alerted of CR #2's meal intake change from the care tracker system due to care tracker documentation of meal intake being 50% to 75%. He said staff did not notify him of CR #2's change in condition. Review of the ,[DATE] Policy and Procedure on Change of Condition documented, in part: A significant change in the residents physical, mental, or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications. A need to alter treatment significantly. Procedure: Observing, Reporting and Documenting a Change in Condition: When a resident is noted to have a change in condition including health and psychosocial status conduct a thorough evaluation using the SBAR form (Situation, Background, Appearance, Review & notify process) and compare against baseline. The attending physician should be notified by the charge nurse when the SBAR is completed. Notify resident's representative. The facility Administrator and DON were notified on [DATE] at 4:06p.m that an IJ was identified due to the above failures and a POR was requested. The POR was submitted by the Administrator on [DATE]. After several revisions, the final plan of removal was accepted on [DATE] at 1:08 pm. The POR read in part: .was sent to the local emergency roiagnom on [DATE] and arrived at the ER at 3:39 pm. Immediate Action The DON .and charge nurses immediately on [DATE] began assessing all residents for change in condition, via walking rounds if any resident has a change in condition, Physician notification will be done based on the Interact IV guidelines. This was completed on [DATE] Education All Licensed Nurses on duty will be provided education on our Diagnostic Testing and communicating panic or critical lab values done by DON and Corporate Nurse. A posttest was provided beginning [DATE] and will end on [DATE]. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure as it relates to diagnostic testing. All Licensed Nurses on duty will be provided education on Notification of Change in condition using the Interact IV to include training on timely and thoroughness of assessing a resident. This education will be provided by DON and Corporate Nurse. A posttest was provided beginning [DATE] and will end 1.9.18. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on change of condition, Physician notification. All C.N.A.'s on duty will be provided education on Notification of a change in resident's condition and reporting change to charge nurse. This education will be provided by DON and Corporate Nurse beginning [DATE] and ending [DATE]. Any C.N.A. that has not been trained will be removed from the schedule and will not work until this education has been provided. All Licensed Nurses on duty will be provided education on Abuse and neglect. This education will be provided by DON and Corporate Nurse. A posttest was provided beginning [DATE] and will end [DATE] Any nurse that has not had this training will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on abuse and neglect. Monitoring DON will review daily all resident with a change in condition to ensure timely notification of Physician The DON and Administration will Review lab tracking log daily to ensure labs results reported to Physician in a timely manner. A QA&A meeting will be conducted by Administrator on [DATE] and weekly to validate that the facility's Notification in change of condition is in place and of sustaining compliance. The Center's medical director was notified at 6:00 pm on [DATE] at 6:15 pm of the Immediate Jeopardy . In an interview on [DATE] at 4:06 pm The Administrator said we did in-services. We did in-service that day or within 48 hours of (CR #1) going to the hospital. The DON saw the resident the day resident was sent later to the hospital and did not follow up. She acknowledged no notification to anyone at that time for CR #1. The Administrator said LVN A nurse was terminated for failure to follow the policy on an unrelated issues. She was informed there were two nurses who identified a change in condition but no action was taken and doctor/NP was not notified. During an interview on [DATE] at 5:49 p.m. the DON said he thought the immediate jeopardy was a result of poor documentation by the nurse. LVN A was to call 911 when the ambulance contracted was not responding. He said they interviewed the nurses to see if they felt overwhelmed or if it was too much and no one said it was. The DON said there was just no communication. They didn't communicate with each other, not even on the 24 hour report. Nothing on the nurse to nurse. The DON said he started in-services. The DON said he ensured staff was educated by conducting in-services and skill checks. Interviews conducted between [DATE] and [DATE] showed that four RN's, five LVN's, two MA, and eight CNA's had attended and understood the in-services conducted related to change in condition. Record review of the [DATE] In-Service Training Report completed by the facility documented 30 nurses signed they were in-serviced on [DATE] have some done over the weekend. Thirteen staff signed the [DATE] In-service Training Report on Change of Condition/ Notification of Physician and Family which included the Policy on Changes of Condition and the SBAR. Record review of the Change of Condition Quiz documented 30 staff were tested on their knowledge of change of condition, notification to physicians and documentation. Review of the Report Sheets for all Halls documented all residents had a baseline vital signs completed on [DATE]. Review of the [DATE] In-Service on SBAR documented, in part: Nurses, an SBAR is to be filled out whenever you have to communicate with the MD, NP, nurses you are giving report to at the hospital, EMT's etc. NO EXCEPTIONS. This has to be done without fail. There were no SBAR documented for CR #1. On [DATE] at 1:20 p.m. the Administrator was informed the IJ was lowered. The facility remained out of compliance at a severity level of harm with a scope of a pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The facility room roster revealed a census of 18 residents in halls 4 and 5.

Based on observation, interview, and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for 2 of 13 residents (CR #1 and CR #2 ) reviewed for residents administration. The Administrator failed to: -- implement the facility Abuse, Neglect, and Exploitation prohibition policy to prevent neglect. --supervise the DON to ensure the DON was performing his duties and supervising the nurses. The DON failed to: - supervise LVN A to ensure she followed instructions of sending CR #1 to the hospital and the DON and LVN A noticed a decline and change in condition. - supervise the nursing staff to ensure they were consulting with physicians regarding resident's change of conditions. These failures resulted in an IJ. While the IJ was lowered the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected two discharged resident and placed 18 residents in hall 4 and 5 at risk of a delay of appropriate medical treatment and a worsening of a resident's condition. Findings include: In an interview on [DATE] at 4:06 pm The Administrator said we did in-services. We did in-service that day or within 48 hours. The DON saw the resident the day resident was sent later to the hospital and did not follow up. She acknowledged no notification to anyone at that time for CR #1. The Administrator said LVN A nurse was terminated for failure to follow the policy on an unrelated issues. She was informed there were two nurses who identified a change in condition but no action was taken and doctor/NP was not notified. During an interview on [DATE] at 5:49 p.m. the DON said he thought the immediate jeopardy was a result of poor documentation by the nurse. LVN A was to call 911 when the ambulance contracted was not responding. He said they interviewed the nurses to see if they felt overwhelmed or if it was too much and no one said it was. The DON said there was just no communication. They didn't communicate with each other, not even on the 24 hour report. Nothing on the nurse to nurse. The DON said he started in-services. Working on other way will continue interview [DATE]. The DON said he ensured staff was educated by conductung in-services and skill checks. CR #1 Record review of CR #1's Face Sheet documented he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's Nurse's Notes documented in part: -[DATE] 12 am Resident observed sitting up by the nurses' station. Stated he wanted to go to bed .yelling from his room, trying to get out of bed .continues to yell waking other residents up .was brought back out of the room in wheelchair .will continue to monitor . - [DATE] at 2:45 a.m. CR #1 was up yelling out help me, get me out of the snow. Resident confused .got resident out of bed in to the lobby .will continue to monitor . - [DATE] at 10:00 a.m. CR #1 lethargic, assessed, stable vital signs blood pressure ,[DATE], Pulse 73, Respiration 19 and oxygen saturation to room air was 97%. - [DATE] at 2:00 p.m. Received critical lab value and NP will send resident to ER, responsible party notified and message left on the answering machine. Record review of CR #1's emergency care center triage report dated [DATE] had documented arrival time and date was [DATE] at 3:39 p.m. with chief complaint of [DIAGNOSES REDACTED], [MEDICAL CONDITION]. Further review of attending physician notes in emergency documented, in part: History of present illness: Due to the patient's abnormal vitals, he was transferred to the emergency room where his blood pressure was found to be ,[DATE]. CR #1 currently remains intubated, he did receive a fluid bolus. CR #1 was diagnosed with [REDACTED]. In an interview with LVN A on [DATE] at 1:20 p.m. she said CR #1 was up and down the hall in his wheelchair and was able to make his needs known. LVN A said that on [DATE] at 10:00 a.m. CR #1 was not looking well. LVN A said she did not notify CR #1's physician or NP when CR #1 was not looking well because his vital signs was stable. LVN A said a critical lab of Potassium was called by the lab on [DATE] at 1:50 p.m. and she then called the NP, that ordered CR #1 to be transferred to the hospital. LVN A said she called the first number on the face sheet to informed CR #1's family about his change of condition. She said she did not realized it was CR #1's cell phone number. LVN A said that she first called the ambulance service to pick up the resident. When they did not show up, she then called 911. In an interview with a family member on [DATE] 12:30 p.m. she said CR #1 was sent to hospital on [DATE] and nobody called the family until [DATE]. The Family member said she had been calling CR #1's cell phone since [DATE] no response, she called the VA hospital and nobody could locate him. She then called the facility on [DATE] and was told CR #1 went to a local hospital. During an interview on [DATE] at 1:54 p.m. the DON said he remembered that before or after breakfast on [DATE] CR #1 he just was not himself and not responding. The DON said he asked LVN A about CR #1's based line. The DON said he noticed the changes on CR #1's condition that morning and asked LVN A to send him out to the hospital. The DON said he did not know that CR #1 was not send out until that afternoon. The DON asked the nurse surveyor: Are we talking about the same CR #1. I thought CR #1 was sent out to the hospital earlier The DON said CR #1 had a wheelchair and moved independently and was able to make his needs known. During an interview on [DATE] at 9:37 a.m. the NP said she was called sometime in [DATE] in the afternoon regarding CR #1's potassium level that was high and he was lethargic. NP said she ordered for CR #1 to be transferred to the hospital. NP said she was already taking care of CR #1 for high K level earlier. The NP confirmed that nobody in the facility had called her that morning to inform her that the resident had a change in condition. During an interview on [DATE] at 10:40 a.m. MA A said she saw CR #1 that morning of [DATE] at 9:00 a.m. She said he was not looking like himself and CR #1 said he was not feeling well. MA A said she reported it to LVN A. MA A said prior to CR #1's change in condition, he was very active and knew what he wanted. During an interview on [DATE] at 2:00 p.m. CNA A said she took care of CR#1 on 200 hall on [DATE]. She said she arrived at work at around 9:00 a.m. because she was working a double shift. CNA A said CR #1 was always awake and able to make needs but on [DATE] CR #1 was not sitting straight on his wheelchair, he was slumping over to his right side, not looking well and that she reported this to LVN A. On [DATE] at 11:47 am a family member contacted the State Agency to inform that CR #1 passed away in the hospital on [DATE]. CR #2: Record review of CR #2's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of the 24 hour report worksheet dated [DATE] revealed a note to monitor CR #2's meal intake. Further record review of CR#2's nurses' notes between [DATE] to [DATE] revealed no other nursing note of monitoring CR #2's change in condition or monitoring for follow-up concerning CR #2 complaint of not feeling well or not eating well. Record review of CR#2's nursing note revealed on [DATE] at 11:30A.M. CR#2 was declared deceased . Physician and guardian were notified. There were no other notes related to CR #1's passing. In an interview with RN A on [DATE] at 5:08 P.M revealed CR #2 meal intake declining was reported to him by CNA D. He said he wrote the nursing note and a note in the 24 hour report worksheet. Further interview with RN A he said he verbally pass CR #2's decline in meal intake and condition to the oncoming nurse for the second shift, however he said he did not report the change in condition to the physician or the resident's guardian. RN A said he did not assess the resident. In an interview with RN A on [DATE] at 12:10 P.M revealed RN A was called into CR#2's for full code of CR#2 until confirmation of DNR was given. Further interview with RN A revealed CR#2 was taking her last breathes upon his entry in to CR#2's room. In an interview with CNA D on [DATE] at 10:26 A.M she said that she notified LVN B of CR #2's decline and not eating all of her food and CR #2 said she was not feeling well. CNA D said CR #2 normally ate all of her food except vegetables and CR #2 started refusing to eat. CNA D said that after notifying LVN B about CR #2 not eating she then told RN A of CR #2 not eating. In an interview with the DON on [DATE] at 10:12 A.M. he said he was not notified of CR #2 decline in meal intake. Further interview with the DON revealed he was not alerted of CR #2's meal intake change from the care tracker system due to care tracker documentation of meal intake being 50% to 75%. He said staff did not notify him of CR #2's change in condition. The facility Administrator and DON were notified on [DATE] at 4:06p.m that an IJ was identified due to the abive failures and a POR was requested. The POR was submitted by the Administrator on [DATE]. After several revisions, the final plan of removal was accepted on [DATE] at 1:08 pm. The POR read in part: .was sent to the local emergency roiagnom on [DATE] and arrived at the ER at 3:39 pm. Immediate Action The DON .and charge nurses immediately on [DATE] began assessing all residents for change in condition, via walking rounds if any resident has a change in condition, Physician notification will be done based on the Interact IV guidelines. This was completed on [DATE] Education All Licensed Nurses on duty will be provided education on our Diagnostic Testing and communicating panic or critical lab values done by DON and Corporate Nurse. A posttest was provided beginning [DATE] and will end on [DATE]. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure as it relates to diagnostic testing. All Licensed Nurses on duty will be provided education on Notification of Change in condition using the Interact IV to include training on timely and thoroughness of assessing a resident. This education will be provided by DON and Corporate Nurse. A posttest was provided beginning [DATE] and will end 1.9.18. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on change of condition, Physician notification. All C.N.A.'s on duty will be provided education on Notification of a change in resident's condition and reporting change to charge nurse. This education will be provided by DON and Corporate Nurse beginning [DATE] and ending [DATE]. Any C.N.A. that has not been trained will be removed from the schedule and will not work until this education has been provided. All Licensed Nurses on duty will be provided education on Abuse and neglect. This education will be provided by DON and Corporate Nurse. A posttest was provided beginning [DATE] and will end [DATE] Any nurse that has not had this training will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on abuse and neglect. Monitoring DON will review daily all resident with a change in condition to ensure timely notification of Physician The DON and Administration will Review lab tracking log daily to ensure labs results reported to Physician in a timely manner. A QA&A meeting will be conducted by Administrator on [DATE] and weekly to validate that the facility's Notification in change of condition is in place and of sustaining compliance. The Center's medical director was notified at 6:00 pm on [DATE] at 6:15 pm of the Immediate Jeopardy . Interviews conducted between [DATE] and [DATE] showed that four RN's, five LVN's, two MA, and eight CNA's had attended and understood the in-services conducted related to change in condition. Record review of the [DATE] In-Service Training Report completed by the facility documented 30 nurses signed they were in-serviced on [DATE] have some done over the weekend. Thirteen staff signed the [DATE] In-service Training Report on Change of Condition/ Notification of Physician and Family which included the Policy on Changes of Condition and the SBAR. Record review of the Change of Condition Quiz documented 30 staff were tested on their knowledge of change of condition, notification to physicians and documentation. Review of the Report Sheets for all Halls documented all residents had a baseline vital signs completed on [DATE]. Review of the [DATE] In-Service on SBAR documented, in part: Nurses, an SBAR is to be filled out whenever you have to communicate with the MD, NP, nurses you are giving report to at the hospital, EMT's etc. NO EXCEPTIONS. This has to be done without fail. There were no SBAR documented for CR #1. On [DATE] at 1:20 p.m. the Administrator was informed the IJ was lowered. The facility remained out of compliance at a severity level of harm with a scope of a pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The facility room roster revealed a census of 18 residents in halls 4 and 5.

Based on interview, and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 2 of 13 residents (CR #1 and CR #2) reviewed for a change of condition: - The physician was not consulted for 4 hours after LVN A, and the DON identified a change in condition to include increased lethargy and unresponsiveness in CR #1. The resident was not transferred to the hospital until the NP was called to report a critical Potassium lab of 6.1 -CR #1 was admitted to the hospital [DATE], had to be intubated, and was diagnosed with [REDACTED]. - The physician was not informed of CR #2's change in condition on [DATE] to include not eating and not feeling well. - CR #2 passed away on [DATE] in the facility. These failures resulted in an IJ on [DATE]. While the IJ was lowered on [DATE] the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected two discharged resident and placed 18 residents in hall 4 and 5 at risk of a delay of appropriate medical treatment and a worsening of a resident's condition. Findings included: CR #1 Record review of CR #1's Face Sheet documented he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of CR #1's [DATE] Admission MDS documented, in part: - His scored a 7 of 15 on his mental status exam (indicating moderate cognitive impairment) - He needed supervision of 1 staff for locomotion and eating - He needed extensive assistance and 1 staff physical assist with activity of daily living. Record review of CR #1's care plan dated [DATE] CR #1 was able to effectively communicate the presence of pain and will notify staff when he had pain. Record review of Nurse's Notes documented, lab result for Potassium (K) level (normal reference level is from 3XXX,[DATE].2) in part: - [DATE] at 2:56 p.m. K level was 6.5 (critical level) NP was notified and repeat K lab ordered. -[DATE] at 3:35 p.m. K level was 6.7 (critical level) NP was notified and [MEDICATION NAME] ordered and given. - [DATE] at 2:45 a.m. CR #1 was up yelling out for help . -[DATE] at 8:00 pm NP was notified of Potassium level of 5.8 (high) in the facility and [MEDICATION NAME] 15 g/60 ml one time ordered and given. NP ordered a repeat of K level in a.m . - [DATE] at 1:50 p.m. K level was 6.1 (critical) and NP was notified at 2:00 p.m. and ordered Resident #1 transferred to a local hospital. Record review of CR #1's Nurse's Notes documented in part: -[DATE] 12 am Resident observed sitting up by the nurses' station. Stated he wanted to go to bed .yelling from his room, trying to get out of bed .continues to yell waking other residents up .was brought back out of the room in wheelchair .will continue to monitor . - [DATE] at 2:45 a.m. CR #1 was up yelling out help me, get me out of the snow. Resident confused .got resident out of bed in to the lobby .will continue to monitor . - [DATE] at 10:00 a.m. CR #1 lethargic, assessed, stable vital signs blood pressure ,[DATE], Pulse 73, Respiration 19 and oxygen saturation to room air was 97%. - [DATE] at 2:00 p.m. Received critical lab value and NP will send resident to ER, responsible party notified and message left on the answering machine. Record review of CR #1's emergency care center triage report dated [DATE] had documented arrival time and date was [DATE] at 3:39 p.m. with chief complaint of [DIAGNOSES REDACTED], [MEDICAL CONDITION]. Further review of attending physician notes in emergency documented, in part: History of present illness: Due to the patient's abnormal vitals, he was transferred to the emergency room where his blood pressure was found to be ,[DATE]. CR #1 currently remains intubated, he did receive a fluid bolus. CR #1 was diagnosed with [REDACTED]. In an interview with LVN A on [DATE] at 1:20 p.m. she said CR #1 was up and down the hall in his wheelchair and was able to make his needs known. LVN A said that on [DATE] at 10:00 a.m. CR #1 was not looking well. LVN A said she did not notify CR #1's physician or NP when CR #1 was not looking well because his vital signs was stable. LVN A said a critical lab of Potassium was called by the lab on [DATE] at 1:50 p.m. and she then called the NP, that ordered CR #1 to be transferred to the hospital. LVN A said she called the first number on the face sheet to informed CR #1's family about his change of condition. She said she did not realized it was CR #1's cell phone number. LVN A said that she first called the ambulance service to pick up the resident. When they did not show up, she then called 911. In an interview with a family member on [DATE] 12:30 p.m. she said CR #1 was sent to hospital on [DATE] and nobody called the family until [DATE]. The Family member said she had been calling CR #1's cell phone since [DATE] no response, she called the VA hospital and nobody could locate him. She then called the facility on [DATE] and was told CR #1 went to a local hospital. Observation of CR #1 on [DATE] at 1:36 p.m. in the hospital, CR #1 was lying in bed alert but not not responsive verbally. He had a naso-gastric tube through right nares with [MEDICATION NAME] via pump at 40 cc/hr. CR #1 had oxygen at 3L/min via nasal cannula. The hospital nurse said at the time of the observation that CR #1 was extubated on [DATE] and only open his eyes sometimes when called by name. During an interview on [DATE] at 2:50 p.m. with the DM, she said that breakfast was served in the facility from 7:30 a.m. to 7:45 a.m. During an interview on [DATE] at 1:54 p.m. the DON said he remembered that before or after breakfast on [DATE] CR #1 he just was not himself and not responding. The DON said he asked LVN A about CR #1's based line. The DON said he noticed the changes on CR #1's condition that morning and asked LVN A to send him out to the hospital. The DON said he did not know that CR #1 was not send out until that afternoon. The DON asked the nurse surveyor: Are we talking about the same CR #1. I thought CR #1 was sent out to the hospital earlier The DON said CR #1 had a wheelchair and moved independently and was able to make his needs known. During an interview on [DATE] at 9:37 a.m. the NP said she was called sometime in [DATE] in the afternoon regarding CR #1's potassium level that was high and he was lethargic. NP said she ordered for CR #1 to be transferred to the hospital. NP said she was already taking care of CR #1 for high K level earlier. The NP confirmed that nobody in the facility had called her that morning to inform her that the resident had a change in condition. During an interview on [DATE] at 2:00 p.m. CNA B said she had worked with CR #1 all the time. She said CR #1 was alert and able to make needs known, he would eat by himself, propels himself on the wheelchair. CR #1 only needed help with transfer from bed to wheelchair. During an interview on [DATE] at 2:26 p.m. CNA C said she had worked with CR #1, he was very alert and he call for help when he wants to use the restroom or adjust his leg on the wheelchair. During an interview on [DATE] at 10:40 a.m. MA A said she saw CR #1 that morning of [DATE] at 9:00 a.m. She said he was not looking like himself and CR #1 said he was not feeling well. MA A said she reported it to LVN A. MA A said prior to CR #1's change in condition, he was very active and knew what he wanted. During an interview on [DATE] at 2:00 p.m. CNA A said she took care of CR#1 on 200 hall on [DATE]. She said she arrived at work at around 9:00 a.m. because she was working a double shift. CNA A said CR #1 was always awake and able to make needs but on [DATE] CR #1 was not sitting straight on his wheelchair, he was slumping over to his right side, not looking well and that she reported this to LVN A. On [DATE] at 11:47 am a family member contacted the State Agency to inform that CR #1 passed away in the hospital on [DATE]. CR #2: Record review of CR #2's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of CR #2's admission MDS assessment dated [DATE] revealed CR #2's BIMS (Brief Interview for Mental Status) score of 3 of 15 indicating severely impaired decision skills. Resident #2 bed mobility coded as extensive assistance needed, eating coded as extensive assistance. Continued review of admission MDS assessment dated [DATE] revealed CAA triggers for nutritional status. Record review of CR #2's care plan with date (unknown) revealed unplanned weight loss care planned. Care plan for unplanned weight loss read: Focus: Unplanned weight loss related to dementia and impaired wound decline, on puree diet with nectar thicken liquids. Goal: Will receive adequate nutrition and fluid intake and weight will stabilize over the next 90days. Approach: Serve diet as ordered and offer subs if < 75% is eaten monitor intake, weight monthly. Record review of CR #2's nursing notes dated [DATE] revealed the resident had a meal intake of < 20%. Further record review of nursing notes revealed continuous monitoring for intake and decline in activities for CR #2. There was no documentation the physician was notified or consulted of the changes in condition or the guardian was notified. Record review of the 24 hour report worksheet dated [DATE] revealed a note to monitor CR #2's meal intake. Further record review of CR#2's nurses' notes between [DATE] to [DATE] revealed no other nursing note of monitoring CR #2's change in condition or monitoring for follow-up concerning CR #2 complaint of not feeling well or not eating well. Record review of CR#2's nursing note revealed on [DATE] at 11:30A.M. CR#2 was declared deceased . Physician and guardian were notified. There were no other notes related to CR #1's passing. In an interview with RN A on [DATE] at 5:08 P.M revealed CR #2 meal intake declining was reported to him by CNA D. He said he wrote the nursing note and a note in the 24 hour report worksheet. Further interview with RN A he said he verbally pass CR #2's decline in meal intake and condition to the oncoming nurse for the second shift, however he said he did not report the change in condition to the physician or the resident's guardian. RN A said he did not assess the resident. In an interview with RN A on [DATE] at 12:10 P.M revealed RN A was called into CR#2's for full code of CR#2 until confirmation of DNR was given. Further interview with RN A revealed CR#2 was taking her last breathes upon his entry in to CR#2's room. In an interview with CNA D on [DATE] at 10:26 A.M she said that she notified LVN B of CR #2's decline and not eating all of her food and CR #2 said she was not feeling well. CNA D said CR #2 normally ate all of her food except vegetables and CR #2 started refusing to eat. CNA D said that after notifying LVN B about CR #2 not eating she then told RN A of CR #2 not eating. In an interview with the DON on [DATE] at 10:12 A.M. he said he was not notified of CR #2 decline in meal intake. Further interview with the DON revealed he was not alerted of CR #2's meal intake change from the care tracker system due to care tracker documentation of meal intake being 50% to 75%. He said staff did not notify him of CR #2's change in condition. Review of the ,[DATE] Policy and Procedure on Change of Condition documented, in part: A significant change in the residents physical, mental, or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications. A need to alter treatment significantly. Procedure: Observing, Reporting and Documenting a Change in Condition: When a resident is noted to have a change in condition including health and psychosocial status conduct a thorough evaluation using the SBAR form (Situation, Background, Appearance, Review & notify process) and compare against baseline. The attending physician should be notified by the charge nurse when the SBAR is completed. Notify resident's representative. The facility Administrator and DON were notified on [DATE] at 4:06p.m that an IJ was identified due to the above failures and a POR was requested. The POR was submitted by the Administrator on [DATE]. After several revisions, the final plan of removal was accepted on [DATE] at 1:08 pm. The POR read in part: .was sent to the local emergency roiagnom on [DATE] and arrived at the ER at 3:39 pm. Immediate Action The DON .and charge nurses immediately on [DATE] began assessing all residents for change in condition, via walking rounds if any resident has a change in condition, Physician notification will be done based on the Interact IV guidelines. This was completed on [DATE] Education All Licensed Nurses on duty will be provided education on our Diagnostic Testing and communicating panic or critical lab values done by DON and RN Corporate Nurse. A posttest was provided beginning [DATE] and will end on [DATE]. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure as it relates to diagnostic testing. All Licensed Nurses on duty will be provided education on Notification of Change in condition using the Interact IV to include training on timely and thoroughness of assessing a resident. This education will be provided by DON and RN Corporate Nurse. A posttest was provided beginning [DATE] and will end 1.9.18. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on change of condition, Physician notification. All C.N.A.'s on duty will be provided education on Notification of a change in resident's condition and reporting change to charge nurse. This education will be provided by DON and Corporate Nurse beginning [DATE] and ending [DATE]. Any C.N.A. that has not been trained will be removed from the schedule and will not work until this education has been provided. All Licensed Nurses on duty will be provided education on Abuse and neglect. This education will be provided by DON and RN Corporate Nurse. A posttest was provided beginning [DATE] and will end [DATE] Any nurse that has not had this training will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on abuse and neglect. Monitoring DON will review daily all resident with a change in condition to ensure timely notification of Physician The DON and Administration will Review lab tracking log daily to ensure labs results reported to Physician in a timely manner. A QA&A meeting will be conducted by Administrator on [DATE] and weekly to validate that the facility's Notification in change of condition is in place and of sustaining compliance. The Center's medical director was notified at 6:00 pm on [DATE] at 6:15 pm of the Immediate Jeopardy . In an interview on [DATE] at 4:06 pm The Administrator said we did in-services. We did in-service that day or within 48 hours. The DON saw the resident the day resident was sent later to the hospital and did not follow up. She acknowledged no notification to anyone at that time for CR #1. The Administrator said LVN A nurse was terminated for failure to follow the policy on an unrelated issues. She was informed there were two nurses who identified a change in condition but no action was taken and doctor/NP was not notified. During an interview on [DATE] at 5:49 p.m. the DON said he thought the immediate jeopardy was a result of poor documentation by the nurse. LVN A was to call 911 when the ambulance contracted was not responding. He said they interviewed the nurses to see if they felt overwhelmed or if it was too much and no one said it was. The DON said there was just no communication. They didn't communicate with each other, not even on the 24 hour report. Nothing on the nurse to nurse. The DON said he started in-services.The DON said he ensured staff was educated by conducting in-services and skill checks. Interviews conducted between [DATE] and [DATE] showed that four RN's, five LVN's, two MA, and eight CNA's had attended and understood the in-services conducted related to change in condition. Record review of the [DATE] In-Service Training Report completed by the facility documented 30 nurses signed they were in-serviced on [DATE] have some done over the weekend. Thirteen staff signed the [DATE] In-service Training Report on Change of Condition/ Notification of Physician and Family which included the Policy on Changes of Condition and the SBAR. Record review of the Change of Condition Quiz documented 30 staff were tested on their knowledge of change of condition, notification to physicians and documentation. Review of the Report Sheets for all Halls documented all residents had a baseline vital signs completed. Review of the [DATE] In-Service on SBAR documented, in part: Nurses, an SBAR is to be filled out whenever you have to communicate with the MD, NP, nurses you are giving report to at the hospital, EMT's etc. NO EXCEPTIONS. This has to be done without fail. There were no SBAR documented for CR #1 On [DATE] at 1:20 p.m. the Administrator was informed the IJ was lowered. The facility remained out of compliance at a severity level of harm with a scope of a pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The facility room roster revealed a census 18 residents in halls 4 and 5.

Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for 2 of 13 residents (CR #1 and CR #2) reviewed for neglect. - The physician was not consulted for 4 hours after LVN A, and the DON identified a change in condition to include increased lethargy and unresponsiveness in CR #1. The resident was not transferred to the hospital until the NP was called to report a critical Potassium lab of 6.1. - The resident was not transferred to the hospital until the NP was called to report a critical Potassium lab of 6.1 -CR #1 was admitted to the hospital [DATE], had to be intubated, and was diagnosed with [REDACTED]. - The physician was not informed of CR #2's change in condition on [DATE] to include not eating and not feeling well. - CR #2 passed away on [DATE] in the facility. These failures resulted in an IJ on [DATE]. While the IJ was lowered on [DATE] the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected two discharged resident and placed 18 residents in halls 4 and 5 at risk of a delay of appropriate medical treatment and a worsening of a resident's condition. Findings included: CR #1 Record review of CR #1's Face Sheet documented he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of CR #1's [DATE] Admission MDS documented, in part: - His scored a 7 of 15 on his mental status exam (indicating moderate cognitive impairment) - He needed supervision of 1 staff for locomotion and eating - He needed extensive assistance and 1 staff physical assist with activity of daily living. Record review of CR #1's care plan dated [DATE] CR #1 was able to effectively communicate the presence of pain and will notify staff when he had pain. Record review of Nurse's Notes documented, lab result for Potassium (K) level (normal reference level is from 3XXX,[DATE].2) in part: - [DATE] at 2:56 p.m. K level was 6.5 (critical level) NP was notified and repeat K lab ordered. -[DATE] at 3:35 p.m. K level was 6.7 (critical level) NP was notified and [MEDICATION NAME] ordered and given. - [DATE] at 2:45 a.m. CR #1 was up yelling out for help -[DATE] at 8:00 pm NP was notified of Potassium level of 5.8 (high) in the facility and [MEDICATION NAME] 15 g/60 ml one time ordered and given. NP ordered a repeat of K level in a.m . - [DATE] at 1:50 p.m. K level was 6.1 (critical) and NP was notified at 2:00 p.m. and ordered Resident #1 transferred to a local hospital. Record review of CR #1's Nurse's Notes documented in part: -[DATE] 12 am Resident observed sitting up by the nurses' station. Stated he wanted to go to bed .yelling from his room, trying to get out of bed .continues to yell waking other residents up .was brought back out of the room in wheelchair .will continue to monitor . - [DATE] at 2:45 a.m. CR #1 was up yelling out help me, get me out of the snow. Resident confused .got resident out of bed in to the lobby .will continue to monitor . - [DATE] at 10:00 a.m. CR #1 lethargic, assessed, stable vital signs blood pressure ,[DATE], Pulse 73, Respiration 19 and oxygen saturation to room air was 97%. - [DATE] at 2:00 p.m. Received critical lab value and NP will send resident to ER, responsible party notified and message left on the answering machine. Record review of CR #1's emergency care center triage report dated [DATE] had documented arrival time and date was [DATE] at 3:39 p.m. with chief complaint of [DIAGNOSES REDACTED], [MEDICAL CONDITION]. Further review of attending physician notes in emergency documented, in part: History of present illness: Due to the patient's abnormal vitals, he was transferred to the emergency room where his blood pressure was found to be ,[DATE]. CR #1 currently remains intubated, he did receive a fluid bolus. CR #1 was diagnosed with [REDACTED]. In an interview with LVN A on [DATE] at 1:20 p.m. she said CR #1 was up and down the hall in his wheelchair and was able to make his needs known. LVN A said that on [DATE] at 10:00 a.m. CR #1 was not looking well. LVN A said she did not notify CR #1's physician or NP when CR #1 was not looking well because his vital signs was stable. LVN A said a critical lab of Potassium was called by the lab on [DATE] at 1:50 p.m. and she then called the NP, that ordered CR #1 to be transferred to the hospital. LVN A said she called the first number on the face sheet to informed CR #1's family about his change of condition. She said she did not realized it was CR #1's cell phone number. LVN A said that she first called the ambulance service to pick up the resident. When they did not show up, she then called 911. In an interview with a family member on [DATE] 12:30 p.m. she said CR #1 was sent to hospital on [DATE] and nobody called the family until [DATE]. The Family member said she had been calling CR #1's cell phone since [DATE] no response, she called the VA hospital and nobody could locate him. She then called the facility on [DATE] and was told CR #1 went to a local hospital. Observation of CR #1 on [DATE] at 1:36 p.m. in the hospital, CR #1 was lying in bed alert but not not responsive verbally. He had a naso-gastric tube through right nares with [MEDICATION NAME] via pump at 40 cc/hr. CR #1 had oxygen at 3L/min via nasal cannula. The hospital nurse said at the time of the observation that CR #1 was extubated on [DATE] and only open his eyes sometimes when called by name. During an interview on [DATE] at 2:50 p.m. with the DM, she said that breakfast was served in the facility from 7:30 a.m. to 7:45 a.m. During an interview on [DATE] at 1:54 p.m. the DON said he remembered that before or after breakfast on [DATE] CR #1 he just was not himself and not responding. The DON said he asked LVN A about CR #1's based line. The DON said he noticed the changes on CR #1's condition that morning and asked LVN A to send him out to the hospital. The DON said he did not know that CR #1 was not send out until that afternoon. The DON asked the nurse surveyor: Are we talking about the same CR #1. I thought CR #1 was sent out to the hospital earlier The DON said CR #1 had a wheelchair and moved independently and was able to make his needs known. During an interview on [DATE] at 9:37 a.m. the NP said she was called sometime in [DATE] in the afternoon regarding CR #1's potassium level that was high and he was lethargic. NP said she ordered for CR #1 to be transferred to the hospital. NP said she was already taking care of CR #1 for high K level earlier. The NP confirmed that nobody in the facility had called her that morning to inform her that the resident had a change in condition. During an interview on [DATE] at 2:00 p.m. CNA B said she had worked with CR #1 all the time. She said CR #1 was alert and able to make needs known, he would eat by himself, propels himself on the wheelchair. CR #1 only needed help with transfer from bed to wheelchair. During an interview on [DATE] at 2:26 p.m. CNA C said she had worked with CR #1, he was very alert and he call for help when he wants to use the restroom or adjust his leg on the wheelchair. During an interview on [DATE] at 10:40 a.m. MA A said she saw CR #1 that morning of [DATE] at 9:00 a.m. She said he was not looking like himself and CR #1 said he was not feeling well. MA A said she reported it to LVN A. MA A said prior to CR #1's change in condition, he was very active and knew what he wanted. During an interview on [DATE] at 2:00 p.m. CNA A said she took care of CR#1 on 200 hall on [DATE]. She said she arrived at work at around 9:00 a.m. because she was working a double shift. CNA A said CR #1 was always awake and able to make needs but on [DATE] CR #1 was not sitting straight on his wheelchair, he was slumping over to his right side, not looking well and that she reported this to LVN A. On [DATE] at 11:47 am a family member contacted the State Agency to inform that CR #1 passed away in the hospital on [DATE]. CR #2: Record review of CR #2's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of CR #2's admission MDS assessment dated [DATE] revealed CR #2's BIMS (Brief Interview for Mental Status) score of 3 of 15 indicating severely impaired decision skills. CR#2 bed mobility coded as extensive assistance needed, eating coded as extensive assistance. Continued review of admission MDS assessment dated [DATE] revealed CAA triggers for nutritional status. Record review of CR #2's care plan with date (unknown) revealed unplanned weight loss care planned. Care plan for unplanned weight loss read: Focus: Unplanned weight loss related to dementia and impaired wound decline, on puree diet with nectar thicken liquids. Goal: Will receive adequate nutrition and fluid intake and weight will stabilize over the next 90days. Approach: Serve diet as ordered and offer subs if < 75% is eaten monitor intake, weight monthly. Record review of CR #2's nursing notes dated [DATE] revealed the resident had a meal intake of < 20%. Further record review of nursing notes revealed continuous monitoring for intake and decline in activities for CR #2. There was no documentation the physician was notified or consulted of the changes in condition or that the guardian was notified. Record review of the 24 hour report worksheet dated [DATE] revealed a note to monitor CR #2's meal intake. Further record review of CR#2's nurses' notes between [DATE] to [DATE] revealed no other nursing note of monitoring CR #2's change in condition, monitoring for follow-up concerning CR #2 complaint of not feeling well or not eating well. Record review of CR#2's nursing note revealed on [DATE] at 11:30A.M. CR#2 was declared deceased . Physician and guardian were notified. There were no other notes related to CR #1's passing. In an interview with RN A on [DATE] at 5:08 P.M revealed CR #2 meal intake declining was reported to him by CNA D. He said he wrote the nursing note and a note in the 24 hour report worksheet. Further interview with RN A he said he verbally pass CR #2's decline in meal intake and condition to the oncoming nurse for the second shift, however he said he did not report to change or condition to the physician or the resident's guardian. RN A said he did not assess the resident. In an interview with RN A on [DATE] at 12:10 P.M revealed RN A was called into CR#2's for full code of CR#2 until confirmation of DNR was given. Further interview with RN A revealed CR#2 was taking her last breathes upon his entry in to CR#2's room. In an interview with CNA D on [DATE] at 10:26 A.M she said that she notified LVN B of CR #2's decline and not eating all of her food and CR #2 said she was not feeling well. CNA D said CR #2 normally ate all of her food except vegetables and CR #2 started refusing to eat. CNA D said that after notifying LVN B about CR #2 not eating she then told RN A of CR#2 not eating. In an interview with the DON on [DATE] at 10:12 A.M. he said he was not notified of CR #2 decline in meal intake. Further interview with the DON revealed he was not alerted of CR #2's meal intake change from the care tracker system due to care tracker documentation of meal intake being 50% to 75%. He said staff did not notify him of CR #2's change in condition. Review of the facility's ,[DATE] Abuse - Reportable Events policy and procedure documented, in part: It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident /event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Definitions: Neglect: the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. The facility Administrator and DON were notified on [DATE] at 4:06p.m that an IJ was identified due to the abive failures and a POR was requested. The POR was submitted by the Administrator on [DATE]. After several revisions, the final plan of removal was accepted on [DATE] at 1:08 pm. The POR read in part: .was sent to the local emergency roiagnom on [DATE] and arrived at the ER at 3:39 pm. Immediate Action The DON .and charge nurses immediately on [DATE] began assessing all residents for change in condition, via walking rounds if any resident has a change in condition, Physician notification will be done based on the Interact IV guidelines. This was completed on [DATE] Education All Licensed Nurses on duty will be provided education on our Diagnostic Testing and communicating panic or critical lab values done by DON and Corporate Nurse. A posttest was provided beginning [DATE] and will end on [DATE]. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure as it relates to diagnostic testing. All Licensed Nurses on duty will be provided education on Notification of Change in condition using the Interact IV to include training on timely and thoroughness of assessing a resident. This education will be provided by DON and Corporate Nurse. A posttest was provided beginning [DATE] and will end 1.9.18. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on change of condition, Physician notification. All C.N.A.'s on duty will be provided education on Notification of a change in resident's condition and reporting change to charge nurse. This education will be provided by DON and Corporate Nurse beginning [DATE] and ending [DATE]. Any C.N.A. that has not been trained will be removed from the schedule and will not work until this education has been provided. All Licensed Nurses on duty will be provided education on Abuse and neglect. This education will be provided by DON and Corporate Nurse. A posttest was provided beginning [DATE] and will end [DATE] Any nurse that has not had this training will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on abuse and neglect. Monitoring DON will review daily all resident with a change in condition to ensure timely notification of Physician The DON and Administration will Review lab tracking log daily to ensure labs results reported to Physician in a timely manner. A QA&A meeting will be conducted by Administrator on [DATE] and weekly to validate that the facility's Notification in change of condition is in place and of sustaining compliance. The Center's medical director was notified at 6:00 pm on [DATE] at 6:15 pm of the Immediate Jeopardy . In an interview on [DATE] at 4:06 pm The Administrator said we did in-services. We did in-service that day or within 48 hours. The DON saw the resident the day resident was sent later to the hospital and did not follow up. She acknowledged no notification to anyone at that time for CR #1. The Administrator said LVN A nurse was terminated for failure to follow the policy on an unrelated issues. She was informed there were two nurses who identified a change in condition but no action was taken and doctor/NP was not notified. During an interview on [DATE] at 5:49 p.m. the DON said he thought the immediate jeopardy was a result of poor documentation by the nurse. LVN A was to call 911 when the ambulance contracted was not responding. He said they interviewed the nurses to see if they felt overwhelmed or if it was too much and no one said it was. The DON said there was just no communication. They didn't communicate with each other, not even on the 24 hour report. Nothing on the nurse to nurse. The DON said he started in-services. Working on other way will continue interview [DATE]. The DON said he ensured staff was educated by conductung in-services and skill checks. Interviews conducted between [DATE] and [DATE] showed that four RN's, five LVN's, two MA, and eight CNA's had attended and understood the in-services conducted related to change in condition. Record review of the [DATE] In-Service Training Report completed by the facility documented 30 nurses signed they were in-serviced on [DATE] have some done over the weekend. Thirteen staff signed the [DATE] In-service Training Report on Change of Condition/ Notification of Physician and Family which included the Policy on Changes of Condition and the SBAR. Record review of the Change of Condition Quiz documented 30 staff were tested on their knowledge of change of condition, notification to physicians and documentation. Review of the Report Sheets for all Halls documented all residents had a baseline vital signs completed. Review of the [DATE] In-Service on SBAR documented, in part: Nurses, an SBAR is to be filled out whenever you have to communicate with the MD, NP, nurses you are giving report to at the hospital, EMT's etc. NO EXCEPTIONS. This has to be done without fail. There were no SBAR documented for CR #1 On [DATE] at 1:20 p.m. the Administrator was informed the IJ was lowered. The facility remained out of compliance at a severity level of harm with a scope of a pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The facility room roster revealed a census of 18 in halls 4 and 5.

Based on interview and record review the facility failed to administered the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of 11 residents (Resident #6) reviewed for effective administration. The Administrator failed to -Supervise the DON to ensure nursing staff conducted accurate assessments of residents, including pain assessments when they had a change in condition or injury after falls. -Supervise the DON to ensure nursing staff monitor and consult with the physician and assessment of residents when they had a change in condition and unrelieved pain. The DON failed to -Train and monitor the nursing staff on assessments and pain assessments of Residents when they had a change in condition after a fall. -Train and monitor the staff on monitoring residents condition when they had a change in condition after a fall. -Train and monitor the staff on consulting with the resident's physician when they had a change in condition to include unrelieved pain after a fall. An Immediate Jeopardy (IJ) was identified on 05/12/16. While the IT was lowered on 05/15/16, the facility remained out of compliance at a scope of pattern and a severity of harm that is not immediate threat due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure affected one resident whose needs were not met and placed the 22 residents that had injuries at risk of not being provided with appropriate and timely medical intervention resulting in a decline in health and quality of life. Complaint # 3 Findings Included: Interview on 05/13/16 at 11:45 a.m. with the Administrator she said the reason the IJ happened was because the nurses ' lack of documentation regarding Resident # 6 changes in condition and increase level of pain that was not relieved with prescribed pain medication ordered and also not communicating findings to the Nurse Practitioner. The Administrator also said the day of the incident the DON was out of the facility on training. I think the nurse should have reassessed Resident # 6 and communicated with the NP. The Administrator said she would be reviewing the falls and follow-ups on how the DON in-serviced the nursing staff. She said she would develop a check and balance system for all of the Nursing staff on each shift. Interview on 05/13/16 at 1:00 p.m. with the DON he said he believed that the reason the facility had and IJ was because of pain . The DON said that he monitored the nursing staff in regards to resident complaints of pain every shift looking at assessments. Any resident with pain assessments should be on the 24 hour report sheet. The DON said that he assigned each ADON a designated hall to look at Medication Administration Record [REDACTED]. These assessments are discussed in meetings along with the 24 hour report sheet. The DON said that he did not have a designated staff to provide training to the nursing staff and he was ultimately responsible for it although the ADON does assist sometimes. Record review of Resident #6's chart revealed a [AGE] year old male admitted to the facility on [DATE] and again on 05/05/16. His [DIAGNOSES REDACTED]. Record review of the incident and accident report dated 04/28/16 at 12 noon revealed in part that Resident #6 was found on the floor in his room saying he was trying to get in bed. The resident complained of pain in both legs. Further review of the investigation follow up revealed that the NP was notified and ordered [MEDICATION NAME] 400 mg every 6 hours for five days. Record review of Nurses Notes on Resident #6 dated 04/28/16 and 4/29/16 revealed Resident #6 continued to complain of pain and staff assessed the resident's pain as 10 of 10 for the next 45 hours. Record review revealed an x-ray was not conducted until 4/29/2016 at 5:30 p.m with the results showing Resident #6 had a [MEDICAL CONDITION] which the x-ray company reported to the facility on [DATE] at 8:00 a.m. Resident #6 was transfered to the hospital on [DATE] at 9:30 a.m. where he received surgery to the hip and returned to the facility on [DATE]. Interview on 05/12/16 at 2:15 p.m. with the DON he said that he read the incident report and the charting of the Nurses Notes related to Resident # 6 ' fall. The DON said the nurses should have gotten orders to send resident out immediately with a continued pain level of 10. He said the facility called the State and their corporate office and reported the incident regarding Resident # 6. The DON said he wanted to terminate the nurses involved in incident but Corporate told him no and to educate them. The DON said since the incident regarding Resident # 6 happened he had in-serviced those 2 nurses regarding assessments, falls and change in a resident condition. The DON said that the 2 nurses were also further in-serviced on critical thinking skills, notification of Physician using the SBAR, and pain with falls. When questioned, the DON said that he only in-serviced those 2 nurses because the issue only involved those two nurses, he said they were the ones involved in the incident. In an interview with the NP on 05/13/16 at 10:30 am she said that she did receive a call from the nurse to tell her that Resident #6 had a fall and she prescribed [MEDICATION NAME] for the pain. She said that she did not receive a call from the facility staff until the next day at approximately 3:00 pm to let her know the resident was still in pain. She said she arrived at the facility, assessed the resident and ordered the X-ray test. She said that she was not aware that the resident had continuous complaints of pain on 04/28 and 04/29. She said staff should have called her to let her know. She also said that after this situation the Physician decided that for any hard fall or complaint of pain after a fall he would order a X-ray to rule out issues. This failure resulted in an Immediate Jeopardy. The Facility Administrator and Director of Nursing were informed of the IJ on 05/12/16 at 4:37 p.m. and a plan of removal was requested. After three revisions the POR was accepted on 05/13/16 at 4:12 p.m. The POR read in part: . -All residents with a fall in the last 30 days were reviewed and evaluated for any change of condition and or acute pain by the DO n and ADON RN on 05/12/16. -The DON and RN ADON completed walking rounds on May 12, 2016 on the other resident to review and evaluate any change of condition and pain. Each resident assessed by the DON and RN/ADON did not observe any new concerns of pain or change of condition. -The MD and family will be notified as necessary and intervention will be implemented if necessary. Any resident with a change of condition will be monitored by charge nurses, Physician, DON and the Administrator will be notified. - On 05/12/16 Licensed Nurses on duty were immediately in-serviced by DON on the following care areas: notification of change in condition and Interact 4 Physician File Cards, notification of Administrator and DON of all fall incidents with or without injury at the time of the fall, pain management guidelines, post fall evaluation, clinical diagnostic and lab guidelines, and post- test will be provided for all in-service topics. -100% of Licensed Nurse staff and Certified aides will be in-serviced by 05/14/16 by the DON. Any nursing staff that did not receive in-service will be removed from the schedule and are not allowed to work until in-service is completed. - Licensed Nurses will notify Administrator and D.O.N of all fall incidents (with or without injury) at the time of the fall to receive any necessary guidance. Effective 5/13/2016 the Facility Medical Director and or Attending Physicians will routinely x-ray residents that sustain a hard fall as part of the initial assessment when pain is exhibited to rule out serious injury. This new system will be a part of the In-Services initiated effective May 12, 2016 and to be completed by Saturday, May 14, 2016. - DON/designee will monitor, using the Post-Fall Assessment tool effective 5/13/2016, all residents with incidents related to falls. ADONs and the Weekend supervisor will monitor the fall incidents daily including weekends to validate physician and families are notified, post fall evaluation is documented, paid is evaluated and Administrator and DON are notified. The monitoring will continue daily times four (4) weeks, then two (2) times per week including the weekends . The facility plan was monitored from 05/13/16 until 05/15/16 with the following results: - Seven nurses from different shifts to include the weekend shift were interviewed regarding in-services provided on changes in condition, assessments, documentation, physician notification, falls, and pain. - Ten CNA ' s from different shifts and the weekend were interviewed regarding in-services regarding falls and who to notify, reporting to the nurse change in resident condition, transfers, and safety. Records were reviewed to indicate head to toe assessments were completed on all residents. The Administrator and DON were informed on 05/15/16 at 4:57 p.m. that the IJ was lowered, however the facility remained out of compliance at a scope of pattern and severity of actual harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility incident and accident report log for April 2016 revealed 22 residents had injuries from incidents.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of 11 (Resident # 6) residents reviewed for quality of care. Staff failed to recognize when Resident #6 experienced a change in condition and experienced unrelieved pain for 45 hours after a fall. An X-Ray revealed Resident # 6 had a fractured left hip and he was transferred to the hospital for surgery. An Immediate Jeopardy (IJ) was identified on 05/12/16. While the IT was lowered on 05/15/16, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate threat due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure affected one resident whose pain was not treated and placed the 21 additional residents that had injuries at risk of not being provided with appropriate and timely medical intervention resulting in a decline in health and quality of life. Intake # 3 Findings Included: Record review of Resident #6's clinical chart revealed a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was readmitted to the facility on readmitted from the hospital on [DATE] with new [DIAGNOSES REDACTED]. Record review of Minimum Data Set assessment dated [DATE] revealed that Resident #6 cognitive level was severely impaired and required limited to extensive assistance with activities of daily living. Record review of Resident #6 care plan date initiated 04/15/14 and revised on 11/20/15 revealed in part potential for falls related to unaware of safety needs, poor communication/comprehension, wandering and balance problems. Resident was being care planned for elopement risk/wanderer, poor muscle dexterity, and activites of daily living self-care performance related to disease process of Dementia. Resident # 6 required limited to extensive assistance of one staff member. Record review of the Incident and Accident report dated 04/28/16 at 12 noon revealed in part that Resident #6 was found on the floor in his room saying he was trying to get in bed. The resident complaint of pain on both legs. Further review of the form revealed that the NP was notified and ordered [MEDICATION NAME] 400 mg every 6 hours as needed for five days. Record review of Nurses Notes on Resident #6 dated 04/28/16 revealed: -at 12:00 p.m . Resident was found on the floor next to bed. Resident reported to nurse that he was trying to get into bed. Non-skid socks noted on feet. Resident complained of pain to both legs. CNA with 2 nurses helped to assist resident up to stand, legs noted shaking and gait unbalanced. Resident was moaning with facial grimacing when he tried to raise legs pain scale 10/10. Head to toe assessment show no scars or bruising to the body. Resident denies pain to head and upper extremities . -12:20 p.m. Nurse Practitioner made aware of fall new order received to give [MEDICATION NAME] 400 mg by mouth every 6 hours as needed for pain times 5 days. The initial dose of [MEDICATION NAME] 400mg by mouth given. -12:35 p.m. Resident assessed for pain rated 10/10 for pain nodding head when asked of pain level. -2:00 p.m. Resident continue to complain of pain to legs. Resident point to leg where it hurt continuing to nod that pain level is 10/10 to bilateral leg, will continue to monitor behavior. There was no documentation that the physician was consulted. -no time, Resident complained of pain to bilateral legs medicated with pain medication as needed as ordered. Bed in lowest position, fall precautions in place will continue to monitor, call light in place. There was no documentation that the physician was consulted. There were no other notes or assessments in the chart for 04/28/16 or for 04/29/16 before 8:00 am. Record review of Nurses Notes for Resident # 6 dated 04/29/16 revealed: - 8:00 am- . received resident in room, alert and responsive .ROM active upper and right lower extremities .denies pain . -1:20 p.m. Resident complained of pain to the left leg pain medication [MEDICATION NAME] 400mg by mouth given as needed, tolerated well. There was no documentation that the physician was consulted. -3:11 p.m. Notified Nurse Practitioner about resident pain to left leg while in facility, ordered X-Ray of left pelvis, spine(lumbar), and left leg femur, called and notified X-Ray company, will continue to monitor. -5:28 p.m. X-ray company in the facility, X-Ray done waiting on results. Record review of Nurses Notes on Resident # 6 dated 04/30/16 revealed: -8:00 a.m. X-Ray results of left pelvis spine and left leg femur indicated a fracture to the femur. Resident who is laying down in bed and refusing to get up for breakfast in attempting to check range of motion, resident grimaced in attempting to move leg. Nurse asked him if he was in pain and he nodded yes. Nurse Practitioner ordered for resident to be transferred to local hospital. -9:30 a.m. Resident taken to Hospital by ambulance, family notified. Interview on 05/12/16 at 1:13 p.m. with LVN- S she said she worked the 6 am to 2 pm shift. She said that Resident #6 was found on the floor in his room by his bed at around noon. She said the nursing staff (CNA ' s) helped assist Resident # 6 to his feet and observed his legs were trembling then assisted him to his bed. Resident # 6 told her he was trying to get in bed. LVN-S said she did a complete assessment after getting resident into bed. LVN-S said when she did range of motion to Resident #6 lower extremities he communicated he was in pain on a scale of 1-10 Resident communicated a 10. LVN-S said she called the Nurse Practitioner and received orders to administer [MEDICATION NAME] 400mg by mouth for pain. LVN-S said that she should have called the Nurse Practitioner back once she checked Resident # 6 ' s pain level again after administering pain medication and Resident # 6 pain level was still at 10. She said that instead she gave Resident # 6 very light massage to his legs because Resident # 6 likes massages, it relaxes him. Interview on 05/12/16 at 3:55 p.m. with LVN-VV she said she worked the 2 pm to 10 pm shift on 04/28/16 and again the 6 am to 2 pm shift on 04/29/16. She said that she was told in report by LVN-S that Resident #6 had fallen on the morning shift and that she did continue to medicate Resident # 6 for complaints of pain with [MEDICATION NAME]. LVN-VV said she did not do effective charting or call the Nurse Practitioner back until the next day when she returned to work on the morning shift. LVN-VV said then it came to her attention that there might be more going on with Resident # 6 due to his continuous complaints of pain. Record review of Resident # 6 X-Ray results done on 04/29/16 and received by the facility on 04/30/16 at 7:30 am revealed subtle left-sided intertrochanteric femur fracture suggested. Would recommend Orthopedic consultation. Record review of Physician orders [REDACTED]. Record review of physician progress notes [REDACTED]. -Orthopedic Physical Exam: Left hip exam reveals sever tenderness with movement and palpitation. -Orthopedic Imaging Reviewed: Left hip and femur radiographs 2 views of the left femur and hip reveal a intertrochanteric left femur fracture. -Would recommend patient undergo surgical intervention for his left [MEDICAL CONDITION]. Record review of Resident # 6 face sheet revealed that he returned back to facility from the hospital with the [DIAGNOSES REDACTED]. Observation on 05/12/16 at 11:40 a.m. of Resident # 6 receiving Physical Therapy. Resident #6 was using the standing frame chair in the standing position. Observation was made of Resident in the standing position for 5 minutes. Attempted to interview Resident #6 at 5/12/16 at 11:40 a.m. Resident #6, looked when his name was called but did not respond to questions asked. Resident # 6 was non-interviewable. Interview on 05/12/16 at 11:40 a.m. the Physical Therapist said that Resident # 6 had very advance Dementia and was alert and oriented to name only. The Physical Therapist said before Resident # 6 fractured his Left hip and had to have surgery he would be all over the Nursing facility. Interview on 05/12/16 at 2:15 p.m. with the DON he said that he read the incident report and the charting of the Nurses Notes related to Resident # 6's fall. The DON said the nurses should have gotten orders to send resident out immediately with a continued pain level of 10. He said the facility called the State and their corporate office and reported the incident regarding Resident # 6. The DON said he wanted to terminate the nurses involved in incident but Corporate told him no and to educate them. The DON said since the incident regarding Resident # 6 happened he had in-serviced those 2 nurses regarding assessments, falls and change in a resident condition. The DON said that the 2 nurses were also further in-serviced on critical thinking skills, notification of Physician using the SBAR, and pain with falls. When questioned, the DON said that he only in-serviced those 2 nurses because the issue only involved those two nurses, he said they were the ones involved in the incident. Record review of facility policy titled Pain Management revision date 12/2003; 2/06, 11/09 read in part: All residents shall be assessed for pain factors and history upon admission to the facility and subsequently thereafter according to the finding of the assessment. All residents shall receive treatment for [REDACTED]. The pain shall be re-evaluated thirty (30) minutes to one hour after medication administration for effectiveness and documented in the medical record, or on a specified alternate schedule when appropriate depending on the type of pain and medication administered. The physician shall be notified when any type of prescribed pain medication management regimen is not effective in relieving resident pain Record review of facility Patient Evaluation Post Fall Guideline dated 06/2013 revealed In part: Upon the occurrence of an incident that may have cause injury to a patient, the patient is evaluated to determine the presence or absence of injuries prior to being moved. The evaluation includes at a minimum range of motion and presence of pain. Record review of facility SBAR Interact Version 4.0 Tool dated 2014 revealed: Change in Condition: When to report the MD/NP/PA Immediate Notification 1. Any symptom, sign or apparent discomfort that is unrelieved by measures already prescribed 2. Fall with any suspected serious injury (e.g. fracture) any hip pain, or more than minor pain elsewhere. 3. Pain that is new severe pain, or marked increase in chronic pain 4. Weakness, arm or leg abrupt onset of noticeable change in strength or use. This failure resulted in an Immediate Jeopardy. The Facility Administrator and Director of Nursing were informed of the IJ on 05/12/16 at 4:37 p.m. and a plan of removal was requested. After three revisions the POR was accepted on 05/13/16 at 4:12 p.m. The POR read in part: . -All residents with a fall in the last 30 days were reviewed and evaluated for any change of condition and or acute pain by the DO n and ADON RN on 05/12/16. -The DON and RN ADON completed walking rounds on May 12, 2016 on the other resident to review and evaluate any change of condition and pain. Each resident assessed by the DON and RN/ADON did not observe any new concerns of pain or change of condition. -The MD and family will be notified as necessary and intervention will be implemented if necessary. Any resident with a change of condition will be monitored by charge nurses, Physician, DON and the Administrator will be notified. - On 05/12/16 Licensed Nurses on duty were immediately in-serviced by DON on the following care areas: notification of change in condition and Interact 4 Physician File Cards, notification of Administrator and DON of all fall incidents with or without injury at the time of the fall, pain management guidelines, post fall evaluation, clinical diagnostic and lab guidelines, and post- test will be provided for all in-service topics. -100% of Licensed Nurse staff and Certified aides will be in-serviced by 05/14/16 by the DON. Any nursing staff that did not receive in-service will be removed from the schedule and are not allowed to work until in-service is completed. - Licensed Nurses will notify Administrator and D.O.N of all fall incidents (with or without injury) at the time of the fall to receive any necessary guidance. Effective 5/13/2016 the Facility Medical Director and or Attending Physicians will routinely x-ray residents that sustain a hard fall as part of the initial assessment when pain is exhibited to rule out serious injury. This new system will be a part of the In-Services initiated effective May 12, 2016 and to be completed by Saturday, May 14, 2016. - DON/designee will monitor, using the Post-Fall Assessment tool effective 5/13/2016, all residents with incidents related to falls. ADONs and the Weekend supervisor will monitor the fall incidents daily including weekends to validate physician and families are notified, post fall evaluation is documented, paid is evaluated and Administrator and DON are notified. The monitoring will continue daily times four (4) weeks, then two (2) times per week including the weekends . The facility plan was monitored from 05/13/16 until 05/15/16 with the following results: - Seven nurses from different shifts to include the weekend shift were interviewed regarding in-services provided on changes in condition, assessments, documentation, physician notification, falls, and pain. - Ten CNA ' s from different shifts and the weekend were interviewed regarding in-services regarding falls and who to notify, reporting to the nurse change in resident condition, transfers, and safety. Records were reviewed to indicate head to toe assessments were completed on all residents. In an interview with the NP on 05/13/16 at 10:30 am she said that she did receive a call from the nurse to tell her that Resident #6 had a fall and she prescribed [MEDICATION NAME] for the pain. She said that she did not receive a call from the facility staff until the next day at approximately 3:00 pm to let her know the resident was still in pain. She said she arrived at the facility, assessed the resident and ordered the X-ray test. She said that she was not aware that the resident had continuous complaints of pain on 04/28 and 04/29. She said staff should have called her to let her know. She also said that after this situation the Physician decided that for any hard fall or complaint of pain after a fall he would order a X-ray to rule out issues. Interview on 05/13/16 at 11:45 a.m. with the Administrator she said the reason the IJ happened was because the nurses ' lack of documentation regarding Resident # 6 changes in condition and increase level of pain that was not relieved with prescribe pain medication orders and also not communicating findings to the Nurse Practitioner. The Administrator also said the day of the incident the DON was out of the facility on training. I think the nurse should have reassessed Resident # 6 and communicated with the NP. The Administrator said she will be reviewing the falls and follow-ups on how the DON in-serviced the nursing staff. She said she would develop a check and balance system for all of the Nursing staff on each shift. Interview on 05/13/16 at 1:00 p.m. with the DON he said he believed that the reason the facility had and IJ was because of pain . The DON said that he monitored the nursing staff in regards to resident complaints of pain every shift looking at assessments. Any resident with pain assessments should be on the 24 hour report sheet. The DON said that he assigned each ADON a designated hall to look at Medication Administration Record [REDACTED]. These assessments are discussed in meetings along with the 24 hour report sheet. The DON said that he did not have a designated staff to provide training to the nursing staff and he was ultimately responsible for it although the ADON does assist sometimes. The Administrator and DON were informed on 05/15/16 at 4:57 p.m. that the IJ was lowered, however the facility remained out of compliance at a scope of pattern and severity of harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility incident and accident report log for April 2016 revealed 22 residents had incidents of falls.

Based on observation, interview, and record review, the facility failed to consult with the resident's physician when the resident experienced a significant change in condition for one of eleven residents (Resident # 6) reviewed for notification of changes. - Resident #6's physician was not consulted when he had a change in condition and experienced pain that was not controlled and assessed as a 10 out of 10. Resident #6 was transferred to the hospital on [DATE] at 9:30 a.m. after an X-Ray revealed a [MEDICAL CONDITION] hip. An Immediate Jeopardy (IJ) was identified on 05/12/16. While the IJ was lowered on 05/15/16, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate threat due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure affected one resident whose needs were not met and placed the 21 additional residents that had injuries at risk of not being provided with appropriate and timely assessments and medical intervention resulting in a decline in health and quality of life. Intake # 3 Findings Included: Record review of Resident #6's clinical chart revealed a [AGE] year old male admitted to the facility on [DATE] . His [DIAGNOSES REDACTED]. He was readmitted to the facility on [DATE] with new [DIAGNOSES REDACTED]. Record review of Minimum Data Set assessment dated [DATE] revealed that Resident #6 cognitive level was severely impaired and required limited to extensive assistance with activities of daily living. Record review of Resident #6 care plan date initiated 04/15/14 and revised on 11/20/15 revealed in part potential for falls related to unaware of safety needs, poor communication/comprehension, wandering and balance problems. Resident was also being care planned for elopement risk/wandering, poor muscle dexterity, and activities of daily living. Resident # 6 required limited to extensive assistance of one staff member. Record review of the Incident and Accident report dated 04/28/16 at 12 noon revealed in part that Resident #6 was found on the floor in his room saying he was trying to get in bed. The resident complained of pain in both legs. Further review of the form revealed that the NP was notified and ordered [MEDICATION NAME] 400 mg every 6 hours as needed for five days. Record review of Nurses Notes on Resident #6 dated 04/28/16 revealed: -at 12:00 p.m . Resident was found on the floor next to bed. Resident reported to nurse that he was trying to get into bed. Non-skid socks noted on feet. Resident complained of pain to both legs. CNA with 2 nurses helped to assist resident up to stand, legs noted shaking and gait unbalanced. Resident was moaning with facial grimacing when he tried to raise legs pain scale 10/10. Head to toe assessment show no scars or bruising to the body. Resident denies pain to head and upper extremities . -12:20 p.m. Nurse Practitioner made aware of fall new order received to give [MEDICATION NAME] 400 mg by mouth every 6 hours as needed for pain times 5 days. The initial dose of [MEDICATION NAME] 400mg by mouth given. -12:35 p.m. Resident assessed for pain rated 10/10 for pain nodding head when asked of pain level. -2:00 p.m. Resident continue to complain of pain to legs. Resident point to leg where it hurt continuing to nod that pain level is 10/10 to bilateral leg, will continue to monitor behavior. There was no documentation that the physician was consulted. -no time, Resident complained of pain to bilateral legs medicated with pain medication as needed as ordered. Bed in lowest position, fall precautions in place will continue to monitor, call light in place. There was no documentation that the physician was consulted. - There were no other notes or assessments in the clinical file for Resident #6 for 04/28/16 or for 04/29/16 before 8:00 am Record review of Nurses Notes for Resident # 6 dated 04/29/16 revealed: - 8:00 am- . received resident in room, alert and responsive .ROM active upper and right lower extremities .denies pain . -1:20 p.m. Resident complained of pain to the left leg pain medication [MEDICATION NAME] 400mg by mouth given as needed, tolerated well. There was no documentation that the physician was consulted. -3:11 p.m. Notified Nurse Practitioner about resident pain to left leg while in facility, ordered X-Ray of left pelvis, spine(lumbar), and left leg femur, called and notified X-Ray company, will continue to monitor. -5:28 p.m. X-ray company in the facility, X-Ray done waiting on results. Record review of Nurses Notes on Resident # 6 dated 04/30/16 revealed: -8:00 a.m. X-Ray results of left pelvis spine and left leg femur indicated a fracture to the femur. Resident who is laying down in bed and refusing to get up for breakfast in attempting to check range of motion, resident grimaced in attempting to move leg. Nurse asked him if he was in pain and he nodded yes. Nurse Practitioner ordered for resident to be transferred to local hospital. -9:30 a.m. Resident taken to Hospital by ambulance, family notified. Interview on 05/12/16 at 1:13 p.m. with LVN- S she said she worked the 6 am to 2 pm shift. She said that Resident #6 was found on the floor in his room by his bed at around noon. She said the nursing staff (CNA ' s) helped assist Resident # 6 to his feet and observed his legs were trembling then assisted him to his bed. Resident # 6 told her he was trying to get in bed. LVN-S said she did a complete assessment after getting resident into bed. LVN-S said when she did range of motion to Resident #6 lower extremities he communicated he was in pain on a scale of 1-10 Resident communicated a 10. LVN-S said she called the Nurse Practitioner and received orders to administer [MEDICATION NAME] 400mg by mouth for pain. LVN-S said that she should have called the Nurse Practitioner back once she checked Resident # 6 ' s pain level again after administering pain medication and Resident # 6 pain level was still at 10. She said that instead she gave Resident # 6 very light massage to his legs because Resident # 6 likes massages, it relaxes him. Interview on 05/12/16 at 3:55 p.m. with LVN-VV she said she worked the 2 pm to 10 pm shift on 04/28/16 and again the 6 am to 2 pm shift on 04/29/16. She said that she was told in report by LVN-S that Resident #6 had fallen on the morning shift and that she did continue to medicate Resident # 6 for complaints of pain with [MEDICATION NAME]. LVN-VV said she did not do effective charting or call the Nurse Practitioner back until the next day when she returned to work on the morning shift. LVN-VV said then it came to her attention that there might be more going on with Resident # 6 due to his continuous complaints of pain. Record review of Resident # 6 X-Ray results done on 04/29/16 and received by the facility on 04/30/16 at 7:30 am revealed subtle left-sided intertrochanteric femur fracture suggested. Would recommend Orthopedic consultation. Record review of Physician orders [REDACTED]. Record review of Resident #6's hospital physician progress notes [REDACTED]. -Orthopedic Physical Exam: Left hip exam revealed severe tenderness with movement and palpitation. -Orthopedic Imaging Reviewed: Left hip and femur radiographs 2 views of the left femur and hip revealed an intertrochanteric left femur fracture. -Would recommend patient undergo surgical intervention for his left [MEDICAL CONDITION]. Record review of Resident # 6 face sheet revealed that he returned back to facility from the hospital with the [DIAGNOSES REDACTED]. Observation on 05/12/16 at 11:40 a.m. of Resident # 6 receiving Physical Therapy. Resident #6 was using the standing frame chair in the standing position. Observation was made of Resident in the standing position for 5 minutes. Attempted to interview Resident #6 at 5/12/16 at 11:40 a.m. Resident #6, looked when his name was called but did not respond to questions asked. Resident # 6 was non-interviewable. Interview on 05/12/16 at 11:40 a.m. the Physical Therapist said that Resident # 6 had very advance Dementia and was alert and oriented to name only. The Physical Therapist said before Resident # 6 fractured his Left hip and had to have surgery he would be all over the Nursing facility. Interview on 05/12/16 at 2:15 p.m. with the DON he said that he read the incident report and the charting of the Nurses Notes related to Resident # 6's fall. The DON said the nurses should have gotten orders to send resident out immediately with a continued pain level of 10. He said the facility called the State and their corporate office and reported the incident regarding Resident # 6. The DON said he wanted to terminate the nurses involved in incident but Corporate told him no and to educate them. The DON said since the incident regarding Resident # 6 happened he had in-serviced those 2 nurses regarding assessments, falls and change in a resident condition. The DON said that the 2 nurses were also further in-serviced on critical thinking skills, notification of Physician using the SBAR, and pain with falls. When questioned, the DON said that he only in-serviced those 2 nurses because the issue only involved those two nurses, he said they were the ones involved in the incident. Record review of facility policy titled Pain Management revision date 12/2003; 2/06, 11/09 read in part: All residents shall be assessed for pain factors and history upon admission to the facility and subsequently thereafter according to the finding of the assessment. All residents shall receive treatment for [REDACTED]. The pain shall be re-evaluated thirty (30) minutes to one hour after medication administration for effectiveness and documented in the medical record, or on a specified alternate schedule when appropriate depending on the type of pain and medication administered. The physician shall be notified when any type of prescribed pain medication management regimen is not effective in relieving resident pain Record review of facility Patient Evaluation Post Fall Guideline dated 06/2013 revealed In part: Upon the occurrence of an incident that may have cause injury to a patient, the patient is evaluated to determine the presence or absence of injuries prior to being moved. The evaluation includes at a minimum range of motion and presence of pain. Record review of facility SBAR Interact Version 4.0 Tool dated 2014 revealed: Change in Condition: When to report the MD/NP/PA Immediate Notification 1. Any symptom, sign or apparent discomfort that is unrelieved by measures already prescribed 2. Fall with any suspected serious injury (e.g. fracture) any hip pain, or more than minor pain elsewhere. 3. Pain that is new severe pain, or marked increase in chronic pain 4. Weakness, arm or leg abrupt onset of noticeable change in strength or use. This failure resulted in an Immediate Jeopardy. The Facility Administrator and Director of Nursing were informed of the IJ on 05/12/16 at 4:37 p.m. and a plan of removal was requested. After three revisions the POR was accepted on 05/13/16 at 4:12 p.m. The POR read in part: . -All residents with a fall in the last 30 days were reviewed and evaluated for any change of condition and or acute pain by the DO N and ADON RN on 05/12/16. -The DON and RN ADON completed walking rounds on May 12, 2016 on the other resident to review and evaluate any change of condition and pain. Each resident assessed by the DON and RN/ADON did not observe any new concerns of pain or change of condition. -The MD and family will be notified as necessary and intervention will be implemented if necessary. Any resident with a change of condition will be monitored by charge nurses, Physician, DON and the Administrator will be notified. - On 05/12/16 Licensed Nurses on duty were immediately in-serviced by DON on the following care areas: notification of change in condition and Interact 4 Physician File Cards, notification of Administrator and DON of all fall incidents with or without injury at the time of the fall, pain management guidelines, post fall evaluation, clinical diagnostic and lab guidelines, and post- test will be provided for all in-service topics. -100% of Licensed Nurse staff and Certified aides will be in-serviced by 05/14/16 by the DON. Any nursing staff that did not receive in-service will be removed from the schedule and are not allowed to work until in-service is completed. - Licensed Nurses will notify Administrator and DON of all fall incidents (with or without injury) at the time of the fall to receive any necessary guidance. Effective 5/13/2016 the Facility Medical Director and or Attending Physicians will routinely x-ray residents that sustain a hard fall as part of the initial assessment when pain is exhibited to rule out serious injury. This new system will be a part of the In-Services initiated effective May 12, 2016 and to be completed by Saturday, May 14, 2016. - DON/designee will monitor, using the Post-Fall Assessment tool effective 5/13/2016, all residents with incidents related to falls. ADONs and the Weekend supervisor will monitor the fall incidents daily including weekends to validate physician and families are notified, post fall evaluation is documented, paid is evaluated and Administrator and DON are notified. The monitoring will continue daily times four (4) weeks, then two (2) times per week including the weekends . The facility plan was monitored from 05/13/16 until 05/15/16 with the following results: - Seven nurses from different shifts to include the weekend shift were interviewed regarding in-services provided on changes in condition, assessments, documentation, physician notification, falls, and pain. - Ten CNA ' s from different shifts and the weekend were interviewed regarding in-services regarding falls and who to notify, reporting to the nurse change in resident condition, transfers, and safety. Records were reviewed to indicate head to toe assessments were completed on all residents. In an interview with the NP on 05/13/16 at 10:30 am she said that she did receive a call from the nurse to tell her that Resident #6 had a fall and she prescribed [MEDICATION NAME] for the pain. She said that she did not receive a call from the facility staff until the next day at approximately 3:00 pm to let her know the resident was still in pain. She said she arrived at the facility, assessed the resident and ordered the X-ray test. She said that she was not aware that the resident had continuous complaints of pain on 04/28 and 04/29. She said staff should have called her to let her know. She also said that after this situation the Physician decided that for any hard fall or complaint of pain after a fall he would order a X-ray to rule out issues. Interview on 05/13/16 at 11:45 a.m. with the Administrator she said the reason the IJ happened was because the nurses ' lack of documentation regarding Resident # 6 changes in condition and increase level of pain that was not relieved with prescribe pain medication orders and also not communicating findings to the Nurse Practitioner. The Administrator also said the day of the incident the DON was out of the facility on training. I think the nurse should have reassessed Resident # 6 and communicated with the NP. The Administrator said she will be reviewing the falls and follow-ups on how the DON in-serviced the nursing staff. She said she would develop a check and balance system for all of the Nursing staff on each shift. Interview on 05/13/16 at 1:00 p.m. with the DON he said he believed that the reason the facility had an IJ was because of pain . The DON said that he monitored the nursing staff in regards to resident complaints of pain every shift looking at assessments. Any resident with pain assessments should be on the 24 hour report sheet. The DON said that he assigned each ADON a designated hall to look at Medication Administration Record [REDACTED]. These assessments were discussed in meetings along with the 24 hour report sheet. The DON said that he did not have a designated staff to provide training to the nursing staff and he was ultimately responsible for it although the ADON does assist sometimes. The Administrator and DON were informed on 05/15/16 at 4:57 p.m. that the IJ was lowered, however the facility remained out of compliance at a scope of pattern and severity of actual harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility incident and accident report log for April 2016 revealed 22 residents had incidents of falls.

Based on interview and record review it was determined the facility failed to promptly notify the attending physician of laboratory findings for 1 (Resident #1) of 12 residents reviewed for laboratory monitoring of [MEDICATION NAME]. - Critical PT/INR lab for Resident #1 was called in to the facility on [DATE] and was not communicated to the physician, which delayed treatment. Resident #1 complained of bleeding to the staff the weekend of 03/29/14-03/30/14 and there was no follow up assessment documented in the clinical records. Resident #1 continued to receive the anticoagulant medication which led to her hospitalization on [DATE]. An IJ was identified on 4/24/14 at 1:24 pm. While the IJ was removed on 4/29/14 at 11:35 am, the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm due to facility needing more time to monitor the plan of removal for effectiveness. These failure affected one resident and placed 11 other residents receiving anticoagulant therapy at risk for unidentified bleeding, delay in medical evaluation and treatment. Intake 3 Findings included: Resident #1: Record review of Resident #1 ' s admission face sheet revealed an admitted [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #1 ' s Quarterly MDS assessment dated [DATE] revealed under Section C: Cognitive Pattern, revealed that the resident was cognitively intact. Under Section G: Functional Status, Resident #1 was independent with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #1 ' s of telephone Physician orders [REDACTED]. -PT/INR lab on 3/31/14 Record review of Resident #1 ' s MAR for March 2014 revealed that she continuously received [MEDICATION NAME] 5 mg from 3/25/14 to 4/1/14. Record review of Resident #1 ' s laboratory results for PT/INR dated 3/31/14 revealed a critical PT value of 27.9 and critical INR value of 5.49. The results were called in by the lab to LVN C on 3/31/14 at 4:14 pm as documented in the lab result: A Lab tech phoned results on 3/31/14 at 16:14 pm Critical Results called to: LVN C Results read back correctly. INR Record review of Resident #1 ' s Nurse ' s notes and other clinical records revealed no documentation that the physician was notified of the PT/INR critical lab values. Record review of Resident #1 ' s Progress Notes/History and Physical dated 4/2/14 and written by Nurse Practitioner A revealed that Resident #1 had a bloodshot left eye, an INR of 5.6 and was bleeding from the left ear and nose. She gave the order for the resident to be transferred to the hospital. There was also a note indicating the following lab result: 3/31/14 PT/INR 5.49. Record review of Resident #1 ' s Nurse ' s notes dated 4/2/14 revealed that Resident #1 was transferred to the emergency room for " unspecified bleeding (internal) and elevated PT/INR. PT 27.9 INR 5.49. Further review of the note " Left eye noted very red can ' t see white ' s of eye. No bleeding noted to any other areas. " Resident #1 was admitted to the hospital from 4/2/14 to 4/10/14. Record review of Resident #1 ' s Nurse ' s notes dated 4/10/14 revealed that Resident #1 came back to the facility on [DATE] at 5:50 pm. Record review of Resident #1 ' s clinical records revealed that there was no " Admission Assessment Data Collection Tool " done when Resident #1 came back to the facility on [DATE]. Record review of Resident #1 ' s Nurse ' s notes dated 4/11/14 at 6:00 am revealed " Resident out in hall yelling down the hall stating she was bleeding. This writer and 2nd night nurse assessed resident and res. had blood in toilet and on wipes in sink. Res. assisted to bed per this writer and mid-lrg (large) blood clots observed coming from vagina ... " A call was placed to Nurse Practitioner A and Resident #1 was transferred to the hospital. Resident #1 was readmitted back to the hospital from 4/11/14 to 4/15/14. Record review of Resident #1 ' s hospital notes dated 4/12/14 revealed: " ...was discharged from the hospital one day earlier. She has been diagnosed with [REDACTED]. She has been on [MEDICATION NAME] because of history of [MEDICAL CONDITION]. The INR was down to 1.6, when she was discharged to nursing home she started having bleeding from the pelvic area, therefore sent back to the hospital for further evaluation and treatment. The patient had a history of [REDACTED]. " Record review of Resident #1 ' s physician's order [REDACTED]. CBC, BMP, HbA1C, TSH, PT/INR on 4/21/14. Continued record review of Resident # 's nurse's notes after she came back from the hospital revealed one no documentation of Resident #1 ' s physical assessment or current condition. Record review of Resident #1's laboratory results ordered on [DATE] revealed the following: TSH 66.09 (Reference: .46 - 4.68) Hemoglobin A1C 7.8 (4.3 - 6.1) PT 16.5 INR - 1.92 The lab results were faxed to the physician on 4/21/14 at 7:20 pm. Record review of Resident #1 ' s Physician orders [REDACTED]. -Discontinue [MEDICATION NAME] 5 mg -Start [MEDICATION NAME] 5 mg po Mon -Fri. -[MEDICATION NAME] 5.5 mg on Saturday and Sunday -PT INR on 4/28/14 -Discontinue [MEDICATION NAME] 50 mcg, start [MEDICATION NAME] 75 mcg 1 tab po before breakfast -TSH lab on 5/21/14 Record review of Resident #1 ' s care plan dated 4/22/14 revealed that Resident #1 was high risk for increase bleeding related to blood thinning agent. Resident currently takes [MEDICATION NAME]. The goal was Resident #1 would have no side effects from medication. The approaches read in part: 3. Lab as ordered 4. Protect resident from bruising self 9. Notify MD if bleeding is not stopped with pressure 10. Notify MD of abnormalities in labs Observation on 4/23/14 at 11:00 am during initial tour revealed that Resident #1 was lying in bed wearing a collared button down pajama top and pajama pants. A blood stain measuring approximately 3 cm x 1 cm was seen on her right collar. Interview with Resident #1 on 4/23/14 at 11:00 am revealed that she had a nose bleeding earlier that morning. She said that she had told the nurse earlier that morning but the nurse " turned around and left " . Resident #1 said that she had told the nurse who checked her blood sugar that morning. Resident #1 said that she was sick and she just came back from the hospital " a week ago " and she still had bleeding from her nose. She said that the nurses do not come to check on her. She said that sometimes she felt sick and she turned the call light on and " they don ' t come " . Resident #1 said that before she went to the hospital the first time, she had blood coming from her ears, nose, vagina and her eyes were shut. She said that she was telling the nurses for " 2 days " but they sent her back to her room. Resident #1 said that nurses told her, " Go back to your room and I will be there " , but the nurses never came to check on her. Resident #1 said that the nurses kept telling her that they would contact the Nurse Practitioner but they never did. Resident #1 said that when Nurse Practitioner A finally came to the facility, she asked Nurse Practitioner A if the nurses had called her about her bleeding and the Nurse Practitioner A said no. Resident #1 said that as soon as Nurse Practitioner A saw her when she came to make rounds on 4/2/14, Nurse Practitioner A " rushed me to the ER " . Interview with Resident #1 on 4/23/14 at 12:20 pm revealed that when she came back to the facility from the hospital the first time (04/11/14), she continued to have bleeding problems. Resident #1 said that the nurses did not come to check on her when she came back from the hospital. Resident #1 said that around 4: 30 am, she had a lot of bleeding. She said that she had turned on her call light for help but nobody came to help her. Resident #1 said that she managed to go to the hallway to call for help. She said that she was yelling for help. Resident #1 said that she had a lot of bleeding and she was sent back to the hospital that day. Interview with LVN C on 4/23/14 at 3:32 pm revealed that she took the call from the lab on 3/31/14 about Resident #1 ' s critical INR result and she relayed the information to LVN A because she was not the nurse for Resident #1. Interview with LVN D on 4/23/14 at 3:34 pm revealed that she took the call from the lab on 3/24/14 about Resident #1 ' s critical INR result and she told LVN A about it. She said that LVN A faxed the result to Nurse Practitioner A. Interview with LVN B on 4/23/14 at 3:40 pm revealed that she remembered that Nurse Practitioner A was all upset because she was not informed of Resident #1 ' s INR critical result. LVN B said that it was a " big hoorah " because LVN C said that she told LVN A but LVN A said that LVN C did not tell her. LVN B said that since then, Nurse Practitioner A had asked that her cellphone number be placed " all over the nurse ' s station " for prompt communication. In an interview on 4/23/14 at 4:06 pm LVN A said that she did not know about the 3/31/14 INR critical value. LVN A said that LVN C took the call from the lab but did not inform her of the critical value. LVN A said that she remembered that 3/31/14 was a Monday and Resident #1 had come to her that day and told her that she was bleeding over the weekend from her nose and ears. LVN A said that Resident #1 told her that she reported the bleeding to the weekend nurses but they did not do anything for her. LVN A said that after Resident #1 told her about the bleeding, she assessed her by checking Resident #1 ' s mouth, ears, nose and there was no bleeding. LVN A said that she did not document the assessment. LVN A said that she did not know that Resident #1 ' s INR result was critical that day. The nurse said that Resident #1 continued to receive [MEDICATION NAME] 5 mg on 4/1/14 and was sent out to the hospital on [DATE]. Further interview with LVN A she said that she was the one who wrote the physician's order [REDACTED].#1. She said that Resident #1 also had an INR critical value on 03/24/14. She said that she had made a mistake in the MAR by writing her initials on [MEDICATION NAME] 5 mg on 3/25/14 which implied that she gave the [MEDICATION NAME] 5 mg instead of starting it on 3/26/14. She said that she actually did not give the [MEDICATION NAME] 5 mg on 3/25/14, she said that there should have been a " line through it " . She said that she accidentally put her initials on 3/25/14. In an interview on 4/23/14 at 4:48 pm Nurse Practitioner A said that she did not know that Resident #1 ' s INR was critical until she went to the facility for rounds on 04/02/14. She said that when she saw that Resident #1 ' s left eye was red and was shut, she immediately sent her out to the hospital without even knowing that her INR was critical. Nurse Practitioner A said that the facility had a " communication problem " in relaying urgent laboratory results. She said that they continued to have communication problems as she had received laboratory results for Resident #1 on 4/21/14 regarding her TSH level of 66.09, HgA1C of 7.8, and PT/INR of 16.5/1.92 via fax machine. Nurse Practitioner A said that these types of abnormal results should not be sent via fax machine. She said that it should have been called in to her. Nurse Practitioner A said that she called the facility after she received the results via fax machine and told the nurse that she should not be faxing abnormal results but instead she should be calling the Nurse Practitioner or Physician. Nurse Practitioner A said that the nurse gave her a bad attitude and told her that she did not call " because she had to attend to other things. " In an interview with the Administrator, ADON A, ADON B on 4/23/14 at 5:30 pm they said that they did not know about Resident #1 ' s INR critical labs on 3/24/14 and 3/31/14. In an interview via phone conference with the DON on 4/23/14 at 5:45 pm she said that she did not know about Resident #1 ' s critical labs on 3/24/14 and 3/31/14. She said it was " never brought to my attention " . The Administrator was in the room. In an interview with ADON A and ADON B on 4/23/14 at 5:30 pm they said that they were not aware that Resident #1 had a nose bleed that morning. They said that they would ask the evening shift charge nurse to check on Resident #1. In an interview on 4/24/14 at 10:30 am the DON said that Nurse Practitioner A did not call her to tell her about issues with Resident #1 ' s critical INR result on 3/31/14. The DON said that she was told by ADON A that Resident #1 went to the hospital on [DATE] but did not tell her that Nurse Practitioner A was upset because the critical INR result was not communicated to her. The DON said that when Resident #1 went to the hospital on [DATE], " they could ' t finds anything at the hospital " . She said that Resident #1 " went to the hospital too much " . The DON said that ADON A was in charge of Resident #1 ' s PT/INR. She said that she had 2 ADONs and they were responsible for monitoring lab results. She said that she should have been notified by Nurse Practitioner A about the issues with Resident #1 ' s INR levels. Further interview with the DON on 4/24/14 at 11:18 am she said that she found out about Resident #1 ' s critical INR on 4/2/14. She said that from what ADON A told her, LVN C took the call from the lab but was not communicated to the LVN A who was assigned to Resident #1. The DON said that she did not know if the lab had faxed a hard copy of the lab results. She said that she typically does not get a copy of the critical lab results. She said that lab results were faxed to the facility throughout the day. She said that the fax machine was in the copy room and there was a designated box for lab results. She said that the ADONs were supposed to check the box throughout the day. The DON said that when the critical lab results were faxed to the facility, the ADON was " probably gone when it was faxed " . She said that her ADONs leave at around 4:30 pm - 5:00 pm. Further interview with the DON on 4/24/14 at 11:30 am revealed that the hospital did not find anything wrong with Resident #1. She said that Resident #1 came back on 4/10/14 and went out again the next day. She said that it was all " anxiety, geri-psych " . In an interview with ADON A on 4/24/14 at 11:45 am she said that lab results were faxed " randomly " and they were picked up from the fax machine by anybody, nurses or administrative staff and placed in the designated box in the copy room. She said that the ADONs check the box regularly, " very frequently " . She said that she was not aware about the 3/24/14 critical INR results for Resident #1. She said that she checked the [MEDICATION NAME] book once a week, no specific day, " just as soon as possible, mostly Wednesday " . ADON A said that she was also not aware of Resident #1 ' s critical INR results on 3/31/14. Further interview at this time with ADON A she said that LVN A should not have given Resident #1 a [MEDICATION NAME] 5 mg on 3/25/14. She said that the physician had held it for 2 days because of the high INR. The ADON A said that the [MEDICATION NAME] 5 mg should have been started on 3/26/14, " like what the physician said in the order " . Interview with Resident #1 ' s Attending Physician on 4/24/14 at 3:30 pm (the DON and Administrator were in the room at the time) he said that Resident #1 was on [MEDICATION NAME] due to [MEDICAL CONDITION] Fibrillation. He said that Resident #1 had gross hematuria while she was at the hospital. . The attending physician said that there was a " danger with that medication " . He said that Resident #1 had bleeding at the hospital. He said that since Resident #1 was also on [MEDICATION NAME], there was an interaction between [MEDICATION NAME] and [MEDICATION NAME] that could lead to an elevated INR. The attending physician also said that some patients do well with high INRs if they have no history of bleeding, but if patients have " bleeding issues " and they are on [MEDICATION NAME] like Resident #1, it becomes a problem and monitoring was necessary. The attending physician further said that he will discontinue Resident #1 ' s [MEDICATION NAME] and she would just take daily Aspirin. Record review of Resident #1 ' s nurse ' s notes dated 4/24/14 written by the DON revealed that Resident #1 ' s attending physician was at the facility and she spoke with him in " in reference to PT/INR and current [MEDICATION NAME] dose. MD stated resident recent hospitalization was not due to PT/INR it was due to bleeding and he would be reviewing her current medications and the order for [MEDICATION NAME] would be discontinued and EC ASA 81 mg 1 po Q D to be started " . Interview with the Administrator on 4/25/14 at 10:05 am he said that he was out for 4 weeks due to a back injury. He said that he was not aware of the critical values on 3/24/14 and 3/31/14 and he did not know that Resident #1 was sent to the hospital on [DATE]. The Administrator said that he knew of Resident #1 ' s hospital stay on 4/11/14. The Administrator said that he believed that the facility had this issue because there was a failure of the staff to communicate and relay the critical lab results to the physician which led to Resident #1 ' s hospital stay. Interview with the DON on 4/25/14 at 11:10 am she said that the facility had this problem because it was " an oversight " that led to Resident #1 ' s hospital stay. Interview with LVN A on 4/26/14 at 3:45 pm she said that she checked the fax machine periodically for lab results. She said that she knew all the residents with routine labs ordered. She said that she did not know about Resident #1 ' s critical INR result on 3/31/14. She said that it was called in to another nurse. She said that she did not remember getting anything that day at the fax machine. She said, " let ' s be realistic, you don ' t remember everything, everybody tries to get them (the lab results ). I don ' t go to the copy room. " LVN A said that she could not remember if she checked for PT/INR labs on 03/31/14, when Resident #1 was telling her that she had " bleeding " over the weekend (03/29 and 03/30) .LVN A continued to say that Resident #1 " says a lot of things that are not true " . Observation of Resident #1 on 4/26/14 at 4:19 pm revealed that she had some blood stains in a tissue. She said that it came from her nose when she sneezed. A Nurse Supervisor was in the resident ' s room and confirmed this. Interview with RN A on 4/29/14 at 9:45 am revealed that they use the form " Admission Assessment Data Collection Tool " when residents come back from the hospital. She said that she did not know if one was done for Resident #1. Interview with the Administrator on 4/29/14 at 10:15 am he said that during his absence, the DON was in charge. He said that the DON was responsible and that if she had questions, she would call the regional directors. The administrator said that the DON did the daily meetings with the staff and department heads. An IJ was identified on 4/24/14 at 1:24 pm and the Administrator was informed at that time. A Plan of Removal (POR) the IJ was submitted and accepted on 04/25/2014 at 4:00 pm. The POR included: The Center immediately reviewed all residents (11) with a [MEDICATION NAME] order and Diagnostic lab orders for PT/INR panic or critical lab values for accuracy and to determine if there were other areas of concern that were not assessed timely or appropriately which may have warranted Physician notification. All residents on medications that require therapeutic labs to monitor administration is being audited, will be completed on April 25, 2014, to validate physician orders [REDACTED]. New Policy: Routine Labs: Lab tracking log is reviewed each night by the licensed Nurse that all requisitions are completed as for the next lab draw. Requisitions are placed in the designated lab folder or lab book. Technician does the lab draw initials and dates the lab, license nurse reviews the lab requisition, completes log and initial Treatment sheet when specimen obtained. DON /ADON reviews the labs to validate lab has been entered on the lab tracking log/labs has been drawn (will be completely 5 days weekly). Critical Labs: Panic or critical labs results are immediately (within from 15 minutes) reported to the center by telephone. Panic or critical labs are communicated to physician or medical director immediately (within 15 minutes). If the physician cannot be contacted or has not returned the call in 20 minutes contact medical director and director of nurses and 911 for hospital transport. Contact family or responsible party. PHYSICIAN ORDERS, CHANGES OF MEDICATIONS CARRIED OUT CORRECTLY 1. Educate the nurses on transcribing medications accurately to the Medication/Treatment record ... 2. Educate the nurses on assessing for side effect of [MEDICATION NAME] i.e. bleeding, bruises, sore joints hematuria, petechiae, fever/chills, skin rash, etc. ... 3. When order received to hold [MEDICATION NAME] Nurses will write the word HOLD on the MAR indicated [REDACTED]. This new policy began yesterday, April 25, 2014. 4. ADON/DON will check physician orders [REDACTED]. This new policy began yesterday, April 25, 2014. 5. After ADON/DON check physician orders [REDACTED]. 6. When a [MEDICATION NAME] dosage is changed from a different strength the previous [MEDICATION NAME] will be removed from the cart by the charge nurse and new [MEDICATION NAME] will be ordered. Family will be notified of change. The DON or designee will validate the removal of the [MEDICATION NAME] from the medication when reviewing telephone orders daily for 2 weeks using a QAPI [MEDICATION NAME] Monitoring Tool, Start date of April 25, 2014. Education Skills Validation All Licensed Nurses on duty will be provided education on our Diagnostic Testing and communicating panic or critical lab values ... A posttest was provided 4/24/14 to demonstrate understanding of our process change and the policy and procedure as it relates to diagnostic testing, Physician orders, Assessment, change of condition, adverse reaction, Physician notification and communication of each normal, panic or critical value ... This new policy began yesterday, April 25, 2014 ...Revised -Lab Tracking Tool attached. This new policy began yesterday, April 25, 2014. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service forms dated 04/23, 04/24, and 04/25 revealed that approximately 90 % of the staff representing all three shifts had been in-serviced on the lab protocols, assessing changes in condition and side effects of anticoagulant therapy. Interviews conducted on 04/26, 04/27 and 04/28 with 11 nursing staff representing all three shifts revealed staff was competent in the understanding of the new laboratory protocol, assessment of changes of condition and side effects of anticoagulant therapy. Record review of the laboratory log finalized on 04/29/14; revealed compliance with the facility Plan of Removal. The Administrator and the DON were informed on 04/29/14 at 11:30 am that the IJ was removed; however the facility remained out of compliance at an isolated level and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. Record review of the facility ' s Policy and Procedure on Diagnostic Test Guide dated 8/2013 and revised on 3/2014 revealed, read in parts, ...b. Panic or critical labs are communicated to the physician or medical director immediately. According to the DON the facility had 11 residents on [MEDICATION NAME] therapy.

Based on interview and record review, the Administrator and the DON failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for 3 of 12 residents (Resident #1, #2 and #3) reviewed for laboratory services and changes of condition. The Administrator failed to supervise the DON to ensure she was doing a thorough job of ensuring nursing staff were complying with their job responsibilities and systems were implemented for monitoring of [MEDICATION NAME] side effects, reporting critical laboratory values to physicians and following doctors ' orders. The Administrator failed to implement the facility's Abuse Prevention Program Policies and Procedures to prevent neglect. The DON failed to supervise the ADONs and the nursing staff to ensure: -Physician-ordered labs were completed and critical results were reported to the physicians for Resident #1. -[MEDICATION NAME] side effects were being monitored for Resident #1. -physician's order [REDACTED].#1 and #2. -Nursing staff was knowledgable of what type of laboratory results should be called or faxed to a physician (critical versus normal) An IJ was identified on 4/24/14 at 1:24 pm. While the IJ was removed on 4/29/14 at 11:35 am, the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm due to facility needing more time to monitor the plan of removal for effectiveness. These failures affected 3 residents whose care was compromised due to staff neglecting to perform labs and report tests results to physician's timely and placed 8 other resident on [MEDICATION NAME] at risk of delay in treatment which could result in increased risk for bleeding and possible hospitalization . Intake #: 3 Findings include: In an interview with the Administrator, ADON A, ADON B on 4/23/14 at 5:30 pm they said that they did not know about Resident #1 ' s INR critical labs on 3/24/14 and 3/31/14. Interview with the Administrator on 4/25/14 at 10:05 am he said that he was out for 4 weeks due to a back injury. He said that he was not aware of the critical values on 3/24/14 and 3/31/14 and he did not know that Resident #1 was sent to the hospital on [DATE]. The Administrator said that he knew of Resident #1 ' s hospital stay on 4/11/14. The Administrator said that he believed that the facility had this issue because there was a failure of the staff to communicate and relay the critical lab results to the physician which led to Resident #1 ' s hospital stay. Interview with the DON on 4/25/14 at 11:10 am she said that the facility had this problem because it was " an oversight " that led to Resident #1 ' s hospital stay. Interview with the Administrator on 4/29/14 at 10:15 am he said that during his absence, the DON was in charge. He said that the DON was responsible and that if she had questions, she would call the regional directors. The administrator said that the DON did the daily meetings with the staff and department heads. In an interview with the DON on 4/23/14 at 5:45 pm she said that she did not know about Resident #1 ' s critical labs on 3/24/14 and 3/31/14. She said it was " never brought to my attention " . In an interview on 4/24/14 at 10:30 am the DON said that Nurse Practitioner A did not call her to tell her about issues with Resident #1 ' s critical INR result on 3/31/14. The DON said that she was told by ADON A that Resident #1 went to the hospital on [DATE] but did not tell her that Nurse Practitioner A was upset because the critical INR result was not communicated to her. The DON said that when Resident #1 went to the hospital on [DATE], " they could ' t find anything at the hospital " . She said that Resident #1 " went to the hospital too much " . The DON said that ADON A was in charge of Resident #1 ' s PT/INR. She said that she had 2 ADONs and they were responsible for monitoring lab results. She said that she should have been notified by Nurse Practitioner A about the issues with Resident #1 ' s INR levels. Further interview with the DON on 4/24/14 at 11:18 am she said that she found out about Resident #1 ' s critical INR on 4/2/14. She said that from what ADON A told her, LVN C took the call from the lab but was not communicated to LVN A who was assigned to Resident #1. The DON said that she did not know if the lab had faxed a hard copy of the lab results. She said that she typically do not get a copy of the critical lab results. She said that lab results were faxed to the facility throughout the day. She said that the fax machine was in the copy room and there was a designated box for lab results. She said that the ADONs were supposed to check the box throughout the day. The DON said that when the critical lab results were faxed to the facility, the ADON was " probably gone when it was faxed " . She said that her ADONS leave around at around 4:30 pm - 5:00 pm. IMMEDIATE JEOPARDY Resident #1: Record review of Resident #1 ' s admission face sheet revealed an admitted [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #1 ' s physician's order [REDACTED]. -Hold [MEDICATION NAME] 6 mg 1 tab po for 2 days 3/13/14 and 3/14/14 then restart on 3/15/14. -Give [MEDICATION NAME] 6.5 mg 1 tab po for 2 days 3/13/14 and 3/14/14 Record review of Resident #1 ' s MAR for March 2014 revealed that: -[MEDICATION NAME] 6.5 mg was given to Resident #1 on 3/14/14 and 3/15/14 instead of 3/13/14 and 3/14/14 as ordered by the physician. -[MEDICATION NAME] 6 mg was held on 3/13/14, 3/14/14 and 3/15/14 instead of holding the medication for 2 days on 3/13/14 and 3/14/14 as ordered by the physician. -[MEDICATION NAME] 6 mg was restarted on 3/16/14 instead of 3/15/14 as ordered by the physician. Record review of Resident #1 ' s physician's order [REDACTED]. -Hold [MEDICATION NAME] 6 mg for 2 days 3/18/14 and 3/19/14 -Give [MEDICATION NAME] 5.5 mg for 2 days 3/18/14 and 3/19/14 -Restart 6 mg 1 tablet po every evening on 3/20/14 Record review of Resident #1 ' s MAR for March 2014 revealed that: -[MEDICATION NAME] 6 mg was held on 3/18/14, 3/19/14 and 3/20/14 instead of holding it only for 2 days 3/18/14 and 3/19/14 as ordered by the physician. -[MEDICATION NAME] 5.5 mg was given on 3/19/14 and 3/20/14 instead of 3/18/14 and 3/19/14 as ordered by the physician -[MEDICATION NAME] 6 mg was restarted on 3/21/14 instead of 3/20/14 as ordered by the physician. Record review of Resident #1 ' s Physician orders [REDACTED]. -Hold [MEDICATION NAME] today and tomorrow 3/24/14 and 3/25/14 -Discontinue [MEDICATION NAME] 6 mg -New order [MEDICATION NAME] 5 mg po daily at 6:00 pm -PT/INR lab on 3/31/14 Record review of Resident #1 ' s MAR for March 2014 revealed that -[MEDICATION NAME] 6 mg was held on 3/24/14 and 3/25/14 -[MEDICATION NAME] 5 mg was started on 3/25/14 Record review of Resident #1 ' s laboratory results for PT/INR dated 3/31/14 revealed a critical PT value of 27.9 and critical INR value of 5.49. The results were called in by the lab to LVN C on 3/31/14 at 4:14 pm as documented in the lab result: Lab tech A phoned results on 3/31/14 at 16:14 pm Critical Results called to: LVN C Results read back correctly. INR Record review of Resident #1 ' s Nurse ' s notes and other clinical records revealed no documentation that the physician was notified of the PT/INR critical lab values. Record review of Resident #1 ' s Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin for March 2014 revealed that there were no side effects marked for the whole month of March 2014. Each shift was initialed by the nurses that there were no side effects seen. Record review of Resident #1 ' s Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin for April 1 to 24, 2014 revealed that there were no side effects marked from April 1 to 24, 2014. Each shift was initialed by the nurses that there were no side effects seen. There was a line drawn on the dates that Resident #1 was at the hospital. On the day that Resident #1 was documented as having " mid-lrg (large) blood clots observed coming from vagina " dated 4/11/14 at 6:00 am, there was none documented on the " Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin " . Record review of Resident #1 ' s physician's order [REDACTED]. CBC, BMP, HbA1C, TSH, PT/INR on 4/21/14. Record review of Resident #1 ' s laboratory results ordered on [DATE] revealed the following: TSH 66.09 (Reference: .46 - 4.68) Hemoglobin A1C 7.8 (4.3 - 6.1) PT 16.5 INR - 1.92 The lab results were faxed to the physician on 4/21/14 at 7:20 pm. Interview with LVN C on 4/23/14 at 3:32 pm revealed that she took the call from the lab on 3/31/14 about Resident #1 ' s critical INR result and she relayed the information to LVN A because she was not the nurse for Resident #1. Interview with LVN B on 4/23/14 at 3:40 pm revealed that she remembered that Nurse Practitioner A was all upset because she was not informed of Resident #1 ' s INR critical result. LVN B said that it was a " big hoorah " because LVN C said that she told LVN A but LVN A said that LVN C did not tell her. LVN B said that since then, Nurse Practitioner A had asked that her cellphone number be placed " all over the nurse ' s station " for prompt communication. In an interview with LVN A on 4/23/14 at 4:06 pm, she said that she was the one who wrote the physician's order [REDACTED].#1. She said that that she made a mistake by writing her initials on 3/25/14. It should have been on 3/26/14. In an interview on 4/23/14 at 4:48 pm Nurse Practitioner A said that she did not know that Resident #1 ' s INR was critical until she went to the facility for rounds on 04/02/14. She said that when she saw that Resident #1 ' s left eye was red and was shut, she immediately sent her out to the hospital without even knowing that her INR was critical. Nurse Practitioner A said that the facility had a " communication problem " in relaying urgent laboratory results. She said that the continued to have communication problems as she had received laboratory results for Resident #1 on 4/21/14 regarding her TSH level of 66.09, HgA1C of 7.8, and PT/INR of 16.5/1.92 via fax machine. Nurse Practitioner A said that these type of abnormal results should not be sent via fax machine. In an interview via phone conference with the DON on 4/23/14 at 5:45 pm she said that she did not know about Resident #1 ' s critical labs on 3/24/14 and 3/31/14. She said it was " never brought to my attention " . The Administrator was in the room. Record review of the the facility's Administrator's duties and responsibilities, undated, included, read in parts: Monitor each department's activities, communicate policies, evaluate performance, provide feedback, and assist, coach and discipline as needed...Conduct regular rounds to monitor delivery of nursing care... Record review of the facility's DON's duties and responsibilities, undated, included, read in parts, "Conduct regular rounds to monitor resident activity, assess resident's physical and psychosocial status, and to monitor care activities and documentation to ensure the delivery of nursing care according to the physician's orders [REDACTED]. An IJ was identified on 4/24/14 at 1:24 pm and the Administrator was informed at that time. A Plan of Removal (POR) the IJ was submitted and accepted on 04/25/2014 at 4:00 pm. The POR included: The Center immediately reviewed all residents (11) with a [MEDICATION NAME] order and Diagnostic lab orders for PT/INR panic or critical lab values for accuracy and to determine if there were other areas of concern that were not assessed timely or appropriately which may have warranted Physician notification. All residents on medications that require therapeutic labs to monitor administration is being audited, will be completed on April 25, 2014, to validate physician orders [REDACTED]. New Policy: Routine Labs: Lab tracking log is reviewed each night by the licensed Nurse that all requisitions are completed as for the next lab draw. Requisitions are placed in the designated lab folder or lab book. Technician does the lab draw initials and dates the lab, license nurse reviews the lab requisition, completes log and initial Treatment sheet when specimen obtained. DON /ADON reviews the labs to validate lab has been entered on the lab tracking log/labs has been drawn (will be completely 5 days weekly). Critical Labs: Panic or critical labs results are immediately (within from 15 minutes) reported to the center by telephone. Panic or critical labs are communicated to physician or medical director immediately (within 15 minutes). If the physician cannot be contacted or has not returned the call in 20 minutes contact medical director and director of nurses and 911 for hospital transport. Contact family or responsible party. PHYSICIAN ORDERS, CHANGES OF MEDICATIONS CARRIED OUT CORRECTLY 1. Educate the nurses on transcribing medications accurately to the Medication/Treatment record ... 2. Educate the nurses on assessing for side effect of [MEDICATION NAME] i.e. bleeding, bruises, sore joints hematuria, petechiae, fever/chills, skin rash, etc. ... 3. When order received to hold [MEDICATION NAME] Nurses will write the word HOLD on the MAR indicated [REDACTED]. This new policy began yesterday, April 25, 2014. 4. ADON/DON will check physician orders [REDACTED]. This new policy began yesterday, April 25, 2014. 5. After ADON/DON check physician orders [REDACTED]. 6. When a [MEDICATION NAME] dosage is changed from a different strength the previous [MEDICATION NAME] will be removed from the cart by the charge nurse and new [MEDICATION NAME] will be ordered. Family will be notified of change. The DON or designee will validate the removal of the [MEDICATION NAME] from the medication when reviewing telephone orders daily for 2 weeks using a QAPI [MEDICATION NAME] Monitoring Tool, Start date of April 25, 2014. Education Skills Validation All Licensed Nurses on duty will be provided education on our Diagnostic Testing and communicating panic or critical lab values ... A posttest was provided 4/24/14 to demonstrate understanding of our process change and the policy and procedure as it relates to diagnostic testing, Physician orders, Assessment, change of condition, adverse reaction, Physician notification and communication of each normal, panic or critical value ... This new policy began yesterday, April 25, 2014 ...Revised -Lab Tracking Tool attached. This new policy began yesterday, April 25, 2014. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service forms dated 04/23, 04/24, and 04/25 revealed that approximately 90 % of the staff representing all three shifts had been in-serviced on the lab protocols, assessing changes in condition and side effects of anticoagulant therapy. Interviews conducted on 04/26, 04/27 and 04/28 with 11 nursing staff representing all three shifts revealed staff was competent in the understanding of the new laboratory protocol, assessment of changes of condition and side effects of anticoagulant therapy. Record review of the laboratory log finalized on 04/29/14; revealed compliance with the facility Plan of Removal. The Administrator and the DON were informed on 04/29/14 at 11:30 am that the IJ was removed; however the facility remained out of compliance at an isolated level and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. NON-IMMEDIATE JEOPARDY Resident #2: Record review of Resident #2 ' s face sheet revealed an admitted [DATE] included the [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #2 ' s Physician order [REDACTED]. -Discontinue [MEDICATION NAME] 5.5 mg po every afternoon -[MEDICATION NAME] 5.0 mg po every afternoon start on 4/1/14 Record review of Resident #2 ' s MAR for March 2014 revealed that Resident #2 continued to receive [MEDICATION NAME] 5.5 mg from 3/26/14 to 3/31/14. In an interview with the ADON B on 4/29/14 at 9:08 am she said that she was the one who carried out the physician orders [REDACTED]. She said, " I missed it " . In an interview with the DON on 4/29/14 at 10:30 am she said that ADON B should have transcribe the physician's order [REDACTED]. The DON said that when there was a hold order on [MEDICATION NAME], the nurses should mark " hold " and put an x sign to the box when the [MEDICATION NAME] would be held. She said that after carrying out a physician order, the nurses should update the MAR indicated [REDACTED] Resident #3: Record review of Resident #3 ' s face sheet revealed an admitted [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #3 ' s physician's order [REDACTED]. PT/INR lab every month Record review of Resident #3 ' s laboratory services section revealed no PT/INR results for October 2013, December 2013 and January 2014. In an interview with ADON A on 4/23/14 at 2:44 pm she said that the laboratory company that they have contract with for lab services changed their computer system. She said that she was not sure what happened and how it was missed in the computer. Interview with the Administrator on 4/23/14 at 2:55 pm he said that their " lab changed to another lab. " He said that the labs were missed but they have since in-serviced the ADON responsible for Resident #3 ' s ordered labs on 4/9/14. According to the DON the facility had 11 residents on [MEDICATION NAME] therapy.

Based on interview, observation and record review, it was determined the facility, failed to keep each resident's drug regimen free from unnecessary drugs, including drugs that require monitoring, for three (Resident #1, #2 and #3) of 12 residents reviewed for a change in condition related to unnecessary medication. IMMEDIATE JEOPARDY The facility failed to follow physician's orders [REDACTED]. The lab reported a critical INR (is a blood test that measure how fast the blood clots) result to the nurse on 03/24/14, a physician order [REDACTED]. Another critical INR lab was called in to the facility on [DATE] and was not communicated to the physician, which resulted in a delay in treatment. Resident #1 complained of bleeding to the staff the weekend of 03/29/14-03/30/14 and there was no follow up assessment documented in the clinical records. Resident #1 continued to receive the anticoagulant medication which led to her hospitalization on [DATE]. NON-IMMEDIATE JEOPARDY The facility failed to follow physician's orders [REDACTED].#2 ' s anticoagulant medication on 3/26/14. Resident #2 continued to receive the anticoagulant medication. Her next INR level had a critical result. The facility failed to obtain Resident #3 ' s laboratory test as ordered by the physician. Resident #3 ' s PT/INR lab test was not done as ordered for 3 months. An IJ was identified on 4/24/14 at 1:24 pm. While the IJ was removed on 4/29/14 at 11:35 am, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. These failures affected 3 residents and placed 8 other resident on [MEDICATION NAME] at risk of not having their PT/INRs monitored, which could result in bleeding, hospitalization and/or death. Intake: # 3 Findings included: IMMEDIATE JEOPARDY Resident #1: Record review of Resident #1 ' s admission face sheet revealed an admitted [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #1 ' s Quarterly MDS assessment dated [DATE] revealed under Section C: Cognitive Pattern, revealed that the resident was cognitively intact. Under Section G: Functional Status, Resident #1 was independent with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #1 ' s summary of Physician order [REDACTED]. -Aspirin EC 81 mg daily -[MEDICATION NAME] 6 mg 1 tablet every evening -[MEDICATION NAME] HCl 50 mg 1 tab every 6 hours as needed for pain -[MEDICATION NAME] HCl ER 100 mg at bedtime daily Record review of Resident #1 ' s telephone physician's order [REDACTED]. -Hold [MEDICATION NAME] 6 mg 1 tab po for 2 days on 3/13/14 and 3/14/14 then restart on 3/15/14. -Give [MEDICATION NAME] 6.5 mg 1 tab po for 2 days on 3/13/14 and 3/14/14 Record review of Resident #1 ' s MAR for March 2014 revealed that: -[MEDICATION NAME] 6.5 mg was given to Resident #1 on 3/14/14 and 3/15/14 instead of 3/13/14 and 3/14/14 as ordered by the physician. -[MEDICATION NAME] 6 mg was held on 3/13/14, 3/14/14 and 3/15/14 instead of holding the medication for 2 days on 3/13/14 and 3/14/14 as ordered by the physician. -[MEDICATION NAME] 6 mg was restarted on 3/16/14 instead of 3/15/14 as ordered by the physician. Record review of Resident #1 ' s telephone physician's order [REDACTED]. -Hold [MEDICATION NAME] 6 mg for 2 days 3/18/14 and 3/19/14 -Give [MEDICATION NAME] 5.5 mg for 2 days 3/18/14 and 3/19/14 -Restart 6 mg 1 tablet po every evening on 3/20/14 Record review of Resident #1 ' s MAR for March 2014 revealed that: -[MEDICATION NAME] 6 mg was held on 3/18/14, 3/19/14 and 3/20/14 instead of holding it only for 2 days 3/18/14 and 3/19/14 as ordered by the physician. -[MEDICATION NAME] 5.5 mg was given on 3/19/14 and 3/20/14 instead of 3/18/14 and 3/19/14 as ordered by the physician -[MEDICATION NAME] 6 mg was restarted on 3/21/14 instead of 3/20/14 as ordered by the physician. Record review of Resident #1 ' s laboratory results for PT/INR dated 3/24/14 revealed a critical PT value of 30.8 ( normal Reference 10.4 - 13.8) and a critical INR value of 6.56 (INR Therapeutic range for residents on anticoagulation therapy: Standard dose therapeutic range: 2.0 - 3.0; Higher intensity therapeutic range: 2.5 - 3.5). The results were called in by the lab to LVN D on 3/24/14 at 2:23 p.m. Record review of Resident #1 ' s of telephone Physician orders [REDACTED]. -Hold [MEDICATION NAME] today and tomorrow 3/24/14 and 3/25/14 -Discontinue [MEDICATION NAME] 6 mg -New order [MEDICATION NAME] 5 mg po daily at 6:00 pm -PT/INR lab on 3/31/14 Record review of Resident #1 ' s MAR for March 2014 revealed that -[MEDICATION NAME] 6 mg was held on 3/24/14 and 3/25/14 -[MEDICATION NAME] 5 mg was started on 3/25/14 Record review of Resident #1 ' s MAR for March 2014 revealed that she continuously received [MEDICATION NAME] 5 mg from 3/25/14 to 4/1/14. Record review of Resident #1 ' s laboratory results for PT/INR dated 3/31/14 revealed a critical PT value of 27.9 and critical INR value of 5.49. The results were called in by the lab to LVN C on 3/31/14 at 4:14 pm as documented in the lab result: A Lab tech phoned results on 3/31/14 at 16:14 pm Critical Results called to: LVN C Results read back correctly. INR Record review of Resident #1 ' s Nurse ' s notes and other clinical records revealed no documentation that the physician was notified of the PT/INR critical lab values. Record review of Resident #1 ' s Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin for March 2014 revealed that " Licensed Nurse has observed this Resident and none of the following side effects have been evidenced: Petechiae (pinpoint, round spots that appear on the skin as a result of bleeding under the skin), Hematuria (blood in the urine), Sore Joints, Epistaxis, Bleeding and or sore Gums: Mouth ulcers, Bruising and Hematoma, Fever/Chills, Nausea, Vomiting and or Diarrhea, Skin Rash " , there were no side effects marked for the whole month of March 2014. Each shift was initialed by the nurses that there were no side effects seen. Record review of Resident #1 ' s Progress Notes/History and Physical dated 4/2/14 and written by Nurse Practitioner A revealed that Resident #1 had a bloodshot left eye, an INR of 5.6 and was bleeding from the left ear and nose. She gave the order for the resident to be transferred to the hospital. There was also a note indicating the following lab result: 3/31/14 PT/INR 5.49. Record review of Resident #1 ' s Nurse ' s notes dated 4/2/14 revealed that Resident #1 was transferred to the emergency room for " unspecified bleeding (internal) and elevated PT/INR. PT 27.9 INR 5.49. Further review of the note " Left eye noted very red can ' t see white ' s of eye. No bleeding noted to any other areas. " Resident #1 was admitted to the hospital from 4/2/14 to 4/10/14. Record review of hospital cardiology notes dated 4/8/14 revealed that Resident #1 ' s INR was 6.7, " still receiving IVF ... A/P- correct coagulopathy - Vitamin K IV. " -PT/INR in the morning. Record review of Resident #1 ' s Nurse ' s notes dated 4/10/14 revealed that Resident #1 came back to the facility on [DATE] at 5:50 pm. Record review of Resident #1 ' s clinical records revealed that there was no " Admission Assessment Data Collection Tool " done when Resident #1 came back to the facility on [DATE]. Record review of Resident #1 ' s Nurse ' s notes dated 4/11/14 at 6:00 am revealed " Resident out in hall yelling down the hall stating she was bleeding. This writer and 2nd night nurse assessed resident and res. had blood in toilet and on wipes in sink. Res. assisted to bed per this writer and mid-lrg (large) blood clots observed coming from vagina ... " A call was placed to Nurse Practitioner A and Resident #1 was transferred to the hospital. Resident #1 was readmitted back to the hospital from 4/11/14 to 4/15/14. Record review of Resident #1 ' s hospital notes dated 4/12/14 revealed: " ...was discharged from the hospital one day earlier. She has been diagnosed with [REDACTED]. She has been on [MEDICATION NAME] because of history of [MEDICAL CONDITION]. The INR was down to 1.6, when she was discharged to nursing home she started having bleeding from the pelvic area, therefore sent back to the hospital for further evaluation and treatment. The patient had a history of [REDACTED]. " Record review of Resident #1 ' s nurse ' s notes dated 4/15/14 revealed that Resident #1 was readmitted back to the facility under the same attending physician. Resident #1 ' s medications were verified by the Nurse Practitioner A and were faxed to the pharmacy. Resident #1 was to have a repeat urine culture and office cystoscopy and her [MEDICATION NAME] was to be held prior to Cystoscopy. Record review of Resident #1 ' s nurse ' s notes on 4/15/14 did not address Resident #1 ' s physical condition and there was no documentation of head to toe assessment. Also there was no " Admission Assessment Data Collection Tool " Record review of Resident #1 ' s Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin for April 1 to 24, 2014 revealed that " Licensed Nurse has observed this Resident and none of the following side effects have been evidenced: Petechiae, Hematuria, Sore Joints, Epistaxis, Bleeding and or sore Gums: Mouth ulcers, Bruising and Hematoma, Fever/Chills, Nausea, Vomiting and or Diarrhea, Skin Rash " , there were no side effects marked from April 1 to 24, 2014. Each shift was initialed by the nurses that there were no side effects seen. There was a line drawn on the dates that Resident #1 was at the hospital. On the day that Resident #1 was documented as having " mid-lrg (large) blood clots observed coming from vagina " dated 4/11/14 at 6:00 am, there was none documented on the " Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin " . Record review of Resident #1 ' s physician's order [REDACTED]. CBC, BMP, HbA1C, TSH, PT/INR on 4/21/14. Continued record review of Resident # 's nurse's notes after she came back from the hospital revealed one more entry on 4/16/14. No further nurse ' s notes entered for Resident #1 ' s current condition and assessment until 4/21/14 when LVN A received new physician's order [REDACTED]. There was no documentation of Resident #1 ' s physical assessment or current condition. Record review of Resident #1's laboratory results ordered on [DATE] revealed the following: TSH 66.09 (Reference: .46 - 4.68) Hemoglobin A1C 7.8 (4.3 - 6.1) PT 16.5 INR - 1.92 The lab results were faxed to the physician on 4/21/14 at 7:20 pm. Record review of Resident #1 ' s Physician orders [REDACTED]. -Discontinue [MEDICATION NAME] 5 mg -Start [MEDICATION NAME] 5 mg po Mon -Fri. -[MEDICATION NAME] 5.5 mg on Saturday and Sunday -PT INR on 4/28/14 -Discontinue [MEDICATION NAME] 50 mcg, start [MEDICATION NAME] 75 mcg 1 tab po before breakfast -TSH lab on 5/21/14 Record review of Resident #1 ' s care plan dated 4/22/14 revealed that Resident #1 was high risk for increase bleeding related to blood thinning agent. Resident currently takes [MEDICATION NAME]. The goal was Resident #1 would have no side effects from medication. The approaches read in part: 1. Administer medications as ordered. 2. Monitor for side effects 3. Lab as ordered 4. Protect resident from bruising self 9. Notify MD if bleeding is not stopped with pressure 10. Notify MD of abnormalities in labs There was no care plan seen for increased in bleeding related to blood thinning agent prior to this care plan. Observation on 4/23/14 at 11:00 am during initial tour revealed that Resident #1 was lying in bed wearing a collared button down pajama top and pajama pants. A blood stain measuring approximately 3 cm x 1 cm was seen on her right collar. Interview with Resident #1 on 4/23/14 at 11:00 am revealed that she had a nose bleeding earlier that morning. She said that she had told the nurse earlier that morning but the nurse " turned around and left " . Resident #1 said that she had told the nurse who checked her blood sugar that morning. Resident #1 said that she was sick and she just came back from the hospital " a week ago " and she still had bleeding from her nose. She said that the nurses do not come to check on her. She said that sometimes she felt sick and she turned the call light on and " they don ' t come " . Resident #1 said that before she went to the hospital the first time, she had blood coming from her ears, nose, vagina and her eyes were shut. She said that she was telling the nurses for " 2 days " but they sent her back to her room. Resident #1 said that nurses told her, " Go back to your room and I will be there " , but the nurses never came to check on her. Resident #1 said that the nurses kept telling her that they would contact the Nurse Practitioner but they never did. Resident #1 said that when Nurse Practitioner A finally came to the facility, she asked Nurse Practitioner A if the nurses had called her about her bleeding and the Nurse Practitioner A said no. Resident #1 said that as soon as Nurse Practitioner A saw her when she came to make rounds on 4/2/14, Nurse Practitioner A " rushed me to the ER " . Interview with Resident #1 on 4/23/14 at 12:20 pm revealed that when she came back to the facility from the hospital the first time (04/11/14), she continued to have bleeding problems. Resident #1 said that the nurses did not come to check on her when she came back from the hospital. Resident #1 said that around 4: 30 am, she had a lot of bleeding. She said that she had turned on her call light for help but nobody came to help her. Resident #1 said that she managed to go to the hallway to call for help. She said that she was yelling for help. Resident #1 said that she had a lot of bleeding and she was sent back to the hospital that day. Interview with LVN C on 4/23/14 at 3:32 pm revealed that she took the call from the lab on 3/31/14 about Resident #1 ' s critical INR result and she relayed the information to LVN A because she was not the nurse for Resident #1. Interview with LVN D on 4/23/14 at 3:34 pm revealed that she took the call from the lab on 3/24/14 about Resident #1 ' s critical INR result and she told LVN A about it. She said that LVN A faxed the result to Nurse Practitioner A. Interview with LVN B on 4/23/14 at 3:40 pm revealed that she remembered that Nurse Practitioner A was all upset because she was not informed of Resident #1 ' s INR critical result. LVN B said that it was a " big hoorah " because LVN C said that she told LVN A but LVN A said that LVN C did not tell her. LVN B said that since then, Nurse Practitioner A had asked that her cellphone number be placed " all over the nurse ' s station " for prompt communication. Interview with Resident #1 on 4/23/14 at 4:00 pm revealed that she tried to clear the blood stain on her collared pajama top with water but it was hard to clear. She said that she told the nurse that morning about her nose bleeding but the nurse never went back to check on her. In an interview on 4/23/14 at 4:06 pm LVN A said that she did not know about the 3/31/14 INR critical value. LVN A said that LVN C took the call from the lab but did not inform her of the critical value. LVN A said that she remembered that 3/31/14 was a Monday and Resident #1 had come to her that day and told her that she was bleeding over the weekend from her nose and ears. LVN A said that Resident #1 told her that she reported the bleeding to the weekend nurses but they did not do anything for her. LVN A said that after Resident #1 told her about the bleeding, she assessed her by checking Resident #1 ' s mouth, ears, nose and there was no bleeding. LVN A said that she did not document the assessment. LVN A said that she did not know that Resident #1 ' s INR result was critical that day. The nurse said that Resident #1 continued to receive [MEDICATION NAME] 5 mg on 4/1/14 and was sent out to the hospital on [DATE]. Further interview with LVN A she said that she was the one who wrote the physician's order [REDACTED].#1. She said that Resident #1 also had an INR critical value on 03/24/14. She said that she had made a mistake in the MAR by writing her initials on [MEDICATION NAME] 5 mg on 3/25/14 which implied that she gave the [MEDICATION NAME] 5 mg instead of starting it on 3/26/14. She said that she actually did not give the [MEDICATION NAME] 5 mg on 3/25/14, she said that there should have been a " line through it " . She said that she accidentally put her initials on 3/25/14. In an interview on 4/23/14 at 4:48 pm Nurse Practitioner A said that she did not know that Resident #1 ' s INR was critical until she went to the facility for rounds on 04/02/14. She said that when she saw that Resident #1 ' s left eye was red and was shut, she immediately sent her out to the hospital without even knowing that her INR was critical. Nurse Practitioner A said that the facility had a " communication problem " in relaying urgent laboratory results. She said that they continued to have communication problems as she had received laboratory results for Resident #1 on 4/21/14 regarding her TSH level of 66.09, HgA1C of 7.8, and PT/INR of 16.5/1.92 via fax machine. Nurse Practitioner A said that these types of abnormal results should not be sent via fax machine. She said that it should have been called in to her. Nurse Practitioner A said that she called the facility after she received the results via fax machine and told the nurse that she should not be faxing abnormal results but instead she should be calling the Nurse Practitioner or Physician. Nurse Practitioner A said that the nurse gave her a bad attitude and told her that she did not call " because she had to attend to other things. " In an interview with the Administrator, ADON A, ADON B on 4/23/14 at 5:30 pm they said that they did not know about Resident #1 ' s INR critical labs on 3/24/14 and 3/31/14. In an interview via phone conference with the DON on 4/23/14 at 5:45 pm she said that she did not know about Resident #1 ' s critical labs on 3/24/14 and 3/31/14. She said it was " never brought to my attention " . The Administrator was in the room. In an interview with ADON A and ADON B on 4/23/14 at 5:30 pm they said that they were not aware that Resident #1 had a nose bleed that morning. They said that they would ask the evening shift charge nurse to check on Resident #1. In an interview on 04/24/14 at 9:35 am, Resident #1 said that she just had a " tiny little bit, almost nothing " when asked if she had any more nose bleeding through the night. Resident #1 said that she used a tissue paper to wipe her nose and she just saw a " tiny little bit " of blood. Record review of Resident #1 ' s clinical records revealed that there was no documentation of the nose bleed on 4/23/14 night shift and 4/24/14 morning shift. The 24 hour communication book revealed that the evening shift charge nurse wrote, " Head to toe assessment done. No decubs, no open areas, slight bruising to abdomen, no bleeding from ears, mouth, nose, vagina. " In an interview on 4/24/14 at 10:30 am the DON said that Nurse Practitioner A did not call her to tell her about issues with Resident #1 ' s critical INR result on 3/31/14. The DON said that she was told by ADON A that Resident #1 went to the hospital on [DATE] but did not tell her that Nurse Practitioner A was upset because the critical INR result was not communicated to her. The DON said that when Resident #1 went to the hospital on [DATE], " they could ' t finds anything at the hospital " . She said that Resident #1 " went to the hospital too much " . The DON said that ADON A was in charge of Resident #1 ' s PT/INR. She said that she had 2 ADONs and they were responsible for monitoring lab results. She said that she should have been notified by Nurse Practitioner A about the issues with Resident #1 ' s INR levels. Interview with the DON on 4/24/14 at 11:09 am she said that she did not call the physician about Resident #1 ' s nose bleeding. The DON said that she did not check on Resident #1, but had the 2-10 nurse checked on her yesterday. The DON said that the nurses used the Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin form for side effects of bleeding. Interview with ADON B on 4/24/14 at 11:15 am revealed that she did not assess Resident #1 " last night " but she had asked the evening shift to do a head to toe assessment on Resident #1. Further interview with the DON on 4/24/14 at 11:18 am she said that she found out about Resident #1 ' s critical INR on 4/2/14. She said that from what ADON A told her, LVN C took the call from the lab but was not communicated to the LVN A who was assigned to Resident #1. The DON said that she did not know if the lab had faxed a hard copy of the lab results. She said that she typically does not get a copy of the critical lab results. She said that lab results were faxed to the facility throughout the day. She said that the fax machine was in the copy room and there was a designated box for lab results. She said that the ADONs were supposed to check the box throughout the day. The DON said that when the critical lab results were faxed to the facility, the ADON was " probably gone when it was faxed " . She said that her ADONs leave at around 4:30 pm - 5:00 pm. Interview with the DON on 4/24/14 at 11:20 am revealed that the evening shift on 4/23/14 did not call Resident #1 ' s physician to inform him of Resident #1 ' s nose bleeding on 4/23/14. She said " if you find bleeding stain, you would have assess where the blood come from especially if a resident was on anticoagulant " . Interview with LVN B on 4/24/14 at 11:23 am she said that if a resident on [MEDICATION NAME] had a history of [REDACTED]. Further interview with the DON on 4/24/14 at 11:30 am revealed that the hospital did not find anything wrong with Resident #1. She said that Resident #1 came back on 4/10/14 and went out again the next day. She said that it was all " anxiety, geri-psych " . In an interview with ADON A on 4/24/14 at 11:45 am she said that lab results were faxed " randomly " and they were picked up from the fax machine by anybody, nurses or administrative staff and placed in the designated box in the copy room. She said that the ADONs check the box regularly, " very frequently " . She said that she was not aware about the 3/24/14 critical INR results for Resident #1. She said that she checked the [MEDICATION NAME] book once a week, no specific day, " just as soon as possible, mostly Wednesday " . ADON A said that she was also not aware of Resident #1 ' s critical INR results on 3/31/14. Further interview at this time with ADON A she said that LVN A should not have given Resident #1 a [MEDICATION NAME] 5 mg on 3/25/14. She said that the physician had held it for 2 days because of the high INR. The ADON A said that the [MEDICATION NAME] 5 mg should have been started on 3/26/14, " like what the physician said in the order " . Interview with Resident #1 ' s Attending Physician on 4/24/14 at 3:30 pm (the DON and Administrator were in the room at the time) he said that Resident #1 was on [MEDICATION NAME] due to [MEDICAL CONDITION] Fibrillation. He said that Resident #1 had gross hematuria while she was at the hospital. . The attending physician said that there was a " danger with that medication " . He said that Resident #1 had bleeding at the hospital. He said that since Resident #1 was also on [MEDICATION NAME], there was an interaction between [MEDICATION NAME] and [MEDICATION NAME] that could lead to an elevated INR. The attending physician also said that some patients do well with high INRs if they have no history of bleeding, but if patients have " bleeding issues " and they are on [MEDICATION NAME] like Resident #1, it becomes a problem and monitoring was necessary. The attending physician further said that he will discontinue Resident #1 ' s [MEDICATION NAME] and she would just take daily Aspirin. Record review of Resident #1 ' s nurse ' s notes dated 4/24/14 written by the DON revealed that Resident #1 ' s attending physician was at the facility and she spoke with him in " in reference to PT/INR and current [MEDICATION NAME] dose. MD stated resident recent hospitalization was not due to PT/INR it was due to bleeding and he would be reviewing her current medications and the order for [MEDICATION NAME] would be discontinued and EC ASA 81 mg 1 po Q D to be started " . Interview with the Administrator on 4/25/14 at 10:05 am he said that he was out for 4 weeks due to a back injury. He said that he was not aware of the critical values on 3/24/14 and 3/31/14 and he did not know that Resident #1 was sent to the hospital on [DATE]. The Administrator said that he knew of Resident #1 ' s hospital stay on 4/11/14. The Administrator said that he believed that the facility had this issue because there was a failure of the staff to communicate and relay the critical lab results to the physician which led to Resident #1 ' s hospital stay. Interview with the DON on 4/25/14 at 11:10 am she said that the facility had this problem because it was " an oversight " that led to Resident #1 ' s hospital stay. Interview with LVN A on 4/26/14 at 3:45 pm she said that she checked the fax machine periodically for lab results. She said that she knew all the residents with routine labs ordered. She said that she did not know about Resident #1 ' s critical INR result on 3/31/14. She said that it was called in to another nurse. She said that she did not remember getting anything that day at the fax machine. She said, " let ' s be realistic, you don ' t remember everything, everybody tries to get them (the lab results ). I don ' t go to the copy room. " LVN A said that she could not remember if she checked for PT/INR labs on 03/31/14, when Resident #1 was telling her that she had " bleeding " over the weekend (03/29 and 03/30) .LVN A continued to say that Resident #1 " says a lot of things that are not true " . Observation of Resident #1 on 4/26/14 at 4:19 pm revealed that she had some blood stains in a tissue. She said that it came from her nose when she sneezed. A Nurse Supervisor was in the resident ' s room and confirmed this. Interview with RN A on 4/29/14 at 9:45 am revealed that they use the form " Admission Assessment Data Collection Tool " when residents come back from the hospital. She said that she did not know if one was done for Resident #1. Interview with the DON on 4/29/14 at 10:30 am she said that there was no Admission Assessment Data Collection Tool done for Resident #1 when she came back to the facility on [DATE] and 4/15/14. Interview with the Administrator on 4/29/14 at 10:15 am he said that during his absence, the DON was in charge. He said that the DON was responsible and that if she had questions, she would call the regional directors. The administrator said that the DON did the daily meetings with the staff and department heads. Record review of the facility ' s Abuse Prohibition Policy and Procedures dated 7/2012 revealed, read in parts, II. Training Employees: Prevention, Intervention, Detection, Reporting and Employee Rights A. All new staff will receive training on the following information during general orientation. All staff will receive annual training on the following information: 1. What constitutes abuse, neglect, and misappropriation of resident property. An IJ was identified on 4/24/14 at 1:24 pm and the Administrator was informed at that time. A Plan of Removal (POR) the IJ was submitted and accepted on 04/25/2014 at 4:00 pm. The POR included: The Center immediately reviewed all residents (11) with a [MEDICATION NAME] order and Diagnostic lab orders for PT/INR panic or critical lab values for accuracy and to determine if there were other areas of concern that were not assessed timely or appropriately which may have warranted Physician notification. All residents on medications that require therapeutic labs to monitor administration is being audited, will be completed on April 25, 2014, to validate physician orders [REDACTED]. New Policy: Routine Labs: Lab tracking log is reviewed each night by the licensed Nurse that all requisitions are completed as for the next lab draw. Requisitions are placed in the designated lab folder or lab book. Technician does the lab draw initials and dates the lab, license nurse reviews the lab requisition, completes log and initial Treatment sheet when specimen obtained. DON /ADON reviews the labs to validate lab has been entered on the lab tracking log/labs has been drawn (will be completely 5 days weekly). Critical Labs: Panic or critical labs results are immediately (within from 15 minutes) reported to the center by telephone. Panic or critical labs are communicated to physician or medical director immediately (within 15 minutes). If the physician cannot be contacted or has not returned the call in 20 minutes contact medical director and director of nurses and 911 for hospital transport. Contact family or responsible party. PHYSICIAN ORDERS, CHANGES OF MEDICATIONS CARRIED OUT CORRECTLY 1. Educate the nurses on transcribing medications accurately to the Medication/Treatment record ... 2. Educate the nurses on assessing for side effect of [MEDICATION NAME] i.e. bleeding, bruises, sore joints hematuria, petechiae, fever/chills, skin rash, etc. ... 3. When order received to hold [MEDICATION NAME] Nurses will write the word HOLD on the MAR indicated [REDACTED]. This new policy began yesterday, April 25, 2014. 4. ADON/DON will check physician orders [REDACTED]. This new policy began yesterday, April 25, 2014. 5. After ADON/DON check physician orders [REDACTED]. 6. When a [MEDICATION NAME] dosage is changed from a different strength the previous [MEDICATION NAME] will be removed from the cart by the charge nurse and new [MEDICATION NAME] will be ordered. Family will be notified of change. The DON or designee will validate the removal of the [MEDICATION NAME] from the medication when reviewing telephone orders daily for 2 weeks using a QAPI [MEDICATION NAME] Monitoring Tool, Start date of April 25, 2014. Education Skills Validation All Licensed Nurses on duty will be provided education on our Diagnostic Testing and communicating panic or critical lab values ... A posttest was provided 4/24/14 to demonstrate understanding of our process change and the policy and procedure as it relates to diagnostic testing, Physician orders, Assessment, change of condition, adverse reaction, Physician notification and communication of each normal, panic or critical value ... This new policy began yesterday, April 25, 2014 ...Revised -Lab Tracking Tool attached. This new policy began yesterday, April 25, 2014. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service forms dated 04/23, 04/24, and 04/25 revealed that approximately 90 % of the staff representing all three shifts had been in-serviced on the lab protocols, assessing changes in condition and side effects of ant

Based on observation, interview and record review the facility failed to implement their written policies and procedures that prohibit neglect of residents for 3 of 12 resident ' s (Resident #1, #2 and #3) who were reviewed for lab services. Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibit neglect of residents for 3 of 12 residents (Resident #1, #2, #3) who were reviewed for lab services. IMMEDIATE JEOPARDY The facility failed to follow physician's orders [REDACTED]. The lab reported a critical INR (is a blood test that measure how fast the blood clots) result to the nurse on 03/24/14, a physician order [REDACTED]. Another critical INR lab was called in to the facility on [DATE] and was not communicated to the physician, wich resulted in delayed in treatment. Resident #1 complained of bleeding to the staff the weekend of 03/29/14-03/30/14 and there was no follow up assessment documented in the clinical records. Resident #1 continued to receive the anticoagulant medication which led to her hospitalization on [DATE]. NON-IMMEDIATE JEOPARDY The facility failed to follow physician's order [REDACTED].#2 ' s anticoagulant medication on 3/26/14. Resident #2 continued to receive the anticoagulant medication. Her next INR level had a critical result. The facility failed to obtain Resident #3 ' s laboratory test as ordered by the physician. Resident #3 ' s PT/INR lad test was not done as ordered for 3 months. An IJ was identified on 4/24/14 at 1:24 pm. While the IJ was removed on 4/29/14 at 11:35 am, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. These failures affected 3 residents whose care was compromised due to staff neglecting to perform labs and report tests results to physician's timely and placed 8 other resident on [MEDICATION NAME] at risk of delayed in treatment which could result in increased risk for bleeding and possible hospitalization . Intake: # 3 Findings included: IMMEDIATE JEOPARDY Record review of the facility ' s Abuse Prohibition Policy and Procedures dated 7/2012 revealed, read in parts, II. Training Employees: Prevention, Intervention, Detection, Reporting and Employee Rights A. All new staff will receive training on the following information during general orientation. All staff will receive annual training on the following information: 1. What constitutes abuse, neglect, and misappropriation of resident property. Resident #1: Record review of Resident #1 ' s admission face sheet revealed an admitted [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #1 ' s Quarterly MDS assessment dated [DATE] revealed under Section C: Cognitive Pattern, revealed that the resident was cognitively intact. Under Section G: Functional Status, Resident #1 was independent with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #1 ' s summary of Physician order [REDACTED]. -Aspirin EC 81 mg daily -[MEDICATION NAME] 6 mg 1 tablet every evening -[MEDICATION NAME] HCl 50 mg 1 tab every 6 hours as needed for pain -[MEDICATION NAME] HCl ER 100 mg at bedtime daily Record review of Resident #1 ' s telephone physician's order [REDACTED]. -Hold [MEDICATION NAME] 6 mg 1 tab po for 2 days on 3/13/14 and 3/14/14 then restart on 3/15/14. -Give [MEDICATION NAME] 6.5 mg 1 tab po for 2 days on 3/13/14 and 3/14/14 Record review of Resident #1 ' s MAR for March 2014 revealed that: -[MEDICATION NAME] 6.5 mg was given to Resident #1 on 3/14/14 and 3/15/14 instead of 3/13/14 and 3/14/14 as ordered by the physician. -[MEDICATION NAME] 6 mg was held on 3/13/14, 3/14/14 and 3/15/14 instead of holding the medication for 2 days on 3/13/14 and 3/14/14 as ordered by the physician. -[MEDICATION NAME] 6 mg was restarted on 3/16/14 instead of 3/15/14 as ordered by the physician. Record review of Resident #1 ' s telephone physician's order [REDACTED]. -Hold [MEDICATION NAME] 6 mg for 2 days 3/18/14 and 3/19/14 -Give [MEDICATION NAME] 5.5 mg for 2 days 3/18/14 and 3/19/14 -Restart 6 mg 1 tablet po every evening on 3/20/14 Record review of Resident #1 ' s MAR for March 2014 revealed that: -[MEDICATION NAME] 6 mg was held on 3/18/14, 3/19/14 and 3/20/14 instead of holding it only for 2 days 3/18/14 and 3/19/14 as ordered by the physician. -[MEDICATION NAME] 5.5 mg was given on 3/19/14 and 3/20/14 instead of 3/18/14 and 3/19/14 as ordered by the physician -[MEDICATION NAME] 6 mg was restarted on 3/21/14 instead of 3/20/14 as ordered by the physician. Record review of Resident #1 ' s laboratory results for PT/INR dated 3/24/14 revealed a critical PT value of 30.8 ( normal Reference 10.4 - 13.8) and a critical INR value of 6.56 (INR Therapeutic range for residents on anticoagulation therapy: Standard dose therapeutic range: 2.0 - 3.0; Higher intensity therapeutic range: 2.5 - 3.5). The results were called in by the lab to LVN D on 3/24/14 at 2:23 p.m. Record review of Resident #1 ' s of telephone Physician orders [REDACTED]. -Hold [MEDICATION NAME] today and tomorrow 3/24/14 and 3/25/14 -Discontinue [MEDICATION NAME] 6 mg -New order [MEDICATION NAME] 5 mg po daily at 6:00 pm -PT/INR lab on 3/31/14 Record review of Resident #1 ' s MAR for March 2014 revealed that -[MEDICATION NAME] 6 mg was held on 3/24/14 and 3/25/14 -[MEDICATION NAME] 5 mg was started on 3/25/14 Record review of Resident #1 ' s MAR for March 2014 revealed that she continuously received [MEDICATION NAME] 5 mg from 3/25/14 to 4/1/14. Record review of Resident #1 ' s laboratory results for PT/INR dated 3/31/14 revealed a critical PT value of 27.9 and critical INR value of 5.49. The results were called in by the lab to LVN C on 3/31/14 at 4:14 pm as documented in the lab result: A Lab tech phoned results on 3/31/14 at 16:14 pm Critical Results called to: LVN C Results read back correctly. INR Record review of Resident #1 ' s Nurse ' s notes and other clinical records revealed no documentation that the physician was notified of the PT/INR critical lab values. Record review of Resident #1 ' s Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin for March 2014 revealed that " Licensed Nurse has observed this Resident and none of the following side effects have been evidenced: Petechiae (pinpoint, round spots that appear on the skin as a result of bleeding under the skin), Hematuria (blood in the urine), Sore Joints, Epistaxis, Bleeding and or sore Gums: Mouth ulcers, Bruising and Hematoma, Fever/Chills, Nausea, Vomiting and or Diarrhea, Skin Rash " , there were no side effects marked for the whole month of March 2014. Each shift was initialed by the nurses that there were no side effects seen. Record review of Resident #1 ' s Progress Notes/History and Physical dated 4/2/14 and written by Nurse Practitioner A revealed that Resident #1 had a bloodshot left eye, an INR of 5.6 and was bleeding from the left ear and nose. She gave the order for the resident to be transferred to the hospital. There was also a note indicating the following lab result: 3/31/14 PT/INR 5.49. Record review of Resident #1 ' s Nurse ' s notes dated 4/2/14 revealed that Resident #1 was transferred to the emergency room for " unspecified bleeding (internal) and elevated PT/INR. PT 27.9 INR 5.49. Further review of the note " Left eye noted very red can ' t see white ' s of eye. No bleeding noted to any other areas. " Resident #1 was admitted to the hospital from 4/2/14 to 4/10/14. Record review of hospital cardiology notes dated 4/8/14 revealed that Resident #1 ' s INR was 6.7, " still receiving IVF ... A/P- correct coagulopathy - Vitamin K IV. " -PT/INR in the morning. Record review of Resident #1 ' s Nurse ' s notes dated 4/10/14 revealed that Resident #1 came back to the facility on [DATE] at 5:50 pm. Record review of Resident #1 ' s clinical records revealed that there was no " Admission Assessment Data Collection Tool " done when Resident #1 came back to the facility on [DATE]. Record review of Resident #1 ' s Nurse ' s notes dated 4/11/14 at 6:00 am revealed " Resident out in hall yelling down the hall stating she was bleeding. This writer and 2nd night nurse assessed resident and res. had blood in toilet and on wipes in sink. Res. assisted to bed per this writer and mid-lrg (large) blood clots observed coming from vagina ... " A call was placed to Nurse Practitioner A and Resident #1 was transferred to the hospital. Resident #1 was readmitted back to the hospital from 4/11/14 to 4/15/14. Record review of Resident #1 ' s hospital notes dated 4/12/14 revealed: " ...was discharged from the hospital one day earlier. She has been diagnosed with [REDACTED]. She has been on [MEDICATION NAME] because of history of [MEDICAL CONDITION]. The INR was down to 1.6, when she was discharged to nursing home she started having bleeding from the pelvic area, therefore sent back to the hospital for further evaluation and treatment. The patient had a history of [REDACTED]. " Record review of Resident #1 ' s nurse ' s notes dated 4/15/14 revealed that Resident #1 was readmitted back to the facility under the same attending physician. Resident #1 ' s medications were verified by the Nurse Practitioner A and were faxed to the pharmacy. Resident #1 was to have a repeat urine culture and office cystoscopy and her [MEDICATION NAME] was to be held prior to Cystoscopy. Record review of Resident #1 ' s nurse ' s notes on 4/15/14 did not address Resident #1 ' s physical condition and there was no documentation of head to toe assessment. Also there was no " Admission Assessment Data Collection Tool " Record review of Resident #1 ' s Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin for April 1 to 24, 2014 revealed that " Licensed Nurse has observed this Resident and none of the following side effects have been evidenced: Petechiae, Hematuria, Sore Joints, Epistaxis, Bleeding and or sore Gums: Mouth ulcers, Bruising and Hematoma, Fever/Chills, Nausea, Vomiting and or Diarrhea, Skin Rash " , there were no side effects marked from April 1 to 24, 2014. Each shift was initialed by the nurses that there were no side effects seen. There was a line drawn on the dates that Resident #1 was at the hospital. On the day that Resident #1 was documented as having " mid-lrg (large) blood clots observed coming from vagina " dated 4/11/14 at 6:00 am, there was none documented on the " Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin " . Record review of Resident #1 ' s physician's order [REDACTED]. CBC, BMP, HbA1C, TSH, PT/INR on 4/21/14. Continued record review of Resident # 's nurse's notes after she came back from the hospital revealed one more entry on 4/16/14. No further nurse ' s notes entered for Resident #1 ' s current condition and assessment until 4/21/14 when LVN A received new physician's order [REDACTED]. There was no documentation of Resident #1 ' s physical assessment or current condition. Record review of Resident #1's laboratory results ordered on [DATE] revealed the following: TSH 66.09 (Reference: .46 - 4.68) Hemoglobin A1C 7.8 (4.3 - 6.1) PT 16.5 INR - 1.92 The lab results were faxed to the physician on 4/21/14 at 7:20 pm. Record review of Resident #1 ' s Physician orders [REDACTED]. -Discontinue [MEDICATION NAME] 5 mg -Start [MEDICATION NAME] 5 mg po Mon -Fri. -[MEDICATION NAME] 5.5 mg on Saturday and Sunday -PT INR on 4/28/14 -Discontinue [MEDICATION NAME] 50 mcg, start [MEDICATION NAME] 75 mcg 1 tab po before breakfast -TSH lab on 5/21/14 Record review of Resident #1 ' s care plan dated 4/22/14 revealed that Resident #1 was high risk for increase bleeding related to blood thinning agent. Resident currently takes [MEDICATION NAME]. The goal was Resident #1 would have no side effects from medication. The approaches read in part: 1. Administer medications as ordered. 2. Monitor for side effects 3. Lab as ordered 4. Protect resident from bruising self 9. Notify MD if bleeding is not stopped with pressure 10. Notify MD of abnormalities in labs There was no care plan seen for increased in bleeding related to blood thinning agent prior to this care plan. Observation on 4/23/14 at 11:00 am during initial tour revealed that Resident #1 was lying in bed wearing a collared button down pajama top and pajama pants. A blood stain measuring approximately 3 cm x 1 cm was seen on her right collar. Interview with Resident #1 on 4/23/14 at 11:00 am revealed that she had a nose bleeding earlier that morning. She said that she had told the nurse earlier that morning but the nurse " turned around and left " . Resident #1 said that she had told the nurse who checked her blood sugar that morning. Resident #1 said that she was sick and she just came back from the hospital " a week ago " and she still had bleeding from her nose. She said that the nurses do not come to check on her. She said that sometimes she felt sick and she turned the call light on and " they don ' t come " . Resident #1 said that before she went to the hospital the first time, she had blood coming from her ears, nose, vagina and her eyes were shut. She said that she was telling the nurses for " 2 days " but they sent her back to her room. Resident #1 said that nurses told her, " Go back to your room and I will be there " , but the nurses never came to check on her. Resident #1 said that the nurses kept telling her that they would contact the Nurse Practitioner but they never did. Resident #1 said that when Nurse Practitioner A finally came to the facility, she asked Nurse Practitioner A if the nurses had called her about her bleeding and the Nurse Practitioner A said no. Resident #1 said that as soon as Nurse Practitioner A saw her when she came to make rounds on 4/2/14, Nurse Practitioner A " rushed me to the ER " . Interview with Resident #1 on 4/23/14 at 12:20 pm revealed that when she came back to the facility from the hospital the first time (04/11/14), she continued to have bleeding problems. Resident #1 said that the nurses did not come to check on her when she came back from the hospital. Resident #1 said that around 4: 30 am, she had a lot of bleeding. She said that she had turned on her call light for help but nobody came to help her. Resident #1 said that she managed to go to the hallway to call for help. She said that she was yelling for help. Resident #1 said that she had a lot of bleeding and she was sent back to the hospital that day. Interview with LVN C on 4/23/14 at 3:32 pm revealed that she took the call from the lab on 3/31/14 about Resident #1 ' s critical INR result and she relayed the information to LVN A because she was not the nurse for Resident #1. Interview with LVN D on 4/23/14 at 3:34 pm revealed that she took the call from the lab on 3/24/14 about Resident #1 ' s critical INR result and she told LVN A about it. She said that LVN A faxed the result to Nurse Practitioner A. Interview with LVN B on 4/23/14 at 3:40 pm revealed that she remembered that Nurse Practitioner A was all upset because she was not informed of Resident #1 ' s INR critical result. LVN B said that it was a " big hoorah " because LVN C said that she told LVN A but LVN A said that LVN C did not tell her. LVN B said that since then, Nurse Practitioner A had asked that her cellphone number be placed " all over the nurse ' s station " for prompt communication. Interview with Resident #1 on 4/23/14 at 4:00 pm revealed that she tried to clear the blood stain on her collared pajama top with water but it was hard to clear. She said that she told the nurse that morning about her nose bleeding but the nurse never went back to check on her. In an interview on 4/23/14 at 4:06 pm LVN A said that she did not know about the 3/31/14 INR critical value. LVN A said that LVN C took the call from the lab but did not inform her of the critical value. LVN A said that she remembered that 3/31/14 was a Monday and Resident #1 had come to her that day and told her that she was bleeding over the weekend from her nose and ears. LVN A said that Resident #1 told her that she reported the bleeding to the weekend nurses but they did not do anything for her. LVN A said that after Resident #1 told her about the bleeding, she assessed her by checking Resident #1 ' s mouth, ears, nose and there was no bleeding. LVN A said that she did not document the assessment. LVN A said that she did not know that Resident #1 ' s INR result was critical that day. The nurse said that Resident #1 continued to receive [MEDICATION NAME] 5 mg on 4/1/14 and was sent out to the hospital on [DATE]. Further interview with LVN A she said that she was the one who wrote the physician's order [REDACTED].#1. She said that Resident #1 also had an INR critical value on 03/24/14. She said that she had made a mistake in the MAR by writing her initials on [MEDICATION NAME] 5 mg on 3/25/14 which implied that she gave the [MEDICATION NAME] 5 mg instead of starting it on 3/26/14. She said that she actually did not give the [MEDICATION NAME] 5 mg on 3/25/14, she said that there should have been a " line through it " . She said that she accidentally put her initials on 3/25/14. In an interview on 4/23/14 at 4:48 pm Nurse Practitioner A said that she did not know that Resident #1 ' s INR was critical until she went to the facility for rounds on 04/02/14. She said that when she saw that Resident #1 ' s left eye was red and was shut, she immediately sent her out to the hospital without even knowing that her INR was critical. Nurse Practitioner A said that the facility had a " communication problem " in relaying urgent laboratory results. She said that they continued to have communication problems as she had received laboratory results for Resident #1 on 4/21/14 regarding her TSH level of 66.09, HgA1C of 7.8, and PT/INR of 16.5/1.92 via fax machine. Nurse Practitioner A said that these types of abnormal results should not be sent via fax machine. She said that it should have been called in to her. Nurse Practitioner A said that she called the facility after she received the results via fax machine and told the nurse that she should not be faxing abnormal results but instead she should be calling the Nurse Practitioner or Physician. Nurse Practitioner A said that the nurse gave her a bad attitude and told her that she did not call " because she had to attend to other things. " In an interview with the Administrator, ADON A, ADON B on 4/23/14 at 5:30 pm they said that they did not know about Resident #1 ' s INR critical labs on 3/24/14 and 3/31/14. In an interview via phone conference with the DON on 4/23/14 at 5:45 pm she said that she did not know about Resident #1 ' s critical labs on 3/24/14 and 3/31/14. She said it was " never brought to my attention " . The Administrator was in the room. In an interview with ADON A and ADON B on 4/23/14 at 5:30 pm they said that they were not aware that Resident #1 had a nose bleed that morning. They said that they would ask the evening shift charge nurse to check on Resident #1. In an interview on 04/24/14 at 9:35 am, Resident #1 said that she just had a " tiny little bit, almost nothing " when asked if she had any more nose bleeding through the night. Resident #1 said that she used a tissue paper to wipe her nose and she just saw a " tiny little bit " of blood. Record review of Resident #1 ' s clinical records revealed that there was no documentation of the nose bleed on 4/23/14 night shift and 4/24/14 morning shift. The 24 hour communication book revealed that the evening shift charge nurse wrote, " Head to toe assessment done. No decubs, no open areas, slight bruising to abdomen, no bleeding from ears, mouth, nose, vagina. " In an interview on 4/24/14 at 10:30 am the DON said that Nurse Practitioner A did not call her to tell her about issues with Resident #1 ' s critical INR result on 3/31/14. The DON said that she was told by ADON A that Resident #1 went to the hospital on [DATE] but did not tell her that Nurse Practitioner A was upset because the critical INR result was not communicated to her. The DON said that when Resident #1 went to the hospital on [DATE], " they could ' t finds anything at the hospital " . She said that Resident #1 " went to the hospital too much " . The DON said that ADON A was in charge of Resident #1 ' s PT/INR. She said that she had 2 ADONs and they were responsible for monitoring lab results. She said that she should have been notified by Nurse Practitioner A about the issues with Resident #1 ' s INR levels. Interview with the DON on 4/24/14 at 11:09 am she said that she did not call the physician about Resident #1 ' s nose bleeding. The DON said that she did not check on Resident #1, but had the 2-10 nurse checked on her yesterday. The DON said that the nurses used the Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin form for side effects of bleeding. Interview with ADON B on 4/24/14 at 11:15 am revealed that she did not assess Resident #1 " last night " but she had asked the evening shift to do a head to toe assessment on Resident #1. Further interview with the DON on 4/24/14 at 11:18 am she said that she found out about Resident #1 ' s critical INR on 4/2/14. She said that from what ADON A told her, LVN C took the call from the lab but was not communicated to the LVN A who was assigned to Resident #1. The DON said that she did not know if the lab had faxed a hard copy of the lab results. She said that she typically does not get a copy of the critical lab results. She said that lab results were faxed to the facility throughout the day. She said that the fax machine was in the copy room and there was a designated box for lab results. She said that the ADONs were supposed to check the box throughout the day. The DON said that when the critical lab results were faxed to the facility, the ADON was " probably gone when it was faxed " . She said that her ADONs leave at around 4:30 pm - 5:00 pm. Interview with the DON on 4/24/14 at 11:20 am revealed that the evening shift on 4/23/14 did not call Resident #1 ' s physician to inform him of Resident #1 ' s nose bleeding on 4/23/14. She said " if you find bleeding stain, you would have assess where the blood come from especially if a resident was on anticoagulant " . Interview with LVN B on 4/24/14 at 11:23 am she said that if a resident on [MEDICATION NAME] had a history of [REDACTED]. Further interview with the DON on 4/24/14 at 11:30 am revealed that the hospital did not find anything wrong with Resident #1. She said that Resident #1 came back on 4/10/14 and went out again the next day. She said that it was all " anxiety, geri-psych " . In an interview with ADON A on 4/24/14 at 11:45 am she said that lab results were faxed " randomly " and they were picked up from the fax machine by anybody, nurses or administrative staff and placed in the designated box in the copy room. She said that the ADONs check the box regularly, " very frequently " . She said that she was not aware about the 3/24/14 critical INR results for Resident #1. She said that she checked the [MEDICATION NAME] book once a week, no specific day, " just as soon as possible, mostly Wednesday " . ADON A said that she was also not aware of Resident #1 ' s critical INR results on 3/31/14. Further interview at this time with ADON A she said that LVN A should not have given Resident #1 a [MEDICATION NAME] 5 mg on 3/25/14. She said that the physician had held it for 2 days because of the high INR. The ADON A said that the [MEDICATION NAME] 5 mg should have been started on 3/26/14, " like what the physician said in the order " . Interview with Resident #1 ' s Attending Physician on 4/24/14 at 3:30 pm (the DON and Administrator were in the room at the time) he said that Resident #1 was on [MEDICATION NAME] due to [MEDICAL CONDITION] Fibrillation. He said that Resident #1 had gross hematuria while she was at the hospital. . The attending physician said that there was a " danger with that medication " . He said that Resident #1 had bleeding at the hospital. He said that since Resident #1 was also on [MEDICATION NAME], there was an interaction between [MEDICATION NAME] and [MEDICATION NAME] that could lead to an elevated INR. The attending physician also said that some patients do well with high INRs if they have no history of bleeding, but if patients have " bleeding issues " and they are on [MEDICATION NAME] like Resident #1, it becomes a problem and monitoring was necessary. The attending physician further said that he will discontinue Resident #1 ' s [MEDICATION NAME] and she would just take daily Aspirin. Record review of Resident #1 ' s nurse ' s notes dated 4/24/14 written by the DON revealed that Resident #1 ' s attending physician was at the facility and she spoke with him in " in reference to PT/INR and current [MEDICATION NAME] dose. MD stated resident recent hospitalization was not due to PT/INR it was due to bleeding and he would be reviewing her current medications and the order for [MEDICATION NAME] would be discontinued and EC ASA 81 mg 1 po Q D to be started " . Interview with the Administrator on 4/25/14 at 10:05 am he said that he was out for 4 weeks due to a back injury. He said that he was not aware of the critical values on 3/24/14 and 3/31/14 and he did not know that Resident #1 was sent to the hospital on [DATE]. The Administrator said that he knew of Resident #1 ' s hospital stay on 4/11/14. The Administrator said that he believed that the facility had this issue because there was a failure of the staff to communicate and relay the critical lab results to the physician which led to Resident #1 ' s hospital stay. Interview with the DON on 4/25/14 at 11:10 am she said that the facility had this problem because it was " an oversight " that led to Resident #1 ' s hospital stay. Interview with LVN A on 4/26/14 at 3:45 pm she said that she checked the fax machine periodically for lab results. She said that she knew all the residents with routine labs ordered. She said that she did not know about Resident #1 ' s critical INR result on 3/31/14. She said that it was called in to another nurse. She said that she did not remember getting anything that day at the fax machine. She said, " let ' s be realistic, you don ' t remember everything, everybody tries to get them (the lab results ). I don ' t go to the copy room. " LVN A said that she could not remember if she checked for PT/INR labs on 03/31/14, when Resident #1 was telling her that she had " bleeding " over the weekend (03/29 and 03/30) .LVN A continued to say that Resident #1 " says a lot of things that are not true " . Observation of Resident #1 on 4/26/14 at 4:19 pm revealed that she had some blood stains in a tissue. She said that it came from her nose when she sneezed. A Nurse Supervisor was in the resident ' s room and confirmed this. Interview with RN A on 4/29/14 at 9:45 am revealed that they use the form " Admission Assessment Data Collection Tool " when residents come back from the hospital. She said that she did not know if one was done for Resident #1. Interview with the DON on 4/29/14 at 10:30 am she said that there was no Admission Assessment Data Collection Tool done for Resident #1 when she came back to the facility on [DATE] and 4/15/14. Interview with the Administrator on 4/29/14 at 10:15 am he said that during his absence, the DON was in charge. He said that the DON was responsible and that if she had questions, she would call the regional directors. The administrator said that the DON did the daily meetings with the staff and department heads. An IJ was identified on 4/24/14 at 1:24 pm and the Administrator was informed at that time. A Plan of Removal (POR) the IJ was submitted and accepted on 04/25/2014 at 4:00 pm. The POR included: The Center immediately reviewed all residents (11) with a [MEDICATION NAME] order and Diagnostic lab orders for PT/INR panic or critical lab values for accuracy and to determine if there were other areas of concern that were not assessed timely or appropriately which may have warranted Physician notification. All residents on medications that require therapeutic labs to monitor administration is being audited, will be completed on April 25, 2014, to validate physician orders [REDACTED]. New Policy: Routine Labs: Lab tracking log is reviewed each night by the licensed Nurse that all requisitions are completed as for the next lab draw. Requisitions are placed in the designated lab folder or lab book. Technician does the lab draw initials and dates the lab, license nurse reviews the lab requisition, completes log and initial Treatment sheet when specimen obtained. DON /ADON reviews the labs to validate lab has been entered on the lab tracking log/labs has been drawn (will be completely 5 days weekly). Critical Labs: Panic or critical labs results are immediately (within from 15 minutes) reported to the center by telephone. Panic or critical labs are communicated to physician or medical director immediately (within 15 minutes). If the physician cannot be contacted or has not returned the call in 20 minutes contact medical director and director of nurses and 911 for hospital transport. Contact family or responsible party. PHYSICIAN ORDERS, CHANGES OF MEDICATIONS CARRIED OUT CORRECTLY 1. Educate the nurses on transcribing medications accurately to the Medication/Treatment record ... 2. Educate the nurses on assessing for side effect of [MEDICATION NAME] i.e. bleeding, bruises, sore joints hematuria, petechiae, fever/chills, skin rash, etc. ... 3. When order received to hold [MEDICATION NAME] Nurses will write the word HOLD on the MAR indicated [REDACTED]. This new policy began yesterday, April 25, 2014. 4. ADON/DON will check physician orders [REDACTED]. This new policy began yesterday, April 25, 2014. 5. After ADON/DON check physician orders [REDACTED]. 6. When a [MEDICATION NAME] dosage is changed from a different strength the previous [MEDICATION NAME] will be removed from the cart by the charge nurse and new [MEDICATION NAME] will be ordered. Family will be notified of change. The DON or designee will validate the removal of the [MEDICATION NAME] from the medication when reviewing telephone orders daily for 2 weeks using a QAPI [MEDICATION NAME] Monitoring Tool, Start date of April 25, 2014. Education Skills Validation All Licensed Nurses on duty will be provided education on our Diagnostic Testing and communicating panic or critical lab values ... A posttest was provided 4/24/14 to demonstrate understanding of our process change and the policy and procedure as it relates to diagnostic testing, Physician orders, Assessment, change of condition, adverse reaction, Physician notification and communication of each normal, panic or critical value ... This new policy began yesterday, April 25, 2014 ...Revised -Lab Tracking Tool attached. This new policy began yesterday, April 25, 2014. The surveyor confirmed the POR had been implemen

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibit neglect of residents for 3 of 12 residents (Resident #1, #2, #3) who were reviewed for lab services. IMMEDIATE JEOPARDY The facility failed to follow physician's orders [REDACTED]. The lab reported a critical INR (is a blood test that measure how fast the blood clots) result to the nurse on 03/24/14, a physician order [REDACTED]. Another critical INR lab was called in to the facility on [DATE] and was not communicated to the physician, which delayed medical treatment. Resident #1 complained of bleeding to the staff the weekend of 03/29/14-03/30/14 and there was no follow up assessment documented in the clinical records. Resident #1 continued to receive the anticoagulant medication which led to her hospitalization on [DATE]. NON-IMMEDIATE JEOPARDY The facility failed to follow physician's order [REDACTED].#2 ' s anticoagulant medication on 3/26/14. Resident #2 continued to receive the anticoagulant medication. Her next INR level had a critical result. The facility failed to obtain Resident #3 ' s laboratory test as ordered by the physician. Resident #3 ' s PT/INR lad test was not done as ordered for 3 months. An IJ was identified on 4/24/14 at 1:24 pm. While the IJ was removed on 4/29/14 at 11:35 am, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. These failures affected 3 residents whose care was compromised due to staff neglecting to perform labs and report tests results to physician's timely and placed 8 other resident on [MEDICATION NAME] at risk of delayed in treatment which could result in increased risk for bleeding and possible hospitalization . Intake: # 3 Findings included: IMMEDIATE JEOPARDY Resident #1: Record review of Resident #1 ' s admission face sheet revealed an admitted [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #1 ' s Quarterly MDS assessment dated [DATE] revealed under Section C: Cognitive Pattern, revealed that the resident was cognitively intact. Under Section G: Functional Status, Resident #1 was independent with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #1 ' s summary of Physician order [REDACTED]. -Aspirin EC 81 mg daily -[MEDICATION NAME] 6 mg 1 tablet every evening -[MEDICATION NAME] HCl 50 mg 1 tab every 6 hours as needed for pain -[MEDICATION NAME] HCl ER 100 mg at bedtime daily Record review of Resident #1 ' s telephone physician's order [REDACTED]. -Hold [MEDICATION NAME] 6 mg 1 tab po for 2 days on 3/13/14 and 3/14/14 then restart on 3/15/14. -Give [MEDICATION NAME] 6.5 mg 1 tab po for 2 days on 3/13/14 and 3/14/14 Record review of Resident #1 ' s MAR for March 2014 revealed that: -[MEDICATION NAME] 6.5 mg was given to Resident #1 on 3/14/14 and 3/15/14 instead of 3/13/14 and 3/14/14 as ordered by the physician. -[MEDICATION NAME] 6 mg was held on 3/13/14, 3/14/14 and 3/15/14 instead of holding the medication for 2 days on 3/13/14 and 3/14/14 as ordered by the physician. -[MEDICATION NAME] 6 mg was restarted on 3/16/14 instead of 3/15/14 as ordered by the physician. Record review of Resident #1 ' s telephone physician's order [REDACTED]. -Hold [MEDICATION NAME] 6 mg for 2 days 3/18/14 and 3/19/14 -Give [MEDICATION NAME] 5.5 mg for 2 days 3/18/14 and 3/19/14 -Restart 6 mg 1 tablet po every evening on 3/20/14 Record review of Resident #1 ' s MAR for March 2014 revealed that: -[MEDICATION NAME] 6 mg was held on 3/18/14, 3/19/14 and 3/20/14 instead of holding it only for 2 days 3/18/14 and 3/19/14 as ordered by the physician. -[MEDICATION NAME] 5.5 mg was given on 3/19/14 and 3/20/14 instead of 3/18/14 and 3/19/14 as ordered by the physician -[MEDICATION NAME] 6 mg was restarted on 3/21/14 instead of 3/20/14 as ordered by the physician. Record review of Resident #1 ' s laboratory results for PT/INR dated 3/24/14 revealed a critical PT value of 30.8 ( normal Reference 10.4 - 13.8) and a critical INR value of 6.56 (INR Therapeutic range for residents on anticoagulation therapy: Standard dose therapeutic range: 2.0 - 3.0; Higher intensity therapeutic range: 2.5 - 3.5). The results were called in by the lab to LVN D on 3/24/14 at 2:23 p.m. Record review of Resident #1 ' s of telephone Physician orders [REDACTED]. -Hold [MEDICATION NAME] today and tomorrow 3/24/14 and 3/25/14 -Discontinue [MEDICATION NAME] 6 mg -New order [MEDICATION NAME] 5 mg po daily at 6:00 pm -PT/INR lab on 3/31/14 Record review of Resident #1 ' s MAR for March 2014 revealed that -[MEDICATION NAME] 6 mg was held on 3/24/14 and 3/25/14 -[MEDICATION NAME] 5 mg was started on 3/25/14 Record review of Resident #1 ' s MAR for March 2014 revealed that she continuously received [MEDICATION NAME] 5 mg from 3/25/14 to 4/1/14. Record review of Resident #1 ' s laboratory results for PT/INR dated 3/31/14 revealed a critical PT value of 27.9 and critical INR value of 5.49. The results were called in by the lab to LVN C on 3/31/14 at 4:14 pm as documented in the lab result: A Lab tech phoned results on 3/31/14 at 16:14 pm Critical Results called to: LVN C Results read back correctly. INR Record review of Resident #1 ' s Nurse ' s notes and other clinical records revealed no documentation that the physician was notified of the PT/INR critical lab values. Record review of Resident #1 ' s Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin for March 2014 revealed that " Licensed Nurse has observed this Resident and none of the following side effects have been evidenced: Petechiae (pinpoint, round spots that appear on the skin as a result of bleeding under the skin), Hematuria (blood in the urine), Sore Joints, Epistaxis, Bleeding and or sore Gums: Mouth ulcers, Bruising and Hematoma, Fever/Chills, Nausea, Vomiting and or Diarrhea, Skin Rash " , there were no side effects marked for the whole month of March 2014. Each shift was initialed by the nurses that there were no side effects seen. Record review of Resident #1 ' s Progress Notes/History and Physical dated 4/2/14 and written by Nurse Practitioner A revealed that Resident #1 had a bloodshot left eye, an INR of 5.6 and was bleeding from the left ear and nose. She gave the order for the resident to be transferred to the hospital. There was also a note indicating the following lab result: 3/31/14 PT/INR 5.49. Record review of Resident #1 ' s Nurse ' s notes dated 4/2/14 revealed that Resident #1 was transferred to the emergency room for " unspecified bleeding (internal) and elevated PT/INR. PT 27.9 INR 5.49. Further review of the note " Left eye noted very red can ' t see white ' s of eye. No bleeding noted to any other areas. " Resident #1 was admitted to the hospital from 4/2/14 to 4/10/14. Record review of hospital cardiology notes dated 4/8/14 revealed that Resident #1 ' s INR was 6.7, " still receiving IVF ... A/P- correct coagulopathy - Vitamin K IV. " -PT/INR in the morning. Record review of Resident #1 ' s Nurse ' s notes dated 4/10/14 revealed that Resident #1 came back to the facility on [DATE] at 5:50 pm. Record review of Resident #1 ' s clinical records revealed that there was no " Admission Assessment Data Collection Tool " done when Resident #1 came back to the facility on [DATE]. Record review of Resident #1 ' s Nurse ' s notes dated 4/11/14 at 6:00 am revealed " Resident out in hall yelling down the hall stating she was bleeding. This writer and 2nd night nurse assessed resident and res. had blood in toilet and on wipes in sink. Res. assisted to bed per this writer and mid-lrg (large) blood clots observed coming from vagina ... " A call was placed to Nurse Practitioner A and Resident #1 was transferred to the hospital. Resident #1 was readmitted back to the hospital from 4/11/14 to 4/15/14. Record review of Resident #1 ' s hospital notes dated 4/12/14 revealed: " ...was discharged from the hospital one day earlier. She has been diagnosed with [REDACTED]. She has been on [MEDICATION NAME] because of history of [MEDICAL CONDITION]. The INR was down to 1.6, when she was discharged to nursing home she started having bleeding from the pelvic area, therefore sent back to the hospital for further evaluation and treatment. The patient had a history of [REDACTED]. " Record review of Resident #1 ' s nurse ' s notes dated 4/15/14 revealed that Resident #1 was readmitted back to the facility under the same attending physician. Resident #1 ' s medications were verified by the Nurse Practitioner A and were faxed to the pharmacy. Resident #1 was to have a repeat urine culture and office cystoscopy and her [MEDICATION NAME] was to be held prior to Cystoscopy. Record review of Resident #1 ' s nurse ' s notes on 4/15/14 did not address Resident #1 ' s physical condition and there was no documentation of head to toe assessment. Also there was no " Admission Assessment Data Collection Tool " Record review of Resident #1 ' s Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin for April 1 to 24, 2014 revealed that " Licensed Nurse has observed this Resident and none of the following side effects have been evidenced: Petechiae, Hematuria, Sore Joints, Epistaxis, Bleeding and or sore Gums: Mouth ulcers, Bruising and Hematoma, Fever/Chills, Nausea, Vomiting and or Diarrhea, Skin Rash " , there were no side effects marked from April 1 to 24, 2014. Each shift was initialed by the nurses that there were no side effects seen. There was a line drawn on the dates that Resident #1 was at the hospital. On the day that Resident #1 was documented as having " mid-lrg (large) blood clots observed coming from vagina " dated 4/11/14 at 6:00 am, there was none documented on the " Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin " . Record review of Resident #1 ' s physician's order [REDACTED]. CBC, BMP, HbA1C, TSH, PT/INR on 4/21/14. Continued record review of Resident # 's nurse's notes after she came back from the hospital revealed one more entry on 4/16/14. No further nurse ' s notes entered for Resident #1 ' s current condition and assessment until 4/21/14 when LVN A received new physician's order [REDACTED]. There was no documentation of Resident #1 ' s physical assessment or current condition. Record review of Resident #1's laboratory results ordered on [DATE] revealed the following: TSH 66.09 (Reference: .46 - 4.68) Hemoglobin A1C 7.8 (4.3 - 6.1) PT 16.5 INR - 1.92 The lab results were faxed to the physician on 4/21/14 at 7:20 pm. Record review of Resident #1 ' s Physician orders [REDACTED]. -Discontinue [MEDICATION NAME] 5 mg -Start [MEDICATION NAME] 5 mg po Mon -Fri. -[MEDICATION NAME] 5.5 mg on Saturday and Sunday -PT INR on 4/28/14 -Discontinue [MEDICATION NAME] 50 mcg, start [MEDICATION NAME] 75 mcg 1 tab po before breakfast -TSH lab on 5/21/14 Record review of Resident #1 ' s care plan dated 4/22/14 revealed that Resident #1 was high risk for increase bleeding related to blood thinning agent. Resident currently takes [MEDICATION NAME]. The goal was Resident #1 would have no side effects from medication. The approaches read in part: 1. Administer medications as ordered. 2. Monitor for side effects 3. Lab as ordered 4. Protect resident from bruising self 9. Notify MD if bleeding is not stopped with pressure 10. Notify MD of abnormalities in labs There was no care plan seen for increased in bleeding related to blood thinning agent prior to this care plan. Observation on 4/23/14 at 11:00 am during initial tour revealed that Resident #1 was lying in bed wearing a collared button down pajama top and pajama pants. A blood stain measuring approximately 3 cm x 1 cm was seen on her right collar. Interview with Resident #1 on 4/23/14 at 11:00 am revealed that she had a nose bleeding earlier that morning. She said that she had told the nurse earlier that morning but the nurse " turned around and left " . Resident #1 said that she had told the nurse who checked her blood sugar that morning. Resident #1 said that she was sick and she just came back from the hospital " a week ago " and she still had bleeding from her nose. She said that the nurses do not come to check on her. She said that sometimes she felt sick and she turned the call light on and " they don ' t come " . Resident #1 said that before she went to the hospital the first time, she had blood coming from her ears, nose, vagina and her eyes were shut. She said that she was telling the nurses for " 2 days " but they sent her back to her room. Resident #1 said that nurses told her, " Go back to your room and I will be there " , but the nurses never came to check on her. Resident #1 said that the nurses kept telling her that they would contact the Nurse Practitioner but they never did. Resident #1 said that when Nurse Practitioner A finally came to the facility, she asked Nurse Practitioner A if the nurses had called her about her bleeding and the Nurse Practitioner A said no. Resident #1 said that as soon as Nurse Practitioner A saw her when she came to make rounds on 4/2/14, Nurse Practitioner A " rushed me to the ER " . Interview with Resident #1 on 4/23/14 at 12:20 pm revealed that when she came back to the facility from the hospital the first time (04/11/14), she continued to have bleeding problems. Resident #1 said that the nurses did not come to check on her when she came back from the hospital. Resident #1 said that around 4: 30 am, she had a lot of bleeding. She said that she had turned on her call light for help but nobody came to help her. Resident #1 said that she managed to go to the hallway to call for help. She said that she was yelling for help. Resident #1 said that she had a lot of bleeding and she was sent back to the hospital that day. Interview with LVN C on 4/23/14 at 3:32 pm revealed that she took the call from the lab on 3/31/14 about Resident #1 ' s critical INR result and she relayed the information to LVN A because she was not the nurse for Resident #1. Interview with LVN D on 4/23/14 at 3:34 pm revealed that she took the call from the lab on 3/24/14 about Resident #1 ' s critical INR result and she told LVN A about it. She said that LVN A faxed the result to Nurse Practitioner A. Interview with LVN B on 4/23/14 at 3:40 pm revealed that she remembered that Nurse Practitioner A was all upset because she was not informed of Resident #1 ' s INR critical result. LVN B said that it was a " big hoorah " because LVN C said that she told LVN A but LVN A said that LVN C did not tell her. LVN B said that since then, Nurse Practitioner A had asked that her cellphone number be placed " all over the nurse ' s station " for prompt communication. Interview with Resident #1 on 4/23/14 at 4:00 pm revealed that she tried to clear the blood stain on her collared pajama top with water but it was hard to clear. She said that she told the nurse that morning about her nose bleeding but the nurse never went back to check on her. In an interview on 4/23/14 at 4:06 pm LVN A said that she did not know about the 3/31/14 INR critical value. LVN A said that LVN C took the call from the lab but did not inform her of the critical value. LVN A said that she remembered that 3/31/14 was a Monday and Resident #1 had come to her that day and told her that she was bleeding over the weekend from her nose and ears. LVN A said that Resident #1 told her that she reported the bleeding to the weekend nurses but they did not do anything for her. LVN A said that after Resident #1 told her about the bleeding, she assessed her by checking Resident #1 ' s mouth, ears, nose and there was no bleeding. LVN A said that she did not document the assessment. LVN A said that she did not know that Resident #1 ' s INR result was critical that day. The nurse said that Resident #1 continued to receive [MEDICATION NAME] 5 mg on 4/1/14 and was sent out to the hospital on [DATE]. Further interview with LVN A she said that she was the one who wrote the physician's order [REDACTED].#1. She said that Resident #1 also had an INR critical value on 03/24/14. She said that she had made a mistake in the MAR by writing her initials on [MEDICATION NAME] 5 mg on 3/25/14 which implied that she gave the [MEDICATION NAME] 5 mg instead of starting it on 3/26/14. She said that she actually did not give the [MEDICATION NAME] 5 mg on 3/25/14, she said that there should have been a " line through it " . She said that she accidentally put her initials on 3/25/14. In an interview on 4/23/14 at 4:48 pm Nurse Practitioner A said that she did not know that Resident #1 ' s INR was critical until she went to the facility for rounds on 04/02/14. She said that when she saw that Resident #1 ' s left eye was red and was shut, she immediately sent her out to the hospital without even knowing that her INR was critical. Nurse Practitioner A said that the facility had a " communication problem " in relaying urgent laboratory results. She said that they continued to have communication problems as she had received laboratory results for Resident #1 on 4/21/14 regarding her TSH level of 66.09, HgA1C of 7.8, and PT/INR of 16.5/1.92 via fax machine. Nurse Practitioner A said that these types of abnormal results should not be sent via fax machine. She said that it should have been called in to her. Nurse Practitioner A said that she called the facility after she received the results via fax machine and told the nurse that she should not be faxing abnormal results but instead she should be calling the Nurse Practitioner or Physician. Nurse Practitioner A said that the nurse gave her a bad attitude and told her that she did not call " because she had to attend to other things. " In an interview with the Administrator, ADON A, ADON B on 4/23/14 at 5:30 pm they said that they did not know about Resident #1 ' s INR critical labs on 3/24/14 and 3/31/14. In an interview via phone conference with the DON on 4/23/14 at 5:45 pm she said that she did not know about Resident #1 ' s critical labs on 3/24/14 and 3/31/14. She said it was " never brought to my attention " . The Administrator was in the room. In an interview with ADON A and ADON B on 4/23/14 at 5:30 pm they said that they were not aware that Resident #1 had a nose bleed that morning. They said that they would ask the evening shift charge nurse to check on Resident #1. In an interview on 04/24/14 at 9:35 am, Resident #1 said that she just had a " tiny little bit, almost nothing " when asked if she had any more nose bleeding through the night. Resident #1 said that she used a tissue paper to wipe her nose and she just saw a " tiny little bit " of blood. Record review of Resident #1 ' s clinical records revealed that there was no documentation of the nose bleed on 4/23/14 night shift and 4/24/14 morning shift. The 24 hour communication book revealed that the evening shift charge nurse wrote, " Head to toe assessment done. No decubs, no open areas, slight bruising to abdomen, no bleeding from ears, mouth, nose, vagina. " In an interview on 4/24/14 at 10:30 am the DON said that Nurse Practitioner A did not call her to tell her about issues with Resident #1 ' s critical INR result on 3/31/14. The DON said that she was told by ADON A that Resident #1 went to the hospital on [DATE] but did not tell her that Nurse Practitioner A was upset because the critical INR result was not communicated to her. The DON said that when Resident #1 went to the hospital on [DATE], " they could ' t finds anything at the hospital " . She said that Resident #1 " went to the hospital too much " . The DON said that ADON A was in charge of Resident #1 ' s PT/INR. She said that she had 2 ADONs and they were responsible for monitoring lab results. She said that she should have been notified by Nurse Practitioner A about the issues with Resident #1 ' s INR levels. Interview with the DON on 4/24/14 at 11:09 am she said that she did not call the physician about Resident #1 ' s nose bleeding. The DON said that she did not check on Resident #1, but had the 2-10 nurse checked on her yesterday. The DON said that the nurses used the Anticoagulant Monitoring for [MEDICATION NAME] and Aspirin form for side effects of bleeding. Interview with ADON B on 4/24/14 at 11:15 am revealed that she did not assess Resident #1 " last night " but she had asked the evening shift to do a head to toe assessment on Resident #1. Further interview with the DON on 4/24/14 at 11:18 am she said that she found out about Resident #1 ' s critical INR on 4/2/14. She said that from what ADON A told her, LVN C took the call from the lab but was not communicated to the LVN A who was assigned to Resident #1. The DON said that she did not know if the lab had faxed a hard copy of the lab results. She said that she typically does not get a copy of the critical lab results. She said that lab results were faxed to the facility throughout the day. She said that the fax machine was in the copy room and there was a designated box for lab results. She said that the ADONs were supposed to check the box throughout the day. The DON said that when the critical lab results were faxed to the facility, the ADON was " probably gone when it was faxed " . She said that her ADONs leave at around 4:30 pm - 5:00 pm. Interview with the DON on 4/24/14 at 11:20 am revealed that the evening shift on 4/23/14 did not call Resident #1 ' s physician to inform him of Resident #1 ' s nose bleeding on 4/23/14. She said " if you find bleeding stain, you would have assess where the blood come from especially if a resident was on anticoagulant " . Interview with LVN B on 4/24/14 at 11:23 am she said that if a resident on [MEDICATION NAME] had a history of [REDACTED]. Further interview with the DON on 4/24/14 at 11:30 am revealed that the hospital did not find anything wrong with Resident #1. She said that Resident #1 came back on 4/10/14 and went out again the next day. She said that it was all " anxiety, geri-psych " . In an interview with ADON A on 4/24/14 at 11:45 am she said that lab results were faxed " randomly " and they were picked up from the fax machine by anybody, nurses or administrative staff and placed in the designated box in the copy room. She said that the ADONs check the box regularly, " very frequently " . She said that she was not aware about the 3/24/14 critical INR results for Resident #1. She said that she checked the [MEDICATION NAME] book once a week, no specific day, " just as soon as possible, mostly Wednesday " . ADON A said that she was also not aware of Resident #1 ' s critical INR results on 3/31/14. Further interview at this time with ADON A she said that LVN A should not have given Resident #1 a [MEDICATION NAME] 5 mg on 3/25/14. She said that the physician had held it for 2 days because of the high INR. The ADON A said that the [MEDICATION NAME] 5 mg should have been started on 3/26/14, " like what the physician said in the order " . Interview with Resident #1 ' s Attending Physician on 4/24/14 at 3:30 pm (the DON and Administrator were in the room at the time) he said that Resident #1 was on [MEDICATION NAME] due to [MEDICAL CONDITION] Fibrillation. He said that Resident #1 had gross hematuria while she was at the hospital. . The attending physician said that there was a " danger with that medication " . He said that Resident #1 had bleeding at the hospital. He said that since Resident #1 was also on [MEDICATION NAME], there was an interaction between [MEDICATION NAME] and [MEDICATION NAME] that could lead to an elevated INR. The attending physician also said that some patients do well with high INRs if they have no history of bleeding, but if patients have " bleeding issues " and they are on [MEDICATION NAME] like Resident #1, it becomes a problem and monitoring was necessary. The attending physician further said that he will discontinue Resident #1 ' s [MEDICATION NAME] and she would just take daily Aspirin. Record review of Resident #1 ' s nurse ' s notes dated 4/24/14 written by the DON revealed that Resident #1 ' s attending physician was at the facility and she spoke with him in " in reference to PT/INR and current [MEDICATION NAME] dose. MD stated resident recent hospitalization was not due to PT/INR it was due to bleeding and he would be reviewing her current medications and the order for [MEDICATION NAME] would be discontinued and EC ASA 81 mg 1 po Q D to be started " . Interview with the Administrator on 4/25/14 at 10:05 am he said that he was out for 4 weeks due to a back injury. He said that he was not aware of the critical values on 3/24/14 and 3/31/14 and he did not know that Resident #1 was sent to the hospital on [DATE]. The Administrator said that he knew of Resident #1 ' s hospital stay on 4/11/14. The Administrator said that he believed that the facility had this issue because there was a failure of the staff to communicate and relay the critical lab results to the physician which led to Resident #1 ' s hospital stay. Interview with the DON on 4/25/14 at 11:10 am she said that the facility had this problem because it was " an oversight " that led to Resident #1 ' s hospital stay. Interview with LVN A on 4/26/14 at 3:45 pm she said that she checked the fax machine periodically for lab results. She said that she knew all the residents with routine labs ordered. She said that she did not know about Resident #1 ' s critical INR result on 3/31/14. She said that it was called in to another nurse. She said that she did not remember getting anything that day at the fax machine. She said, " let ' s be realistic, you don ' t remember everything, everybody tries to get them (the lab results ). I don ' t go to the copy room. " LVN A said that she could not remember if she checked for PT/INR labs on 03/31/14, when Resident #1 was telling her that she had " bleeding " over the weekend (03/29 and 03/30) .LVN A continued to say that Resident #1 " says a lot of things that are not true " . Observation of Resident #1 on 4/26/14 at 4:19 pm revealed that she had some blood stains in a tissue. She said that it came from her nose when she sneezed. A Nurse Supervisor was in the resident ' s room and confirmed this. Interview with RN A on 4/29/14 at 9:45 am revealed that they use the form " Admission Assessment Data Collection Tool " when residents come back from the hospital. She said that she did not know if one was done for Resident #1. Interview with the DON on 4/29/14 at 10:30 am she said that there was no Admission Assessment Data Collection Tool done for Resident #1 when she came back to the facility on [DATE] and 4/15/14. Interview with the Administrator on 4/29/14 at 10:15 am he said that during his absence, the DON was in charge. He said that the DON was responsible and that if she had questions, she would call the regional directors. The Administrator said that the DON did the daily meetings with the staff and department heads. Record review of the facility ' s Abuse Prohibition Policy and Procedures dated 7/2012 revealed, read in parts, II. Training Employees: Prevention, Intervention, Detection, Reporting and Employee Rights A. All new staff will receive training on the following information during general orientation. All staff will receive annual training on the following information: 1. What constitutes abuse, neglect, and misappropriation of resident property. An IJ was identified on 4/24/14 at 1:24 pm and the Administrator was informed at that time. A Plan of Removal (POR) the IJ was submitted and accepted on 04/25/2014 at 4:00 pm. The POR included: The Center immediately reviewed all residents (11) with a [MEDICATION NAME] order and Diagnostic lab orders for PT/INR panic or critical lab values for accuracy and to determine if there were other areas of concern that were not assessed timely or appropriately which may have warranted Physician notification. All residents on medications that require therapeutic labs to monitor administration is being audited, will be completed on April 25, 2014, to validate physician orders [REDACTED]. New Policy: Routine Labs: Lab tracking log is reviewed each night by the licensed Nurse that all requisitions are completed as for the next lab draw. Requisitions are placed in the designated lab folder or lab book. Technician does the lab draw initials and dates the lab, license nurse reviews the lab requisition, completes log and initial Treatment sheet when specimen obtained. DON /ADON reviews the labs to validate lab has been entered on the lab tracking log/labs has been drawn (will be completely 5 days weekly). Critical Labs: Panic or critical labs results are immediately (within from 15 minutes) reported to the center by telephone. Panic or critical labs are communicated to physician or medical director immediately (within 15 minutes). If the physician cannot be contacted or has not returned the call in 20 minutes contact medical director and director of nurses and 911 for hospital transport. Contact family or responsible party. PHYSICIAN ORDERS, CHANGES OF MEDICATIONS CARRIED OUT CORRECTLY 1. Educate the nurses on transcribing medications accurately to the Medication/Treatment record ... 2. Educate the nurses on assessing for side effect of [MEDICATION NAME] i.e. bleeding, bruises, sore joints hematuria, petechiae, fever/chills, skin rash, etc. ... 3. When order received to hold [MEDICATION NAME] Nurses will write the word HOLD on the MAR indicated [REDACTED]. This new policy began yesterday, April 25, 2014. 4. ADON/DON will check physician orders [REDACTED]. This new policy began yesterday, April 25, 2014. 5. After ADON/DON check physician orders [REDACTED]. 6. When a [MEDICATION NAME] dosage is changed from a different strength the previous [MEDICATION NAME] will be removed from the cart by the charge nurse and new [MEDICATION NAME] will be ordered. Family will be notified of change. The DON or designee will validate the removal of the [MEDICATION NAME] from the medication when reviewing telephone orders daily for 2 weeks using a QAPI [MEDICATION NAME] Monitoring Tool, Start date of April 25, 2014. Education Skills Validation All Licensed Nurses on duty will be provided education on our Diagnostic Testing and communicating panic or critical lab values ... A posttest was provided 4/24/14 to demonstrate understanding of our process change and the policy and procedure as it relates to diagnostic testing, Physician orders, Assessment, change of condition, adverse reaction, Physician notification and communication of each normal, panic or critical value ... This new policy began yesterday, April 25, 2014 ...Revised -Lab Tracking Tool attached. This new policy began yesterday, April 25, 2014. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service forms dated 04/23, 04/24, and 04/25 revealed that approximately 90 % of the staff representing all three shifts had been in-serviced on the lab protocols, assessing changes in c

Based on interview and record review the facility failed to ensure that 1 of 1 LVN monitor for feeding complications and administer corrective actions to relieve complications for 1 of 4 residents reviewed for gastrostomy tube feeding as evidenced by: --LVN A failed to intervene appropriately and in a timely manner when Resident #3 had a change in condition. On [DATE] at 07:00p.m., Resident #3 had experienced episodes of vomiting, decreased oxygen levels, decreased responsiveness, respiratory distress and assessed with [REDACTED]. -- LVN A also administered another [MEDICATION NAME] feeding after Resident #3 had the earlier episode of vomiting and respiratory distress. Resident #3 was not sent out to the hospital until the next shift at approximately 11:00 p.m. Resident #3 was admitted to the hospital with [REDACTED]. This failure affected 1 resident and could potentially place the other 6 residents receiving feedings through a gastrostomy tube at risk of not receiving corrective actions to allay complications and could increased their risk of aspiration. Complaint # 2 Findings included: Record review of Resident #3 closed clinical record revealed resident was an [AGE] year old female who was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3 was sent to the hospital on [DATE] and later admitted to hospital inhouse hospice on [DATE]. The resident expired on [DATE]. Record review of Resident #3 " Out-of-Hospital Do- Not-Resuscitate Order " form located in the record revealed that it was signed by responsible party, physician and 2 witnesses and dated [DATE] with instructions " ...I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation ... " . Record review of Resident #3 Interdisciplinary Care Plan dated [DATE] revealed " ...Concerns/Needs/Problems: Potential for aspiration r/t enteral tube feedings ...Objective/Goal: Resident will have no s/s of aspiration during the next 90 days ... " Record review of Resident #3's Nurse ' s Notes dated [DATE] at 03:00 p.m. revealed " Resident alert at this time [MEDICATION NAME] feeding tolerated well no bleeding noted around [DEVICE] site or (nausea and vomiting) to feeding ... " signed by LVN A. Record review of SBAR (change of condition form) for Resident #3 dated [DATE] at 06:00 p.m. revealed in part that the resident had a change in condition related to wet lungs and that oxygen at 2 L was applied. Further review of the from revealed that her vital signs were: BP ,[DATE], HR 86, RR 18, Temperature of 97.8, Pulse Oxigen was 80% on room air. at 2L/min via mask. Advance directives section was marked as DNR and last section revealed "Request- I suggest or request-Transfer to the hospital" was checked. Form signed by LVN A. Record review of Resident #3 Nurse ' s Notes dated [DATE] at 07:00 p.m. revealed " Res vomiting up tube feeding with coughing lung sounds wet in upper lobes Dr called VS 96.8,,[DATE],85,20 O2 sat 89% Res put on O2 at 2L (nasal cannula)... Res has DNR status code will monitor. " signed by LVN A. Record review of Resident #3 Nurse ' s Notes dated [DATE] at 07:15 p.m. revealed " family made aware of change of condition. " signed by LVN A. Nurse's note on ,[DATE] 10:00 p.m. revealed that family requested for resident to be transported to the hospital and the physician was called. Further notes revealed that 911 was called at 10:52 p.m. Record review of Resident #3 ' s hospital records revealed: -EMS Patient Care Report form with Date of Service [DATE] revealed in part that at 11:00 p.m. they arrived to the facility. According to the report the facility stated that the resident was having trouble breathing. Further review of the form revealed that EMS asssessed the resident and she was having breathing problems with left upper, lower, and right upper and lower rales and crackles, labored breathing and that she was unresponsive. Her vital signs at 11:09 p.m. were BP ,[DATE], Pulse 103,Respiratory 30,oxygen level was 85%. EMS had to administer 15 liters of oxygen through a mask. Further report revealed: " According to the nursing staff of the nursing home, he stated that patient had been experiencing difficulty breathing for couple of hours. He also stated the patient has a DNR ...(Fire Department) stated that patient was on nasal cannula at 2 LPM upon their arrival and her oxygen saturation was 70%..." -Emergency Physician form dated [DATE] revealed " ...Chief complaint: shortness of breath ...Physical Exam ...Respiratory ...wheezes/rales ...CXR ... patchy Bilateral Infiltrate (hand written on form) ...Clinical Impression ...Pneumonia ..." -Hospital history and physical by attending physician dated [DATE] revealed " ...History of Present Illness: The patient last night was noted to have some respiratory distress. Her saturation dropped to about 74. The patient was then rushed to the emergency room , was found to have some evidence of pneumonia with leukocytosis and was subsequently admitted ...Assessment 1. Pneumonia, bilateral, most likely aspiration ...Plan: Will continue with GI and [MEDICAL CONDITION], continue with [MEDICAL CONDITION] toilet ..." -Infectious disease physician consult dated [DATE] revealed " ...Impression/Plan 1. Aspiration pneumonia, 2. Hypoxemia resp. failure ... " -Chest X-Ray Report taken [DATE] revealed " ...Impression: Bilateral extensive [MEDICAL CONDITION] opacities, consistent with pneumonia ..." -History and Physical by hospice physician with dictation date [DATE] revealed " ...Date of Admission: [DATE] ...Chief Complaint: Hospice care for terminal hypoxic [MEDICAL CONDITION] ...admitted for respiratory distress with bilateral pneumonia, most likely aspiration pneumonia. Through the course of the stay in acute care, the patient had not been showing improvement condition getting worse...the patient expired last night on [DATE] at 11:30 p.m. ... " During an interview on [DATE] at 02:50 p.m., LVN C stated that if a resident was showing signs of aspiration to notify the physician and if the physician would not give any new orders because the resident was a DNR and he was not comfortable with the physician's orders [REDACTED]. During a phone interview on [DATE] at 06:10 p.m., Resident #3's family member stated on [DATE] LVN A called and stated resident was not doing well. Also was told by LVN A that because resident was a DNR they were not sending resident to the hospital. She received a call a few hours later and was told by LVN A that resident was worse and was throwing up the formula they fed her through the tube and choking on it. She told him that she wanted resident sent to the hospital. When resident got to the hospital they had to pump milk out of her lungs. The doctor said the milk in the lungs was from resident choking on the milk she had thrown up. One of the CNA ' s at the facility said they had told LVN A about 05:30 p.m. that the resident was vomiting and coughing but he did not do anything except tell them to clean the resident up. During an interview on [DATE] at 04:10 p.m., Resident#3's physician stated that on [DATE] he received a call from LVN A that Resident #1 had low oxygen saturation " I told him to put oxygen on the resident and to notify the family to see what they wanted to do because resident had a DNR and some families do not want to send a resident to the hospital who have a DNR. " Also stated he was not informed by LVN A that resident had vomited the tube feeding formula or had choked. During an interview on [DATE] at 11:25 a.m., LVN E stated signs and symptoms of aspiration included coughing, gasping for air, lowered oxygen saturation, and lethargy. Also stated that if resident was choking would do what can be done to help the resident, call 911 if needed, and if the resident was a DNR would do the same. During an interview on [DATE] at 12:20 p.m., LVN F stated if a resident was showing signs and symptoms of aspiration (coughing, gasping for air, decreased oxygen saturation, or decreased responsiveness) he would call the physician to see if he could get a chest x-ray done or send to the emergency room so they could check the resident out. He would then notify the family and let them know there was a problem and that the resident needs to go to the emergency room . Also stated that it did not matter if a resident is a DNR, DNR means that you do not do chest compressions if their heart stops or if they have stopped breathing because of a [MEDICAL CONDITION]. During an interview on [DATE] at 12:30 p.m., the Administrator stated that if a resident was a DNR that CPR was not to be done but if they were in distress whatever needed to be done should be done. She also stated that she had received a call on [DATE] after 10:00 p.m. that Resident #3 was in respiratory distress and was being sent to the hospital but that she was not told that the resident had vomited or choked. During an interview on [DATE] at 04:00 p.m., RN B stated he was clocking in at the time clock after 10 pm when he heard Resident #3 breathing (her room was near the time clock) and it was bad. He went into the resident's room and she was in respiratory distress and he did not notice any oxygen on the resident. LVN A came into the room and he asked him what was going on with the resident and LVN A stated she was dying. He noticed that the resident sounded like she was "drowning" so he got a suction machine, suctioned her and got a lot of thick yellow liquid that looked like formula for the tube feeding, and then he put her on oxygen. While he was doing this he had LVN A notify the physician and family and call 911 to send her out. He also stated that even though the resident was a DNR that " she did not require anything related to the DNR, she was in distress and needed help. " During an interview on [DATE] at 04:15 p.m., CNA G stated that she found Resident #1 at 05:45 p.m. with vomit on her gown that looked like "milk " She reported this to LVN A and he went to check on the resident and stated that there was nothing that he could do because the resident was a DNR then he told her to clean her and watch her. CNA G also stated that the resident was still in her room at the facility when she left at 10:00 p.m. In an interview on [DATE] at 09:45 a.m., LVN A returned phone call from messages left on [DATE] and stated that Resident #3 was normally up and ambulatory and could be combative at times. When she came back from the hospital with the feeding tube she was on the feeding pump, he was concerned about her agitation and the pump so he received an order from the doctor to change her to [MEDICATION NAME] feedings on [DATE]. On [DATE] about 06:00 or 07:00 p.m. he noticed a change in condition and about 07:30 p.m. she was coughing and vomited which helped the cough. He heard some wheezing with her breathing and which could mean she was possibly not tolerating the feeding and when he checked her oxygen saturation it was 89%. When he called the physician, he ordered oxygen and said the saturation of 89% could be questionable then told him about the wheezing. The physician told LVN A to contact the family to find out if they wanted resident to go to the hospital. He then called the family and they said to monitor her because she was a DNR. LVN A said that he administered another [MEDICATION NAME] feeding and at 08:30 or 09:00 p.m. the nurse aide told him that he needed to look at the resident because she was not looking good. At that time he noticed wetness in her lungs (by this time he had given her another tube feeding), she looked flushed and the wheezing was louder. He then notified the physician. He stated she was not sent out at that time because she was a DNR. LVN A continued to say that at 10:00 p.m. RN B came on duty and he suctioned what looked like a mixture of tube feeding and mucus from her and put O2 on her because of gurgling sound she was making. RN B had him notify the physician and family and to call 911. LVN A stated that when someone was " coughing/choking that the person needed to be left alone to get it up themselves but if they were to stop breathing then the [MEDICATION NAME] maneuver should be done. " He also stated that " wet lung sounds are not indicative of aspiration" and " you don't know when a person has aspirated until you get a chest x-ray ". According to Lippincott ' s Nursing Procedures Fifth Edition (2009) revealed in part: ...Tube feedings special considerations ...if the patient becomes nauseated or vomits, stop the feeding immediately. The patient may vomit if the stomach becomes distended from overfeeding or delayed [MEDICAL CONDITION] emptying ...complications ...nursing interventions ...Aspiration of [MEDICAL CONDITION] secretions-discontinue feeding immediately, perform tracheal suction of aspirated contents, if possible, notify the practitioner ...vomiting-reduce flow rate ...for 30 minutes after feeding, position the patient on the right side with head elevated ..." According to the CMS 672 the facility had 6 residents receiving tube feedings.

Based on interview and record review the facility failed to ensure that 1 of 1 LVN provided services that met professional standards of quality for 1 of 2 residents reviewed for change in condition as evidenced by: --LVN A failed to intervene appropriately and in a timely manner when Resident #3 had a change in condition. On [DATE] at 06:00 p.m., Resident #3, who received nutrition through a gastrostomy tube, experienced episodes of vomiting, decreased oxygen levels, decreased responsiveness, respiratory distress, and wet lung sounds. Resident #3 was not sent out to the hospital until the next shift at approximately 11:00 p.m. Resident #3 was admitted to the hospital with [REDACTED]. This failure affected 1 resident and could potentially place the other 6 residents receiving feedings through a gastrostomy tube at risk of of not receive services being provided according to accepted standards of clinical practice for nurses. Complaint # 2 Findings included: Excerpt from the Board of Nursing's Rules and Regulations 217.11. Standards of Nursing Practice The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses ... The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted ... 1. Standards Applicable to All Nurses. All vocational nurses, registered nurses, and registered nurses with advanced practice authorization shall: ...(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same. (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; ... (iv) administration of medications and treatments; (v) client responses; ... (M) Institute appropriate nursing interventions that might be required to stabilize a client's conditions and/or prevent complications ..." Record review of Resident #3 closed clinical record revealed resident was an [AGE] year old female who was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3 was sent to the hospital on [DATE] and later admitted to hospital inhouse hospice on [DATE]. The resident expired on [DATE]. Record review of Resident #3's " Out-of-Hospital Do- Not-Resuscitate Order " form located in the record revealed that it was signed by responsible party, physician and 2 witnesses and dated [DATE] with instructions " ...I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation ... " . Record review of Interdisciplinary Care Plan for Resident #3 dated [DATE] revealed " ...Concerns/Needs/Problems: Potential for aspiration r/t Enteral tube feedings ...Objective/Goal: Resident will have no s/s of aspiration during the next 90 days ... " Record review of Resident #3's Nurse ' s Notes dated [DATE] at 03:00 p.m. revealed " Resident alert at this time [MEDICATION NAME] feeding tolerated well no bleeding noted around [DEVICE] site or (nausea and vomiting) to feeding ... " signed by LVN A. Record review of SBAR (change of condition form) for Resident #3 dated [DATE] at 06:00 p.m. revealed in part that the resident had a change in condition related to wet lungs and that oxygen at 2 L was applied. Further review of the from revealed that her vital signs were: BP ,[DATE], HR 86, RR 18, Temperature of 97.8, Pulse Oxigen was 80% on room air. Advance directives section was marked as DNR and last section revealed "Request- I suggest or request-Transfer to the hospital" was checked. Form signed by LVN A. Record review of Resident #3 Nurse ' s Notes dated [DATE] at 07:00 p.m. revealed " Res vomiting up tube feeding with coughing lung sounds wet in upper lobes Dr called VS 96.8,,[DATE],85,20 O2 sat 89% Res put on O2 at 2L (nasal cannula)... Res has DNR status code will monitor. " signed by LVN A. Record review of Resident #3 Nurse ' s Notes dated [DATE] at 07:15 p.m. revealed " family made aware of change of condition. " signed by LVN A. Nurse's note on [DATE] at 10:00 p.m. revealed that family requested for resident to be transported to the hospital. Further notes revealed that 911 was called at 10:52 p.m. Record review of Resident #3 ' s hospital records revealed: -EMS Patient Care Report form with Date of Service [DATE] revealed in part that at 11:00 p.m. they arrived to the facility. According to the report the facility stated that the resident was having trouble breathing. Further review of the form revealed that EMS asssessed the resident and she was having breathing problems with left upper, lower, and right upper and lower rales and crackles, labored breathing and that she was unresponsive. Her vital signs at 11:09 p.m. were BP ,[DATE], Pulse 103,Respiratory 30,oxygen level was 85%. EMS had to administer 15 liters of oxygen through a mask. Further report revealed: " According to the nursing staff of the nursing home, he stated that patient had been experiencing difficulty breathing for couple of hours. He also stated the patient has a DNR ...(Fire Department) stated that patient was on nasal cannula at 2 LPM upon their arrival and her oxygen saturation was 70%..." -Emergency Care Center Triage Report form with dated/time [DATE] 23:29 (11:29 p.m.) revealed " ...BP ,[DATE] ...Temperature 97.1 ...Pulse 99 bpm ...Respirations 30 ...SpO2 91%... GCS 3 ... " -Emergency Physician form dated [DATE] revealed " ...Chief complaint: shortness of breath ...Physical Exam ...Respiratory ...wheezes/rales ...CXR ... patchy Bilateral Infiltrate (hand written on form) ...Clinical Impression ...Pneumonia ..." -Hospital history and physical by attending physician dated [DATE] revealed " ...History of Present Illness:..The patient last night was noted to have some respiratory distress. Her saturation dropped to about 74. The patient was then rushed to the emergency room , was found to have some evidence of pneumonia with leukocytosis and was subsequently admitted ...Assessment 1. Pneumonia, bilateral, most likely aspiration ...Plan: Will continue with GI and [MEDICAL CONDITION], continue with [MEDICAL CONDITION] toilet ..." -Infectious disease physician consult dated [DATE] revealed " ...Impression/Plan 1. Aspiration pneumonia, 2. Hypoxemia resp. failure ... " -Chest X-Ray Report taken [DATE] revealed " ...Impression: Bilateral extensive [MEDICAL CONDITION] opacities, consistent with pneumonia ..." -History and Physical by hospice physician with dictation date [DATE] revealed " ...Date of Admission: [DATE] ...Chief Complaint: Hospice care for terminal hypoxic [MEDICAL CONDITION] ...admitted for respiratory distress with bilateral pneumonia, most likely aspiration pneumonia. Through the course of the stay in acute care, the patient had not been showing improvement condition getting worse ...the patient expired last night on [DATE] at 11:30 p.m ... " In an interview on [DATE] at 12:00 p.m., LVN C stated when a resident had a change in condition the nurse was to assess the resident and if immediate intervention was needed then the nurse was to do the interventions and notify the physician to obtain orders. If a resident was a DNR the nurse was to still notify the physician after assessment and any interventions the resident required and the nurse should give complete details about anything that happened prior to the change in condition that could be a factor. In an interview on [DATE] at 12:45 p.m., CNA D stated that if a resident began choking after vomiting she would turn the resident to their side and try to get whatever was choking them out. Also stated if resident was a DNR that you would still have to assist the resident and call for help. In an interview on [DATE] at 01:00 p.m., ADON stated that if he was monitoring residents and a resident began vomiting/choking he would do what was necessary to help the resident and if the resident were a DNR " it did not matter. " The ADON also stated that when a resident had a change in condition the physician was to be notified and given all details of resident assessment as to the change in condition since the physician was not there to see the resident and then to notify the family. In an interview on [DATE] at 02:50 p.m., LVN C stated that if a resident was showing signs of aspiration to notify the physician and if the physician would not give any new orders because the resident was a DNR and he was not comfortable with the physician's order [REDACTED]. In a phone interview on [DATE] at 06:10 p.m., Resident #3 ' s family member stated on that on [DATE] LVN A called and stated resident was not doing well. She was also told by LVN A that because resident was a DNR they were not sending resident to the hospital. She received a call a few hours later and was told by LVN A that resident was worse and was throwing up the formula they fed her through the tube and choking on it. She told him that she wanted resident sent to the hospital. When resident got to the hospital they had to pump milk out of her lungs. The doctor said the milk in the lungs was from resident choking on the milk she had thrown up. The family member said that one of the CNA ' s at the facility said they had told LVN A at about 05:30 p.m. that the resident was vomiting and coughing but he did not do anything except tell them to clean the resident up. During an interview on [DATE] at 04:10 p.m., Resident#3 ' s physician said that on [DATE] he received a call from LVN A stating that Resident #3 had low oxygen saturation, " I told him to put oxygen on the resident and to notify the family to see what they wanted to do because resident had a DNR and some families do not want to send a resident to the hospital who have a DNR. " The physician said that he was not informed by LVN A that the resident had vomited the tube feeding formula or had choked. During an interview on [DATE] at 11:25 a.m., LVN E stated signs and symptoms of aspiration included coughing, gasping for air, lowered oxygen saturation, and lethargy. Also stated that if a resident was choking would do what can be done to help the resident, call 911 if needed, and if the resident was a DNR would do the same. During an interview on [DATE] at 12:20 p.m., LVN F stated if a resident was showing signs and symptoms of aspiration (coughing, gasping for air, decreased oxygen saturation, or decreased responsiveness) he would call the physician to see if he could get a chest x-ray done or send to the emergency room so they could check the resident out. He would then notify the family and let them know there was a problem and that the resident needs to go to the emergency room . Also stated that it did not matter if a resident is a DNR, DNR meant that you do not do chest compressions if their heart stops or if they have stopped breathing because of a [MEDICAL CONDITION]. During an interview on [DATE] at 12:30 p.m., the Administrator stated that if a resident was a DNR that CPR was not to be done but if they were in distress whatever needed to be done should be done. She also stated that she had received a call on [DATE] after 10:00 p.m. that Resident #3 was in respiratory distress and was being sent to the hospital but she was not told that the resident had vomited or choked before she was sent out. During an interview on [DATE] at 04:00 p.m., RN B stated that on [DATE] he was clocking in at the time clock after 10 pm when he heard Resident #3 breathing (her room was near the time clock) and it was bad. He went into the resident ' s room and she was in respiratory distress and he did not notice any oxygen on the resident. LVN A came into the room and he asked him what was going on with the resident and LVN A stated she was dying. He noticed that the resident sounded like she was " drowning " so he got a suction machine, suctioned her and got a lot of thick yellow liquid that looked like formula for the tube feeding, and then he put her on oxygen. While he was doing this he had LVN A notify the physician and family and call 911 to send her out. He also stated that even though the resident was a DNR that she did not require anything related to the DNR, she was in distress and needed help. During an interview on [DATE] at 04:15 p.m., CNA G stated that she found Resident #1 at around 05:45 p.m. with vomit on her gown that looked like " milk " . She reported this to LVN A and he went to check on the resident and stated that there was nothing that he could do because the resident was a DNR then he said to clean her and watch her. She also stated that " the resident was still in her room at the facility when I left at 10:00 p.m. " In an interview on [DATE] at 09:45 a.m., LVN A returned phone call from messages left on [DATE] and stated that Resident #3 was normally up and ambulatory and could be combative at times. When she came back from the hospital with the feeding tube she was on the feeding pump, he was concerned about her agitation and the pump so he received an order from the doctor to change her to [MEDICATION NAME] feedings on [DATE]. On [DATE] about 06:00 or 07:00 p.m. he noticed a change in condition and about 07:30 p.m. she was coughing and vomited which helped the cough. He heard some wheezing with her breathing and which could mean she was possibly not tolerating the feeding and when he checked her oxygen saturation it was 89%. When he called the physician, he ordered oxygen and said the saturation of 89% could be questionable then told him about the wheezing. He said that the physician told him to contact the family to find out if they wanted resident to go to the hospital. LVN A said that he then called the family and they said to monitor her because she was a DNR. LVN A said that he administered another [MEDICATION NAME] feeding and at around 08:30pm or 09:00 p.m. the nurse aide told him that he needed to look at the resident because she was not looking good. At that time he noticed wetness in her lungs, she looked flushed and the wheezing was louder. He then notified the physician. He stated again that she was not sent out at that time because she was a DNR. LVN A said that at 10:00 p.m. RN B came on duty and he suctioned what looked like a mixture of tube feeding and mucus from her and put O2 on her because of gurgling sound she was making. RN B had him notify the physician and family and to call 911. LVN A stated that when someone was coughing/choking that the person needs to be left alone to get it up " themselves but if they were to stop breathing then the [MEDICATION NAME] maneuver should be done. " He also stated that " wet lung sounds are not indicative of aspiration " and " you don ' t know when a person has aspirated until you get a chest x-ray " . Record review of facility ' s policy (no date) " Recognition of Change of Condition " revealed " 1. Criteria: Resident-Eats or drinks less than usual, Is less talkative, Is sleepier, more confused, or more agitated, Needs more help with ADLs, Complains of not feeling well, fever or pain, Roommate, family, or other observer expresses concern that resident is " looking/sounding funny " ... 2. If " Yes " response to any above: Suspect Illness ...3. Assess the Resident-Take Vitals, Pain, Assess: 1. respiratory, 2. abdomen, 3. skin ...Observe-1. Respiratory rate, 2. Oral food/fluid intake, 3. Bowel record, 4.Skin for redness, discharge, swelling, Listen: 1. Lung sounds, 2. Bowel sounds, Palpate: 1. Abdomen for tenderness, 2. Digital examination of rectum for hard stool ... 4. Contact the attending physician or designee. If the attending MD fails to respond within 5 minutes, contact again. If still no response, contact Medical Director. If no response from Medical Director within 5 minutes, send resident to the nearest E.R. to be evaluated. Have the chart to provide this checklist of information when MD responds: Diagnoses, allergies [REDACTED]. 5. Receive orders from physician or designee, 6. Implement order, 7. Provide nursing care, 8. Continue assessment as listed above for AT LEAST every 8 hours for 72 hours. " According to the CMS 672 dated [DATE] the facility had 6 residents receiving nutrition via gastrostomy tube.