Every finding on record at Silver Pines Nursing and Rehabilitation Center

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for four of ten (Resident #50, Resident #65, Resident #67 and Resident #75) reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Resident #50's room was in a position accessible to the resident, on 08/11/2026. 2. The facility failed to ensure the call light system in Resident #65's room was in a position accessible to the resident, on 08/11/2026. 3. The facility failed to ensure the call light system in Resident #67's room was in a position accessible to the resident, on 08/11/2026.4. The facility failed to ensure the call light system in Resident #75's room was in a position accessible to the resident, on 08/11/2026. These failures could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings include: 1.During an observation on 08/11/2026 at 9:45 AM and 11:18 AM, Resident #50 was observed lying in her bed in the lowest position with a fall mat beside it. Her call light was observed on the bedside table beside her bed. The call light was not within reach Record review of Resident #50's admission Record, dated 08/12/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #50's Diagnosis Report, dated 08/12/2026, reflected diagnoses which included unspecified Dementia (a mental disorder characterized by persistent feelings of sadness, loss of interest, and difficulty functioning), muscle wasting (refers to the loss of body mass and strength), and low back pain. Record review of Resident #50's Annual MDS, dated [DATE], reflected Resident #50 had a BIMS score of 0, which indicated she was severely cognitively impaired. Resident #50 was dependent on her self-care needs and mobility needs. Record review of Resident #50's, undated, Care Plan accessed on 08/12/2026, reflected Resident #50 was at risk for falls and poor safety awareness, initiated 08/20/2018 and revision on 05/21/2026. An intervention included Be sure the resident's pad call light is within reach and encourage the resident to use it for assistance as needed. 2.During observations on 08/11/2026 at 6:06 AM and 7:36 AM, Resident #65 was observed lying in his bed in the lowest position with a fall mat beside it. His call light was observed on the bedside table beside his bed. The call light was not within reach. Record review of Resident #65's admission Record, dated 08/12/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #65's Diagnosis Report, dated 08/12/2026, reflected diagnoses which included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), depression (condition that affects mood and daily functioning, resulting in sadness, low energy, and reduced interest in usual activities), muscle wasting and type 2 diabetes ( body does not produce enough insulin). Record review of Resident #65's Annual MDS, dated [DATE], reflected Resident #65 had a BIMS score of 0, which indicated he was severely cognitively impaired. Resident #65 was dependent on his self-care needs and mobility needs. Record review of Resident #65's, undated, Care Plan, accessed on 08/12/2026, reflected Resident #65 was at risk for falls and poor safety awareness, initiated 07/14/2021 and revised on 11/04/2024. An intervention included Be sure the resident's touch pad call light is within reach and encourage the resident to use it for assistance as needed. 3. During an observation on 08/11/2026 at 7:36 AM, Resident #67 was observed lying in her bed with her call light behind the bed out of the resident's reach. Record review of Resident #67's admission Record, dated 08/11/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #67s Diagnosis Report, dated 08/11/2026, reflected diagnoses which included hypothyroidism (underactive thyroid), dementia (progressive memory loss), muscle wasting and atrophy (the shrinking of muscle or nerve tissue), and type 2 diabetes mellitus without complications (blood sugar regulation disorder). Record review of Resident #67's Annual MDS, dated [DATE], reflected Resident #67 had a BIMS score of 00, which indicated she was severely cognitively impaired. Resident #67 was dependent on her self-care needs and mobility needs. Record review of Resident #67's, undated, Care Plan accessed on 08/11/2026, reflected Resident #67 was at risk for falls and poor safety awareness initiated on 12/16/2024. An intervention included The resident's call light is within reach and encourage the resident to use it for assistance as needed. 4. Record review of Resident #75's, undated, admission Record for Resident #75 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #75's, undated, Diagnosis Report included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing -related problems), muscle wasting and atrophy (loss of muscle tissue and strength), major depressive disorder (a mental disorder characterized by persistent feeling of sadness, loss of interest, and difficulty functioning) and anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Record review of Resident 75's quarterly MDS assessment, dated 12/03/2025, reflected a BIMS score of 09, which indicated a moderate cognitive impairment. Resident #75 required supervision or touching assistance on staff for transfers out of bed, which indicated helper provides verbal cues or touching or contact guard assistance as resident completed the activity. Record review of Resident #75's, undated, Care Plan accessed on 08/12/2026, reflected Resident #75 had an ADL self-care performance deficit because of impaired mobility, dated 02/02/2026. An intervention included Encourage the resident to use bell to call for assistance. During an observation on 08/11/2026 at 9:45 AM and 11:18 AM and on 08/12/2026 at 10:15 AM, Resident #75 was sitting in her chair with her call light attached to her bed rail near the head of the bed with the bed spread covering it. During an interview with Resident #75 on 08/11/2026 at 9:45 AM, She said she was lactose intolerant and wanted to eat something else. Resident #75 stated she did not let the staff know because she had to either walk down the hall or wait until a nurse came down the hall into her room. When the resident was asked if she had a call light, she picked up her remote control and said she used to have one but did not anymore. The said she was not aware her call light was attached to the bedrail covered by the bed spread. During an interview on 08/12/2026 at 12:30 PM, CNA E said the call light should not be on the floor or on a bedside table when the resident was in bed. The call light should be on the bed where the resident could reach it. CNA E said if the call light was not within reach, the resident could get hurt if they tried to get up by themselves. CNA E said it was everyone's responsibility to make sure the call light was within reach of the resident. During an interview on 08/12/2026 at 12:34 PM, CNA F said the call light should be on the bed with the residents when they were in bed. CNA F stated if the call light was not placed where residents could reach it, they would not be able to ask for help. CNA F said it was everyone's responsibility to make sure the call light was where the resident could reach it. During an interview on 08/13/2026 at 9:36 with CNA G, she stated the policy was for the call lights to be hooked on the cover or pillow where residents could reach it. CNA G said CNAs were responsible for making sure the call light was within the resident's reach. She stated the call light should always be in reach so they could use it if they needed help. CNA G stated anything could happen if the call light was not in reach of the resident. During an interview on 08/13/2026 at 7:50 AM, the DON stated her expectation was when residents were in bed, call lights should be on the bed where the resident could reach it and if the resident was sitting up in a chair, the call light should still be within reach. All staff were trained to place the call light on residents' beds, within reach. She stated all staff were in service on call light placement and should be monitored when staff went into the residents' room. The DON stated her expectation was call lights were always within reach of the resident when they were in bed or sitting up in the chair. During an interview on 08/13/2026 at 08:10 AM and 10:57 AM with the ADM, she stated he expected all staff to place the call light on the bed where it could be reached and if the resident was sitting up in the chair it was in sight so the resident could use it if needed. The ADM said the CNA or hospitality aide monitored to ensure the call lights were within reach, but it was everyone's responsibility. The ADM said if the residents did not have their call light, they could not call for help and might fall. Record review of the facility's policy, Call Lights: Accessibility and Timely Response, Date implemented 10/13/2022, reflected Policy StatementThe purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines:5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview, and record review the facility failed ensure the resident had the right to receive notices orally and in writing in a format and a language he or she understood which included a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation or resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community for 7 of 7 confidential residents reviewed for resident rights. The facility failed to provide residents notices orally and in writing a statement that the resident may file a complaint with the State Survey Agency. This failure could place residents at risk of not exercising their rights to voice a formal complaint to the State Survey Agency. Findings include:Observation after the confidential group interview on 08/12/2026 at 2:00 PM revealed the Ombudsman gave the residents a copy of new resident rights with information on how to contact State Survey Agency to voice a complaint.During a confidential group interview on an undisclosed date and undisclosed time, 7 of 7 residents revealed they did not know the residents had the opportunity to call State Survey Agency and voice a complaint. The residents in the confidential group did not understand or were aware the opportunity to call the State Survey Agency was available for them if they did not want to voice a complaint to the staff at the facility. The residents in the confidential group stated they felt this was very important to know they could call State Agency if they needed to report a complaint.Interview with the ADM on 08/13/2026 at 12:39 PM revealed the residents had the right to file a complaint. There were postings throughout the facility, and it was discussed upon admission. The Ombudsman came to resident council meetings and passed out a paper with resident rights on it after the meeting and those rights reflected state guidelines. The Administration went by the resident rights listed in the admission packet. The Administration ensured the postings were there. Residents' rights were discussed upon admission, Resident Council meetings, and on an as-needed basis. The Administration was responsible for going over the residents' rights with the residents. The ADM stated she was responsible for ensuring residents received information on how to file a complaint. Record review of the admission packet on 08/13/2026 at 12:45 PM, revealed resident rights were listed in the admission packet. Rights listed include: Right to complain.

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food that accommodates resident allergies, intolerances and preferences and were appealing options of similar nutritive value to residents who choose not to eat food that was initially serviced or who required a different meal choice from 1 of 1 kitchen for 10 residents who ate pureed diets reviewed for food and nutrition services. The facility failed to ensure Dietary [NAME] D refrained from adding unmeasured cream of mushroom soup to fried fish and bread, pureed meal during lunch service on 08/12/2026. This failure could place residents at risk for a diminished or altered nutritional status and potential weight loss. Findings include: Observation and interview via translator Dietary Aide C conducted on 08/12/2026 at 10:45 a.m. revealed Dietary [NAME] D used scoop #12 and placed an unmeasured amount of cream mushroom soup into the puree blender with the fried fish and bread. She did not measure the broth. She did not answer question of why she did not measure. Dietary [NAME] D proceeded to puree the fish and bread. She stated there were 10 residents on puree diets. Dietary [NAME] D stated pureed food was supposed to be a creamy texture. The puree fish and bread was a runny consistency. She poured the puree fish and bread mixture into a silver container. Dietary [NAME] D pureed extra puree fish, bread and added cream of mushroom soup and poured this into the fish and bread mixture into the silver container. Dietary [NAME] D stated she was trying to ensure it was thicker. Dietary [NAME] D stated she was not to use cream of mushroom soup to puree the fish and bread. She was expected to use milk. She stated she did not know what size scoop she was to use when measuring the cream of mushroom soup. Record review of the puree fish with Dietary Manager revealed milk was to be used to puree the fish and not cream of mushroom soup. In an interview via interpreter Dietary Aide C on 08/12/2026 at 11:00 a.m., Dietary [NAME] D stated she had been working as a cook approximately 3 years. She stated she was trained on pureed diets by previous the dietary manager. She stated because she had pureed food for so long, she relied on her own judgment. She also stated she did not read English, and the recipes was not provided for her in Spanish. Dietary [NAME] D stated she did not request for someone to interpret the recipes for her. She did not respond why she did not have someone to translate for her. She stated she would have another staff to translate the recipes to her. In an interview on 08/12/2026 at 11:15 a.m., the Dietary Manager stated they pureed the bread and fish together to enhance the meal to reflect the other residents meal of having fish on a bun. She stated the recipe for puree breaded fish fillets did not reflect to puree bread with the fish. She stated Dietary [NAME] D was expected to use milk and use scoop #8. She stated using the wrong size scoop had a potential of affecting the outcome of the consistency of pureed food. She did not elaborate how it affected the outcome of pureed food. She stated the recipe reflected to use hot milk 1 1/4 cup for 10 residents on puree diets. She stated Dietary [NAME] D was also expected to use 2 tablespoons plus 1 1/2 teaspoons of food thickener bulk. She stated Dietary [NAME] D did not follow the proper protocol of pureeing breaded fish fillets. She did not respond to any further questions about following recipe. In an interview on 08/13/2026 at 8:38 a.m. the Dietary Manager stated there were staff on the schedule who could interpret for Dietary [NAME] D. She stated Dietary [NAME] D did not follow the puree fish recipe. In an interview on 08/13/2026 at 10:10 a.m., the Administrator stated her expectations were for the recipes to be followed when preparing puree food for the residents. She stated the company who printed recipes did not have a Spanish version. The Administrator stated she would need to consult with corporate on the next step to ensure the facility had printed Spanish recipes. She stated there was an interpreter on staff if Dietary [NAME] D needed any assistance with translating the recipes. The Administrator stated she expected Dietary [NAME] D to use an interpreter when cooking to ensure the recipe was followed properly. She stated if puree food was not prepared properly there was a potential a resident on a puree diet may have difficulty swallowing their food. The Administrator did not elaborate what may happen to a resident if they had difficulty with swallowing and did not respond to any further questions about puree diets. In an interview on 08/13/2026 at 10:37 a.m., the Dietary Consultant stated she expected Dietary [NAME] D to follow the recipe for puree food. She did not respond to any further questions about puree diets, consistency, or what possibly could happen to a resident if the resident did not receive the correct consistency of puree diet. She stated if a staff in the kitchen was unable to read English, she expected there be an interpreter to translate recipes to Dietary [NAME] D. Record review of the Facility's Policy on Menu Planning, dated 06/01/2019, reflected The facility believes that nutrition is an important part of maintaining the well-being and health of its residents and is committed to providing a menu that is well-balanced, nutritious and meets the preferences of the resident population. Record review of an email on 08/12/2026 at 10:16 a.m. The Administrator stated the request of preparing puree food, to review meal planning policy, however, she emailed the menu planning policy.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchens reviewed for kitchen sanitation.The facility failed to ensure Dietary Aide C wore a hair net when standing by clean plates on food preparation table in the kitchen. These failures can place residents at risk for foodborne illness. Findings include:Observation on 08/11/2026 at 6:00 a.m. Dietary Aide C stood in the kitchen by clean plates on the food prep table without wearing a hair net.Interview on 08/11/2026 at 6:04 a.m., Dietary Aide C stated she forgot to place a hair net on when she entered the kitchen a few minutes prior to 6:00 a.m. She stated before she entered the kitchen, she was expected to place a hair net on her head. Dietary Aide C stated there was a possibility hair could fall on plates where food would be placed for residents. She stated if a resident ingested hair there was a potential a resident may become ill with stomach problems from bacteria on the hair. She stated she was in serviced on wearing hair nets. She did not recall the date of the in-service given by the Dietary Manger. In an interview on 08/13/2026 at 8:38 a.m., the Dietary Manager stated hair nets were required for all staff while in the kitchen. The Dietary Manager stated it could negatively affect a resident if hair restraints were not worn and a resident could receive food with hair in it. She stated there was a possibility hair may fall on a clean plate to be used for meals. She stated it was a possibility the staff may not see the hair on the plate and may serve food over the hair to a resident. She stated if a resident ingested hair there was a possibility the resident may become physically ill according to what type of bacteria was on the hair such as: stomach problems. She did not respond to any further questions of what type of stomach issues. She stated she did in-service the staff on wearing hair nets. The Dietary Manager stated she did not know the exact date of the in-service. She stated it was her responsibility to ensure staff wore hair nets when in the kitchen.In an interview on 08/13/2026 at 10:10 a.m., the Administrator stated her expectation was that hair nets were worn by all staff in the kitchen. The Administrator stated if hair nets were not worn there was a possibility hair may fall onto a clean plate and food could be served over the hair on the plate. She did not respond to any further questions about hair nets in the kitchen and if there was a possibility hair could fall on residents food and the possibility of a resident ingesting bacteria from staff hair.Record review of the facility's Policy on Employee Sanitation, dated 10/01/2018, reflected The Nutrition and Foodservice employees of the facility will practice good sanitation practices in accordance with the state in order to minimize the risk of infection and food borne illness. Employee Cleanliness Requirements:Hairnets, head bands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food -contact surfaces.

Based on interview, observation, and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident , encouraging both independence and interaction in the community for two of five residents (Resident #7 and Resident #10 reviewed for activities. The facility failed to provide Resident #7 and Resident #10 in room activities on the dates of 05/01/2025 thru 05/13/2025. This failure could place residents at risk for boredom, depression, and diminished quality of life. Findings included: Review of Resident #7's Face sheet, dated 06/04/2025, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnosis: vascular dementia, moderate, with psychotic disturbance ( problems with blood flow to the brain with psychotic symptoms such as delusions and hallucinations), generalized anxiety disorder (a mental health condition characterized by persistent and excessive worry about everyday things, which can be difficult to control), and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side ( hemiplegia is paralysis, hemiplegia causes muscle weakness- they are similar conditions in that they both can affect one side of the body. Cerebral infarction- a condition where the brain tissue is damaged due to lack of blood flow). Review of Resident #7's Annual MDS, dated [DATE], reflected Resident #7 had a BIMS score of 2 which indicated her cognition was severely impaired. Resident #7's activity preference was listening to music, being around pets, participating in religious activities or practices. Review of Resident #7's Comprehensive Care Plan, dated 5/08/2025, reflected Resident #7 was dependent on staff with meeting emotional, intellectual, physical, and social needs related to cognitive deficits, and physical limitations. Intervention: Resident #7 required 1:1 beside/in-room visits and activities. Review of Resident #7's Activity Initial Review Form, dated 03/25/2024, reflected she required assistance in attending group activities such as singing hymns, crafts, bible study, coffee social, bean bag games, balloon tennis, community outings and trivia. Resident #7 's activities was required to be modified to address communication deficit (provide time for resident to respond to questions). Review of Resident #7's Activity Progress Note Assessments after, 03/25/2024, reflected the Activity Director did not complete annual or quarterly activity progress notes. Review of Resident #7's Activity Participation Records for the month of May 2025, reflected Resident #7 did not receive in room activities from 05/01/2025 thru 05/13/2025. Observation on 06/06/2025 at 8:46 AM revealed Resident #7 was in her bed. She would open and close her eyes. She was not interviewable. Resident #7's television was on in her room. Observation on 06/07/2025 at 8:30 AM Resident #7 was in her bed. She was not interviewable. Resident #7's eyes were opened, and she looked toward wall in front of her. There was no stimulation in her room such as: television or music. Review of Resident # 10's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old male was admitted on [DATE] and readmitted on [DATE] with a diagnoses of multiple sclerosis ( a condition where the body's immune system mistakenly attacks the protective covering of the nerve cells in the brain and spinal cord), anxiety disorder (a mental health condition characterized by persistent and excessive worry about everyday things, which can be difficult to control), schizoaffective disorder, unspecified (a mental health condition, this is a mix of schizophrenia symptoms, such as hallucinations and delusions- perception of something that is not actually there such as hearing voices or seeing things). Review of Resident #10's Annual MDS, dated [DATE], reflected Resident #10 had a BIMS score of 8 which indicated his cognition was moderately impaired. Resident #10's activity preference was listening to music, watching news, and participate in religious services or practices. Attending group activities was not important to him. Review of Resident #10's Comprehensive Care Plan, dated 05/15/2025, reflected Resident #10 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations and schizophrenia. Interventions: Resident #10 needed 1:1 bedside/in-room activities. Provide a program of activities of Resident #10's interest. Review of Resident #10's Initial Activity Assessment, dated 08/30/2024, reflected Resident #10 enjoyed listening to music and watch movies. He did not want to attend group activities and preferred 1:1 activities with staff. Review of Resident #10's progress notes reflected the Activity Director did not complete a progress note after the date of 08/30/2024. Resident #10's last progress note was completed on 07/14/2022. Review of Resident #10's Activity Participation Record reflected Resident #10 did not receive in room /1:1 activities during the time frame of 05/01/2025 - 05/13/2025. Observation and interview on 06/03/2025 at 8:56 AM Resident #10 was in his room lying in bed listening to music. He stated he wanted more visits from the activity staff. Resident #10 stated he did become lonely sometimes and would prefer for activity staff to visit him three or four times a week. He stated the Activity Director would come in sometimes, however, in May she did not visit very much. Resident #10 did not respond to question if he requested more visits from the Activity Director. He stated he listens to music and watches TV. Resident #10 stated he wanted someone to visit and talk to him. Interview on 06/04/2025 at 1:15 PM The Activity Director stated Resident #10 and Resident #7 was on the in-room activity program. She stated Resident #10 very seldom was out of room. She stated Resident #7 had increased being in bed over the past 6 months. The Activity Director stated Resident#7 or Resident #10 did not receive in room activities during the dates of 05/01/2025 to 05/13/2025. She stated she was responsible for ensuring all the residents received activities. The Activity Director stated Resident #10 and Resident #7 was expected to receive visits from the activity staff in her room. Interview on 06/05/2025 at 8:45 AM The Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if a resident was not receiving any type of activities there was a possibility a resident may become bored, depressed or have a decline in their quality of life. She stated not receiving activities would affect their overall quality of life. The Activity Director stated if she was not in the facility, she instructed the Activity Assistant to visit in room residents. She stated she was off few days during the time Resident #10 and Resident #7 did not receive in room activities. The Activity Director stated she did not know why the Activity Assistant did not visit Resident #10 or Resident #7. She stated she was responsible to monitor Activity Assistant. Interview on 06/05/2025 at 10:15 AM the Activity Assistant stated she was trained on in room activities by the Activity Director. She stated she did not recall the date of the training. The Activity Assistant stated when the Activity Director was on vacation during first week of May she was instructed to visit residents on the in-room activity program. She stated she did not visit Resident #7 or Resident #10. She did not respond to the question of the reason why she did not visit Resident #7 or Resident #10. She stated if a resident was not receiving in room activities there was a possibility a resident may become depressed, isolated, or decline in mental status. Interview on 06/05/2025 at 11:00 AM the Administrator stated she expected in room activities be provided to the residents needing these type of activities. She stated if the Activity Director was not in the facility, she expected the Activity Assistant to provide in room activities. The Administrator stated if a resident was not receiving in room activities there was a possibility a resident may become depressed, bored, and isolated. She stated the Activity Director was responsible for monitoring the activity programs and the Activity Assistant. Requested via email the Facility Policy on Activity Programming and Documentation on 06/04/2025 at 2:50 PM. The Administrator responded via email on 06/04/2025 at 2:51 PM the facility did not have a policy on activity programming or documentation.

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 3 (Resident #56,Resident #22, and Resident #293) of 5 residents reviewed for infection control practices, in that: The facility failed to: 1. Ensure CNA B changed dirty gloves when handling clean items while providing peri care to Resident #56 2. Ensure MA E sanitized blood pressure monitor in between Resident #22 and Resident #293 while obtaining blood pressure. These failures could place residents at risk for healthcare associated cross-contamination and infections. Findings included: Review of Resident #56's face sheet dated 06/04/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, type 2 diabetes, hypertension, psychotic disturbance, mood disturbance, anxiety, need for assistance with personal care and unsteadiness on feet. Review of Resident #56's quarterly MDS assessment, dated 03/07/25 reflected a BIMS score of 0, indicating he had severely impaired cognition. MDS indicated Resident #56 was always incontinent with bowel and bladder. Review of Resident #56's care plan, dated 02/21/25, reflected Resident #56 had ADL self-care performance deficit r/t Alzheimer's, dementia. The relevant intervention was providing extensive one staff assistance with personal hygiene and oral care. During an observation on 06/03/25 at 8:34am CNA B was providing peri care for Resident #56 while CNA A assisted her. CNA B put on gloves after washing her hands. After that she opened the brief and cleaned Resident #56's front and back with wet wipes dispensed directly from the wipe's packet. In that process she handled the whole wipe packet with the soiled gloves. After the completion of peri care she saved the contaminated wipe packet containing wet wipes in Resident #56's room at his bedside. During an interview on 06/03/25 at 10:20am CNA B stated she worked at the facility for two years, mostly in the night shift and recently started working in the day shifts. CNA B stated she received training on peri care and had attended in- service recently. CNA B said, from the trainings and in-services she learned all the aspects of peri care procedure and infection control protocols. When the investigator walked through the peri care that she had done on Resident #56, CNA B stated she understood she should not have contaminated the wet wipe packet by handling it with soiled gloves, due to the danger of spreading germs. Review of Resident #22's face sheet dated 06/04/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including seizures, hypertension, acquired absence of right leg above knee, adult failure to thrive, altered mental status, depressive disorders, need for assistance with personal care, and dementia. Review of Resident #22's quarterly MDS assessment, dated 05/07/25 reflected a BIMS score of 8, indicating he had moderately impaired cognition. Review of Resident #22's care plan, dated 05/07/25, reflected Resident #22 was at risk for hypertensive crisis . The relevant intervention was obtaining blood pressure readings and administering anti-hypertensive medications as ordered by MD. Review of Resident #22' s medication order reflected : Lisinopril Tablet 5 MG: Give 1tablet by mouth one time a day for HTN .Hold for SBP less than 110. -Start date : 02/06/25. Review of Resident #293's face sheet dated 06/04/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of type 2 diabetes, hypertension, chronic congestive heart failure, alcoholic cirrhosis, atrial fibrillation (irregular fluttering of heart) , cough and adjustment disorder with mixed anxiety and depressed mood. Review of Resident #293's quarterly MDS assessment, dated 04/30/25, reflected a BIMS score of 12, indicating he had moderately impaired cognition. Review of Resident #293's care plan, dated 05/27/25 reflected Resident #293 was at risk for hypertensive crisis. The relevant intervention was obtaining blood pressure readings and administer antihypertensive medications as ordered by MD. Review of Resident #293's physician's order reflected: Prazosin HCl Oral Capsule 5 MG (Prazosin HCl): Give 1 capsule by mouth at bedtime related to essential (primary) hypertension . Give with 5mg to=7 mg. Hold for SBP<110, Pulse <60. -Start Date- 10/28/2024. During an observation on 06/04/25 at 9:35am MA E took the blood pressure of Resident #22 with a blood pressure monitor without sanitizing it. After administering the medications to Resident #22 she moved on to Resident #293 and used the same blood pressure monitor on him without sanitizing it. MA E did not sanitize the monitor after the use on Resident #293 until the investigator pointed it out. During an interview on 06/04/25 at 10:15 a.m., MA E stated sanitizing blood pressure cuffs in between the residents was important and, in a rush, she forgot to do it so. She continued, mistakes could happen with anyone and the best way to resolve it was learning from their mistakes. MA E stated, following infection control protocol was important to minimize spreading diseases from one resident to another. MA E stated she received trainings on infection control previous month and there were no in-services specifically on sanitizing medical equipment. During an interview on 06/05/25 at 11:35am the DON stated CNA B should not have handled the wet wipe packet with soiled gloves. She stated CNA B was supposed to throw away the contaminated wet wipe packet instead of saving for future. The DON stated she already completed a one-to-one in service with CNA B and would be doing an in service for all the staff members for peri care. The DON stated , the IP is on long leave, and she was responsible for the duties of IP until she returns. She said, as per facility's infection control protocol all the medical equipment in use including blood pressure cuffs should be sanitized immediately after they use it on residents. This was one of the ways minimizing contagious diseases and staff were trained for this. The DON stated she could not remember exactly when the staff received in services on infection control however she could find out the days by reviewing the in-service folder at the facility. Review of the in-service records from 03/01/25 to 06/01/25 revealed there were separate in services on 04/10/25 on hand hygiene and using gloves during nursing care. Record review of facility's policy Perineal care dated 10/24/22 reflected : Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. 6. Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate. 7. Set up supplies. 9. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. a. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. b. Thoroughly dry. 10. Re-position resident in supine position. Change gloves if soiled and continue with perineal care. Review of facility's policy Infection Prevention and Control Program revised in November 2024 reflected: . Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. b. Single-use disposable equipment is an alternative to sterilizing reusable medical instruments. Single-use devices must be discarded after use and are never used for more than one resident. c. Reusable items potentially contaminated with infectious materials shall be placed in an impervious clear plastic bag. Label bag as CONTAMINATED and place in the soiled utility room for pickup and processing

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary [NAME] changed her gloves during food preparation after touching a bread bag and a piece of paper. This failure could place residents who ate food from the kitchen at risk for foodborne illness. Findings include: Observation on 06/04/2025 at 3:55 PM, revealed the Dietary [NAME] was wearing gloves. She touched a piece of paper with her forefinger and middle finger on her right hand. She touched outside of the bread bag with all fingers on both hands. She reached inside the bread bag and obtained 4 pieces of bread. She placed the bread in the puree processor. The Dietary [NAME] touched outside the bread bag when she obtained 8 pieces of bread. She placed the 8 pieces of bread into the puree processor. The Dietary [NAME] did not change her gloves in between tasks and continued to puree the bread. Her middle finger and fore finger on her right hand touched inside the puree processor and touched the pureed bread. During the entire process of pureeing the bread, Dietary [NAME] did not change her gloves. Interview on 06/04/2025 at 4:05 PM, the Dietary [NAME] stated she did not change her gloves after she touched the piece of paper and touched outside of the bread bag. She stated the paper, and the bread bag was considered contaminated. She stated the bread came from a manufacturer plant and there was a possibility a lot of people had touched the bread bag before being delivered to the facility. She stated the paper was also considered contaminated. The Dietary [NAME] stated she was expected to change her gloves and wash her hands after touching anything contaminated. She stated there was a possibility germs on her gloves may spread to the bread. The Dietary [NAME] stated if the bread was contaminated and a resident ate the bread, there was a potential a resident may become physically ill such as vomiting and diarrhea. She stated she had been in-service on hand hygiene. The Dietary [NAME] did not recall the date of the in-service. Interview on 06/05/2025 at 10:35 AM, the Dietary Manager stated all staff were required to change their gloves and wash hands between tasks and whenever they touched anything contaminated. She stated the bread bag, and a piece of paper was considered contaminated. She stated if a resident ingested contaminated food, there was a potential a resident may become ill with some type of food borne illness. The Dietary Manager stated the staff were in-serviced on hand hygiene. She stated she did not recall the date of the in-service. Interview on 06/05/2025 at 11:00 AM, the Administrator stated she expected the dietary staff to change their gloves and wash their hands in between tasks or when they touched any contaminated item. She stated if dietary staff did not wash their hands after touching anything considered contaminated, there was a potential a resident may become ill with an upset stomach such as nausea or vomiting if a resident ingested any type of bacteria in their food. The Administrator stated the Dietary Manager was responsible to monitor the kitchen and it was her responsibility to monitor the Dietary Manager. Review of the Facility's Handwashing Policy, dated 10/01/2018, reflected The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition and Foodservice employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (Resident #193) of three residents reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #193. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Review of Resident #193's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of chronic diastolic heart failure (left heart ventricle is stiff and has difficulty relaxing and filling with blood between heart beats), atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (when arteries that carry blood to your heart become narrowed and blocked), paroxysmal atrial fibrillation (irregular heart beat), and difficulty in walking (any changes in the normal walking pattern that makes it difficult or unusual). Review of Resident#193's MDS Assessment, dated 05/30/2025, reflected Resident #193 had a BIMS score of 14 which indicated his cognition was intact. Resident #193 required partial/moderate assistance- (helper did less than half the effort) with toileting hygiene, showers, lower body dressing, transfers, and personal hygiene. He required supervision with upper body dressing, and oral hygiene. Resident #193 had shortness of breath when lying flat. He was at risk of developing pressure ulcers and required pressure reducing device for his bed. Review of Resident #193's Baseline Care Plan, on 06/04/2025, reflected it was not completed in the electronic medical record. Review of the facility's nurse's admission checklist, not dated, reflected baseline care was to be completed by the nurse. Interview on 06/05/2025 at 9:55 AM the Director of Nurses stated baseline care plans were to be completed within 48 hours of the resident's admission date. She stated it was the nurse in charge of the resident responsibility to complete baseline care plan. The Director of Nurses stated the nurses had a checklist to follow when admitting a resident to the facility and complete a baseline care plan was on this check list. She stated when the nurse completed the baseline care plan it was her responsibility to review the care plan and ensure it was correct. The Director of Nurses stated, I would sign and date the baseline care plan to ensure it was correct. She stated there was no explanation of why Resident #193's care plan was missed. The Director of Nurses stated it was her responsibility to monitor the baseline care plans. She stated if a resident did not have a baseline care plan there was a potential a resident may not receive the appropriate care such as transfers, bathing, hygiene, toileting, etc. She stated a resident required a Hoyer lift for transfer and the staff did not use the Hoyer lift, there was a possibility the resident may fall. The Director of Nurses stated the resident sustain an injury from the fall such as broken bone. Interview on 06/05/2025 at 10:30 AM LVN C stated it was the nurse's responsibility to complete baseline care plan upon admission. He stated the nurse admitting a resident was to complete the baseline care plan. LVN C stated there was an admission checklist to follow and completing baseline care plan was on the checklist. He stated the information on the baseline care plan would transfer to the Kardex. He stated the Kardex was the electronic medical record the CNAs used to know what type of ADL care a resident needed at the time of admission. LVN C stated there was a possibility a resident may not receive the appropriate resulting in an injury. LVN C did not specify what type of injury or how a resident may sustain an injury. Record review of the facility's policy on Baseline Care Plan, dated 10/5/2023, reflected the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. social services. vi. PASARR recommendation, if applicable. 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. b. Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. iii. Any special needs such as for IV therapy, dialysis, or wound care. c. Once established, goals and interventions shall be documented in the designated format. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.

Based on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 3 of 4 residents (Resident #27, Resident #74 and Resident #45) reviewed for quality of care. The facility failed to ensure Resident #27, Resident #74 and Resident #45's nebulizing mask and tubing, that were observed on 06/03/25, were bagged for sanitation when not in use. This failure could affect residents who received nebulizing treatment and place them at risk for respiratory infections. The findings included: Record review of Resident #27's face sheet dated 06/03/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were dementia, behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hypotension, history of transient ischemic attack and cerebral infarction(stroke), shortness of breath, unsteadiness on feet and cognitive communication deficit. Record review of Resident #27's quarterly MDS assessment, dated 05/06/25 revealed a BIMS score of 02 indicating his cognition was severely impaired. Record review of Resident #27's care plan dated 05/25/25 reflected he had asthma. The relevant intervention was giving medications as ordered and educating resident/family/caregivers regarding side effects and overuse of inhalers and nebulizers. Record review of Resident #27's physician's order reflected : NEB: Clean mask weekly and PRN. Change mask, tubing, and bag monthly. and PRN, every night shift starting on the 1st and ending on the 1st every month change. -Start Date-12/01/2023. Record review of Resident #74's face sheet on 06/03/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were hypertension, behavioral disturbance, chronic obstructive pulmonary disease(difficulty to breath), obstructive acute respiratory failure with hypoxia(low oxygen level), dementia, depression, shortness of breath and unsteadiness on feet. Record review of Resident #74's quarterly MDS assessment, dated 10/13/24 revealed a BIMS score of 06 indicating his cognition was severely impaired. He was coded for oxygen therapy while he was at the facility. Record review on 06/03/25 of Resident #74's care plan dated 05/27/25 revealed the resident had COPD and at risk for ineffective airway clearance. The intervention was giving aerosol or bronchodilators as ordered and monitoring any side effects and effectiveness. Record review of Resident #74's physician's order reflected : 1.Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate):1vial inhale orally via nebulizer two times a day related to chronic obstructive pulmonary disease. -Start date-2/21/2023. 2. Clean mask weekly and PRN. Change mask, tubing, and bag monthly and PRN, every night shifts every Sun for resident care. -Start Date-11/12/2023. Review of Resident #45's face sheet dated 06/04/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic pain syndrome, dependence on supplemental oxygen, muscle wasting, basal cell carcinoma of skin(skin cancer) and altered mental status. Review of Resident #45's quarterly MDS assessment, dated 05/13/25, reflected a BIMS score of 15, indicating his cognition was intact. He was ordered for oxygen therapy while he was at the facility. Review of Resident #45's care plan, dated 01/14/25, reflected Resident #45 had COPD and at risk for ineffective airway clearance. The relevant intervention was giving aerosol or bronchodilators as ordered. Review of Resident #45's physician's order reflected: NEB: Clean mask weekly and PRN. Change mask, tubing, and bag monthly and PRN. every night shifts every Sun for resident care. -Start Date-11/12/2023 Observation and interview on 06/03/25 at 10:45am of Resident #27, Resident #74, and Resident #45's room revealed there were nebulizers on the side tables. The masks and tubing of the nebulizers were exposed to the environment as they were not stored in a protective bag. LVN D who witnessed the nebulizer masks stated they were supposed to be sanitized before and after use and should have been stored in a protective bag whenever not in use. He stated this was necessary to avoid infections especially respiratory. During an interview on 06/05/25 at 11:30am the DON stated all staff were supposed to be compliant with the facility policy for using the oxygen cannula and nebulizers. She stated the nebulizer masks were to be cleaned and DON safely stored in the protective bags provided. She stated there was a potential for respiratory infectious diseases due to this deficiency. DON stated she or ADON did routine inspection to ensure if the mask and tubing were appropriately sanitized and stored in protective bags. Record review of the facility's policy, titled Oxygen Safety dated 01/26/24 had not reflected the necessity for storing oxygen/nebulizer tubing, cannulas, and facemasks in protective bags when not in use. Record review of web site https://www.nhlbi.nih.gov/sites/default/files/publications/How-to-Use-a-Nebulizer-21-HL-8163.pdf reviewed on 06/10/25 reflected: . Between uses: o Store nebulizer parts in a dry, clean plastic storage bag. If the nebulizer is used by more than one person, keep each person's medicine cup, mouthpiece or mask, and tubing in a separate, labeled bag to prevent the spread of germs. o Wipe surface with a clean, damp cloth as needed. Cover nebulizer machine with a clean, dry cloth and store as stated in the instructions. o Replace medicine cup, mouthpiece, mask, tubing, filter, and other parts as stated in the instructions or when they appear worn or damaged

Based on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (200 Hall Med Aide Cart) reviewed for medication storage . The facility failed to ensure that the 200 Hall Med Aide Cart did not contain personal belongings of MA E, along with the medications for residents. This failure could place residents at risk for contamination and medication errors through confusion and distraction among the medication administration staff . Findings include: During an observation and interview on 06/04/25 at 9:35am it was revealed that the 200-hall med cart was operated by MA E. It was observed there was an orange-colored handbag at the bottom drawer of the cart that belonged to MA E. MA E immediately removed it from the drawer and placed it elsewhere. She stated she should not have placed her bag in the med cart drawer as it was against the facility policy. MA E stated the Med cart supposed to have only resident's medications that were in use to avoid confusion and not introducing germs into the cart. During an observation and interview on 06/04/25 at 10:20am LVN C stated he was the nurse in charge for the shift. He was present when the investigator going through the 200 hall Med Aide Cart, as part of the survey process. After witnessing the hand bag of MA E in the drawer of the Med cart, LVN C stated personal items needed to be kept away in designated staff rooms or any other places safely. He said personal items might not be clean and could potentially introduce germs into the med cart. LVN C added, Med carts were used to handle medications only and should be kept clean and sterile all the time. In an interview on 06/05/25 at 11:30am, the DON said nursing staff were expected to check their med carts daily for inappropriately placed medications and any other items other than residents' medications. She stated personal belongings should not be in a med cart in a nursing facility to prevent medication errors, maintain safety, and ensure proper medication administration practices. She stated med cart procedures should prioritize medication organization and safety and introducing personal items was a deviation from these established procedures . Med carts were specifically designed to hold medications and treatment related supplies. She said introducing non-essential items caused confusion and distraction that potentially lead to mistakes, also contaminate the medications and treatment supplies stored in the cart. Record review of the facility policy titled Medication Carts and Supplies for Administering Meds revised on 10/01/2019 reflected: Policy: The facility maintains equipment and supplies necessary for the preparation and administrations of medications to residents. The mobile medication cart will be used to facilitate administration of medications to residents. The purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications The licensed nurse or medication aide should maintain a clean top surface on the medication cart. while passing medications and clean and replenish the medication cart after each use. Equipment and supplies relating to medication administration are clean and orderly

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to properly label food and store food by not sealing/covering food items. in one of one walk in refrigerators and dry storage shelves located in the kitchen. 2. The facility failed to ensure a visitor wore a hair net and a beard guard when he entered the kitchen from the exit side door leading to the outside near parking area. These failures placed residents at risk for health complications and foodborne illnesses. Findings included: 1. Observation on [DATE] at 9:02 AM reflected the following food and drinks were not covered and/or not labeled in the walk-in refrigerator: - Leftover chicken in a white container dated ,d+[DATE] was not covered. - Two bowls of pureed fruit and two bowls of pureed bread pudding not covered or labeled and dated. The pureed fruit had a brownish color crust around the edges of the fruit. - Three trays with approximately 15 bowls of fruit on each tray not labeled or dated - Leftover boiled eggs in a container not labeled or dated. Observation on [DATE] at 9:15 AM on the dry storage shelf next to the oven reflected a large container of brown sugar not labeled or dated. A large clear plastic bag opened dated [DATE] had the following items in the clear bag: - An opened chicken gravy packet - the date was smeared and was unable to read the date. - An opened biscuit gravy mix packet dated [DATE]. - An opened chili seasoning mix packet dated [DATE]. - An opened brown gravy mix dated [DATE]. 2. Observation on [DATE] at 9:25 AM a male Visitor J entered the kitchen from the kitchen side door from the outside of the facility near the parking area. He had long hair passed his shoulders and a long beard below his neck. The male visitor did walk by the food prep table near the stove and walked by clean dishes on another food prep table in the main kitchen area. There were hair nets and did not observe any beard guards near the door. In an interview on [DATE] at 9:27 AM Visitor J stated he never wore a hair net or beard guard when he entered the kitchen. He stated he came to the facility a few times per week. He also stated he was a contractor but did not respond to what he was working on in the kitchen . Visitor J never donned a beard net or hair net when in the kitchen. In an interview on [DATE] at 9:33 AM the Dietary Aide K stated all food was expected to be labeled and dated. She stated if there was any leftover food such as boiled eggs and they did not know when the boiled eggs were placed in the refrigerator, it was a possibility the boiled eggs may be spoiled. She also stated if the boiled eggs were served to a resident there was a potential the resident might become sick with food poisoning. She stated she had been in-serviced on labeling and dating foods and not to leave any containers opened. She stated the visitor came into the kitchen several times. She did not answer what repairs he was doing in the kitchen. In an interview on [DATE] at 9:00 AM the Dietary Manager stated the chicken was expected to be covered. She stated all left over foods were to be dated, covered, or sealed. She stated all foods were required to be labeled and dated. The Dietary Manager stated if a date was smeared the item was to be discarded. She stated she discarded all the packets with the different dates in the clear plastic bag. She stated the dates on the packets did not match the dates on the clear plastic bag. She also stated the gravy mix, seasoning, and biscuit mix needed to be discarded and not used in the food due to being expired. She also stated the boiled eggs was expected to be labeled, dated, and covered. The dietary manager stated the visitor in the kitchen on [DATE] was not a contractor. She stated he previously worked at another facility owned by the same company on the same road as this facility. She stated he came in the kitchen several times per week and would bring a bucket to get food scraps for his chickens. She also stated he was informed by her to wear a hair net and beard guard when he entered the kitchen. The Dietary Manager stated he would wear a baseball cap sometimes, but it did not cover all his hair. She stated the hair net and beard policy applied to anyone entered the kitchen. The Dietary Manager stated hair could fall onto plates or food if someone was not wearing a hair net or beard guard. She stated if hair was on the food or plate and a resident ingested the hair, there was a potential a resident may become ill with some type of stomach illness. She stated there was bacteria on people's hair and hair was considered contaminated. She also stated if the left-over food had been in the refrigerator for over a week and the staff served the food to the residents, there was a possibility the resident may become physically ill with food poisoning. She stated she did an in-service for the dietary staff on labeling, dating, and covering leftover foods. She stated any foods that have been in the refrigerator or anywhere over 72 hours was expected to discard the food. She stated if there was not a date on when the leftover food was placed in the refrigerator, the staff were expected to discard the food immediately. The dietary manager stated there were beard guards and hair nets beside the door. In an interview on [DATE] at 9:16 AM the Administrator stated she expected all foods to be covered, sealed, and with the correct label. She stated there was potential a resident may become physically ill such as food poisoning. She stated it was possible for a resident to have symptom of vomiting. The Administrator also stated anyone that enters the kitchen, including visitors, were expected to wear a hair net. She stated if the visitor was a male and had a beard, he was expected to wear a beard net. She stated hair was considered contaminated. The Administrator also stated if a resident ingested the hair the resident may become sick with some type of stomach issue. She stated a person that did not work at the facility or was in the facility to do any type of contract work was not allowed in the kitchen for any reason. She stated the visitor was not a contractor. The Administrator stated he was not to be allowed to walk into the kitchen to get food scraps. She stated the Dietary Manager was responsible to monitor the kitchen and she was over the Dietary Manager. Record review of the Facility's Policy on Food Storage, revised on [DATE], reflected refrigerators: date, label, and tightly seal all refrigerated foods. To ensure freshness, store opened, and bulk items in tightly covered containers. All containers must be labeled and dated. Record review of the Facility's Policy on Employee Sanitation, dated [DATE], reflected hairnets, head bands, caps, beard coverings, or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Review of the Food and Drug Administration Food Code, dated 2022, reflected, XXX,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food ,d+[DATE].11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observations, interviews, and record review, the facility failed to provide maintenance services necessary to maintain a safe, orderly, and comfortable homelike environment for five (room [ROOM NUMBER], 451, 460, 461, and 463) of twelve rooms reviewed in the facility's secure unit for environmental conditions. The facility failed to cut down and cap the two mounting bolts that secure the toilet's base to the floor, which ensures that the toilet does not move or leak in room [ROOM NUMBER], 451, 460, and 463. The facility failed to ensure that room [ROOM NUMBER]'s bathroom walls were painted after having two portions of drywall repaired. These failures could place residents at risk of living in an unsafe, unhomelike, and uncomfortable environment. Findings included: Observation on 05/21/2024 at 10:09 AM, room [ROOM NUMBER]'s bathroom toilet had the two base mounting bolts exposed, uncut, and not capped. Observation on 05/21/2024 at 10:19 AM, room [ROOM NUMBER]'s bathroom toilet had the two base mounting bolts exposed, uncut, and not capped. Observation on 05/21/2024 at 10:39 AM, room [ROOM NUMBER]'s bathroom walls had two sections of the drywall that had been repaired but were not repainted to match the rest of the bathroom's paint color. Observation on 05/21/2024 at 10:41 AM, room [ROOM NUMBER]'s bathroom toilet's two base mounting bolts were rusted, exposed, uncut, and not capped. Observation on 05/21/2024 at 12:30 PM, room [ROOM NUMBER]'s bathroom toilet's two base mounting bolts were rusted, exposed, uncut, and not capped. Observations on 05/23/2024 from 8:00 AM through 8:02 AM revealed that room [ROOM NUMBER] and #463's toilet bowl mounting bolts remained exposed, uncut, and not capped, and room [ROOM NUMBER]'s drywall repairs had not been painted. Interview and observation on 05/23/2024 at 9:38 AM, the Maintenance Director stated that she was responsible for all building maintenance, which included patches, painting, and toilets. The Maintenance Director stated that she has no additional staff under her that assist with maintenance. At 9:44 AM, the Maintenance Director entered the bathroom of room [ROOM NUMBER] and stated that the walls should have been painted after the drywall was patched. The Maintenance Director stated that she repaired and patched the dry wall sections approximately two weeks ago and should have painted them to maintain a homelike environment. At 9:46 AM, the Maintenance Director entered the bathroom of room [ROOM NUMBER] and stated that the exposed toilet mounting bolts should have been cut and covered to prevent residents from hurting themselves on the exposed bolts. Interview and observation on 05/23/2024 at 9:48 AM, the Administrator stated that it was her expectation that the interior and exterior of the facility be safe and maintained in a homelike manner. The Administrator stated that the Maintenance Director was responsible for the overall care of the grounds and resident rooms. At 9:51 AM, the Administrator entered the bathroom of room [ROOM NUMBER] and stated that the toilet mounting bolts should have been cut and covered to prevent resident contact and possible injury. At 9:53 AM, the Administrator entered the bathroom of room [ROOM NUMBER] and stated the dry wall patches should have been painted as soon as they dried to maintain a homelike environment. Review of the facility's undated General Housekeeping Policies revealed, The facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. Nursing personnel are not assigned to routine housekeeping duties. Review of how-to install a toilet through https://www.[NAME].com/n/how-to/replace-a-toilet revealed, make sure the nuts are firm but don't tighten them too much; the bowl could crack. Then use a [NAME] saw to cut off the excess bolt. Snap on the caps. Further review revealed, toilet bolt caps cover up rusted or protruding toilet floor bolts, which will help update the look of the bathroom and secure safety of your family.

Based on interviews and record review, the facility failed to ensure all PASARR- Level I positive residents diagnosed with mental illness were provided with a PASARR- Level II Screening for 1 of 3 residents (Resident #70) reviewed for mental illness, intellectual disability, or developmental disability. The facility failed to ensure Resident #70 received a PASARR Level 2 evaluation. This failure could place residents at risk for not receiving necessary mental health services and causing a possible decline in mental health. Findings included: Record review of Resident #70's face sheet dated 05/23/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage-unspecified (also known as intracranial bleed is bleeding within the skull), hemiplegia (one sided paralysis) and hemiparesis (partial weakness on one side of the body) following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting left dominant side, and bipolar disorder-unspecified (a mental health condition that causes extreme mood swings between emotional highs and lows). Record review of Resident #70's MDS assessment dated [DATE] revealed a BIMS score of 13 suggesting cognition intact. Section I of the MDS assessment reflected active diagnosis of anxiety disorder, depression, and bipolar disorder. Record review of Resident#70's care plan reflected: [Resident #70] uses psychotropic medications related to anxiety, insomnia, depression, bipolar disorder, and hallucinations. Initiated 11/12/22, last revised 11/22/23. The relevant interventions were Administer psychotropic medications as order by physician. Monitor for side effects and effectiveness every shift. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. Discuss with MD, family ongoing need for the use of medication. Review behaviors/ interventions and alternate therapies attempted and their effectiveness as per facility policy. Educate the resident/ family/ caregivers about risks, benefits, and the side effects and/ or toxic symptoms of psychotropic medication drugs being given. Initiated 11/15/22. Record review of Resident #70's PASARR-Level 1 screening dated 11/15/22 read in part, is there evidence or an indicator this is an individual that has a Mental Illness? The answer was: Yes. In an interview on 05/23/24 at 01:02 PM with the Assessment Nurse, she stated that after looking for Resident #70's PASARR level 2 assessment she determined that the level 2 assessment was not completed for Resident #70. The Assessment Nurse said it would have been her responsibility to ensure that the level 2 assessment was completed to determine if Resident #70 would have qualified for additional services. The Assessment Nurse stated she would complete and submit the appropriate documentation in order for a QMHP to come evaluate Resident #70 and determine if she qualified for additional services. In an interview on 05/23/24 at 02:00 PM with the DON, she stated it was her expectation that PASARR screenings were completed on admission and that positive level 1 screenings have a level 2 completed. The DON stated it was the responsibility of the Assessment Nurse to complete the PASARR screenings and ensure accuracy. She stated a potential negative outcome could be residents would miss additional mental health services. In an interview on 05/23/24 at 02:15 PM with the Administrator, she stated it was her expectation that PASARR level 1 screenings were done upon admission and that residents were referred the same day for a level 2 screening if positive on the level 1. The Administrator stated it was the responsibility of the Assessment Nurse to ensure level 2 screenings were completed. She stated a negative outcome to not completing a PASARR would be the potential for a resident to not have additional needed services. The facility PASARR policy was requested 05/23/24 at 03:00 PM and The Administrator stated there was not a PASARR policy.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections. AD and CNA I failed to use proper hand hygiene techniques when assisting 2 unidentified residents each (4 residents total) to eat during lunch meal service. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation on 05/21/24 at 12:14 PM revealed AD and CNA I feeding 2 different unidentified residents each at lunch service in the dining room. Both AD and CNA I did not perform hand hygiene between feeding the 2 separate unidentified residents at each of their tables. During an interview on 05/21/24 at 01:46 PM AD stated it was normal for the facility to have staff sit between two residents to assist with feedings. AD stated she knew she should have sanitized in between feeding the two residents and that by not doing so there was potential for cross contamination. AD stated she remembered to sanitize while passing trays but forgot when it came to sitting and assisting the 2 separate unidentified residents with their meals. During an interview on 05/21/24 at 02:20 PM CNA I stated that the facility encourages staff to assist two residents at once when possible, during meal services. CNA I stated that staff are supposed to sanitize in between helping residents and she said she was not paying attention and just forgot to sanitize. CNA I said that a potential negative outcome to not sanitizing while feeding the 2 separate unidentified residents was cross contamination and an infection control issue. During an interview on 05/23/24 at 02:00 PM the DON stated that by the staff not performing HH while feeding the residents any type of acute illness can be passed back and forth. During an interview on 05/23/24 at 02:15 PM with the Administrator she stated it was her expectation that staff assisting residents with feedings should be sanitizing and using separate utensils in order to prevent cross contamination. Record Review of facility provided policy Infection Prevention and Control Program, dated 05/13/23, revealed, 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. All staff are responsible for following all policies and procedures related to the program. Standard Precautions: - All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. - Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 dining room reviewed for environment. The facility failed to ensure the dining room was free of flies during the resident meal services. These failures could place residents at risk for infection and not receiving a home free of pest or comfortable environment to live. Findings Included: In an observation on 05/21/24 at 12:14 PM multiple flies were seen in and around residents' food throughout the dining room during meal service. A staff member was heard saying to an unidentified resident eat your food the flies are eating it all. AD and CNA I were observed swatting flies as they assisted in feeding 2 unidentified residents each. In an observation on 05/22/24 at 12:20 PM in the dining room multiple flies were observed again during meal services. The DON and SNA were observed swatting flies that were landing on food and flying around as they assisted in feeding two unidentified residents . In an interview on 05/21/24 at 01:46 PM with AD she stated she had not noticed flies being an issue until today. The AD said that flies in and around residents' food was an infection control issue and can lead to contamination. In an interview on 05/21/24 at 02:20 PM with CNA I, she stated it was very common seeing flies in and around residents' food during meal services. NA said she has verbalized the issue with some of the other staff members but has never made an official report of the pest problem. She stated that she remembered there was a section to report flies in the pest control book located at the nurses' station, but she never thought to go write it down. CNA I said flies have the potential to spread bacteria and larva to residents' food. In an interview on 05/23/24 at 02:00 PM with the DON she stated she has recently noticed more flies around during meal services but she had not in the past and had not had to report them previously. She stated a negative outcome to flies in residents' food would be the potential for illness. In an interview on 05/23/24 at 02:15 PM with the Administrator she stated that due to the heavy rain recently she has noticed more flies in the building. She stated flies in residents' food was a disruption but could potentially also cause contamination. The Administrator stated there was no policy for pest control. Record review of the facility pest control log reflected that prior to the report made on 05/21/24 by the AD after being notified of the fly concern there were no prior reports on flies made to notify pest control in the last 12 months.

Based on observation, interviews and record review the facility failed to ensure each resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility for two (Resident #57 and Resident #66) out of seven residents reviewed for dignity. 1.The facility failed to treat Resident #57 with respect and dignity by providing privacy during care when Resident #57 was left exposed after a fall and incontinent episode. 2.The facility failed to treat Resident #66 with respect and dignity when he was left with long untrimmed fingernails which could cause skin breakdown, damage and become a source of infection. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. Findings included: Review of the Face Sheet for Resident #57 reflected he was admitted on [DATE] with diagnosis of: COPD, a single Pulmonary Nodule, Atrial Fibrillation, Heart Failure, Type 2 Diabetes, Morbid Obesity, Major Depressive disorder, Acute and Chronic respiratory Failure with Hypoxia, and Obstructive Uropathy. Review of the MDS assessment for Resident #57 dated 3/18/24 reflected a BIMS score of 15 indicating normal cognitive function. His physical assessment reflected he required supervision or one person assistance for all ADLs. He was assessed as occasionally incontinent of bowel and had a Foley catheter in place. Review of the Care Plan for Resident #57 reflected interventions were in place for: drug allergies, DNR status, ADL self-performance deficit r/t Dementia, limited mobility d/t heart failure, refusing to wear BiPAP breathing assist, Diabetes, fall risk, foley catheter, behavior of insomnia, rash to right back r/t herpes zoster (shingles), oxygen therapy, Observation at 10:47 am on 5/21/24 revealed Resident #57 had fallen from his bed to the floor. He was face down on the floor with his brief around his ankles. His catheter remained in place, draining clear yellow urine. LVN C and a NA were at bedside attempting to assist him, and LVN E entered the room. LVN C stated Resident #57 was confused and had become more confused since yesterday. He stated Resident #57 had gone out to hospital for a Shingles infection this weekend and they also diagnosed a UTI. He was receiving antibiotics for both. The Resident stated he had slipped in water at bedside attempting to reach pants on his bedside table. No pants were visible on the bedside table. Resident argued with staff some, as they put down towels to soak up water. In an interview on 5/21/24 at 11:10 am LVN C stated he was summoned to Resident #57's room by a housekeeper who stated he had fallen. LVN stated he had not worked with Resident #57 for a while, but he was definitely more confused than normal. He stated Resident #57 indicated he was not hurt in the fall. LVN C stated Resident #57 was able to sit up and then sat in his wheelchair to transfer back to bed. LVN C stated Resident #57 had cardiac and respiratory problems which limited his ability to perform ADLs. LVN C stated Resident #57 may need to return to the hospital for evaluation. Review of Progress Notes for Resident #57 reflected on 5/23/24 he demonstrated increased level of confusion. On 5/21/24 the resident was sent to the hospital after fall without injury. He was observed by staff on the floor face down, and his brief was around his ankles. Resident #57 stated he had turned off his oxygen concentrator because a doctor was in the room talking to him. Resident #57 was previously sent to the hospital on 5/18/24 for confusion and shaking. In an interview on 5/23/24 at 8:55 am Resident #57 stated he was unsure why he had removed his clothing and his brief prior to his fall. Resident #57 stated he did not recall the fall. He stated his confusion could be related to his UTI or his Shingles outbreak. In an interview on 5/23/24 at 9:30 am LVN D stated Resident #57 had a history of removing his briefs. She stated she was not sure if the behavior was related to his dementia or his recent UTI. In an interview on 5/23/24 at 9:35 am the DON stated the facility had been actively watching Resident #57. She stated he was sent to the hospital the first time for a UTI, but the antibiotics prescribed did not yield the desired effect. She stated he was sent out a second time on 5/21/24 after he fell from bed. The DON stated Resident #57 was monitored because he had a Foley catheter. The DON stated his behavior could be added to care plan pointing out his fall was the first incident of #57 removing his brief she had found. In an interview on 5/23/24 at 11:50 am the Administrator stated Resident #57 came down with a UTI on 5/18/24 and was sent out to hospital. She stated interventions could have been added to deal with his confusion, disrobing behaviors, and other symptoms of the UTI. She stated other than the fall on 5/21/24 no other falls were noted for Resident #57. This state surveyor pointed out he was listed as a high fall risk. The Administrator stated when Resident #57 was observed with his brief down around his ankles or incontinent of bowel, staff should have taken action to protect his dignity. She stated the door should have been closed during care, curtains pulled, and the resident covered. The State Surveyor stated after Resident #57 fell three staff were in the room (C, [NAME], A) and no one took measures to protect the resident's dignity. She stated staff should have responded to the situation wholly. Review of the Face Sheet for Resident #66 reflected he was admitted on [DATE] with diagnosis of: Congestive Heart Failure, Prostate Cancer, Kidney cancer, Schizophrenia, HTN, Glaucoma, and dependence on supplemental Oxygen. Review of the Annual MDS assessment for Resident #66 dated 4/13/24 reflected a BIMS score of 10 or moderate cognitive impairment. His physical assessment reflected he required supervision or one person assistance for most ADLs. Resident #66 was unable to walk, he utilized an electric wheelchair. He was assessed as occasionally incontinent of bowel and bladder. Review of the Care Plan for Resident #66 reflected interventions were in place for: Schizophrenia, Non-compliance with rules and regulations regarding VA contract, ADL self-care deficit, verbally aggressive toward staff, Congestive Heart Failure, fall, risk, and oxygen therapy. In an interview on 5/22/24 at 1:07 pm LVN A stated Residents on hall 100 should have their nails trimmed. She stated Resident #66 had a history of Schizophrenia and could say almost anything. She did not know why his fingernails were long and untrimmed. She stated aides should be trimming resident nails unless otherwise directed. In an interview on 5/22/24 at 10:37 am CNA H stated she was unsure why Resident #66 had long untrimmed fingernails and toenails. She stated she worked mainly on memory care and she stated nails are normally trimmed on shower day. In an interview on 5/22/24 at 3:40 pm the DON stated Resident #66 would refuse to have his fingernails cut and would refuse showers. No progress notes to verify refusing showers or nail cutting were found by the DON as she reviewed records on the facility computer. The behaviors reported by the DON were not found in the care plan. Review of the facility policy Promoting/Maintaining Resident Dignity dated 1/13/23 reflected all staff were involved in providing care to residents and to promote and maintain resident dignity, respect, and resident rights. Staff to maintain resident privacy.

Based on interviews and record review, the facility failed to ensure a resident's assessment was completed within 7 and 14 days, and electronically transmit encoded, accurate, and complete MDS data to the CMS system for a subset of items upon a resident's discharge from the facility for one (Resident #88) of eight residents reviewed for encoding and transmitting resident assessments. The facility failed to complete, encode, and submit a Discharge MDS Assessment for Resident #88. This failure to place discharged residents at risk of not having a proper discharge and not receiving services post discharge. Findings included: Closed record review of Resident #88's Face Sheet, dated 05/23/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged from the facility on 02/19/2024 with the following diagnoses: Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and Vascular Dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Closed record review of Resident #88's Care Plan initiated on 01/04/2024 revealed, Problem [Resident #88] has a terminal prognosis. admitted to [Hospice Provider] on 1/2/24 Dx: Alzheimer's Disease. Closed record review of Resident #88's undated MDS Assessment list revealed, accepted Entry MDS on 12/22/2023 and an accepted Admission MDS on 1/3/2024. Resident #88's MDS Assessment list did not contain a Discharge MDS Assessment at any stage in the preparation, submission, or acceptance process. Closed record review of Resident #88's Discharge Plan and Summary dated 02/19/2024 revealed that Resident #88 was discharged from the facility at his family's request under hospice care of [Hospice Provider] on 02/19/2024. In an interview on 05/23/2024 at 2:53 PM, the Assessment Nurse stated that she was responsible for MDS Assessments and submissions for residents in the facility. The Assessment Nurse stated that they were required to complete a Discharge MDS Assessment within 14 days of a resident's discharge from the facility. The Assessment Nurse reviewed the electronic MDS records for Resident #88 and stated that it was not accurate. The Assessment Nurse stated that she should have completed and submitted it within 14 days as a Discharge Without Expected Return MDS Assessment for Resident #88. The Assessment Nurse stated that Resident #88's Discharge MDS Assessment was missed. The Assessment Nurse stated that the MDS Assessment and submissions were necessary to ensure that TMHP (Texas Medicaid and Healthcare Partnership) was aware of the resident's status as well as for billing and patient needs documentation. In an interview on 05/23/2024 at 3:00 PM, the DON stated that the Assessment Nurse was responsible for the MDS Assessments and that she signs off on them. The DON stated that she believed the MDS submissions needed to be completed within five days but would need to look up the information to be certain. The DON stated that when a resident was discharged from the facility they must complete and submit a Discharge MDS Assessment. The DON stated that failure to properly and accurately report MDS Assessments could result in billing issues. In an interview on 05/23/2024 at 3:03 PM, the Administrator stated that MDS Assessments must be completed and reported to provide an accurate picture of the resident and for billing purposes. The Administrator stated that the Assessment Nurse was responsible for MDS reporting and that Discharge MDS Assessments should be completed within seven days. The Administrator reviewed the MDS Assessment list for Resident #88 and stated they failed to submit a Discharge MDS Assessment for Resident #88 and should have done so. Review of the facility's Assessment Frequency / Timeliness policy dated 10/24/2022 revealed, Policy: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. Policy Explanation and Compliance Guidelines: 1. The MDS/RAI Coordinator will be responsible for tracking due dates for all MDS assessments, including OBRA and Medicare PPS assessments. 6. An OBRA discharge assessment will be completed within 14 days of the discharge date .

Based on observations, record review, and interviews the facility failed to update one (Resident #57) out of seven residents reviewed for care plan in relation to changes in health, changes in behavior and significant changes. The facility failed to update Resident #57's care plan and adjust it r/t physician orders or behaviors. The deficient practice could affect residents by delaying treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of the Face Sheet for Resident #57 reflected he was admitted on [DATE] with diagnosis of: COPD, a single Pulmonary Nodule, Atrial Fibrillation, Heart Failure, Type 2 Diabetes, Morbid Obesity, Major Depressive disorder, acute and chronic respiratory failure with hypoxia, and obstructive uropathy. Review of the MDS assessment for Resident #57 dated 3/18/24 reflected a BIMS score of 15 indicating normal cognitive function. His physical assessment reflected he required supervision or one person assistance for all ADLs. He was assessed as occasionally incontinent of bowel and had a Foley catheter in place. Review of the Care Plan for Resident #57 reflected interventions were in place for: drug allergies, DNR status, ADL self-performance deficit r/t Dementia, Limited mobility d/t heart failure, Refusing to wear BiPAP breathing assist, Diabetes, Fall Risk, Foley catheter, behavior of Insomnia, Rash to right back r/t Herpes zoster (Shingles), Oxygen therapy. No changes related to diagnosis of UTI, Antibiotics or confused behaviors. Review of Progress Notes for Resident #57 reflected on 5/23/24 he demonstrated increased level of confusion. On 5/23/24 the Nurse Practitioner changed the antibiotic for the UTI to Cipro 500 mg twice a day. On 5/21/24 the resident was sent to hospital after a fall without injury. He was observed by staff on the floor face down and his brief was around his ankles. Resident #57 stated he had turned off his oxygen concentrator because a doctor was in the room talking to him. On 5/20/24 the resident was continued on Keflex antibiotic 500 mg every 12 hours and Valacyclovir 500 mg every 8 hours for Shingles. On 5/19/24 Resident #57's antibiotic was changed to Keflex 500 mg every 12 hours for UTI. Resident #57 was previously sent to hospital on 5/18/24 for confusion and shaking. On 5/21/24 at 9:25 Resident#57 was observed lying in bed incontinent of stool with his brief pulled down exposing his buttocks. Resident did not respond to voice. Observation at 10:47 am on 5/21/24 revealed Resident #57 had fallen from his bed to the floor. He was face down on the floor with his brief around his ankles. His catheter remained in place, draining clear yellow urine. Two staff were at bedside attempting to assist him. LVN C and a NA, Charge Nurse/ LVN E entered the room. He stated Resident #57 was confused and had become more confused since yesterday. He stated Resident #57 had gone out to hospital for a Shingles infection this weekend and they also diagnosed a UTI, he was receiving antibiotics for both. The Resident stated he had slipped in water at bedside attempting to reach pants on his bedside table. No pants were visible on the bedside table. Resident argued with staff some as they put down towels to soak up water. The charge nurse stated Resident #57 may need to return to hospital for evaluation. In an interview on 5/21/24 at 11:10 am LVN C stated he was summoned to Resident #57's room by a housekeeper who stated he had fallen. LVN C stated he had not worked with Resident #57 for a while, but he was definitely more confused than normal. He stated Resident #57 indicated he was not hurt in the fall. LVN C stated Resident #57 was able to sit up and then sat in his wheelchair to transfer back to bed. LVN C stated Resident #57 had cardiac and respiratory problems which limited his ability to perform ADLs. In an interview on 5/23/24 at 8:55 am Resident #57 stated he was unsure why he had removed his clothing and his brief prior to his fall. Resident #57 stated he did not recall the fall; he stated his confusion could be related to his UTI or his Shingles outbreak. Observation revealed his Foley catheter was draining clear yellow urine. Resident #57 was receiving a breathing/nebulizer treatment at the time of the interview. In an interview on 5/23/24 at 9:30 am LVN A stated Resident #57 had a history of removing his briefs. She stated she was not sure if the behavior was related to his dementia or his recent UTI. In an interview on 5/23/24 at 9:35 am the DON stated the facility had been actively watching Resident #57. She stated he was sent to hospital the first time for a UTI, but the antibiotics prescribed did not yield the desired effect. She stated he was sent out a second time on 5/21/24 after he fell from bed. The DON stated Resident #57 was monitored because he had a Foley catheter. The DON stated his behavior could be added to care plan pointing out his fall was the first incident of #57 removing his brief she had found. The DON stated staff should have followed policy and covered Resident #57 to protect his dignity. In an interview on 5/23/24 at 11:50 am the Administrator stated Resident #57 came down with a UTI on 5/18/24 and was sent out to hospital. She stated interventions could have been added to deal with his confusion, disrobing behaviors and other symptoms of the UTI. She stated other than the fall on 5/21/24 no other falls were noted for Resident #57, the surveyor pointed out he was listed as a high fall risk. The Administrator stated when Resident #57 was observed with his brief down around his ankles or incontinent of bowel staff should have taken action to protect his dignity. She stated the door should have been closed during care, curtains pulled, and the resident covered. Surveyor stated after Resident #57 fell three staff were in the room (C, [NAME], A) and no one took measures to protect the resident's dignity. She stated staff should have responded to the situation wholly. Review of the Facility's Care Plan Development Policy dated October 2022 reflected the care plan must be updated within 7 days of a comprehensive MDS assessment. The facility's rational for proceeding with care planning will be evidenced in the clinical record (such as a change in condition).

Based on observations, record review, and interviews the facility failed to update the Resident's (#57) care plan in relation to changes in health, changes in behavior and significant changes for one (Resident #57) out of 8 residents reviewed. The facility failed to update Resident #57's care plan and adjust it in relation to physician orders. The deficient practice could affect residents by delaying treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of the Face Sheet for Resident #57 reflected he was admitted on [DATE] with diagnosis of: COPD, a single Pulmonary Nodule, Atrial Fibrillation, Heart Failure, Type 2 Diabetes, Morbid Obesity, Major Depressive disorder, acute and chronic respiratory failure with hypoxia, and obstructive uropathy. Review of the MDS assessment for Resident #57 dated 3/18/24 reflected a BIMS score of 15 indicating normal cognitive function. His physical assessment reflected he required supervision or one person assistance for all ADLs. He was assessed as occasionally incontinent of bowel and had a Foley catheter in place. Review of the Care Plan for Resident #57 reflected interventions were in place for: drug allergies, DNR status, ADL self-performance deficit r/t Dementia, Limited mobility d/t heart failure, Refusing to wear BiPAP breathing assist, Diabetes, Fall Risk, Foley catheter, behavior of Insomnia, Rash to right back r/t Herpes zoster (Shingles), Oxygen therapy. No changes related to diagnosis of UTI, Antibiotics or confused behaviors. Review of Progress Notes for Resident #57 reflected on 5/23/24 he demonstrated increased level of confusion. On 5/23/24 the Nurse Practitioner changed the antibiotic for the UTI to Cipro 500 mg twice a day. On 5/21/24 the resident was sent to hospital after a fall without injury. He was observed by staff on the floor face down and his brief was around his ankles. Resident #57 stated he had turned off his oxygen concentrator because a doctor was in the room talking to him. On 5/20/24 the resident was continued on Keflex antibiotic 500 mg every 12 hours and Valacyclovir 500 mg every 8 hours for Shingles. On 5/19/24 Resident #57's antibiotic was changed to Keflex 500 mg every 12 hours for UTI. Resident #57 was previously sent to hospital on 5/18/24 for confusion and shaking. Observation and interview at 10:47 am on 5/21/24 revealed Resident #57 had fallen from his bed to the floor. He was face down on the floor with his brief around his ankles. His catheter remained in place, draining clear yellow urine. Two staff were at bedside attempting to assist him. LVN C and a NA, LVN E entered the room. He stated Resident #57 was confused and had become more confused since yesterday. He stated Resident #57 had gone out to hospital for a Shingles infection this weekend and they also diagnosed a UTI, he was receiving antibiotics for both. The Resident stated he had slipped in water at bedside attempting to reach pants on his bedside table. No pants were visible on the bedside table. Resident #57 argued with staff some as they put down towels to soak up water. In an interview on 5/21/24 at 11:10 am LVN C stated she was summoned to Resident #57's room by a housekeeper who stated Resident #57 had fallen. LVN C stated he had not worked with Resident #57 for a while, but he was definitely more confused than normal. He stated Resident #57 indicated he was not hurt in the fall. LVN C stated Resident #57 was able to sit up and then sat in his wheelchair to transfer back to bed. LVN C stated Resident #57 had cardiac and respiratory problems which limited his ability to perform ADLs. The LVN C stated Resident #57 may need to return to hospital for evaluation. In an interview on 5/23/24 at 8:55 am Resident #57 stated he was unsure why he had removed his clothing and his brief prior to his fall. Resident #57 stated he did not recall the fall; he stated his confusion could be related to his UTI or his Shingles outbreak. Observation revealed his Foley catheter was draining clear yellow urine. Resident #57 was receiving a breathing/nebulizer treatment at the time of the interview. In an interview on 5/23/24 at 9:30 am LVN A stated Resident #57 had a history of removing his briefs. She stated she was not sure if the behavior was related to his dementia or his recent UTI. In an interview on 5/23/24 at 9:35 am the DON stated the facility had been actively watching Resident #57. She stated he was sent to hospital the first time for a UTI, but the antibiotics prescribed did not yield the desired effect. She stated he was sent out a second time on 5/21/24 after he fell from bed. The DON stated Resident #57 was monitored because he had a Foley catheter. The DON stated his behavior could be added to care plan pointing out his fall was the first incident of #57 removing his brief she had found. The DON stated staff should have followed policy and covered Resident #57 to protect his dignity. In an interview on 5/23/24 at 11:50 am the Administrator stated Resident #57 came down with a UTI on 5/18/24 and was sent out to hospital. She stated interventions could have been added to deal with his confusion, disrobing behaviors and other symptoms of the UTI. She stated other than the fall on 5/21/24 no other falls were noted for Resident #57, the surveyor pointed out he was listed as a high fall risk. The Administrator stated when Resident #57 was observed with his brief down around his ankles or incontinent of bowel staff should have taken action to protect his dignity. She stated the door should have been closed during care, curtains pulled, and the resident covered. Surveyor stated after Resident #57 fell three staff were in the room (C, [NAME], A) and no one took measures to protect the resident's dignity. She stated staff should have responded to the situation wholly. Review of the Facility's Care Plan Development Policy dated October 2022 reflected the care plan must be updated within 7 days of a comprehensive MDS assessment. The facility's rational for proceeding with care planning will be evidenced in the clinical record (such as a change in condition).

Based on observations, interviews, and record review, the facility failed to have all residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, for 1 of 3 (Resident # 54) residents reviewed for edema care. The facility failed to follow physician orders, the comprehensive care plan, and provide treatment for Resident #54's edema. This failure could place residents at risk for untreated medical issues and diminished quality of care. Findings included: Record review of Resident # 54's face sheet dated 05/22/2024 reflected a [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] with a diagnoses of pain in the right foot (a localized or generalized unpleasant bodily sensation or complex of sensations that causes mild to severe physical discomfort), need for assistance with personal care (anything that a person needs to maintain hygiene, well-being, self-esteem, and dignity), essential hypertension (is often due to obesity, family history, and an unhealthy diet), and hemiplegia unspecified affecting right dominant side (paralysis or the right side of the body after injury to the brain or spinal cord). Record review of Resident #54's Quarterly MDS assessment dated [DATE] reflected Resident #54 had a BIMS score of 9, which indicated moderately impaired cognition. Resident #54 was assessed for not rejecting care. She required assistance with ADLs such as: personal hygiene, toileting, showers, upper and lower body dressing, putting on/taking off footwear, transfers, and oral hygiene. Record review of Resident #54's Comprehensive Care Plan revised on 05/14/2024 reflected Resident #54 had ADL self -care performance deficit related to impaired balance and limited mobility. Intervention: resident required assistance with bathing, bed mobility, dressing, eating, personal hygiene, toileting, and transfers. Resident #54 had hypertension and was at risk for hypotensive (blood pressure suddenly becomes low) or hypertensive crisis (blood pressure suddenly becomes high). Intervention: give medications as ordered. Monitor for and document any edema. Resident #54 was assessed to require diuretic therapy related to edema. Interventions: Administer diuretic medications as ordered. Compression socks one time a day for BLE edema (date initiated on 03/21/2024). Observation on 05/21/2024 at 9:50 AM revealed Resident #54 was lying in bed in her room. She kept pointing to her feet. Resident's right foot and right leg had edema. In an interview on 05/21/2024 at 9:52 AM Resident #54 stated yes when asked if her leg felt swollen. Resident #54 would only respond to yes/ no type questions. She stated no when asked if she was in pain. Record review on 05/21/2024 at 11:05 AM of Resident #54's Physician Orders last review date of 05/08/2024 reflected Resident #54 had edema with a start date of 12/13/2023. She also had a physician order for compression socks -Large, 10mmHG compression- on in the AM, off in the PM (start date 03/02/2024). Record review on 05/21/2024 at 11:15 AM of Resident #54's Skilled Administration Record in the electronic medical record dated 05/01/reflected Resident #54 was scheduled to have compression socks (large, 10mmHG compression -in the AM, off in the PM. One time a day for BLE edema and remove per schedule. Apply 7:00 AM and Remove 7:00 PM start date 03/02/2024. It was documented on 5/21/2024 a nurse applied compression socks on Resident #54 at 7:00 AM. Observation on 05/21/2024 at 11:24 AM revealed Resident #54 was sitting outside on the front porch. She had on bright yellow non-skid house sock on her right leg. She was not wearing compression socks on her left or her right leg. Resident #54's right leg was swollen and was propped on the wheelchair leg rest. Resident #54 will respond to yes/no type questions. However, she does not elaborate on any of her responses. In an interview on 05/21/2024 at 11:26 AM Resident #54 stated no when asked if she was wearing her hose/socks to prevent her legs from swelling. She also stated no when asked if she refused to wear the compression socks or did someone take the compression socks off of her earlier in the day. She did not respond to any other questions about the staff or her compression socks. Observation on 05/21/2024 at 1:53 PM Resident #54 revealed she was sitting in her wheelchair on the front porch. The activity director was asking Resident #54 if she wanted to attend bingo. Resident #54 was wearing a bright yellow nonskid sock on her right leg. Resident #54's right leg was swollen. In an interview on 05/21/2024 at 1:55 PM the Activity Director stated the sock Resident #54 was wearing on her right leg was a non-skid sock to keep her from falling. Observation on 05/21/2024 at 3:55 PM revealed Resident #54 was sitting in her wheelchair on the front porch wearing bright yellow non-skid sock on her right leg. Observation and interview on 05/22/2024 at 7:15 AM revealed Resident #54 was in bed and kept pointing to her feet. She was not wearing her compression socks. Resident #54 stated no when asked if she was in pain. She also stated yes when asked if she wore special hose for her feet and legs to help with the swelling. She stated no when asked if the staff placed the hose on her every day. Resident #54 did not respond to other questions about the hose or how many days she did not wear the compression socks. She stated no when asked if she was wearing the hose yesterday. Observation and interview on 05/22/2024 at 8:05 AM revealed Resident #54 was in bed and pointed to her feet. She was not wearing her compression socks. Her right leg was swollen. Resident #54 stated no when asked if she was in pain. She stated no when asked if anyone offered to place the socks on her feet to keep them from swelling. Resident #54 stated yes when asked if she wore special compression socks. She stated yes when asked if the compression socks were white. Record review on 5/22/2024 at 9:10 AM of Resident #54's Skilled Administration Record in the electronic medical record dated 05/2024 reflected Resident #54 was scheduled to have compression socks (large, 10mmHG compression -in the AM, off in the PM. One time a day for BLE edema and remove per schedule. Apply 0700 AM and Remove 1900 PM start date 03/02/2024. A nurse did not document compression socks were applied to Resident #54's right and left legs. Observation and interview on 05/22/2204 at 9:15 AM revealed Resident #54 was lying in bed and was not wearing compression socks. Resident #54 stated no when asked if anyone came in her room to offer to place her compression socks on her feet to help with her feet and legs from swelling. She smiled and stated, no no no. When asked her what color the socks were to keep her feet from swelling, she stated white. Resident #54 stated no when asked if she refused today not to wear the compression socks. Observation and interview on 05/22/2024 at 9:47 AM revealed Resident #54 was lying in bed. She was not wearing compression socks. Resident #54's right leg was swollen. She stated no when asked if she was in pain. Resident #54 stated no when asked if anyone attempted to place her socks on her feet to keep them from swelling. She also stated white when asked the color of the socks the nurses placed on her feet to prevent her feet from swelling. Observation and interview on 05/22/2024 at 10:53 AM revealed Resident #54 was sitting outside in her wheelchair. Her right foot was propped on the wheelchair leg rest. Resident #54 was wearing a bright pink non-skid sock. Resident #54 stated no when asked if this was the sock the nurses put on to keep her feet from swelling. She stated color white when asked what color the socks were, that she wore to keep feet and legs from swelling. Resident #54 stated no when asked if anyone had attempted to put the white color socks on her feet prior to placing the pink sock on her right foot. Record review on 05/22/2024 at 12:30 PM of Resident #54's reflected Skilled Administration Record in the electronic medical record dated 05/24/2024 reflected Resident #54 was scheduled to have compression socks (large, 10mmHG compression -in the AM, off in the PM. One time a day for BLE edema and remove per schedule. Apply 0700 AM and Remove 7:00 PM start date 03/02/2024. It was documented on 5/22/2024 LVN A applied compression socks on Resident #54 at 7:00 AM. Observation and interview on 05/22/2024 at 12:50 PM Resident #54 was sitting outside on the front porch in her wheelchair. Her right foot was not propped on the wheelchair leg rest. Her right foot was swollen, and she had an indention in her right leg where the top of the non-skid sock was located on her leg (approximately 6 inches above her right ankle). Resident #54 stated no when asked if she was in pain. She stated no when asked if anyone attempted to place the white socks to prevent her legs from swelling on her feet today. She also stated no when asked if she refused wearing the white socks yesterday or today. Observation and interview on 05/22/2024 at 1:00 PM LVN A observed Resident #54 (sitting on the front porch) feet and legs. She stated the pink sock was a non-skid sock the residents wear to prevent falls. LVN A stated Resident #54 wore these socks frequently. In an interview on 05/22/2024 at 1:04 PM LVN A stated Resident #54 was expected to wear compression socks on both feet. She stated Resident #54's order was to place the compression socks on both feet at 7:00 AM and remove the compression socks at night. LVN A stated she did not observe Resident #54 prior to documenting she applied the compression socks on 05/22/2024. She also stated she did not know whether Resident #54 had the compression socks on her feet or not when she documented on the electronic medical form. LVN A stated she was required to observe Resident #54 and place the compression socks on her feet. LVN A stated she became busy and forgot to go observe Resident #54 and documented she had the compression socks on her feet. LVN A stated it was her responsibility to place the compression socks on Resident #54. She also stated she made a mistake, and she was responsible for Resident #54 not having the compression socks on both feet. LVN A also stated Resident #54's right leg was swollen and there was an indent in her right leg at the top of where the nonskid sock was located on the right leg. LVN A stated if Resident #54 did not wear compression socks there was a possibility her leg may become more swollen, she may develop a wound, and/or she may have severe pain. LVN A stated Resident #54 may need to be transferred to the hospital for further evaluation. She also stated if Resident #54 had compression socks on the staff would not remove the socks without consulting with her. She stated no one had reported to her they applied the compression socks or removed the compression socks. LVN A stated Resident #54 did not have on the compression socks. She also stated she was not aware of Resident #54 refusing to wear compression socks. She stated if a resident refused care it would be documented in the nurses' notes, on their care plan, and on the MAR or the skilled administration record. LVN A also stated Resident #54 loved to sit outside and she did not always keep her right foot on the wheelchair footrest. She stated with Resident #54 sitting outside and not wanting to leave her foot on the footrest. This was also an issue due to Resident #54's feet and legs become more swollen and the compressed socks would help prevent her legs from swelling. LVN A stated she did not follow Resident #54's physician order or care plan on 5/22/2024. She stated the compression socks color was white. In an interview on 05/22/2024 at 1:46 PM the Assessment Nurse stated all nurses were required to follow physician orders. She stated if Resident #54 had a physician order to wear compression hose on BLE the nurses were expected to follow the physician order. She also stated if it was on the skilled administration record to apply the compression hose at 7:00 AM, the nurse was expected to apply the compression socks at the following times between 6:00 AM and 9:00 AM. She stated the nurse had an hour before and hour after 7:00 AM to apply the compression socks. She also stated if Resident #54 was not wearing her compression socks there was a potential Resident #54 may develop a wound or may have redness on the skin of her legs and feet. Assessment Nurse also stated if Resident #54 refused to wear the compression socks it would be documented in the nurses' notes, care plan, and the skilled administration record. She stated she was not aware of Resident #54 refusing to wear compression socks. She stated anytime a resident refused any type of care including compression socks it would be discussed during the morning meeting. She stated she would document on Resident #54's care plan she refused to wear compression socks. In an interview on 05/22/2024 at 2:20 PM The Director of Nurses stated her expectations were all nurses to follow the physician orders at all times. She stated LVN A was expected to observe Resident #54 prior to documenting anything on the skilled administration record if the compression socks had been applied to Resident #54. She stated it was her expectation for the nurse to apply the compression socks to Resident #54. The Director of Nurses also stated LVN A did not follow the physician orders or the care plan. She stated it was imperative for all Residents to receive the care the physician had ordered every day. The Director of Nurses also stated if Resident #54 was not wearing her compression socks there was a possibility Resident #54's edema on her legs and feet might become worse and she may develop a wound. She stated it was her responsibility to monitor the nurses. The Director of Nurses also stated if Resident #54 refused to wear the compression socks the nurse would document the refusal on the skilled administration record. She stated the nurses would document it in the nurses notes if Resident #54 wanted the compression socks off her feet during the day. She stated it was her expectations for all refusals to be documented in the electronic medical record on the appropriate form and in the nurses' notes. She stated she was not aware of Resident #54 refusing to wear compression socks. She stated she would look to find a policy for not following physician orders. (Policy not provided at time of exit). Record review of Resident #54's Nurses Notes on 05/23/2024 at 8:15 AM reflected Resident #54 did not refuse compression socks for the month of May 2024, and she did not ask anyone to remove the compression socks. In an interview on 05/23/2024 at 9:16 AM the Administrator stated all nurses were expected to follow the physician orders. She stated if there was an issue with the resident not complying with the physician order, the nurse was expected to call the physician and document accordingly. The Administrator stated LVN A was expected to visibly see Resident #54 to ensure Resident #54 was wearing compression socks prior to documenting the compression socks had been applied to Resident #54. She also stated if Resident #54 was not wearing compression socks there was a potential for her legs to increase with swelling and Resident #54 may develop discomfort to her legs. She stated it was the Director of Nurses responsibility to monitor the nurses and it was her responsibility to monitor all staff. In an interview on 05/23/2024 at 10:30 AM CNA E stated she had not observed Resident #54 refusing compression socks. She stated she did not notice if Resident #54 had compression socks on today. She stated the nurse usually placed the compression socks on Resident #54. In an interview on 05/23/2024 at 10:44 AM LVN B stated he had not witnessed Resident #54 refusing compression socks. He stated he was not assigned to Resident #54's hall today and did not know if she was wearing compression socks.

Based on observation, interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of 12 residents reviewed. The facility failed to ensure Resident #1 received effective treatment of pain which resulted in Resident #1 having untreated pain of 10/10. These failures resulted in an Immediate Jeopardy (IJ) situation on 04/10/2023. While the IJ was removed on 04/13/2023 the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place the resident at risk of medical complications, untreated pain and harm. Findings included: Review of Resident #1's face sheet dated 04/10/2023 revealed Resident #1 was admitted to the facility on [DATE] with a diagnoses of alcoholic cirrhosis of the liver without ascites (alcohol-induced liver disease that does not have fluid build-up in the abdomen), liver cell carcinoma (liver cancer), esophageal varices with bleeding (enlarged veins in the esophagus, the tube the that connects the throat and stomach) and dysphagia (difficulty swallowing). Review of Resident #1's Baseline Care Plan dated 04/03/2023 revealed Resident #1 had an ADL self-care performance deficit related liver cell carcinoma and pain. Resident #1 required extensive assistance for bathing/showering, bed mobility, personal hygiene and toileting. Resident #1 was noted to be under the care of hospice and his level of consciousness was noted to be alert and cognitively intact. Resident #1 was on pain medication therapy (SPECIFY medication) related [not specified] with a goal of the resident will be free of any discomfort or adverse side effects from pain medications through the review date. Interventions included administer analgesic medications as ordered by physician, monitor and document side effects and effectiveness every shift. In addition, Pain Care Planning the goal was the resident will voice a level of comfort from pain through the review date with the intervention to monitor/document for side effects of pain medication and signs/symptoms of non-verbal pain. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/09/2023 hydrocodone-acetaminophen 10-325 MG tablet with instructions to give one tablet every four hours as needed for pain. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/07/2023 hydrocodone-acetaminophen 10-325 MG tablet with instructions to give one tablet four times a day for pain. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/02/2023 morphine sulfate (concentrate) oral solution with instructions to give 0.25 ml by mouth every 1 hours as needed for pain and shortness of breath. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/02/2023 morphine sulfate (concentrate) oral solution with instructions to give 0.5 ml by mouth every 1 hours as needed for pain and shortness of breath. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/02/2023 morphine sulfate (concentrate) oral solution with instructions to give 0.75 ml by mouth every 1 hours as needed for pain and shortness of breath. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/02/2023 morphine sulfate (concentrate) oral solution with instructions to give 1.0 ml by mouth every 1 hours as needed for pain and shortness of breath. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/05/2023 acetaminophen suppository 650 mg with instructions to insert one suppository rectally every 12 hours as needed for pain. In an observation on 04/10/2023 at 8:11 AM, Resident #1 was in bed lying on his side facing the wall and was not wearing clothing. Resident #1's backside was visible from the doorway of the room. TX Nurse adjusted Resident #1's catheter and then closed the door to his room. In a follow-up observation and interview on 04/10/2023 at 8:15 AM, Resident #1 stated he guessed he was alright. When asked additional questions, he would answer yeah, yeah. He was pleasantly confused. In an interview on 04/10/2023 at 9:00 AM, Resident #1's RP's stated Resident #1 was treated horribly since being admitted to the facility. She stated staff do not care if Resident #1 dies with dignity. She stated there have been issues that she reported and were still unresolved. She stated Resident #1 was admitted under hospice care on 04/01/2023 and she stayed with him throughout that day. She stated she was unable to return to visit Resident #1 until 04/04/2023 and found him lying in his feces with no clothes on and he was very confused. She stated she met with facility administration on 04/06/2023 and thought issues with Resident #1's care was resolved. She said over the past weekend on 04/08/2023 Resident #1 fell and the facility notified the hospice nurse who then notified her. She called up to the facility and asked for information about what happened and LVN A said Resident #1 fell and that Resident #1 was fine. She stated she asked for additional information and LVN A would not give her any additional information about the circumstances around the fall. She stated the facility lost Resident #1's cell phone and she was unable to check on him. She stated she kept trying to call back to the facility find out if Resident #1 was okay as he was on hospice and Resident #1's RP was worried about whether he was comfortable. She stated she called the on call HOSPICE NURSE B and asked that HOSPICE NURSE B check on Resident #1. She stated HOSPICE NURSE B called back and LVN A refused to speak with Resident #1's RP anymore. She stated she became very upset and HOSPICE NURSE B agreed at 10:30 PM on 04/08/2023 to check on Resident #1 at the facility. She stated HOSPICE NURSE B called her later that night around 11:30 PM and said Resident #1 was in 10/10 pain upon arrival at the facility. HOSPICE NURSE B told her LVN A offered a Tylenol suppository for his pain which was not indicated for 10/10 pain. Resident #1's RP said she did not understand why the facility would not treat Resident #1 for pain in the last days of his life when Resident #1 was dying of liver cancer. She stated Resident #1 was a former veteran and deserved to die with dignity with no pain. She said she felt like the facility was trying to get her to move him to a different nursing home by not treating Resident #1 well. In an interview on 04/10/2023 at 9:18 AM, HOSPICE NURSE B stated she went to the facility on [DATE] around 11:00 PM after Resident #1's RP requested she check on Resident #1 because Resident #1 had a fall at the facility earlier that day. She stated upon arrival at the facility Resident #1 reported to be in pain at a 10/10 level. She told LVN A of his pain level and LVN A said all they had available to him was Tylenol suppository. She told LVN A the hospice physician would give an order for a stronger PRN pain medication as Resident #1 had PRN liquid morphine ordered but the family members did not want the liquid morphine given. She stated LVN A told even if HOSPICE NURSE B got the order for the PRN pain medication it would be tomorrow (04/11/2023) before the facility had the medication from the pharmacy. HOSPICE NURSE B stated she asked if LVN A could use the facility's medication e-kit for the PRN pain medication and LVN A said yes. HOSPICE NURSE B stated she did not know why LVN A had to be reminded that if a resident experienced 10/10 pain a doctor should be notified and PRN newly ordered medication could be given from the e-kit. She stated LVN A did not seem to take Resident #1's report of 10/10 pain seriously. She stated it felt like pulling teeth to get LVN A to administer the PRN pain medication to Resident #1. She stated she gave the order to LVN A and had to say please go to e-kit and get it. She stated the Tylenol suppository would never be indicated for 10/10 pain, especially in a resident dying of terminal liver cancer. In an interview on 04/10/2023 at 10:25 AM, the DON stated in regard to the issues with Resident #1 being in pain on the night of 04/08/2023 she stated LVN A told her she was the one to suggest an order for PRN medication from the e-kit and not HOSPICE NURSE B. The DON stated LVN A said when she assessed Resident #1 for pain that night, Resident #1 said to LVN A he had no pain. She stated she did not know why LVN A refused to speak with Resident #1's RP and his condition after the fall on 04/08/2023. She stated a Tylenol suppository would not be indicated for a 10/10 pain level. In an interview on 04/10/2023 at 2:00 PM, the ADON stated he assisted with Resident #1 care when Resident #1 was admitted to the facility. He stated HOSPICE NURSE B gave them a set of written orders for pain management and other comfort medications. He stated in regards to pain medication for Resident #1, if Resident #1 expressed a 10/10 pain level a Tylenol suppository would not be indicated. He stated a resident's physician will give guidelines regarding what type of pain medication would be indicated for varying levels of pain, for instance at a pain level of four or above a narcotic medication may be indicated. He stated if the resident did not have an appropriate PRN pain medication for 10/10 pain level then the nurse should page the doctor and the medication can be obtained from the e-kit. He stated morphine could have been used for Resident #1 but the family did not want morphine used unless absolutely necessary for Resident #1. An Immediate Jeopardy (IJ) was identified on 04/10/2023 at 4:30 PM, due to the above failures. The Administrator and the DON was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. In an observation on 04/11/2023 at 10:25 AM, HOSPICE NURSE E took the vital signs of Resident #1 and Resident #1 said his bottom and belly hurt bad. Resident #1 stated to HOSPICE NURSE E he was having bad bone pain and it was 10/10. He stated to HOSPICE NURSE E he would like a heating bad pad or warm towel. HOSPICE NURSE E went to nurse's station and notified LVN F of Resident #1 reporting 10/10 pain. In an observation on 04/11/2023 at 10:42 AM, Resident #1 was calling out nurse please help me I'm in real bad pain. In an observation on 04/11/2023 at 10:55 AM, LVN F administered Hydrocodone 10mg/325 mg crushed in applesauce to Resident #1. In an interview on 04/11/2023 at 10:57 AM, RNC G stated Resident #1's pain medication regimen would need to be reviewed again because his scheduled pain medication was not lasting between doses. She stated they were planning to speak with Resident #1's family about his possible need for morphine. In an observation on 04/11/2023 at 11:04 AM, Resident #1 was sitting up in bed calling for help due to the bad pain. In an interview on 04/11/2023 at 11:06 AM, the DON stated they contacted Resident #1's RP about giving morphine due to his high pain level at this time and Resident #1's RP gave consent for the morphine to be given. In an observation on 04/11/2023 at 11:12 AM, LVN F administered 1 ml of liquid morphine to Resident #1. In an interview on 04/11/2023 at 11:46 AM, RNC G stated Resident #1's mentation (mental activity) was changing throughout the day and it was difficult to tell when he was in pain. She said he would say he was in 10/10 pain and but later tell his RP he was not in pain. She stated regardless nurses should assess and address any reported pain and notify hospice if current pain regimen was not effective. In an observation and interview on 04/11/2023 at 12:23 PM, Resident #1 was sitting up in his wheelchair and showed no signs of distress. ST stated Resident #1 was to complete a bed side evaluation with his lunch and did not report any pain or appear to be distressed. Review of Resident #1 Nursing Pain Evaluation dated 04/03/2023 revealed Resident #1 complained of pain the last five days and interventions were effective. Resident #1 experienced pain score of 5 out of 10 and had general pain to all extremities, abdomen and buttocks. Review of Complaint/Grievance Follow-up Report dated 04/06/2023 received by the DON revealed Resident #1's RP expressed concern regarding multiple issues including Resident #1's pain medications not helping. The final resolution was hospice increased pain medication hydrocodone 10/325 mg from three times per day to four times per day. Review of Social Services progress note dated 04/06/2023 revealed Resident #1's RP requesting changes in pain medication stating Resident #1 is in pain and feels current regimen needs review. Resident #1 states he does not like morphine and feels most in pain around 4-5 PM. Hospice Nurse H alerted and came to facility to visit with this writer, RP and resident. During visit with Hospice Nurse H, Resident #1 denied any current pain. Review of Complaint/Grievance Follow-up Report dated 04/06/2023 received by the ADMIN revealed Resident #1 RP2 expressed concern Resident #1 was in a lot of pain, wants more pain medications. Review of Resident #1 Nursing progress notes dated 04/08/2023 at 8:15 PM revealed heard Resident #1 yelling for help. Upon entering room noted resident lying on floor mat with blanket behind head. Asked if resident had any pain. Repeated he was fine. No moaning, groaning, grimacing, or guarding noted. Review of Resident #1 Nursing Pain Evaluation dated 04/08/2023 at 8:15 PM revealed Resident #1 had not complained of pain in the last five days. No further questions were answered on the evaluation. Review of Resident #1 Nursing Pain Evaluation dated 04/10/2023 revealed Resident #1 had not complained of pain the last five days. Review of Resident #1 Nursing progress notes dated 04/09/2023 at 12:40 AM documented by LVN A, revealed HOSPICE NURSE B in facility for follow up visit related to fall. Per HOSPICE NURSE B during assessment resident reporting 10/10 to bottom. Received new order for: Hydrocodone/apap 10/325 mg one tablet orally (crushed) every four hours for pain. RP aware of order currently on phone with HOSPICE NURSE B at time of visit when order given . Upon the nurse assessment resident declined bottom hurting 10/10. Although resident did report all over body pain. Administered PRN medication as per MD order. Review of Medication Administration Policy dated 10/24/2022 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of Pain Management Policy dated 08/15/2022 revealed the facility must ensure that pain management is provided to resident who require such services . 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain . The Plan of Removal was accepted on 04/13/2023 at 8:10 AM and is as follows: LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On April 10, 2023, at approximately 4:30pm the Administrator was notified by the surveyor that an Immediate Jeopardy had been called for Resident #1. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag: 760 Significant Medication Error Identify residents who could be affected Fourteen residents with orders for Lactulose Problem: The facility did not administer Lactulose to resident #1. Action Taken: Effective immediately on 4/10/2023, the DON reviewed orders for resident #1 to ensure order for Lactulose was in place. Fourteen residents are noted with orders for Lactulose. o The DON/designee will review and be responsible for monitoring new orders including those for admissions/readmissions and validating that orders are transcribed correctly during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing Effective immediately on 4/10/2023, DON audited resident #1's chart to ensure an order for prn Hydrocodone- Acetaminophen was in place. o The DON/designee reeducated facility nurses on obtaining prn orders when indicated, medication administration, medication reconciliation, and facility emergency kit. The DON/designee will be responsible for continued reeducation of facility nurses on topics above. Start date 4/10/2023 and ongoing. ? Reviewed and monitored by Administrator and DON. Start date 4/10/2023 and ongoing. o The DON/designee will review and be responsible for monitoring administration of prn medication use during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/11/2023 and ongoing. ? Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing. Effective immediately on 4/10/2023, the DON/Assessment Nurse conducted medication order reconciliation for all thirteen residents on hospice services to ensure all medications were accounted for and match physician's orders. Medication order reconciliation was started on 4/10/2023 and finished on 4/11/2023 in the am. o The DON/designee will review and be responsible for monitoring new orders including those for admissions/readmissions during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing Effective immediately on 4/10/2023, the Assessment Nurse completed a pain evaluation on resident #1. o The DON/designee reeducated facility nurses assessing a resident for pain and providing consideration for administering pain medications for prn use. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/10/2023 and ongoing Effective immediately on 4/10/2023, the Administrator/Assessment Nurse reeducated contracted hospice companies on process for sending orders via fax and confirming receipt via phone. Five hospice companies are noted to be contracted with the facility and were all reeducated on the above process. Reeducation started 4/10/2023 and was completed 4/11/2023. o The Administrator/designee will educate any new hospice company onboarded in the future and will monitor compliance with above process. Start date 4/11/2023 and ongoing Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 4/10/2023. The Administrator will review the follow up findings from this plan with the Medical Director weekly. Involvement of QA: On 4/10/2023 an Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, Regional Clinical Specialist, Assistant Director of Nursing, Assessment Nurse, Regional [NAME] President of Operations, and Pharmacy Consultant to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the new process. The new process/system was started on 4/11/2023. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 4/10/2023. Monitoring was completed from 04/13/2023 and was as follows: In an interview on 04/13/2023 at 10:09 AM, LVN D stated she received education regarding physician order process at the facility. She stated she would read and confirm the order and confirm the right patient, right time, right route etc before administering medication. She stated if a resident was out of medication or needed a PRN medication immediately, they could use medication from the e-kit. LVN D stated she was educated for assessing a resident for pain and administering pain medications for PRN use. LVN D stated she was educated regarding medication reconciliation and ensuring physician orders matched the prescription order. In an observation and interview on 04/13/2023 at 10:15 AM, Resident #1 was in bed wearing clothes with no visible signs of distress. He reported no pain and did not need anything. In an interview on 04/13/2023 at 10:25 AM, LVN J stated he received education regarding medication administration, medication reconciliation and use of the e-kit medication if a medication was unavailable. He stated he received education on assessing a resident's pain level and using non-verbal cues if needed. In an interview on 04/13/2023 at 11:24 AM, LVN K stated she received education regarding pain assessments and paging doctor if a PRN medication was indicated. She stated if they did not have the medication she would use the e-kit. She received education regarding medication reconciliation in comparison with physician orders to ensure residents received the medication they needed. Interviews with additional medication aides on 04/13/2023 revealed they would notify charge nurse if a resident complained of pain. Staff would notify charge nurse if a resident was out of a medication and the nurse could access the medication from the e-kit. Review of Resident #11 Nursing Pain Evaluation dated 04/11/2023 revealed Resident #1 complained of pain the last five day and interventions were effective. Review of QAPI Action Team Report dated 04/10/2023 revealed QAPI team members held an ad hoc QAPI meeting regarding F-tag 760. Summary of data collection included: Medication administration audit report Medication summary report for all resident currently on hospice Medication cart audit to ensure medication availability Steps to resolution included: Medication cart audit Medication order reconciliation (with hospice) Staff education on medication reconciliation Medication Administration and Ekit Hospice companies educated on process for calling in/receiving medication orders Auditing of new orders for admissions/readmissions during daily clinical meetings Goal: To maintain compliance of pharmacy services and ensure that residents are free of any significant medication errors. Projected completion date: 04/11/2023 Review of Inservice Training Report dated 04/10/2023 - 04/13/2023 revealed Nursing training on Emergency Kit with summary of while waiting for ordered medications to arrive from pharmacy, nurses may use medication from e-kit on hand and follow-up with pharmacy until the medication is at hand. Utilize electronic e-kit for emergency control medication for control meds. Review of Inservice Training Report dated 04/10/2023 - 04/13/2023 revealed Nursing training on medication reconciliation and signed by nursing staff. There were a total of 50 staff who attended the training. Review of Inservice Training Report dated 04/10/2023 revealed Nursing training on medication administration and reconciliation policy and procedure. Completed by the DON. There were a total of 50 staff who attended the training. Review of Inservice Training Report dated 04/10/2023 revealed the ADMIN was educated on monitoring the facility's medication administration and reconciliation system. Review of Inservice Training Report dated 04/10/2023 revealed nursing staff educated regarding monitoring of medication administration/order process. Review of Inservice Training Report dated 04/11/2023 revealed education completed by nursing facility staff with hospice companies regarding if faxing orders call facility for confirmation of received. Preferred method is a telephone order or written order. On 04/13/2023 at 12:30 PM, the administrator was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated, due to the facility need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure that residents are free from any significant medication error for one resident (Resident #1) out of 12 residents reviewed for significant medication errors. The facility failed to ensure Resident #1 received lactulose as ordered by the physician which caused a rise in ammonia levels which was exhibited by Resident #1 having increased confusion and decreased cognition. These failures resulted in an Immediate Jeopardy (IJ) situation on 04/10/2023. While the IJ was removed on 04/13/2023 the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place the resident at risk of medical complications, not receiving the therapeutic effects of their medications and harm. Findings included: Review of Resident #1's face sheet dated 04/10/2023 revealed Resident #1 was admitted to the facility on [DATE] with a diagnoses of alcoholic cirrhosis of the liver without ascites (alcohol-induced liver disease that does not have fluid build-up in the abdomen), liver cell carcinoma (liver cancer), esophageal varices with bleeding (enlarged veins in the esophagus, the tube the that connects the throat and stomach) and dysphagia (difficulty swallowing). Review of Resident #1's Baseline Care Plan dated 04/03/2023 revealed Resident #1 had an ADL self-care performance deficit related liver cell carcinoma and pain. Resident #1 required extensive assistance for bathing/showering, bed mobility, personal hygiene and toileting. Resident #1 was noted to be under the care of hospice and his level of consciousness was noted to be alert and cognitively intact. Resident #1 was on pain medication therapy (SPECIFY medication) related [not specified] with a goal of the resident will be free of any discomfort or adverse side effects from pain medications through the review date. Interventions included administer analgesic medications as ordered by physician, monitor and document side effects and effectiveness every shift. In addition, Pain Care Planning the goal was the resident will voice a level of comfort from pain through the review date with the intervention to monitor/document for side effects of pain medication and signs/symptoms of non-verbal pain. Review of hospice physician orders dated 04/01/2023 revealed Resident #1 ordered Lactulose 10g/15 mL syrup effective date 04/01/2023 with instructions to give 15 mL by mouth twice a day. Review of fax confirmation page dated 04/01/2023 revealed physician orders faxed to [FACILITY FAX NUMBER] on 04/01/2023 with transmission complete 04/01/2023 at 7:33 PM with Job ID 838944911 and the status as Success. The document further revealed new orders for Lactulose 10g/15mL syrup effective date 04/01/2023 with instructions to give 15 mL by mouth twice a day. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/05/2023 lactulose oral solution 10GM/15ml with instructions to give 15 ml by mouth two times per day for cirrhosis (used to treat high blood levels of ammonia resulting from impaired liver function). In an observation on 04/10/2023 at 8:11 AM, Resident #1 was in bed lying on his side facing the wall and was not wearing clothing. Resident #1's backside was visible from the doorway of the room. TX Nurse adjusted Resident #1's catheter and then closed the door to his room. In a follow-up observation and interview on 04/10/2023 at 8:15 AM, Resident #1 stated he guessed he was alright. When asked additional questions, he would answer yeah, yeah. He was pleasantly confused. In an interview on 04/10/2023 at 9:00 AM, Resident #1's RP's stated Resident #1 was treated horribly since being admitted to the facility. She stated staff do not care if Resident #1 dies with dignity. She stated there have been issues that she reported and were still unresolved. She stated Resident #1 was admitted under hospice care on 04/01/2023 and she stayed with him throughout that day. She stated she was unable to return to visit Resident #1 until 04/04/2023 and found him lying his feces with no clothes on and he was very confused. She stated Resident #1 was not aware of his name and was not himself. She asked the charge nurse about his medications and thought maybe Resident #1 was given some type of sedative making him more confused. She said after reviewing Resident #1's medication list with the charge nurse she realized he was not receiving his lactulose medication and had not been receiving it since he was admitted to the facility. She said his increased confusion was due to the ammonia buildup from not having the lactulose medication. She said she was upset about him not receiving his medications as now he did not recognize her or other loved ones in the last days of his life. She stated the charge nurse said they did not receive the order for him to receive lactulose. She said Resident #1 suffered a fall with head laceration that required a trip to theER on [DATE]. Resident #1's RP said Resident #1 not having the lactulose likely caused him to fall due to increased confusion. She said he did not eat for three days from what the staff told her because he was so confused. She said she felt like the facility was trying to get her to move him to a different nursing home by not treating Resident #1 well. In an interview on 04/10/2023 at 9:18 AM, HOSPICE NURSE B was the on call nurse who admitted Resident #1 to the hospice agency on 04/01/2023 at the same time that he was admitted to the facility. She had the physician order the standard comfort medications for hospice residents and then texted the hospice physician about whether to order lactulose due to Resident #1 having liver failure. She stated Resident #1 was on lactulose at the hospital when he was discharged to the facility on [DATE]. She stated the hospice physician sent back to order the lactulose and she faxed the orders to the facility and called to confirm they received the orders. HOSPICE NURSE B stated the lactulose was ordered through the pharmacy and the medication wasn't time stamped when it was delivered but the order did say 04/01/2023. She said she did not know why Resident #1 did not receive the lactulose from 04/01/2023 - 04/04/2023. In an interview on 04/10/2023 at 10:25 AM, the DON stated she was unaware of the issues with Resident #1's lactulose not being given when he was admitted . She said the order was not received from the hospital or hospice for the lactulose to be given. She stated when a new resident was admitted the charge nurse reviewed the orders from the hospital and then entered the orders into the EMR. In an observation and interview on 04/10/2023 at 11:10 AM, CMA C stated there was no order for lactulose for Resident #1 when he was first admitted . She stated when she administered medications, the order would have popped up for the lactulose as she administered medications. She stated one day last week one of the hospice nurses wanted to review Resident #1's orders because he did not receive lactulose. She stated the hospice nurse was able to clarify with nursing staff the order for the lactulose with Resident #1 that day. The medication cart contained one bottle of lactulose dated 04/02/2023 prescribed to Resident #1. CMA C stated this was the second bottle of lactulose as the bottle was observed to be nearly full. In an interview on 04/10/2023 at 12:12 PM, the ADMIN stated they did not receive the order for the lactulose until 04/04/2023. She stated she brought a copy of the hand written orders that had not been scanned into the EMR from the admitting hospice nurse on 04/01/2023 and lactulose was not on the orders. She stated she was not aware of additional orders being sent over by the hospice nurse. She said if the hospice nurse did not follow their protocol for how orders were to be sent it was not their fault that a physician order was not received. She said she did not know whether the hospice nurse had followed the facility's protocol. She said all hospice providers know how to send physician orders either hand written in facility or a verbal over the phone. She said if they fax the order they should call afterward to verify it was received. She stated she and the DON were in the process of setting up a care plan meeting with Resident #1's RP because Resident #1's RP expressed multiple concerns regarding Resident #1's care. In an interview on 04/10/2023 at 12:29 PM, LVN D stated Resident #1's RP visited on Tuesday 04/04/2023 and thought Resident #1 was sedated because Resident #1 did not recognize Resident #1's RP and did not know his own name. She stated Resident #1's RP wanted to know what medications Resident #1 had been given. She stated there was no order for lactulose and they paged the hospice nurse who gave the order LVN D for the lactulose. She stated she was not at the facility when the lactulose was delivered. She said she was not sure when the first bottle of lactulose was delivered for Resident #1 to the facility. In an interview on 04/10/2023 at 12:53 PM, the HOSPICE MD stated lactulose was used to treat hepatic encephalopathy (loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage) caused by liver failure which causes a build up of ammonia in a resident's blood. He stated the buildup of ammonia causes severe and rapid decline in cognition but can be reversed with the administration of lactulose. He stated symptoms of the build up of ammonia in the blood were confusion, poor memory/cognition and possibly hallucinations. He stated he remembered giving the physician order for Resident #1 to have lactulose when he was admitted [DATE] to hospice as Resident #1 received lactulose while hospitalized . He stated HOSPICE NURSE B would have been responsible for relaying the order to the facility. In an interview on 04/10/2023 at 2:00 PM, the ADON stated he assisted with Resident #1 care when Resident #1 was admitted to the facility. He stated HOSPICE NURSE B gave them a set of written orders for pain management and other comfort medications. He stated there confusion with Resident #1's orders upon admission because the hospital sent no medication orders for Resident #1. He stated HOSPICE NURSE B did not arrive until later in the day on 04/01/2023 to give orders. He stated normally if a new resident was admitted without orders they would contact the hospital for orders. He stated they waited for the hospice agency to provide the orders since sometimes medications were not approved when a resident was on hospice. He stated there was not an order received for the lactulose upon admission. He stated he was unaware of fax received with the physician order for lactulose. He stated physician orders were received as verbal, written in person or by fax. An Immediate Jeopardy (IJ) was identified on 04/10/2023 at 4:30 PM, due to the above failures. The Administrator and the DON was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. Review of Resident #1's MAR dated April 2023 revealed Resident #1 received the first dose of lactulose at the facility on 04/05/2023 at 8:00 PM. In an interview on 04/11/2023 at 1:32 PM, the MED DIR stated physician order clarification can take time and lactulose was not a critical medication. He stated increased ammonia levels caused confusion from hepatic encephalopathy and caused a change in baseline mentation. He stated he could not say the importance of whether a resident at end of life might want to have less confusion and clearer mentation. He stated he could not say what impact it may have for Resident #1 and his family members visiting when it was noted Resident #1 could not recognize himself or them in the final stages of Resident #1's life after being admitted to the facility. He stated the facility was also starting Resident #1 on physical therapy and he did not see the point in that either when Resident #1 was on hospice. Review of Medication Administration Policy dated 10/24/2022 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of Hospice and Nursing Facility Service Agreement dated 04/01/2018 revealed all physician orders communicated to the nursing facility on behalf of Hospice in connection with Hospice Plan of Care shall either be in writing and signed by applicable attending physician, consulting physician, or hospice medical director or be communicated by the attending physician, consulting physician or hospice medical director orally or by facsimile transmission and promptly confirmed in writing thereafter. Review of Lactulose Medication from National Library of Medicine from the National Center of Biotechnology Information dated 07/11/2022 revealed Lactulose is used in preventing and treating clinical portal-systemic encephalopathy. Its chief mechanism of action is by decreasing the intestinal production and absorption of ammonia. It further revealed treatment with lactulose will reduce ammonia levels to decrease symptoms of encephalopathy which include confusion, decreased cognition and personality or mood changes. The Plan of Removal was accepted on 04/13/2023 at 8:10 AM and is as follows: LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On April 10, 2023, at approximately 4:30pm the Administrator was notified by the surveyor that an Immediate Jeopardy had been called for Resident #1. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag: 760 Significant Medication Error Identify residents who could be affected Fourteen residents with orders for Lactulose Problem: The facility did not administer Lactulose to resident #1. Action Taken: Effective immediately on 4/10/2023, the DON reviewed orders for resident #1 to ensure order for Lactulose was in place. Fourteen residents are noted with orders for Lactulose. o The DON/designee will review and be responsible for monitoring new orders including those for admissions/readmissions and validating that orders are transcribed correctly during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing Effective immediately on 4/10/2023, DON audited resident #1's chart to ensure an order for prn Hydrocodone- Acetaminophen was in place. o The DON/designee reeducated facility nurses on obtaining prn orders when indicated, medication administration, medication reconciliation, and facility emergency kit. The DON/designee will be responsible for continued reeducation of facility nurses on topics above. Start date 4/10/2023 and ongoing. ? Reviewed and monitored by Administrator and DON. Start date 4/10/2023 and ongoing. o The DON/designee will review and be responsible for monitoring administration of prn medication use during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/11/2023 and ongoing. ? Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing. Effective immediately on 4/10/2023, the DON/Assessment Nurse conducted medication order reconciliation for all thirteen residents on hospice services to ensure all medications were accounted for and match physician's orders. Medication order reconciliation was started on 4/10/2023 and finished on 4/11/2023 in the am. o The DON/designee will review and be responsible for monitoring new orders including those for admissions/readmissions during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing Effective immediately on 4/10/2023, the Assessment Nurse completed a pain evaluation on resident #1. o The DON/designee reeducated facility nurses assessing a resident for pain and providing consideration for administering pain medications for prn use. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/10/2023 and ongoing Effective immediately on 4/10/2023, the Administrator/Assessment Nurse reeducated contracted hospice companies on process for sending orders via fax and confirming receipt via phone. Five hospice companies are noted to be contracted with the facility and were all reeducated on the above process. Reeducation started 4/10/2023 and was completed 4/11/2023. o The Administrator/designee will educate any new hospice company onboarded in the future and will monitor compliance with above process. Start date 4/11/2023 and ongoing Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 4/10/2023. The Administrator will review the follow up findings from this plan with the Medical Director weekly. Involvement of QA: On 4/10/2023 an Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, Regional Clinical Specialist, Assistant Director of Nursing, Assessment Nurse, Regional [NAME] President of Operations, and Pharmacy Consultant to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the new process. The new process/system was started on 4/11/2023. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 4/10/2023. Monitoring was completed from 04/13/2023 and was as follows: In an interview on 04/13/2023 at 10:09 AM, LVN D stated she received education regarding physician order process at the facility. She stated she would read and confirm the order and confirm the right patient, right time, right route etc before administering medication. She stated if a resident was out of medication or needed a PRN medication immediately, they could use medication from the e-kit. LVN D stated she was educated for assessing a resident for pain and administering pain medications for PRN use. LVN D stated she was educated regarding medication reconciliation and ensuring physician orders matched the prescription order. In an observation and interview on 04/13/2023 at 10:15 AM, Resident #1 was in bed wearing clothes with no visible signs of distress. He reported no pain and did not need anything. In an interview on 04/13/2023 at 10:25 AM, LVN J stated he received education regarding medication administration, medication reconciliation and use of the e-kit medication if a medication was unavailable. He stated he received education on assessing a resident's pain level and using non-verbal cues if needed. In an interview on 04/13/2023 at 11:24 AM, LVN K stated she received education regarding pain assessments and paging doctor if a PRN medication was indicated. She stated if they did not have the medication she would use the e-kit. She received education regarding medication reconciliation in comparison with physician orders to ensure residents received the medication they needed. Interviews with additional medication aides on 04/13/2023 revealed they would notify charge nurse if a resident complained of pain. Staff would notify charge nurse if a resident was out of a medication and the nurse could access the medication from the e-kit. Review of Resident #11 Nursing Pain Evaluation dated 04/11/2023 revealed Resident #1 complained of pain the last five day and interventions were effective. Review of QAPI Action Team Report dated 04/10/2023 revealed QAPI team members held an ad hoc QAPI meeting regarding F-tag 760. Summary of data collection included: Medication administration audit report Medication summary report for all resident currently on hospice Medication cart audit to ensure medication availability Steps to resolution included: Medication cart audit Medication order reconciliation (with hospice) Staff education on medication reconciliation Medication Administration and Ekit Hospice companies educated on process for calling in/receiving medication orders Auditing of new orders for admissions/readmissions during daily clinical meetings Goal: To maintain compliance of pharmacy services and ensure that residents are free of any significant medication errors. Projected completion date: 04/11/2023 Review of Inservice Training Report dated 04/10/2023 - 04/13/2023 revealed Nursing training on Emergency Kit with summary of while waiting for ordered medications to arrive from pharmacy, nurses may use medication from e-kit on hand and follow-up with pharmacy until the medication is at hand. Utilize electronic e-kit for emergency control medication for control meds. Review of Inservice Training Report dated 04/10/2023 - 04/13/2023 revealed Nursing training on medication reconciliation and signed by nursing staff. There were a total of 50 staff who attended the training. Review of Inservice Training Report dated 04/10/2023 revealed Nursing training on medication administration and reconciliation policy and procedure. Completed by the DON. There were a total of 50 staff who attended the training. Review of Inservice Training Report dated 04/10/2023 revealed the ADMIN was educated on monitoring the facility's medication administration and reconciliation system. Review of Inservice Training Report dated 04/10/2023 revealed nursing staff educated regarding monitoring of medication administration/order process. Review of Inservice Training Report dated 04/11/2023 revealed education completed by nursing facility staff with hospice companies regarding if faxing orders call facility for confirmation of received. Preferred method is a telephone order or written order. On 04/13/2023 at 12:30 PM, the administrator was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated, due to the facility need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #1) resident of 12 residents reviewed for nutrition. The facility failed to ensure Resident #1 whose diet order was for pureed texture and required eating assistance maintained acceptable parameters of nutritional status resulting in a significant weight loss in less than one month of admission This failure put residents at risk for malnutrition, weight loss and harm. Findings included: Review of Resident #1's face sheet dated 04/10/2023 revealed Resident #1 was admitted to the facility on [DATE] with a diagnoses of alcoholic cirrhosis of the liver without ascites (alcohol-induced liver disease that does not have fluid build-up in the abdomen), liver cell carcinoma (liver cancer), esophageal varices with bleeding (enlarged veins in the esophagus, the tube the that connects the throat and stomach) and dysphagia (difficulty swallowing). Review of Resident #1's Baseline Care Plan dated 04/03/2023 revealed Resident #1 had an ADL self-care performance deficit related liver cell carcinoma and pain. Resident #1 required extensive assistance for bathing/showering, bed mobility, personal hygiene and toileting. Resident #1 had a pureed diet ordered. Resident #1 was noted to require set up help only with eating. In an observation on 04/10/2023 at 8:11 AM, Resident #1 was in bed lying on his side facing the wall and was not wearing clothing. Resident #1's backside was visible from the doorway of the room. TX Nurse adjusted Resident #1's catheter and then closed the door to his room. Review of Resident #1 Diet order dated 04/10/2023 revealed on 04/01/2023 Resident #1 was ordered a regular diet, pureed texture, regular liquids consistency. Review of Resident #1 weight change from hospital weight to weight on 04/06/2023 revealed: Hospital record weight 04/01/2023: 186 lbs Weight on 04/06/2023: 162.5 lbs Weight on 04/13/2023: 158.5 lbs 12.6 % change to 04/06/2023 to indicate severe weight loss in less than two weeks. 14.8 % change to 04/13/2023 to indicate severe weight loss in less than two weeks. In a follow-up observation and interview on 04/10/2023 at 8:15 AM, Resident #1 stated he guessed he was alright. When asked additional questions, he would answer yeah, yeah. He was pleasantly confused. In an observation on 04/10/2023 at 8:12 AM, Resident #1's breakfast tray was on the tray cart on the 100 hallway. At 8:14 AM CNA L set Resident #1's tray on his bedside table and asked him if he felt like eating to which he replied yes. CNA L took the plate cover off of the plate and placed Resident #1's drinks within reach and then left the room. At 8:16 AM the DON and CNA L entered the room and the DON said Resident #1 required assistance with eating and instructed CNA L to assist Resident #1 with eating. CNA L fed Resident standing up beside his bed. In an interview on 04/10/2023 at 8:30 AM, CNA L stated this was her first day back at work and had not worked with Resident #1 before today. She stated the DON educated her that Resident #1 required assistance with eating. She stated she left the room earlier to see if Resident #1 required a clothing protector but realized he was not wearing clothing and went to get a suitable cover . In an interview on 04/10/2023 at 9:00 AM, Resident #1's RP stated she had to feed Resident #1 on the day he was admitted [DATE]. She stated she was unable to visit him again until 04/04/2023 and when she returned he was not himself due to increased confusion because Resident #1 had not been receiving his lactulose which caused him to not be able to identify himself or her as his RP. She stated he was unable to feed himself and staff were unaware that he required assistance. She said when she returned on 04/04/2023 she told staff they could not just set his tray in front of him and not feed him. She said she believed Resident #1 did not eat for almost three days and was losing weight. Review of Resident #1 weight records in the EMR dated 04/10/2023 revealed no weight records for Resident #1. Review of Resident #1 hospital discharge records dated 04/01/2023 revealed Resident #1 weighed 186 lbs. In an interview on 04/10/2023 at 10:06 AM, the DON stated Resident #1 should have had his weight taken on admission and then weekly for four weeks. She stated his weight was completed on 04/06/2023 and it was 162.5 lbs but it had not been recorded in the EMR and was only documented in the weekly weight book. She stated she was unsure of weight loss due to him not being weighed when he arrived on 04/01/2023. She stated when Resident #1 was admitted he was able to feed himself. She stated Resident #1's RP did report to her on 04/06/2023 concerns of Resident #1 not being able to feed himself and that he required assistance. She stated the Resident #1's RP would assist with him eating and would bring outside food for him when she visited. She stated Resident #1 did not like the pureed food as much as the food brought from outside, but due to concerns of dysphagia (difficulty swallowing) and esophageal varices (enlarged veins in the esophagus, the tube the that connects the throat and stomach) his diet could not be upgraded. She stated they educated their staff regarding Resident #1 requiring feeding assistance on 04/06/2023. In an interview on 04/10/2023 at 2:00 PM, the ADON stated he came in to help with Resident #1's admission on 04/01/2023. He stated when Resident #1 was admitted he was NPO (no food by mouth) but then upgraded to a pureed diet. He stated Resident #1 was able to feed himself upon admission but would only take a bite or two and required assistance to eat more. In an interview on 04/11/2023 at 9:30 AM, LVN M stated Resident #1 was very tired when he was admitted on [DATE] and Resident #1's RP fed him his meals. She stated Resident #1's RP insisted on feeding him and wanted to staff to assist that day as well. She stated Resident #1 was asking for milkshakes or health shakes when he first arrived and they did offer him a health shake. She stated she was unaware of a physician order or other recommendations for Resident #1's diet to be supplemented when his intake was poor. She stated anytime a resident doesn't eat well they offer an alternative or a health shake. She stated later in the week after she was off for a few days she was educated that Resident #1 required assistance with eating at each meal. In an interview on 04/13/2023 at 12:05 PM, the DON stated the facility took a new weight on Resident #1 and he weighed weight 158.5 lbs and was weighed using the mechanical lift. She stated his weight on 04/06/2023 was also completed with the mechanical lift. She stated the dietitian had not evaluated him at this time because she had not returned to the facility and the DON was not aware of any interventions put into place to prevent weight loss. She stated they did implement weekly weight for four weeks. Review of Resident #1 Amount eaten records dated 04/03/2023 - 04/09/2023 revealed Resident #1 ate: 04/03/2023 at 3:47 PM: 76%-100% 04/03/2023 at 3:49 PM: 51%-75% 04/03/2023 at 5:00 PM: Resident Refused 04/04/2023 at 9:13 AM: Resident Refused 04/04/2023 at 1:10 PM: Resident Refused 04/04/2023 at 6:27 PM: Resident Refused 04/08/2023 at 10:21 AM: Resident Refused 04/09/2023 at 1:48 PM: 76%-100% 04/09/2023 at 1:19 PM: 51%-75% 04/09/2023 at 5:00 PM: 76%-100% There were no records for 04/01/2023, 04/02/2023, 04/05/2023-04/07/2023. Review of Complaint/Grievance Follow-up Report dated 04/06/2023 and completed by the DON revealed Resident #1's RP made a complaint regarding multiple issues including Resident not able to feed himself. The resolution was for staff to be educated to feed Resident #1. Review of Complaint/Grievance Follow-up Report dated 04/06/2023 and completed by the ADMIN revealed Resident #2's RP made a complaint regarding multiple issues including Resident #1 needs assistance feeding. The resolution was resident added to feeder list and staff inserviced. Review of Inservice Training Report dated 04/06/2023 revealed education with staff in regarding to feeding Resident #1. The summary of the training session included please encourage Resident to get out of bed and come to dining room for meals - resident needs assistance feeding all meals whether that is in dining room or in resident room. Review of Weight Management System policy (undated) revealed residents are weighed at admission, readmission and per physician orders. In addition the policy noted residents are to be weighed on admission and readmission. These weights are to be completed within 24 hours of admission/readmission. Weight how obtained (standing, lift or wheelchair) is to be recorded in the HER clinical record. It further noted residents with a significant weight loss or gain (5%, 7.5% or 10% or more) will be placed on weekly weights x 4 weeks or until weight is stable . If weight concerns are noted/weights are not stable , implement interim nutrition interventions, notify RDN/NTR via referral form and continue weekly weight until stable .All weight changes are considered unplanned unless the MD has documented a plan for desired weight change and the facility has care planned PRIOR to the weight change occurring.

Based on observation, interview, 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 in response to a COVID-19 [MEDICAL CONDITION] outbreak. Twenty-four residents resided on Hall B, six residents were on quarantine for unknown COVID-19 status and 18 were considered negative COVID-19 status. The facility failed to ensure dedicated staff were assigned to care for cohort residents. Staff work both the quarantine hall and three other negative halls in the facility the same day. The facility failed to establish an apparent barrier to separate the quarantine unit and the rest of the facility. The facility failed to ensure staff wore PPE appropriately. The facility failed to appropriately monitor three of five residents (resident #1, #2, and #4) for signs and symptoms of COVID. The facility failed to maintain PPE supply in an area to ensure staff had access without cross contaminating. An IJ was identified on 11/10/20 at 6:40 PM. While the IJ was lowered on 11/16/20 at 2:00 PM, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not IJ identified as patterned due to the facility's need to evaluate the effectiveness of their Plan of Removal. The facility was provided the IJ Template on 11/10/20. These failures placed residents at risk of exposure to COVID-19, which could result in illness, hospitalization , or death. Findings included: Observations on 11/10/20 at 9:45 AM revealed staff were crossing back and forth from the quarantine section to the non-quarantine area. Staff were not dedicated to cohort residents. CNAs, MAs, AD, HK, LVNs, all observed working with quarantine residents and non-quarantine residents. MAs and the AD were observed providing medications and providing in room activities to resident on both the quarantine hall and non-quarantine residents. In an interview on 11/10/20 at 9:45 AM, LVN B stated she is the treatment nurse for the facility. She provided treatments to residents residing on Hall B. Hall B included residents of unknown COVID status in quarantine located at the end of the hall and residents with no suspected COVID were at the front of the hall. In an interview on 11/10/20 at 10:00 AM CNA G stated she worked the B hall at times when staff need assistance. She stated staff are not dedicated to that hall because staff typically are assigned to two halls. Observation on 11/10/20 at 10:05 AM revealed MA L provided medications to residents on quarantine in the B hall. After providing medications to the quarantine hall, she provided medications to a resident on the front lobby area. She exited the quarantine hall with her medication cart into the non-quarantine area and into the main lobby. In an interview on 11/10/20 at 10:10 AM MA L stated she is a floater, meaning she works all halls to provide care for residents wherever needed. She stated she currently works the B hall and the D hall and provides medications to all residents on each hall including the quarantine residents. She stated she did leave the quarantine section to provide medications to resident in the front lobby. Observation on 11/10/20 at 10:15 AM revealed the AD entering and exiting residents' rooms on isolation unit. The AD entered three resident rooms while wearing the same PPE, including a gown, facemask, and shield, and gloves. Further observations at 10:30 AM revealed the AD entering and exiting residents' rooms on cold units without changing PPE. In an interview on 11/10/2020 at 10:45 AM the AD stated, I use PPE when I enter any room on the isolation hall. I take off the PPE before I exit the rooms. I do go on other halls in the facility and visit other residents after visiting residents on isolation. Interview on 11/10/20 at 10:30 AM, CNA H stated she normally works the 2pm-10pm shift and is assigned to work Hall A. She said she was asked to work a double today (11/10/20) to ride along/escort a resident for a medical appointment. She said she will float around on all the halls to help with resident care as needed. If she is helping on the Hall B she will care for any of the residents whether they are quarantined or not. An observation on 11/10/20 at 11:40 AM TA R walked Resident #1 out of his quarantine hall/room through the main building to the front entrance for a mobile swallow study outside. The resident was wearing a gown and a mask. The TA R wore a mask but no other PPE. The two walked past seven residents within four feet of them. Two residents did not wear a mask over their nose. The TA R brought the resident back through the front entrance to the quarantine room. She continued to not don PPE and held his hand and shoulder to guide him towards his room. She further stated it's a rare occasion for residents on quarantine to leave for a swallow study and was not provided guidance for that process. In an interview at 11/10/20 at 12:00 PM TA R, stated she took Resident #1 outside for a mobile swallow study. She stated she considered wearing PPE but was not sure what to do. She is trained to doff PPE after providing care to the resident in his room but in this case, she brought the resident out of quarantine to the front door. She felt it was better to remove the PPE upon exiting the resident's room. She stated she had not considered using the exit door at the end of the therapy hall to ensure residents in quarantine did not leave the quarantine area and travel through the main building. In an interview on 11/10/20 at 3:35 PM LVN A stated she is the charge nurse for hall quarantine and C hall. She stated she provides care to all residents on each hall. She stated staff are not dedicated to just one hall and they assist each other. In an interview on 11/10/20 at 4:00 PM MA M stated she passes medications on the quarantine hall, and the D hall locked unit. An observation on 11/10/20 at 4:25 PM revealed CNA I was entering a quarantine room without donning PPE. CNA I was checking water pitchers. An observation on 11/10/20 at 4:25 PM revealed CNA I was entering a quarantine room without donning PPE. CNA I was checking water pitchers. Further observation revealed the resident room was quarantine but did not have a sign indicating the resident was on isolation. In an interview on 11/10/20 at 4:35 PM CNA I stated I am not assigned to the isolation hall. I will be assigned to the isolation hall about an hour and will be going to another hall to work. I have been in- serviced by management about wearing PPE when entering isolation room and place it in containers before leaving a resident's room. I did make a mistake. She further stated she did not know where the quarantine unit began and since there was no sign on the resident's door indicating they were on isolation, she was unaware of the COVID status. Interview on 11/10/20 at 4:30 PM, LVN C stated she is routinely assigned to Hall A and half of Hall C. If she saw a call light was not being answered on Hall B she would answer it, just like any other hall. In an interview on 11/10/2020 at 4:48 PM MA O stated, I give medications to residents on isolation and to residents not on isolation. Observation on 11/13/20 at 10:30 pm revealed CNA J wearing a KN95 mask with the ear loops wrapped around her ears twice causing a gap on both sides of the mask approximately one inch in width. An interview with LVN D charge nurse revealed she was the supervisor for CNA J but she had not noticed she was wearing her KN95 mask incorrectly. Note: CNA J was assigned to the general population of the B hall. In an interview on 11/10/20 at 4:57 PM, the ADON/Infection Preventionist stated she would like staff to be dedicated to the quarantine hall but has not been able to accomplish that. She stated it seems like a good idea to separate quarantine residents from non-quarantine residents. She stated there is a potential for cross contamination when staff are not dedicated to one cohort. She could see the potential problem with staff going in and out of that warn unit. She stated residents with unknown status should be treated as if you do not know if they are COVID positive. She stated she would dedicate staff for quarantine hall if it were up to her. She stated residents with unknown status should be treated as if you do not know if they are COVID positive or not. She stated if there were COVID in the building there is a plan for dedicating staff to the COVID unit but there was no policy to dedicate staff to residents with unknown COVID status. The ADON/Infection Control Preventionist stated there were signs on the wall indicating staff were entering the quarantine unit. She stated she was looking for ideas, any suggestion on how to establish a meaningful separation to ensure staff could visibly see they were entering a different unit. An observation on 11/10/20 at 5:40 PM revealed the DON mask did not cover her nose appropriately. In an interview on 11/10/20 at 5:40 PM the DON stated all staff should be able to work with quarantine and non-quarantine residents at all times as long as staff wear PPE. There is no dedicated staff in the facility because staff are to wear PPE appropriately. The DON stated residents with unknown COVID status are treated like quarantined, did not believe COVID-19 positive residents and unknown should be treated the same. She stated if a resident was COVID positive they would dedicate staff to them. She added there is no policy for dedicating staff to residents with unknown COVID status. She acknowledged that it was possible for someone to have COVID with no signs and symptoms. She stated any resident being transported from the quarantine unit through the rest of the building should wear full PPE including the staff who is with them. When asked why not use the exit door on the quarantine hall for mobile services to prevent cross contamination, she stated she had not considered that. The DON stated she is kept up to date with CMS, CDC guidelines regarding COVID-19 through webinars and training provided by the state. Observation on 11/13/20 at 10:30 pm revealed CNA J wearing a KN95 mask with the ear loops wrapped around her ears twice causing a gap on both sides of the mask approximately one inch in width. An interview with LVN D charge nurse revealed she was the supervisor for CNA J but she had not noticed she was wearing her KN95 mask incorrectly. Note: CNA J was assigned to the general population of the B hall. In an interview on 11/10/20 at 6:20 PM the ADM stated her expectation is to limit the number of people that are working on the quarantine unit. She stated she did not think it was necessary to have a system in place to ensure specific dedicated staff to the quarantine hall. She stated she felt there were times based on staffing that some staff may be pulled form one hall to come help that unit. She felt if staff are donning and doffing PPE there should be no concern if staff are dedicated or not to the quarantine hall. She stated there is always a change of exposure by not having dedicated staff but there is always a chance with any staff at all times. She added she preferred not to use agency staff to limit staff in the building because you don't know where they work or where they've been. The ADM stated she is kept up to date with CMS, CDC guidelines regarding COVID-19 through webinars, email alerts, and checks the HHS website frequently. The ADM stated there were no policies regarding dedicating staff to cohort residents such as residents with unknown COVID status. The ADM stated the facility utilizes signs on resident doors indicating they are on isolation and a sign on the wall in Hall B indicating one is entering the quarantine unit. Review of the facility's provided Infection Control Policies regarding COVID-19 pandemic revealed no policy regarding dedicated staff for cohort residents. Including those of unknown status. Further review reflected no policy was provided at the time of exit on 11/16/20. Review of Resident #1's Admission record reflected a [AGE] year-old male resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Progress notes and nursing monitoring notes for November reflected Resident #1 was not monitored for signs and symptoms of COVID-19 per facility protocol. Further review reflected Resident #1 was monitored for signs and symptoms of COVID once a day on 11/01/20, 11/03/20, 11/04/20, 11/05/20, 11/06/20, and 11/07/20. Further review reflected no monitoring on 11/08/20 and 11/09/20. Review of R#2's admission record reflected a [AGE] year-old male with an admission date of [DATE], and [DIAGNOSES REDACTED]. Review of R#2's Progress Notes and nursing monitoring notes reflected R#2 was not monitored for signs and symptoms of COVID-19 each shift per facility protocol on 11/05/20, 11/07/20, 11/08/20, and 11/09/20. Further review reflected no monitoring on 11/06/20. Observation on 11/10/20 at 12:15 PM revealed Resident #2 was in his quarantine room with the door wide open. The resident had a loud cough with audible lung congestion (from approximately 20 feet away) and not wearing a mask. Review of Resident # 4's Progress notes and nursing monitoring notes for November reflected Resident #4's was not monitored for signs and symptoms of COVID-19 per facility protocol. Further review reflected Resident #4 was monitored for signs and symptoms of COVID once a day on 11/01/20, 11/02/20, 11/03/20 and 11/08/2020. In an interview on 11/10/20 at 4:57 PM, the ADON/Infection Control Preventionist her expectation is that nurse's check vital signs, respirations, symptoms such as coughing, nausea vomiting, temperature, shortness of breath, or anything out of the ordinary on every shift. She stated residents on quarantine are monitored due to their unknown COVID status to prevent the spread of the infection. She stated should document vitals and all monitoring for signs and symptoms of COVID-19 on the nursing monitoring forms. In an interview on 11/10/20 at 5:40 PM, the DON stated nurses are to check vitals and signs and symptoms of COVID each shift for resident on quarantine. She stated nurses document monitoring on the nursing monitoring form or in the nurse's progress notes. In an interview on 11/10/20 at 6:20 PM, the ADM stated her expectation is that residents on the quarantine unit are screened for signs and symptoms of COVID once per shift to ensure residents have not been admitted with COVID during the quarantine period. Observations on 11/10/20 at 9:45 AM, revealed Staff were observed crossing back and forth from the quarantine section to the non-quarantine area. All staff retrieved PPE from the quarantine area storage regardless of what area of the facility staff were assigned to work. In an interview on 11/10/20 at 9:55 AM LVN M stated staff go down through the quarantine hall to get more PPE. The PPE storage is at the end of the hall past the quarantine residents. In an interview on 11/10/20 at 10:00 AM CNA stated if she needs more PPE or to replace her mask she goes to the B hall quarantine unit where the PPE storage is located and grabs whatever PPE she requires. In an interview on 11/10/20 at 10:05 AM the Van Driver, CNA F stated when she need more PPE she retrieves it from the storage closet at the end of the quarantine hall, Hall B. In an interview on 11/10/20 at 10:10 AM MA L stated extra PPE is in storage on the quarantine hall. In an interview on 11/10/20 at 4:00 PM MA M stated if she needs more PPE she goes to the PPE storage at the end of the COVID unit. In an interview on 11/10/20 at 3:35 PM, LVN A stated when she needs more PPE she goes to the PPE storage area on the quarantine hall to retrieve items she needs including mask. In an interview on 11/10/20 at 6:20 PM, the ADM stated she was unaware staff were entering the quarantine unit to grab more PPE. She stated her main concern is to ensure staff properly wore PPE when in residents' rooms and not the location of the PPE storage. The ADM was notified an IJ situation was identified due to the above failures on 11/10/20 at 6:40 PM. The first POR was submitted 11/11/20 at 12:25 PM and was not accepted. The final and accepted POR was submitted 11/15/20 at 12:02 PM and accepted. The POR was as follows: November 10, 2020 PLAN OF REMOVAL FOR REMOVAL OF IMMEDIATE JEOPARDY On November 10, 2020, an infection control survey was initiated at Silver Pines Nursing and Rehab Center. On November 10, 2020, the facility was notified by the surveyor that an immediate jeopardy had been called and needed to submit a letter of credible allegation. The Facility respectfully submits this Letter of Credible Allegation pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The immediate jeopardy allegations are as follows: Issue identified by surveyor: The facility failed to develop and implement Infection Control Policies and Procedures to prevent the spread of COVID-19 virus. 1. The facility failed to appropriately screen visitors, prior to entering the building, three Surveyors were screened after entering the facility on two occasions. o On 11/11/20, the screening process has been moved to the outside of the facility and staff has been educated on this process. o The Administrator / DON reviewed the past 14 days of screening forms and there were no signs or symptoms of COVID-19 documented. o All staff working on this day will be reeducated and all staff oncoming will be reeducated prior to the start of their next scheduled shift or via telephone. o The Administrator / Designee will monitor the completion of the expectation three times a week for three months and randomly thereafter. 2. The facility failed to ensure dedicated staff worked for cohort residents. Staff work both the quarantine hall and all other halls in the facility the same day. o On 11/10/20, the DON was able to assign a dedicated licensed nurse and CNA to the warm unit. o The DON / Designee reviewed the past two months of the facility infection control logs and no adverse outcome was noted due to this process. o On 11/10/20, the Administrator / Designee reeducated nursing department including all CNAs and medication aides on having dedicated staff to work on the warm unit and the expectation of the staff staying on the warm unit throughout their shift to prevent cross contamination. Staff should not change designation from one day to another, unless required in order to maintain adequate staffing for a cohort. All staff working on this day will be reeducated and all staff oncoming will be reeducated prior to the start of their next scheduled shift or via telephone. o The DON/Designee will ensure dedicated staff work with cohort residents going forward, starting 11/10/20. The Administrator / Designee will monitor the completion of the expectation weekly for three months. 3. The facility failed to maintain an implement a policy regarding dedicated staff for cohort residents. o On 11/10/20, the DON was able to assign a dedicated licensed nurse and CNA to the warm unit. o The DON / Designee reviewed the past two months of the facility infection control logs and no adverse outcome was noted due to this process. o On 11/10/20, the Administrator / Designee reeducated nursing department including all CNAs and Medication Aides on having dedicated staff to work on the warm unit and the expectation of the staff staying on the warm unit throughout their shift to prevent cross contamination. Staff should not change designation from one day to another, unless required in order to maintain adequate staffing for a cohort. All staff working on this day will be reeducated and all staff oncoming will be reeducated prior to the start of their next scheduled shift or via telephone. o The DON/Designee will ensure dedicated staff work with cohort residents going forward, starting 11/10/20. The Administrator / Designee will monitor the completion of the expectation weekly for three months. 4. The facility failed to ensure staff did not cross contaminate when facility staff walked on to the quarantine/unknown unit and on the non-quarantine area. A medication aide provided medications to quarantine and non-quarantine residents, and her med cart crossed into the quarantine unit. The wound care nurse provides treatments to residents on the quarantine unit and the non-quarantine area. A CNA stated she works with both quarantine residents and non-quarantine residents. Speech therapist took a resident on the quarantine unit through the building to the front door to receive a swallow study, then returned him to his quarantine room. o On 11/10/20, the DON / Designee set up a dedicated medication cart for use only on the warm unit. o The DON / Designee reviewed the past two months of the infection control logs and no adverse outcome was noted by this practice. o On 11/11/2020, DON / designee initiated reeducating facility staff including all CNA and Medication Aides as indicated above that dedicated staff, a dedicated med cart and other resident equipment will stay on the warm unit, thus preventing cross contamination from the warm unit to the cold unit. o On 11/11/2020, DON / Designee has reeducated the therapy staff on the process for taking isolated residents off the warm / quarantine unit for appointments. For the purpose of avoiding contact with residents on the cold unit, residents on the warm unit who have appointments will be escorted out of the building using the exit door located at the end of the warm unit and both resident and escort will be in full PPE. All staff working on this day will be reeducated and all staff oncoming will be reeducated prior to the start of their next scheduled shift or via telephone. o The DON / Designee will monitor the completion of these expectation three times a week. 5. The facility's PPE supply area is located at the end of the quarantine hall. Staff must pass through the quarantine hall to retrieve PPE. o On 11/10/20, additional PPE supply areas were created throughout facility for staff members who work off of the warm unit, in the event it is needed. o The DON / Designee reviewed the past two months of infection control logs and there was no noted adverse reaction due to this practice. o On 11/10/2020, the Administrator / Designee has reeducated staff on only using the PPE closet on the warm unit if they are assigned to work on that unit. o On 11/11/2020, DON / designee began reeducating facility staff regarding DON/DOFF PPE expectations for the warm / quarantine unit and any resident on isolation/droplet precautions. As part of this training, DON /designee will demonstrate the process for donning, doffing, and disposal of PPE. Following demonstration, the DON will continue education with ongoing monitoring of staff PPE use. All staff will demonstrate understanding through return demonstration. All staff working on this day will be reeducated and all staff oncoming will be reeducated prior to the start of their shift or via telephone. o The Administrator / Designee will monitor the compliance of the expectation three times a week for three months. 6. The facility failed to separate or establish a barrier between the quarantine/unknown unit, and the rest of the facility. o On 11/10/2020, the Administrator established separation between the quarantine/unknown unit and the rest of the facility using red tape and red signs indicating the start of the warm zone. o The DON / Designee reviewed the past two months of infection control logs and there was no noted adverse reaction due to this practice. o The Administrator / Designee reeducated staff on the separation between the quarantine/unknown unit and the rest of the facility using red tape and red signs indicating the start of the warm zone. o The Administrator / Designee will monitor the compliance of this expectation three times a week. 7. The facility failed to monitor residents for COVID signs and symptoms, daily or three times a day per facility process. o The DON / Designee assessed facility residents and no residents were noted to have any signs or symptoms of COVID-19. o On 11/10/2020, the DON / Designee reviewed the past 72 hours of nursing documentation for the residents in the facility and there were no documented signs or symptoms of COVID-19. o The DON /Designee reviewed the past two months of infection control logs and no adverse outcome was noted related to this practice. The facility has maintained being COVID free throughout this pandemic. o On 11/10/2020 reeducated nursing staff on the importance of monitoring residents for COVID signs and symptoms per shift. All staff working on this day will be reeducated and all staff oncoming will be reeducated prior to the start of their next scheduled shift or via telephone. o The DON / Designee will monitor the completion of the expectation three times a week. An Ad hoc QAPI meeting held on 11/10/20 with the Inter Disciplinary Team (IDT) to review and discuss items identified by surveyor regarding the citations. A Plan of Removal was developed, implemented, and completed as designed in this document. Monitoring of the POR: Observations on 11/13/20 at 12:30 PM revealed the facility had placed meaningful separation of 6 ft area marked off from general population residents with an orange cone in the hall to indicate entering the warm zone and placed signage on each door on the isolation/quarantine unit. Further observation revealed additional storage areas for PPE outside of the warm zone. In an interview on 11/13/20 at 12:30 PM CN stated there was a designated LVN and CNA for the warm unit and the census was 9 residents. She added there is a designated breakroom for the staff and each resident has a cart for PPE outside the room by the door. An observation on 11/13/20 at 2:00 PM revealed the ADON providing in-service to a nurse coming of for her shift. She was providing education on dedicating staff to cohort residents and not cross contaminating from the quarantine unit to the non-quarantine unit. In an interview on 11/13/20 at 2:10 PM DON stated the facility had now dedicated staff to each cohort group including unknown COVID-19 status. The staff on the quarantine hall work on the unit for 12-hour shifts. Staff enter and exit through the back door as to not cross contaminate. In an interview on 11/14/20 at 9:30 PM two LVNs and three CNAs on the evening shift stated they received in-service training on having dedicated staff to work on the warm unit and the expectation of the staff staying on the warm unit throughout their shift to prevent cross contamination. Staff should not change designation from one day to another. Staff were able to identify appropriate areas to access PPE. An observation on 11/15/20 at 11:25 AM revealed the designated screener checking temperatures of staff entering the facility at the front door before allowing them in. In an interview on 11/15/20 at 11:30 AM two LVNs and two CNAs on the morning shift stated they received in-service training on having dedicated staff to work on the warm unit and the expectation of the staff staying on the warm unit throughout their shift to prevent cross contamination. Staff should not change designation from one day to another. Staff were able to identify appropriate areas to access PPE. In an interview on 11/16/20 at 10:00 AM two LVNs and four CNAs on the morning shift stated they received in-service training on having dedicated staff to work on the warm unit and the expectation of the staff staying on the warm unit throughout their shift to prevent cross contamination. Staff should not change designation from one day to another. Staff were able to identify appropriate areas to access PPE. A record review on 11/16/20 at 1:30 PM reflected in-service that included having dedicated staff to work on the warm unit and the expectation of the staff staying on the warm unit throughout their shift to prevent cross contamination. Staff should not change designation from one day to another, unless required in order to maintain adequate staffing for a cohort. In an interview on 11/16/20 at 1:45 PM TA R stated she received in-service training regarding transferring residents on the warm unit through the back-exit door for appointments to prevent cross contamination. Record review on 11/16/20 at 2:00 PM revealed residents were monitored for signs and symptoms of COVID-19 every shift per facility protocol. Record review on 11/16/20 at 2:00 PM revealed the facility developed and implemented a policy regarding dedicated staffing for cohort residents. The Administrator was informed on 11/16/20 at 2:00 PM the Immediate Jeopardy was removed, and that the facility remained out of compliance at severity level of no actual harm but potential for more than minimal harm and a scope of pattern.

Based on observation, interview, and record review the facility failed to ensure that a resident received care to prevent pressure ulcers and did not develop pressure ulcers, received necessary treatment and services to promote healing, and prevent infection for one (1) of three (3) residents (Resident #4) reviewed for pressure ulcers. The facility failed to provide Resident #4 a physician ordered air mattress to prevent further deterioration of a pressure ulcer. The facility also failed to provide Resident #4 an appropriate treatment for [REDACTED]. This deficient practice affected Resident #4 and could affect 4 other residents with pressure ulcers at risk for worsening of the pressure ulcers, developing more pressure ulcers, infected wounds, and [MEDICAL CONDITION] from infected wounds. Findings include: Review of the Face Sheet for Resident #4 reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Annual MDS Assessment for Resident #4 dated 08/12/2016 reflected she was severely cognitively impaired. She was dependent on one staff for ADLs. She had no pressure ulcers. She had a pressure relieving device for her bed and ointments or medications were applied. Review of the Quarterly MDS Assessment for Resident #4 dated 04/13/2017 reflected she was moderately cognitively impaired. She needed extensive assistance of one staff for bed mobility, hygiene, and incontinent care. Resident #4 had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present on some parts of the wound bed) on her coccyx with measurements of 1.0 cm x 0.2 cm x 1.0 cm. The pressure ulcer had slough in the wound bed. The treatments used were pressure ulcer care, a dressing, and application of ointment or medications. Review of Resident #4's Care Plan dated 11/09/2016 reflected she had a Stage 2 Pressure Ulcer (partial thickness loss of dermis presenting as a shallow open ulcer on her coccyx with a red or pink wound bed, without slough; an intact or open/ruptured blister) with an onset date of 10/10/2016. The staff was to Perform treatment per order, if no improvement within two weeks-report to MD .Keep family/responsible party, resident and MD informed of residents progress . The staff were also to apply a dressing Duoderm and change the dressing every three (3) days and as needed. The care plan also reflected to apply a barrier cream after incontinent care and provide a pressure reducing device for the bed and chair. Review of Resident #4's Care Plan dated 11/14/2016 reflected a new care plan was initiated for a Stage 3 Pressure Ulcer (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) on her coccyx with an onset date of 11/11/2016. The new care plan reflected the ulcer changed from a Stage 2 to a Stage 3. The staff interventions were not changed. No other interventions were written for this care plan. Review of the Skin Assessment Flow Sheet dated 10/10/2016-11/28/2016 reflected Resident #4's pressure ulcer progressed from a stage 2 to stage 3. Review of the Nurse's Notes for Resident #4 concerning the Pressure Ulcer dated 10/10/2016 to 11/22/2016 reflected LVN C attempted contact with the Resident's MD four (4) times and requested new wound care orders from the NP five (5) times. At no time did the MD contact LVN C and at no time did the NP approve changes in Resident #4's wound care. No attempts were made to contact an alternate physician. There was no mention of the air mattress or for new orders for an air mattress in the nurse's notes. Review of the NP Progress Notes for Resident #4 dated 10/25/2016 reflected the NP reviewed her chart and she had a pressure sore to her coccyx. The treatment plan for Resident #4 was for position changes and air mattress, duoderm dressing, and continue to monitor. Review of the Facsimile for Resident #4 dated 11/04/2016 reflected LVN C sent the facsimile to the MD and the note reflected Stage 2 to coccyx has necrotic wound bed & duoderm has been in place as an order for [REDACTED]. The facsimile reflected the NP noted keep skin prep & barrier continue to monitor. The facsimile was noted by the facility as returned on 11/17/2016 (13 days later). Review of the Wound Treatments Flow Sheet for Resident #4 dated 11/01/2016-11/30/2016 reflected the treatment dated 10/24/2016 was to cleanse, dry, and apply a duoderm to the Stage 2 on the coccyx every three (3) days. Then another treatment was hand written for 10/24/2016 to cleanse the Stage 3 to the coccyx, dry, and apply a duoderm every 3 days-this order started on this TAR on 11/08/2016. On 11/15/2016 the order was added to apply a skin prep to the periwound and then the duoderm every other day. Review of the same Wound Treatments Flow sheet for Resident #4 dated 11/01/2016-11/30/2016 reflected on 11/22/2016 (the date in which the Resident's new wound care specialist assumed care of the resident) a new sheet was transcribed and the order changed to cleanse, dry, and apply medi honey to the wound bed, cover with a foam dressing and secure with tape every Monday, Wednesday, and Friday. And on 11/29/2016 the order changed to cleanse and apply [MEDICATION NAME] ointment, Santyl, and [MEDICATION NAME] to the wound bed and cover with a foam dressing and change every day. There was also an order [REDACTED]. Review of the NP Progress Notes for Resident #4 dated 11/11/2016 reflected the NP reviewed her chart and she had a pressure sore. The treatment plan for Resident #4 was not changed. In an interview on 05/10/2017 at 5:00 PM RNC stated an air mattress was ordered for Resident #4, will need to find the invoice for the date. Review of the Invoice for equipment for Resident #4 dated 04/30/2017 reflected the air mattress was originally started on 11/16/2016. (This was 22 days after the NP had it in the Progress Notes from 10/25/2016.) Review of the Facsimile for Resident #4 dated 11/22/2016 reflected LVN C sent the facsimile to the MD and the note reflected Wound worsening & covered in slough please eval, recommend different drsg wound now presenting as unstageable please consider having resident seen by wound care Dr. The words different drsg were circled and the question beside the words were ? Keep using skin prep & barrier & duoderm dressing every day?? Recommend change position (How often?) Recommend air mattress (using?) Also the words by wound care Dr. were circled and the facsimile reflected handwritten already changed to (different Dr). This facsimile was signed at the bottom by the NP. Review of the Facsimile for Resident #4 dated 11/22/2016 and sent by LVN C to the MD and reflected Resident family requested to change Drs. & care has been resumed & taken over by (different Dr.) This facsimile was also signed by the NP and a handwritten note by her signature reflected the first MD name and the DON. Review of the Skin Assessment Flow Sheet dated 12/06/2016-12/22/2016 reflected Resident #4's pressure ulcer progressed from unstageable to stage 4 and continued to be a healing stage 4 to the date of the survey. Review of Resident #4's Care Plan dated 12/22/2016 reflected the Resident had a Stage 4 Pressure Ulcer to her coccyx. The interventions for the staff were changed to add a wound vac and for the wound doctor to evaluate and treat when needed. Observation on 05/12/2017 at 3:15 PM revealed Resident #4 lying in her bed, with the WCS prepared to perform the wound assessment and debridement with LVN C. Resident #4's Stage 4 Pressure Ulcer measured 0.7 cm x 0.2 cm x 0.7 cm, was debrided, and had granulation tissue. The treatment continued to include the [DEVICE]. She also was lying on an air mattress. In an interview on 05/10/2017 at 9:53 PM LVN C stated Resident #4 had a Stage 2 Pressure Ulcer to her coccyx. She stated she had requested Resident #4 see the WCS but MD would not order the wound consult. LVN C also stated the NP would not order a wound consult, change the treatment, or debride the wound. LVN C stated the wound was necrotic and had slough when she asked the MD and NP to see the wound. LVN C stated she had a language barrier with the NP; all the NP would say was (MD) see. LVN C stated NP assessed the wound but would not change the treatment on the wound. LVN C stated the previous Administrator was aware of the communication problems she was having with the MD and NP. She stated she would not have sent Resident #4 to an emergency room because Resident #4 was not having a systemic problem. She stated she did not even think to send Resident #4 to the emergency room . In an interview on 05/10/2017 at 11:46 AM Resident #4's previous MD stated he had found some notes for Resident #4 where his NP had seen Resident #4 on 10/25/2016. He stated there was a superficial pressure ulcer on her coccyx and the NP had ordered an air mattress and position changes. MD stated he did not assess Resident #4's Pressure Ulcer, his NP did. In an interview on 05/11/2017 at 3:42 PM Resident #4's previous MD stated My NP pretty much takes care of the faxes. I get 100+ a day and I do not read all of them. If someone wants me to know of a change of condition, they should call me or come to my office; it's half a mile down the street. The staff has my cell phone number. I would have expected the facility to phone me directly for something like this. They should have called me. If the facility faxed me and there was not a response, they should have called me. I would have responded. I am a trained orthopedic surgeon and I do my own wound care. This communication was between the NP and the facility and I was unaware. The NP is brand new out of school last September and she didn't realize the seriousness of the situation. I'm not sure of her training with pressure sores, but I'm sure she is competent. We are in the same office and we talk every day. I never saw the wound on Resident #4. I never knew there was a wound with necrosis. Oh my gosh, no, a duoderm will only make it worse (discussing treatment options). I definitely would not have kept the same treatment with necrosis. It should have been debrided. I do 101% of my wound care now. I think all of this happened in November 2016 and no one ever told me about it until about three (3) months ago. I did not know the family had changed doctors. The facility normally calls both doctors when there is a change in physicians but I was not called or notified. I found out about all of this about three (3) months ago. I think (NP) told me. I don't recall talking to the Administrator until (NP) told me. I was quite upset so I came here and talked to the Administrator. I told her I was very upset and asked why I wasn't told of this. I had not talked to the (previous) DON (about Resident #4). In an interview on 05/10/2017 at 4:55 PM the current DON stated she would expect for the nursing staff to follow up on the facsimiles sent to the MD within 24 hours by calling the MD. In an interview on 05/10/2017 at 5:10 PM Resident #4's previous NP stated she assessed Resident #4's Pressure Ulcer to her coccyx in October and November 2016. She stated it was located on her coccyx and was a Stage 2. She stated the wound bed was not necrotic and had no slough. NP stated she ordered a regular dressing and an air mattress and for the staff to reposition Resident #4. She stated she did not remember receiving a notification or facsimile about the Stage 2 Pressure Ulcer having slough or being necrotic. She stated she only received the notification about Resident #4's RP changing Physicians. In an interview on 05/11/2017 at 2:15 PM the previous Administrator stated she had several meetings with the MD about reaching him timely and responding timely. She also stated she was aware Resident #4 had a Pressure Ulcer. The previous Administrator stated she was aware MD and NP would not order a wound consultant for his residents. She stated an option was given to the RP to change the Physician in late November, 2016. At that time, when the RP was given that choice, the change occurred. The previous Administrator stated MD did not talk to her about Resident #4; she was not a clinical person. She stated Corporate also talked to MD about timeliness of communication. In an interview on 05/17/2017 at 11:31 AM the previous DON stated she did not remember anything specific about the pressure ulcer on Resident #4. She stated it was the policy of the facility to only use an air mattress on residents with multiple Stage 2 pressure ulcers, Stage 3, Stage 4, or Unstageable. She also stated the MD should have been notified of the policy since Resident #4 did not meet the criteria for an air mattress when ordered on [DATE]. She stated she also expected LVN C to notify her (previous DON) if she had any issues contacting MD about the pressure ulcer. The previous DON stated she did remember LVN C would become frustrated when trying to contact MD or NP, but did not remember the specific resident involved. She stated she expected the nursing staff to alert her or Corporate so they could contact the Medical Director of the facility when a resident needed a treatment change if the attending physician was not communicating with the nursing staff. Review of the facility's policy entitled Skin-Preventative Guideline for Resident at Risk for Pressure Injury revised 07/2016 reflected .a resident who enters the home without a pressure injury will not develop pressure injury . The policy reflected the definition of Avoidable: The resident developed a pressure injury(s), or that an existing pressure injury deteriorated or failed to heal adequately (or heal as well as could be expected for end-of-life conditions) and that the home failed to thoroughly perform the steps of recognition, problem and cause identification, prevention and management, or monitoring in accordance with recognized standards of practice. The policy also reflected the Procedure which included the Braden Scale to determine risk level and the licensed nursing staff consulting with the physician to determine if the area was avoidable or unavoidable. The policy reflected pressure relief devices including an air mattress and discussed areas prone to breakdown including the coccyx. Review of the facility's policy entitled Skin-Treatment Guidelines for Pressure Injuries revised 10/2016 reflected .this home to utilize treatment guidelines when providing care for residents with pressure injury and to prevent further deterioration of pressure injury. The policy reflected the definition of each Stage of Pressure Injuries and the procedure to care for each Stage. The policy reflected for a Stage 2 Pressure Injury to identify the underlying cause and institute pressure reducing devices for the bed and chair, repositioning techniques and times, confirm physician and interested family/friend notification, and documentation in the progress/nurses' notes. Next were the guidelines for treatments depending on the amount of drainage and Physician orders. Then the staff were to assess the area weekly on the form for weekly assessments, use the TAR for the daily treatment documentation, and perform a Braden Score for updates as necessary. The policy reflected the same information for each Stage and specific to the Stage, drainage, and if the area had slough or eschar. Review of the facility's policy entitled Change in Condition-Observing, Reporting and Recording revised 03/2012 reflected the home will inform the Physician of a significant change in a resident's physical status like a deterioration in health and/or a clinical complication. The policy also reflected when the treatment needed altering the Physician would be notified. The policy reflected the notification to the physician should be immediate. If the facility was unable to reach the resident's physician, call an alternate physician, a medical director, or send the resident to the emergency room . The facility provided a Form CMS-672 reflecting 5 residents had pressure ulcers excluding Stage 1.

Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when a significant change in the resident's physical status (that is, a deterioration in health status in either life-threatening conditions or clinical complications) and a need to alter treatment significantly (that is, a need to commence a new form of treatment) for one (1) of three (3) residents (Resident #4) reviewed for pressure ulcers. LVN C failed to follow-up on repeated communications to Resident #4's MD in October and November of 2016 when the resident's Stage 2 Pressure Ulcer on her coxxyx became necrotic and deteriorated to a stage 4. This deficient practice affected Resident #4 and could affect 4 other residents with pressure ulcers at risk for no immediate notification to the Physician of the worsening of the pressure ulcers, developing more pressure ulcers, infected wounds, and [MEDICAL CONDITION] from infected wounds. Findings include: Review of the Face Sheet for Resident #4 reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Annual MDS Assessment for Resident #4 dated 08/12/2016 reflected she was severely cognitively impaired. She was dependent on one staff for ADLs. She had no pressure ulcers. She had a pressure relieving device for her bed and ointments or medications were applied. Review of the Quarterly MDS Assessment for Resident #4 dated 04/13/2017 reflected she was moderately cognitively impaired. She needed extensive assistance of one staff for bed mobility, hygiene, and incontinent care. Resident #4 had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present on some parts of the wound bed) on her coccyx with measurements of 1.0 cm x 0.2 cm x 1.0 cm. The pressure ulcer had slough in the wound bed. The treatments used were pressure ulcer care, a dressing, and application of ointment or medications. Review of Resident #4's Care Plan dated 11/09/2016 reflected she had a Stage 2 Pressure Ulcer (partial thickness loss of dermis presenting as a shallow open ulcer on her coccyx with a red or pink wound bed, without slough; an intact or open/ruptured blister) with an onset date of 10/10/2016. The staff was to Perform treatment per order, if no improvement within two weeks-report to MD .Keep family/responsible party, resident and MD informed of residents progress . The staff were also to apply a dressing Duoderm and change the dressing every three (3) days and as needed. The care plan also reflected to apply a barrier cream after incontinent care and provide a pressure reducing device for the bed and chair. Review of Resident #4's Care Plan dated 11/14/2016 reflected a new care plan was initiated for a Stage 3 Pressure Ulcer (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) on her coccyx with an onset date of 11/11/2016. The new care plan reflected the ulcer changed from a Stage 2 to a Stage 3. The staff interventions were not changed. No other interventions were written for this care plan. Review of the Skin Assessment flow sheet dated10/10/16 - 11/28/16 reflected Resident #4's pressure ulcer progressed from a stage 2 to stage 3. Review of the Nurse's Notes for Resident #4 concerning the Pressure Ulcer dated 10/10/2016 to 11/22/16 reflected LVN C attempted contact with the Resident's MD four (4) times and requested new wound care orders from the NP five (5) times. At no time did the MD contact LVN C and at no time did the NP approve changes in Resident #4's wound care. No attempts were made to contact an alternate physician. Review of the Facsimile for Resident #4 dated 11/04/2016 reflected LVN C sent the facsimile to the MD and the note reflected Stage 2 to coccyx has necrotic wound bed & duoderm has been in place as an order for [REDACTED]. The facsimile reflected the NP noted keep skin prep & barrier continue to monitor. The facsimile was noted by the facility as returned on 11/17/2016. (13 days later) Review of the Facsimile for Resident #4 dated 11/22/2016 reflected LVN C sent the facsimile to the MD and the note reflected Wound worsening & covered in slough please eval, recommend different drsg wound now presenting as unstageable please consider having resident seen by wound care Dr. The words different drsg were circled and the question beside the words were ? Keep using skin prep & barrier & duoderm dressing every day?? Recommend change position (How often?) Recommend air mattress (using?) Also the words by wound care Dr. were circled and the facsimile reflected handwritten already changed to (different Dr). This facsimile was signed at the bottom by the NP. Review of the NP Progress Notes for Resident #4 dated 10/25/2016 reflected the NP reviewed her chart and she had a pressure sore to her coccyx. The treatment plan for Resident #4 was for position changes and air mattress, duoderm dressing, and continue to monitor. Review of the NP Progress Notes for Resident #4 dated 11/11/2016 reflected the NP reviewed her chart and she had a pressure sore. The treatment plan for Resident #4 was not changed. Review of the Facsimile for Resident #4 dated 11/22/2016 and sent by LVN C to the MD and reflected Resident family requested to change Drs. & care has been resumed & taken over by (different Dr.) This facsimile was also signed by the NP and a handwritten note by her signature reflected the first MD name and the DON. Review of Resident #4's Medical Record reflected a new Wound Care Specialist assumed the Resident's care on 11/29/16. Review of the Skin Assessment flow sheet dated12/06/16 - 12/22/16 reflected Resident #4's pressure ulcer progressed from unstageable to stage 4 and continued to be a healing stage 4 to the date of the survey. Review of Resident #4's Care Plan dated 12/22/2016 reflected the Resident had a Stage 4 Pressure Ulcer to her coccyx. The interventions for the staff were changed to add a wound vac and for the wound doctor to evaluate and treat when needed. Review of the Wound Treatments Flow sheet for Resident #4 dated 11/01/2016-11/30/2016 reflected the treatment dated 10/24/2016 was to cleanse, dry, and apply a duoderm to the Stage 2 on the coccyx every three (3) days. Then another treatment was hand written for 10/24/2016 to cleanse the Stage 3 to the coccyx, dry, and apply a duoderm every 3 days-this order started on this TAR on 11/08/2016. On 11/15/2016 the order was added to apply a skin prep to the periwound and then the duoderm every other day. Review of the same Wound Treatments Flow sheet for Resident #4 dated 11/01/2016-11/30/2016 reflected on 11/22/2016 (the date in which the Resident's new wound care specialist assumed care of the resident) a new sheet was transcribed and the order changed to cleanse, dry, and apply medi honey to the wound bed, cover with a foam dressing and secure with tape every Monday, Wednesday, and Friday. And on 11/29/2016 the order changed to cleanse and apply [MEDICATION NAME] ointment, Santyl, and [MEDICATION NAME] to the wound bed and cover with a foam dressing and change every day. There was also an order [REDACTED]. Observation on 05/12/2017 at 3:15 PM revealed Resident #4 lying in her bed, with the WCS prepared to perform the wound assessment and debridement with LVN C. Resident #4's Stage 4 Pressure Ulcer measured 0.7 cm x 0.2 cm x 0.7 cm, was debrided, and had granulation tissue. The treatment continued to include the [DEVICE]. She also was lying on an air mattress. In an interview on 05/10/2017 at 9:53 PM LVN C stated Resident #4 had a Stage 2 Pressure Ulcer to her coccyx. She stated she had requested Resident #4 see the WCS but MD would not order the wound consult. LVN C also stated the NP would not order a wound consult, change the treatment, or debride the wound. LVN C stated the wound was necrotic and had slough when she asked the MD and NP to see the wound. LVN C stated she had a language barrier with the NP; all the NP would say was (MD) see. LVN C stated NP assessed the wound but would not change the treatment on the wound. LVN C stated the previous Administrator was aware of the communication problems she was having with the MD and NP. She stated she would not have sent Resident #4 to an emergency room because Resident #4 was not having a systemic problem. She stated she did not even think to send Resident #4 to the emergency room . In an interview on 05/10/2017 at 11:46 AM Resident #4's previous MD stated he had found some notes for Resident #4 where his NP had seen Resident #4 on 10/25/2016. He stated there was a superficial pressure ulcer on her coccyx and the NP had ordered an air mattress and position changes. MD stated he did not assess Resident #4's Pressure Ulcer, his NP did. In an interview on 05/11/2017 at 3:42 PM Resident #4's previous MD stated My NP pretty much takes care of the faxes. I get 100+ a day and I do not read all of them. If someone wants me to know of a change of condition, they should call me or come to my office; it's half a mile down the street. The staff has my cell phone number. I would have expected the facility to phone me directly for something like this. They should have called me. If the facility faxed me and there was not a response, they should have called me. I would have responded. I am a trained orthopedic surgeon and I do my own wound care. This communication was between the NP and the facility and I was unaware. The NP is brand new out of school last September and she didn't realize the seriousness of the situation. I'm not sure of her training with pressure sores, but I'm sure she is competent. We are in the same office and we talk every day. I never saw the wound on Resident #4. I never knew there was a wound with necrosis. Oh my gosh, no, a duoderm will only make it worse (discussing treatment options). I definitely would not have kept the same treatment with necrosis. It should have been debrided. I do 101% of my wound care now. I think all of this happened in November 2016 and no one ever told me about it until about three (3) months ago. I did not know the family had changed doctors. The facility normally calls both doctors when there is a change in physicians but I was not called or notified. I found out about all of this about three (3) months ago. I think (NP) told me. I don't recall talking to the Administrator until (NP) told me. I was quite upset so I came here and talked to the Administrator. I told her I was very upset and asked why I wasn't told of this. I had not talked to the (previous) DON (about Resident #4). In an interview on 05/10/2017 at 4:55 PM the current DON stated she would expect for the nursing staff to follow up on the facsimiles sent to the MD within 24 hours by calling the MD. She stated she has talked to MD about a month ago and MD was responsive to her calls timely. In an interview on 05/10/2017 at 5:00 PM the RNC stated, that on an earlier date unknown, she met with the previous Administrator and MD and discussed timely visits and communication. She stated specific residents were not discussed. In an interview on 05/10/2017 at 5:10 PM Resident #4's previous NP stated she assessed Resident #4's Pressure Ulcer to her coccyx in October and November 2016. She stated it was located on her coccyx and was a Stage 2. She stated the wound bed was not necrotic and had no slough. NP stated she ordered a regular dressing and an air mattress and for the staff to reposition Resident #4. She stated she did not remember receiving a notification or facsimile about the Stage 2 Pressure Ulcer having slough or being necrotic. She stated she only received the notification about Resident #4's RP changing Physicians. In an interview on 05/11/2017 at 2:15 PM the previous Administrator stated she had several meetings with the MD about reaching him timely and responding timely. She also stated she was aware Resident #4 had a Pressure Ulcer. The previous Administrator stated she was aware MD and NP would not order a wound consultant for his residents. She stated an option was given to the RP to change the Physician in late November, 2016. At that time, when the RP was given that choice, the change occuoccurred. The previous Administrator stated MD did not talk to her about Resident #4, she was not a clinical person. She stated Corporate also talked to MD about timeliness of communication. In an interview on 05/17/2017 at 11:31 AM the previous DON stated she did not remember anything specific about the pressure ulcer on Resident #4. She stated it was the policy of the facility to only use an air mattress on residents with multiple Stage 2 pressure ulcers, Stage 3, Stage 4, or Unstageable. She also stated the MD should have been notified of the policy since Resident #4 did not meet the criteria for an air mattress when ordered on [DATE]. She stated she also expected LVN C to notify her (previous DON) if she had any issues contacting MD about the pressure ulcer. The previous DON stated she did remember LVN C would become frustrated when trying to contact MD or NP, but did not remember the specific resident involved. She stated she expected the nursing staff to alert her or Corporate so they could contact the Medical Director of the facility when a resident needed a treatment change if the attending physician was not communicating with the nursing staff. Review of the facility's policy entitled Skin-Preventative Guideline for Resident at Risk for Pressure Injury revised 07/2016 reflected .a resident who enters the home without a pressure injury will not develop pressure injury . The policy reflected the definition of Avoidable: The resident developed a pressure injury(s), or that an existing pressure injury deteriorated or failed to heal adequately (or heal as well as could be expected for end-of-life conditions) and that the home failed to thoroughly perform the steps of recognition, problem and cause identification, prevention and management, or monitoring in accordance with recognized standards of practice. The policy also reflected the Procedure which included the Braden Scale to determine risk level and the licensed nursing staff consulting with the physician to determine if the area was avoidable or unavoidable. The policy reflected pressure relief devices including an air mattress and discussed areas prone to breakdown including the coccyx. Review of the facility's policy entitled Skin-Treatment Guidelines for Pressure Injuries revised 10/2016 reflected .this home to utilize treatment guidelines when providing care for residents with pressure injury and to prevent further deterioration of pressure injury. The policy reflected the definition of each Stage of Pressure Injuries and the procedure to care for each Stage. The policy reflected for a Stage 2 Pressure Injury to identify the underlying cause and institute pressure reducing devices for the bed and chair, repositioning techniques and times, confirm physician and interested family/friend notification, and documentation in the progress/nurses' notes. Next were the guidelines for treatments depending on the amount of drainage and Physician orders. Then the staff were to assess the area weekly on the form for weekly assessments, use the TAR for the daily treatment documentation, and perform a Braden Score for updates as necessary. The policy reflected the same information for each Stage and specific to the Stage, drainage, and if the area had slough or eschar. Review of the facility's policy entitled Change in Condition-Observing, Reporting and Recording revised 03/2012 reflected the home will inform the Physician of a significant change in a resident's physical status like a deterioration in health and/or a clinical complication. The policy also reflected when the treatment needed altering the Physician would be notified. The policy reflected the notification to the physician should be immediate. If the facility was unable to reach the resident's physician, call an alternate physician, a medical director, or send the resident to the emergency room . The facility provided a Form CMS-672 reflecting 5 residents had pressure ulcers excluding Stage 1.

Based on observation, interview, and record review, the facility failed to ensure residents remain free of significant medications errors for two (2) of five (5) residents reviewed for receiving physician ordered [MEDICATION NAME]es (Resident # 1 and Resident # 11) when: A. MA Z and MA Y failed to remove Resident #1's Nitro-Dur 24 hour 0.2 mg/hr. [MEDICATION NAME]es prior to applying a new one. On 07/22/15 Resident #1 had a blood pressure of 68/27 and requested to go to the hospital. Upon arrival, emergency room staff determined the cause of Resident#1's [MEDICAL CONDITION] was due to having three Nitro-Dur 24 hour patches in place, which resulted in a 24 hour hospital stay. (Nitro-Dur 24 hour patches are used to treat chest pain by relaxing blood vessels and lower blood pressure, and old patches should be removed prior to applying a new one.) B. MA X and MA Z did not remove Resident #11 ' s [MEDICATION NAME]'s patch dated 07/14/15 prior to applying new ones, or identify it was still in place as of 07/30/15. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/15 at 3:35 PM. While the IJ was removed on 07/31/15 at 1:36 PM, the facility remained out of compliance at a severity of atual harm that is not IJ, with a scope identified as pattern. This deficient practice could place a facility census of 16 residents receiving physician ordered medications delivered via [MEDICATION NAME]es (medications applied to the skin in patch form for continuous absorption while in place) at risk for adverse side effects, long [MEDICATION NAME] medical complications, unnecessary hospitalization s and death. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old with an original admission date of [DATE], a re-admission date of [DATE], and [DIAGNOSES REDACTED]. Review of an admission MDS for Resident # 1 dated 06/06/15 reflected a BIMS score of 11 (indicating minimal cognitive impairment), incontinent of bowel and bladder, and required assistance of two staff for transfers with a mechanical lift. Review of an admission care plan for Resident #1 dated 06/11/15 reflected: Problem #25 Cardiac- Assess vital signs, monitor for signs and symptoms of heart failure. Review of physician orders [REDACTED]. Special instructions-remove old patch prior to applying new one. Review of a hospital History and Physical summary for Resident #1 dated 07/23/15 reflected the following: This [AGE] year old female who has multiple medical problems is a nursing home resident sent to the hospital because she had been feeling weak and dizzy with black shadows in front of her eyes, and nurses noted that she was hypotensive. The patient when arrived at the hospital emergency room noted to have three nitro patches on her body which were removed following which the blood pressure started to get better. The emergency room physician was ready to discharge the patient, and was given a tray to eat and she was eating and then fell asleep and choked on the food and became hypoxic. The patient was put on oxygen, food tray was removed and I was asked to admit the patient for aspiration. Assessment and Plan: 1.) Acute [MEDICAL CONDITION] and [MEDICAL CONDITION], most probably due to aspiration and choking. She is feeling much better. We will admit her to IMC {Intermediate Medical Care}, keep an eye on her oxygen and monitor oxygen saturation . 3.) [MEDICAL CONDITION], which is due to 3 nitro patches. We have removed the nitro patches and monitor blood pressure. www.nlh.nih.gov Low blood pressure occurs when blood pressure is much lower than normal. This means the heart, brain, and other parts of the body do not get enough blood. Normal blood pressure is usually between 90/60 mmHg and 130/80 mmHg. The medical name for low blood pressure is [MEDICAL CONDITION]. In an interview on 07/30/15 at 1:30 PM Resident #1 stated she had to go to the hospital recently due to feeling weak and dizzy. Resident #1 went on to say the hospital staff told her she had really low blood pressure due to having 3 patches on her body. Resident #1 added the emergency room staff told her at one point her blood pressure was as low as 57/19. Resident #1 stated she was so tired, weak and hungry in the emergency room that she was trying to eat and either feel asleep or passed out and choked on the sandwich. She added that during her stay at the hospital she had a swallow study which cleared her from having a swallowing problem. Review of a nursing progress note written by charge nurse, LVN A dated 07/22/15 reflected the following: Resident came inside from a smoke break and stated Im lightheaded and I want to go to the hospital. Vital signs blood pressure 68/27, respirations 20 {normal 12-16 per minute}, pulse 115 {normal 60-100 beats per minute}. Called ambulance for transport. Transported at 2:15 PM. In an interview on 07/30/15 at 2:50 PM, MA Z stated she did not see any other patches (Nitro-Dur) when she applied one on the morning of 07/22/15. When asked if she could not find a patch that would have been placed the day before what would she do, MA Z stated she would tell a charge nurse. MA Z stated she thought maybe she might have informed LVN A that there were no patches on Resident #1 on 07/22/15. MA Z confirmed she had not documented on the MAR that an old patch was removed and/or that she notified a nurse. MA Z also stated there was a LVN that informed her on 07/22/15 that hospital emergency room staff called to report they found 3 Nitro-Dur patches on Resident # 1. Review of a July 2015 MAR for Resident #1 reflected there was no documentation to indicate the old Nitro-Dur patches were removed prior to applying a new one for dates 07/19/15, 07/20/15 and 07/21/15. In an interview on 07/30/15 at 5:45 PM, MA Y stated there was no way she would ever apply a new Nitro-Dur patch without removing the old one first, or any type of [MEDICATION NAME]. MA Y reviewed the July 2015 MAR for Resident #1 and confirmed her initials for the dates of 07/19/15, 07/20/15, and 07/21/15 indicating she had applied a patch on those dates. MA Y had no explanation for not initialing the MAR to indicate she had removed the patches on the dates she initialed she applied them. In an interview on 07/30/15 at 5:40 PM, charge nurse LVN A stated she did not recall a MA notifying her of missing Nitro Dur patches for Resident #1. LVN A did say she received a phone call from the hospital emergency room staff on 07/22/15, and they reported to her Resident #1 had 3 Nitro-Dur patches on her when she arrived to the emergency room . LVN A stated she did not feel the report from the emergency room needed to be acted on immediately, because the resident was admitted to the hospital. LVN A later stated she thought she had discussed the emergency room report with the ADON and MA Z, but did not inform the DON or Resident #1's physician. LVN A stated she was aware there were other residents in the facility receiving [MEDICATION NAME]es. In an interview on 07/30/15 at 4:00 PM the ADON denied LVN A informed her about a phone call from the emergency room staff on 07/22/15 to report Resident #1 had 3 Nitro-Dur patches in place upon arrival causing her to have [MEDICAL CONDITION]. In an interview on 07/30/15 at 3:32 PM the DON stated the day Resident #1 went to the hospital (07/22/15) she had seen her (Resident #1) earlier in the day and asked how she was feeling, because the resident appeared weak and tired. The DON stated later in the day she was informed Resident #1 was being transferred to the emergency room due to [MEDICAL CONDITION]. The DON went on to say the only thing she knew about Resident #1 ' s admission to the hospital was she was hypotensive. The DON stated no one had reported to her the emergency room found 3 Nitro-Dur patches on Resident #1, and facility staff had not reported any missing patches. The DON added when Resident #1 returned to the facility she reviewed the admission orders [REDACTED]. The DON stated LVN A was in the morning meeting when Resident #1 ' s re-admission was discussed, and LVN A did not report the emergency room staff had called to inform them of 3 patches being in place. B. Review of a Face Sheet for Resident #11 reflected he was [AGE] years old with original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. One patch [MEDICATION NAME] daily at bedtime. Special instructions- remove old patch before applying new one rotate site. Diagnosis: [REDACTED]. Special instructions remove old patch before applying new one and rotate site. Review of a facility Incident Report dated 07/30/15 reflected following: A sweep of residents with medications patches was completed in the facility and Resident #11 was found to have two [MEDICATION NAME]es in place. One patch was dated 07/14/15 and the other dated 07/30/15. The patch dated 07/14/15 was brought to the DON. The nurse was instructed to assess the resident and report any distress to the physician and responsible party, and complete a medication error report. Review of the July 2015 MAR for Resident # 11 reflected MA Z and MA X had initialed applying new patches from 07/14/15 through 07/30/15. In an interview on 07/31/15 at 10:00 AM, the DON stated after the facility sweep of all residents with [MEDICATION NAME]es Resident #11 was found with and old patch dated 07/14/15. The DON added attempts to contact MA X for a statement regarding the medication error had gone unanswered. (The investigator was unable to contact MA X as well.) In an interview on 07/31/15 at 1:30 PM, the ADM stated (and the DON agreed) there were several system breakdowns that led to the significant medication error and the facility's failure to identify the error and notify/consult Resident #1's physician. First of all, the Medication Aides should have been following physician orders [REDACTED]. The ADM went on to say LVN A should have informed the DON when she received the phone call from the emergency room regarding Resident #1 having the multiple Nitro Dur patches in place causing the [MEDICAL CONDITION]. The ADM stated LVN A should have imitated a medication error incident report on 07/22/15, notified/consulted with the physician, and informed the DON and the ADM on 07/24/15 during the morning meeting when the interdisciplinary team reviewed her (Resident #1) re-admission. In an interview on 07/28/15 at 2:28 PM the Medical /Director was informed of Substandard Quality of Care for Significant Medication Errors. The Medical Director stated he knew of the 3 Nitro Dur patches being in place on Resident # 1 when she arrived to the hospital, because he had read the hospital records; but no one at the facility had informed him of the medication error and the subsequent [MEDICAL CONDITION] and hospitalization , which he would have expected. The Medical Director also stated he had not communicated his knowledge of the medication error to the facility DON or Administrator because the resident lived through the episode and so I though we just move on to the next problem. Review of the facility ' s undated Procedure for Medication Administration reflected the following: #15. [MEDICATION NAME] Drug Delivery System (Patch) Administration Procedure Purpose To administer medication through the skin for continuous absorption while the patch is in place through proper placement of the patch and care of the application. Procedures: c. remove old patch with alcohol wipe d. cleanse area of old patch with alcohol wipe e. remove new patch from package and envelope f. label patch with date and nurse/CMA initials . h. apply new patch firmly against skin . j. document placement site on MAR Note: If resident is found without an ordered patch on the body -The discovering nurse shall investigate and search for the medication patch -Check package insert for instructions for replacing a missing or loose patch -The prescriber shall be notified and further instruction obtained -Recommend notifying the DON to document incident for potential trending . Review of the facility ' s undated Medication Errors and Adverse Drug Reaction Reporting Policy reflected the following: Policy: Significant medication errors and adverse reactions are assessed, documented and reported as appropriate to the resident ' s attending physician and the QA (Quality Assurance) Definitions: Significant: Medication errors and adverse drug reactions that- -require discontinuing a medication or modifying the dose -require hospitalization -are life threatening -result in death The facility Administrator, DON, and Corporate DON were notified on 07/30/15 at 3:35 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 07/30/14 at 6:05 PM. The final Plan of Removal was accepted by the investigator on 07/30/14 at 6:28 PM. Plan of Removal 07/30/2015 Problem: Failure to prevent undo medication consequences and neglect Plan: 1. Both medication aides involved have been suspended pending further investigation. They will be required to be in serviced on medication administration and ethics prior to returning to work. Completion Date: 07/30/2015 2. Resident # 1 was assessed for multiple medication patches and none found. Blood pressure was within normal parameters. Completion Date: 07/30/15 3. All residents receiving medication patches will be immediately assessed by DON/Designee to ensure only authorized medication patches are being applied, and only the prescribed patches are present. Completion Date: 07/30/15 4. Any residents found to have more patches than the prescribed amount, will be accessed by DON/Designee, and their physician will be notified. Completion Date: 07/30/15 5. All licensed staff will be in serviced by DON/Designee currently working staff not present will be in serviced before starting shift to include: Completed by 8-3-15 · Proper disposal and destruction of used patches. · Proper administration of medication patches, documentation of old patches being removed and new patches being applied. · Only licensed nurses will apply medication patches. · Proper notification of medication errors will be reported to DON, Administrator, Physician, and family. · All changes in orders will be written on the 24 hr report, to include med errors. · Proper protocol on reviewing admission and re-admission orders [REDACTED] 6. Newly hired licensed nurses and med aides will be trained regarding proper medication administration. Completion Date: 07/30/15 7. New admission and re-admission charts will be reviewed by DON/Designee/Administrator in morning meeting to include review of hospital records for accuracy. Completion Date: 07/30/15 8. RNC will do random audits on admissions and re-admissions during his routine visits. Completion Date: 07/30/15 9. Results of audits will be brought to QA for three months. QA will make recommendations based on findings of audits. Completion Date: 07/30/15 10. Medical Director, was notified on 07/30/15 @ 5:15 PM of IJ status. QA conference was held via phone to review plan of removal. 11. A med error report will be written and DR and RP notified. 12. LVN A will be suspended pending investigation. 13. All staff involved in incident will be counseled and possible disciplinary action up to and including termination. Signed by the Administrator The investigator monitored the current plan of removal as follows: Observations on 07/31/15 revealed Resident #1, #11, # 5 and had accurately dated patches in place and there were no additional patches found on the residents. Interviews on 07/31/15 with licensed nursing staff revealed they were knowledgeable of their responsibility for administering all [MEDICATION NAME]es, how to administer them, proper removal and disposal of old patches, informing the DON and Administrator of missing or multiple patches, reporting of medication errors, notification of the physician, DON, and Administrator of medical information communicated to the facility by outside providers and changes in condition, documentation in the nurses ' notes, 24 hour report and an incident report of medication errors and/or pertinent medical conditions or changes. On 07/31/15 at 2:36 PM, the Administrator, DON and Corporate DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility DON provided a list of 16 residents receiving medications via [MEDICATION NAME]es.

Based on interview, and record review, the facility failed to provide pharmaceuticals services and procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident for two (2) of five (5) residents reviewed for receiving physician ordered transdermal patches (Resident # 1 and Resident # 11) when: A. MA Z and MA Y failed to remove Resident #1 ' s Nitro-Dur 24 hour 0.2 mg/hr. transdermal patches prior to applying a new one. On 07/22/15 Resident #1 had a blood pressure of 68/27,requested to go to the hospital. Upon arrival, emergency room staff determined the cause of Resident#1's hypotension was due to having three Nitro-Dur 24 hour patches in place, which resulted in a 24 hour stay. (Nitro-Dur 24 hour patches are used to treat chest pain by relaxing blood vessels and lower blood pressure, and old patches should be removed prior to applying a new one.) B. MA X and MA Z did not remove Resident #11 ' s Exelon ' s patch dated 07/14/15 prior to applying new ones, or identify it was still in place as of 07/30/15. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/15 at 3:35 PM. While the IJ was removed on 07/31/15 at 1:36 PM, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope identified as pattern. This deficient practice could place a facility census of 16 residents receiving physician ordered medications delivered via transdermal patches (medications applied to the skin in patch form for continuous absorption while in place) at risk for adverse side effects, long lasting medical complications, unnecessary hospitalization s and death. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old with an original admission date of [DATE], a re-admission date of [DATE], and [DIAGNOSES REDACTED]. Review of an admission MDS for Resident # 1 dated 06/06/15 reflected a BIMS score of 11 (indicating minimal cognitive impairment), incontinent of bowel and bladder, and required assistance of two staff for transfers with a mechanical lift. Review of an admission care plan for Resident #1 dated 06/11/15 reflected: Problem #25 Cardiac- Assess vital signs, monitor for signs and symptoms of heart failure. Review of physician orders [REDACTED]. Special instructions-remove old patch prior to applying new one. Review of a hospital History and Physical summary for Resident #1 dated 07/23/15 reflected the following: This [AGE] year old female who has multiple medical problems is a nursing home resident sent to the hospital because she had been feeling weak and dizzy with black shadows in front of her eyes, and nurses noted that she was hypotensive. The patient when arrived at the hospital emergency room noted to have three nitro patches on her body which were removed following which the blood pressure started to get better. The emergency room physician was ready to discharge the patient, and was given a tray to eat and she was eating and then fell asleep and choked on the food and became hypoxic. The patient was put on oxygen, food tray was removed and I was asked to admit the patient for aspiration. Assessment and Plan: 1.) Acute respiratory failure and hypoxia, most probably due to aspiration and choking. She is feeling much better. We will admit her to IMC {Intermediate Medical Care}, keep an eye on her oxygen and monitor oxygen saturation . 3.) Hypotension, which is due to 3 nitro patches. We have removed the nitro patches and monitor blood pressure. www.nlh.nih.gov Low blood pressure occurs when blood pressure is much lower than normal. This means the heart, brain, and other parts of the body do not get enough blood. Normal blood pressure is usually between 90/60 mmHg and 130/80 mmHg. The medical name for low blood pressure is hypotension. In an interview on 07/30/15 at 1:30 PM Resident #1 stated she had to go to the hospital recently due to feeling weak and dizzy. Resident #1 went on to say the hospital staff told her she had really low blood pressure due to having 3 patches on her body. Resident #1 added the emergency room staff told her at one point her blood pressure was as low as 57/19. Resident #1 stated she was so tired, weak and hungry in the emergency room that she was trying to eat and either feel asleep or passed out and choked on the sandwich. She added that during her stay at the hospital she had a swallow study which cleared her from having a swallowing problem. Review of a nursing progress note written by charge nurse LVN A dated 07/22/15 reflected the following: Resident came inside from a smoke break and stated I ' m lightheaded and I want to go to the hospital. Vital signs blood pressure 68/27, respirations 20 {normal 12-16 per minute}, pulse 115 {normal 60-100 beats per minute}. Called ambulance for transport. Transported at 2:15 PM. In an interview on 07/30/15 at 2:50 PM, MA Z stated she did not see any other patches (Nitro-Dur) when she applied one on the morning of 07/22/15. When asked if she could not find a patch that would have been placed the day before what would she do, MA Z stated she would tell a charge nurse. MA Z stated she thought maybe she might have informed LVN A that there were no patches on Resident #1 on 07/22/15. MA Z confirmed she had not documented on the MAR that an old patch was removed and/or that she notified a nurse. MA Z also stated there was a LVN that informed her on 07/22/15 that hospital emergency room staff called to report they found 3 Nitro-Dur patches on Resident # 1. Review of a July 2015 MAR for Resident #1 reflected there was no documentation to indicate the old Nitro-Dur patches were removed prior to applying a new one for dates 07/19/15, 07/20/15 and 07/21/15. In an interview on 07/30/15 at 5:45 PM, MA Y stated there was no way she would ever apply a new Nitro-Dur patch without removing the old one first, or any type of transdermal patch. MA Y reviewed the July 2015 MAR for Resident #1 and confirmed her initials for the dates of 07/19/15, 07/20/15, and 07/21/15 indicating she had applied a patch on those dates. MA Y had no explanation for not initialing the MAR to indicate she had removed the patches on the dates she initialed she applied them. In an interview on 07/30/15 at 5:40 PM, charge nurse LVN A stated she did not recall a MA notifying her of missing Nitro Dur patches for Resident #1. LVN A did say she received a phone call from the hospital emergency room staff on 07/22/15, and they reported to her Resident #1 had 3 Nitro-Dur patches on her when she arrived to the emergency room . LVN A stated she did not feel the report from the emergency room needed to be acted on immediately, because the resident was admitted to the hospital. LVN A later stated she thought she had discussed the emergency room report with the ADON and MA Z, but did not inform the DON or Resident #1 ' s physician. LVN A stated she was aware there were other residents in the facility receiving transdermal patches. In an interview on 07/30/15 at 4:00 PM the ADON denied LVN A informed her about a phone call from the emergency room staff on 07/22/15 to report Resident #1 had 3 Nitro-Dur patches in place upon arrival causing her to have hypotension. In an interview on 07/30/15 at 3:32 PM the DON stated the day Resident #1 went to the hospital (07/22/15) she had seen her (Resident #1) earlier in the day and asked how she was feeling, because the resident appeared weak and tired. The DON stated later in the day she was informed Resident #1 was being transferred to the emergency room due to hypotension. The DON went on to say the only thing she knew about Resident #1 ' s admission to the hospital was she was hypotensive. The DON stated no one had reported to her the emergency room found 3 Nitro-Dur patches on Resident #1, and facility staff had not reported any missing patches. The DON added when Resident #1 returned to the facility she reviewed the admission orders [REDACTED]. The DON stated LVN A was in the morning meeting when Resident #1 ' s re-admission was discussed, and LVN A did not report the emergency room staff had called to inform them of 3 patches being in place. B. Review of a Face Sheet for Resident #11 reflected he was [AGE] years old with original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician's order [REDACTED]. One patch transdermal daily at bedtime. Special instructions- remove old patch before applying new one rotate site. Diagnosis: [REDACTED]. Special instructions remove old patch before applying new one and rotate site. Review of a facility Incident Report dated 07/30/15 reflected following: A sweep of residents with medications patches was completed in the facility and Resident #11 was found to have two Exelon patches in place. One patch was dated 07/14/15 and the other dated 07/30/15. The patch dated 07/14/15 was brought to the DON. The nurse was instructed to assess the resident and report any distress to the physician and responsible party, and complete a medication error report. Review of the July 2015 MAR for Resident # 11 reflected MA Z and MA X had initialed applying new patches from 07/14/15 through 07/30/15. In an interview on 07/31/15 at 10:00 AM, the DON stated after the facility sweep of all residents with transdermal patches Resident #11 was found with and old patch dated 07/14/15. The DON added attempts to contact MA X for a statement regarding the medication error had gone unanswered. (The investigator was unable to contact MA X as well.) In an interview on 07/31/15 at 1:30 PM, the ADM stated (and the DON agreed) there were several system breakdowns that led to the significant medication error and the facility's failure to identify the error and notify/consult Resident #1's physician. First of all, the Medication Aides should have been following physician orders [REDACTED]. The ADM went on to say LVN A should have informed the DON when she received the phone call from the emergency room regarding Resident #1 having the multiple Nitro Dur patches in place causing the hypotension. The ADM stated LVN A should have imitated a medication error incident report on 07/22/15, notified/consulted with the physician, and informed the DON and the ADM on 07/24/15 during the morning meeting when the interdisciplinary team reviewed her (Resident #1) re-admission. In an interview on 07/28/15 at 2:28 PM the Medical /Director was informed of Substandard Quality of Care for Significant Medication Errors. The Medical Director stated he knew of the 3 Nitro Dur patches being in place on Resident # 1 when she arrived to the hospital, because he had read the hospital records; but no one at the facility had informed him of the medication error and the subsequent hypotension and hospitalization , which he would have expected The Medical Director also stated he had not communicated his knowledge of the medication error to the facility DON or Administrator because the resident lived through the episode, and so I though we just move on to the next problem. Review of the facility ' s undated Procedure for Medication Administration reflected the following: #15. Transdermal Drug Delivery System (Patch) Administration Procedure Purpose To administer medication through the skin for continuous absorption while the patch is in place through proper placement of the patch and care of the application. Procedures: c. remove old patch with alcohol wipe d. cleanse area of old patch with alcohol wipe e. remove new patch from package and envelope f. label patch with date and nurse/CMA initials . h. apply new patch firmly against skin . j. document placement site on MAR Note: If resident is found without an ordered patch on the body -The discovering nurse shall investigate and search for the medication patch -Check package insert for instructions for replacing a missing or loose patch -The prescriber shall be notified and further instruction obtained -Recommend notifying the DON to document incident for potential trending . Review of the facility ' s undated Medication Errors and Adverse Drug Reaction Reporting Policy reflected the following: Policy: Significant medication errors and adverse reactions are assessed, documented and reported as appropriate to the resident ' s attending physician and the QA (Quality Assurance) Definitions: Significant: Medication errors and adverse drug reactions that- -require discontinuing a medication or modifying the dose -require hospitalization -are life threatening -result in death The facility Administrator, DON, and Corporate DON were notified on 07/30/15 at 3:35 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 07/30/14 at 6:05 PM. The final Plan of Removal was accepted by the investigator on 07/30/14 at 6:28 PM. . Plan of Removal 07/30/2015 Problem: Failure to prevent undo medication consequences and neglect Plan: 1. Both medication aides involved have been suspended pending further investigation. They will be required to be in serviced on medication administration and ethics prior to returning to work. Completion Date: 07/30/2015 2. Resident # 1 was assessed for multiple medication patches and none found. Blood pressure was within normal parameters. Completion Date: 07/30/15 3. All residents receiving medication patches will be immediately assessed by DON/Designee to ensure only authorized medication patches are being applied, and only the prescribed patches are present. Completion Date: 07/30/15 4. Any residents found to have more patches than the prescribed amount, will be accessed by DON/Designee, and their physician will be notified. Completion Date: 07/30/15 5. All licensed staff will be in serviced by DON/Designee currently working staff not present will be in serviced before starting shift to include: Completed by 8-3-15 · Proper disposal and destruction of used patches. · Proper administration of medication patches, documentation of old patches being removed and new patches being applied. · Only licensed nurses will apply medication patches. · Proper notification of medication errors will be reported to DON, Administrator, Physician, and family. · All changes in orders will be written on the 24 hr report, to include med errors. · Proper protocol on reviewing admission and re-admission orders [REDACTED] 6. Newly hired licensed nurses and med aides will be trained regarding proper medication administration. Completion Date: 07/30/15 7. New admission and re-admission charts will be reviewed by DON/Designee/Administrator in morning meeting to include review of hospital records for accuracy. Completion Date: 07/30/15 8. RNC will do random audits on admissions and re-admissions during his routine visits. Completion Date: 07/30/15 9. Results of audits will be brought to QA for three months. QA will make recommendations based on findings of audits. Completion Date: 07/30/15 10. Medical Director, was notified on 07/30/15 @ 5:15 PM of IJ status. QA conference was held via phone to review plan of removal. 11. A med error report will be written and DR and RP notified. 12. LVN A will be suspended pending investigation. 13. All staff involved in incident will be counseled and possible disciplinary action up to and including termination. Signed by the Administrator The investigator monitored the current plan of removal as follows: Observations on 07/31/15 revealed Resident #1, #11, # 5 and had accurately dated patches in place and there were no additional patches found on the residents. Interviews on 07/31/15 with licensed nursing staff revealed they were knowledgeable of their responsibility for administering all transdermal patches, how to administer them, proper removal and disposal of old patches, informing the DON and Administrator of missing or multiple patches, reporting of medication errors, notification of the physician, DON, and Administrator of medical information communicated to the facility by outside providers and changes in condition, documentation in the nurses ' notes, 24 hour report and an incident report of medication errors and/or pertinent medical conditions or changes. On 07/31/15 at 2:36 PM, the Administrator, DON and Corporate DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility DON provided a list of 16 residents receiving medications via transdermal patches.

Based on observation, interview and record review the facility failed to ensure it was 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 when: A. The Director of Nursing (DON) failed to train and supervise nursing staff to ensure residents with medication errors resulting in adverse reactions were reported by licensed staff to the DON and the resident's physician was consulted. B. The DON further failed to thoroughly review medical records for Resident #1 during the re-admission process, which clearly stated the reason for the admission was due to a facility significant medication error. C. The DON failed to ensure facility policies were followed for medication error reporting and medication administering of [MEDICATION NAME]es. D. emergency room staff notified charge nurse LVN A by telephone that Resident #1 ' s [MEDICAL CONDITION] episode was due to her having three Nitro-Dur patches in place. LVN A failed to consult with Resident #1's physician when she learned of the medication error, complete a medication error incident report or inform the DON. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/15 at 3:35 PM. While the IJ was removed on 07/31/15 at 1:36 PM, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope identified as pattern. This deficient practice could place a facility census of 16 residents receiving physician ordered medications delivered via [MEDICATION NAME]es (medications applied to the skin in patch form for continuous absorption while in place) at risk for adverse side effects, long [MEDICATION NAME] medical complications, unnecessary hospitalization s and death. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old with an original admission date of [DATE], a re-admission date of [DATE], and [DIAGNOSES REDACTED]. Review of an admission MDS for Resident # 1 dated 06/06/15 reflected a BIMS score of 11 (indicating minimal cognitive impairment), incontinent of bowel and bladder, and required assistance of two staff for transfers with a mechanical lift. Review of an admission care plan for Resident #1 dated 06/11/15 reflected: Problem #25 Cardiac- Assess vital signs, monitor for signs and symptoms of heart failure. Review of physician orders [REDACTED]. Special instructions-remove old patch prior to applying new one. Review of a hospital History and Physical summary for Resident #1 dated 07/23/15 reflected the following: This [AGE] year old female who has multiple medical problems is a nursing home resident sent to the hospital because she had been feeling weak and dizzy with black shadows in front of her eyes, and nurses noted that she was hypotensive. The patient when arrived at the hospital emergency room noted to have three nitro {Nitro-Dur 24 0.2 mg/hour patches on her body which were removed following which the blood pressure started to get better. The emergency room physician was ready to discharge the patient, and was given a tray to eat and she was eating and then fell asleep and choked on the food and became hypoxic. The patient was put on oxygen, food tray was removed and I was asked to admit the patient for aspiration. Assessment and Plan: 1.) Acute [MEDICAL CONDITION] and [MEDICAL CONDITION], most probably due to aspiration and choking. She is feeling much better. We will admit her to IMC {Intermediate Medical Care}, keep an eye on her oxygen and monitor oxygen saturation . 3.) [MEDICAL CONDITION], which is due to 3 nitro patches. We have removed the nitro patches and monitor blood pressure. {www.nlh.nih.gov Low blood pressure occurs when blood pressure is much lower than normal. This means the heart, brain, and other parts of the body do not get enough blood. Normal blood pressure is usually between 90/60 mmHg and 130/80 mmHg. The medical name for low blood pressure is [MEDICAL CONDITION].} In an interview on 07/30/15 at 1:30 PM Resident #1 stated she had to go to the hospital recently due to feeling weak and dizzy. Resident #1 went on to say the hospital staff told her she had really low blood pressure due to having 3 patches on her body. Resident #1 added the emergency room staff told her at one point her blood pressure was as low as 57/19. Resident #1 stated she was so tired, weak and hungry in the emergency room that she was trying to eat and either feel asleep or passed out and choked on the sandwich. She added that during her stay at the hospital she had a swallow study which cleared her from having a swallowing problem. Review of a nursing progress note written by charge nurse LVN A dated 07/22/15 reflected the following: Resident came inside from a smoke break and stated I'm lightheaded and I want to go to the hospital. Vital signs blood pressure 68/27, pulse 115 {normal 60-100 beats per minute}. Called ambulance for transport. Transported at 2:15 PM. In an interview on 07/30/15 at 2:50 PM, MA Z stated she did not see any other patches (Nitro-Dur) when she applied one on the morning of 07/22/15. When asked if she could not find a patch that would have been placed the day before what would she do, MA Z stated she would tell a charge nurse. MA Z stated she thought maybe she might have informed LVN A that there were no patches on Resident #1 on 07/22/15. MA Z confirmed she had not documented on the MAR that an old patch was removed and/or that she notified a nurse. MA Z also stated there was a LVN that informed her on 07/22/15 the hospital emergency room staff called to report they found 3 Nitro-Dur patches on Resident # 1. Review of a July 2015 MAR for Resident #1 reflected there was no documentation to indicate the old Nitro-Dur patches were removed prior to applying a new one for dates 07/19/15, 07/20/15 and 07/21/15. In an interview on 07/30/15 at 5:45 PM, MA Y repeatedly stated there was no way she would ever apply a new Nitro-Dur patch without removing the old one first, or any other type of [MEDICATION NAME]. MA Y reviewed the July 2015 MAR for Resident #1 and confirmed her initials for the dates of 07/19/15, 07/20/15, and 07/21/15 indicating she had applied a patch on those dates. MA Y had no explanation for not initialing the MAR to indicate she had removed the patches on the dates she initialed she applied them. In an interview on 07/30/15 at 5:40 PM, LVN A stated she did not recall a MA notifying her of missing Nitro Dur patches for Resident #1. LVN A did say she received a phone call from the hospital emergency room staff on 07/22/15, and they reported to her Resident #1 had 3 Nitro-Dur patches on her when she arrived to the emergency room . LVN A stated she did not feel the report from the emergency room needed to be acted on immediately, because the resident was still at the hospital. LVN A later stated she thought she had discussed the emergency room report with the ADON and MA Z, but did not inform the DON or Resident #1 ' s physician. LVN A stated she was aware there were other residents in the facility receiving [MEDICATION NAME]es. In an interview on 07/30/15 at 4:00 PM the ADON denied LVN A informed her about a phone call from the emergency room staff on 07/22/15 to report Resident #1 had 3 Nitro-Dur patches in place upon arrival causing her to have [MEDICAL CONDITION]. In an interview on 07/30/15 at 3:32 PM the DON stated the day Resident #1 went to the hospital (07/22/15) she had seen her (Resident #1) earlier in the day and asked how she was feeling, because the resident appeared weak and tired. The DON stated later in the day she was informed Resident #1 was being transferred to the emergency room due to [MEDICAL CONDITION]. The DON went on to say the only thing she knew about Resident #1 ' s admission to the hospital was she was hypotensive. The DON stated no one had reported to her the emergency room found 3 Nitro-Dur patches on Resident #1, and facility staff had not reported any missing patches. - Review of a Face Sheet for Resident #11 reflected he was [AGE] years old with original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician's order [REDACTED]. One patch [MEDICATION NAME] daily at bedtime. Special instructions- remove old patch before applying new one rotate site. Diagnosis: [REDACTED]. Special instructions remove old patch before applying new one and rotate site. Review of a facility Incident Report dated 07/30/15 reflected following: A sweep of residents with medications patches was completed in the facility and Resident #11 was found to have two [MEDICATION NAME]es in place. One patch was dated 07/14/15 and the other dated 07/30/15. The patch dated 07/14/15 was brought to the DON. The nurse was instructed to assess the resident and report any distress to the physician and responsible party, and complete a medication error report. Review of the July 2015 MAR for Resident # 11 reflected MA Z and MA X had initialed applying new patches from 07/14/15 through 07/30/15. In an interview on 07/31/15 at 10:00 AM, the DON stated after the facility sweep of all residents with [MEDICATION NAME]es Resident #11 was found with and old patch dated 07/13/15. The DON added attempts to contact MA X for a statement regarding the medication error had gone unanswered. (The investigator was unable to contact MA X as well.) In an interview on 07/28/15 at 2:28 PM the Medical /Director was informed of Substandard Quality of Care for Significant Medication Errors. The Medical Director stated he knew of the 3 Nitro Dur patches being in place on Resident # 1 when she arrived to the hospital, because he had read the hospital records; but no one at the facility had informed him of the medication error and the subsequent [MEDICAL CONDITION] and hospitalization . The Medical Director also stated he had not communicated his knowledge of the medication error to the facility DON or Administrator because the resident lived through the episode and so I though we just move on to the next problem. Review of the facility ' s undated Procedure for Medication Administration reflected the following: #15. [MEDICATION NAME] Drug Delivery System (Patch) Administration Procedure Purpose To administer medication through the skin for continuous absorption while the patch is in place through proper placement of the patch and care of the application. Procedures: c. remove old patch with alcohol wipe d. cleanse area of old patch with alcohol wipe e. remove new patch from package and envelope f. label patch with date and nurse/CMA initials . h. apply new patch firmly against skin . j. document placement site on MAR Note: If resident is found without an ordered patch on the body -The discovering nurse shall investigate and search for the medication patch -Check package insert for instructions for replacing a missing or loose patch -The prescriber shall be notified and further instruction obtained -Recommend notifying the DON to document incident for potential trending . Review of the facility ' s undated Medication Errors and Adverse Drug Reaction Reporting Policy reflected the following: Policy: Significant medication errors and adverse reactions are assessed, documented and reported as appropriate to the resident ' s attending physician and the QA (Quality Assurance) Definitions: Significant: Medication errors and adverse drug reactions that- -require discontinuing a medication or modifying the dose -require hospitalization -are life threatening -result in death Review of the facility ' s undated Admission and Re-admission Protocol reflected the following: 1.) Nurse to assess resident when resident enters the building for admission or re-admission. 2.) MD {physician} is notified of new admissions and re-admissions. Medications and orders are verified with the MD. 3.) Resident is put on the 24 hour report. 4.) all new admissions and re-admissions charts are brought to the clinical meeting. Charts are reviewed for diagnoses, completion, and discharge summary. 5.) MD notified of any omissions or possible additions. In a continued interview on 07/30/15 at 3:32 PM, the DON stated when Resident #1 returned to the facility on [DATE] she reviewed the admission orders [REDACTED]. The DON stated LNV A was in the morning meeting when Resident #1 ' s re-admission was discussed, and she did not report the emergency room staff had called to inform them of 3 patches being in place. The DON confirmed failing to review Resident #1's re-admission medical information, according to the facility protocol, resulted in an unidentified significant medication error. The DON also confirmed LVN A was unaware the medication aides were not removing old [MEDICATION NAME]es prior to applying new ones as physician ordered. In an interview on 07/31/15 at 1:30 PM, the ADM stated (and the DON agreed) there were several system breakdowns that led to the significant medication error and the facility's failure to identify the error First of all, the Medication Aides should have been following physician orders [REDACTED]. The ADM went on to say LVN A should have informed the DON when she received the phone call from the emergency room regarding Resident #1 having the multiple Nitro Dur patches in place causing the [MEDICAL CONDITION]. The ADM stated LVN A should have imitated a medication error incident report on 07/22/15, and should have informed the DON and the ADM on 07/24/15 during the morning meeting when the interdisciplinary team reviewed her (Resident #1) re-admission. The DON stated she will also have the facility's newly hired treatment nurse report any duplicate [MEDICATION NAME]es when she is doing weekly skin assessments. The facility Administrator, DON, and Corporate DON were notified on 07/30/15 at 3:35 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 07/30/14 at 6:05 PM. The final Plan of Removal was accepted by the investigator on 07/30/14 at 6:28 PM. Plan of Removal 07/30/2015 Problem: Failure to prevent undo medication consequences and neglect Plan: 1. Both medication aides involved have been suspended pending further investigation. They will be required to be in serviced on medication administration and ethics prior to returning to work. Completion Date: 07/30/2015 2. Resident # 1 was assessed for multiple medication patches and none found. Blood pressure was within normal parameters. Completion Date: 07/30/15 3. All residents receiving medication patches will be immediately assessed by DON/Designee to ensure only authorized medication patches are being applied, and only the prescribed patches are present. Completion Date: 07/30/15 4. Any residents found to have more patches than the prescribed amount, will be accessed by DON/Designee, and their physician will be notified. Completion Date: 07/30/15 5. All licensed staff will be in serviced by DON/Designee currently working staff not present will be in serviced before starting shift to include: Completed by 8-3-15 · Proper disposal and destruction of used patches. · Proper administration of medication patches, documentation of old patches being removed and new patches being applied. · Only licensed nurses will apply medication patches. · Proper notification of medication errors will be reported to DON, Administrator, Physician, and family. · All changes in orders will be written on the 24 hr report, to include med errors. · Proper protocol on reviewing admission and re-admission orders [REDACTED] 6. Newly hired licensed nurses and med aides will be trained regarding proper medication administration. Completion Date: 07/30/15 7. New admission and re-admission charts will be reviewed by DON/Designee/Administrator in morning meeting to include review of hospital records for accuracy. Completion Date: 07/30/15 8. RNC will do random audits on admissions and re-admissions during his routine visits. Completion Date: 07/30/15 9. Results of audits will be brought to QA for three months. QA will make recommendations based on findings of audits. Completion Date: 07/30/15 10. Medical Director, was notified on 07/30/15 @ 5:15 PM of IJ status. QA conference was held via phone to review plan of removal. 11. A med error report will be written and DR and RP notified. 12. LVN A will be suspended pending investigation. 13. All staff involved in incident will be counseled and possible disciplinary action up to and including termination. Signed by the Administrator The investigator monitored the current plan of removal as follows: Observations on 07/31/15 revealed Resident #1, #11, # 5 and had accurately dated patches in place and there were no additional patches found on the residents. Interviews on 07/31/15 with licensed nursing staff revealed they were knowledgeable of their responsibility for administering all [MEDICATION NAME]es, how to administer them, proper removal and disposal of old patches, informing the DON and Administrator of missing or multiple patches, reporting of medication errors, notification of the physician, DON, and Administrator of medical information communicated to the facility by outside providers and changes in condition, documentation in the nurses ' notes, 24 hour report and an incident report of medication errors and/or pertinent medical conditions or changes. On 07/31/15 at 2:36 PM, the Administrator, DON and Corporate DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility DON provided a census of 16 residents receiving medications via [MEDICATION NAME]es.

Based on observation, interview, and record review, the facility failed to consult with the resident's physician for a change in resident status for one (1) of five (5) residents reviewed for changes in status (Resident # 1) when: LVN A failed to consult with Resident #1's physician regarding a significant medication error discovered by emergency room staff. emergency room licensed staff determined the cause of Resident#1's [MEDICAL CONDITION] was due to having three Nitro-Dur 0.2 mg/ 24 hour patches in place and notified charge nurse LVN A by telephone of the findings on 07/22/15. (Nitro-Dur 24 hour patches are used to treat chest pain by relaxing blood vessels and lower blood pressure, and old patches should be removed prior to applying a new one.) This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/15 at 3:35 PM. While the IJ was removed on 07/31/15 at 1:36 PM, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope identified as pattern. This deficient practice could place a facility census of 16 residents receiving physician ordered medications delivered via [MEDICATION NAME]es (medications applied to the skin in patch form for continuous absorption while in place) at risk for delayed physician interventions, adverse side effects, long [MEDICATION NAME] medical complications, unnecessary hospitalization s and death. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old with an original admission date of [DATE], a re-admission date of [DATE], and [DIAGNOSES REDACTED]. Review of an admission MDS for Resident # 1 dated 06/06/15 reflected a BIMS score of 11 (indicating minimal cognitive impairment), incontinent of bowel and bladder, and required assistance of two staff for transfers with a mechanical lift. Review of an admission care plan for Resident #1 dated 06/11/15 reflected: Problem #25 Cardiac- Assess vital signs, monitor for signs and symptoms of heart failure. Review of physician orders [REDACTED]. Special instructions-remove old patch prior to applying new one. Review of a hospital History and Physical summary for Resident #1 dated 07/23/15 reflected the following: This [AGE] year old female who has multiple medical problems is a nursing home resident sent to the hospital because she had been feeling weak and dizzy with black shadows in front of her eyes, and nurses noted that she was hypotensive. The patient when arrived at the hospital emergency room noted to have three nitro patches on her body which were removed following which the blood pressure started to get better. The emergency room physician was ready to discharge the patient, and was given a tray to eat and she was eating and then fell asleep and choked on the food and became hypoxic. The patient was put on oxygen, food tray was removed and I was asked to admit the patient for aspiration. Assessment and Plan: 1.) Acute [MEDICAL CONDITION] and [MEDICAL CONDITION], most probably due to aspiration and choking. She is feeling much better. We will admit her to IMC {Intermediate Medical Care}, keep an eye on her oxygen and monitor oxygen saturation . 3.) [MEDICAL CONDITION], which is due to 3 nitro patches. We have removed the nitro patches and monitor blood pressure. www.nlh.nih.gov Low blood pressure occurs when blood pressure is much lower than normal. This means the heart, brain, and other parts of the body do not get enough blood. Normal blood pressure is usually between 90/60 mmHg and 130/80 mmHg. The medical name for low blood pressure is [MEDICAL CONDITION]. In an interview on 07/30/15 at 1:30 PM Resident #1 stated she had to go to the hospital recently due to feeling weak and dizzy. Resident #1 went on to say the hospital staff told her she had really low blood pressure due to having 3 patches on her body. Resident #1 added the emergency room staff told her at one point her blood pressure was as low as 57/19. Resident #1 stated she was so tired, weak and hungry in the emergency room that she was trying to eat and either feel asleep or passed out and choked on the sandwich. She added that during her stay at the hospital she had a swallow study which cleared her from having a swallowing problem. Review of a nursing progress note written by charge nurse LVN A dated 07/22/15 reflected the following: Resident came inside from a smoke break and stated I'm lightheaded and I want to go to the hospital. Vital signs blood pressure 68/27, respirations 20 {normal 12-16 per minute}, pulse 115 {normal 60-100 beats per minute}. Called ambulance for transport. Transported at 2:15 PM. In an interview on 07/30/15 at 2:50 PM, MA Z stated she did not see any other patches (Nitro-Dur) when she applied one on the morning of 07/22/15. When asked if she could not find a patch that would have been placed the day before what would she do, MA Z stated she would tell a charge nurse. MA Z stated she thought maybe she might have informed LVN A that there were no patches on Resident #1 on 07/22/15. MA Z confirmed she had not documented on the MAR that an old patch was removed and/or that she notified a nurse. MA Z also stated there was a LVN that informed her on 07/22/15 that hospital emergency room staff called to report they found 3 Nitro-Dur patches on Resident # 1. Review of a July 2015 MAR for Resident #1 reflected there was no documentation to indicate the old Nitro-Dur patches were removed prior to applying a new one for dates 07/19/15, 07/20/15 and 07/21/15. In an interview on 07/30/15 at 5:45 PM, MA Y stated there was no way she would ever apply a new Nitro-Dur patch without removing the old one first, or any type of [MEDICATION NAME]. MA Y reviewed the July 2015 MAR for Resident #1 and confirmed her initials for the dates of 07/19/15, 07/20/15, and 07/21/15 indicating she had applied a patch on those dates. MA Y had no explanation for not initialing the MAR to indicate she had removed the patches on the dates she initialed she applied them. In an interview on 07/30/15 at 5:40 PM, charge nurse LVN A stated she did not recall a MA notifying her of missing Nitro Dur patches for Resident #1. LVN A did say she received a phone call from the hospital emergency room staff on 07/22/15, and they reported to her Resident #1 had 3 Nitro-Dur patches on her when she arrived to the emergency room . LVN A stated she did not feel the report from the emergency room needed to be acted on immediately, because the resident was admitted to the hospital. LVN A later stated she thought she had discussed the emergency room report with the ADON and MA Z, but did not inform the DON or Resident #1 ' s physician. LVN A stated she was aware there were other residents in facility receiving [MEDICATION NAME]es. In an interview on 07/30/15 at 4:00 PM the ADON denied LVN A informed her about a phone call from the emergency room staff on 07/22/15 to report Resident #1 had 3 Nitro-Dur patches in place upon arrival causing her to have [MEDICAL CONDITION]. In an interview on 07/30/15 at 3:32 PM the DON stated the day Resident #1 went to the hospital (07/22/15) she had seen her (Resident #1) earlier in the day and asked how she was feeling, because the resident appeared weak and tired. The DON stated later in the day she was informed Resident #1 was being transferred to the emergency room due to [MEDICAL CONDITION]. The DON went on to say the only thing she knew about Resident #1 ' s admission to the hospital was she was hypotensive. The DON stated no one had reported to her the emergency room found 3 Nitro-Dur patches on Resident #1, and facility staff had not reported any missing patches. The DON added when Resident #1 returned to the facility she reviewed the admission orders [REDACTED]. The DON stated LVN A was in the morning meeting when Resident #1 ' s re-admission was discussed, and LVN A did not report the emergency room staff had called to inform them of 3 patches being in place. In an interview on 07/31/15 at 1:30 PM, the ADM stated (and the DON agreed) there were several system breakdowns that led to the significant medication error and the facility's failure to identify the error and notify/consult Resident #1's physician. First of all, the Medication Aides should have been following physician orders [REDACTED]. The ADM went on to say LVN A should have informed the DON when she received the phone call from the emergency room regarding Resident #1 having the multiple Nitro Dur patches in place causing the [MEDICAL CONDITION]. The ADM stated LVN A should have imitated a medication error incident report on 07/22/15, notified/consulted with the physician, and informed the DON and the ADM on 07/24/15 during the morning meeting when the interdisciplinary team reviewed her (Resident #1) re-admission. In an interview on 07/28/15 at 2:28 PM the Medical /Director was informed of Substandard Quality of Care for Significant Medication Errors. The Medical Director stated he knew of the 3 Nitro Dur patches being in place on Resident # 1 when she arrived to the hospital, because he had read the hospital records; but no one at the facility had informed him of the medication error and the subsequent [MEDICAL CONDITION] and hospitalization , which he would have expected. The Medical Director also stated he had not communicated his knowledge of the medication error to the facility DON or Administrator because the resident lived through the episode, and so I thought we just move on to the next problem. Review of the facility ' s Change of Condition-Observing, Reporting, and Recording dated 01/2008 and revised in 03/2012 reflected: It is the policy of this home to inform the resident ' s physician, and if indicated the resident ' s responsible party of the following: .2. A significant change in the resident ' s physical, mental, or psychosocial status, such as a deterioration in health, mental or psychosocial status in life threatening conditions or clinical complications. Procedure: .#3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable Review of the facility ' s undated Procedure for Medication Administration reflected the following: #15. [MEDICATION NAME] Drug Delivery System (Patch) Administration Procedure Purpose To administer medication through the skin for continuous absorption while the patch is in place through proper placement of the patch and care of the application. Procedures: c. remove old patch with alcohol wipe d. cleanse area of old patch with alcohol wipe e. remove new patch from package and envelope f. label patch with date and nurse/CMA initials . h. apply new patch firmly against skin . j. document placement site on MAR Note: If resident is found without an ordered patch on the body -The discovering nurse shall investigate and search for the medication patch -Check package insert for instructions for replacing a missing or loose patch -The prescriber shall be notified and further instruction obtained -Recommend notifying the DON to document incident for potential trending . Review of the facility ' s undated Medication Errors and Adverse Drug Reaction Reporting Policy reflected the following: Policy: Significant medication errors and adverse reactions are assessed, documented and reported as appropriate to the resident ' s attending physician and the QA (Quality Assurance) Definitions: Significant: Medication errors and adverse drug reactions that- -require discontinuing a medication or modifying the dose -require hospitalization -are life threatening -result in death The facility Administrator, DON, and Corporate DON were notified on 07/30/15 at 3:35 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 07/30/14 at 6:05 PM. The final Plan of Removal was accepted by the investigator on 07/30/14 at 6:28 PM. Plan of Removal 07/30/2015 Problem: Failure to prevent undo medication consequences and neglect Plan: 1. Both medication aides involved have been suspended pending further investigation. They will be required to be in serviced on medication administration and ethics prior to returning to work. Completion Date: 07/30/2015 2. Resident # 1 was assessed for multiple medication patches and none found. Blood pressure was within normal parameters. Completion Date: 07/30/15 3. All residents receiving medication patches will be immediately assessed by DON/Designee to ensure only authorized medication patches are being applied, and only the prescribed patches are present. Completion Date: 07/30/15 4. Any residents found to have more patches than the prescribed amount, will be accessed by DON/Designee, and their physician will be notified. Completion Date: 07/30/15 5. All licensed staff will be in serviced by DON/Designee currently working staff not present will be in serviced before starting shift to include: Completed by 8-3-15. · Proper disposal and destruction of used patches. · Proper administration of medication patches, documentation of old patches being removed and new patches being applied. · Only licensed nurses will apply medication patches. · Proper notification of medication errors will be reported to DON, Administrator, Physician, and family. · All changes in orders will be written on the 24 hr report, to include med errors. · Proper protocol on reviewing admission and re-admission orders [REDACTED] 6. Newly hired licensed nurses and med aides will be trained regarding proper medication administration. Completion Date: 07/30/15 7. New admission and re-admission charts will be reviewed by DON/Designee/Administrator in morning meeting to include review of hospital records for accuracy. Completion Date: 07/30/15 8. RNC will do random audits on admissions and re-admissions during his routine visits. Completion Date: 07/30/15 9. Results of audits will be brought to QA for three months. QA will make recommendations based on findings of audits. Completion Date: 07/30/15 10. Medical Director, was notified on 07/30/15 @ 5:15 PM of IJ status. QA conference was held via phone to review plan of removal. 11. A med error report will be written and DR and RP notified. 12. LVN A will be suspended pending investigation. 13. All staff involved in incident will be counseled and possible disciplinary action up to and including termination. Signed by the Administrator The investigator monitored the current plan of removal as follows: Observations on 07/31/15 revealed Resident #1, #11, # 5 and had accurately dated patches in place and there were no additional patches found on the residents. Interviews on 07/31/15 with licensed nursing staff revealed they were knowledgeable of their responsibility for administering all [MEDICATION NAME]es, how to administer them, proper removal and disposal of old patches, informing the DON and Administrator of missing or multiple patches, reporting of medication errors, notification of the physician, DON, and Administrator of medical information communicated to the facility by outside providers and changes in condition, documentation in the nurses ' notes, 24 hour report and an incident report of medication errors and/or pertinent medical conditions or changes. On 07/31/15 at 2:36 PM, the Administrator, DON and Corporate DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility DON provided a list of 16 residents receiving medications via [MEDICATION NAME]es.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect for two (2) of five (5) residents reviewed for neglect for significant medication errors (Resident # 1 and Resident # 11) when: A. MA Z and MA Y failed to remove Resident #1's Nirtro-Dur 24 hour 0.2 mg/hr. [MEDICATION NAME]es prior to applying a new one. On 07/22/15 Resident #1 had a blood pressure of 68/27, and requested to go to the hospital. Upon arrival, emergency room staff determined the cause of Resident#1's [MEDICAL CONDITION] was due to having three Nitro-Dur 24 hour patches in place.which resulted in a 24 hour stay. (Nitro-Dur 24 hour patches are used to treat chest pain by relaxing blood vessels and lower blood pressure, and old patches should be removed prior to applying a new one.) B. MA X and MA Z did not remove Resident #11 ' s [MEDICATION NAME] ' s patch dated 07/14/15 prior to applying new ones, or identify it was still in place as of 07/30/15. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/15 at 3:35 PM. While the IJ was removed on 07/31/15 at 1:36 PM, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope identified as pattern. This deficient practice could place a facility census of 16 residents receiving physician ordered medications delivered via [MEDICATION NAME]es (medications applied to the skin in patch form for continuous absorption while in place) at risk for adverse side effects, long [MEDICATION NAME] medical complications, unnecessary hospitalization s and death. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old with an original admission date of [DATE], a re-admission date of [DATE], and [DIAGNOSES REDACTED]. Review of an admission MDS for Resident # 1 dated 06/06/15 reflected a BIMS score of 11 (indicating minimal cognitive impairment), incontinent of bowel and bladder, and required assistance of two staff for transfers with a mechanical lift. Review of an admission care plan for Resident #1 dated 06/11/15 reflected: Problem #25 Cardiac- Assess vital signs, monitor for signs and symptoms of heart failure. Review of physician orders [REDACTED]. Special instructions-remove old patch prior to applying new one. Review of a hospital History and Physical summary for Resident #1 dated 07/23/15 reflected the following: This [AGE] year old female who has multiple medical problems is a nursing home resident sent to the hospital because she had been feeling weak and dizzy with black shadows in front of her eyes, and nurses noted that she was hypotensive. The patient when arrived at the hospital emergency room noted to have three nitro {Nitro-Dur 24 0.2 mg/hour patches on her body which were removed following which the blood pressure started to get better. The emergency room physician was ready to discharge the patient, and was given a tray to eat and she was eating and then fell asleep and choked on the food and became hypoxic. The patient was put on oxygen, food tray was removed and I was asked to admit the patient for aspiration. Assessment and Plan: 1.) Acute [MEDICAL CONDITION] and [MEDICAL CONDITION], most probably due to aspiration and choking. She is feeling much better. We will admit her to IMC {Intermediate Medical Care}, keep an eye on her oxygen and monitor oxygen saturation . 3.) [MEDICAL CONDITION], which is due to 3 nitro patches. We have removed the nitro patches and monitor blood pressure. {www.nlh.nih.gov Low blood pressure occurs when blood pressure is much lower than normal. This means the heart, brain, and other parts of the body do not get enough blood. Normal blood pressure is usually between 90/60 mmHg and 130/80 mmHg. The medical name for low blood pressure is [MEDICAL CONDITION].} In an interview on 07/30/15 at 1:30 PM Resident #1 stated she had to go to the hospital recently due to feeling weak and dizzy. Resident #1 went on to say the hospital staff told her she had really low blood pressure due to having 3 patches on her body. Resident #1 added the emergency room staff told her at one point her blood pressure was as low as 57/19. Resident #1 stated she was so tired, weak and hungry in the emergency room that she was trying to eat and either feel asleep or passed out and choked on the sandwich. She added that during her stay at the hospital she had a swallow study which cleared her from having a swallowing problem. Review of a nursing progress note written by charge nurse LVN A dated 07/22/15 reflected the following: Resident came inside from a smoke break and stated I ' m lightheaded and I want to go to the hospital. Vital signs blood pressure 68/27, pulse 115 {normal 60-100 beats per minute}. Called ambulance for transport. Transported at 2:15 PM. In an interview on 07/30/15 at 2:50 PM, MA Z stated she did not see any other patches (Nitro-Dur) when she applied one on the morning of 07/22/15. When asked if she could not find a patch that would have been placed the day before what would she do, MA Z stated she would tell a charge nurse. MA Z stated she thought maybe she might have informed LVN A that there were no patches on Resident #1 on 07/22/15. MA Z confirmed she had not documented on the MAR that an old patch was removed and/or that she notified a nurse. MA Z also stated there was a LVN that informed her on 07/22/15 the hospital emergency room staff called to report they found 3 Nitro-Dur patches on Resident # 1. Review of a July 2015 MAR for Resident #1 reflected there was no documentation to indicate the old Nitro-Dur patches were removed prior to applying a new one for dates 07/19/15, 07/20/15 and 07/21/15. In an interview on 07/30/15 at 5:45 PM, MA Y stated there was no way she would ever apply a new Nitro-Dur patch without removing the old one first, or any other type of [MEDICATION NAME]. MA Y reviewed the July 2015 MAR for Resident #1 and confirmed her initials for the dates of 07/19/15, 07/20/15, and 07/21/15 indicating she had applied a patch on those dates. MA Y had no explanation for not initialing the MAR to indicate she had removed the patches on the dates she initialed she applied them. In an interview on 07/30/15 at 5:40 PM, LVN A stated she did not recall a MA notifying her of missing Nitro Dur patches for Resident #1. LVN A did say she received a phone call from the hospital emergency room staff on 07/22/15, and they reported to her Resident #1 had 3 Nitro-Dur patches on her when she arrived to the emergency room . LVN A stated she did not feel the report from the emergency room needed to be acted on immediately, because the resident was still at the hospital. LVN A later stated she thought she had discussed the emergency room report with the ADON and MA Z, but did not inform the DON or Resident #1 ' s physician. LVN A stated she was aware there were other residents in the facility receiving [MEDICATION NAME]es. In an interview on 07/30/15 at 4:00 PM the ADON denied LVN A informed her about a phone call from the emergency room staff on 07/22/15 to report Resident #1 had 3 Nitro-Dur patches in place upon arrival causing her to have [MEDICAL CONDITION]. In an interview on 07/30/15 at 3:32 PM the DON stated the day Resident #1 went to the hospital (07/22/15) she had seen her (Resident #1) earlier in the day and asked how she was feeling, because the resident appeared weak and tired. The DON stated later in the day she was informed Resident #1 was being transferred to the emergency room due to [MEDICAL CONDITION]. The DON went on to say the only thing she knew about Resident #1 ' s admission to the hospital was she was hypotensive. The DON stated no one had reported to her the emergency room found 3 Nitro-Dur patches on Resident #1, and facility staff had not reported any missing patches. The DON added when Resident #1 returned to the facility she reviewed the admission orders [REDACTED]. The DON stated LVN A was in the morning meeting when Resident #1 ' s re-admission was discussed, and LVN A did not report the emergency room staff had called to inform them of 3 patches being in place. B. Review of a Face Sheet for Resident #11 reflected he was [AGE] years old with original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician's order [REDACTED]. One patch [MEDICATION NAME] daily at bedtime. Special instructions- remove old patch before applying new one rotate site. Diagnosis: [REDACTED]. Special instructions remove old patch before applying new one and rotate site. Review of a facility Incident Report dated 07/30/15 reflected following: A sweep of residents with medications patches was completed in the facility and Resident #11 was found to have two [MEDICATION NAME]es in place. One patch was dated 07/14/15 and the other dated 07/30/15. The patch dated 07/14/15 was brought to the DON. The nurse was instructed to assess the resident and report any distress to the physician and responsible party, and complete a medication error report. Review of the July 2015 MAR for Resident # 11 reflected MA Z and MA X had initialed applying new patches from 07/14/15 through 07/30/15. In an interview on 07/31/15 at 10:00 AM, the DON stated after the facility sweep of all residents with [MEDICATION NAME]es Resident #11 was found with and old patch dated 07/14/15. The DON added attempts to contact MA X for a statement regarding the medication error had gone unanswered. (The investigator was unable to contact MA X as well.) In an interview on 07/31/15 at 1:30 PM, the ADM stated (and the DON agreed) there were several system breakdowns that led to the significant medication error and the facility's failure to identify the error and notify/consult Resident #1's physician. First of all, the Medication Aides should have been following physician orders [REDACTED]. The ADM went on to say LVN A should have informed the DON when she received the phone call from the emergency room regarding Resident #1 having the multiple Nitro Dur patches in place causing the [MEDICAL CONDITION]. The ADM stated LVN A should have imitated a medication error incident report on 07/22/15, notified/consulted with the physician, and informed the DON and the ADM on 07/24/15 during the morning meeting when the interdisciplinary team reviewed her (Resident #1) re-admission. In an interview on 07/28/15 at 2:28 PM the Medical /Director was informed of Substandard Quality of Care for Significant Medication Errors. The Medical Director stated he knew of the 3 Nitro Dur patches being in place on Resident # 1 when she arrived to the hospital, because he had read the hospital records; but no one at the facility had informed him of the medication error and the subsequent [MEDICAL CONDITION] and hospitalization , which he would have expected. The Medical Director also stated he had not communicated his knowledge of the medication error to the facility DON or Administrator because the resident lived through the episode and so I though we just move on to the next problem. Review of the facility ' s Abuse/Neglect policy dated 01/2008 and revised on 05/2014 reflected: Neglect is the failure to provide goods and services to avoid physical harm. Review of the facility ' s undated Procedure for Medication Administration reflected the following: #15. [MEDICATION NAME] Drug Delivery System (Patch) Administration Procedure Purpose To administer medication through the skin for continuous absorption while the patch is in place through proper placement of the patch and care of the application. Procedures: c. remove old patch with alcohol wipe d. cleanse area of old patch with alcohol wipe e. remove new patch from package and envelope f. label patch with date and nurse/CMA initials . h. apply new patch firmly against skin . j. document placement site on MAR Note: If resident is found without an ordered patch on the body -The discovering nurse shall investigate and search for the medication patch -Check package insert for instructions for replacing a missing or loose patch -The prescriber shall be notified and further instruction obtained -Recommend notifying the DON to document incident for potential trending . Review of the facility ' s undated Medication Errors and Adverse Drug Reaction Reporting Policy reflected the following: Policy: Significant medication errors and adverse reactions are assessed, documented and reported as appropriate to the resident ' s attending physician and the QA (Quality Assurance) Definitions: Significant: Medication errors and adverse drug reactions that- -require discontinuing a medication or modifying the dose -require hospitalization -are life threatening -result in death The facility Administrator, DON, and Corporate DON were notified on 07/30/15 at 3:35 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 07/30/14 at 6:05 PM. The final Plan of Removal was accepted by the investigator on 07/30/14 at 6:28 PM. Plan of Removal 07/30/2015 Problem: Failure to prevent undo medication consequences and neglect Plan: 1. Both medication aides involved have been suspended pending further investigation. They will be required to be in serviced on medication administration and ethics prior to returning to work. Completion Date: 07/30/2015 2. Resident # 1 was assessed for multiple medication patches and none found. Blood pressure was within normal parameters. Completion Date: 07/30/15 3. All residents receiving medication patches will be immediately assessed by DON/Designee to ensure only authorized medication patches are being applied, and only the prescribed patches are present. Completion Date: 07/30/15 4. Any residents found to have more patches than the prescribed amount, will be accessed by DON/Designee, and their physician will be notified. Completion Date: 07/30/15 5. All licensed staff will be in serviced by DON/Designee currently working staff not present will be in serviced before starting shift to include: Completed by 8-3-15 · Proper disposal and destruction of used patches. · Proper administration of medication patches, documentation of old patches being removed and new patches being applied. · Only licensed nurses will apply medication patches. · Proper notification of medication errors will be reported to DON, Administrator, Physician, and family. · All changes in orders will be written on the 24 hr report, to include med errors. · Proper protocol on reviewing admission and re-admission orders [REDACTED] 6. Newly hired licensed nurses and med aides will be trained regarding proper medication administration. Completion Date: 07/30/15 7. New admission and re-admission charts will be reviewed by DON/Designee/Administrator in morning meeting to include review of hospital records for accuracy. Completion Date: 07/30/15 8. RNC will do random audits on admissions and re-admissions during his routine visits. Completion Date: 07/30/15 9. Results of audits will be brought to QA for three months. QA will make recommendations based on findings of audits. Completion Date: 07/30/15 10. Medical Director, was notified on 07/30/15 @ 5:15pm of IJ status. QA conference was held via phone to review plan of removal. 11. A med error report will be written and DR and RP notified. 12. LVN A will be suspended pending investigation. 13. All staff involved in incident will be counseled and possible disciplinary action up to and including termination. Signed by the Administrator The investigator monitored the current plan of removal as follows: Observations on 07/31/15 revealed Resident #1, #11, # 5 and had accurately dated patches in place and there were no additional patches found on the residents. Interviews on 07/31/15 with licensed nursing staff revealed they were knowledgeable of their responsibility for administering all [MEDICATION NAME]es, how to administer them, proper removal and disposal of old patches, informing the DON and Administrator of missing or multiple patches, reporting of medication errors, notification of the physician, DON, and Administrator of medical information communicated to the facility by outside providers and changes in condition, documentation in the nurses ' notes, 24 hour report and an incident report of medication errors and/or pertinent medical conditions or changes. On 07/31/15 at 2:36 PM, the Administrator, DON and Corporate DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility DON provided a list of 16 residents receiving medications via [MEDICATION NAME]es.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect for two (2) of five (5) residents reviewed for neglect for significant medication errors (Resident # 1 and Resident # 11) when: A. MA Z and MA Y failed to remove Resident #1 ' s Nitro-Dur 24 hour 0.2 mg/hr. [MEDICATION NAME]es prior to applying a new one. On 07/22/15 Resident #1 had a blood pressure of 68/27, and requested to go to the hospital. Upon arrival, emergency room staff determined the cause of Resident#1's [MEDICAL CONDITION] was due to having three Nitro-Dur 24 hour patches in place, which resulted in a 24 hour stay. (Nitro-Dur 24 hour patches are used to treat chest pain by relaxing blood vessels and lower blood pressure, and old patches should be removed prior to applying a new one.) B. MA X and MA Z did not remove Resident #11 ' s [MEDICATION NAME] ' s patch dated 07/14/15 prior to applying new ones, or identify it was still in place as of 07/30/15. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/15 at 3:35 PM. While the IJ was removed on 07/31/15 at 1:36 PM, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope identified as pattern. This deficient practice could place a facility census of 16 residents receiving physician ordered medications delivered via [MEDICATION NAME]es (medications applied to the skin in patch form for continuous absorption while in place) at risk for adverse side effects, long [MEDICATION NAME] medical complications, unnecessary hospitalization s and death. The Findings Include: Review of the facility's Abuse/Neglect policy dated 01/2008 and revised on 05/2014 reflected: Neglect is the failure to provide goods and services to avoid physical harm. Review of the facility ' s undated Procedure for Medication Administration reflected the following: #15. [MEDICATION NAME] Drug Delivery System (Patch) Administration Procedure Purpose To administer medication through the skin for continuous absorption while the patch is in place through proper placement of the patch and care of the application. Procedures: c. remove old patch with alcohol wipe d. cleanse area of old patch with alcohol wipe e. remove new patch from package and envelope f. label patch with date and nurse/CMA initials . h. apply new patch firmly against skin . j. document placement site on MAR Note: If resident is found without an ordered patch on the body -The discovering nurse shall investigate and search for the medication patch -Check package insert for instructions for replacing a missing or loose patch -The prescriber shall be notified and further instruction obtained -Recommend notifying the DON to document incident for potential trending . Review of the facility ' s undated Medication Errors and Adverse Drug Reaction Reporting Policy reflected the following: Policy: Significant medication errors and adverse reactions are assessed, documented and reported as appropriate to the resident ' s attending physician and the QA (Quality Assurance) Definitions: Significant: Medication errors and adverse drug reactions that- -require discontinuing a medication or modifying the dose -require hospitalization -are life threatening -result in death Review of a Face Sheet for Resident #1 reflected she was [AGE] years old with an original admission date of [DATE], a re-admission date of [DATE], and [DIAGNOSES REDACTED]. Review of an admission MDS for Resident # 1 dated 06/06/15 reflected a BIMS score of 11 (indicating minimal cognitive impairment), incontinent of bowel and bladder, and required assistance of two staff for transfers with a mechanical lift. Review of an admission care plan for Resident #1 dated 06/11/15 reflected: Problem #25 Cardiac- Assess vital signs, monitor for signs and symptoms of heart failure. Review of physician orders [REDACTED]. Special instructions-remove old patch prior to applying new one. Review of a hospital History and Physical summary for Resident #1 dated 07/23/15 reflected the following: This [AGE] year old female who has multiple medical problems is a nursing home resident sent to the hospital because she had been feeling weak and dizzy with black shadows in front of her eyes, and nurses noted that she was hypotensive. The patient when arrived at the hospital emergency room noted to have three nitro {Nitro-Dur 24 0.2 mg/hour patches on her body which were removed following which the blood pressure started to get better. The emergency room physician was ready to discharge the patient, and was given a tray to eat and she was eating and then fell asleep and choked on the food and became hypoxic. The patient was put on oxygen, food tray was removed and I was asked to admit the patient for aspiration. Assessment and Plan: 1.) Acute [MEDICAL CONDITION] and [MEDICAL CONDITION], most probably due to aspiration and choking. She is feeling much better. We will admit her to IMC {Intermediate Medical Care}, keep an eye on her oxygen and monitor oxygen saturation . 3.) [MEDICAL CONDITION], which is due to 3 nitro patches. We have removed the nitro patches and monitor blood pressure. {www.nlh.nih.gov Low blood pressure occurs when blood pressure is much lower than normal. This means the heart, brain, and other parts of the body do not get enough blood. Normal blood pressure is usually between 90/60 mmHg and 130/80 mmHg. The medical name for low blood pressure is [MEDICAL CONDITION].} In an interview on 07/30/15 at 1:30 PM Resident #1 stated she had to go to the hospital recently due to feeling weak and dizzy. Resident #1 went on to say the hospital staff told her she had really low blood pressure due to having 3 patches on her body. Resident #1 added the emergency room staff told her at one point her blood pressure was as low as 57/19. Resident #1 stated she was so tired, weak and hungry in the emergency room that she was trying to eat and either feel asleep or passed out and choked on the sandwich. She added that during her stay at the hospital she had a swallow study which cleared her from having a swallowing problem. Review of a nursing progress note written by charge nurse LVN A dated 07/22/15 reflected the following: Resident came inside from a smoke break and stated I' m lightheaded and I want to go to the hospital. Vital signs blood pressure 68/27, pulse 115 {normal 60-100 beats per minute}. Called ambulance for transport. Transported at 2:15 PM. In an interview on 07/30/15 at 2:50 PM, MA Z stated she did not see any other patches (Nitro-Dur) when she applied one on the morning of 07/22/15. When asked if she could not find a patch that would have been placed the day before what would she do, MA Z stated she would tell a charge nurse. MA Z stated she thought maybe she might have informed LVN A that there were no patches on Resident #1 on 07/22/15. MA Z confirmed she had not documented on the MAR that an old patch was removed and/or that she notified a nurse. MA Z also stated there was a LVN that informed her on 07/22/15 the hospital emergency room staff called to report they found 3 Nitro-Dur patches on Resident # 1. Review of a July 2015 MAR for Resident #1 reflected there was no documentation to indicate the old Nitro-Dur patches were removed prior to applying a new one for dates 07/19/15, 07/20/15 and 07/21/15. In an interview on 07/30/15 at 5:45 PM, MA Y stated there was no way she would ever apply a new Nitro-Dur patch without removing the old one first, or any other type of [MEDICATION NAME]. MA Y reviewed the July 2015 MAR for Resident #1 and confirmed her initials for the dates of 07/19/15, 07/20/15, and 07/21/15 indicating she had applied a patch on those dates. MA Y had no explanation for not initialing the MAR to indicate she had removed the patches on the dates she initialed she applied them. In an interview on 07/30/15 at 5:40 PM, charge nurse LVN A stated she did not recall a MA notifying her of missing Nitro Dur patches for Resident #1. LVN A did say she received a phone call from the hospital emergency room staff on 07/22/15, and they reported to her Resident #1 had 3 Nitro-Dur patches on her when she arrived to the emergency room . LVN A stated she did not feel the report from the emergency room needed to be acted on immediately, because the resident was still at the hospital. LVN A later stated she thought she had discussed the emergency room report with the ADON and MA Z, but did not inform the DON or Resident #1 ' s physician. LVN A stated she was aware there were other residents in the facility receving [MEDICATION NAME]es. In an interview on 07/30/15 at 4:00 PM the ADON denied LVN A informed her about a phone call from the emergency room staff on 07/22/15 to report Resident #1 had 3 Nitro-Dur patches in place upon arrival causing her to have [MEDICAL CONDITION]. In an interview on 07/30/15 at 3:32 PM the DON stated the day Resident #1 went to the hospital (07/22/15) she had seen her (Resident #1) earlier in the day and asked how she was feeling, because the resident appeared weak and tired. The DON stated later in the day she was informed Resident #1 was being transferred to the emergency room due to [MEDICAL CONDITION]. The DON went on to say the only thing she knew about Resident #1 ' s admission to the hospital was she was hypotensive. The DON stated no one had reported to her the emergency room found 3 Nitro-Dur patches on Resident #1, and facility staff had not reported any missing patches. The DON added when Resident #1 returned to the facility she reviewed the admission orders [REDACTED]. The DON stated LVN A was in the morning meeting when Resident #1 ' s re-admission was discussed, and LVN A did not report the emergency room staff had called to inform them of 3 patches being in place. B. Review of a Face Sheet for Resident #11 reflected he was [AGE] years old with original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician's order [REDACTED]. One patch [MEDICATION NAME] daily at bedtime. Special instructions- remove old patch before applying new one rotate site. Diagnosis: [REDACTED]. Special instructions remove old patch before applying new one and rotate site. Review of a facility Incident Report dated 07/30/15 reflected following: A sweep of residents with medications patches was completed in the facility and Resident #11 was found to have two [MEDICATION NAME]es in place. One patch was dated 07/14/15 and the other dated 07/30/15. The patch dated 07/14/15 was brought to the DON. The nurse was instructed to assess the resident and report any distress to the physician and responsible party, and complete a medication error report. Review of the July 2015 MAR for Resident # 11 reflected MA Z and MA X had initialed applying new patches from 07/14/15 through 07/30/15. In an interview on 07/31/15 at 10:00 AM, the DON stated after the facility sweep of all residents with [MEDICATION NAME]es Resident #11 was found with and old patch dated 07/14/15. The DON added attempts to contact MA X for a statement regarding the medication error had gone unanswered. (The investigator was unable to contact MA X as well.) In an interview on 07/31/15 at 1:30 PM, the ADM stated (and the DON agreed) there were several system breakdowns that led to the significant medication error and the facility's failure to identify the error and notify/consult Resident #1's physician. First of all, the Medication Aides should have been following physician orders [REDACTED]. The ADM went on to say LVN A should have informed the DON when she received the phone call from the emergency room regarding Resident #1 having the multiple Nitro Dur patches in place causing the [MEDICAL CONDITION]. The ADM stated LVN A should have imitated a medication error incident report on 07/22/15, notified/consulted with the physician, and informed the DON and the ADM on 07/24/15 during the morning meeting when the interdisciplinary team reviewed her (Resident #1) re-admission. In an interview on 07/28/15 at 2:28 PM the Medical /Director was informed of Substandard Quality of Care for Significant Medication Errors. The Medical Director stated he knew of the 3 Nitro Dur patches being in place on Resident # 1 when she arrived to the hospital, because he had read the hospital records; but no one at the facility had informed him of the medication error and the subsequent [MEDICAL CONDITION] and hospitalization , which he would have expected. The Medical Director also stated he had not communicated his knowledge of the medication error to the facility DON or Administrator because the resident lived through the episode, and so I though we just move on to the next problem. The facility Administrator, DON, and Corporate DON were notified on 07/30/15 at 3:35 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 07/30/14 at 6:05 PM. The final Plan of Removal was accepted by the investigator on 07/30/14 at 6:28 PM. Plan of Removal 07/30/2015 Problem: Failure to prevent undo medication consequences and neglect Plan: 1. Both medication aides involved have been suspended pending further investigation. They will be required to be in serviced on medication administration and ethics prior to returning to work. Completion Date: 07/30/2015 2. Resident # 1 was assessed for multiple medication patches and none found. Blood pressure was within normal parameters. Completion Date: 07/30/15 3. All residents receiving medication patches will be immediately assessed by DON/Designee to ensure only authorized medication patches are being applied, and only the prescribed patches are present. Completion Date: 07/30/15 4. Any residents found to have more patches than the prescribed amount, will be accessed by DON/Designee, and their physician will be notified. Completion Date: 07/30/15 5. All licensed staff will be in serviced by DON/Designee currently working staff not present will be in serviced before starting shift to include: Completed by 8-3-15 · Proper disposal and destruction of used patches. · Proper administration of medication patches, documentation of old patches being removed and new patches being applied. · Only licensed nurses will apply medication patches. · Proper notification of medication errors will be reported to DON, Administrator, Physician, and family. · All changes in orders will be written on the 24 hr report, to include med errors. · Proper protocol on reviewing admission and re-admission orders [REDACTED] 6. Newly hired licensed nurses and med aides will be trained regarding proper medication administration. Completion Date: 07/30/15 7. New admission and re-admission charts will be reviewed by DON/Designee/Administrator in morning meeting to include review of hospital records for accuracy. Completion Date: 07/30/15 8. RNC will do random audits on admissions and re-admissions during his routine visits. Completion Date: 07/30/15 9. Results of audits will be brought to QA for three months. QA will make recommendations based on findings of audits. Completion Date: 07/30/15 10. Medical Director, was notified on 07/30/15 @ 5:15 PM of IJ status. QA conference was held via phone to review plan of removal. 11. A med error report will be written and DR and RP notified. 12. LVN A will be suspended pending investigation. 13. All staff involved in incident will be counseled and possible disciplinary action up to and including termination. Signed by the Administrator The investigator monitored the current plan of removal as follows: Observations on 07/31/15 revealed Resident #1, #11, # 5 and had accurately dated patches in place and there were no additional patches found on the residents. Interviews on 07/31/15 with licensed nursing staff revealed they were knowledgeable of their responsibility for administering all [MEDICATION NAME]es, how to administer them, proper removal and disposal of old patches, informing the DON and Administrator of missing or multiple patches, reporting of medication errors, notification of the physician, DON, and Administrator of medical information communicated to the facility by outside providers and changes in condition, documentation in the nurses ' notes, 24 hour report and an incident report of medication errors and/or pertinent medical conditions or changes. On 07/31/15 at 2:36 PM, the Administrator, DON and Corporate DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility DON provided a list of 16 residents receiving medications via [MEDICATION NAME]es.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (1) of five(5) residents reviewed for assistance of staff for transfers (Resident #1) On 06/17/15 CNA X failed to transfer Resident #1 according to her care plan (two person assist) when she transferred her alone without a gait belt. Resident #1 weighed 294 lbs, had left side weakness and required assistance of two staff for transfers using a gait belt. Resident #1 sustained a traumatic injury to her left knee causing bleeding in the left knee joint, a suspected patella (knee) fracture, and pain. This deficient practice affected Resident # 1 and placed an additional 42 residents that required assistance during transfers at risk for unsafe transfers resulting in injuries, worsening of medical conditions, pain, decreased mobility and increased need for ADL assistance. The Findings Include: Review of a face sheet for Resident #1 reflected she was [AGE] years old with an original admission date of [DATE], a re-admission date of [DATE], and [DIAGNOSES REDACTED]. Review of the facility Initial Nursing assessment dated [DATE] reflected Resident # 1 required assistance of two (2) staff for bed mobility and positioning and assistance of two (2) staff for transfers. Review of a facility Nursing Assistant Care Plan for Resident #1 dated 06/12/15 reflected the following: · Assist of two persons for transfers, bed mobility, and positioning. · Alert and oriented to person, place and time. Review of a facility Incident Report dated 06/17/15 reflected the following the incident time was 8:15 PM; and Resident was lowered to the floor while being transferred to the wheelchair. Resident unable to maintain stand and pivot position due to agitation. Redirected for aggressive behavior. After 20 minutes resident allowed staff to assist her from the floor to the bed, total assist of four staff. In an interview on 06/18/15 at 9:45 AM during initial tour, Resident #1 stated her left knee and hip were hurting and she needed pain medication. When asked why she was hurting Resident #1 stated I fell to the ground yesterday. Observation on 06/18/15 at 9:50 AM, with the DON, reflected Resident #1's left knee was swollen and there was a thin linear bruise on the inner aspect of the knee. Resident #1 would not allow the DON to move her left leg, because she stated movement increased the pain in her left hip and knee. In in interview on 06/18/15 at 6:15 PM LVN Z stated it was reported to her by CNA X that Resident #1 was upset the 6:30 PM smoke break was late and it was almost 8:00 PM, when she (CNA X) volunteered to take residents out to smoke. LVN Z added CNA X reported when she was transferring Resident #1, from the bed to her wheelchair, the resident became agitated and could not pivot or bear her weight, so she was lowered to the floor. In an interview on 06/18/15 at 2:29 PM, CNA X stated her normal role at the facility is as a MA, but she had been a CNA since 2008. CNA X stated the facility was short staffed on the evening of 05/17/15, so she volunteered to take residents on the smoke break. CNA X stated when she went into Resident #1's room around 8:00 PM, she was upset and yelling that she felt discriminated against for not allowing disabled people to get their smoke breaks on time. CNA X stated she asked Resident #1 if she wanted help out of the bed and Resident #1 told her yes. CNA X added Resident #1 sat up on the side of the bed and stated she could pivot and bear weight. CNA X stated when she assisted Resident #1 to a standing position she could not bear weight or pivot, and had to be lowered to the ground. CNA X stated she did not use a gait belt or check Resident #1's CNA care plan for how she should be transferred. CNA X added she remembered signing something about using a gait belt when she was hired, but did not know where they are kept and didn't ask anyone for help. CNA X did not have an explanation for how she had control of Resident #1 to lower her to the ground without a gait belt and she was only wearing a hospital gown. LVN Z stated when she went into the room to assess Resident #1 she found her on the floor on her side and screaming for her cell phone to call 911. LVN Z stated Resident #1 refused to let staff assist her off the floor and instructed LVN Z to leave the room and not to provide care for her. LNV Z stated after 20-25 minutes of lying on the floor, Resident #1 allowed staff to put her back in bed and it took 4 staff using a sheet to get her back in bed. In an interview on 06/18/15 at 1:00 PM, Resident #1 stated CNA X transferred her alone on the evening of 06/17/15, and did not use a gait belt. Observation on 06/18/15 at 3:00 PM, revealed Resident #1 being transferred from her bed to a stretcher by emergency medical services for transport a local hospital for evaluation of her pain and to rule out a fracture(s). Resident #1 screamed in pain when her left leg was moved. She also refused incontinent care because of the pain. Review of a hospital emergency room triage nurses' notes reflected: patient is complaining of pain to left hip/knee/ankle since a fall on 06/17/15. Pain is 10 out of a possible 10 using a numeric scale. Tramadol 50 mg one tablet given at 11:30 AM and 1:30 PM. Review of a hospital CT Scan (computed tomography - a process of many computer processed x-ray images) dated 06/18/15 time 6:20 PM reflected the following: · There is a moderate hemathrosis (bleeding in the joint) of the knee,Suspect a subtle nondisplaced fracture of there lateral tibial plateau. Consider confirmation with a MRI (magnetic resonance image). In an observation/interview on 06/19/15 at 10:00 AM Resident #1 was not in her room and her bed was stripped of linens. When asked where Resident #1 was, LVN Y stated she had returned to the facility late in the evening (on 06/18/15) but was transferred to a local emergency room for evaluation of altered mental status and elevated blood pressure at approximately 9:45 AM. (as of exit on 06/19/15 at 3:00 PM, Resident #1 remained in the emergency room with unstable vital signs and a MRI had not been scheduled) In an interview on 06/18/15 at 3:30 PM, the DON stated CNAs are informed during orientation to check the CNA care plan for instructions on how residents are to be transferred, and they know to ask their charge nurse if in doubt. The DON added it is the expectation CNAs use gait belts that require assistance of one or two staff for transfers. Review of the facility policy dated January, 2008 regarding transfering of residents did not reflect the use of gait belts. Review of the facility's 'Safety' portion of personnel orientation paperwork, and signed upon hire date, reflected gait belts are to be used. Per interview on 06/19/2015 at 3:30 PM the DON stated there were 43 residents who required assistance with transfers.

Based on observation, interview and record review the facility failed to ensure it was 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. The Director of Nursing (DON) failed to monitor, train and supervise nursing staff to ensure residents were monitored for changes in condition, and nurses consulted with residents physician when a change of condition was identified. The DON further failed to monitor and supervise nursing staff in the assessment of residents with indwelling urinary catheters to ensure a resident's clinical condition demonstrated that catheterization was necessary. Resident #2 was admitted on [DATE] with an indwelling urinary catheter, from 04/30/2015 to 05/05/2015 without a physician order [REDACTED].>There was not a medical [DIAGNOSES REDACTED].#2 when the Resident's clinical condition did not demonstrate catheterization was necessary. Resident #2 exhibited signs and symptoms of a urinary tract infection beginning 04/26/2015 which were not communicated to Resident #2's Physician. Resident #2's abnormally high CBC lab report received by the facility on 05/02/2015 was not communicated to Resident #2's Physician until 05/05/2015 and resulted in Resident #2 being sent to the hospital in the early morning hours of 05/06/2015 with septic shock secondary to a catheter associated urinary tract infection. These deficient practices affected Resident #2 and placed four (4) other residents with catheters at risk for the development of/or worsening of a urinary tract infection,[MEDICAL CONDITION], undue pain and discomfort and possible trauma such as bleeding or accidental removal of the catheters or death. Findings include: Review of Resident #2's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with diagnoses of [MEDICAL CONDITION] Disease, Dysphagia, [MEDICAL CONDITION], Pressure Ulcer, Dementia, Diabetes Mellitus, Infection Resistant to Drugs, and Hypertension. Review of Resident #2's Admission MDS assessment dated [DATE] reflected Resident #2 was assessed to have severe cognitive impairment. Resident #2 was assessed to require dependent assist with ADLs. Resident #2 was assessed to always be incontinent of bladder and bowel. Resident #2 was not assessed to have an indwelling urinary catheter. Resident #2 was assessed to have a UTI in the last 30 days. Resident #2 was assessed to have an abdominal feeding tube and received 51% or more of his calories through the tube feeding. Resident #2 was assessed to be at risk for pressure ulcers. Resident #2 was coded to not have pressure ulcers. Review of Resident #2's Admission Data Summary dated 04/23/2015 at 4:45 PM reflected Resident #2 was assessed to have Bilateral Lower Extremity Amputations. Resident #2's assessment reflected he had an indwelling urinary catheter; there was not a reason, [DIAGNOSES REDACTED]. Resident #2 was assessed to have redness to his coccyx. No pressure ulcers were noted. Review of Resident #2's Admission Care Plan dated 04/23/2015 reflected a problem Infection Alert with the interventions to monitor for signs/ symptoms of infection. Further review reflected a problem Bowl and Bladder Incontinence/ Catheter Care with the interventions to check for incontinence every two (2) hours, catheter care per guidelines and briefs, depends or pant liners when out of bed. Review of Resident #2's Care Plan for UTI dated 05/02/2015 reflected Resident #2 was at risk for recurrent UTI's, urosepsis, and renal damage. The interventions included; do labs as ordered by physician and report results; monitor for [MEDICAL CONDITION] (bacterial infection of the kidneys), fever, nausea, vomiting, flank pain, and report to physician if noted; monitor for [MEDICATION NAME] continued symptoms of frequency, urgency, malaise, foul smelling urine, dysuria (Pain during urination, or difficulty urinating) and report to physician. Observation/ Interview on 06/05/2015 at 4:15 PM revealed Resident #2 in bed. Resident #2 did not answer questions just stated he was ok. No Foley catheter was noted. In an interview on 06/05/2015 at 4:20 PM LVN D stated Resident #2 recently went out to the hospital [MEDICAL CONDITION]. LVN D stated prior to Resident # 2's hospitalization he came to the facility with a catheter and [MEDICAL CONDITION] at the facility from a UTI. LVN D stated Resident #2 had a real high white blood cell count when he was sent out. Review of Resident #2's Admission Start Up Orders dated 04/23/2015 through 04/30/2015 reflected under treatments that Foley Catheter was checked. Resident #2's Physician signed theses orders on 05/06/2015. Resident # 2's Admission Start Up Orders had no [DIAGNOSES REDACTED]. There was no order for catheter care or changing parameters. Review of Resident #2's Consolidated Physician order [REDACTED].>Review of Resident #2's TAR for April 2015 did not reflect an entry for a urinary catheter, catheter care, or changing parameters. Review of Resident #2's Nurses Notes from 04/26/2015 through 04/28/2015 reflected Resident #2 developed a low grade temperature of 99.6 degrees that persisted on and off throughout the time frame. Resident #2 had vomiting on 04/26/2015. Resident #2 had complaints of back (lumbar) pain on 04/27/2015 (flank pain (or low back) is often the sign of kidney problems). On 04/28/2015 at 1:45 PM Resident #2's temperature was 99.4 degrees and the nurses note reflected Resident #2 appeared diaphoretic (preon arms and was cold to touch.) Resident #2's blood sugar was assessed to be 215 mg/dl. LVN A documented Resident #2's Physician was messaged and no call back was received. On 04/28/2015 at 3:00 PM Resident #2's nurses note by LVN A reflected Resident #2 continued to be cold and clammy to upper extremities and his temperature was down to 97.3 degrees. LVN A further documented no signs and symptoms of infections to surgical wounds on bilateral lower extremities. LVN A further documented she spoke to the DON and ADON about not getting a response from Resident #2's physician. LVN A further documented Decision to monitor vital signs and urine output and to notify MD again if any drastic changes occur. MD to return in AM from vacation. In an interview on 06/05/2015 at 6:00 PM the ADON, after reviewing Resident #2's physician orders; stated Resident #2 did not have an order for [REDACTED]. In an interview on 06/05/2015 at 7:07 PM the DON stated she remembered LVN A contacting her on 04/28/2015 and thinking Resident #2's blood sugar was the cause of his change. The DON stated she did not remember what else she told LVN A. Review of the Facility's Policy Change of Condition- Observing, Reporting and Recording dated 03/2012 reflected If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director or the emergency room physician. Review of Resident #2's Nurses Notes from 04/29/2015 through 05/02/2015 reflected Resident #2 had amber colored urine on 04/29/2015. On 04/30/2015 at 2:50 PM Nurse's Notes reflected Resident #2's Physician's office was notified about Resident #2 wheezing and a chest x-ray was ordered to rule out aspiration. On 05/02/2015 at 1:00 AM LVN B documented Resident #2's Foley Catheter was leaking and she changed the Foley. LVN B further documented while removing the old catheter a large amount of pus discharge from his urethra mixed with blood was noted. Resident #2 temperature was documented as 99 degrees. LVN B documented to call dr. for possible UA C&S. In an iIn an interview on 06/05/2015 at 7:53 PM LVN B stated she did not call Resident #2's Physician on the night of 05/02/2015. LVN B stated she wrote a note on the 24 hour report for the next shift to call the Physician. RevieReview of the Facility's 24 Hour Report dated 05/02/2015 reflected no entry for Resident #2 regarding his signs and symptoms of UTI, changing the Foley catheter, or physician notification. Review of Resident #2's Nurses Notes dated 05/02/2015 at 11:30 AM (10 hours later) reflected Resident #2 had hematuria (bloody urine) in Foley bag and Resident #2's Physician was notified and a new order for a STAT (immediately) CBC and UA. Review of Resident #2's Physician Telephone orders dated 05/02/2015 reflected an order for [REDACTED]. Review of Resident #2's Nurses Notes dated 05/02/2015 at 2:30 PM reflected Resident #2 had small amount of emesis. Further review reflected at 9:00 PM Resident had tea colored urine and the nurse was waiting for his lab results. In an interview on 06/05/2015 at 8:15 PM LVN C stated she worked with Resident #2 on the evening of 05/02/2015. LVN C did not recall seeing Resident #2's CBC results only his UA. LVN C stated she did not fax Resident #2's CBC results to Resident #2's Physician. LVN C stated she thought she faxed Resident #2's UA results to Resident #2's Physician because he was on a antibiotic. Review of the Facility's 24 Hour Report from 05/02/2015 through 05/05/2015 reflected no entries regarding Resident #2's CBC or UA results and no communication between shifts regarding his condition. Review of Resident #2's Nurses Notes from 05/02/2015 through 05/05/2015 reflected no entries regarding his labs. Review of Resident #2's CBC lab results dated 05/02/2015 reflected the lab was faxed to the facility at 8:57 PM on 05/02/2015. Resident #2's WBC count was high at 17.6 with the normal range being 3.8 to 10.1. Resident #2's Urinalysis report which was also faxed to the facility on [DATE] at 9:03 PM reflected a large amount of blood with WBCs TNTC (to numerous to count.) Hand written on Resident #2's CBC lab report was a circle around the WBC count 17.6 with a explanation point (!) and written on the lab was When was this faxed ?! signed by Resident #2's Physician on 05/05/2015. Review of Resident #2's Physician's Telephone Orders reflected an order dated 05/05/2015 STAT CBC Now signed by Resident #2's Physician and dated 05/05/2015. The order was noted by the nurse at 9:05 PM. In an interview on 06/05/2015 at 7:55 PM LVN B stated on the morning of 05/06/2015 around 3:30 AM or 4:00 AM she went into Resident #2's room and she noticed a change in condition. LVN B stated Resident #2 was unresponsive. LVN B stated the CNAs had told her Resident #2 was real sweaty so she took his blood sugar. LVN B stated Resident #2's blood sugar was high at 501 mg/dl and his blood pressure was real low 90/60. LVN B stated she gave Resident #2 insulin but it did not work to bring down his blood sugar so she transferred him to the ER. Review of Resident #2's CBC Lab Report drawn on 05/06/2015 at 2:40 AM and received by the facility on 05/06/2015 at 10:50 AM, after Resident #2 was transfered to the hospital, reflected a WBC count of 40.9 which was critically high. Resident #2's urine culture lab report reflected a colony count of Proteus Mirabilis (A bacteria from the gastrointestinal tract.) was greater than 100,000. The sensitivity analysis reflected the bacteria Proteus Mirabilis was resistant to Bactrim DS. Review of Resident #2's Hospital Record dated 05/06/2015 reflected Resident #2 was received from the nursing home with altered mental status and [MEDICAL CONDITION]. Resident #2 was making gurgling sounds. Resident #2's had a temperature of 99.4 degrees and a blood pressure of 94/48. The note reflected he would be admitted to the intensive care unit for further evaluation. [DIAGNOSES REDACTED]. Further review reflected an entry dated 05/09/2015 Presents with septic shock secondary to catheter associated urinary tract infection (present on arrival) .He also has a catheter in place that has been there for about a month. We will try to liberate him from that and do post void residual. Review of Resident #2's WBC count at the hospital on [DATE] at 5:13 AM reflected a WBC count of 42.8 with the normal range being 3.6 to 11.2. Review of the website: <http://www.merckmanuals.com/home/infections/bacteremia-sepsis-and-septic-shock/sepsis-and-septic->: Sepsis is a serious body wide response to bacteremia or another infection. Septic shock is life-threatening low blood pressure (shock) due [MEDICAL CONDITION] . At first, people have a high (or sometimes low) body temperature, sometimes with shaking chills and weakness . Review of Resident #2's Hospital Discharge Summary reflected his primary [DIAGNOSES REDACTED]. Further review reflected Foley catheter was discontinued and the Resident was able to void with no post void residual. In an interview on 06/09/2015 at 11:30 AM Resident #2's Physician stated he was not made aware of Resident #2's changes in condition and Resident #2's labs were not reported to him. Resident #2's Physician stated he came to the facility and saw the CBC results in the chart and said Wow. Resident #2's Physician stated if he had been made aware of Resident #2's changes and lab reports he would have put him in the hospital sooner. Resident #2's Physician stated Resident #2 came from the hospital after surgery with his Foley. Resident #2's Physician stated he did not like Foley's and Resident #2 would only need a Foley if he had a coccyx wound to keep the urine out of the wound. In an interview on 06/05/2015 at 7:07 PM the DON stated she was not aware of Resident #2's labs not being reported to the physician until the VA (Veterans Affair) Nurse came to the facility and made her aware after Resident #2 was transferred to the hospital. The DON stated she investigated the situation and discovered the labs were not reported Resident #2's Physician and in-serviced the staff on notifying the physician of abnormal lab results. Review of the Facility's In-service Training Report reflected an in-service prior to Resident #2's admitted d 04/21/2015 which reflected critical and/or abnormal lab values require contacting the physician. LVN B, and LVN C were in attendance. Review of the Facility's In-service Training Report dated 05/15/2015 reflected all STAT labs need to be ordered immediately, and once results received the doctor needs to be notified immediately with the results. The in-service training did not cover notifying the physician of change of conditions or the care of indwelling urinary catheters. Review of Resident #2's Bladder Incontinence Evaluation admission assessment (not dated) reflected Resident #2 had a catheter inserted in the hospital and the reason for the catheter was surgery. Resident #2 was assessed to have perception of the need the void. The assessment further reflected Resident #2 had urinary disorders (prostate, bladder). Review of Resident #2's History and Physical exam dated 05/06/2015 did not reflect Resident #2 to have a urinary disorder of [MEDICAL CONDITIONS] bladder, or begin prostate hypertrophy. In an interview on 06/09/2015 at 3:00 PM the DON stated the only medically justified reasons for a resident to have an indwelling urinary catheter were [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], or Stage III or IV pressure ulcer to coccyx or sacral areas. The DON stated Resident #2 did not have a medically justified reason for his Foley catheter as he did not have Stage III or IV pressure ulcers or a [DIAGNOSES REDACTED]. The DON stated she investigated the situation in regards to Resident #2's change of condition. The DON stated she felt Resident #2 had been neglected in regards to his abnormal lab values not being reported to his physician but did not factor in the Foley as part of his problem. The DON stated the nursing staff should have contacted Resident #2's Physician and made him aware of the Foley and that Resident #2 did not have a need for the Foley. In an interview on 06/09/2015 at 3:57 PM the Administrator stated the facility had some major systemic issues. The Administrator stated the DON should have caught the lack of follow up with Resident #2's condition changes and failure to report lab results to the physician. The Administrator stated he expected the facility's policy's to be followed and expected the DON to monitor residents with Foley catheters. Review of the Website: <http://www.sepsisalliance.org/sepsis_and/urinary_tract_infections/> reflected Urinary tract infections, or UTIs . Most often, they are treated quickly and effectively with antibiotics,the infection becoming a distant memory. Unfortunately, not all UTIs are treated quickly and some aren't even identified quickly, particularly in people who have limited or no sensation below the waist or who are unable to speak for themselves. An untreated UTI may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITION] .The term urosepsis is usually used to [MEDICAL CONDITION] caused by a UTI. Sometimes called blood poisoning ,sepsis is the body's often deadly response to infection or injury.[MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. More than half the cases of urosepsis among older adults are caused by a UTI. Review of the Facility's Policy Catheters- Insertion and Care -Indwelling, Straight, Suprapubic and External dated 03/2012 reflected It is the policy of this home htat the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications. Physician order [REDACTED]. Order should contain the following: Type of catheter, size, and size of bulb, frequency to change catheter . Review of the Facility's Policy Change of Condition- Observing, Reporting and Recording dated 03/2012 reflected It is the policy of this home to inform the resident, the residents physician and if indicted the residents responsible party for the following A significant change in the residents physical, mental, or psychosocial status, such as a deterioration in health .in life-threatening conditions or clinical complication .a need to alter treatment significantly . Review of the Facility's Policy Lab Orders dated 03/2012 reflected .The home must notify the attending physician of the lab results .The Director of Nursing/designee will be responsible to monitor lab orders to assure that all ordered labs have been drawn as ordered by the physician . In an interview on 06/09/2015 at 5:00 PM the DON stated the facility did not have a policy on justification for the use of indwelling urinary catheters. Review of the facility's Director of Nursing Job Description dated 06/01/2001 reflected The overall purpose of the director of nursing position is to direct the prevision of nursing services to facility residents. Incumbents oversee the development and implementation of resident care plans and assure the provision of the best available quality of care for facility residents .Essential Functions- Oversees/directs/coordinates nursing staff to provide proper resident care consistent with standard nursing practices .Assures provision of appropriate medication, treatments and nursing services according to care plans and physician instructions . The Facility provided CMS 672 reflected four (4) resident with indwelling urinary catheters.

Based on observation, interview and record review the facility failed to ensure one (1) of five (5) Residents (Resident #2) reviewed for indwelling catheters were not catheterized unless the resident's clinical condition demonstrated that catheterization was necessary; and received appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Resident #2 was admitted on [DATE] with an indwelling urinary catheter, from 04/30/2015 to 05/05/2015 there was no physician order for [REDACTED].>There was not a medical [DIAGNOSES REDACTED].#2 when the Resident's clinical condition did not demonstrate catheterization was necessary. Resident #2 exhibited signs and symptoms of a urinary tract infection beginning 04/26/2015 which were not communicated to Resident #2's Physician. Resident #2's abnormally high CBC lab report received by the facility on 05/02/2015 was not communicated to Resident #2's Physician until 05/05/2015 and resulted in Resident #2 being sent to the hospital in the early morning hours of 05/06/2015 with septic shock secondary to a catheter associated urinary tract infection. These deficient practices affected Resident #2 and placed four (4) other residents with catheters at risk for the development of/or worsening of a urinary tract infection,[MEDICAL CONDITION], undue pain and discomfort and possible trauma such as bleeding or accidental removal of the catheters or death. Findings include: Review of Resident #2's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with diagnoses of [MEDICAL CONDITION] Disease, Dysphagia, [MEDICAL CONDITION], Pressure Ulcer, Dementia, Diabetes Mellitus, Infection Resistant to Drugs, and Hypertension. Review of Resident #2's Admission MDS assessment dated [DATE] reflected Resident #2 was assessed to have severe cognitive impairment. Resident #2 was assessed to require dependent assist with ADLs. Resident #2 was assessed to always be incontinent of bladder and bowel. Resident #2 was not assessed to have an indwelling urinary catheter. Resident #2 was assessed to have a UTI in the last 30 days. Resident #2 was assessed to have an abdominal feeding tube and received 51% or more of his calories through the tube feeding. Resident #2 was assessed to be at risk for pressure ulcers. Resident #2 was coded to not have pressure ulcers. Review of Resident #2's Admission Data Summary dated 04/23/2015 at 4:45 PM reflected Resident #2 was assessed to have Bilateral Lower Extremity Amputations. Resident #2's assessment reflected he had an indwelling urinary catheter; there was not a reason, [DIAGNOSES REDACTED]. Resident #2 was assessed to have redness to his coccyx. No pressure ulcers were noted. Review of Resident #2's Admission Care Plan dated 04/23/2015 reflected a problem Infection Alert with the interventions to monitor for signs/ symptoms of infection. Further review reflected a problem Bowl and Bladder Incontinence/ Catheter Care with the interventions to check for incontinence every two (2) hours, catheter care per guidelines and briefs, depends or pant liners when out of bed. Review of Resident #2's Care Plan for UTI dated 05/02/2015 reflected Resident #2 was at risk for recurrent UTI's, urosepsis, and renal damage. The interventions included; do labs as ordered by physician and report results; monitor for [MEDICAL CONDITION] (bacterial infection of the kidneys), fever, nausea, vomiting, flank pain, and report to physician if noted; monitor for [MEDICATION NAME] continued symptoms of frequency, urgency, malaise, foul smelling urine, dysuria (Pain during urination, or difficulty urinating) and report to physician. Observation/ Interview on 06/05/2015 at 4:15 PM revealed Resident #2 in bed. Resident #2 did not answer questions just stated he was ok. No Foley catheter was noted. In an interview on 06/05/2015 at 4:20 PM LVN D stated Resident #2 recently went out to the hospital [MEDICAL CONDITION]. LVN D stated prior to Resident # 2's hospitalization he came to the facility with a catheter and [MEDICAL CONDITION] at the facility from a UTI. LVN D stated Resident #2 had a high white blood cell count when he was sent out. Review of Resident #2's Admission Start Up Orders dated 04/23/2015 through 04/30/2015 reflected under treatments that Foley Catheter was checked. Resident #2's Physician signed theses orders on 05/06/2015. Resident # 2's Admission Start Up Orders had no [DIAGNOSES REDACTED]. There was no order for catheter care or changing parameters. Review of Resident #2's Consolidated Physician Orders dated 04/30/2015 did not reflect an order for [REDACTED].>Review of Resident #2's TAR for April 2015 did not reflect an entry for a urinary catheter, catheter care, or changing parameters. Review of Resident #2's Nurses Notes from 04/26/2015 through 04/28/2015 reflected Resident #2 developed a low grade temperature of 99.6 degrees that persisted on and off throughout the time frame. Resident #2 had vomiting on 04/26/2015. Resident #2 had complaints of back (lumbar) pain on 04/27/2015 (flank pain (or low back) is often the sign of kidney problems). On 04/28/2015 at 1:45 PM Resident #2's temperature was 99.4 degrees and the nurses note reflected Resident #2 appeared diaphoretic (preon arms and was cold to touch.) Resident #2's blood sugar was assessed to be 215 mg/dl. LVN A documented Resident #2's Physician was messaged and no call back was received. On 04/28/2015 at 3:00 PM Resident #2's nurses note by LVN A reflected Resident #2 continued to be cold and clammy to upper extremities and his temperature was down to 97.3 degrees. LVN A further documented no signs and symptoms of infections to surgical wounds on bilateral lower extremities. LVN A further documented she spoke to the DON and ADON about not getting a response from Resident #2's physician. LVN A further documented Decision to monitor vital signs and urine output and to notify MD again if any drastic changes occur. MD to return in AM from vacation. In an interview on 06/05/2015 at 6:00 PM the ADON, after reviewing Resident #2's physician orders; stated Resident #2 did not have an order for [REDACTED]. In an interview on 06/05/2015 at 7:07 PM the DON stated she remembered LVN A contacting her on 04/28/2015 and thinking Resident #2's blood sugar was the cause of his change. The DON stated she did not remember what else she told LVN A. Review of the Facility's Policy Change of Condition- Observing, Reporting and Recording dated 03/2012 reflected If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director or the emergency room physician. Review of Resident #2's Nurses Notes from 04/29/2015 through 05/02/2015 reflected Resident #2 had amber colored urine on 04/29/2015. On 04/30/2015 at 2:50 PM Nurse's Notes reflected Resident #2's Physician's office was notified about Resident #2 wheezing and a chest x-ray was ordered to rule out aspiration. On 05/02/2015 at 1:00 AM LVN B documented Resident #2's Foley Catheter was leaking and she changed the Foley. LVN B further documented while removing the old catheter a large amount of pus discharge from his urethra mixed with blood was noted. Resident #2 temperature was documented as 99 degrees. LVN B documented to call dr. for possible UA C&S. In an iIn an interview on 06/05/2015 at 7:53 PM LVN B stated she did not call Resident #2's Physician on the night of 05/02/2015. LVN B stated she wrote a note on the 24 hour report for the next shift to call the Physician. RevieReview of the Facility's 24 Hour Report dated 05/02/2015 reflected no entry for Resident #2 regarding his signs and symptoms of UTI, changing the Foley catheter, or physician notification. Review of Resident #2's Nurses Notes dated 05/02/2015 at 11:30 AM (10 hours later) reflected Resident #2 had hematuria (bloody urine) in Foley bag and Resident #2's Physician was notified and a new order for a STAT (immediately) CBC and UA. Review of Resident #2's Physician Telephone orders dated 05/02/2015 reflected an order for [REDACTED]. Review of Resident #2's Nurses Notes dated 05/02/2015 at 2:30 PM reflected Resident #2 had small amount of emesis. Further review reflected at 9:00 PM Resident had tea colored urine and the nurse was waiting for his lab results. In an interview on 06/05/2015 at 8:15 PM LVN C stated she worked with Resident #2 on the evening of 05/02/2015. LVN C did not recall seeing Resident #2's CBC results only his UA. LVN C stated she did not fax Resident #2's CBC results to Resident #2's Physician. LVN C stated she thought she faxed Resident #2's UA results to Resident #2's Physician because he was on a antibiotic. Review of the Facility's 24 Hour Report from 05/02/2015 through 05/05/2015 reflected no entries regarding Resident #2's CBC or UA results and no communication between shifts regarding his condition. Review of Resident #2's Nurses Notes from 05/02/2015 through 05/05/2015 reflected no entries regarding his labs. Review of Resident #2's CBC lab results dated 05/02/2015 reflected the lab was faxed to the facility at 8:57 PM on 05/02/2015. Resident #2's WBC count was high at 17.6 with the normal range being 3.8 to 10.1. Resident #2's Urinalysis report which was also faxed to the facility on [DATE] at 9:03 PM reflected a large amount of blood with WBCs TNTC (to numerous to count.) Hand written on Resident #2's CBC lab report was a circle around the WBC count 17.6 with a explanation point (!) and written on the lab was When was this faxed ?! signed by Resident #2's Physician on 05/05/2015. Review of Resident #2's Physician's Telephone Orders reflected an order dated 05/05/2015 STAT CBC Now signed by Resident #2's Physician and dated 05/05/2015. The order was noted by the nurse at 9:05 PM. In an interview on 06/05/2015 at 7:55 PM LVN B stated on the morning of 05/06/2015 around 3:30 AM or 4:00 AM she went into Resident #2's room and she noticed a change in condition. LVN B stated Resident #2 was unresponsive. LVN B stated the CNAs had told her Resident #2 was real sweaty so she took his blood sugar. LVN B stated Resident #2's blood sugar was high at 501 mg/dl and his blood pressure was real low 90/60. LVN B stated she gave Resident #2 insulin but it did not work to bring down his blood sugar so she transferred him to the ER. Review of Resident #2's CBC Lab Report drawn on 05/06/2015 at 2:40 AM and received by the facility on 05/06/2015 at 10:50 AM, after Resident #2 was transfered to the hospital, reflected a WBC count of 40.9 which was critically high. Resident #2's urine culture lab report reflected a colony count of Proteus Mirabilis (A bacteria from the gastrointestinal tract.) was greater than 100,000. The sensitivity analysis reflected the bacteria Proteus Mirabilis was resistant to Bactrim DS. Review of Resident #2's Hospital Record dated 05/06/2015 reflected Resident #2 was received from the nursing home with altered mental status and [MEDICAL CONDITION]. Resident #2 was making gurgling sounds. Resident #2's had a temperature of 99.4 degrees and a blood pressure of 94/48. The note reflected he would be admitted to the intensive care unit for further evaluation. [DIAGNOSES REDACTED]. Further review reflected an entry dated 05/09/2015 Presents with septic shock secondary to catheter associated urinary tract infection (present on arrival) .He also has a catheter in place that has been there for about a month. We will try to liberate him from that and do post void residual. Review of Resident #2's WBC count at the hospital on [DATE] at 5:13 AM reflected a WBC count of 42.8 with the normal range being 3.6 to 11.2. Review of the website: <http://www.merckmanuals.com/home/infections/bacteremia-sepsis-and-septic-shock/sepsis-and-septic->: Sepsis is a serious body wide response to bacteremia or another infection. Septic shock is life-threatening low blood pressure (shock) due [MEDICAL CONDITION] . At first, people have a high (or sometimes low) body temperature, sometimes with shaking chills and weakness . Review of Resident #2's Hospital Discharge Summary dated 05/11/2015 reflected his primary [DIAGNOSES REDACTED]. Further review reflected Foley catheter was discontinued and the Resident was able to void with no post void residual. In an interview on 06/09/2015 at 11:30 AM Resident #2's Physician stated he was not made aware of Resident #2's changes in condition and Resident #2's labs were not reported to him. Resident #2's Physician stated he came to the facility and saw the CBC results in the chart and said Wow. Resident #2's Physician stated if he had been made aware of Resident #2's changes and lab reports he would have put him in the hospital sooner. Resident #2's Physician stated Resident #2 came from the hospital after surgery with his Foley. Resident #2's Physician stated he did not like Foley's and Resident #2 would only need a Foley if he had a coccyx wound to keep the urine out of the wound. In an interview on 06/05/2015 at 7:07 PM the DON stated she was not aware of Resident #2's labs not being reported to the physician until the VA (Veterans Affair) Nurse came to the facility and made her aware after Resident #2 was transferred to the hospital. The DON stated she investigated the situation and discovered the labs were not reported Resident #2's Physician and in-serviced the staff on notifying the physician of abnormal lab results. Review of the Facility's In-service Training Report reflected an in-service prior to Resident #2's admitted d 04/21/2015 which reflected critical and/or abnormal lab values require contacting the physician. LVN B, and LVN C were in attendance. Review of the Facility's In-service Training Report dated 05/15/2015 reflected all STAT labs need to be ordered immediately, and once results received the doctor needs to be notified immediately with the results. The in-service training did not cover notifying the physician of change of conditions or the care of indwelling urinary catheters. Review of Resident #2's Bladder Incontinence Evaluation admission assessment (not dated) reflected Resident #2 had a catheter inserted in the hospital and the reason for the catheter was surgery. Resident #2 was assessed to have perception of the need the void. The assessment further reflected Resident #2 had urinary disorders (prostate, bladder). Review of Resident #2's History and Physical exam dated 05/06/2015 did not reflect Resident #2 to have a urinary disorder of [MEDICAL CONDITIONS] bladder, or begin prostate hypertrophy. In an interview on 06/09/2015 at 3:00 PM the DON stated the only medically justified reasons for a resident to have an indwelling urinary catheter were [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], or Stage III or IV pressure ulcer to coccyx or sacral areas. The DON stated Resident #2 did not have a medically justified reason for his Foley catheter as he did not have Stage III or IV pressure ulcers or a [DIAGNOSES REDACTED]. The DON stated she investigated the situation in regards to Resident #2's change of condition. The DON stated she felt Resident #2 had been neglected in regards to his abnormal lab values not being reported to his physician but did not factor in the Foley as part of his problem. The DON stated the nursing staff should have contacted Resident #2's Physician and made him aware of the Foley and that Resident #2 did not have a need for the Foley. In an interview on 06/09/2015 at 3:57 PM the Administrator stated the facility had some major systemic issues. The Administrator stated the DON should have caught the lack of follow up with Resident #2's condition changes and failure to report lab results to the physician. The Administrator stated he expected the facility's policy's to be followed and expected the DON to monitor residents with Foley catheters. Review of the Website: <http://www.sepsisalliance.org/sepsis_and/urinary_tract_infections/> reflected Urinary tract infections, or UTIs . Most often, they are treated quickly and effectively with antibiotics,the infection becoming a distant memory. Unfortunately, not all UTIs are treated quickly and some aren't even identified quickly, particularly in people who have limited or no sensation below the waist or who are unable to speak for themselves. An untreated UTI may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITION] .The term urosepsis is usually used to [MEDICAL CONDITION] caused by a UTI. Sometimes called blood poisoning ,sepsis is the body's often deadly response to infection or injury.[MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. More than half the cases of urosepsis among older adults are caused by a UTI. Review of the Facility's Policy Catheters- Insertion and Care -Indwelling, Straight, Suprapubic and External dated 03/2012 reflected It is the policy of this home htat the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications. Physician order is required for all catheters. Order should contain the following: Type of catheter, size, and size of bulb, frequency to change catheter . Review of the Facility's Policy Change of Condition- Observing, Reporting and Recording dated 03/2012 reflected It is the policy of this home to inform the resident, the residents physician and if indicted the residents responsible party for the following A significant change in the residents physical, mental, or psychosocial status, such as a deterioration in health .in life-threatening conditions or clinical complication .a need to alter treatment significantly . Review of the Facility's Policy Lab Orders dated 03/2012 reflected .The home must notify the attending physician of the lab results .The Director of Nursing/designee will be responsible to monitor lab orders to assure that all ordered labs have been drawn as ordered by the physician . In an interview on 06/09/2015 at 5:00 PM the DON stated the facility did not have a policy on justification for the use of indwelling urinary catheters Review of The Lippincott Manual of Nursing Practice, 7th Edition, page 694, Care of the Indwelling Catheter reflected Properly securing the catheter prevents catheter movement and traction on the urethra .Pulling on the catheter may be painful. Backward and forward displacement of the catheter introduces contaminants into the urinary tract. The Facility provided CMS 672 reflected four (4) resident with indwelling urinary catheters.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for two (2) of eight (8) residents reviewed for neglect (Resident #2 and #7). A) Resident #2 was admitted on [DATE] with an indwelling urinary catheter, from 04/30/2015 to 05/05/2015 without a physician order [REDACTED].>There was not a medical [DIAGNOSES REDACTED].#2 when the Resident's clinical condition did not demonstrate catheterization was necessary. Resident #2 exhibited signs and symptoms of a urinary tract infection beginning 04/26/2015 which were not communicated to Resident #2's Physician. Resident #2's abnormally high CBC lab report received by the facility on 05/02/2015 was not communicated to Resident #2's Physician until 05/05/2015 and resulted in Resident #2 being sent to the hospital in the early morning hours of 05/06/2015 with septic shock secondary to a catheter associated urinary tract infection. These deficient practices affected Resident #2 and placed four (4) other residents with catheters at risk for the development of/or worsening of a urinary tract infection,[MEDICAL CONDITION], undue pain and discomfort and possible trauma such as bleeding or accidental removal of the catheters or death. B) Resident #7 had an unwitnessed fall and sustained a fractured right elbow on 05/03/2015. The facility failed to thoroughly investigate the incident according to their abuse/neglect policy when they did not interview residents and staff to determine if possible abuse or neglect had occurred. This deficient practice placed 18 residents who were at risk for falls at risk for unidentified abuse/neglect or injuries, delayed physician ordered treatments and/or interventions, worsening of conditions, and pain. Findings include: Review of the facility's Policy Abuse- Reportable Events dated 01/2008 and revised 05/2014 reflected It is the policy of this home 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 .Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .The home's administration will conduct and investigate allegations of crimes, suspected abuse, neglect, or misappropriation of property, and will provide notification and release of information to the proper authorities, in accordance with federal and state regulations. Review of the facility's Policy Abuse- Reportable Events dated 01/2008 reflected Neglect: The failure to provide goods and services necessary to avoid physical harm . Investigation .Begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family, and/or residents . A) Review of Resident #2's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with diagnoses of [MEDICAL CONDITION] Disease, Dysphagia, [MEDICAL CONDITION], Pressure Ulcer, Dementia, Diabetes Mellitus, Infection Resistant to Drugs, and Hypertension. Review of Resident #2's Admission MDS assessment dated [DATE] reflected Resident #2 was assessed to have severe cognitive impairment. Resident #2 was assessed to require dependent assist with ADLs. Resident #2 was assessed to always be incontinent of bladder and bowel. Resident #2 was not assessed to have an indwelling urinary catheter. Resident #2 was assessed to have a UTI in the last 30 days. Resident #2 was assessed to have an abdominal feeding tube and received 51% or more of his calories through the tube feeding. Resident #2 was assessed to be at risk for pressure ulcers. Resident #2 was coded to not have pressure ulcers. Review of Resident #2's Admission Data Summary dated 04/23/2015 at 4:45 PM reflected Resident #2 was assessed to have Bilateral Lower Extremity Amputations. Resident #2's assessment reflected he had an indwelling urinary catheter; there was not a reason, [DIAGNOSES REDACTED]. Resident #2 was assessed to have redness to his coccyx. No pressure ulcers were noted. Review of Resident #2's Admission Care Plan dated 04/23/2015 reflected a problem Infection Alert with the interventions to monitor for signs/ symptoms of infection. Further review reflected a problem Bowl and Bladder Incontinence/ Catheter Care with the interventions to check for incontinence every two (2) hours, catheter care per guidelines and briefs, depends or pant liners when out of bed. Review of Resident #2's Care Plan for UTI dated 05/02/2015 reflected Resident #2 was at risk for recurrent UTI's, urosepsis, and renal damage. The interventions included; do labs as ordered by physician and report results; monitor for [MEDICAL CONDITION] (bacterial infection of the kidneys), fever, nausea, vomiting, flank pain, and report to physician if noted; monitor for [MEDICATION NAME] continued symptoms of frequency, urgency, malaise, foul smelling urine, dysuria (Pain during urination, or difficulty urinating) and report to physician. Observation/ Interview on 06/05/2015 at 4:15 PM revealed Resident #2 in bed. Resident #2 did not answer questions just stated he was ok. No Foley catheter was noted. In an interview on 06/05/2015 at 4:20 PM LVN D stated Resident #2 recently went out to the hospital [MEDICAL CONDITION]. LVN D stated prior to Resident # 2's hospitalization he came to the facility with a catheter and [MEDICAL CONDITION] at the facility from a UTI. LVN D stated Resident #2 had a high white blood cell count when he was sent out. Review of Resident #2's Admission Start Up Orders dated 04/23/2015 through 04/30/2015 reflected under treatments that Foley Catheter was checked. Resident #2's Physician signed theses orders on 05/06/2015. Resident # 2's Admission Start Up Orders had no [DIAGNOSES REDACTED]. There was no order for catheter care or changing parameters. Review of Resident #2's Consolidated Physician order [REDACTED].>Review of Resident #2's TAR for April 2015 did not reflect an entry for a urinary catheter, catheter care, or changing parameters. Review of Resident #2's Nurses Notes from 04/26/2015 through 04/28/2015 reflected Resident #2 developed a low grade temperature of 99.6 degrees that persisted on and off throughout the time frame. Resident #2 had vomiting on 04/26/2015. Resident #2 had complaints of back (lumbar) pain on 04/27/2015 (flank pain (or low back) is often the sign of kidney problems). On 04/28/2015 at 1:45 PM Resident #2's temperature was 99.4 degrees and the nurses note reflected Resident #2 appeared diaphoretic (preon arms and was cold to touch.) Resident #2's blood sugar was assessed to be 215 mg/dl. LVN A documented Resident #2's Physician was messaged and no call back was received. On 04/28/2015 at 3:00 PM Resident #2's nurses note by LVN A reflected Resident #2 continued to be cold and clammy to upper extremities and his temperature was down to 97.3 degrees. LVN A further documented no signs and symptoms of infections to surgical wounds on bilateral lower extremities. LVN A further documented she spoke to the DON and ADON about not getting a response from Resident #2's physician. LVN A further documented Decision to monitor vital signs and urine output and to notify MD again if any drastic changes occur. MD to return in AM from vacation. In an interview on 06/05/2015 at 6:00 PM the ADON, after reviewing Resident #2's physician orders; stated Resident #2 did not have an order for [REDACTED]. In an interview on 06/05/2015 at 7:07 PM the DON stated she remembered LVN A contacting her on 04/28/2015 and thinking Resident #2's blood sugar was the cause of his change. The DON stated she did not remember what else she told LVN A. Review of the Facility's Policy Change of Condition- Observing, Reporting and Recording dated 03/2012 reflected If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director or the emergency room physician. Review of Resident #2's Nurses Notes from 04/29/2015 through 05/02/2015 reflected Resident #2 had amber colored urine on 04/29/2015. On 04/30/2015 at 2:50 PM Nurse's Notes reflected Resident #2's Physician's office was notified about Resident #2 wheezing and a chest x-ray was ordered to rule out aspiration. On 05/02/2015 at 1:00 AM LVN B documented Resident #2's Foley Catheter was leaking and she changed the Foley. LVN B further documented while removing the old catheter a large amount of pus discharge from his urethra mixed with blood was noted. Resident #2 temperature was documented as 99 degrees. LVN B documented to call dr. for possible UA C&S. In an interview on 06/05/2015 at 7:53 PM LVN B stated she did not call Resident #2's Physician on the night of 05/02/2015. LVN B stated she wrote a note on the 24 hour report for the next shift to call the Physician. Review of the Facility's 24 Hour Report dated 05/02/2015 reflected no entry for Resident #2 regarding his signs and symptoms of UTI, changing the Foley catheter, or physician notification. Review of Resident #2's Nurses Notes dated 05/02/2015 at 11:30 AM (10 hours later) reflected Resident #2 had hematuria (bloody urine) in Foley bag and Resident #2's Physician was notified and a new order for a STAT (immediately) CBC and UA. Review of Resident #2's Physician Telephone orders dated 05/02/2015 reflected an order for [REDACTED]. Review of Resident #2's Nurses Notes dated 05/02/2015 at 2:30 PM reflected Resident #2 had small amount of emesis. Further review reflected at 9:00 PM Resident had tea colored urine and the nurse was waiting for his lab results. In an interview on 06/05/2015 at 8:15 PM LVN C stated she worked with Resident #2 on the evening of 05/02/2015. LVN C did not recall seeing Resident #2's CBC results only his UA. LVN C stated she did not fax Resident #2's CBC results to Resident #2's Physician. LVN C stated she thought she faxed Resident #2's UA results to Resident #2's Physician because he was on a antibiotic. Review of the Facility's 24 Hour Report from 05/02/2015 through 05/05/2015 reflected no entries regarding Resident #2's CBC or UA results and no communication between shifts regarding his condition. Review of Resident #2's Nurses Notes from 05/02/2015 through 05/05/2015 reflected no entries regarding his labs. Review of Resident #2's CBC lab results dated 05/02/2015 reflected the lab was faxed to the facility at 8:57 PM on 05/02/2015. Resident #2's WBC count was high at 17.6 with the normal range being 3.8 to 10.1. Resident #2's Urinalysis report which was also faxed to the facility on [DATE] at 9:03 PM reflected a large amount of blood with WBCs TNTC (to numerous to count.) Hand written on Resident #2's CBC lab report was a circle around the WBC count 17.6 with a explanation point (!) and written on the lab was When was this faxed ?! signed by Resident #2's Physician on 05/05/2015. Review of Resident #2's Physician's Telephone Orders reflected an order dated 05/05/2015 STAT CBC Now signed by Resident #2's Physician and dated 05/05/2015. The order was noted by the nurse at 9:05 PM. In an interview on 06/05/2015 at 7:55 PM LVN B stated on the morning of 05/06/2015 around 3:30 AM or 4:00 AM she went into Resident #2's room and she noticed a change in condition. LVN B stated Resident #2 was unresponsive. LVN B stated the CNAs had told her Resident #2 was real sweaty so she took his blood sugar. LVN B stated Resident #2's blood sugar was high at 501 mg/dl and his blood pressure was real low 90/60. LVN B stated she gave Resident #2 insulin but it did not work to bring down his blood sugar so she transferred him to the ER. Review of Resident #2's CBC Lab Report drawn on 05/06/2015 at 2:40 AM and received by the facility on 05/06/2015 at 10:50 AM, after Resident #2 was transfered to the hospital, reflected a WBC count of 40.9 which was critically high. Resident #2's urine culture lab report reflected a colony count of Proteus Mirabilis (A bacteria from the gastrointestinal tract.) was greater than 100,000. The sensitivity analysis reflected the bacteria Proteus Mirabilis was resistant to Bactrim DS. Review of Resident #2's Hospital Record dated 05/06/2015 reflected Resident #2 was received from the nursing home with altered mental status and [MEDICAL CONDITION]. Resident #2 was making gurgling sounds. Resident #2's had a temperature of 99.4 degrees and a blood pressure of 94/48. The note reflected he would be admitted to the intensive care unit for further evaluation. [DIAGNOSES REDACTED]. Further review reflected an entry dated 05/09/2015 Presents with septic shock secondary to catheter associated urinary tract infection (present on arrival) .He also has a catheter in place that has been there for about a month. We will try to liberate him from that and do post void residual. Review of Resident #2's WBC count at the hospital on [DATE] at 5:13 AM reflected a WBC count of 42.8 with the normal range being 3.6 to 11.2. Review of the website: <http://www.merckmanuals.com/home/infections/bacteremia-sepsis-and-septic-shock/sepsis-and-septic->: Sepsis is a serious body wide response to bacteremia or another infection. Septic shock is life-threatening low blood pressure (shock) due [MEDICAL CONDITION] . At first, people have a high (or sometimes low) body temperature, sometimes with shaking chills and weakness . Review of Resident #2's Hospital Discharge Summary dated 05/11/2015 reflected his primary [DIAGNOSES REDACTED]. Further review reflected Foley catheter was discontinued and the Resident was able to void with no post void residual. In an interview on 06/09/2015 at 11:30 AM Resident #2's Physician stated he was not made aware of Resident #2's changes in condition and Resident #2's labs were not reported to him. Resident #2's Physician stated he came to the facility and saw the CBC results in the chart and said Wow. Resident #2's Physician stated if he had been made aware of Resident #2's changes and lab reports he would have put him in the hospital sooner. Resident #2's Physician stated Resident #2 came from the hospital after surgery with his Foley. Resident #2's Physician stated he did not like Foley's and Resident #2 would only need a Foley if he had a coccyx wound to keep the urine out of the wound. In an interview on 06/05/2015 at 7:07 PM the DON stated she was not aware of Resident #2's labs not being reported to the physician until the VA (Veterans Affair) Nurse came to the facility and made her aware after Resident #2 was transferred to the hospital. The DON stated she investigated the situation and discovered the labs were not reported Resident #2's Physician and in-serviced the staff on notifying the physician of abnormal lab results. Review of the Facility's In-service Training Report reflected an in-service prior to Resident #2's admitted d 04/21/2015 which reflected critical and/or abnormal lab values require contacting the physician. LVN B, and LVN C were in attendance. Review of the Facility's In-service Training Report dated 05/15/2015 reflected all STAT labs need to be ordered immediately, and once results received the doctor needs to be notified immediately with the results. The in-service training did not cover notifying the physician of change of conditions or the care of indwelling urinary catheters. Review of Resident #2's Bladder Incontinence Evaluation admission assessment (not dated) reflected Resident #2 had a catheter inserted in the hospital and the reason for the catheter was surgery. Resident #2 was assessed to have perception of the need the void. The assessment further reflected Resident #2 had urinary disorders (prostate, bladder). Review of Resident #2's History and Physical exam dated 05/06/2015 did not reflect Resident #2 to have a urinary disorder of [MEDICAL CONDITIONS] bladder, or begin prostate hypertrophy. In an interview on 06/09/2015 at 3:00 PM the DON stated the only medically justified reasons for a resident to have an indwelling urinary catheter were [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], or Stage III or IV pressure ulcer to coccyx or sacral areas. The DON stated Resident #2 did not have a medically justified reason for his Foley catheter as he did not have Stage III or IV pressure ulcers or a [DIAGNOSES REDACTED]. The DON stated she investigated the situation in regards to Resident #2's change of condition. The DON stated she felt Resident #2 had been neglected in regards to his abnormal lab values not being reported to his physician but did not factor in the Foley as part of his problem. The DON stated the nursing staff should have contacted Resident #2's Physician and made him aware of the Foley and that Resident #2 did not have a need for the Foley. In an interview on 06/09/2015 at 3:57 PM the Administrator stated the facility had some major systemic issues. The Administrator stated the DON should have caught the lack of follow up with Resident #2's condition changes and failure to report lab results to the physician. The Administrator stated he expected the facility's policy's to be followed and expected the DON to monitor residents with Foley catheters. Review of the Website: <http://www.sepsisalliance.org/sepsis_and/urinary_tract_infections/> reflected Urinary tract infections, or UTIs . Most often, they are treated quickly and effectively with antibiotics,the infection becoming a distant memory. Unfortunately, not all UTIs are treated quickly and some aren't even identified quickly, particularly in people who have limited or no sensation below the waist or who are unable to speak for themselves. An untreated UTI may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITION] .The term urosepsis is usually used to [MEDICAL CONDITION] caused by a UTI. Sometimes called blood poisoning ,sepsis is the body's often deadly response to infection or injury.[MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. More than half the cases of urosepsis among older adults are caused by a UTI. Review of the Facility's Policy Catheters- Insertion and Care -Indwelling, Straight, Suprapubic and External dated 03/2012 reflected It is the policy of this home htat the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications. Physician order [REDACTED]. Order should contain the following: Type of catheter, size, and size of bulb, frequency to change catheter . Review of the Facility's Policy Change of Condition- Observing, Reporting and Recording dated 03/2012 reflected It is the policy of this home to inform the resident, the residents physician and if indicted the residents responsible party for the following A significant change in the residents physical, mental, or psychosocial status, such as a deterioration in health .in life-threatening conditions or clinical complication .a need to alter treatment significantly . Review of the Facility's Policy Lab Orders dated 03/2012 reflected .The home must notify the attending physician of the lab results .The Director of Nursing/designee will be responsible to monitor lab orders to assure that all ordered labs have been drawn as ordered by the physician . In an interview on 06/09/2015 at 5:00 PM the DON stated the facility did not have a policy on justification for the use of indwelling urinary catheters. The Facility provided CMS 672 reflected four (4) resident with indwelling urinary catheters. B) Review of a Face sheet for Resident #7 reflected she was an [AGE] year old female with an original admission date of [DATE] and a re-admission of 08/27/2013 with diagnoses that included Dementia, [MEDICAL CONDITION], Diabetes, [MEDICAL CONDITION], Hypertension, End Stage [MEDICAL CONDITION] and Anxiety. Review of Resident #7's Quarterly MDS assessment dated [DATE] reflected moderately impaired cognition, assistance of one person for ADLs and she could self propel her wheelchair. The assessment reflected no falls in the past 90 days prior to the assessment. Review of Resident #7's Psychiatric Evaluation dated 02/12/2015 reflected Resident #7 was alert and oriented times one (oriented to person only) for thought process. The evaluation reflected Resident # 7 continued to exhibit emotional and/or cognitive disorder that interfered with day to day function. Review of Resident #7's Incident Report dated 05/03/2015 reflected at 11:30 AM a resident informed the nurse that Resident #7 was on the floor in the dining room. The Incident Report further reflected No injury noted resident complained of pain to the right elbow. Notified MD and received new order for X-ray of the right elbow. The incident report was signed by LVN D. (There were no witness statements from residents or staff with the Incident Report.) In an interview on 06/08/2015 at 3:25 PM, LVN D stated she was a charge nurse on duty when Resident #9 alerted her Resident #7 was on the floor in the dining room. LVN D stated she went to the dining room and Resident #7 was on the floor close to her wheelchair. LVN D stated Resident #7 showed no visible signs of injury, but was complaining of right arm pain. LVN D stated she notified the DON by telephone due to it being a weekend and she was not in the facility. In an interview on 06/08/2015 at 4:35 PM, the DON stated she received a phone call on 05/03/2015 to inform her of Resident #7's fall and later in the day she received a call with the report of the fractured right elbow. The DON stated the following Monday 05/04/2015 the previous Administrator reviewed the incident report and stated there was no need to investigate or report the injury. The DON stated there was no evidence the facility completed an investigation with statements from staff or residents. Further review of the Incident Report for Resident #7's unwitnessed fall on 05/03/2015 reflected the former Administrator's signature and a comment that read no need to report. In an interview on 06/08/2015 at 3:40 PM, Resident #9 stated he could recall an incident when he found Resident #7 on the floor in the dining room and went to the hallway to get help. Resident #9 stated he saw her (Resident #7) on the floor, but did not see what happened. Resident #9 further stated facility staff did not interview him or ask him for a witness statement. (Resident #9 had a BIMS score of 15 indictating the Resident was cognitively intact and was on the facility list of interviewable residents). The facility DON provided a list of 18 residents at risk for falls.

Based on observation, interview, and record review the facility failed to implement policies and procedures to prohibit neglect for one (1) of eight (8) residents (Resident #2) reviewed for abuse and neglect when: Resident #2 was admitted on [DATE] with an indwelling urinary catheter, from 04/30/2015 to 05/05/2015 there was no physician order for [REDACTED].>There was not a medical [DIAGNOSES REDACTED].#2 when the Resident's clinical condition did not demonstrate catheterization was necessary. Resident #2 exhibited signs and symptoms of a urinary tract infection beginning 04/26/2015 which were not communicated to Resident #2's Physician. Resident #2's abnormally high CBC lab report received by the facility on 05/02/2015 was not communicated to Resident #2's Physician until 05/05/2015 and resulted in Resident #2 being sent to the hospital in the early morning hours of 05/06/2015 with septic shock secondary to a catheter associated urinary tract infection. These deficient practices affected Resident #2 and placed four (4) other residents with catheters at risk for the development of/or worsening of a urinary tract infection,[MEDICAL CONDITION], undue pain and discomfort and possible trauma such as bleeding or accidental removal of the catheters or death. Findings include: Review of Resident #2's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with diagnoses of [MEDICAL CONDITION] Disease, Dysphagia, [MEDICAL CONDITION], Pressure Ulcer, Dementia, Diabetes Mellitus, Infection Resistant to Drugs, and Hypertension. Review of Resident #2's Admission MDS assessment dated [DATE] reflected Resident #2 was assessed to have severe cognitive impairment. Resident #2 was assessed to require dependent assist with ADLs. Resident #2 was assessed to always be incontinent of bladder and bowel. Resident #2 was not assessed to have an indwelling urinary catheter. Resident #2 was assessed to have a UTI in the last 30 days. Resident #2 was assessed to have an abdominal feeding tube and received 51% or more of his calories through the tube feeding. Resident #2 was assessed to be at risk for pressure ulcers. Resident #2 was coded to not have pressure ulcers. Review of Resident #2's Admission Data Summary dated 04/23/2015 at 4:45 PM reflected Resident #2 was assessed to have Bilateral Lower Extremity Amputations. Resident #2's assessment reflected he had an indwelling urinary catheter; there was not a reason, [DIAGNOSES REDACTED]. Resident #2 was assessed to have redness to his coccyx. No pressure ulcers were noted. Review of Resident #2's Admission Care Plan dated 04/23/2015 reflected a problem Infection Alert with the interventions to monitor for signs/ symptoms of infection. Further review reflected a problem Bowl and Bladder Incontinence/ Catheter Care with the interventions to check for incontinence every two (2) hours, catheter care per guidelines and briefs, depends or pant liners when out of bed. Review of Resident #2's Care Plan for UTI dated 05/02/2015 reflected Resident #2 was at risk for recurrent UTI's, urosepsis, and renal damage. The interventions included; do labs as ordered by physician and report results; monitor for [MEDICAL CONDITION] (bacterial infection of the kidneys), fever, nausea, vomiting, flank pain, and report to physician if noted; monitor for [MEDICATION NAME] continued symptoms of frequency, urgency, malaise, foul smelling urine, dysuria (Pain during urination, or difficulty urinating) and report to physician. Observation/ Interview on 06/05/2015 at 4:15 PM revealed Resident #2 in bed. Resident #2 did not answer questions just stated he was ok. No Foley catheter was noted. In an interview on 06/05/2015 at 4:20 PM LVN D stated Resident #2 recently went out to the hospital [MEDICAL CONDITION]. LVN D stated prior to Resident # 2's hospitalization he came to the facility with a catheter and [MEDICAL CONDITION] at the facility from a UTI. LVN D stated Resident #2 had a high white blood cell count when he was sent out. Review of Resident #2's Admission Start Up Orders dated 04/23/2015 through 04/30/2015 reflected under treatments that Foley Catheter was checked. Resident #2's Physician signed theses orders on 05/06/2015. Resident # 2's Admission Start Up Orders had no [DIAGNOSES REDACTED]. There was no order for catheter care or changing parameters. Review of Resident #2's Consolidated Physician Orders dated 04/30/2015 did not reflect an order for [REDACTED].>Review of Resident #2's TAR for April 2015 did not reflect an entry for a urinary catheter, catheter care, or changing parameters. Review of Resident #2's Nurses Notes from 04/26/2015 through 04/28/2015 reflected Resident #2 developed a low grade temperature of 99.6 degrees that persisted on and off throughout the time frame. Resident #2 had vomiting on 04/26/2015. Resident #2 had complaints of back (lumbar) pain on 04/27/2015 (flank pain (or low back) is often the sign of kidney problems). On 04/28/2015 at 1:45 PM Resident #2's temperature was 99.4 degrees and the nurses note reflected Resident #2 appeared diaphoretic (preon arms and was cold to touch.) Resident #2's blood sugar was assessed to be 215 mg/dl. LVN A documented Resident #2's Physician was messaged and no call back was received. On 04/28/2015 at 3:00 PM Resident #2's nurses note by LVN A reflected Resident #2 continued to be cold and clammy to upper extremities and his temperature was down to 97.3 degrees. LVN A further documented no signs and symptoms of infections to surgical wounds on bilateral lower extremities. LVN A further documented she spoke to the DON and ADON about not getting a response from Resident #2's physician. LVN A further documented Decision to monitor vital signs and urine output and to notify MD again if any drastic changes occur. MD to return in AM from vacation. In an interview on 06/05/2015 at 6:00 PM the ADON, after reviewing Resident #2's physician orders; stated Resident #2 did not have an order for [REDACTED]. In an interview on 06/05/2015 at 7:07 PM the DON stated she remembered LVN A contacting her on 04/28/2015 and thinking Resident #2's blood sugar was the cause of his change. The DON stated she did not remember what else she told LVN A. Review of the Facility's Policy Change of Condition- Observing, Reporting and Recording dated 03/2012 reflected If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director or the emergency room physician. Review of Resident #2's Nurses Notes from 04/29/2015 through 05/02/2015 reflected Resident #2 had amber colored urine on 04/29/2015. On 04/30/2015 at 2:50 PM Nurse's Notes reflected Resident #2's Physician's office was notified about Resident #2 wheezing and a chest x-ray was ordered to rule out aspiration. On 05/02/2015 at 1:00 AM LVN B documented Resident #2's Foley Catheter was leaking and she changed the Foley. LVN B further documented while removing the old catheter a large amount of pus discharge from his urethra mixed with blood was noted. Resident #2 temperature was documented as 99 degrees. LVN B documented to call dr. for possible UA C&S. In an interview on 06/05/2015 at 7:53 PM LVN B stated she did not call Resident #2's Physician on the night of 05/02/2015. LVN B stated she wrote a note on the 24 hour report for the next shift to call the Physician. Review of the Facility's 24 Hour Report dated 05/02/2015 reflected no entry for Resident #2 regarding his signs and symptoms of UTI, changing the Foley catheter, or physician notification. Review of Resident #2's Nurses Notes dated 05/02/2015 at 11:30 AM (10 hours later) reflected Resident #2 had hematuria (bloody urine) in Foley bag and Resident #2's Physician was notified and a new order for a STAT (immediately) CBC and UA. Review of Resident #2's Physician Telephone orders dated 05/02/2015 reflected an order for [REDACTED]. Review of Resident #2's Nurses Notes dated 05/02/2015 at 2:30 PM reflected Resident #2 had small amount of emesis. Further review reflected at 9:00 PM Resident had tea colored urine and the nurse was waiting for his lab results. In an interview on 06/05/2015 at 8:15 PM LVN C stated she worked with Resident #2 on the evening of 05/02/2015. LVN C did not recall seeing Resident #2's CBC results only his UA. LVN C stated she did not fax Resident #2's CBC results to Resident #2's Physician. LVN C stated she thought she faxed Resident #2's UA results to Resident #2's Physician because he was on a antibiotic. Review of the Facility's 24 Hour Report from 05/02/2015 through 05/05/2015 reflected no entries regarding Resident #2's CBC or UA results and no communication between shifts regarding his condition. Review of Resident #2's Nurses Notes from 05/02/2015 through 05/05/2015 reflected no entries regarding his labs. Review of Resident #2's CBC lab results dated 05/02/2015 reflected the lab was faxed to the facility at 8:57 PM on 05/02/2015. Resident #2's WBC count was high at 17.6 with the normal range being 3.8 to 10.1. Resident #2's Urinalysis report which was also faxed to the facility on [DATE] at 9:03 PM reflected a large amount of blood with WBCs TNTC (to numerous to count.) Hand written on Resident #2's CBC lab report was a circle around the WBC count 17.6 with a explanation point (!) and written on the lab was When was this faxed ?! signed by Resident #2's Physician on 05/05/2015. Review of Resident #2's Physician's Telephone Orders reflected an order dated 05/05/2015 STAT CBC Now signed by Resident #2's Physician and dated 05/05/2015. The order was noted by the nurse at 9:05 PM. In an interview on 06/05/2015 at 7:55 PM LVN B stated on the morning of 05/06/2015 around 3:30 AM or 4:00 AM she went into Resident #2's room and she noticed a change in condition. LVN B stated Resident #2 was unresponsive. LVN B stated the CNAs had told her Resident #2 was real sweaty so she took his blood sugar. LVN B stated Resident #2's blood sugar was high at 501 mg/dl and his blood pressure was real low 90/60. LVN B stated she gave Resident #2 insulin but it did not work to bring down his blood sugar so she transferred him to the ER. Review of Resident #2's CBC Lab Report drawn on 05/06/2015 at 2:40 AM and received by the facility on 05/06/2015 at 10:50 AM, after Resident #2 was transfered to the hospital, reflected a WBC count of 40.9 which was critically high. Resident #2's urine culture lab report reflected a colony count of Proteus Mirabilis (A bacteria from the gastrointestinal tract.) was greater than 100,000. The sensitivity analysis reflected the bacteria Proteus Mirabilis was resistant to Bactrim DS. Review of Resident #2's Hospital Record dated 05/06/2015 reflected Resident #2 was received from the nursing home with altered mental status and [MEDICAL CONDITION]. Resident #2 was making gurgling sounds. Resident #2's had a temperature of 99.4 degrees and a blood pressure of 94/48. The note reflected he would be admitted to the intensive care unit for further evaluation. [DIAGNOSES REDACTED]. Further review reflected an entry dated 05/09/2015 Presents with septic shock secondary to catheter associated urinary tract infection (present on arrival) .He also has a catheter in place that has been there for about a month. We will try to liberate him from that and do post void residual. Review of Resident #2's WBC count at the hospital on [DATE] at 5:13 AM reflected a WBC count of 42.8 with the normal range being 3.6 to 11.2. Review of the website: <http://www.merckmanuals.com/home/infections/bacteremia-sepsis-and-septic-shock/sepsis-and-septic->: Sepsis is a serious body wide response to bacteremia or another infection. Septic shock is life-threatening low blood pressure (shock) due [MEDICAL CONDITION] . At first, people have a high (or sometimes low) body temperature, sometimes with shaking chills and weakness . Review of Resident #2's Hospital Discharge Summary dated 05/11/2015 reflected his primary [DIAGNOSES REDACTED]. Further review reflected Foley catheter was discontinued and the Resident was able to void with no post void residual. In an interview on 06/09/2015 at 11:30 AM Resident #2's Physician stated he was not made aware of Resident #2's changes in condition and Resident #2's labs were not reported to him. Resident #2's Physician stated he came to the facility and saw the CBC results in the chart and said Wow. Resident #2's Physician stated if he had been made aware of Resident #2's changes and lab reports he would have put him in the hospital sooner. Resident #2's Physician stated Resident #2 came from the hospital after surgery with his Foley. Resident #2's Physician stated he did not like Foley's and Resident #2 would only need a Foley if he had a coccyx wound to keep the urine out of the wound. In an interview on 06/05/2015 at 7:07 PM the DON stated she was not aware of Resident #2's labs not being reported to the physician until the VA (Veterans Affair) Nurse came to the facility and made her aware after Resident #2 was transferred to the hospital. The DON stated she investigated the situation and discovered the labs were not reported Resident #2's Physician and in-serviced the staff on notifying the physician of abnormal lab results. Review of the Facility's In-service Training Report reflected an in-service prior to Resident #2's admitted d 04/21/2015 which reflected critical and/or abnormal lab values require contacting the physician. LVN B, and LVN C were in attendance. Review of the Facility's In-service Training Report dated 05/15/2015 reflected all STAT labs need to be ordered immediately, and once results received the doctor needs to be notified immediately with the results. The in-service training did not cover notifying the physician of change of conditions or the care of indwelling urinary catheters. Review of Resident #2's Bladder Incontinence Evaluation admission assessment (not dated) reflected Resident #2 had a catheter inserted in the hospital and the reason for the catheter was surgery. Resident #2 was assessed to have perception of the need the void. The assessment further reflected Resident #2 had urinary disorders (prostate, bladder). Review of Resident #2's History and Physical exam dated 05/06/2015 did not reflect Resident #2 to have a urinary disorder of [MEDICAL CONDITIONS] bladder, or begin prostate hypertrophy. In an interview on 06/09/2015 at 3:00 PM the DON stated the only medically justified reasons for a resident to have an indwelling urinary catheter were [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], or Stage III or IV pressure ulcer to coccyx or sacral areas. The DON stated Resident #2 did not have a medically justified reason for his Foley catheter as he did not have Stage III or IV pressure ulcers or a [DIAGNOSES REDACTED]. The DON stated she investigated the situation in regards to Resident #2's change of condition. The DON stated she felt Resident #2 had been neglected in regards to his abnormal lab values not being reported to his physician but did not factor in the Foley as part of his problem. The DON stated the nursing staff should have contacted Resident #2's Physician and made him aware of the Foley and that Resident #2 did not have a need for the Foley. In an interview on 06/09/2015 at 3:57 PM the Administrator stated the facility had some major systemic issues. The Administrator stated the DON should have caught the lack of follow up with Resident #2's condition changes and failure to report lab results to the physician. The Administrator stated he expected the facility's policy's to be followed and expected the DON to monitor residents with Foley catheters. Review of the Website: <http://www.sepsisalliance.org/sepsis_and/urinary_tract_infections/> reflected Urinary tract infections, or UTIs . Most often, they are treated quickly and effectively with antibiotics,the infection becoming a distant memory. Unfortunately, not all UTIs are treated quickly and some aren't even identified quickly, particularly in people who have limited or no sensation below the waist or who are unable to speak for themselves. An untreated UTI may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITION] .The term urosepsis is usually used to [MEDICAL CONDITION] caused by a UTI. Sometimes called blood poisoning ,sepsis is the body's often deadly response to infection or injury.[MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. More than half the cases of urosepsis among older adults are caused by a UTI. Review of the Facility's Policy Catheters- Insertion and Care -Indwelling, Straight, Suprapubic and External dated 03/2012 reflected It is the policy of this home htat the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications. Physician order is required for all catheters. Order should contain the following: Type of catheter, size, and size of bulb, frequency to change catheter . Review of the Facility's Policy Change of Condition- Observing, Reporting and Recording dated 03/2012 reflected It is the policy of this home to inform the resident, the residents physician and if indicted the residents responsible party for the following A significant change in the residents physical, mental, or psychosocial status, such as a deterioration in health .in life-threatening conditions or clinical complication .a need to alter treatment significantly . Review of the Facility's Policy Lab Orders dated 03/2012 reflected .The home must notify the attending physician of the lab results .The Director of Nursing/designee will be responsible to monitor lab orders to assure that all ordered labs have been drawn as ordered by the physician . In an interview on 06/09/2015 at 5:00 PM the DON stated the facility did not have a policy on justification for the use of indwelling urinary catheters. Review of the facility's Policy Abuse- Reportable Events dated 01/2008 and revised 05/2014 reflected It is the policy of this home 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 .Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .The home's administration will conduct and investigate allegations of crimes, suspected abuse, neglect, or misappropriation of property, and will provide notification and release of information to the proper authorities, in accordance with federal and state regulations. The Facility provided CMS 672 reflected four (4) resident with indwelling urinary catheters.

Based on observation, interview, and record review the facility failed to consult with the resident's physician regarding a need to alter treatment significantly for three (3) of seven (7)residents (Resident #2, #6 and #7) reviewed for notifying the physician when: A) a) The facility failed to communicate with Resident #2's physician when the Resident exhibited signs and symptoms of a urinary tract infection beginning [DATE]. The facility was made aware Resident #2 had an abnormally high CBC lab on [DATE] and did not communicate the abnormal lab to Resident #2's Physician until [DATE]. This resulted in Resident #2 being sent to the hospital in the early morning hours of [DATE] with septic shock secondary to a catheter associated urinary tract infection. These deficient practices affected Resident #2 and placed four (4) other residents with catheters at risk for the development of/or worsening of a urinary tract infection, undue pain,[MEDICAL CONDITION], or death. b) Resident #2 developed redness to his sacral area on [DATE] which was reported to LVN E. LVN E failed to assess Resident #2 or notify Resident #2's Physician for an order regarding the redness to his sacral area resulting in Resident #2 developing three (3) Stage II pressure ulcers on [DATE]. B) Resident #6's Stage III pressure ulcer to his right heel declined from a Stage III to an unstageable pressures on [DATE]. The Treatment Nurse failed to identify the change and notify Resident #6's Physician until surveyor intervention on [DATE] at 4:00 pm. This deficient practice placed 45 residents who were at risk for pressure ulcers and five (5) residents with pressure ulcers at risk for developing new or worsening pressure ulcers, [MEDICAL CONDITION] (skin infection), [DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), and pain. C) The facility failed to notify Resident # 7's physician when the Resident's physician ordered sling to immobilize and prevent fruther damage was not able to be carried out. Resident # 7 sustained a displaced fracture (a break in the bone which the two pieces of bone become incorrectly aligned) of the right elbow on [DATE]. The physician ordered a sling to be applied to immobilize and prevent further damage until she had an orthopedic evaluation. Licensed staff could not locate a sling in the facility and did not notify the physician. Resident #7 experienced increased swelling and pain in her right arm and was transferred to a local hospital on [DATE] where a long splint was applied. This deficient practice placed 18 residents at risk for falls, at risk for delayed physician interventions and treatments, possible worsening of injuries, and pain. Findings include: A) a) Review of Resident #2's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's Admission MDS assessment dated [DATE] reflected Resident #2 was assessed to have severe cognitive impairment. Resident #2 was assessed to require dependent assist with ADLs. Resident #2 was assessed to always be incontinent of bladder and bowel. Resident #2 was not assessed to have an indwelling urinary catheter. Resident #2 was assessed to have a UTI in the last 30 days. Resident #2 was assessed to have an abdominal feeding tube and received 51% or more of his calories through the tube feeding. Resident #2 was assessed to be at risk for pressure ulcers. Resident #2 was coded to not have pressure ulcers. Review of Resident #2's Admission Data Summary dated [DATE] at 4:45 pm reflected Resident #2 was assessed to have Bilateral Lower Extremity amputations. Resident #2's assessment reflected he had an indwelling urinary catheter; there was not a reason, [DIAGNOSES REDACTED]. Resident #2 was assessed to have redness to his coccyx. No pressure ulcers were noted. Review of Resident #2's Admission Care Plan dated [DATE] reflected a problem Infection Alert with the interventions to monitor for signs/ symptoms of infection. Further review reflected a problem Bowl and Bladder Incontinence/ Catheter Care with the interventions to check for incontinence every two (2) hours, catheter care per guidelines and briefs, depends or pant liners when out of bed. Review of Resident #2's Care Plan for UTI dated [DATE] reflected Resident #2 was at risk for recurrent UTI's, urosepsis, and renal damage. The interventions included; do labs as ordered by physician and report results; monitor for [MEDICAL CONDITION] (bacterial infection of the kidneys), fever, nausea, vomiting, flank pain, and report to physician if noted; monitor for [MEDICATION NAME] continued symptoms of frequency, urgency, malaise, foul smelling urine, dysuria (Pain during urination, or difficulty urinating) and report to physician. Observation/ Interview on [DATE] at 4:15 pm revealed Resident #2 in bed. Resident #2 did not answer questions just stated he was ok. No Foley catheter was noted. In an interview on [DATE] at 4:20 pm LVN D stated Resident #2 recently went out to the hospital [MEDICAL CONDITION]. LVN D stated he came to the facility with a catheter and [MEDICAL CONDITION] at the facility from a UTI. LVN D stated Resident #2 had a high white blood cell count when he was sent out. Review of Resident #2's Admission Start Up Orders dated [DATE] through [DATE] reflected under treatments that the Foley Catheter was checked. Resident #2's Physician signed theses orders on [DATE]. Review of Resident #2's Consolidated Physician order [REDACTED].>Review of Resident #2's TAR for [DATE] did not reflect an entry for a urinary catheter, catheter care, or changing parameters. Review of Resident #2's Nurses Notes from [DATE] through [DATE] reflected Resident #2 developed a low grade temperature of 99.6 degrees that persisted on and off throughout that time frame. Resident #2 had vomiting on [DATE]. Resident #2 had complaints of back (lumbar) pain on [DATE] (flank pain (or low back) is often the sign of kidney problems). On [DATE] at 1:45 pm Resident #2's temperature was 99.4 degrees and the nurses note reflected Resident #2 appeared diaphoretic (perspiring profusely) on arms and was cold to touch. Resident #2's blood sugar was assessed to be 215 mg/dl. LVN A documented Resident #2's Physician was messaged and no call back was received. On [DATE] at 3:00 pm Resident #2's nurses note by LVN A reflected Resident #2 continued to be cold and clammy to upper extremities and his temperature was down to 97.3 degrees. LVN A further documents no signs and symptoms of infections to surgical wounds on bilateral lower extremities. LVN A further documents she spoke to the DON and ADON about not getting a response from Resident #2's physician. LVN A further documents Decision to monitor vital signs and urine output and to notify MD again if any drastic changes occur. MD to return in am from vacation. In an interview on [DATE] at 6:00 pm the ADON stated; after reviewing Resident #2's physician orders; stated Resident #2 did not have an order for [REDACTED]. In an interview on [DATE] at 7:07 pm the DON stated she remembered LVN A contacting her on [DATE] and thinking Resident #2's blood sugar was the cause of his change. The DON stated she did not remember what else she told LVN A. Review of the Facility's Policy Change of Condition- Observing, Reporting and Recording dated ,[DATE] reflected If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director or the emergency room physician. Review of Resident #2's Nurses Notes from [DATE] through [DATE] reflected Resident #2 had amber colored urine on [DATE]. On [DATE] at 2:50 pm Nurse's Notes reflected Resident #2's Physician's office was notified about Resident #2 wheezing and a chest x-ray was ordered to rule out aspiration. On [DATE] at 1:00 am LVN B documented Resident #2's Foley Catheter was leaking and she changed the Foley. LVN B further documented while removing the old catheter a large amount of pus discharge from his urethra mixed with blood was noted. Resident #2 temperature was documented as 99 degrees. LVN B documented to call dr. for possible UA C&S. In an interview on [DATE] at 7:53 pm LVN B stated she did not call Resident #2's Physician on the night of [DATE]. LVN B stated she wrote a note on the 24 hour report for the next shift to call the Physician. Review of the Facility's 24 Hour Report dated [DATE] reflected no entry for Resident #2 regarding his signs and symptoms of UTI, changing the Foley catheter, or physician notification. Review of Resident #2's Nurses Notes dated [DATE] at 11:30 am (10 hours later) reflected Resident #2 had hematuria (bloody urine) in Foley bag and Resident #2's Physician was notified and a new order for a STAT (immediately) CBC and UA. Review of Resident #2's Physician Telephone orders dated [DATE] reflected an order for [REDACTED]. Review of Resident #2's Nurses Notes dated [DATE] at 2:30 pm reflected Resident #2 had small amount of emesis. Further review reflected at 9:00 pm Resident had tea colored urine and the nurse was waiting for his lab results. In an interview on [DATE] at 8:15 pm LVN C stated she worked with Resident #2 on the evening of [DATE]. LVN C did not recall seeing Resident #2's CBC results only his UA. LVN C stated she did not fax Resident #2's CBC results to Resident #2's Physician. LVN C stated she thought she faxed Resident #2's UA results to Resident #2's Physician because he was on a antibiotic. Review of the Facility's 24 Hour Report from [DATE] through [DATE] reflected no entries regarding Resident #2's CBC or UA results and no communication between shifts regarding his condition. Review of Resident #2's Nurses Notes from [DATE] through [DATE] reflected no entries regarding his labs. Review of Resident #2's CBC lab results dated [DATE] reflected the lab was faxed to the facility at 8:57 pm on [DATE]. Resident #2's WBC count was high at 17.6 with the normal range being 3.8 to 10.1. Resident #2's Urinalysis report which was also faxed to the facility on [DATE] at 9:03 pm reflected a large amount of blood with WBCs TNTC (to numerous to count.) Hand written on Resident #2's CBC lab report was a circle around the WBC count 17.6 with a explanation point (!) and written on the lab was When was this faxed ?! signed by Resident #2's Physician on [DATE]. Review of Resident #2's Physician's Telephone Orders reflected an order dated [DATE] STAT CBC Now signed by Resident #2's Physician and dated [DATE]. The order was noted by the nurse at 9:05 pm. In an interview on [DATE] at 7:55 pm LVN B stated on the morning of [DATE] around 3:30 am or 4:00 am she went into Resident #2's room and she noticed a change in condition. LVN B stated Resident #2 was unresponsive. LVN B stated the CNAs had told her Resident #2 was real sweaty so she took his blood sugar. LVN B stated Resident #2's blood sugar was high at 501 mg/dl and his blood pressure was real low ,[DATE]. LVN B stated she gave Resident #2 insulin but it did not work to bring down his blood sugar so she transferred him to the ER. Review of Resident #2's CBC Lab Report drawn on [DATE] at 2:40 am and received by the facility on [DATE] at 10:50 am, after Resident #2 was transferred to the hospital, reflected a WBC count of 40.9 which was critically high. Resident #2's urine culture lab report reflected a colony count of Proteus Mirabilis (A bacteria from the gastrointestinal tract.) was greater than 100,000. The sensitivity analysis reflected the bacteria Proteus Mirabilis was resistant to Bactrim DS. Review of Resident #2's Hospital Record dated [DATE] reflected Resident #2 was received from the nursing home with altered mental status and [MEDICAL CONDITION]. Resident #2 was making gurgling sounds. Resident #2's had a temperature of 99.4 degrees and a blood pressure of ,[DATE]. The note reflected he would be admitted to the intensive care unit for further evaluation. [DIAGNOSES REDACTED]. Further review reflected an entry dated [DATE] Presents with septic shock secondary to catheter associated urinary tract infection (present on arrival) .He also has a catheter in place that has been there for about a month. We will try to liberate him from that and do post void residual. Review of Resident #2's WBC count at the hospital on [DATE] at 5:13 am reflected a WBC count of 42.8 with the normal range being 3.6 to 11.2. Review of the website: <http://www.merckmanuals.com/home/infections/bacteremia-sepsis-and-septic-shock/sepsis-and-septic->: Sepsis is a serious body wide response to bacteremia or another infection. Septic shock is life-threatening low blood pressure (shock) due [MEDICAL CONDITION] . At first, people have a high (or sometimes low) body temperature, sometimes with shaking chills and weakness . Review of Resident #2's Hospital Discharge Summary dated [DATE] reflected his primary [DIAGNOSES REDACTED]. Further review reflected Foley catheter was discontinued and the Resident was able to void with no post void residual. In an interview on [DATE] at 11:30 am Resident #2's Physician stated he was not made aware of Resident #2's changes in condition and Resident #2's labs were not reported to him. Resident #2's Physician stated he came to the facility and saw the CBC results in the chart and said Wow. Resident #2's Physician stated if he had been made aware of Resident #2's changes and lab reports he would have put him in the hospital sooner. Resident #2's Physician stated Resident #2 came from the hospital after surgery with his Foley. Resident #2's Physician stated he did not like Foley's and Resident #2 would only need a Foley if he had a coccyx wound to keep the urine out of the wound. In an interview on [DATE] at 7:07 pm the DON stated she was not aware of Resident #2's labs not being reported to the physician until the VA (Veterans Affair) Nurse came to the facility and made her aware after Resident #2 was transferred to the hospital. The DON stated she investigated the situation and discovered the labs were not reported Resident #2's Physician and in-serviced the staff on notifying the physician of abnormal lab results. Review of the Facility's In-service Training Report reflected an in-service prior to Resident #2's admitted d [DATE] which reflected critical and/or abnormal lab values require contacting the physician. LVN B, and LVN C were in attendance. Review of the Facility's In-service Training Report dated [DATE] reflected all STAT labs need to be ordered immediately, and once results received the doctor needs to be notified immediately with the results. The in-service training did not cover notifying the physician of change of conditions or the care of indwelling urinary catheters. In an interview on [DATE] at 3:00 pm the DON stated when she investigated the situation in regards to Resident #2's change of condition, she felt Resident #2 had been neglected in regards to his abnormal lab values not being reported to his physician. In an interview on [DATE] at 3:57 pm the Administrator stated the facility had some major systemic issues. The Administrator stated the DON should have caught the lack of follow up with Resident #2's condition changes and failure to report lab results to the physician. Review of the Website: <http://www.sepsisalliance.org/sepsis_and/urinary_tract_infections/> reflected Urinary tract infections, or UTIs . Most often, they are treated quickly and effectively with antibiotics,the infection becoming a distant memory. Unfortunately, not all UTIs are treated quickly and some aren't even identified quickly, particularly in people who have limited or no sensation below the waist or who are unable to speak for themselves. An untreated UTI may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITION] .The term urosepsis is usually used to [MEDICAL CONDITION] caused by a UTI. Sometimes called blood poisoning ,sepsis is the body's often deadly response to infection or injury.[MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. More than half the cases of urosepsis among older adults are caused by a UTI. Review of the Facility's Policy Lab Orders dated ,[DATE] reflected .The home must notify the attending physician of the lab results .The Director of Nursing/designee will be responsible to monitor lab orders to assure that all ordered labs have been drawn as ordered by the physician . The Facility provided CMS 672 reflected four (4) resident with indwelling urinary catheters. b) Review of Resident #2's Admission MDS dated [DATE] reflected Resident #2 was assessed to have severe cognitive impairment. Resident #2 was assessed to require dependent assist with ADLs. Resident #2 was assessed to not have pressure ulcers. Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was assessed to be at risk for pressure ulcers. Resident #2 was assessed to not have pressure ulcers. Review of Resident #2's Admission Data Summary dated [DATE] at 4:45 pm reflected Resident #2 was assessed to have Bilateral Lower Extremity amputations. Resident #2 was assessed to have redness to his coccyx. No pressure ulcers were noted. Review of Resident #2's Comprehensive Care Plan dated [DATE] reflected a plan of care for skin integrity with high risk for alteration in skin integrity related to immobility, incontinence and recent bilateral above the knee amputations. Interventions for care included the staff to examine his skin daily for signs of redness and discoloration in areas prone to breakdown over bony prominences. Review of the Facility's Pressure Sore Surveillance Form dated [DATE] reflected Resident #2 was not listed as having a pressure ulcer. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Weekly Skin assessment dated [DATE] reflected Resident #2 had no areas of skin impairment. Observation on [DATE] at 2:15 pm revealed Resident #2 in bed. CNA G and CNA H rolled Resident #2 to his side and removed his brief to reveal Resident #2 had a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) pressure ulcer to his right sacral area approximately 0.5 cm by 1 cm, with a red wound bed and red wound edges. Resident #2 had a second Stage II pressure ulcer to his left sacral area approximately 1 cm by 1cm with a red wound bed and red wound edges. Resident #2 had a third Stage II pressure ulcer to his coccyx area approximately 1cm by 0.5 cm with a red wound bed and red wound edges. (approximations by Surveyor) In an interview on [DATE] at 2:22 pm CNA G stated the areas to Resident #2's bottom were new. CNA G stated she told LVN E on [DATE] that Resident #2's buttock was red. In an interview on [DATE] at 2:30 pm LVN E stated the CNA's told her that Resident #2's buttock area was red yesterday. LVN E stated she did not know if the redness to Resident #2 was blanchable. LVN E stated she did not perform an assessment to Resident #2's buttock or sacral area because she thought the Treatment Nurse was going to look at his skin. LVN E stated the redness to Resident #2's sacral area was not a change because he was usually red. LVN E stated she did not notify Resident #2's Physician regarding the redness to Resident #2's buttock or sacral area. LVN E stated she thought Resident #2 had orders for barrier cream to his buttock. LVN E stated she should have assessed Resident #2 to see if his redness was blanchable. Review of the Facility's policy Skin Integrity Monitoring System dated ,[DATE] reflected Stage I: Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Review of Resident #2's Physician Telephone Orders from [DATE] reflected an order to clean Resident #2's sacral area with wound cleanser and apply [MEDICATION NAME] cream every shift and after incontinent episodes for 14 days. The order expired on [DATE]. In an interview on [DATE] at 3:00 pm the Treatment Nurse stated she did not assess Resident #2's buttock or sacral area on [DATE]. In an interview on [DATE] at 3:30 pm the DON stated, after assessing Resident #2's coccyx and sacral area, that Resident #2 had Stage II pressure ulcers to his sacral and coccyx area. The DON stated LVN E should have assessed Resident #2 on [DATE] when the CNA's reported the redness to Resident #2's sacral area and notified the physician. The DON provided Surveyor an assessment of Resident #2's pressure ulcers. Review of Resident #2's Skin Assessment Flow Sheet- Pressure Ulcer reflected an assessment on [DATE] reflected Resident had a Stage II pressure ulcers to his right and left sacral areas and coccyx area. Written on the assessment was a new order to apply hydrogel and foam dressing everyday. Review of the Facility's policy Skin Integrity Monitoring System dated ,[DATE] reflected It is the policy of this home that: A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown. A system will be in place to assure that all residents will be assessed and preventive measures will be in place to prevent the development of pressure ulcers .If pressure causes changes in the resident's skin, it is the responsibility of the nursing staff to imitate guidelines for pressure ulcers per physician orders. The facility provided CMS 672 reflected 45 residents receiving preventive skin care. B) Review of Resident #6's Quarterly MDS assessment dated [DATE] reflected Resident #6 was assessed to have a long and short term memory problems and was moderately cognitively impaired. Resident #6 was assessed to be dependent on staff for all ADLs. Resident #6 was assessed to have one (1) Stage II pressure ulcer with the wound bed being described as granulation tissue. Review of Resident #6's Comprehensive Care Plan reflected a problem dated [DATE] that Resident #6 was at risk for skin breakdown related to incontinence, immobility, physical impairment, Diabetes Mellitus and [MEDICAL CONDITION]. Further review of Resident #6's care plan reflected a care plan for a dark purple discoloration to his right heel and a blister to his right heel that was fluid filled with intact skin and was maroon in color. Review of Resident #6's Physician Telephone Orders dated [DATE] reflected an order to clean Resident #6's right heel with wound cleanser and apply santyl and foam dressing every day. Review of the Facility's Pressure Sore Surveillance Form dated [DATE] reflected Resident #6 had a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure ulcer to his right heel 7 cm by 3 cm by 0.1 cm with slough to wound bed. Observation/ Interview on [DATE] at 12:16 pm reflected Resident #6 in bed. Resident #6 stated he was doing ok but did not engage in conversation. The Treatment Nurse was in Resident #6's room to perform wound care. The Treatment Nurse removed Resident #6's dressing to his right heel to reveal an Unstageable pressure ulcer approximately 3 cm by 1 cm. The wound bed was covered in a yellow/ brown slough with no wound bed visible. Review of Resident #6's Skin Assessment Flow Sheet Pressure Ulcer reflected an assessment done on [DATE]. Resident #6's right heel pressure ulcer was staged at a Stage III measuring 2.5 cm by 0.8 cm with 0.2 cm depth with slough and necrotic tissue. In an interview on [DATE] a 1:00 pm the Treatment Nurse stated if she observes a change in a resident's pressure ulcer she needed to notify the DON to perform an assessment and notify the resident's physician. The Treatment Nurse stated she was unable to see Resident #6's wound bed and the pressure ulcer had declined since yesterday. The Treatment Nurse stated she did Resident #6's treatment at 4:00 am and 12:00 Noon on [DATE]. The Treatment Nurse stated she did not notify the DON or Resident #6's Physician. The Treatment Nurse stated she would notify the DON and Physician. In an interview on [DATE] at 3:00 pm the DON stated Resident #6's pressure ulcer to his right heel was unstageable and the physician would be made aware. The DON stated she expected the Treatment Nurse to report any decline in Resident pressure ulcers. In an interview on [DATE] at 3:39 pm LVN F stated she did the treatment on Resident #6's pressure ulcer on [DATE] and she was able to see the wound bed in the center of the pressure ulcer and the yellow slough was around the edges of the pressure ulcer. Review of Resident #6's Nurses Notes dated [DATE] reflected an entry at 4:00 pm that Resident #6's Physician and Responsible Party were notified of the change in his pressure ulcer.(After Surveyor intervention) Review of the Website: <http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/>: reflected Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV .(EPUAP/NPUAP, 2009). Review of the facility's policy dated ,[DATE] reflected: Unstageable 6. Confirm the physician has been notified . and is aware of the current status. Document in the progress notes. 7. Confirm the resident and interested party has been notified .and is aware of the current status. Document in the progress notes. The facility provided CMS 672 reflected 45 residents with preventive skin care and five (5) with pressure ulcers. C) Review of a Face Sheet for Resident #7 reflected she was an [AGE] year old female with an original admission date of [DATE], a re-admission of [DATE] and [DIAGNOSES REDACTED]. Review of Resident # 7's Quarterly MDS Assessment for Resident #7 dated [DATE] reflected moderately impaired cognition, assistance of one person for ADLs, she could self propel her wheelchair, and had no falls in the past 90 days prior to the assessment. Review of a facility Incident Report dated [DATE] for Resident #7 reflected at 11:30 am a resident informed staff that Resident #7 was on the floor in the dining room. No injury noted resident complained of pain to the right elbow. Notified MD and received new order for X-ray of the right elbow. The incident report was completed by LVN D. Review of a Radiology Report for Resident #7 dated [DATE] reflected a displaced [MEDICAL CONDITION] elbow with soft tissue damage. Review of Nurses' Notes completed by LVN C dated [DATE] at 5:15 pm reflected: facial grimacing, medicated with [MEDICATION NAME] ,[DATE] mg one tab by mouth at this time. Will monitor. Review of Nurses' Notes completed by LVN C on [DATE] at 8:20 pm reflected an X-ray report showed an acute mildly displaced [MEDICAL CONDITION] process (elbow). There were new physician orders [REDACTED].# 7 was to see an Orthopedic Physician in the morning ([DATE]). In an interview on [DATE] at 3:55 pm, LVN B started she was the charge nurse on duty for the 10:00 pm - 6:00 am shift on [DATE]. LVN B stated when she came on duty, LVN C reported to her Resident #7 had a physician's orders [REDACTED]. LVN B stated LVN C had not notified Resident #7's physician a sling had not been placed on her as ordered. LVN B further stated when she assessed Resident #7 at 10:30 pm her right arm did not have a sling in place and it was very swollen and she was in pain. LVN B stated she telephoned Resident #7's physician and informed him of her assessment and was instructed to send Resident #7 to a local hospital for evaluation. Review of LVN B's Nurses' Notes for Resident #7 dated [DATE] 10:30 pm reflected Resident #7 was moaning and crying due to the pain in her arm and there was not a sling in place to immobilize the joint. Resident's arm was swollen. Physician called and orders received to send to the emergency room . Review of LVN B's Nurses Notes dated [DATE] at 2:45 am reflected Resident #7 returned from the emergency room with a long splint on the right arm. Review of Nurses' Notes for Resident #7 dated [DATE] reflected the orthopedic physician treating Resident #7 reported the type of fracture she had could only be repaired with surgery and she (Resident #7) was not a good candidate for surgery. Resident is to continue with the cast in place for 2 additional weeks and will have some limitations to right arm. In an interview on [DATE] at 3:30 the DON stated staff did not telephone her to let her know they could not locate a sling in the facility for Resident #7. The DON also stated it would have been the expectation that licensed staff notify the physician as well, so a decision could be made about the arm not being stabilzed in a sling as ordered. Review of the Facility's Policy Change of Condition- Observing, Reporting and Recording dated ,[DATE] reflected It is the policy of this home to inform the resident, the residents physician and if indicted the residents responsible party for the following A significant change in the residents physical, mental, or psychosocial status, such as a deterioration in health .in life-threatening conditions or clinical complication .a need to alter treatment significantly . The facility DON provided a list of 18 residents identified as high risk for falls.

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 for one (1) of three (3) residents reviewed for changes in skin conditions (Resident #1) when: Resident #1 developed a 2 inch by 2 ? inch fluid filled blister on her right breast and licensed staff failed to assess the wound for changes over a 6 day period when the blistered area opened and deteriorated into multiple [MEDICAL CONDITION] with [MEDICAL CONDITION]. The [MEDICAL CONDITION] did not respond to initial treatment and an area had to have debridement (surgical removal of dead tissue). This deficient practice could place a facility census of 11 residents who currently have changes in skin conditions that are non-pressure related at risk for worsening of the condition without physician ordered treatments and interventions. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED].), [MEDICAL CONDITION], Chronic pain, Idiopathic [MEDICAL CONDITION] (nerve pain with an unknown cause) and hypertension. Review of a MDS assessment for Resident #1 reflected Resident #1 requires limited assistance of one for transfers and bed mobility, supervision for bathing and dressing, is ambulatory by self-propelling her wheelchair or occasionally uses a walker for short distances and had a BIMS score of 10 (moderate cognitive impairment). Observation on 11/13/14 at 2:00 pm of Resident #1's right breast revealed multiple areas of discoloration from adhesive tape and 7 dry open [MEDICAL CONDITION]. The largest lesion (which had been debrided), located approximately in the center of the others, was dry with defined margins and yellow outer edges and approximately 3 inches x 3 inches in size. The inner portion of the lesion was red and pink and it was hard and mobile. There was a linear lesion on the right outer edge with yellow edges as well. There were no odors or exudate noted. This observation was documented with photographs. In an interview on 11/13/14 at 2:30 pm Resident # 1 stated she first noticed the blister while she was showering on 10/21/14 and she showed a nurse when she was finished, but it was about a week or more before they started any treatments. Resident #1 stated she was sad and worried about the area on her breast that had to be debrided. She stated she thought it will turn [MEDICAL CONDITION] because "it's so hard" and she asked the doctor to order a mammogram. Review of a nurse's note for Resident #1 written by LVN X reflected- 10/21/14, 3:30 AM Resident reports a blister on her right breast from being in the sun today. Blister measures 2 inches x 2 ? inches. Review of an undated facility physician written communication form completed by LVN Z reflected, "Resident states she has a blister on her right breast from the sun. Please advise." In an interview on 11/13/14 at 11:45 am LVN Z stated she was told by LVN X during shift report on the morning of 10/21/14 that Resident #1 had a blister on her breast from sunburn. LVN Z stated she completed a written communication form to the physician on the morning of 10/21/14, but added she did not measure or assess the blister herself. LVN Z stated she cared for Resident #1 between 10/21/14 when the blister was first identified until 10/27/14 when she was seen by the NP and orders were received for antibiotic therapy and [MEDICATION NAME] cream (is used for treating and preventing bacterial infections in second and third degree burns). LVN Z stated she applied a gauze dressing a few times during this time frame when Resident #1 requested one because her clothes were rubbing on the area and it was as bothering her. LVN Z stated she thought the treatment nurse was aware the area had deteriorated and that it was her responsibility to document the changes and to notify the physician. However, LVN Z also added she had not completed the initial paperwork to notify the treatment nurse of the blister/s on 10/21/14 for her to be able to assess and monitor. Review of nurses' notes for Resident #1 from 10/21/14 to 10/24/14 reflected nurses documented a blister on the right breast and to monitor for 3 days. There were no measurements, description or changes documented. In an interview on 11/13/14 at 8:20 am the facility treatment nurse, LVN Y, stated she had had the position for about one month. LVN Y stated she was not informed by staff of Resident #1's blistered area to her right breast. LVN Y stated she first became aware of Resident #1's burn during a scheduled weekly skin assessment she performed on Friday 10/24/14. She further stated she was concerned about infection and informed the DON. LVN Y stated she was told Resident #1 had an appointment the following week, but the DON didn't say which day and she didn't ask to ensure she was seen as soon as possible. LVN Y stated when she returned to work on the following Monday 10/27/14 she saw the orders for the antibiotics and [MEDICATION NAME] cream and she initiated treatment. Review of the treatment nurse's documentation for Resident #1's skin assessment dated [DATE] reflected the following: Open blisters on the right breast. Waiting to go the doctor for prescription. Review of a physician's consult report generated by the nurse practitioner for Resident #1 dated 10/27/14 reflected the following: Three areas of the right breast with dry burn and redness of surrounding areas. [DIAGNOSES REDACTED]. twice daily for 7 days ordered, Burn of unspecified degree [MEDICATION NAME] cream twice daily to right breast [MEDICAL CONDITION]. In an interview on 11/13/14 at 12:45 pm the nurse practitioner stated she received a telephone call from a facility nurse on the morning of 10/27/14 (she couldn't remember who) and was asked to see Resident #1 regarding the burn to her breast.. She stated there were several open areas on her right breast with a large area of redness. The nurse practitioner added that she diagnosed [MEDICAL CONDITION] and prescribed antibiotics and [MEDICATION NAME] cream. When asked if she would have been informed when the blistered area first changed from a single large intact blister to multiple open areas of infection if that would have made an impact on the outcome of the wound she stated she could not say for certain; but the initial notification on 10/21/14 should have been more detailed for the physician to make an informed decision for treatment or medical interventions. The NP also stated she was not aware the wound care physician had to debride the largest of the open areas on 11/04/14 and had ordered an antibiotic cream twice daily. Review of a physician consult report for Resident #1 dated 11/04/14 reflected the following: Burn to right breast- Wound size 15 cm x 14 cm x 0.1 cm. Cluster wound with light serous exudate with 30 % yellow necrotic tissue. Plan-Surgical Decisional Debridement of Subcutaneous tissue. Indication: Remove Necrotic tissue and establish margins of visible tissue. [MEDICATION NAME] ointment (antibiotic) once daily with a dry protective dressing. In a continued interview on 11/13/14 LVN Y stated after 7 days of the treatments ordered on [DATE] there was no improvement and on 11/04/14 she requested the wound care physician to see Resident #1. She added she did had not reviewed the wound care physician's notes from 11/04/14 and was not aware the largest area of the wound had been debrided. LVN Y stated during the wound care physician's visit with Resident #1 she didn't stay in the room because she was asked to get clinical information from the chart for the physician due to this being the first time seeing her. LVN Y went on to say she did not realize she wound had been debrided until the investigators asked to see the wound care physician's documentation. LVN Y did not have an explanation as to how when she provided treatment following the debridement she had not recognize a change in the area. In an interview on 11/13/13 at 9:00 am the DON stated she had found the physician communication form for Resident #1 's burn blister in a folder at the nurses' station and it was undated and the physician 's signature was undated as well. The DON went on to say the facility had recently started having the written physician notifications delivered to their offices for review and signatures because there was a delay in their responses to faxed concerns. The DON added LVN Z should have assessed and measured the blister and given the physician a more detailed notification, rather than just documenting the resident stated she had a blister on her breast from the sun. The DON confirmed no licensed staff had notified the physician of the changes until the morning of 10/27/14. She also confirmed there had not been ongoing assessments, communication and documentation by licensed staff from the onset of the blister. The DON stated she had not assessed the wound or reviewed communication from the wound care physician for the visits on 11/04/14 and 11/11/14 to learn there had been the need for debridement. She added the current process in place for reviewing notes from the wound care physician is they are placed in a folder for the treatment nurse's review only. But since this incident and the fact the treatment nurse is new to the position she will review them as well and personally follow up on any resident changes in skin. Review of the Incident Report dated 10/21/14 for Resident #1 reflected that there was no assessment of the blister completed. Continued review reflected there was no Skin Assessment Flow Sheet for Non Pressure Ulcers completed until 10/24/14, as per the facility policy. Review of a facility Skin Integrity Management Policy of Non-Pressure Ulcers dated 3/2012 reflected the following: -Non-pressure sore may present as a surgical site, bruise, skin tear, tape burn, maceration, excoriation, etc. -Physician, interested party, and resident are to be notified of alteration in skin. -Assessment of the skin area is documented using the Skin Assessment Flow Sheet for Non Pressure Ulcers -Continue to assess the area at least weekly and document the assessment The facility provided a list of 11 residents with non-pressure sores

Based on observation, interview and record review the facility failed to immediately consult with the resident's physician for a need to alter treatment for one (1) of three (3) residents reviewed for changes in skin conditions (Resident #1). The facility failed to notify the physician when Resident #1 developed a 2 inch by 2 ? inch fluid filled blister on her right breast. Over a 6 day period, the blistered area opened and deteriorated into multiple [MEDICAL CONDITION] with [MEDICAL CONDITION] before there was a request for the physician to see her. The [MEDICAL CONDITION] did not respond to initial treatment and an area had to have debridement (surgical removal of dead tissue) and may require additional debridement. This deficient practice could place a facility census of 11 residents who currently have changes in skin conditions that are non-pressure related at risk for worsening of the condition without physician ordered treatments and interventions. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED].), [MEDICAL CONDITION], Chronic pain, Idiopathic [MEDICAL CONDITION] (nerve pain with an unknown cause) and hypertension. Review of a MDS assessment for Resident #1 reflected Resident #1 requires limited assistance of one for transfers and bed mobility, supervision for bathing and dressing, is ambulatory by self-propelling her wheelchair or occasionally uses a walker for short distances and had a BIMS score of 10 (moderate cognitive impairment). Observation on 11/13/14 at 2:00 pm of Resident #1's right breast revealed multiple areas of discoloration from adhesive tape and 7 dry open [MEDICAL CONDITION]. The largest lesion (which had been debrided), located approximately in the center of the others, was dry with defined margins and yellow outer edges and approximately 3 inches x 3 inches in size. The inner portion of the lesion was red and pink and it was hard and mobile. There was a linear lesion on the right outer edge with yellow edges as well. There were no odors or exudate noted. This observation was documented with photographs. In an interview on 11/13/14 at 2:30 pm Resident # 1 stated she first noticed the blister while she was showering on 10/21/14 and she showed a nurse when she was finished, but it was about a week or more before they started any treatments. Resident #1 stated she was sad and worried about the area on her breast that had to be debrided. She stated she thought it will turn [MEDICAL CONDITION] because "it's so hard" and she asked the doctor to order a mammogram. Review of a nurse's note for Resident #1 written by LVN X reflected- 10/21/14, 3:30 AM Resident reports a blister on her right breast from being in the sun today. Blister measures 2 inches x 2 ? inches. Review of an undated facility physician written communication form completed by LVN Z reflected, "Resident states she has a blister on her right breast from the sun. Please advise." In an interview on 11/13/14 at 11:45 am LVN Z stated she was told by LVN X during shift report on the morning of 10/21/14 that Resident #1 had a blister on her breast from sunburn. LVN Z stated she completed a written communication form to the physician on the morning of 10/21/14, but did not fax it. Instead it was placed in a folder to be taken to the physician's office for review by the facility's medical records person. LVN Z added she did not measure or assess the blister or give the physician the most complete or detailed information as possible about the change in Resident #1's skin condition. LVN Z stated she cared for Resident #1 between 10/21/14 when the blister was first identified until 10/27/14 when she was seen by the NP and orders were received for antibiotic therapy and [MEDICATION NAME] cream (is used for treating and preventing bacterial infections in second and third degree burns). LVN Z stated she thought the treatment nurse was aware the area had deteriorated and it was her responsibility to notify the physician. However, LVN Z also added she had not completed the necessary paperwork to initially notify the treatment nurse of the blister/s on 10/21/14 or thereafter. Review of a physician's consult report generated by the nurse practitioner for Resident #1 dated 10/27/14 reflected the following: Three areas of the right breast with dry burn and redness of surrounding areas. [DIAGNOSES REDACTED]. twice daily for 7 days ordered, Burn of unspecified degree [MEDICATION NAME] cream twice daily to right breast [MEDICAL CONDITION]. In an interview on 11/13/14 at 12:45 pm the nurse practitioner stated she received a telephone call on 10/27/14 from a nurse (she couldn't remember a name) and was asked to see Resident #1 regarding the burn to her breast. She stated there were several open areas on her right breast with a large area of redness. The nurse practitioner added that she diagnosed [MEDICAL CONDITION] and prescribed antibiotics and [MEDICATION NAME] cream. When asked if she would have been informed when the blistered area first changed from a single large intact blister to multiple open areas of infection if that would have made an impact on the outcome of the wound she stated she could not say for certain; but the initial notification on 10/21/14 should have been more detailed for the physician to make an informed decision for treatment or medical interventions. The NP also stated she was not aware the wound care physician had to debride the largest of the open areas on 11/04/14 and had ordered an antibiotic cream twice daily In a continued interview on 11/13/14 LVN Y stated after 7 days of the treatments ordered on [DATE] there was no improvement and on 11/04/14 she requested the wound care physician to see Resident #1. In an interview on 11/13/14 at 8:20 am the facility treatment nurse, LVN Y, stated she had had the position for about one month. LVN Y stated she was not informed by staff of Resident #1's blistered area to her right breast, but first became aware of Resident #1's burn during a scheduled weekly skin assessment she performed on Friday 10/24/14. She further stated she was concerned about possible infection and asked the DON to request Resident #1 be seen by her physician. LVN Y stated she was told Resident #1 had an appointment the following week but she didn't ask when to ensure she was seen as soon as possible. LVN Y stated when she returned to work on the following Monday 10/27/14 she saw the orders for the antibiotics and [MEDICATION NAME] cream and initiated treatment. In a continued interview on 11/13/14 LVN Y stated after 7 days of the treatments ordered on [DATE] there was no improvement and on 11/04/14 she requested the wound care physician to see Resident #1. Review of a physician consult report for Resident #1 dated 11/04/14 reflected the following: Burn to right breast- Wound size 15 cm x14 cm x 0.1 cm. Cluster wound with light serous exudate with 30 % yellow necrotic tissue. Plan-Surgical Excisional Debridement of Subcutaneous tissue. Indication: Remove Necrotic tissue and establish margins of visible tissue. [MEDICATION NAME] ointment (antibiotic) once daily with a dry protective dressing. In an interview on 11/13/13 at 9:00 am the DON stated she had just found the physician communication form for Resident #1's burn blister in a folder at the nurses ' station and it was undated and the physician's signature was undated as well. The DON went on to say the facility had recently started having the written physician notifications delivered to their offices for review and signatures because there was a delay in their responses to faxed concerns. The DON went on to the say LVN Z should have assessed and measured the blister and given the physician a more detailed notification, rather than just documenting the resident stated she had a blister on her breast from the sun. The DON confirmed no licensed staff had notified the physician of the changes until the morning of 10/27/14. Review of the Incident Report dated 10/21/14 for Resident #1 reflected that there was no assessment of the blister completed. Continued review reflected there was no Skin Assessment Flow Sheet for Non Pressure Ulcers completed until 10/24/14, as per the facility policy. Review of a facility Skin Integrity Management Policy of Non-Pressure Ulcers dated 3/2012 reflected the following: -Non-pressure sore may present as a surgical site, bruise, skin tear, tape burn, maceration, excoriation, etc. -Physician, interested party, and resident are to be notified of alteration in skin. -Assessment of the skin area is documented using the Skin Assessment Flow Sheet for Non Pressure Ulcers -Continue to assess the area at least weekly and document the assessment The facility provided a list of 11 residents with non-pressure sores

Based on observation, interview and record review the facility failed ensure that one (1) of 8 residents ( Resident #1) who had been identified at risk for falls and wandering/elopement behaviors who eloped from the facility received adequate monitoring and supervision to prevent prevent elopement when: The facility staff failed to monitor and supervise Resident #1, who wore a Wanderguard bracelet ( A bracelet worn adjacent to the resident's body that alarms to alert staff the resident is nearing or exiting a door of the facility.), had a history of [REDACTED]. Resident #1 was located laying face down in the grass approximately 100 feet from the facility next to the nail salon. Resident #1 was located approximately 30 feet from the road by three bypassers. Staff were not aware Resident #1 had exited the facility. Resident #1 experienced a medical emergency, went into cardiac arrest. Cardiopulmonary Resuscitation (CPR) was performed by paramedics at the scene prior to the resident being transported to another city hospital via helicopter. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a Severity level of "Actual Harm" that is not Immediate Jeopardy and Scope of "Isolated," because the facility had yet to in-service all staff and install a magnetic lock system that is activated by the Wanderguard each at risk resident wears. This deficient practice placed 8 residents with cognitive impairment and wandering/elopement behaviors at risk for leaving the facility without staff knowledge placing them at risk for accidents or injuries. Findings included: Review of Face Sheet dated [DATE] for Resident #1 reflected a [AGE] year old male with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) Resident Assessment and Care Screening dated [DATE] for Resident #1 reflected memory deficits and disorganized thinking. Review of Comprehensive Care Plan dated [DATE] for Resident #1 reflected plan for Wanderguard on ankle related to decreased cognition and voiced wanting to leave. Review of Psychiatrist Note date [DATE] reflected Resident #1 was wandering more often and had increasing falls. Note also reflected Resident #1 " Propels self independently in wheelchair and ambulates short distances. " . Review of Psychiatrist Note date [DATE] reflected Resident #1 was wandering more often and had increasing falls. Note also reflected Resident #1 " Propels self independently in wheelchair and ambulates short distances. " Review of a Psychiatrist's telephone order dated [DATE] reflected an order for [REDACTED]. Physician orders [REDACTED]. The physician orders [REDACTED]. In an interview on [DATE] at 6:25 PM Resident #1 ' s son stated on [DATE] he was driving by the nursing home when he saw his father at the end of the driveway almost on the street. He pulled off the road and an Aide came running out of the nursing facility and stopped his father from going in the street. He does not know what time of day the incident happened but it was daylight. Review of Nurse ' s Notes about Resident #1 reflected on [DATE] " Resident somewhat agitated and stating he wants to go home. Note on [DATE] reflected " Resident has made several attempts to leave facility. " Note on [DATE] reflected Resident continued to get agitated when redirected due to elopement behavior. Record Review of Incident/Accident Reports dated September through [DATE] reflected falls on the following dates and times for Resident #1 [DATE] at 10:30 AM, [DATE] at 12:00 PM, [DATE] at 12:00 PM, [DATE] at 7:10 PM, [DATE] at 7:45 AM,[DATE] at 5:15 AM, [DATE] at 9:00 PM and [DATE] at 5:20 AM. In an interview on [DATE] at 11:30 AM by phone Witness #1 stated that on Sunday [DATE] at about 8:20 PM he was going north on Hasler Blvd. and stopped at the stop sign at Old Austin Highway. He said he saw a wheelchair in his headlights and something lying in the grass. Witness #1 used his cell phone to call his friend (Witness # 2) who was behind him and asked him to pull over and help him investigate what he saw. Witness #1 said there was a man (Resident #1) lying face down in the grass. As he approached Resident #1 tried to get into his wheelchair. Witness #1 said they asked Resident #1 his name and he gave his name to them. Witness #1 stated that he and Witness #2 assisted Resident #1 into the wheelchair, but Resident #1 could not stay in the chair. Witness #1 said Resident #1 ' s left side wouldn't work. Witness #1 stated Witness #3 joined them and offered to go into the nearest nursing home to see if they knew Resident #1. Witness #1 stated Certified Nursing Assistant CNA A and Medication Aide (MA A) came out to assist but also could not get Resident #1 to stay in his chair. Registered Nurse (RN A) came out to where the resident was lying on the ground. Witness #1 said the Resident quit being able to answer questions and it was decided to call an ambulance so his friend, Witness #2 called 911. Witness #1 said RN A went back inside after saying she was going to get the paperwork together. CNA A and MA A stayed with the resident. Witness #1 said several officers from the local Police Department showed up at the scene and an ambulance came. He saw someone do Cardoipulmonary Resuscitation (CPR) on Resident #1 and then they stopped and put oxygen on him and hooked him up to a cardiac monitor. They loaded the Resident in the ambulance and met helicopter ambulance in a nearby parking lot. Witness #1 said he worried about what happened all night. Witness #1 stated that when he got back into his truck the outside temperature reading on the dash was 51 degrees Fahrenheit. In an interview on [DATE] at 9:10 AM by phone Witness #2 stated on the night of [DATE] he was in the vehicle behind Witness #1. Witness #1 called his cellular phone and said there was something lying in the grass next to a wheelchair and asked him to stop with him to see what was going on. Witness #2 stated he looked at his dashboard clock and saw that it was 8:22 PM Witness #2 said Resident #1 was lying face down in the grass on the east side of the facility next to the nail salon . Witness #2 said Resident #1 was talking and was able to tell them his name. Witness #2 said Resident #1 could not get his left side to move when he tried to get up or sit in his wheelchair. Witness #2 said his other friend Witness #3 went to see if he was from the nursing home next door. Witness #2 stated Witness #3 then returned with two staff members from the nursing home (CNA A and MA A) that knew the resident and tried to take him back in the nursing home, but Resident #1 could not stay in the chair. Witness #2 said a nurse joined them and then the Resident could no longer answer questions. Witness #2 stated he called 911 and a city police officer was the first to arrive. The nurse went back into the nursing home and was still in the nursing home when the ambulance arrived. The Resident lost his pulse and CPR was done briefly to bring it back. The nurse came out with the paperwork after the ambulance staff had called for a helicopter to take the Resident to the hospital in a nearby town. The ambulance took the paperwork from the nurse and left to meet the helicopter in front of the school. In an interview on [DATE] at 1:58 PM by phone Witness #3 said on the night of [DATE] he had not arrived on the scene until Witness #1 an Witness #2 had tried to help Resident #1 into his wheelchair and realized he could not stay sitting up in the wheelchair. Witness #3 said he volunteered to go see if Resident #1 was from the nearest nursing home after he heard him say his name. Witness #3 said he went into the nursing home and found the desk which was not visible from the front door. Witness #3 stated there were 3 ladies at the desk so he asked them if they knew the Resident. Witness #3 said one of them made a face and covered her mouth and they asked why. He told them the Resident was lying outside on ground and then he took two of them to the Resident. Witness #3 said Witness #1 and Witness #2 had put Resident #1 back in his chair but were having trouble keeping him in the chair. Witness #3 said the two staff members tried to take the Resident into the building but could not keep him in the chair. Witness #3 said they all assisted to lay Resident #1 on the ground. Witness #3 stated he does not know exactly when RN A came outside but she came out and went back into the building and then came back outside. Witness #3 said Resident #1 quit breathing at one point and the ambulance crew did CPR but he was breathing when they left the scene with him. In an interview on [DATE] at 10:53 AM RN A stated on the night of [DATE] around 8:20 PM she heard the front door alarm sound but she was talking to a resident ' s family member who was upset and did not leave to go check the door. RN A said the alarm was still going off about 10 minutes later when she went to check on it. RN A stated she shut the alarm off and stepped out onto the front porch to look around the parking lot but did not see any residents. RN A stated she then went back inside and was summoned out the back door to the gazebo where the residents who smoked were taking a smoke break. CNA B was having trouble with a resident. Once that problem was solved, RN A stated she went back to the nurse ' s station to do charting, but a man came in asking about Resident #1 and said the Resident was outside. RN A said she, CNA A and MA A went to go get the resident. RN A said Resident #1 was in his wheelchair and was able to state his name. CNA A started to wheel Resident #1 in his wheelchair back into the facility but noticed he was dragging his left side and he started to shake. RN A said staff from the facility and the men who found Resident #1 worked together to lay the Resident down on the ground. RN A said MA A had a blood pressure cuff and took Resident #1 ' s blood pressure. RN A said one of the men who found Resident #1 called 911 so she decided to go back into the facility to get the paperwork for the ambulance. RN A said she also called the doctor and the family while she was inside. RN A stated when she returned to where Resident #1 was the police and ambulance were on scene and had the Resident on a stretcher with an oxygen mask covering his face. RN A said Resident #1 was loading on the ambulance to meet the helicopter that was picking him up to take him to a hospital in another city. Review of Ambulance Report dated [DATE] for Resident #1 reflected call to dispatch was received at 8:47 PM and ambulance arrived on scene at 8:59 PM. The report reflected the resident was reported to have been seen by the nursing home staff approximately one hour before ambulance arrival on scene. Report also reflected that Resident #1 was reported to have had a brief episode of cardiac arrest and CPR was performed for approximately two minutes with spontaneous return of circulation. Assessment reflected paralysis to left side of Resident #1 ' s body. In an interview on [DATE] at 2:05 PM CNA A said around 7:30 PM she was putting her assigned residents to bed when she noticed that Resident #1 was not in his room. She stated she was not concerned because she had not heard the door alarm sound and it was not unusual for Resident #1 to be somewhere else in the facility. CNA A stated she finished helping the residents to bed that wanted to go to bed. CNA A said she went to the front to clock out for lunch and a man she didn ' t know came into the facility asking if they (also at the nurse ' s station was RN A and MA A) knew Resident # 1. CNA A stated the three of them went out to get Resident #1 who was in a wheelchair in front of the nail salon next door to the facility. CNA A said Resident #1 was alert and talking when they arrived but was having trouble sitting up in the wheelchair. CNA A said it was decided to lay Resident #1 on the ground and call 911. CNA A stated RN A went back into the facility to get Resident #1 ' s paperwork for the ambulance while MA A took the Resident ' s blood pressure. CNA A said the police and ambulance came and Resident #1 quit breathing so they did CPR and he started breathing again. CNA A said the paramedics called a helicopter to come get Resident #1. CNA A said they loaded Resident #1 on the ambulance because they had to meet the helicopter down the road. In an interview on [DATE] at 11:05 AM by phone CNA B stated she took the residents who smoke outside at 8:30 PM on [DATE]. CNA B said that smoke times are scheduled is the reason she knows what time it was. She asked RN A to come out to the smoking area, which is out one of the back doors at the gazebo, about 5 to 10 minutes after she took the residents outside. CNA B said RN A was only at the gazebo a few minutes then she went back inside the building. CNA B said when she brought the residents back in the building around 9:00 PM or 9:10 PM RN A was going in and out of the front door. CNA B stated she did not find out what happened until later. In an interview on [DATE] at 8:30 AM Assistant Director of Nursing (ADON) stated the residents who have Wanderguards (device worn on the wrist or ankle that activates an alarm when it gets within a certain distance of a door) are allowed to go out the front door. ADON said the Wanderguard is to let staff know when one of those residents goes outside so they can keep an eye on them. ADON said that on Sunday, [DATE] Resident #1 went outside and had a medical emergency and is currently hospitalized . ADON said Resident #1 was allowed to go outside when he wanted. In an interview on [DATE] at 2:55 PM DON stated that they have allowed residents with Wanderguard devices on to go out on the front porch where they could be seen by the therapy department during business hours. DON said the facility management realized after the incident with Resident #1 on [DATE] that changes needed to be made to the way the facility handles preventing elopement. DON stated they are checking into a system that locks the door when a resident with a Wanderguard approaches. DON said they are also looking into other possible approaches. DON said she started in-servicing staff at 8:30 AM today that when they hear the alarm sound they are to make sure the resident they are caring for is safe and go to the door that is sounding the alarm. DON stated there are 8 residents who have been identified at risk for wandering and wear a Wanderguard. In an interview on [DATE] at 1:00 PM DON stated the staff on duty the evening of [DATE] did not respond appropriately to the door alarm. Observation on [DATE] at 8:05 AM revealed the design of the facility is such that only the front offices have a view of the front door. Resident hallways and nurse ' s station cannot be seen from the front lobby and living area. Observation on [DATE] at 1:05 PM revealed Resident #2 was sitting outside at the flagpole next to the street. There was one staff member on the porch approximately 30 feet away. Observation on [DATE] at 4:05 PM revealed Resident #2 attempted to go out the front door setting the alarm off with the Wanderguard he was wearing. The Administrator and RN A tried to redirect Resident #2 but were unsuccessful. The Administrator ordered a staff member to take Resident #2 out front to sit for a while. The facility Administrator was notified on [DATE] at 5:03 PM that an Immediate Jeopardy (IJ) existed. An observation of the front door on [DATE] at 5:32 PM revealed the facility Administrator had stationed a staff person at the front door and promised someone would be stationed at the front door at all times until alternate placement could be found for high elopement risk residents. The final facility Plan of Removal was provided on [DATE] at 9:45 AM. and was accepted on [DATE] at 2:15 PM and included: On [DATE] @ 5:30 pm, the Administrator designated an employee sit at the front door to monitor to ensure that no wandering resident leaves the facility. There will be a sign in sheet to insure staff coverage 24 hours a day, all three shifts, until all high elopement risk residents have been alternately placed. The identified wandering resident will be monitored at all times by " line of sight " until alternate placement can be accomplished. The DON/designee will immediately assess all 50 residents for wandering/elopement risk. A priority list will be established for low, medium and high risk. Determination will be made to establish if alternate placement is necessary according to the priority list. DON/designee will check residents at risk plans of care and updates done as appropriate. This will be accomplished by 9pm on [DATE]. Discharge planning will begin for those in need of alternate placement at this time. Staff interviews will be done to determine if they have knowledge of any resident that have tried or talked about eloping. Interviews will be started [DATE] and completed by [DATE]. The DON /designee will review individual Incident/Accident Log for last 3 months for residents who have eloped or attempted to elope to ensure any residents at risk are addressed for alternate placement and safety. Started [DATE] and completed by 5pm. The administrator or designee will in-service all staff on: If they see any resident trying to get outside, they will re-direct and maintain eye contact of the resident until charge nurse is contacted. They will report to their direct supervisor and/or adm/don/ or designee. Will be completed by [DATE]. The administrator or designee will in-service all staff on: All potential new admissions will be reviewed prior to admission to determine if they are a wandering/elopement risk. Any pre admission Resident with a history of elopement history will not be admitted . Any resident that is not re-direct able alternate placement will be pursued. Start [DATE]. Residents who have been assessed as exit seeking will be visually monitored at all times until the mag lock install on the front door. Will continue 24 hour monitoring until installation. An evaluation was completed as of [DATE] at 8:30 a.m. In-services on the following begin on [DATE]for the following areas. Current staff will be in-serviced by [DATE]. *Elopements *Front Door Alarm sounds To check for any resident to ensure they are safe and accounted for ? Always check the parking lot to ensure no resident are in the parking with a wander guard and or any potential wanders ? If staff does not find a resident outside they are required to do a head count to ensure all residents are accounted for. ? All potential new admissions will be reviewed prior to admission to determine if they are a wandering/elopement risk. Any pre admission Resident with a history of elopement history will not be admitted . Any resident that is not re-direct able alternate placement will be pursued. The IJ was lowered on [DATE] at 3:00 PM but the facility remained out of compliance at a Severity level of "Actual Harm" that is not Immediate Jeopardy, and Scope of "Isolated" because the facility had yet to in-service all staff on responding to the door alarm and complete installation of the Wanderguard door locks. These failures resulted in Resident #1 eloping and the likelihood to cause the other seven residents (Residents #2, 3, 4, 5, 6, 7 and 8) who have a [DIAGNOSES REDACTED]. The Director of Nurses (DON) provided a list of 8 residents with cognitive impairment, had wandering/elopement behaviors and wore Wanderguard bracelets.